Emergency Diagnosis of Subarachnoid Hemorrhage: An Evidence-Based Debate

Farzad, Ali; Radin, Bethany; Oh, Jason S.; Teague, Heidi M.; Euerle, Brian D.; Nable, Jose V.; Liferidge, Aisha T.; Windsor, Thomas; Witting, Michael D.

doi:10.1016/j.jemermed.2012.10.001

Cited by 21 publications

(10 citation statements)

References 68 publications

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“…Despite advances in CT imaging, substantial debate persists surrounding the necessity of LP following a negative head CT, particularly within the first 6 hours after onset of headache . While CSF can provide crucial diagnostic information for alternative etiologies of headache like meningitis, it remains an imperfect test for SAH.…”

Section: Discussionmentioning

confidence: 99%

Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta‐analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds

Carpenter

Hussain

Ward

et al. 2016

Academic Emergency Medicine

101

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Background Spontaneous subarachnoid hemorrhage (SAH) is a rare, but serious etiology of headache. The diagnosis of SAH is especially challenging in alert, neurologically intact patients, as missed or delayed diagnosis can be catastrophic. Objectives To perform a diagnostic accuracy systematic review and meta-analysis of history, physical examination, cerebrospinal fluid (CSF) tests, computed tomography (CT), and clinical decision rules for spontaneous SAH. A secondary objective was to delineate probability of disease thresholds for imaging and lumbar puncture (LP). Methods PUBMED, EMBASE, SCOPUS, and research meeting abstracts were searched up to June 2015 for studies of emergency department (ED) patients with acute headache clinically concerning for spontaneous SAH. QUADAS-2 was used to assess study quality and, when appropriate, meta-analysis was conducted using random effects models. Outcomes were sensitivity, specificity, positive (LR+) and negative (LR−) likelihood ratios. To identify test- and treatment-thresholds, we employed the Pauker-Kassirer method with Bernstein test-indication curves using the summary estimates of diagnostic accuracy. Results A total of 5,022 publications were identified, of which 122 underwent full text-review; 22 studies were included (average SAH prevalence 7.5%). Diagnostic studies differed in assessment of history and physical exam findings, CT technology, analytical techniques used to identify xanthochromia, and criterion standards for SAH. Study quality by QUADAS-2 was variable; however, most had a relatively low-risk of biases. A history of neck pain (LR+ 4.1 [95% CI 2.2-7.6]) and neck stiffness on physical exam (LR+ 6.6 [4.0-11.0]) were the individual findings most strongly associated with SAH. Combinations of findings may rule out SAH, yet promising clinical decision rules await external validation. Non-contrast cranial CT within 6 hours of headache onset accurately ruled-in (LR+ 230 [6-8700]) and ruled-out SAH (LR− 0.01 [0-0.04]); CT beyond 6 hours had a LR− of 0.07 [0.01-0.61]. CSF analyses had lower diagnostic accuracy, whether using red blood cell (RBC) count or xanthochromia. At a threshold RBC count of 1,000 × 106/L, the LR+ was 5.7 [1.4-23] and LR− 0.21 [0.03-1.7]. Using the pooled estimates of diagnostic accuracy and testing risks and benefits, we estimate LP only benefits CT negative patients when the pre-LP probability of SAH is on the order of 5%, which corresponds to a pre-CT probability greater than 20%. Conclusions Less than one in ten headache patients concerning for SAH are ultimately diagnosed with SAH in recent studies. While certain symptoms and signs increase or decrease the likelihood of SAH, no single characteristic is sufficient to rule-in or rule-out SAH. Within 6 hours of symptom onset, non-contrast cranial CT is highly accurate, while a negative CT beyond 6 hours substantially reduces the likelihood of SAH. LP appears to benefit relatively few patients within a narrow pre-test probability range. With improvements in CT technology and an e...

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Section: Discussionmentioning

confidence: 99%

Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta‐analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds

Carpenter

Hussain

Ward

et al. 2016

Academic Emergency Medicine

101

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“…In addition, patient reluctance to go through a procedure that they perceive as invasive and painful can lead to a failure to perform the procedure. Given these patient and provider difficulties surrounding the LP when evaluating for SAH, other strategies have been presented that often forego these issues, including NCCT alone and NCCT combined with computed tomography angiogram (CTA) of the brain (15). The purpose of this paper is to review the available medical literature on these diagnostic modalities and to offer evidence-based recommendations for a safe approach for the diagnosis or ruling out of SAH.…”

Section: Introductionmentioning

confidence: 99%

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

Meurer

Walsh

Vilke

et al. 2016

The Journal of Emergency Medicine

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, Abstract-Background: Subarachnoid hemorrhage (SAH) is frequently caused by the rupture of an intracranial aneurysmal vessel or arteriovenous malformation, leading to a cascade of events that can result in severe disability or death. When evaluating for this diagnosis, emergency physicians have classically performed a noncontrast computed tomography (NCCT) scan, followed by a lumbar puncture (LP). Recently, however, as CT technology has advanced, many studies have questioned the necessity of the LP in the SAH diagnostic algorithm and have instead advocated for noninvasive techniques, such as NCCT alone or NCCT with CT angiogram (CTA). Objective: The primary goal of this literature search was to determine the appropriate emergency department (ED) management of patients with suspected SAH. Methods: A MEDLINE literature search from October 2008 to June 2015 was performed using the keywords computed tomography AND subarachnoid hemorrhage AND lumbar puncture, while limiting the search to human studies written in the English language. General review articles and single case reports were omitted. Each of the selected articles then underwent a structured review. Results: Ninety-one articles were identified, with 31 papers being considered appropriate for analysis. These studies then underwent a rigorous review from which recommendations were developed. Conclusions: The literature search supports that NCCT followed by CTA is a reasonable approach in the evaluation of ED patients with possible SAH. Ó 2016 Elsevier Inc.

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“…A recent article comparing diagnostic strategies for patients in the emergency department with suspected SAH showed that CT along with CTA was considered the most sensitive and rapid test for diagnosing aneurysm, but had the highest radiation exposure. 5 However, the limitation of a large amount of radiation exposure to patients might be overcome by the advent of dual-energy. Dual-energy simultaneously acquires datasets at 2 different photon spectra in a single acquisition.…”

mentioning

confidence: 99%

Evaluation of Virtual Noncontrast Images Obtained from Dual-Energy CTA for Diagnosing Subarachnoid Hemorrhage

Jiang¹,

Zhang

Xie

et al. 2015

AJNR Am J Neuroradiol

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Emergency Diagnosis of Subarachnoid Hemorrhage: An Evidence-Based Debate

Cited by 21 publications

References 68 publications

Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta‐analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds

Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta‐analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

Evaluation of Virtual Noncontrast Images Obtained from Dual-Energy CTA for Diagnosing Subarachnoid Hemorrhage

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