Nontraumatic Subarachnoid Hemorrhage in the Setting of Negative Cranial Computed Tomography Results: External Validation of a Clinical and Imaging Prediction Rule

Mark, Dustin G.; Hung, Yun‐Yi; Offerman, Steven R.; Rauchwerger, Adina S.; Reed, Mary; Chettipally, Uli K.; Vinson, David R.; Ballard, Dustin

doi:10.1016/j.annemergmed.2012.09.003

Cited by 45 publications

(41 citation statements)

References 53 publications

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“…There are several ways to interpret the data as reported by Mark et al 29 The most conservative approach is to assume that all 11 cases were true missed SAH (worse case scenario). An intermediate approach would be to assume that only the 7 cases that had associated vascular lesions found were true SAH (intermediate case scenario).…”

Section: Discussionmentioning

confidence: 99%

“…Four had retrospective design 13,18,20,29 and one was prospective. 11 We estimated that Table I in the online-only Data Supplement.…”

Section: Study Characteristicsmentioning

confidence: 99%

“…35 In the study by Perry et al, 11 there were 4 instances of scans read as negative by emergency physicians or radiology trainees, and all subsequently read correctly as positive by the attending radiologist. 11 In the studies by Mark et al 29 and Blok et al, 20 some of the scans initially read as negative by general radiologists were later over read as positive. 20,36,37 It is therefore critical that individuals experienced in reading brain CTs interpret the scan and that the clinician clearly communicates the indication for the scan to the radiologist.…”

mentioning

confidence: 99%

“…Our analysis does not apply to patients who present with atypical features (eg, primary neck pain, syncope, or seizure) or any new finding on neurological examination. Such patients do not meet entry criteria for this particular study and the extremely high sensitivity demonstrated here may not apply in these populations.There are several ways to interpret the data as reported by Mark et al 29 The most conservative approach is to assume that all 11 cases were true missed SAH (worse case scenario). An intermediate approach would be to assume that only the 7 cases that had associated vascular lesions found were true SAH (intermediate case scenario).…”

mentioning

confidence: 99%

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Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage

Dubosh

Bellolio

Rabinstein

et al. 2016

Stroke

123

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H eadache accounts for ≈2% of all emergency department (ED) visits. 1 A subset of these patients present with abrupt onset of a severe headache reaching peak intensity within 60 s referred to as a thunderclap headache. 2 The most serious cause of thunderclap headache is aneurysmal subarachnoid hemorrhage (SAH), which accounts for 4% to 12% of ED patients with a thunderclap headache. [3][4][5][6] Current clinical practice calls for a noncontrast computed tomography (CT) of the brain followed by a lumbar puncture (LP) if the CT scan is negative to exclude SAH. [7][8][9][10] This is because the sensitivity of CT scans for detecting subarachnoid blood ranges from 90% to 100% when performed within the first 24 hours after symptom onset. The sensitivity decreases as time from onset to CT elapses because the blood is progressively diluted by the normal flow of cerebrospinal fluid. 6,[11][12][13][14][15][16] Recent data suggest that in neurologically intact patients, the sensitivity of modern CT scanners for SAH approaches 100% when performed within 6 hours of headache onset and interpreted by qualified radiologists. 11,13,[17][18][19][20] These data suggest that in this early-presenting population, an LP is not necessary to rule out SAH and an initial negative CT can be considered a rule-out test. An LP is associated with patient anxiety and discomfort and can be complicated by postprocedure headache (15%-20% of patients). 21 Traumatic taps, which occur in 10% to 15% of patients, may lead to unnecessary vascular imaging and other downstream consequences. 3,[20][21][22] We conducted a systematic review and meta-analysis to determine the diagnostic accuracy of early CT only in the diagnosis of spontaneous SAH. Our objective was to determine the sensitivity, specificity, and positive and negative Background and Purpose-Emerging evidence demonstrating the high sensitivity of early brain computed tomography (CT) brings into question the necessity of always performing lumbar puncture after a negative CT in the diagnosis of spontaneous subarachnoid hemorrhage (SAH). Our objective was to determine the sensitivity of brain CT using modern scanners (16-slice technology or greater) when performed within 6 hours of headache onset to exclude SAH in neurologically intact patients. Methods-After conducting a comprehensive literature search using Ovid MEDLINE, Ovid EMBASE, Web of Science, and Scopus, we conducted a meta-analysis. We included original research studies of adults presenting with a history concerning for spontaneous SAH and who had noncontrast brain CT scan using a modern generation multidetector CT scanner within 6 hours of symptom onset. Our study adheres to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). Results-A total of 882 titles were reviewed and 5 articles met inclusion criteria, including an estimated 8907 patients.Thirteen had a missed SAH (incidence 1.46 per 1000) on brain CTs within 6 hours. Overall sensitivity of the CT was 0.987 (95% confidence intervals, 0.971-0.994) and s...

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Section: Discussionmentioning

confidence: 99%

“…Four had retrospective design 13,18,20,29 and one was prospective. 11 We estimated that Table I in the online-only Data Supplement.…”

Section: Study Characteristicsmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

See 2 more Smart Citations

Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage

Dubosh

Bellolio

Rabinstein

et al. 2016

Stroke

123

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“…NCCT alone also may be a more costeffective strategy in the diagnosis of SAH (25). However, a validation study regarding CT scan within 6 h of headache onset found that NCCT alone missed approximately 20% of SAHs (19). Furthermore, NCCT sensitivity decreases as the time from the onset of the headache increases (27,40).…”

Section: Ncct Alonementioning

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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High-Stakes Diagnostic Decision Rules for Serious Disorders

Newman‐Toker

Edlow

2013

JAMA

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Diagnostic errors lead to death or disability for an estimated 150 000 patients in the United States each year. 1 The emergency department is a known high-risk location for misdiagnosis. 2 Missed ischemic stroke and brain hemorrhage are recognized sources of diagnostic error, with approximately 9% of cerebrovascular events missed at first emergency department contact, 3 including an estimated 20% of subarachnoid hemorrhages in patients presenting with normal mental status. 4 Because effective treatments are available, diagnostic delays increase morbidity and mortality 3-to 8-fold, 4,5 so accurate early diagnosis is important.Rates of missed subarachnoid hemorrhage in the 1980s and 1990s were estimated at 32%, 6 although more recent estimates suggest the rate is approximately 12%, with about half occurring in the emergency department. 7 Some improvement is probably from newergeneration computed tomography (CT), 7,8 but most is not. 9 The current recommended standard of care is to obtain cranial CT for patients with new, rapid-onset, severe headaches and, for those with nondiagnostic CTs who are still suspected of having possible subarachnoid hemorrhages, to follow with diagnostic lumbar puncture. 10 This "CT-LP" rule is a proven method, with sensitivity for subarachnoid hemorrhage close to 100% when performed correctly. 11 However, because the real-world emergency department miss rate for subarachnoid hemorrhage is approximately 6%, 7 the CT-LP rule either is not applied to all at-risk patients or is used incorrectly (eg, lumbar puncture is obtained too early or too late, when spinal fluid findings may be misleading).In this issue of JAMA, Perry and colleagues 12 seek to enhance the clinical capabilities for diagnosing subarachnoid hemorrhage through validation and refinement of the Ottawa SAH Rule. The authors present the results of a prospective, cross-sectional study involving 2131 patients with acute headache and demonstrate that their best bedside decision rule identified all cases of subarachnoid hemorrhage (n = 132) among emergency department patients presenting with new, isolated headaches. The final rule relies on the presence of any 1 of 6 findings (age ≥40 years; neck pain or stiffness; witnessed loss of consciousness; onset during exertion; thunderclap headache [instantly peaking pain]; limited neck flexion on examination) and has an estimated sensitivity of 100% for detecting atraumatic subarachnoid hemorrhage. This rule offers the potential to reduce missed subarachnoid hemor-

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Nontraumatic Subarachnoid Hemorrhage in the Setting of Negative Cranial Computed Tomography Results: External Validation of a Clinical and Imaging Prediction Rule

Cited by 45 publications

References 53 publications

Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage

Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage

Clinical Guidelines for the Emergency Department Evaluation of Subarachnoid Hemorrhage

High-Stakes Diagnostic Decision Rules for Serious Disorders

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