Use of Follow-Up Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

Kalra, Vivek B.; Wu, Xiao; Matouk, Charles; Malhotra, Ajay

doi:10.1161/strokeaha.114.007370

Cited by 49 publications

(40 citation statements)

References 68 publications

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“…However, only six of these individuals underwent neurosurgical intervention (ventricular drain, aneurysm coiling, or clipping), which equates to a NN LP = 258 (6/1546 = 0.38%, 1/0.0038 = 258) to identify one aneurysm amenable to neurosurgical intervention following a negative cranial CT. Sayer et al reported NN LP = 250 to identify one additional aneurysmal SAH. Blok et al identified one perimesencephalic bleed among 760 CT‐negative patients with suspected aneurysmal SAH, which they extrapolated to NN LP = 15,200 to identify one additional aneurysmal SAH given that one in 20 perimesencephalic bleeds are ultimately linked to an aneurysm (760 × 20 = 15,200) …”

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

106

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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

106

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“…Due to economical restrictions and/or expedient use of MRI nowadays not every patient receives further diagnostic work-up [28]. This retrospective study assessed the yield of MR-imaging of the complete spinal axis in 190 NASAH patients.…”

Section: Discussionmentioning

confidence: 99%

MRI-detection rate and incidence of lumbar bleeding sources in 190 patients with non-aneurysmal SAH

et al. 2017

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BackgroundUp to 15% of all spontaneous subarachnoid hemorrhages (SAH) have a non-aneurysmal SAH (NASAH). The evaluation of SAH patients with negative digital subtraction angiography (DSA) is sometimes a diagnostic challenge. Our goal in this study was to reassess the yield of standard MR-imaging of the complete spinal axis to rule out spinal bleeding sources in patients with NASAH.MethodsWe retrospectively analyzed the spinal MRI findings in 190 patients with spontaneous NASAH, containing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH, diagnosed by computer tomography (CT) and/or lumbar puncture (LP), and negative 2nd DSA.Results190 NASAH patients were included in the study, divided into PM-SAH (n = 87; 46%) and NPM-SAH (n = 103; 54%). Overall, 23 (22%) patients had a CT negative SAH, diagnosed by positive LP. MR-imaging of the spinal axis detected two patients with lumbar ependymoma (n = 2; 1,05%). Both patients complained of radicular sciatic pain. The detection rate raised up to 25%, if only patients with radicular sciatic pain received an MRI.ConclusionRoutine radiological investigation of the complete spinal axis in NASAH patients is expensive and can not be recommended for standard procedure. However, patients with clinical signs of low-back/sciatic pain should be worked up for a spinal pathology.

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“…Additionally, comparison of different imaging strategies found no statistically significant benefit of performing DSA during initial or follow-up evaluation of these patients. The authors concluded that patients with pretruncal PSAH and presentations compatible with a nonaneurysmal etiology can undergo initial evaluation with CTA alone and do not require follow-up imaging [20]. This meta-analysis is limited by inconsistent definitions of PSAH used in the constituent studies, and clinical implementation of such recommendations is limited by inter-observer variability in terms of characterizing SAH patterns [21,22].…”

Section: Discussionmentioning

confidence: 99%