Cranial Computed Tomography in the Emergency Evaluation of Adult Patients without a Recent History of Head Trauma: A Prospective Analysis

Abstract

I ABSTRACTObjectives: To examine the pattern of nontrauma cranial CT use in an urban ED, to identify the rate of significant CT abnormalities in this setting, and to develop criteria for restricting the ordering of CT scans. Methods: A prospective, observational study of a case series of adults who underwent cranial CT scanning for nontraumatic cases was performed at the EDs of an urban teaching hospital and an affiliated community hospital with a combined annual census of 110,000. Clinically significant CT scans were defined as: 1) acute stroke, 2) CNS malignancy, 3 ) acute hydrocephalus, 4) intracranial bleeding, or 5) intracranial infection. x2recursive partitioning was used to derive a decision rule to restrict ordering of CT scans. Results: Only 61 (8%) of 806 CT scans revealed clinically significant abnormalities. The presence of any of the following: age 260 years, focal neurologic deficit, headache with vomiting, or altered mental status, was 100% sensitive (95% CI: 94-100%) and 31% specific (95% CI: 28-33%) in detecting clinically significant CT scans. This set of features had positive and negative predictive values of 11% (95% CI: 8-13%) and 100% (95% C1: 98-loo%), respectively. If these criteria had been used to restrict cranial CT use, 229 fewer patients (28%) would have had CT scans obtained and no clinically significant abnormalities would have been missed. Conclusion: Clinically significant CT abnormalities were uncommon in this study population, suggesting that current criteria for ordering nontrauma cranial CT scans may be too liberal. In this study, a set of clinical criteria was derived that may be useful at separating patients into high-and low-risk categories for clinically significant cranial CT abnormalities. Before these results are applied clinically, these criteria should be validated in larger, prospective studies.

Prospective study of patients with altered mental status: clinical features and outcome

“…Among the various aetiologies, neurological causes are the most common, and our findings agree with what had been reported by Kanich et al [5]. Futhermore, this has important downstream implications for triaging and cost-effective use of investigations, especially CT scan of the brain [6, 7]. …”

Clinical Yield of Computed Tomography Brain Scans in Older General Medical Patients

“…Thus, reserving scans in the older population for patients with new focal neurological changes would markedly improve the clinical yield of brain CT scans. These findings reinforce those of previous studies that sought to use clinical criteria to improve the yield of brain CT scans in various populations 22–26,30 . Some physicians may lack confidence in their neurological examinations in older, hospitalized, cognitively impairedpatients, but the results of the current study indicate that brain CT scans should not be used in lieu of a neurological examination.…”

High yield criteria for emergency cranial computed tomography in adult patients with no history of head injury

“…A more recent study by Rothrock and colleagues, which included only non-trauma patients, proved more successful in deriving criteria. 6 They found that if cranial computed tomography was restricted to only patients fulfilling any of four clinical criteria (age 60 years or older, focal neurology, headache with nausea or vomiting, altered mental status), then no significant pathology would have been missed and 28% fewer scans would have been performed.…”