CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals

Blok, Katelijn M.; Rinkel, Gabriël J. E.; Majoie, Charles B. L. M.; Hendrikse, Jeroen; Braaksma, Meriam; Tijssen, Cees; Wong, Yu Yi M.; Hofmeijer, Jeannette; Extercatte, Jorunn; Kerklaan, Bertjan J.; Schreuder, Tobien H.C.M.L.; Holter, Susanne ten; Verheul, Freek; Harlaar, Laurike; Pruissen, D. Martijn O.; Kwa, Vincent I H; Brouwers, P. J. A. M.; Remmers, Michel J M; Schonewille, Wouter J.; Kruyt, Nyika D.; Vergouwen, Mervyn D.I.

doi:10.1212/wnl.0000000000001562

Cited by 60 publications

(47 citation statements)

References 15 publications

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“…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).…”

mentioning

confidence: 87%

“…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%

“…The studies by Backes et al, 13 Stewart et al, 18 Blok et al, 20 and Mark et al 29 used medical records review for ascertainment of the cases and follow-up of the cohorts. In the study by Perry et al, 11 patients were identified prospectively the day of the ED visit and then followed by telephone, medical records, review of regional center records, and coroner reports.…”

Section: Quality and Risk Of Bias Assessmentmentioning

confidence: 99%

“…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.Our analysis has several limitations. First, we included only studies involving ED patients presenting with complaints concerning for nontraumatic SAH and with CT scans performed within 6 hours.…”

mentioning

confidence: 99%

“…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).…”

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

130

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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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