Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: A Contemporary Analysis

Mark, Dustin G.; Kene, Mamata V.; Vinson, David R.; Ballard, Dustin

doi:10.1111/acem.13252

Cited by 6 publications

(5 citation statements)

References 51 publications

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“…We also observed that 5% of SAH and 18% of bacterial meningitis cases were possibly misdiagnosed at index ED visits, estimates which are consistent with prior literature . Although we did not observe a significant change in the proportion of missed diagnoses over time, the small number of cases limited detection of differences.…”

Section: Discussionsupporting

confidence: 90%

“…Nontraumatic subarachnoid hemorrhage (SAH) causes approximately 5% of acute-onset headaches in emergency department (ED) patients and has a 50% risk of serious disability or death at 1 year. 1 , 2 , 3 , 4 , 5 The first-line diagnostic test for SAH is noncontrast head computed tomography (CT), which is most sensitive within the first 6 hours of headache onset. 2 , 6 When CT is nondiagnostic and clinical suspicion remains high, lumbar puncture (LP) is the recommended second-line test (CT-LP approach).…”

Section: Introductionmentioning

confidence: 99%

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Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021

Mark,

Horton,

Reed

2024

JAMA Netw Open

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ImportanceSubarachnoid hemorrhage is typically diagnosed by noncontrast head computed tomography (CT); lumbar puncture is recommended if computed tomography is nondiagnostic, although CT cerebral angiography has been promoted as an alternative to lumbar puncture in this diagnostic pathway. The outcomes of this debate in practice have not been studied.ObjectiveTo determine whether CT cerebral angiography use has increased in lieu of lumbar puncture among emergency department (ED) patients with headache, with an increase in unruptured intracranial aneurysm detection.Design, Setting, and ParticipantsThis retrospective cohort study took place in 21 community EDs of an integrated health care system in Northern California between 2015 and 2021. Participants were adult (aged &gt;17 years) health plan members with a chief concern of headache. Exclusions were prior diagnoses of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral arteriovenous malformation, or cerebrospinal fluid shunt. Data were analyzed from October to November 2023.ExposuresCT cerebral angiography and/or lumbar puncture during the ED encounter.Main Outcomes and MeasuresPrimary and secondary outcomes were 14-day and 90-day unruptured intracranial aneurysm detection, respectively. Safety outcomes were missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. The annual incidence of unruptured intracranial aneurysm detection was normalized to the incidence of subarachnoid hemorrhage (UIA:SAH ratio). Average annualized percentage changes were quantified using joinpoint regression analysis.ResultsAmong 198 109 included ED encounters, the mean (SD) age was 47.5 (18.4) years; 140 001 patients (70.7%) were female; 29 035 (14.7%) were Black or African American, 59 896 (30.2%) were Hispanic or Latino, and 75 602 (38.2%) were White. Per year, CT cerebral angiography use increased (18.8%; 95% CI, 17.7% to 20.3%) and lumbar punctures decreased (−11.1%; 95% CI, −12.0% to −10.4%), with a corresponding increase in the 14-day UIA:SAH ratio (3.5%; 95% CI, 0.9% to 7.4%). Overall, computed tomography cerebral angiography use increased 6-fold relative to lumbar puncture, with a 33% increase in the detection of UIA. Results were similar at 90 days and robust to sensitivity analyses. Subarachnoid hemorrhage (1004 cases) and bacterial meningitis (118 cases) were misdiagnosed in 5% and 18% of cases, respectively, with no annual trends (P = .34; z1003 = .95 and P = .74; z117 = −.34, respectively).Conclusions and RelevanceIn this cohort study of ED patients with headache, increases in CT cerebral angiography use were associated with fewer lumbar punctures and higher detection of unruptured intracranial aneurysms, with no significant change in missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. While this shift in diagnostic strategy appeared safe in the short-term, the long-term consequences remain unclear.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021

Mark,

Horton,

Reed

2024

JAMA Netw Open

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“…5 Statistical models have suggested that, when using a threshold for disability in a delayed or missed SAH, CT/LP may not be costeffective. 26,27 Our results would refute this. If LP were to be abandoned, 6% patients with SAH would be missed causing significant harm.…”

Section: Abandoning Lpsupporting

confidence: 49%

Evaluating xanthochromia in the diagnosis of subarachnoid haemorrhage in Scotland in the Era of modern computed tomography

et al. 2022

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Aim Cerebrospinal fluid (CSF) analysis for xanthochromia is routinely used to exclude subarachnoid haemorrhage (SAH). In this study, we evaluated the sensitivity and specificity of xanthochromia (by NEQAS-spectrophotometry) in routine clinical practice in three acute hospitals, in patients with suspected SAH. We explored whether including CSF red cell count (RCC) with xanthochromia improved diagnostic accuracy. Methods In this retrospective analysis, all xanthochromia results were assessed over three consecutive years. Clinical information and Registry data were analysed to find all patients diagnosed with SAH. We correlated xanthochromia data with clinical and radiological findings. Results There were 1761 xanthochromia performed. Of these, 26 (1.5%) were positive, 1624 (92%) negative and 72 (4.1%) were inconclusive. Of the 26 tests that were positive, 9 (35%) had confirmed SAH, 17 (65%) were falsely positive, with no false negative tests in our series. Xanthochromia identified 6% of all SAH diagnosed in the study. Incorporating RCC <1000 with xanthochromia, reducing false positive tests by 38% and inconclusive test by 85%. Conclusion The positive yield of xanthochromia is low but identified 6% of SAH. NEQAS-spectrophotometry is an excellent diagnostic method with 100% sensitivity, 99% specificity. Incorporating RCC markedly reduces false positive and inconclusive tests reducing need for further imaging.

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“…The authors analyzed clinical course of patients finally diagnosed with SAH who through 14 days prior the diagnosis were examined due to suspicion of SAH with negative conclusion. They found that probable overlooking of SAH did not influence negatively their prognosis [16]. Chong et al reported similar observation as only 1.3% of patients with CT-negative SAH experienced further re-bleeding [15].…”

Section: Discussionmentioning

confidence: 87%

CT negative subarachnoid hemorrhage in emergency department

Szypenbejl¹,

Siemiński²,

Szurowska³

et al. 2020

Eur J Trans Clin Med

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Background: Subarachnoid hemorrhage (SAH) is rare but potentially life-threatening cause of acute headache. First diagnostic test performed in the Emergency Department (ED) for acute "thunderclap" headache is computed tomography of the head (CT) without contrast enhancement. Negative non-contrast head CT may be erroneously interpreted as an exclusion of SAH and lead to ED discharge. The consequences of overlooking SAH are of special interest to the Emergency Physician. The aim of this study was to assess prevalence and clinical picture of CT-negative cases of SAH admitted to the ED. Material and methods: Retrospective analysis of charts of patients admitted to the ED and diagnosed with SAH during 18 consecutive months. Results: Our data gives information about clinical picture of patients with CT-negative SAH and their further clinical course. Out of 126 patients diagnosed with SAH, 5 (4.0%) were diagnosed with SAH despite negative non-contrast head CT scan. All cases were diagnosed by means of lumbar puncture and analysis of cerebrospinal fluid. In all patients with CT-negative SAH computed tomographic angiography (CTA) was performed and no vascular abnormalities were found. In one case digital subtraction angiography was performed due to equivocal CTA picture and it demonstrated small unruptured aneurysm of the medial cerebral artery. All patients with CT-negative SAH were admitted to a neurological ward and later discharged from the hospital without neurological deficit. There were no episodes of clinical deterioration and none of the patients required an urgent neurosurgical intervention. Conclusions: Although lumbar puncture remains a gold standard in exclusion of SAH, head CT scan without contrast enhancement appears to be a satisfying diagnostic tool in ED.

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Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: A Contemporary Analysis

Cited by 6 publications

References 51 publications

Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021

Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021

Evaluating xanthochromia in the diagnosis of subarachnoid haemorrhage in Scotland in the Era of modern computed tomography

CT negative subarachnoid hemorrhage in emergency department

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