Utility of CT head in the acute setting: value of contrast and non-contrast studies

Background Globally, adults presenting with seizures account for 1% – 2% of visits to emergency departments (EDs), of which 25% are new-onset seizures. Neuroimaging is essential as part of the initial workup. Multiple studies have demonstrated abnormal CT brain (CTB) findings in these patients. Objectives To review the CTB findings in adults presenting with new-onset seizures in a resource restricted setting. Method A retrospective review of 531 CTBs was conducted at a tertiary hospital in Gauteng on adults presenting to the ED with new-onset seizures. Results The mean age of the patients was 45.6 ± 17.1 years, and the male to female ratio was 1.2:1. Generalised and focal seizure types were almost equally represented. Of the total 531 patients, 168 (31.6%) were HIV positive. The CTB findings were abnormal in 257 (48.4%) patients, albeit vascular pathology accounted for 21.9%. Infective pathology accounted for 14.1% with a statistically significant association with HIV ( p = 0.003). Trauma related pathology was 2.4%, whilst neoplastic pathology was seen in 3.0%. Other causes included congenital pathology, calcifications, atrophy and gliosis. Clinical factors associated with abnormal CTB findings were age ≥ 40 years, HIV infection, hypertension, focal seizures, low Glasgow Coma Scale (GCS), raised cerebrospinal fluid (CSF) protein and presence of lymphocytes. Conclusion A high yield of abnormal CTB findings was noted in adult patients who presented with new-onset seizures, supporting the use of urgent CTB in patients with certain clinical risk factors. Patients without these risk factors can be scanned within 24–48 h in a resource restricted setting.

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“…Studied literature indicated that administration of intravenous contrast does little to change the sensitivity of CTB findings. 1 , 22 , 23 , 24 …”

Section: Discussionmentioning

confidence: 99%

An audit of CT brain findings in adults with new-onset seizures in a resource restricted setting in South Africa

Mabaso

Bhana-Nathoo

Lucas

2022

South African Journal of Radiology

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“…36 However, in our systematic review, we found only 1 study that discussed the cost of CTH studies. 18 Computed tomographic studies are associated with significant radiation exposure and cancer risk. A single CT study's mean radiation dose is typically 15 mSv in adults and 30 mSv in neonates.…”

Section: Discussionmentioning

confidence: 99%

Use of Computed Tomography of the Head in Patients With Acute Atraumatic Altered Mental Status

et al. 2022

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ImportanceThe usefulness of computed tomography of the head (CTH) in patients with acute-onset atraumatic altered mental status (AMS) is poorly understood, but use in these patients remains high.ObjectiveTo evaluate the use of CTH (event rate) in patients with AMS and the positive outcome event rate of the performed CTH studies.Data SourcesThe PubMed/MEDLINE, PubMed Central, Embase, and CINAHL databases were searched using predefined Boolean parameters. All studies that met inclusion criteria until January 31, 2022, were included.Study SelectionRandomized clinical trials and observational, cohort, and case-control studies were included. Conference abstracts, reviews, letters, case reports, case series, systematic literature, and meta-analyses were excluded.Data Extraction and SynthesisThe systematic literature review was performed per Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data were independently extracted by 2 authors. Data were pooled using a random-effects method.Main Outcomes and MeasuresEvent rate of CTH use in patients with acute atraumatic AMS. The CTH event rates and positive CTH event rates were calculated with 95% CIs.ResultsOf 9338 studies identified, 26 qualified for the systematic review and 25 for the meta-analysis. The 25 studies in the meta-analysis included a total of 79 201 patients. The CTH event rate was 94% (proportion, 0.94; 95% CI, 0.76-1.00), and the positive CTH event rate was 11% (proportion, 0.11; 95% CI, 0.07-0.15). There was significant heterogeneity among the studies included (I2 &gt; 50%, P &lt; .001), for which a random-effects model was used. There was significant publication bias, as evident by an asymmetric funnel plot. There was no fluctuation of the results during the sensitivity analysis, which reassured the reliability of the data.Conclusions and RelevanceIn this meta-analysis, CTH use among patients with acute-onset atraumatic AMS was very high with a low yield. Large-scale studies are needed to guide clinical decision-making in such a situation.

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“…47,48 Overall, this process may also introduce delays in the reporting of the studies of other patients in the emergency department, thus increasing patient turnaround time and potentially leading to overcrowding, bed shortages, and a potential negative impact patient care. 49 -53…”

Section: Discussionmentioning

confidence: 99%

Evaluating Radiology Result Communication in the Emergency Department

et al. 2020

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Purpose: To assess the pattern of result communication that occurs between radiologists and referring physicians in the emergency department setting. Methods: An institutional review board–approved prospective study was performed at a large academic medical center with 24/7 emergency radiology cover. Emergency radiologists logged information regarding all result-reporting communication events that occurred over a 168-hour period. Results: A total of 286 independent result communication events occurred during the study period, the vast majority of which occurred via telephone (232/286). Emergency radiologists spent 10% of their working time communicating results. Similar amounts of time were spent discussing negative and positive cross-sectional imaging examinations. In a small minority of communication events, additional information was gathered through communication that resulted in a change of interpretation from a normal to an abnormal study. Conclusions: Effective and efficient result communication is critical to care delivery in the emergency department setting. Discussion regarding abnormal cases, both in person and over the phone, is encouraged. However, in the emergency setting, time spent on routine direct communication of negative examination results in advance of the final report may lead to increased disruptions, longer turnaround times, and negatively impact patient care. In very few instances, does the additional information gained from the communication event result in a change of interpretation?

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Utility of CT head in the acute setting: value of contrast and non-contrast studies

Abstract: Head CT in ED non-traumatic neurological presentations with CECTH is not generally indicated and represents a calculable cost savings in the management of these patients.

Cited by 16 publications

References 23 publications

An audit of CT brain findings in adults with new-onset seizures in a resource restricted setting in South Africa

An audit of CT brain findings in adults with new-onset seizures in a resource restricted setting in South Africa

Use of Computed Tomography of the Head in Patients With Acute Atraumatic Altered Mental Status

Evaluating Radiology Result Communication in the Emergency Department

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