BACKGROUND: Patients with acute severe headache, normal neurological examination, and a normal noncontrast head computed tomography (NCCT) may still have subarachnoid hemorrhage, cerebral venous thrombosis (CVT), cervical arterial dissection, or reversible cerebral vasoconstriction syndrome (RCVS). Computed tomography angiography (CTA) is used increasingly in the emergency department for evaluating this, but its added value remains controversial.
METHODS: We retrospectively collected data on the diagnostic yield of CTA in patients with acute severe headache, normal neurological examination, and normal NCCT who received additional CTA in the acute phase in 2 secondary referral centers for vascular neurology. We combined data of our patients with those from the literature and performed a meta-analysis.
RESULTS: We included 88 patients from our hospital files and 641 patients after literature search. Of 729 patients 54 had a vascular abnormality on CTA (7.4%; 95% confidence interval [CI] 5.5%-9.3%). Abnormalities consisted of aneurysms (n = 42; 5.4%; 95% CI 3.8%-7.0%), CVT (n = 3, .5%), RCVS (n = 4, .5%), Moyamoya syndrome (n = 2, .3%), arterial dissection (n = 2, .3%), and ischemia (n = 1, .1%). Because most of the aneurysms were probably incidental findings, only 12 (1.6%) patients had a clear relation between the headache and CTA findings. The number needed to scan to find an abnormality was 14 overall, and 61 for an abnormality other than an aneurysm.
CONCLUSION: Diagnostic yield of CTA in patients with acute headache, normal neurological examination, and normal NCCT is low, but because of the possible therapeutic consequences, its use might be justified in the emergency setting. Prospective studies confirming these results including cost-effectiveness analyses are needed.
ANTECEDENTES: La hemorragia subaracnoidea espontánea (SAH) es una causa rara, pero grave de dolor de cabeza. El diagnóstico de hemorragia subaracnoidea es especialmente difícil en alerta, los pacientes neurológicamente intactos, como perdida o retraso en el diagnóstico puede ser catastrófico.
OBJETIVOS: El objetivo fue realizar un diagnóstico de la enfermedad revisión sistemática y meta-análisis de la historia, examen físico, pruebas de líquido cefalorraquídeo (LCR), la tomografía computarizada (TC), y reglas de decisión clínica para hemorragia subaracnoidea espontánea. Un objetivo secundario fue para delimitar los umbrales de probabilidad de enfermedad para la imagen y la punción lumbar (PL).
MÉTODOS: PubMed, Embase, Scopus, y resúmenes de congresos de investigación se realizaron búsquedas hasta junio de 2015 para estudios de pacientes del servicio de urgencias con dolor de cabeza agudo clínicamente relativa a la HSA espontánea. QUADAS-2 se utilizó para evaluar la calidad del estudio y, en su caso, meta-análisis se realizó mediante modelos de efectos aleatorios. Los resultados fueron la sensibilidad, especificidad y positivo (LR +) y (LR-) cocientes de probabilidad negativos. Para identificar los umbrales de la prueba y tratamiento, se empleó el método Pauker-Kassirer con Bernstein curvas de indicación de prueba utilizando las estimaciones de resumen del diagnóstico de la enfermedad.
RESULTADOS: Un total de 5.022 publicaciones fueron identificados, de los cuales 122 fueron sometidos a revisión de texto completo; 22 estudios fueron incluidos (SAH prevalencia media = 7,5%). Los estudios de diagnóstico difieren en la evaluación de la historia y examen físico hallazgos, la tecnología computarizada, técnicas analíticas utilizadas para identificar xantocromía, y las normas de criterio para la HSA. La calidad del estudio por QUADAS-2 fue variable; Sin embargo, la mayoría tenían un riesgo relativamente bajo de los sesgos. Una historia de dolor de cuello (LR + = 4,1; 95% intervalo de confianza [IC] = 2/2 a 7/6) y rigidez en el cuello en el examen físico (LR + = 6,6; IC del 95% = 4,0 a la 11.0) fueron los hallazgos individuales que más se relacionan con HSA . Las combinaciones de resultados pueden descartar hemorragia subaracnoidea, sin embargo, las reglas de decisión clínica prometedores espera de la validación externa. TC craneal sin contraste dentro de las 6 horas del inicio de la cefalea regidas con precisión en (LR + = 230; 95% CI = 6 a 8.700) y descartó la HSA (LR = 0,01; IC del 95% = 0 a 0,04); CT más allá de 6 horas tuvo un LR- de 0,07 (IC del 95% = 0,01 a 0,61). Los análisis de LCR tuvo menor precisión diagnóstica, si el uso de glóbulos rojos (RBC) contar o xantocromía. En un umbral RBC recuento de 1000 × 10 (6) / L, la LR + fue de 5,7 (IC 95% = 1,4 a 23) y LR- era 0,21 (IC del 95% = 0,03 a 1,7). El uso de las estimaciones combinadas de precisión diagnóstica y prueba de los riesgos y beneficios, estimamos que el propano líquido sólo beneficia a los pacientes CT-negativos cuando la probabilidad pre-LP de la HSA es del orden de 5%, lo que corresponde a un pre-CT probabilidad superior al 20 %.
Conclusiones: Menos de uno de cada 10 pacientes con cefalea relativas a la HSA son finalmente diagnosticados con HSA en estudios recientes. Mientras que ciertos síntomas y signos aumentan o disminuyen la probabilidad de hemorragia subaracnoidea, hay una sola característica es suficiente para descartar o descartar la HSA. Dentro de 6 horas de inicio de los síntomas, TC craneal sin contraste es muy precisa, mientras que una TC negativa más allá de 6 horas reduce sustancialmente el riesgo de hemorragia subaracnoidea. LP parece beneficiar a relativamente pocos pacientes dentro de un estrecho rango de probabilidad previa. Con las mejoras en la tecnología computarizada y una ampliación de cuerpo de evidencia, los umbrales de ensayo para LP pueden llegar a ser más preciso, evitando la necesidad de un post-CT LP en pacientes con cefalea más agudos. reglas de decisión clínica SAH existentes aguardan validación externa, pero ofrecen el potencial para identificar subgrupos con más probabilidades de beneficiarse de post-CT LP, angiografía o más ensayos. Este artículo está protegido por derechos de autor. Todos los derechos reservados.
PURPOSE: The aim of this study was to determine the diagnostic accuracy of conventional CT versus any other imaging strategies to diagnose non-traumatic subarachnoid hemorrhage. We included METHODS: cross-sectional, case-control and cohort studies conducted between January 1, 1980 and December 31, 2013. No language restrictions were imposed. Studies should include people of any age and gender group with clinically suspected non-traumatic SAH. Participants must be in the detection phase of the disease entering to the emergency department. There were no preferences in any other demographic characteristic of participants. We intended to compare Conventional CT (index test – including multidetector CT) versus angiography, angiotomography (Computed tomography angiography), digital subtraction angiography (DSA) and Magnetic Resonance (MR). We excluded studies assessing aneurysms with the selected tests. W e designed a search strategy for studies published in Medline via PubMed, CENTRAL, LILACS and EMBASE. No language or publication status restrictions. Other electronic sources were used to find additional studies, such as conference abstracts, Google scholar, DARE and PROSPERO. We looked for additional studies in reference lists of selected articles, contact with authors about knowledge of published or unpublished articles. The results of searches were crosschecked in order to eliminate duplicates. Two investigators independently and blindly screened the titles and abstracts to determine the potential usefulness of the articles. Eligibility criteria were applied to the full text articles during the final selection. The risk of bias was assessed independently by at least two researches using the QUADAS2 tool. No meta-analysis was performed due to lack of data. RESULTS: 588 articles (3630 patients) were found with the search strategies designed, after exclusions, three studies were included in qualitative analyses (Mitchell et al., 2001; Perry et al., 2011; Van dijk, Hupperts, Van der Jagt, Bijvoet, & Hasan, 2001). The overall sensibility and specificity for the computed tomography for Perry et al., 2011 were 92.9% (CI95% 89-95.5%) and 100% (CI95% 99.9-100%) respectively. Van dijk et al., 2001 found a sensibility of 30% for observer 1 and 46% of observer 2. The specificity was 100% in both cases. Mitchell et al., 2001 found the sensibility for CT of 95%. The sensibility for MR T2 phase was 94% and the specificity was 98.5% compared to CT. There was high risk of bias mainly for flow and timing and patient selection. There is a vast clinical and CONCLUSIONS: methodological heterogeneity of studies evaluating CT for NTSAH. There is not a gold standard to diagnose this condition. There was high risk of bias related to these studies.
Patients with acute severe headache, normal neurological examination, and a normal noncontrast head computed tomography (NCCT) may still have subarachnoid hemorrhage, cerebral venous thrombosis (CVT), cervical arterial dissection, or reversible cerebral vasoconstriction syndrome (RCVS). Computed tomography angiography (CTA) is used increasingly in the emergency department for evaluating this, but its added value remains controversial.
METHODS:
We retrospectively collected data on the diagnostic yield of CTA in patients with acute severe headache, normal neurological examination, and normal NCCT who received additional CTA in the acute phase in 2 secondary referral centers for vascular neurology. We combined data of our patients with those from the literature and performed a meta-analysis.
RESULTS:
We included 88 patients from our hospital files and 641 patients after literature search. Of 729 patients 54 had a vascular abnormality on CTA (7.4%; 95% confidence interval [CI] 5.5%-9.3%). Abnormalities consisted of aneurysms (n = 42; 5.4%; 95% CI 3.8%-7.0%), CVT (n = 3, .5%), RCVS (n = 4, .5%), Moyamoya syndrome (n = 2, .3%), arterial dissection (n = 2, .3%), and ischemia (n = 1, .1%). Because most of the aneurysms were probably incidental findings, only 12 (1.6%) patients had a clear relation between the headache and CTA findings. The number needed to scan to find an abnormality was 14 overall, and 61 for an abnormality other than an aneurysm.
CONCLUSION:
Diagnostic yield of CTA in patients with acute headache, normal neurological examination, and normal NCCT is low, but because of the possible therapeutic consequences, its use might be justified in the emergency setting. Prospective studies confirming these results including cost-effectiveness analyses are needed.
