Abstract
The purpose of this study was twofold: (1) to determine the incidence of positive computed tomography (CT) findings in patients presenting to the emergency department (ED) with non-traumatic headache at our institution and (2) to examine follow-up exams, including lumbar puncture, non-enhanced CT, CT angiogram, CT venogram, and magnetic resonance imaging (MRI), to see how often the use of further testing changes the diagnosis. With IRB approval, 865 patients were identified through ED requisitions for CT head with the indication of headache during the calendar year 2011. Exclusion criteria included head trauma, prior intracranial surgery, focal neurologic symptoms, and known intracranial mass. CT results were divided into three categories: P0, P1, and P2. Negative studies were graded as P0. Positive studies were subdivided into clinically insignificant or P1 and clinically significant or P2. Clinically significant was defined as requiring medical treatment. Subsequently, the electronic medical records and picture archiving and communication system (PACS) were reviewed to determine the incidence of follow-up exams, including lumbar puncture or imaging. The secondary tests were divided into the same P0, P1, and P2 categories. There were 254 positive studies: P1 clinically insignificant (27.1 %, 235/865) and P2 clinically significant (2.2 %, 19/865). Of 257 follow-up exams performed, the majority were lumbar punctures (36.0 %) or CT angiograms (29.5 %). In 19/257 exams or 7.4 %, the additional testing changed the clinically insignificant (P0/P1) diagnosis to a significant (P2) result. At our institution, there was a 2.2 % incidence of significant positive CT findings in patients presenting to the ED with non-traumatic headache. Follow-up testing was variable and resulted in a 7.4 % increase in the severity of diagnosis compared to the initial negative CT scan.
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Stovner L, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, Steiner T, Zwart JA (2007) The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 27(3):193–210. doi:10.1111/j.1468-2982.2007.01288.x
Jordan YJ, Lightfoote JB, Jordan JE (2009) Computed tomography imaging in the management of headache in the emergency department: cost efficacy and policy implications. J Natl Med Assoc 101(4):331–335
Kahn CE Jr, Sanders GD, Lyons EA, Kostelic JK, MacEwan DW, 7Gordon WL (1993) Computed tomography for nontraumatic headache: current utilization and cost-effectiveness. Can Assoc Radiol J 44(3):189–193
Jordan JE, Ramirez GF, Bradley WG, Chen DY, Lightfoote JB, Song A (2000) Economic and outcomes assessment of magnetic resonance imaging in the evaluation of headache. J Natl Med Assoc 92(12):573–578
Akpek S, Arac M, Atilla S, Onal B, Yucel C, Isik S (1995) Cost-effectiveness of computed tomography in the evaluation of patients with headache. Headache 35(4):228–230
Gilbert JW, Johnson KM, Larkin GL, Moore CL (2012) Atraumatic headache in US emergency departments: recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology. Emerg Med J 29(7):576–581. doi:10.1136/emermed-2011-200088
Perry JJ, Stiell IG, Sivilotti ML, Bullard MJ, Hohl CM, Sutherland J, Emond M, Worster A, Lee JS, Mackey D, Pauls M, Lesiuk H, Symington C, Wells GA (2013) Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA 310(12):1248–1255. doi:10.1001/jama.2013.278018
Bent C, Lee PS, Shen PY, Bang H, Bobinski M (2015) Clinical scoring system may improve yield of head CT of non-trauma emergency department patients. Emerg Radiol. doi:10.1007/s10140-015-1305-x
Gupta A, Ip IK, Raja AS, Andruchow JE, Sodickson A, Khorasani R (2014) Effect of clinical decision support on documented guideline adherence for head CT in emergency department patients with mild traumatic brain injury. J Am Med Inform Assoc 21(e2):e347–e351. doi:10.1136/amiajnl-2013-002536
Gunes Tatar I, Aydin H, Kizilgoz V, Yilmaz KB, Hekimoglu B (2014) Appropriateness of selection criteria for CT examinations performed at an emergency department. Emerg Radiol 21(6):583–588. doi:10.1007/s10140-014-1234-0
Knaus WA, Davis DO (1978) Utilization and cost-effectiveness of cranial computed tomography at a university hospital. J Comput Assist Tomogr 2(2):209–214
Knaus WA, Wagner DP, Davis DO (1981) CT for headache: cost/benefit for subarachnoid hemorrhage. AJR 136(3):537–542. doi:10.2214/ajr.136.3.537
Larson EB, Omenn GS, Lewis H (1980) Diagnostic evaluation of headache. Impact of computerized tomography and cost-effectiveness. JAMA 243(4):359–362
Sempere AP, Porta-Etessam J, Medrano V, Garcia-Morales I, Concepcion L, Ramos A, Florencio I, Bermejo F, Botella C (2005) Neuroimaging in the evaluation of patients with non-acute headache. Cephalalgia 25(1):30–35. doi:10.1111/j.1468-2982.2004.00798.x
Douglas AC, Wippold FJ 2nd, Broderick DF, Aiken AH, Amin-Hanjani S, Brown DC, Corey AS, Germano IM, Hadley JA, Jagadeesan BD, Jurgens JS, Kennedy TA, Mechtler LL, Patel ND, Zipfel GJ (2014) ACR Appropriateness Criteria Headache. J Am Coll Radiol 11(7):657–667. doi:10.1016/j.jacr.2014.03.024
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Quon, J.S., Glikstein, R., Lim, C.S. et al. Computed tomography for non-traumatic headache in the emergency department and the impact of follow-up testing on altering the initial diagnosis. Emerg Radiol 22, 521–525 (2015). https://doi.org/10.1007/s10140-015-1314-9
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DOI: https://doi.org/10.1007/s10140-015-1314-9