Acute Headache: Who should we CT? Steven A. Godwin, MD, FACEP Assistant Professor Program Director  Department of Emergenc...
“ When the headaches, all the body is worse ” - English Proverb
Case Presentation <ul><li>35 year old female presents to the emergency department with sudden onset of severe headache aft...
Background <ul><li>Headache accounts for 1% of all ED visits in the US (1 million patients/year) 1 </li></ul><ul><li>An es...
How do we narrow down which patients need further studies? <ul><li>History </li></ul><ul><ul><li>Presentation of ominous h...
What Is the Goal of Neuroimaging in the ED? <ul><li>To identify a treatable lesion. </li></ul><ul><li>ACEP and AAN have ca...
Practice Guidelines:What is the evidence? <ul><li>In 1994, AAN published “Practice Parameter: The utility of neuroimaging ...
AAN 1994 Guidelines <ul><ul><li>Evidence based recommendations </li></ul></ul><ul><ul><li>1. Neuroimaging is not warranted...
The 2000 US Headache Consortium <ul><li>Reviewed articles dealing with chronic headache </li></ul><ul><li>Key findings: </...
The US Headache Consortium Conclusions <ul><li>Neuroimaging should be considered in patients with nonacute headache and an...
The US Headache Consortium Conclusions <ul><li>Insufficient evidence to make neuroimaging recommendations in patients with...
Predictors of Intracranial Pathology in Patients with Headache <ul><li>Retrospective random chart review of 468 patients p...
“Sudden Worst Headache” <ul><li>Is this predictive?   </li></ul><ul><li>One retrospective study found a 29% yield for posi...
“Sudden Worst Headache” <ul><li>Prospective study of 27 patients  </li></ul><ul><ul><li>All patients had acute sudden-onse...
“Sudden Worst Headache” <ul><li>Some studies have failed to demonstrate a significant correlation </li></ul><ul><li>One re...
Headache in HIV Related Disorders <ul><li>Prospective study </li></ul><ul><li>49 consecutive HIV patients with headache </...
ED Utilization of Noncontrast Head CT in HIV Infected Patients <ul><li>Prospective convenience sample of 110 HIV patients ...
Patient Management Recommendations <ul><li>Level A Recommendations   </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Lev...
Patient Management Recommendations <ul><li>Level C Recommendations   </li></ul><ul><ul><li>Patients who are older than 50 ...
Gracias!
References <ul><li>1  Dhopesh V, Anwar R, Herring C. A retrospective assessment of emergency department patients with comp...
References <ul><li>7  Lledo A, calandre L, Marinez-Menendez B, et al.  Acute headache of recent onset and subarachnoid hem...
Upcoming SlideShare
Loading in …5
×

Power Point Show

755 views

Published on

0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
755
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
33
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide

Power Point Show

  1. 1. Acute Headache: Who should we CT? Steven A. Godwin, MD, FACEP Assistant Professor Program Director Department of Emergency Medicine University of Florida HSC/Jacksonville
  2. 2. “ When the headaches, all the body is worse ” - English Proverb
  3. 3. Case Presentation <ul><li>35 year old female presents to the emergency department with sudden onset of severe headache after stating she had been outside reading all day in the sun. She admits to taking 2 of a friend’s hydroxycodone and now is feeling better. Her physical exam is normal. </li></ul><ul><li>Does she need a CT scan? </li></ul>
  4. 4. Background <ul><li>Headache accounts for 1% of all ED visits in the US (1 million patients/year) 1 </li></ul><ul><li>An estimated 1-4% of all patients presenting to the ED with headache complaint have emergent or urgent diagnosis 1,2 </li></ul>1 Dhopesh V, Anwar R, Herring C. A retrospective assessment of emergency department patients with complaint of headache. Headache. 1979;19:37-42 (Retrospective review; 872 patients) 2 Ramirez-Lassepas M, Espinosa C, Cicero J, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol 1997;54:1506-1509. (Retrospective review; 329 patients)
  5. 5. How do we narrow down which patients need further studies? <ul><li>History </li></ul><ul><ul><li>Presentation of ominous headaches vary but important factors that provide a clue for the clinician include: </li></ul></ul><ul><ul><ul><li>Severity </li></ul></ul></ul><ul><ul><ul><li>Onset </li></ul></ul></ul><ul><ul><ul><li>Quality of pain </li></ul></ul></ul><ul><ul><ul><li>Associated symptoms </li></ul></ul></ul>
  6. 6. What Is the Goal of Neuroimaging in the ED? <ul><li>To identify a treatable lesion. </li></ul><ul><li>ACEP and AAN have categorized neuroimaging </li></ul><ul><ul><li>Emergent - essential for a timely decision regarding potentially life-threatening or severely disabling entities </li></ul></ul><ul><ul><li>Urgent - arranged prior to discharge from the ED or, performed prior to disposition when follow-up cannot be assured </li></ul></ul><ul><ul><li>Routine - indicated when the studies results are not considered to make a change in the patients disposition from the ED </li></ul></ul>
  7. 7. Practice Guidelines:What is the evidence? <ul><li>In 1994, AAN published “Practice Parameter: The utility of neuroimaging in the evaluation of headache patients with normal neurologic examination” </li></ul>3 American College of Neurology. Practice parameter: The utility of neuroimaging in the evaluation of headache patients with normal neurologic examination. Neurology . 1994;44:1353-1354.
  8. 8. AAN 1994 Guidelines <ul><ul><li>Evidence based recommendations </li></ul></ul><ul><ul><li>1. Neuroimaging is not warranted in patients with migraine presenting with a typical event </li></ul></ul><ul><ul><li>2. Neuroimaging should be considered in patients with atypical headaches, history of seizures, or focal neurologic findings </li></ul></ul><ul><ul><li>3. Insufficient evidence to define role of MRI vs CT in headache patients without a migraine </li></ul></ul>
  9. 9. The 2000 US Headache Consortium <ul><li>Reviewed articles dealing with chronic headache </li></ul><ul><li>Key findings: </li></ul><ul><li>Abnormality on neurologic exam increased the likelihood of positive results with neuroimaging by 3 fold (95% CI 2.3 to 4.0) </li></ul><ul><li>Normal findings with a neurologic exam reduced the odds of positive findings in a neuroimaging study by 30% </li></ul>4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000
  10. 10. The US Headache Consortium Conclusions <ul><li>Neuroimaging should be considered in patients with nonacute headache and an unexplained abnormality on neurologic examination </li></ul><ul><li>Insufficient evidence to make neuroimaging recommendations based on the presence or absence of neuro finding (in patients with chronic headache </li></ul><ul><li>Neuroimaging is not warranted in typical migraine and no neuro findings </li></ul>4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000
  11. 11. The US Headache Consortium Conclusions <ul><li>Insufficient evidence to make neuroimaging recommendations in patients with tension-type headaches </li></ul><ul><li>Insufficient data for evidence-based recommendations regarding CT versus MRI in the evaluation of nonacute headache </li></ul>4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology, 2000
  12. 12. Predictors of Intracranial Pathology in Patients with Headache <ul><li>Retrospective random chart review of 468 patients presenting with chief complaint of headache </li></ul><ul><ul><li>Abnormal neurologic exam had a 39% PPV for intracranial pathology </li></ul></ul><ul><ul><li>Age greater than 55 was associated with increase risk of intracranial process </li></ul></ul><ul><ul><li>No association found between type of HA and the final diagnosis </li></ul></ul>2 Ramirez-Lassepas M, Espinosa CE, Cicero JJ, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol. 1997;54:1506-1509 (III)
  13. 13. “Sudden Worst Headache” <ul><li>Is this predictive? </li></ul><ul><li>One retrospective study found a 29% yield for positive head CT in patients complaining of “worst headache” but no correlation with diagnosis of subarachnoid hemorrhage 4 </li></ul><ul><li>Harling et al. in a prospective study of patients presenting with thunderclap headache found 35/49 to have SAH on CT or LP 5 </li></ul>5 Mills ML, Russo LS, Vines FS, et al. High yield criteria for urgent cranial computed tomography scans. Ann Emerg Med. 1986;15:1167-1172 (III) 6 Harling DW, Peatfield RC, Van Hille PT, et al Thunderclap headache: is it a migraine? Cephalagia. 1989;9:87-90 (II)
  14. 14. “Sudden Worst Headache” <ul><li>Prospective study of 27 patients </li></ul><ul><ul><li>All patients had acute sudden-onset HA with normal neurologic findings </li></ul></ul><ul><ul><li>All patients had CT, if negative an LP was performed and were then followed for 3 months </li></ul></ul><ul><ul><li>9 patients had SAH, 1 intraventricular hemorrhage, 1 bacterial meningitis, 1 with viral meningitis </li></ul></ul>7 Lledo A, calandre L, Marinez-Menendez B, et al. Acute headache of recent onset and subarachnoid hemorrhage: a prospective study. Headache. 1994;34:172-174 (I)
  15. 15. “Sudden Worst Headache” <ul><li>Some studies have failed to demonstrate a significant correlation </li></ul><ul><li>One retrospective review of 333 ED patients complaining of acute or acutely worsening HA </li></ul><ul><ul><li>17 patients had “worst headache of life”; only one had positive CT results 7 </li></ul></ul><ul><li>Another study found only 1/27 patients with “worst headache complaint to have intracranial pathology 8 </li></ul>8 Reinus WR, Wippold FJ, Erickson KK. Practical Selection Criteria for Unenhanced Cranial CT in Patients With Acute Headache. Emerg Radiol. 1994;94:67-70(II) 9 Mitchell CS, Osborn RE, Grosskreutz SR. Computed tomography in the headache patient: is routine evaluation really necessary? Headache.1993;33:82-86 (III)
  16. 16. Headache in HIV Related Disorders <ul><li>Prospective study </li></ul><ul><li>49 consecutive HIV patients with headache </li></ul><ul><ul><li>82% had a serious identifiable cause. </li></ul></ul><ul><li>HIV positive patients with headache should be considered for CT and LP </li></ul>10 Lipton RB, Feraru ER, Weiss G, et al. Headache in HIV Related Disorders. Headache. 1991;31:518-522 (II)
  17. 17. ED Utilization of Noncontrast Head CT in HIV Infected Patients <ul><li>Prospective convenience sample of 110 HIV patients with neurologic complaints </li></ul><ul><ul><li>New seizure, depressed or altered mental status, and headache that was different in character or lasted longer than 3 days </li></ul></ul><ul><li>New or different HA was reported in 25% of the cases </li></ul><ul><li>All cases of focal lesions identified </li></ul>11 Rothman RE, Keyl PM, McArthur JC, et al . A decision guideline for the utilization of noncontrast head CT in HIV infected patients. Acad Emerg Med. 1999;6:1010-1019 (II)
  18. 18. Patient Management Recommendations <ul><li>Level A Recommendations </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Level B Recommendations </li></ul><ul><ul><li>Patients presenting to the ED with headache and abnormal findings on neurologic examination should undergo emergent noncontrast head CT. </li></ul></ul><ul><ul><li>Patients presenting with acute sudden-onset headache should be considered for emergent head CT scan. </li></ul></ul><ul><ul><li>HIV positive patients with a new type of headache should be considered for urgent neuroimaging study. </li></ul></ul>
  19. 19. Patient Management Recommendations <ul><li>Level C Recommendations </li></ul><ul><ul><li>Patients who are older than 50 years old with a new type of headache without abnormal finding on neurologic exam should be considered for urgent neuroimaging. </li></ul></ul>
  20. 20. Gracias!
  21. 21. References <ul><li>1 Dhopesh V, Anwar R, Herring C. A retrospective assessment of emergency department patients with complaint of headache. Headache. 1979;19:37-42 (Retrospective review, 872 patients; III) </li></ul><ul><li>2 Ramirez-Lassepas M, Espinosa C, Cicero J, et al. Predictors of intracranial pathologic findings in patients who seek emergency care because of headache. Arch Neurol 1997;54:1506-1509. (Retrospective review, 329 patients; III) </li></ul><ul><li>3 American College of Neurology. Practice parameter: The utility of neuroimaging in the evaluation of headache patients with normal neurologic examination. Neurology . 1994;44:1353-1354. (Evidence based guidelines, (III) </li></ul><ul><li>4 US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. American Academy of Neurology . 2000 (Evidence based review, II) </li></ul><ul><li>5 Mills ML, Russo LS, Vines FS, et al. High yield criteria for urgent cranial computed tomography scans. Ann Emerg Med. 1986;15:1167-1172 (Prospective, 407 patients; III) </li></ul><ul><li>6 Harling DW, Peatfield RC, Van Hille PT, et al Thunderclap headache: is it a migraine? Cephalagia . 1989;9:87-90 (Prospective, 49 patients; II) </li></ul>
  22. 22. References <ul><li>7 Lledo A, calandre L, Marinez-Menendez B, et al. Acute headache of recent onset and subarachnoid hemorrhage: a prospective study. Headache. 1994;34:172-174 (Prospective, 27 patients; I) </li></ul><ul><li>8 Reinus WR, Wippold FJ, Erickson KK. Practical Selection Criteria for Unenhanced Cranial CT in Patients With Acute Headache. Emerg Radiol. 1994;94:67-70(Retrospective, 333 patients; II) </li></ul><ul><li>9 Mitchell CS, Osborn RE, Grosskreutz SR. Computed tomography in the headache patient: is routine evaluation really necessary? Headache.1993;33:82-86 (Prospective, 350 patients; III) </li></ul><ul><li>10 Lipton RB, Feraru ER, Weiss G, et al. Headache in HIV Related Disorders. Headache. 1991;31:518-522 (Prospective, 49 patients; II) </li></ul><ul><li>11 Rothman RE, Keyl PM, McArthur JC, et al . A decision guideline for the utilization of noncontrast head CT in HIV infected patients. Acad Emerg Med. 1999;6:10101-1019 (Prospective, 110 patients; II) </li></ul>

×