Abstract

Background
Physicians often face a dilemma to investigate alert and neurologically intact
patients presenting with acute headache to emergency departments. Two
Canadian prospective cohort studies evaluated high-risk clinical
characteristics for subarachnoid haemorrhage in such patients and proposed
clinical decision rules (Canadian rules 1, 2, 3, and Ottawa) for investigation of
acute headache. We aimed to determine investigation rates for subarachnoid
haemorrhage in a cohort of neurologically intact patients presenting with
acute headache.
Methods
We performed a retrospective case note review of alert and neurologically
intact patients presenting with acute headache to Aintree University
Hospital, Liverpool, UK, between Jan 1 and March 1, 2013. The case notes of
these patients were independently reviewed by two investigators to
determine clinical characteristics. Criteria for inclusion were: age over 18
years, fully alert (Glasgow coma scale 15), new acute headache with no
recent history of head injury (14 days), absence of focal neurological deficit
or papilloedema, and absence of known cerebral aneurysm, brain neoplasm,
or hydrocephalus. Canadian rules were applied retrospectively to determine
the specificity, sensitivity, and negative predictive values for subarachnoid
haemorrhage. Two-tailed Fisher's exact test and McNemar's test were used to
determine differences.
Findings
403 patients presented with acute headache, of whom 162 patients satisfied
the criteria for inclusion. In three (19%) of these 162 patients subarachnoid
haemorrhage was diagnosed by CT, 11 (68%) had a final diagnosis of other
cerebral disease, and 148 (913%) were diagnosed with benign causes of
headaches. 69 patients (426%) had unenhanced CT, 28 (173%) had a
lumbar puncture, and 25 (154%) had both investigations. There were no re-
admissions with a subarachnoid haemorrhage for patients not fully
investigated in our practice. Retrospective application of Canadian rules 1, 2,
3, and Ottawa to our cohort would have increased CT investigation rates to
543%, 648%, 500%, and 617%, respectively, compared with 426% in our
practice (p<00001). If rule 3 was applied, one patient who had suffered a
subarachnoid haemorrhage would have been classifed as low risk and not
investigated, leading to a missed diagnosis.
Interpretation
The rates of subarachnoid haemorrhage in our study were lower than those
in the Canadian studies. In our smaller group of neurologically intact
patients, retrospective application of the Canadian rules would have led to a
significantly higher investigation rate and longer hospital stay. This study
also highlights the need for further large scale prospective studies in the UK
before adopting rigid decision rules for investigation of acute headache in
neurologically intact patients in the National Health Service.