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Acta Radiologica
2014, Vol. 55(7) 847854
! The Foundation Acta Radiologica
2013
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DOI: 10.1177/0284185113506137
acr.sagepub.com
Abstract
Background: Computed tomography (CT) of the brain is used extensively in the urgent work-up of patients with a
suspicion of intracranial pathology, but is often normal. Previously proposed selection criteria aim at limiting the ordering
of urgent cranial CT in the non-trauma population, while maintaining high sensitivity for diagnoses demanding immediate
attention.
Purpose: To retrospectively evaluate these selection criteria in a general non-trauma population from a Swedish tertiary
hospital, as well as in a nested subgroup that lacks guidelines at present, namely where the chief complaint was not
headache, symptoms clearly indicating stroke, seizures, or vertigo.
Material and Methods: Medical records of 346 patients (114 in the nested group) who had undergone urgent cranial
CT were reviewed. Selection criteria as proposed by Rothrock (patient age 60 years, presence of new onset focal
neurologic deficit, headache with vomiting, or altered mental status) were used. Acute cerebral infarction, intracranial
hemorrhage, malignancy, infection, cerebral edema, or hydrocephalus were considered significant findings.
Results: The prevalence of significant findings was 10.1%. The Rothrock criteria had a sensitivity of 97.1% (identifying 34
of 35 significant findings) among all 346 patients and 100% (10/10) among the 114 patients in the subgroup and resulted in
a potential scan reduction rate of 22.8% and 11.4%, respectively. In the patient with significant pathology, that was not
selected for CT, focal neurological symptoms were not described as newly onset.
Conclusion: Although 100% sensitivity was not achieved, our results may contribute to the evidence that in the absence
of focal neurologic deficit, headache with vomiting or altered mental status in patients aged <60 years cranial tomography can be refrained from, in the general population as well as in the subgroup defined above. Further research might
validate patient history as a parameter.
Keywords
Emergency, cranial computed tomography, diagnostic study, cerebral, observational
Date received: 12 June 2013; accepted: 1 September 2013
Introduction
Cranial computed tomography (CT) is a readily obtainable service and is commonly employed in the work-up
of patients with suspected intracranial pathology. With
the geographically widespread and round-the-clock
availability of CT scanners (1), American emergency
departments (EDs) have seen a remarkable increase in
the use of CT. The proportion of patients visiting an
American ED that underwent a CT or magnetic
Corresponding author:
Danielle van Westen, Department of Radiology, Skane University
Hospital, SE 221 85 Lund, Sweden.
Email: danielle.van_westen@med.lu.se
848
resonance imaging (MRI) scan of any kind increased
from 2.4% in 1992 (2) to 11.2% in 2005 (3). Similarly,
the number of urgent cranial CT scans performed in
both in- and outpatients at our hospital, the Skane
University Hospital Lund, has increased by approximately 60% from 2003 (5100 studies) to 2009 (8200
studies), while the number of visits to the ED in this
period increased by approximately 40% (45,000 in 2003
and 65,400 in 2009). In this context, the word urgent
denotes those examinations that the referring physician
thought necessary to be performed within 24 h. The
assumption that the disease spectrum in the population
has been relatively unchanged during this period seems
reasonable, suggesting that more negative examinations
are performed. A recent radiation dose survey from the
German agency for radiation protection stated that CT
examinations account for 7% of all radiological examinations but contribute with 56% of the total population dose of all radiological examinations (4). Thus, an
attempt to prevent an increase of CT examinations with
negative ndings is warranted in order to reduce costs
and limit extraneous radiation exposure. For the wellcharacterized group of patients with minor head
trauma, clinical selection guidelines for utilization of
cranial computed tomography are available (58).
However, urgent cranial CT is commonly ordered in
a large number of non-trauma patients with a heterogeneous collection of subgroups, many of which lack
guidelines pertaining to the use of CT. As a result, clinicians are often uncertain whether urgent cranial CT is
warranted.
Previous selection clinical criteria by which physicians might limit the number of cranial CT scans
performed in the adult non-trauma general ED population, have been proposed by Rothrock et al. (9). In
their material of 806 patients, all 61 (8%) patients with
the a priori dened signicant ndings of acute cerebral
infarct, intracranial hemorrhage, malignancy, infection,
cerebral edema, hydrocephalus, or a combination
thereof, were identied by any of the four clinical:
patient age 60 years, presence of new onset focal
neurologic decit, headache with vomiting or altered
mental status; henceforth these are denoted the
Rothrock criteria (Table 1). Presence of any one or
more items of these Rothrock criteria was found in
72% of the study population so that application of
these criteria would have reduced the number of cranial
CT scans by 28%. The Rothrock criteria were further
validated in a prospective study on 1911 patients where
the signicant nding rate was 21.7%, while the sensitivity of the Rothrock criteria was 98.8% (95% CI
97.299.6%) (10).
Guidelines for subgroups on the general non-trauma
are available for some common conditions, notably
headache, stroke, and seizure (1117). However, the
Tung et al.
849
Fig. 1. Age distribution of the general study population (n 360), counts, and years.
>24 h after hospital admission; (iv) previous neuroimaging-conrmed diagnosis of intracranial pathology or
CT for preoperative or post-therapeutic use; (v) incomplete medical record. Subsequently data from 346
patients (114 in the nested group) were available for
analysis; the age distribution is shown in Fig. 1, specifically, 221 patients were aged >60 years. Medical records including CT referrals and reports were reviewed
for clinical information and for information pertaining
to the Rothrock criteria as well as to the CT ndings.
No age limit was imposed in the patient selecting
process.
Patients chief complaints were construed from the
reason for visit, urgent problem, and anamnesis
entries in the medical records and sorted as headache,
suspicion of stroke/TIA, seizures, vertigo, altered
mental status, impaired general condition, syncope,
confusion, or gait disturbance. Sudden onset aphasia,
unilateral weakness or paresthesia, and symptom constellations primarily raising concerns regarding cerebrovascular insult were categorized as suspected
stroke/TIA. Instances in which the provided journal
information did not allow for condent categorization
into any of the above were categorized as miscellaneous. In addition, a group of patients within the total
group, henceforth denoted the nested group was
dened to comprise those patients whose chief complaint was not headache, seizures, vertigo, nor primarily raised suspicion of acute cerebral infarct or
hemorrhage, i.e. those complaints where selection criteria for urgent CT are not available at present.
The Rothrock criteria were adapted to Swedish
standards, specically altered mental status was
expressed using the in Scandinavia commonly used
Reaction Level Scale (RLS) instead of the Glasgow
Coma Scale (GCS) (19). While the GCS score is the
composite of three ordinal scales (eye, verbal, and
motor, with a high score indicating level of consciousness closer to normal), the RLS is a hierarchically
ordered scale with eight categories (reaction levels)
850
Table 2. Demographics and clinical characteristics of the general and nested population.
General population
(n 346)
n (%)*
Residual populationy
(n 232)
n (%), [95% CI]*
Nested population
(n 114)
n (%), [95% CI]
221 (63.9%)
126 (54.3%)
[47.760.9]z
40 (17.3%)
[12.622.7]
15 (6.5%)
[3.710.4]
76 (32.8%)
[26.839.2]
11 (4.7%)
[2.48.3]
126 (54.3%)
57.9
[55.260.7]
63
25 (10.8%)
[7.115.5]
95 (83.3%)
[75.289.7]
1 (0.9%)
[0.024.8]
1 (0.9%)
[0.024.8]
35 (30.7%)
[22.440.0]
31 (27.2%)
[19.336.3]
59 (51.8%)
71.8
[67.273.5]
76
10 (8.8%)
[4.315.5]
41 (11.8%)
16 (4.6%)
111 (32.1%)
RLS 2
42 (12.1%)
Female
Mean age
185 (53.5%)
62.5
Median age
Significant findings
67.5
35 (10.1%)
*The total number is shown as the count, and as the percentage of respective population in brackets, while 95% CIs are shown in square brackets. The
Students t-test was used for calculating CIs for mean age and for comparison between groups.
y
The residual population contains the patients whose chief complaint was headache, vertigo, TIA/stroke, or seizures.
z
Significant differences between the nested and residual populations are in bold format.
Altered mental status and GCS <14 were substituted for by the RLS, level 2 (20).
Results
Demographics
As mentioned above, in total 805 patients were identied as having undergone urgent cranial CT after referral from the ED during the period from 1 January to
30 April 2009, using the Department of Radiologys
database. Exclusion criteria eliminated the following
numbers of patients from each category: (i) head
trauma during the last 72 h, n 201; (ii) hospitalization,
ED admission, visit to an outpatient clinic, or neuroimaging during the last 7 days, n 39; (iii) referral for
cranial CT >24 h after admission to hospital, n 105;
(iv) known neuroimaging-conrmed diagnosis, or CT
performed for preoperative or post-therapeutic use,
n 85; (v) incomplete medical record, n 29. Thus,
Tung et al.
851
Symptoms of stroke/TIA
Headache
Vertigo
Seizures
Impaired general condition
Altered mental status
Syncope
Confusion
Gait disturbance
Miscellaneous
Primary
complaint
(n 346)
n (%)
Significant
CT finding
(n 35)
n (%)
78
87
48
19
15
20
10
17
8
44
14
6
4
1
2
3
2
1
0
2
(22.5%)
(25.1%)
(13.9%)
(5.5%)
(4.3%)
(5.8%)
(2.9%)
(4.9%)
(2.3%)
(12.7%)
(17.9%)
(14.5%)
(8.3%)
(5.3%)
(13.3%)
(15.0%)
(20.0%)
(5.9%)
(0%)
(4.5%)
Cranial CT findings
Signicant CT ndings were found in 35 patients,
resulting in an overall prevalence rate of 35/346 patients
(10.1%); non-signicant ndings, newly discovered or
noteworthy progressed were found in 102 (29.5%)
patients; normal or unaltered appearance was demonstrated in 209 (60.4%) patients. The signicant ndings
in the general population were: acute cerebral infarct
(n 15), cerebral parenchymal hemorrhage (n 5), subarachnoid hemorrhage (n 2), subdural hemorrhage
(n 4), intracerebral tumor with surrounding edema
or mass eect (n 4), and metastatic malignancy
(n 5). In the nested population signicant ndings
were found in 10 patients (10/114, 8.8 %), divided as
follows: acute cerebral infarct (n 4), cerebral parenchymal hemorrhage (n 1), subdural hemorrhage
(n 3), intracerebral tumor with edema (n 1), and
metastatic malignancy (n 1).
The most prevalent non-signicant ndings were
chronic small vessel disease (n 49/346, 14.2%), nonacute cerebral ischemic infarction (n 32/346, 9.2%),
and hypertrophic sinonasal mucosa (n 22/346,
6.4%). Also, the non-signicant intracranial ndings
included a 5-mm-wide hygroma without mass eect, a
meningioma without mass eect, an arachnoid cyst, a
dermoid cyst, minor (<5 mm) herniation of the cerebellar tonsils, and two cases with calcications of benevolent appearance. Diagnoses most commonly suspected
or asked by the referring physician to be ruled out were
intracerebral hemorrhage (260/346, 75.1%) and ischemia (193/346, 55.8%), followed by expansive lesion
(91/346, 26.3%) and unspecied enquiries for pathology (52/346,15.0%). The mean number of query
terms entered on the radiology referrals was 2.11.
852
97.1
25.1
12.7
98.7
74.9
2.9
(85.199.9)
(20.430.3)
(9.017.3)
(93.299.97)
(69.779.6)
(0.114.9)
100
12.5
9.9
100
87.5
0
(74.1100)
(6.820.4)
(4.917.5)
(79.4100)
(79.693.2)
(025.9)
0.076
0.662
2.11 (0.934.78)
1.25 (0.463.43)
0.29
2.01 (0.557.39)
0.003
2.88 (1.425.84)
RLS 2
0.004
3.31 (1.467.47)
0.998
0.999
0.999
0.039
4.09 (1.0815.53)
RLS 2
0.028
4.50 (1.1817.15)
Discussion
For nancial and healthcare purposes, i.e. radiation
exposure, a highly sensitive decision rule in addition
to clinical practice guidelines, that selects patients of a
wide range of complaints for radiological investigation,
would be of high value. The aim of our study was to
Tung et al.
status was replaced by GCS <14, and the criterion
age 60 years was removed (22). In their own material, these modied Harris criteria were retrospectively sucient to detect all 22 (35%) of the 62
patients with signicant CT ndings. Had the original
Rothrock criteria been applied in the Harris study, the
amount of scans would be reduced by 11%. Tan et al.
found reduced sensitivity for the Harris criteria in comparison to the Rothrock criteria suggesting the age criterion is of importance; in our material, this was also
the case, thus we have chosen not to report results from
the Harris criteria.
Urgent cranial CT is an important tool in the
workup of patients with suspected intracranial pathology that attend the ED. However, development of
highly sensitive clinical selection criteria for common
patient groups such as those in the non-trauma general
population with symptoms that may hint of intracranial pathology remains alluring. While it is highly
improbable to attain 100% sensitivity for the aforementioned signicant ndings using reasonable clinical
selection criteria, a very high sensitivity in conjunction
with a substantial scan reduction rate may be of value
for clinicians; the latter being dependent on the local
prevalence rate in patients undergoing cranial CT. An
additional parameter to validate for possible inclusion
in the decision rule would be previous history (as was
the case in the patient not selected by the Rothrock
criteria in our material). Apart from the sensitivity
not being 100%, in a clinical setting where practice
guidelines play an augmented role, simplicity and pragmatism is often depreciated. In the ED, the surging seek
for medical attention prompting fast sorting of patients
where ruling out disease has become increasingly
important.
Some limitations of this study include that 29
patients were excluded solely on the grounds of incomplete medical records. Quality of the medical documentation of neurologic examinations varied and the
conclusion that neurologic signs had been ruled out
may have based on incomplete description of patients
status. The patients chief complaint had to be constructed from three dierent headings in the medical
records. Due to clinicians varying descriptions on
what type of information was recorded under the
reason for visit and urgent problem headings, it
was often necessary to seek additional information provided under the patient history heading; hence interobserver reliability is limited.
As pointed out previously, there may be a selection
bias due to the fact that only patients that did undergo
cranial CT were included, which may inuence the
results. There was no control group in this study,
hence it is unknown how the criteria would have performed on patients suspected of having intracranial
853
pathology but did not undergo an urgent cranial CT.
The criteria, we therefore believe, should not be used to
select patients for CT who normally would not be
referred. Examples of such situations are that gastroenteritis patients with headache and vomiting or
patients aged 60 years whose complaint is of apparent
extracranial cause, are normally not referred for urgent
cranial CT. Rather the criteria may provide justication
for abstaining CT in patients not exhibiting any of the
criteria items nor whom have specic risk factors.
In addition, our analysis will miss false-negatives
caused by patients whose ED visit does not result in a
cranial CT, but who return within 7 days with a signicant nding, by means of the exclusion criteria.
In conclusion, although 100% sensitivity was not
achieved, our results may contribute to the evidence
that in the absence of focal neurologic decit, headache
with vomiting, or altered mental status in patients aged
<60 years cranial CT can be refrained from. Further
research might validate patient history as a parameter.
Funding
This research received no specic grant from any funding
agency in the public, commercial, or not-for-prot sectors.
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