Clinical decision rules to rule out subarachnoid hemorrhage for acute headache.
OBJECTIVE
Three clinical decision rules were previously derived to identify patients with headache requiring investigations to rule out subarachnoid hemorrhage.


OBJECTIVE
To assess the accuracy, reliability, acceptability, and potential refinement (ie, to improve sensitivity or specificity) of these rules in a new cohort of patients with headache.


METHODS
Multicenter cohort study conducted at 10 university-affiliated Canadian tertiary care emergency departments from April 2006 to July 2010. Enrolled patients were 2131 adults with a headache peaking within 1 hour and no neurologic deficits. Physicians completed data forms after assessing eligible patients prior to investigations.


METHODS
Subarachnoid hemorrhage, defined as (1) subarachnoid blood on computed tomography scan; (2) xanthochromia in cerebrospinal fluid; or (3) red blood cells in the final tube of cerebrospinal fluid, with positive angiography findings.


RESULTS
Of the 2131 enrolled patients, 132 (6.2%) had subarachnoid hemorrhage. The decision rule including any of age 40 years or older, neck pain or stiffness, witnessed loss of consciousness, or onset during exertion had 98.5% (95% CI, 94.6%-99.6%) sensitivity and 27.5% (95% CI, 25.6%-29.5%) specificity for subarachnoid hemorrhage. Adding "thunderclap headache" (ie, instantly peaking pain) and "limited neck flexion on examination" resulted in the Ottawa SAH Rule, with 100% (95% CI, 97.2%-100.0%) sensitivity and 15.3% (95% CI, 13.8%-16.9%) specificity.


CONCLUSIONS
Among patients presenting to the emergency department with acute nontraumatic headache that reached maximal intensity within 1 hour and who had normal neurologic examination findings, the Ottawa SAH Rule was highly sensitive for identifying subarachnoid hemorrhage. These findings apply only to patients with these specific clinical characteristics and require additional evaluation in implementation studies before the rule is applied in routine clinical care.
Department of Emergency Medicine, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. jperry@ohri.ca
Jeffrey J
JJ
Perry
Ian G
IG
Stiell
Marco L A
ML
Sivilotti
Michael J
MJ
Bullard
Corinne M
CM
Hohl
Jane
J
Sutherland
Marcel
M
Émond
Andrew
A
Worster
Jacques S
JS
Lee
Duncan
D
Mackey
Merril
M
Pauls
Howard
H
Lesiuk
Cheryl
C
Symington
George A
GA
Wells
D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003661:Decision Support Techniques; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D004912:Erythrocytes; D005260:Female; D051270:Headache Disorders, Primary / Q000000981:diagnostic imaging / Q000209:etiology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010808:Physical Examination; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013129:Spinal Puncture; D013345:Subarachnoid Hemorrhage / Q000134:cerebrospinal fluid / Q000150:complications / Q000000981:diagnostic imaging*; D062606:Tertiary Care Centers; D014057:Tomography, X-Ray Computed; D055815:Young Adult