title: Sensitivity of a Clinical Decision Rule and Early Computed Tomography in Aneurysmal Subarachnoid Hemorrhage.
abstract: BACKGROUND
  Application of a clinical decision rule for subarachnoid hemorrhage, in combination with cranial computed tomography (CT) performed within six hours of ictus (early cranial CT), may be able to reasonably exclude a diagnosis of aneurysmal subarachnoid hemorrhage (aSAH). This study's objective was to examine the sensitivity of both early cranial CT and a previously validated clinical decision rule among emergency department (ED) patients with aSAH and a normal mental status.
  
  
  METHODS
  Patients were evaluated in the 21 EDs of an integrated health delivery system between January 2007 and June 2013. We identified by chart review a retrospective cohort of patients diagnosed with aSAH in the setting of a normal mental status and performance of early cranial CT. Variables comprising the SAH clinical decision rule (age≥40, presence of neck pain or stiffness, headache onset with exertion, loss of consciousness at headache onset) were abstracted from the chart and assessed for inter-rater reliability.
  
  
  RESULTS
  One hundred fifty-five patients with aSAH met study inclusion criteria. The sensitivity of early cranial CT was 95.5% (95% CI [90.9-98.2]). The sensitivity of the SAH clinical decision rule was also 95.5% (95% CI [90.9-98.2]). Since all false negative cases for each diagnostic modality were mutually independent, the combined use of both early cranial CT and the clinical decision rule improved sensitivity to 100% (95% CI [97.6-100.0]).
  
  
  CONCLUSIONS
  Neither early cranial CT nor the SAH clinical decision rule demonstrated ideal sensitivity for aSAH in this retrospective cohort. However, the combination of both strategies might optimize sensitivity for this life-threatening disease.
authors.affiliation: Kaiser Permanente, Department of Emergency Medicine, Oakland, California.
authors.forename: Dustin G
authors.initials: DG
authors.lastname: Mark
authors.affiliation: Kaiser Permanente, Department of Emergency Medicine, San Leandro, California.
authors.forename: Mamata V
authors.initials: MV
authors.lastname: Kene
authors.affiliation: Kaiser Permanente Northern California, Division of Research, Oakland, California.
authors.forename: Natalia
authors.initials: N
authors.lastname: Udaltsova
authors.affiliation: Kaiser Permanente, Department of Emergency Medicine, Roseville, California ; Kaiser Permanente Northern California, Division of Research, Oakland, California.
authors.forename: David R
authors.initials: DR
authors.lastname: Vinson
authors.affiliation: Kaiser Permanente Northern California, Division of Research, Oakland, California ; Kaiser Permanente, Department of Emergency Medicine, San Rafael, California.
authors.forename: Dustin W
authors.initials: DW
authors.lastname: Ballard
mesh_terms: D003661:Decision Support Techniques; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D002532:Intracranial Aneurysm / Q000175:diagnosis* / Q000000981:diagnostic imaging; D008297:Male; D008875:Middle Aged; D059906:Neuroimaging; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis* / Q000000981:diagnostic imaging; D014057:Tomography, X-Ray Computed