Utility of emergency cranial computed tomography in patients without trauma.

ACADEMIC EMERGENCY MEDICINE 2012; 19: 1055–1060 © 2012 by the Society for Academic Emergency Medicine Abstract Objectives: The objectives of this study were to determine, in patients admitted to the hospital from the emergency department (ED) without evidence of trauma, 1) the prevalence of clinically important abnormalities on cranial computed tomography (CCT) and 2) the frequency of emergent therapeutic interventions required because of these abnormalities. Methods: The authors retrospectively reviewed the records of all patients from 2007 between the ages of 18 and 89 years who had CCT as part of their ED evaluations prior to hospitalization. Patients with any indication of trauma were excluded, as were those who had a lumbar puncture (LP). Chief complaint, results of the ED neurologic examination, tomogram findings, and whether patients had emergent interventions were recorded. Patients presenting with altered mental status (AMS) were analyzed separately. Results: Of the 766 patients meeting inclusion criteria, 83 (11%) had focal neurologic findings, and 61 (8%) had clinically important abnormalities on computed tomography. Emergent interventions occurred in only 12 (1.6%), 11 (92%) of whom had focal neurologic findings. In the subgroup of 287 patients with AMS as their presenting problem, 14 (4.9%) had focal findings, six (2%) had clinically important abnormalities on tomography, and only two (0.7%) required emergent interventions, both of whom had focal findings. Patients presenting with AMS were less likely to have positive findings on tomography (odds ratio [OR] = 0.16, 95% confidence interval [CI] = 0.07 to 0.39). Patients presenting with motor weakness or speech abnormalities, or who were unresponsive, were more likely to have positive findings on tomography (OR = 4.7, 95% CI = 2.6 to 8.6; OR = 4.4, 95% CI = 1.5 to 2.7; and OR = 3.3, 95% CI = 1.6 to 7.1, respectively). Conclusions: Of patients without evidence of trauma who receive CCT in the ED, the prevalence of focal neurologic findings and clinically important abnormalities on tomography is low, the need for emergent intervention is very low, and the large majority of patients requiring emergent intervention have focal findings. The yield of CCT was lower for patients presenting with AMS, and higher for patients presenting with motor weakness or speech abnormalities, and for those who were unresponsive. Resumen Objetivos: Los objetivos de este estudio fueron determinar, en los pacientes ingresados en el hospital desde el servicio de urgencias (SU) sin evidencia de traumatismo, los siguientes aspectos: 1) la prevalencia de alteraciones clinicamente significativas en la tomografia computarizada (TC) de craneo; y 2) la frecuencia de intervenciones terapeuticas urgentes requeridas como consecuencia de estas alteraciones. Metodo: Se reviso retrospectivamente las historias clinicas desde 2007 de todos los pacientes de edades comprendidas entre 18 y 89 anos que tenian una TC de craneo como parte de su evaluacion en el SU previamente a su ingreso. Se excluyo a los pacientes con cualquier indicacion de traumatismo, asi como aquellos a los que se les realizo una puncion lumbar. Se recogio el motivo de consulta, los resultados de la exploracion neurologica de urgencias, los hallazgos de la tomografia y si los pacientes tuvieron intervenciones urgentes. Los pacientes que presentaron alteracion del nivel de conciencia se analizaron de forma independiente. Resultados: De los 766 pacientes que cumplieron los criterios de inclusion, 83 (11%) tuvieron hallazgos de focalidad neurologica, y 61 (8%) tuvieron alteraciones clinicamente significativas en la TC. Las intervenciones urgentes ocurrieron solo en 12 (1,6%) pacientes, 11 (92%) de los cuales tenian hallazgos de focalidad neurologica. En el subgrupo de 287 pacientes con alteracion del nivel de conciencia como sintoma de presentacion, 14 (4,9%) tuvieron hallazgos de focalidad, 6 (2%) tuvieron alteraciones significativas en la TC y solo 2 (0,7%) requirieron intervenciones urgentes, ambos presentaban hallazgos de focalidad neurologica. Los pacientes que presentaron alteracion del nivel de conciencia eran menos dados a tener hallazgos positivos en la TC (odds ratio [OR] 0,16; IC 95%= 0,07 a 0,39). Los pacientes que presentaron debilidad motora o alteraciones del lenguaje, o aquellos que no respondian, tenian mayor probabilidad de tener hallazgos positivos en la tomografia (OR 4,7; IC 95% = 2,6 a 8,6; OR 4,4; IC 95% = 1,5 a 2,7; y OR 3,3, IC 95% = 1,6 a 7,1; respectivamente). Conclusiones: En aquellos pacientes sin evidencia de traumatismo en los que se realiza una TC de craneo en el SU, la prevalencia de hallazgos de focalidad neurologica y alteraciones clinicamente significativas en la tomografia es baja, la necesidad de intervencion urgente es muy baja y la gran mayoria de los pacientes que requieren intervencion urgente tienen signos de focalidad neurologica. El rendimiento de la TC de craneo fue menor para los pacientes que presentaron alteracion del nivel de conciencia y mayor para los pacientes que presentaron debilidad motora o alteraciones del lenguaje y para aquellos que no respondian.