Clinical Decision Rules to Rule Out Subarachnoid Hemorrhage for Acute Headache
Authors: Jeffrey J Perry, Ian G Stiell, Marco L A Sivilotti, Michael J Bullard, Corinne M Hohl, Jane Sutherland, Marcel Émond, Andrew Worster, Jacques S Lee, Duncan Mackey, Merril Pauls, Howard Lesiuk, Cheryl Symington, George A Wells
Journal: JAMA (2013)

Investigation of the neurologically intact (ie, no neurologic deficits) patient with headache is a potentially difficult clinical decision for physicians.2][3][4] Although the decision to evaluate patients with new neurologic deficits is relatively straightforward, it is much more difficult to determine which alert, neurologically intact patients who present with headache alone require investigations-yet such patients account for half of all subarachnoid hemorrhages at initial presentation. 5This diagnostic dilemma is illustrated by the report that 5.4% of confirmed subarachnoid hemorrhages were misdiagnosed during the patients' initial emergency department assessment. 6atients suspected of having subarachnoid hemorrhage are typically evaluated with an unenhanced computed tomography (CT) scan followed by a lumbar puncture if results of the CT scan are negative.Computed tomography is highly sensitive when performed soon after headache onset. 7Lumbar puncture can be a painful procedure and can result in a headache that may be worse than the original headache. 80][11][12] These rules help clinicians with diagnostic or thera-IMPORTANCE 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.DESIGN, SETTING, AND PATIENTS 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.MAIN OUTCOMES AND MEASURES 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. RESULTSOf 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 AND RELEVANCE 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.