scholarly journals LO54: Emergency department prevalence of intracranial aneurysm on computed tomography angiography (EPIC-ACT)

CJEM ◽  
2020 ◽  
Vol 22 (S1) ◽  
pp. S26-S27
Author(s):  
B. Sheppard ◽  
G. Beller ◽  
C. O'Rielly ◽  
Charles Wong
Keyword(s):  
Emergency Department ◽  
Intracranial Aneurysm ◽  
Head And Neck ◽  
Cerebral Artery ◽  
Intracranial Aneurysms ◽  
Acute Hemorrhage ◽  
Invasive Angiography ◽  
Incidental Aneurysms ◽  
Emergency Department Patients ◽  
Rule Out

Introduction: Evidence is accumulating that a CT plus a CT angiogram (CTA) of the head and neck may be adequate to rule out subarachnoid haemorrhage (SAH) in patients with a thunderclap headache, thus potentially negating the need for lumbar puncture. One of the most widely cited objections to this strategy is the fear of detecting “incidental asymptomatic aneurysms,” lesions seen on angiography that are not in fact the cause of the patient's symptoms. Currently existing data on the background rate of aneurysms are based on cadaveric studies, invasive angiography, or MRI, and thus does not reflect the true rate of incidental aneurysms that would be detected using a CT plus CTA strategy. This study characterizes the rate of incidental aneurysms identified on CTA in an emergency department population. Methods: In this multicentre retrospective cohort study we analyzed the electronic medical records of all emergency department patients ≥ 18 years of age who underwent CTA of the head and neck over a two month period across four urban tertiary care emergency departments. Two independent reviewers evaluated the final radiology reports and extracted relevant data. The primary outcome of interest was the presence of incidental intracranial aneurysm, defined as a newly diagnosed aneurysm not associated with evidence of acute hemorrhage. Secondary outcomes included aneurysm location and size. Results: Of 739 charts meeting inclusion criteria, incidental intracranial aneurysms were detected in 21 cases or 2.85% (95% confidence interval, 1.77 - 4.32). An additional 20 aneurysms were identified but excluded from the analysis as they were previously known (n = 9) or were associated with evidence of acute hemorrhage (n = 11) and thus were not considered incidental. Of 21 patients with identified incidental aneurysms, 7 had multiple aneurysms. The most common aneurysm sites were internal carotid artery (n = 13), middle cerebral artery (n = 6) and anterior cerebral artery (n = 4). The average size of incidental aneurysm was 4.1 mm. Conclusion: The rate of incidental intracranial aneurysm among emergency department patients undergoing CTA of the head and neck is lower than many previously described estimates obtained through invasive angiography and MRI studies. To our knowledge, this is the first study on the prevalence of incidental intracranial aneurysms in an emergency department specific population and may therefore help guide clinicians when considering using a CT plus CTA rule out strategy for patients presenting with acute headache suspicious for SAH.

Diagnostic and prognostic value of the D-dimer test in emergency department patients: secondary analysis of an observational study

2019 ◽  
Vol 57 (11) ◽  
pp. 1730-1736 ◽  
Author(s):  
Alaadin Vögeli ◽  
Mohammad Ghasemi ◽  
Claudia Gregoriano ◽  
Angelika Hammerer ◽  
Sebastian Haubitz ◽  
...  
Keyword(s):  
Emergency Department ◽  
False Positive ◽  
Prognostic Value ◽  
Secondary Analysis ◽  
Area Under The Curve ◽  
Thromboembolic Disease ◽  
Predictive Values ◽  
Emergency Department Patients ◽  
D Dimer ◽  
Rule Out

Abstract Background D-dimer measurement improves the rule-out of thromboembolic disease. However, little is known about the risk of false positive results for the diagnosis of thromboembolic disease and its prognostic value. Herein, we investigated factors influencing the accuracy of D-dimer and its prognostic value in a large cohort of emergency department (ED) patients. Methods This is a secondary analysis of a prospective observational single center, cohort study. Consecutive patients, for whom a D-dimer test was requested by the treating physician, were included. Associations of clinical parameters on admission with false positive D-dimer results for the diagnosis of thromboembolic disease were investigated with logistic regression analysis. Results A total of 3301 patients were included, of which 203 (6.1%) had confirmed thromboembolic disease. The negative and positive predictive values of the D-dimer test at the 0.5 mg/L cut-off were 99.9% and 11.4%, respectively. Several factors were associated with positive D-dimer results potentially falsely indicating thromboembolic disease in multivariate analysis including advanced age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.04–1.05, p < 0.001), congestive heart failure (CHF) (OR 2.79, 95% CI 1.77–4.4, p < 0.01), renal failure (OR 2.00, 95% CI 1.23–3.24, p = 0.005), history of malignancy (OR 2.6, 95% CI 1.57–4.31, p < 0.001), C-reactive protein (CRP) (OR 1.02, 95% CI 1.01–1.02, p < 0.001) and glomerular filtration rate (GFR) (OR 0.99, 95% CI 0.99–1.00, p = 0.003). Regarding its prognostic value, D-dimer was associated with a 30-day mortality (adjusted OR 1.05, 95% CI 1.02–1.09, p = 0.003) with an area under the curve (AUC) of 0.79. Conclusions While D-dimer allows an accurate rule-out of thromboembolic disease, its positive predictive value in routine ED patients is limited and largely influenced by age, comorbidities and acute disease factors. The strong prognostic value of D-dimer in this population warrants further investigation.

Traumatic Intracranial Aneurysms Caused by Missiles: Their Presentation and Management

Neurosurgery ◽  
1991 ◽  
Vol 28 (1) ◽  
pp. 1-7 ◽  
Author(s):  
Fuad Sami Haddad ◽  
Georges F. Haddad ◽  
Jamal Taha
Keyword(s):  
Intracranial Aneurysm ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Subdural Hematoma ◽  
Intracranial Aneurysms ◽  
Acute Subdural Hematoma ◽  
Intracerebral Hematoma ◽  
Secondary Branch ◽  
Missile Injury ◽  
Level Of Consciousness

Abstract Only 30 cases of traumatic intracranial aneurysm (TICA) secondary to missile injury have been reported to date. To these we add 15 more cases. Missile TICAs are often seen on a secondary branch of the middle cerebral artery and are usually accompanied by a intracerebral hematoma (80%) or by an acute subdural hematoma (26%). Fourteen of our cases were secondary to shrapnel injuries and only one was secondary to a bullet. None of the injuries was through-and-through. TICAs may enlarge in time and, seemingly inoffensive, may rupture and lead to death. All seven TICAs studied histologically proved to be false aneurysms. TICAs are best treated through trapping and excision. The outcome depends on the patient's status and level of consciousness before surgery. Indications for angiography are discussed.

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