Perry Jeffrey J, Sivilotti Marco L A, Sutherland Jane, Hohl Corinne M, Émond Marcel, Calder Lisa A, Vaillancourt Christian, Thirganasambandamoorthy Venkatesh, Lesiuk Howard, Wells George A, Stiell Ian G
Department of Emergency Medicine (Perry, Sutherland, Calder, Vaillancourt, Thirganasambandamoorthy, Stiell); School of Epidemiology, Public Health and Preventative Medicine (Perry, Calder, Vaillancourt, Thirganasambandamoorthy, Wells, Stiell); Division of Neurosurgery (Lesiuk), University of Ottawa, the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont.; Departments of Emergency Medicine and Biomedical and Molecular Sciences (Sivilotti), Queen's University, Kingston, Ont.; Department of Emergency Medicine (Hohl), University of British Columbia, Vancouver, BC; Department of Emergency Medicine (Émond), Université Laval, Québec, Que.
CMAJ. 2017 Nov 13;189(45):E1379-E1385. doi: 10.1503/cmaj.170072.
We previously derived the Ottawa Subarachnoid Hemorrhage Rule to identify subarachnoid hemorrhage (SAH) in patients with acute headache. Our objective was to validate the rule in a new cohort of consecutive patients who visited an emergency department.
We conducted a multicentre prospective cohort study at 6 university-affiliated tertiary-care hospital emergency departments in Canada from January 2010 to January 2014. We included alert, neurologically intact adult patients with a headache peaking within 1 hour of onset. Treating physicians in the emergency department explicitly scored the rule before investigations were started. We defined subarachnoid hemorrhage as detection of any of the following: subarachnoid blood visible upon computed tomography of the head (from the final report by the local radiologist); xanthochromia in the cerebrospinal fluid (by visual inspection); or the presence of erythrocytes (> 1 × 10/L) in the final tube of cerebrospinal fluid, with an aneurysm or arteriovenous malformation visible upon cerebral angiography. We calculated sensitivity and specificity of the Ottawa SAH Rule for detecting or ruling out subarachnoid hemorrhage.
Treating physicians enrolled 1153 of 1743 (66.2%) potentially eligible patients, including 67 with subarachnoid hemorrhage. The Ottawa SAH Rule had 100% sensitivity (95% confidence interval [CI] 94.6%-100%) with a specificity of 13.6% (95% CI 13.1%-15.8%), whereas neuroimaging rates remained similar (about 87%).
We found that the Ottawa SAH Rule was sensitive for identifying subarachnoid hemorrhage in otherwise alert and neurologically intact patients. We believe that the Ottawa SAH Rule can be used to rule out this serious diagnosis, thereby decreasing the number of cases missed while constraining rates of neuroimaging.
我们之前制定了渥太华蛛网膜下腔出血规则，以识别急性头痛患者中的蛛网膜下腔出血（SAH）。我们的目的是在新的一组连续就诊于急诊科的患者中验证该规则。
2010年1月至2014年1月，我们在加拿大6家大学附属三级医疗医院急诊科进行了一项多中心前瞻性队列研究。我们纳入了起病1小时内头痛达到高峰的清醒、神经系统完好的成年患者。急诊科的治疗医生在开始检查前明确对该规则进行评分。我们将蛛网膜下腔出血定义为检测到以下任何一种情况：头颅计算机断层扫描显示蛛网膜下腔出血（根据当地放射科医生的最终报告）；脑脊液黄变（通过肉眼检查）；或脑脊液最后一管中存在红细胞（>1×10/L），脑血管造影显示有动脉瘤或动静脉畸形。我们计算了渥太华SAH规则检测或排除蛛网膜下腔出血的敏感性和特异性。
治疗医生纳入了1743名潜在符合条件患者中的1153名（66.2%），其中67名有蛛网膜下腔出血。渥太华SAH规则的敏感性为100%（95%置信区间[CI]94.6%-100%），特异性为13.6%（95%CI 13.1%-15.8%），而神经影像学检查率保持相似（约87%）。
我们发现渥太华SAH规则在识别其他方面清醒且神经系统完好的患者中的蛛网膜下腔出血方面具有敏感性。我们认为渥太华SAH规则可用于排除这一严重诊断，从而减少漏诊病例数，同时限制神经影像学检查率。
