University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, USA.
Department of Emergency Medicine, Stanford University Medical Center, Palo Alto, USA.
Neurocrit Care. 2019 Oct;31(2):321-328. doi: 10.1007/s12028-019-00679-7.
Spontaneous subarachnoid hemorrhage (SAH) from a brain aneurysm, if untreated in the acute phase, leads to loss of functional independence in about 30% of patients and death in 27-44%. To evaluate for SAH, the American College of Emergency Physicians (ACEP) Clinical Policy recommends obtaining a non-contrast brain computed tomography (CT) scan followed by a lumbar puncture (LP) if the CT is negative. On the other hand, current evidence from prospectively collected data suggests that CT alone may be sufficient to rule out SAH in patients who present within 6 h of symptom onset while anecdotal evidence suggests that CT angiogram (CTA) may be used to detect aneurysms, which are the probable cause of SAH. Since many different options are available to emergency physicians, we examined their practice pattern variation by observing their diagnostic approaches and their adherence to the ACEP Clinical Policy.
We developed, validated, and distributed a survey to emergency physicians at three practice sites: (1) Stanford Healthcare, California, (2) Intermountain Healthcare (five emergency departments), Utah, and (3) Ottawa General Hospital, Toronto. The survey questions examined physician knowledge on CT and LP's test performance and used case-based scenarios to assess diagnostic approaches, variation in practice, and adherence to guidelines. Results were presented as proportions with 95% CIs.
Of the 216 physicians surveyed, we received 168 responses (77.8%). The responses by site were: (1) (n = 38, 23.2%), (2) (n = 70, 42.7%), (3) (n = 56, 34.1%). To the CT and LP test performance question, most physicians indicated that CT alone detects > 90% of SAH in those with a confirmed SAH [n = 150 (89.3%, 95% CI 83.6-93.5]. To the case-based questions, most physicians indicated that they would perform a CTA along with a CT [n = 110 (65.5%, 95% CI 57.8-72.6)], some indicated a LP along with a CT [n = 57, 33.9% 95% CI 26.8-41.6)], and a few indicated both a CTA and a LP [n = 16, 9.5%, 95% CI 5.5-15.0]. We also observed practice site variation in the proportion of physicians who indicated that they would use CTA: (1) (n = 25, 65.8%), (2) (n = 54, 77.1%), and (3) (n = 28, 50.0%) (p = 0.006).
Survey responses indicate that physicians use some or all of the imaging tests, with or without LP to diagnose SAH. We observed variation in the use of CTA by site and academic setting and divergence from ACEP Clinical Policy.
未经急性治疗的自发性蛛网膜下腔出血（SAH）会导致约 30%的患者丧失功能独立性，并导致 27-44%的患者死亡。为了评估 SAH，美国急诊医师学院（ACEP）临床政策建议在 CT 阴性时进行非对比脑计算机断层扫描（CT）检查，然后进行腰椎穿刺（LP）。另一方面，来自前瞻性收集数据的当前证据表明，在症状发作后 6 小时内就诊的患者，单独使用 CT 可能足以排除 SAH，而轶事证据表明 CT 血管造影（CTA）可用于检测动脉瘤，这可能是 SAH 的原因。由于急诊医师有许多不同的选择，因此我们通过观察他们的诊断方法和对 ACEP 临床政策的遵守情况，研究了他们的实践模式变化。
我们在三个实践地点（1）加利福尼亚州斯坦福医疗保健，（2）爱默生医疗保健（五个急诊部门），犹他州和（3）安大略省总医院，多伦多开发、验证和分发了一项针对急诊医师的调查。调查问题考察了医师对 CT 和 LP 检测性能的知识，并使用基于案例的情景来评估诊断方法、实践差异和对指南的遵守情况。结果以比例和 95%置信区间（CI）表示。
在接受调查的 216 名医师中，我们收到了 168 名医师的回复（77.8%）。各地点的回复情况如下：（1）（n=38，23.2%），（2）（n=70，42.7%），（3）（n=56，34.1%）。对于 CT 和 LP 检测性能的问题，大多数医师表示，单独使用 CT 可检测到确诊 SAH 患者中超过 90%的 SAH[ n=150（89.3%，95%CI 83.6-93.5]。对于基于案例的问题，大多数医师表示他们会同时进行 CTA 和 CT[n=110（65.5%，95%CI 57.8-72.6]），有些医师表示同时进行 LP 和 CT[n=57，33.9%95%CI 26.8-41.6）]，少数医师表示同时进行 CTA 和 LP[n=16，9.5%95%CI 5.5-15.0）]。我们还观察到在表示他们将使用 CTA 的医师比例方面存在实践地点差异：（1）（n=25，65.8%），（2）（n=54，77.1%）和（3）（n=28，50.0%）（p=0.006）。
调查回复表明，医师使用一些或全部影像学检查，有或无 LP 来诊断 SAH。我们观察到 CTA 的使用因地点和学术背景而异，与 ACEP 临床政策不一致。
