Diagnosis of subarachnoid hemorrhage in the emergency department

To decide which patients with headache ought to be evaluated for SAH, physicians should focus on specific elements of the patient history, such as onset, severity, and quality of the headache and associated symptoms. These questions should be asked and the responses documented for every patient with a headache. The physical examination should be compulsive with regard to vital signs, HEENT. and neurologic signs. Then, the physician should form an explicit differential diagnosis and have reasons for diagnosing migraine, tension, or sinus headache and other benign causes. If there is no clear-cut alternative hypothesis, the patient should be evaluated by CT and LP (if the CT is negative, equivocal, or technically inadequate). Physicians should understand the limitations of this diagnostic algorithm. In addition, the CSF should be carefully analyzed, including measuring the opening pressure. In patients whose CT scans and CSF analyses are normal, further testing is rarely indicated.     

Ambient air pollution and daily emergency department visits for headache in Ottawa, Canada

Background.— No extensive studies exist on the relation between ambient air pollution and health outcomes such as migraine or headache. From other side, existing publications indicated that air pollutants can trigger migraine or headache.
Objective.— To examine associations between emergency department (ED) visits for headache and environmental conditions: ambient air pollution concentrations adjusted for weather factors (atmospheric pressure, temperature, and relative humidity).
Design and Methods.— This is a time-series study of 8012 ED visits for headache (International Classification for Diseases ninth revision: 784) recorded at an Ottawa hospital between 1992 and 2000. The generalized linear mixed models technique is used to model relation between daily counts of ED visits for headache and ambient air pollutants (gases: sulphur dioxide [SO₂], nitrogen dioxide [NO₂], carbon monoxide [CO]). The counts of visits for all patients, male and female patients, are analyzed separately.
Results.— The percentage increase in daily ED visits for headache was 4.2% (95% CI: 0.2, 6.4) and 4.9% (95% CI: 1.2, 8.8) for 1-day and 2-day lagged exposure to SO₂ for an increase in the interquartile range (IQR, IQR = 3.9 ppb). The positive statistically significant associations were also observed for exposure to NO₂ and CO for all and male ED visits for headache.
Conclusions.— Presented findings provide support for the hypothesis that ED visits for headache are related to ambient air pollution.     

冰帽在蛛网膜下隙出血病人头痛中的应用

蛛网膜下隙出血(SAH)是各种原因引起的脑血管突然破裂血液流入蛛网膜下隙的统称[1].在临床实践中发现,SAH病人呕吐、头痛症状较为突出,尤其是头痛常成为病人的主诉.为减少病人呕吐、头痛症状,我科在常规治疗的基础上加用冰帽持续头部物理降温,取得了满意疗效,现报告如下.……     

A non-traumatic,rapid-onset headache that is as dangerous as subarachnoid hemorrhage (SAH) seen in the emergency department

A 36yo male with multiple non-traumatic, rapid-onset headaches had Emergency Department visits on days 3 and 10 after onset of symptoms. He is a social smoker and drinker. CT head imaging was negative. An MRI/MRA was obtained. The image represents multiple foci of vasoconstriction and dilation in medium and large cerebral vessels consistent with Reversible Cerebral Vasoconstriction Syndrome (RCVS). Multiple rapid-onset headaches and "string of beads" on MRA imaging are pathognomonic for RCVS, which has a 4:1 female to male ratio. Manifestations include the pure cephalic form, characterized by a headache; subarachnoid hemorrhage and cerebral infarction have also been reported. Vasoactive drugs and the post-partum period are recognized as common inciting events. Symptoms usually resolve in 3-6 months. Treatment with nimodipine, 1-2mg/kg/hr IV and/or 30-60mg PO QID orally over 4-8 weeks, has been reported to be effective.     

冰帽在蛛网膜下隙出血病人头痛中的应用

蛛网膜下隙出血（SAH）是各种原因引起的脑血管突然破裂血液流入蛛网膜下隙的统称。在临床实践中发现。SAH病人呕吐、头痛症状较为突出，尤其是头痛常成为病人的主诉。为减少病人呕吐、头痛症状，我科在常规治疗的基础上加用冰帽持续头部物理降温。取得了满意疗效，现报告如下。     

急诊医学临床决策方法学初探

目的 了解急诊临床实践中临床决策方法的应用现状，探讨急诊医学临床决策方法应用方面存在的问题。方法 由独立研究人员分析人选的1115份病例的诊断和处理过程，解析其临床决策方法的实践应用情况，比较低年制住院医师组（PG1）和高年制住院医师组（PG3＋）临床决策方法应用的异同。结果 临床应用四种主要临床决策方法分别为模式识别法（47．0％）、假设-演绎法（26．5％）、事件驱动法（12．3％）、运用规则法（3．2％）。PG1组和PG3＋组临床决策方法的实践应用比较差异有统计学意义（χ^2=153．21，P〈0．001）。结论 模式识别法和假设-演绎法是目前最常用的急诊医学临床决策方法。急诊高年制住院医师应用模式识别法更加普遍，而低年制住院医师更倾向于选择假设-演绎法。运用规则临床决策法在急诊中的应用明显不足。     

Aneurysmal subarachnoid hemorrhage: update for emergency physicians

Aneurysmal subarachnoid hemorrhage (SAH) is a serious cause of stroke that affects 30,000 patients in North America annually. Due to a wide spectrum of presentations, misdiagnosis of SAH has been reported to occur in a significant proportion of cases. Headache, the most common chief complaint, may be an isolated finding; the neurological examination may be normal and neck stiffness absent. Emergency physicians must decide which patients to evaluate beyond history and physical examination. This evaluation--computed tomography (CT) scanning and lumbar puncture (LP)--is straightforward, but each test has important limitations. CT sensitivity falls with time from onset of symptoms and is lower in mildly affected patients. Traumatic LP must be distinguished from true SAH. Cerebrospinal fluid analysis centers on measuring xanthochromia. Debate exists about the best method to measure it--visual inspection or spectrophotometry. An LP-first strategy is also discussed. If SAH is diagnosed, the priority shifts to specialist consultation and cerebrovascular imaging to define the offending vascular lesion. The sensitivity of CT and magnetic resonance angiography are approaching that of conventional catheter angiography. Emergency physicians must also address various management issues to treat or prevent early complications. Endovascular therapy is being increasingly used, and disposition to neurovascular centers that offer the full range of treatments leads to better patient outcomes. Emergency physicians must be expert in the diagnosis and initial stabilization of patients with SAH. Treatment in a hospital with both neurosurgical and endovascular capability is becoming the norm.     

消炎痛栓塞肛治疗蛛网膜下隙出血引起的头痛

[目的]观察消炎痛（吲哚美辛）栓直肠给药对蛛网膜下隙出血（SAH）引起头痛的治疗效果。[方法]选取60例蛛网膜下隙出血引起头痛的病人，随机分为两组，分别采用消炎痛栓塞肛和颅痛定口服，评估疼痛的缓解情况。[结果]消炎痛栓塞肛组治疗前中度、重度疼痛和剧痛者30例（93.8％），治疗后有18例（56．3％），减少了37．5％；口服颅痛定组治疗前中度、重度疼痛和剧痛有26例（92．9％），治疗后有18例（64．3％），减少了28．6％。[结论]消炎痛栓塞肛能缓解蛛网膜下隙出血后头痛程度，且给药方便。     

The utility of clinical features in patients presenting with nontraumatic headache: an investigation of adult patients attending an emergency department

OBJECTIVE: When patients present to an emergency department because of nontraumatic headache, they often present a diagnostic challenge. This study aimed to examine the utility of clinical features in detecting serious underlying causes of nontraumatic headache in adult patients presenting to an emergency department. METHODS: A prospective observational study of alert adult patients presenting to 1 UK emergency department over a period of 14 months was conducted. Patients were excluded if their headache was related to trauma or they had been previously recruited into the study. A standardized data collection form was used to record details of the history and examination findings. Investigation and management were conducted according to the existing departmental protocols. Patients were followed up for 3 months following their initial presentation. Each factor in the history and examination was examined for its ability to predict a serious underlying cause of headache. RESULTS: Five hundred and eighty-nine patients were included in the study with complete follow-up details obtained on 558 (94.7%) patients. Seventy-five (13.4%) patients were found to have a serious pathological cause of their headache. Four features were found to be significant independent predictors of serious pathology, these were age >50 years (likelihood ratio (LR) = 2.34), sudden onset, (LR = 1.74), any abnormality on neurological examination (LR = 3.56), and presentation due to associated features (LR = 2.27). Taken in combination, the presence of any 1 of the first 3 features has a sensitivity of 98.6% and specificity of 34.4% (Positive LR = 1.50, Negative LR = 0.04). CONCLUSION: Three features, age greater than 50, sudden onset, and an abnormal neurological examination, are identified as significant independent predictors of serious pathology, which, in combination, can exclude the presence of such pathology in adult patients presenting with nontraumatic headache.     

蛛网膜下腔出血炎性抑制与头痛的相关性研究

目的 :探讨蛛网膜下腔出血 (SAH)头痛的发生机制是否与 SAH时炎性改变有关 ,同时观察地塞米松的免疫抑制作用对头痛的疗效。方法 :选择意识清醒能主诉头痛者 ,凡病情严重伴有意识障碍以及继发大面积脑梗死伴有痴呆不能主诉头痛者除外。将患者随机分为 4组治疗 :单独应用甘露醇治疗头痛 (甘露醇组 )及在甘露醇应用的基础上行脑脊液置换 (置换组 )、地塞米松鞘内注射 (鞘内组 )和静脉注射 (静脉组 ) ,对比观察 4个组的止痛效果。结果 :根据疗效判定标准 ,各组总有效率分别是 :甘露醇组 2 7.2 7%、置换组 6 6 .6 7%、鞘内组92 .36 %、静脉组 30 .0 0 % ,鞘内组与其它组比较均有显著统计学意义 (P均 <0 .0 1) ,其头痛缓解时间显著延长。结论 :鞘内注射地塞米松治疗 SAH头痛效果显著 ,表明发生质变的血性脑脊液引起蛛网膜下腔广泛的免疫炎性反应是导致头痛的重要原因。     

The Ottawa Ankle Rules in Asia: validating a clinical decision rule for requesting X-rays in twisting ankle and foot injuries

This was a study to determine if the Ottawa Ankle Rules (OAR) for requesting x-ray studies in twisting ankle and foot injuries are applicable in our Asian population. Four hundred ninety-four consecutive eligible patients presenting to the emergency department with twisting injuries about the ankle were examined by emergency physicians for clinical criteria requiring ankle and foot x-ray studies according to the OAR. Four hundred eighty-eight of these patients underwent x-ray studies that were interpreted by a radiologist. The sensitivity and specificity of the OAR for predicting the presence of fracture were calculated to be 0.9 and 0.34, respectively. When the rules were modified to cast a wider screening net, sensitivity improved to 0.99. We conclude that the OAR are not applicable to our population because of inadequate sensitivity, but when modified become acceptable and can reduce the number of x-ray studies requested by 28%.     

炎性抑制与蛛网膜下腔出血后头痛的关系

目的探讨蛛网膜下腔出血(SAH)后头痛的发生是否与蛛网膜下腔炎性改变有关,同时观察地塞米松的免疫抑制作用对头痛的疗效.方法将80例意识清醒、能主诉头痛的SAH患者随机分为4组:单独应用甘露醇治疗组(甘露醇组)、在应用甘露醇基础上行脑脊液置换组(置换组)、地塞米松鞘内注射组(鞘内组)和静脉注射组(静脉组),观察各组患者的止痛效果.结果各组的总有效率分别为:甘露醇组27.27%、置换组66.67%、鞘内组92.36%、静脉组30.00%,鞘内组疗效与其他组疗效的差异有显著性意义,且头痛缓解时间显著延长( P<0.01).结论发生质变的血性脑脊液引起的蛛网膜下腔广泛免疫炎性反应是导致头痛的重要原因,鞘内注射地塞米松治疗SAH后头痛效果显著.     

Characterization and prediction of emergency department use in chronic daily headache patients

OBJECTIVE: To examine the characteristics of chronic daily headache sufferers who use emergency departments (EDs) and identify factors predictive of ED visits. BACKGROUND: Several large clinical trials have found that a sizable subset of headache patients uses EDs frequently, although such visits should be preventable. METHODS: Participants in two large clinical trials provided baseline data on ED use, hospitalizations, disability, daily activities, and quality of life. RESULTS: Of the 785 patients included, 182 (23.2%) reported at least 1 ED visit over the past year. Most of these patients (82.9%) reported one to six visits; however, 4.4% reported>/=21 visits (mean 5.0; SD 8.5). The percentage of patients with overnight hospitalizations during the previous year was significantly greater in the ED user group than non-ED user group (17.6% vs 1.7%; P<.001), as was the number of visits to healthcare practitioners (median 24.3 vs 11.8; P<.001). Compared with non-ED users, a higher percentage of ED users reported severe disability on the Migraine Disability Assessment Scale (MIDAS) (85.7% vs 69.3%, P<.001) and indicated that their headache more negatively impacted mood and daily activities (all P<.05). ED users also had significantly higher depression scores and lower scores on all domains of the Short Form--36 (SF--36) (all P<.05). In a logistic regression model, patient age, neurologist visit, severe (vs not severe) rating on the MIDAS, Role Physical (SF--36), and prior overnight hospitalization were significant predictors of ED use (max--rescaled R(2)=21.0%). CONCLUSIONS: Patients seeking ED treatment for chronic daily headache are more severely affected and have more unmet medical needs than those who do not use the ED. Management strategies that help prevent frequent ED use might be possible.