Sensitivity of New-generation Computed Tomography in Subarachnoid Hemorrhage

Objective: To determine the sensitivity of the initial new-generation CT (NGCT) scan interpretation for detection of acute nontraumatic subarachnoid hemorrhage (SAH) and to decide whether lumbar puncture (LP) should follow a "normal" NGCT scan.
Methods: A retrospective chart review was performed of patients admitted between March 1988 and July 1994 with proven SAH. Exclusion criteria were age <2 years, diagnosis other than acute SAH, history of head trauma within 24 hours before symptom onset, NGCT scan not done before diagnosis, and records not available. Patients were placed into two groups: symptom duration <24 hours (group 1) and >24 hours (group 2) prior to CT scan. The resolution of each NGCT scanner was recorded. An NGCT sceinner was defined as a third-generation scanner or more recent.
Results: Of 349 SAH patients, 181 met inclusion criteria. The sensitivity of NGCT scans for SAH was 93.1% for the group 1 patients ( n = 144) and 83.8% for the group 2 patients ( n = 37). The overall sensitivity was 91.2%. All the patients who had SAH not detected by NGCT scans were diagnosed by LP. There was no significant relationship between NGCT scanner resolution and sensitivity for SAH.
Conclusion: Initial interpretation of NGCT scans to detect SAH does not approach 100% sensitivity. A "normal" NGCT scan does not reliably exclude the need for LP in patients who have symptoms suggestive of SAH.     

Subarachnoid hemorrhage diagnosis by computed tomography and lumbar puncture: Are fifth generation CT scanners better at identifying subarachnoid hemorrhage?

This study sought to determine the sensitivity and specificity of modern computed tomography (CT) scans for the diagnosis of subarachnoid hemorrhage (SAH). No studies have been done recently with fifth generation CT scanners to look at the diagnosis of SAH. A retrospective chart review was done of Emergency Department (ED), laboratory, and hospital records at Pitt County Memorial Hospital in Greenville, North Carolina over 1 year from January 1, 2002 to December 31, 2002. Patients presented with headache and had a CT scan of the head with a fifth generation multi-detector CT scanner followed by a lumbar puncture (LP) to rule out SAH. There were 177 patients who presented to the ED with headache and went on to have a CT scan and an LP to rule out SAH. No patients who had a negative CT were found to have a subarachoid hemorrhage. It is concluded that fifth generation CT scanners are probably more sensitive than earlier scanners at detecting SAH.     

Sensitivity of newer-generation computed tomography scanners for subarachnoid hemorrhage: a Bayesian analysis

Background

Subarachnoid hemorrhage (SAH) is a life-threatening condition considered in patients presenting to the emergency department (ED) with acute and severe-onset headache. Currently, the practice pattern for suspected SAH is to perform a non-contrasted computed tomography (CT) scan of the head, followed by lumbar puncture (LP) if the CT is negative. Newer-generation 16-slice CT scanners have been shown in one study to be very sensitive for SAH.

Objective

We sought to validate these findings at our institution by retrospectively analyzing the sensitivity of our 16-slice or better CT scanner and performing a bayesian analysis with the results.

Methods

We utilized ED electronic medical records and the Department of Neurosurgery research database to search for patients admitted from the ED with a diagnosis of SAH from January 1, 2005 to December 31, 2008. We found a total of 134 patients admitted with SAH during this time frame.

Results

Average age was 53.8 years; 62% were female. Presenting complaint was headache in 57%, paresthesia or weakness in 7%, unresponsive in 10%, confusion or altered mental status in 5%, and “other” in 10%. Sensitivity of 16-slice or better CT scanner in our study was 131/134, or 97.8% (95% confidence interval 93.1–99.4%). No patient with a negative CT had a lesion requiring intervention.

Conclusion

Our study confirms the high sensitivity of 16-slice or better CT scanners for SAH. This calls into question the need for LP after negative head CT when 16-slice CT or better is used.     

Computed Tomography Scanning and Delirium in Elder Patients

Objective: 1 ) To examine the ordering of head CT scans in elder patients with delirium and cognitive impairment; and 2) to report CT scan findings associated with these conditions.
Methods : This was a 2-part study. Part 1 was a prospective, observational study of 560 adults >70 years of age evaluated at 3 separate EDs using a 200-hour stratified sampling process at each ED. During Part 1, the frequencies of specific findings (i.e., delirium, impaired consciousness, and impaired cognition) and CT scan rates for these groups were determined. Part 2 was a retrospective analysis of CT scan reports and medical records ( n = 279) for patients >70 years of age in the prospective sample ( n = 79) and from a sample ( n = 200) of CT scans obtained at a fourth ED. Part 2 examined clinical findings detected in the ED to determine those factors that were associated with acute findings on CT scan.
Results : Part 1: There were 333 (59.4%) patients prospectively classified as having impaired cognition, impaired consciousness, or delirium; 79 (23.7%) of these patients had a head CT scan. Of these 3 groups, delirious patients were more frequently scanned (p < 0.001). Part 2: Of 279 CT scans, 42 (15.0%) were positive for an acute condition (hemorrhage, hematoma, space-occupying lesion, infarct). Of 42 positive scans, 40 (95.1%) were found in the 102 (36.6%) patients with either impaired consciousness or a new focal neurologic finding detected in the ED.
Conclusions : Considerable variability in ED CT scan ordering exists for elder patients with neurologic findings. Impaired consciousness and/or new focal neurologic signs are associated with acute findings on CT scan in elder patients. Acute CT abnormalities are uncommon in elder ED patients with other neurologic findings. Additional prospective evaluation is warranted prior to guideline development for CT scans in this patient population.     

Identification of Ethanol-intoxicated Patients with Minor Head TVauma Requiring Computed Tomography Scans

Objective: To determine whether clinical parameters and neurologic scores can be used to guide the decision to obtain computed tomography (CT) head scans for ethanol-intoxicated patients with presumed-minor head injuries.
Methods: In a prospective cohort analysis, 107 consecutive adult patients who presented to a county emergency department (ED) with serum ethanol levels >80 mg/dL and minor head trauma were studied. Commonly used clinical variables were determined for each patient. Each patient also underwent an abbreviated neurologic scoring examination and a Glasgow coma scale (GCS) score evaluation at the time of presentation and one hour later, after which a cranial CT scan was done. For purposes of analysis, patients with and patients without intracerebral injuries visible on CT scans of the head were compared.
Results: Nine of 107 patients (8.4%; 95% confidence interval [CI] = 3.9–15.4%) had CT scans that were positive for intracerebral injury. Two patients (1.9%; 95% CI = 0.2–6.6%) needed craniotomy. Five patients had hemotympanum and two patients had bilateral periorbital ecchy-mosis, but CT scans were negative for intracerebral injury in these patients. There was no statistically significant difference between the patients with and without CT scan abnormalities, based on the clinical variables, the GCS scores, or the abbreviated neurologic scoring examinations at presentation or at one hour.
Conclusion: The prevalence of intracerebral injury in CT scans of ethanol-intoxicated patients with minor head injuries was 8.4%. Commonly used clinical parameters and neurologic scores at presentation and one hour later were unable to predict which patients would have intracerebral injuries as evidenced by CT scans. Our low (1.9%) neurosurgical intervention rate supports the need to develop a selective approach to CT scanning in this population.     

Prospective Assessment of Presenting Serum Markers for Cardiac Risk Stratification

Objective: To quantify the association of initial ED serum cardiac markers with the risk for life-threatening events (LEs) or need for lifesaving interventions (Lis) or administration of IV nitroglycerin.
Methods: A prospective, observational study was performed using a cohort of hemodynamically stable, hospitalized patients (age > 25 years) presenting with nontraumatic chest discomfort. Patients with ST-segment elevation on their initial ECGs were excluded. Presenting serum samples were assayed for serum myoglobin and creatine kinase-MB isomer (CK-MB) using the Opus and Stratus systems. Target cases were defined as patients having LEs (e.g., cardiogenic shock, ventricular fibrillation, cardiac arrest), requiring Lis (e.g., intubation, cardioversion, pacing, reperfusion therapy), or needing IV nitroglycerin within 48 hours. Manufacturer's thresholds defined abnormal marker levels. Abnormal ECGs were defined using the Brush criteria.
Results: Of the 178 eligible patients, 44 (25%) were target cases . Most (55%) target cases had blood drawn for assays within four hours of chest discomfort onset. The relative risk and sensitivity of the serum markers and the ECG for target cases follow:
Of the seven patients with an LE/LI, six had blood drawn four hours or less after symptom onset; two LE/LI patients had abnormal myoglobin levels' no LE/LI patient had an abnormal CK-MB level.
Conclusions: Isolated serum myoglobin and CK-MB levels obtained at patient ED presentation were not strongly associated with the 48-hour risk for LEs, Lis, or the use of IV nitroglycerin. Future studies of risk stratification should address the merits of serial serum marker measurements that extend up to 12 hours beyond patient symptom onset.     

Cranial Computed Tomography in the Emergency Evaluation of Adult Patients without a Recent History of Head Trauma: A Prospective Analysis

Objectives: To examine the pattern of nontrauma cranial CT use in an urban ED, to identify the rate of significant CT abnormalities in this setting, and to develop criteria for restricting the ordering of CT scans. Methods: A prospective, observational study of a case series of adults who underwent cranial CT scanning for nontraumatic cases was performed at the EDs of an urban teaching hospital and an affiliated community hospital with a combined annual census of 110,000. Clinically significant CT scans were defined as: 1) acute stroke, 2) CNS malignancy, 3) acute hydrocephalus, 4) intracranial bleeding, or 5) intracranial infection, χ² recursive partitioning was used to derive a decision rule to restrict ordering of CT scans. Results: Only 61 (8%) of 806 CT scans revealed clinically significant abnormalities. The presence of any of the following: age ≥60 years, focal neurologic deficit, headache with vomiting, or altered mental status, was 100% sensitive (95% CI: 94–100%) and 31% specific (95% CI: 28–33%) in detecting clinically significant CT scans. This set of features had positive and negative predictive values of 11% (95% CI: 8–13%) and 100% (95% CI: 98–100%), respectively. If these criteria had been used to restrict cranial CT use, 229 fewer patients (28%) would have had CT scans obtained and no clinically significant abnormalities would have been missed.
Conclusion: Clinically significant CT abnormalities were uncommon in this study population, suggesting that current criteria for ordering nontrauma cranial CT scans may be too liberal. In this study, a set of clinical criteria was derived that may be useful at separating patients into high- and low-risk categories for clinically significant cranial CT abnormalities. Before these results are applied clinically, these criteria should be validated in larger, prospective studies.     

Acute Headache of Recent Onset and Subarachnoid Hemorrhage: A Prospective Study

SYNOPSIS
Twenty-seven patients with acute severe headache of recent onset were prospectively recruited in the Emergency Room. Mean duration of headache was 61 hours. CT scan disclosed subarachnoid bleeding in 4 patients and spinal tap revealed subarachnoid hemorrhage (SAH) in 5 patients with normal CT scan. In most SAH cases pain was bilateral, very intense and involving the occipital region. Four of these patients had doubtful or no nuchal rigidity and in one, pain improved while in the Emergency Room.
In every case with an intense acute severe headache of recent onset CT scan and (if normal) a lumbar puncture are warranted to help rule out a SAH.     

Availability and Quality of Computed Tomography and Magnetic Resonance Imaging Equipment in U.S. Emergency Departments

Objectives:  The objective was to determine the availability and quality of computed tomography (CT) and magnetic resonance imaging (MRI) equipment in U.S. emergency departments (EDs). The authors hypothesized that smaller, rural EDs have less availability and lower-quality equipment.
Methods:  This was a random selection of 262 (5%) U.S. EDs from the 2005 National Emergency Department Inventories (NEDI)-USA ( http://www.emnet-usa.org/ ). The authors telephoned radiology technicians about the presence of CT and MRI equipment, availability for ED imaging, and number of slices for the available CT scanners. The analysis was stratified by site characteristics.
Results:  The authors collected data from 260 institutions (99% response). In this random sample of EDs, the median annual patient visit volume was 19,872 (interquartile range = 6,788 to 35,757), 28% (95% confidence interval [CI] = 22% to 33%) were rural, and 27% (95% CI = 21% to 32%) participated in the Critical Access Hospital program. CT scanners were present in 249 (96%) institutions, and of these, 235 (94%) had 24/7 access for ED patients. CT scanner resolution varied: 28% had 1–4 slice, 33% had 5–16 slice, and 39% had a more than 16 slice. On-site MRI was available for 171 (66%) institutions, and mobile MRI for 53 (20%). Smaller, rural, and critical access hospitals had lower CT and MRI availability and less access to higher-resolution CT scanners.
Conclusions:  Although access to CT imaging was high (>90%), CT resolution and access to MRI were variable. Based on observed differences, the availability and quality of imaging equipment may vary by ED size and location.     

Can Computed Tomography Angiography of the Brain Replace Lumbar Puncture in the Evaluation of Acute‐onset Headache After a Negative Noncontrast Cranial Computed Tomography Scan?

Objectives: The primary goal of evaluation for acute‐onset headache is to exclude aneurysmal subarachnoid hemorrhage (SAH). Noncontrast cranial computed tomography (CT), followed by lumbar puncture (LP) if the CT is negative, is the current standard of care. Computed tomography angiography (CTA) of the brain has become more available and more sensitive for the detection of cerebral aneurysms. This study addresses the role of CT/CTA versus CT/LP in the diagnostic workup of acute‐onset headache. Methods: This article reviews the recent literature for the prevalence of SAH in emergency department (ED) headache patients, the sensitivity of CT for diagnosing acute SAH, and the sensitivity and specificity of CTA for cerebral aneurysms. An equivalence study comparing CT/LP and CT/CTA would require 3,000 + subjects. As an alternative, the authors constructed a mathematical probability model to determine the posttest probability of excluding aneurysmal or arterial venous malformation (AVM) SAH with a CT/CTA strategy. Results: SAH prevalence in ED headache patients was conservatively estimated at 15%. Representative studies reported CT sensitivity for SAH to be 91% (95% confidence interval [CI] = 82% to 97%) and sensitivity of CTA for aneurysm to be 97.9% (95% CI = 88.9% to 99.9%). Based on these data, the posttest probability of excluding aneurysmal SAH after a negative CT/CTA was 99.43% (95% CI = 98.86% to 99.81%). Conclusions: CT followed by CTA can exclude SAH with a greater than 99% posttest probability. In ED patients complaining of acute‐onset headache without significant SAH risk factors, CT/CTA may offer a less invasive and more specific diagnostic paradigm. If one chooses to offer LP after CT/CTA, informed consent for LP should put the pretest risk of a missed aneurysmal SAH at less than 1%. ACADEMIC EMERGENCY MEDICINE 2010; 17:444–451 © 2010 by the Society for Academic Emergency Medicine     

Rapid Response to Stroke Symptoms: The Delay in Accessing Stroke Healthcare (DASH) Study

Objective: To assess the determinants of prehospital delay for patients with presumed acute cerebral ischemia (ACI) in order to provide the background necessary to develop interventions to shorten such delays.
Methods: A prospective registry of patients presenting to the ED with signs and symptoms of stroke was established at a university hospital from July 1995 to March 1996. Trained nurses performed a structured ED interview, which assessed prehospital delay and potential confounders.
Results: The median delay (interquartile range) from symptom onset to ED arrival for all patients seeking care for stroke-like symptoms ( n = 152) was 3.0 hours (1.5–7.8 hr). The median delay from symptom onset to ED arrival was less in cases where a witness first recognized that there was a serious problem than it was when the patient first identified the problem. A heightened sense of urgency by the patient about his or her symptoms, and use of 911/emergency medical services (EMS) transport were also associated with rapid arrival in the ED within 3 hours of symptom onset. After adjusting for all predictor variables in a multivariable logistic regression model, only recognition of symptoms by a witness and calling 911/EMS transport remained statistically significant.
Conclusions: These data suggest that future efforts to intervene on prolonged prehospital delay for patients with ACI should include strategies for the community as a whole as well as persons at risk for stroke and should reinforce the use of 911 and EMS transport.     

Prevalence of Herniation and Intracranial Shift on Cranial Tomography in Patients With Subarachnoid Hemorrhage and a Normal Neurologic Examination

Objectives: Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift. Methods: This was a retrospective study that included all patients with a normal neurologic examination and nontraumatic SAH diagnosed by CT presenting to a tertiary care medical center from August 1, 2001, to December 31, 2004. Two neuroradiologists, blinded to clinical information and outcomes, rereviewed the initial ED head CT for evidence of herniation or midline shift. Results: Of the 172 patients who presented to the ED with spontaneous SAH diagnoses by cranial CT, 78 had normal neurologic examinations. Of these, 73 had initial ED CTs available for review. Four of the 73 (5%; 95% confidence interval [CI] = 2% to 13%) had evidence of brain herniation or midline shift, including three (4%; 95% CI = 1% to 12%) with herniation. In only one of these patients was herniation or shift noted on the initial radiology report. Conclusions: Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH. ACADEMIC EMERGENCY MEDICINE 2010; 17:423–428 © 2010 by the Society for Academic Emergency Medicine     

Evaluation of a New Assay for Cardiac Troponin I vs Creatine Kinase-MB for the Diagnosis of Acute Myocardial Infarction

Objective : To compare a new assay for cardiac troponin I (cTn-I) with an assay for creatine kinase-MB (CK-MB) for the diagnosis of acute myocardial infarction (AMI).
Methods : A prospective cross-sectional study of patients presenting with symptoms consistent with cardiac ischemia was performed at a university teaching hospital. Serum sampling for cTn-I and CK-MB was performed at 0, 1, 3, 8, and 16 hours after presentation. Normal values were defined as CK-MB ≤ 7 ng/mL and a relative index ≤ 2%, cTn-I ≤ 1.4 ng/mL. Final diagnosis was made using World Health Organization criteria, including standard enzyme sampling. Consecutive patients with AMI were compared with a randomly selected subset of patients without AMI to determine the sensitivity and specificity of the cTn-I and CK-MB assays for AMI, stratified by time from symptom onset. The ability of the biochemical cardiac markers obtained within 6 hours of symptom onset to predict later complications or need for interventions was assessed using odds ratios (ORs).
Results : Thirty-five patients who had AMI were compared with 136 patients who did not have AMI. The sensitivities and specificities of the cTn-I and CK-MB assays, stratified by time from symptom onset, were: Patients who had elevations in either CK-MB or cTn-I within 6 hours of symptom onset were at increased risk for cardiovascular complications and/or interventions (CK-MB, OR 5.8; cTn-I, OR 6.3).
Conclusion : cTn-I was as sensitive and specific for AMI as was CK-MB in ED patients who presented within 24 hours of symptom onset. However, cTn-I was more sensitive in patients who presented ≥ 24 hours after symptom onset. Elevations of either marker within 6 hours of symptom onset predict an increased risk of complications and/or need for interventions.     

The Ottawa subarachnoid hemorrhage clinical decision rule for classifying emergency department headache patients

BackgroundSubarachnoid hemorrhage (SAH) is a serious cause of headaches. The Ottawa subarachnoid hemorrhage (OSAH) rule helps identify SAH in patients with acute nontraumatic headache with high sensitivity, but provides limited information for identifying other intracranial pathology (ICP).ObjectivesTo assess the performance of the OSAH rule in emergency department (ED) headache patients and evaluate its impact on the diagnosis of intracranial hemorrhage (ICH) and other ICP.MethodWe conducted a retrospective cohort study from January 2016 to March 2017. Patients with acute headache with onset within 14 days of the ED visit, were included. We excluded patients with head trauma that occurred in the previous 7 days, new onset of abnormal neurologic findings, or consciousness disturbance. According to the OSAH rule, patients with any included predictors required further investigation.ResultsOf 913 patients were included, 15 of them were diagnosed with SAH. The OSAH rule had 100% (95% CI, 78.2%–100%) sensitivity and 37.0% (95% CI, 33.8–40.2%) specificity for identifying SAH. Twenty-two cases were identified as SAH or ICH with 100% sensitivity (95% CI, 84.6%–100%) and 37.3% (95% CI, 34.1%–40.5%) specificity. As for non-hemorrhagic ICP, both the sensitivity and negative predictive values (NPV) decreased to 75.0% (95% CI, 53.3%–90.2%) and 98.2% (95% CI, 96.1%–99.3%), respectively.ConclusionsThe OSAH rule had 100% sensitivity and NPV for diagnosing SAH and ICH with acute headache. The sensitivity and specificity were lower for non-hemorrhagic ICP. The OSAH rule may be an effective tool to exclude acute ICH and SAH in our setting.     

动脉瘤性蛛网膜下腔出血后头痛病因学分析

目的分析动脉瘤性蛛网膜下腔出血(SAH)后头痛的病因。方法对107例发病后24h内CT诊断为SAH,并经全脑动脉造影(DSA)明确存在颅内动脉瘤的患者,分别在出血后1、2、3、5、7、10、14d行头痛数字评分(NRS),对中、重度头痛患者行头颅CT和经颅三维多普勒(TCD)检查,分析头痛发生原因,观察不同类型头痛的临床特点。结果86.9%(93/107)的动脉瘤性SAH患者病程中存在中、重度头痛,其中9.7%(9/93)源自动脉瘤再出血,其临床特点是突然出现剧烈头痛或原有头痛骤然加重,常伴有意识障碍或其他神经系统阳性体征;16.1%(15/93)的头痛患者CT显示继发性脑积水,且头痛多持续性加重,但有时可突然自行缓解;TCD检查显示12.9%(12/93)的头痛患者存在颅内血管痉挛,并可因病情持续加重出现局灶性神经功能缺损及意识障碍,61.3%(57/93)的患者无阳性发现,但临床表现类似。结论大多数动脉瘤性SAH患者存在中、重度头痛。     

Computerized tomography of the brain for elderly patients presenting to the emergency department with acute confusion

Objective: Confusion is a common reason for presentation of elderly patients to the ED. There are many potential causes of confusion, which include acute neurological events. Computerized tomography (CT) scans are often routinely ordered to investigate confusion, despite the recommendation of guidelines against routine use. The aim of the present study was to determine the usefulness of CT brain scans in a prospective cohort of confused elderly patients presenting to an ED. Methods: The progress notes of 106 consecutive patients over 70 years of age who had a CT brain scan for a presentation of acute confusion were reviewed for indications for the scan and the presence of neurological examination findings. Official radiology reports of CT brain scans were assessed for the presence of abnormalities. Results: Of the 106 patients, 12 (11%, 95% CI 5.29–17.35) had no documented neurological examination. Fifteen patients (14%, 95% CI 7.51–20.79) had acute abnormalities on CT scan, one of whom had two abnormalities. There were ten acute ischaemic strokes, four cerebral haemorrhages and two meningiomas. Thirteen of the patients with positive CT findings (93%, 95% CI 80.7–105.96) had new findings on neurological examination. The only patient with no neurological findings with a positive CT scan had had a fall. A history of a fall or the presence of neurological findings on examination was predictive of a positive CT scan (odds ratio 17.07, 95% CI 2.15–135.35). Conclusion: The results add further support to guidelines that suggest that CT scans of the brain for confused elderly patients should only be performed for those with acute neurological findings, head trauma or a fall.     

Elder Patients with Closed Head Trauma: A Comparison with Nonelder Patients

Abstract. Objective: Little is known about the circumstances surrounding closed head trauma (CHT) in elders, and how they differ from nonelders. The study objective was to compare the 2 populations for outcome (positive cranial CT scan depicting traumatic injury, or the need for neurosurgery), mechanism of injury, and the value of the neurologic examination to predict a CT scan positive for traumatic injury or the need for neurosurgical intervention. Methods: A retrospective study was conducted by collecting a case series of patients with blunt head trauma who underwent CT scanning, and comparing elder (aged s60 years) with nonelder patients. The setting was the ED of a university-affiliated Level-1 trauma center. Results: Twenty percent of the elders and 13% of the nonelders had CT scans positive for traumatic injury, which conferred a risk ratio of 1.58 (95% CI 1.21–2.05). Older women were more at risk for the need for neurosurgery than were younger ones (3.1 vs 0.3%, RR 10.66, 95% CI 1.26–90.46). Among the elders, falls were the dominant mechanism of closed head trauma, followed by motor vehicle collisions (MVCs), then being struck as a pedestrian. In the nonelders, MVCs, falls, and assaults were the most important mechanisms of injury. A focally abnormal neurologic examination imparted an increased risk for both a CT scan positive for traumatic injury (elder 4.39, 95% CI 2.91–6.62; nonelder 7.75, 95% CI 5.53–10.72) and the need for neurosurgery (elder 35.68, 95% CI 4.58–275.89; nonelder 142.58, 95% CI 19.11–1064.22) in both age groups. Conclusions : Significant differences exist between elder and nonelder victims of CHT with respect to mechanisms of trauma and outcomes (CT scan positive for traumatic injury, or the need for neurosurgery).     

Serial Myoglobin Levels for Patients with Possible Myocardial Infarction

Objectives: To determine the sensitivity and specificity of a new myoglobin assay for acute myocardial infarction (AMI), considering both the total amount of serum myoglobin and its percentage change over 2 hours.
Methods: A prospective, observational test performance study for the recognition of AMI was done using serial myoglobin assays of 42 admitted chest pain patients at a large, urban teaching hospital ED. Myoglobin testing was performed at presentation (time 0) and at 1 and 2 hours after arrival. A myoglobin level >100 g/L (ng/mL) or a change >50% from baseline (increase or decrease) any time during the 2–hour period was considered positive. Patients and their physicians were blinded to the myoglobin results. The managing clinician's final diagnosis of the presenting event was used as the diagnostic criterion standard.
Results: The sensitivity of the myoglobin technique for detection of AMI in the first hours in the ED was 13/14 (93%; 95% CI: 66–100%). The 1 patient who had a false-negative test had evidence of AMI on the ECG and an initially abnormal creatine kinase-MB (CK-MB) assay. The specificity was 22/28 (79%; 59–92%). However, of the 6 patients who had "false-positive" myoglobin tests, all had serious illness: significant cardiac disease (n = 4), in-hospital death (n = 1), or deep venous thrombosis (n = 1).
Conclusion: Myoglobin level determinations are sensitive tests to detect AMI during the first 2 hours of a patient's stay in the ED and may complement current clinical tools.     

急性大面积脑梗死早期CT征象

目的分析CT平扫对发病24h内急性大面积脑梗死的阳性率及其影响因素,主要评价早期CT征象的意义。方法收集统计24h内急性大面积脑梗死患者38例,均有复查片证实。结果38例急性大面积脑梗死患者24h内CT阴性6例（15．8％）,阳性所见有脑实质低密度征、大脑中动脉高密度征、局部脑肿胀,总阳性率为84．2％。结论在熟悉急性脑梗死临床神经解剖和CT定位的基础上,熟悉各早期CT征象,24h内常规CT对急性大面积脑梗死有较高的准确性,可为临床早期治疗及判断预后提供有用的信息。