Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study

TLDR

The study aimed to assess the sensitivity of modern third‑generation computed tomography for detecting subarachnoid haemorrhage in emergency patients, particularly when performed within six hours of headache onset. A prospective cohort of 3,132 neurologically intact adults presenting with a new acute headache at 11 Canadian tertiary emergency departments was evaluated, with CT scans ordered to rule out SAH and SAH defined by CT, CSF xanthochromia, CSF red blood cells, or angiography. CT detected 240 of 3,132 SAH cases (overall sensitivity 92.9%, specificity 100%) and identified all 121 SAH cases scanned within six hours (sensitivity 100%, specificity 100%), confirming that modern third‑generation CT is highly sensitive when performed early and read by a qualified radiologist.

Abstract

Objective To measure the sensitivity of modern third generation computed tomography in emergency patients being evaluated for possible subarachnoid haemorrhage, especially when carried out within six hours of headache onset. Design Prospective cohort study. Setting 11 tertiary care emergency departments across Canada, 2000-9. Participants Neurologically intact adults with a new acute headache peaking in intensity within one hour of onset in whom a computed tomography was ordered by the treating physician to rule out subarachnoid haemorrhage. Main outcome measures Subarachnoid haemorrhage was defined by any of subarachnoid blood on computed tomography, xanthochromia in cerebrospinal fluid, or any red blood cells in final tube of cerebrospinal fluid collected with positive results on cerebral angiography. Results Of the 3132 patients enrolled (mean age 45.1, 2571 (82.1%) with worst headache ever), 240 had subarachnoid haemorrhage (7.7%). The sensitivity of computed tomography overall for subarachnoid haemorrhage was 92.9% (95% confidence interval 89.0% to 95.5%), the specificity was 100% (99.9% to 100%), the negative predictive value was 99.4% (99.1% to 99.6%), and the positive predictive value was 100% (98.3% to 100%). For the 953 patients scanned within six hours of headache onset, all 121 patients with subarachnoid haemorrhage were identified by computed tomography, yielding a sensitivity of 100% (97.0% to 100.0%), specificity of 100% (99.5% to 100%), negative predictive value of 100% (99.5% to 100%), and positive predictive value of 100% (96.9% to 100%). Conclusion Modern third generation computed tomography is extremely sensitive in identifying subarachnoid haemorrhage when it is carried out within six hours of headache onset and interpreted by a qualified radiologist.