Investigation of suspected aneurysmal subarachnoid haemorrhage: a single-centre quality improvement project
Notice bibliographique
Résumé
Introduction Aneurysmal subarachnoid haemorrhage (aSAH) has a global incidence of 6/100,000 person-years, affects people of working age and is associated with a high case fatality rate. 1,2 Between 10% and 43% of cases present with a sentinel headache, which necessitates investigation including a non-contrast computed tomography (CT) head and lumbar puncture (LP). 3 The Ottawa SAH rule is sensitive but only 15% specific, resulting in many people being investigated. 4 This project assessed the investigation of suspected aSAH at the Royal Liverpool University Hospital to guide service improvements, with reference to National Institute of Health and Care Excellence (NICE) guidelines. 5 Materials and Methods Cases were identified by searching the Telepath laboratory management system for all cerebrospinal fluid (CSF) samples that underwent xanthochromia analysis in 2024. Acute medicine clinicians screened the electronic patient records, only included cases where suspected aSAH was the primary reason for undertaking the LP, and extracted clinical, laboratory and radiological data. Statistical analyses were conducted using R v 4.4.2. Results and Discussion There were 187 CSF samples evaluated for xanthochromia, of which 107 (57.2%) were cases where aSAH was the primary reason for investigation and were included in this analysis. Ottawa SAH Rules were fulfilled as follows: thunderclap headache, 63.6%; age ≥40, 59.8%; neck pain or stiffness, 33.6%; onset during exertion, 17.8%; limited neck flexion, 13.1%; and loss of consciousness, 12.1%. There were 6 (5.6%) cases that underwent LP where all Ottawa criteria were either negative or not documented. The median time interval from admission to LP was 23.0 h (IQR 12.7–36.9 h; Fig 1). There were 15 (14%) cases who were triaged within 5 h of headache onset, for whom NICE guidelines advise that aSAH can be excluded based on a non-contrast computed tomography (CT) head performed within 6 h of headache onset, without the need for LP. Nine (60%) of these cases had a non-contrast CT within 6 h of headache onset, yet all proceeded to LP, which were all negative for xanthochromia. Patients admitted or streamed to the same-day emergency care (SDEC) unit had a significantly lower time to LP, compared with cases admitted to the emergency department and transferred to a ward (median 20.2 h vs 44.5 h; Mann-Whitney U, p<0.001). Clotting studies were undertaken for 101 (94.4%) cases, which were unnecessary in 90 (89.1%) cases. The xanthochromia result was positive in 3 (2.8%) cases, negative in 99 (92.5%), inconclusive in 3 (2.8%), and invalid in 2 (1.9%). Among the three cases with a positive xanthochromia, one had an aneurysm identified, which was coiled. Serious LP-related complications were post-LP headaches, which resulted in a prolonged hospital stay (n=2) or re-admission (n=3). Conclusion Multiple adaptations to provide timely diagnosis, and reduce cost and reduce length of hospital stay were identified, including: better adherence to Ottawa SAH rules; when possible, undertaking an urgent CT head within 6 h of headache onset; appropriate use of clotting studies; and streaming appropriate cases to SDEC. Our aSAH pathway is being updated to reflect these recommendations and NICE guidelines. 5
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Comment cette classification a été obtenuedéplier
Prédiction distillée sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Apprise à partir de 10 348 étiquettes directes de Codex et de 10 348 étiquettes directes de Gemma. Le mode candidate est l'union des têtes enseignantes seuillées; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont ni des étiquettes humaines ni des étiquettes directes de modèles de pointe.
Scores Codex et Gemma par catégorie
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,001 | 0,002 |
| Méta-épidémiologie (sens strict) | 0,000 | 0,000 |
| Méta-épidémiologie (sens large) | 0,001 | 0,000 |
| Bibliométrie | 0,000 | 0,001 |
| Études des sciences et des technologies | 0,000 | 0,001 |
| Communication savante | 0,000 | 0,000 |
| Science ouverte | 0,000 | 0,000 |
| Intégrité de la recherche | 0,000 | 0,000 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,000 | 0,000 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule tête enseignante, pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».