Predictors of intracranial pathologic findings in patients who seek emergency care because of headache
M. Ramirez-Lassepas, C. E. Espinosa, J. J. Cicero, K. L. Johnston, R. J. Cipolle and D. L. Barber
Department of Neurology, St Paul-Ramsey Medical Center, St Paul, Minn.
BACKGROUND: Clinical criteria to select patients with headache in whom
structural diagnostic studies (computed tomography) have a high yield
disclosing intracranial pathologic findings, independent of abnormal
findings on neurologic examination, have not been defined. OBJECTIVE: To
determine which clinical characteristics predict the presence of
intracranial pathologic findings, independently of neurologic examination,
in patients with headache. DESIGN: Case-control, consecutive sample.
SETTING: Major metropolitan trauma center emergency department. PATIENTS
AND MATERIALS: Hospital records of 139 hospitalized and 329 randomly
selected patients from 1720 nonhospitalized adult patients, consecutively
evaluated for headache in the emergency department, were reviewed.
Demographic data, clinical characteristics of the headache, results of
neurologic and physical examinations, and diagnostic radiologic and
laboratory results were correlated with final diagnosis and outcome at 6
months after emergency department visit. DATA ANALYSIS: Nonparametric
statistical analysis. RESULTS: Intracranial pathologic findings were found
in 18 (3.8%) of 468 patients. Acute onset and occipitonuchal location of
headache, presence of associated symptoms, and patient age of 55 years or
older were significantly associated with the finding of intracranial
pathology, independently of the findings from neurologic examination.
Abnormal findings on neurologic examination alone, whether focal or
nonfocal, had a highly significant association and a positive predictive
value for intracranial pathology of 39%. CONCLUSIONS: Abnormal results from
neurologic examination are the best clinical parameters to predict
structural intracranial pathology; however, in patients 55 years or older
with headache of acute onset located in the occipitonuchal region that has
associated symptoms, computed tomographic scan of the head is justified as
part of their clinical evaluation independently of the findings of the
neurologic examination.
