Clinical criteria to exclude acute vascular pathology on CT angiogram in patients with dizziness.

Autor: Tu LH; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America., Malhotra A; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America., Venkatesh AK; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America., Taylor RA; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America., Sheth KN; Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America., Yaesoubi R; Health Policy and Management, Yale School of Public Health, New Haven, CT, United States of America., Forman HP; Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America., Sureshanand S; Yale Center for Clinical Investigation, Yale School of Medicine, New Haven, CT, United States of America., Navaratnam D; Department of Neurology, Yale School of Medicine, New Haven, CT, United States of America.
Jazyk: angličtina
Zdroj: PloS one [PLoS One] 2023 Mar 09; Vol. 18 (3), pp. e0280752. Date of Electronic Publication: 2023 Mar 09 (Print Publication: 2023).
DOI: 10.1371/journal.pone.0280752
Abstrakt: Background: Patients presenting to the emergency department (ED) with dizziness may be imaged via CTA head and neck to detect acute vascular pathology including large vessel occlusion. We identify commonly documented clinical variables which could delineate dizzy patients with near zero risk of acute vascular abnormality on CTA.
Methods: We performed a cross-sectional analysis of adult ED encounters with chief complaint of dizziness and CTA head and neck imaging at three EDs between 1/1/2014-12/31/2017. A decision rule was derived to exclude acute vascular pathology tested on a separate validation cohort; sensitivity analysis was performed using dizzy "stroke code" presentations.
Results: Testing, validation, and sensitivity analysis cohorts were composed of 1072, 357, and 81 cases with 41, 6, and 12 instances of acute vascular pathology respectively. The decision rule had the following features: no past medical history of stroke, arterial dissection, or transient ischemic attack (including unexplained aphasia, incoordination, or ataxia); no history of coronary artery disease, diabetes, migraines, current/long-term smoker, and current/long-term anti-coagulation or anti-platelet medication use. In the derivation phase, the rule had a sensitivity of 100% (95% CI: 0.91-1.00), specificity of 59% (95% CI: 0.56-0.62), and negative predictive value of 100% (95% CI: 0.99-1.00). In the validation phase, the rule had a sensitivity of 100% (95% CI: 0.61-1.00), specificity of 53% (95% CI: 0.48-0.58), and negative predictive value of 100% (95% CI: 0.98-1.00). The rule performed similarly on dizzy stroke codes and was more sensitive/predictive than all NIHSS cut-offs. CTAs for dizziness might be avoidable in 52% (95% CI: 0.47-0.57) of cases.
Conclusions: A collection of clinical factors may be able to "exclude" acute vascular pathology in up to half of patients imaged by CTA for dizziness. These findings require further development and prospective validation, though could improve the evaluation of dizzy patients in the ED.
Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: LT reported receiving royalties for 2 textbooks, Search Pattern: A Systematic Approach to Diagnostic Imaging (2020) and A Brief Guide to the Neuroradiology Fellowship (2021), and was a student in the Yale University Investigative Medicine Program, which receives funding from the National Center for Advancing Translational Science, a component of the National Institutes of Health (NIH). KS reported receiving grants from Hyperfine during the conduct of the study and from the NIH, American Heart Association, and Biogen outside the submitted work. KS also reported receiving personal fees from Zoll (data and safety monitoring board chair), Alva Equity, and Cerovasc outside the submitted work. AV reported receiving grants from the US Centers for Medicare and Medicaid Services, Moore Foundation, American College of Radiology, and American College of Emergency Physicians outside the submitted work. RT reported receiving grants from the FDA, Moore Foundation, NIH, Society for Improving Diagnosis in Medicine (SIDM). No other disclosures were reported. The contents of this work are solely the responsibility of the authors and do not necessarily represent the official view of the NIH. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
(Copyright: © 2023 Tu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)
Databáze: MEDLINE
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