Neurosurgeon: Limiting scans for headache ‘laudable,’ but could lead to missed diagnosis

Recommendations for the use of neuroimaging for headaches issued by a number of national organizations, including the American Board of Internal Medicine Foundation’s Choosing Wisely initiative, could result in negative outcomes for patients with undiagnosed brain tumors, according to Ammar H. Hawasli, MD, PhD, of the Washington University School of Medicine in St. Louis.

“Neurological imaging is a very important part in the assessment of patients with headaches and neurological conditions,” Hawasli told Health Imaging. “Current guidelines are laudable, but may lead to missed-diagnoses in patients with brain tumors.”

As lead author of the article entitled, “Choosing Wisely: A Neurosurgical Perspective on Neuroimaging for Headaches,” published in the January issue of Neurosurgery, Hawasli and colleagues argue that proposed population-based regulation meant to reduce excess spending on medical imaging would limit patient-specific care options such as neuroimaging for headaches, which Hawasli describes as “crucial for timely diagnosis of brain tumors.”

To support this claim, Hawasli and his team performed a retrospective review focused on presenting symptoms and preoperative histories of patients diagnosed with brain neoplasms through the use of open brain biopsies at Washington University.

Of the 95 patients evaluated, 11 presented with headaches as their only symptom. Using similar Choosing Wisely guidelines proposed by the American Headache Society, the American Academy of Neurology, and jointly by the American College of Radiology and Consumer Reports, the authors determined that brain tumors would have been missed in three to seven of those patients studied, most likely resulting in negative outcomes.

“Our preliminary retrospective evaluation determines that the current models fail to diagnose 27 percent to 64 percent of patients with brain tumor with isolated headaches,” the authors concluded.

While Hawasli and his team’s findings reinforce the need for neuroimaging in select patients presenting with headache symptoms, he is quick to point out the role careful and deliberate clinical evaluation plays in determining which patients should and shouldn’t be considered candidates for headache-related neuroimaging. “Clinical history taking and physical examinations remain the cornerstone of the clinical neurosciences,” said Hawasli. “Neuroimaging cannot replace these critical parts of patient evaluation.”

Despite the divide that exists between well-intentioned, population-driven guidelines aimed at reducing wasteful spending within the medical profession and the need for patient-centered clinical decision-making, Hawasli believes neurosurgeons and industry regulators share a common goal—and that a mutually beneficial solution exists.

“The stakes are so high,” he said. “Hence, guidelines for the use of neuroimaging for headaches must be developed using evidence-based methods and must be validated before wide-spread implementation.”