CT angiograms help providers 'cut to the chase' when triaging severe headaches in the ED

The way headaches are evaluated in the emergency room has seen a dramatic shift in recent years, with doctors tending to utilize CT angiograms in lieu of lumbar punctures more and more often. 

That’s according to a new analysis from Kaiser Permanente that examined diagnostic trends as they pertain to patients presenting to emergency departments with severe headaches, which often lead to CT scans to rule out a potential bleed in the brain. 

In the past, when initial CT scans didn’t uncover anything suspicious, patients were often referred for a lumbar puncture to check for blood in their spinal fluid. But those recommendations have started to change.

“Emergency physicians know that CT scans don’t always find the bleeding, especially if it’s been more than a day since the aneurysm burst and the pain developed,” lead author Dustin G. Mark, MD, an adjunct investigator with the Kaiser Permanente Division of Research and an emergency medicine physician with The Permanente Medical Group, said in a release. “We spent decades recommending patients have a lumbar puncture so we could look for blood in their spinal fluid. But we came to realize it might make more sense to just cut to the chase and look more closely at the brain for what may have caused the bleeding, and we can do that with a CT cerebral angiogram.” 

Lumbar punctures are invasive, and they require specialized staff, including an interventional radiologist, to complete. They also carry their own unique risks to patients, like triggering a severe and long-lasting headache. Perhaps that is part of the reason these exams have been utilized less and less in recent years. 

According to the study, CT cerebral angiography relative to lumbar puncture increased 6-fold between 2015 and 2021. During that same time, the use of lumbar punctures as a second test to rule out bleeding decreased by 11%. 

That trend also resulted in a 33% increase in the detection of unruptured intracranial aneurysms

Although this trend is perceived as safe in the short-term, the authors acknowledge that more research is needed to understand whether there might be long-term consequences associated with an uptick in CT angiograms, including how to manage the detection of unruptured intracranial aneurysms. 

The detailed study can be found in JAMA Network Open

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In addition to her background in journalism, Hannah also has patient-facing experience in clinical settings, having spent more than 12 years working as a registered rad tech. She joined Innovate Healthcare in 2021 and has since put her unique expertise to use in her editorial role with Health Imaging.

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