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Utukuri PS, Shih RY, Ajam AA, Callahan KE, Chen D, Dunkle JW, Hunt CH, Ivanidze J, Ledbetter LN, Lee RK, Malu O, Pannell JS, Pollock JM, Potrebic SX, Setzen M, Shih RD, Soares BP, Staudt MD, Wang LL, Burns J. ACR Appropriateness Criteria® Headache: 2022 Update. J Am Coll Radiol 2023; 20:S70-S93. [PMID: 37236753 DOI: 10.1016/j.jacr.2023.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 02/27/2023] [Indexed: 05/28/2023]
Abstract
Headache is an ancient problem plaguing a large proportion of the population. At present, headache disorders rank third among the global causes of disability, accounting for over $78 billion per year in direct and indirect costs in the United States. Given the prevalence of headache and the wide range of possible etiologies, the goal of this document is to help clarify the most appropriate initial imaging guidelines for headache for eight clinical scenarios/variants, which range from acute onset, life-threatening etiologies to chronic benign scenarios. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Robert Y Shih
- Panel Chair, Uniformed Services University, Bethesda, Maryland
| | | | - Kathryn E Callahan
- Wake Forest School of Medicine, Winston Salem, North Carolina; American Geriatrics Society
| | - Doris Chen
- Stanford University, Stanford, California, Primary care physician
| | - Jeffrey W Dunkle
- Indiana University School of Medicine, Indianapolis, Indiana; Committee on Emergency Radiology-GSER
| | - Christopher H Hunt
- Mayo Clinic, Rochester, Minnesota; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | - Ryan K Lee
- Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Omojo Malu
- Fort Belvoir Community Hospital, Fort Belvoir, Virginia; American Academy of Family Physicians
| | | | | | - Sonja X Potrebic
- Southern California Permanente Medical Group, Pasadena, California; American Academy of Neurology
| | - Michael Setzen
- Weill Cornell Medical College, New York, New York; American Academy of Otolaryngology-Head and Neck Surgery
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida; American College of Emergency Physicians
| | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | - Michael D Staudt
- Oakland University William Beaumont School of Medicine, Rochester, Michigan; American Association of Neurological Surgeons/Congress of Neurological Surgeons
| | - Lily L Wang
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Judah Burns
- Specialty Chair, Montefiore Medical Center, Bronx, New York
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2
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Doig D, Thorne L, Rees J, Fersht N, Kosmin M, Brandner S, Jäger HR, Thust S. Clinical, Imaging and Neurogenetic Features of Patients with Gliomatosis Cerebri Referred to a Tertiary Neuro-Oncology Centre. J Pers Med 2023; 13:jpm13020222. [PMID: 36836456 PMCID: PMC9960048 DOI: 10.3390/jpm13020222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/19/2023] [Indexed: 01/31/2023] Open
Abstract
INTRODUCTION Gliomatosis cerebri describes a rare growth pattern of diffusely infiltrating glioma. The treatment options are limited and clinical outcomes remain poor. To characterise this population of patients, we examined referrals to a specialist brain tumour centre. METHODS We analysed demographic data, presenting symptoms, imaging, histology and genetics, and survival in individuals referred to a multidisciplinary team meeting over a 10-year period. RESULTS In total, 29 patients fulfilled the inclusion criteria with a median age of 64 years. The most common presenting symptoms were neuropsychiatric (31%), seizure (24%) or headache (21%). Of 20 patients with molecular data, 15 had IDH wild-type glioblastoma, with an IDH1 mutation most common in the remainder (5/20). The median length of survival from MDT referral to death was 48 weeks (IQR 23 to 70 weeks). Contrast enhancement patterns varied between and within tumours. In eight patients who had DSC perfusion studies, five (63%) had a measurable region of increased tumour perfusion with rCBV values ranging from 2.8 to 5.7. A minority of patients underwent MR spectroscopy with 2/3 (66.6%) false-negative results. CONCLUSIONS Gliomatosis imaging, histological and genetic findings are heterogeneous. Advanced imaging, including MR perfusion, could identify biopsy targets. Negative MR spectroscopy does not exclude the diagnosis of glioma.
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Affiliation(s)
- David Doig
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
- Correspondence: ; Tel.: +44-20-3456-7890
| | - Lewis Thorne
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Jeremy Rees
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Naomi Fersht
- Department of Neuro-Oncology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Michael Kosmin
- Department of Neuro-Oncology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Sebastian Brandner
- Department of Neurodegenerative Disease, UCL Institute of Neurology and Division of Neuropathology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UK
| | - Hans Rolf Jäger
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
- Neuroradiological Academic Unit, Department of Brain Rehabilitation and Repair, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
- Imaging Department, University College Hospital, London WC1N 3BG, UK
| | - Stefanie Thust
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
- Neuroradiological Academic Unit, Department of Brain Rehabilitation and Repair, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
- Imaging Department, University College Hospital, London WC1N 3BG, UK
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3
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McCullagh K, Castillo M, Zamora C. Headache Attributed to Non-vascular Intracranial Disorder: Neoplasms, Infections, and Substance Abuse. Neurol Clin 2022; 40:531-546. [PMID: 35871783 DOI: 10.1016/j.ncl.2022.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Evaluation of headaches warrants a careful history and neurologic assessment to determine the need for further workup and imaging. Identifying patients who are at risk for underlying pathology is important and this includes individuals with known or suspected malignancy and those who are immunocompromised and at increased risk for intracranial infection. While CT is helpful in the acute setting and to screen for intracranial hypertension, MRI is the modality of choice for the evaluation of underlying pathologies. Imaging in substance abuse may show injury related to direct toxicity or secondary to vascular complications.
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Affiliation(s)
- Kassie McCullagh
- Division of Neuroradiology, Department of Radiology, The University of North Carolina at Chapel Hill, CB 7510 2000 Old Clinic, 101 Manning Drive, Chapel Hill, NC 27599, USA.
| | - Mauricio Castillo
- Division of Neuroradiology, Department of Radiology, The University of North Carolina at Chapel Hill, CB 7510 2000 Old Clinic, 101 Manning Drive, Chapel Hill, NC 27599, USA
| | - Carlos Zamora
- Division of Neuroradiology, Department of Radiology, The University of North Carolina at Chapel Hill, CB 7510 2000 Old Clinic, 101 Manning Drive, Chapel Hill, NC 27599, USA
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4
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Zienius K, Ozawa M, Hamilton W, Hollingworth W, Weller D, Porteous L, Ben-Shlomo Y, Grant R, Brennan PM. Verbal fluency as a quick and simple tool to help in deciding when to refer patients with a possible brain tumour. BMC Neurol 2022; 22:127. [PMID: 35379182 PMCID: PMC8978365 DOI: 10.1186/s12883-022-02655-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 03/21/2022] [Indexed: 11/14/2022] Open
Abstract
Background Patients with brain tumours often present with non-specific symptoms. Correctly identifying who to prioritise for urgent brain imaging is challenging. Brain tumours are amongst the commonest cancers diagnosed as an emergency presentation. A verbal fluency task (VFT) is a rapid triage test affected by disorders of executive function, language and processing speed. We tested whether a VFT could support identification of patients with a brain tumour. Methods This proof-of-concept study examined whether a VFT can help differentiate patients with a brain tumour from those with similar symptoms (i.e. headache) without a brain tumour. Two patient populations were recruited, (a) patients with known brain tumour, and (b) patients with headache referred for Direct-Access Computed-Tomography (DACT) from primary care with a suspicion of a brain tumour. Semantic and phonemic verbal fluency data were collected prospectively. Results 180 brain tumour patients and 90 DACT patients were recruited. Semantic verbal fluency score was significantly worse for patients with a brain tumour than those without (P < 0.001), whether comparing patients with headache, or patients without headache. Phonemic fluency showed a similar but weaker difference. Raw and incidence-weighted positive and negative predictive values were calculated. Conclusion We have demonstrated the potential role of adding semantic VFT score performance into clinical decision making to support triage of patients for urgent brain imaging. A relatively small improvement in the true positive rate in patients referred for DACT has the potential to increase the timeliness and efficiency of diagnosis and improve patient outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02655-9.
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Affiliation(s)
- Karolis Zienius
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Mio Ozawa
- Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Willie Hamilton
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Will Hollingworth
- Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - David Weller
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Lorna Porteous
- GP Lead for Cancer and Palliative Care, NHS Lothian, Edinburgh, UK
| | - Yoav Ben-Shlomo
- Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Robin Grant
- Department of Clinical Neurosciences, NHS Lothian, Western General Hospital, Edinburgh, UK
| | - Paul M Brennan
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK. .,Department of Clinical Neurosciences, NHS Lothian, Western General Hospital, Edinburgh, UK. .,Centre for Clinical Brain Sciences, University of Edinburgh, Little France Crescent, Edinburgh, EH16, UK.
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5
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Cameron JM, Brennan PM, Antoniou G, Butler HJ, Christie L, Conn JJA, Curran T, Gray E, Hegarty MG, Jenkinson MD, Orringer D, Palmer DS, Sala A, Smith BR, Baker MJ. Clinical validation of a spectroscopic liquid biopsy for earlier detection of brain cancer. Neurooncol Adv 2022; 4:vdac024. [PMID: 35316978 PMCID: PMC8934542 DOI: 10.1093/noajnl/vdac024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Diagnostic delays impact the quality of life and survival of patients with brain tumors. Earlier and expeditious diagnoses in these patients are crucial to reducing the morbidities and mortalities associated with brain tumors. A simple, rapid blood test that can be administered easily in a primary care setting to efficiently identify symptomatic patients who are most likely to have a brain tumor would enable quicker referral to brain imaging for those who need it most.
Methods
Blood serum samples from 603 patients were prospectively collected and analyzed. Patients either had non-specific symptoms that could be indicative of a brain tumor on presentation to the Emergency Department, or a new brain tumor diagnosis and referral to the neurosurgical unit, NHS Lothian, Scotland. Patient blood serum samples were analyzed using the Dxcover®Brain Cancer liquid biopsy. This technology utilizes infrared spectroscopy combined with a diagnostic algorithm to predict the presence of intracranial disease.
Results
Our liquid biopsy approach reported an area under the receiver operating characteristic curve of 0.8. The sensitivity-tuned model achieves a 96% sensitivity with 45% specificity (NPV 99.3%) and identified 100% of glioblastoma multiforme patients. When tuned for a higher specificity, the model yields sensitivity of 47% with 90% specificity (PPV 28.4%).
Conclusions
This simple, non-invasive blood test facilitates the triage and radiographic diagnosis of brain tumor patients, while providing reassurance to healthy patients. Minimizing time to diagnosis would facilitate identification of brain tumor patients at an earlier stage, enabling more effective, less morbid surgical and adjuvant care.
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Affiliation(s)
- James M Cameron
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
| | - Paul M Brennan
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, EH4 2XU, UK
| | - Georgios Antoniou
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
| | - Holly J Butler
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
| | - Loren Christie
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
| | - Justin J A Conn
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
| | - Tom Curran
- Children’s Mercy Research Institute at the Children’s Mercy Hospital, Kansas City, KS, USA
| | - Ewan Gray
- Independent Health Economics Consultant, Edinburgh, UK
| | - Mark G Hegarty
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
| | - Michael D Jenkinson
- Institute of Translational Medicine, University of Liverpool & The Walton Centre NHS Foundation Trust, Lower Lane, Liverpool, L9 7LJ, UK
| | - Daniel Orringer
- Department of Neurosurgery, New York University Grossman School of Medicine, New York, NY 10018, USA
| | - David S Palmer
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
| | - Alexandra Sala
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
- Department of Pure and Applied Chemistry, Thomas Graham Building, 295 Cathedral Street, University of Strathclyde, Glasgow G11XL, UK
| | - Benjamin R Smith
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
| | - Matthew J Baker
- Dxcover Ltd , Suite RC534, Royal College Building, 204 George Street, Glasgow, G1 1XW, UK
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6
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Fremanezumab autoinjector pen for the prevention of migraine. Ther Deliv 2021; 12:645-650. [PMID: 34392708 DOI: 10.4155/tde-2021-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Ajovy (fremanezumab, Teva Pharmaceuticals, Israel) is a fully humanized monoclonal antibody that selectively binds both isoforms of the calcitonin gene-related peptide. Calcitonin gene-related peptide is a 37-amino acid neuropeptide involved in central and peripheral pathophysiological events in migraine. It is indicated for prophylaxis of migraine in adults who have at least four migraine days per month, and can be administered as a subcutaneous injection using an autoinjector device, with two dosing options: 225 mg once a month or 675 mg quarterly. In this article, I present data from Phase III clinical trials of fremanezumab in episodic and chronic migraine, in which fremanezumab demonstrated efficacy and had a favorable tolerability profile, with no serious treatment-related adverse events.
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7
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Abstract
Background Chronic migraine is an under-recognized and under-treated disorder. A greater understanding of the pathophysiology of migraine and transformation to chronic migraine has led to the first targeted treatments for chronic migraine. In this review, we review current approaches to the diagnosis and management of chronic migraine and discuss recent and emerging novel therapies. Objective The aim of this study was to provide an update on the diagnosis and management of chronic migraine. Methods and Material The PubMed database was searched for relevant articles published on or before October 2020. Results and Conclusions Chronic migraine is an under-recognized and under-treated disorder. Prompt diagnosis and appropriate management can lead to a significant improvement in the quality of life with subsequent socioeconomic benefits.
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Affiliation(s)
- Catriona L Gribbin
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Krishna A Dani
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Alok Tyagi
- Department of Neurology, Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, United Kingdom
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8
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Brennan PM, Butler HJ, Christie L, Hegarty MG, Jenkinson MD, Keerie C, Norrie J, O'Brien R, Palmer DS, Smith BR, Baker MJ. Early diagnosis of brain tumours using a novel spectroscopic liquid biopsy. Brain Commun 2021; 3:fcab056. [PMID: 33997782 PMCID: PMC8111062 DOI: 10.1093/braincomms/fcab056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 02/15/2021] [Accepted: 02/17/2021] [Indexed: 12/05/2022] Open
Abstract
Early diagnosis of brain tumours is challenging and a major unmet need. Patients with brain tumours most often present with non-specific symptoms more commonly associated with less serious diagnoses, making it difficult to determine which patients to prioritize for brain imaging. Delays in diagnosis affect timely access to treatment, with potential impacts on quality of life and survival. A test to help identify which patients with non-specific symptoms are most likely to have a brain tumour at an earlier stage would dramatically impact on patients by prioritizing demand on diagnostic imaging facilities. This clinical feasibility study of brain tumour early diagnosis was aimed at determining the accuracy of our novel spectroscopic liquid biopsy test for the triage of patients with non-specific symptoms that might be indicative of a brain tumour, for brain imaging. Patients with a suspected brain tumour based on assessment of their symptoms in primary care can be referred for open access CT scanning. Blood samples were prospectively obtained from 385 of such patients, or patients with a new brain tumour diagnosis. Samples were analysed using our spectroscopic liquid biopsy test to predict presence of disease, blinded to the brain imaging findings. The results were compared to the patient’s index brain imaging delivered as per standard care. Our test predicted the presence of glioblastoma, the most common and aggressive brain tumour, with 91% sensitivity, and all brain tumours with 81% sensitivity, and 80% specificity. Negative predictive value was 95% and positive predictive value 45%. The reported levels of diagnostic accuracy presented here have the potential to improve current symptom-based referral guidelines, and streamline assessment and diagnosis of symptomatic patients with a suspected brain tumour.
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Affiliation(s)
- Paul M Brennan
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh EH4 2XU, UK
| | - Holly J Butler
- ClinSpec Diagnostics Limited, Royal College Building, Glasgow G1 1XW, UK
| | - Loren Christie
- ClinSpec Diagnostics Limited, Royal College Building, Glasgow G1 1XW, UK
| | - Mark G Hegarty
- ClinSpec Diagnostics Limited, Royal College Building, Glasgow G1 1XW, UK
| | - Michael D Jenkinson
- Institute of Translational Medicine, University of Liverpool & The Walton Centre NHS Foundation Trust, Liverpool L9 7LJ, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute-University of Edinburgh, Edinburgh EH16 4UX, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute-University of Edinburgh, Edinburgh EH16 4UX, UK
| | - Rachel O'Brien
- Emergency Medicine Research Group (EMERGE), Royal Infirmiry of Edinburgh, Edinburgh EH16 4SA, UK
| | - David S Palmer
- ClinSpec Diagnostics Limited, Royal College Building, Glasgow G1 1XW, UK.,Department of Pure and Applied Chemistry, Thomas Graham Building, University of Strathclyde, Glasgow G11XL, UK
| | - Benjamin R Smith
- ClinSpec Diagnostics Limited, Royal College Building, Glasgow G1 1XW, UK
| | - Matthew J Baker
- ClinSpec Diagnostics Limited, Royal College Building, Glasgow G1 1XW, UK
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Abstract
Headache is one of the leading symptoms often associated with brain tumours. Secondary headaches attributed to intracranial neoplasias have been included in subchapter 7.4 of the third edition of the International Classification of Headache Disorders (ICHD-3). According to ICHD-3, the headache may be attributed to a brain tumour if it has developed in close temporal relation with the development of the neoplasia, has significantly worsened in parallel with the worsening of the tumour, and/or has significantly improved following the successful treatment of the neoplasia. Brain tumour headache was traditionally thought to display some specific clinical characteristics, including worsening in the morning and/or when lying down, being aggravated by Valsalva-like manoeuvres and accompanied by nausea and/or vomiting; however, the studies performed after the advent of modern neurodiagnostic techniques have pointed out that the "classic" brain tumour headache is uncommon, particularly at the time of clinical presentation. Therefore, it becomes critical to seek some specific factors associated with the presence of an intracranial mass (the so-called "red flags") that can guide the physician to establish an accurate diagnosis.
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Affiliation(s)
- Antonio Palmieri
- Headache Centre, Neurological Division, Portogruaro Hospital, Portogruaro, Venice, Italy
| | - Luca Valentinis
- Headache Centre, Neurological Division, Portogruaro Hospital, Portogruaro, Venice, Italy
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10
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Keeney E, Mohiuddin S, Zienius K, Ben-Shlomo Y, Ozawa M, Grant R, Hamilton W, Weller D, Brennan PM, Hollingworth W. Economic evaluation of GPs' direct access to computed tomography for identification of brain tumours. Eur J Cancer Care (Engl) 2020; 30:e13345. [PMID: 33184924 DOI: 10.1111/ecc.13345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 07/18/2020] [Accepted: 08/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND When GPs suspect a brain tumour, a referral for specialist assessment and subsequent brain imaging is generally the first option. NICE has recommended that GPs have rapid direct access to brain imaging for adults with progressive sub-acute loss of central nervous function; however, no studies have evaluated the cost-effectiveness. METHODS We developed a cost-effectiveness model based on data from one region of the UK with direct access computed tomography (DACT), routine data from GP records and the literature, to explore whether unrestricted DACT for patients with suspected brain tumour might be more cost-effective than criteria-based DACT or no DACT. RESULTS Although criteria-based DACT allows some patients without brain tumour to avoid imaging, our model suggests this may increase costs of diagnosis due to non-specific risk criteria and high costs of diagnosing or 'ruling out' brain tumours by other pathways. For patients diagnosed with tumours, differences in outcomes between the three diagnostic strategies are small. CONCLUSIONS Unrestricted DACT may reduce diagnostic costs; however, the evidence is not strong and further controlled studies are required. Criteria-based access to CT for GPs might reduce demand for DACT, but imperfect sensitivity and specificity of current risk stratification mean that it will not necessarily be cost-effective.
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Affiliation(s)
- Edna Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Syed Mohiuddin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Karolis Zienius
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Mio Ozawa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Robin Grant
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - William Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, College House, St Luke's Campus, University of Exeter, Exeter, UK
| | - David Weller
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul M Brennan
- Translational Neurosurgery Unit, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.,Brain Tumour Research Group, Institute of Clinical Neuroscience, Learning and Research Building, Southmead Hospital, University of Bristol, Bristol, UK
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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11
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Whitehead MT, Cardenas AM, Corey AS, Policeni B, Burns J, Chakraborty S, Crowley RW, Jabbour P, Ledbetter LN, Lee RK, Pannell JS, Pollock JM, Powers WJ, Setzen G, Shih RY, Subramaniam RM, Utukuri PS, Bykowski J. ACR Appropriateness Criteria® Headache. J Am Coll Radiol 2020; 16:S364-S377. [PMID: 31685104 DOI: 10.1016/j.jacr.2019.05.030] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 12/20/2022]
Abstract
Headache is one of the most common human afflictions. In most cases, headaches are benign and idiopathic, and resolve spontaneously or with minor therapeutic measures. Imaging is not required for many types of headaches. However, patients presenting with headaches in the setting of "red flags" such as head trauma, cancer, immunocompromised state, pregnancy, patients 50 years or older, related to activity or position, or with a corresponding neurological deficit, may benefit from CT, MRI, or noninvasive vascular imaging to identify a treatable cause. This publication addresses the initial imaging strategies for headaches associated with the following features: severe and sudden onset, optic disc edema, "red flags," migraine or tension-type, trigeminal autonomic origin, and chronic headaches with and without new or progressive features. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | | | - Amanda S Corey
- Panel Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
| | - Bruno Policeni
- Panel Vice-Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | | | - Santanu Chakraborty
- Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada, Canadian Association of Radiologists
| | - R Webster Crowley
- Rush University Medical Center, Chicago, Illinois, Neurosurgery expert
| | - Pascal Jabbour
- Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, Neurosurgery expert
| | | | - Ryan K Lee
- Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Jeffrey S Pannell
- University of California San Diego Medical Center, San Diego, California
| | | | - William J Powers
- University of North Carolina School of Medicine, Chapel Hill, North Carolina, American Academy of Neurology
| | - Gavin Setzen
- Albany ENT & Allergy Services, PC, Albany, New York, American Academy of Otolaryngology-Head and Neck Surgery
| | - Robert Y Shih
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | | | | | - Julie Bykowski
- Specialty Chair, University of California San Diego Health Center, San Diego, California
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12
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Grant R, Dowswell T, Tomlinson E, Brennan PM, Walter FM, Ben-Shlomo Y, Hunt DW, Bulbeck H, Kernohan A, Robinson T, Lawrie TA. Interventions to reduce the time to diagnosis of brain tumours. Cochrane Database Syst Rev 2020; 9:CD013564. [PMID: 32901926 PMCID: PMC8082957 DOI: 10.1002/14651858.cd013564.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Brain tumours are recognised as one of the most difficult cancers to diagnose because presenting symptoms, such as headache, cognitive symptoms, and seizures, may be more commonly attributable to other, more benign conditions. Interventions to reduce the time to diagnosis of brain tumours include national awareness initiatives, expedited pathways, and protocols to diagnose brain tumours, based on a person's presenting symptoms and signs; and interventions to reduce waiting times for brain imaging pathways. If such interventions reduce the time to diagnosis, it may make it less likely that people experience clinical deterioration, and different treatment options may be available. OBJECTIVES To systematically evaluate evidence on the effectiveness of interventions that may influence: symptomatic participants to present early (shortening the patient interval), thresholds for primary care referral (shortening the primary care interval), and time to imaging diagnosis (shortening the secondary care interval and diagnostic interval). To produce a brief economic commentary, summarising the economic evaluations relevant to these interventions. SEARCH METHODS For evidence on effectiveness, we searched CENTRAL, MEDLINE, and Embase from January 2000 to January 2020; Clinicaltrials.gov to May 2020, and conference proceedings from 2014 to 2018. For economic evidence, we searched the UK National Health Services Economic Evaluation Database from 2000 to December 2014. SELECTION CRITERIA We planned to include studies evaluating any active intervention that may influence the diagnostic pathway, e.g. clinical guidelines, direct access imaging, public health campaigns, educational initiatives, and other interventions that might lead to early identification of primary brain tumours. We planned to include randomised and non-randomised comparative studies. Included studies would include people of any age, with a presentation that might suggest a brain tumour. DATA COLLECTION AND ANALYSIS Two review authors independently assessed titles identified by the search strategy, and the full texts of potentially eligible studies. We resolved discrepancies through discussion or, if required, by consulting another review author. MAIN RESULTS We did not identify any studies for inclusion in this review. We excluded 115 studies. The main reason for exclusion of potentially eligible intervention studies was their study design, due to a lack of control groups. We found no economic evidence to inform a brief economic commentary on this topic. AUTHORS' CONCLUSIONS In this version of the review, we did not identify any studies that met the review inclusion criteria for either effectiveness or cost-effectiveness. Therefore, there is no evidence from good quality studies on the best strategies to reduce the time to diagnosis of brain tumours, despite the prioritisation of research on early diagnosis by the James Lind Alliance in 2015. This review highlights the need for research in this area.
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Affiliation(s)
- Robin Grant
- Edinburgh Centre for Neuro-Oncology (ECNO), Western General Hospital, Edinburgh, UK
| | - Therese Dowswell
- C/o Cochrane Pregnancy and Childbirth Group, Department of Women's and Children's Health, The University of Liverpool, Liverpool, UK
| | - Eve Tomlinson
- Cochrane Gynaecological, Neuro-oncology and Orphan Cancers, 1st Floor Education Centre, Royal United Hospital, Bath, UK
| | - Paul M Brennan
- Translational Neurosurgery Department, Western General Hospital, Edinburgh, UK
| | - Fiona M Walter
- Public Health & Primary Care, University of Cambridge, Cambridge, UK
| | - Yoav Ben-Shlomo
- Population Health Sciences, Bristol Medical School, Bristol, UK
| | - David William Hunt
- Foundation School/Dept of Clinical and Experimental Medicine, Royal Surrey County Hospital/University of Surrey, Guildford, UK
| | | | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tomos Robinson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Grant R, Lawrie TA, Brennan PM, Walter FM, Ben-Shlomo Y, Hunt DW, Tomlinson E, Bulbeck H, Kernohan A, Robinson T, Vale L. Interventions to reduce the time to diagnosis of brain tumours. Hippokratia 2020. [DOI: 10.1002/14651858.cd013564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Robin Grant
- Western General Hospital; Edinburgh Centre for Neuro-Oncology (ECNO); Crewe Road Edinburgh Scotland UK EH4 2XU
| | - Theresa A Lawrie
- The Evidence-Based Medicine Consultancy Ltd; 3rd Floor Northgate House Upper Borough Walls Bath UK BA1 1RG
| | - Paul M Brennan
- Western General Hospital; Translational Neurosurgery Department; Edinburgh UK EH4 2XR
| | - Fiona M Walter
- University of Cambridge; Public Health & Primary Care; Strangeways Research Laboratory, Worts Causeway Cambridge UK CB1 8RN
| | - Yoav Ben-Shlomo
- Canynge Hall; Department of Social Medicine; Whiteladies Road Bristol UK BS8 2PR
| | - David William Hunt
- Royal Surrey County Hospital/University of Surrey; Foundation School/Dept of Clinical and Experimental Medicine; 10 Barrack Road Guildford Surrey UK GU2 9SR
| | - Eve Tomlinson
- 1st Floor Education Centre, Royal United Hospital; Cochrane Gynaecological, Neuro-oncology and Orphan Cancers; Combe Park Bath UK BA1 3NG
| | - Helen Bulbeck
- brainstrust; Director of Services; 4 Yvery Court Castle Road Cowes Isle of Wight UK PO31 7QG
| | - Ashleigh Kernohan
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
| | - Tomos Robinson
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
| | - Luke Vale
- Newcastle University; Institute of Health & Society; Baddiley-Clark Building, Richardson Road Newcastle upon Tyne UK NE2 4AA
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Kim BS, Kim SK, Kim JM, Moon HS, Park KY, Park JW, Sohn JH, Song TJ, Chu MK, Cha MJ, Kim BK, Cho SJ. Factors Associated with Incidental Neuroimaging Abnormalities in New Primary Headache Patients. J Clin Neurol 2020; 16:222-229. [PMID: 32319238 PMCID: PMC7174120 DOI: 10.3988/jcn.2020.16.2.222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/24/2019] [Accepted: 10/24/2019] [Indexed: 12/12/2022] Open
Abstract
Background and Purpose Deciding whether or not to perform neuroimaging in primary headache is a dilemma for headache physicians. The aim of this study was to identify clinical predictors of incidental neuroimaging abnormalities in new patients with primary headache disorders. Methods This cross-sectional study was based on a prospective multicenter headache registry, and it classified 1,627 consecutive first-visit headache patients according to the third edition (beta version) of the International Classification of Headache Disorders (ICHD-3β). Primary headache patients who underwent neuroimaging were finally enrolled in the analysis. Serious intracranial pathology was defined as serious neuroimaging abnormalities with a high degree of medical urgency. Univariable and multivariable logistic regression analyses were conducted to identify factors associated with incidental neuroimaging abnormalities. Results Neuroimaging abnormalities were present in 170 (18.3%) of 927 eligible patients. In multivariable analysis, age ≥40 years [multivariable-adjusted odds ratio (aOR)=3.37, 95% CI=2.07–6.83], male sex (aOR=1.61, 95% CI=1.12–2.32), and age ≥50 years at headache onset (aOR=1.86, 95% CI=1.24–2.78) were associated with neuroimaging abnormalities. In univariable analyses, age ≥40 years was the only independent variable associated with serious neuroimaging abnormalities (OR=3.37, 95% CI=1.17–9.66), which were found in 34 patients (3.6%). These associations did not change after further adjustment for neuroimaging modality. Conclusions Incidental neuroimaging abnormalities were common and varied in a primary headache diagnosis. A small proportion of the patients incidentally had serious neuroimaging abnormalities, and they were predicted by age ≥40 years. These findings can be used to guide the performing of neuroimaging in primary headache disorders.
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Affiliation(s)
- Byung Su Kim
- Department of Neurology, Bundang Jesaeng General Hospital, Daejin Medical Center, Seongnam, Korea
| | - Soo Kyoung Kim
- Department of Neurology, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Jae Moon Kim
- Department of Neurology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Heui Soo Moon
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kwang Yeol Park
- Department Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeong Wook Park
- Department of Neurology, Uijeongbu St.Mary's Hospital, The Catholic University of Korea College of Medicine, Uijeongbu, Korea
| | - Jong Hee Sohn
- Department of Neurology, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Korea
| | - Tae Jin Song
- Department of Neurology, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Min Kyung Chu
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Myoung Jin Cha
- Department of Neurology, National Police Hospital, Seoul, Korea
| | - Byung Kun Kim
- Department of Neurology, Eulji Hospital, Eulji University, Seoul, Korea
| | - Soo Jin Cho
- Department of Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea.
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Zienius K, Chak-Lam I, Park J, Ozawa M, Hamilton W, Weller D, Summers D, Porteous L, Mohiuddin S, Keeney E, Hollingworth W, Ben-Shlomo Y, Grant R, Brennan PM. Direct access CT for suspicion of brain tumour: an analysis of referral pathways in a population-based patient group. BMC FAMILY PRACTICE 2019; 20:118. [PMID: 31431191 PMCID: PMC6702708 DOI: 10.1186/s12875-019-1003-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 07/31/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Brain tumour patients see their primary care doctor on average three or more times before diagnosis, so there may be an opportunity to identify 'at risk' patients earlier. Suspecting a brain tumour diagnosis is difficult because brain tumour-related symptoms are typically non-specific. METHODS We explored the predictive value of referral guidelines (Kernick and NICE 2005) for brain imaging where a tumour is suspected, in a population-based patient group referred for direct access CT of the head. A consensus panel reviewed whether non-tumour findings were clinically important or whether further investigation was necessary. RESULTS Over a 5-year period, 3257 head scans were performed; 318 scans were excluded according to pre-specified criteria. 53 patients (1.8%) were reported to have intracranial tumours, of which 42 were significant (diagnostic yield of 1.43%). There were no false negative CT scans for tumour. With symptom-based referral guidelines primary care doctors can identify patients with a 3% positive predictive value (PPV). 559 patients had non-tumour findings, 31% of which were deemed clinically significant. In 34% of these 559 patients, referral for further imaging and/or specialist assessment from primary care was still thought warranted. CONCLUSION Existing referral guidelines are insufficient to stratify patients adequately based on their symptoms, according to the likelihood that a tumour will be found on brain imaging. Identification of non-tumour findings may be significant for patients and earlier specialist input into interpretation of these images may be beneficial. Improving guidelines to better identify patients at risk of a brain tumour should be a priority, to improve speed of diagnosis, and reduce unnecessary imaging and costs. Future guidelines may incorporate groups of symptoms, clinical signs and tests to improve the predictive value.
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Affiliation(s)
- K. Zienius
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ip Chak-Lam
- University of Edinburgh Medical School, Edinburgh, UK
| | - J. Park
- University of Edinburgh Medical School, Edinburgh, UK
| | - M. Ozawa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - W. Hamilton
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - D. Weller
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - D. Summers
- Department of Neuroradiology, NHS Lothian, Western General Hospital, Edinburgh, UK
| | - L. Porteous
- North Berwick Group Practice, North Berwick, East Lothian UK
| | - S. Mohiuddin
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - E. Keeney
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - W. Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Y. Ben-Shlomo
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - R. Grant
- Department of Clinical Neurosciences, NHS Lothian, Western General Hospital, Edinburgh, UK
| | - P. M. Brennan
- Translational Neurosurgery, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Neurosciences, NHS Lothian, Western General Hospital, Edinburgh, UK
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16
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Missed opportunities for diagnosing brain tumours in primary care: a qualitative study of patient experiences. Br J Gen Pract 2019; 69:e224-e235. [PMID: 30858332 PMCID: PMC6428480 DOI: 10.3399/bjgp19x701861] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 11/26/2018] [Indexed: 12/11/2022] Open
Abstract
Background Brain tumours are uncommon, and have extremely poor outcomes. Patients and GPs may find it difficult to recognise early symptoms because they are often non-specific and more likely due to other conditions. Aim To explore patients’ experiences of symptom appraisal, help seeking, and routes to diagnosis. Design and setting Qualitative study set in the East and North West of England. Method In-depth interviews with adult patients recently diagnosed with a primary brain tumour and their family members were analysed thematically, using the Model of Pathways to Treatment as a conceptual framework. Results Interviews were carried out with 39 patients. Few participants (n = 7; 18%) presented as an emergency without having had a previous GP consultation; most had had one (n = 15; 38%), two (n = 9; 23%), or more (n = 8; 21%) GP consultations. Participants experienced multiple subtle ‘changes’ rather than ‘symptoms’, often noticed by others rather than the patient, which frequently led to loss of interest or less ability to engage with daily living activities. The most common changes were in cognition (speaking, writing, comprehension, memory, concentration, and multitasking), sleep, and other ‘head feelings’ such as dizziness. Not all patients experienced a seizure, and few seizures were experienced ‘out of the blue’. Quality of communication in GP consultations played a key role in patients’ subsequent symptom appraisal and the timing of their decision to re-consult. Conclusion Multiple subtle changes and frequent GP visits often precede brain tumour diagnosis, giving possible diagnostic opportunities for GPs. Refined community symptom awareness and GP guidance could enable more direct pathways to diagnosis, and potentially improve patient experiences and outcomes.
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"Worst Headache of Life" in a Migraineur: Marginal Value of Emergency Department CT Scanning. J Am Coll Radiol 2019; 16:683-690. [PMID: 30661996 DOI: 10.1016/j.jacr.2018.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 11/22/2022]
Abstract
PURPOSE The ACR Appropriateness Criteria recommend performing noncontrast head CT (NCCT) for patients with sudden severe headache ("worst headache of life" [WHOL] or "thunderclap headache" [TCH]). The aim of this study was to assess the value of NCCT scanning in patients with known migraine histories and WHOL or TCH. The hypothesis was that there would be little utility in performing emergency department (ED) NCCT scans in migraineurs without other red flags, even if they had WHOL or TCH. METHODS The ED NCCT scans of all patients reporting WHOL or TCH who had established diagnoses of migraine were retrospectively reviewed over a 5-year period. Patients without known intracranial pathology, cancer, or immunocompromising disease or recent head trauma were included as the main study group. For comparison, patients with any of those factors were included as the comparison group. Scans were graded as (1) normal, (2) minor unimportant findings, (3) findings requiring intervention or follow-up, or (4) critical. RESULTS Two hundred twenty-four patients with the chief symptom of WHOL or TCH and a history of migraine who underwent ED NCCT were studied. In the main study group, no patients had grade 4 imaging findings (0%), one had a false-positive grade 3 finding (0.8%), and there were no cases of subarachnoid hemorrhage (0%). In the comparison group, six patients had grade 4 imaging findings (6.5%) and three had grade 3 findings (3.3%). CONCLUSIONS NCCT in known migraineurs with WHOL or TCH who do not have intracranial pathology, cancer, immunocompromising disease, or recent head trauma yielded no critical findings. Therefore, the value of scanning these patients is questionable.
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Do TP, Remmers A, Schytz HW, Schankin C, Nelson SE, Obermann M, Hansen JM, Sinclair AJ, Gantenbein AR, Schoonman GG. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology 2019; 92:134-144. [PMID: 30587518 PMCID: PMC6340385 DOI: 10.1212/wnl.0000000000006697] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 08/27/2018] [Indexed: 01/03/2023] Open
Abstract
A minority of headache patients have a secondary headache disorder. The medical literature presents and promotes red flags to increase the likelihood of identifying a secondary etiology. In this review, we aim to discuss the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. We review the following red flags: (1) systemic symptoms including fever; (2) neoplasm history; (3) neurologic deficit (including decreased consciousness); (4) sudden or abrupt onset; (5) older age (onset after 65 years); (6) pattern change or recent onset of new headache; (7) positional headache; (8) precipitated by sneezing, coughing, or exercise; (9) papilledema; (10) progressive headache and atypical presentations; (11) pregnancy or puerperium; (12) painful eye with autonomic features; (13) posttraumatic onset of headache; (14) pathology of the immune system such as HIV; (15) painkiller overuse or new drug at onset of headache. Using the systematic SNNOOP10 list to screen new headache patients will presumably increase the likelihood of detecting a secondary cause. The lack of prospective epidemiologic studies on red flags and the low incidence of many secondary headaches leave many questions unanswered and call for large prospective studies. A validated screening tool could reduce unneeded neuroimaging and costs.
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Affiliation(s)
- Thien Phu Do
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland
| | - Angelique Remmers
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland
| | - Henrik Winther Schytz
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland
| | - Christoph Schankin
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland
| | - Sarah E Nelson
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland
| | - Mark Obermann
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland
| | - Jakob Møller Hansen
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland
| | - Alexandra J Sinclair
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland
| | - Andreas R Gantenbein
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland
| | - Guus G Schoonman
- From the Headache Diagnostic Laboratory (T.P.D., H.W.S.), Danish Headache Center and Department of Neurology (J.M.H.), Rigshospitalet-Glostrup, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark; Department of Neurology (A.R., G.G.S.), Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands; Department of Neurology (C.S.), Inselspital, Bern University Hospital, University of Bern, Switzerland; Department of Neurology and Anesthesiology/Critical Care Medicine (S.E.N.), Johns Hopkins University, Baltimore, MD; Center for Neurology (M.O.), Asklepios Hospitals Schildautal, Seesen; Department of Neurology (M.O.), University Hospital Essen, University of Duisburg-Essen, Germany; Neurometabolism (A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, UK; and Neurorehabilitation (A.R.G.), RehaClinic Bad Zurzach and University of Zürich, Switzerland.
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Wang R, Liu R, Dong Z, Su H, Ao R, Liu Y, Wang Y, Ma L, Yu S. Unnecessary Neuroimaging for Patients With Primary Headaches. Headache 2018; 59:63-68. [PMID: 30136725 DOI: 10.1111/head.13397] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2018] [Indexed: 01/05/2023]
Abstract
Background - Headache may be due to either a primary or secondary disorder, and neuroimaging assessments can play an important role when differentiating between these types of headache. Although many studies have reported no significant differences between primary headache patients and the general population in terms of abnormal neuroimaging findings, others have shown that neuroimaging may be employed to rule out secondary causes of headache that could impact morbidity and mortality. This issue remains under debate. Thus, the present study compared the neuroimaging findings of headache patients and healthy controls. Methods - This study recruited 1070 healthy controls and 1070 primary headache patients from the Chinese People's Liberation Army General Hospital. The primary headache patients were diagnosed by computerized clinical decision support systems, and re-diagnosed by a specialist. All participants were assessed with either computed tomography or magnetic resonance imaging (MRI) scans. The neuroimaging findings were classified as significant abnormalities, non-significant abnormalities, or normal. Results - All the significant abnormalities were found using MRI scans. Significant abnormalities were identified in 4 primary headache patients (0.58%) and 5 healthy controls (0.73%); the rate of significant abnormalities was not significant different between both groups (P > .05). Conclusions - The present study found that neuroimaging was unnecessary for the primary headache patients.
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Affiliation(s)
- Rongfei Wang
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Ruozhuo Liu
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhao Dong
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Hui Su
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Ran Ao
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yinglu Liu
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Yan Wang
- Department of Radiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Lin Ma
- Department of Radiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Shengyuan Yu
- Department of Neurology, Chinese People's Liberation Army General Hospital, Beijing, China
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Abstract
BACKGROUND/OBJECTIVE Headaches present commonly in general practice, and doctors face uncertainties and pressures in dealing with them. This study identifies key characteristics of headaches investigated through head imaging, in the hope of strengthening existing guidelines. METHOD A 7-year retrospective analysis of head imaging scans ordered for investigating headaches among patients aged ≥18 in an Australian general practice setting. RESULTS A total of 109 of the 517 (21.1%) patients required head imaging, although 14 (2.7%) of these had repeat scans. Three-quarters were females, and most of the headaches were recurrent (56.9%), severe (62.4%) or had associated red flags (78.0%). Computed tomography (CT) and magnetic resonance imaging (MRI) were the only scans adopted (4:1 and 1:1 for first and repeat scans, respectively). Twelve (11.0%) scans had findings likely to explain the headaches after the initial scans, with no difference in findings between diagnoses from CTs and MRIs (P = 0.41). Repeat scans offered no additional benefits, and roughly one in three patients were referred to third-party carers (mostly neurologists). Females had more recurrent headaches (OR = 2.63; CI = 1.09-6.35; P = 0.03). Patients with psycho-morbidities were less likely to have scan findings that explained their headaches (OR = 0.22; CI = 0.06-0.88; P = 0.03), and, though not quite significant, were also more likely to undergo imaging (OR = 1.47; CI 0.96-2.27; P = 0.08). CONCLUSION Significant intracranial findings were uncommon following imaging for headaches, and MRIs offer no advantages over CTs. Repeating head scans within 5 years offers no clear benefits. Psycho-morbidities should be considered when deciding the imaging needs, given the lesser chance of findings. Larger studies will help validate these findings.
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Affiliation(s)
- Chris O Ifediora
- School of Medicine, Griffith University, Gold Coast Campus, Southport, Australia
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Underwood R, Kilner R, Ridsdale L. Primary care management of headaches and how direct-access MRI fits: a qualitative study of UK general practitioners' views. BMJ Open 2017; 7:e018169. [PMID: 29127230 PMCID: PMC5695367 DOI: 10.1136/bmjopen-2017-018169] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/01/2017] [Accepted: 09/18/2017] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To develop a better understanding of general practitioners' (GPs) views and experiences of the management of patients with headaches and use of direct-access MRI scans, and observe outcomes of an educational session offered by a GP with a special interest (GPwSI) to GPs. DESIGN A qualitative study using semistructured interviews, analysed using thematic analysis. A GPwSI in headaches visited practices delivering a talk on headache medication, diagnosis and management. SETTING Sixteen (16) primary care family practices in South London, UK. PARTICIPANTS Twenty (20) GPs. RESULTS Not all GPs were aware of the availability of direct-access MRI, but all acknowledged having used referral or direct scans to manage patients' concern about their headaches. A normal scan result helped resolve uncertainty for patient and GP and helped management towards discussion of preventative treatment. However, patients with psychological and/or severe headache symptoms could not necessarily be reassured. GPs reported difficulty interpreting radiology reports, particularly incidental abnormalities. Those who received the educational talk gained knowledge in diagnosis and medication, improving their confidence in management. CONCLUSIONS Increased access to imaging, training in headache management, addressing physical and psychological symptoms and standardised reporting of scans may improve GPs' use of direct-access MRI in the future.
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Affiliation(s)
- Raphael Underwood
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | | | - Leone Ridsdale
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
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Rai GS, Rai T, Jain L, Vyas MM, Roshan R. Evaluation of CT and MRI Findings among Patients Presented with Chief Complaint of Headache in Central India. J Clin Diagn Res 2016; 10:TC21-5. [PMID: 27042557 PMCID: PMC4800623 DOI: 10.7860/jcdr/2016/16852.7249] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 12/22/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Headache is one of the most common presenting complaints in day to day medical practice however the secondary causes of headache are uncommon. Thus, appropriate selection of headache patient (Pt) is important to determine those that require neuroimaging due to likely secondary cause. Red flags and Clinical warning criterion (CWC) act as a screening tool to help in identifying those who may get benefit from neuroimaging. AIM To evaluate the findings of computed tomography (CT) and Magnetic Resonance Imaging (MRI) among patients presented with the chief complaint of headache and to compare the findings between two groups of patients. MATERIALS AND METHODS This retrospective observational study was carried out in 500 selected patients, who underwent CT or MRI scan of head in Peoples College of Medical Sciences and Research centre, Bhopal, MP during the period of 2 year in between Jan 2013 to Dec 2014. Siemens Somatom sensation 40 slice MDCT and Siemens magnetom 1.5T MRI scanner were used for imaging. Five hundred patients of 10 to 70 year age were selected for the study based on our criterions of selection. RESULTS All 500 patients were divided in to two groups A and B based on presence or absence of red flag signs and CWC signs. Group A consists of 48 patients having one or more red flag or CWC signs and group B consists of 452 patients those don't have any above signs. 29 cases (60.4%) out of total 48 cases of group A is suffering from chronic headache as compared to 97 cases (21.5%) out of total 452 patients of group B is having positive findings (p-value<0.05). Out of 500 patients, only 29 cases (5.8%) revealed some form of brain parenchymal pathology whereas other associated findings were seen in 97 cases e.g. sinusitis in 58 (11.6%), bone related pathology in 26 (5.2%) and chronic suppurative otitis media (CSOM) in 13 (2.6%) patients. CONCLUSION CT/MRI in patients without red flag or CWC sign yields very low percentage of clinically significant positive findings in neuroimaging. In the absence of these, the only reason for CT or MRI scan seems to reassure the patients and their loved ones. CT or MRI as a screening tool in these patients has limited value in term of cost effectiveness.
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Affiliation(s)
- Garjesh Singh Rai
- Associate Professor, Department of Radiodiagnosis, Peoples College of Medical Sciences and Research Center, Bhopal, MP, India
| | - Tina Rai
- Assistant Professor, Department of Pathology, Peoples College of Medical Sciences and Research Center, Bhopal, MP, India
| | - Leena Jain
- Assistant Professor, Department of Ear, Nose and Throat, Peoples College of Medical Sciences and Research Center, Bhopal, MP, India
| | - Mahendra Mohan Vyas
- Assistant Professor, Department of Radiodiagnosis, Peoples College of Medical Sciences and Research Center, Bhopal, MP, India
| | - Rakesh Roshan
- Post Graduate Student, Department of Radiodiagnosis, Peoples College of Medical Sciences And Research Center, Bhopal, MP, India
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Abstract
Migraine is the most common disabling brain disorder. Chronic migraine, a condition characterized by the experience of migrainous headache on at least 15 days per month, is highly disabling. Patients with chronic migraine present to primary care, are often referred for management to secondary care, and make up a large proportion of patients in specialist headache clinics. Many patients with chronic migraine also have medication overuse, defined as using a compound analgesic, opioid, triptan or ergot derivative on at least 10 days per month. All doctors will encounter patients with chronic headaches. A basic working knowledge of the common primary headaches, and a rational manner of approaching the patient with these conditions, allows a specific diagnosis of chronic migraine to be made quickly and safely, and by making this diagnosis one opens up a substantial number of acute and preventive treatment options. This article discusses the current state of management of chronic migraine.
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Affiliation(s)
- Mark W Weatherall
- Princess Margaret Migraine Clinic, Imperial College NHS Healthcare Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK
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Abstract
"Do I have a tumor?" This is a question in every person's mind when first confronted with a new-onset headache, a question that causes considerable anxiety among patients, leading them to seek medical evaluation. This publication reviews the current literature with respect to the epidemiology, pathophysiology presentation, and treatment of headaches in association with intracranial neoplasm.
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Douglas AC, Wippold FJ, Broderick DF, Aiken AH, Amin-Hanjani S, Brown DC, Corey AS, Germano IM, Hadley JA, Jagadeesan BD, Jurgens JS, Kennedy TA, Mechtler LL, Patel ND, Zipfel GJ. ACR Appropriateness Criteria Headache. J Am Coll Radiol 2014; 11:657-67. [PMID: 24933450 DOI: 10.1016/j.jacr.2014.03.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Accepted: 03/30/2014] [Indexed: 10/25/2022]
Abstract
Most patients presenting with uncomplicated, nontraumatic, primary headache do not require imaging. When history, physical, or neurologic examination elicits "red flags" or critical features of the headache, then further investigation with imaging may be warranted to exclude a secondary cause. Imaging procedures may be diagnostically useful for patients with headaches that are: associated with trauma; new, worse, or abrupt onset; thunderclap; radiating to the neck; due to trigeminal autonomic cephalgia; persistent and positional; and temporal in older individuals. Pregnant patients, immunocompromised individuals, cancer patients, and patients with papilledema or systemic illnesses, including hypercoagulable disorders may benefit from imaging. Unlike most headaches, those associated with cough, exertion, or sexual activity usually require neuroimaging with MRI of the brain with and without contrast to exclude potentially underlying pathology before a primary headache syndrome is diagnosed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
| | | | | | | | - Sepideh Amin-Hanjani
- University of Illinois College of Medicine, Chicago, Illinois; American Association of Neurological Surgeons, Rolling Meadows, Illinois/Congress of Neurological Surgeons, Schaumburg, Illinois
| | | | | | - Isabelle M Germano
- Mount Sinai School of Medicine, New York, New York; American Association of Neurological Surgeons, Rolling Meadows, Illinois/Congress of Neurological Surgeons, Schaumburg, Illinois
| | - James A Hadley
- Physicians Regional Medical Center, Naples, Florida; American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia
| | | | - Jennifer S Jurgens
- Walter Reed National Military Medical Center, Bethesda, Maryland, Society of Nuclear Medicine and Molecular Imaging, Reston, Virginia
| | | | - Laszlo L Mechtler
- Dent Neurologic Institute, Amherst, New York; American Academy of Neurology, Minneapolis, Minnesota
| | | | - Gregory J Zipfel
- Washington University School of Medicine, St. Louis, Missouri, American Association of Neurological Surgeons, Rolling Meadows, Illinois/Congress of Neurological Surgeons, Schaumburg, Illinois
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Abstract
Headaches are described as primary, where no contributing cause is found, or secondary, where a discrete lesion or other condition has triggered the phenotype. Primary headache is a common condition; migraine causes much of the morbidity in this population, at great personal and economic cost. The decision to use MRI is a common dilemma facing clinicians, particularly as primary headache phenotypes can be triggered by secondary causes. Studies demonstrate that there is no appreciable difference in the frequency of pathological and incidental findings in common headache populations compared with the general community. Imaging is therefore not routinely required where a primary headache diagnosis can be made. Clinicians must be aware of the risk of manufacturing morbidity in uncovering incidental and nonsignificant imaging changes. However, patients demonstrating 'red flags' on medical history and examination do require imaging to help exclude a secondary cause of symptoms. Other headache phenotypes, such as the trigeminal autonomic cephalalgias, also generally require MRI.
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Affiliation(s)
- Michael Eller
- Headache Group-Department of Neurology, University of California, San Francisco, CA, USA
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Ali N, Lau G, Plant GT. The Urgency of Neuroimaging Among UK Neuro-Ophthalmologists: Consensus and Disagreement. Neuroophthalmology 2013; 37:63-67. [DOI: 10.3109/01658107.2013.771675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 01/27/2013] [Accepted: 01/28/2013] [Indexed: 11/13/2022] Open
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Abstract
When deciding to perform imaging for headache, it is important to consider many factors including the pretest probability, prevalence of diseases, sensitivity of imaging, and implications for treatment. For the first presentation of a headache or a change in headache pattern, if the characteristics do not perfectly fit a primary headache type, imaging may be indicated according to the ICHD-2 criteria to exclude a secondary cause before a primary headache is diagnosed. The value of negative imaging should not be underestimated in the cost-benefit analysis, which often only takes into account number needed to treat or likelihood of finding a significant treatable abnormality. One study has shown that some groups of patients are less likely to overuse other parts of the health care system after negative neuroimaging. Further studies with stronger methodologies, finer differentiation of acute and chronic headache presentations, more advanced imaging technology, among other factors, can improve decision making on when to use imaging and assess the impact of imaging on patient satisfaction and quality of life. In addition, functional MRI, MRS, and voxel-based morphometry MRI are only some of the neuroimaging techniques currently used in research to further understand the pathophysiology and mechanisms of headache. In conclusion, although most headaches are a primary headache disorder with a benign course, imaging is an important part of the diagnostic evaluation to exclude the presence of a secondary cause of headache that could cause fatal results or severe neurologic morbidity. In headache patients without focal neurologic examination abnormalities, the yield of neuroimaging for significant intracranial findings is generally low. However, specific subgroups of headache patients and headache presentations can have much higher rates of significant intracranial abnormalities.
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Affiliation(s)
- Malisa S Lester
- Section of Neuroradiology, Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, USA
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The changing relationship between neurology and general practice in the UK. Br J Gen Pract 2012; 59:599-604. [PMID: 22751237 DOI: 10.3399/bjgp09x453837] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 01/06/2009] [Accepted: 01/28/2009] [Indexed: 10/31/2022] Open
Abstract
The full involvement of primary care in an organised and balanced health service is vital to neurological patients' health. However, the available evidence suggests that GPs are, if anything, withdrawing or being pushed out of caring for this patient group. This article tries to identify why this may be happening, considers the implications, and suggests alternative ways forward.
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Duncan CW. Neuroimaging and other investigations in patients presenting with headache. Ann Indian Acad Neurol 2012; 15:S23-32. [PMID: 23024561 PMCID: PMC3444223 DOI: 10.4103/0972-2327.99995] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2011] [Revised: 04/16/2012] [Accepted: 05/17/2012] [Indexed: 11/04/2022] Open
Abstract
Headache is very common. In the United Kingdom, it accounts for 4.4% of primary care consultations, 30% of referrals to neurology services and 0.5-0.8% of alert patients presenting to emergency departments. Primary headache disorders account for the majority of patients and most patients do not require investigation. Warning features (red flags) in the history and on examination help target those who need investigation and what investigations are required. This article summarizes the typical presentations of the common secondary headaches and what neuroimaging and other investigations are appropriate for each headache type.
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Affiliation(s)
- Callum W. Duncan
- Department of Neurology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK
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Elliot S, Kernick D. Why do GPs with a special interest in headache investigate headache presentations with neuroradiology and what do they find? J Headache Pain 2011; 12:625-8. [PMID: 21956455 PMCID: PMC3208048 DOI: 10.1007/s10194-011-0375-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 07/22/2011] [Indexed: 11/27/2022] Open
Abstract
The general practitioner with a special interest in headache offers an important contribution to the management of headache in primary care where the majority of presentations take place. A number of guidelines have been developed for neuroradiological investigation of headache, but their clinical utility and relevance is not known. Fourteen general practitioners with a special interest in headache recorded consecutive headache consultations over a 3-month period, whether patients were investigated with neuroradiology and if so the reason for investigation and outcome. Reason for investigation was compared to the guidelines published for the use in primary care. 895 patients were seen, of whom 270 (30.1%) were investigated. 47% of indications were outside the guidance framework used, the most common reason for investigation being reassurance. Of those investigated, 5.6% showed positive findings but only 1.9% of findings were felt to be of clinical significance. General practitioners with a special interest investigated with neuroradiology a greater level than general practitioners, but less than neurologists. However, yields of significant findings are broadly comparative across all groups. This report confirms other studies that suggest that even when there is a high level of clinical suspicion, yields of significant findings are very low.
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Affiliation(s)
- Steven Elliot
- Horizon Centre, 94 Littleton Road, Salford, M7 3SE UK
| | - David Kernick
- St Thomas Health Centre, Cowick Street, Exeter, EX4 1HJ UK
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Should GPs have direct access to neuroradiological investigation when adults present with headache? Br J Gen Pract 2011; 61:409-11. [PMID: 21801533 DOI: 10.3399/bjgp11x578124] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Abstract
BACKGROUND The diagnostic yield of neuroimaging in chronic headache is low, but can reduce the use of health services. AIM To determine whether primary care access to brain computed tomography (CT) referral for chronic headache reduces referral to secondary care. DESIGN OF STUDY Prospective observational analysis of GP referrals to an open access CT brain scanning service. SETTING Primary care, and outpatient radiology and neurology departments. METHOD GPs in Tayside and North East Fife, Scotland were given access to brain CT for patients with chronic headache. All referrals were analysed prospectively over 1 year, and questionnaires were sent to referrers to establish whether imaging had resulted in or stopped a referral to secondary care. The Tayside outpatient clinic database identified scanned patients referred to the neurology clinic for headache from the start of the study period to at least 1 year after their scan. RESULTS There were 232 referrals (55.1/100 000/year, 95% confidence interval = 50.4 to 59.9) from GPs in 59 (82%) of 72 primary care practices. CT was performed on 215 patients. Significant abnormalities were noted in 3 (1.4%) patients; there were 22 (10.2%) non-significant findings, and 190 (88.4%) normal scans. Questionnaires of the referring GPs reported that 167 (88%) scans stopped a referral to secondary care. GPs referred 30 (14%) scanned patients to a neurologist because of headache. It is estimated that imaging reduced referrals to secondary care by 86% in the follow-up period. CONCLUSION An open access brain CT service for patients with chronic headache was used by most GP practices in Tayside, and reduced the number of referrals to secondary care.
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Imaging results in a consecutive series of 530 new patients in the Birmingham Headache Service. J Neurol 2010; 257:1274-8. [DOI: 10.1007/s00415-010-5506-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2009] [Revised: 02/08/2010] [Accepted: 02/09/2010] [Indexed: 10/19/2022]
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