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Original research
Subarachnoid haemorrhage in the emergency department (SHED): a prospective, observational, multicentre cohort study
  1. The Trainee Emergency Research Network (TERN)
    1. The Royal College of Emergency Medicine, London, London, UK
    1. Correspondence to Tom Roberts; tom.roberts{at}bristol.ac.uk; tom.roberts{at}bristol.ac.uk

    Abstract

    Background People presenting to the ED with acute severe headache often undergo investigation to exclude subarachnoid haemorrhage (SAH). International guidelines propose that brain imaging within 6 hours of headache onset can exclude SAH, in isolation. The safety of this approach is debated. We sought to externally validate this strategy and evaluate the test characteristics of CT-brain beyond 6 hours.

    Methods A prospective, multicentre, observational cohort study of consecutive adult patients with non-traumatic acute headache presenting to the ED within a UK National Health Service setting. Investigation, diagnosis and management of SAH were all performed within routine practice. All participants were followed up for 28 days using medical records and direct contact as necessary. Uncertain diagnoses were independently adjudicated.

    Results Between March 2020 and February 2023, 3663 eligible patients were enrolled from 88 EDs (mean age 45.8 (SD 16.6), 64.1% female). 3268 patients (89.2%) underwent CT-brain imaging. There were 237 cases of confirmed SAH, a prevalence of 6.5%. CT within 6 hours of headache onset (n=772) had a sensitivity of 97% (95% CI 92.5% to 99.2%) for the diagnosis of SAH and a negative predictive value of 99.6% (95% CI 98.9% to 99.9%). The post-test probability after a negative CT within 6 hours was 0.5% (95% CI 0.2% to 1.3%). The negative likelihood ratio was 0.03 (95% CI 0.01 to 0.08). CT within 24 hours of headache onset (n=2008) had a sensitivity of 94.6% (95% CI 91.0% to 97.0%). Post-test probability for SAH was consistently less than 1%. For aneurysmal SAH, post-test probability was 0.1% (95% CI 0.0% to 0.4%) if the CT was performed within 24 hours of headache onset.

    Conclusion Our data suggest a very low likelihood of SAH after a negative CT-brain scan performed early after headache onset. These results can inform shared decision-making on the risks and benefits of further investigation to exclude SAH in ED patients with acute headache.

    • headache
    • Computed Tomography
    • headache
    • stroke

    Data availability statement

    Data are available upon reasonable request. We will share anonymous data with others upon reasonable request in line with ethical and data protection requirements.

    https://doi.org/10.1136/emermed-2024-214068

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      Data availability statement

      Data are available upon reasonable request. We will share anonymous data with others upon reasonable request in line with ethical and data protection requirements.

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      Footnotes

      • Handling editor David Metcalfe

      • Collaborators TERN Collaborators: Writing committee: Tom Roberts, Robert Hirst, Fraser Birse, Camilla Powell, Dan Horner. Local collaborators: Aberdeen Royal Infirmary (Abigail Proctor, Catriona Chisholm, Jamie Cooper, Katie Roberts, Kirsty McCrorie, Leia Kane, Louis-Pierre Girard, Rosslyn Waite, Samah Azaldeen, Sinéad McCarthy, Claire Chernouski, Conal Mulholland, Gareth Evans, Sylvia Drozdzik); Addenbrooke’s Hospital (Josephine Phizacklea, Sapna Sharma Hajela, William Neale, Audrey Campbell, Danielle Johnson, Johanna Selway, Kerry Meynell, Olubusola Odesanya, Richard Keshi, Sam Love, Susie Hardwick, Kashif Ijaz Malik); Aintree University Hospital (James Pratt, John Gilbert, Kate Fenlon, Tanya Ingram, Abdo Sattout); Barnsley Hospital (Charlotte Green, Sian Jones); Barts Health NHS Trust (Ruth Sneep, Marco Bonsano, Mathew Alex, Raine Astin-Chamberlain, Adrian Perera, Grace Tunesi, Mahmood Soomro, Nimca Omer, Noemi Caponi, Imogen Skene, Ben Bloom); Basingstoke and North Hampshire Hospital (Maria Alvares, Denise Griffin, Emma Christmas, Maria Alvarez-Corral, Mildred Sitonik,Daniel Jackman); Bedford Hospital (Deepak Babu,Manoj James, Rami Abdullatif, Tabsheer Joyo, Lakshmi Coates, Mohamed Awadelkarim, Sita Anala, Tochukwu Udoka Ikeazota,Aldelrahman Hussein,Rachel Lorusso); Bristol Royal Infirmary (Irene Grossi, Carl Robinson); Chelsea and Westminster Hospital (Claudia Passalacqua, Lim Mun, Zoe Cass-Tansey, Fiqry Fadhlillah, Lorna Galbraith, Mun Kiong Lim, Saskia Ross, Shashank Patil); Cheltenham General and Gloucestershire Royal Hospital (Asad Ali Shah, Jaymik Patel, Nick Vallotton); Chesterfield Royal Hospital (Amy Neal, Lee Herring, Nurkamalia Hasni, Vittoria Sorice); Colchester General Hospital (Hazel Yeoh, Jose Morales Kohlmann, Muhammad Umer Khayyam Sayyed, Ooi Huah Chiang, Sudharsan Nagendran, Ahmad Mohamed, Alison Ghosh, Ernest Isokpehi, Jhalakkumar Patel, Kali-Jade Gunfield, Keshmira Gill; Shuail Noor, Udara Wickramanayake, Mattia Kolletzek,Rupa Chatterjee); Conquest Hospital (Kelly Death); Crosshouse Hospital (Laura McKechnie, Bernadette Mallon); Derriford Hospital (Henry Shirreff, Joan Danglosi, Luci Jackson, Rory J. Heath, Rosalyn Squire); Doncaster Royal Infirmary (Emily Hall, Gillian Herdman, Rojina Shresta, Sheriff Adewunmi); Dumfries and Galloway Royal Infirmary (Raymond Jouwena, Alice Staunton, Edel Pyke); East Surrey Hospital (Christopher Woods, Csaba Szekeres, Edward, Rippingale-Combes, John Stygle, Sonia Haris, Yathin Thammaiah, Edward Combes, Ellen Jessup-Dunton, Nancy Jones, Ruth Habibi, William Porter, Chris Dixon); Epsom Hospital and St. Helier Hospital (Manuel Rebolledo, Rebecca Macfarlane, Emese Balogh, Grace Blows, Lisa Evans); Fairfield General Hospital (Mark Richardson Riley, Alan Neal, Carol Lunney, Denise McSorland, Jijimol Antony, Julie Melville, Marie Gibson, Pamela Bradley, Rosane Joseph, Sakib Mahmood, Sanniah Hussain, Taslima Khatun); Frimley Park Hospital (Aarathi Devi, Alison Horne, Karen Singler, Kyi New, Manjit Riyat, Temi Sonoiki, Vasant Mohandas); Great Western Hospital (Anne Wang, Catherine Flitney, James Pickard, Emily Fowler, Laura McCafferty, Maud McCutcheon, Nicola Clark, Suzannah Pegler, Tim Slade); Hillingdon Hospital (Amjad Raza Khan, Faraz Iftikhar Malik, Hashini Gunathilake, Hira Raees, Lyra Romero, Marwa Osman, Mohammed Haseeb Soya, Parminder Kaur, Alvin Man, Anza Muhammad, Charlotte Cleasby, Paul Bisnar, Purity Mutea, Shanthi Ramraj,Nichole Shahi); Horton General Hospital (Venkata Kowlur); Huddersfield Royal Infirmary (Huw Masson); Ipswich Hospital (Arifin Aprjanto, David Hartin, Georgina Gray, Iqteder Uddin, Jay Patel, Kevin Breitsprecher, Rebecca Francis, Vanessa Rivers, Janet Sinclair, Toni Defreitas, Sally Knight); John Radcliffe Hospital (Alexis Espinosa, Ana Catarina, Lopes Viera, Dharamveer Tatwavedi, Tanya Baron, Samuel Jonathan Glover, Sally Beer, Tinelly Sambo); Kettering General Hospital (Sareesh Bandapaati, Hannah Britton, John Obiakor, Juliemol Sebastian, Parizade Raymode); King George Hospital and Queen’s Hospital (Sam King, Darryl Wood); Leicester Royal Infirmary (Benjamin Feist, James Van Oppen); Leighton Hospital (Richard Lowsby, Grace Mairs, Martin Griffin, Natalie Critchley); Luton and Dunstable University Hospital (Amir Reyahi, Aamir Tarique, Cleo Holmes, Dinkar Bisht, Gyorgyi Kamaras, Jawad Malik, Krishna Pillai, Muhammad Asaria, Satish Kumar, Rachel Lorusso, Ahmad Mchaourab, Amir Reyahi, Manoj Viegas, Charlotte Whitehouse); Macclesfield District General Hospital (Charlotte Dean, Katherine Rose, Natalie Keenan); Maidstone Hospital and Tunbridge Wells Hospital (Cheuk Tung Kam, Kavitha Anoop, Banher Sandhu, Bethany Jones, Elena Harry, Emily Phiri, Eulalie Edorh, Jack Dickinson, John Clulow, Lagath Wanigabadu, Miriam Davey, Nnadi Chisom, Ragavan Navaratnam, Stefan Sleiman, Mohammed Waqar); Manchester Royal Infirmary (Charlotte Taylor, Patricia Van Den Berg, Elizabeth Wooffinden); Musgrove Park Hospital (Charmaine Shovelton, Eric Mbogu, Jayne Foot, Paul Eubank-Scott, Wayne Battishill); North Manchester General Hospital (Helen T-Michael, Joanne Rothwell, Karen Connolly, Lisa Cooper, Sharon Baxter-Dore, Tracy Hodgkiss); North Tees Hospital (Heather MacFarlane, Gala Stancev, Hillie Corr, Laura O’Rourke); Northumbria Specialist Emergency Care Hospital (Angela Dawson, Anna Homes, Anna Mushi, Gail Waddell, Gemma McCafferty, Hannah Peggie, Hayley McKie, Jessica Bell, Lisa Gallagher, Mark Harrison, Paul Crispin, Rachel Joseph, Rebecca Emmonds, Stacey Short, Thomas, Beeby, Toni Hall, Tracy Smith, Joshua Beck); Northwick Park Hospital (Sreena Sreedevi Raj, Ekaterina Watson, Lara Barcella, Najwa Soussi, Sambasivarao Gurram, Sheena Quaid, Sreena Raj); Peterborough City Hospital (Alex Oram, Dayo Afolabi, John Scott Frazer); Pinderfields Hospital (Amy Major, Chandra Temburnikar, Eugene Henry, Jaizal Issac, Sarah Robertshaw, Alex Metcalfe, Elizabeth Denis, Sarah Buckley); Queen Elizabeth Hospital (Jenny Ritzema, Julian Donovan, Richard Grimwood, Jennifer Wright); Queen Elizabeth Hospital and University Hospital Lewisham (Hamid Zafar, Daniel Beasley, Kirsty Cunningham, Mandy Lewis, Samia Pilgrim, Najia Ali); Queen Elizabeth University Hospital (Malcolm Gordon, Adam Gill, Emma Hughes, Jessica Dunn, Kareem Austin, Mark Wilson, Nicola Baxter); Queen’s Medical Centre (Martin Dent, Alison Wells, Amy Clark, Cecilia Peters, Megan Meredith, Stephen Ojo, Usman Yusuff); Royal Alexandria Hospital (Alasdair Corfield, Janice Sutherland); Royal Berkshire Hospital (Charlotte Knowles, Emma Grierson, Giulia Mascia, Jennifer Armistead, Luke Armstrong, Nicola Jacques, Parminder Bhuie, Sabi Gurung Rai, Shauna Bartley, Silvia Panetta, David Metcalfe); Royal Bolton Hospital (Ruby Blevings, Sean Lee, Thomas Maughan); Royal Cornwall Hospital (Cathal Murphy, Steven Godfrey, Christine Hall, Claire James, Fiona Hammonds, Sally Thomas); Royal Derby Hospital (Alison Fletcher, Alison Matthews, Andrew Tabner, Elisha Cousins, Graham Johnson, Nicholas Tilbury, Stephanie Pike, Thomas Ward); Royal Devon and Exeter Hospital (Stephanie Stone, Hamza Malik, Sam Scotcher, Andrew Pitt, Daisy Sykes, Ellen Matkins, Laura Johns, Letizia Zitter); Royal Hampshire County Hospital (Ana Maria Arias Tejedor, Giles Chick, Mark Brewer, Caroline Wrey Brown, Jane Martin, Jemima Parry, Jose Arpita); Royal Infirmary of Edinburgh (Alexander Rollings, Benjamin Earle-Wright, Gregory Flowerdew, Hanmo Zhang, Joseph Jermy, Joseph Boyle, Linzi Marie, Rachel O’Brien, Rosemary Andrew, Stuart Robert,Campbell Davis, Caroline Blackstock, David Birrell, Emily Crichard, Greg Flowerdew, Isameldein Mahmoud, James Hargreaves, Joanne Pryde, Julia Grahamslaw, Katherine Howie, Lei Hua, Linzi Marie Clark, Mhairi Farquhar, Rory Anderson, Sophie Macdonald, Stephen Ross, Stuart Davis,Alexandra Franiek, Matthew J Reed); Royal Liverpool University Hospital (Basak Ustael, Danielle McLaughlan, Fran Westwell, Francesco Ferraro; Sophie Holder, Wojciech Sawicki); Royal Oldham Hospital (John-Paul Williamson, Jennifer Philbin); Royal Stoke University Hospital (Lucy Bailey, Julie Norton); Royal United Hospital (Gabrielle Evans, Lidia Ramos, Lucy Howie, Sarah Hierons); Salford Royal Hospital (Daniel Horner, Amber Sampson, Jane Perez, Lisa Swindells, Melanie Slaughter, Reece Doonan, Samantha Dodds, Stephanie Lee); Salisbury District Hospital (Abby Rand, Fiona Trim, Holly Morgan, Peter Ellis); Scarborough Hospital and York Hospital (Jennifer Baker; Ose Inegbenijie; Siobhan Sutton; Steven Crane); Southmead Hospital (Christopher Raj, Edward Carlton, Ammar Habbal, Anurag Sinha, Callum Taylor, Celestine Weegenaar, Connor Moore, Danny McLernon-Billows, Hannah Courtney, Harry Quin, Jack Sadler, Jack Wildman, Juhi Patel, Michael Connelly, Michael McGovern, Rebecca Sainsbury, Samuel Byrne, Sarah Leathem, Ysabelle Thackray); Southport and Formby General Hospital (Craig Rimmer; Zena Haslam); St George’s Hospital (Adil Nazmuddin, Adrian Robinson, Ahmed Abdoellateif Hamed Hendam, Alex Pickard, Melissa Hempling, Rupinder Kaur Gill, Camilla Paget, Daniel Howden, Eyal Kalmar, Gokul Sagar Bailur, Hannah Marriott, Harriet Asquith, Jessica Butler, Mohammad Nasif, Yukiko Kubota-Sjogren, Zunaira Khan, Amir Mohamed, Amy Harris, Caspar Norris, Claire Durrans, Craig Buddery-Davidson, Hannah Marcarian, Joe Garrett, Kirsty Wilde, Phil Moss, Sobika Gangeswaran, Stuart Chapman, Natasha Corbin); St John’s Hospital (Giles Lewis-Morgan, Aakash Gupta, Alexandra Franiek); St. Mary’s Hospital and Charing Cross Hospital (Oluwatofunmi Gbenedio, Mohamed Bedri); St. Thomas’ Hospital (Laura J Hunter,Benjamin Trenwith, Bruno Coelho); Stoke Mandeville Hospital (Helen Burton-Gow, Katarina Manso, Nicola Gray); University Hospital Hairmyres (Mohamed Chekroud); University Hospital Monklands (Fiona Hunter,Gautham Balachandran, Gordon McNeish, Neil Hughes, Sikiru Ishola Sanusi, Abbie McAlinden, Nicola Moultrie, Tracy Baird); University Hospital Wishaw (Alan Mackay, Alex Bann); University Hospitals Coventry (Daniel Bulman, Hazel Luck, Carl Hawkins, Caroline Leech, Geraldine Ward, Sophie Jackman); Warwick Hospital (Elaine Hardy, Indy Atwal, Angela Day, Bridget Campbell, Emma Vines, Inderjit Atwal, Penny Parsons); Wexham Park Hospital (Joana Gomes da Rocha, Sarah Wilson, Shahab Manouchehri); Whiston Hospital (Ala Al-Qudah, Adam Zone, Chelcie Jewitt, Robert Fuller, Stuart Booth); Whittington Hospital (Femi Felix); Yeovil Hospital (Bilal Ahmed, Mohamad Alsaadany, Lucy Pippard, Mostafa Esmael, Sarah Board, Amr Abdu, Avanti Koirala, Joseph Rowton, Nigel Miranda, Sarmad Shah, Shanvanth Jonnalagadda)

      • Contributors This study was conducted by TERN. The writing committee consisted of TR, DH, RH, FB and CP. TR was responsible for the initial concept and design with support from DH. TR designed all study related materials. TR, RH and FB were all responsible for the study delivery. CP conducted all statistical analysis. The writing committee were all involved in authorship of this manuscript and take responsibility for its contents. The TERN collaborators were responsible for the patient level recruitment and local approvals. TR is the guarantor of the data and manuscript.

      • Funding RCEM Grant number: G/2018/1. TR, RH and FB all received funding as TERN Fellows from RCEM. DH received funding as RCEM Professor from RCEM.

      • Competing interests None declared.

      • Patient and public involvement There was no study specific patient and public involvement but the research questions were developed following the publication of the 2017 James Lind Alliance Emergency Medicine priority setting exercise.

      • Provenance and peer review Not commissioned; externally peer reviewed.

      • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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