11-10-2021: Please see and review Emergency Medicine Cases’ Ep 161 Red Flag Headaches: General Approach and Cervical Artery Dissections.*
The big 4 causes of emergency headaches that are not routinely identified on plain CT
Headaches are one the most common ED presentations. About 98% of these patients have a benign cause of their headache. Of the remaining 2%, 1% can be diagnosed with a CT head or LP, such as a subarachnoid hemorrhage or meningitis, however the final 1% causes of headaches cannot be ruled out on plain CT/LP alone. The big four commonly missed emergency causes of headaches that cannot routinely be ruled out on plain CT:
- Cervical artery dissection (carotid and vertebral)
- Cerebral venous thrombosis (CVT)
- CO poisoning
- Giant cell arteritis
In this part 1 of our 2-part podcast on red flag headaches we focus on a general approach to headaches in the ED and cervical artery dissection – one of the big five causes of emergency headaches that does not show up routinely on plain CT, requiring a CT angiogram of the head and neck to confirm the diagnosis.
*Helman, A. Shah, A. Baskind, B. Episode 161 Red Flag Headaches: General Approach and Cervical Artery Dissections. Emergency Medicine Cases. November, 2021. https://emergencymedicinecases.com/red-flag-headaches-cervical-artery-dissections. Accessed 11-9-2021.
Here are resources that I reviewed after reading the case report below.
Prospective validation of Canadian TIA Score and comparison with ABCD2 and ABCD2i for subsequent stroke risk after transient ischaemic attack: multicentre prospective cohort study [PubMed Abstract] [Full-Text HTML]. BMJ. 2021; 372: n49.
Published online 2021 Feb 4. doi: 10.1136/bmj.n49
Carotid Artery Dissection
Updated: Feb 19, 2019 from emedicine.medscape.com
Vertebral Artery Dissection
Updated: Feb 21, 2019 from emedicine.medscape.com
European Stroke Organisation (ESO) guidelines on management of transient ischaemic attack [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Eur Stroke J. 2021 Jun;6(2):V.
The aim of the present European Stroke Organisation Transient Ischaemic Attack (TIA) management guideline document is
to provide clinically useful evidence-based recommendations on approaches to triage, investigation and secondary prevention, particularly in the acute phase following TIA. The guidelines were prepared following the Standard Operational
Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic
principle, we defined TIA clinically and pragmatically for generalisability as transient neurological symptoms, likely to be due to focal cerebral or ocular ischaemia, which last less than 24 hours. High risk TIA was defined based on clinical features in
patients seen early after their event or having other features suggesting a high early risk of stroke (e.g. ABCD2 score* of 4
or greater, or weakness or speech disturbance for greater than five minutes, or recurrent events, or significant ipsilateral
large artery disease e.g. carotid stenosis, intracranial stenosis). Overall, we strongly recommend using dual antiplatelet
treatment with clopidogrel and aspirin short term, in high-risk non-cardioembolic TIA patients, with an ABCD2 score* of 4
or greater, as defined in randomised controlled trials (RCTs). We further recommend specialist review within 24 hours
after the onset of TIA symptoms. We suggest review in a specialist TIA clinic rather than conventional outpatients, if
managed in an outpatient setting. We make a recommendation to use either MRA or CTA in TIA patients for additional
confirmation of large artery stenosis of 50% or greater, in order to guide further management, such as clarifying degree of
carotid stenosis detected with carotid duplex ultrasound. We make a recommendation against using prediction tools (eg
ABCD2 score) alone to identify high risk patients or to make triage and treatment decisions in suspected TIA patients as
due to limited sensitivity of the scores, those with score value of 3 or less may include significant numbers of individual
patients at risk of recurrent stroke, who require early assessment and treatment. These recommendations aim to emphasise the importance of prompt acute assessment and relevant secondary prevention. There are no data from randomised controlled trials on prediction tool use and optimal imaging strategies in suspected TIA.
Transient ischaemic attack (TIA), TIA clinic, dual anti-platelet treatment (DAPT), clopidogrel, ticagrelor, aspirin,
secondary prevention, large vessel stenosis, clinical prediction tools, ABCD2*
Date received: 4 October 2020; accepted: 16 January 20score21
*Link to the ABCD2 from MDCalc.
Diagnosis and Management of Transient Ischemic Attack [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Continuum (Minneap Minn). 2017 Feb 3; 23(1): 82–92.
Cardioembolic Stroke [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Circ Res. 2017 Feb 3;120(3):514-526.
Cryptogenic Stroke: Research and Practice [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Circ Res. 2017 Feb 3;120(3):527-540.
In this post, I link to and excerpt from the Sept 21 post from the EMDocs. net post of Medical Malpractice Insights: Teens can have strokes too. 16-year-old female with sudden unilateral paralysis is partially paralyzed for life. Was cervical artery dissection considered?
All that follows is from the above resource.
Teens can have strokes too.
16-year-old female with sudden unilateral paralysis is partially paralyzed for life. Was cervical artery dissection considered?
Facts: A 16-year-old female presents to the ED only 30 minutes after noticing sudden loss of left sided motor function with “numbness.” Past medical history is remarkable only for occasional headaches and “numbness” in her L arm over the past few weeks. She has an appointment with her PCP in 4 days to address her earlier headaches and numbness. The physical exam states only that “the L arm is tucked to her chest with the hand clenched.” Gait is not documented. A head CT is normal. The patient improves during the visit and is discharged to see her PCP as planned in 4 days. Discharge dx is “”numbness” and “weakness” L side. She suffers a stroke a few hours after discharge due to a carotid artery dissection. She is left with a L hemiplegia and is unable to perform many basic ADL’s. An attorney is consulted and a lawsuit filed against the ED physician. Plaintiff: I was having a major TIA. You didn’t do anything except tell me I did not have a stroke. A normal CT scan does not rule out a stroke OR a TIA, both of which can be caused by a cervical artery dissection. Even a brief paralysis of one side of my body is serious, and you just brushed it off. You didn’t even tell me or my parents that a stroke was anything you were concerned about. You never even considered a TIA in your differential. If you had, you would have realized I needed more tests and should see a neurologist immediately, especially when I’m only 16-year-old. Defense: I thought of a stroke and ruled it out by getting the CT scan. You didn’t complain of neck pain. You had no risk factors. Because you weren’t having a stroke, I didn’t need to consider a dissection. You got better in the ED.
Result: Settled pre-trial for an undisclosed (but likely at least 7 figures) amount.
- Even teenagers can have a stroke or TIA.
- Sudden onset of unilateral neuro symptoms deserve one’s utmost concern, regardless of age.
- The cost of missing this diagnosis increases the younger the patient because of the “Quality of Life Years” ahead of them.
- Include cervical artery dissection in the differential when considering stroke/TIA.
- A normal CT scan does not rule out a stroke OR TIA (duh).
- Could an assumption that this was a histrionic female teenage have played a role?
- If you can only do ONE neurological test, gait is the simplest and most comprehensive. Walk (“Road Test”) your neuro patients before discharge.