Research: Newman-Toker R et al. HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness. Acad Em Med 2013.
Research: Easter et al. Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma. Acad Em Med 2013
AIR: Neuro II
5 comments
Easter et al. TBI in intoxicated patients with minor head trauma
.
Nicely done study. While it doesn’t “mandate” that CT should be obtained in all intoxicated patients with signs of head trauma as suggested by New Orleans Rules (my least favorite), but it certainly confirmed our concern for occult injuries in these high risk patients.
This study reaffirms the lack of reliability of clinical decision rules for head injury in this patient population.
.
Personally, I have a very low threshold to CT intoxicated patients with obvious signs of head trauma unless they look awesome. The other reasonable alternative is very close observation and frequent reassessments.
HINTS article
.
Overall a well executed study. However. keep in mind their pt selection: At least one stroke risk factor, and all with acute vestibular syndrome. Not all of our dizziness patients fit in this category.
.
It’s nice to know how HINTS performed in ED patients. However, they still have neuroophthalmologists do the HINTS exams! NOT EM physicians. So it’s still hard to say how generalizable this is.
.
I am excited about these devices that can do the exam for you. Might be a worthwhile investment once the data comes out about their efficacy.
.
We know ABCD2 sucks. However, we use “clinical gestalt”, which is based in most cases on stroke risk factors, many of which is already included in ABCD2. So maybe our gestalt isn’t as good as we thought either, esp in younger patients with no risk factors.
.
Can’t wait to see the data on EM docs performing HINTS.
Intracranial Injury in intox patients
1.Str engths: Good methods. Per author, first study to look at intracranial injury in intoxicated patients. Liked that they also analyzed their data w/I context of NEXUS, Canadian CT rules, etc. Two independent radiologists determined presence of intracranial injury w/ good interrater reliability.
2. Weaknesses: Prospective cohort. Only one site. Study was 80% men.
3. Outcomes: 8% prevalence of clinically important intracranial injury in intoxicated patients with minor head injury. Canadian CT head rules and NEXUS criteria do not have adequate sensitivity.
4. Change in practice? Two things make me more likely to pull the trigger on getting a CT on an intoxicated patient p/w minor head trauma: (1) the prevalence of intracranial injury in intoxicated patients – although on par with non-intoxicated patients – was higher than I anticipated; (2) interesting to see that both the NEXUS and Canadian CT rules missed patients with intracranial injury! Maybe I won’t go all New Orleans criteria and scan every intoxicated patient, but I’ll be more likely to as a result of the evidence.
HINTS vs ABCD2
1. Strengths: I like that the study took on a difficult presenting complaint and provides a feasible option that performed better than ABCD2 (and MRI!). The author makes a persuasive case on how employing the HINTS Rule can catch more strokes and save a significant amount of $ and resources. I also liked that they enrolled patients with a shorter duration of sxs to increase generalizability of results to EDs.
2. Weaknesses: Cross-sectional study – no sample size, power calculations. Single academic center. I thought it was interesting that inclusion criteria required that patients were required to have at least one stroke risk factor (and therefore study’s finding not applicable to “risk free” patients). Although study focused on presentation in the ED, it was not an EP who performed the HINTS, rather a neuroophthalmologist.
3. Outcomes: HINTS > ABCD2 regarding sensitivity/specificity in stroke w/I first 2 days of sxs in patients with AVS (including vs initial MRI!).
4. Change in practice: Will definitely add HINTS to my neuro exam. As the study points out, the HINTS rule is well suited to the ED. I’ve tried it in the past with a little difficulty but I think I’ll study a few youtube videos before giving it another shot.
Strengths: First study to look at only intoxicated patients and compare their presentations with multiple of the already studied head CT rules. Systematic approach and the same for all. 2 radiologist looking at the images with excellent corelation of reads.
Weaknesses: Only alcohol intoxication was measured but in reality multiple other substances can impair our patient and caused trauma. Majority of their population was male (84%). The way they determine head injury could potentially miss patients with head injury just because they do not have physical evidence of it. Age range is difficult to control ina consecutive enrollment but out patient population though it containes this age ranges, I fell our population of commonly seen intoxicated patients are more in their 50s which puts them at an even higher risk for intracranial injuries.
Outcomes: Found an 8% prevalence of clinically significant intracranial injuries (vx 5% that was reported prior to this study). NEXUS and Canadian rule missed patient with this presentations which in our practice will require admission for observations at least. To their defense, none of the missed injuries required acute NSY intervention even though some required anti-epileptics upon discharge. New Orleans rules captured all of the patient but just becuase among their criteria is intoxications which was an inclusion criteria for this study.
Change in practice: I never used any of this criteria in my intoxicated patient because I do not feel like it is reliable. As a rule I scan patient with LOC or those who do not hace visual head trauma but do not sober appropriately. I will have a more frequent re-asssessment of these patient just because htye have sucha higher risk of injury.