IMAGING RESULTS IN 530 NEW PTS IN BIRMINGHAM HEADACHE

IMAGING RESULTS IN A CONSECUTIVE SERIES OF 530 NEW PATIENTS IN THE BIRMINGHAM HEADACHE SERVICE : 

IMAGING RESULTS IN A CONSECUTIVE SERIES OF 530 NEW PATIENTS IN THE BIRMINGHAM HEADACHE SERVICE NEUROLOGY JOURNAL CLUB KSHITIJA KARI, MD PGY-III

INTRODUCTION: 

INTRODUCTION Which patients with headache disorders should undergo neuroimaging? UK & USA guidelines (National Institute for Health, American Academy of Neurology) suggest selective policy for imaging as prevalence of significant findings is low High referral rate leads to increased discovery of incidental findings on imaging However, clinicians continue to refer such patients for imaging for reassurance and patient satisfaction

STUDY DESIGN: 

STUDY DESIGN Single center, prospective observational study over a period of 5 years Birmingham Headache Service O utpatient consultation service 3 consultants 1 diagnostic headache nurse specialist Imaging performed in the same hospital and reported by general radiologists.

METHODS: 

METHODS Patients referred to outpatient consultation service. The nurse takes a headache and general medical history and performs a neurological exam. Diagnosis based on ICHD-2 classification (International Classification of Headache Disorders) . 50% of new patients discussed with consultants regarding imaging. Guidance for general practitioners on imaging in headache (Imaging patients with suspected brain tumor: guidance for primary care. Kernick DP, Br J Gen Pract 2008) .

Slide 5: 

METHODS Urgent imaging ‘red flags’: raised intra cranial pressure focal neurological signs epilepsy cognitive disturbance recent diagnosis of cancer Routine imaging ‘orange/yellow flags’: recent headache, change in character no diagnostic pattern, wakes from sleep Precipitated by coughing, straining, etc. hemiplegic migraine, cluster headache

Slide 6: 

Significant abnormalities: 1º or 2º brain tumor Chiari abnormality Insignificant abnormalities: A rachnoid cyst cerebrovascular disease white matter abnormalities Normal findings. METHODS

RESULTS: 

RESULTS Aug 2004 – July 2009, 3655 new patients seen 69% female, mean age 42yrs 56% white, 34% Asian and 11% Afro-Caribbean Total of 530 of the 3655 patients were referred for imaging Differences in proportion of patients imaged by the 3 consultants

RESULTS: 

RESULTS

RESULTS: 

RESULTS Total 11 significant abnormalities (2.1%) 6 brain tumors: 4 clinically suspected 2 not suspected 167 Migraine patients imaged: 2 significant abnormalities (1.2%) 212 tension type headache: 2 significant abnormalities (0.9%) 55 Intracranial abnormalities: 3 significant abnormalities (5.5%)

DISCUSSION: 

DISCUSSION 530 Headache patients with worrying features only 2.1% significant abnormalities. Study showed more significant abnormalities with MRI compared with CT. Selection of MRI over CT- reduce radiation exposure dose, better imaging quality, more sensitive However, do not know if patients who were not imaged had any significant intracranial pathology

OTHER STUDIES: 

OTHER STUDIES Meta-analysis of 11 studies of imaging migraine patients with normal neuro exam & no red flags - 0.18% [1] 2 studies in tension-type headache - 83 pts. [1] Spanish study: 1876 patients p/w non acute headache 1.2% (0.4% migraine & 0.8% tension) significant abnormalities. [2] Meta-analysis of 16 studies of MRI in 19,559 normal people found 0.7% neoplastic & 2.0% of non-neoplastic incidental findings. [3]

DISCUSSION: 

So, prevalence of significant findings in migraine and tension headache is similar to that in normal individuals. MRI showed more frequent insignificant and incidental findings in this study (occult CV disease). Already worried patients may deteriorate if told of such coincidental findings. DISCUSSION

DISCUSSION: 

Number of patients referred for imaging fell from 35% to 13.5% the following year after results were disclosed. Feedback had an effect on consultants, as proportion of patients imaged lowered than at the outset. Excluding cases with known pre-existing pathology and with unrelated pathology (meningioma, pineal tumor) reduces incidence to 1.1% (Spanish-1.2%). DISCUSSION

Discussion Question: 

Discussion Question Can you think of any problems generalizing these results to the population we serve?

CONCLUSION: 

CONCLUSION The study supports current UK and American guidelines in advising the selective use of neuroimaging in small proportion of headache pts with sinister features either in history, exam or other investigations. The proportion of headache patients imaged by consultants can be reduced by giving feed back on data on their rate of imaging and its sensitivity.

Thank You: 

Thank You Dr. B. Desai Dr. A. Acharya Dr. N. Nelson Dr. A. Haefner Dr. M. Do

References: 

References References: [1] The utility of Neuroimaging in the evaluation of headache in patients with normal neurological examinations. American Academy of Neurology 2008 [2] Neurimaging in the evaluation of patients with non-acute headache. Sempere AP, et al, Cephalalgia 2005 [3] Incidential findings on brain magnetic resonance imaging:systematic review and meta-analysis. Morris Z, et al, BMJ 2009