Likelihood and Predictors of Acute Findings on CTA Head and Neck for Neurologic Presentations to the Emergency...

CT angiography of the head and neck (CTAHN) is commonly obtained in the emergency department (ED) for patients with acute neurologic symptoms to guide interventions. There are limited data on which clinical characteristics predict these changes. The primary objective of this study was to assess the yield of CTAHN across common neurologic ED presentations and identify patient and clinical factors associated with CTAHN findings that result in acute management change.

We performed a retrospective cohort study of 1,445 ED patients at an academic Level 1 trauma center who underwent CTAHN in 2023 for 5 common neurologic presentations: stroke code, headache, dizziness, altered mental status, and vision changes. Multivariable logistic regression models with LASSO variable selection were used to identify predictors of acute management change. Odds ratios (OR), 95% CIs, and p values were reported for each independent predictor.

Overall, 216 of 1,445 CTA head and neck sudies (CTAHNs; 14.9%) resulted in acute management change. The highest yield of CTAHN acute management change was for stroke codes (21.2%) and vision changes (14.7%), and the lowest for dizziness (4.0%). For stroke codes, independent predictors included abnormal CT head (OR 2.84, p = 0.0001), focal neurologic deficit (OR 2.2, p = 0.0119), new vs recurring symptoms (OR 2.39, p = 0.0272), maximal symptom severity at onset (OR 3.95, p = 0.0011), and tobacco use (OR 2.02, p = 0.0016). National Institutes of Health Stroke Scale (NIHSS) scores of 10-14 had the highest likelihood of CTAHN acute management change. Previous neurologic disorder was protective (OR 0.66, p = 0.0317). For headache, abnormal CT head (OR 4.98, p = 0.0303) and thunderclap presentation (OR 5.31, p = 0.0276) were associated with CTAHN acute management change. Only univariate trends could be identified for dizziness, altered mental status, and vision changes. CTAHN was most useful in those presenting with vision loss or diplopia, but not cases of blurry vision or positive visual phenomena. Abnormalities on the preceding CT head increased the yield for altered mental status, while CTAHNs were low yield for isolated dizziness.

These results highlight specific, obtainable clinical predictors that can guide judicious use of CTAHN in the ED. Recognizing these predictors can inform emergency physicians' and neurologists' clinical judgment, optimize imaging utilization, improve resource allocation, and reduce patient burden.