Head Computed Tomography in the Emergency Department

A Collection of Easily Missed Findings That Are Life-Threatening or Life-Changing

Camille Malatt, BA; Mazen Zawaideh, MD; Cherng Chao, MD; John R. Hesselink, MD; Roland R. Lee, MD; James Y. Chen, MD

Disclosures

J Emerg Med. 2014;47(6):646-659. 

In This Article

Abstract and Introduction

Abstract

Background The use of noncontrast head computed tomography (CT) has become commonplace in the emergency department (ED) as a means of screening for a wide variety of pathologies. Approximately 1 in 14 ED patients receives a head CT scan, and analyzing and interpreting this high volume of images in a timely manner is a daily challenge.

Objectives Minimizing interpretation error is of paramount importance in the context of life-threatening and time-sensitive diagnoses. Therefore, it is prudent for the physician to recognize particular pitfalls in head CT interpretation and establish search patterns and practices that minimize such errors. In this article, we discuss a collection of common ED cases with easily missed findings, and identify time-effective practices and patterns to minimize interpretation error.

Discussion There are numerous reasons for false-negative interpretations, including, but not limited to, incomplete or misleading clinical history, failure to review prior studies, suboptimal windowing and leveling, and failure to utilize multiple anatomic views via multi-planar reconstructions and scout views. We illustrate this in four specific clinical scenarios: stroke, trauma, headache, and altered mental status.

Conclusion Accurate and timely interpretation in the emergent setting is a daily challenge for emergency physicians. Knowledge of easily overlooked yet critical findings is a first step in minimizing interpretation error.

Introduction

With the mounting volume of cross-sectional imaging studies, emergency physicians are challenged to provide comprehensive and accurate image interpretation in an increasingly efficient manner. Computed tomography (CT) is the one of the most commonly utilized imaging modalities in the emergency setting, second only to conventional radiography.[1] Approximately 1 in 14 emergency department (ED) patients receive a head CT scan, sometimes for time-sensitive and life-threatening diagnoses.[2] It is thus prudent to recognize commonly missed pathologic conditions and establish search patterns and practices that minimize such errors.

Errors in interpretation may be classified as perceptual errors (not recognizing a finding) or cognitive errors (not correctly interpreting or understanding a finding).[3,4] In the context of commonly missed findings as described in this article, the radiologist is prone to perceptual errors. Overall resident miss rates reported in the literature range from 0.9–41%, depending on the definition and severity of interpretation error, whereas a 2.8% disagreement rate amongst practicing radiologists is reported for difficult cases.[5,6] For head CT scans performed in the setting of trauma, reported major and minor interpretation discrepancy rates between residents and staff radiologists equal 1.7% and 2.6%, respectively.[7]

There are numerous reasons for false-negative interpretations, including, but not limited to, incomplete or misleading clinical history, failure to review prior studies, suboptimal windowing and leveling, and failure to utilize multiple anatomic views via multi-planar reconstructions and scout views.

In this article, we demonstrate and discuss a collection of common time-sensitive and life-threatening ED cases with easily missed findings, and identify time-effective practices to minimize interpretation error.

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