Steven Elliot
GPwSI Tier 2 Neurology
Salford

Assess
 adherence to and
 relevance of the BASH guidelines on imaging patients with suspected brain tumour

 Record all patients seen
 Record numbers of patients scanned
 Record reasons for scans
 Reflect on non-guideline scans

 95% of scans would be red or orange flags as stipulated by guidelines

 Papilloedema
 New epileptic seizure
 New onset cluster headache
 Abnormal findings on examination/neurological symptoms
 History of cancer especially lung/breast
 Significant alteration consciousness, memory, confusion or co-ordination.

 Aggravated by exertion/Valsalva
 Headache associated with vomiting
 Headache which has increased in frequency
 New onset >50
 Headache waking from sleep
 Confusion

 3 month baseline measurement 2010
 Standard audit tool
 Anonymised collated analysis
 Reflection and recommendation
 Personal and/or group re-audit 2011

 14 GPwSIs
 3month period
 895 patients
 270 scans (30.16%)
 173 (64%) Red or orange flags


54 red flags
16/270 “positive” (5.6%)
 Average scan rate 32.86%

160
140
120
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13
% scan
Seen
Positive
Scanned

100
80
60
40
20
0
160
140
120
1 2 3 4 5 6 7 8 9 10 11 12 13
Indication
Positive

70
60
50
40
30
20
10
0
R ea ss
A ty ur an ce pi ca l h ea da ch e
P ro lo ng
H ea ed
a ur a da ch e on
O rg
e xe rti on ic
h as m ea da ch e ra
U ni la te
C ou gh
/V l t in ni tu s lv a in du ce d al sa
Th un de rc la p
N
D
PH pl ex
a ur a
C om
O th er
Series1

Indication 7


Intracranial hypotension
Bilateral subdurals


Grade 1 Chiari
Left orbital abnormality
 Mild Chiari
 Chiari
Indication 8
 Sinus thickening
Indication 9


1cm lesion right temporal lobe
Aneurysm
Indication 13
 CVST






Multiple emboli
Frontal lobe infarct
Aneurysm
Infarct left parietal lobe
Left parietal infarct
Glioma

 Not adherent
 Need for personal reflection
 Need for group reflection
 Not clear that guidelines are relevant
 Need for non-cancer indications
 What do we do about the anxious patient?
 True positive rate 1.5%

 Change scanning habits?
 Change criteria?
 Give up!

 New undifferentiated headache where a pattern has not emerged after 8 weeks
 Headache aggravated or precipitated by exertion or Valsalva manoevre, cough or sex and not migraine
 Headache associated with vomiting and not migraine
 Headache which has increased in frequency/severity in the last six months despite appropriate treatment

 New headache in age >50 whose onset is less than 6 months ago
 Headache that wakes from sleep that is not migraine
 Thunderclap headache
 Patient whose anxiety is not relieved by explanation and is aware of the implications of incidental findings

 New daily persistent headache
 Headache suggestive of low intracranial pressure
 Recent onset headache in HIV or immmunocompromised

 Suggestions?
 Agree criteria
 Repeat recording of activity in January to
March 2012
 Any volunteers?