The Ottawa subarachnoid hemorrhage clinical decision rule for classifying emergency department headache patients

Am J Emerg Med. 2020 Feb;38(2):198-202. doi: 10.1016/j.ajem.2019.02.003. Epub 2019 Feb 7.


Background: Subarachnoid hemorrhage (SAH) is a serious cause of headaches. The Ottawa subarachnoid hemorrhage (OSAH) rule helps identify SAH in patients with acute nontraumatic headache with high sensitivity, but provides limited information for identifying other intracranial pathology (ICP).

Objectives: To assess the performance of the OSAH rule in emergency department (ED) headache patients and evaluate its impact on the diagnosis of intracranial hemorrhage (ICH) and other ICP.

Method: We conducted a retrospective cohort study from January 2016 to March 2017. Patients with acute headache with onset within 14 days of the ED visit, were included. We excluded patients with head trauma that occurred in the previous 7 days, new onset of abnormal neurologic findings, or consciousness disturbance. According to the OSAH rule, patients with any included predictors required further investigation.

Results: Of 913 patients were included, 15 of them were diagnosed with SAH. The OSAH rule had 100% (95% CI, 78.2%-100%) sensitivity and 37.0% (95% CI, 33.8-40.2%) specificity for identifying SAH. Twenty-two cases were identified as SAH or ICH with 100% sensitivity (95% CI, 84.6%-100%) and 37.3% (95% CI, 34.1%-40.5%) specificity. As for non-hemorrhagic ICP, both the sensitivity and negative predictive values (NPV) decreased to 75.0% (95% CI, 53.3%-90.2%) and 98.2% (95% CI, 96.1%-99.3%), respectively.

Conclusions: The OSAH rule had 100% sensitivity and NPV for diagnosing SAH and ICH with acute headache. The sensitivity and specificity were lower for non-hemorrhagic ICP. The OSAH rule may be an effective tool to exclude acute ICH and SAH in our setting.

Keywords: Computed tomography; Emergency department; Headache; Ottawa subarachnoid hemorrhage rule.

MeSH terms

  • Adult
  • Aged
  • Cohort Studies
  • Decision Support Systems, Clinical / trends*
  • Emergency Service, Hospital / organization & administration
  • Female
  • Headache / classification*
  • Headache / diagnosis
  • Headache / physiopathology
  • Humans
  • Male
  • Middle Aged
  • Retrospective Studies
  • Severity of Illness Index
  • Subarachnoid Hemorrhage / diagnosis*