Radiation exposure in patients with subarachnoid hemorrhage: a quality improvement target

Clinical article

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The care of patients with subarachnoid hemorrhage (SAH) has improved dramatically over the last decades. These gains are the result of improved microsurgical, endovascular, and medical management techniques. This intensive management subjects patients to multiple radiographic studies and thus increased radiation exposure. As greater understanding of the risks of radiation exposure develops, physicians must be better equipped to balance the need for optimal SAH management with the minimization of patient exposure to radiation from imaging studies. The goal in the current study was to determine if there is an opportunity for a reduction in radiation dose without a change in the quality of treatment in patients with SAH.


A retrospective chart review of all patients hospitalized for SAH at the Brigham and Women's Hospital in the period from January 1, 2009, to August 31, 2010, was performed. The authors calculated cumulative and imaging study–specific radiation doses, determined the time of day that imaging studies were performed, and surveyed neurosurgeons regarding issues surrounding imaging-related radiation exposure.


The data for 77 patients were analyzed. The mean cumulative radiation dose during hospitalization was 2.76 Gy per patient (range 0.46–8.32 Gy). The mean radiation exposure from each CT, CT angiography (CTA), and angiography study was 0.08, 0.29, and 0.77 Gy (ranges 0.02–0.40, 0.15–0.99, and 0.11–4.36 Gy, respectively). Subgroup analysis of the top quartile of patients in terms of total radiation dose revealed a mean cumulative radiation dose of 4.78 Gy (range 3.42–8.32 Gy), mean cumulative number of CT and CTA scans of 14, and mean CT or CTA scan per day of 0.5 (maximum 0.8). Seventeen percent of the noncontrast head CT studies were performed just prior to morning rounds, more than double the 8% expected rate at random. Thirty-four percent of the repeat noncontrast head CTs did not show any change between scans, as documented on radiology reports. When surveyed, a majority of neurosurgeons incorrectly estimated the radiation dose typically received from CT, CTA, and angiography studies, and 65% asserted that radiation exposure is “not important” or only “somewhat important” when considering whether to order an imaging study.


Study findings suggested that patients with SAH have significant imaging-related exposure to radiation. The authors believe it is possible to continue the current improved outcomes in SAH with a significant reduction in radiation exposure from imaging studies. This analysis highlights the significance of accurate assessment of radiation exposure as a quality improvement target.

Abbreviations used in this paper:CAK = cumulative air kerma; CTA = CT angiography; CTDIvol = volume CT dose index; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Judith M. Wong, M.D., M.P.H., Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115. email: jwong17@partners.org.

Please include this information when citing this paper: published online April 26, 2013; DOI: 10.3171/2013.3.JNS12253.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Bar graph showing survey responses of neurosurgeons regarding the specific radiation dose delivered by individual imaging studies and the minimum dose required for skin burn risk. Gray bars indicate resident responses; black bars, attending responses; and white bars, overall responses.

  • View in gallery

    Bar graph of survey responses of neurosurgeons regarding the importance of considering radiation exposure when ordering radiographic studies. Black bars indicate attending responses; gray bars, resident responses.



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