Management of Patients With Traumatic Intracranial Injury in Hospitals Without Neurosurgical Service

Abstract

Many patients with intracranial bleeding (ICB) are being evaluated in hospitals with no neurosurgical service. Some of the patients may be safely managed in the primary hospital without transferring them to a designated neurosurgical center. In Israel, there are three approaches to alert patients with ICB: mandatory transfer, remote telemedicine neurosurgical consultation, and clinical-radiologic guidelines. We evaluated the outcome of alert patients with low-risk ICB who were managed in centers without neurosurgical service. A retrospective cohort comparative study. Patients with ICB and a Glasgow Coma Score >12 were included. Low-risk ICB was defined as solitary brain contusion of <1 cm in diameter, limited small subarachnoid hemorrhage, or subdural hematoma of <5 mm in maximal width and length. The decision to transfer the patients to a neurosurgical center was based on one of the three models. Hospital A: mandatory transfer. Hospital B: telemedicine-based consultation with a remote neurosurgeon. Hospital C: clinical-radiologic algorithm-based guidelines. Primary endpoint was the neurologic outcome of patients at discharge. There were 152 patients in group A, 98 patients in group B, and 73 patients in group C. All patients of group A were transferred to a neurosurgical center. Fifty-eight percent of patients from hospital B and 26% of patients from hospital C were hospitalized in the primary center despite a proven ICB. These patients were discharged without any neurologic sequel of their injury. Two patients from group B and one patient from group C needed a delayed transfer to a neurosurgical center. None of the patient needed delayed neurosurgical intervention. Despite the small sample size of this study, the presented data suggest that some patients with ICB can be safely and definitively managed in centers with no on-site neurosurgical service. The need for transfer may be based on telemedicine consultation or clinical -radiologic guidelines. Further larger scale studies are warranted.