RESUMO
PURPOSE: Transitional care (TC) is increasingly crucial, particularly in neurosurgery, where optimal follow-through of patients' care is paramount. Challenges of transition are exacerbated by the complexity of neurosurgical conditions, with pediatric and adult neurosurgery often managed separately by different attending neurosurgeons or in different institutions. While numerous models for transitioning have been proposed, several barriers persist, impeding successful transfer from pediatric to adult settings. Our review focuses on important roles neurosurgeons can play in facilitating successful transition, exploring some existing TC models, with emphasis on the benefits of maintaining a single provider. METHODS: Clinic visits data between 2019 to 2023 of patients between the ages of 16 to 26 was compiled retrospectively. Successful transition was defined as continued follow-up moving from pediatric to adulthood with lost to follow-up being that of unsuccessful transition. Age, diagnosis and whether patients were successfully transitioned or lost to follow-up were documented. RESULTS: 1829 neurosurgical patients between the ages of 16 to 26 were identified over 5 years. A snapshot review identified 78 adolescent patients deemed to require follow-up into adulthood. 13 patients had epilepsy, 32 central nervous system (CNS) tumors, 17 congenital conditions, 14 neurovascular, and 2 patients had idiopathic intracranial hypertension. All 78 were noted to have successfully transited into their adulthood (age 21 and beyond). Having the same providers; having pediatric and adult neurosurgery within the same institution, was the single most important factor in facilitating successful transition. CONCLUSION: Neurosurgeons in institutions, particularly those with experience and competencies in both pediatric and adult care, can serve as crucial anchors during the transitional period. At our institution, the implementation of this continuity of care model has demonstrated remarkable success. Institutions with both pediatric and adult services would be uniquely positioned to develop and implement effective transitional care.
RESUMO
The comparability of endovascular coiling over neurosurgical clipping has not been firmly established in elderly patients with aneurysmal subarachnoid haemorrhage (aSAH). Data were obtained from all patients with aSAH aged ≥60 across three tertiary hospitals in Singapore from 2014 to 2019. Outcome measures included modified Rankin Scale (mRS) score at 3 and at 6 months, and in-hospital mortality. Of the 134 patients analyzed, 84 (62.7%) underwent coiling and 50 (37.3%) underwent clipping. The endovascular group showed a higher incidence of good mRS score 0-2 at 3 months (OR = 2.45 [95%CI:1.16-5.20];p = 0.018), and a lower incidence of in-hospital mortality (OR = 0.31 [95%CI:0.10-0.91];p = 0.026). There were no significant difference between the two treatment groups in terms of good mRS score at 6 months (OR = 1.98 [95%CI:0.97-4.04];p = 0.060). There were no significant differences in the incidence of complications, such as aneurysm rebleed, delayed hydrocephalus, delayed ischemic neurological deficit and venous thromboembolism between the two treatment groups. However, fewer patients in the coiling group developed large infarcts requiring decompressive craniectomy (OR = 0.32 [95%CI:0.12-0.90];p = 0.025). Age, admission WFNS score I-III, and coiling were independent predictors of good functional outcomes at 3 months. Only age and admission WFNS score I-III remained significant predictors of good functional outcomes at 6 months. Endovascular coiling, compared with neurosurgical clipping, is associated with significantly better short term outcomes in carefully selected elderly patients with aSAH. Maximal intervention is recommended for aSAH in the young elderly age group and those with favorable WFNS scores.