The value of performing cerebrovascular CT angiography in major trauma patients: a 5-year retrospective review.

AIM: To assess whether routine cerebrovascular imaging is required in all major trauma (MT) patients. MATERIALS AND METHODS: All MT patients with cerebrovascular imaging between January 2015 and December 2020 were included in the study. Data were collated regarding the type of indication for computed tomography (CT) angiography imaging, time interval from the initial trauma, relevant trauma diagnoses on initial trauma imaging, and CT angiography. Findings, such as aneurysms, vascular malformations, luminal thrombus, venous sinus thrombosis, or vascular injury, were collated. Subsequent treatment with anti-coagulants/anti-platelets or surgical/radiological intervention was noted. Follow-up imaging was assessed for residual injury or complications. RESULTS: Two hundred and fifty of the 6,251 MT patients underwent dedicated cerebrovascular imaging and were included in the study. Of these 41 (16.4%) had cervical artery or venous sinus injury. Further positive vascular findings were identified in 25/250 patients who presented with an incidental stroke or a vascular abnormality and were mislabelled as MT patients at presentation. One patient with a carotid injury subsequently died following a large infarction. Another patient with vertebral artery injury suffered a non-lethal stroke. No patients underwent surgery or intervention. CONCLUSION: The present study showed that the overall incidence of detected blunt cerebrovascular injuries was very low (0.6%) and even lower for symptomatic vascular injury (0.03%). Routine cerebrovascular imaging is not recommended in all MT trauma patients, but instead, a continued case-by-case basis should be considered.

Intracranial hypertension in subarachnoid hamorrhage: outcome after decompressive craniectomy.

Intracranial hypertension can occur following aneurysmal subarachnoid haemorrhage (SAH). It can be treated with decompressive craniectomy (DC) with the aim of reducing intracranial pressure, increasing cerebral perfusion and reducing further morbidity and mortality. We studied the outcome of patients undergoing DC following SAH at our institution, to ascertain whether the use of this treatment can be rationalized.

On-call neurosurgery: can this continue as a free service?

Since 2005, Acute National Health Service (NHS) Trusts have been funded using a system called Payment by Results. This provides a national or regionally set tariff per patient treated, according to a health resource group code. Health resource group codes vary according to diagnosis or procedures carried out and patient co-morbidities. This only funds trusts admitting patients rather than those advising remotely, as neurosurgical centres do for the majority of emergency referrals. Numbers of referrals and emergency admissions to our unit were analysed for the last 4 years in addition to consultant and secretarial time devoted to these cases. This demonstrated an increase in the number of referrals and time spent advising. For the trust hosting the neurosurgical department, this represents a funding deficit for services offered. In our region, this has been remedied by charging neighbouring trusts a fee for emergency neurosurgical referral advice. However, this is difficult to administrate and would be better served as a service-level agreement with our commissioners. Only when this has been achieved, can neurosurgical centres provide a comprehensive consultant-led emergency service without it being to the detriment of the host trust.