Routine but risky: a multi-centre analysis of the outcomes of cranioplasty in the Northeast of England.

BACKGROUND: Cranioplasty is undertaken as a routine secondary operation following craniectomy. At a time when decompressive craniectomy is being evaluated by several large trials, we aimed to evaluate the morbidity associated with cranioplasty and investigate its potential effect on outcome. METHODS: The outcomes of 166 patients undergoing cranioplasty at two centres in the United Kingdom between June 2006 and September 2011 were retrospectively analysed. Outcome measures included mortality, morbidity and functional outcome determined by the modified Rankin score (mRS) at last follow-up. A logistic regression analysis was performed to model and predict determinants related to neurological outcome following cranioplasty. RESULTS: Sixty-seven out of 166 patients (40.4 %) experienced at least one complication during a median follow-up time of 15 months (inter-quartile range 5-38 months). Thirty six patients (21.7 %) developed infection requiring antibiotics, with 27 (16.3 %) requiring removal of the cranioplasty. Nine of 25 patients (36 %) with bi-frontal defects developed an infection whereas 21 of the 153 patients (16.4 %) with a defect other than bi-frontal developed an infection (Chi square p = 0.009). Further surgery in the two groups was required in 16.4 % and 11.7, % respectively. Pseudomeningocoele (9 %), seizures (8.4 %) and poor cosmesis (7.2 %) were also commonly observed. Logistic regression analysis identified initial operation (p < 0.03), mRS at the time of cranioplasty (p < 0.0001) and complications (p < 0.04) as being predictive of neurological outcome at last follow-up. Age at the time of cranioplasty and the timing of cranioplasty were not predictive of last mRS score at follow-up. CONCLUSIONS: Cranioplasty harbours significant morbidity, a risk that appears to be higher with a bifrontal defect. The complications experienced influence subsequent functional outcome. The timing of cranioplasty, early or late, after the initial operation does not impact on the ultimate outcome. These findings should be considered when making decisions relating to craniectomy and cranioplasty.

Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better?

INTRODUCTION: District general hospital scanners have historically been linked to regional neuroscience units for specialist opinions on scans and to make decisions on transfer of patients requiring neurosurgical management. The implementation of digital picture archiving and communication systems (PACS) in all hospitals in the UK has disrupted these dedicated links and technical and information governance issues have delayed reprovision of electronic transfer of images for rapid expert decision making in this group of patients. We studied improvement in image transfer to acute neurosurgery units over a 4-year period. METHODS: Four-year sequential review of national provision of image transfer facilities into neurosurgery units; observational study of delays associated with image transfer modalities in one representative tertiary referral centre. RESULTS: During the 4 years of study, all hospitals nationally have implemented digital PACS systems for image viewing. Remote image viewing facilities have gradually changed with dedicated image links being replaced by remote PACS access. However, a minority of referrals (12%) still require images to be physically transferred between hospitals using couriers for CD-ROMs. The detailed study within our own unit shows that this adds a mean delay of 5.8 h to decision making. CONCLUSIONS: Image transfer in neuroscience has been neglected following the shift to PACS servers. The recommendations of the 2004 Neuroscience Critical Care Report are unmet and patient safety is being threatened by a continued failure to implement a coordinated solution to this problem.