Evaluation of safety, effectiveness and reproducibility of telemedicine for neurosurgical screening / Avaliação da segurança, da efetividade e da reprodutibilidade na utilização de telemedicina para triagem neurocirúrgica

ABSTRACT Objective: To ascertain the safety, effectiveness and reproducibility of screening potential neurosurgical patients by means of smartphones. Methods: This is a retrospective and multicentric study. Data were collected from the medical records of patients subjected to real emergency neurosurgical evaluations and compared with assessments by neurosurgeons using smartphones to determine the feasibility of identifying changes in cranial computed tomography scans, potentially serious conditions of patients, and the need for transfer to reference centers. Results: We analyzed 232 cases. The main diagnosis was traumatic brain injury, with 119 cases (51.3%). Of this, 105 (45.3%) patients were discharged immediately after the assessment. The telemedicine evaluators presented 95.69% accuracy in the identification of changes in computed tomography scans, with 0.858 concordance. Accuracy in the identification of severity was 95.26%, with 0.858 concordance. As for procedure, the concordance among evaluators was 0.672, increasing to 100% in cases that required surgical treatment. Conclusion: Our study indicated that the use of telemedicine for screening patients with acute neurological disorders was safe, effective and reproducible. Implementation of the method shows a promising potential to improve the patient's outcome by reducing unnecessary transfers and decreasing the time elapsed until a specialist can be consulted.

RESUMO Objetivo: Verificar a segurança, a efetividade e a reprodutibilidade da triagem de pacientes potencialmente neurocirúrgicos feita por smartphones. Métodos: Estudo retrospectivo e multicêntrico. Dados de prontuários dos pacientes submetidos à avaliação neurocirúrgica de urgência foram coletados e comparados com a avaliação realizada por neurocirurgiões por meio de smartphones, determinando a capacidade de identificar alterações na tomografia computadorizada de crânio, pacientes potencialmente graves e necessidade de transferência. Resultados: Foram analisados 232 casos. O principal diagnóstico foi traumatismo crânio encefálico, com 119 casos (51,3%). Destes, 105 (45,3%) tiveram alta após a avaliação. Os avaliadores por telemedicina apresentaram acurácia de 95,69% para identificação de alteração na tomografia computadorizada, com concordância de 0,858. Com relação à identificação de gravidade, a acurácia foi de 95,26%, com concordância de 0,858. Com relação à conduta, os avaliadores apresentaram concordância de 0,672, aumentando para 100% nos casos de tratamento cirúrgico. Conclusão: O uso da telemedicina em nosso estudo foi seguro, efetivo e reprodutível para triagem dos pacientes com afecções neurológicas agudas. A implementação do método tem potencial de impacto na melhora do resultado para o paciente devido à redução das transferências desnecessárias e do tempo até o atendimento.

Carotid endarterectomy

Carotid endarterectomy should be considered for patients with symptoms of focal cerebral ischemia, when it can be performed with a combined morbidity and mortality below the annual risk of stroke (5 per cent). The experience with 815 carotid endarterectomies performed from 1979 to 1992 is presented. There were 530 (65 per cent) men and 285 (35 per cent) women of ages from 34 to 82 (median 65); risk factors included diabetes mellitus 196 (24 per cent), hypertension 554 (68 per cent), and smoking 570 (70 per cent). Clinical presentation consisted of transient ischemic attacks 464 (57 per cent), cerebral infarction with minimal neurological residual 228 (28 per cent), stroke in evolution 2 (0.2 per cent), and asymptomatic stenosis 121 (15 per cent). By Sundt's classification of medical risk the groups were: grade I, 106 (13 per cent); grade II, 350 (43 per cent); grade III, 357 (44 per cent); grade IV, 2 (0.2 per cent). All patients received endotracheal anesthesia. Thiopental (3-5 mg/kg) and lidocaine (1 mg/kg) were given for induction and at 15 minutes intervals during carotid cross-clamping. Intraluminal shunts were used in 14 (2 per cent). A conventional (open) endarterectomy was performed in 379 (46 per cent) and a limited endarterectomy (closed) in 436 (54 per cent). Complications included 8 (1 per cent) deaths, 24 (3 per cent) developed a major neurological deficit that persisted, 24 (3 per cent) had perioperative TIA's which resolved completely. Of the patients with preoperative neurological deficits, 32 (4 per cent) recovered. Therefore, at one month after surgery, 782 (96 per cent) were either as well or better than preoperatively.Of 483 (59 per cent) postoperative angiograms, 40 (5 per cent) showed an internal carotid artery occlusion. Six of these patients developed and immediate postoperative cerebral infarction and one died. Non-neurologic complications were: cardiac 40 (5 per cent), peripheral nerve 24 (3 per cent), and local wound problems 16 (2 per cent). A carotid endarterectomy can be performed safely when it is done with meticulous attention to detail and consistent surgical technique.