Emergency craniotomy: should it be or must it be performed in a regional hospital?
Abstract
Background: Most patients with severe head injuries are transported to and operated on in the neurosurgical unit. Some patients are still occasionally operated on in regional hospitals by general surgeons to avert progressive neurological injuries and death. The aim of this paper is to analyze this type of surgical activity in our general hospital.
Methods: Between 1995 and 2005, 7 patients underwent decompressive surgery performed by general surgeons. All were confirmed by the computerized tomography (CT) scan with minimum 5 mm midline shift, severe ventricular compression, or both. We have analyzed the reason why all patients were deemed to be too unstable for transport to the nearest neurosurgical unit which is situated 75 km from our hospital.
Results: The group of patients consisted of 2 females aged 21–50 years and 5 males aged 32–46 years. All 4 patients with epidural hematoma (EDH) had a good recovering with Glasgow Outcome Scale (GOS) 5 (good recovery with minimal or no disability). With 3 patients with subdural hematoma (SDH), the outcome was not that good and the mean GOS was 2,6, ranging from 4 to 1. The overall mortality was 14.28 %. The time from recognition of the nature of the injury by the CT scan to the start of anesthetization ranged from 70 to 20 minutes (with the average of 47 minutes). In EDH, the average time was 37 minutes.
Conclusions: In a modern society with fast communications, there is enough time to transfer patients with EDH or SDH to a neurosurgical unit before the onset of uncal herniation. The aim is to improve the competence and speed of general hospitals in detection of candidates for surgical decompression, and stress the importance of these patients to be transferred to a neurosurgical unit without any unnecessary delay. The dilemma arises because the condition of patients with expanding mass lesions can deteriorate extremely rapidly, with catastrophic consequences. In some less frequent cases, the rapidly expanding intracranial hematomas (usually EDH) may be imminently life-threatening and may not allow time for transfer to a neurosurgical unit. In those exceptional circumstances emergency craniotomy should be performed by general surgeons without unnecessary delay.
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