Time-Critical Transfers for Paediatric Neurosurgical Emergencies Operated on Out-of-Hours at a Tertiary Neurosurgical Centre: A Single Centre Experience

Abstract

INTRODUCTION: Recommendations suggest operating within 4 hr of acute brain injury. Centralization of paediatric neurosurgical and intensive care facilities therefore necessitates prompt assessment and transfer. METHOD(S): A retrospective audit of out-of-hours operations at a tertiary neurosurgical center over 2013 to 2016 identified 36 patients (mean age 8 yr (SD = 5); male n = 21) from consultant records and case notes. Initial GCS, transfer timings and 3-mo Glasgow Outcome Score (GOS) were recorded. RESULT(S): A total of 36 emergency surgeries were performed: hematoma evacuation (n = 17), CSF diversion (n = 16), posterior fossa tumor debulking (n = 1), depressed skull fracture elevation (n = 1) and decompressive craniectomy (n = 1). MedianGCS at presentation was 8.5 (range: 3-15). Twenty operations began within 4 hr of CT. Twenty-nine patients presented to district general hospitals, underwent imaging before transfer; their mean CT to arrival time was 197.8 (SD = 70.7) min and CT to operation time was 271.7 (SD = 123.1) min. Threemo outcomes were: GOS 5 (n = 24), 4 (n = 5), 3 (n = 2) and 1 (n = 5); these were dichotomized into favorable (GOS 4-5) or unfavorable (GOS 1-3). Fisher's exact tests found no significant association between outcome favorability and timing of operation (whether within 4 hr of CT) (P = .43), or operation type (hematoma evacuation vs CSF diversion) (P = .22). Initial GCS did not significantly correlate with GOS (rs = 0.30, P = .10). CONCLUSION(S): The majority of outcomes were favorable regardless of whether surgery occurred within 4 hr of CT. This suggests underlying pathology may have a greater impact on poor outcomes than the transfer time, highlighting the importance of early scanning and neurosurgical referral to facilitate prompt decision-making.