What intracranial pathologies are most likely to receive intervention? A preliminary study on referrals from an emergency centre with no on-site neurosurgical capabilities

Access to neurosurgical facilities remains limited in resource-restricted medical environ- ments worldwide, including Africa. Many hospitals refer patients to off-site facilities if they require inter- vention. Unnecessary referrals, however, can be detrimental to the patient and/or costly to the healthcare system itself. The aim of this study was to determine the frequency and associated intracranial pathology of patients who did and did not receive active neurosurgical intervention after having presented to an academic emergency centre at a hospital without on-site neurosurgical capabilities. Methods: A one-year, retrospective record review of all patients who presented with potential neurosur- gical pathology to a tertiary academic emergency centre in Johannesburg, South Africa was conducted. Results: A total of 983 patients received a computed tomography brain scan for suspected neurosurgical pathology. There were 395 positive scans; 67.8% with traumatic brain injury (TBI) and 32.3% non- traumatic brain injury (non-TBI). Only 14.4% of patients received neurosurgical intervention, mostly non-TBI-related. The main intervention was a craniotomy for both TBI and non-TBI patients. The main TBI haemorrhages that received an intervention were subdural (SDH) (16.5%) and extradural (10.4%) haemorrhages. More than half the patients with non-TBI SDHs as well as those with aneurysms and sub- arachnoid haemorrhages received an intervention. Discussion: Based on this study’s findings, in a resource-restricted setting, the patients who should receive preference for neurosurgical referral and intervention are (1) those with intracranial haemor- rhages (2) those with non-traumatic SDH more than traumatic SDH and (3) those patients with non- traumatic subarachnoid haemorrhages caused by aneurysms.