Neurosurgical Emergency Transfers: An Analysis of Deterioration and Mortality

Neurological deterioration and mortality are frequent in neurosurgical patients transferred to tertiary centers, but the precise predictors leading to them are unclear.

To analyze and quantify risk factors predicting deterioration and death in neurosurgery transfers.

A consecutive review of all transfers with cranial pathology to a tertiary academic neurosurgery service was performed over a 2-year period. Risk factors including demographics, medical comorbidities, hydrocephalus, anticoagulant use, transfer diagnosis, Glasgow Coma Scale score, and transfer time were reviewed.

A total of 1429 transfers were studied, including 154 (10.8%) instances of neurological decline in transit and 99 mortalities (6.9%). On multivariate analysis, significant predictors of decline were hydrocephalus ( P = .005, odds ratio [OR] 2) and use of clopidogrel ( P = .003, OR 4.3), warfarin ( P = .004, OR 2.6), or other systemic anticoagulants ( P < .001, OR 10.1). Age ( P = .004), hydrocephalus ( P = .006, OR 2.1), renal failure ( P = .05, OR 2.3), and use of clopidogrel ( P = .003, OR 4.6) or warfarin ( P = .03, OR 2.3) were found to be predictive of death. Analysis by transfer diagnosis found patients with intracerebral hemorrhage had the highest incidence of mortality (12.7%, P = .003, OR 2). Patients who ultimately died were transferred faster than survivors, but this did not achieve significance.

Neurosurgery patients are vulnerable to deterioration in transit and exhibit several patterns predictive of mortality. Hydrocephalus, use of clopidogrel and warfarin, and intracerebral hemorrhage are each independently associated with elevated risk of deterioration and death.