The inpatient neurology consultation service: value and cost.

Neurological conditions comprise a significant proportion of patient admissions to hospital but, in the majority of cases, are admitted under the care of non-neurological physicians. As a consequence, neurological ward consultations are commonly requested by the admitting medical teams to review diagnoses and management plans. The outcomes of neurological ward consultations were examined and the time required for the referral process recorded by performing a detailed prospective three-month audit of inpatient referrals to the neurology service. The consultations of 120 patients were recorded, categorised and analysed. These consultations were beneficial in the vast majority of cases, with a clear impact on patient diagnoses or management plans. The consultation process was time consuming, however, both in respect of the initial review, but also with follow-up visits. This audit highlights the importance of neurological input in the diagnosis and management of hospital inpatients. The time taken for this process should be resourced appropriately.

Imaging results in a consecutive series of 530 new patients in the Birmingham Headache Service.

Guidelines recommend imaging only headache patients with sinister features in the history or on examination. We prospectively collected data on imaging newly presenting patients to a UK headache service. CT and MRI results were classified as normal or showing an insignificant or significant abnormality. Over 5 years, 3,655 new patients (69% female; mean age 42.0 years) with headache disorders were seen. Five hundred thirty (14.5%) underwent imaging with large differences in the proportion referred by each consultant. There were more insignificant abnormalities on MRI (46%) than CT (28%). There were 11 significantly abnormal results (2.1% of those imaged). Significant abnormalities were found in patients diagnosed with migraine in 1.2% and in 0.9% of those with tension-type headache. Significant abnormalities in those suspected to have an intracranial abnormality occurred in 5.5%. This supports the practice of selecting patients with suspicious findings for imaging, rather than imaging all patients.

Ability of a nurse specialist to diagnose simple headache disorders compared with consultant neurologists.

OBJECTIVE: To compare the ability of a headache nurse specialist and consultant neurologists in diagnosing tension-type headache and migraine. METHODS: An experienced neurology ward sister was trained in the differential diagnosis of headache disorders. Over six months, patients with non-acute headache disorders and role players trained to present with benign or sinister headaches were seen by both the nurse and a consultant neurologist. Both reached independent diagnoses of various headache disorders. RESULTS: Consultants diagnosed 239 patients with tension-type headache (47%), migraine (39%), or other headache disorders (14%). The nurse agreed with the consultant in 92% of cases of tension-type headache, 91% of migraine, and 61% of other diagnoses. Where the nurse did not agree with the diagnosis, most would have been referred for a consultant opinion. Both the nurse and the doctors misdiagnosed the same three of 13 role players. The investigation rate of the consultants varied between 18% and 59%. Only one clinically relevant abnormality was found on head scans and this was strongly suspected clinically. CONCLUSIONS: A headache nurse specialist can be trained to diagnose tension-type headache and migraine. A nationwide nurse led diagnostic headache service could lead to substantial reduction in neurology waiting times.

Effect of treatment of carotid artery stenosis on blood pressure: a comparison of hemodynamic disturbances after carotid endarterectomy and endovascular treatment.

BACKGROUND AND PURPOSE: Carotid intervention by carotid endarterectomy (CEA) or endovascular treatment may cause hemodynamic change. The immediate and long-term effects on blood pressure after these procedures were assessed. METHODS: Patients were randomized to CEA (n=49) or endovascular treatment (n=55) that comprised percutaneous transluminal angioplasty alone (n=31), balloon-expandable stent (n=13), or self-expandable stent (n=11). A baseline 24-hour ambulatory blood pressure recording was made before carotid intervention and repeated at 24 hours, 1 month, and 6 months after the procedure. RESULTS: In the first 24 hours after the procedure, episodes of hypotension occurred in 75% of the CEA group and 76% of the endovascular group; hypertension occurred in 11% and 13%, respectively. There was a significant fall in blood pressure at 1 hour after the procedure in both groups (24 and 16 mm Hg fall in CEA and endovascular groups, respectively), but this was only sustained in the endovascular group. The pattern of blood pressure response in the first 24 hours was significantly different (P<0.0001, ANCOVA). Systolic blood pressure was significantly lower at 1 and 6 months only in the surgical group (6 and 5 mm Hg fall, respectively). CONCLUSIONS: Both CEA and endovascular treatment have an effect on blood pressure stability, particularly within the first 24 hours after the procedure.

Middle cerebral artery blood velocity, embolisation, and neurological outcome during carotid endarterectomy: a prospective comparison of the Javid and the Pruitt-Inahara shunts.

OBJECTIVES: To investigate the in vivo haemodynamic performance and neurological outcome of two types of carotid shunt. DESIGN: Randomised single surgeon study of consecutive symptomatic patients. SETTING: 163 consecutive patients undergoing carotid endarterectomy for symptomatic carotid disease were randomised to the Javid or Pruitt shunt. CHIEF OUTCOME MEASURES: Middle cerebral artery velocity (MCAV), preoperatively, during clamping, during shunting and post-restoration of flow, embolic episodes, neurological outcome. MAIN RESULTS: The MCAV preoperatively, at carotid clamping, and postoperatively was the same for both groups (p > 0.15). During shunting the MCAV was significantly lower in the Pruitt group, p < 0.005, 59% of the Javid and 34% of the Pruitt shunts maintained MCAV at preoperative levels p < 0.005, chi 2 = 8.92. The Javid shunt produced significantly more emboli (73% of cases) at declamping than the Pruitt (41%), p < 0.0002, chi 2 = 14.7. Four Javid patients and one Pruitt had disabling thromboembolic strokes; overall thromboembolic stroke rate 3.7%. The difference in stroke rates was not statistically significant (p = 0.14). CONCLUSIONS: The Pruitt shunt was unable to maintain preoperative MCAV in 66% of cases, the Javid shunt had a higher incidence of emboli on declamping. These factors may lead to an increased risk of stroke; however, the numbers required for statistical confirmation would be large.

European carotid angioplasty trial.

The Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS) is an international multicenter randomized trial, the primary aims of which are: (1) to determine the risks and benefits of carotid and vertebral artery transluminal angioplasty; and (2) to compare these with surgical treatment (carotid endarterectomy) or best medical treatment. Through the end of October 1995, 193 patients have been randomized (90 at our center). In this article, the rationale for the trial, its design and protocol, and the experience of our institution within the trial will be discussed.