THE IMPACT OF THE ACCESSIBILITY OF CRANIAL CT SCANS ON PATIENT-EVALUATION AND MANAGEMENT DECISIONS

Objectives. Cranial CT scans are amongst the most frequently performed radiological investigations performed in most developed countries. Ho wever, these tests are relatively expensive and economic realities sho uld compel physicians to re-evaluate the utilization of this technolog y. The aim of this study was to review the utilization pattern and eff ect on management decisions of cranial CT scanning. Design. Retrospect ive chart review. Setting. University-affiliated community teaching ho spital. Subjects. The clinical data on 451 consecutive patients underg oing cranial CT scanning in our radiology department were reviewed. Ei ghty-five patients were referred from outside the hospital and were su bsequently excluded from further analysis. Interventions. None. Main o utcome measures. The following data was abstracted from each patient's chart: the presenting clinical syndrome, the physician ordering the s can, details of the neurological examination performed prior to scanni ng, the CT scan findings and the impact the CT scan findings had on ma nagement decisions. Results. The largest percentage of patients were r eferred from the emergency department (61%). Chronic intracranial lesi ons were present in 77 (21%) patients. New pathological findings were found in 91 (25%) patients. The commonest new lesions were ischaemic i nfarcts (43%), followed by intracerebral haemorrhage (13%) and space o ccupying lesions (11%). Ninety-seven per cent of patients presenting w ith new focal neurological signs had new findings on the CT scan, comp ared to 28% of patients with severe headache and 27% with a history of loss of consciousness. Head trauma was the presenting problem in 139 patients. New pathological findings were diagnosed in 24 of these pati ents. Fifty-four patients had no signs or symptoms referable to the ce ntral nervous system. None of these patients had new findings on CT sc an. In the vast majority of patients the neurological examination perf ormed prior to CT scanning was incomplete. CT scanning was considered to have altered the management or provided a new diagnosis in 162 (44% ) patients; of these patients 61 (67%) were in the group with new find ings on CT scanning and 101 (37%) in the group with no new findings. C onclusion. In this study cranial CT scanning affected clinical managem ent decisions in less than half of the patients. Furthermore, a carefu l history and neurological examination was performed in the minority o f patients undergoing CT scanning. It would therefore appear that the easy accessability of CT scans largely determines the utilization of t his diagnostic tool.