Want to know whether a patient recovering from brain surgery will need to go back to the operating room? Clinical evaluations might prove more valuable than CT scans, according to a new study.

Doctors at Loyola University Medical Center in Maywood, Ill. found that the presence of neurological deficits following brain surgery bested routine head CT scans in determining when someone needed to go back under the knife to treat post-op complications like bleeding.

As reported in the December 18 online edition of Journal of Neurosurgery, doctors at Loyola examined all cases of initial, routine post-op head CT scans done by three surgeons during 2006.

Of the 251 exams, only those ordered after the doctors identified a neurological deficit ever required a return to surgery. Deficits generally include speech impairments not present before surgery, slow revival after anesthesia and seizures.

"Routine scanning of patients had no yield in terms of bringing patients back to the operating room," Thomas Origitano, M.D., Ph.D., a neurosurgeon at Loyola and senior researcher of the study, tells DOTmed News. "If, however, a patient had a new neurological deficit, then getting a scan was important because 30 percent of those patients returned to the operating room."

Better results for those who wait

But that wasn't all the study found. It also discovered that the best time to get a CT scan wasn't immediately after brain surgery: it was around a day later.

"What we would recommend is a scan directly after surgery should only be done if there's a new neurological deficit, and that if you want to get a scan to help manage consequences of surgery, wait 12 to 24 hours," Dr. Origitano says.

In the study, Dr. Origitano and colleagues found, by checking follow-up scans ordered within 96 hours of the surgery, that many patients' acuity changed, sometimes worsening, well after their initial exam that was ordered only hours after the operation. In fact, of the 14 patients who had a change in acuity, 13 had CT scans within four hours of surgery that were normal or only showed minor changes in patient condition.

Although none of the follow-up scans run after 24 hours promoted putting patients back on the operating table, many showed changes in acuity of the sort that could require significant differences in management. Examples of the kind of differences include prescribing medication to decrease swelling or keeping the patient in the intensive care unit for further observation.

Dr. Origitano and his colleagues worry that ordering a scan in the first several hours following surgery isn't just non-productive, it could actually lull doctors into a "false sense of security," they write in the paper, "leading to patient dispositions where less frequent neurological exam and monitoring are performed."

No CT bashing

But Dr. Origitano is quick to point out that the study is not an exercise in CT "bashing."

"It does not say CT scans aren't any good," he says. "It says, if you're going to get a scan, [see] if the patient has a new neurological deficit. And if you want to see consequences for surgery, wait at least till the next day. If you get a scan too early you'll miss a lot of changes ... to occur down the line."

CT scans after brain surgery are still often required to check if a device is properly positioned, he notes, and to see how much of a tumor was removed (though he suggests MR imaging could work better for the latter).

He also notes the limitations of the study. It was conducted at one institution, so more research is needed to say how well the results carry to other health care centers.

Best practice

Dr. Origitano says the real point of the study is to identify the best practice and account for variations in how medicine is performed.

"What we're trying to do is a classical event that happens in medicine," he says. "You find out there are a number of different practices, none of which are wrong. So do we have evidence which would direct us to best practice?"

In the study, for example, one of the three doctors ordered almost nine-tenths of his CT scans within the first seven hours following surgery. The reason? That's how he learned to do it.

"In medicine, there are a lot of cultural, institutional practices which we carry forward because that's basically how we're taught," Dr. Origitano says. "A lot of what we do is not bad medicine, but it's medicine derived out of culture, habit, different schools of thinking. And as medical resources become more expensive--and any test we do including a CT scan has some risk to it--we need to be thoughtful about when we're going to apply these studies," he says.