Clinical utility and cost analysis of routine postoperative head CT in elective aneurysm clippings

Objective Postoperative head CT scanning is performed routinely at the authors' institution on all neurosurgical patients after elective aneurysm clippings. The goal of this study was to determine how often these scans influence medical management and to quantify the associated imaging costs. Methods The authors reviewed the medical records and accounting database of 304 patients who underwent elective (i.e., nonruptured) aneurysm clipping performed by 1 surgeon (M.T.L.) from 2010 to 2014 at the University of California, San Francisco. Specifically, the total number of postoperative head CT scans, radiographic findings, and the effect of these studies on patient management were determined. The authors obtained the total hospital costs for these patients, including the cost of imaging studies, from the hospital accounting database. Results Overall, postoperative CT findings influenced clinical management in 3.6% of cases; specifically, they led to permissive hypertension in 4 patients for possible ischemia, administration of mannitol for edema and high-flow oxygen for pneumocephalus in 2 patients each, seizure prophylaxis in 1 patient, Plavix readjustment in 1 patient, and return to the operating room for an asymptomatic epidural hematoma evacuation in 1 patient. When patients were stratified on the basis of postoperative neurological examination, findings on CT scans altered management in 1.1%, 4.8%, and 9.0% of patients with no new neurological deficits, a nonfocal examination, and focal deficits, respectively. The mean total hospital cost for treating patients who undergo elective aneurysm clipping was $72, 227 (± $53, 966) (all values are US dollars), and the cost of obtaining a noncontrast head CT scan was $292. Neurologically intact patients required 99 head CT scans, at a cost of $28, 908, to obtain 1 head CT scan that influenced medical management. In contrast, patients with a focal neurological deficit required only 11 head CT scans, at a cost of $3212, to obtain 1 head CT scan that changed clinical management. Conclusions Although there are no clear guidelines, the large number and high cost of CT scans needed to treat neurologically intact elective aneurysm patients suggest that careful neurological monitoring may be more clinically useful and a better use of hospital resources than routine postoperative CT.