Clinical Profile of Neurosurgical Consultations from the Emergency Department : A Retrospective Analysis

Article information

J Korean Neurosurg Soc. 2026;69(2):247-255

Publication date (electronic) : 2026 February 4

doi : https://doi.org/10.3340/jkns.2025.0160

Bekir Tunç^,1, Oğuzhan Uzlu¹, Ömer Faruk Şahin¹, Egemen Ünal²

¹Department of Neurosurgery, Ordu University Faculty of Medicine, Ordu, Turkey

²Department of Public Health, Ankara Yıldırım Beyazıt University Faculty of Medicine, Ankara, Turkey

Address for correspondence : Bekir Tunç Department of Neurosurgery, Ordu University Faculty of Medicine, Cumhuriyet Street, Altınordu, Ordu 52200, Turkey Tel : +90-5302333641, E-mail : bekir5099@hotmail.com

Received 2025 August 7; Revised 2025 September 24; Accepted 2025 October 9.

Abstract

INTRODUCTION

Emergency departments (EDs) play a vital role within healthcare systems by enabling rapid intervention in life-threatening conditions and thereby reducing morbidity and mortality [2,7]. EDs stand out as the most accessible component of healthcare systems worldwide, owing to their 24/7 uninterrupted service, lack of appointment requirements, and ease of access [27]. The primary characteristic of EDs is that they serve as the initial point of care for patients presenting with sudden-onset health problems requiring urgent intervention [32].

Current research has shown that approximately 10% to 40% of patients evaluated in the EDs require urgent consultation [22]. It is of great importance to ensure that all relevant information is accurately conveyed and that the appropriate patient is referred to the correct specialty. Otherwise, unnecessary consultations may prolong the length of stay in the EDs and contribute to overcrowding [1]. Practices such as the early identification of patients requiring consultation and timely referral to the appropriate department may help reduce the length of stay in the EDs [34].

Neurosurgery (NS), as one of the most frequently consulted departments from the EDs, plays a critical role in the prompt diagnosis and management of both traumatic and non-traumatic neurological cases. Therefore, a structured and efficient consultation process is essential to minimize delays in the diagnostic and therapeutic management of such patients.

The primary aim of this study is to retrospectively analyze neurosurgical consultations requested from the ED of a tertiary care hospital, and to comprehensively evaluate the clinical characteristics, referral reasons, and diagnostic and therapeutic processes of these cases. In this study, not only diagnostic accuracy and treatment approaches were assessed, but also dynamics such as seasonal variations, consultation frequency, and workload were analyzed to elucidate the structural burden of neurosurgical patient management in the EDs. Accordingly, the study aims to provide concrete recommendations for strategic objectives such as optimizing hospital workflow, strengthening interphysician coordination, and standardizing consultation processes. It is anticipated that the findings will offer an evidence-based foundation to enhance both triage accuracy and the referral and decision-making skills of emergency physicians (EPs).

MATERIALS AND METHODS

The study was conducted in accordance with the approval obtained from the Ordu Unıversity Ethics Commitee (decision No. : 2025/05; date : 2025 January 3).

This single-center, retrospective study included patients who presented to the ED of a tertiary care hospital and were referred for a NS consultation between January 1, 2024 and December 31, 2024.As part of the study, demographic data, consultation request notes prepared by EPs, consultation responses provided by NS specialists, and radiological imaging findings were reviewed in detail through the hospital information management system.

EPs consultation request note is a brief medical record summarizing the patient’s presenting complaints, neurological examination findings, and available radiological imaging, including the presumptive diagnosis, as assessed by the EPs.

The NS consultation response is a comprehensive medical report provided by the NS specialist based on the patient’s clinical status, neurological examination findings, and available radiological data, as referred by the EPs. It includes the definitive diagnosis, recommended further investigations, treatment plan, and indicated surgical or conservative management approaches.

The patients’ radiological imaging refers to the diagnostic materials obtained to support the diagnostic process in ED patients, including brain, spinal, or other relevant system evaluations performed using computed tomography (CT), magnetic resonance imaging (MRI), or plain radiography, along with the corresponding interpretation reports provided by radiologists.

The preliminary diagnosis made by the EP requesting consultation was compared with the final diagnosis established by the neurosurgeon based on clinical and radiological evaluation, as well as with the radiologist’s imaging report. In this study, the concordance between preliminary and final diagnoses, together with the clinical and radiological consistency between imaging findings and radiology reports, was defined as diagnostic accuracy.

Based on these data, the patients’ presenting reasons were categorized into two main groups : 1) traumatic causes (fall, invehicle traffic accident [IVTA], out-of-vehicle traffic accident [OVTA], blunt trauma, gunshot wound [GSW]) and 2) non-traumatic causes (headache, altered mental status, syncope, motor weakness, seizure, amnesia, dizziness, vomiting, facial paralysis, dysphasia, ptosis, etc.).

The admission diagnoses were classified as follows : 1) traumatic : cranial fracture, cranial hemorrhage, and spinal fracture and 2) non-traumatic : intracerebral hemorrhage (ICH), subdural hemorrhage (SDH), subarachnoid hemorrhage (SAH), hydrocephalus, and intracranial/spinal mass lesions.

Inclusion criteria : the study included only consultations requested by the ED to the NS department. Patients were included if their radiological imaging data were fully accessible, and if both the consultation request note written by the EPs and the consultation response provided by the NS specialist were complete. Patients in whom the final diagnosis established by the neurosurgeon and the radiology report demonstrated clinical and radiological concordance were considered diagnostically consistent. Multiple neurosurgical consultations performed during the same admission were evaluated as a single consultation.

Exclusion criteria : patients whose radiological imaging data were incomplete, or those with complete imaging data but with missing consultation request notes from the EPs and/or incomplete consultation responses from the NS specialist, were excluded from the study. In addition, neurosurgical consultations requested from inpatient wards outside the ED were not included.

RESULTS

An analysis of the reasons for presentation revealed that, over the course of 2024, a total of 386 patients (male, 222 [57.5%]; female, 164 [42.5%]) presenting to the ED and receiving a neurosurgical consultation were classified into two groups : traumatic and non-traumatic. The traumatic group (267 patients, 69%) included cases presenting with falls, IVTA, OVTA, blunt trauma, and GSW, which were categorized under the main diagnostic headings of cranial fracture, cranial hemorrhage, and spinal fracture. The non-traumatic group (119 patients, 31%) comprised cases presenting with altered consciousness, syncope, motor weakness, amnesia, seizure, headache, cauda equina symptoms, dysphasia, dizziness, vomiting, nausea, facial paralysis, dyspnea, and ptosis, and were classified under the main diagnostic headings of intracranial and spinal mass lesions, SDH, ICH, SAH, and hydrocephalus.

The monthly distribution of patients consulted from the ED to NS, categorized as traumatic and non-traumatic, is presented; the number of consultations peaked during the summer months, primarily due to an increase in traumatic cases, although a noticeable rise was also observed in non-traumatic cases (Fig. 1).

Fig. 1.

Monthly distribution of neurosurgical consultations in the emergency departmant. The blue line shows total consultations, the red line trauma-related cases, and the green line non-traumatic cases. Values represent the number of patients per month.

In our study, patients evaluated during the day shift (07:00 to 19:00) and night shift (19:00 to 07:00) were analyzed separately. Among traumatic cases, 174 were assessed during the day and 93 at night. Falls were the most common cause in both shifts, with a more pronounced increase during daytime hours. Diagnostic accuracy for spinal fractures was high in both shifts, whereas accuracy for cranial fractures and hemorrhages was lower, particularly at night. Among non-traumatic cases, 79 were evaluated during the day and 33 at night. Although patient volume was higher during the day, diagnostic accuracy was 59.5% compared to 66.7% at night. By diagnostic category, ICH demonstrated 100% accuracy during the day, while mass lesions showed consistently high accuracy in both shifts (76.2% during the day and 80% at night).

Of the 386 cases, 173 (44.8%) were safely triaged by EPs as not requiring urgent neurosurgical intervention, whereas 40 cases (10.4%) were identified with pathologies necessitating surgical management.The numerical and descriptive distribution of diagnostic outcomes among patients presenting to the ED and consulted to NS is presented in Table 1.

Table 1.

Numerical distribution of patients presenting to the emergency department according to diagnostic accuracy outcomes

The numerical distribution of patients according to traumatic causes of presentation is presented, with falls identified as the most common cause of trauma (70.8%) (Table 2).

Table 2.

Distribution of traumatic patients by cause of presentation and number of cases

Among traumatic patients, spinal fractures demonstrated the highest diagnostic accuracy when compared to cranial hemorrhages and cranial fractures. Table 3 presents the distribution of diagnostic accuracy by number of cases, categorized into the subgroups of hemorrhage and fracture. Distribution of traumatic patients according to diagnostic categorization, with subgroups of hemorrhage and fracture.

Table 3.

Distribution of traumatic patients according to diagnostic categorization, with subgroups of hemorrhage and fracture

Among trauma patients, 29 cases were triaged with suspected cranial fracture; however, in 11 of these cases (37.9%), the presumptive diagnosis was not confirmed upon neurosurgical evaluation, with the majority of unconfirmed cases occurring in children aged 0–2 years.

Of the 29 patients who presented after a fall and were triaged with a presumptive diagnosis of cranial hemorrhage that was not confirmed by neurosurgical evaluation, eight were initially consulted with a presumptive diagnosis of SDH; however, subsequent neurosurgical assessment identified these cases as subdural effusion.

Non-traumatic patients were classified according to their reasons for presentation to the ED, with headache identified as the most common non-traumatic cause (31.1%) (Table 4). Among non-traumatic patients, the highest rates of diagnostic concordance following neurosurgical confirmation were observed in ICH (90.9%) and intracranial/spinal mass lesions (77.4%) (Table 5). Of the 19 non-traumatic patients who were initially suspected of having a SDH, eight were later determined to have a subdural effusion.

Table 4.

Distribution of non-traumatic patients by reason for presentation and number of cases

Table 5.

Distribution of diagnostic evaluation and final diagnosis in non-traumatic patients

DISCUSSION

EDs provide uninterrupted services in cases of trauma, accidents, natural disasters, and other life-threatening conditions, ensuring rapid and effective intervention. The primary objective is to promptly identify patients who require urgent medical care and direct them to appropriate treatment. However, presentations by individuals without emergency complaints increase the workload of ED; thus, the triage process plays a critical role in distinguishing true emergencies from non-urgent cases [9,29]. As emphasized in the literature, the fundamental priority in emergency medicine is to avoid overlooking life-threatening conditions and to establish exclusion diagnoses with high sensitivity. In our study, it was demonstrated that EPs did not miss life-threatening diagnoses and adopted a safe, high-sensitivity-based triage approach. Following this secure triage process, we aimed to comprehensively evaluate the aspects of consultation practices that could be improved and the areas requiring further development.

EDs are units where the initial management of critically ill patients is performed and subsequent treatments are planned through various consultations. In this context, NS serves a large number of critically ill patients [31]. According to the literature, the majority of patients presenting to the ED and referred to NS are trauma patients [31]. Similarly, in our study, trauma patients accounted for the largest proportion at 69%, with falls (48.9%) and traffic accidents (15.5%) being the most common causes among trauma cases. Among non-traumatic patients, headaches ranked first, accounting for 9% of cases. When all trauma patients were evaluated, our study found that consultations were most frequently performed during the summer months. Similarly, the literature also reports an increase in trauma-related presentations to EDs during the summer [17,30] (Fig. 1). Considering the increase in patient admissions during the summer months, effective collaboration between ED and NS teams should be ensured to enhance the accuracy of preliminary diagnoses and prevent unnecessary consultations. Furthermore, appropriate planning should be implemented to address fluctuations in seasonal workload.

The prompt and accurate identification of skull injuries in trauma cases is critical to prevent further damage. Cranial CT is widely regarded as the standard diagnostic modality in suspected traumatic head injuries; however, in current clinical practice, the detection of fractures through slice-by-slice examination of CT images remains labor-intensive, subjective, and prone to error. Automating CT image analysis for skull fracture detection could significantly improve both the speed and accuracy of diagnosis—particularly in scenarios where emergency intervention and definitive diagnosis are vital, and specialist availability may be limited [24]. In our study, among 29 patients presenting with suspected fractures due to falls, diagnostic accuracy was not achieved in 11 cases (37.9%), the majority of whom were in the 0–2-year age group. There are several fundamental reasons why the detection of skull fractures using CT in children aged 0–2 years is more prone to diagnostic errors compared to other age groups. Maintaining infants in a still position during CT imaging is often challenging, leading to degraded image quality and making the detection of subtle fractures more difficult. Moreover, vascular channels in the bone may be mistaken for non-displaced fractures, as they also appear as radiolucent (dark) lines within the bone [5]. Additionally, fracture lines are often oriented perpendicular to the imaging plane, resulting in each slice depicting only a small segment of the lesion; this limitation stems from the inherently three-dimensional nature of fractures, while the radiologist’s view is confined to a two-dimensional plane that may not align with the fracture line [8]. The implementation of clinical decision rules is essential to improve the accuracy of preliminary diagnoses and prevent unnecessary CT utilization. In particular, the Pediatric Emergency Care Applied Research Network (PECARN) rule has demonstrated high sensitivity in pediatric head trauma, providing reliable diagnostic accuracy of 97.5% in patients aged ≥2 years and 97.9% in those <2 years [12]. Furthermore, it has been reported that cases requiring neurosurgical intervention or intensive care were not overlooked [4]. Application of the PECARN rule can reduce unnecessary CT examinations, minimize radiation exposure, and allow for greater emphasis on clinical observation. This approach is currently recommended to ensure safe and high-quality care, especially in pediatric populations [4,19]. Therefore, adopting PECARN-based decision-making rather than focusing on minor radiological details without life-threatening implications in pediatric trauma will enable neurosurgeons and EPs to conduct interdisciplinary consultations more effectively and in the best interest of the patient.

Cauda equina syndrome (CES) is a rare (1–3 per 100000) but devastating surgical emergency associated with significant morbidity and mortality [26]. The most important clinical findings for diagnosis include bilateral radicular pain, perianal sensory loss, and bladder/bowel dysfunction [11]. While the most common etiology is disc herniation, degenerative joints, tumors, and infections may also contribute [26]. The United Kingdom guidelines recommend same-day imaging in patients presenting with urinary, bowel, or sexual dysfunction or perineal sensory changes [13], and the literature consistently emphasizes the necessity of urgent MRI in suspected cases [16]. Furthermore, the involvement of the spinal surgery team within the ED has been reported to shorten MRI waiting times, reduce unnecessary admissions, and significantly improve patient management [3]. In the future, standardized MRI request forms and the provision of 24-hour emergency MRI services may enhance diagnostic accuracy while strengthening cost-effectiveness [10]. In our study, all 16 patients evaluated by EPs with suspected CES based on history and physical examination underwent lumbar MRI and were subsequently referred to NS. Following a detailed history and physical examination by a neurosurgeon, CES was confirmed in four of these patients, who underwent surgical treatment. No CES-consistent findings were identified in the remaining cases. These results suggest that joint evaluation by EPs and neurosurgeons in suspected cases may improve diagnostic accuracy. In particular, shared history-taking and physical examination (especially for red-flag symptoms) prior to direct MRI referral may strengthen the clinical experience of EPs while also reducing unnecessary imaging. Neurological examination remains the cornerstone of CES diagnosis, with definitive confirmation established by MRI [25]. This approach not only enhances cost-effectiveness and the quality of patient care but also contributes to the clinical development of EPs and may reduce workload in the long term.

Spontaneous SAH is a critical clinical condition associated with high morbidity and mortality, requiring urgent diagnosis and treatment. The literature reports a prehospital mortality rate of 22–26% related to SAH [20]. Therefore, in patients presenting with sudden and severe headache, it is vital for EPs to maintain a high level of clinical suspicion to ensure early diagnosis and appropriate referral. Any delay in diagnosis and treatment has been shown to increase mortality and the risk of permanent neurological sequelae [6]. In our study, among 16 patients consulted with a preliminary diagnosis of SAH, the diagnosis was confirmed in eight cases following neurosurgical evaluation. Although no life-threatening pathology was found in the remaining patients, the early consultation initiated by EPs on the basis of high clinical suspicion was considered a positive approach for patient safety and timely intervention. The 2023 AHA/ASA (American Heart Association/American Stroke Association) guidelines clearly outline the principles of early management of SAH, recommending rapid neuroimaging for diagnostic confirmation, securing ruptured aneurysms within the first 24 hours when possible, meticulous blood pressure monitoring, and urgent reversal of anticoagulant therapy in eligible patients [18]. Supportive measures such as airway protection, maintenance of normovolemia, avoidance of hypoxia and hyperoxia, and control of seizures and fever also represent integral components of management [18]. These findings once again emphasize the critical importance of multidisciplinary collaboration and rapid, organized communication in the early diagnosis and treatment of SAH. Establishing direct communication pathways between emergency, radiology, and NS teams, expediting CT reporting, and prioritizing the evaluation of suspected SAH cases may not only reduce unnecessary consultations and alleviate workload but also ensure timely treatment of high-risk patients, thereby lowering mortality and morbidity [18,35]. As highlighted in recent literature, innovative strategies such as artificial intelligence-based image analysis and telemedicine applications may further enhance diagnostic accuracy, promote equity in healthcare delivery, and improve long-term patient outcomes [33].

Subdural effusion and SDH are distinct clinical entities, both characterized by fluid accumulation between the meningeal layers [21]. In subdural effusions, the fluid is typically cerebrospinal fluid (CSF), whereas in SDHs it is blood. In certain cases, a subdural effusion may appear on imaging as a CSF-density collection in the subdural space, and reduced brain volume—as seen in hydrocephalus ex vacuo—can mimic the radiographic appearance of a SDH [28]. Most subdural effusions are asymptomatic and resolve spontaneously once brain expansion or CSF resorption exceeds the effusion. Unlike SDH, effusions generally do not demonstrate sulcal effacement or signs of mass effect [23]. In our study, among non-traumatic patients referred to NS with a presumptive diagnosis of SDH, nine were ultimately diagnosed with subdural effusion. Similarly, among 29 trauma patients with suspected cranial hemorrhage in whom diagnostic accuracy was not achieved, eight were found to have subdural effusion. Given that the management and follow-up protocols for effusions and hemorrhages differ substantially, accurate radiologic differentiation between these two entities is of critical importance. Careful radiologic interpretation combined with clinical judgment—or waiting for the formal CT report in stable patients without midline shift—may help reduce unnecessary neurosurgical consultations from the ED.

Spontaneous ICH is recognized as the most fatal form of acute stroke, with an early mortality rate of approximately 30–40% [14]. Early diagnosis, prompt medical treatment, and neurosurgical intervention when indicated are essential to optimize outcomes [15]. In our study, the detection rate of ICH by CT imaging was high among 22 patients presenting to the ED, and of the 20 patients who received a definitive diagnosis following consultation, only one underwent decompressive craniectomy and one required external ventricular drainage. The remaining cases were predominantly managed and monitored by neurologists in the intensive care unit. According to the 2022 AHA/ASA Spontaneous ICH Guideline, rapid activation of the prehospital emergency response system and prehospital notification significantly reduce diagnostic and treatment times. In the ED, prompt neuroimaging—particularly CT—forms the cornerstone of ICH diagnosis. Moreover, early diagnosis and rapid triage in the ED are emphasized to have a direct impact on both mortality and prognosis [14]. These findings underscore the importance of an effective multidisciplinary approach involving emergency medicine, neurology, NS, and radiology in improving diagnostic accuracy and patient outcomes.

CONCLUSION

Our study demonstrated that the majority of consultations from the ED to NS were trauma-related; however, a substantial proportion did not require surgical intervention. The increase in patient admissions during the summer months highlights the need for workload planning tailored to seasonal variations.

In pediatric head trauma, the application of the PECARN rules may reduce unnecessary CT examinations, thereby ensuring safe and high-quality care. In suspected CES, joint history-taking and physical examination by both EPs and neurosurgeons may facilitate better recognition of red-flag symptoms, helping to prevent unnecessary MRI studies.

For conditions with high mortality rates, such as SAH and ICH, rapid access to care can be supported through telemedicine applications, artificial intelligence-based imaging analysis, and image-sharing-driven diagnostic training. Furthermore, joint educational meetings conducted in accordance with current guidelines and the use of standardized consultation templates may contribute to making the process faster, more systematic, and more effective.

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