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For referring physicians

Send the images, not the report.

Most of these decisions are made from the pictures. A reported “small aneurysm” or “vascular malformation” tells me very little; the source images tell me almost everything. Second opinions are welcome from anywhere, and the honest answer is often that nothing needs doing.

What makes an opinion useful

  • The images themselves — DICOM on a drive or a link, not screenshots of the report. Send them on WhatsApp to +91 91379 16422, or by email to mumbaistrokecare@gmail.com. Large studies are easiest as a Drive or WeTransfer link.
  • Why the scan was done, and what the patient actually complains of. An incidental aneurysm and a symptomatic one are different problems.
  • Anticoagulants and antiplatelets, the indication, and whether they can safely be interrupted.
  • For an aneurysm: any family history of aneurysm or subarachnoid haemorrhage, blood pressure control and smoking history.
  • For pulsatile tinnitus: whether the sound stops on compressing the neck, and what the ENT and audiology workup has already shown.
  • For a suspected chronic subdural: the fall, however trivial, and how quickly the change in the patient has come on.

Acute emergencies — a thunderclap headache, a suspected rupture, or a large-vessel stroke — should come by phone to the emergency line at any hour rather than by message. Whichever route you use, put the patient name and one contact number in the message so the images can be matched to the history.

Referral thresholds

When it is worth a call

These are the presentations most often investigated in the wrong direction. None of them needs to be certain before you pick up the phone.

  • Pulsatile tinnitus with a normal ENT workupA sound synchronous with the pulse warrants vascular imaging. A normal MRI does not exclude a dural fistula.
  • Incidental aneurysm on MRI or CTWorth an opinion before the patient is either alarmed or reassured. Many need surveillance rather than treatment.
  • Confusion or decline in an anticoagulated older adultA plain CT excludes chronic subdural haematoma in minutes.
  • First adult seizure with any vascular abnormality on imagingAVM and cavernoma change the management entirely.
  • Progressive myelopathy with cord signal changeAsk for the MRI to be reviewed for perimedullary vessels before attributing it to degenerative disease.
  • Red, proptosed or pulsatile eyeParticularly after head injury, or where drops have failed.

Joint management is welcome

Patients referred for an opinion are returned to you with a written note setting out the reasoning, not just the recommendation — including where surveillance rather than intervention is advised, and what should prompt re-referral.

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