No Routine Postoperative Head CT following Elective Craniotomy – A Paradigm Shift?
April
No Routine Postoperative Head CT following Elective Craniotomy - A Paradigm Shift?
Ralph T. Schär 2 3
Michael Fiechter 2 3
Werner J. Z'Graggen 0 2 3
Nicole Söll 2 3
Vladimir Krejci 1 3
Roland Wiest 3 4
Andreas Raabe 2 3
Jürgen Beck 2 3
0 Department of Neurology, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
1 Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
2 Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
3 Editor: Luigi Maria Cavallo, Universita' degli Studi di Napoli Federico II , ITALY
4 Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern , Bern , Switzerland
Patient management following elective cranial surgery often includes routine postoperative computed tomography (CT). We analyzed whether a regime of early extubation and close neurological monitoring without routine CT is safe, and compared the rate of postoperative emergency neurosurgical intervention with published data.
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Competing Interests: The authors have declared
that no competing interests exist.
Methods
Results
Four hundred ninety-two patients were prospectively analyzed; 360 had supra- and 132 had infratentorial lesions. Extubation within one hour after skin closure was aimed for in all cases. CT was performed within 48 hours only in cases of unexpected neurological findings.
Four-hundred sixty-nine of the 492 patients (95.3%) were extubated within one hour, 20
(4.1%) within 3 hours, and three (0.6%) within 3 to 10 hours. Emergency CT within 48 hours
was performed for 43/492 (8.7%) cases. Rate of recraniotomy within 48 hours for patients
with postoperative hemorrhage was 0.8% (n = 4), and 0.8% (n = 4) required placement of
an external ventricular drain (EVD). Of 469 patients extubated within one hour, 3 required
recraniotomy and 2 required EVD placements. Of 23 patients with delayed extubation, 1
recraniotomy and 2 EVDs were required. Failure to extubate within one hour was
associated with a significantly higher risk of surgical intervention within 48 hours (rate 13.0%, p =
0.004, odds ratio 13.9, 95% confidence interval [3.11–62.37]).
Discussion
Early extubation combined with close neurological monitoring is safe and omits the need for routine postoperative CT. Patients not extubated within one hour do need early CT, since they had a significantly increased risk of requiring emergency neurosurgical intervention.
Trial Registration
ClinicalTrials.gov NCT01987648
Introduction
Postoperative patient management following elective cranial surgery varies substantially
between different neurosurgical institutions. The common objective in this crucial period is to
avoid or detect any early postoperative complications such as intracranial bleeding, ischemia,
or brain swelling. Since the introduction of computed tomography (CT) in the 1970s,
postoperative head CT within the first hours after neurosurgery has been advocated [
1
]. These imaging
studies are often ordered even in the absence of unexpected neurological findings in order to
rule out complications. In many departments patients are not transferred to the wards until
they have been “cleared” by CT scanning. This practice of routine head CT scanning has not
been substantiated by any prospective evidence, but is perpetuated by common procedural
standards and training background of the neurosurgeons [
2, 3
]. However, there is growing
evidence from retrospective series that routine head CT may not be necessary after neurosurgical
cranial procedures [
2, 4
]. Results of recent studies and clinical reasoning argue that repetitive
neurological examination and surveillance is key for detection of complications with the need
for return to the operating room (OR). Early termination of anesthesia and early extubation is,
of course, mandatory for a thorough neurological examination. Today most neurosurgical
patients are awakened directly postoperatively in the OR for clinical assessment. Still, some
institutions—at least within Europe—prefer a delayed extubation with parameter focused
monitoring on the intensive care unit (ICU) over an early extubation in the OR with
clinicalneurological monitoring of the awakened patient. The concerns for latter strategy may
originate from a fear of too much cardiopulmonary and metabolic distress to the just trephined
patient caused by an immediate (“forced”) awakening and extubation with potential sequelae
(e.g. postoperative hemorrhage, brain swelling). No evidence from prospective studies exist to
support these assumptions.
Therefore we prospectively analyzed a strategy of early extubation without routine head CT
after elective cranial neurosurgical procedures. The hypothesis was that the early extubation
with dedicated neurological monitoring and no routine head CT strategy provides sufficient
patient safety as compared with reported data in the lit (...truncated)