No Routine Postoperative Head CT following Elective Craniotomy – A Paradigm Shift?

PLOS ONE, Dec 2019

Introduction 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. Methods 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. Results 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

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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. - 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)


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Ralph T. Schär, Michael Fiechter, Werner J. Z'Graggen, Nicole Söll, Vladimir Krejci, Roland Wiest, Andreas Raabe, Jürgen Beck. No Routine Postoperative Head CT following Elective Craniotomy – A Paradigm Shift?, PLOS ONE, 2016, Volume 11, Issue 4, DOI: 10.1371/journal.pone.0153499