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

Abstract

IntroductionPatient 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.MethodsFour 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.ResultsFour-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]).DiscussionEarly 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 RegistrationClinicalTrials.gov NCT01987648

How safe are elective craniotomies in elderly patients in neurosurgery today? A prospective cohort study of 1452 consecutive cases

“…As we have previously reported, failure to extubate within 1 hour after skin closure was considered delayed extubation. 16 Surgical and anesthesia reports of all included patients and histopathological reports, where applicable, were reviewed.…”

International practice variation in postoperative imaging of chronic subdural hematoma patients

“…Schär et al (2016) 34 demonstrated in a cohort of 492 patients who had undergone elective craniotomy that routine Distribution of number of postoperative CT scans per patient. Patients received a median of 0 postoperative scans in the UMCU versus 4 in the BWH (p < 0.001).…”

Efficacy of routine post-operative head computed tomography on cranial surgery patients outcome

“…1 Postoperative brain CT is done routinely after cranial procedures to predict the possibility of early complications, including hemorrhage and significant brain edema. 2 Other less urgent indications are the gross assessment of the extent of resection and ventricular catheter placement in cerebrospinal fluid diversion procedures. 3 Imaging studies in our institute are done routinely for the postoperative cranial surgeries, even in the absence of clinical indication or postoperative complications; thus, raising suspicion about the role and efficacy of routine postoperative imaging.…”