Routine early CT scanning after craniotomy: is it effective for the early detection of postoperative intracranial hematoma?

To scan or not to scan? A retrospective cohort study analysing the efficacy of routine post-operative CT after brain biopsy

PURPOSE

Postoperative management following elective cranial surgery, particularly after biopsy procedures, varies significantly across neurosurgical centres. Routine postoperative head CT scans, traditionally performed to detect complications such as intracranial bleeding or cerebral oedema, lack substantial evidence supporting their necessity.

METHODS

This study is a retrospective cohort analysis conducted at a regional neurosurgical department of 236 patients who underwent brain biopsies between 2018 and 2022. Patient data, including demographics, surgical details, and postoperative outcomes, were collected and analysed. The outcomes investigated were the incidence and impact of postoperative CT scans on time to discharge, management changes, and the influence of preoperative anticoagulation.

RESULTS

Out of 236 patients, 205 (86.86%) underwent postoperative CT scans. There was no significant relationship between postoperative hematoma, as detected on a CT scan, and neurological deficit (p = 0.443), or between preoperative anticoagulation and postoperative bleeding on CT scans (p = 0.464). Patients who had postoperative CT scans had a significantly longer length of stay (LOS) compared to those who did not (p < 0.001). Intraoperative bleeding was a predictor of hematoma on postoperative CT (p = 0.017) but not of postoperative neurological deficit. The routine postoperative CT scan showed limited predictive value for symptomatic deficits, with a positive predictive value of 6.67% and a negative predictive value of 96.88%.

CONCLUSIONS

Routine postoperative CT scans after brain biopsies do not significantly impact management or improve patient outcomes but are associated with longer hospital stays. CT scans should be reserved for patients showing clinical signs of complications rather than used as a routine procedure after a brain biopsy.

Poroelastic modelling of brain tissue swelling and decompressive craniectomy treatment in ischaemic stroke

Brain oedema or tissue swelling that develops after ischaemic stroke can cause detrimental effects, including brain herniation and increased intracranial pressure (ICP). These effects can be reduced by performing a decompressive craniectomy (DC) operation, in which a portion of the skull is removed to allow swollen brain tissue to expand outside the skull. In this study, a poroelastic model is used to investigate the effect of brain ischaemic infarct size and location on the severity of brain tissue swelling. Furthermore, the model will also be used to evaluate the effectiveness of DC surgery as a treatment for brain tissue swelling after ischaemia. The poroelastic model consists of two equations: one describing the elasticity of the brain tissue and the other describing the changes in the interstitial tissue pressure. The model is applied on an idealized brain geometry, and it is found that infarcts with radius larger than approximately 14 mm and located near the lateral ventricle produce worse brain midline shift, measured through lateral ventricle compression. Furthermore, the model is also able to show the positive effect of DC treatment in reducing the brain midline shift by allowing part of the brain tissue to expand through the skull opening. However, the model does not show a decrease in the interstitial pressure during DC treatment. Further improvement and validation could enhance the capability of the proposed poroelastic model in predicting the occurrence of brain tissue swelling and DC treatment post ischaemia.

The timing and value of early postoperative computed tomography after head surgery in traumatic brain injury patients

OBJECTIVE

To analyze the timing of the early postoperative computed tomography (CT) in traumatic brain injury (TBI) patients, and compare CT and neurological examination (NE) findings.

METHODS

Retrospective analysis included 353 TBI patients admitted to two level 1 trauma centers (2016-2020) who underwent head surgery and postoperative CT within 24 h. Analyzed variables: age, Injury Severity Score (ISS), Glasgow Coma Score (GCS), Abbreviated Injury Scale head (AISh), comorbidities, CT and NE findings and timing, head surgery type, and mortality.

RESULTS

Patients mean age was 61.9 years, ISS 25.1, GCS 11.0, AISh 4.7. Postoperatively, mean time to first positive CT was 6.1 h and to first positive NE was 13.2 h. Positive CT alone was more accurate in identifying need for 2nd head surgery than positive NE alone (21.8 % vs 6.0 %, p = 0.04). There was no difference between patients with CT done earlier than 6 h compared to patients with CT done after 6 h in mortality (26.1 % vs 22.0 %, p = 0.4) or 2nd surgery rate (12.2 % vs 12.2 %, p = 1.0). Reversal of postoperative CT findings occurred in 1/6 of patients and was more common when CT was done earlier than 6 h compared to CT done later (25.7 % vs 0.8 %, p < 0.001). Early CT within 1 h rarely leads to the change of management but often is followed by another CT within 12 h.

CONCLUSION

In TBI patients postoperative CT was more effective than NE in predicting a need for 2nd head surgery. Postoperative head CT at 6 h is recommended to allow timely detection of intracranial deterioration, reduce the number of CTs and reversal findings as it does not increase 2nd surgery rates and mortality.

Relevance of Routine Postoperative CT Scans Following Aneurysm Clipping-A Retrospective Multicenter Analysis of 423 Cases

AIM

Postoperative head computed tomography (POCT) is routinely performed in numerous medical institutions, mainly to identify possible postsurgical complications. This study sought to assess the clinical appropriateness of POCT in asymptomatic and symptomatic patients after ruptured or unruptured aneurysm clipping.

METHODS

This is a retrospective multicenter study involving microsurgical procedures of ruptured (RA) and unruptured intracranial aneurysm (UA) surgeries performed in the Centers associated with the Pomeranian Department of the Polish Society of Neurosurgeons. A database of surgical procedures of intracranial aneurysms from 2017 to 2020 was created. Only patients after a CT scan within 24 h were included.

RESULTS

A total of 423 cases met the inclusion criteria for the analysis. Age was the only significant factor associated with postoperative blood occurrence on POCT. A total of 37 (8.75%) cases of deterioration within 24 h with urgent POCT were noted, 3 (8.1%) required recraniotomy. The highest number necessary to predict (NNP) one recraniotomy based on patient deterioration was 50 in the RA group.

CONCLUSION

We do not recommend POCTs in asymptomatic patients after planned clipping. New symptom onset requires radiological evaluation. Simultaneous practice of POCT after ruptured aneurysm treatment within 24 h is recommended.

Routine postoperative computed tomography scan after craniotomy: systematic review and evidence-based recommendations

Over the last few years, the role of early postoperative computed tomography (EPOCT) after cranial surgery has been repeatedly questioned, but there is yet no consensus on the practice. We conducted a systematic review to address the usefulness of EPOCT in association with neurological examination after elective craniotomies compared to the neurological examination alone. Studies were eligible if they provided information about the number of patients scanned, how many were asymptomatic or presented neurological deterioration before the scan and how many of each of those groups had their management changed due to imaging findings. CTs had to be performed in the first 48 h following surgery to be considered early. Eight studies were included. The retrospective studies enrolled a total of 3639 patients, with 3737 imaging examinations. Out of the 3696 CT scans performed in asymptomatic patients, less than 0.8% prompted an intervention, while 100% of patients with neurological deterioration were submitted to emergency surgery. Positive predictive values of altered scans were 0.584 for symptomatic patients and 0.125 for the asymptomatic. The number of altered scans necessary to predict (NNP) one change in management for the asymptomatic patients was 8, while for the clinically evident cases, it was 1.71. The number of scans needed to diagnose one clinically silent alteration is 134.75, and postoperative imaging of neurologically intact patients is 132 times less likely to issue an emergency intervention than an altered neurological examination alone. EPOCT following elective craniotomy in neurologically preserved patients is not supported by current evidence, and CT scanning should be performed only in particular conditions. The authors have developed an algorithm to help the judgment of each patient by the surgeon in a resource-limited context.

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

Objectives:

To identify the role of routine postoperative head CT in changing postoperative management after elective craniotomies.

Methods:

We conducted a retrospective study on adult patients who underwent cranial surgery. Exclusion criteria includes cranial CTs done postoperatively for urgent clinical indications, pediatric patients, CSF diversion procedures and sedated patients. Patients were placed into “positive” group if the physical assessment changed from the baseline in the form of clinical deterioration, and the “negative” group if the exam did not change. The data then were analyzed to identify which patients needed further medical or surgical management based on CT findings only with “negative” physical examination.

Results:

Total of 222 were included in the study. 151 patients had negative physical examination. Only 8 out of 151 patients had positive CT findings. Two patients out of 222 (0.9%) had a negative physical exam and positive CT findings that required additional action that wouldn’t be done urgently without routine postoperative brain CT. Only one patient out of 222 (0.4%) who was re-operated urgently based CT findings only and negative physical examination.

Conclusion:

Routine postoperative routine brain CT did not alter the course of medical management, even in the presence of significant radiological findings.

Microvascular decompression: is routine postoperative CT imaging necessary?

BACKGROUND

Postoperative head CT imaging is routinely performed for detection of postoperative complications following intracranial procedures. However, it remains unclear whether with regard to radiation exposure, costs, and possibly lack of consequences this practice is truly justified in various operative procedures. The objective of this study was to analyze whether routine postoperative CT imaging after microvascular decompression (MVD) is necessary or whether it may be abandoned.

METHODS

A series of 202 MVD surgeries for trigeminal neuralgia (179), hemifacial spasm (17), vagoglossopharyngeal neuralgia (2), paroxysmal vertigo (2), and pulsatile tinnitus (2) operated by the senior surgeon (JKK) and who had postoperative routine CT imaging was analyzed.

RESULTS

Routine postoperative CT imaging detected small circumscribed postoperative hemorrhage in 9/202 (4.4%) instances. Hemorrhage was localized at the site of the Teflon felt (1/9), the cerebellum (4/9), in the frontal subdural space (3/9), and in the frontal subarachnoid space (1/9). In two patients, asymptomatic hemorrhage was accompanied by mild cerebellar edema (1%), and another patient had mild transient hydrocephalus (0.5%). Furthermore, there were small accumulations of intracranial air in 86/202 instances. No other complications such as infarction or skull fracture secondary to fixation with the Mayfield clamp were detected. MVD had been performed for trigeminal neuralgia in 6/9 patients, for hemifacial spasm in 2/9, and in one patient with both. No patient underwent a second surgery. Hemorrhage was symptomatic at the time of imaging in only one instance who had mild postoperative gait ataxia. Two patients with hemorrhage developed delayed facial palsy most likely unrelated to hemorrhage which remitted with corticosteroid treatment. At 3-month follow-up and at long-term follow-up, they had no neurological deficits.

CONCLUSION

Routine postoperative CT imaging is not necessary after MVD in a standard setting in patients who do not have postoperative neurological deficits.

The Utility of Early Postoperative Neuroimaging in Elective/Semielective Craniotomy Patients: A Single-Arm Prospective Trial

BACKGROUND

The necessity and timing of early postoperative imaging (POI) are debated in many studies. Despite the consensus that early POI does not change patient management, these examinations are routinely performed. This is the first prospective study related to POI. Our aims were to assess the necessity of early POI in asymptomatic patients and to verify accuracy of the presented algorithm.

METHODS

This was an algorithm-based prospective single-center study. The algorithm addressed preoperative, perioperative, and postoperative considerations, including estimated pathology type, device placement, and postoperative neurologic change. Early computed tomography scans were obtained in all patients, but if postoperative algorithm indications did not recommend a scan, the treating team was blinded to them, and patient management was conducted based on clinical examinations alone. A neuroradiologist and study-independent neurosurgeon reviewed all the scans.

RESULTS

Of 103 enrolled patients, 88 remained asymptomatic, and 15 experienced symptoms postoperatively. Pathology was present on POI in 1% of the asymptomatic patients and 53% of the symptomatic patients (P < 0.001). In the asymptomatic group, no treatment modifications were made postoperatively. Blinding of the surgical team was not removed, and 20% of the symptomatic patients returned to the operating room because of imaging and neurologic findings. The goal of <5% algorithm failure was reached with statistical significance.

CONCLUSIONS

In asymptomatic postoperative patients in whom early imaging is not performed for oncologic indications, device placement verification, or similar reasons, POI is unnecessary and does not change the management of these patients.

Routine Postoperative Computed Tomography Is Not Helpful After Elective Craniotomy

BACKGROUND

Next-day postoperative computed tomography (CT) has been routinely used to obtain radiographic "clearance" for transferring patients after elective craniotomy out of the intensive care unit. The value of this traditional policy, however, has repeatedly been questioned. However, the limited patient numbers might have underestimated the very rare, but catastrophic, events. Therefore, we analyzed the value of routine postoperative CT in a larger cohort of elective tumor, epilepsy, and vascular cases.

METHODS

All the patients who had undergone elective craniotomy were included in our study. The routine postoperative CT scans were analyzed by a neuroradiologist who was unaware of the clinical data. The medical records were retrospectively reviewed for events of arterial hypertension and clinical deterioration.

RESULTS

The data from 660 patients with tumors (n = 393; 59.5%), aneurysms (n = 107; 16.2%), and skull base lesions were evaluated. In nearly one half of the patients (n = 264; 45.8%), CT depicted the presence of blood that was not associated with symptoms. Of the 660 patients, 21 (3.6%) showed a mass effect radiographically, 11 of whom underwent revision surgery. Arterial hypertension was documented in only 8 patients (1.3%) and was related to the revision surgery (P = 0.018). The overall revision rate was 2.7% (n = 18). All patients who had undergone revision for postoperative hematoma had presented with a new neurological deficit immediately before CT.

CONCLUSION

Routine postoperative CT did not reveal 1 patient with a serious hematoma that would not have been identified by clinical examination. Patients could be transferred safely from the intensive care unit, if the weaning process and clinical observation findings were uneventful, without deterioration of neurological symptoms or consciousness.

Incidence of Postoperative Hematomas Requiring Surgical Treatment in Neurosurgery: A Retrospective Observational Study

OBJECTIVE

We aimed to characterize the occurrence of postoperative hematoma (POH) after neurosurgery overall and according to procedure type and describe the prevalence of possible confounders.

METHODS

Patient data between 2010 and 2012 at the Department of Neurosurgery in Helsinki University Hospital were retrospectively analyzed. A data search was performed according to the type of surgery including craniotomies; shunt procedures, spine surgery, and spinal cord stimulator implantation. We analyzed basic preoperative characteristics, as well as data about the initial intervention, perioperative period, revision operation and neurologic recovery (after craniotomy only).

RESULTS

The overall incidence of POH requiring reoperation was 0.6% (n = 56/8783) to 0.6% (n = 26/4726) after craniotomy, 0% (n = 0/928) after shunting procedure, 1.1% (n = 30/2870) after spine surgery, and 0% (n = 0/259) after implantation of a spinal cord stimulator. Craniotomy types with higher POH incidence were decompressive craniectomy (7.9%, n = 7/89), cranioplasty (3.6%, n = 4/112), bypass surgery (1.7%, n = 1/60), and epidural hematoma evacuation (1.6%, n = 1/64). After spinal surgery, POH was observed in 1.1% of cervical and 2.1% of thoracolumbar operations, whereas 46.7% were multilevel procedures. 64.3% of patients with POH and 84.6% of patients undergoing craniotomy had postoperative hypertension (systolic blood pressure >160 mm Hg or lower if indicated). Poor outcome (Glasgow Outcome Scale score 1-3), whereas death at 6 months after craniotomy was detected in 40.9% and 21.7%. respectively, of patients with POH who underwent craniotomy.

CONCLUSIONS

POH after neurosurgery was rare in this series but was associated with poor outcome. Identification of risk factors of bleeding, and avoiding them, if possible, might decrease the incidence of POH.