====== 🩸 Postoperative Bleeding ======

===== 📌 Definition =====
**Postoperative bleeding** refers to any hemorrhagic event that occurs after a surgical procedure. It can be **external (wound site)** or **internal (intracranial, intrathoracic, intra-abdominal, etc.)**, and ranges from minor oozing to life-threatening hemorrhage.

In neurosurgery, **intracranial postoperative bleeding** is a major cause of morbidity and may require urgent reoperation.

===== 🧩 Classification =====

^ Type ^ Description ^ Examples in Neurosurgery ^
| **Superficial bleeding** | External bleeding from incision or subgaleal hematoma | Wound ooze, subcutaneous hematoma |
| **Intracranial bleeding** | Hemorrhage inside the skull | Epidural hematoma, subdural hematoma, intracerebral hemorrhage |
| **Rebleeding** | New or worsened bleeding at the surgical site | Tumor bed hemorrhage, aneurysm clip failure |
| **Remote bleeding** | Hemorrhage at a site distant from the surgical field | Contralateral EDH, cerebellar hemorrhage after supratentorial surgery |

===== ⏱️ Timing =====
  * **Immediate**: within 6 hours post-op
  * **Early**: 6–72 hours post-op
  * **Delayed**: after 3 days; often due to coagulopathy, infection, or CSF drainage

===== 📉 Risk Factors =====
  * Inadequate intraoperative hemostasis
  * Coagulopathy (congenital, acquired, medication-induced)
  * Hypertension
  * Use of anticoagulants or antiplatelet agents
  * NSAIDs (theoretical risk, under evaluation)
  * Excessive CSF drainage (may cause brain shift and vessel tearing)
  * Hypothermia and acidosis during surgery

===== 🩺 Clinical Presentation =====
  * Wound swelling, drainage, or hematoma
  * Neurological deterioration (headache, confusion, vomiting, seizures, anisocoria)
  * Hypotension, tachycardia, pallor (in systemic bleeding)
  * Drop in hemoglobin/hematocrit

===== 🖼️ Imaging in Neurosurgery =====
  * **CT scan** is the modality of choice for early detection
  * Typical findings:
    - **Epidural hematoma**: biconvex, hyperdense
    - **Subdural hematoma**: crescent-shaped
    - **Intracerebral hemorrhage**: localized parenchymal bleed
    - **Midline shift** or ventricle compression

===== 🛠️ Management =====
  * **Surgical intervention** if mass effect or neurological decline
    - Craniotomy, burr holes, decompression
  * **Hemodynamic support**: fluids, blood transfusion
  * **Reversal of anticoagulation** (vitamin K, PCC, platelets)
  * **Blood pressure control**
  * **Monitoring in ICU**
  * Identify and correct underlying cause (e.g., coagulopathy)

===== 📋 Prevention =====
  * Meticulous intraoperative hemostasis
  * Judicious use of NSAIDs and anticoagulants
  * Blood pressure control in the perioperative period
  * Careful management of CSF drainage
  * Early postoperative imaging in high-risk cases

===== 📌 Summary =====
Postoperative bleeding is a critical complication that must be promptly recognized and managed. In neurosurgery, **intracranial bleeding can be fatal** and requires **high vigilance**, particularly in the first 24–48 hours after surgery.