Postoperative intracranial hemorrhage

An accurate definition of postoperative intracranial hemorrhage remains unclear.

The role of routine early postoperative computed tomography (CT) scanning in the detection of POIH remains controversial.

The range of reported rates in the literature varies substantially (from 0.8% to 50%) ¹⁾.

Of 492 electively performed craniotomies the rate for emergency neurosurgical intervention within 48 hours was 1.6% with only half of these patients (0.8%) requiring recraniotomy for postoperative hemorrhage ²⁾.

These figures are comparable to published data regarding incidence of postoperative hemorrhage (0.8–2.1%) and recraniotomy (0.7–2.1%) ^{3) 4) 5) 6)}.

There is controversy whether or not factor XIII (FXIII) deficiency leads to bleeding complications after craniotomy. Decreased fibrinogen levels have been associated with an increased incidence of bleeding complications in cardiac and orthopaedic surgery.

The individual bleeding risk is likely minimized by the administration of reduced doses of Low molecular weight heparin (LMWH) relatively late after craniotomy and by delaying the start of warfarin after surgery ⁷⁾.

Fibrinogen as potentially modifiable risk factor for perioperative bleeding in intracranial surgery, needs future randomized controlled trials to identify patients who might benefit from fibrinogen substitution during neurosurgical procedures ⁸⁾.

In a study of Senders et al. from Boston and Utrecht, patients were extracted from the National Surgical Quality Improvement Program registry (2005-2015) and analyzed using multivariable logistic regression.

A total of 7376 patients were identified, of which 948 (12.9%) experienced a major complication. The most common major complications were reoperation (5.1%), venous thromboembolism (3.5%), and death (2.6%). Furthermore, 15.6% stayed longer than 10 d, and 11.5% were readmitted within 30 d after surgery. The most common reasons for reoperation and readmission were intracranial hemorrhage (18.5%) and wound-related complications (11.9%), respectively. Multivariable analysis identified older age, higher body mass index, higher American Society of Anesthesiologists (ASA) classification, dependent functional status, elevated preoperative white blood cell count (white blood cell count WBC, >12 000 cells/mm3), and longer operative time as predictors of major complication (all P < .001). Higher ASA classification, dependent functional status, elevated WBC, and ventilator dependence were predictors of extended length of stay (all P < .001). Higher ASA classification and elevated WBC were predictors of reoperation (both P < .001). Higher ASA classification and dependent functional status were predictors of readmission (both P < .001). Older age, higher ASA classification, and dependent functional status were predictors of death (all P < .001).

This study provides a descriptive analysis and identifies predictors for short-term complications, including death, after craniotomy for primary malignant brain tumors ⁹⁾.

A total of 1,148 patients undergoing craniotomy were included in a study; 28 of these patients developed POIH. The majority of POIH cases (15/28, 54 %) were detected during the first 6 h following craniotomy. A routine CT scan was performed on all included patients but two; however, CT scans detected only 16 POIH cases. During the first 6 h, the rate at which CT scans detected POIH was 1.9 % (15/786); subsequently, the rate decreased to only 0.3 % (1/360; p < 0.05, compared with the rate during the first 6 h). Among patients without clinical manifestations, the rate at which the routine post-craniotomy CT scan detected POIH was only 0.7 % (5/721) (p < 0.05, compared with the incidence of POIH). Finally, among high-risk POIH patients, the POIH-positive rate of routine CT scanning was elevated.

It appears that routine early CT scan is ineffective for the detection of POIH in patients undergoing craniotomy. However, if the strategy for routine scanning can be improved, its effect may be beneficial ¹⁰⁾.

6668 operations were performed and 71 postoperative hematomas were surgically evacuated, accounting for an overall rate of 1.1% of operations. The records were available for 69 cases. The most frequent diagnosis leading to postoperative hematoma was intracranial meningioma surgery with a rate of 6.2% of cases (13 of 211); followed by craniotomy for trauma, 3.7% (7 of 192); aneurysm surgery, 2.6% (11 of 428); and intrinsic supratentorial tumors, 2.2% (10 of 451). Postoperative hematomas were intraparenchymal in 43% of cases, subdural in 5%, extradural in 33%, mixed in 8%, and confined to the superficial wound in 11%. The overall mortality was 32% (37% for intraparenchymal and 12% for extradural). Risk factors for a perioperative bleeding disorder were present in two-thirds of the patients. Administration of antiplatelet agents (aspirin and nonsteroidal anti-inflammatory drugs) was the most commonly associated risk factor. At least 75% of these identified risk factors could potentially have been avoided or corrected ¹¹⁾.