gms | German Medical Science

Objective: Patient management following elective cranial surgery varies between different neurosurgical institutions. Early routine postoperative cranial computed tomography (CT) is often performed while keeping patients sedated and ventilated for several hours. We hypothesize that fast track management without routine CT scanning, i.e. early extubation within one hour allowing neurological monitoring, is safe and does not increase the rate of return to OR compared to published data.

Method: We prospectively screened 1118 patients with cranial procedures performed at our department over a period of two years. 420 patients with elective brain surgery older than 18 years with no history of prior cranial surgery were included. Routine neurosurgical practice as it is performed at our department was not altered for this observational study. Fast track management was aimed for all cases, extubated and awake patients were further monitored. CT scanning within 48 hours after surgery was not performed except for unexpected neurological deterioration. This study was registered at ClinicalTrials.gov (NCT01987648).

Results: 420 elective craniotomies were performed for 310 supra- and 110 infratentorial lesions. 398 patients (94.8%) were able to be extubated within 1 hour, 21 (5%) within 6 hours, and 1 patient (0.2%) was extubated 9 hours after surgery. Emergency CT within 48 hours was performed for 42 patients (10%, 30 supra- and 12 infratentorial cases) due to unexpected neurological worsening. Of these 42 patients 6 (14%) had to return to the OR (hemorrhage in 3, swelling in 2 cases, pneumencephalon in 1 case). Return to OR rate of all included cases was 1.4%. This rate compares favourably with 1-4% as quoted in the current literature. No patient returned to the OR without prior CT imaging. Of 398 patients extubated within one hour 3 (0.8%) returned to the OR. Patients who weren’t able to be extubated within the first hour had a higher risk of returning to the OR (3 of 22, i.e. 14%). Overall 30-day mortality was 0.2% (1 patient in palliative care), this patient was in the CT group, but no revision was indicated.

Conclusions: Early extubation and CT imaging performed only for patients with unexpected neurological worsening after elective craniotomy procedures is safe and does not increase patient mortality or the return to OR rate. With this fast track approach early postoperative cranial CT for detection of postoperative complications in the absence of an unexpected neurological finding is not justified.