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A 38-year-old woman with a history of medically refractory epilepsy since childhood underwent frontoparietal temporal craniotomy for implantation of subdural electrode array. Seven days after the initial craniotomy, the patient returned to the operating room (OR) for reelevation of her prior craniotomy site, removal of her electrode strip, and multiple pial transections. The area of epileptiform discharge was ablated and her intraoperative course was benign. Upon transfer to the neurologic intensive care unit (NICU, NeuroICU), the patient was unable to move her right arm and was sent for an urgent computed tomographic (CT) scan. The CT scan revealed no abnormalities and the patient recovered four-fifths motor function in her arm upon completion of the CT scan.

What complications are expected in this patient and what are her risk factors?

Given her history, this patient is at high risk for postoperative seizure. Therefore, her postoperative monitoring should include electroencephalographic (EEG) monitoring and seizure prophylaxis. Her focal neurologic deficit quickly resolved, which is not unusual in the immediate postoperative setting. Her team elected for CT to rule out an urgent cerebrovascular complication, such as a subdural hematoma, which may present acutely in the postoperative period.

Postoperative patients represent a large fraction of cases seen in the NICU. Many neurosurgical procedures involve a craniotomy (removal of a section of the cranium that is replaced). Procedures that may require craniotomy include:

  • Brain tumor resection

  • Aneurysmectomy

  • Epilepsy grid placement

  • Hematoma evacuation

  • Brain abscess removal

  • Implantation of a deep brain stimulator

  • Insertion of a monitoring probe

  • Ventriculostomy

The range of postoperative complications depends on the location of the operative site, length of operation, and patient characteristics.1,2 Adverse postoperative events (eg, neoplasm, cerebrovascular insult, high intracranial pressure [ICP]) are associated with, and often directly result from, the disease process. In a small subset of patients, craniotomy itself can lead to unintended postoperative complications. The most common postcraniotomy complications are:

General medical complications:

  • Hypotension/hypertension

  • Nausea

  • Infections

  • Deep vein thrombosis

  • Pulmonary embolism

  • Pneumonia

Neurologic complications:

  • Cerebrovascular complications

  • Cerebrospinal fluid (CSF) leaks

  • Hydrocephalus

  • Edema and increased ICP

  • Seizures

Medical complications are common in the NICU and affect more than 50% of neurosurgical patients.3 History of psychiatric illness, asthma, carotid stenosis, and male sex are associated with increased risk of medical complications.4 Neurologic complications are more commonly seen in patients with carotid stenosis and preexisting mental illness.4 Infratentorial meningioma and craniopharyngioma are also associated with particularly high rates of neurologic and general medical complication rates.3,4 Rates of postcraniotomy complications vary widely by procedure (Table 24-1).2

Table 24-1.Rates of Complications of Procedures Requiring Craniotomy

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