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Chapter 26: Postcraniotomy Complication Management

Blake E. S. Taylor; Christopher P. Kellner; E. Sander Connolly, Jr.

Case

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A 41-year-old man with no significant past medical history presents with tinnitus, vertigo, and right-sided unilateral hearing loss that has worsened over the past year. Magnetic resonance imaging (MRI) demonstrates a 3-cm tumor in the right cerebellopontine (CP) angle. He undergoes a right retrosigmoid craniotomy, and the tumor is completely resected. His intraoperative course is uncomplicated, and he is transferred to the neurologic intensive care unit (NeuroICU). On postoperative day 6, the patient complains of worsening headache and neck stiffness. On examination, the patient is febrile to 102.1°F, and there is drainage of clear, watery substance from his right ear. Neurologic examination is notable for meningismus. Computed tomography (CT) scan is negative for hematoma in the cerebellopontine angle, and there is mild ventricular enlargement.

What are the indications for a craniotomy?

A craniotomy is a common neurosurgical procedure in which a bone flap is removed from the skull in order to access certain regions of the brain or overlying meninges. Among cranial procedures, which represent roughly a third of neurosurgery, craniotomies are performed in approximately half of the cases. Craniotomies may be performed in a number of locations (eg, pterional, suboccipital, frontal) to treat a wide variety of intracranial conditions (Table 26-1), including cerebrovascular lesions and brain tumors and for implantation of hardware (eg, cerebrospinal fluid shunts (CSF) or deep brain stimulators).

Table 26-1.Common Indications for a Craniotomy
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Table 26-1. Common Indications for a Craniotomy
Category Common Indications
Cerebrovascular

Clipping of a ruptured aneurysm (ie, in subarachnoid hemorrhage)

Clipping of an unruptured aneurysm

Resection of a vascular malformation (eg, arteriovenous malformations, cavernous malformations)

Evacuation of a hematoma (eg, subdural, epidural, intracerebral hemorrhage)

Intracranial-extracranial bypass

Decompressive hemicraniectomy (eg, due to cerebral edema after malignant MCA-territory ischemic stroke)
Brain neoplasms

Total or subtotal resection of benign or malignant primary CNS neoplasms (eg, meningioma, glioblastoma multiforme)

Resection of a metastatic lesion

Open or stereotactic needle biopsy

Aspiration of a tumor-associated cyst
Functional

Placement of epilepsy electrode grids

Resection of epileptogenic tissue

Placement of DBS
Infectious Resection or stereotactic needle drainage of a brain abscess
Other

Obstructive hydrocephalus (eg, secondary to a tumor)

Microvascular decompression (eg, for trigeminal neuralgia)

Insertion of a shunt (eg, ventriculoperitoneal or ventriculoatrial)

Insertion of an Ommaya reservoir

Trauma

Abbreviations: CNS, central nervous system; DBS, deep brain stimulation; MCA, middle cerebral artery.

What complications occur after a craniotomy?

A variety of complications affect up to 1 in 4 patients undergoing a craniotomy1, and these may be related to the craniotomy itself, specific to the condition being treated, or to hospitalization in general. Complications that may occur after most craniotomies (Table 26-2) include neurologic complications (eg, intracranial hemorrhage, seizures), medical complications (eg, blood pressure derangements, cardiac events), infection (eg, pneumonia, meningitis), and general surgical complications ...

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