Regional complications, such as hemorrhage, infection, and hydrocephalus, or systemic complications, including deep vein thrombosis and septicemia, may follow neurosurgical procedures. Significant morbidity and mortality can result from delaying the diagnosis of these complications or deferring their management. Hospitalists need to be familiar with the most frequently encountered postoperative complications so that they can take immediate and appropriate actions to improve outcomes.
The incidence of postoperative hemorrhage in a survey of 4992 intracranial procedures done in 1988 was estimated to be 0.8%. Of these, intracerebral hemorrhage accounted for 60%, epidural hemorrhage 28%, subdural hemorrhage 7.5%, and intrasellar hemorrhage 5%. In a series of 1771 craniotomies, the incidence of postoperative hematomas requiring surgery was estimated to be 1.4%. Among these 0.7% were epidural, 0.2% subdural, and 0.5% were hemorrhages in the tumor bed. The later type of hemorrhage was fatal in two cases.
Early postoperative hemorrhage from whatever cause usually presents with drowsiness, focal neurologic deficit, or seizure. It can be diagnosed by an urgent CT and often necessitates immediate return to the operating room (OR). Late hemorrhage may be intraparenchymal or subdural at the procedure site or at a remote location. In traumatic brain injury (TBI), coalescence of multiple contusions and small hematomas may form a large hematoma that causes additional mass effect requiring immediate intervention.
Early postoperative hemorrhage from whatever cause usually presents with drowsiness, focal neurologic deficit, or seizure.
Late hemorrhage may be intraparenchymal or subdural at the procedure site or at a remote location.
- An intracerebral hemorrhage typically occurs in the bed of a resected tumor. The patient usually presents with symptoms and signs of increased ICP including headache, nausea, vomiting, and alteration in consciousness level. The clinical picture also may be variable according to the site of the hematoma.
- The suspicion of postoperative SDH should be raised when a patient develops neurologic deterioration while in the recovery room or in the intensive care unit.
- Ventricular hemorrhage due to continued ooze of blood into the ventricles may cause headache, vomiting, confusion, and alteration of the consciousness level depending on the severity of the hemorrhage. External ventricular drainage should be considered.
In traumatic brain injury (TBI), coalescence of multiple contusions and small hematomas may form a large hematoma that causes additional mass effect requiring immediate intervention.
Low platelet count, platelet dysfunction, and deficiency of clotting factors as in liver diseases may contribute to postoperative hemorrhage. Severe TBI patients should be screened for coagulopathy because of risk of disseminated intravascular coagulation (DIC) from tissue destruction and release of cerebral thromboplastin. Massive blood transfusion also can cause significant hemolysis, which impedes hemostasis. Hemorrhages are discussed below according to their sites.
Uncontrolled oozing from the main scalp arteries and deep muscles may cause subgaleal hematoma. Presenting as a soft fluctuant mass beneath the scalp, it ...