No Routine Postoperative Head CT following Elective Craniotomy – A Paradigm Shift?

Introduction
Patient management following elective cranial surgery often includes routine postoperative computed tomography (CT). We analyzed whether a regime of early extubation and close neurological monitoring without routine CT is safe, and compared the rate of postoperative emergency neurosurgical intervention with published data.
Methods
Four hundred ninety-two patients were prospectively analyzed; 360 had supra- and 132 had infratentorial lesions. Extubation within one hour after skin closure was aimed for in all cases. CT was performed within 48 hours only in cases of unexpected neurological findings.
Results
Four-hundred sixty-nine of the 492 patients (95.3%) were extubated within one hour, 20 (4.1%) within 3 hours, and three (0.6%) within 3 to 10 hours. Emergency CT within 48 hours was performed for 43/492 (8.7%) cases. Rate of recraniotomy within 48 hours for patients with postoperative hemorrhage was 0.8% (n = 4), and 0.8% (n = 4) required placement of an external ventricular drain (EVD). Of 469 patients extubated within one hour, 3 required recraniotomy and 2 required EVD placements. Of 23 patients with delayed extubation, 1 recraniotomy and 2 EVDs were required. Failure to extubate within one hour was associated with a significantly higher risk of surgical intervention within 48 hours (rate 13.0%, p = 0.004, odds ratio 13.9, 95% confidence interval [3.11–62.37]).
Discussion
Early extubation combined with close neurological monitoring is safe and omits the need for routine postoperative CT. Patients not extubated within one hour do need early CT, since they had a significantly increased risk of requiring emergency neurosurgical intervention.
Trial Registration
ClinicalTrials.gov NCT01987648

引言
择期颅脑手术后的患者管理通常需行常规术后计算机断层扫描（computed tomography, CT）。本研究旨在评估不进行常规CT、采用早期拔管联合密切神经功能监测的方案是否安全，并将术后急诊神经外科干预率与已发表数据进行对比。

方法
本研究前瞻性分析了492例患者，其中360例患有幕上病变，132例患有幕下病变。所有病例均以皮肤缝合后1小时内完成拔管为目标。仅当出现意外神经功能异常时，才在术后48小时内行CT检查。

结果
492例患者中，469例（95.3%）在1小时内完成拔管，20例（4.1%）在3小时内完成拔管，3例（0.6%）在3至10小时内完成拔管。492例患者中有43例（8.7%）在术后48小时内接受了急诊CT检查。术后出血患者中，术后48小时内再次开颅手术率为0.8%（n=4），另有0.8%（n=4）需行脑室外引流（external ventricular drain, EVD）。在469例1小时内拔管的患者中，3例需行再次开颅手术，2例需行脑室外引流。在23例拔管延迟的患者中，1例需行再次开颅手术，2例需行脑室外引流。未能在1小时内拔管的患者，术后48小时内接受外科干预的风险显著更高（发生率13.0%，p=0.004，优势比13.9，95%置信区间[3.11–62.37]）。

讨论
早期拔管联合密切神经功能监测是安全的，可省去常规术后CT检查。未在1小时内拔管的患者确实需要早期行CT检查，因为这类患者需要急诊神经外科干预的风险显著升高。

临床试验注册
ClinicalTrials.gov NCT01987648