Postoperative Hematoma in Cranial and Spinal Surgery

Highlights

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The cranial perspective
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  Postoperative hemorrhage is one of the most serious complications of any cranial neurosurgical procedure.
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  The incidence figures for clinically significant postoperative hemorrhage for cranial surgery ranges from 0.8% to 6.9%.
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  Hemostatic disturbances including coagulopathy and thrombocytopenia, as well as administration of antiplatelet agents, have been identified as general risk factors for postoperative hematomas after neurosurgical procedures.
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  Many of the best recommendation practices for preventing, detecting, and treating postoperative hemorrhage seem intuitive and are likely to be in practice in most neurosurgery units; however, dealing with this iatrogenic disaster just comes down to “doing the simple things right, each and every time.”
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The spinal perspective
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  Symptomatic postoperative spinal epidural hematoma is a rare, yet well-recognized, complication of spinal surgery with the potential for leaving patients with devastating consequences.
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  The reported incidence of symptomatic postoperative spinal epidural hematoma in the literature varies significantly from 0.1% up to 1%.
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  Most clinically significant postoperative spinal epidural hematomas occur in the first few hours after surgery, highlighting the importance of close neurologic monitoring of patients during this period.
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  It usually requires emergent surgical evacuation, and early intervention is likely to result in better neurologic recovery.
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  Larger studies are needed to accurately identify those at high risk of developing spinal epidural hematoma after spinal surgery.

“The practice of neurosurgery, inherently, is more sensitive to any deficit in hemostasis than many of the other surgical disciplines.” MERRIMAN ET AL. (1970)

Introduction

Postoperative hemorrhage (POH) can develop after any neurosurgical operation and tends to have a devastating effect on the outcome, if not detected at an early stage. Thus avoidance of such a complication is of vital interest. Merriman et al. accurately noted “the practice of neurosurgery, inherently, is more sensitive to any deficit in hemostasis than many of the other surgical disciplines.” This puts the impetus squarely on the operating neurosurgeon to prevent this postoperative complication and, in the event of its occurrence, to detect and treat it early before the patient develops a lasting neurologic deficit. Due to the variation in the presentation, detection, and management of this complication in cranial vis-à-vis spinal surgery, we have dealt with these in two separate sections.

The Cranial Perspective

POH is one of the most serious complications of any cranial neurosurgical procedure. A number of studies have demonstrated the significant morbidity and mortality associated with intracranial bleeding after neurosurgery. The rates of POH after intracranial procedures reported in the literature vary greatly, ranging from 0.8% to 50.0%. However, meaningful comparison is difficult due to the variance in the definition of POH. It is generally defined as bleeding at the operative site after surgery; however, it may be argued that in most operative beds, some residual blood is to be expected. Also, it is clinico-radiologically difficult to acutely differentiate between expected residual blood and small de novo hemorrhages that are benign. Incidence figures thus vary depending on definition, with rates of 0.8% to 6.9% reported for postoperative clinical deterioration and rates of 10.8% to 50.0% based on routine radiologic monitoring. Postoperative clinical deterioration is the most consistent sign directing clinicians to suspect significant intracranial hematoma. Hence, as per existing literature, the best definition for a postoperative intracranial hemorrhage is a hematoma, which is clinically significant and requires surgical evacuation.

Location of Postoperative Hemorrhage

POH after a cranial surgery can occur at any of the following locations: epidural, subdural, intraparenchymal, remote, or mixed. Many studies have found that the majority of postoperative hematomas were epidural or intraparenchymal. Kalfas and Little analyzed a series of 4992 intracranial procedures performed over an 11-year period for the occurrence of POH. Forty patients (0.8%) experienced POH, out of which 24 (60%) were intracerebral, 11 (28%) were epidural, 3 (7.5%) were subdural, and 2 (5%) were intrasellar. POH in 33 patients occurred at the operative site, and in 7 it occurred remote from the operative site. Palmer et al., in a review of 6668 operations performed over 5 years, reported 71 surgically evacuated POH, accounting for an incidence of 1.1%. POHs were intraparenchymal in 43% of cases, subdural in 5%, extradural in 33%, mixed in 8%, and confined to the superficial wound in 11%. In a study by Gerlach et al., 21 out of 296 patients operated for intracranial meningiomas developed a POH and needed resurgery. Out of those 21, 9 patients had extradural hematoma (EDH), 3 patients had intraparenchymal hematoma (IPH), and the remaining 9 patients had mixed [EDH/subdural hematoma(SDH)/IPH] hematomas. In 2305 cranial neurosurgical procedures reviewed by Taylor et al., 50 (2.2%) developed a hematoma. The hematomas were extradural in 26 patients (52%), intracerebral in 22 (44%) patients, and subdural in two (4%) patients.

Remote intracerebral hemorrhage is a rare complication of craniotomy with significant morbidity and mortality. Brisman et al. reviewed 37 cases of remote POH occurring after cranial neurosurgery and concluded that such hemorrhages likely develop at or soon after surgery, tend to occur preferentially in certain locations, and can be related to the craniotomy site, operative positioning, and nonspecific mechanical factors. They are not related to hypertension, coagulopathy, cerebrospinal fluid drainage, or underlying pathologic abnormalities.

Analysis of Causative Factors

A postoperative hematoma after elective surgery can have a devastating effect on the patient’s outcome. However, in most of the patients with POH, no obvious cause for the hematoma can be found; it is related neither to the surgical technique nor to hemostatic parameters. Various predisposing risk factors have been analyzed: Hypertension was generally found to be significant in most studies, whereas diabetes mellitus, cerebral amyloid angiopathy, and atherosclerosis were generally not significant. Basali et al. noted that patients with postoperative intracranial hemorrhage had a significantly greater rate of intraoperative and postoperative/prehemorrhage hypertension. Intraoperative hypertension occurs during brain manipulation, head pin application, use of epinephrine containing anesthetics, periosteal dissection, and emergence. Basali et al. also found a significantly high odds ratio for intracranial hemorrhage when patients had blood pressure <160/90 intraoperatively but then had elevated blood pressure postoperatively. This suggests that some vessels may not have been adequately tested intraoperatively for the possibility of leaking when blood pressure rises.

Age is a significant risk factor for hematoma development—sixfold more likely at age over 70 and 12-fold over 75. It remains speculative why the risk of bleeding increases with age. It can be speculated that POH in the elderly is attributed to changes in the blood vessels themselves and to the function of platelets. It was found that elderly patients have more thrombin activation/generation and fibrinolytic activity before surgery than younger patients. Other risk factors include antiplatelet use, including aspirin and nonsteroidal antiinflammatory drugs, preoperative mannitol administration, excessive alcohol use, coagulopathies, disseminated intravascular coagulation, thrombocytopenia, acute decreases in platelet counts postoperatively, excessive intraoperative blood loss, poor response to preoperative platelet transfusions, factor XIII deficiencies, and decreased fibrinogen levels.

One might expect that surgeons with greater levels of experience should encounter fewer postoperative hematomas. However, in the study by Taylor et al., there was no correlation between the rank of the surgeon and the occurrence of postoperative hematoma, with 27 hematomas (54%) occurring after operations by consultants and 23 (46%) after operations by registrars or senior registrars.

Kim et al. conclude that large intraoperative blood loss and wide craniotomy area are risk factors for postoperative EDH after intracranial surgery. However, this study had significant limitations because it did not examine the role of established risk factors for POH. In another series of patients, who underwent surgery to remove brain tumors, the highest rate of postoperative hematomas was found after meningioma surgery. POH remains a major cause of poor outcome after meningioma surgery.

Timing of Occurrence of Postoperative Hemorrhage and Overall Outcome

Gerlach et al. found that the majority of their hematomas were discovered within 3 days of the initial operation. Kalfas and Little found that 35% of their ICH cases were discovered within 12 hours. Taylor et al., in their review of 2305 patients in which 50 developed postoperative hematomas, noted that 44 out of the 50 developed within 6 hours. What has emerged through the literature review is that there are two distinct time periods in which neurologic deterioration secondary to a hematoma occurs, the first being within 6 hours of surgery and the second being 24 hours or more from the time of surgery. The first group likely represents continued active bleeding at the operative site, and the second group represents patients in whom active bleeding is likely to have come to a halt; their clinical deterioration may represent secondary swelling and edema formation around the hematoma. Desai et al., in their review of 3109 cranial operations, noted that when the initial operation was for evacuation of intraparenchymal hematoma, the return to the operating room for evacuation of a postoperative hematoma occurred sooner than for any other type of operation.

Generally, outcome is poor with a range of mortality from 13% to 41% depending on the type of initial operation (tumor vs traumatic ICH, etc.). Good recovery, defined as Glasgow Outcome Scale (GOS) 4 or 5, has been reported in the range of 39% to 71% of the cases in which POH developed.

Strategies—Preventive and Treatment

Close clinical and neurologic observations in the immediate postoperative period are the usual means of POH detection. Failure to adequately awaken from general anesthesia or deterioration of observation parameters would prompt for an urgent scan to check for and treat POH.

Thus, our recommendations for clinical practice based on the literature reviewed would include:

1.

Preoperative: Cease any antiplatelet and anticoagulant therapy for an adequate period; stop alcohol consumption; ensure platelet count, function, and coagulation parameters are normal; consider factor XIII screening; and optimize medical management of preexisting conditions, particularly hypertension.
2.

Intraoperative: Avoid hypertension and excessive blood loss; replace blood losses promptly and sufficiently; aim for gross total resection of tumor wherever possible; meticulous technique and hemostasis including dural tenting, appropriate use of electrocoagulation and topical hemostats; Valsalva maneuver at the end of surgery; and a slow, gentle wean from general anesthesia.
3.

Postoperative: Avoid hypertension; replace blood losses adequately; avoid upright patient positioning in the initial phase; close clinical monitoring in the first 6 h postsurgery; consider ICP monitoring or early postoperative imaging. ICP monitoring may be useful if there have been significant problems with hemostasis during surgery, if the lesion has been very vascular, if blood loss has been great during surgery, or if the patient needs to remain sedated and/or ventilated after surgery.