FIGURE 16.1 A) MRI shows large ependymona in the 4th ventricle. B) CT scan about 10 days after surgery shows multiple hypodensities. C) The cerebral angiogram (sample of multiple series) shows cerebral vasospasm in the anterior circulation.
What do you do now?
In order to detect deterioration patients undergoing elective brain tumor surgery are commonly observed overnight in an intensive or intermediate care unit. Most patients will leave the intensive care unit without any complications. When neurointensivists are asked by neurosurgeons to become involved in postoperative care it is because the current clinical condition is unexplained and unusual, because seizures have occurred, or because a major systemic complication needs very close attention. Complications after craniotomy are relatively uncommon but may be more frequent after extensive and complex neurosurgery. To give some sense of what to consider, Table 16.1 lists several causes of deterioration after a craniotomy.
Any patient with an early deterioration may be having seizures, but most patients who are stuporous or comatose from seizures will have already shown focal twitches that then became more generalized and evolved into a nonconvulsive status epilepticus. The cause may not be clear or simply related to removal of brain tumor tissue. Best treatment options in these patients include intravenous levetiracetam loading with 1500–2000 mg or intravenous loading with 20 mg per kg of (fos) phenytoin.
Postoperative hemorrhage in the operative bed may or may not be symptomatic. When mass effect occurs, patients are more likely to decline. A more recently identified cause of neurologic deterioration is the appearance of a hematoma remote from the surgical site. These surprising venous hemorrhages may be in the opposite hemisphere or in the cerebellum in patients with surgery of cerebral hemispheres. It may also occur after drainage of an acute subdural hematoma. The mechanism is therefore most likely mechanical shift of the brain (“sagging”) after reducing intracranial pressure. These remote hemorrhages can become clinically relevant and because they are lobar in nature may actually present with new seizures. Hemorrhage in the cerebellar peduncles have produced new onset slurred speech, tremor, cerebellar ataxia, and nystagmus. Most of the time, these hemorrhages resolve on their own, and the impact on outcome is not substantial.
TABLE 16.1 Causes of Deterioration after Craniotomy
| Seizures (partial or generalized) and status epilepticus |
| Postoperative hemorrhage (operative bed or remote) |
| Cerebral infarction (sacrifice of an arterial branch or cerebral vein) |
| Postoperative cerebral edema |
| Diffuse cerebral vasospasm |
| Medical complications (e.g., hyponatremia or hypernatremia after pituitary surgery) |
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