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Postoperative intracranial haemorrhage: a review

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Abstract

Postoperative haemorrhage (POH) is one of the most serious complications of any cranial neurosurgical procedure and is associated with significant morbidity and mortality. The relative paucity of work investigating this postoperative complication prompted us to undertake a review of the literature, focussing on demographic, clinical, and surgical risk factors. A literature search was undertaken using Ovid MEDLINE (1950–2009) using keywords including craniectomy, craniotomy, neurosurgery, intracranial, reoperation, repeat craniotomy, postoperative, haemorrhage, haematoma, and bleeding. The rates of POH following intracranial procedures reported in the literature vary greatly, and meaningful comparison is difficult. We defined postoperative haemorrhage as that following craniotomy, which is clinically significant and requires surgical evacuation. Risk factors include pre-existing medical comorbidities including hypertension, coagulopathies and haematological abnormalities, intraoperative hypertension and blood loss, certain lesion pathologies including tumours, chronic subdural haematomas, and deficiencies in haemostasis. We conclude by providing recommendations for clinical practice based on the literature reviewed to aid clinicians in the detection and avoidance of POH.

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Acknowledgement

This work was supported by the Alfred Hospital Henry O'Hara Surgical Research Award.

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Authors and Affiliations

  1. Department of Neurosurgery, The Alfred Hospital, Commercial Road, Melbourne, VIC, 3004, Australia

    Marc A. Seifman, Phillip M. Lewis, Jeffrey V. Rosenfeld & Peter Y. K. Hwang

  2. Department of Surgery, Monash University, Melbourne, Australia

    Jeffrey V. Rosenfeld & Peter Y. K. Hwang

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  1. Marc A. Seifman
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  2. Phillip M. Lewis
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  3. Jeffrey V. Rosenfeld
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  4. Peter Y. K. Hwang
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Correspondence to Peter Y. K. Hwang.

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Comments

Ignacio J. Previgliano, Buenos Aires, Argentina

This review by Dr. Seifman et al. is extremely useful and there's little to add to it.

Nevertheless, I would like to remember some anaesthetic and critical care situations that might contribute to postoperative intracranial haemorrhage:

(a) Excessive brain dehydration due to mannitol or mannitol plus furosemide administration to have a more adequate surgical field.

(b) Acidosis and hypothermia, two common findings in neurosurgeries lasting from more than 3 h and in traumatic brain injury surgical patients.

(c) Dilution coagulopathy, often seen in traumatic brain injury, which is associated with acidosis and hypothermia is known as “the triad of death”.

(d) Nonsteroidal antiinflamatory drugs use should be obsessively asked in the preoperative period. Clopidogrel use is associated with postoperative haemorrhages and should be suspended at least 5 days before surgery.

(e) Excessive cerebrospinal fluid drainage in the aim of treating intracranial hypertension.

(f) Excessive CFS drainage after shunt placement in Hakim Adams Syndrome (normal pressure hydrocephalus).

I will also want to highlight the role of remote intracranial haemorrhage. It is seen much often than most of us believe; Friendman reported it in 0.6% of all supratentorial craniectomies, in 2.8% of incidental aneurysmal surgery, and in 1.4% of temporal lobectomies. Kalfas y Little observed it in 18% of postoperative period of spontaneous cerebral hematomas.

I strongly agree with the recommendation of postoperative intracranial pressure monitoring at least for the first 24 h. Another tool that is very useful in our experience is Transcranial Doppler monitoring in the case of neurological worsening in the postoperative period while awaiting the performance of imaging studies in patients without IPC monitoring.

References

1. Camputaro L, Barrios C. Complicaciones posneuroquirúrgicas. In Previgliano I (ed). Neurointensivismo Basado en la Evidencia. Corpus Editorial, Rosario 2007. Pag 272–285

2. Friedman J A; Piepgras D G; Duke D A; McClelland R L; Bechtle P S; Maher C O; Morita A; Perkins W J; Parisi J E; Brown R D. Remote cerebellar haemorrhage after supratentorial surgery. Neurosurgery 2001; 49:1327–1340.

3. Previgliano I, Tamagnone F, Martinez E, Blejman S, Rubianes J. Effectiveness of transcraneal doppler in identifying cerebral hypoperfusion in comatose patients prior to diagnostic imaging procedures. Abstract. European Federation of Neurological Societies Meeting, Geneve, 2010.

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Seifman, M.A., Lewis, P.M., Rosenfeld, J.V. et al. Postoperative intracranial haemorrhage: a review. Neurosurg Rev 34, 393–407 (2011). https://doi.org/10.1007/s10143-010-0304-3

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