Obtain a Computed Tomography Scan of the Head Immediately after any Craniotomy or Intracranial Procedure if Patient’s Neurologic Examination is Different from Preoperative Assessments
Jose I. Suarez MD
Management of the critically ill patient after a craniotomy poses special challenges for the intensivist. Not only do practitioners have to manage the systemic alterations, but they must also understand how such alterations interact and affect brain functions. For instance, patients who develop intracerebral hemorrhage (ICH) after a craniotomy are more likely to experience hypertensive episodes both intraoperatively and in the first few hours postoperatively. Patients who undergo craniotomy for subdural hematoma (SDH) evacuation are more likely to experience recurrent SDH if they were coagulopathic before the surgical procedure was performed. Also the timing of neurological deterioration may vary depending on when they experience the intracranial complication. For instance, postoperative ICH will mostly present within 6 hours after surgery.
Neurologic Examination
Whenever possible, patients undergoing craniotomy should have a baseline neurologic examination prior to surgery. Such evaluation should include assessment of the level of consciousness; cranial nerves; motor strength; reflexes; coordination (i.e., finger-to-nose and heel-to-shin maneuvers); sensory perception (light touch and pain and temperature); and meningeal signs. Immediately after craniotomy the patient’s neurological status should be reassessed and compared with the baseline. The two major limitations to the immediate postoperative neurologic examination are sedation and mechanical ventilation. Performing the Glasgow Coma Scale (GCS) before and after craniotomy is a very reliable way of assessing level of consciousness. As discussed in Chapter 192, GCS has been validated widely across medical and surgical specialties and can be performed in intubated patients using a predictive verbal score from the eye and the motor scores. It is of the utmost importance to act upon observed neurologic changes. The airway should be assessed and blood pressure evaluated. Patients with
GCS ≤8 should be intubated (if not done already). Extreme blood pressure levels (hypo- or hypertension) should be corrected. Seizures should be treated if present. Once the initial stabilization of the patient has been achieved, a head computed tomography (CT) scan should be the next step.
GCS ≤8 should be intubated (if not done already). Extreme blood pressure levels (hypo- or hypertension) should be corrected. Seizures should be treated if present. Once the initial stabilization of the patient has been achieved, a head computed tomography (CT) scan should be the next step.
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