title: No Routine Postoperative Head CT following Elective Craniotomy--A Paradigm Shift?
abstract: BACKGROUND
  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]).
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01987648.
authors.affiliation: Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Ralph T
authors.initials: RT
authors.lastname: Schär
authors.affiliation: Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Michael
authors.initials: M
authors.lastname: Fiechter
authors.affiliation: Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.|Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Werner J
authors.initials: WJ
authors.lastname: Z'Graggen
authors.affiliation: Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Nicole
authors.initials: N
authors.lastname: Söll
authors.affiliation: Department of Anesthesiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Vladimir
authors.initials: V
authors.lastname: Krejci
authors.affiliation: Department of Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Roland
authors.initials: R
authors.lastname: Wiest
authors.affiliation: Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Andreas
authors.initials: A
authors.lastname: Raabe
authors.affiliation: Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Beck
mesh_terms: D000328:Adult; D060666:Airway Extubation / Q000379:methods; D003399:Craniotomy / Q000379:methods*; D017558:Elective Surgical Procedures / Q000379:methods; D005260:Female; D006257:Head / Q000000981:diagnostic imaging; D006801:Humans; D008297:Male; D008875:Middle Aged; D011184:Postoperative Period; D012886:Skull / Q000000981:diagnostic imaging* / Q000601:surgery*; D014057:Tomography, X-Ray Computed