R. Stalder1, 2, B. Davis3, M. Darya1, 2, J. W. Knight2, 3, M. Gomez3, 4, A. A. Fokin1, 2, I. Puente1, 2, 3, 4 1Florida Atlantic University, Charles E. Schmidt College Of Medicine, Department Of Surgery, Boca Raton, FL, USA 2Delray Medical Center, Trauma And Critical Care Services, Delray Beach, FL, USA 3Broward Health Medical Center, Trauma And Critical Care Services, Fort Lauderdale, FL, USA 4Florida International University, Herbert Wertheim College Of Medicine, Department Of Surgery, Miami, FL, USA
Introduction: Immediate postoperative computed tomography (CT) after head surgery is commonly performed after elective procedures; however, its clinical importance is currently debatable. The value and timing of early postoperative CT in patients with head surgery after traumatic brain injury (TBI) is scarcely addressed.
Methods: Our IRB approved retrospective cohort study included 353 patients with blunt TBI admitted to two urban level 1 Trauma Centers who underwent emergency head procedure (craniotomy, craniectomy, burr hole) and postoperative head CT within 24 hours. Analyzed variables included: age, gender, mechanism of injury (MOI), Injury Severity Score (ISS), Glasgow Coma Score (GCS), Marshall score, Abbreviated Injury Score for head (AISh), American Society of Anesthesiologists (ASA) score, CT findings and timing, neurological examination dynamics, type of surgery, intensive care unit and hospital lengths of stay (ICULOS, HLOS), and mortality. TBI was defined as AISh ≥2, intracranial hemorrhage or skull fracture.
Results: Mean age of patients was 61.9 years, 61.8% were male, and falls were the dominant MOI (70.5%). Mean values at admission were: ISS 25.1; GCS 11.0; AISh 4.7; Marshall Score 3.3; ASA 3.6. Craniotomy was performed in 79.8% of patients, followed by craniectomy (13.3%) and burr hole (6.8%). Negative CT changes after first head surgery (progressions of intracranial lesion, re-bleeding, contralateral injury, or new lesion finding) were observed in 40.5% of patients, while negative neurological dynamic was observed in 31.4% [Figure 1]. Mean time to first post-operative CT was 5.4 hours. Analysis of post-operative CT timing revealed that in 41.0% of cases CT was done within 1 hour after surgery, in 59.2% within 2 hours, in 65.1% within 6 hours. Second head surgery was performed in 12.2% of patients, who all had negative changes on CT, however only 27.9% of them had deterioration in neurological status. Mean ICULOS was 8.0 days and HLOS of 17.0 days. Overall mortality was 24.6%, including in-hospital mortality of 10.2% and 14.4% discharge to hospice. Multivariable analysis showed age, GCS, Marshall and ASA scores as significant predictors of mortality.
Conclusion: Postoperatively, in TBI patients with CT scanning done within 24 hours, negative CT changes were observed in 41% and were not always paralleled by deterioration of neurological status (31% of patients). Negative dynamic detected on early postoperative CT allowed prompt treatment adjustments, including second head surgery. In patients with severe TBI, early, routine post-operative head CT remains a valid diagnostic procedure allowing for accurate and timely diagnostic of negative intracranial changes and preventing delay of secondary intervention.
