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The Conundrum of Postoperative Hematoma in Intracranial Surgery

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Challenging Topics in Neuroanesthesia and Neurocritical Care

Abstract

Postoperative intracranial hematoma is a devastating complication following intracranial surgery and entails high degree of morbidity and mortality unless evacuated urgently. It commonly occurs at the operative site and mostly evolves during the first few hours after surgery but can become clinically evident as late as 24 h. The commonly held belief is that inadequate surgical hemostasis is the leading cause of postoperative hematoma but other factors such as fluctuations in intraoperative blood pressure, violent awakening, type and location of tumor, alteration in patient’s coagulation profile, venous pressure, hemodynamic state, and genetic predisposition can all be of significant import in the pathogenesis of a postoperative hematoma. This chapter would dwell on the subject of postoperative hematoma, its etiology, incidence, outcome and finally introduce a novel strategy in curtailing its incidence following intracranial surgery.

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References

  1. Palmer JD, Sparrow OC, Iannotti F. Postoperative hematoma: a 5-year survey and identification of avoidable risk factors. Neurosurgery. 1994;35(6):1061–5.

    Article  CAS  PubMed  Google Scholar 

  2. Vassilouthis J, Anagnostaras S, Papandreou A, Dourdounas E. Is postoperative haematoma an avoidable complication of intracranial surgery? Br J Nurosurg. 1999;13(2):154–7.

    Article  CAS  Google Scholar 

  3. Seifman MA, Lewis PM, Rosenfeld JV, Hwang PY. Postoperative intracranial haemorrhage: a review. Neurosurg Rev. 2011;34(4):393–407.

    Article  PubMed  Google Scholar 

  4. Kalfas IH, Little JR. Postoperative hemorrhage: a survey of 4992 intracranial procedures. Neurosurgery. 1988;23(3):343–7.

    Article  CAS  PubMed  Google Scholar 

  5. Taylor WA, Thomas NW, Wellings JA, Bell BA. Timing of postoperative intracranial hematoma development and implications for the best use of neurosurgical intensive care. J Neurosurg. 1995;82(1):48–50.

    Article  CAS  PubMed  Google Scholar 

  6. Fukamachi A, Koizumi H, Nukui H. Postoperative intracerebral hemorrhages: a survey of computed tomographic findings after 1074 intracranial operations. Surg Neurol. 1985;23(6):575–80.

    Article  CAS  PubMed  Google Scholar 

  7. Koizumi H, Fukamachi A, Nukui H. Postoperative subdural fluid collections in neurosurgery. Surg Neurol. 1987;27(2):147–53.

    Article  CAS  PubMed  Google Scholar 

  8. Haines SJ, Maroon JC, Jannetta PJ. Supratentorial intracerebral hemorrhage following posterior fossa surgery. J Neurosurg. 1978;49(6):881–6.

    Article  CAS  PubMed  Google Scholar 

  9. Harders A, Gilsbach J, Weigel K. Supratentorial space occupying lesions following infratentorial surgery early diagnosis and treatment. Acta Neurochir. 1985;74(1–2):57–60.

    Article  CAS  PubMed  Google Scholar 

  10. Waga S, Shimosaka S, Sakakura M. Intracerebral hemorrhage remote from the site of the initial neurosurgical procedure. Neurosurgery. 1983;13(6):662–5.

    Article  CAS  PubMed  Google Scholar 

  11. Waga S, Shimizu T, Shimosaka S, Tochio H. Intratumoral hemorrhage after a ventriculoperitoneal shunting procedure. Neurosurgery. 1981;9(3):249–52.

    CAS  PubMed  Google Scholar 

  12. Palmer JD, Francis DA, Roath OS, Francis JL, Iannotti F. Hyperfibrinolysis during intracranial surgery: effect of high dose aprotinin. J Neurol Neurosurg Psychiatry. 1995;58(1):104–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  13. Olsen KS, Pedersen CB, Madsen JB, Ravn LI, Schifter S. Vasoactive modulators during and after craniotomy: relation to postoperative hypertension. J Neurosurg Anesth. 2002;14(3):171–9.

    Article  Google Scholar 

  14. Singh VP, Jain D, Mohan R, Bhatia R, Bhargava M. Haemostatic abnormalities in brain tumours. Acta Neurochir. 1990;102(3-4):103–7.

    Article  CAS  PubMed  Google Scholar 

  15. Manjunath Prasad KS, Sharma BS, Marwaha N, Sarode RS, Kak VK. Haemostatic derangement in patients with intracranial tumours. Br J Neurosurg. 1994;8(6):695–702.

    Article  Google Scholar 

  16. Sawaya R, Donlon JA. Chronic disseminated intravascular coagulation and metastatic brain tumor: a case report and review of the literature. Neurosurgery. 1983;12(5):580–4.

    Article  CAS  PubMed  Google Scholar 

  17. Sawaya R, Glas-Greenwalt P. Postoperative venous thromboembolism and brain tumors. J Neurooncol. 1992;14:127–34.

    CAS  PubMed  Google Scholar 

  18. Oka K, Tsuda H, Kamikaseda K, Nakamura R, Fukui M, Nouzuka Y, Sueishi K. Meningiomas and hemorrhagic diathesis. J Neurosurg. 1988;69(3):356–60. 80

    Article  CAS  PubMed  Google Scholar 

  19. Ariesen MJ, Claus SP, Rinkel GJ, Algra A. Risk factors for intracerebral hemorrhage in the general population a systematic review. Stroke. 2003;34(8):2060–5.

    Article  CAS  PubMed  Google Scholar 

  20. Kongstad L, Grände PO. Arterial hypertension increases intracranial pressure in cat after opening of the blood-brain barrier. J Trauma Acute Care Surg. 2001;51(3):490–6.

    Article  CAS  Google Scholar 

  21. Mayhan WG. Disruption of blood-brain barrier during acute hypertension in adult and aged rats. Am J Physiol Heart Circ Physiol. 1990;258(6):H1735–8.

    CAS  Google Scholar 

  22. Hatashita S, Hoff JT, Ishii S. Focal brain edema associated with acute arterial hypertension. J Neurosurg. 1986;64(4):643–9.

    Article  CAS  PubMed  Google Scholar 

  23. Forster A, Van Horn K, Marshall LF, Shapiro HM. Anesthetic Effects on Blood—brain barrier function during acute arterial hypertension. Anesthesiology. 1978;49(1):26–30.

    Article  CAS  PubMed  Google Scholar 

  24. Leweh W, Hummel R, Littlewood K. Recovery from anesthe-sia and cerebral blood flow velocity. Anesth Analg. 1992;74:S186.

    Google Scholar 

  25. Gibson BE, Black S, Maass L, Cucchiara RF. Esmolol for the control of hypertension after neurologic surgery. Clin Pharmacol Ther. 1988;44(6):650–3.

    Article  CAS  PubMed  Google Scholar 

  26. Mackenzie AF, Colvin JR, Kenny GN, Bisset WI. Closed loop control of arterial hypertension following intracranial surgery using sodium nitroprusside. Anaesthesia. 1993;48(3):202–4.

    Article  CAS  PubMed  Google Scholar 

  27. Todd MM, Warner DS, Sokoll MD, Maktabi MA, Hindman BJ, Scamman FL, Kirschner J. A prospective, comparative trial of three anesthetics for elective supratentorial craniotomy. Propofol/fentanyl, isoflurane/nitrous oxide, and fentanyl/nitrous oxide. Anesthesiology. 1993;78(6):1005–20.

    Article  CAS  PubMed  Google Scholar 

  28. Basali A, Mascha EJ, Kalfas I, Schubert A. Relation between perioperative hypertension and intracranial hemorrhage after craniotomy. Anesthesiology. 2000;93(1):48–54.

    Article  CAS  PubMed  Google Scholar 

  29. Felding M, Cold GE, Jagobsen CJ, Stjernholm P, Voss K. The effect of ketanserin upon postoperative blood pressure, cerebral blood flow and oxygen metabolism in patients subjected to craniotomy for cerebral tumours. Acta Anaesthesiol Scand. 1995;39(5):582–5.

    Article  CAS  PubMed  Google Scholar 

  30. Bruder N, Ravussin P. Recovery from anesthesia and postoperative extubation of neurosurgical patients: a review. J Neurosurg Anesth. 1999;11(4):282–93.

    Google Scholar 

  31. Grillo P, Bruder N, Auquier P, Pellissier D, Gouin F. Esmolol blunts the cerebral blood flow velocity increase during emergence from anesthesia in neurosurgical patients. Anesth Analg. 2003;96(4):1145–9.

    Article  CAS  PubMed  Google Scholar 

  32. Kovac AL, Masiongale A. Comparison of nicardipine versus esmolol in attenuating the hemodynamic responses to anesthesia emergence and extubation. J Cardiothorac Vasc Anesth. 2007;21(1):45–50.

    Article  CAS  PubMed  Google Scholar 

  33. Haas CE, LeBlanc JM. Acute postoperative hypertension: a review of therapeutic options. Am J Health Syst Pharm. 2004;61(16):1661–75.

    CAS  PubMed  Google Scholar 

  34. Puchstein C. Treatment of hypertensive crisis in neurosurgery. Ann Fr Anesth Reanim. 1989;8:598–602.

    Article  CAS  PubMed  Google Scholar 

  35. Bekker A, Sturaitis MK. Dexmedetomidine for neurological surgery. Operative Neurosurgery. 2005;57(1):1–10.

    Article  Google Scholar 

  36. Günes Y, Gündüz M, Özcengiz D, Özbek H, Isik G. Dexmedetomidine-remifentanil or propofol-remifentanil anesthesia in patients undergoing intracranial surgery. Neurosurgery Quarterly. 2005;15(2):122–6.

    Article  Google Scholar 

  37. Owen Jr CA, Bowie EW. Surgical hemostasis. J Neurosurg. 1979;51(2):137–46.

    Article  CAS  PubMed  Google Scholar 

  38. Levy ML, Amar AP. The use of oxidized regenerated cellulose in neurosurgical procedures. Surg Technol Int. 1998;7:467.

    CAS  PubMed  Google Scholar 

  39. Scarff JE, Stookey B, Garcia F. The use of dry oxidized cellulose as a primary hemostatic agent in neurosurgery. J Neurosurg. 1949;6(4):304–6.

    Article  CAS  PubMed  Google Scholar 

  40. Dutton JJ, David TT, Anderson RL. Compressive optic neuropathy following use of intracranial oxidized cellulose hemostat. Ophthalmic Surg, Lasers Imaging Retina. 1983;14(6):487–90.

    CAS  Google Scholar 

  41. Menovsky T, Plazier M, Rasschaert R, Maas AI, Parizel PM, Verbeke S. Massive swelling of Surgicel® Fibrillar™ hemostat after spinal surgery. Case report and a review of the literature. Minim Invasive Neurosurg MIN. 2011;54(5–6):257–9.

    CAS  PubMed  Google Scholar 

  42. Kothbauer KF, Jallo JI, Stiffert J, Jimenez E, Allen JC, Epstein FJ. Foreign body reaction to hemostatic materials mimicking recurrent brain tumor. Report of three cases. J Neurosurg. 2001;95:503–6.

    Article  CAS  PubMed  Google Scholar 

  43. Menovsky T, Kamerling N, Sener S, Parizel PM, Maas AIR. New hemostatic powder ( Gelitacel Ca Powder TM) and its application in cranial neurosurgery. Open J Modern Neurosurg. 2014;4:142–9.

    Article  Google Scholar 

  44. Merriman E, Bell W, Long DM. Surgical postoperative bleeding associated with aspirin ingestion: report of two cases. J Neurosurg. 1979;50(5):682–4.

    Article  CAS  PubMed  Google Scholar 

  45. Touho H, Hirakawa K, Hino A, Karasawa J, Ohno Y. Relationship between abnormalities of coagulation and fibrinolysis and postoperative intracranial hemorrhage in head injury. Neurosurgery. 1986;19(4):523–31.

    Article  CAS  PubMed  Google Scholar 

  46. Go Y-C, Tsoi WC, Feng CS, Wickham N, Poon WS. Hemostatic changes during surgery for primary brain tumors. J Neurol Neurosurg Psychiatry. 1997;63:334–8.

    Article  Google Scholar 

  47. Chan KH, Mann KS, Chan TK. The significance of thrombocytopenia in the development of postoperative intracranial hematoma. J Neurosurg. 1989;71(1):38–41.

    Article  CAS  PubMed  Google Scholar 

  48. Kwaan HC. Diseases of hemostasis. In: Beal JM, editor. Critical care for surgical patients. New York: Macmillan; 1982. p. 588–98.

    Google Scholar 

  49. Bullock R, Hannemann CO, Murray L, Teasdale GM. Recurrent hematomas following craniotomy for traumatic intracranial mass. J Neurosurg. 1990;72(1):9–14.

    Article  CAS  PubMed  Google Scholar 

  50. Colman RW, Robboy SJ, Minna JD. Disseminated intravascular coagulation (DIC): an approach. Am J Med. 1972;52(5):679–89.

    Article  CAS  PubMed  Google Scholar 

  51. Gerlach R, Raabe A, Zimmermann M, Siegemund A, Seifert V. Factor XIII deficiency and postoperative hemorrhage after neurosurgical procedures. Surg Neurol. 2000;54(3):260–6.

    Article  CAS  PubMed  Google Scholar 

  52. Gerlach R, Tölle F, Raabe A, Zimmermann M, Siegemund A, Seifert V. Increased risk for postoperative hemorrhage after intracranial surgery in patients with decreased factor XIII activity implications of a prospective study. Stroke. 2002;33(6):1618–23.

    Article  PubMed  Google Scholar 

  53. Dickinson LD, Miller LD, Patel CP, Gupta SK. Enoxaparin increases the incidence of postoperative intracranial hemorrhage when initiated preoperatively for deep venous thrombosis prophylaxis in patients with brain tumors. Neurosurgery. 1998;43(5):1074–9.

    Article  CAS  PubMed  Google Scholar 

  54. Kenet G, Walden R, Eldad A, Martinowitz U. Treatment of traumatic bleeding with recombinant factor VIIa. Lancet. 1999;354(9193):1879.

    Article  CAS  PubMed  Google Scholar 

  55. Khan ZH, Soltani AE, Rahmani P. Postoperative pulmonary thromboembolism possibly associated with recombinant activated factor VII infusion for the treatment of uncontrolled hemorrhage during vertebral instrumentation. J Anesth. 2007;21(2):258–60.

    Article  PubMed  Google Scholar 

  56. Mayer SA, Brun NC, Begtrup K, Broderick J, Davis S, Diringer MN, Skolnick BE, Steiner T. Recombinant activated factor VII for acute intracerebral hemorrhage. N Engl J Med. 2005;352(8):777–85.

    Article  CAS  PubMed  Google Scholar 

  57. Zetterling M, Ronne-Engström E. High intraoperative blood loss may be a risk factor for postoperative hematoma. J Neorosurg Anesthesiol. 2004;16(2):151–5.

    Article  Google Scholar 

  58. Palmer JD, Francis JL, Pickard JD, Iannotti F. The efficacy and safety of aprotinin for hemostasis during intracranial surgery. J Neurosurg. 2003;98(6):1208–16.

    Article  CAS  PubMed  Google Scholar 

  59. Arand AG, Sawaya R. Intraoperative chemical hemostasis in neurosurgery. Neurosurgery. 1986;18(2):223–33.

    Article  CAS  PubMed  Google Scholar 

  60. Wilson C. General considerations. In: Apuzzo M, editor. Brain surgery: complication, avoidance and management. New York: Churchill Livingston; 1993. p. 177–85.

    Google Scholar 

  61. Seiler RW, Zurbrügg HR. Supratentorial intracerebral hemorrhage after posterior fossa operation. Neurosurgery. 1986;18(4):472–4.

    Article  CAS  PubMed  Google Scholar 

  62. Thiarajah S. Postoperative care of neurosurgical patients. Int Anesth clin. 1983;21(1):139–56.

    Article  Google Scholar 

  63. Rohde V, Rohde I, Thiex R, Küker W, Ince A, Gilsbach JM. The role of intraoperative magnetic resonance imaging for the detection of hemorrhagic complications during surgery for intracerebral lesions an experimental approach. Surg Neurol. 2001;56(4):266–74.

    Article  CAS  PubMed  Google Scholar 

  64. Butler WE, Piaggio CM, Constantinou C, Niklason L, Gonzalez RG, Cosgrove GR, Zervas NT. A mobile computed tomographic scanner with intraoperative and intensive care unit applications. Neurosurgery. 1998;42(6):1304–10.

    Article  CAS  PubMed  Google Scholar 

  65. Izumihara A, Ishihara T, Iwamoto N, Yamashita K, Ito H. Postoperative outcome of 37 patients with lobar intracerebral hemorrhage related to cerebral amyloid angiopathy. Stroke. 1999;30(1):29–33.

    Article  CAS  PubMed  Google Scholar 

  66. Johnston IH, Jennett B. The place of continuous intracranial pressure monitoring in neurosurgical practice. Acta Neurochir. 1973;29(1–2):53–63.

    Article  CAS  PubMed  Google Scholar 

  67. Kaye AH, Brownbill D. Postoperative intracranial pressure in patients operated on for cerebral aneurysms following subarachnoid hemorrhage. J Neurosurg. 1981;54(6):726–32.

    Article  CAS  PubMed  Google Scholar 

  68. Khan ZH, Tabatabai SA, Saberi H, Aliari M. Vigilant surgical hemostasis challenged by ketamine or hypervolemia induced hemodynamic stress to minimize postoperative hemorrhage in patients with parasagittal/or parafalcian meningiomas: an interventional study. Acta Anaesthesiol Taiwan. 2005;43(4):217–22.

    PubMed  Google Scholar 

  69. Innerhofer P, Fries D, Margreiter J, Klingler A, Kühbacher G, Wachter B, Oswald E, Salner E, Frischhut B, Schobersberger W. The effects of perioperatively administered colloids and crystalloids on primary platelet-mediated hemostasis and clot formation. Anesth Analg. 2002;95(4):858–65.

    Article  PubMed  Google Scholar 

  70. Bruder N, Cohen B, Pellissier D, Francois G. The effect of hemodilution on cerebral blood flow velocity in anesthetized patients. Anesth Analg. 1998;86(2):320–4.

    CAS  PubMed  Google Scholar 

  71. Boldt J, Knothe C, Zickmann B, Andres P, Dapper F, Hempelmann G. Influence of different intravascular volume therapies on platelet function in patients undergoing cardiopulmonary bypass. Anesth Analg. 1993;76(6):1185–90.

    Article  CAS  PubMed  Google Scholar 

  72. Mielke LL, Entholzner EK, Kling M, Breinbauer BE, Burgkart R, Hargasser SR, Hipp RF. Preoperative acute hypervolemic hemodilution with hydroxyethylstarch: an alternative to acute normovolemic hemodilution. Anesth Analg. 1997;84(1):26–30.

    Article  CAS  PubMed  Google Scholar 

  73. Lindahl SG. Thinner than blood. Anesth Analg. 1995; 80(2), 217–18. Marlow R, Reich DL, Neustein S, Silvay G. Haemodynamic response to induction of anaesthesia with ketamine/midazolam. Can J of Anaesth. 1991;38(7):844–8.

    Google Scholar 

  74. Strebel S, Kaufmann M, MAÎRE L, Schaefer HG. Effects of ketamine on cerebral blood flow velocity in humans Influence of pretreatment with midazolam or esmolol. Anaesthesia. 1995;50(3):223–8.

    Article  CAS  PubMed  Google Scholar 

  75. Åkeson J, Björkman S, Messeter K, Rosen I, Helfer M. Cerebral pharmacodynamics of anaesthetic and subanaesthetic doses of ketamine in the normoventilated pig. Acta Anaesthesiol Scand. 1993;37(2):211–8.

    Article  PubMed  Google Scholar 

  76. Albanese J, Arnaud S, Rey M, Thomachot L, Alliez B, Martin C. Ketamine decreases intracranial pressure and electroencephalographic activity in traumatic brain injury patients during propofol sedation. Anesthesiology. 1997;87(6):1328–34.

    Article  CAS  PubMed  Google Scholar 

  77. Gardner AE, Olson BE, Lichticer M. Cerebrospinal-fluid pressure during dissociative anesthesia with ketamine. Anesthesiology. 1971;35(2):226–8.

    Article  CAS  PubMed  Google Scholar 

  78. Cavazzuti M, Porro CA, Biral GP, Benassi C, Barbieri GC. Ketamine effects on local cerebral blood flow and metabolism in the rat. J Cereb Blood Flow Metab. 1987;7(6):806–11.

    Article  CAS  PubMed  Google Scholar 

  79. Ohata H, Iida H, Nagase K, Dohi S. The effects of topical and intravenous ketamine on cerebral arterioles in dogs receiving pentobarbital or isoflurane anesthesia. Anesth Analg. 2001;93(3):697–702.

    Article  CAS  PubMed  Google Scholar 

  80. Shapiro HM, Drummond JC. Neurosurgical anesthesia. In: Miller RD, et al., editors. Anesthesia. New York: Churchill Livingstone; 1994. p. 1897–946.

    Google Scholar 

  81. Gopinath SP, Robertson CS, Contant CF, Hayes C, Feldman Z, Narayan RK, Grossman RG. Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psychiatry. 1994;57(6):717–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  82. Dearden NM. Jugular bulb venous oxygen saturation in the management of severe head injury. Cur Opin Anesth. 1991;4(2):279–86.

    Article  Google Scholar 

  83. Gopinath S, Cormio M, Ziegler J, Raty S, Valadka A, Robertson C. Intraoperative jugular desaturation during surgery for traumatic intracranial hematomas. Anesth Analg. 1996;83(5):1014–21.

    Article  CAS  PubMed  Google Scholar 

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  1. Department of Anesthesiology and Intensive Care, Tehran University of Medical Sciences, Tehran, Iran

    Zahid Hussain Khan MD

  2. Department of Surgery, Swabi Medical College, Pukhtoonkhwa province, Pakistan

    Shahid Nisar Khalid MBBS, FCPS

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  1. Zahid Hussain Khan MD
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    Zahid Hussain Khan

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Khan, Z.H., Khalid, S.N. (2017). The Conundrum of Postoperative Hematoma in Intracranial Surgery. In: Khan, Z. (eds) Challenging Topics in Neuroanesthesia and Neurocritical Care. Springer, Cham. https://doi.org/10.1007/978-3-319-41445-4_25

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