Post-operative intensive care unit admissions following elective craniotomy for primary brain tumor: A narrative review

Abstract

Primary brain tumors (PBTs) refer to the growth of abnormal cells originating in the brain. These tumors account for approximately two percent of all cancers in the adult population of the United States. Patients diagnosed with glioblastoma, one of the most common malignant PBTs, often require treatments in intensive care unit (ICU). Surgical removal of PBTs through craniotomy is often the firstline treatment for many types of brain tumors. ICU admission following major surgery like craniotomy is considered a standard of care in many healthcare systems. ICU provides access to specialized equipment, such as mechanical ventilators, continuous renal replacement therapy machines, continuous electroencephalogram monitoring, and invasive hemodynamic monitoring devices, which might be essential for the care of these patients. Understanding potential complications is essential for healthcare professionals to monitor patients more effectively and guide decision-making for optimal management. Over the years, perceptions of ICU utilization have shifted, raising questions about whether ICU admission is always the right choice for patients who have undergone brain surgery. Traditional scoring systems may not always demonstrate the necessity of ICU care for patients undergoing elective craniotomy for PBTs. Further research is needed to identify the most effective strategies for optimizing patient care, determining the need for ICU care in specific cases, and minimizing costs in neurosurgery.

Keywords

Neurosurgery / Craniotomy / Primary brain tumor patients / Intensive care unit

Acknowledgments

None.

Funding

None.

Conflict of interest

The authors declare they have no competing interests.

Author contributions

Conceptualization: Pavel Salvador Pichardo-Rojas, Siddharth Shah, Mariali Palacios-Cruz

Visualization: Siddharth Shah, Pavel Salvador Pichardo-Rojas, Jose Alfonso Alvarez-Castro, Mario Torres-Chavez

Writing-original draft: Mariali Palacios-Cruz, Emmanuel Beltran-Gutierrez, Mario Torres-Chavez, Jose Alfonso Alvarez-Castro

Writing-review & editing: Pavel Salvador Pichardo-Rojas, Siddharth Shah, Mario Torres-Chavez, Adrian Coria-Medrano

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Availability of data

Not applicable.

References

[1] Louis DN, Perry A, Wesseling P, et al.The 2021 WHO classification of tumors of the central nervous system: A summary. Neuro Oncol. 2021; 23(8):1231-1251. doi: 10.1093/neuonc/noab106

[2] Perkins A, Liu G. Primary brain tumors in Adults: Diagnosis and treatment. Am Fam Physician. 2016; 93(3):211-217.

[3] Zarnett OJ, Sahgal A, Gosio J, et al. Treatment of elderly patients with glioblastoma: A systematic evidence-based analysis. JAMA Neurol. 2015; 72(5):589-596. doi: 10.1001/jamaneurol.2014.3739

[4] De Almeida CC, Boone MD, Laviv Y, Kasper BS, Chen CC, Kasper EM. The utility of routine intensive care admission for patients undergoing intracranial neurosurgical procedures: A systematic review. Neurocrit Care. 2018; 28(1):35-42. doi: 10.1007/s12028-017-0433-4

[5] Gabel BC, Martin J, Crawford JR, Levy M. Questioning the need for ICU level of care in pediatric patients following elective uncomplicated craniotomy for brain tumors. J Neurosurg Pediatr. 2016; 17(5):564-568. doi: 10.3171/2015.8.peds15191

[6] Hanak BW, Walcott BP, Nahed BV, et al. Postoperative intensive care unit requirements after elective craniotomy. World Neurosurg. 2014; 81(1):165-172. doi: 10.1016/j.wneu.2012.11.068

[7] White JL, Sheth KN, editors. Neurocritical Care for the Advanced Practice Clinician. Berlin, Germany: Springer International Publishing; 2018. doi: 10.1007/978-3-319-48669-7

[8] Altieri R, Cofano F, Agnoletti A, et al. Postoperative care of patients with high-grade glioma: Is there a real need for the neurocritical ICU and early CT scan? J Neurol Surg A Cent Eur Neurosurg. 2018; 79(1):25-30. doi: 10.1055/s-0037-1599238

[9] Chan AY, Choi EH, Oh MY, et al. Elective versus nonelective brain tumor resections: A 5-year propensity score matching cost comparison analysis. J Neurosurg. 2022; 136(1):40-44. doi: 10.3171/2020.12.jns203401

[10] Duncan GG, Goodman GB, Ludgate CM, Rheaume DE. The treatment of adult supratentorial high grade astrocytomas. J Neurooncol. 1992; 13(1):63-72. doi: 10.1007/BF00172947

[11] Lonjaret L, Guyonnet M, Berard E, et al. Postoperative complications after craniotomy for brain tumor surgery. Anaesth Crit Care Pain Med. 2017; 36(4):213-218. doi: 10.1016/j.accpm.2016.06.012

[12] Cinotti R, Bruder N, Srairi M, et al. Prediction score for postoperative neurologic complications after brain tumor craniotomy: A multicenter observational study. Anesthesiology. 2018; 129(6):1111-1120. doi: 10.1097/aln.0000000000002426

[13] Newton HB. Primary brain tumors: Review of etiology, diagnosis and treatment. Am Fam Physician. 1994; 49(4):787-797.

[14] Hani U, Bakhshi SK, Shamim MS. Enhanced recovery after elective craniotomy for brain tumours. J Pak Med Assoc. 2019; 69(5):749-751.

[15] Sarnthein J, Stieglitz L, Clavien PA, Regli L. A patient registry to improve patient safety: Recording general neurosurgery complications. PLoS One. 2016; 11(9):e0163154. doi: 10.1371/journal.pone.0163154

[16] Van Niftrik CHB, van der Wouden F, Staartjes VE, et al. Machine learning algorithm identifies patients at high risk for early complications after intracranial tumor surgery: Registry-based cohort study. Neurosurgery. 2019; 85(4):E756-E764. doi: 10.1093/neuros/nyz145

[17] Elf K, Ronne-Engstr.m E, Semnic R, Rostami-Berglund E, Sundblom J, Zetterling M. Continuous EEG monitoring after brain tumor surgery. Acta Neurochir (Wien). 2019; 161(9):1835-1843. doi: 10.1007/s00701-019-03982-6

[18] De la Garza-Ramos R, Kerezoudis P, Tamargo RJ, Brem H, Huang J, Bydon M. Surgical complications following malignant brain tumor surgery: An analysis of 2002-2011 data. Clin Neurol Neurosurg. 2016; 140:6-10. doi: 10.1016/j.clineuro.2015.11.005

[19] Franko LR, Hollon T, Linzey J, et al. Clinical factors associated with ICU-specific care following supratentoral brain tumor resection and validation of a risk prediction score. Crit Care Med. 2018; 46(8):1302-1308. doi: 10.1097/CCM.0000000000003207

[20] Gu WJ, Zhou JX, Ji RQ, Zhou LY, Wang CM. Incidence, risk factors, and consequences of emergence delirium after elective brain tumor resection. Surgeon. 2022; 20(5):e214-e220. doi: 10.1016/j.surge.2021.09.005

[21] Xu T, Zhang S, Zhang X, Guo L. Remote intracranial hemorrhage secondary to brain tumor surgery. J Craniofac Surg. 2020; 31(1):e53-e57. doi: 10.1097/SCS.0000000000005866

[22] Wang C, Niu X, Ren Y, Lan Z, Zhang Y. Risk factors for postoperative intracranial hemorrhage after resection of intracranial tumor in 2259 consecutive patients. World Neurosurg. 2019; 129:e663-e668. doi: 10.1016/j.wneu.2019.05.239

[23] Huang HW, Zhang GB, Li HY, et al. Development of an early prediction model for postoperative delirium in neurosurgical patients admitted to the ICU after elective craniotomy (E-PREPOD-NS): A secondary analysis of a prospective cohort study. J Clin Neurosci. 2021; 90:217-224. doi: 10.1016/j.jocn.2021.06.004

[24] Yao J, Li S, Cui Q, et al. Intraoperative hypotension and postoperative stroke in older patients who had brain tumor resections: A retrospective cohort analysis. World Neurosurg. 2023; 174:e72-e81. doi: 10.1016/j.wneu.2023.02.136

[25] Johans SJ, Garst JR, Burkett DJ, et al. Identification of preoperative and intraoperative risk factors for complications in the elderly undergoing elective craniotomy. World Neurosurg. 2017; 107:216-225. doi: 10.1016/j.wneu.2017.07.177

[26] Viken HH, Iversen IA, Jakola A, Sagberg LM, Solheim O. When are complications after brain tumor surgery detected? World Neurosurg. 2018; 112:e702-e710. doi: 10.1016/j.wneu.2018.01.137

[27] Laan MT, Roelofs S, Van Huet I, Adang EMM, Bartels RHMA. Selective intensive care unit admission after adult supratentorial tumor craniotomy: Complications, length of stay, and costs. Neurosurgery. 2020; 86(1):E54-E59. doi: 10.1093/neuros/nyz388

[28] Al-Dorzi HM, Alruwaita AA, Marae BO, et al. Incidence, risk factors and outcomes of seizures occurring after craniotomy for primary brain tumor resection. Neurosciences (Riyadh). 2017; 22(2):107-113. doi: 10.17712/nsj.2017.2.20160570

[29] Prediction score for postoperative neurologic complications after brain tumor craniotomy: A multicenter observational study: Erratum. Anesthesiology. 2021; 135(6):1168. doi: 10.1097/ALN.0000000000003881

[30] Dickinson H, Carico C, Nu. o M, et al. Unplanned readmissions and survival following brain tumor surgery. J Neurosurg. 2015; 122(1):61-68. doi: 10.3171/2014.8.jns1498

[31] Magill ST, Han SJ, Li J, Berger MS. Resection of primary motor cortex tumors: Feasibility and surgical outcomes. J Neurosurg. 2018; 129(4):961-972. doi: 10.3171/2017.5.jns163045

[32] Decavèle M, Rivals I, Marois C, et al. Etiology and prognosis of acute respiratory failure in patients with primary malignant brain tumors admitted to the intensive care unit. J Neurooncol. 2019; 142(1):139-148. doi: 10.1007/s11060-018-03074-y

[33] Blot S, Ruppé E, Harbarth S, et al. Healthcare-associated infections in adult intensive care unit patients: Changes in epidemiology, diagnosis, prevention and contributions of new technologies. Intensive Crit Care Nurs. 2022; 70:103227. doi: 10.1016/j.iccn.2022.103227

[34] O’Horo JC, Sampathkumar P. Infections in neurocritical care. Neurocrit Care. 2017; 27(3):458-467. doi: 10.1007/s12028-017-0420-9

[35] Munari M, De Cassai A, Sandei L, et al. Optimizing post anesthesia care unit admission after elective craniotomy for brain tumors: A cohort study. Acta Neurochir (Wien). 2022; 164(3):635-641. doi: 10.1007/s00701-021-04732-3

[36] Nassiri F, Li L, Badhiwala JH, et al. Hospital costs associated with inpatient versus outpatient awake craniotomy for resection of brain tumors. J Clin Neurosci. 2019; 59:162-166. doi: 10.1016/j.jocn.2018.10.110

[37] O’horo JC, Sampathkumar P. Infections in neurocritical care. Neurocrit Care. 2017; 27(3):458-467. doi: 10.1007/s12028-017-0420-9

[38] Wang L, Cai H, Wang Y, et al. Enhanced recovery after elective craniotomy: A randomized controlled trial. J Clin Anesth. 2022; 76:110575. doi: 10.1016/j.jclinane.2021.110575

[39] Qu L, Liu B, Zhang H, et al. Management of postoperative pain after elective craniotomy: A prospective randomized controlled trial of a neurosurgical enhanced recovery after surgery (ERAS) program. Int J Med Sci. 2020; 17(11):1541-1549. doi: 10.7150/ijms.46403

[40] Stumpo V, Staartjes VE, Quddusi A, et al. Enhanced recovery after surgery strategies for elective craniotomy: A systematic review. J Neurosurg. 2021; 135(6):1857-1881. doi: 10.3171/2020.10.jns203160

[41] Lutman B, Bloom J, Nussenblatt B, Romo V. A contemporary perspective on the management of post-craniotomy headache and pain. Curr Pain Headache Rep. 2018; 22(10):69. doi: 10.1007/s11916-018-0722-4

[42] Azad TD, Shah PP, Kannapadi NV, et al. Reexamining the role of postoperative ICU admission for patients undergoing elective craniotomy: A systematic review. Crit Care Med. 2022; 50(9):1380-1393. doi: 10.1097/CCM.0000000000005588

[43] Wilcox ME, Vaughan K, Chong CAKY, Neumann PJ, Bell CM. Cost-effectiveness studies in the ICU: A systematic review. Crit Care Med. 2019; 47(8):1011-1017. doi: 10.1097/CCM.0000000000003768

[44] Zygourakis CC, Liu CY, Yoon S, et al. Analysis of cost variation in craniotomy for tumor using 2 national databases. Neurosurgery. 2017; 81(6):972-979. doi: 10.1093/neuros/nyx133

[45] Mooney MA, Yoon S, Cole T, et al. Cost transparency in neurosurgery: A single-institution analysis of patient out-ofpocket spending in 13 673 consecutive neurosurgery cases. Neurosurgery. 2019; 84(6):1280-1289. doi: 10.1093/neuros/nyy185

[46] Menger RP, Guthikonda B, Storey CM, Nanda A, McGirt M, Asher A. Neurosurgery value and quality in the context of the affordable care act: A policy perspective. Neurosurg Focus. 2015; 39(6):E5. doi: 10.3171/2015.9.FOCUS15376

[47] McLaughlin N, Upadhyaya P, Buxey F, Martin NA. Valuebased neurosurgery: Measuring and reducing the cost of microvascular decompression surgery. J Neurosurg. 2014; 121(3):700-708. doi: 10.3171/2014.5.JNS131996

[48] Smith TR, Rambachan A, Cote D, Cybulski G, Laws ER. Market-based health care in specialty surgery: Finding patient-centered shared value. Neurosurgery. 2015; 77(4):509-516; discussion 516. doi: 10.1227/NEU.0000000000000879

[49] Sheshadri V, Venkatraghavan L, Manninen P, Bernstein M. Anesthesia for same day discharge after craniotomy: Review of a single center experience. J Neurosurg Anesthesiol. 2018; 30(4):299-304. doi: 10.1097/ANA.0000000000000483

[50] Venkatraghavan L, Bharadwaj S, Au K, Bernstein M, Manninen P. Erratum to: Same-day discharge after craniotomy for supratentorial tumour surgery: A retrospective observational single-center study. Can J Anaesth. 2017; 64(3):345-346. doi: 10.1007/s12630-016-0811-y

[51] Mirza FA, Wang C, Pittman T. Can patients safely be admitted to a ward after craniotomy for resection of intraaxial brain tumors? Br J Neurosurg. 2017; 32(2):201-205. doi: 10.1080/02688697.2017.1390064

[52] Bui JQH, Mendis RL, van Gelder JM, Sheridan MMP, Wright KM, Jaeger M. Is postoperative intensive care unit admission a prerequisite for elective craniotomy? J Neurosurg. 2011; 115(6):1236-1241. doi: 10.3171/2011.8.jns11105

[53] Osorio JA, Safaee MM, Viner J, et al. Cost-effectiveness development for the postoperative care of craniotomy patients: A safe transitions pathway in neurological surgery. Neurosurg Focus. 2018; 44(5):E19. doi: 10.3171/2018.2.FOCUS1812

[54] Beauregard CL, Friedman WA. Routine use of postoperative ICU care for elective craniotomy: A cost-benefit analysis. Surg Neurol. 2003; 60(6):483-489; discussion 489. doi: 10.1016/s0090-3019(03)00517-2

[55] Dunn LK, Naik BI, Nemergut EC, Durieux ME. Postcraniotomy pain management: Beyond opioids. Curr Neurol Neurosci Rep. 2016; 16(10):93. doi: 10.1007/s11910-016-0693-y

[56] Gan TJ, Belani KG, Bergese S, et al. Fourth consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg. 2020; 131(2):411-448. doi: 10.1213/ANE.0000000000004833

[57] Weibel S, Pace NL, Schaefer MS, et al. Drugs for preventing postoperative nausea and vomiting in adults after general anesthesia: An abridged cochrane network meta-analysis. J Evid Based Med. 2021; 14(3):188-197. doi: 10.1111/jebm.12429

[58] Kourbeti IS, Vakis AF, Ziakas P, et al. Infections in patients undergoing craniotomy: Risk factors associated with postcraniotomy meningitis. J Neurosurg. 2015; 122(5):1113-1119. doi: 10.3171/2014.8.JNS132557

[59] AVERT Trial Collaboration Group. Efficacy and safety of very early mobilisation within 24 h of stroke onset (AVERT): A randomised controlled trial. Lancet. 2015; 386(9988):46-55. doi: 10.1016/S0140-6736(15)60690-0

[60] Kelly DF. Neurosurgical postoperative care. Neurosurg Clin N Am. 1994; 5(4):789-810.

[61] Panda NB, Mahajan S, Chauhan R. Management of postoperative neurosurgical patients. J Neuroanaesth Crit Care. 2019; 6(2):80-86. doi: 10.1055/s-0039-1689055

[62] Marigil M, Bernstein M. Outpatient neurosurgery in neurooncology. Neurosurg Focus. 2018; 44(6):E19. doi: 10.3171/2018.3.focus1831

[63] Florman JE, Cushing D, Keller LA, Rughani AI. A protocol for postoperative admission of elective craniotomy patients to a non- ICU or step-down setting. J Neurosurg. 2017; 127(6):1392-1397. doi: 10.3171/2016.10.jns16954

[64] Syrous NS Sundstr.m T, S.fteland E, Jammer I. Effects of intraoperative dexmedetomidine infusion on postoperative pain after craniotomy: A narrative review. Brain Sci. 2021; 11(12):1636. doi: 10.3390/brainsci11121636

[65] Gertler R, Brown HC, Mitchell DH, Silvius EN. Dexmedetomidine: A novel sedative-analgesic agent. Proc (Bayl Univ Med Cent). 2001; 14(1):13-21. doi: 10.1080/08998280.2001.11927725

[66] Moningi S, Patki A, Padhy N, Ramachandran G. Enhanced recovery after surgery: An anesthesiologist’s perspective. J Anaesthesiol Clin Pharmacol. 2019; 35(Suppl 1):S5-S13. doi: 10.4103/joacp.JOACP_238_16

[67] Kvolik S, Koruga N, Skiljic S. Analgesia in the neurosurgical intensive care unit. Front Neurol. 2021; 12:819613. doi: 10.3389/fneur.2021.819613