Elective Cranial Neurosurgery Research Articles

Cyclooxygenase 2 Inhibitors for Headache After Elective Cranial Neurosurgery: Results from a Systematic Review of Efficacy of Cyclooxygenase 2 Inhibitors for Headache After Acute Brain Injury.

Headache management after acute brain injury (ABI) is challenging. Although opioids are commonly used, selective cyclooxygenase 2 inhibitors (COXIBs) may be promising alternatives. However, concerns about cardiovascular effects and bleeding risk have limited their use. We aimed at summarizing available data on efficacy of COXIBs for headache management following ABI. A systematic review was conducted through MEDLINE and Embase for articles published through September 2023 (PROSPERO identifier: CRD42022320453). No language filters were applied to the initial searches. Interventional or observational studies and systematic reviews assessing efficacy of COXIBs for headache in adults with ABI were eligible. Article selection was performed by two independent reviewers using DistillerSR. Descriptive statistics were used for data analysis, and meta-analysis was unfeasible because of study heterogeneity. Of 3190 articles identified, 6 studies met inclusion criteria: 4 randomized controlled trials and 2 retrospective cohort studies, all conducted in elective cranial neurosurgical patients (total N = 738) between 2006 and 2022. Five studies used COXIBs in the intervention group only. Of the six studies, four found a reduction in overall pain scores in the intervention group, whereas one showed improvement only at 6h postoperatively, and one did not find significant differences. Pain scores decreased between 4 and 15%, the largest shift being from moderate to mild severity. Three studies found an overall opioid use reduction throughout hospitalization in the intervention group, whereas one reported a reduction at 12h postoperatively only. Opioid consumption decreased between 9 and 90%. Two studies found a decrease in hospital length of stay by ~ 1day in the intervention group. The one study reporting postoperative hemorrhage found a statistically nonsignificant 3% reduction in the intervention group. COXIBs may serve as opioid-sparing adjunctive analgesics for headache control after elective cranial surgery. Limited or no literature exists for other forms of ABI, and additional safety data remain to be elucidated.

Leukocyte- and platelet-rich fibrin in cranial surgery: a single-blinded, prospective, randomized controlled noninferiority trial.

CSF leakage is a major complication after cranial surgery, and although fibrin sealants are widely used for reinforcing dural closure, concerns exist regarding their safety, efficacy, and cost. Leukocyte- and platelet-rich fibrin (L-PRF), an autologous platelet concentrate, is readily available and inexpensive, making it a cost-effective alternative for commercially available fibrin sealants. This study aimed to demonstrate the noninferiority of L-PRF compared with commercially available fibrin sealants in preventing postoperative CSF leakage in supra- and infratentorial cranial surgery, with secondary outcomes focused on CSF leakage risk factors and adverse events. In a single-blinded, prospective, randomized controlled interventional trial conducted at a neurosurgery department of a tertiary care center (UZ Leuven, Belgium), patients undergoing elective cranial neurosurgery were randomly assigned to receive either L-PRF (active treatment) or commercially available fibrin sealants (control) for dural closure in a 1:1 ratio. Among 350 included patients, 328 were analyzed for the primary endpoint (44.5% male, mean age 52.3 ± 15.1 years). Six patients (5 in the control group, 1 in the L-PRF group) presented with CSF leakage requiring any intervention (relative risk [RR] 0.20, one-sided 95% CI -∞ to 1.02, p = 0.11), confirming noninferiority. Of these 6 patients, 1 (in the control group) presented with CSF leakage requiring revision surgery. No risk factors for reconstruction failure in combination with L-PRF were identified. RRs for adverse events such as infection (0.72, 95% CI -∞ to 1.96) and meningitis (0.36, 95% CI -∞ to 1.25) favored L-PRF treatment, although L-PRF treatment showed slightly more bleeding events (1.44, 95% CI -∞ to 4.66). Dural reinforcement with L-PRF proved noninferior to commercially available fibrin sealants, with no safety issues. Introducing L-PRF to standard clinical practice could result in important cost savings due to accessibility and lower cost. Clinical trial registration no.: NCT03812120 (ClinicalTrials.gov).

Is the Patient State Index a reliable parameter as guide to anaesthesiology in cranial neurosurgery? A first intraoperative study and a literature review

BackgroundPatient State Index (PSI) and Suppression Ratio (SR) are two indices calculated by quantitative analysis of EEG used to estimate the depth of anaesthesia but their validation in neurosurgery must be done. Our aim was to investigate the congruity PSI and SR with raw EEG monitoring in neurosurgery. MethodsWe included 34 patients undergoing elective cranial neurosurgery. Each patient was monitored by a SedLine device (PSI and SR) and by raw EEG. To appraise the agreement between PSI, SR and EEG Suppr%, Bland-Altman analysis was used. We also correlated the PSI and SR recorded at different times during surgery to the degree of suppression of the raw EEG data by Spearman's rank correlation coefficient. For a comparison with previous data we made an international literature review according to PRISMA protocol. ResultsAt all recording times, we found that there is a strong agreement between PSI and raw EEG. We also found a significant correlation for both PSI and SR with the EEG suppression percentage (p < 0.05), but with a broad dispersion of the individual values within the confidence interval. ConclusionThe Masimo SedLine processed EEG monitoring system can be used as a guide in the anaesthetic management of patients during elective cranial neurosurgery, but the anaesthesiologist must be aware that previous correlations between PSI and SR with the suppression percentage may not always be valid in all individual patients. The use of an extended visual raw EEG evaluated by an expert electroencephalographer might help to provide better guidance.

Routine screening for hepatitis C viral infection in patients undergoing elective cranial neurosurgery.

Undiagnosed hepatitis C virus (HCV) and HIV in patients present risks of transmission of bloodborne infections to surgeons intraoperatively. Presurgical screening has been suggested as a protocol to protect surgical staff from these pathogens. The authors sought to determine the incidence of HCV and HIV infection in elective craniotomy patients and analyze the cost-effectiveness of universal and risk factor-specific screening for protection of the surgical staff. All patients undergoing elective craniotomy between July 2009 and July 2016 at the National Brain Aneurysm Center who did not refuse screening were included in this study. The authors utilized rapid HCV and HIV tests to screen patients prior to elective surgery, and for each patient who tested positive using the rapid HCV or HIV test, qualitative nucleic acid testing was used to confirm active viral load, and risk factor information was collected. Patients scheduled for nonurgent surgery who were found to be HCV positive were referred to a hepatologist for preoperative treatment. The authors compared risk factors between patients who tested positive on rapid tests, patients with active viral loads, and a random sample of patients who tested negative. The authors also tracked the clinical and material costs of HCV and HIV rapid test screening per patient for cost-effectiveness analysis and calculated the cost per positive result of screening all patients and of screening based on all patient risk factors that differed significantly between patients with and those without positive HCV test results. The study population of patients scheduled for elective craniotomy included 1461 patients, of whom 22 (1.5%) refused the screening. Of the 1439 patients screened, 15 (1.0%) tested positive for HCV using rapid HCV screening; 9 (60%) of these patients had active viral loads. No patient (0%) tested positive for HIV. Seven (77.8%) of the 9 patients with active viral loads underwent treatment with a hepatologist and were referred back for surgery 3-6 months after sustained virologic response to treatment, but the remaining 2 patients (22.2%) required urgent surgery. Of the 9 patients with active viral loads, 1 patient (11%) had a history of both intravenous drug abuse and tattoos. Two of the 9 patients (22%) had tattoos, and 3 (33%) were born within the age-screening bracket (born 1945-1965) recommended by the Centers for Disease Control and Prevention. Rates of smoking differed significantly (p < 0.001) between patients who had active viral loads of HCV and patients who were HCV negative, and rates of smoking (p < 0.001) and IV drug abuse (p < 0.01) differed significantly between patients who were HCV rapid-test positive and those who were HCV negative. Total screening costs (95% CI) per positive result were $3,877.33 ($2,348.05-$11,119.28) for all patients undergoing HCV rapid screening, $226.29 ($93.54-$312.68) for patients with a history of smoking, and $72.00 ($29.15-$619.39) for patients with a history of IV drug abuse. The rate of undiagnosed HCV infection in this patient population was commensurate with national levels. While the cost of universal screening was considerable, screening patients based on a history of smoking or IV drug abuse would likely reduce costs per positive result greatly and potentially provide cost-effective identification and treatment of HCV patients and surgical staff protection. HIV screening found no infected patients and was not cost-effective.

Simple Preoperative Patient-Reported Factors Predict Adverse Outcome After Elective Cranial Neurosurgery.

Patient-reported preoperative factors hold promise in improving the prediction of postoperative adverse events, but they have been poorly studied. To study the role of patient-reported factors in the preoperative risk stratification of elective craniotomy patients. A prospective, unselected cohort of 322 adult patients underwent elective craniotomy in Helsinki, Finland. We preoperatively recorded the American Society of Anesthesiologists (ASA) score, Helsinki ASA score, and 3 questionnaire-based patient-reported factors including overall health status, ability to climb 2 flights of stairs, and cognitive function (Test Your Memory test). Outcome measures comprised in-hospital major and overall morbidity. Receiver-operating characteristic curves served to calculate area under the curve (AUC) values for a composite score of patient-reported factors and both ASA scores with regard to outcomes. In-hospital major and overall morbidity rate was 15.2%. Only preoperatively diminished cognitive function remained a significant predictor of major morbidity after multivariable logistic regression analysis (P < .001, odds ratio 1.1, confidence interval 1.0-1.1). A composite score of our 3 patient-reported factors had a higher AUC (0.675) for major morbidity than original ASA score (0.543) or Helsinki ASA score (0.572). In elderly patients, the composite score had an AUC of 0.726 for major morbidity. Preoperative patient-reported factors had higher sensitivity for detecting major morbidity compared to the ASA scores in this study. Particularly, the simple composite score seems to predict adverse outcomes in elective cranial surgery surprisingly well, especially in the elderly. These results are interesting and worth confirming in other centers.

Letter: Simple Preoperative Patient-Reported Factors Predict Adverse Outcome After Elective Cranial Neurosurgery.

Letter: Simple Preoperative Patient-Reported Factors Predict Adverse Outcome After Elective Cranial Neurosurgery.

In Reply: Simple Preoperative Patient-Reported Factors Predict Adverse Outcome After Elective Cranial Neurosurgery.

BACKGROUND Patient-reported preoperative factors hold promise in improving the prediction of postoperative adverse events, but they have been poorly studied. OBJECTIVE To study the role of patient-reported factors in the preoperative risk stratification of elective craniotomy patients. METHODS A prospective, unselected cohort of 322 adult patients underwent elective craniotomy in Helsinki, Finland. We preoperatively recorded the American Society of Anesthesiologists (ASA) score, Helsinki ASA score, and 3 questionnaire-based patient-reported factors including overall health status, ability to climb 2 flights of stairs, and cognitive function (Test Your Memory test). Outcome measures comprised in-hospital major and overall morbidity. Receiver-operating characteristic curves served to calculate area under the curve (AUC) values for a composite score of patient-reported factors and both ASA scores with regard to outcomes. RESULTS In-hospital major and overall morbidity rate was 15.2%. Only preoperatively diminished cognitive function remained a significant predictor of major morbidity after multivariable logistic regression analysis (P < .001, odds ratio 1.1, confidence interval 1.0-1.1). A composite score of our 3 patient-reported factors had a higher AUC (0.675) for major morbidity than original ASA score (0.543) or Helsinki ASA score (0.572). In elderly patients, the composite score had an AUC of 0.726 for major morbidity. CONCLUSION Preoperative patient-reported factors had higher sensitivity for detecting major morbidity compared to the ASA scores in this study. Particularly, the simple composite score seems to predict adverse outcomes in elective cranial surgery surprisingly well, especially in the elderly. These results are interesting and worth confirming in other centers.

Transitional care services: a quality and safety process improvement program in neurosurgery.

OBJECTIVE Readmissions increasingly serve as a metric of hospital performance, inviting quality improvement initiatives in both medicine and surgery. However, few readmission reduction programs have targeted surgical patient populations. The objective of this study was to establish a transitional care program (TCP) with the goal of decreasing length of stay (LOS), improving discharge efficiency, and reducing readmissions of neurosurgical patients by optimizing patient education and postdischarge surveillance. METHODS Patients undergoing elective cranial or spinal neurosurgery performed by one of 5 participating surgeons at a quaternary care hospital were enrolled into a multifaceted intervention. A preadmission overview and establishment of an anticipated discharge date were both intended to set patient expectations for a shorter hospitalization. At discharge, in-hospital prescription filling was provided to facilitate medication compliance. Extended discharge appointments with a neurosurgery TCP-trained nurse emphasized postoperative activity, medications, incisional care, nutrition, signs that merit return to medical attention, and follow-up appointments. Finally, patients received a surveillance phone call 48 hours after discharge. Eligible patients omitted due to staff limitations were selected as controls. Patients were matched by sex, age, and operation type-key confounding variables-with control patients, who were eligible patients treated at the same time period but not enrolled in the TCP due to staff limitation. Multivariable logistic regression evaluated the association of TCP enrollment with discharge time and readmission, and linear regression with LOS. Covariates included matching criteria and Charlson Comorbidity Index scores. RESULTS Between 2013 and 2015, 416 patients were enrolled in the program and matched to a control. The median patient age was 55 years (interquartile range 44.5-65 years); 58.4% were male. The majority of enrolled patients underwent spine surgery (59.4%, compared with 40.6% undergoing cranial surgery). Hospitalizations averaged 62.1 hours for TCP patients versus 79.6 hours for controls (a 16.40% reduction, 95% CI 9.30%-23.49%; p < 0.001). The intervention was associated with a higher proportion of morning discharges, which was intended to free beds for afternoon admissions and improve patient flow (OR 3.13, 95% CI 2.27-4.30; p < 0.001), and decreased 30-day readmissions (2.5% vs 5.8%; OR 2.43, 95% CI 1.14-5.27; p = 0.02). CONCLUSIONS This neurosurgical TCP was associated with a significantly shorter LOS, earlier discharge, and reduced 30-day readmission after elective neurosurgery. These results underscore the importance of patient education and surveillance after hospital discharge.

Modified Rankin Scale and Short-Term Outcome in Cranial Neurosurgery: A Prospective and Unselected Cohort Study

The modified Rankin Scale (mRS) was developed to monitor functional recovery after stroke, but nowadays it is a treatment outcome measure in elective neurosurgery. Our objective was to study how mRS changes associate with short-term postoperative outcome. Preoperative, in-hospital, and 30-day mRS scores came from a prospective, consecutive and unselected cohort of 418 adult elective craniotomy patients enrolled between December 2011 and December 2012 in Helsinki, Finland. Recorded data included subjective and objective postoperative in-hospital complications as well as changes in mRS score after surgery. Minor or major complications were detectable in 46% of the patients. In-hospital and 30-day postoperative increases in mRS score were inconsistent; among patients with no complications, 17% had a greater mRS score at discharge and 24% at 30 days, whereas 28% of the patients with major complications showed no increase in mRS score at discharge. Of individual complications, only new or worsened hemiparesis, silent stroke, and pneumonia were associated with postoperative increase (>2) in mRS score after multivariable analysis. For mRS-score difference > 1 at discharge in detecting major complications (including mortality), sensitivity was 45% and specificity 94%. The mRS changes after elective cranial neurosurgery are inconsistent. The mRS seems to represent functional changes, which do not necessarily associate with detected in-hospital complications.

Patient-Reported Outcomes in Elective Cranial Neurosurgery

The role of patient-reported outcomes (PROs) in elective cranial neurosurgery has been poorly studied, and their significance in reflecting complication rates is unclear. A prospective, consecutive, and unselected cohort of 418 adult patients underwent elective intracranial operations between 7 December, 2011 and 31 December, 2012 in Helsinki University Hospital, Finland. The questionnaire-based PROs included subjective postoperative assessments of overall health, cognitive function, and subjective change in functional status. Outcome measures included in-hospital major morbidity (including mortality) and in-hospital overall morbidity. We compared the usefulness of PROs with postoperative modified Rankin Scale (mRS) score. In univariable analyses, all recorded PROs and 30-day mRS scores ≥ 3 were associated with in-hospital major and overall morbidity. After multivariable analyses, postoperative deterioration of subjective functional status remained associated with in-hospital major morbidity (P = 0.001, odds ratio [OR] 4.9, confidence interval [CI] 1.9-12.0, sensitivity 71%, and specificity 70%) and overall in-hospital morbidity (P < 0.001, OR 5.7, CI 3.1-10.7, sensitivity 59%, and specificity 84%). Postoperatively impaired functional status was more sensitive but less specific in detecting in-hospital major and overall morbidity than the widely used mRS cut-off value of 2. A simple composite score combining the 3 recorded PROs was highly sensitive and specific in detecting in-hospital major (sensitivity 87%, specificity 98%) and overall (sensitivity 72%, specificity 99%) morbidity. In elective craniotomy patients, PROs seem promising patient-centered tools for outcomes reporting. Furthermore, neurosurgery-specific patient-reported outcome measures (PROMs) can perhaps be implemented to clinical use to improve patient safety and outcome comparisons in elective cranial neurosurgery.

Patient Satisfaction and Short-Term Outcome in Elective Cranial Neurosurgery.

Patient-reported experience is often used as a measure for quality of care, but no reports on patient satisfaction after cranial neurosurgery exist. To study the association of overall patient satisfaction and surgical outcome and to evaluate the applicability of overall patient satisfaction as a proxy for quality of care in elective cranial neurosurgery. We conducted an observational study on the relationship of overall patient satisfaction at 30 postoperative days with surgical and functional outcome (modified Rankin Scale [mRS] score) in a prospective, consecutive, and unselected cohort of 418 adult elective craniotomy patients enrolled between December 2011 and December 2012 at Helsinki University Hospital, Helsinki, Finland. Postoperative overall (subjective and objective) morbidity was present in 194 (46.4%) patients; yet almost 94% of all study patients reported high overall satisfaction. Low overall patient satisfaction at 30 days was not associated with postoperative major morbidity in elective cranial neurosurgery. Dependent functional status (mRS score ≥3) at 30 days, minor infections, poor postoperative subjective overall health status, and patient-reported severe symptoms (double vision, poor balance) may contribute to unsatisfactory patient experience. Overall patient satisfaction with elective cranial neurosurgery is high. Even 9 of 10 patients with postoperative major morbidity rated high overall patient satisfaction at 30 days. Overall patient satisfaction may merely reflect patient experience and subjective postoperative health status, and therefore it is a poor proxy for quality of care in elective cranial neurosurgery.

In Reply: Patient Satisfaction and Short-term Outcome in Elective Cranial Neurosurgery.

BACKGROUND Patient-reported experience is often used as a measure for quality of care, but no reports on patient satisfaction after cranial neurosurgery exist. OBJECTIVE To study the association of overall patient satisfaction and surgical outcome and to evaluate the applicability of overall patient satisfaction as a proxy for quality of care in elective cranial neurosurgery. METHODS We conducted an observational study on the relationship of overall patient satisfaction at 30 postoperative days with surgical and functional outcome (modified Rankin Scale [mRS] score) in a prospective, consecutive, and unselected cohort of 418 adult elective craniotomy patients enrolled between December 2011 and December 2012 at Helsinki University Hospital, Helsinki, Finland. RESULTS Postoperative overall (subjective and objective) morbidity was present in 194 (46.4%) patients; yet almost 94% of all study patients reported high overall satisfaction. Low overall patient satisfaction at 30 days was not associated with postoperative major morbidity in elective cranial neurosurgery. Dependent functional status (mRS score ≥3) at 30 days, minor infections, poor postoperative subjective overall health status, and patient-reported severe symptoms (double vision, poor balance) may contribute to unsatisfactory patient experience. CONCLUSION Overall patient satisfaction with elective cranial neurosurgery is high. Even 9 of 10 patients with postoperative major morbidity rated high overall patient satisfaction at 30 days. Overall patient satisfaction may merely reflect patient experience and subjective postoperative health status, and therefore it is a poor proxy for quality of care in elective cranial neurosurgery.

Evidence for the Use of Preoperative Risk Assessment Scores in Elective Cranial Neurosurgery

Evidence for the Use of Preoperative Risk Assessment Scores in Elective Cranial Neurosurgery

Evidence for the use of preoperative risk assessment scores in elective cranial neurosurgery: a systematic review of the literature.

Preoperative risk scores are designed to guide patient management by providing a means of predicting operative outcome. Several risk scores are used in neurosurgery, but studies on their clinical relevance are scarce. Therefore, it is not clear whether these risk scores are beneficial or helpful in predicting outcome after elective cranial neurosurgery. In this review, we summarize the current scientific evidence for using preoperative risk scores in elective cranial neurosurgery. A systematic review of the MEDLINE, Embase, and PubMed databases in November 2013 yielded 25 relevant studies with a minimum of 30 patients per study. The studies evaluated the value of the preoperative ASA physical status classification, the Karnofsky performance score (KPS), the Charlson comorbidity score, the modified Rankin Scale and the sex, KPS, ASA physical status classification, location, and edema (SKALE) score in assessing postoperative outcome in cranial neurosurgery. Surgery-related and nonsurgical complications were assessed separately whenever reported in the original article. For this purpose, the studies were placed into 4 categories based on the reported outcome: surgery-related outcome, nonsurgical outcome, morbidity, and mortality. The Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines for systematic reviews were followed. KPS has the strongest support in the literature for predicting surgery-related outcomes. There is no strong support in the literature for the use of any preoperative scores in predicting nonsurgical outcomes after elective craniotomies. KPS and ASA physical status classification seem to predict early (≤ 30-day) morbidity of intracranial tumor patients. The Charlson comorbidity score may be applicable in predicting mortality of elective intracranial aneurysm patients. Only 4 studies were prospective in design. Large prospective studies are needed to validate the use of the reviewed risk scores in elective cranial neurosurgery. It appears, however, that the patient's preoperative physical and functional status can be used to predict the short- and long-term outcome in elective cranial neurosurgery.

Preoperative anemia increases postoperative morbidity in elective cranial neurosurgery.

Background:Preoperative anemia may affect postoperative mortality and morbidity following elective cranial operations.Methods:The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to identify elective cranial neurosurgical cases (2006-2012). Morbidity was defined as wound infection, systemic infection, cardiac, respiratory, renal, neurologic, and thromboembolic events, and unplanned returns to the operating room. For 30-day postoperative mortality and morbidity, adjusted odds ratios (ORs) were estimated with multivariable logistic regression.Results:Of 8015 patients who underwent elective cranial neurosurgery, 1710 patients (21.4%) were anemic. Anemic patients had an increased 30-day mortality of 4.1% versus 1.3% in non-anemic patients (P < 0.001) and an increased 30-day morbidity rate of 25.9% versus 14.14% in non-anemic patients (P < 0.001). The 30-day morbidity rates for all patients undergoing cranial procedures were stratified by diagnosis: 26.5% aneurysm, 24.7% sellar tumor, 19.7% extra-axial tumor, 14.8% intra-axial tumor, 14.4% arteriovenous malformation, and 5.6% pain. Following multivariable regression, the 30-day mortality in anemic patients was threefold higher than in non-anemic patients (4.1% vs 1.3%; OR = 2.77; 95% CI: 1.65-4.66). The odds of postoperative morbidity in anemic patients were significantly higher than in non-anemic patients (OR = 1.29; 95% CI: 1.03-1.61). There was a significant difference in postoperative morbidity event odds with a hematocrit level above (OR = 1.07; 95% CI: 0.78-1.48) and below (OR = 2.30; 95% CI: 1.55-3.42) 33% [hemoglobin (Hgb) 11 g/dl].Conclusions:Preoperative anemia in elective cranial neurosurgery was independently associated with an increased risk of 30-day postoperative mortality and morbidity when compared to non-anemic patients. A hematocrit level below 33% (Hgb 11 g/dl) was associated with a significant increase in postoperative morbidity.

The incidence of complications in elective cranial neurosurgery associated with dural closure material

Dural closure with synthetic grafts has been suggested to contribute to the incidence of infection and CSF leak. The objective of this study was to assess the contribution of choice of dural closure material, as well as other factors, to the incidence of infection and CSF leak. A retrospective, consecutive cohort study of adult patients undergoing elective craniotomy was established between April 2010 and March 2011 at a single center. Exclusion criteria consisted of trauma, bur hole placement alone, and temporary CSF fluid diversion. Three hundred ninety-nine patients were included (mean follow-up 396.6 days). Nonautologous (synthetic) dural substitute was more likely to be used (n = 106) in cases of reoperation (p = 0.001). Seventeen patients developed a surgical site infection and 12 patients developed a CSF leak. Multivariate logistic regression modeling identified estimated blood loss (OR 1.002, 95% CI 1.001-1.003; p < 0.001) and cigarette smoking (OR 2.198, 95% CI 1.109-4.238; p = 0.019) as significant predictors of infection. Synthetic dural graft was not a predictor of infection in multivariate analysis. Infratentorial surgery (OR 4.348, 95% CI 1.234-16.722; p = 0.024) and more than 8 days of postoperative corticosteroid treatment (OR 3.886, 95% CI 1.052-16.607; p = 0.048) were significant predictors for the development of CSF leak. Synthetic dural graft was associated with a lower likelihood of CSF leak (OR 0.072, 95% CI 0.003-0.552; p = 0.036). The use of synthetic dural closure material is not associated with surgical site infection and is associated with a reduced incidence of CSF leak. Modifiable risk factors exist for craniotomy complications that warrant vigilance and further study.

Venous Thromboembolism Prophylaxis in Patients Undergoing Cranial Neurosurgery: A Systematic Review and Meta-analysis

Randomized clinical trials (RCTs) have usually supported using heparin prophylaxis against venous thromboembolism (VTE) in patients undergoing cranial neurosurgery. The tradeoff between benefit and bleeding risk, however, has not been adequately characterized. To conduct a systematic review and meta-analysis assessing the extent to which low-dose unfractionated heparin (LDUH) or low-molecular-weight heparin (LMWH) prophylaxis reduces the rate of VTE and increases the rate of intracerebral hemorrhage (ICH) and other bleeding in patients undergoing elective cranial neurosurgery. We selected RCTs that evaluated LDUH or LMWH prophylaxis of VTE in patients undergoing elective cranial neurosurgery. A meta-analysis assessing heparins vs no heparin (either with or without mechanical methods) was performed. Eight RCTs were identified. Six RCTs involving 1170 patients evaluated LDUH or LMWH vs a control group. Five of 6 trials found a significant reduction in the risk of symptomatic and asymptomatic VTE with heparin prophylaxis. The pooled risk ratio was 0.58 (95% confidence interval, 0.45-0.75). ICH was more common in those receiving heparin, but not statistically significantly. For every 1000 patients who receive heparin prophylaxis, 91 VTE events will be prevented (approximately 35 of which are proximal deep vein thrombosis or pulmonary embolism and 9 to 18 of which are symptomatic), whereas 7 ICHs and 28 more minor bleeds will occur. Heparin prophylaxis for patients undergoing elective cranial neurosurgery reduces the risk of VTE but may also increase bleeding risks with a ratio of serious or symptomatic VTE relative to serious bleeding that is only slightly favorable.