What is the standard preoperative and postoperative care for patients undergoing neurosurgery?

Standard Preoperative and Postoperative Care for Neurosurgery

All neurosurgical patients should undergo multidisciplinary preoperative evaluation including brain MRI with and without gadolinium contrast, comprehensive neuropsychological assessment, and documentation of informed consent that explicitly addresses surgical risks, benefits, and alternatives. 1

Preoperative Diagnostics and Imaging

Standard Imaging Protocol

• Brain MRI with gadolinium-based contrast is the diagnostic gold standard, including T2-weighted, T2-FLAIR sequences, and 3D T1-weighted sequences before and after contrast administration 1
• Perfusion MRI and amino acid PET can define metabolic hotspots for tissue sampling, particularly useful when biopsy rather than open resection is planned 1
• Advanced functional imaging (fMRI, DTI for fiber tracking) should be integrated into surgical planning to reduce neurological deficits, though long-term benefits remain questionable for many indications 2
• MR tractography provides critical anatomical information that impacts surgical resection planning in 82% of cases, modifying surgical approach in 21% and defining resection margins in 64% 3

COVID-19 Era Considerations

• Mandatory preoperative COVID-19 testing is required for all neurosurgical patients regardless of symptoms, given that 30-day mortality reaches 23.8% and pulmonary complications occur in 51.2% of COVID-19-positive surgical patients 1
• For elective/semi-emergent inpatients: RT-PCR testing with 6-18 hour turnaround time 1
• For outpatient day-care procedures: Schedule RT-PCR 72-96 hours before the procedure date 1
• For emergency procedures: CB-NAAT or TrueNAT rapid assays with <3 hour turnaround time 1
• Chest CT is reserved for symptomatic cases after infectious disease consultation 1

Preoperative Management

Multidisciplinary Assessment

• Patient management must follow written standard operating procedures with multidisciplinary tumor board discussions including neuroradiologists, neuropathologists, neurosurgeons, radiation oncologists, and neuro-oncologists 1
• All candidates should undergo comprehensive neuropsychological assessment evaluating cognitive abilities, psychiatric status, personality, interpersonal functioning, surgical goals and expectations, treatment adherence, and psychosocial support 1

Medical Optimization

• Corticosteroids can be administered to decrease symptomatic tumor-associated edema unless primary cerebral lymphoma or inflammatory lesions are suspected 1
• Patients with prior seizures should receive anticonvulsant drugs preoperatively, though primary prophylaxis does not reduce first seizure risk in seizure-naive patients 1
• Electroencephalography is helpful for monitoring tumor-associated epilepsy and determining causes of altered consciousness 1

Informed Consent Requirements

• Informed consent must include explicit explanation of surgical risks, benefits, alternatives, and what is and is not known about long-term consequences 1
• Risks include not only known surgical complications but also unknown risks associated with intervention at novel sites 1
• Patients must understand that neurosurgery aims for symptomatic treatment but may not cure the underlying disease process 1
• The consent process must occur in a context of free choice without therapeutic misconception 1

Postoperative Care

Immediate Postoperative Monitoring

• Neurological intensive care monitoring is required for at least 24 hours postoperatively 1
• Blood pressure monitoring via arterial catheter and urine output monitoring via indwelling catheter are standard 1
• Maintain normotensive and euvolemic conditions, though tight blood pressure control with non-CNS-acting agents may be appropriate for selected patients 1

Postoperative Imaging and Assessment

• Angiography should be performed during the immediate postoperative period to confirm complete resection when applicable 1
• New neurological deficits after surgery require CT scan to rule out hemorrhage or hydrocephalus 1
• MRI with diffusion-weighted imaging is appropriate if infarction is suspected 1

Progressive Care

• After ICU monitoring, transfer to standard surgical floor for mobilization 1
• Perioperative antibiotics, steroids, and seizure medications are used variably based on institutional protocols 1

Critical Pitfalls to Avoid

Preoperative Errors

• Do not perform liver biopsy in patients with suspected vascular malformations due to high bleeding risk 4
• Do not rely solely on symptom-based COVID-19 screening, as 56.2% of positive patients may be asymptomatic at testing 1
• Do not proceed without histological diagnosis unless biopsy risk is prohibitively high or prognosis is very unfavorable with high comorbidity burden 1

Postoperative Monitoring Failures

• Do not discharge patients from ICU monitoring before 24 hours without compelling justification 1
• Do not ignore new neurological deficits—immediate imaging is mandatory 1
• The morbidity and mortality related to neurosurgical procedures remains high, necessitating vigilant postoperative monitoring as an integral component of the continuum of care 5