What is the recommended postoperative management after burr‑hole surgery for intracranial hemorrhage?

Postoperative Management After Burr Hole Surgery for Intracranial Hemorrhage

All patients require at least 24 hours of neurological intensive care monitoring with continuous arterial blood pressure monitoring via arterial catheter and urine output monitoring via indwelling catheter. 1

Immediate Postoperative Monitoring (First 24 Hours)

Hemodynamic Management

• Maintain systolic blood pressure ≥100 mmHg or mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion and prevent secondary brain injury. 2
• Target cerebral perfusion pressure (CPP) of 60-70 mmHg if ICP monitoring is established (CPP = MAP - ICP). 3, 1, 2
• Do not routinely target CPP >70 mmHg, as this increases the risk of respiratory distress syndrome five-fold without improving neurological outcomes. 3, 2
• Use arterial catheter for continuous blood pressure monitoring; remove only after confirming hemodynamic stability. 1

Neurological Surveillance

• Perform serial neurological examinations at least every 4 hours initially, documenting Glasgow Coma Scale motor score, pupil size and reactivity (checking for anisocoria or bilateral mydriasis), and focal neurological deficits. 2
• Any new neurological deficit mandates immediate non-contrast head CT scan to rule out rebleeding, residual hematoma, or hydrocephalus. 1, 2
• If infarction is suspected, obtain MRI with diffusion-weighted imaging. 1

Intracranial Pressure Monitoring

• Continue ICP monitoring postoperatively if any of the following criteria were present: preoperative GCS motor score ≤5, preoperative anisocoria or bilateral mydriasis, preoperative hemodynamic instability, compressed basal cisterns or midline shift >5mm on imaging, intraoperative cerebral edema, or new intracranial lesions on postoperative imaging. 3, 2
• Prefer intraparenchymal pressure probes over ventricular drains due to lower infection rates (2.5% vs 10%) and lower hemorrhage risk (0-1% vs 2-4%). 3, 2

Management of Complications

Rebleeding and Hematoma Reaccumulation

• Monitor for hematoma reaccumulation, which occurs in 6.6-18.5% of cases, typically within 16 days of initial surgery. 4, 5, 6
• Risk factors for recurrence include anticoagulant use, history of stroke, and mixed hematoma density on CT. 5
• Reoperation is indicated only when patients demonstrate both clinical and radiological deterioration, not for asymptomatic radiographic findings alone. 5, 6

Remote Hemorrhage from Overdrainage

• Carefully monitor subdural catheter drainage to prevent overdrainage of cerebrospinal fluid, which can cause remote intracerebral or subarachnoid hemorrhage in the contralateral hemisphere. 7
• Maintain closed-system drainage for 2-4 days postoperatively. 6
• Avoid sudden drainage of large volumes of subdural fluid over 24 hours. 7

Increased Intracranial Pressure

• For threatened intracranial hypertension or signs of brain herniation, administer mannitol 20% at 250 mOsm dose (0.25-2 g/kg) infused over 15-20 minutes after controlling secondary brain insults. 3, 2
• Maximum effect occurs at 10-15 minutes, lasting 2-4 hours. 2
• Alternatively, use hypertonic saline 3%. 2
• Monitor fluid, sodium, and chloride balance; target serum osmolality 300-310 mOsmol/kg. 2

Early Postoperative Imaging

• Obtain MRI (or CT if MRI unavailable) within 24-48 hours post-surgery to assess extent of hematoma evacuation and detect perioperative ischemia or new hemorrhage. 1
• For vascular lesions (AVMs), perform angiography during the immediate postoperative period to confirm complete resection. 1

Pharmacological Management

Anticoagulation

• Do not restart anticoagulation immediately postoperatively; timing of resumption depends on bleeding risk versus thrombotic risk and should be individualized based on indication. 2
• Prophylactic low-molecular weight heparin and compression stockings are recommended for preventing perioperative thromboembolic complications after 4-5 days post-surgery if no hemorrhagic complications. 3

Seizure Prophylaxis

• Perioperative anticonvulsant treatment can be prescribed for patients who have had seizures; in patients without prior seizures, prophylaxis is optional and should be tailored to individual risk factors. 3
• Use single-drug treatment as first-line. 3
• Consider any inducing or potentiating effects on chemotherapy toxicity if applicable. 3

Antibiotics and Corticosteroids

• Perioperative antibiotics are used variably without rigorous evidence supporting routine use. 1
• Corticosteroids are used variably without strong supporting evidence. 1

Delirium Prevention

• Use validated preoperative cognitive screening tools (Mini-Cog) for baseline assessment in at-risk patients. 1
• Monitor at-risk older surgical patients using validated delirium screening tools (4AT or Confusion Assessment Method) before discharge from recovery room, then ideally twice daily until Day 5 or discharge. 1
• Implement multicomponent programs: early mobilization as soon as medically safe, frequent cognitive reorientation with familiar objects and family presence, and sleep hygiene with minimized nighttime disruptions. 1
• Avoid benzodiazepines when possible, as routine cognitive screening has resulted in reduced benzodiazepine use. 1

Transition from ICU to Floor

• Minimum ICU stay is 24 hours of neurological intensive care monitoring. 1
• Patient must demonstrate stable or improving neurological examination before transfer to standard surgical floor. 1
• Arterial line may be removed only after confirming hemodynamic stability. 1

Critical Pitfalls to Avoid

• Never allow systolic blood pressure to drop below 90-100 mmHg—this is the most preventable cause of secondary brain injury. 2
• Do not underestimate small residual hematomas in anticoagulated elderly patients—30-40% of subdural hematomas expand in the first 12-36 hours. 2
• Do not delay immediate CT imaging for any new neurological deficit—early detection of rebleeding is critical. 1, 2
• Do not allow rapid overdrainage of subdural fluid—this can cause remote hemorrhage. 7
• Do not routinely target CPP >70 mmHg—this increases respiratory complications without neurological benefit. 3, 2