Raised ICP, neurotrauma and brain-stem death

Post-craniotomy care

Reviewed Nov 2026·1 references
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First 24-48 h after elective or emergency craniotomy: neuro-observations, BP, seizure, sodium and complication surveillance.

Definition
After craniotomy, the main early complications are post-operative haematoma (most within 6-24 h), cerebral oedema, seizures, sodium disorders (SIADH, cerebral salt wasting, diabetes insipidus), CSF leak, infection and VTE.

At the bedside

Timed steps
  1. 1

    Handover

    Arrival

    Lesion, procedure, intra-op events (blood loss, brain swelling), drains, extubation status, BP and sodium targets, antiepileptic, steroid plan (tumour), anticoagulation restart plan.

  2. 2

    Neuro-observations

    Hourly

    GCS, pupils and limb power hourly for 24 h (15-min initially). Any fall in GCS ≥ 2 or new focal deficit: urgent CT and neurosurgical review.

  3. 3

    Blood pressure

    Avoid hypertension (haematoma risk): typical SBP < 140-160 mmHg as per surgeon; avoid hypotension (CPP).

  4. 4

    Analgesia and nausea

    Paracetamol, low-dose opioid (fentanyl/morphine), scalp block; antiemetics (ondansetron). Avoid oversedation that masks deterioration.

  5. 5

    Sodium and fluids

    Isotonic fluids; Na 6-12 hourly. Polyuria with rising Na = DI (desmopressin); low Na with euvolaemia = SIADH (fluid restriction); low Na with hypovolaemia/natriuresis = cerebral salt wasting (saline, fludrocortisone).

  6. 6

    Seizure, glucose, temperature

    Continue antiepileptic as prescribed; glucose 140-180 mg/dL; treat fever. Dexamethasone for tumour oedema (not TBI).

  7. 7

    Drains and VTE

    EVD level and drainage as ordered; subgaleal drain output. Mechanical VTE prophylaxis; pharmacological after 24-48 h if surgeon agrees.

Red flag · call your senior now
Delayed awakening, new hemiparesis, unequal pupils or seizures after craniotomy: urgent CT for haematoma, oedema, pneumocephalus or infarct.
Pitfall
Treating post-op hyponatraemia with fluid restriction when it is cerebral salt wasting (hypovolaemic): worsens ischaemia, especially after SAH.
Pearl
Tension pneumocephalus ('Mount Fuji sign' on CT) can cause deterioration after craniotomy; high-flow oxygen and surgical review.

Calculators for this topic

Glasgow Coma Scale

Eye + Verbal + Motor (3-15). Record components, e.g. E3 V4 M5.

References

  1. 1

    Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017;80:6-15.

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