Neurocrit Care
DOI 10.1007/s12028-017-0433-4
ORIGINAL ARTICLE
The Utility of Routine Intensive Care Admission for Patients
Undergoing Intracranial Neurosurgical Procedures: A Systematic
Review
Cesar Cimonari de Almeida1 • M. Dustin Boone2 • Yosef Laviv1 • Burkhard S. Kasper3
Clark C. Chen4 • Ekkehard M. Kasper1
Ó Springer Science+Business Media, LLC 2017
Abstract
Background Patients who have undergone intracranial
neurosurgical procedures have traditionally been admitted
to an intensive care unit (ICU) for close postoperative
neurological observation. The purpose of this study was to
systematically review the evidence for routine ICU
admission in patients undergoing intracranial neurosurgical
procedures and to evaluate the safety of alternative post-
operative pathways.
Methods We were interested in identifying studies that
examined selected patients who presented for elective, non-
emergent intracranial surgery whose postoperative outcomes
were compared as a function of ICU versus non-ICU admission.
A systematic review was performed in July 2016 using the
Preferred Reporting Items for Systematic Reviews and Meta-
Analyses checklist of the Medline database. The search strategy
was created based on the following key words: ‘‘craniotomy,’’
‘‘neurosurgical procedure,’’ and ‘‘intensive care unit.’’
Results The nine articles that satisfied the inclusion criteria
yielded a total of 2227 patients. Of these patients, 879 were
Cesar Cimonari de Almeida and M. Dustin Boone have contributed
equally to this manuscript.
& M. Dustin Boone
mboone@bidmc.harvard.edu
1
Department of Surgery, Division of Neurosurgery, Beth
Israel Deaconess Medical Center, Lowry Medical Building
3B, 02215 Boston, MA, USA
2
Department of Anesthesia, Critical Care and Pain Medicine,
Beth Israel Deaconess Medical Center, Boston, MA, USA
3
Department of Neurology, University of Erlangen, Erlangen,
Germany
4
Department of Neurosurgery, University of California San
Diego, San Diego, CA, USA
•
observed in a non-ICU setting. The most frequent diagnoses
were supratentorial brain tumors, followed by patients with
cerebrovascular diseases and infratentorial brain tumors.
Three percent (30/879) of the patients originally assigned to
floor or intermediate care status were transferred to the ICU.
The most frequently observed neurological complications
leading to ICU transfer were delayed postoperative neuro-
logical recovery, seizures, worsening of neurological deficits,
hemiparesis, and cranial nerves deficits.
Conclusion Our systematic review demonstrates that rou-
tine postoperative ICU admission may not benefit carefully
selected patients who have undergone elective intracranial
neurosurgical procedures. In addition, limiting routine ICU
admission may result in significant cost savings.
Keywords Craniotomy
Neurosurgical procedures

Intensive care
Postoperative complications

Resource allocation
Healthcare quality
Introduction
Patients who have undergone intracranial neurosurgical
procedures have traditionally been admitted to an intensive
care unit (ICU) for close postoperative neurological
observation. Although complications from neurosurgical
procedures are infrequent, postoperative neurocritical care
allows for rapid detection of neurological deterioration and
close hemodynamic monitoring [1–3]. Over the last dec-
ade, however, the practice of routine postoperative ICU
admission has been re-evaluated [4, 5].
Fortunately, most patients recovering from an intracra-
nial neurosurgical procedure do not require an intervention
during their ICU stay [5–7]. Based on these observations,
investigators have examined ways to eliminate or reduce
123

the use of ICU resources (length of stay) [8, 9], by sug-
gesting that the capabilities of intermediate care units (step-
down) [3, 6] or the postanesthesia care unit (PACU) be
expanded [5, 10, 11]. Other investigations have studied the
safety and feasibility of performing intracranial procedures
on an outpatient day-care basis [12, 13].
To date, no systematic review has evaluated the benefit
of routine postoperative admission to an intensive care unit
for patients undergoing intracranial neurosurgical proce-
dures. The purpose of this study was to systematically
review the evidence for routine ICU admission in patients
undergoing intracranial neurosurgical procedures and to
evaluate the safety of alternative postoperative pathways.
Materials and Methods
We defined our question using the PICO (patient, inter-
ventions, comparisons, and outcomes) strategy: We were
interested in identifying studies that examined selected
patients who presented for elective, non-emergent
intracranial surgery whose postoperative outcomes were
compared as a function of ICU versus non-ICU admission.
A systematic review was performed in July 2016 using the
Preferred Reporting Items for Systematic Reviews and
Meta-Analyses (PRISMA) checklist of the Medline data-
base. The search strategy was created based on the
following key words: ‘‘craniotomy,’’ ‘‘neurosurgical pro-
cedure,’’ and ‘‘intensive care unit.’’
This initial search yielded 455 studies (Fig. 1). All 455
abstracts were reviewed by at least two reviewers, C.C.A.
and Y.L., for inclusion in the study. We included cohort
studies, case reports, and randomized controlled trials that
compared the safety and rate of postoperative complica-
tions associated with ICU versus non-ICU admission for
patients undergoing elective intracranial surgeries. Studies
were limited to English language and adult subjects. In
addition, we only included articles published after 1991
with the intention of evaluating all studies published in the
post-MRI era.
The inclusion screening was performed in three steps:
Of the 455 retrieved abstracts, we excluded 64 studies that
involved neurosurgical emergencies or trauma patients; of
the remaining 391 abstracts, 372 articles were excluded for
unrelated outcomes, such as the evaluation of thrombotic
and infectious complications while in the ICU, evaluation
of anesthetic technique and risk factors for stroke or
spontaneous intracranial hematomas. The remaining 19
articles were full text screened for eligibility. To be
included, studies must have presented demographic infor-
mation, complication rates, and postoperative assignment
(ICU vs. non-ICU). After applying our exclusion criteria,
nine studies remained for analysis according to our
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Neurocrit Care
inclusion criteria. We defined our outcome variables as
complications as a function of admission status.
Results
The nine articles that satisfied the inclusion criteria yielded
a total of 2227 patients (Table 1). Of these patients, 879
were observed in a non-ICU setting. The most frequent
diagnoses were supratentorial brain tumors, followed by
patients with cerebrovascular diseases and infratentorial
brain tumors. We then examined complications that led to a
transfer to an ICU. Three percent (30/879) of the patients
originally assigned to floor or intermediate care status were
transferred to the ICU. Table 2 describes the complications
leading to ICU admission for this cohort. The most fre-
quently observed neurological complications leading to
ICU admission were delayed postoperative neurological
recovery [4, 5, 14–17], seizures [4, 5, 12, 14, 15, 17, 18],
worsening of neurological deficits, hemiparesis, and cranial
nerves deficits [4, 5, 12–14, 17].
We evaluated risk factors that could predict the need for
postsurgical ICU admission or readmission. Patient-related
risk factors included preoperative clinical conditions such
as asthma, carotid stenosis, mental illness [5], diabetes
mellitus [4, 5], any seizures prior to surgery, male gender,
ataxia [5], and older age [4, 15]. Two of the studies used
the Acute Physiology and Chronic Health Evaluation
(APACHE) III score to triage patients with low scores to
either the floor or an intermediate care unit [5, 19]. This
large cohort had a low risk of perioperative complications
(<10%). Procedure-related risk factors included surgical
duration, which was identified as a risk factor for postop-
erative critical care in four studies. Cases lasting longer
than 4 h were associated with an increased risk of ICU
admission [4, 14, 15, 17]. Other risk factors included the
lateral surgical position [14]. Intraoperative complications
such as hypotension [15], blood loss over 1 L, blood pro-
duct transfusion [4, 15], fluid administration greater than
5 L, unplanned or increased use of hyperosmolar agents,
and initiation of vasopressors [17] were found to increase
ICU utilization.
Although important differences existed with regard to
the reporting of complications among the selected articles,
none reported preventable death attributed to postoperative
destination. In addition, no increase in morbidity was
apparent [5, 15, 16]. The majority of complications that
occurred to patients outside of the ICU were minor and
managed on the floor or intermediate unit. These problems
ranged from transient worsening of dysphagia and head-
aches [13] to arterial hypotension, transient respiratory
distress, and minor seizures [15]. Considering the entire
population, several other medical complications were
Neurocrit Care

Fig. 1 PRISMA flow diagram

that details the results of the
PRISMA 2009 Flow Diagram
search and selection of studies.
From [41] Records Identified Through Additional Records Identified

IDENTIFICATION
Database Searching Through Other Sources
N=622 N=23

Records Identified After

Exclusion Criteria
N=455
SCREENING Records Excluded After
Screening: N=436
-Trauma: N=64
-Unrelated Outcomes: N=372
Full Texts Accessed
For Eligibility
ELIGIBILITY

N=19
Full Texts Excluded and
Reasons: N=10
-Not addressed of risk factors
for complications: N=3
-Mixed neurosurgical and
INCLUSION

non-neurosurgical population:
Studies Included in
N=2
Qualitative Synthesis
-Mixed trauma and
N=9
elective/cranial and spinal
cases: N=1
-Not addressed safety of
postoperative assignment out
of ICU: N=2
-Lack of details on floor
assignment group: N=1
-Included only biopsies: N=1

encountered, the most frequent and critical of which were
respiratory failure [5, 14, 16] and diabetes insipidus [5, 14].
Other clinical complications mentioned in lower frequen-
cies or in only a single study were pneumonia, urinary tract
infection, meningitis, other infections, cardiac dysrhyth-
mia, cardiac arrest, drug overdose or drug-related reaction,
deep venous thrombosis and pulmonary embolus, elec-
trolyte disturbance, uncontrolled hypertension, and
intestinal perforation.
Postoperative imaging as part of a routine protocol was
similar among all studies, and in the majority of cases,
imaging did not reveal any relevant findings. Surgical bed
hematoma was observed in 27 cases of the entire pooled
sample of 2227 patients, and ten of them required surgical
intervention [4, 5, 12, 14, 16]. Hydrocephalus was present
in 21 cases [4, 5, 15, 17]. Other relevant imaging findings
were pneumocephalus, brain edema, and brain ischemia.
When considering our pooled cohort of patients, man-
agement of blood pressure accounted for the majority of
active interventions, for both hyper- and hypotension [4],
while reoperation for postoperative hemorrhage or hydro-
cephalus, or re-intubation for acute respiratory failure was
the most critical events requiring transfer to an ICU
[4, 5, 14, 16, 17]. Across all studies, every patient received
close neurological and vital signs monitoring.
Two studies reported a cost analysis; not surprisingly,
both showed significant cost savings for cases in which
non-ICU-level assignment was implemented [5, 17]. Esti-
mated savings ranged from 871 US dollars per patient to
5224 US dollars for patients who were assigned to a
postoperative placement destination bypassing the ICU
(values adjusted for inflation to 2016 US dollars) [5, 17].
Discussion
Our systematic review provides evidence to suggest that
patients presenting for elective intracranial surgery may not
require routine postoperative ICU care. This is not to say
that this population does not require specialized care.

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Table 1 Search results

Study Patients Non-ICU Diagnosis Design

Beauregard and Friedman [5] 429 193 (61/132)+ Microvascular decompression: 82 (14/25)+ Retrospective
Chiari decompression: 13 (1/4)+
Intrinsic tumor, supratentorial: 106 (4/55)+
Intrinsic tumor, infratentorial: 30 (4/11)+
Meningioma, supratentorial: 62 (4/19)+
Meningioma, infratentorial: 19 (1/1)+
Acoustic schwannoma: 30 (5/2)+
Craniopharyngioma: 9 (1/1)+
Pituitary tumor: 63 (27/14)+
Terada et al. [15] 296 166 Vascular: 135 (-/70)+ Retrospective
Tumor: 161 (-/96)+ Propensity score
Bui et al. [14] 394 343 Tumor supratentorial: 220(-/205)+ retrospective
Tumor infratentorial: 37 (-/22)+
Transsphenoidal: 63 (-/61)+
Vascular supratentorial: 20 (-/11)+
Vascular infratentorial: 11 (-/9)+
Ventriculostomy supratentorial: 21 (-/19)+
Ventriculostomy infratentorial: 1 (-/1)+
Developmental: 13 (-/11)+
Skull base: 8 (-/4)+
Grundy et al. [13] 177 177 Tumor—awake: 9 Prospective
Tumor—general anesthesia: 2 Interventional
No control group
Boulton and Bernstein [12] * * Tumor—awake: 154 Prospective
Tumor—general anesthesia: 12 Interventional
No control group
Rhondali et al. [16] 306 – Meningioma: 80 Prospective
Malignant glioma: 86 Observational Cohort
Brain metastasis: 42
Cortectomy for palsy: 23
Cavernous angioma: 18
Aneurysm: 14
Other: 41
Missing: 2
Nitahara et al. [17] 67 – Tumor Retrospective
Ziai et al. [18] 158 – Tumor Retrospective
Hanak et al. [19] 400 – Tumor—resection: 260 Prospective
Tumor—open biopsy: 4 Observational cohort
Vascular—aneurysm: 62
Vascular—cavernous malformation: 5
Vascular—AVM: 5
Microvascular Decompression: 21
Epilepsy—temporal lobectomy: 19
Chiari decompression: 8
Total 2227 879 Tumors: 1682 Vascular: 270 MVD: 104
AVM arteriovenous malformation, MVD microvascular decompression
+
Total (intermediate care/floor unit)
* Included with [13]

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Table 2 Complications leading to ICU transfer
Study Complications leading to ICU transfer
Beauregard and Venous infarction: 1
Friedman [5] CSF leak requiring several correction
procedures: 1
Terada et al. [15]* Acute respiratory failure: 5
Reoperation: 3
Acute cardiac failure: 1
Bui et al. [14] Slow neurological recovery: 3
Increased intraoperative blood loss: 2
Unanticipated prolonged operation: 1
Arterial hypertension: 1
Refractory seizures: 1
(3 cases identified from OR and 5 from
recovery unit)
Boulton et al. [12] Familial anxiety: 2
Headache: 2
Seizures: 3
Hemiparesis: 1
Air embolus: 1
Grundy et al. [13] Transient worsening of motor strength: 1
Patient preference: 1
Total 30/879 (3.41%)
CSF cerebrospinal fluid, ICU intensive care unit, OR operating room
* Presumed ICU transfer
Across all studies, non-ICU locations had the capability to
provide close neurological and hemodynamic monitoring.
It was reassuring to note the low incidence of postoperative
complications, in part attributed to modern neurosurgical
techniques and improved intraoperative care [16].
In 1981, Knaus reported that patients undergoing elec-
tive craniotomy rarely required additional care other than
hemodynamic and neurological monitoring while in the
ICU. In their cohort of 91 patients, only one patient
required ongoing, active treatment for postoperative sei-
zures [7]. Shortly after, Teplick demonstrated that routine
admission to an ICU for patients undergoing neurosurgical
procedures may be unnecessary. Again, these authors
found that the majority of patients did not require an active
intervention during their stay in the ICU and concluded that
ICU care beyond 4 h may not confer additional benefit
[20]. Zimmerman and colleagues corroborated these earlier
findings in a more contemporary study. Their study showed
that patients who presented to the ICU in stable condition
rarely required active treatment; in fact, in this cohort, 96%
received only monitoring and general nursing care [6]. The
authors used a regression model to predict which patients
were at low risk of active management (defined as <10%
risk) and found APACHE III score [19], age, diagnosis,
and patient location prior to ICU admission to be important
predictors. When considering surgical diagnoses, the
highest proportion of low-risk patients included
transsphenoidal surgery (90%), spine surgery (73%), and
craniotomy for neoplasm (71%). More recently, Beaure-
gard demonstrated that patients undergoing elective
craniotomies may not benefit from routine ICU admission
[5]. With these studies providing evidence to support the
safety of non-ICU triage for this cohort, what are the
practical implications for patient triage?
Safe triage decisions depend on proper patient selection,
which take baseline comorbidities, surgical diagnosis,
planned operation, and procedural risks into consideration.
When taking into account comorbidities, Reponen exam-
ined the discriminative abilities of the Karnofsky
Performance Scale (KPS), the American Society of Anes-
thesiologists (ASA) physical classification, and the
Charlson comorbidity index to predict surgical complica-
tions [21]. They found that both KPS and ASA scores had
good predictive power for complications following elective
intracranial tumor surgery, and a similar relationship was
demonstrated for the Charlson comorbidity score and
mortality in elective surgery for intracranial aneurysms.
Age as a risk factor was an inconsistent finding. Hanak and
Bui considered age as a risk factor, while Ziai, Rhondali,
and Beauregard did not find it to be a reliable predictor of
postoperative complications. The same authors presented a
sizable cohort study of 418 patients in 2015 in which age
over 60–65 years, elevated C-reactive protein level, and
high Helsinki ASA score (Class 4) were factors associated
with in-hospital systemic and infectious complications
[22]. Other studies have evaluated the relationship between
preexisting disease and the risk of postoperative compli-
cations [23]. Diabetes was the only clinical condition to
appear in more than one article as a clearly identifiable risk
factor for medical complications [4, 5]. Not surprisingly,
surgical duration, increased blood loss, and lateral position
were associated with an increased risk of complications
[4, 14, 15, 17].
Brain tumors were the most common diagnosis in our
cohort (1682/2227 patients). Of these patients, cranio-
pharyngiomas and infratentorial tumors were associated
with the majority of medical complications and neurolog-
ical complications observed [5]. In particular,
postoperative respiratory failure following infratentorial
surgery remains a significant concern. Risk factors
demonstrated to predict re-intubation following infraten-
torial tumor surgery included a previous history of
craniotomy, preoperative lower cranial nerve dysfunction,
tumor size >30 mm, and tumor compression of the
brainstem [24]. Whether patients presenting with these risk
factors would benefit from direct ICU admission remains to
be determined.
Surgical bed hematomas and acute hydrocephalus are
among the most concerning life-threatening complications.
123

The evidence presented in this review suggests that a
majority of these events occurred during an early obser-
vation period comprising the first 6 h after surgery [25].
Delayed emergence, seizures, and early postoperative
neurologic deterioration were most frequently observed in
the early postoperative period [4, 5, 14–17]. With the
exception of delayed hematoma formation, which may not
be apparent on early postoperative computed tomography
scan, most complications were detected by neurological
examination. This highlights the importance of close
postoperative neurological monitoring, which may be as
important in detecting complications as routine postoper-
ative imaging findings [26]. A study by Dube et al. [27]
noted that deterioration of the neurological examination
was the main cause for re-intubation after elective
craniotomy.
A comparison of the total estimated costs associated with
each postoperative destination demonstrated significant
savings in the group in which an algorithm for selective ICU
assignment was implemented. Ziai found a difference of
595 US dollars (currency value as in 1999) [17], while
Beauregard estimated cost savings of about 4026 US dollars
(currency value in 2003) [5]. A different type of study by
McLaughlin and colleagues in 2014 demonstrated an
average decrease in the costs of microvascular decompres-
sion surgery of 6291 US dollars if a series of measures was
implemented, including selective ICU assignment translat-
ing in overall savings in the order of 25% [8].
The general costs of hospital stay and surgical procedures
have increased over time, which may partially account for
the increasing values over time on the aforementioned
savings. Nevertheless, it has long been observed that ICU
costs represent a significant portion of the total inpatient
hospitalization costs, comprising up to 1/3 of the total cost at
some hospitals [28–32]. The adoption of standardized pro-
tocols, implementation of dedicated neurological ICUs
wherever possible, and further technological advances (such
as better imaging and monitoring options), as well as better
training programs (for neurocritical care as well as for
monitoring interpretation) have been proven worthwhile,
improving the overall outcomes in neurosurgery
[20, 21, 33–37]. The rational use of these resources is
therefore one of the key efforts in order to contain overall
costs and optimize the relation among care value and
incurring costs [38].
This systematic review has several limitations. Of the
nine studies evaluated, none were randomized controlled
prospective trials. Thus, selection bias is a major concern. In
addition, the majority of patients had brain tumors, which
may limit the general applicability of our interpretation to
other conditions. Also, it is not possible to exclude publi-
cation bias with respect to studies with negative results not
only for the respective clinical and neurological outcomes,
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Neurocrit Care
Table 3 Proposed candidates for non-ICU management
Age under 65
ASA I–II and/or KPS over 80 and/or predicted APACHE III
score <10% of risk
Elective craniotomy
Consider ICU-level management for the following conditions:
Diabetes
Epilepsy
Craniopharyngioma or infratentorial meningioma
Intraoperative findings prompting ICU disposition
Duration of surgery >8 h
Increased blood loss or need for blood products
Hypotension and/or need for vasopressors
Postoperative findings prompting ICU disposition
Delayed emergence
Unexpected neurological deficits
Seizures
Lower cranial nerves deficits
Respiratory insufficiency
Abnormal findings in postoperative image
APACHE Acute Physiology and Chronic Health Evaluation, ASA
American Society of Anesthesiologists, ICU intensive care unit, KPS
Karnofsky Performance Scale
but also for the cost analysis since some other studies
demonstrated that overall, long-term costs are not different
[39, 40]. Therefore, our results should be considered
hypothesis generating and caution should be exercised when
making triage decisions based on this study.
Healthy patients under 65 years of age presenting for
elective intracranial surgery may not benefit from routine
ICU admission. Based on the available evidence, a 6-h
period of close observation in the PACU prior to trans-
ferring a patient to a step-down unit or neuroscience floor
may be safe for these patients. Special consideration for
admission to an intensive care unit is warranted for patients
presenting with certain comorbidities as outlined in
Table 3.
Conclusion
Our systematic review demonstrates that routine postop-
erative ICU admission may not benefit carefully selected
patients who have undergone elective intracranial neuro-
surgical procedures. In addition, limiting routine ICU
admission may result in significant cost savings. However,
the results of this systematic review should be interpreted
with caution until additional prospective studies are
conducted.
Neurocrit Care
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