Outpatient brain tumor craniotomy under general anesthesia

Full access

OBJECTIVE

Outpatient craniotomy has many advantages to the psychological and physical well-being of patients, as well as benefits to the health care system. Its efficacy and safety have been well demonstrated, but barriers to its widespread adoption remain. Among the challenges is a perception that its application is limited to cases performed under conscious sedation, which is not always feasible given certain patient or surgeon factors. The object of this study was to characterize the rate of patient discharge from the day surgery unit (DSU) following craniotomy for tumor resection in a patient under general anesthesia. The authors identify postoperative complications and discuss appropriate patient selection for day surgery craniotomy.

METHODS

Patients undergoing elective craniotomy for supratentorial tumors between January 2010 and June 2014 were prospectively considered for outpatient management. Authors of the present study performed a retrospective chart review of these patients, analyzing cases by intention to treat.

RESULTS

Of 318 craniotomies undertaken in the study period, 141 were performed with the patient under general anesthesia. The day surgery protocol was initiated in 44 cases and completed in 38 (86%). Five patients required admission from the DSU, and 1 was discharged but admitted within the 1st postoperative day. In-hospital medical complications were fewer in the outpatient group, and no patients experienced an adverse outcome due to early discharge.

CONCLUSIONS

Close clinical and imaging surveillance in the early postoperative period allows for safe discharge of patients following craniotomy for tumor resection performed under general anesthesia. Therefore, general anesthesia does not preclude the application of outpatient craniotomy.

ABBREVIATIONSDSU = day surgery unit.

OBJECTIVE

Outpatient craniotomy has many advantages to the psychological and physical well-being of patients, as well as benefits to the health care system. Its efficacy and safety have been well demonstrated, but barriers to its widespread adoption remain. Among the challenges is a perception that its application is limited to cases performed under conscious sedation, which is not always feasible given certain patient or surgeon factors. The object of this study was to characterize the rate of patient discharge from the day surgery unit (DSU) following craniotomy for tumor resection in a patient under general anesthesia. The authors identify postoperative complications and discuss appropriate patient selection for day surgery craniotomy.

METHODS

Patients undergoing elective craniotomy for supratentorial tumors between January 2010 and June 2014 were prospectively considered for outpatient management. Authors of the present study performed a retrospective chart review of these patients, analyzing cases by intention to treat.

RESULTS

Of 318 craniotomies undertaken in the study period, 141 were performed with the patient under general anesthesia. The day surgery protocol was initiated in 44 cases and completed in 38 (86%). Five patients required admission from the DSU, and 1 was discharged but admitted within the 1st postoperative day. In-hospital medical complications were fewer in the outpatient group, and no patients experienced an adverse outcome due to early discharge.

CONCLUSIONS

Close clinical and imaging surveillance in the early postoperative period allows for safe discharge of patients following craniotomy for tumor resection performed under general anesthesia. Therefore, general anesthesia does not preclude the application of outpatient craniotomy.

Technological advances in neurosurgery and neuroanesthesia have markedly reduced the morbidity and mortality of craniotomy for tumor resection.10,15 The timing and frequency of hemorrhagic complications are recognized, allowing for optimal clinical and imaging surveillance.17 The safety and efficacy of outpatient craniotomy, whereby the patient is admitted the morning of surgery and is discharged home after the procedure without spending the night in the hospital, has been established.1,7,13 Compared with an inpatient admission, same-day discharge probably reduces patient exposure to nosocomial infection, thromboembolic complications, and medical error and decreases case cancellations due to the unavailability of an inpatient bed, thus improving patient flow. A previous series has demonstrated no excess morbidity resulting from early discharge following surgery.13 In addition, the avoidance of an overnight hospital stay often alleviates the psychological impact of brain tumor diagnosis and treatment, and high patient satisfaction is reported following outpatient craniotomy.9

The protocols established in existing series of outpatient craniotomy have incorporated awake craniotomy, during which the patient receives a local anesthetic to the scalp at the start of the procedure and intravenous sedation for its duration. Awake craniotomy's advantages include the ability to apply stimulation for mapping of cortical function, intraoperative functional monitoring of neurological status, rapid postoperative clinical assessment, and decreased fluctuation in hemodynamic parameters.16 In some cases, however, certain factors favor the use of general anesthesia, including tumor locations requiring awkward patient positioning, extraaxial lesions associated with pain during resection, anticipated lengthy procedures, and patient preference. The indications for general anesthesia are separate from the exclusion criteria for day surgery; thus, we have found that the use of general anesthesia does not preclude same-day discharge following craniotomy. In the present study, we reviewed patients who had undergone craniotomy for tumor resection while under general anesthesia and attempted to identify distinguishing factors between those admitted as inpatients and those discharged home the same day of surgery.

Methods

Eligibility for day surgery is prospectively determined at the preoperative office visit. This decision is made by the neurosurgeon in collaboration with assessment by the anesthesia service, following a well-established protocol.3 Inclusion and exclusion criteria are outlined in Table 1. All patients with supratentorial tumors who are electively scheduled for craniotomy are considered for day surgery. The presence of major cardiorespiratory comorbidity, airway concerns, uncontrolled seizures, or significant neurological deficit precludes same-day discharge. However, size and location of tumor, presence of mass effect or edema, and repeat surgery are not contraindications to outpatient surgery. The need for general anesthesia is also determined at the time of the preoperative consultation and may arise from patient factors or surgical concerns, such as patient anxiety or psychological unsuitability for awake surgery, tumor location requiring prone positioning, a dura-based lesion that may cause pain with manipulation, or an anticipated operative time longer than 4 hours.

TABLE 1.

Inclusion and exclusion criteria for outpatient craniotomy

Inclusion criteria
  Supratentorial tumor
  Patient caregiver available
  Patient relatively close to hospital
Exclusion criteria
  Already an inpatient
  Significant cardiorespiratory comorbidity
  Airway management concerns
  Uncontrolled seizures or poor neurological status
  Long procedure duration expected
  Psychological unsuitability/patient preference

The established protocol for outpatient awake craniotomy2 was modified for craniotomy performed under general anesthesia. Patients arrive at the day surgery unit (DSU) at 6:00 am on the day of surgery and undergo MRI with gadolinium contrast. This study is used with the StealthStation surgical navigation system (Medtronic) for intraoperative navigation. General anesthesia and endotracheal intubation are established under monitoring by electrocardiography, end-tidal capnography, pulse oximetry, and arterial catheterization. Electrodes are placed for somatosensory evoked potential monitoring, which is maintained for the duration of the procedure. The patient is positioned as appropriate for access to the tumor using the Sugita head holder and registration to neuronavigation. Prophylactic antibiotics and steroids are administered prior to the skin incision, and antiepileptics are given if the patient has previously had a seizure.5 The craniotomy and tumor resection are performed in standard fashion using microneurosurgical technique. At the completion of surgery, the patient is awakened from general anesthesia and examined for neurological function. The patient is monitored in the postanesthesia recovery unit for 2 hours and is then transferred to the DSU for a minimum of 4 additional hours. A plain CT scan is obtained 4 hours postoperatively, and the surgeon examines the patient to verify his or her fitness for discharge. The CT must not demonstrate undue hemorrhage or edema, and patients must have a stable neurological status, adequate control of pain and nausea,11 and a family member or friend to accompany them overnight. The patient is given a prescription for an analgesia and a steroid taper, as well as written instructions for pain control, possible adverse symptoms, and follow-up. The patient and family member are instructed to present to the emergency department if any clinical deterioration occurs, including a decreased level of consciousness, seizure, or new and/or worsened neurological deficit. Patients who are scheduled for admission receive similar perioperative medical care and undergo head CT in the morning of the 1st postoperative day. All patients with malignant brain tumors are urgently referred to medical and radiation oncology for postsurgical MRI and adjuvant treatment as appropriate.

All operative craniotomy cases performed by the senior author between January 2010 and June 2014 were identified. Clinic and hospital charts were retrospectively reviewed for elective procedures performed with the patient under general anesthesia, and the planned postoperative disposition was noted. Patient demographics and details pertaining to the postoperative course, as well as the target lesion, were collected. Analysis was performed according to intention to treat. The study protocol was approved by the Research Ethics Board of the University Health Network.

Results

During the period from January 2010 and June 2014, the senior author performed 318 craniotomies for tumor resection, 141 of them with the patient under general anesthesia. Same-day discharge was planned for 44 of these cases, according to the described criteria (Table 1). Compared with the patients with planned admissions, those in the same-day discharge group had fewer preoperative neurological deficits, fewer extraaxial tumors, and shorter operative times (Table 2). Lesions in these latter patients also demonstrated Gd enhancement less often, although this was not a specific selection criterion. Thirty-eight patients (86%) successfully completed the day surgery protocol (Fig. 1). Of the cases requiring conversion to inpatient admission, 5 were from the DSU: 1 was admitted for ongoing difficulties with wound hemostasis, 1 for new cognitive impairment, 2 for new or worsened weakness, and 1 for the new onset of seizure. One patient was discharged from the DSU but was admitted on the 1st postoperative day for new aphasia, with no adverse findings on CT. Patient characteristics requiring admission are detailed in Table 3. Between these patients and those successfully discharged, there was no difference in age, presence of preoperative neurological deficit, presence or absence of preoperative seizures, whether the procedure was a primary or repeat surgery, duration of operation, or extraaxial versus intraaxial pathology. The average length of stay for converted admissions was 1.2 days.

TABLE 2.

Characteristics of patients undergoing general anesthesia for tumor craniotomy

ParameterInpatientOutpatientp Value
No. of patients9744
Male sex (%)37 (38)19 (43)NS
Mean age in yrs55.946.8
Preop neurological deficit (%)42 (43)5 (11)0.0002
  Sensorimotor25 (26)2 (4)
  Language2 (2)2 (4)
  Visual field defect6 (6)0 (0)
  Cognitive impairment16 (16)1 (2)
Preop seizure (%)22 (23)14 (32)NS
  Partial6 (6)3 (7)
  Generalized16 (16)11 (25)
Repeat craniotomy (%)
  1st procedure (at target location)71 (73)31 (70)NS
  Repeat procedure26 (27)13 (30)
Surgical position (%)
  Supine75 (77)38 (86)NS
  Lateral8 (8)4 (9)
  Prone14 (14)2 (4)
Length of surgery in mins1591210.002
Tumor radiographic features (%)
  Lt side35 (36)15 (34)NS
  Extraaxial56 (58)7 (16)0.0001
  Gd enhancement present94 (97)38 (86)0.03
  Peritumoral edema present59 (61)27 (61)NS
  ≥2 cm deep to cortical surface7 (7)0 (0)NS

NS = not significant.

FIG. 1.
FIG. 1.

Patient selection and outcome for outpatient craniotomy protocol. All patients scheduled for elective craniotomy for resection of supratentorial tumors were considered for outpatient management.

TABLE 3.

Characteristics of patients requiring conversion to inpatient admission

CaseAge (yrs)SexPreop DeficitPreop SeizureSurgeryDuration of Surgery (mins)PathologyReason for AdmissionLOS (days)
142FNoNoFirst65MeningNew seizure1
233MNoNoRepeat135GBMIncision oozing1
356FNoYesRepeat110GBMCognitive impairment1
430MNoYesFirst160AANew hemiparesis2
553MMild weaknessNoRepeat165GBMWorsened hemiparesis1
654FNoYesFirst120GBMDysphasia POD10

AA = anaplastic astrocytoma; GBM = glioblastoma; LOS = length of stay; Mening = meningioma; POD = postoperative day.

Twenty cases overall were found to have worsened or new neurological deficits postoperatively (Table 4). In 3 patients the deficits were attributable to a significant hematoma; 2 of the patients required urgent surgery for evacuation of an epidural hematoma identified while the patient was in the postanesthesia recovery area, and 1 patient developed an intracerebral hemorrhage that caused obstructive hydrocephalus and required external ventriculostomy on the 3rd postoperative day. All 3 of these patients had been scheduled as inpatient cases. Of the remaining 17 cases of postoperative neurological worsening, 14 were scheduled inpatients.

TABLE 4.

Postoperative results for cases of tumor craniotomy under general anesthesia*

ParameterInpatientOutpatient
No. of patients9744
New neurological deficit17 (18)3 (7)
  Sensorimotor14 (14)2 (4)
  Visual field defect3 (7)1 (2)
Significant hematoma3 (7)0 (0)
Converted to inpatientNA6 (14)
Medical complication in hospital9 (9)1 (2)
  Venous thromboembolism1 (1)0 (0)
  Delirium1 (1)0 (0)
  New seizure5 (5)1 (2)
  Wound infection1 (1)0 (0)
  Progressive functional decline1 (1)0 (0)
Length of stay (days)1–1140–2
Pathological diagnosis
  High-grade glioma21 (22)17 (39)
  Low-grade glioma0 (0)2 (4)
  Metastasis13 (13)11 (25)
  Meningioma54 (56)6 (14)
  Other9 (9)8 (18)

NA = not applicable.

Values are number of patients (%) except where noted otherwise.

Nine cases (9%) of other complications arose during the admission for surgery. Venous thromboembolism and acute delirium occurred once each, and 5 patients experienced new-onset seizures. One patient developed a wound infection requiring repeat surgery for irrigation and debridement. Another patient experienced a progressive decline in function and ultimately died during the same admission; the underlying pathology in this case was metastatic renal cell carcinoma. No acute coronary syndrome, urinary tract infection, or pneumonia occurred in either the inpatient or the outpatient group. No adverse events occurred as a result of early discharge among the day surgery cases.

Discussion

The opportunity to be discharged home the day of craniotomy may yield psychological and physical benefits to patients and can reduce health system costs. Having brain surgery as an outpatient makes the disease seem less serious and gives patients a greater sense of control, contributing to their emotional well-being. Many patients feel that their home is a more comfortable environment for recovery, and for patients with malignant glioma or brain metastases, who are frequently in and out of the hospital, minimizing admissions allows their medical care to cause fewer disruptions to their lives. Qualitative research reports high rates of satisfaction with the outpatient experience, and in the current study, no patients required conversion to inpatient admission due to preference.

Avoiding inpatient admission can reduce patient exposure to in-hospital medical complications and medical error. Adverse events occur in hospitals at a median incidence of 9.2%; 7.0% of these events result in permanent disability, and 7.4% result in death.4 Therefore, inpatient admission must not be regarded as an altogether benign intervention. In the current study, 9% of the electively admitted patients experienced an adverse event in the hospital, in keeping with the expected rate. The outpatient group experienced a 2% rate of in-hospital adverse events. These numbers must be considered with caution, as the groups are nonuniform and the patients were not randomized between them, although this series appears to support the concept that patients whose time in the hospital is limited will experience fewer in-hospital complications.

An additional benefit of not requiring a postoperative inpatient admission is the avoidance of case cancellation due to bed availability limitations. Undergoing surgery requires psychological and logistical preparation on the part of patients and their families, and last-minute cancellation and rescheduling of the surgery results in considerable emotional and financial stress. Planned outpatient procedures reduce the likelihood of case cancellation and thus decrease delays in treatment as well as anxiety and frustration. Because a patient may require conversion to an inpatient admission, some hospitals may require a postoperative bed to be available, which would not relieve the challenge of bed shortages. However, successfully discharged patients would directly reduce the financial requirements of each case. Finite resources in every health care system continue to push for greater cost-effectiveness in providing care, and reducing inpatient stays is an established means of increasing care efficiency.

Along with its benefits, the safety of outpatient craniotomy has been established in previous series. In an initial pilot study of 46 patients, 41 (89%) completed the outpatient protocol.1 A subsequent series included 145 patients who underwent tumor resection; of these patients, 136 (94%) were successfully discharged from the DSU.2 The applicability of the protocol was demonstrated at another neurosurgical center, where 9 (82%) of 11 patients prospectively selected for outpatient management had early discharge.7 The largest series evaluated 249 patients undergoing tumor resection as day cases; 231 of these patients (92.8%) were successfully managed on an outpatient basis.13 In these studies, the protocol included awake craniotomy, which allows for ongoing and immediate postoperative evaluation of a patient's clinical status. Close monitoring of patients following tumor resection is necessary given the risk of intracerebral hemorrhage with neurological deterioration, which has been shown to occur generally within the first 6 hours following surgery, or after 24 hours.17 For this reason, patients must be cleared clinically and on imaging 6 hours after surgery before they are discharged. In the Purzner et al. series,13 no adverse effects as a result of same-day discharge were identified. Preoperative selection is essential to identify patients who are suitable for outpatient surgery, as those with significant neurological deficits and/or functional impairment before surgery will generally be unable to tolerate early discharge.

Although one of the advantages of awake craniotomy is the ability to evaluate the patient's neurological function during and immediately following surgery, in some cases the surgeon or the patient may feel that general anesthesia is indicated. Same-day discharge of patients who have undergone general anesthesia is standard practice in other surgical disciplines including spine surgery (lumbar microdiscectomy, anterior cervical discectomy and fusion13), general surgery (laparoscopic cholecystectomy,8 inguinal hernia repair14), and orthopedic surgery (shoulder arthroscopy12), and its feasibility in cranial surgery has been demonstrated in the setting of unruptured aneurysm repair.6 The current study is, to the best of our knowledge, the largest to demonstrate the safety and efficacy of outpatient management following craniotomy for tumor resection performed with the patient under general anesthesia. Of the 44 patients prospectively selected for same-day discharge, 38 (86%) successfully completed the protocol, a rate similar to the 93% rate seen in previous studies of outpatient craniotomy13 and comparable to the rate of same-day discharge (81%) for laparoscopic cholecystectomy in a recent meta-analysis.18 No adverse effects occurred in the current study as a result of early discharge.

While only limited statistical comparison can be made between the planned inpatient and outpatient groups in the present study, one major difference between them is the selection of patients with preoperative neurological deficit for elective admission, which is in keeping with a relative exclusion criterion for outpatient management. The inpatient group also had more extraaxial lesions, which was not a specific selection criterion, but could result in greater anticipated case complexity and operative length; the slightly more frequent gadolinium enhancement in this group may reflect these lesions, as does the longer mean procedure duration. Notably, other characteristics such as age, preoperative seizure, repeat procedure, and peritumoral edema on imaging were not different between the groups. Among the patients initially entered into the day surgery protocol, no specific risk factors for failure were identified; age, preoperative neurological function, previous seizure, duration of procedure, and intra- and/or extraaxial lesions were similarly distributed, and all patients had met the same inclusion and exclusion criteria for outpatient craniotomy. The most frequent indication for conversion to inpatient admission was postoperative neurological deficit, similar to the preoperative exclusion of patients with existing deficits for outpatient management. Although some patients were disappointed about being unable to go home because of weakness, seizure, or bleeding, they were relieved that the option of staying in the hospital was available and were reassured by the flexibility of the system in managing their immediate medical needs.

The feasibility of outpatient craniotomy after general anesthesia broadens its potential application, especially for extraaxial pathology and tumor locations that necessitate a patient position other than supine. In these settings, surgery can be difficult or impossible to perform while the patient is awake. In other cases, the surgeon may have little familiarity or comfort with an awake craniotomy protocol, or the patient may not be suitable for an awake procedure. This study demonstrates that the indications for outpatient surgery should be considered independently of those for awake craniotomy and that the need for general anesthesia does not preclude successful same-day discharge.

This study is a retrospective review of a single surgeon's practice, and given the small cohort size and the nonrandomized assignment of patients to inpatient and outpatient groups, conclusions cannot be drawn regarding factors that may predict successful outpatient management beyond the defined inclusion and exclusion criteria.

Conclusions

The day surgery craniotomy protocol has demonstrated applicability in settings outside our institution, as well as beyond the tumor resection context. Therefore, our demonstration of the safety and feasibility of same-day discharge following general anesthesia may provide support for the adoption of day surgery programs, especially for surgeons less familiar with awake craniotomy. Of course, each patient must be individually considered, but outpatient surgery should be presented as a well-informed option.

Acknowledgments

We thank Ms. Taskia Mir for her assistance in retrieving patient records.

References

  • 1

    Bernstein M: Outpatient craniotomy for brain tumor: a pilot feasibility study in 46 patients. Can J Neurol Sci 28:1201242001

  • 2

    Boulton MBernstein M: Outpatient brain tumor surgery: innovation in surgical neurooncology. J Neurosurg 108:6496542008

  • 3

    Carrabba GVenkatraghavan LBernstein M: Day surgery awake craniotomy for removing brain tumours: technical note describing a simple protocol. Minim Invasive Neurosurg 51:2082102008

  • 4

    de Vries ENRamrattan MASmorenburg SMGouma DJBoermeester MA: The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 17:2162232008

  • 5

    Glantz MJCole BFForsyth PARecht LDWen PYChamberlain MC: Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 54:188618932000

  • 6

    Goettel NChui JVenkatraghavan LTymianski MManninen PH: Day surgery craniotomy for unruptured cerebral aneurysms: a single center experience. J Neurosurg Anesthesiol 26:60642014

  • 7

    Grundy PLWeidmann CBernstein M: Day-case neurosurgery for brain tumours: the early United Kingdom experience. Br J Neurosurg 22:3603672008

  • 8

    Gurusamy KJunnarkar SFarouk MDavidson BR: Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy. Br J Surg 95:1611682008

  • 9

    Khu KJDoglietto FRadovanovic ITaleb FMendelsohn DZadeh G: Patients' perceptions of awake and outpatient craniotomy for brain tumor: a qualitative study. J Neurosurg 112:105610602010

  • 10

    Lassen BHelseth ERønning PScheie DJohannesen TBMæhlen J: Surgical mortality at 30 days and complications leading to recraniotomy in 2630 consecutive craniotomies for intracranial tumors. Neurosurgery 68:125912692011

  • 11

    Manninen PHTan TK: Postoperative nausea and vomiting after craniotomy for tumor surgery: a comparison between awake craniotomy and general anesthesia. J Clin Anesth 14:2792832002

  • 12

    Mattila KLahtela MHynynen M: Health-related quality of life following ambulatory surgery procedures: assessment by RAND-36. BMC Anesthesiol 12:302012

  • 13

    Purzner TPurzner JMassicotte EMBernstein M: Outpatient brain tumor surgery and spinal decompression: a prospective study of 1003 patients. Neurosurgery 69:1191272011

  • 14

    Rosenberg JBisgaard TKehlet HWara PAsmussen TJuul P: Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults. Dan Med Bull 58:C42432011

  • 15

    Sawaya RHammoud MSchoppa DHess KRWu SZShi WM: Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 42:104410561998

  • 16

    Serletis DBernstein M: Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors. J Neurosurg 107:162007

  • 17

    Taylor WAThomas NWWellings JABell BA: Timing of postoperative intracranial hematoma development and implications for the best use of neurosurgical intensive care. J Neurosurg 82:48501995

  • 18

    Vaughan JGurusamy KSDavidson BR: Day-surgery versus overnight stay surgery for laparoscopic cholecystectomy. Cochrane Database Syst Rev 7:CD0067982013

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: all authors. Acquisition of data: Au. Analysis and interpretation of data: Bernstein, Au. Drafting the article: Au. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Bernstein. Study supervision: Bernstein.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

INCLUDE WHEN CITING Published online March 4, 2016; DOI: 10.3171/2015.11.JNS152151.

Correspondence Mark Bernstein, West Wing 4W-451, Division of Neurosurgery, Toronto Western Hospital, 399 Bathurst St., Toronto, ON M5T 2S8, Canada. email: mark.bernstein@uhn.ca.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Patient selection and outcome for outpatient craniotomy protocol. All patients scheduled for elective craniotomy for resection of supratentorial tumors were considered for outpatient management.

References

  • 1

    Bernstein M: Outpatient craniotomy for brain tumor: a pilot feasibility study in 46 patients. Can J Neurol Sci 28:1201242001

  • 2

    Boulton MBernstein M: Outpatient brain tumor surgery: innovation in surgical neurooncology. J Neurosurg 108:6496542008

  • 3

    Carrabba GVenkatraghavan LBernstein M: Day surgery awake craniotomy for removing brain tumours: technical note describing a simple protocol. Minim Invasive Neurosurg 51:2082102008

  • 4

    de Vries ENRamrattan MASmorenburg SMGouma DJBoermeester MA: The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 17:2162232008

  • 5

    Glantz MJCole BFForsyth PARecht LDWen PYChamberlain MC: Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 54:188618932000

  • 6

    Goettel NChui JVenkatraghavan LTymianski MManninen PH: Day surgery craniotomy for unruptured cerebral aneurysms: a single center experience. J Neurosurg Anesthesiol 26:60642014

  • 7

    Grundy PLWeidmann CBernstein M: Day-case neurosurgery for brain tumours: the early United Kingdom experience. Br J Neurosurg 22:3603672008

  • 8

    Gurusamy KJunnarkar SFarouk MDavidson BR: Meta-analysis of randomized controlled trials on the safety and effectiveness of day-case laparoscopic cholecystectomy. Br J Surg 95:1611682008

  • 9

    Khu KJDoglietto FRadovanovic ITaleb FMendelsohn DZadeh G: Patients' perceptions of awake and outpatient craniotomy for brain tumor: a qualitative study. J Neurosurg 112:105610602010

  • 10

    Lassen BHelseth ERønning PScheie DJohannesen TBMæhlen J: Surgical mortality at 30 days and complications leading to recraniotomy in 2630 consecutive craniotomies for intracranial tumors. Neurosurgery 68:125912692011

  • 11

    Manninen PHTan TK: Postoperative nausea and vomiting after craniotomy for tumor surgery: a comparison between awake craniotomy and general anesthesia. J Clin Anesth 14:2792832002

  • 12

    Mattila KLahtela MHynynen M: Health-related quality of life following ambulatory surgery procedures: assessment by RAND-36. BMC Anesthesiol 12:302012

  • 13

    Purzner TPurzner JMassicotte EMBernstein M: Outpatient brain tumor surgery and spinal decompression: a prospective study of 1003 patients. Neurosurgery 69:1191272011

  • 14

    Rosenberg JBisgaard TKehlet HWara PAsmussen TJuul P: Danish Hernia Database recommendations for the management of inguinal and femoral hernia in adults. Dan Med Bull 58:C42432011

  • 15

    Sawaya RHammoud MSchoppa DHess KRWu SZShi WM: Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors. Neurosurgery 42:104410561998

  • 16

    Serletis DBernstein M: Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors. J Neurosurg 107:162007

  • 17

    Taylor WAThomas NWWellings JABell BA: Timing of postoperative intracranial hematoma development and implications for the best use of neurosurgical intensive care. J Neurosurg 82:48501995

  • 18

    Vaughan JGurusamy KSDavidson BR: Day-surgery versus overnight stay surgery for laparoscopic cholecystectomy. Cochrane Database Syst Rev 7:CD0067982013

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 433 433 33
PDF Downloads 237 237 14
EPUB Downloads 0 0 0

PubMed

Google Scholar