Sudden Neurologic Worsening in the Postoperative Patient

Many neurosurgical patients are brought to the Intensive Care Unit (ICU) for close monitoring in the acute postoperative period, and for good reason: a variety of postoperative complications can occur, and rapid recognition and prompt intervention are often crucial for a good outcome. Intracranial hemorrhage can occur after any open (and some endovascular) procedures, and seizures and hydrocephalus are commonly associated with certain pathologies. In the setting of aneurysmal subarachnoid hemorrhage, sudden neurologic worsening may reflect the development of secondary vasospasm with delayed cerebral ischemia rather than a direct complication of the operative intervention used to treat it. Sudden neurologic change in the postoperative spine patient may reflect the influence of the underlying pathology or suggest a secondary process related to the operative intervention (such as spinal cord hypoperfusion, with resultant ischemia, or reperfusion syndrome). In each of these cases, the differential diagnosis is derived from careful consideration of medical history, hospital course, and details of the procedure, in conjunction with a thorough neurological examination. Once an appropriate differential has been generated, further testing can be pursued to guide any further interventions that may be required.