- ICU: Admit to an intensive care unit for hourly neurological checks, close monitoring of vital signs, and laboratory examinations as needed. End-tidal pC02 monitoring may be considered.
- Prolonged postoperative intubation: This may be considered for patients who require long operations, receive multiple units of blood, or have extensive manipulation of cranial nerves, thereby raising the risk for their being unable to protect their airways.
- Imaging to assess resection and rule out hydrocephalus: An urgent CT scan should be obtained for progressive lethargy or neurological changes in the immediate postoperative period to look for hemorrhage or acute hydrocephalus. A postoperative brain MRI should be obtained within 48 – 72 hours after surgery, if possible, because enhancement thereafter may not represent residual disease (11).
- Transfer to regular floor: Transfer usually occurs after 24 – 48 hours in the ICU, and then the patient is mobilized.
- Discharge from hospital: Discharge may proceed when the patient is eating well, at neurological baseline, and not requiring IV pain medication.
- Dexamethasone taper: Dexamethasone is tapered to off over approximately 7 – 10 days if the patient is doing well clinically and the postoperative MRI scan demonstrates a complete or near-complete tumor resection.
Hydrocephalus after tumor resection
- Unusual: Permanent CSF diversion after complete or near-complete tumor resection is usually not required.
- Large tumors in young children major risk factor: The need for postoperative shunt placement is more likely in younger patients and those with large tumors or long-standing ventriculomegaly (7).
- Relative indications for treatment: Large ventricles associated with symptoms of elevated ICP can be present after surgery and may indicate hydrocephalus in need of treatment. Additionally, one may encounter progressive ventriculomegaly on postoperative imaging studies as well as an enlarging pseudomeningocele, or a CSF leak indicative of developing hydrocephalus in need of treatment.
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