Introduction: Returning to the operating room (OR) for evacuation of hematoma after craniotomy is commonly attributed to faulty technique; however, other factors may contribute. We sought to identify those clinical factors predictive of patients returning to the OR for hemorrhage after craniotomy.

Methods: A national surgical quality database (American College of Surgeons National Surgical Quality Improvement Project, ACS-NSQIP) was reviewed for patients undergoing craniotomy based on current procedural terminology (CPT) code. Data were further sorted based on reoperation CPT codes to determine cases for hematoma evacuation.

Results: A total of 5,520 patients undergoing craniotomy in 2012 were identified. A total of 88 (1.6%) patients had a reoperation with a CPT code indicating craniotomy for hematoma evacuation. Preoperative and intraoperative factors associated with reoperation for hemorrhage included age greater than 60, bleeding disorder, and primary procedure entailing craniotomy for hematoma evacuation. Postoperative factors included >48 hours ventilator dependence, unplanned reintubation, and transfusion after surgery. A risk score was created based on these factors and was highly predictive of reoperation for hemorrhage with a receiver operating characteristics curve area under the curve (AUC) of 0.779. Restricting the score to preoperative and intraoperative factors was still predictive of reoperation (AUC=0.664). Cox proportional hazards regression identified all factors identified by multivariate binary logistic regression as significant factors at all time points.

Conclusions: Reoperation for evacuation of hematoma is influenced by several clinical factors. Utilization of only those preoperative and intraoperative factors is also capable of stratifying patients based on risk. A risk score based on these factors is highly predictive of return to the OR and may be used in identify patients at risk.

Patient Care: Identify risk factors for return to OR for hemorrhage in patients undergoing craniotomy.

Learning Objectives: 1) Determine baseline data regarding frequency of reoperation for hemorrhage post-craniotomy 2) Identify factors placing craniotomy patients at increased risk for reoperation for hemorrhage 3) Examine potential of a risk score to predict those at risk for reoperation for hemorrhage

References: 1. Parker, S. L.; McGirt, M. J., Determination of the minimum improvement in pain, disability, and health state associated with cost-effectiveness: introduction of the concept of minimum cost-effective difference. Neurosurgery 2015, 76 Suppl 1, S64-70. 2. McGirt, M. J.; Speroff, T.; Dittus, R. S.; Harrell, F. E., Jr.; Asher, A. L., The National Neurosurgery Quality and Outcomes Database (N2QOD): general overview and pilot-year project description. Neurosurgical focus 2013, 34 (1), E6. 3. Asher, A. L.; Speroff, T.; Dittus, R. S.; Parker, S. L.; Davies, J. M.; Selden, N.; Nian, H.; Glassman, S.; Mummaneni, P.; Shaffrey, C.; Watridge, C.; Cheng, J. S.; McGirt, M. J., The National Neurosurgery Quality and Outcomes Database (N2QOD): a collaborative North American outcomes registry to advance value-based spine care. Spine 2014, 39 (22 Suppl 1), S106-16. 4. Kolias, A. G.; Bulters, D. O.; Cowie, C. J.; Wilson, M. H.; Afshari, F. T.; Helmy, A.; Broughton, E.; Joannides, A. J.; Zebian, B.; Harrisson, S. E.; Hill, C. S.; Ahmed, A. I.; Barone, D. G.; Thakur, B.; McMahon, C. J.; Adlam, D. M.; Bentley, R. P.; Tolias, C. M.; Mitchell, P. M.; Whitfield, P. C.; Critchley, G. R.; Belli, A.; Brennan, P. M.; Hutchinson, P. J., Proposal for establishment of the UK Cranial Reconstruction Registry (UKCRR). British journal of neurosurgery 2014, 28 (3), 310-4. 5. Rolston, J. D.; Han, S. J.; Lau, C. Y.; Berger, M. S.; Parsa, A. T., Frequency and predictors of complications in neurological surgery: national trends from 2006 to 2011. Journal of neurosurgery 2014, 120 (3), 736-45. 6. Alcala-Cerra, G.; Young, A. M.; Moscote-Salazar, L. R.; Paternina-Caicedo, A., Efficacy and safety of subdural drains after burr-hole evacuation of chronic subdural hematomas: systematic review and meta-analysis of randomized controlled trials. World neurosurgery 2014, 82 (6), 1148-57. 7. Jack, A.; O'Kelly, C.; McDougall, C.; Max Findlay, J., Predicting recurrence after chronic subdural haematoma drainage. The Canadian journal of neurological sciences. Le journal canadien des sciences neurologiques 2015, 42 (1), 34-9. 8. Seifman, M. A.; Lewis, P. M.; Rosenfeld, J. V.; Hwang, P. Y., Postoperative intracranial haemorrhage: a review. Neurosurgical review 2011, 34 (4), 393-407. 9. Ingraham, A. M.; Richards, K. E.; Hall, B. L.; Ko, C. Y., Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Advances in surgery 2010, 44, 251-67. 10. Orr, N. T.; Davenport, D. L.; Roth, J. S., Outcomes of simultaneous laparoscopic cholecystectomy and ventral hernia repair compared to that of laparoscopic cholecystectomy alone. Surgical endoscopy 2013, 27 (1), 67-73. 11. Moghadamyeghaneh, Z.; Hanna, M. H.; Carmichael, J. C.; Nguyen, N. T.; Stamos, M. J., A nationwide analysis of postoperative deep vein thrombosis and pulmonary embolism in colon and rectal surgery. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract 2014, 18 (12), 2169-77. 12. Kester, B. S.; Merkow, R. P.; Ju, M. H.; Peabody, T. D.; Bentrem, D. J.; Ko, C. Y.; Bilimoria, K. Y., Effect of post-discharge venous thromboembolism on hospital quality comparisons following hip and knee arthroplasty. The Journal of bone and joint surgery. American volume 2014, 96 (17), 1476-84. 13. Grant, D. W.; Mlodinow, A.; Ver Halen, J. P.; Kim, J. Y., Catastrophic Outcomes in Free Tissue Transfer: A Six-Year Review of the NSQIP Database. Plastic surgery international 2014, 2014, 704206. 14. Hall, B. L.; Hamilton, B. H.; Richards, K.; Bilimoria, K. Y.; Cohen, M. E.; Ko, C. Y., Does surgical quality improve in the American College of Surgeons National Surgical Quality Improvement Program: an evaluation of all participating hospitals. Annals of surgery 2009, 250 (3), 363-76. 15. Guillamondegui, O. D.; Gunter, O. L.; Hines, L.; Martin, B. J.; Gibson, W.; Clarke, P. C.; Cecil, W. T.; Cofer, J. B., Using the National Surgical Quality Improvement Program and the Tennessee Surgical Quality Collaborative to improve surgical outcomes. Journal of the American College of Surgeons 2012, 214 (4), 709-14; discussion 714-6. 16. Osborne, N. H.; Nicholas, L. H.; Ryan, A. M.; Thumma, J. R.; Dimick, J. B., Association of hospital participation in a quality reporting program with surgical outcomes and expenditures for Medicare beneficiaries. Jama 2015, 313 (5), 496-504. 17. American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). User Guide for the 2012 ACS NSQIP Participant Use Data File. www.acsnsqip.org 18. Caprini, J. A.; Arcelus, J. I.; Hasty, J. H.; Tamhane, A. C.; Fabrega, F., Clinical assessment of venous thromboembolic risk in surgical patients. Seminars in thrombosis and hemostasis 1991, 17 Suppl 3, 304-12. 19. Lucas, D. J.; Haider, A.; Haut, E.; Dodson, R.; Wolfgang, C. L.; Ahuja, N.; Sweeney, J.; Pawlik, T. M., Assessing readmission after general, vascular, and thoracic surgery using ACS-NSQIP. Annals of surgery 2013, 258 (3), 430-9. 20. Jian, M.; Li, X.; Wang, A.; Zhang, L.; Han, R.; Gelb, A. W., Flurbiprofen and hypertension but not hydroxyethyl starch are associated with post-craniotomy intracranial haematoma requiring surgery. British journal of anaesthesia 2014, 113 (5), 832-9. 21. Kim, S. H.; Lee, J. H.; Joo, W.; Chough, C. K.; Park, H. K.; Lee, K. J.; Rha, H. K., Analysis of the risk factors for development of post-operative extradural hematoma after intracranial surgery. British journal of neurosurgery 2014, 1-6.