Post-craniotomy infections: A point-by-point approach
Giovanni Carone, Marta Bonada, Evelyn Gisell Belotti, Eugenia D'angeli, Annica Piccardi, Fabio Martino Doniselli, Guido Gubertini, Cecilia Casali, Francesco DiMeco, Massimiliano Del Bene
Abstract
Post-craniotomy neurosurgical infections (PCNIs) significantly challenge daily neurosurgical practice, affecting patient outcomes and imposing economic burdens on healthcare systems. Despite advances in surgical techniques and infection control protocols, PCNIs still contribute to surgical-related morbidity and mortality. To address these unresolved questions through a comprehensive literature review. We conducted a detailed literature review using the keywords "Infection, Craniotomy, Neurosurgery," on PubMed, which yielded 2330 articles. Out of these, 171 were selected, based on relevance, and rigorously reviewed. The review aimed to answer thirteen major questions stemming from the management of PCNIs. PCNI incidences range from 0.7% to 8%, predominantly caused by gram-positive bacteria, especially Staphylococcus species. Significant risk factors identified include CSF leakage, emergency surgery, and certain tumour types, with infections typically manifesting post-discharge. Diagnostic approaches integrate clinical, radiological, and laboratory assessments, with advances in molecular diagnostics showing promising precision. While antibiotic prophylaxis remains effective, emerging resistance warrants cautious application. Surgical intervention is often indispensable for managing organ-space infections, with a trend towards bone flap preservation and one-step cranioplasty procedures in certain cases. The management of PCNIs remains a major challenge. There is a critical need for standardization of definitions and data reporting. Advancements in diagnostic and therapeutic strategies may bring future improvements in clinical outcomes, despite antibiotic resistance phenomena and the complexity of surgical decisions required. Ultimately, major engagement is aimed at refining and updating clinical protocols to improve and standardize the management of PCNIs. • PCNIs pose significant challenges, with incidences ranging up to 8% despite advances in surgical techniques and protocols. • Key risk factors include CSF leakage, emergency surgeries, and benign tumour histology. • Advanced diagnostics, such as DWI MRI, PCR, and MALDI-TOF MS, improve precision in infection management. • Surgery is favored for organ-space infections, with evidence supporting one-step bone flap sterilization/eimplantation. • Use cefazolin/vancomycin 45 min pre incision and limi post-ope use to 24 h for effective stewardship.