Complications Predicting Perioperative Mortality in Patients Undergoing Elective Craniotomy: A Population-Based Study

Objective: The objective of this study was to assess the independent effect of complications on 30-day mortality in 32,695 patients undergoing elective craniotomy. Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried for patients undergoing elective craniotomy from 2006 to 2015. Multivariate logistic regression was used to examine the effect of complications on mortality independent of preoperative risk and other postoperative complications. This effect was further assessed in risk-stratified patient subgroups using the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator. Results: Of 13 complications analyzed, the 5 most strongly associated with mortality independent of preoperative risk factors were unplanned intubation (odds ratio [OR], 12.1; 95% confidence interval [CI], 9.5–15.4; P < 0.001), stroke (OR, 11.1; 95% CI, 8.3–14.9; P < 0.001), ventilator requirement >48 hours after surgery (OR, 9.9; 95% CI, 7.9–12.6; P < 0.001), and renal failure (OR, 8.5; 95% CI, 4.4–16.2; P < 0.001). These same complications were also the 5 most associated with mortality independent of other postoperative complications. They were also associated with mortality across all risk-stratified patient subgroups. On the contrary, venous thromboembolism (OR, 1.3; 95% CI, 0.98–1.7; P = 0.06), urinary tract infection (OR, 1.1; 95% CI, 0.76–1.6; P = 0.61), unplanned reoperation (OR, 1.1; 95% CI, 0.83–1.4; P = 0.55), and surgical site infection (OR, 0.35; 95% CI, 0.18–0.71; P = 0.004) showed no significant link with increased mortality independent of other complications. Conclusions: Of 13 complications analyzed, myocardial infarction, unplanned intubation, prolonged ventilator requirement, stroke, and renal failure showed the strongest association with mortality independent of preoperative risk, independent of other complications, and across all risk-stratified subgroups. These findings help identify causes of perioperative mortality after elective craniotomy. Dedicating additional resources toward preventing and treating these complications postoperatively may help reduce rates of failure-to-rescue in the neurosurgical population.