A prospective assessment of peri-orbital edema and ecchymosis among patients of supra-tentorial craniotomy

                                      http://doi.org/10.33698/NRF0262 –  Poonam Kumari, Meenakshi Agnihotri, Manju Dhandapani, S S Dhandapani

Abstract: Patients can have surgery related complications such as hematomas, peri-orbital edema and ecchymosis as a consequence of surgical injury during the immediate postoperative phase of supra-tentorial craniotomy. Objective: To assess the peri-orbital edema and ecchymosis among patients of supra-tentorial craniotomy. Methodology: A prospective study was conducted to assess the peri-orbital edema and ecchymosis among patients of supra-tentorial craniotomy, 45 patients were included. Ethical clearance was obtained from Institute Ethics Committee. Consecutive sampling technique was used. The patient information sheet was given to adult patient with peri-orbital edema and ecchymosis after supra-tentorial craniotomy. Peri-orbital edema and ecchymosis were assessed by using Kara and Gokalan scale. Results: The prevalence, as well as severity of peri-orbital edema and prevalence of ecchymosis of patients of supra-tentorial craniotomy were increased from baseline observation till 4th postoperative day. At baseline, the median peri-orbital edema grade was 2(IQR: 1-3). There was signicant increase in median peri-orbital edema score from 1st day to 4th day in patients. On 3rd and 4th post- operative day median peri-orbital edema score was 3(IQR: 3-4) and 3(IQR: 2.50-4) respectively. Conclusion: It is very important to assess peri-orbital edema and ecchymosis so that appropriate intervention can be taken to promote comforts of the patients of supra-tentorial craniotomy.

Keywords: Supra-tentorial craniotomy, peri-orbital edema, ecchymosis

Address for correspondence:

Poonam Kumari

M.Sc. (Medical-Surgical Nursing) NINE, PGIMER, Chandigarh-12 Phone no. 7589077289 (M)

Kashyap.poonam123@gmail.com

Introduction

Craniotomy is one of the commonest surgical approaches to access various kinds of intracranial lesions. It may be done for diagnosing, removing or treating brain tumors, clipping or repairing of an aneurysm, removing blood or blood clots from a leaking blood vessel, removing an arteriovenous malformation (AVM) and an abnormal mass of blood vessels etc. Localized complications such as peri- orbital edema and ecchymosis can occur after craniotomy. These complications can occur for few days after craniotomy but can cause discomfort to the patients. So appropriate measures can be used to reduce the severity of these complications.1

Surgical approaches to the skull have been   periorbital edema formation and its relatedextended, revised and modied to give the   discomfort  to  the  patients.10,11     It  can  be good possible exposure with minimal associated complications for the patient. Based on the approach through the skull, craniotomy can be classied into two major categories i . e . supratentorial and infratentorial. Supratentorial craniotomy involves brain structures above the tentorium including frontal lobe, temporal lobe and occipital lobe (supratentorial compartment). Infratentorial craniotomy involves the structures below the tentorium including cerebellum and brain stem (posterior fossa). 2,3 Under supratentorial craniotomy, there are further various approaches like frontal, parietal, temporal, occipital, pterional, temporoparietal, parietal-occipital and retromastoid-sub-occipital etc. in which intracranial lesions are accessed depending prevented to an extent by placing suction drain on the sub-periosteum. Despite the preventive measures, incidence of subgaleal collection can vary from 7% to 33%, and periorbital edema from 2.8% to 100%.11,12 There is impact of periorbital edema and ecchymosis on patients as well as on health care professionals while providing care to these patients. Periorbital edema and ecchymosis may disturb patient’s vision, causes pain and eye infection, hampers eye hygiene and it also affects patient’s self- image. It makes neurological examination difcult such as eye response in GCS, pupillary reaction, decreases visual acuity or visual eld, also hampers the ndings of neurological examination and creates problems in eye instillation. Peri- orbital upon  location . 4 T h e i m m e d i a t e edema and ecchymosis remain in patients complications includes cerebellar haemorrhage, cerebral edema, increased intracranial pressure and subgaleal collection due to surgical trauma during the postoperative period. Increased intracranial pressure can result in symptoms such as headache, papilloedema, vomiting, increased blood pressure, confusion, double vision and altered level of consciousness.1,5-9

Subgaleal collection was reported as a complication of supratentorial craniotomy due to surgical trauma in skull and scalp by Dawes et al, 2007 and Torres et al, 2015. The subgaleal collection can result in periorbital edema and ecchymosis. Subgaleal collection has some signicance on the postoperative days because of the underwent supratentorial craniotomy for 4 to 7 days. 5,13,14

Supra-tentorial craniotomy is one of the most common surgical procedure for the treatment of brain tumor, aneurysm, trigeminal neuralgia etc. During the immediate postoperative phase of supra- tentorial craniotomy, patients can have surgery related complications such as hematomas, peri-orbital edema and ecchymosis as a consequence of surgical injury.6-10 It was observed by the researcher that peri-orbital edema and ecchymosis remains in patients of supra-tentorial craniotomy for 4-7 days, which affect the comforts of patients and interfere with nursing care. It suggests that there is a need for active assessment and management to solve this problem.

Objective: To assess the peri-orbital edema and ecchymosis among patients of supra- tentorial craniotomy.

Materials and Methods

A prospective study was conducted to assess the peri- orbital edema and ecchymosis among patients of supra- tentorial craniotomy in Neurosurgical units. All adult patients of supra-tentorial craniotomy for non-traumatic lesion with peri-orbital edema or ecchymosis within 20 supratentorial craniotomy with peri-orbital edema were consecutively screened for eligibility criteria. Patient information sheet was lled, and informed written consent was taken before enrolling the patients. Patients who met the inclusion criteria were enrolled. Socio-demographic prole and clinical prole of the patient was collected using patient proforma Peri- orbital edema and ecchymosis were assessed by using Kara and Gokalan scale. Peri-orbital edema and ecchymosis score was assessed between 7:30am to 8:30am on hours of surgery were included in study.

1st post-operative day. Assessment of the Periorbital edema due to other reasons like pregnancy, hyperthyroidism, cardiac failure, renal failure, liver failure were excluded. The methods of data collection were interview, observation and hospital records. Peri-orbital edema and ecchymosis among patients of supra tentorial craniotomy were assessed by using Kara and Gokalan scale.14,15 It has given different grading for both peri-orbital edema and ecchymosis. For peri-orbital edema score ranges from 0 to 4 and is interpreted as none edema, minimal edema, edema extending onto the iris, edema covering the iris, massive edema with the eyelid swollen shut respectively. For ecchymosis score ranges from 0 to 4 and is interpreted as none ecchymosis, ecchymosis on medial aspect, ecchymosis extending to the pupil, past the pupil, to the lateral canthus respectively.

Permission was obtained from Head, Department of Neurosurgery, PGIMER Chandigarh and ethical approval was obtained from Institute Ethics Committee of PGIMER Chandigarh. All the patients of peri-orbital edema and ecchymosis were done at the end of every day till 4th post- operative days from 4:30pm to 5:30pm. Data was entered and coded in SPSS (Statistical Package for Social Sciences) version 20. Appropriate descriptive statistics, percentage was used for analysis based on the study objectives. Analyzed data was depicted in tables and interpreted.

Results

Table 1 depicts that nearly half of the patients (51.1%) were in 41-60 years of age. More than half of the subjects (57.8 %) were males. Majority of the subjects (77.8%) were married. More than half of the patients took elementary/ senior secondary education (51.1%). Furthermore, 64.4% of subjects were from Hindu religion. Nearly half (46.7%) of the subjects live in rural area. Two third of participants (64.4%) were employed and were living in nuclear families

Table 2 depicts clinical variables of the patients. Approximately half of the patients

Table 1: Socio-demographic variable of the patients n=45

 

Socio-demographic variables of patients	f(%)
Age (years) * 18-40(Young adult) 41-60(Middle adult) 60-68(Older adult)	17(37.8) 23(51.1) 5(11.1)
Gender Male Female	26(57.8) 19(42.2)
Qualification Illiterate and primary school Upto secondary Graduate and above	08 (17.8) 23 (51.1) 13 (28.9)
Marital status Unmarried Separated/Divorced Married	8(17.8) 2(4.4) 35(77.8)
Religion Hindu Muslim Sikh Christian	29(64.4) 1(2.2) 14(31.1) 1(2.2)
Occupation Student Unemployed Employed	01 (2.2) 15 (33.3) 29 (64.4)
Type of family Nuclear Joint	29(64.4) 16(35.6)
Monthly per capita income (Rs.)* >6254 3125-6253 1876-3126 938-1875 <938	17(37.8) 15(33.3) 17(15.6) 5(11.1) 1(2.2)
Habitat Rural Urban Sub urban	21(46.7) 15(33.3) 9(20.0)

 (42.2%) of the patients were diagnosed with aneurysm. More than half of the patient (53%) had undergone left side craniotomy. Mean of duration of surgery was 2.02 ±0.69 hours. Forty percent of the patients had undergone pterional craniotomy. GCS of 35.6% patients was between 10-11 and 28.9% patients had 14-15 GCS score. Mean GCS was 12.00+2.27.

Table 2: Clinical variable of patients of control n=45

 

Clinical variable of the patient	f%
Diagnosis of patient
Aneurysm	19(42.2)
Frontal SOL	6(13.30)
Meningioma	7(15.6)
Others *	13(28.9)
Side of surgery Left side craniotomy Right side craniotomy	24 (53.3)
	21 (46.7)
Craniotomy approach
Frontal	10 (22.2)
Parietal	2 (4.4)
Temporal	2 (4.4)
Occipital	5 (11.1)
Pterional	18 (40.0)
Others**	08 (17.8)
Duration of surgery 60 min-120 min 120 min-180 min 180 min-240 min	10(22.2) 24(53.3) 11(24.4)
GCS of patient	7(15.6) 16(35.6) 9(20.0) 13(28.9)
8-9
10-11
12-13
14-15

* ( schwannoma, oligodendroglioma, ependymomas, frontotemporal SOL, suprasellar SOL, gangliothalamic SOL) ** (tempoparietal, parietoccipital, retromastoid-sub occipital # yate correction Mean+SD(range): Duration of surgery: 2.02 ±0.69(60min-210min), GCS: 12.00±2.2(8-15)

Table 3 depicts prevalence of peri-orbital edema in patients which was measured by using Kara and Gokalan scale on 1st, 2nd, 3rd, 4th post – operative day. At baseline (on the day of surgery 7.30-8.30 AM), 40% of the patients had grade 2 peri-orbital edema and 33.3% of patients had grade 2 peri-orbital edema on 1st post-op day. Majority of the patients i.e. 42.2% had grade 3 on 2nd post- operative day and 44.4 %, 42.2% had grade 4 on 3rd and 4th post-op day respectively.

Table 3: Prevalence of peri-orbital edema among patients of supratentorial craniotomy at different point of observation

   n=45

 

Baseline/ Follow -up	Assessment time	Grade of peri-orbital edema	f%
Baseline 7.30AM – 8.30 AM	1st post-up day	1 2 3 4	13(28.9) 18(40.0) 10(22.2) 4(8.9)
Follow -up 4.30 PM – 5.30 PM	1st post-up day	1 2 3 4	7(15.6) 15(33.3) 13(28.9) 10(22.2)
	2nd post-up day	2 3 4	11(24.4) 19(42.2) 15(33.3)
	3rd post-up day	1 2 3 4	0 6(13.3) 19(42.2) 20(44.4)
	4th post-up day	0 1 2 3 4	1(2.2) 2(4.4) 8(17.8) 15(33.3) 19(42.2)

 

Table 4 depicts the median of peri-orbital edema score in patients of supratentorial craniotomy. At baseline, the median peri- orbital edema grade was was 2(IQR: 1-3). There was signicant increase in median peri-orbital edema score from 1st day to 4th

Table 5 depicts prevalence of ecchymosis  a m o n g p a t i e n t s o f s u p r a t e n t o r i a l craniotomy. Peri- orbital ecchymosis was present in 17.8% of the patients at baseline ( 1st post-operative day 7.30 AM – 8.30 AM). Prevalence of peri-orbital ecchymosis was day  in  patients.  On  3rd   and  4th  post-increased from evening (4.30AM -5.30AM) operative day median peri-orbital edema score was 3(IQR: 3-4) and 3(IQR: 2.50-4) respectively. of 1st post-operative day (33.3%) to 3rd post- operative day ( 40.0%) and then decreases on 4th day of follow-up in patients i.e. 35.6%.

Table 4: Peri-orbital edema grade among patients of supratentorial craniotomy

 

Post- operative day	Control group n1=45
	Median (IQR)	Mean rank
Baseline observation	2(1-3)	40.44
1st post-up day	3(2-3)	39.09
2nd post-up day	3(2-3)	49.52
3rd post-up day	3(3-4)	57.36
4th post-up day	3(2.50-4)	62.01

Table 5: Prevalence of ecchymosis among patients of supratentorial craniotomy

n = 45

	Assessment time	Ecchymosis Present/absent	Total patients (n=45) f%
Baseline observation 7.30AM- 8.30AM)	1st post-up day	Present Absent	8(17.8) 37(82.2)
	1st post-up day	Present	15(33.3)
		Absent	30(66.7)
	2nd post-up day	Present	18(40.0)
Follow-up (4.30 PM- 5.30 PM)		Absent	27(60.0)
	3rd post-up day	Present Absent	18(40.0) 27(60.0)
	4th post-up day	Present	16(35.6)
		Absent	29(64.4)

 

Discussion

Supratentorial craniotomy is an approach in which various kinds of intracranial lesions are accessed above the tentorium including frontal lobe, temporal lobe and occipital hematomas, infection, periorbital edema and ecchymosis as a result of surgical trauma.

Surgical injury results in two basic mechanisms of increased vascular lobe.1,4 There can be immediate and late permeability. It is associated with histamine surgical complications in patients undergoing supra-tentorial craniotomy for and  histamine-like  permeability  factors. 5

The  second  mechanism,  is  the  surgical various brain lesions.16 – 19 During the injury itself which results in increased immediate postoperative period of supra- tentorial craniotomy, patients can have vascular permeability. Generally, vasodilatation remains for 4 days after the surgical injury. Shin et al, 2009 has reported that post-traumatic edema shown to be maximal at 72 hours after a closed soft tissue injury.13

Peri-orbital edema and ecchymosis lead to pain and discomforts in patients. It interferes with eye response of GCS, pupillary response, interference with eye instillation and eye care. Peri-orbital edema after supratentorial craniotomy is often ignored and appropriate intervention can be taken for reducing peri-orbital edema and ecchymosis among patients of supra- tentorial craniotomy.Very few studies are available related to peri-orbital and ecchymosis among patients of supra-

Conclusion: Nurses have an important role in identifying peri- orbital edema and ecchymosis using Kara and Gokalan scale so that appropriate intervention can be taken to promote comforts of the patients.

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