Silent Leaks, Loud Alarms: Nursing Vigilance in a Complex Neurosurgical Recovery

Punitha Selvi1, Fathima. S2, Sabari Divya Nandhini3

1ANS, Neuro Intensive Critical Care Unit, Kauvery Hospital, Vadapalani

2Registered Nurse, Neuro Intensive Critical Care Unit, Kauvery Hospital, Vadapalani

3Nurse Educator, Kauvery Hospital, Vadapalani

Abstract

This case presents a 19-year-old female with a large extra-axial lesion in the right parieto occipital region who underwent neurosurgical excision. Postoperative complications including cerebrospinal fluid (CSF) leak, recurrent fever, and pulmonary infection demanded three surgical interventions. This article highlights the role of continuous nursing surveillance, postoperative care, and interdisciplinary teamwork in successfully managing prolonged recovery in a neurosurgical patient.

Introduction

Large extra-axial intracranial lesions often remain undetected until significant symptoms arise. Neurosurgical excision, though curative, carries risk of complications like CSF leaks, infections, and wound breakdown. This case illustrates how timely nursing assessment and escalation contribute to the management of a young patient’s complex postoperative course.

Background History

A 19-year-old female presented with right ear pain and persistent ringing. Though the otological examination was unremarkable, MRI revealed a large, lobulated extra-axial lesion in the right parieto occipital region with calcification and mass effect. She had a history of childhood seizures but had remained asymptomatic later.

Case Presentation

Initial Management

She underwent a right parietal craniotomy and lesion excision. Intraoperative findings showed a calcified, necrotic tumor mass. Postoperative imaging showed no residual lesion. She was discharged with instructions for wound care.

Nursing Assessment & Complication Recognition

Two weeks post-op: Returned with fever and wound soakage. CSF leak suspected.

Nursing Observation: Clear fluid at surgical site, low-grade fever.

Intervention: Wound resuturing and antibiotics initiated. Symptomatic relief achieved.

Re-admission with Persistent CSF Leak

One month post-op: Continuous fever, headache, and discharge.

Second Surgery: Thecoperitoneal (TP) shunt + wound re-suturing

Nursing Support: Monitored fever spikes, seizures, and headache progression. Escalated signs of infection and assisted with neurologist/pulmonologist coordination.

Escalation & Third Surgery

Status epilepticus developed; patient was intubated.

MRI showed collection suggesting of abscess.

Third Surgery: Re-craniotomy and necrotic tissue removal.

Nursing Focus: ICU management, ventilator weaning, infection control, seizure monitoring, and emotional support to patient/family.

Pulmonary Complication:

Following extubation, X-ray revealed bilateral lung opacities. Klebsiella pneumonia was confirmed.

Antibiotic Management: Based on culture sensitivity

Nursing Interventions: Chest physiotherapy, monitoring oxygen saturation, and respiratory support.

Multidisciplinary Team Approach

Neurosurgery: Timely decision-making and repeated interventions

Nurses: Recognized CSF leak early, escalated signs of deterioration, administered timely medications

Infectious Disease: Assisted with diagnosis of drug-induced fever

Pulmonologist: Guided pneumonia treatment

Radiology: Provided critical imaging follow-ups

Postoperative Plan and Nursing Implications:

Regular wound assessment and care

Monitoring for re-leakage of CSF

Seizure precautions and medication titration

Nutritional support and early ambulation

Psychosocial counseling for patient and parents

Health Education

Medication: Antibiotics, anticonvulsants, analgesics

Activity: Bedside mobility, avoid straining

Wound Care: Daily dressing, signs of infection to report

Family Education: Signs of raised ICP, fever, and wound leakage

Psychological Support & Nursing Advocacy

Throughout the course, the nursing team explained procedures, offered emotional reassurance, and built rapport with the family—supporting them during critical events including intubation and seizure episodes.

Conclusion

This case underlines the unpredictable course of neurosurgical recovery and reinforces the essential role of vigilant nursing care. From the first identification of a CSF leak to post-extubation pneumonia management, nurses played a crucial role in bridging surgical interventions and patient stability. It emphasizes the significance of critical thinking, early complication identification, and multidisciplinary collaboration in managing complex neuro patients.

Nightingale Journals

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