Abstract
Immediate postcraniotomy headache frequently occurs within the first 48 h after surgery. The mechanisms underlying immediate postcraniotomy headache are not yet fully understood, and effective treatments are not yet established. This study aimed to identify the factors associated with immediate postcraniotomy headache in patients who underwent clipping surgery with frontotemporal craniotomy and to examine the effects of these factors on postcraniotomy headache. A total of 51 patients were included in this study. Immediate postcraniotomy headache was defined as pain with numerical rating scale score ≥4 on postoperative day 7. Sixteen patients (31.4%) had immediate postcraniotomy headache. The headache-positive group had a higher incidence of preoperative analgesic use (50.0% vs. 5.7%, respectively, p < 0.001), increased temporal muscle swelling ratio (137.0%±30.2% vs. 112.5%±30.5%, respectively, p = 0.01), and higher postoperative analgesic use (12.9±5.8 vs. 6.7±5.2, respectively, p < 0.001) than the headache-negative group. The risk factors independently associated with immediate postcraniotomy headache were preoperative analgesic use and temporal muscle swelling by >115.15% compared with the contralateral side in the receiver operating characteristic analysis. Postcraniotomy headache was significantly more common in patients with preoperative analgesic use and temporal muscle swelling than in those without (p < 0.001 and p = 0.002, respectively). Altogether, patients with immediate postcraniotomy headache had greater preoperative analgesic use, greater temporal muscle swelling ratio, and higher postoperative analgesic use than those without. Thus, temporal muscle swelling is a key response to immediate postcraniotomy headache.
Keywords: clipping, frontotemporal craniotomy, immediate postcraniotomy headache, temporal muscle swelling
Introduction
Postcraniotomy headache (PCH) is the most common adverse event (60%-87%) occurring after surgery.1-3) According to the third edition of the International Classification of Headache Disorders (ICHD-3), PCH can be classified as acute PCH (APCH), which persists for less than 3 months, and persistent, chronic PCH (CPCH), which persists for more than 3 months.4) PCH occurs most frequently within 48 h, and APCH that occurs earlier than 48 h is described as immediate PCH (IPCH).1,2,5) IPCHs comprise the majority of APCHs, and most studies on APCH also apply to IPCH.
The characteristics of patients with PCH have been reported. Frequent and severe APCHs are reportedly more common in women and younger patients;1,6) APCH is 40% more common in women than in men and less common in those over 75 years old.7) In particular, posterior craniotomy is strongly associated with the incidence of APCH and CPCH.6,7) Opioids, nonsteroidal anti-inflammatory drugs, acetaminophen, and icing have been used in the postoperative management of APCH.8) Furthermore, preventive treatments for APCH have been reported to include the preoperative use of gabapentin, acetaminophen, and steroids as well as the intraoperative use of local anesthesia, nerve block, and opioids.6,7,9-12) Despite the existence of multiple treatments and preventive methods, no effective treatment has been established, making it difficult to manage PCH. Thus, PCH management relies on the surgeon's assessment and tends to be neglected. APCH can affect the length of hospital stay and medical costs.13) It has been reported that one-fourth of patients who undergo craniotomy transition to CPCH,14) which can impair their quality of life. Although several causative factors, including damage to tissues such as the scalp, muscles, dura mater, periosteum, and nerves, as well as leakage of cerebrospinal fluid, have been suggested to contribute to PCH, the mechanisms are not yet fully understood.1,15-18) Elucidating the mechanisms underlying PCH could lead to the development of effective treatments.
Clipping surgery for unruptured cerebral aneurysms is largely standardized. As there are no reports on the mechanisms of PCH in a single procedure, investigation of IPCH in a single procedure, such as clipping surgery for unruptured cerebral aneurysm, may help elucidate the mechanism of IPCH. This study investigated the factors associated with IPCH in patients who underwent clipping surgery with frontotemporal craniotomy. In addition, it examined the effects of these factors on IPCH.
Materials and Methods
Study design
The study protocol was approved by our hospital's ethics committee (approval no.: R05-081). The study was conducted in accordance with the tenets of the Declaration of Helsinki. Clinical data were anonymized and retrospectively collected. Owing to the retrospective nature of the study, the institutional review board waived the requirement for written informed consent, providing participants with an opt-out option, as per the Personal Information Protection Law and National Research Ethics Guidelines in Japan. The study procedures were performed in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.
Patient population
We investigated 51 patients who underwent clipping surgery for unruptured cerebral aneurysms with frontotemporal craniotomy at our institution between January 2016 and June 2022. No patients with symptomatic unruptured cerebral aneurysm underwent clipping surgery during the study period. Patients with postoperative unconsciousness and missing data were excluded from the study.
Procedure
Clipping surgery during this period was performed by three operators (Y. I., A. M., and H. H.) using an identical procedure.19-21) Propofol-based total intravenous anesthesia was induced. Patients were placed in the supine position with the head elevated by 10°-15° and rotated by approximately 45°. The head was stabilized using pins. A curvilinear skin incision was made at the zygomatic arch, 1 cm anterior to the tragus and arched to the midline, just behind the hairline. The skin flap was elevated using the interfascial dissection technique. The temporalis muscle was incised from the zygomatic arch to the superior temporal line, along the skin incision, and anteriorly on the superior temporal to the frontotemporal lines. The temporalis muscle was separated cranially from the base using a raspatorium. Frontotemporal craniotomy was performed using three burr holes. The dura was opened in a semicircular manner around the Sylvian fissure. After aneurysm clipping, the dura was closed, and the bone flap was fixed with three titanium plates. Then, the temporal muscle fascia was sutured. Subcutaneous drainage was retained until postoperative day (POD) 1 in all patients.
Postoperation
After surgery, the patients were transferred to the intensive care unit. On POD 1, all patients underwent blood tests and head computed tomography (CT). Postoperative pain management consisted of intravenous analgesics until oral intake of analgesics was initiated. The type of analgesic used was left to the surgeon's discretion. The daily numerical rating scale (NRS) score and analgesic use were evaluated. The NRS score was evaluated upon waking to minimize the effect of analgesics.
Assessment
ICHD-3 has not previously described the severity of PCH.4) In previous studies, the NRS and visual analog scale (VAS) were employed to assess headache severity, and generally, an NRS or VAS score of 1-3 was defined as mild; 4-6, moderate; and 7-10, severe pain.2,6) In this study, PCH was defined as NRS score ≥4 and IPCH as PCH on POD 7. The following information was collected from the medical records of each patient: age, sex, body mass index, aneurysm location, classification of preoperative headache, preoperative analgesic use, operation time, intraoperative infusion volume, C-reactive protein (CRP) level, white blood cell (WBC) count on POD 1, cross-sectional area of the ipsilateral and contralateral temporal muscles, temporal muscle swelling ratio, and total number of analgesics used from PODs 1 to 7. “Temporal muscle swelling ratio” was defined as the ratio of the areas of the temporal muscle with the swelling to that of the temporal muscle of the contralateral side. It was measured using anonymized head CT on POD 1; outline of the temporal muscle was manually traced at the 5-mm slice above the orbital roof (Fig. 1).22)
Fig. 1.
Method of measurement of the temporal muscle cross-sectional area.
(A) A 5-mm slice above the orbital roof on the head computed tomography performed on postoperative day 1 was used. (B) The outline of the temporal muscle was manually traced and the cross-sectional area calculated.
Statistical analysis
Continuous variables were expressed as mean ± standard deviation and discrete data as counts and percentages. Differences in background factors between the groups were evaluated using Fisher's exact test for discrete data and two-sample Student's t-test for continuous data. The receiver operating characteristic (ROC) curve of sensitivity and specificity was used to evaluate the cutoff value for the temporal muscle swelling ratio for IPCH. The cutoff value was measured using Youden's index. Stepwise multivariate linear regression analyses were employed to determine the association between predictive factors (age, sex, body mass index, preoperative analgesic use, operation time, intraoperative infusion volume, ipsilateral and contralateral temporal muscle cross-sectional area, and temporal muscle swelling) and IPCH. The Kaplan-Meier curves were employed to estimate the association between the duration of PCH and the presence of preoperative analgesic use or presence of temporal muscle swelling. A comparison with and without PCH was performed using the long-rank test. SPSS (version 27.0; IBM, Armonk, NY) was used for all analyses. P < 0.05 was considered to indicate statistical significance.
Results
This study included 51 patients, of whom 34 were women (66.7%) (Table 1). The mean age of the patients was 60.9 ± 10.9 years. Of the patients, 9 (17.6%) had cerebral aneurysms in the internal carotid artery, 36 (70.6%) in the middle cerebral artery, and 6 (11.8%) in the anterior communicating artery. No patients had intraoperative aneurysm rupture. The number of patients with PCH on POD 1 was 31 (60.8%), which gradually decreased to 17 (33.3%) on POD 4 and then remained unchanged until POD 7 (Supplementary Figure 1).
Table 1.
Patient characteristics and comparison between IPCH (+) and IPCH (−)
| Total | IPCH (+) | IPCH (−) | p | ||
|---|---|---|---|---|---|
| Number | 16 (31.4%) | 35 (68.6%) | |||
| Age (yo) | 60.9 ± 10.9 | 58.8 ± 9.6 | 61.9 ± 11.4 | 0.34 | |
| Female | 34 (66.7%) | 11 (68.8%) | 23 (65.8%) | 0.83 | |
| Right | 36 (70.6%) | 7 (43.8%) | 29 (82.9%) | 0.004 | |
| Body mass index | 22.9 ± 3.2 | 22.8 ± 3.9 | 22.9 ± 2.8 | 0.91 | |
| Preoperative headache | 14 (27.5%) | 10 (62.5%) | 4 (11.4%) | < 0.001 | |
| Migraine | 5 | 2 | 3 | ||
| Tension headache | 9 | 8 | 1 | ||
| Preoperative analgesic use | 10 (19.6%) | 8 (50.0%) | 2 (5.7%) | <0.001 | |
| Operation time (min) | 293.1 ± 57.8 | 299.4 ± 45.8 | 290.3 ± 63.0 | 0.60 | |
| Intraoperative infusion volume (mL) | 2107.3 ± 544.7 | 2210.9 ± 581.8 | 2059.9 ± 528.8 | 0.36 | |
| Temporal muscle cross-sectional area | Ipsilateral (mm2) | 412.4 ± 178.8 | 396.9 ± 182.9 | 419.5 ± 179.2 | 0.68 |
| Contralateral (mm2) | 360.8 ± 173.6 | 311.8 ± 186.9 | 383.2 ± 165.1 | 0.20 | |
| Temporal muscle swelling ratio (%) | 120.2 ± 32.2 | 137.0 ± 30.2 | 112.5 ± 30.5 | 0.01 | |
| White blood cell (×103/μL) | 11.4 ± 3.5 | 12.1 ± 4.1 | 11.0 ± 3.2 | 0.28 | |
| C-reactive protein (mg/dL) | 3.2 ± 2.0 | 2.8 ± 2.0 | 3.4 ± 2.0 | 0.32 | |
| Total number of analgesics used | 8.7 ± 6.1 | 12.9 ± 5.8 | 6.7 ± 5.2 | < 0.001 |
IPCH: Immediate postcraniotomy headache
A total of 16 patients (31.4%) had IPCH. In the univariate analysis, the IPCH(+) group had a higher incidence of preoperative headache (62.5% vs. 11.4%, respectively, p < 0.001), preoperative analgesic use (50.0% vs. 5.7%, respectively, p < 0.001), temporal muscle swelling ratio (137.0%±30.2% vs. 112.5%±30.5%, respectively, p = 0.01), and total number of analgesics use from PODs 1 to 7 (12.9 ± 5.8 vs. 6.7 ± 5.2, respectively, p < 0.001) (Table 1). No significant differences were observed in terms of age, sex, body mass index, operative time, or intraoperative infusion between the IPCH(+) and IPCH(−) groups. Furthermore, no significant differences were observed in the cross-sectional area of the ipsilateral and contralateral sides, CRP levels, and WBC counts on POD 1. ROC analysis revealed an area under the curve value of 0.756 for the temporal muscle swelling ratio and IPCH, and the cutoff value of the temporal muscle swelling ratio was determined as 115.15%, with a sensitivity and specificity of 81.3% and 65.7%, respectively (Supplementary Figure 2). In the multivariate stepwise regression, the risk factors independently associated with IPCH were preoperative analgesic use and temporal muscle swelling by 115.15% or greater compared with the contralateral side (Table 2).
Table 2.
Multivariate linear regression analysis of immediate postcraniotomy headache
| Variable | Unstandardized coefficient | Standardization coefficient | t | p | 95% Confidence interval | ||
|---|---|---|---|---|---|---|---|
| B | SE | B | Lower limit | Upper limit | |||
| Constant | 0.057 | 0.078 | 0.739 | 0.464 | −0.99 | 0.214 | |
| Preoperative analgesic use | 0.521 | 0.137 | 0.447 | 3.796 | <0.001 | 0.245 | 0.797 |
| Temporal muscle swelling | 0.317 | 0.110 | 0.339 | 2.885 | 0.006 | 0.096 | 0.538 |
SE: Standard error
The Kaplan-Meier curve showed that preoperative analgesic use and temporal muscle swelling affected the persistence of PCH. PCH was significantly more common in patients with preoperative analgesic use and temporal muscle swelling than in those without (p < 0.001 and p = 0.002, respectively) (Fig. 2).
Fig. 2.
Kaplan-Meier curves of postcraniotomy headache in the presence of preoperative analgesic use and presence of temporal muscle swelling.
(A) Postcraniotomy headache (defined as numerical rating scale score ≥4) was significantly more common in patients with preoperative analgesic use (black line) than in those without (gray line) (p < 0.001). (B) Postcraniotomy headache (defined as numerical rating scale score ≥4) was significantly more common in patients with temporal muscle swelling (black line) than in those without (gray line) (p = 0.002).
The temporal muscle swelling ratio was weakly correlated with the contralateral temporal muscle cross-sectional area (Spearman's correlation coefficient, r = −0.388, p = 0.005), as described by a linear regression model (y = −0.072× + 146.2) (Fig. 3).
Fig. 3.
Correlation between temporal muscle swelling ratio and contralateral temporal muscle cross-sectional area.
The correlation was weak (r = −0.388, p = 0.005). The dotted line indicates a temporal muscle swelling ratio of 115.15%.
IPCH: immediate postcraniotomy headache
Discussion
The factors associated with APCH and CPCH may vary and should be investigated separately. APCH is defined as a headache occurring within 3 months postoperatively in ICHD-3;4) however, most APCH cases occur in the early postoperative period. The present study defined IPCH as PCH occurring on POD 7 and investigated its risk factors.
IPCH has been associated with young age, female sex, surgery lasting more than 4 h, and preoperative depression.5,23) IPCH can be refractory to treatment, lead to prolonged hospital stay, and increase medical costs.13) There have been studies on the preventive and postoperative management of IPCH; however, in clinical practice, decisions are generally left at the surgeon's discretion or the management is neglected.3,6-12,16) Several causative factors, including damage to tissues (e.g., scalp, muscles, dura mater, periosteum, and nerve tissue) and cerebrospinal fluid leakage, have been suggested to contribute to the incidence of IPCH.1,15-18) Most studies on IPCH have focused on patient characteristics, and the exact pathophysiology of IPCH remains unclear. A major drawback of previous studies is that they lumped multiple surgical approaches together for evaluation. Therefore, we hypothesized that investigation of IPCH in a single surgical approach would help elucidate its underlying mechanism and pathophysiology.
The present study included patients who underwent the same procedure of frontotemporal craniotomy for unruptured cerebral aneurysms at a single institution throughout the study period. There are few studies on IPCH associated with a singular surgical approach, such as frontotemporal craniotomy. Therefore, this study provides valuable insights to elucidating the underlying mechanism and treatment of PCH. PCH in this study was most common on POD 1 (60.8%), as in previous studies (60%-76%).1,16) Subsequently, PCH gradually decreased to 33.3% on POD 4 and remained stable thereafter. Patients with IPCH had a significantly higher incidence of preoperative analgesic use and temporal muscle swelling ratio. Furthermore, the use of postoperative analgesics was significantly higher, although this is not surprising. Contrarily, no association was observed between sex, age, and operative time, unlike previous studies. A cutoff value for the temporal muscle swelling ratio was calculated using ROC analysis, and multivariate analysis revealed that temporal muscle swelling and preoperative analgesic use were strongly associated with IPCH. The temporal muscle swelling ratio indicates the severity of muscle injury. PCH is reportedly more common in subtemporal and suboccipital approaches involving major muscle incisions.1,16) Furthermore, craniotomy-related muscle injury has been reported to be significantly associated with higher NRS and increased use of analgesics.24) Based on these results, we inferred that surgical damage in major muscle tissues is possibly associated with IPCH. The causes of muscle injury include incision, avulsion, traction, and venous injury of the temporal muscle. However, as this surgery was performed using a singular approach and the same procedure, the amounts of invasive manipulation and traction applied to the temporal muscle were almost the same. Because previous studies have not mentioned the direct cause of muscle swelling, it is unlikely that it was caused by a specific procedure.
The temporal muscle swelling ratio was negatively correlated with the cross-sectional area of the contralateral temporal muscle. We initially speculated that larger temporal muscles are more likely to swell and produce PCHs; however, the results of the present study were contradictory. The thickness of the temporal muscle has been reported to play a role in the prognosis of patients with glioma and stroke.25,26) Patients with more muscles are less prone to sarcopenia, whereas patients with thinner temporal muscles may be less resistant to injury. Despite this knowledge, the reason why patients with thinner temporal muscles are more likely to develop temporal muscle swelling is unknown. Biochemical evaluations may reveal the cause and lead to the prevention of PCH in the future.
The results of this study do not address the impact of IPCH on the patient's quality of life. However, the total number of analgesics used was about twice as high in the IPCH(+) group than in the IPCH(−) group. The IPCH(+) group had more patients with preoperative analgesic use, suggesting that these patients may be comfortable with the use of analgesics. Nevertheless, traditional postoperative treatments for IPCH are not always effective, indicating that IPCH has a significant impact on postdischarge life.17) It is difficult to predict IPCH preoperatively based on previous studies and the results of the present study. This study demonstrated that IPCH was significantly more common in patients with preoperative analgesic use and temporal muscle swelling. There remains a need for preoperative predictive assessment to prevent IPCH. Furthermore, preoperative treatment of temporal muscle swelling may be prophylactic for IPCH. Tailor-made treatment for patients with thin temporal muscles or preoperative analgesic use may also be worth considering.
The present study has some limitations. First, it was a retrospective case-control study conducted at a single center involving a small number of cases. Thus, larger multicenter prospective studies must be conducted in the future. Second, the intra- and postoperative pain management and the type and amount of medication were left to the discretion of the anesthesiologists and neurosurgeons, respectively. However, it is unlikely that intraoperative analgesics affected the headache on POD 7. Third, the effect of analgesics cannot be denied if the patient took them the previous night. Therefore, headache was evaluated early in the morning, when the effect of analgesics was minimal.
In standard frontotemporal craniotomy for unruptured cerebral aneurysms, patients with PCH on POD 7, i.e., the IPCH(+) group, had a significantly higher incidence of preoperative analgesic use, temporal muscle swelling ratio, and postoperative analgesic use. Furthermore, PCH was significantly more common in patients with preoperative analgesic use and temporal muscle swelling than in those without. Furthermore, the temporal muscle swelling ratio was negatively correlated with the cross-sectional area of the contralateral temporal muscle. Consequently, temporal muscle swelling is a key response to IPCH.
Funding
This study was funded by JSPS KAKENHI Grant Number JP20K17950.
Conflicts of Interest Disclosure
The authors report no conflicts of interest concerning the materials or methods used in this study or the findings specified in this manuscript.
Supplementary Material
Frequency of postcraniotomy headache during the first week after craniotomy
Postcraniotomy headache (PCH) was defined as a numerical rating scale score ≥ 4.
Receiver operating characteristic curve for temporal muscle swelling and immediate postcraniotomy headache
The area under the curve value was 0.788, and the cutoff value of the temporal muscle swelling ratio was determined as 115.15%, with a sensitivity and specificity of 81.3% and 65.7%, respectively.
Acknowledgments
We would like to thank Editage (www.editage.com) for the English language editing.
References
- 1). De Benedittis G, Lorenzetti A, Migliore M, Spagnoli D, Tiberio F, Villani RM: Postoperative pain in neurosurgery: a pilot study in brain surgery. Neurosurgery 38: 466-469; discussion 469-470, 1996 [DOI] [PubMed] [Google Scholar]
- 2). Thibault M, Girard F, Moumdjian R, Chouinard P, Boudreault D, Ruel M: Craniotomy site influences postoperative pain following neurosurgical procedures: a retrospective study. Can J Anaesth 54: 544-548, 2007 [DOI] [PubMed] [Google Scholar]
- 3). Santos CMT, Pereira CU, Chaves PHS, Tôrres PTRL, Oliveira DMDP, Rabelo NN: Options to manage postcraniotomy acute pain in neurosurgery: no protocol available. Br J Neurosurg 35: 84-91, 2021 [DOI] [PubMed] [Google Scholar]
- 4). Headache Classification Committee of the International Headache Society (IHS) : The international classification of headache disorders, ed 3. Cephalalgia 38: 1-211, 2018 [DOI] [PubMed] [Google Scholar]
- 5). de Oliveira Ribeiro C, Pereira CU, Sallum AM, et al. : Immediate post-craniotomy headache. Cephalalgia 33: 897-905, 2013 [DOI] [PubMed] [Google Scholar]
- 6). Gottschalk A, Berkow LC, Stevens RD, et al. : Prospective evaluation of pain and analgesic use following major elective intracranial surgery. J Neurosurg 106: 210-216, 2007 [DOI] [PubMed] [Google Scholar]
- 7). Ryzenman JM, Pensak ML, Tew JM Jr.: Headache: a quality of life analysis in a cohort of 1,657 patients undergoing acoustic neuroma surgery, results from the acoustic neuroma association. Laryngoscope 115: 703-711, 2005 [DOI] [PubMed] [Google Scholar]
- 8). Vadivelu N, Kai AM, Tran D, Kodumudi G, Legler A, Ayrian E: Options for perioperative pain management in neurosurgery. J Pain Res 9: 37-47, 2016 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9). Law-Koune JD, Szekely B, Fermanian C, Peuch C, Liu N, Fischler M: Scalp infiltration with bupivacaine plus epinephrine or plain ropivacaine reduces postoperative pain after supratentorial craniotomy. J Neurosurg Anesthesiol 17: 139-143, 2005 [DOI] [PubMed] [Google Scholar]
- 10). Ghaffarpasand F, Dadgostar E, Ilami G, et al. : Intravenous acetaminophen (paracetamol) for postcraniotomy pain: systematic review and meta-analysis of randomized controlled trials. World Neurosurg 134: 569-576, 2020 [DOI] [PubMed] [Google Scholar]
- 11). Türe H, Sayin M, Karlikaya G, Bingol CA, Aykac B, Türe U: The analgesic effect of gabapentin as a prophylactic anticonvulsant drug on postcraniotomy pain: a prospective randomized study. Anesth Analg 109: 1625-1631, 2009 [DOI] [PubMed] [Google Scholar]
- 12). Haldar R, Kaushal A, Gupta D, Srivastava S, Singh PK: Pain following craniotomy: reassessment of the available options. Biomed Res Int 2015: 509164, 2015 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13). Leslie K, Troedel S, Irwin K, et al. : Quality of recovery from anesthesia in neurosurgical patients. Anesthesiology 99: 1158-1165, 2003 [DOI] [PubMed] [Google Scholar]
- 14). de Gray LC, Matta BF: Acute and chronic pain following craniotomy: a review. Anaesthesia 60: 693-704, 2005 [DOI] [PubMed] [Google Scholar]
- 15). Rocha-Filho PA, Gherpelli JL, de Siqueira JT, Rabello GD: Post-craniotomy headache: characteristics, behaviour and effect on quality of life in patients operated for treatment of supratentorial intracranial aneurysms. Cephalalgia 28: 41-48, 2008 [DOI] [PubMed] [Google Scholar]
- 16). Molnár L, Simon É, Nemes R, Fülesdi B, Molnár C: Postcraniotomy headache. J Anesth 28: 102-111, 2014 [DOI] [PubMed] [Google Scholar]
- 17). Rocha-Filho PA: Post-craniotomy headache: a clinical view with a focus on the persistent form. Headache 55: 733-738, 2015 [DOI] [PubMed] [Google Scholar]
- 18). Kim TK, Yoon JR, Kim YS, et al. : Pneumocephalus and headache following craniotomy during the immediate postoperative period. BMC Surg 22: 252, 2022 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19). Yaşargil MG: In: Microsurgical Anatomy of the Basal Cisterns and Vessels of the Brain, Diagnostic Studies, General Operative Techniques and Pathological Considerations of the Intracranial Aneurysms. Thieme, Germany, 1984 [Google Scholar]
- 20). Lawton MT: In: Seven Aneurysms: Tenets and Techniques for Clipping. Thieme, Germany, 2011 [DOI] [PubMed] [Google Scholar]
- 21). Raabe A, Meyer B: In: The Craniotomy Atlas. Thieme, Germany, 2019 [Google Scholar]
- 22). Katsuki M, Yamamoto Y, Uchiyama T, Wada N, Kakizawa Y: Clinical characteristics of aneurysmal subarachnoid hemorrhage in the elderly over 75; would temporal muscle be a potential prognostic factor as an indicator of sarcopenia? Clin Neurol Neurosurg 186: 105535, 2019 [DOI] [PubMed] [Google Scholar]
- 23). Rimaaja T, Haanpää M, Blomstedt G, Färkkilä M: Headaches after acoustic neuroma surgery. Cephalalgia 27: 1128-1135, 2007 [DOI] [PubMed] [Google Scholar]
- 24). Huckhagel T, Westphal M, Klinger R: The impact of surgery-related muscle injury on prevalence and characteristics of acute postcraniotomy headache - A prospective consecutive case series. J Neurol Surg A Cent Eur Neurosurg 83: 242-251, 2022 [DOI] [PubMed] [Google Scholar]
- 25). Ten Cate C, Huijs SMH, Willemsen ACH, et al. : Correlation of reduced temporal muscle thickness and systemic muscle loss in newly diagnosed glioblastoma patients. J Neurooncol 160: 611-618, 2022 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26). Nagano A, Shimizu A, Maeda K, et al. : Predictive value of temporal muscle thickness for sarcopenia after acute stroke in older patients. Nutrients 14: 5048, 2022 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Frequency of postcraniotomy headache during the first week after craniotomy
Postcraniotomy headache (PCH) was defined as a numerical rating scale score ≥ 4.
Receiver operating characteristic curve for temporal muscle swelling and immediate postcraniotomy headache
The area under the curve value was 0.788, and the cutoff value of the temporal muscle swelling ratio was determined as 115.15%, with a sensitivity and specificity of 81.3% and 65.7%, respectively.