No ICU Unless 2.0 - Refining ICU admission criteria after elective craniotomy.

Objective: Routine intensive care unit (ICU) admission following elective craniotomy is still standard practice in most neurosurgical centers, despite growing evidence supporting selective monitoring strategies. Research question: We aimed to refine ICU admission criteria by identifying predictors of ultimately required postoperative ICU transfers and by developing a pragmatic risk score. Material and methods: We retrospectively analyzed adult patients who underwent elective craniotomy from 2021 to 2024. Patients were divided into two cohorts: Cohort A included patients transferred to the general ward as planned, while Cohort B included those requiring unplanned ICU admission after initial general ward assignment. Baseline and surgical characteristics, complication rates and outcome parameters were compared. Univariate and multivariable logistic regression were performed to identify predictors of ultimately required ICU admission. A risk score was developed based on significant predictors. Results: Of 1441 patients undergoing elective craniotomy, 1162 (81 %) were preoperatively scheduled for postoperative care on the general ward. Of these, 153 patients (13 %) required unplanned ICU admission. Analysis identified independent risk factors: surgical time >143 min (OR 4.73; p < 0.0001), blood loss >500 mL (OR 1.89; p = 0.0098), age >72 years (OR 2.18; p = 0.0037), and intraventricular lesion location (OR 16.92; p < 0.0001). A 3-point risk score was constructed, with ICU admission rates increasing from 2.5 % (0 points) to 36 % (3 points). Discussion and conclusions: Selective ICU admission after elective craniotomy appears safe when guided by risk assessment. The score may support clinical decision-making, reduce unnecessary ICU utilization, and promote resource-efficient postoperative care - even in complex or infratentorial cases.