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PubMed2002

Preservation of the olfactory tract in bifrontal craniotomy.

The bifrontal craniotomy approach used to be associated with a high percentage of olfactory tract damage. We present our experience with this technique, that was used with excellent results in a series of 11 patients that underwent the surgical approach described in this paper. We support the idea that bilateral subfrontal craniotomy allows a wide operative exposure as well as the complete anatomic and functional preservation of the olfactory tracts bilaterally.

Adult↗
PubMed2005

[Postoperative pain in craniotomy].

In the postoperative period, 47% to 75% of the patients report some degree of pain. This study aimed to evaluate pain in the pre and postoperative period of patients submitted to craniotomy. This prospective research was carried out at the neurosurgery unit of a large Brazilian hospital. For a quantitative evaluation of pain, the verbal numeric 0-10 rating scale was used. Forty patients with a mean age of 36 years were evaluated. In the preoperative period, 34 (85%) patients indicated headache as the main cause of pain. In the postoperative period, 37 (93%) patients complained of pain while three (7%) reported absence of pain. Pain peaks were observed on the 2nd postoperative day, when 12 (32%) of the patients reported severe pain and 10 (27%) moderate pain. Absence of severe pain occurred after the 8th postoperative day. It was concluded that protocols of analgesia in craniotomy are needed, such as training nurses to better evaluate and handle pain.

Adult↗
PubMed1999

Lumbar spinal subdural hematoma following craniotomy--case report.

A 52-year-old female complained of lumbago and weakness in the lower extremities 6 days after craniotomy for clipping an aneurysm. Neurological examination revealed symptoms consistent with lumbosacral cauda equina compression. The symptoms affecting the lower extremities spontaneously disappeared within 3 days. Magnetic resonance (MR) imaging 10 days after the operation demonstrated a lumbar spinal subdural hematoma (SSH). She had no risk factor for bleeding at this site, the symptoms appeared after she began to walk, and MR imaging suggested the SSH was subacute. Therefore, the SSH was probably due to downward movement of blood from the cranial subdural space under the influence of gravity. SSH as a complication of cranial surgery is rare, but should be considered if a patient develops symptoms consistent with a lumbar SSH after craniotomy.

Brain↗
PubMed2000

Pseudoaneurysm of the superficial temporal artery following craniotomy--case report.

A 48-year-old male without marked blood coagulation disorder developed a pseudoaneurysm of the superficial temporal artery (STA) following craniotomy. Cerebral angiography revealed a pseudoaneurysm on the parietal branch of the STA. Total extirpation was performed, and the postoperative course was uneventful. Most pseudoaneurysms of the STA develop after trauma. Lesions rarely develop after craniotomy. However, pseudoaneurysm of the STA should be considered as a possible surgical complication.

Aneurysm, False↗
PubMed2004

Rapid regrowth of intracranial clear cell meningioma after craniotomy and gamma knife radiosurgery--case report.

A 24-year-old woman underwent craniotomy for falx meningioma (5 cm in diameter) on October 24, 1995. The deepest part of the tumor was located in the anterior horn of the lateral ventricle, which was not resected. The histology was clear cell meningioma (CCM), aggressive in nature. The MIB-1 labeling index was high (11%). She underwent gamma knife (GK) radiosurgery for the residual tumor with an irradiation dose of 16 Gy at the tumor periphery on May 24, 1996. The postradiosurgical course was uneventful. The residual intraventricular tumor gradually decreased in size, but the peripheral portion gradually grew into the diencephalic region. The patient remained in good condition for 5 years until September 2001, when she exhibited memory disturbance and lethargy. Magnetic resonance imaging demonstrated a large tumor (4.5 cm in diameter) in the diencephalon, compressing the optic nerves and fornix. The calculated tumor doubling time was 120 days. A second craniotomy was performed on October 9, 2001. The tumor was totally resected through the anterior transcallosal approach. The histology and the MIB-1 labeling index of the tissue from the second operation did not differ markedly from those of the first operation. Neither tumor recurrence nor metastasis has been observed to date. GK radiosurgery contributed to control of the residual intraventricular tumor, but the peripheral portion of the tumor, which received a relatively low radiation dose (16 Gy), grew rapidly. This suggests that a marginal dose of 16 Gy may not be sufficient for control of CCM.

Adult↗
PubMed1990

Effect of cloxacillin prophylaxis on the bacterial flora of craniotomy wounds.

During a double-blind placebo-controlled study, the effect of cloxacillin prophylaxis in craniotomies on samples taken for culture from 334 operation wounds in 279 patients was assessed. Patients and operations were equally divided over the cloxacillin and placebo groups. In the cloxacillin group significantly fewer samples contained microorganisms than was the case in the placebo group both just after the incision was made (p less than 0.05) and just before closure of the wound (p less than 0.001). The contaminating bacteria found most frequently were Propionibacterium acnes and Staphylococcus epidermidis. For material collected immediately after the incision, the percentage of cultures positive for S. epidermidis was significantly (p = 0.001) lower in the cloxacillin group than in the placebo group; the percentage of cultures with P. acnes did not differ between the two groups. For samples taken just before the wound was closed, the percentage of cultures with P. acnes or S. epidermidis was significantly (p = 0.008 and 0.003, respectively) lower in the cloxacillin than in the placebo group. In the placebo group neurosurgical infections occurred with P. acnes and/or S. epidermidis as causative microorganisms; in almost all cases those bacteria could be cultured from the edge of the wound. In none of the patients with an infection caused by S. aureus was the bacteria found in the operation area. In 2/6 infections in the cloxacillin group the infecting microorganisms could be cultured from the operation area. These findings support a significant reduction in the infection rate after craniotomy under cloxacillin prophylaxis compared with placebo.

Cloxacillin↗
PubMed1991

One-session operation via bilateral craniotomies for multiple aneurysms after subarachnoid haemorrhage.

One-session bilateral craniotomies for radical clipping of multiple aneurysms have been performed in 14 patients after subarachnoid haemorrhage. Bilateral small or medium sized aneurysms in pre-operatively good-grade Hunt and Hess (HH)I-III) patients (nine cases) were clipped without mortality or morbidity. Four poor-grade patients (HH IV at admission, improving to HH III pre-operatively) were treated, with unfavourable outcome in one patient. Another poor-grade patient (HH IV at surgery) with bilateral large middle cerebral artery aneurysms, a large intracerebral haematoma and a pontine angle meningioma survived with dysphasia and short-memory dysfunction. A slack brain at surgery and a short operation time justify one-session bilateral craniotomies also in the early post-bleeding period.

Adult↗
PubMed1998

RGTA11, a new healing agent, triggers developmental events during healing of craniotomy defects in adult rats.

RGTA are chemically defined compounds which proved to be very potent healing agents in various tissue repair models including skin, muscle and nerve. These chemicals are believed to protect endogenously released heparin-binding growth factors and enhance their bioavailability during healing. In craniotomy defects that do not heal spontaneously in adults, RGTA promoted dose-dependent skull closure. The aim of this work was to characterize, in the same model, the events associated with wound closure by studying the expression of the osteoblastic phenotype and the distribution of some matrix proteins during RGTA11-induced bone healing. Craniotomy defects in rats were implanted with collagen plasters soaked in a solution of RGTA11 (1.5 micrograms per piece). The skulls were removed 30 days after wounding, a stage of almost complete bone filling in treated samples. Bone formed only at the edges of the defect in controls, while it formed also at the center in the form of nodules in the treated samples. RGTA11 modified the amount and distribution of the tissues including bone in the wounds. In some RGTA11-treated samples, skull closure by bone occurred and the median suture was restored. In the treated defects, alkaline phosphatase-positive (osteoprogenitor) cells were far more numerous and were distributed differently. Type I and III collagen and fibronectin deposition was markedly enhanced in the bone compartment of the wounds. Secretory osteoblasts released type III collagen. Osteocalcin expression was enhanced by RGTA11. RGTA11 thus modified the healing pattern by increasing both the cellularity and the synthesis of a bone-competent extracellular matrix, thereby restoring the original anatomy of the skull. Flat bone regeneration can be triggered in adults through developmental events (i.e. nodule formation, secretion of type III collagen by osteoblasts, suture restoration...) that are no longer operative in the wounds of mature individuals.

Alkaline Phosphatase↗
PubMed1980

Evolution of craniotomy as a debridement technique for penetrating craniocerebral injuries.

A craniotomy debridement technique was recommended for penetrating craniocerebral injuries as early as 1940, in World War II. However, with due consideration for the bacterial contamination of penetrating injuries, the safety of this technique was questionable. The technique has been recommended in each succeeding war, but no data substantiating the safety or eventual sequelae have been available. Analysis of the data from the large Head Injury Registry of Vietnam casualties indicates that, in properly selected cases, debridement by craniotomy technique can be safe and efficacious.

Adult↗
PubMed1987

Craniotomy flap osteomyelitis: a diagnostic approach.

Nine cases of suspected craniotomy flap osteomyelitis evaluated by combined bone and gallium scanning are presented. In six cases, the clinical data were inconclusive and evaluation by radionuclide imaging provided an accurate negative diagnosis. The other three cases considered positive by this technique were proven infected at subsequent exploration and flap removal. The use of radionuclide bone and gallium imaging should be considered in cases of possible craniotomy flap osteomyelitis.

Adolescent↗
PubMed1989

Treatment of colloid cysts of the third ventricle by stereotaxic microsurgical laser craniotomy.

The therapeutic strategies employed in the management of anterior third-ventricular mass lesions remain controversial. Resection by conventional craniotomy, whether via a transcallosal or transcortical approach, carries well-known risks and limitations. Alternatively, in this region traditional stereotaxy has been relegated to use with biopsy only or cyst aspiration procedures. Combining aspects of both conventional and stereotaxic techniques has allowed total removal of 12 colloid cysts in six women and six men ranging in age from 25 to 71 years. No mortality and minimal morbidity have been associated with the procedures. There has been no evidence of recurrence in an average follow-up period of 19 months. By coupling the benefits of stereotaxic precision and localization to the microsurgical management of colloid cysts, several rewards have been realized: 1) only a limited cortical dissection is needed; 2) the hazards of callosal or forniceal injury can be avoided; 3) the lesion is easily localized regardless of ventricular size; 4) hemostasis can be readily achieved with bipolar cautery or defocused laser power; and 5) most importantly, a total resection is possible with little risk to the patient. Stereotaxic microsurgical laser craniotomy provides a new option for the management of colloid cysts and other anterior third-ventricular lesions.

Adult↗
PubMed1990

Recurrent hematomas following craniotomy for traumatic intracranial mass.

Of 850 patients who underwent craniotomy for evacuation of a traumatic intracranial mass, 59 (6.9%) developed a second hematoma at the operation site, which required a second operation. Compared to those who did not, patients who developed postcraniotomy hematoma (PCH) had a significantly higher incidence of evidence of alcohol intake and preoperative mannitol administration; a higher percentage had a bad outcome. Coagulopathy was frequent in PCH patients. Although three-quarters of the initial hematomas were intradural, 69% of the PCH's were predominantly extradural. The large potential space underlying a craniotomy bone flap may predispose to development of a PCH. Intracranial pressure (ICP) was monitored in 39 of the 59 PCH patients, which allowed earlier detection of the PCH in 22 (56%). In 17 patients, the ICP failed to rise despite clinical deterioration, and detection of the PCH was delayed, significantly worsening the outcome in this group.

Adult↗
PubMed1993

Subdural empyema: burr holes or craniotomy? A retrospective computerized tomography-era analysis of treatment in 90 cases.

Ninety patients with subdural empyema were treated in the period after computerized tomography (CT) became available (1979 to 1991). Males predominated by a ratio of 2:1, and 40 patients were between 11 and 20 years old. The site of origin was the paranasal air sinuses in 53 patients, the middle ear in 19, and a superficial infection in eight; the source of infection was not known in 10. The most common clinical presentation was headache, fever, neck stiffness, seizures, or periorbital swelling; only seven patients had status epilepticus. While the erythrocyte sedimentation rate and white blood cell count were invariably elevated, the cerebrospinal fluid showed nonspecific pleocytosis in the 60 patients who underwent lumbar puncture. The definitive preoperative diagnosis was made by contrast-enhanced CT in all cases. Surgical treatment was by multiple burr holes in 37 patients, burr holes and small craniectomies in 33, burr holes with catheter drainage in seven, and a large craniotomy in 12. One patient was treated without surgery. The mortality rate was 7.7%, with 86% making a good recovery. These results compare favorably with those reported in other studies using craniotomy alone, and suggest that burr holes should not be disregarded as a method of treating subdural empyema where contrast-enhanced CT facilities are available.

Adolescent↗
PubMed1993

Supraorbital craniotomy by fracture of the anterior orbital roof. Technical note.

The authors describe a new and rapid method to safely perform a supraorbital craniotomy. This technique can be used when tumor does not invade the orbital roof. Previous descriptions of the supraorbital craniotomy involved exposure of the frontal sinus by removing its anterior wall and using the Gigli saw to separate the orbital roof. This new approach avoids removal of the anterior sinus wall and separates the supraorbital bone flap from the calvaria by fracturing the anterior orbital roof forward. In addition, a method for harvesting a laterally based pericranium and muscle pedicle that contains a section of contralateral temporalis muscle is described. This vascularized pedicle can be used for repair of cerebrospinal fluid leaks or bone defects along the anterior fossa floor and orbit.

Craniotomy↗
PubMed1996

Acute pulmonary edema after low-level air embolism during craniotomy. Case report.

Acute pulmonary edema after a large air embolus occurring during neurosurgery is a recognized phenomenon. The authors describe the course of a 76-year-old man who presented with noncardiogenic pulmonary edema shortly after undergoing resection of a high convexity meningioma. Transthoracic Doppler sonography, however, showed no evidence of a large intraoperative emboli; the evidence for ongoing but low-magnitude air embolus included visualization of bone aspiration of irrigant before bone-edge waxing, transient intraoperative declines in end-tidal CO2 tension, and an increase of the fraction of inspired oxygen to maintain adequate saturation after removal of the craniotomy flap. There was no hemodynamic instability noted. The airspace disease was self-limited and resolved on supportive treatment after approximately 1 week, as would be expected for pulmonary edema caused by a single large intravenous air embolus. The authors present this case as the first report of pulmonary edema resulting from low-level air embolus occurring during craniotomy. This situation may go unrecognized intraoperatively but can cause the same significant postoperative morbidity as larger, more easily identified air emboli.

Aged↗
PubMed1998

Efficacy and biocompatibility of a photopolymerized, synthetic, absorbable hydrogel as a dural sealant in a canine craniotomy model.

OBJECT: A canine craniotomy model was used to evaluate the dural sealing efficacy and biocompatibility of a novel, synthetic, bioresorbable hydrogel. METHODS: Bilateral craniotomies were performed in 24 dogs assigned to six survival periods. In each animal a parasagittal durotomy was created and then repaired. At the treatment sites the hydrogel sealant was applied over the dural repair and photopolymerized. The repair was tested for leaks to 20 cm H2O by using a Valsalva maneuver. At the control sites the incisions were sutured and tested for leaks only. After uneventful survival periods, the leak test was repeated in three of the four animals in each group. Bone-dura adhesion was evaluated, after which the dura and underlying brain were removed, fixed, and examined histologically. En bloc histological investigation was performed on a specimen obtained from the fourth animal in each group. Over a 56-day period, 18 treated sites were tested for leaks. A leak was detected at a site remote from that of the repair in one animal; this was excluded from analysis. Thus 17 of 17 treated sites remained free of leaks. On the control side of one animal, there was a leak from a new dural tear at the cranial end of the durotomy, which occurred when the bone flap was removed. This site was also excluded from analysis. Eleven of 17 leak-tested control sites remained free of leaks over the study period. Bone-dura adhesions occurred in 15 of 19 control sites and had a mean adhesion score of 1.37 (range 0-4), whereas adhesions occurred in 10 of 19 treated sites with a mean adhesion score of 0.84 (range 0-3). No cortical reaction was noted. CONCLUSIONS: This novel hydrogel sealant is efficacious in sealing dural repair sites measuring up to 2 mm. Healing of the underlying dura is not compromised and exposed cortical tissue is not altered histologically.

Absorption↗
PubMed1998

Sequential outer table craniotomy a in hyperossified meningioma. Technical note.

A hyperossified meningioma with significant calvarial thickening is fairly common. Craniectomy of the involved region followed by cranioplasty is usually required to resect the bone overgrowth. However, in some cases, the hyperossified calvaria is too thick to allow safe penetration with a craniotome or trephine. In this report, the authors present a technique for preserving the outer calvaria while still resecting the majority of the underlying tumor mass. The key is to perform a craniotomy in a region adjacent to the hyperossified bone and to remove the tumorous, ossified inner table through this "window" by means of a high-speed drill. A second craniotomy can then be performed over the undermined area; this maneuver can be advanced and repeated until the tumor is resected. Frameless stereotactic guidance and microplates are useful in performing this procedure.

Craniotomy↗
PubMed1999

Dural sinus thrombosis and pseudotumor cerebri: unexpected complications of suboccipital craniotomy and translabyrinthine craniectomy.

OBJECT: The goal of this study was to document the hazards associated with pseudotumor cerebri resulting from transverse sinus thrombosis after tumor resection. Dural sinus thrombosis is a rare and potentially serious complication of suboccipital craniotomy and translabyrinthine craniectomy. Pseudotumor cerebri may occur when venous hypertension develops secondary to outflow obstruction. Previous research indicates that occlusion of a single transverse sinus is well tolerated when the contralateral sinus remains patent. METHODS: The authors report the results in five of a total of 107 patients who underwent suboccipital craniotomy or translabyrinthine craniectomy for resection of a tumor. Postoperatively, these patients developed headache, visual obscuration, and florid papilledema as a result of increased intracranial pressure (ICP). In each patient, the transverse sinus on the treated side was thrombosed; patency of the contralateral sinus was confirmed on magnetic resonance (MR) imaging. Four patients required lumboperitoneal or ventriculoperitoneal shunts and one required medical treatment for increased ICP. All five patients regained their baseline neurological function after treatment. Techniques used to avoid thrombosis during surgery are discussed. CONCLUSIONS: First, the status of the transverse and sigmoid sinuses should be documented using MR venography before patients undergo posterior fossa surgery. Second, thrombosis of a transverse or sigmoid sinus may not be tolerated even if the sinus is nondominant; vision-threatening pseudotumor cerebri may result. Third, MR venography is a reliable, noninvasive means of evaluating the venous sinuses. Fourth, if the diagnosis is made shortly after thrombosis, then direct endovascular thrombolysis with urokinase may be a therapeutic option. If the presentation is delayed, then ophthalmological complications of pseudotumor cerebri can be avoided by administration of a combination of acetazolamide, dexamethasone, lumbar puncture, and possibly lumboperitoneal shunt placement.

Acetazolamide↗