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PubMed1987

Cerebellar haemorrhage as a complication after supratentorial craniotomy.

Four cases are presented, in whom cerebellar haemorrhages appeared as a complication following supratentorial craniotomy for a giant aneurysm, for tumours in three cases. Two patients died. Intracranial hypotension in combination with disturbed blood coagulation is discussed as possible pathogenesis. Because this seems to be a rare complication--similar cases have not yet been described in the literature--its timely diagnosis may be missed.

Adult↗
PubMed1993

Thallium-201 technetium-99m HMPAO single-photon emission computed tomography (SPECT) imaging for guiding stereotactic craniotomies in heavily irradiated malignant glioma patients.

SPECT scanning with Tl-201 and Tc-99m offers a unique, inexpensive functional imaging modality to combine with CT stereotactic craniotomy for guiding resection of necrosis and/or tumour in patients treated with escalated doses of radiation (> 6000 cGy) by either brachytherapy or radiosurgery. Thirty-two cases were analyzed, with a detailed description of the imaging and operative techniques.

Astrocytoma↗
PubMed1980

Blood pressure response to administration of local anaesthetics with noradrenaline in craniotomies.

Infiltration with local anaesthetics with addition of adrenaline or noradrenaline has been used since 1910 prior to skin incision for craniotomy. In a controlled series of patients scheduled for intracranial operations, systemic blood pressure was measured intra-arterially after infiltration with 15-20 ml 0.5% lignocaine with nonradrenaline 1 mu gr/ml. A marked increase in systemic blood pressure was seen (125% of values prior to infiltration). In a control series, where saline was injected, a slight fall in blood pressure was registered (p smaller than 0.01). As hypertensive episodes increase intracranial pressure in patients with impaired cerebral autoregulation, or promote the risk of haemorrhage in aneurysm surgery, this technique is considered a hazard to patients undergoing intracranial operations.

Adult↗
PubMed1987

Phenytoin plasma levels after intraoperative administration, for the prevention of post-craniotomy seizures.

Since in a previous study (preliminary report) (18) the iv. administration of 15 mg X kg-1 of phenytoin (PNT) over 30 min in men produced toxic levels (25 micrograms/ml), a smaller iv. dose of 7 mg X kg-1 was given during anaesthesia to 80 patients under going craniotomy, for the prevention of post-operative seizures. Plasma PNT concentrations were studied in 22 patients before its iv. infusion 20 min, 40 min, and 1, 2, 3, 5, 8 and 12 hours later. Mean serum phenytoin levels were 9.3, 31.9, 27.8, 25.5, 19.4, 17.2, 15.4 and 19.2 micrograms/ml respectively. In this study it appeared that although the initial dose was 50% smaller than before, toxic levels were still encountered one hour after PNT administration (therapeutic range 10-25 micrograms/ml). Bearing in mind that in both our studies PNT appeared to have approximately the same efficacy in seizure prevention (from 95-97%), we suggest, that 7-10 mg X kg-1 would be adequate if administered as an intraoperative iv. infusion over an hour and that whenever possible serial serum levels should be monitored.

Adolescent↗
PubMed1990

Anticonvulsant therapy increases fentanyl requirements during anaesthesia for craniotomy.

This study was designed to determine whether patients receiving chronic anticonvulsant therapy demonstrate an altered requirement for fentanyl during anaesthesia. Sixty-one patients undergoing craniotomy were studied; 20 controls (MED = 0) who had never received anticonvulsants and 41 epileptics in whom therapeutic plasma concentrations of either one (MED = 1), two (MED = 2), or three (MED = 3) different anticonvulsants were documented. During anaesthesia with 60-70 per cent N2O in O2 and 0.2 per cent isoflurane, a maintenance dose (MD) of fentanyl was administered using a continuous variable-rate IV fentanyl infusion, supplemented by intermittent 50 micrograms IV boluses. In order to define the minimal dosage of fentanyl required, the MD was titrated according to increases or decreases in the heart rate and/or mean arterial pressure exceeding 15 per cent of baseline ward values. A progressively higher fentanyl MD was required in the epileptic patients (MED = 1-4.3 +/- 0.5 microgram.kg-1.hr-1; MED = 2-5.4 +/- 0.6; MED = 3-7.6 +/- 0.6) compared with the control MD (MED = 0-2.6 +/- 0.5) (P less than 0.001). These findings indicate that there appears to be a dose-effect relationship between the number of anticonvulsants received and the maintenance dose of fentanyl required during balanced anaesthesia.

Adolescent↗
PubMed1990

Preoperative beta-blockade for patients undergoing craniotomy: a comparison between propranolol and atenolol.

This study was undertaken to establish if beta-blocking drugs given orally before surgery could reduce the pressor responses to laryngeal instrumentation and tracheal intubation in neurosurgical patients. Forty-two neurosurgical patients undergoing craniotomy were randomized into three groups. Groups 1 and 2 received atenolol (100 mg) and propranolol (80 mg) respectively. Group 3 were controls and given no beta-blockers. A standard anaesthetic technique was used and blood pressure and heart rate were measured continuously from induction of anaesthesia until five minutes after tracheal intubation. There were increases in both heart rate and systolic blood pressure in all three groups but the rises in the treated groups were significantly less than in the control group (P less than 0.01). There were no significant differences in the haemodynamic responses between the propranolol and atenolol treated patients.

Adolescent↗
PubMed2001

Anesthesia for Cesarean section and posterior fossa craniotomy in a patient with von Hippel-Lindau disease.

PURPOSE: To describe the care of a pregnant woman with von Hippel-Lindau disease (VHLD) and intracranial mass lesions. CLINICAL FEATURES: A 30-yr-old primigravida with VHLD at 35 weeks gestation was seen at the obstetric anesthesia clinic because she wished an epidural analgesia during labour. She had a history of headaches and dizziness. Further investigations showed an enlarged cerebellar hemangioblastoma with significant local mass effects. A combined Cesarean section delivery and posterior fossa craniotomy was performed at 37 weeks gestation. A general anesthetic with fentanyl, rocuronium, nitrous oxide, oxygen and isoflurane was given for Cesarean section delivery. After delivery, isoflurane was reduced and propofol infusion at 4-8 mg x kg(-1) x hr(-1) was initiated. The patient had an uneventful operative course and recovery. CONCLUSIONS: Patients with VHLD may have worsening of preexisting lesions or develop other lesions during pregnancy. Some asymptomatic lesions can increase the risk for anesthesia complications. These patients need comprehensive assessment before administration of anesthesia.

Adult↗
PubMed2006

["Asleep-awake-asleep"-anaesthetic technique for awake craniotomy].

Awake craniotomy in tumor and epilepsy surgery or for the implantation of electrodes for deep brain stimulation requires specific anesthesiological strategies. Propofol allows for quick emergence and has little effect on the respiratory function of the usually spontaneously breathing patient. Pain control may be instituted by hemiscalp block for trepanation or local infiltration for deep brain electrode implantation. In addition, low dose remifentanil is recommended for trepanation (i.e. tumor or epilepsy surgery). The airway may be secured by an ordinary Magill tube placed transnasally with its tip underneath the epiglottis. To protect the patient against vomiting an adequate antiemetic prophylaxis is required.

Anesthesia↗
PubMed1998

Computer simulation of a neurosurgical operation: craniotomy for hypothalamic hamartoma.

Although magnetic resonance imaging has revolutionised the management of intracranial lesions with improved visualisation of anatomical structures, it only produces two-dimensional images, from which the clinician has to extrapolate a three-dimensional interpretation. Several approaches can be used to create 3D images; the discipline of image segmentation has encompassed a number of these techniques. Such techniques allow the clinician to delineate areas of interest. The resulting computer-generated outlines can be reconstructed in a three-dimensional arrangement. Although a plethora of "generic" segmentation techniques exist, we have developed a refined form, dependent on general and particular properties of the anatomical structures under investigation. High-contrast structures such as the ventricles and external surface of the head are found by using a localised adaptive thresholding technique. Less definable structures, with poor or nonexistent signal change across neighbouring structures, such as brain stem or pituitary, are found by applying an "energy minimisation"-based technique. To demonstrate the techniques we used the example of an 8-year-old boy with uncontrolled gelastic seizures due to a hypothalamic hamartoma, who is being considered for surgery. We were able to demonstrate the anatomical relationships between the hypothalamic hamartoma and adjacent structures such as optic chiasm, brain stem and ventricular system. We were subsequently able to create a video, reproducing the stages of craniotomy for excision of this tumour. By creating true 3D objects, we were able at any stage of the simulation to visualise structures situated contralaterally to the approaching surgical dissector. These 3D representations of the structures can be either invisible or opaque, in order to afford 3D localisation as the "virtual" surgical dissection proceeds. The clinical application of such techniques will enable surgeons to improve their understanding of anatomical relations of intracranial lesions and has obvious implications in image-guided surgery.

Child↗
PubMed2002

The effects of 10 degrees reverse trendelenburg position on ICP and CPP in prone positioned patients subjected to craniotomy for occipital or cerebellar tumours.

BACKGROUND: Control of ICP-hypertension is of utmost importance during craniotomy. The effects of reverse Trendelenburg position (RTP) upon ICP and CPP have recently been studied in supine positioned patients. METHOD: In this study we investigated changes in intracranial pressure (ICP), mean arterial blood pressure (MABP), CPP and jugular bulb pressure (JBP) before and one minute after 10( degrees ) RTP in 26 prone positioned patients with either occipital (n=12) or cerebellar tumours (n=14). ICP was measured by a subdural approach after removal of the bone flap. Tension of the dura was estimated by the surgeons by digital palpation before and after change in position. FINDINGS: In patients with occipital tumours ICP decreased from 21.0 to 15.6 mm Hg (p<0.05). MABP decreased from 87.9 to 83.3 mm Hg (p<0.05), JBP decreased from 14.3 to 7.7 mm Hg (P<0.05), while CPP was unchanged. In patients with cerebellar tumours ICP decreased from 18.3 to 14.2 mm Hg (p<0.05). MABP decreased from 93,8 to 90.5 mm Hg (p<0.05), JBP decreased from 12.1 to 5.0 mm Hg (P<0.05), while CPP was unchanged. There were no significant differences between the two groups with regard to changes in ICP, MABP, CPP and JBP. The change in ICP was accompanied by a significant decrease in dural tension (p<0.05). INTERPRETATION: In prone positioned patients 10 degrees RTP significantly reduces ICP, JPB and MABP within one minute, while CPP is unchanged.

Adult↗
PubMed1989

Mechanical prophylaxis of venous thrombosis in patients undergoing craniotomy: a randomized trial.

A randomized, prospective clinical trial of 70 patients undergoing craniotomy was performed to compare and evaluate two forms of mechanical prophylaxis of deep vein thrombosis. Thirty-eight patients received antiembolism stockings, whereas 32 patients received external pneumatic compression. Prophylaxis was begun preoperatively and continued intraoperatively and post-operatively until the patients were ambulatory. Impedance plethysmography was used to detect deep vein thrombosis both preoperatively and postoperatively. Two patients, one from each group, developed thromboembolic complications postoperatively. Impedance plethysmography showed false-positive findings in two additional patients. There were no deaths. The data suggest that either form of mechanical prophylaxis is effective against the development of deep vein thrombosis in this high-risk patient population.

Clinical Trials as Topic↗
PubMed1993

Cerebellar hemorrhage complicating supratentorial craniotomy: report of two cases.

One of the rare complications of supratentorial craniotomy is the occurrence of a hematoma in the cerebellum. Only seven previous cases have been published, and these have been ascribed to disturbed blood coagulation or decreased intracranial pressure. We present two similar patients, in whom, however, the pathogenetic role of these factors seems improbable.

Cerebellar Diseases↗
PubMed1996

Cosmetic reconstruction of temporal defect following pterional [corrected] craniotomy.

BACKGROUND: Depression of the temporal fossa that is often caused by atrophy of the temporalis muscle or superficial temporal fat pad may be an unavoidable defect following pterional craniotomy. Various techniques have been previously described to correct this disfiguring defect. Most techniques, however, require drilling holes into the cranium or the synthetic grafts for attachment of the temporalis muscle. METHODS: A simple method is described by which a temporal fossa depression is repaired with methylmethacrylate bone cement and a new superior temporal line is created for attachment of the temporalis muscle without the need to drill suture holes into the acrylic or the cranium. RESULTS AND CONCLUSIONS: The technique described has been used on several patients with excellent cosmetic outcome.

Craniotomy↗
PubMedDate not supplied

Monitoring therapeutic efficacy of decompressive craniotomy in space occupying cerebellar infarcts using brain-stem auditory evoked potentials.

Brain-stem auditory evoked potentials (BAEPs) have been used to gauge effects of brain-stem dysfunction in humans and animal models. The purpose of this study was to evaluate the usefulness of BAEP in monitoring patients undergoing decompressive surgery of the posterior fossa for space occupying cerebellar infarcts. We report on serial BAEP recordings in 11 comatose patients with space occupying cerebellar infarcts undergoing decompressive craniotomy. BAEP studies were performed within 12 h after admission, 24 h following surgery and prior to extubation. BAEP signals were analyzed using latency determination and cross-correlation. Following surgery, 9 patients regained consciousness; 2 patients persisted in a comatose state and died subsequently. BAEP interpeak latency (IPL) I-V assessed prior to surgery exceeded normal values in all patients in whom it could be reliably measured (N = 9). Following decompressive surgery BAEP wave I-V IPL normalized in 5 patients, but remained prolonged despite dramatic clinical improvement in 4 patients. We prospectively computed the coefficient of cross-correlation (MCC) of combined ipsilateral BAEP trials after right and left ear stimulation. In all patients increasing MCC was associated with clinical improvement. Unchanging or decreasing MCC indicated poor outcome. We conclude that serial BAEP studies are an appropriate perioperative monitoring modality in patients with space occupying cerebellar infarcts undergoing decompressive surgery of the posterior fossa. Our study suggests advantages of cross-correlation analysis as an objective signal processing strategy; relevant information can be extracted even if BAEP wave discrimination is impossible due to severe brain-stem dysfunction.

Acoustic Stimulation↗
PubMedDate not supplied

Anesthesia for craniotomy: total intravenous anesthesia with propofol and alfentanil compared to anesthesia with thiopental sodium, isoflurane, fentanyl, and nitrous oxide.

STUDY OBJECTIVE: To compare a total intravenous (IV) anesthetic technique based on propofol and alfentanil with a commonly used anesthetic technique for craniotomy. DESIGN: Open-label, randomized, clinical study. SETTING: Neurosurgical clinic at a university hospital. PATIENTS: Forty patients, aged 18 to 55 years, scheduled for brain tumor surgery. INTERVENTIONS: In 20 patients, anesthesia was induced with fentanyl and thiopental sodium and maintained with fentanyl, dehydrobenzperidol, isoflurane, nitrous oxide (N2O), and a thiopental sodium infusion. Twenty patients were anesthetized with a propofol loading infusion followed by a maintenance infusion at a fixed rate. In addition, alfentanil was administered as a loading bolus, followed by a variable-rate infusion, with additional doses as necessary to maintain hemodynamic stability. MEASUREMENTS AND MAIN RESULTS: A decrease in blood pressure (BP) after induction with thiopental sodium was followed by a significant increase in BP and heart rate (HR) during intubation. BP and HR did not change during the propofol loading infusion. However, the administration of alfentanil was followed by a similar decrease in BP with a return to baseline values during the intubation period. Return of normal orientation (7 +/- 5 minutes vs 27 +/- 23 minutes) and concentration (12 +/- 12 minutes vs 35 +/- 37 minutes) was shorter and more predictable for the propofol-alfentanil-treated patients than for the thiopental sodium patients. Maintenance propofol concentration (nine patients) was between 3 +/- 0.69 micrograms/ml and 3.36 +/- 1.17 micrograms/ml, while the concentration at awakening was 1.09 microgram/ml. Alfentanil concentration at extubation (nine patients) was 79 +/- 34 ng/ml. CONCLUSION: A total IV anesthetic technique with propofol and alfentanil is a valuable alternative to a more commonly used technique based on thiopental sodium, N2O, fentanyl, and isoflurane.

Adult↗