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PubMed2003

Mainstream vs. sidestream capnometry for prediction of arterial carbon dioxide tension during supine craniotomy.

We compared the performance of mainstream capnometry as a measure of arterial carbon dioxide tension (Paco2) with sidestream recordings in adult neurosurgical patients undergoing supine craniotomy. Two hundred and forty patients were randomly assigned so that the end-tidal carbon dioxide tension (PEco2) was measured using either a mainstream or sidestream infrared capnometer. All patients received propofol anaesthesia and ventilation was adjusted according to clinical requirement. Arterial blood gas analyses were performed after induction, prior to dural incision, during surgery and before wound closure. Simultaneous haemodynamic and ventilatory parameters were also recorded. For 1007 paired measurements of PEco2 and Paco2 (mainstream, n = 503; sidestream, n = 504), the mean (SD) mainstream arterial to end-tidal carbon dioxide tension difference, 0.64 (0.16) kPa, was smaller than the corresponding sidestream values, 0.99 (0.40) kPa (p < 0.001). The limits of agreement for the mainstream analyser, 0.32-0.96 kPa, were also narrower than the sidestream recordings, 0.19-1.79 kPa (p < 0.001). In both capnometers, the arterial to end-tidal difference in carbon dioxide tension did not change with time. However, there was greater within-patient variation in the sidestream group. Our study showed that mainstream PEco2 provided a more accurate estimation of Paco2 than sidestream measurement.

Adolescent↗
PubMed1997

Anaesthetic management during awake craniotomy in a 12-year-old boy.

We present our approach to the preoperative preparation and anaesthetic management for awake craniotomy in a 12-year-old boy. Management included conscious sedation with a propofol infusion plus local anaesthetic infiltration of the scalp, periosteum, and dura. The complications which may be encountered during such procedures and their treatments are reviewed.

Anesthesia, Local↗
PubMed2001

Posture-related headaches and pachymeningeal enhancement in CSF leaks from craniotomy site.

Cerebrospinal fluid (CSF) leak is recognized to cause headaches that typically but not invariably have orthostatic features (present in upright posture, relieved by recumbency). Head magnetic resonance imaging (MRI) typically shows diffuse pachymeningeal enhancement. A 24-year-old woman, after resection of a right temporoparietal glioma, developed CSF leak from the craniotomy site, resulting in subgaleal fluid collection and associated with diffuse pachymeningeal gadolinium enhancement as well as posture-related headaches. The headaches, however, were present in a recumbent position and relieved after several minutes of being in an upright position. It is postulated that CSF leak took place when the patient was recumbent and ceased when she was upright, a position in which there is decrease in intracranial pressure. After cessation of the leak, along with disappearance of subgaleal collection of CSF, both the headaches and the pachymeningeal enhancement resolved.

Adult↗
PubMed2001

Minimally invasive craniotomy using the Steiner-Lindquist stereotaxic guide.

Thirty-three obscure intracranial lesions were located using the Steiner-Lindquist microsurgical stereotaxic guide and then surgically resected. Seventeen of the lesions were located in the parietal region, six in the frontal region, three in the parietooccipital region, three in the temporoparietal region, one in the thalamic region, one in the centrum semiovale, one in the brainstem, and one in the third ventricle. Twenty-three lesions were in subcortical or cortical locations. In 28 cases, the lesion was totally removed, while in 5 the lesion was subtotally resected. Pathological examinations confirmed glial tumor in eight patients, metastasis in seven, meningioma in two, cavernous angioma in eight, arteriovenous malformation (AVM) in four, hematoma in two, dysembryoblastic neuroepithelial tumor in one, and septum pellucidum cyst in one. Two patients developed transient complications postsurgery. Mean lesion size was 23 +/- 0.97 mm. The hospitalization period ranged from 1 to 6 days (mean 3.4 +/- 1.3 days). Surgeries were performed under general anesthesia, or under local anesthesia with the patient awake. The Steiner-Lindquist microsurgical stereotaxic guide is useful for pinpointing small lesions, especially those in the subcortical and deep areas. Knowing the precise location of the lesion facilitates removal through a small craniotomy incision. This minimally invasive procedure reduces the number of postoperative neurological complications, and also cuts costs by shortening the hospital stay.

Adolescent↗
PubMed1980

[Cranioplasty after extensive decompressive craniotomy with displacement of the cerebral hemisphere. CA analysis (author's transl)].

Cosmetic aspects and protection of the brain from mechanical injuries are the most common indications for the repair of traumatic and operative cranial defects. We suggest two additional indications: Cranioplasty is not only important in the treatment of space-occupying fluid cysts, but also in preventing or overcoming hemisphere collapse with its resultant displacement of the midline structures. This complication was almost exclusively found in patients subjected to extensive lateral craniotomies and also led to psycho-organic syndromes with disturbances of mood and drive. In few cases a crippling hemiparesis and epileptiform fits were also present. The recovery of the patients was almost complete after the repair of the cranial defect. Clinical improvement was due to restitution of physiological intracranial pressure state and re-expansion of the cerebral hemispheres as could be shown by computer tomography. The operative procedure of auto-, homo- and heteroplastic cranioplasty is described, with particular emphasis on the new technique with acrylic plastic, developed by the authors.

Acrylic Resins↗
PubMed1987

[Decompressive craniotomy in severe craniocerebral trauma following unsuccessful treatment with barbiturates].

During the period from September 1983 to October 1984 the intracranial pressure of 51 patients who had suffered cranio-cerebral trauma was continuously recorded. In 21 patients (41%) the intracranial pressure remained within normal limits (10-25 mm Hg) and apart from hyperventilation and corticosteroids no other treatment was required. All these patients recovered satisfactorily. In 28 patients the raised intracranial pressure could not be reduced by means of hyperventilation, corticosteroids and osmotherapy so that barbiturates had to be administered. Seven patients did not respond to this additional treatment and a decompression craniotomy was necessary. The progress, treatment, complications and prognosis of such patients are discussed.

Adolescent↗
PubMed2000

Studies of regional subdural pressure gradients during craniotomy.

We investigated subdural pressure gradients within the operative field of the exposed intact dura in 53 patients with space-occupying lesions during craniotomy. In 37 patients with supratentorial brain tumour paired measurements of subdural pressure were studied in either the same horizontal or vertical plane. In 16 patients with infratentorial brain tumours the influence of a tumour was studied by measuring subdural pressure bilaterally over the right and left cerebellar hemisphere. Significant correlation between the vertical distance and the difference in subdural pressure was found, with the highest pressure in the most downward part of the brain. In patients with tumour in one cerebellar hemisphere, subdural pressure ipsilateral to the tumour was significantly higher than the subdural pressure on the contralateral side. The present study demonstrates subdural pressure gradients within the area of the exposed dura. The subdural pressure was influenced by the underlying tumour and/or gravity. This must be taken into consideration when a dura incision is made.

Adolescent↗
PubMed2006

Craniotomy with prosthetic heart valves: a clinical dilemma.

The authors report two cases of spontaneous intracranial haemorrhage after elective craniotomy for resection of cerebral tumour. Both patients had mechanical aortic valve prostheses and were on regular warfarin therapy. In both cases, warfarin therapy was discontinued 5 days prior to surgery and unfractionated heparin administered intravenously until 12 h before surgery. Both patients were re-anticoagulated with subcutaneous low molecular weight heparin within the first week postcraniotomy-both developed life-threatening intracranial haemorrhage requiring urgent evacuation. The authors emphasize the risk of re-anticoagulation without postoperative imaging and the disadvantages of therapeutic dose, low molecular weight heparin in the postoperative period.

Anticoagulants↗
PubMed1996

"Subdural' pressure measurement during craniotomy. Correlation with tactile estimation of dural tension and brain herniation after opening of dura.

In 30 patients subjected to craniotomy, subdural pressure was measured with a 22G/0.8 mm Venflon cannula connected to a pressure transducer system. The measurements were performed after removal of the bone flap and just before opening of the dura. The subdural pressure was correlated with the tactile estimation of dural tension and the tendency to brain herniation after opening the dura. The results indicate that generally there is a poor agreement between the tactile feeling of dural tension and subdural pressure. Thus, in some patients with a relatively high dural pressure the dural tension was evaluated as relaxed. At subdural pressure below 6 mmHg brain herniation never occurred. On the other hand, at tensions over 7 mmHg some brain herniation occurred in all patients, and at tension over 11 mmHg pronounced brain herniation occurred. The method of subdural pressure used in this study is simple, the duration of the measurement is less than 1 min. It is concluded that measurement of subdural pressure before opening of the dura gives important information.

Adult↗
PubMed1998

Multiple postoperative intracerebral haematomas remote from the site of craniotomy.

A postoperative haemorrhage is a common and serious complication of a neurosurgical procedure. It usually occurs at the site of the surgery, but on occasion a postoperative haematoma is found at a distance from the previous craniotomy. Multiple postoperative haemorrhages are extremely rare. We report the case of a 63-year-old woman, operated on for the removal of a supratentorial astrocytoma, who developed in the early post-operative period multiple bilateral intracerebral haematomas without involvement of the surgical bed.

Astrocytoma↗
PubMed1999

Subdural haematomas in the elderly: experience with treatment by trephine craniotomy and not closing the dura or replacing the bone plate.

A surgical technique was devised to treat chronic subdural haematomas (SDH) in elderly patients. Initial good results encouraged the author to use this technique in elderly patients with acute SDH. This small group is also reported. The goal was to do definitive, not expectant or incremental surgery on these fragile patients who have a high incidence of co-morbid conditions and cerebral atrophy, and to obliterate the subdural space by allowing the skin to sink into the cranial defect. The surgical technique consists of trephine craniotomy and not closing the dura or replacing the bone plate. Experience with six elderly patients with acute SDH and 23 patients with chronic SDH is reported. Of six patients with acute SDH, mean age 80 years, 2 months, three died, all with a Glasgow Coma Score (GCS) less than 9. Three recovered to preoperative status, one with initial GCS of 7 and the other of 8. Of 23 patients with chronic SDH, mean age 77 years, 21 recovered to preoperative status. The two deaths were in patients with GSC of 5 and 7. There were no recurrent SDH or postoperative surgical or cosmetic complications. All patients were followed for at least 6 months. These excellent results suggest that the procedure could be considered as a first procedure in the elderly patient. At first glance, the operation appears to be overly aggressive, but it is an example of 'aggressive-conservative' treatment which produces good long-term results with few complications and no need for second operations.

Acute Disease↗
PubMed1991

Effects of flumazenil on cerebral blood flow and oxygen consumption after midazolam anaesthesia for craniotomy.

Cerebral blood flow (CBF) and cerebral metabolic rate for oxygen (CMRO2) were measured by a modification of the Kety-Schmidt technique using i.v. xenon-133 in 20 patients undergoing craniotomy for supratentorial cerebral tumours. Anaesthesia was induced and maintained with midazolam, fentanyl and nitrous oxide. Pancuronium was given for neuromuscular block. The lungs were ventilated to normocapnia. The first flow measurements were performed approximately 1 h after induction of anaesthesia. At the end of operation the patients were allocated to two groups. Ten patients were given flumazenil 0.01 mg kg-1 and 5 min later the second flow measurement was performed. In the other 10 patients the second flow measurement was performed before the administration of flumazenil. Plasma concentrations of midazolam were measured at the time of each measurement of CBF. There was no difference between the groups in plasma concentration of midazolam, CBF or CMRO2. Flumazenil had no effect on CBF and CMRO2.

Adult↗
PubMed1995

Ketamine does not increase cerebral blood flow velocity or intracranial pressure during isoflurane/nitrous oxide anesthesia in patients undergoing craniotomy.

Ketamine's effect on cerebral hemodynamics is controversial. We hypothesized that ketamine would not increase intracranial pressure (ICP) and cerebral blood flow (CBF) velocity in anesthetized, ventilated patients. Twenty patients requiring craniotomy for brain tumor or cerebral aneurysm were studied. After induction with thiopental, anesthesia was maintained with isoflurane and nitrous oxide in oxygen. During controlled ventilation (PaCO2 34 +/- 1 mm Hg); middle cerebral artery blood flow velocity (VMCA), mean arterial blood pressure (MAP), bilateral frontooccipital processed electroencephalogram (EEG), and ICP were measured before and for 10 min after intravenous ketamine 1.0 mg/kg. Cerebral arteriovenous oxygen content difference (AVDO2) and cerebral perfusion pressure (CPP) were calculated. After ketamine, MAP, CPP, PaCO2, and AVDO2 were unchanged. ICP decreased from 16 +/- 1 mm Hg to 14 +/- 1 mm Hg (mean +/- SE; P < 0.001) and VMCA decreased from 44 +/- 4 cm/s to 39 +/- 4 cm/s (P < 0.001). Total EEG power decreased (P < 0.02). These results suggest that ketamine can be used in anesthetized, mechanically ventilated patients with mildly increased ICP without adversely altering cerebral hemodynamics.

Anesthesia, Inhalation↗
PubMed1996

Effects of ondansetron on emesis in the first 24 hours after craniotomy in children.

Children undergoing neurosurgical resection are at high risk for postoperative nausea and vomiting. Ondansetron, a selective serotonergic (5-HT3) antagonist, is effective in reducing postoperative vomiting in several high-risk populations. In a prospective, randomized study, we compared the prophylactic use of intravenous ondansetron, 0.15 mg/kg, versus placebo for the prevention of emesis in 60 children, aged 2-18 yr, undergoing craniotomies for resective procedures. Patients with preoperative emesis were excluded from the study. All patients were tracheally extubated at the conclusion of surgery, and each episode of emesis during the first 24 postoperative hours was recorded. For the entire 24-h interval, the incidence of emesis in children who received ondansetron (57%) was not significantly different from that in those who received placebo (66%); however, in the first 8 h, the incidence was 25% (ondansetron) vs 44% (placebo) (P = not significant). In those receiving placebo, there was no difference in emesis between patients undergoing operations above versus below the tentorium. Although our sample size was too small to completely exclude any beneficial effect, ondansetron appears ineffective in preventing postoperative emesis in this patient population.

Adolescent↗
PubMed1996

Intracranial pressure and hemodynamic effects of remifentanil versus alfentanil in patients undergoing supratentorial craniotomy.

Remifentanil hydrochloride is an ultra-short-acting esterase metabolized mu-opioid receptor agonist. The purpose of this study was to provide preliminary information regarding the effects of this drug on intracranial pressure (ICP) and mean arterial pressure (MAP) in patients scheduled for craniotomy. Twenty-six patients undergoing excision of supratentorial space-occupying lesions were anesthetized with 0.3-0.8 vol% isoflurane in a 2:1 mixture of nitrous oxide:oxygen. Ventilation was adjusted to provide a Paco2 of < 30 mm Hg. After the first burr hole was drilled, patients (n = 5-6 per group) were administered an intravenous infusion of study drug (placebo, remifentanil 0.5 micrograms/kg or 1.0 micrograms/kg, or alfentanil 10 micrograms/kg or 20 micrograms/kg) over 1 min. Epidural ICP and MAP values were recorded at baseline, at completion of infusion, and every minute for the next 10 min. Blood study drug concentrations were measured immediately after completion of infusion. Neither opioid caused a significant increase in ICP. Both drugs were associated with a dose-dependent decrease in MAP. Remifentanil was 31 times more potent than alfentanil for effects on MAP. We conclude that remifentanil produces similar cerebral perfusion pressure effects as does alfentanil.

Adult↗
PubMed1997

Propofol sedation during awake craniotomy for seizures: electrocorticographic and epileptogenic effects.

This prospective study evaluated the effects of propofol sedation on the incidence of intraoperative seizures and the adequacy of electrocorticographic (ECoG) recordings during awake craniotomy performed for the management of refractory epilepsy. Thirty patients scheduled for temporal or frontal lobectomy for epilepsy under bupivacaine scalp block were randomized to receive patient-controlled propofol sedation (PCS) combined with a basal infusion of propofol (n = 15) or neurolept analgesia using an initial bolus dose of fentanyl (0.7 microg/kg) and droperidol (0.04 mg/kg) followed by a fentanyl infusion (n = 15). Propofol administration was suspended 15 min before ECoG recording in the PCS group. The occurrence of inappropriate intraoperative seizures was noted and, based on blind review, the adequacy of ECoG recordings was compared. A higher incidence of intraoperative seizures was noted among the neurolept patients (6 vs 0, P = 0.008). Intraoperatively, ECoG recordings were adequate to proceed with resection in both groups. Evidence of low spike activity on ECoG did not correlate with the type of sedation administered. Higher frequency background ECoG activity was noted among patients who received propofol, but this did not interfere with ECoG interpretation. The use of propofol sedation does not appear to interfere with ECoG during epilepsy surgery, provided administration is suspended at least 15 min before recording.

Adjuvants, Anesthesia↗