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Hyponatremia following craniotomy.
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Cryohypophysectomy and transfrontosphenoidal craniotomy in pituitary tumors.
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Direct extracranial spread of a brain metastasis through a craniotomy defect.
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Multinucleated giant cells elicited around hydroxyapatite particles implanted in craniotomy defects are not osteoclasts.
BACKGROUND: The nature of the multinucleated giant cells (MNGC) elicited in contact with implantable biomaterials is still indecisive. METHOD: In Wistar rats the MNGC recruited after the implantation of hydroxyapatite (HA) particles in standardized skull defects were examined morphologically (at both the light and electron microscope levels), enzymatically (tartrate-resistant acid phosphatase and non-specific esterase), and after a challenge with salmon calcitonin. RESULTS: The MNGC were of great size and contained abundant mitochondria, vacuoles, and vesicles throughout the cytoplasm; they were either tightly apposed to the HA surface or had long and thin processes penetrating the material. When processed for tartrate-resistant acid phosphatase, only a few cells were weakly stained. The staining was totally suppressed when samples were pretreated with cyanuric chloride in the MNGC but not in the host osteoclasts. Calcitonin induced the withdrawal of the host osteoclasts from the bone surface while the MNGC remained in contact with the HA material. CONCLUSION: The MNGC recruited to HA particles did not exhibit the morphologic, enzymatic and functional characteristics of the osteoclasts, and consequently must be regarded as macrophage polykaryons.
Craniotomy for the resection of metastatic brain tumors in the U.S., 1988-2000: decreasing mortality and the effect of provider caseload.
BACKGROUND: To assist in selecting treatment for patients with brain metastases, the current study assessed the risk of adverse outcomes after contemporary resection of metastatic brain tumors in relation to patient, surgeon, and hospital characteristics, with particular attention to the volume of care and trends in outcomes. METHODS: A retrospective cohort study of 13,685 admissions from the Nationwide Inpatient Sample between 1988-2000 was performed. Multivariate logistic, ordinal, and loglinear regression were used with endpoints of mortality, discharge disposition, length of stay, and total hospital charges. RESULTS: The overall in-hospital mortality rate was 3.1% and an additional 16.7% of patients were not discharged directly home. In multivariate analyses, larger-volume centers were found to have lower mortality rates for intracranial metastasis resection (odds ratio [OR], 0.79; 95% confidence interval [95% CI], 0.59-1.03 [P = 0.09]). An adverse discharge disposition also was less likely at higher-volume hospitals (OR, 0.75; 95% CI, 0.65-0.86 [P < 0.001]). For surgeon caseload, mortality was lower with higher-caseload providers (OR, 0.49; 95% CI, 0.30-0.80 [P = 0.004]) and an adverse discharge disposition occurred significantly less frequently (OR, 0.51; 95% CI, 0.40-0.64 [P < 0.001]). The annual number of resections increased by 79% during the study period, from 3900 (1988) to 7000 (2000). In-hospital mortality rates decreased from 4.6% (1988-1990) to 2.3% (1997-2000), a 49% relative decrease. Length of stay was reported to be significantly shorter with higher-volume providers. Hospital charges were not found to be associated significantly with hospital caseload and were found to be significantly lower after surgery that was performed by higher-caseload surgeons. CONCLUSIONS: The results of the current study found that higher-volume hospitals and surgeons provided superior short-term outcomes after resection of intracranial metastasis was performed, with shorter lengths of stay and a trend toward lower charges.
Recombinant human bone morphogenetic protein-2 is superior to demineralized bone matrix in repairing craniotomy defects in rats.
The purpose of this study was to measure bone-regenerative effects of recombinant human bone morphogenetic protein-2 (rhBMP-2) in rat calvarial critical-size defects (CSDs). CSDs (8 mm in diameter) were treated with either 1) 2.2 micrograms rhBMP-2 combined with insoluble collagenous bone matrix (ICBM), 2) 6.5 micrograms rhBMP-2 plus ICBM, 3) ICBM alone, or 4) demineralized bone matrix (DBM), for 7, 14, or 21 days. Multiple linear regression showed that rhBMP-2 had a significant time- and dose-dependent effect on bone regeneration (P < .05). After 7 days, new calcifying cartilage and remineralizing ICBM, with an occasional zone of new woven bone, was evident in defects treated with rhBMP-2/ICBM. By 14 days, both doses of rhBMP-2 reconstituted with ICBM had induced more bone formation than ICBM alone or DBM, and 6.5 micrograms was superior to 2.2 micrograms. There was no evidence of adverse cellular response. This study shows for the first time that rhBMP-2 could restore osseous form to a calvarial defect. In addition, osteoregeneration was accelerated by the higher dose of rhBMP-2.
Stereotactic open craniotomy and laser resection of brain tumours. A five years experience.
In 23 cases of deep-seated brain tumours stereotactically guided laser vaporization has been done, using a 60 watts CO2 laser. The experiences and results of the 18 first cases with a follow-up of 10 months to 5 years are presented. The technique is described.
Abnormalities of water metabolism in children and adolescents following craniotomy for a brain tumor.
We conducted a retrospective analysis of the cases of 122 children operated on for various brain tumors, to determine the incidence and natural history of postoperative diabetes insipidus (DI), and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Abnormalities of water homeostasis were observed in 15 patients (12%). DI, with or without SIADH, was observed in 10 patients (8%), while SIADH alone was seen in five (4%). DI was permanent in five subjects (50%), whereas SIADH resolved completely in all affected individuals. Parenteral desmopressin (dDAVP) was an effective mode of therapy in the postoperative period. The effect did not correlate with a dosage strictly based on body weight.
Spread of blood in cerebrospinal fluid following craniotomy simulates spinal metastases.
Postoperative myelography with water-soluble contrast media was performed in 36 children with a diagnosis of posterior cranial fossa tumour. The myelograms were normal in 15. In 5 an intramedullary tumour was present and 3 of these had in addition subarachnoid changes as evidence of tumour spread. The remaining 16 patient had subarachnoid changes of a different character, mainly located in the posterior thoracic region and similar to those seen after subarachnoid haemorrhage. It is suggested that they represent adhesions caused by blood from the operation. The blood is assumed to be distributed by the large cerebrospinal fluid pulsations to the cervical and thoracic regions. It is important to recognise and differentiate subarachnoid changes due to tumour and to postoperative adhesions to avoid unnecessary radiotherapy to the spinal cord.
Biparieto-occipital craniotomy with hyperextended neck--"sea lion" position.
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Renal tubular sodium and water metabolism in brain tumour patients submitted to craniotomy.
PURPOSE: To evaluate the effect of Brain Tomour (BT) and Neurosurgery (NS) on the renal handling of H2O and Na, and the clinical importance of SIADH in this setting. METHODS: Fourteen patients with BT pre-op for NS and 6 controls (C) pre-op for general surgery, were assessed in a controlled prospective trial. All patients were normovolaemic, with normal renal function. They received 400 mg of lithium carbonate (Li) 8 hours before each of two test periods (I and II) and a standard water load only before period II. Clearances studies were performed pre-op (period I) and 24 hours post-op (period II). RESULTS: Serum Na was normal at all times. Despite normovolaemia, a 1% decrement in serum osmolality and the water load, ADH dramaticaly increased from time I to II mainly in the BT group (36.2 +/- 9.4 vs 7.1 +/- 0.6 pmol/L, p = 0.02). FENa, FELi and FEUricA were significantly more elevated in the BT group pre and post-op (at time II respectively 4.6 +/- 1.6 vs 1.1 +/- 0.3%; 29.3 +/- 4.9 vs 22.6 +/- 5.5; 26.0 +/- 8.1 vs 11.3 +/- 2.2, p = 0.03). Proximal and distal H2O re-absorption and distal fractional Na re-absorption were identical in both groups pre and post-operatively. CONCLUSIONS: 1-BT and NS always induce a SIADH. 2-There was a primary Na loss at the proximal tubule level not explained by ADH increment, that did not significantly changed H2O handling. 3-To prevent hyponatraemia, hypotonic I.V. fluids should be avoided, but more importantly saline must be provided to this potentially salt-wasting condition.
Incidence of wound infection in patients undergoing craniotomy: influence of type of shaving.
How the method of shaving affects the incidence of deep postoperative wound infections was examined in 475 patients. It is shown that the rate of infection is not lower after wet shaving than after dry shaving. The overall infection rate was 4.2%, 2.9% in patients who had been shaved wet versus 5.5% in patients shaved dry. The difference is, however, not significant on the 5% level. With respect to dry shaving, the infection rate was not affected by whether the hair was removed with electric clippers alone (2.8%) or whether a disposable razor was also used for additional hair removal in the area of skin incision (3.2%).
Precision resection of intra-axial CNS lesions by CT-based stereotactic craniotomy and computer monitored CO2 laser.
This report describes an open stereotactic technique by which a tumour volume reconstructed in stereotactic space from CT data is removed by stereotactic CO2 laser vaporization. The position of the laser beam in relation to the tumour outlines is monitored by computer and displayed to the surgeon on a graphics display terminal in the operating room. Twenty-six (26) of these procedures have been performed on twenty-four (24) patients with deep-seated intra-axial neoplasms (23) and arteriovenous malformation (1). Post-operative CT scanning revealed no evidence of contrast enhancing lesions in nineteen (19) patients while a small amount of residual tumour was noted in five (5) patients post-operatively. This method has proven itself valuable for maintaining three-dimensional surgical orientation for the resection of intra-axial neoplasms from neurologically important areas.
[Resection of thickened cranial periosteum, craniotomy of the posterior tract of the skull cap & combination of both procedures as new surgical technics in craniostenoses].
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[New bone formation in the area of the posterior cranial fossa after suboccipital craniotomy].
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Stereotactically-guided craniotomy for cavernous angiomas presenting wit epilepsy.
With the wider availability of magnetic resonance imaging cavernous malformations are being recognised with increasing frequency in those patients presenting with intractable epilepsy. Surgical resection is the treatment of choice. However, because these lesions are usually small and may be located in eloquent areas stereotactic resection should be considered. Stereotactically-guided resection of pathologically verified cavernous angiograms was performed in 10 patients in this series presenting with epilepsy (8 males, 2 females, mean age 32 years). Eight patients presented with medically intractable epilepsy (5 complex partial seizures, 3 grand mal seizures). Of the remaining patients one experienced multiple episodes of haemorrhage and the other headaches (with a non-diagnostic scan) both in association with epilepsy. Pre-operative localisation of the motor strip was determined in one case by functional MRI. Following resection of these lesions all patients experienced improved seizure control with a mean follow-up period of 22 months. The mean postoperative hospital stay was 5.1 days with no surgical complications recorded. We conclude that stereotactically-guided resection offers significant advantages in the management of cavernous malformations. Surgical indications for operative resection would include medically refractory epilepsy, repeated haemorrhage and those cases where there is diagnostic uncertainty.
Ankylosis of the temporo-mandibular joint after temporal craniotomy: a cause of difficult intubation.
It is not generally appreciated that surgery in the region of the temporal fossa commonly produces, within a few weeks, a contracture of the temporalis muscle with "pseudo" ankylosis of the jaw. This usually, but not always, resolves within six months. The aetiological possibilities include, singly or in combination: Postincisional scar formation within the muscle. A Volkman's contracture due to devascularization of the muscle. Organization of haematoma. It is recommended that active and passive jaw exercises be started early after surgery in the temporal fossa and that such postcraniectomy patients be carefully assessed for jaw ankylosis prior to undertaking anaesthesia.