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PubMed2004

Risk factors for intraoperative hypotension in traumatic intracranial hematoma.

Patients suffering from traumatic intracranial hemorrhage (TICH) may experience an episode of catastrophic intraoperative hypotension (IHT), after decompression of the brain. The aim of this study was to investigate the risk factors for IHT during emergency craniotomy A total of 67 patients, who underwent emergency craniotomy due to TICH, were divided into two groups: IHT ( n=31 ) or without IHT ( n=36 ). Data concerning (1) age; (2) gender; (3) mechanism of injury; (4) Glasgow Coma Scale (GCS) on admission; (5) abnormality of the pupils (anisocoria or mydriasis); (6) mean arterial blood pressure; (7) heart rate; (8) time elapsed before craniotomy from injury; (9) initial brain CT scans; (10) duration of craniotomy; and (11) total infusion or urine volume until craniotomy were collected prospectively as IHT risk factors. Low GCS score (<5), tachycardia (heart rate >112min(-1)) and hypertension (mean blood pressure >131mmHg) before emergency craniotomy were strongly ( P<0.05 ) associated with IHT. Delayed surgery (>173min until craniotomy) also had a significant ( P<0.005 ) effect on IHT. The risk factors for IHT were considered as a low GCS score on admission, tachycardia, hypertension before emergency craniotomy and delayed surgery. These results suggested the patients with IHT had a high sympathetic tone before emergency craniotomy A sudden reduction in sympathetic tone after surgical decompression of the brain might cause IHT. We concluded that an important factor in the occurrence of IHT was not only the injury severity, but also the balance between sympathetic and parasympathetic activity before decompression surgery.

Adolescent↗
PubMed1997

Surgical treatment of 70 patients with brain metastases from breast carcinoma.

BACKGROUND: Brain metastases are diagnosed in 15% of patients with metastatic breast carcinoma. Most patients are treated with whole-brain radiotherapy (WBRT) and/or chemotherapy. The information on surgical results is sparse. METHODS: Among 709 patients with tumors metastatic to the brain who underwent craniotomy at Memorial Hospital, New York, New York, between January 1974 and December 1993, 70 (10%) had a primary breast carcinoma. Their treatment outcomes were analyzed retrospectively. RESULTS: The median age at diagnosis of primary breast carcinoma and brain metastasis was 46 and 50 years, respectively. All but two patients had metachronous diagnoses of breast carcinoma and brain metastasis. The median interval between both diagnoses in this subgroup was 28 months. In all 70 patients, the overall median survival was 54 months after diagnosis of the primary breast tumor and 16.2 months after diagnosis of the brain tumor. Only 5 patients (7%) were alive at last follow-up. The overall median survival after brain surgery was 14 months. Four patients died within 30 days of craniotomy. Twelve patients had a solitary cerebellar metastasis and 16 had multiple metastases; their median survival was 10.9 months and 14.8 months, respectively. There was no statistical difference in survival for patients who had single or multiple lesions. The median survival of 22 patients with positive hormonal receptor (estrogen receptor [ER] or progesterone receptor [PR]) was significantly longer than the median survival of 20 patients with negative ER/PR (21.9 vs. 12.5 months, P < 0.05). For 35 patients (50%) who had brain lesions > or =4 cm, the median survival was 11 months, compared with 16.3 months for patients with smaller lesions (P = 0.16, not significant [NS]). Patients age < or =50 years versus >50 years had survival of 17.3 and 11.1 months, respectively (P = NS). Neurologic deficit prior to craniotomy shortened survival for 24 patients to 11.5 months, compared with 17.4 months for patients without deficit (P = NS). Fifteen patients experienced failure with WBRT prior to undergoing craniotomy, and their median survival was shorter than for those who underwent craniotomy as the initial treatment (6.3 vs. 15.8 months, P < 0.03). However, their survival after diagnosis of brain metastasis was not significantly different (19.2 vs. 16.1). Forty-seven patients received WBRT postoperatively, and 9 patients did not receive adjuvant radiation therapy. Subsequent relapse in the brain was diagnosed in 27 patients, and 8 of them underwent reresection. One-year, 2-year, 3-year, and 5-year survival rates were 53%, 25.7%, 18.6%, and 7%, respectively. In multivariate analysis, the adjuvant WBRT after craniotomy and the absence of meningeal carcinomatosis were the only significant predictive variables for longer survival. CONCLUSIONS: In a subset of selected patients, craniotomy followed by WBRT can positively impact survival.

Adult↗
PubMed2003

Debulking or biopsy of malignant glioma in elderly people - a randomised study.

BACKGROUND: Patients with radiologically (MRI and/or CT images) suspected malignant glioma is referred to radiotherapy after craniotomy and resection of the tumour or after diagnostic biopsy. Patients with poor preoperative status and elderly patients are diagnosed more often by biopsy and treated by radiotherapy rather than by craniotomy and tumour resection. However, based on previous retrospective studies it is not possible to conclude which procedure is better for elderly patients. Thus a prospective study comparing these two procedures with elderly patients was planned. METHODS: 30 patients older than 65 years with radiologically (CT and/or MRI) obvious malignant glioma were randomised into two groups: I) stereotactic biopsy and II) open craniotomy and resection of the tumour. Nineteen patients were diagnosed to have grade IV glioma and four patients grade III glioma. Seven out of 30 (23%) were followed in the "intention-to-treat" group with diagnosis of stroke (n=3), metastasis (n=2), malignant lymphoma (n=1) and one with out histological diagnosis. Patients with histologically verified malignant glioma (grade III-IV) were diagnosed by stereotactic biopsy (n=13) or by open craniotomy and resection (n=10) and all the patients were referred to radiotherapy. Survival and time of deterioration were followed. FINDINGS: The overall median survival time was 146 (95% CI 89-175) days after the procedure. The estimated median survival time was 171 (95% CI 146-278) days after the craniotomy versus 85 (95% CI 55-157) days after the biopsy (p=0.035). The estimated survival time was 2.757 times longer (95% CI 1.004-7.568, p=0.049) after craniotomy. However, there was no significant difference in the time of deterioration between these two treatments (p=0.057). Amount of radiotherapy given had a significant effect on survival (p=0.001). INTERPRETATION: Longer survival time is achieved after open craniotomy and resection of tumour. However, overall benefit of open surgery to patient seems to be modest, while time of deterioration did not differ between two treatment groups. Our results support previous studies on the benefit of radiotherapy in the treatment of malignant glioma.

Age Factors↗
PubMed2006

Predicting the need for early tracheostomy: a multifactorial analysis of 992 intubated trauma patients.

BACKGROUND: Tracheostomy has few, severe risks, while prolonged endotracheal intubation causes morbidity. The need for tracheostomy was assessed, based on early clinical parameters. METHODS: Adult trauma patients (January 1994-August 2004), intubated for resuscitation, ventilated >24 hours, were retrospectively evaluated for demographics, physiology, brain, and pulmonary injury. Tracheostomy patients were compared with those without. Chi-square, Mann-Whitney, and multivariate logistic regression were used with statistical significance at p < 0.05.* RESULTS: Of 992 patients, 430 (43%) underwent tracheostomy at 9.22 +/- 5.7 days. Risk factors were age (45.6* +/- 18.8 vs. 36.7 +/- 15.9, OR: 2.1 (18 years increments), ISS (30.3* +/- 12.5 vs. 22.0 +/- 10.3, OR: 2.1 (12u increments), damage control (DC) [68%*(n = 51) vs. 32%*(n = 51), OR: 3.8], craniotomy [70%*(n = 21) versus 30%(n = 9), OR: 2.6], and intracranial pressure monitor (ICP) [65.4%*(n = 87) vs. 34.6%(n = 46), OR: 2.1]. A 100% tracheostomy rate (n = 30, 3.0%) occurred with ISS (injury severity score) = 75, ISS >or=50, and age >or=55, admit/24 hour GCS (Glasgow Coma Scale) = 3 and age >or=70, AIS abdomen, chest or extremities >or=5 and age >or=60, bilateral pulmonary contusions (BPC) and >or=8 rib fractures, craniotomy and age >or=50, craniotomy with intracranial pressure (ICP) and age >or=40, or craniotomy and GCS or=90% (n = 105, 10.6%) was found with ISS >or=54, ISS >or=40, and age >or=40, admit/24 hour GCS = 3 and age >or=55, paralysis and age >or=40, BPC and age >or=55.A tracheostomy rate >or=80% (n = 248, 25.0%) occurred with ISS >or=38, age >or=80, admit/24 hour GCS = 3 and age >or=45, DC and age >or=50, BPC and age >or=50, aspiration and age >or=55, craniotomy with ICP, craniotomy with GCS or=90% risk undergo early tracheostomy and that it is considered in the >or=80% risk group to potentially decreased morbidity, increased patient comfort, and optimize resource utilization.

Adult↗
PubMed2005

Surgery for primary supratentorial brain tumors in the United States, 1988 to 2000: the effect of provider caseload and centralization of care.

Contemporary reports of patient outcomes after biopsy or resection of primary brain tumors typically reflect results at specialized centers. Such reports may not be representative of practices in nonspecialized settings. This analysis uses a nationwide hospital discharge database to examine trends in mortality and outcome at hospital discharge in 38,028 admissions for biopsy or resection of supratentorial primary brain tumors in adults between 1988 and 2000, particularly in relation to provider caseload. Multivariate analyses showed that large-volume centers had lower in-hospital postoperative mortality rates than centers with lighter caseloads, both for craniotomies (odds ratio [OR] 0.75 for a tenfold larger caseload) and for needle (closed) biopsies (OR 0.54). Adverse discharge disposition was also less likely at high-volume hospitals, both for craniotomies (OR 0.77) and for needle biopsies (OR 0.67). The annual number of surgical admissions increased by 53% during the 12-year study period, and in-hospital mortality rates decreased during this period, from 4.8% to 1.8%. Mortality rates decreased over time, both for craniotomies and for needle biopsies. Subgroup analyses showed larger relative mortality rate reductions at large-volume centers than at small-volume centers (73% vs. 43%, respectively). The number of US hospitals performing one or more craniotomies annually for primary brain tumors decreased slightly, and the number performing needle biopsies increased. There was little change in median hospital annual craniotomy caseloads, but the largest centers had disproportionate growth in volume. The 100 highest-caseload US hospitals accounted for an estimated 30% of the total US surgical primary brain tumor caseload in 1988 and 41% in 2000. Our findings do not establish minimum volume thresholds for acceptable surgical care of primary brain tumors. However, they do suggest a trend toward progressive centralization of craniotomies for primary brain tumor toward large-volume US centers during this interval.

Adult↗
PubMed2005

Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision.

OBJECTIVE: More than ever before, the priority in contemporary neurosurgery is to achieve the greatest therapeutic effect while causing the least iatrogenic injury. The evolution of microsurgical techniques with refined instrumentation and illumination and the enormous development of preoperative and intraoperative diagnostic tools enable neurosurgeons to treat different lesions through limited and specific keyhole approaches. METHODS: Based on our surgical experience, the technique of supraorbital subfrontal craniotomy is described in detail in this article. After an eyebrow skin incision is made, a limited supraorbital craniotomy is performed with a width of 15 to 25 mm and a height of 10 to 15 mm. RESULTS: We have been using the supraorbital keyhole craniotomy since 1985 and have approached a variety of lesions within the anterior, middle, and posterior cranial fossae. During a 10-year period between July 1994 and June 2004, the lesions treated via the supraorbital approach in our department comprised 1125 intracranial tumors or cystic lesions, cerebral aneurysms, and other miscellaneous diseases, performed by 23 different surgeons and residents. Of these 1125 patients, we operated on 471 of them, and information obtained from 450 contributed to the follow-up data. Three months after surgery, the Glasgow Outcome Scale scores for this very heterogeneous group of patients were as follows: 5 in 387 patients (86.0%), 4 in 29 patients (6.4%), 3 in 16 patients (3.5%), 2 in 10 patients (2.2%), and 1 in 8 patients (1.8%). Of the 450 patients, 229 were treated for intracranial aneurysms, 93 for cranial base meningiomas, 39 for craniopharyngiomas, 23 for pituitary adenomas, 18 for deep-seated brainstem tumors, and 48 for other miscellaneous frontotemporal or suprasellar lesions. CONCLUSION: In our experience, the supraorbital craniotomy allows a wide, intracranial exposure for extended, bilaterally situated, or even deep-seated intracranial areas, according to the strategy of keyhole craniotomies. The supraorbital craniotomy offers equal surgical possibilities with less approach-related morbidity owing to limited exposure of the cerebral surface and minimal brain retraction. In addition, the short skin incision within the eyebrow and careful soft tissue dissection result in a pleasing cosmetic outcome.

Craniopharyngioma↗
PubMed2006

Extradural anterior clinoidectomy as an alternative approach for optic nerve decompression: anatomic study and clinical experience.

OBJECTIVE: We introduce pterional craniotomy extradural anterior clinoidectomy as a new alternative approach for optic nerve decompression in patients with traumatic optic neuropathy. METHODS: Intracranial structures pertinent to pterional craniotomy extradural anterior clinoidectomy were carefully studied in 10 dry craniums and 10 cranial bases with dura mater. Important parameters of these structures were measured. Stepwise dissections simulating pterional craniotomy extradural anterior clinoidectomy were performed in 20 cadaver heads bilaterally. Pterional craniotomy extradural anterior clinoidectomy was then applied to 12 patients (13 eyes) with traumatic optic neuropathy and severe visual dysfunction. RESULTS: The anatomic features and their variations of optic canal, ophthalmic artery, falciform ligament, and Zinn's ring (annular tendon) were studied and measured in detail. Extensive opening of the optic canal and optic nerve sheath was successfully achieved in all 12 patients without major surgical complications. Significant visual acuity improvement occurred in eight (nine eyes) out of our 12 patients after surgery. The surgical techniques and advantages of pterional craniotomy extradural anterior clinoidectomy for optic nerve decompression are presented and discussed in detail. CONCLUSION: Pterional craniotomy extradural anterior clinoidectomy is a promising new alternative approach for optic nerve decompression in patients with traumatic optic neuropathy.

Adolescent↗
PubMed2006

Acetylcholine and choline dynamics provide early and late markers of traumatic brain injury.

We assessed acetylcholine (ACh) and choline (Ch) dynamics 2.5 h, 1, 4 and 14 days after cerebral cortex impact injury or craniotomy only in adult male Sprague-Dawley rats. Cortical endogenous ACh (D0ACh), endogenous free Ch (D0Ch), deuterium-labeled Ch (D4Ch), and ACh synthesized from D4Ch (D4ACh) were measured by gas-chromatography mass-spectrometry after intravenous injection of D4Ch followed in 1 min by microwave fixation of the brain. D0Ch increased in and around the impact up to 700% of control within 1 day after trauma. Smaller D0Ch increases were found in the cortex contralateral to the impact and in both hemispheres after craniotomy only. D4Ch contents increased to 200% in the impact and surrounding regions 4-14 days post-trauma, with lower increases 2.5 h post-trauma. D0ACh decreased at all times post-trauma in the impact center, and initially in the periphery and adjacent regions with a recovery at 14 days. Similar D0ACh decreases, although of lesser extent and magnitude were present in the craniotomy only group. D4ACh showed a peak at one day post-trauma in all regions studied in the impact and craniotomy groups. In conclusion, D0Ch tissue level was an early marker of trauma, while 14 days after trauma Ch uptake from blood was enhanced in and around the traumatized cortex. Craniotomy by itself induced a generalized increase in ACh turnover 1 day after this minimal trauma. Choline acetyltransferase activity was reduced in the impact center region but not affected in the adjacent and contralateral regions or by craniotomy.

Acetylcholine↗
PubMed2006

Effect of pinealectomy and melatonin replacement on morphological and biochemical recovery after traumatic brain injury.

Numerous studies showed that melatonin, a free radical scavenger, is neuroprotective. In this study, we investigated the effect of pinealectomy and administration of exogenous melatonin on oxidative stress and morphological changes after experimental brain injury. The animals were divided into six groups, each having 12 rats. Group 1 underwent craniotomy alone. Group 2 underwent craniotomy followed by brain trauma and received no medication. Group 3 underwent craniotomy followed by brain trauma and received melatonin. Group 4 underwent pinealectomy and craniotomy alone. Group 5 underwent pinealectomy and craniotomy followed by brain injury and received no medication. Group 6 underwent pinealectomy and craniotomy followed by brain trauma and received melatonin. Melatonin (100 mg/kg) was given intraperitoneally immediately after trauma to the rats in Groups 3 and 6. Pinealectomy caused a significant increase in the malondialdehyde (MDA), nitric oxide (NO), glutathione (GSH), and xanthine oxidase (XO) levels, and a decrease in GSH levels as compared to the control group. Trauma to pinealectomized rats causes significantly higher oxidative stress. Exogeneous melatonin administration significantly reduced MDA, XO and NO levels, increased GSH levels, and attenuated tissue lesion area. These findings suggest that reduction in endogenous melatonin after pinealectomy makes the rats more vulnerable to trauma, and exogenous melatonin administration has an important neuroprotective effect.

Animals↗
PubMed2002

Bilateral supraorbital keyhole approach for multiple aneurysms via superciliary skin incisions.

BACKGROUND: Considering that multiple aneurysms carry a high risk for fatal rupture, there is a need for complete treatment of all lesions in one surgical session using either unilateral-contralateral or bilateral approaches. Contralateral approaches have been used mainly for small anteriorly projecting middle cerebral and medially expanding ophthalmic types of aneurysms. They are limited by the narrow space for surgical manipulation, forced elevation of frontal lobes, and stretching of the olfactory nerves. These problems might result in damage to structures along the unusually long intracranial way of the approach. The complications associated with the unnecessarily large conventional fronto-temporal and bifrontal craniotomies, and the developments in visualization, neuroanaesthesia, microneurosurgery, cerebrospinal fluid (CSF) drainage, and brain protection have led to less invasive methods in cerebral base surgery. These achievements have supplied the background for the supraorbital keyhole approach to aneurysms of the anterior circulation or basilar tip. Because the supraorbital keyhole approach offers several advantages over the classic fronto-temporal craniotomies to the anterior skull base, it was extended for both sides in one surgical session to treat bilateral multiple aneurysms as well. METHODS: Out of a series of 150 patients harboring 188 saccular aneurysms operated on via a supraorbital keyhole approach with a superciliar skin incision, 36 had multiple aneurysms. Thirty patients with multiple aneurysms underwent surgery for their ruptured aneurysms (17 cases in the acute phase and 13 patients during the chronic stage); in 6 cases silent aneurysms were operated on. The multiple aneurysms were managed from one side in 18 cases. A bilateral supraorbital keyhole approach was performed during one surgical session in 11 patients, and in 7 cases the unilateral supraorbital keyhole approach was combined with contralateral fronto-temporal (3 cases), suboccipital (2 cases), or frontal-parasagittal (2 cases) exploration. The operations were carried out through an approximately 2.5 x 3 cm supraorbital keyhole craniotomy following a skin incision just above the eyebrow. The roughly 4 cm superciliar skin incision begins medial to the supraorbital nerve and ends 3 to 10 mm beyond the lateral edge of the eyebrow. The technical details of the method are presented, and the benefits, limitations, and complications are discussed. RESULTS: In the 36 patients operated on via the supraorbital keyhole approach 74 aneurysms were clipped successfully. In 2 cases premature intraoperative rupture of the aneurysms occurred, but these events were managed successfully. Despite the small size of the craniotomy the approach allows enough room for intracranial manipulation with maximal protection of the brain and other intracranial structures. One patient died because of pulmonary embolism. There were no craniotomy-related complications in the present series. CONCLUSION: The supraorbital keyhole approach together with the advent of the modern neuroanaesthesia, CSF drainage, and microsurgical techniques is a safe approach in the hands of experienced neurosurgeons for the treatment of supratentorial or basilar tip aneurysms. Because the approach is simple and swift, the bilateral single-session craniotomy does not have any disadvantages compared to two-stage procedures. However, the one-sitting surgery reduces the high risk of fatal rupture in the perioperative period associated with multiple aneurysms.

Cerebral Angiography↗
PubMed1993

Priorities in the management of multiple trauma: intracranial versus intra-abdominal injury.

UNLABELLED: Setting priorities in the management of patients with suspected injuries to both the head and the abdomen is difficult and depends on the likelihood of different injuries. Eight hundred trauma patients were retrospectively reviewed to determine the likelihood of a surgically correctable cerebral injury. All 800 patients, at the time of initial evaluation, were thought to have potentially correctable injuries to both the head and the abdomen. Of these, 52 had a head injury requiring craniotomy; 40 required a therapeutic celiotomy. Only three patients required both craniotomy and therapeutic celiotomy. There were more cases of delay in therapeutic celiotomy because of negative results of computed tomographic (CT) scanning of the head (13 cases) than there were delays in craniotomy because of nontherapeutic celiotomy (four cases). Need for craniotomy, based on emergency department evaluation, was indicated by the presence of lateralizing neurologic signs. Low Glasgow Coma Scale score, anisocoria, fixed/dilated pupils, loss of consciousness, facial or scalp injuries, and age were of no independent value in predicting the need for craniotomy. CONCLUSIONS: Patients with surgically correctable injuries of both the head and the abdomen are rare. In stable patients with altered mental status and potential injuries to both the head and the abdomen, the abdomen is best evaluated first by diagnostic paracentesis. If paracentesis does not return gross blood, CT scanning of the head should be done.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries↗
PubMed2003

Outcome of contemporary surgery for chronic subdural haematoma: evidence based review.

OBJECTIVE: To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria. METHODS: A review based on a Medline search from 1981 to October 2001 using the phrases "subdural haematoma" and "subdural haematoma AND chronic". Articles selected for evaluation had at least 10 patients and less than 10% of patients were lost to follow up. The articles were classified by three classes of evidence according to criteria of the American Academy of Neurology. Strength of recommendation for different treatment options was derived from the resulting degrees of certainty. RESULTS: 48 publications were reviewed. There was no article that provided class I evidence. Six articles met criteria for class II evidence and the remainder provided class III evidence. Evaluation of the results showed that twist drill and burr hole craniostomy are safer than craniotomy; burr hole craniostomy and craniotomy are the most effective procedures; and burr hole craniostomy has the best cure to complication ratio (type C recommendation). Irrigation lowers the risk of recurrence in twist drill craniostomy and does not increase the risk of infection (type C recommendation). Drainage reduces the risk of recurrence in burr hole craniostomy, and a frontal position of the drain reduces the risk of recurrence (type B recommendation). Drainage reduces the risk of recurrence in twist drill craniostomy, and the use of a drain does not increase the risk of infection (type C recommendation). Burr hole craniostomy appears to be more effective in treating recurrent haematomas than twist drill craniostomy, and craniotomy should be considered the treatment of last choice for recurrences (type C recommendation). CONCLUSIONS: The three principal techniques-twist drill craniostomy, burr hole craniostomy, and craniotomy-used in contemporary neurosurgery for chronic subdural haematoma have different profiles for morbidity, mortality, recurrence rate, and cure rate. Twist drill and burr hole craniostomy can be considered first tier treatment, while craniotomy may be used as second tier treatment. A cumulative summary of data shows that, overall, the postoperative outcome of chronic subdural haematoma has not improved substantially over the past 20 years.

Chronic Disease↗