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PubMed2006

The role of the superciliary approach in the surgical management of intracranial neoplasms.

OBJECTIVE: The authors present and evaluate the experiences with 76 frontolateral keyhole craniotomies performed for supratentorial intracranial tumors via superciliary skin incisions. METHOD: The exploration is a modification of the generally used pterional approach. Out of a series of 302 cases operated on with frontolateral keyhole craniotomies via superciliary skin incisions, 76 had various tumors at the frontal base, intra-, supra-, parasellar and intraorbital regions. The operations were carried out through a approximately 2.5 x 3 cm frontolateral miniaturized craniotomy following a skin incision at the upper edge of the eyebrow. CONCLUSION: Despite the small size of craniotomy the superciliary approach is a suitable technique for resection of skull base tumors in the anterior fossa, orbit, sellar, parasellar and suprasellar regions. The exploration allows enough room for intracranial surgical manipulation with maximal protection of normal brain, vessel and nerve structures. The presented patients did not have any craniotomy-related complication.

Adolescent↗
PubMed1989

Surgical treatment of primary lung cancer and solitary intracranial metastasis.

From 1976 through 1986, 12 patients underwent 14 thoracotomies (two patients had a second thoracotomy for recurrence) and 16 craniotomies (two patients had three craniotomies for recurrence) for carcinoma of the lung and solitary intracranial metastasis. Age ranged from 40 to 65 years. Adjuvant therapy (chemotherapy and thoracic irradiation) was employed in three patients prior to thoracotomy and in four patients following thoracotomy. Whole-brain irradiation was used in four patients after craniotomy. Improvement in neurologic symptoms following craniotomy was noted in 15 of 16 instances. There were no operative mortalities. Overall survival from the time of initial diagnosis ranged from 13 to 63 months. Survival following initial craniotomy ranged from 12 to 56 months. Eight patients are currently alive and well with no disabling neurological symptoms. These results support an aggressive approach to the resection of solitary brain metastasis from bronchogenic carcinoma, both for palliation and prolongation of survival.

Adenocarcinoma↗
PubMed1990

The management of patients with an intrinsic supratentorial brain tumour.

The management of patients presenting with supratentorial glioma between 1978 and 1986 is reviewed. Complete follow-up in 517 cases was obtained. One hundred and fifty eight patients were not submitted to any form of surgery, 299 patients were biopsied and 60 patients underwent craniotomy and internal decompression. The no surgery group contained a higher proportion of patients with poor prognostic indicators than either the biopsy or craniotomy groups. The craniotomy group consisted of patients with better prognostic indicators than the biopsy group, in particular, younger age and more favourable site, type and grade of tumour. This was reflected in the difference in outcome between the groups. Median survival was 14 months in the craniotomy group, four months in the biopsy group and 2.2 months in the no surgery group. The outcome in patients with histologically proven malignant gliomas was best in those patients who received radiotherapy. The craniotomy group had a median survival of 18.5 months, a two year survival of 48% and a five year survival of 9%. The median survival following radiotherapy of those patients with proven malignant gliomas who had a biopsy was 9.5 months with a two year survival of 16% and a five year survival of 2%. These results compare favourably with studies which have adopted a more aggressive approach, suggesting that outcome is determined as much by patient selection using favourable prognostic indicators as by the treatment itself. The need for prospective trials of the management of unselected consecutive glioma patients randomizing them to conservative and radical treatment groups in order to define the role of both conventional therapy and radical therapy is discussed.

Adolescent↗
PubMed1997

Cerebral arteriovenous oxygen difference: a predictor of cerebral infarction and outcome in patients with severe head injury.

Jugular bulb oxygen monitoring can be used to estimate the adequacy of cerebral blood flow to support cerebral metabolism after severe head injury. In the present study, the authors studied the cerebral arteriovenous oxygen difference (AVDO[2]) before and after treatment in 32 head-injured patients (Glasgow Coma Scale scores < or = 8) to examine the relationships among AVDO and cerebral perfusion pressure (CPP), delayed cerebral infarction, and outcome. Fifteen patients (Group A) underwent craniotomy for hematoma evacuation and 17 (Group B) received mannitol for sustained intracranial hypertension (intracranial pressure > 20 mm Hg, > 10 minutes). Radiographic evidence of delayed cerebral infarction was observed in 14 patients. Overall, 17 patients died or were severely disabled. Cerebral AVDO(2) was elevated before craniotomy or mannitol administration; the mean AVDO(2) for all patients before treatment was 8.6 +/- 1.8 vol%. Following craniotomy or mannitol administration, the AVDO(2) decreased in 27 patients and increased in five patients (mean AVDO(2) 6.2 +/- 2.1 vol% in all patients; 6 +/- 1.9 vol% in Group A; and 6.4 +/- 2.4 vol% in Group B). The mean CPP was 75 +/- 9.8 mm Hg and no relationship with AVDO(2) was demonstrated. Before treatment, the AVDO(2) was not associated with delayed cerebral infarction or outcome. By contrast, a limited improvement in elevated AVDO(2) after craniotomy or mannitol administration was significantly associated with delayed cerebral infarction (Group A: p < 0.001; Group B: p < 0.01). Similarly, a limited improvement in elevated AVDO(2) after treatment was significantly associated with an unfavorable outcome (Group A: p < 0.01; Group B: p < 0.001). In conclusion, these findings strongly indicate that, despite adequate cerebral perfusion, limited improvement in elevated cerebral AVDO(2) after treatment consisting of either craniotomy or mannitol administration may be used to help predict delayed cerebral infarction and poor outcome after traumatic brain injury.

Adult↗
PubMed2005

A superciliary approach for anterior cranial fossa lesions in children. Technical note.

Many subfrontal and orbitofrontal craniotomy techniques have been proposed and developed for anterior cranial fossa lesions. The purpose of this study was to evaluate the surgical experience with the frontolateral keyhole craniotomy through a superciliary skin incision in children. The keyhole craniotomy is a modification of the traditional pterional approach. This modified approach, a craniotomy with a 2.5 x 3-cm bone opening just above the eyebrow through a superciliary incision, has been previously described in adults for many lesions situated in the anterior cranial fossa, including tumors and aneurysms. The authors review their experience in using this approach in 27 children for a variety of intracranial lesions. This approach was used for 28 procedures in children ranging in age from 1 to 16 years (mean age 10 years). The lesions included arachnoid cysts, cerebrospinal fluid fistulas, and tumors; no vascular lesions were treated. The authors have found this craniotomy to be a safe and simple approach for treating anterior cranial fossa and suprasellar lesions in children.

Adolescent↗
PubMed2001

[Surgical treatment of chronic subdural hematoma in the adult. Review of the literature].

There are various methods to treat chronic subdural hematomas in adults. "Open craniotomy" (craniotomy-membranectomy, burr-hole craniotomy) and "closed craniotomy" (twist-drill craniotomy, subdural tapping) are the most frequent technics, but endoscopy and shunts are also possible. No difference in results can be identified from a review of the literature. Different factors of recurrence are analysed.

Adult↗
PubMed2005

Is repeated head computed tomography necessary for traumatic intracranial hemorrhage?

This study was performed to determine the need for repeat head computed tomography (CT) in patients with blunt traumatic intracranial hemorrhage (ICH) who were initially treated nonoperatively and to determine which factors predicted observation failure or success. A total of 1,462 patients were admitted to our level II trauma center for treatment of head injury. Seventeen per cent (255/1,462) were diagnosed with ICH on initial head CT. Craniotomy was initially performed in 15.7 per cent (40/255) of patients with ICH. Two hundred sixteen patients with ICH were initially observed. Ninety-seven per cent (179/184) of observed patients with ICH and repeat head CT never underwent a craniotomy, 2.7 per cent (5/184) of patients with ICH initially observed underwent craniotomy after repeat head CT, and four patients (80%) had deteriorating neurologic status. Multivariate analysis revealed the following significant admission risk factors were associated with a need for repeat head CT indicating the need for craniotomy: treatment with anticoagulation and/or antiplatelet medications, elevated prothrombin time (PT), and age greater than 70 years. In patients with blunt traumatic intracranial hemorrhage initially observed, there is little utility of repeated head CT in the absence of deteriorating neurologic status. The only admission risk factors for a repeat CT indicating the need for craniotomy were advanced age and coagulopathy.

Adolescent↗
PubMed1990

Surgical treatment of brain metastases from renal cell carcinoma.

Between January 1976 and December 1986, 22 patients with renal cell carcinoma underwent surgical resection of brain metastases at Memorial Sloan-Kettering Cancer Center. Ten of the patients had metastases limited to the brain and 12 also had extracranial metastases. Twenty patients received external radiotherapy. Five had craniotomy after failing radiation therapy and 15 had adjuvant radiotherapy. Two patients died within thirty days following craniotomy; the median survival of the remaining 20 patients was 20.9 +/- 6.8 months calculated according to a Weibull survival model. Variables examined in relation to survival included absence or presence of extracranial metastases at time of craniotomy, time interval between nephrectomy and diagnosis of cerebral metastases, neurologic status prior to craniotomy, location of the brain tumor, and patient age. None of the variables was significant at the 10 percent level by the Weibull analysis. However, three favorable prognostic factors, namely metachronous brain metastasis more than one year after nephrectomy, minimal or no neurologic deficit at time of craniotomy, and infratentorial lesions show a trend toward improved survival with p less than 0.20. The data suggest that surgical resection of a single and occasionally multiple brain metastases is warranted in selected patients with renal cell carcinoma.

Adrenal Gland Neoplasms↗
PubMed2006

Total intravenous anaesthesia with propofol and remifentanil for elective neurosurgical procedures: an audit of early postoperative complications.

BACKGROUND AND OBJECTIVES: This was a prospective audit to assess the incidence and characteristics of early postoperative complications in the recovery room in extubated patients after elective neurosurgical procedures using propofol and remifentanil-based total intravenous anaesthesia. METHODS: Vital signs (temperature, conscious level, respiratory rate, oxygen saturation, pulse and blood pressure) and postoperative complications (shivering, nausea, vomiting and cardiorespiratory) were analysed in 145 adult patients over a 1-yr period. RESULTS: The overall shivering, postoperative nausea and vomiting and postoperative hypertension (systolic blood pressure more than 25% of the preoperative value) incidences were 30.3%, 16.6% and 35.2%, respectively. Fifty-one percent of the patients had at least one of the above complications. The complication rates were found to be widely different among various types of neurosurgery. The surgical procedures were divided into five groups: supratentorial craniotomy, posterior fossa craniotomy, intracranial vascular procedures, transphenoidal hypophysectomy and extracranial procedures. Median extubation time was similar in all groups and patients were fully conscious with no hypoxia in the recovery room. The intracranial vascular group had the highest shivering and postoperative nausea and vomiting rates (58.8% and 29.4%, respectively). In the supratentorial craniotomy group, 46% of the patients had hypertension. The overall complication rate (presence of any complications) was highest in the supratentfial craniotomy (55.4%), posterior fossa craniotomy (75%) and intracranial vascular (76.5%) groups. Shivering and overall complication rate was significantly related to the anaesthetic time (P<or=0.001 and 0.02, respectively). CONCLUSIONS: Despite the potential advantages of total intravenous anaesthesia in titratability, rapid return of consciousness and reduced respiratory complications, making it suitable for planned extubation at the end of neurosurgery, the postoperative complications of shivering, postoperative nausea and vomiting and hypertension were still high.

Anesthesia, Intravenous↗
PubMed1999

Infratentorial approach to internal acoustic meatus.

Surgical exposure of internal acoustic meatus via typical suboccipital retrosigmoid craniotomy is limited by inner ear structures that should remain intact if hearing preservation is attempted. Feasibility of supracerebellar-infratentorial approach to the meatus with more medial angle of exposure and with preservation of inner ear structures was studied on fresh cadavers and on computed tomography pictures of temporal bones. Anatomical relationships of internal acoustic meatus and adjacent structures show marked individual variability. When typical retrosigmoid craniotomy is used to expose meatal fundus, significant medial retraction of cerebellar hemisphere is required in 47% of the patients to avoid opening endolymphatic spaces. Internal acoustic foramen and meatus can be exposed via craniotomy situated under transverse sinus, with 10-15 mm downward retraction of cerebellum. Medial extent of craniotomy can be planned on preoperative imaging studies. Infratentorial supracerebellar exposure of internal acoustic meatus allows for more medial angle of surgical approach than standard retrosigmold craniotomy. It can be used when preoperative imaging studies show that anatomical relationships between internal acoustic meatus and inner ear structures would require excessive cerebellar retraction to visualize a whole tumor inside meatus.

Journal Article↗
PubMed1996

Studies in cranial suture biology: part II. Role of the dura in cranial suture fusion.

The biology underlying normal and premature cranial suture fusion remains unknown. The purpose of this study was to investigate the role of the dura mater in cranial suture fusion. In the Sprague Dawley rat model, the posterior frontal cranial suture fuses between 10 and 20 days of postnatal life. The effect of separating the posterior frontal cranial suture from its underlying dura mater with an intervening silastic sheet was studied. Sixty rat pups, age 8 days, were divided into four groups of 15. Group A served as unoperated controls. Group B, the experimental group, underwent craniotomy, dural elevation, and insertion of a silicone sheet between the posterior frontal cranial suture and the underlying dura. Two operative sham groups were included. Group C underwent craniotomy and dural deflection only. Group D underwent craniotomy alone without dural deflection. The rats were sacrificed at 15, 22, and 30 days of age. The results showed that the unoperated animals (group A) demonstrated normal initiation of suture fusion at 15 days and complete fusion by 22 days. Group B animals, with silicone sheet barriers placed, showed persistent patency of sutures at 22 days. Initiation of suture fusion was delayed until 30 days. Sham group C, animals with craniotomy and dural deflection, showed that initiation of fusion was delayed until 22 days with complete fusion by 30 days of age. Sham group D, craniotomy alone, had the same normal temporal sequence of suture fusion as the unoperated control group A. These data indicate that normal cranial suture fusion is delayed when the suture-dural interaction is interrupted by a surgically place barrier or by simple dural deflection. Furthermore, interaction between the dura and the overlying suture appears to direct suture fusion.

Animals↗
PubMed2006

The hazards of using administrative data to measure surgical quality.

Administrative claims data have been used to measure risk-adjusted clinical outcomes of hospitalized patients. These data have been criticized because they cannot differentiate risk factors present at the time of admission from complications that occur during hospitalization. This paper illustrates how valid risk-adjustment can be achieved by enhancing administrative data with a present-on-admission code, admission laboratory data, and admission vital signs. Examples are presented for inpatient mortality rates following craniotomy and rates of postoperative sepsis after elective surgical procedures. Administrative claims data alone yielded a risk-adjustment model with 10 variables and a C-statistic of 0.891 for mortality after craniotomy, and a model with 18 variables and a C-statistic of 0.827 for postoperative sepsis. In contrast, the combination of administrative data and clinical data abstracted from medical records increased the number of variables in the craniotomy model to 21 with a C-statistic of 0.923, and the number of variables in the postoperative sepsis model to 29 with a C-statistic of 0.858. Use of only administrative data resulted in unacceptable amounts of systematic bias in 24 per cent of hospitals for craniotomy and 19 per cent of hospitals for postoperative sepsis. Addition of a present-on-admission code, laboratory data, and vital signs reduced the percentage of hospitals with unacceptable bias to two percent both for craniotomy and for postoperative sepsis. These illustrations demonstrate suboptimal risk stratification with administrative claims data only, but show that present-on-admission coding combined with readily available laboratory data and vital signs can support accurate risk-adjustment for the assessment of surgical outcomes.

Adult↗
PubMed2004

Surgical mortality as an indicator of hospital quality: the problem with small sample size.

CONTEXT: Surgical mortality rates are increasingly used to measure hospital quality. It is not clear, however, how many hospitals have sufficient caseloads to reliably identify quality problems. OBJECTIVE: To determine whether the 7 operations for which mortality has been advocated as a quality indicator by the Agency for Healthcare Research and Quality (coronary artery bypass graft [CABG] surgery, repair of abdominal aortic aneurysm, pancreatic resection, esophageal resection, pediatric heart surgery, craniotomy, hip replacement) are performed frequently enough to reliably identify hospitals with increased mortality rates. DESIGN AND SETTING: The US national average mortality rates and hospital caseloads of the 7 operations were determined using the 2000 Nationwide Inpatient Sample (NIS), and sample size calculations were performed to determine the minimum caseload necessary to reliably detect increased mortality rates in poorly performing hospitals. A 3-year hospital caseload was used for the baseline analysis, and poor performance was defined as a mortality rate double the national average. MAIN OUTCOME MEASURE: Proportion of hospitals in the United States that performed more than the minimum caseload for each operation. RESULTS: The national average mortality rates for the 7 procedures examined ranged from 0.3% for hip replacement to 10.7% for craniotomy. Minimum hospital caseloads necessary to detect a doubling of the mortality rate were 64 cases for craniotomy, 77 for esophageal resection, 86 for pancreatic resection, 138 for pediatric heart surgery, 195 for repair of abdominal aortic aneurysm, 219 for CABG surgery, and 2668 for hip replacement. For only 1 operation did the majority of hospitals exceed the minimum caseload, with 90% of hospitals performing CABG surgery having a caseload of 219 or higher. For the remaining operations, only a small proportion of hospitals met the minimum caseload: craniotomy (33%), pediatric heart surgery (25%), repair of abdominal aortic aneurysm (8%), pancreatic resection (2%), esophageal resection (1%), and hip replacement (<1%). CONCLUSION: Except for CABG surgery, the operations for which surgical mortality has been advocated as a quality indicator are not performed frequently enough to judge hospital quality.

Aortic Aneurysm, Abdominal↗
PubMed2006

Clinical characteristics of postoperative contralateral intracranial hematoma after traumatic brain injury.

OBJECTIVES: To investigate the clinical characteristics of contralateral intracranial hematoma (ICH) after traumatic brain injury. METHODS: The subjects included 149 patients with traumatic ICH treated by hematoma evacuation. The patients were retrospectively divided into a bilateral ICH (B-ICH) group and unilateral ICH (U-ICH) group after craniotomy using brain CT scans for comparison of the following parameters: complicated expanded brain bulk from the cranial window, hypotension during craniotomy, and outcome. RESULTS: Post-craniotomy brain CT scans revealed U-ICH in 106 patients and B-ICH in 43 patients. Average Glasgow Coma Scale on arrival did not differ between the groups, but a higher proportion of patients in the B-ICH group deteriorated after admission (p = 0.02). The B-ICH patients also exhibited a significantly higher rate of expanded brain bulk from the cranial window (p < 0.05). No significant difference was observed between the groups with hypotension during craniotomy. The B-ICH group exhibited a lower rate of favorable outcome (p < 0.05) and higher mortality (p < 0.05). CONCLUSION: The B-ICH patients had a worse outcome than the U-ICH patients. Contralateral ICH was difficult to forecast based on pre- and intraoperative clinical conditions. Subdural hematoma or contusional ICH was frequently observed as a contralateral ICH.

Adolescent↗
PubMed1984

Ultrasound in follow-up of the postoperative brain. Preliminary report on six cases.

The authors report on their early results in the ultrasound (US) follow-up of postoperative brain pathology, both supra- and infratentorial. The use of US is dependent on the presence of an acoustic window in the skull after craniotomy. Five patients were investigated via a suboccipital craniotomy and one patient via a temporal skull defect. In the patients with a suboccipital craniotomy the greatest part of the posterior fossa, the 3rd and lateral ventricle could be made visible. In a patient with a temporal craniotomy the involved parts of the brain were demonstrated satisfactorily. If a skull defect persists after surgery US may be of value in the follow-up of postoperative conditions, such as the assessment of tumour residue or recurrence, hydrocephalus, postoperative complications and response to radio- or chemotherapy.

Adolescent↗
PubMed2001

MRimaging findings after ventricular puncture in patients with SAH.

OBJECT: Using magnetic resonance (MR) imaging, we studied brain injury from ventricular puncture performed during craniotomy in the acute stage of subarachnoid hemorrhage (SAH). METHODS: 80 patients underwent craniotomy for aneurysm obliteration within 48 hr after SAH, ventricular puncture for drainage of cerebrospinal fluid (CSF) was performed to reduce intracranial pressure. MR imaging was performed within 3 days following surgery to measure the size of the lesion, and was repeated on postoperative days 14 and 30. CONCLUSIONS: Of the 80 patients with ventricular puncture preceding craniotomy, 65 (81%) showed MR evidence of brain injury from the puncture. Overall, 149 lesions were detected. According to coronal images, cortical injuries (54 cases), penetrating injury to tracts along the ventricular tube (55 cases), caudate injury (25 cases), and corpus callosum injury (15 cases). Brain injuries from ventricular puncture did not correlate significantly to patient outcome. While ventricular puncture and drainage of CSF can readily be performed to decrease brain volume at the time of craniotomy in acute-stage SAH, neurosurgeons should be aware of a surprisingly high incidence of brain injury complicating puncture.

Acute Disease↗
PubMed2001

Surgical treatment of chronic subdural hematoma based on intrahematomal membrane structure on MRI.

BACKGROUND: To determine the optimal surgical management of chronic subdural hematoma (CSDH), we assessed which operative procedure, burr holes or small craniotomy, was more effective on 49 consecutive patients. METHOD: We retrospectively classified all cases into two groups according to the intrahematomal membrane structure of CSDH on T2*-weighted magnetic resonance (MR) imaging. The first group, labeled type B, included hematomas which had no intrahematomal membrane and/or were monolayer multilobule. The second group, labeled type C, consisted of hematomas which were divided into multiple layers by the intrahematomal membrane. FINDINGS: The outcome of type C patients treated with burr holes was significantly inferior to that of those who underwent a small craniotomy in terms of the relative outcome of neurological grading. re-operation ratio, and postoperative hospital stay (p < 0.05). Type C hematomas treated with burr holes also had inferior outcome compared with a small craniotomy in terms of the duration of hematoma until disappearance on postoperative CT (p < 0.05). INTERPRETATION: We concluded that a considerable number of cases appeared to need craniotomy and resection of intrahematomal membrane for complete recovery in CSDH, and that T2*-weighted MR imaging could be used as a basis for selecting the operative procedure for CSDH.

Adult↗
PubMed2006

Shunt-related craniocerebral disproportion: treatment with cranial vault expanding procedures.

Two patients with intracranial arachnoid cysts, one with myelomeningocele-hydrocephalus and the other with a subdural fluid collection, were given a cerebrospinal (CSF) extracranial shunt. All four patients developed features of CSF overdrainage following shunting and were treated by cranial vault expanding procedures. Before undergoing decompressive craniotomy, the patients were treated by a variety of procedures, including changing of obstructed ventricular catheters (n=4), insertion or upgrading of programmable valves (n=3), and foramen magnum decompression (n=1). Clinical manifestations of these four patients were attributed to craniocerebral disproportion caused by chronic and progressive skull changes due to dampening of the CSF pulse pressure, which is necessary for maintaining normal cranial growth. On the basis of our previous experience with expanding craniotomies in cases of minimal forms of craniosynostosis, we treated these patients with bilateral parietal craniotomies, with satisfactory results. In conclusion, biparietal decompressive craniotomy constitutes a useful and safe procedure for relieving the clinical manifestations of some CSF overdrainage syndromes, especially in cases with slit-ventricle syndrome and craniocerebral disproportion that prove to be refractory to simpler management procedures.

Adolescent↗