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PubMed1996

Application of transcranial Doppler sonography in surgical aspects of hypertensive putaminal haemorrhage.

From May 1992 to February 1993, 22 cases of hypertensive putaminal haemorrhage (HPH) treated at our hospital were serially measured with transcranial Doppler (TCD) sonography. Among them, 13 patients underwent surgical intervention (3 stereotaxic surgery and 10 craniotomies), and 9 were conservatively treated. Most of the patients of the two operative groups had larger haematomas and developed clinical and/or neurological deterioration, which was the indication for subsequent surgery. Therefore the groups represent different clinical and physiological entities. On admission, the peak MCA velocities (Vs) in the surgical group (stereotaxic and craniotomy) were significantly lower than those in the conservative group (mean +/- S.E.M.: 38.33 +/- 4.26 and 42.00 +/- 2.62 cm/sec vs. 57.22 +/- 3.23 cm/sec; p < 0.005, respectively). The surgical group also had significantly lower diastolic (Vd) and mean (Vm) velocities than those of the conservative group (p < 0.001). Rather, the admission pulsatility indices (PI = (Vs-Vd)/Vm) in the surgical group were significantly higher than those of the conservative group (mean +/- S.E.M.: 1.42 +/- 0.04 and 1.31 +/- 0.09 vs. 0.95 +/- 0.01; p < 0.005, respectively). Time course velocity curves reached a peak around the 3rd hospital day in all the 3 groups. The Glasgow coma scale (GCS) scores positively correlated with the mean MCA velocities (n = 22; r = 0.63, p < 0.005; y = 2.04 x + 8.74), but negatively with PI values on admission (n = 22; r = -0.53, p < 0.05; y = 1.68-0.053 x). On the 7th hospital day, 2 patients with peak MCA velocities below 50 cm/sec had an unfavourable outcome. All the 3 patients in the stereotaxic group had higher peripheral resistance, as compared with those in conservative craniotomy groups (mean +/- S.E.M.: 1.28 +/- 0.13 vs. 0.99 +/- 0.07 and 0.87 +/- 0.06; p < 0.05, respectively). Our study supports TCD as a safe and valid monitoring method in patients with HPH. "Compromised cerebral haemodynamic status" (Vs < 50 cm/sec, Vd < 15 cm/sec, Vm < 25 cm/sec, PI > 1.15) may offer an aid in the decision for surgical intervention in HPH. Postoperatively, patients who made a favourable recovery had a significant increment in the MCA velocities in contrast to those severely disabled, whose MCA velocities remained low.

Adult↗
PubMed1985

Infections in neurosurgery: a retrospective study of 1143 patients and 1517 operations.

The files of 1143 neurosurgical patients, operated on between November 1, 1979 and June 4, 1981 were examined for records of post-operative infections. Eighty-three patients had developed infections (7%). In addition there were 33 instances of aseptic meningitis. Patients with a shunt were prone to infection (12%). Bone flap infections accounted for more than half of all infections after supratentorial craniotomy. Bacterial meningitis accounted for more than half of all infections after suboccipital craniotomy and translabyrinthine operations. In these patients bacterial meningitis was six times more common, and aseptic meningitis three times more common than in those who had had supratentorial operations. Shunt infection was more common after repeated shunt operations in quick succession. Craniotomy increased the risk of a shunt becoming infected. Antibiotic prophylaxis should be used not only in shunt operations but in all operations performed on patients with a shunt. If bacteria are recovered in a suspected shunt infection, immediate removal of the shunt is the best treatment. However, if the shunt's removal or replacement is exceptionally difficult intraventricular antibiotic treatment may be tried. The age of the patient, the duration of the operation, the individual surgeon and the number of operations did not affect the rate of infection. Clinical signs and conventional laboratory tests, apart from bacterial culture, cannot differentiate between bacterial and aseptic meningitis, but a drop in the level of consciousness suggests bacterial meningitis.

Adolescent↗
PubMed2004

Determinants of intellectual outcome after surgical revascularization in pediatric moyamoya disease: a multivariate analysis.

OBJECTS: The aim of this study was to clarify predictors for poor intellectual outcome in pediatric moyamoya disease. METHODS: Fifty-two pediatric patients were included. Clinical diagnosis was transient ischemic attacks (TIA) in 35 and completed stroke in 17. Ten patients underwent indirect synangiosis through "small craniotomy," whereas the other 42 underwent superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis and indirect synangiosis through "large craniotomy." Full-scale IQ (FSIQ) was measured using the Wechsler intelligence scale for children (WISC) after surgery. Multivariate logistic regression models were applied to test the effect of clinical factors on intellectual outcome. RESULTS AND CONCLUSION: Eight patients revealed mentally impaired status (FSIQ<70). Multivariate analysis revealed that completed stroke and "small craniotomy" surgery were significantly associated with poor intellectual outcome. Odds ratios of each factor were 33.4 (95% CI, 2.4-474) and 19.6 (95% CI, 1.8-215) respectively. Early diagnosis and the revascularization procedure over as wide an area as possible may be essential to improve their intellectual outcome.

Cerebral Revascularization↗
PubMed1999

Surgical and medical management of patients with massive cerebellar infarctions: results of the German-Austrian Cerebellar Infarction Study.

Surgical intervention (ventricular drainage or decompressive craniotomy) may be necessary in patients with cerebellar infarction if mass effect develops. However, patient selection and timing of surgery remain controversial, and there are few data on clinical signs in the early course that are predictive for outcome. The clinical course and neuroradiological features of 84 patients (aged 22-78, mean 58.5 years) with massive cerebellar infarction confirmed by computed tomography were prospectively observed for 21 days after admission and at 3-month follow-up using a standardized protocol. Data were gathered from 1992 to 1996 in 17 centers. The patients were assigned to three treatment groups depending on the decision of the primary caretaker: 34 underwent craniotomy and evacuation, 14 received ventriculostomy, and 36 were treated medically. Treatment groups differed regarding the level of consciousness, signs of mass effect in computed tomography and signs of brainstem involvement. The overall risk for poor outcome depended on the level of consciousness after clinical deterioration (odds ratio = 2.8). Subgroup analysis of awake/drowsy or somnolent/stupor patients revealed no relationship to treatment. The vascular territory involved did not affect outcome. Surgical treatment for massive cerebellar infarctions was not found to be superior to medical treatment in awake/drowsy or somnolent/stupor patients. Half of all patients deteriorating to coma treated with ventricular drainage or decompressive craniotomy had a meaningful recovery. We were unable to compare surgical versus medical therapy in this subgroup due to lack of control group. This study supports the notion that the level of consciousness is the most powerful predictor of outcome, superior to any other clinical sign and treatment assignment. Deterioration of consciousness typically occurred between days 2 and 4, with a maximum on day 3.

Adult↗
PubMed2006

Emergency management of epidural haematoma through burr hole evacuation and drainage. A preliminary report.

BACKGROUND: Blood clot evacuation through an osteoplastic craniotomy, a procedure requiring neurosurgical expertise and modern medical facilities, is the accepted method for treatment of a pure traumatic epidural haematoma following closed head injury. In certain emergency situations and/or in less sophisticated settings, however, use of this procedure may not be feasible. The present study was undertaken to ascertain whether placement of a burr hole and drainage under negative pressure constituted a rapid, effective and safe approach to manage patients with simple epidural haematomas. METHODS: Thirteen patients suffering from a traumatic epidural haematoma were treated from January, 1999 to October, 2002. Twelve patients presented with skull fracture but no fracture was depressed. Placement of flexible tubes through a burr hole, followed by continuous suction under negative pressure, enabled aspiration of the clot and drainage of the cavity. In 8 cases, the procedure was performed under local anaesthesia with 2% Xylocaine and with intravenous sedation with propofol as needed. The operative procedure was accomplished within 30 min, and the drainage tube was left in place for 3-5 days. CT scans were performed daily from days 1 to 5. RESULTS: In 11 of 13 cases, clots were evacuated successfully and patients regained consciousness within 2 hours. Recoveries occurred without significant sequelae. In the remaining 2 cases, the drainage tube was found to be obstructed by a blood clot such that the haematoma was unaffected. A traditional craniotomy was performed within 8-12 hours, and these 2 patients recovered consciousness within the subsequent 6 hours. CONCLUSION: Burr hole evacuation followed by drainage under negative pressure is a safe and effective method for emergency management of a pure traumatic epidural haematoma. To assure safety patients given this procedure should be monitored by daily CT scans. Decompressive craniotomy should be performed if consciousness does not improve within several hours.

Adult↗
PubMed2004

A simple technique for expansive suboccipital cranioplasty following foramen magnum decompression for the treatment of syringomyelia associated with Chiari I malformation.

The benefits of osteoplastic suboccipital craniotomies over the traditional suboccipital craniectomies have been recognized. We describe a simple method of expansive suboccipital cranioplastic craniotomy using a free bone flap and report satisfactory clinical results in 16 patients with syringomyelia associated with Chiari I malformation. A free suboccipital bone flap is created from the rostral part of the occiput by placing two to four burr holes and connecting them with a craniotome. The posterior bony margin of the foramen magnum and the posterior arch of C1 are removed thereafter. Then dural plasty using a patch graft of dural substitutes is performed. The expansive suboccipital cranioplasty is performed by positioning the free bone flap caudal to the original location and fixing it with titanium miniplates to construct a bony frame to cover the foramen magnum. The rostral part of the cranial defect is filled with bone chips created during the craniotomy. Sixteen patients underwent this procedure. There was no operative mortality and no major complication, such as persistent pseudomeningocele. Preoperative symptoms improved significantly in all patients except for one who had persistent dysesthetic pain. Our simple method of expansive suboccipital cranioplasty for the treatment of syringomyelia associated with Chiari I malformation proved useful and achieved satisfactory long-term results.

Adolescent↗
PubMed1986

Intracranial pressure monitors. Epidemiologic study of risk factors and infections.

An increase in the number of cases of gram-negative ventriculomeningitis in patients followed with intracranial pressure monitors when compared with patients with craniotomy alone was revealed by routine surveillance data. A study was undertaken at four area institutions to describe the infections, risk factors, and management. Two hundred fifty-five patients with diagnoses of intracerebral hemorrhage (n = 86), closed trauma (n = 66), open trauma (n = 21), tumor (n = 66), and miscellaneous other conditions were compared with their nonmonitored counterparts for type of intracranial pressure monitor used, use of drains, prophylactic antibiotics, and steroids, and remote presence of infection. The presence of intracranial pressure monitor with craniotomy was associated with an 11 percent infection rate whereas craniotomy alone demonstrated a 6 percent rate. Of the intracranial pressure monitors used, the subarachnoid screw was associated with the lowest infection rate (7.5 percent) followed by the subdural cup catheter (14.9 percent) and the ventriculostomy catheter (21.9 percent). Regardless of the monitor used, infection was twice as likely to develop in patients with open trauma or hemorrhage. The use of bacitracin flush solutions for maintenance of lumen patency was more often associated with infections. Use of prophylactic antibiotics did not significantly influence outcome.

Adolescent↗
PubMed1993

Unilateral pterional approach to bilateral cerebral aneurysms.

Between 1976 and 1991, we determined that 19 patients harboring bilateral supratentorial aneurysms should be approached in a single sitting through a unilateral pterional craniotomy. Using microsurgical techniques, the Sylvian cistern was opened widely to expose the aneurysms located ipsilateral to the craniotomy. These aneurysms were clipped in the usual fashion. Following clipping, a tunnel was developed over the contralateral anterior cerebral artery and over or under the contralateral optic nerve allowing access to the opposite carotid and middle cerebral arteries. The contralateral nonruptured aneurysms were clipped in a routine fashion. We were able to clip or wrap with muscle all bilateral aneurysms in 15 cases, and we have concluded that this approach can be safely employed in selected patients with bilateral supratentorial aneurysms, and thus a second craniotomy can be avoided.

Adult↗
PubMed2006

An unusual intracranial tumour presenting in pregnancy.

We describe a patient who presented in late pregnancy with deteriorating neurological status due to an intracranial capillary haemangioma causing mass effect and raised intracranial pressure. She became confused and uncooperative leading to practical difficulties in performing adequate radiological imaging. Decision regarding timing of delivery and craniotomy was not straightforward and required discussion between the neurosurgeon, obstetrician and anaesthetist based on assessment of fetal maturity and the need to perform a craniotomy to excise what was initially thought to be a meningioma. Caesarean section was performed under general anaesthesia. The tumour was resected three weeks later. Management of obstetric patients with brain tumours is complex, requiring knowledge of the physiological effects of pregnancy on tumour size and labour on intracranial pressure. Both of these may influence the choice of labour analgesia or anaesthesia for caesarean section. Anaesthetists must be aware of the difficulties of radiological imaging during pregnancy, particularly in confused patients. The conflicting requirements of general anaesthesia for craniotomy and caesarean section should be considered.

Adult↗
PubMed2006

Patient-specific model of brain deformation: application to medical image registration.

This contribution presents finite element computation of the deformation field within the brain during craniotomy-induced brain shift. The results were used to illustrate the capabilities of non-linear (i.e. accounting for both geometric and material non-linearities) finite element analysis in non-rigid registration of pre- and intra-operative magnetic resonance images of the brain. We used patient-specific hexahedron-dominant finite element mesh, together with realistic material properties for the brain tissue and appropriate contact conditions at boundaries. The model was loaded by the enforced motion of nodes (i.e. through prescribed motion of a boundary) at the brain surface in the craniotomy area. We suggest using explicit time-integration scheme for discretised equations of motion, as the computational times are much shorter and accuracy, for practical purposes, the same as in the case of implicit integration schemes. Application of the computed deformation field to register (i.e. align) the pre-operative images with the intra-operative ones indicated that the model very accurately predicts the displacements of the tumour and the lateral ventricles even for limited information about the brain surface deformation. The prediction accuracy improves when information about deformation of not only exposed (during craniotomy) but also unexposed parts of the brain surface is used when prescribing loading. However, it appears that the accuracy achieved using information only about the deformation of the exposed surface, that can be determined without intra-operative imaging, is acceptable. The presented results show that non-linear biomechanical models can complement medical image processing techniques when conducting non-rigid registration. Important advantage of such models over the previously used linear ones is that they do not require unrealistic assumptions that brain deformations are infinitesimally small and brain stress-strain relationship is linear.

Brain↗
PubMed2006

Intracranial complications of pediatric sinusitis.

OBJECTIVE: To study intracranial extension of pediatric sinusitis, an infrequent but potentially fatal complication. STUDY DESIGN AND SETTING: Ten-year retrospective review at a tertiary children's hospital identified 21 cases of intracranial complications of sinusitis. RESULTS: Thirteen males and eight females with mean age of 13.3 years were identified. Overall 18 of 21 (81%) exhibited abscess formation, most commonly epidural. Only 3 of 21 (14%) had meningitis alone. All but 4 patients were managed surgically, requiring craniotomy in 13 of 21 (61.9%) and endoscopic sinus surgery (ESS) in 10 of 21 (48%). Seven patients (33%) required multiple operations during admission. Nineteen patients (90%) had a total of 30 organisms cultured. Oral flora was observed in 12 of 21 (57%). Polymicrobial infections, seen in 9 of 21 (43%), were significantly associated with the need for craniotomy (P=0.02). Mean hospital stay was 15 days, and mean length of IV antibiotic was 5 weeks. CONCLUSIONS: Intracranial complications of pediatric sinusitis often require craniotomy. Oral flora and polymicrobial infections were prominent in this series. EBM RATING: C-4.

Adolescent↗
PubMed2004

[Usefulness of risk indexes for the prediction of surgical site infection in patients undergoing neurosurgical procedures].

BACKGROUND AND OBJECTIVE: The use of risk indexes, originally developed in the US for the assessment of SSI risk, is an useful instrument that must be analyzed according to each specific procedure. The addition of other possible SSI risk factors, like the use of perioperative antibiotic prophylaxis, could improve the predictive value of these indexes. The aim of this study was to determine the SSI incidence rate for craniotomy in patients admitted to the Neurosurgical Unit of the Hospital Clinic of Barcelona (Spain), to assess the use of standard NNIS and SENIC indexes, and to assess the possible effect of the addition of a new risk factor (adequate or inadequate use of perioperative antibiotic prophylaxis) to these indexes. PATIENTS AND METHOD: Risk factors for SSI were assessed following common standard definitions and procedures (CDC-NNIS) over a three-year period (1999-2001). NNIS and SENIC risk indexes were calculated. The effect of the addition of a new variable, namely perioperative antibiotic prophylaxis adequate (0 points) or inappropriate/no prophylaxis (1 point) on these indexes (modified indexes NNISa and SENICa) was also assessed. Statistical analysis included both parametric and non-parametric standard tests. RESULTS: The study included a total of 203 patients undergoing a craniotomy procedure (40% of all neurosurgical procedures). The overall SSI incidence rate was 6.8% (14 patients developed SSI). The cut-off point (75 percentile) for the duration of the procedure was 180 minutes instead of the commonly US reported 240 minutes. Patients who develop SSI had a trend towards having shorter operation times. For those patients in the lower risk groups, the SSI incidence rate was: NNIS (0, 1): 6.9%; SENIC (0, 1): 6.2%. If the modified indexes were used, the SSI incidence rate was: NNISa (0, 1): 4.2%; SENICa (0, 1): 4.9%. When NNIS and SENIC indexes, both standard and modified (NNISa and SENICa), were compared, no statistically significant differences between infected and non-infected patients were observed. CONCLUSIONS: When applied to a health system other than the US, SENIC and NNIS indexes could be useful if adapted to each specific situation and procedure. The added value of a new risk factor (perioperative antibiotic prophylaxis) on standard NNIS and SENIC indexes shows a slight improvement in their prediction rate for SSI in patients undergoing craniotomy, mainly in those patients at lower risk for developing superficial SSI.

Antibiotic Prophylaxis↗
PubMed2000

Bone flap fixation with titanium clamps: a new technique.

BACKGROUND: Craniotomy bone flaps are replaced for both cosmetic and protective purposes. The purpose of this study was to determine the facility, strength, timing, and cost effectiveness of an alternative system for securing bone flaps. The system consists of titanium discs that clamp the bone flap to the skull edge. METHODS AND RESULTS: Ten cadaver craniotomy flaps each were reattached with either 24-gauge wire, miniplates, or titanium clamps. The titanium clamp system required significantly less time to fix than either wire or miniplates. The clamps were stronger than wire and cost less than miniplates. CONCLUSION: The titanium clamp system is a reasonable alternative to present craniotomy fixation methods with respect to ease of use, time consumption, strength, and relative cost.

Craniotomy↗
PubMed2002

Severe intraoperative air embolism during convexity meningioma surgery in the supine position. Case report.

BACKGROUND: Acute venous air embolism (AE) is a well-known intraoperative complication of neurosurgical procedures, especially during surgical procedures performed in the sitting position, but it is a rare complication in the supine position. A case of a patient who developed an AE during a supratentorial craniotomy in the supine position is presented and the literature is reviewed. CASE DESCRIPTION: A 45-year-old man had a large left frontal convexity meningioma. He was operated upon and, during craniotomy in the supine position, suffered a massive episode of air embolism with severe respiratory and hemodynamic changes. The AE episode occurred while we were cutting the bone for the craniotomy before turning the bone flap. Because the patient was bleeding profusely, the bone flap was quickly removed to achieve hemostasis. Aspiration of irrigant into the cut bone surfaces through several venous diploic channels in the bone edges was observed. The procedure was terminated when hemostasis was achieved. The meningioma was successfully removed in a second operation. CONCLUSION: We think that our case should serve to warn the neurosurgical community about the risk of AE in supratentorial procedures in the supine or semisitting positions when preoperative radiological imaging studies show the presence of important venous channels in relation to the site of the tumor.

Craniotomy↗
PubMed1999

Endoscopic management of nasal glioma in infancy.

In the surgical treatment of nasal glioma, craniotomy has been recommended for excluding the possibility of intracranial extension of the lesion. We describe a case in whom intranasal glioma was successfully removed by endoscopic surgery without craniotomy at 4 months old. Intranasal endoscopic surgery is considered appropriate for the removal of intranasal glioma having no intracranial extension, since the procedure is less invasive and does not result in postoperative facial deformity. Intranasal endoscopic surgery is also proposed as the preferable procedure to craniotomy for excluding intracranial extension of intranasal glioma.

Brain↗
PubMed1995

Use of computed tomography of the head in the hypotensive blunt-trauma patient.

STUDY OBJECTIVE: To identify patients presenting with hypotension due to blunt trauma who should undergo computed tomography (CT) of the head before urgent chest or abdominal operation. DESIGN: Retrospective registry-based record review. SETTING: Urban Level I trauma center. PARTICIPANTS: Consecutive trauma patients with suspected head injury, blunt mechanism of injury, and hypotension who were discharged between January 1, 1989, and December 31, 1991. Patients who were dead on arrival or died within 15 minutes of arrival were judged unsalvageable and excluded. Review of 3,224 trauma patients identified 212 as the study population. INTERVENTIONS: Frequency of neurosurgical intervention or general surgical intervention within 6 hours of admission and the time required for completion of CT of the head were noted. RESULTS: Overall, 40 general surgical operations (19%) and 16 craniotomies (8%) were performed, with a mortality rate of 18%. Patients with Glasgow Coma Scale scores of less than 8 had a 19% rate of craniotomy, and those with scores between 8 and 13 had a 9% rate. Sixteen patients had CT before surgery, with an average delay of 68 minutes. No patient who responded to initial resuscitation experienced hemodynamic instability in the CT suite, including 15 patients with positive diagnostic peritoneal lavage. CONCLUSION: CT scan of the head before general surgical operation appears to be safe in patients who respond to initial resuscitation. The likelihood of craniotomy in patients with Glasgow Coma Scale scores of 13 or less is comparable to the likelihood of general surgical operation. Physicians should be encouraged to make CT of the head a high priority in this group.

Adult↗
PubMed1989

The surgical correction of fronto-ethmoidal meningo-encephaloceles.

One-stage correction of fronto-ethmoidal meningo-encephaloceles and related stigmata, via an orbito-cranial approach, is recommended. A bifrontal craniotomy is only required when simultaneous correction of hypertelorism is to be undertaken. A combined intra- and extracranial approach is essential. The possibility of a high relapse rate for repaired fronto-ethmoidal meningo-encephaloceles, together with the possibility of prolonged postsurgical cerebrospinal fluid leakage, meningitis and other complications is invited when either a transcranial bifrontal craniotomy surgical approach, or an extracranial approach via the facial lesion, is undertaken alone. Modification of existing craniofacial surgical approaches in order to avoid a frontal craniotomy, allowed for good repair of the encephalocele together with significant benefits in terms of simplification of the surgical procedure, operating time, blood loss, frontal lobe retraction and complications.

Bone Transplantation↗
PubMed2001

Preoperative and postoperative seizures in patients with astrocytic tumours: analysis of incidence and influencing factors.

To evaluate the incidence and influencing factors related to preoperative and postoperative seizures, a retrospective analysis was performed in 190 patients with astrocytic tumours. Preoperative seizures occurred in 50 (26%) patients and 27 (54%) of the m had recurrent seizures. Late-onset seizures developed after craniotomy in 11 (8%) of 140 patients. Seizures at presentation were significantly correlated with age at diagnosis (P=0.0204) and pathological grade of tumour (P=0.0040). The patients aged less than 40 years had a high risk of seizures at presentation (odds ratio=3.076, P=0.0134). Postoperative seizures were significantly associated with the presence of preoperative seizures (P<0.0001), type or duration of preoperative seizures (P<0.0001, P<0.0001, respectively) and serum level of anticonvulsant drug (P=0.0068). However, only the presence of preoperative seizures had a potential for prediction of postoperative seizures when evaluated by logistic regression model (odds ratio=20.859, P=0.0001). Fifty-nine percent of patients with recurrent seizures and 64% of patients with late-onset seizures had seizures which occurred within 6 months after craniotomy. Despite therapeutic anticonvulsant levels, most postoperative seizures were associated with tumour recurrence or haemorrhage. Postoperative seizures commonly occurred relatively soon after craniotomy and prophylactic anticonvulsants should be given. In patients with postoperative seizures, particularly in the presence of therapeutic anticonvulsant level, brain computed tomography should be performed to exclude tumour recurrence or haemorrhage.

Adolescent↗