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PubMed1994

Incidence of postoperative epilepsy in children following subfrontal craniotomy for tumor.

Thirty-one children who underwent 36 subfrontal craniotomies were retrospectively studied to determine the incidence of postoperative epilepsy and the effectiveness of antiepileptic drugs for seizure prophylaxis. The incidence of postoperative epilepsy following a subfrontal craniotomy did not exceed 12% when examined at various time periods during a 3-year postoperative course. Antiepileptic drugs were not warranted to reduce the incidence of postoperative seizures after the 1-month postoperative period and should not be used for long-term prophylactic therapy in children following a subfrontal craniotomy.

Anticonvulsants↗

PubMed2006

Effect of scalp block on postoperative pain relief in craniotomy patients.

The efficacy of scalp nerve block using 0.5% bupivacaine with adrenaline for postoperative pain relief in craniotomy patients was evaluated in 40 ASA I or II adult patients undergoing supratentorial craniotomy. A standard general anaesthesia technique was followed. Patients were randomly divided into two groups. Group B received 0.5% bupivacaine with 1:400,000 adrenaline and group S received normal saline with 1:400,000 adrenaline, both after skin closure. Postoperative pain was assessed at 30 seconds and 1, 2, 4, 6, 8 and 12 hours using a numerical rating scale. Diclofenac IM was administered as rescue analgesia if patients reported a numerical rating scale of 40 or more. Tramadol IV was administered as second rescue analgesia. Sixty per cent of patients in group S experienced moderate to severe pain (numerical rating scale of 40 or more) at some time during the first 12 postoperative hours in comparison to 25% patients in group B. Median pain scores were significantly lower in group B for up to 6 hours. Significantly more patients were pain free up to four hours in group B. Median duration for the requirement of first dose of diclofenac was longer in group B compared to group S (360 min vs 30 min, P < 0.01). The number of doses of diclofenac (5 vs 19) was significantly lower in group B compared to group S (P < 0.01). Tramadol was required by six patients in group S only. Scalp nerve block using 0.5% bupivacaine with 1:400,000 adrenaline decreases the incidence and severity of postoperative pain in patients undergoing supratentorial craniotomy.

Adrenergic Agonists↗

PubMed2004

The comparative effects of desflurane and isoflurane on lumbar cerebrospinal fluid pressure in patients undergoing craniotomy for supratentorial tumors.

UNLABELLED: We compared the effects of desflurane and isoflurane on cerebral perfusion pressure (CPP), lumbar cerebrospinal fluid pressure (LCSFP), and mean arterial blood pressure (MAP) in patients anesthetized with desflurane or isoflurane undergoing craniotomy for supratentorial mass lesions. Additionally, emergence from anesthesia was examined to determine if neurologic function could be assessed earlier after isoflurane or desflurane anesthesia. Thirty-six patients were randomized to receive either desflurane or isoflurane for maintenance of anesthesia at 1.2 minimum alveolar concentration (MAC). Patients were hyperventilated (PaCO(2), 30 +/- 2 mm Hg) after baseline LCSFP was obtained via the subarachnoid catheter. At a MAC of 1.2, mean LCSFP was not statistically different between the two study groups either before or after hyperventilation. Additionally, CPP was not significantly different between the two groups. Finally, patient's time to respond to commands was 50% shorter in the desflurane group (30 +/- 36 min) (mean +/- SD) when compared with the isoflurane group (72 +/- 126 min); however, this was not significant (P = 0.17). In patients undergoing craniotomy for supratentorial mass lesions, desflurane and isoflurane have similar effects on CPP and MAP. Additionally, desflurane in the setting of hyperventilation does not cause significant changes in LCSFP. IMPLICATIONS: This is the largest study to date comparing the effects of desflurane and isoflurane on patients undergoing craniotomy for supratentorial mass lesion with evidence of midline shift or edema. Neither desflurane nor isoflurane significantly altered lumbar cerebrospinal fluid pressure when moderate hypocapnia was maintained.

Aged↗

PubMed2006

The incidence and risk factors for hypotension during emergent decompressive craniotomy in children with traumatic brain injury.

We conducted a retrospective cohort study in children <13 yr with traumatic brain injury (TBI) at a Level 1 pediatric trauma center to describe risk factors for intraoperative hypotension (IH) during emergent decompressive craniotomy. Between 1994 and 2004, 108 children underwent emergent decompressive craniotomy for TBI. Overall, 56 (52%) patients had IH. Independent risk factors for IH were each 10 mL estimated blood loss/kg (ARR 1.15 95% CI 1.08-1.22), each mm of computed tomography (CT) midline shift (ARR 1.04 95%CI 1.01-1.07), each 10 mL of CT lesion volume (ARR 1.03 95%CI 1.01-1.05), and emergency department (ED) hypotension (5/5 patients with ED hypotension had IH). CT midline shift > or =4 mm predicted IH (ARR 1.67 95% CI 1.06-2.63), independent of blood loss. IH occurred frequently during emergent decompressive craniotomy in children with TBI. ED hypotension, blood loss, CT lesion volume, and CT midline shift predicted IH. Anesthesiologists can expect children with preoperative CT midline shift > or =4 mm to have IH during this procedure.

Age Factors↗

PubMed1992

Modified supraorbital craniotomy: technical note.

The authors present a surgical approach that incorporates the frontal sinus and extends a supraorbital craniotomy to include the lateral orbital rim and zygoma. The craniotomy provides wide exposure of the anterior fossa, orbit, ipsilateral middle fossa, and cavernous sinus. The procedure can be performed easily, and the bone flaps can be secured rapidly back into the anatomical position at the time of closure. This modified supraorbital craniotomy is ideal for large benign lesions originating along the sphenoid wing or orbit that expand into the anterior fossa.

Craniotomy↗

PubMed2005

Craniotomy for fenestration of multiloculated hydrocephalus in pediatric patients.

OBJECTIVE: To assess the treatment of progressive multiloculated hydrocephalus by craniotomy for microsurgical fenestration of cerebrospinal fluid (CSF) compartments to minimize the number of ventricular catheters. METHODS: We studied 33 pediatric patients who underwent craniotomies for fenestration of progressive multiloculated hydrocephalus between 1989 and 2003. In 20 of 33 patients, hydrocephalus was attributed to intraventricular hemorrhage associated with prematurity. Twenty-three of 33 patients had previous central nervous system infections. Craniotomy was typically performed via a posterior parietal approach. Communication between bilateral supratentorial loculated compartments and posterior fossa compartments was achieved. Surgical and neurological outcomes were assessed. RESULTS: Fenestration of loculated CSF spaces was performed successfully in all patients. No new neurological deficits were noted after surgery, and no patients required intraoperative blood transfusions. CSF infections within 3 months after surgery occurred in 4 of 33 patients. Over a median follow-up period of 3.7 years (range, 1.5 mo to 8.7 yr), 19 of 33 patients required additional fenestration procedures. The number of repeat fenestration procedures ranged from one to six, and a total of 47 additional fenestrations were performed in these 19 patients. The majority of patients (n = 25) ultimately required shunt systems with only one ventricular catheter. The neurological status of these patients was extremely poor both before and after surgery. Twenty-nine of 33 patients were severely delayed, and four were mildly delayed. CONCLUSION: Fenestration of multiloculated CSF compartments can enable most patients to function with a single ventricular catheter shunt system. Neurological status remains poor in this patient population.

Catheterization↗

PubMed2006

Eyebrow surgery: the supraciliary craniotomy: technical note.

OBJECTIVE: Many approaches have been recommended for the surgical treatment of anterior and middle cranial fossa lesions. The frontobasal approach and its many modifications have been proposed and developed for such situated lesions. An alternative approach is the frontolateral craniotomy through a supraciliary skin incision. METHODS: This minimally invasive technique, a 2.5 x 3.0 cm craniotomy, just above the eyebrow through a supraciliary incision, is a simple but elegant modification of the traditional approach to the anterior cranial fossa. RESULTS: A step-by-step description of the approach is offered in this report to facilitate a clear understanding of the lesions treatable with this minimally invasive technique. CONCLUSION: The supraciliary frontolateral keyhole craniotomy is a minimally invasive cosmetic approach that provides excellent exposure to a variety of intracranial lesions. This approach cannot be used for all intracranial pathologies, but is recommended for many anterior and middle cranial fossa lesions.

Adolescent↗

PubMed2006

Postoperative pain management after craniotomy: evaluation and cost analysis.

OBJECTIVE: Patients undergoing craniotomies have traditionally received opiates for the management of their postoperative pain. The use of narcotic pain medications can be costly, can decrease early walking, can lengthen hospital stay, and can alter a patient's neurological examination results. The use of alternative pain medications such as cyclooxygenase-2 (COX-2) inhibitors may benefit patients by resolving many of these issues. Compared with traditional nonsteroidal anti-inflammatory drugs, these anti-inflammatory medications may be used safely in neurosurgical patients because of their selective inhibition of the COX-2 enzyme, which avoids the platelet dysfunction caused by other nonsteroidal anti-inflammatory drugs. METHODS: A randomized, single-blinded prospective study was used to evaluate the efficacy of alternative pain management strategies for patients who have undergone craniotomy. Twenty-seven patients were randomly assigned to a control group (n = 13) receiving narcotics alone or an experimental group (n = 14) receiving a COX-2 inhibitor in addition to narcotic pain medications. RESULTS: The narcotics group was noted to have statistically significantly higher visual analog scale scores, increased length of stay, and increased narcotic use compared with the COX-2 group. The narcotics group also had increased hospitalization costs when compared with the COX-2 group. CONCLUSION: The use of scheduled atypical analgesics, such as COX-2 inhibitors, in addition to narcotics for the management of postoperative pain after craniotomy may provide better pain control, may decrease side effects associated with narcotic pain medications, may encourage earlier walking, and may reduce total hospitalization costs.

Acetaminophen↗

PubMed1983

Mini-craniotomy for management of CSF otorrhea from tegmen defects.

CSF otorrhea arising from defects in the tegmen and middle fossa dura may be congenital or acquired. It may be spontaneous or secondary to trauma, chronic ear disease, tumor or surgical treatment. In the six cases presented, the tegmen defect and associated CSF leak were secondary to chronic ear disease in two cases, to mastoid surgery in two cases, to temporal bone fracture and congenital origin in one case each. The successful management of these patients utilizing a mini-craniotomy in conjunction with mastoid surgery is described. Mini-craniotomy facilitates precise extradural, intracranial placement of an autogenous graft over the tegmen defect which can be technically difficult in the transmastoid approaches, yet avoids the morbidity and potential complications of a full middle fossa craniotomy. It does not significantly add to the length of the mastoid procedure or its complications.

Cerebrospinal Fluid Otorrhea↗

PubMed2000

Posterior fossa craniotomy. Technical report.

The use of craniotomy to approach supratentorial lesions is quite well established in the literature. The use of craniotomy for posterior fossa approaches, however, is not well described. The aim of this article is to describe the technical aspects of this approach and to delineate the important landmarks. In our cases, posterior fossa craniotomies have been utilized for treat different pathologies. Additionally, the technique has not added any additional risk, and the cosmetic results have been excellent.

Adult↗

PubMed1995

Postoperative chronic subdural hematoma following craniotomy--four case reports.

Postoperative chronic subdural hematoma (CSH) following craniotomy developed in only four of 372 patients undergoing craniotomy for aneurysm surgery (1 patient) and brain tumor surgery (3 patients) between April, 1991 and November, 1993, an incidence of only 1.1%. There were three males and one female, aged from 32 to 66 years (mean 56 yrs). The period between craniotomy and development of CSH ranged from 3 to 5 months (mean 4.3 mos). Postoperative hematomas were located on the operative sides in three patients and the contralateral side in the other. Early postoperative computed tomographic scans found subdural fluid collection in all patients. Magnetic resonance images showed linear meningeal enhancement in all patients. Postoperative CSH may be caused by mixture of blood in subdural cerebrospinal fluid collection which persists due to reduced brain elasticity and wide subarachnoid membrane opening resulting in neomembrane formation and finally development of hematoma.

Adult↗

PubMed2001

Organized chronic subdural hematoma requiring craniotomy--five case reports.

Two child and three elderly patients underwent craniotomy for organized and/or partially calcified chronic subdural hematomas (CSHs). The characteristic feature of magnetic resonance imaging was a heterogeneous web-like structure in the hematoma cavity. Both children had undergone one side subduroperitoneal shunt for bilateral CSHs when infants. As a result, the opposite hematoma cavities persisted and developed into calcified CSHs after a couple of years. All three elderly patients with senile brain atrophy showed various systemic complications such as cerebral infarction, diabetes mellitus, leg ulceration, cirrhosis, and bleeding tendency. Craniotomy for removal of the hematoma and calcification achieved good results in all patients. Subdural space created by shunt, craniotomy, or brain atrophy and persisting for a certain period, and additional various brain damage such as microcirculatory disorder, meningitis, encephalitis, or premature delivery may be important in generating calcified or organized CSH.

Aged↗

PubMed2005

Use of a rivet-like titanium clamp closure system to replace an external frontal bone flap after transfrontal craniotomy in a dog.

A 10-year-old spayed female dog was referred for surgical removal of a brain tumor that had been identified following an acute onset of seizure activity 2 weeks earlier. A computed tomographic evaluation involving contrast agent revealed the presence of a contrast-enhanced mass within the left olfactory lobe of the brain. After removal of the mass via a transfrontal craniotomy, the overlying frontal bone flap was replaced and secured by use of a biologically inert rivet-like titanium clamp closure system and 3 titanium alloy craniotomy line clamps. On reevaluation 4 weeks after tumor removal, the dog was free of seizure activity and had no proprioceptive deficits; according to the owner, the dog had marked improvement in its overall behavior and attitude. The titanium clamp closure system appears to offer an effective and rapid technique for the secure replacement of craniotomy bone flaps in dogs.

Animals↗

PubMed1991

Efficacy of cloxacillin prophylaxis in craniotomy: a one year follow-up study.

A previous prospective double-blind placebo-controlled study showed that cloxacillin prophylaxis significantly reduces the rate of infection after craniotomy. The purpose of the present follow-up study was to find out whether the data on routine cloxacillin prophylaxis would confirm the decreased infection rate after craniotomy. During this 1-year study, 8 infections occurred after 201 operations (4.0%) in 175 patients. No prophylaxis was given during 17 operations in 15 patients; 4 infections occurred in this group. The most frequently isolated microorganisms were Staphylococcus aureus, S. epidermidis, and Propionibacterium acnes, all of which were sensitive to cloxacillin. We conclude that cloxacillin is beneficial as prophylaxis in patients undergoing craniotomy.

Adolescent↗

PubMed2002

Factors affecting profitability for craniotomy.

OBJECT: The authors studied factors influencing hospital profitability after craniotomy in patients who underwent craniotomy coded as diagnosis-related group (DRG) 1 (17 years of age with nontraumatic disease without complication) and who met their hospital's craniotomy pathway criteria and had a hospital length of stay 4 days or less during a 20-month period. METHODS: Data in all patients meeting these criteria (76 cases) were collected and collated from various hospital databases. Twenty-one cases were profitable and 55 were not. Variables traditionally influencing cost of care, such as surgeon, procedure, length of operation, and pharmacy use had no significant effect on whether a patient was profitable. The most important influence on profitability was the individual payor. Cases in which care was reimbursed under the prospective payment system based on DRGs were nearly always profitable whereas those covered by per diem plans were nearly always nonprofitable. CONCLUSIONS: 1) Hospital information systems should be customized to deliver consolidated data for timely analysis of cost of care for individual patients. This information may be useful in negotiating profitable contracts. 2) A clinical pathway was successful in reducing the difference in cost of care between profitable and nonprofitable postcraniotomy cases. 3) In today's health care environment both cost containment and revenue assume importance in determining profitability.

Adolescent↗

PubMed2003

Anatomy of the combined retrolabyrinthine-middle fossa craniotomy.

The goal of combined retrolabyrinthine-middle fossa craniotomy is to provide exposure of both the middle and posterior cranial fossae via a partial petrosectomy and division of the tentorium. Its major benefits over others are that hearing and facial nerve function are preserved and only minimal brain retraction is required. The retrolabyrinthine approach involves a presigmoid posterior fossa craniotomy that preserves the structures of the inner ear. Additionally, a middle fossa craniotomy, extending to the zygomatic root, is performed to gain access to the superior aspect of the temporal bone in the middle cranial fossa. This approach works well in cases of lesions involving the petroclival junction, including petroclival meningiomas, trigeminal schwannomas, epidermoids, and large chondrosarcomas or chordomas with intradural components. The authors describe the surgical technique of this approach.

Cranial Fossa, Middle↗

PubMed1985

Evaluation of the risks of anticoagulation therapy following experimental craniotomy in the rat.

The risk of hemorrhagic complications with anticoagulation therapy in patients following intracranial surgery has prevented investigation of the potential use of heparin in the early postoperative period. The authors have evaluated the safety of anticoagulation therapy following experimental craniotomy in male Holtzman rats. The dose and schedule of heparin administration, which elevated and maintained the activated partial thromboplastin time (APTT) within the therapeutic range of 1 1/2 to 3 X control APTT, was alternating doses of 400 and 500 IU/kg injected subcutaneously every 6 hours. This schedule was initiated 2, 4, 7, 10, and 14 days after craniotomy and was continued for 72 hours thereafter. The results demonstrated that the incidence of intracerebral hemorrhage declined as the postoperative interval prior to initiation of anticoagulation increased. If anticoagulation therapy was initiated during the first 7 postoperative days, the risk of intracerebral hemorrhage was high (mean 14.7%): however, if an additional 3 to 7 days elapsed prior to initiation of anticoagulation, the incidence of intracerebral hemorrhage dropped significantly (mean 0%) (p less than 0.05). These results suggest that anticoagulation therapy can be safely initiated 10 to 14 days after craniotomy.

Animals↗

PubMed1991

Stereotactic craniotomy in the resection of small arteriovenous malformations.

Surgical resection of 10 obscure arteriovenous malformations (AVM's) was accomplished with craniotomy guided by computerized tomography (CT) or angiography and the use of the Brown-Roberts-Wells stereotactic frame. Stereotactic craniotomy was invaluable for resection of the following types of AVM's: 1) AVM's with a nidus less than 2 cm in diameter, 2) AVM's located in an eloquent area of the brain, and 3) AVM's located deep in the brain. Stereotactic localization of these AVM's on preoperative radiological studies provides a precise route to the nidus, often avoiding important areas of the brain. This series included six male and four female patients with a mean age of 32 years. All patients presented with an intracerebral hemorrhage, from which eight made a complete neurological recovery prior to surgery. Two AVM's were located on the cortex, three were found subcortically, and five were situated near the ventricles or in the deep white matter. As a guide, angiography was used in six cases and CT in four cases. In each instance, the study providing the best image of the AVM nidus was employed. Postoperatively, no neurological deficits were found in eight patients and, in the two patients with preoperative deficits, neurological improvement was observed after recovery from surgery. Postoperative studies revealed complete removal of the AVM in all patients, and all lesions were confirmed histologically. The authors conclude that stereotactic craniotomy provides the optimum operative approach for the localization and microsurgical resection of AVM's that are either obscure or located deep in the brain.

Adolescent↗