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Electroconvulsive therapy (ECT) was used to treat a patient with a large left frontal craniotomy and remaining frontal meningioma. Treatment was successful and uneventful. ECT should be considered in the treatment of drug-resistant depressed patients with craniotomies and remaining tumor.
In this study we investigated the effect of topical application of cool irrigation fluid on brain tissue temperature during craniotomy. Eight patients were given a standard general anaesthetic for craniotomy. Distal oesophageal and nasopharyngeal temperatures were measured continuously and systemic normothermia was maintained. A sterile needle temperature probe was inserted 18 mm into the cerebrum to measure brain temperature. Brain temperatures were recorded for five minutes while the brain was irrigated with 1000 ml of normal saline at a temperature of 30 degrees C. Measurement continued until the brain temperature returned to baseline. The mean maximum decrease in cerebralparenchymal temperaturefollowing irrigation was 1.6 +/- 0.5 degrees C (P<0.01). The average time to return to baseline temperature after cessation of irrigation was 5.3 +/- 1.5 minutes. Cooling the brain has a marked protective effect after brain injury, but systemic hypothermia can produce significant harmful effects. This study demonstrates that the use of cool irrigation fluid during neurosurgery is a simple and effective method of cooling the brain whilst minimizing the use of systemic hypothermia.
OBJECTIVE: To describe a new craniotomic technique that eliminates burr holes and minimizes bone loss along the craniotomic line. PATIENTS AND METHODS: Fifty burr hole free craniotomies were performed in varied locations using an image-guided micro-oscillating saw. Care was taken to avoid cutting the inner cortical layer. Upon completing the micro-oscillating saw cut the inner table could then be gently fractured along the craniotomic line with a thin bladed osteotome. Simple silk sutures were used to resecure the bone flap. RESULTS: The craniotomic time required for this procedure ranged from 7 to 24 minutes (mean: 13 minutes). We observed no dural lacerations or signs of brain damage in any of these procedures. The use of image guidance allows a continuous measure of bone thickness along the craniotomic line. In all of the cases we report the cosmetic result was excellent. CONCLUSION: This alternative technique of craniotomy can be used in selected cases to achieve excellent cosmetic results which avoid the time and cost of complex reconstruction techniques.
BACKGROUND: Supratentorial intracerebral hematomas often are evacuated in rapidly deteriorating patients. Surgery may prevent death but not necessarily disability. The authors studied the outcome of emergent clot evacuation in patients with worsening massive intracerebral hemorrhage. METHODS: The authors reviewed data on 26 consecutive, acutely worsening patients with nontraumatic intracerebral hemorrhage who had surgery for clot evacuation. All patients had clinical (stupor or coma, loss of pontomesencephalic brainstem reflexes, extensor posturing) or radiologic (midline shift of septum pellucidum > or =1 cm downward or obliteration of the ambient and suprasellar cisterns caused by displacement of the temporal uncus) signs of herniation. Outcome was defined using the Glasgow Outcome Scale (GOS). RESULTS: Fifty-six percent of patients died (GOS 1), 22% remained severely disabled (GOS 3), and 22% regained independence (GOS 4-5). Considering findings before surgery, upper brainstem reflexes were preserved more often in survivors (66% vs. 14%; p = 0.01). All patients who had a combination of absent pupillary, corneal, and oculocephalic reflexes and extensor posturing before craniotomy died. No patient lacking corneal or oculocephalic reflexes prior to surgery regained functional independence. CONCLUSIONS: Craniotomy for rapidly worsening patients with supratentorial intracerebral hemorrhage and radiologic signs of brain tissue shift may result in functional independence in approximately a quarter of patients. However, all comatose patients who lost upper brainstem reflexes and had extensor posturing died despite surgery.
UNLABELLED: Because anesthetic technique has the potential to dramatically affect cerebral blood flow and metabolism (two determinants of brain thermoregulation), we tested the hypothesis that, after craniotomy, anesthetic technique would influence brain temperature independent of core temperature. Twenty-one cats (2.7 +/- 0.4 kg; mean +/- SD) undergoing a uniform right parasagittal craniotomy received 1) halothane 1.5% end-expired and normocapnia (HN), 2) halothane 1.5% and hypocapnia (HH), or 3) large-dose pentobarbital and normocapnia (PN) (n = 7 per group). Heating devices initially maintained core and right subdural normothermia (38.0 degrees C). Thereafter, cranial heating was discontinued. Brain-to-core temperature gradients during the 3 h study were greatest in the right subdural area, averaging -2.5 degrees C +/- 0.9 degrees C in HN, -2.5 degrees C +/- 0.8 degrees C in HH, and -4.1 degrees C +/- 1.1 degrees C in PN. Gradients within the unexposed left subdural area and in the right cortex 0.5 and 1.0 cm below the brain surface were -0.8 degrees C +/- 0.5 degrees C to -1.1 degrees C +/- 0.6 degrees C for both HN and HH but were twice this amount in PN (-1.9 degrees C +/- 0.5 degrees C to -2.1 degrees C +/- 0.7 degrees C) (P < 0.05 for PN versus HN and HH). Deep barbiturate anesthesia can reduce brain temperature independently of core temperature, presumably by reducing the metabolic rate and associated brain heat production. The magnitude is sufficient to augment any direct cerebroprotective properties of the barbiturates. IMPLICATIONS: Deep barbiturate anesthesia reduced brain temperature independently of body temperature in cats and significantly more than the reduction seen with halothane anesthesia. The magnitude of temperature reduction was sufficient to account for cerebral protection by barbiturates independently of any other properties of the drug.
In this study we compared the effectiveness of the use of remifentanil to fentanyl in conjunction with propofol in providing conscious sedation for awake craniotomy for tumor surgery and to assess patient satisfaction with both techniques. The ability to maintain appropriate levels of sedation, adequate analgesia, and hemodynamic stability was assessed in 50 patients randomized to receive either fentanyl or remifentanil. All complications were documented. Patients were interviewed at 1 h, 4 h, and 24 h after surgery to note their recall of procedure and pain and their overall satisfaction. There were no differences in sedation and pain scores or in hemodynamic and respiratory variables between the two groups. The incidence of intraoperative complications was not different (fentanyl, 14; remifentanil, 16). Respiratory complications occurred in 9 (18%) patients (fentanyl 6, remifentanil 3). The recall and satisfaction scores were not different; 93% of all patients were completely satisfied at all interview times. The use of remifentanil infusion in conjunction with propofol is a good alternative to fentanyl and propofol for conscious sedation for the awake craniotomy and these techniques are both well accepted by the patient.
Dexmedetomidine, approved for providing sedation in the critical care environment, is also used during awake craniotomies to facilitate procedures such as cortical mapping. Herein, we describe the use of dexmedetomidine as a rescue drug during awake craniotomy avoiding conversion to general anesthesia, thus allowing completion of cortical mapping.
A series of 42 patients who had large decompressive craniotomies for acute subdural hematoma has been reviewed with regard to long term results. Postoperative mortality (within 30 days of surgery) was 36%. Delayed but related deaths accounted for an additional 19% mortality, for a total mortality of 55%. Fourteen patients (33%) were able to return home, but there was a significant morbidity in terms of intellectual impairment, hemiparesis, and dysphasia. Recommended management includes establishment of an adequate airway, intravenous administration of mannitol, and performance of an emergency computerized tomographic (CT) scan before operation. A large decompressive craniotomy is performed, with removal of the blood clot, establishment of hemostasis, patch-grafting of the dura, and removal of the bone flap to allow the edematous, swollen brain to expand away from the brain stem. The mortality and morbidity will probably always remain high because in the majority of the cases significant structural damage to the cortical and brain stem structures occurs at the time of the injury.
The authors report 57 patients in whom craniotomies for solitary intracranial metastatic tumor were performed in Vancouver General Hospital between 1970 and 1980. The median survival after craniotomy varied between 3.5 and 10 months depending upon the types of primary tumors. Patients with metastatic central nervous system (CNS) tumor from breast, kidney, or an unknown primary site had longer periods of survival than those with bronchogenic carcinoma. The outcome for metastatic melanoma was poor. Eighty-two per cent of the patients were able to enjoy home life and were self-dependent at the time of discharge from the hospital. A long latent interval between the primary tumor diagnosis and secondary CNS metastasis favored longer survival for patients with bronchogenic carcinoma, but not for those with melanoma. The presence of systemic metastases was an adverse factor. There was no significant difference in the duration of survival between patients with right- or left-sided cerebral lesions, but those with right hemispheric involvement had a better quality of survival. The use of computed tomographic scanning improved both the duration and the quality of postoperative survival.
It has been demonstrated that central conduction time (CCT) is slowed and that attenuation of cortical potentials occurs with reduced cerebral perfusion. During 11 craniotomies for aneurysm, arteriovenous malformation (AVM), or extracranial-intracranial (EC-IC) bypass, we continuously monitored somatosensory evoked potentials (SSEPs) and regional cortical blood flow (rCBF) as determined by a thermal flow probe. The CCT was calculated and correlated with the rCBF. In 8 of the 11 cases, the rCBF values varied within 1 SD of normal values derived from 25 measurements of nonischemic cerebral cortex. All initial CCT values were within 1 SD of normal, but 4 of 11 patients had a prolonged CCT intraoperatively. Three of these were associated with a low rCBF (14 to 31 ml/100 g/minute). One patient had postoperative confusion at the time of discharge. One patient who underwent AVM embolization had a permanent loss of SSEPs postoperatively, and his preexisting hemiparesis was more profound after operation. Finally, 1 patient's CCT improved after EC-IC bypass. This is a preliminary study that demonstrates the feasibility of monitoring CCT and rCBF during craniotomy. When rCBF values fall and the CCT slows, neurological deficit will probably occur.
Prospective payment systems using the diagnostic related group (DRG) mechanism are being phased in for Medicare inpatient hospital care. The purpose of this study was to examine a common neurosurgical procedure (001), craniotomy without trauma, and characterize the cost dynamics of this DRG. All patients (n = 50) treated in this DRG at the Long Island Jewish Medical Center during 1983 had their financial charges exclusive of physician fees examined. The findings were: (a) each hospital service category had wide charge variances around the mean; (b) emergency (ER) admissions were 200% more expensive than nonemergency (non-ER) admissions; (c) ER admissions seemed to have no greater severity of illness than non-ER admissions, but had a significantly different referral pattern (i.e., admission from the ER to a nonneurosurgical service with a subsequent neurosurgical referral); (d) this DRG when grouped into clinical "subproducts" (i.e., craniotomy for tumor, hematoma, hydrocephalus, aneurysm, benign cyst, and other) showed marked charge differences; and (e) the most expensive 25% of patients had five times higher charges than the least expensive 25% for both ER and non-ER admissions. This type of financial analysis may give surgeons a methodology with which to address the problems of cost containment in a more serious manner.
The mastoid air cell was illuminated to estimate the location of the sigmoid sinus in 12 cases of a retrosigmoid suboccipital craniotomy for cerebellopontine angle tumors. A special illuminator system was designed, and the tip of the illuminator was placed inside the external auditory canal. The posterior margin of the illuminated air cell was delineated on the outer surface of the skull after the skin flap was turned and the position of the sigmoid sinus was estimated with reference to the preoperative computed tomographic scan. The posterior margin of the mastoid air cell in an axial slice, including the internal auditory canal, usually exists within the breadth of the sigmoid sinus. A gap between the posterior margin of the mastoid air cell and the position of the sigmoid sinus was easily corrected by the computed tomographic finding. This method was found to be simple and reliable in performing the suboccipital craniotomy with safety and exactness.
We describe a surgical technique to improve visualization of deep brain structures during craniotomy. The technique, developed in a cadaveric model, combines the use of an operating microscope and a solid-rod lens endoscope. Addition of the endoscope during craniotomy allows the operator to visualize structures that otherwise might not have been seen. An approach to the brain stem is demonstrated.
OBJECTIVE: Elevation of the lateral orbital rim and zygomatic arch during an orbitozygomatic craniotomy requires a bone cut across the zygoma, which commonly extends into the lateral edge of the inferior orbital fissure. The zygomaticofacial foramen has been identified as a superficial landmark for the cut that extends into the inferior orbital fissure. This study examined the usefulness of the zygomaticofacial foramen during orbitozygomatic craniotomy. METHODS: One-hundred two dry hemicrania were used in this study. The zygomaticofacial foramen was considered to be related to the inferior orbital fissure when it was located on the zygoma in the area between lines extending in the medial-to-lateral direction along the long axis of the fissure and crossing the anterior and posterior ends of the lateral edge of the fissure. RESULTS: The zygomaticofacial foramen varied from being absent to representing as many as four small openings. A single foramen was observed in one-half of the specimens. Of the 115 zygomaticofacial foramina, 93 were related to the inferior orbital fissure. Among the 51 specimens with a single foramen, 49 foramina met the criteria for being related to the inferior orbital fissure; in those cases, there would have been no difference in the amount of bone resected using the inferior orbital fissure or the zygomaticofacial foramen as the landmark for the zygomatic cut. CONCLUSION: The zygomaticofacial foramen was a reliable landmark for locating the inferior orbital fissure and making the cut across the zygoma in only 50% of the specimens.
OBJECTIVE: Several novel sealing materials have been proposed as an adjunct to sutured dural closure to help insure watertight closure, thus diminishing the risk of pseudomeningocele formation. This evaluation was undertaken to clarify the in vivo magnetic resonance imaging (MRI) and computed tomographic (CT) scan characteristics of one such sealant, which has a high water content, permitting similar imaging characteristics to pseudomeningoceles and inflammatory collections. METHODS: After a craniotomy in two canine subjects, we sprayed a novel, water-soluble, self-polymerizing, absorbable, hydrogel sealant onto the dura and the bone flap was replaced. After recovery, both animals underwent MRI and CT scans after 3 days and again at 2, 4, 6, 8, and 10 weeks after the craniotomy. The appearance of the gel at each timepoint was characterized and compared with the macroscopic and microscopic findings obtained 14 weeks after implantation. RESULTS: Both animals remained neurologically intact. Hydrogel sealant was readily apparent with all imaging techniques through Week 6. Diagnostic distinction from inflammatory collections and pseudomeningoceles was possible with MRI, using inversion recovery and contrast-enhanced sequences; such distinctions were occasionally challenging with a contrast-enhanced CT scan. Temporal absorption of the gel and subsequent closure of the remaining void was documented. Histopathology showed minimal changes, and excellent tissue compatibility of the gel was noted. CONCLUSION: The hydrogel sealant can be observed with cross sectional imaging and can be distinguished from cerebrospinal fluid using a CT scan, complemented by an occasional MRI scan. In addition, complete absorption of the hydrogel, with closure of the remaining void was noted. Histological examination found an unremarkable response with no neurotoxicity or space-filling defect.
OBJECTIVE: Meningiomas of the anterior cranial base can be approached with a variety of techniques. The extended bifrontal approach is often thought to be associated with increased morbidity because of the need for extensive removal of the bone and longer surgical times. The authors have attempted to quantitate retraction-related edema occurring after surgery to determine whether the extra bone removal limits retraction and reduces the chance of brain injury. METHODS: Charts were reviewed for patients who underwent extended bifrontal craniotomies performed for meningiomas at the University of California, San Francisco, between 1997 and 2005. Magnetic resonance imaging scans obtained before and after surgery were reviewed for brain edema as indicated by fluid-attenuated inversion recovery/T2 abnormality and grouped into four categories: A, no edema; B, edema restricted to the gyrus rectus; C, edema beyond the gyrus rectus; and D, extensive bifrontal edema. RESULTS: Forty-five patients were identified. Fifty-four percent of patients had tumors with a diameter of more than 4 cm. Simpson Grade 2 or 3 resection was achieved in 82% of patients, and the average operative time was 12.3 hours. Vision outcome was favorable in 74% of patients. Extent of fluid-attenuated inversion recovery abnormality remained unchanged in 87.5%, with 91% of patients in categories A or B edema remaining in those categories after surgery. There were no infections and there were two cerebrospinal fluid leaks. CONCLUSION: The extended bifrontal approach is a safe surgical procedure with limited morbidity that the authors think: 1) prevents secondary brain injury from excessive retraction; 2) offers great flexibility of view for the surgeon; and 3) should be considered the preferred approach compared with the standard bifrontal craniotomy for large tumors of the anterior cranial base.
The authors present the results observed with large bifrontal decompressive craniotomy performed on 12 patients with severe cerebral edema, 10 of them related to cerebral contusion, which did not respond to conventional methods of therapy. All patients had before surgery very bad prognosis, with severe neurological signs of higher brain stem compression. Bilateral carotid angiography was sistematically performed before and after surgery, constituting as a matter of fact the decisive element indicating cerebral decompression. Six patients (50 per cent) survived and 5 of them (41.6 per cent) had an excellent neurological and mental improvement. Considering these results, we think that a large bifrontal decompressive craniotomy is the best method of treatment in such cases, specially when performed precociously. These patients, however, need very special care after surgery, if possible in units of intensive therapy, owing to the large incidence of complications.
Patients with intracranial aneurysm(s) of the carotid artery territory, treated with pterional craniotomy, were prospectively and randomly addressed to one layer flap (n = 36) or myocutaneous (MC) versus two layers' dieresis (n = 32) or interfascial (IF). The study protocol included the patient's sex, age, area of craniotomy, time of flap dieresis and synthesis, time of bone dieresis and synthesis, the intracranial time, including dura mater dieresis and synthesis and time of flap retraction. Before and after surgery, the patients were evaluated with examination specially oriented to V and VII cranial nerves, bi-temporal diameter measurement, the symmetry of the temporal region, tempora-mandibularis joint (TMJ) movements and cranial CT scan. The evaluations of the TMJ dysfunctions were postoperative pain, movement limitations at mastication, occlusion, mouth aperture and lateral movements of the jaw. The statistical analysis showed that the incidence of pain at TMJ and moderate and severe temporalis muscle atrophy was observed, comparing MC and IF, and there were significant differences among these ones, being greater in IF group. We concluded that both techniques permit equivalent access to the studied intracranial aneurysm(s), and the atrophy of temporalis muscle, pain and movement limitations of the temporomandibularis joint were prevalent, worse and more long-lasting in two-layers flap dieresis than in one-layer flap dieresis.