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23 OKTOBER 2012
Cranial Surgery
Indication For Cranial surgery
Types of Cranial Surgery
Burr Hole
Craniotomy
For larger access to the cranium compared to burr hole For evacuation or removal of cranial content, include
Tumour
Hematoma
Abscess/Infective organism
Open biopsy
Vascular repair/ excision / clipping/ trapping/ bypass
Hydrocephalus
Pneumocranium
Foreign body
Wound debridement
Decompressive cranial cavity
Depressed fracture
Dura repair
etc
Craniotomy
Shave the scalp minimally Infiltration of the incision line (mixture of local
anesthetic and vasoconstrictive agents) Single-layer flap (no risks of temporal muscle
atrophy or injury to the upper branch of the facial nerve)
Good retraction system (such as fish hooks) One burr hole or additional burr hole (in the elderly) High-speed electric microdrills / diamond-tipped
burrs (near eloquent structures) / bone-biting ultrasound aspirator (Skull base)
Operating microscope Microinstruments
Craniotomy
Craniectomy
Craniectomy
Cranioplasty / Reconstruction
Skull base Surgery
Cranial surgery confined to skull base Include surgery involving
Anterior skull base
Middle skull base
Posterior skull base
Craniocervical junction
Pituitary fossa
Surgical approaches may include Open craniotomy
Minimal invasive procedure- transcranial, transoral-skull base, transnasal-skull base by microscopic or endoscopic assisted
Vascular
Aneurysm
Unruptured- Craniotomy and clipping / Edovascular
Ruptured- Treat also complications IVH or hydrocephalus- Burr hole and External
ventricular drainage ICH – Craniotomy and evacuation of clots Cerebral edema/ Infarct – Decompressive
craniectomy Post-operative Care
Maintaining a normal circulating blood volume with a normal arterial blood pressure
Monitor for potential complications, such as vasospasm (triple-H therapy) or chronic hydrocephalus (LP, VP Shunt)
Arteriovenous Malformations Of The Brain
Intracranial Cavernomas
Treatment- Craniotomy and excision
Adjunct- Neuronavigation
Intraoperative ultrasound
continuous electrophyiological monitoring (SEP,MEP, AEBP, direct cranial nerve EMG).
Brain Revascularization By Extracranial–intracranial Arterial Bypasses Indications
to prevent recurrence of cerebral ischemia in cases with hemodynamic failure
Moyamoya angiopathy
Combination of bypass surgery with therapeutic occlusion of parent artery of aneurysms
Brain Revascularization By Extracranial–intracranial Arterial Bypasses
Treatment-
Craniotomy and
End-side microvascular anastomosis (STA-MCA)
Others-
STA-ACA bypass
STA-SCA bypass
OA-PICA bypass
OA-PCA bypass
Brain Revascularization By Extracranial–intracranial Arterial Bypasses
Peri- and intraoperative management and follow-up Anticoagulant therapy and or Aspirin therapy should
be discontinued prior to surgery, mostly 3 days before.
Appropriate hydration is necessary and dehydration is contraindicated.
Postoperative blood pressure is kept in normal pressure range, especially systolic pressure is kept under 160 mmHg.
Aspirin can be administered again after 24 hours postoperatively.
Oral anticoagulant therapy can be resumed after a week.
Patency of the bypass is followed up by Doppler sonography and whole postoperative follow-up hemodynamic check with angiography and water PET is done in 2–3 months postoperatively.
Intracranial VenousPathologies
Pathologies affect the cerebral venous system Traumatic injury to the major dural sinuses Carotico-cavernous fistulae Dural arteriovenous fistulae Developmental venous anomalies Arterial venous malformations Meningiomas involving the dural sinuses Pineal and glomus tumors Cerebral venous thrombosis Pseudotumor cerebri syndrome (PTCS, benign
intracranial hypertension (BIH), idiopathic intracranial hypertension (IIH))
Giant arachnoid granulations.
Intracranial VenousPathologies
Treatments: Divide bridging vein
Venous bypass grafts (occluded by a tumour, venous thrombosis and jugular stenosis)
Venous Stenting (venous thrombosis, exacerbating PTCS)
Tumour
Histological criteria for the WHO classification system
Tumour
Treatment: Surgery (Craniotomy)
Extra-axial lesions: Radical resection while preserving vital structures like cranial nerves, cerebral arteries or large draining veins (i.e. meningiomas, schwannomas)
Intra-axial tumors of glial origin: Radical resection with boundaries free of tumor-cells is not possible despite modern technologies like neuronavigation, intraoperative imaging or fluorescent-aided resections.
Radiation therapy SRS, SRT, WBRT
Systemic chemotherapy
Meningioma
Tumour: Stereotactic Biopsies
Indication: Intrinsic brain tumours, either primary or secondary;
differential diagnosis is of brain tumour, is to obtain material for the purpose of pathological diagnosis, and on occasion additionally to aspirate fluid from a cyst or abscess cavity.
In some environments infective lesions, like tuberculoma, remain common, and often the differential diagnosis of tumor will remain even after scanning.
In specific risk groups, for example chronic ear disease, valvular heart disease, immunosuppression, or HIV infection a predisposition to an infective brain lesion has to be considered.
In patients with a known primary malignant tumor not only single, but sometimes multiple, brain lesions may turn out not to be metastatic and brain biopsy has to be considered on an individual basis.
Differential of CNS Lymphoma Eloquent area
Tumour: Stereotactic Biopsies
Technique: Cosman–Roberts–Wells (CRW) Stereotactic System Frameless (Neuronavigation)
Excision Biopsy
Tumour: Pituitary Tumour
Surgical treatment Craniotomy
Transphenoidal:
Endoscopic, microscopic
Non-surgical: For functional tumour-medical, Radiation
Non-functional- Radiation
Tumour: Craniopharyngioma
Surgical treatment Craniotomy
Transphenoidal: Endoscopic, microscopic
Non-surgical: Chemoradiotherapy
Tumour: Intraventricular
Tumour: Intraventricular
Surgical Options Open surgery:
good microsurgical techniques the morbidity/mortality of open surgery is not higher than the minimally invasive procedures.
Endoscopic approaches:
With the goal of achieving a total removal are best suited for lesions not exceeding 2–3 cm in size and are not very vascular.
Endoscopy is also useful for biopsy and opening of the floor of the ventricle
Tumour: Colloid Cyst
Colloid cysts are histologically benign tumors that represent between 0.5 and 2% of all intracranial neoplasms.
They are mostly located at the anterior part of the third ventricle and are able to produce occlusion of the foramina of Monro, resulting in biventricular hydrocephalus.
Surgical Treatment: Open surgical removal and percutaneous
aspiration procedures. Simple shunting of cerebrospinal fluid (CSF)
without removal of the cyst Endoscopic approach removal of cyst
Tumour: Colloid Cyst
Tumour: Pineal Region Tumours
Surgical Treatment: Total surgical resection:
surgery alone can be curative for benign pineal tumors (pineocytoma, meningioma, neurocytomas, mature teratomas, hemangioblastomas, cavernous hemangiomas, gangliogliomas, and symptomatic pineal cysts
Non-radical surgical resection: (decided based on prior biopsy/frozen section intra-op)
For more aggressive tumours, such as malignant teratomas, pinealoblastomas, embryonal carcinomas, choroicarcinomas and yolk sac tumors require a combination of surgery, radiation therapy and chemotherapy.
Biopsy If a newly diagnosed pineal mass is accessible by
stereotactic or endoscopic biopsy and the cranial MRI is compatible with a germinoma
Congenital
Arachnoid Cysts
Arachnoid Cysts
Other treatment option:endoscope-assisted microsurgicalfenestration is the second line
treatment.
Congenital: Craniosynostoses
Congenital: Craniosynostoses
Corrective surgery
Encephaloceles
Cephalocele is a herniation of intracranial contents through a defect on the skull and according to the nature of the contents: Meningoceles: if they contain only meninges Encephaloceles: contain brain Meningoencephaloceles:contain both Ventriculocele: If the herniated brain contents
include a portion of the ventricle Cephaloceles are also classified according to their
location occipital (70–75%) frontal (25–30%).
The overall incidence of cephaloceles is about 0.8–3.0 per 10,000 live births with encephaloceles being the most common form.
Encephaloceles
Classification
Encephaloceles
Surgical treatment: Closure of occipital encephalocele
Frontal: Repair and +/- craniofacial reconstruction
Hydrocephalus
Hydrocephalus: Ventriculoperitoneal shunt
Hydrocephalus
Postoperative Care of CSF Shunting Wounds are kept dry under sterile dressings. Skin sutures on the head and those on the abdomen
on the 7th day. Plain radiographs of the implanted shunt provides
control of the position of the shunt and connections as well as a good baseline for the future.
In patients with variable pressure valve it confirms the setting of the opening pressure.
Postoperative CT scan is used to document ventricular size, although a scan performed shortly before the operation may suffice.
Patients with high brain compliance should be mobilized and brought to the upright position gradually to reduce the incidence of over drainage and subdural haematoma formation.
Epilepsy
The prerequisite for any surgical consideration is a medical approach in order to localize the single or multiple epileptic foci and to identify the cause of the seizure disorder.
Types of surgery Cerebral Resection
limited to the epileptogenic focus, i.e., the initial starting point of the seizures and the regions of immediate propagation.
Disconnective Surgery functional hemispherectomy and hemispherotomy
Palliative Surgery to limit the propagation of the seizure discharges by
disrupting certain pathways Types:
Callosotomy Subpial transection: parallel transsections of the short
cortico-cortical fibers,
Dermoid cyst Cystic teratoma that contains developmentally mature skin
complete with hair follicles and sweat glands
Almost benign
Trauma
Skull Fracture Depressed fractures Scalp lacerations and compound vault fractures Anterior fossa floor with dura tear Temporal bone fracture (mostly transverse) with
immediate but partial facial nerve palsy Foreign body
Haemorrhage Scalp Injury Epidural hemorrhage Subdural hemorrhage Intraparenchymal hemorrhage Intraventricular hemorrhage and SAH causing
Hydrocephalus
Fractures
Trauma
Criteria for emergency surgery
EDH
SDH
Trauma
Trauma
Infection: Cerebral abscess
Infection: Cerebral abscess
Classical surgical indications: (a) abscess diameter of >2 cm; (b) intracranial hypertension; (c) risk of intraventricular rupture; (d) absence of response to medical treatment;
and (e) mycotic infections.
When an etiologic diagnosis is not established following MRI and systemic studies, surgical aspiration and sampling is indicated.
Subdural empyema represents a neurosurgical emergency-Urgent craniotomy and evacuation
Infection: Cerebral abscess
Surgical Options: open surgical evacuation
needle aspiration:
Free hand
stereotactic approaches
Frame based
Frameless
Infection: Brain hydatid cyst (BHC)
Hydatid is a word derived from the Greek “ydatos” which means water.
Hydatid disease is a parasitic infestation caused by a dog tapeworm larvae
It is common in sheep farming in underdeveloped countries such as those located in Asia, Africa, South and Central America or in the Mediterranean area.
Involvement of brain, 2–3% of all body localisations
Usually, the infestation goes up the systemic circulation to the parietal lobe via the middle cerebral artery as in all embolic diseases.
Brain hydatid cysts (BHC) are spherical, or balloon-shaped, and are characterized by slow growth.
At diagnosis, their size varies from few centimetres to huge volume of 15 cm or more.
Infection: Brain hydatid cyst (BHC)
Operative treatment: total surgical excision remains the only treatment. Complete removal of an unruptured cyst with preservation
of adjacent brain parenchyma leads to cure.
Infection: Neurocysticercosis (NCC). Neurocysticercosis, infection of the central nervous
system by Taenia solium metacestodes, is the commonest encountered cerebral parasitic infection in the world.
Humans are the only natural defi nitive hosts for the Taenia solium, which are aquired by the ingestion of undercooked or raw meat (most commonly pork) infested by larvae
Infection: Neurocysticercosis (NCC). Surgical treatment:
Ventricular shunt placement is the high prevalence of shunt dysfunction
Neuroendoscopy can be used for resection of intraventricular cysts, with much less morbidity
Open surgery Surgery should be the first choice of treatment in the presence of
increased intracranial pressure secondary to giant cysts causing mass effect and hydrocephalus due to CSF circulation blockage.
Nursing management of Cranial Surgery
Nursing management of Cranial Surgery
Nursing management of Cranial Surgery
Ventriculostomy Drain CSF
Intrathecal drug administration
ICP monitoring
Nursing management of Cranial Surgery
Summary
Thank You