Procedures

Craniotomy Review

A & P Review

A & P Review

Craniocerebral Trauma

Types of Skull Fractures• Linear

– Simple, clean break; low velocity injuries

• Comminuted– Bone crushed to small, fragmented pieces;

high-impact injuries

• Depressed– Inward depression of bone fragments– Powerful blow; dura may or may not be intact

• Basilar– Base of skull– May be linear, comminuted, or depressed

Pathophysiology: Hematoma

•Accumulation of blood in the subdural or epidural space

• Epidural vs Subdural

Three types of hematomas: epidural, subdural, intracerebral

Management of ICP: Possible locations of burr holes

Craniotomy: portion of skull and overlying scalp is removed to allow access to brain

Pathophysiology: Tumor• See Table 24-2• Symptoms are caused

by: • Compression of

cranial nerves• Destruction of brain

tissue• Irritation of cerebral

cortex• Increased ICP

Pathophysiology: Tumor

Pathophysiology:Acoustic Neuroma

Pathophysiology: Aneurysm

Aneurysm Treatment:STST

Procedure24-2

Procedural Steps:

1. Enter cranium as for craniotomy (Procedure 24-1)

Aneurysm Repair

• Sylvian fissure is split by bipolar cautery dissection of meningeal layers for separation of frontal and temporal lobes.

• ETC.

Pathophysiology: Arteriovenous Malformation

Instruments, Equipment, Supplies

See

Craniotomy Instrumentation

Craniotomy : What are these?

?

?

?

Procedural Steps

Refer to AST Exemplar Handout

Procedures

Advanced Format

Posterior Fossa Craniectomy

Procedures

Intermediate Format

Cranioplasty

Advanced Format: Craniectomy

Objectives• Assess the related terminology and

pathophysiology of the ________________.

• Analyze the diagnostic interventions for a patient undergoing a craniectomy.

• Plan the intraoperative course for a patient undergoing_____________.

• Assemble supplies, equipment, and instrumentation needed for the procedure.

Objectives

• Choose the appropriate patient position

• Identify the incision used for the procedure

• Analyze the procedural steps for cranioplasty.

• Describe the care of the specimen

Terms and Definitions

• See MAVCC Unit 11

• STST Red and italicized or bolded terms

Definition/Purpose of Procedure

• Craniectomy

• Cranioplasty

Anatomy

Physiology

• Cerebrum• Cerebellum• Brain stem (Medulla)

Pathophysiology

See prior slide: Acoustic Neuroma

Craniectomy also performed for:

Posterior Fossa Procedures, epidural or subdural removal, ventriculostomy, ICP Placement, or

stereotactic cranial procedures

Surgical Intervention:Special Considerations

• Patient Factors– Hair removal and handling

• Room Set-up– Depending on position of patient, must strategically

place all equipment

– EMG, ESU units (mono and Bipolar, Headlights, microscope &/or loupes, CUSA, laser if used, 2 suctions, Mayfield table if used

• Anesthesia: General

Surgical Intervention: Positioning & Prepping

• Position during procedure– Depends on tumor location– May be prone or semi-Fowler’s

• Supplies and equipment– 3-pt fixation device often used(Gardner-Wells or Mayfield)- pillows, pads, sheets, blankets, wide tape,Chest or axillary rolls

• Special considerations: high risk areas– Depends on position: bony prominences, axilla, genitals, eyes

• Prep: protect eyes and ears from prep solution– Once circulator scrubs, neurosurgeon often paints with iodophor and

alcohol

Surgical Intervention: Special Considerations/Incision

• Special Considerations– X-rays in room at start– Saline at room

temp– Close monitor of amt

irrigation used

• State/Describe incision

Surgical Intervention: Supplies

• General: basic pk, craniotomy pack or drape, basin set, gowns & gloves, dressing materials, medications, suction x 2, asepto, ESU pencil for monopolar, raytex & laparotomy sponges

• Specific– Drapes: square drape w/towels that may be sutured in place

w/silk on cutter; craniotomy drape w/adhesive fenestration– Suture & Blades

• #10, #11, #15• 4-0 silk and 4-0 neurolon

– Medications on field : • Meds: antibiotic irrigation; hemostatic agents (Gelfoam

w/topical thrombin, Surgicel, Avitene)

Surgical Intervention: Supplies

• Catheters & Drains: Hemovac; Foley cath• Nerve stimulator for ID 7th cranial nerve• Control syringe & hypodermic needles• Bipolar cord to attach to Bayonet forceps• Cottonoids of various sizes• Raney scalp clips • MRI compatible hemostatic clips• Telfa, cotton balls• Ultrasound wand drape

Surgical Intervention: Instruments

• General

• Specific– Basic Neuro or craniotomy– Microsurgical (available)– Anspach or Midas Rex power instruments

w/attachments or cranial perforator & craniotome

– If no Anspach or Midas Rex, air drill w/bits and burrs

Surgical Intervention: Equipment

• General

• Specific– EMG, ESU units (mono and Bipolar,

Headlights, microscope &/or loupes, CUSA, laser if used, 2 suctions, Mayfield table if used

Surgical Intervention: Procedure Steps

• Follow steps 24-1 for entry into cranium

• See Procedure 24-3

Surgical Intervention: Procedure Steps

Counts

• Initial: Sponges, sharps

• First closing

• Final closing– Sponges– Sharps

Specimen & Care

• Identified as acoustic neuroma or as informed by surgeon

• Handled: usually routine

Immediate Post op

• Remain sterile until the patient is safely out of OR• Managing the head while removing pin fixation

device takes much skill and care (not to drop!)—usually surgeon or anesthesia takes this on

• Multiple lines can be easily displaced upon transfer—extreme caution!

Postoperative Complications & Recovery

• General: (Neurological Deficits/S & S)– Increasing drowsiness or sleepiness, Increasing weakness – Visual problems – Persistent, severe headache – Fever – Vomiting – Seizures or abnormal movements – Redness, swelling or drainage of fluid around the incision

• Specific– Hearing loss and facial hemiparesis from damage to 7th

and 8th cranial nerves are most common– Wound infection, meningitis– Subdural or Epidural hematoma or Intracerebral

hemorrhage

What are stereotactic procedures?Technique used for precise localization of

intercranial masses using CAT and MRI using three-dimensional navigation system

What is a Gamma Knife?

Resources• STST pp. 966-974; 979-984. Procedure 24-1; 24-3• AST Exemplar: Craniotomy-Tumor Excision• Lemone & Burke pp. 1375-1382; 1388-1391• www.surgery.uchicago.edu• www.sentara.com• www.sd-neurosurgeon.com/…/glioblastoma.htm• MAVCC Module Unit 11• Alexander’s Ch 23

Questions

C9: List two materials that can be implanted during cranioplasty and that can be molded to fit the cranial defect.

C10: List two methods by which the bone flap is secured to the cranium following a craniotomy.