Procedures

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Procedures

• Craniotomy Review

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A P Review
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A P Review
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Craniocerebral Trauma
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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

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Pathophysiology Hematoma

• Accumulation of blood in the subdural or epidural
  space
• Epidural vs Subdural

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Three types of hematomas epidural, subdural,
intracerebral
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Management of ICP Possible locations of burr
holes
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Craniotomy portion of skull and overlying scalp
is removed to allow access to brain
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Pathophysiology Tumor

• See Table 24-2
• Symptoms are caused by
• Compression of cranial nerves
• Destruction of brain tissue
• Irritation of cerebral cortex
• Increased ICP

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Pathophysiology Tumor
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PathophysiologyAcoustic Neuroma
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Pathophysiology Aneurysm
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Aneurysm TreatmentSTSTProcedure24-2
Procedural Steps 1. Enter cranium as for
craniotomy (Procedure 24-1)
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Aneurysm Repair

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

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Pathophysiology Arteriovenous Malformation
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Instruments, Equipment, Supplies

• See

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Craniotomy Instrumentation
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Craniotomy What are these?
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?
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?
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?
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Procedural Steps

• Refer to AST Exemplar Handout

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Procedures

• Advanced Format
• Posterior Fossa Craniectomy

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Procedures

• Intermediate Format
• Cranioplasty
• Advanced Format Craniectomy

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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.

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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

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Terms and Definitions

• See MAVCC Unit 11
• STST Red and italicized or bolded terms

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Definition/Purpose of Procedure

• Craniectomy
• Cranioplasty

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Anatomy
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Physiology

• Cerebrum
• Cerebellum
• Brain stem (Medulla)

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Pathophysiology

• See prior slide Acoustic Neuroma
• Craniectomy also performed for
• Posterior Fossa Procedures, epidural or subdural
  removal, ventriculostomy, ICP Placement, or
  stereotactic cranial procedures

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Surgical InterventionSpecial 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

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Surgical Intervention Positioning Prepping

• Position during procedure
• Depends on tumor location
• May be prone or semi-Fowlers
• 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

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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

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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)

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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

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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

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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

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Surgical Intervention Procedure Steps

• Follow steps 24-1 for entry into cranium
• See Procedure 24-3

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Surgical Intervention Procedure Steps
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Counts

• Initial Sponges, sharps
• First closing
• Final closing
• Sponges
• Sharps

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Specimen Care

• Identified as acoustic neuroma or as informed by
  surgeon
• Handled usually routine

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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
  transferextreme caution!

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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

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What are stereotactic procedures?

• Technique used for precise localization of
  intercranial masses using CAT and MRI using
  three-dimensional navigation system

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What is a Gamma Knife?
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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
• Alexanders Ch 23

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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.