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