6. 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
7. 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
12. 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
14. 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)
17. 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
19. 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.
20. Intracranial Venous
Pathologies
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.
21. Intracranial Venous
Pathologies
Treatments:
Divide bridging vein
Venous bypass grafts
(occluded by a tumour,
venous thrombosis and
jugular stenosis)
Venous Stenting (venous
thrombosis, exacerbating
PTCS)
22. Tumour
Histological criteria for the WHO classification system
23. 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
25. 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
31. 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
32. 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
34. 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
40. 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.
45. 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.
46. 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,
47. Dermoid cyst
Cystic teratoma that contains developmentally mature skin
complete with hair follicles and sweat glands
Almost benign
48. 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
56. 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
57. Infection: Cerebral
abscess
Surgical Options:
open surgical evacuation
needle aspiration:
Free hand
stereotactic approaches
Frame based
Frameless
58. 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.
59. 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.
60. 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
61. 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.
