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Cranial Surgery

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  • 1. 23 OKTOBER 2012
  • 2. Cranial Surgery
  • 3. Indication For Cranialsurgery
  • 4. Types of Cranial Surgery
  • 5. Burr Hole
  • 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
  • 8. Craniotomy
  • 9. Craniectomy
  • 10. Craniectomy
  • 11. Cranioplasty /Reconstruction
  • 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
  • 13. Vascular
  • 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)
  • 15. ArteriovenousMalformations Of TheBrain
  • 16. Intracranial Cavernomas  Treatment- Craniotomy and excision  Adjunct-  Neuronavigation  Intraoperative ultrasound  continuous electrophyiological monitoring (SEP,MEP, AEBP, direct cranial nerve EMG).
  • 17. Brain RevascularizationBy Extracranial–intracranialArterial 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
  • 18. Brain RevascularizationBy Extracranial–intracranialArterial BypassesTreatment-Craniotomy andEnd-side microvascular anastomosis(STA-MCA)Others-STA-ACA bypassSTA-SCA bypassOA-PICA bypassOA-PCA bypass
  • 19. Brain RevascularizationBy Extracranial–intracranialArterial 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 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.
  • 21. Intracranial VenousPathologies 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
  • 24. Meningioma
  • 25. Tumour: StereotacticBiopsies 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
  • 26. Tumour: StereotacticBiopsies Technique:  Cosman–Roberts–Wells (CRW) Stereotactic System  Frameless (Neuronavigation)
  • 27. Excision Biopsy
  • 28. Tumour: Pituitary Tumour  Surgical treatment  Craniotomy  Transphenoidal:  Endoscopic, microscopic  Non-surgical:  For functional tumour-medical, Radiation  Non-functional- Radiation
  • 29. Tumour:Craniopharyngioma  Surgical treatment  Craniotomy  Transphenoidal:  Endoscopic, microscopic  Non-surgical:  Chemoradiotherapy
  • 30. Tumour: Intraventricular
  • 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
  • 33. Tumour: Colloid Cyst
  • 34. Tumour: Pineal RegionTumours  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
  • 35. Congenital
  • 36. Arachnoid Cysts
  • 37. Arachnoid Cysts Other treatment option: endoscope-assisted microsurgical fenestration is the second line treatment.
  • 38. Congenital:Craniosynostoses
  • 39. Congenital:Craniosynostoses  Corrective surgery
  • 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.
  • 41. Encephaloceles  Classification
  • 42. Encephaloceles Surgical treatment:  Closure of occipital encephalocele  Frontal: Repair and +/- craniofacial reconstruction
  • 43. Hydrocephalus
  • 44. Hydrocephalus:Ventriculoperitoneal shunt
  • 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
  • 49. Fractures
  • 50. Trauma  Criteria for emergency surgery
  • 51. EDH
  • 52. SDH
  • 53. Trauma
  • 54. Trauma
  • 55. Infection: Cerebralabscess
  • 56. Infection: Cerebralabscess  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: Cerebralabscess  Surgical Options:  open surgical evacuation  needle aspiration:  Free hand  stereotactic approaches  Frame based  Frameless
  • 58. Infection: Brain hydatidcyst (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 hydatidcyst (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.
  • 62. Nursing management ofCranial Surgery
  • 63. Nursing management ofCranial Surgery
  • 64. Nursing management ofCranial Surgery  Ventriculostomy  Drain CSF  Intrathecal drug administration  ICP monitoring
  • 65. Nursing management ofCranial Surgery
  • 66. Summary
  • 67. Thank You

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