Craniotomy

About: Craniotomy is a research topic. Over the lifetime, 5605 publications have been published within this topic receiving 103637 citations.

Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors

Abstract: OBJECTIVE The goals were to critically review all complications resulting within 30 days after craniotomies performed for excision of intra-axial brain tumors relative to factors likely to affect complication rates and to assess the value of these data in predicting the risk of surgical morbidity, particularly for surgery in eloquent brain regions. METHODS Neurosurgical outcomes were studied for 327 patients who underwent 400 craniotomies for removal of intra-axial parenchymal brain neoplasms in a 21-month period. Tumors removed included gliomas (206 tumors) and metastases (194 tumors) located both supratentorially (358 tumors) and infratentorially (42 tumors). RESULTS The major complication incidence was 13%, and the operative mortality rate was 1.7%. The overall morbidity rate was 32%, but more types of complications were considered than in previous studies. The major neurological morbidity rate was 8.5%. Based on pre- versus postoperative (at 4 wk) Karnofsky Performance Scale scores, 9% of patients deteriorated neurologically, 32% improved, and 58% showed no change. The median postoperative hospital stay was 5 days. Tumors were defined as Grade I, II, or III based on their location relative to brain function, and this tumor functional grade was the most important variable affecting the incidence of any neurological deficit. Patients with tumors in eloquent (Grade III) or near-eloquent (Grade II) brain areas incurred more neurological deficits than did patients with tumors in noneloquent areas (Grade I). Neither repeat surgery for recurrent disease nor extent of surgical resection affected outcome significantly. Although most tumors in this study, including those in eloquent regions, were removed by gross total resection, this did not lead to more major neurological deficits. Regional complications (at the surgical sites) and systemic complications (medical) were more prevalent among older patients (age >60 yr) with lower preoperative Karnofsky Performance Scale scores (< or = 50) and posterior fossa masses. We showed how our data can be used to predict the total risk of surgical morbidity for a given patient, to facilitate patient counseling and surgical decision-making. CONCLUSION The finding that gross total resections could be performed in eloquent brain regions with an acceptable level of neurological impairment suggested that the mere presence of a tumor in eloquent brain does not automatically contraindicate surgery. Our results have practical risk-predictive value, and they should aid in the construction of subsequent outcome studies, because we have identified the key areas to monitor.

Outcome following decompressive craniectomy for malignant swelling due to severe head injury.

Abstract: Object The aim of this study was to assess outcome following decompressive craniectomy for malignant brain swelling due to closed traumatic brain injury (TBI). Methods During a 48-month period (March 2000–March 2004), 50 of 967 consecutive patients with closed TBI experienced diffuse brain swelling and underwent decompressive craniectomy, without removal of clots or contusion, to control intracranial pressure (ICP) or to reverse dangerous brain shifts. Diffuse injury was demonstrated in 44 patients, an evacuated mass lesion in four in whom decompressive craniectomy had been performed as a separate procedure, and a nonevacuated mass lesion in two. Decompressive craniectomy was performed urgently in 10 patients before ICP monitoring; in 40 patients the procedure was performed after ICP had become unresponsive to conventional medical management as outlined in the American Association of Neurological Surgeons guidelines. Survivors were followed up for at least 3 months posttreatment to determine their Glasgow...

Management of 1000 vestibular schwannomas (acoustic neuromas): surgical management and results with an emphasis on complications and how to avoid them.

Abstract: OBJECTIVE : To identify the actual benefits and persisting problems in treating vestibular schwannomas by the suboccipital approach, the results and complications in a consecutive series of 1000 tumors surgically treated by the senior author were analyzed and compared with experiences involving other treatment modalities. METHODS : Pre- and postoperative clinical statuses were determined and radiological and surgical findings were collected and evaluated in a large database for 962 patients undergoing 1000 vestibular schwannoma operations at Nordstadt's neurosurgical department from 1978 to 1993. RESULTS : By the suboccipital transmeatal approach, 979 tumors were completely removed ; in 21 cases, deliberate partial removal was performed either in severely ill patients for decompression of the brain stem or in an attempt to preserve hearing in the last hearing ear. Anatomic preservation of the facial nerve was achieved in 93% of the patients and of the cochlear nerve in 68%. Major neurological complications included 1 case of tetraparesis, 10 cases of hemiparesis, and caudal cranial nerve palsies in 5.5% of the cases. Surgical complications included hematomas in 2.2% of the cases, cerebrospinal fluid fistulas in 9.2%, hydrocephalus in 2.3%, bacterial meningitis in 1.2%, and wound revisions in 1.1%. There were 11 deaths occurring at 2 to 69 days postoperatively (1.1%). The techniques that were developed for avoidance of complications are reported. The analysis identifies preexisting severe general and/or neurological morbidity, cystic tumor formation, and major caudal cranial nerve deficits as relevant risk factors. CONCLUSION : The current treatment options of complete tumor resection with ongoing reduction of morbidity are well fulfilled by the suboccipital approach. By careful patient selection, the mortality rate should be further reduced to below 1%.

Measurement of Intraoperative Brain Surface Deformation Under a Craniotomy

Abstract: We measured the deformation of the dura and brain surfaces between the time of imaging and the start of surgical resection for 21 patients. All patients underwent intraoperative functional mapping, allowing us to measure brain surface motion at two times that were separated by nearly an hour after opening the dura but before resection. The positions of the dura and brain surfaces were recorded and transformed to the coordinate space of a preoperative MR image using the Acustar neurosurgical navigation system. The mean displacements of the dura and the first and second brain surfaces were 1.2, 4.4, and 5.6 mm, respectively, with corresponding mean volume reductions under the craniotomy of 6, 22, and 29 ml. The maximum displacement was greater than 10 mm in approximately one-third of the patients for the first brain surface measurement and one-half of the patients for the second. In all cases the direction of brain shift corresponds to a “sinking” of the brain intraoperatively, compared with its preoperative position. We observed two patterns of the brain surface deformation field depending on the inclination of the craniotomy with respect to gravity. Separate measurements of brain deformation within the closed cranium caused by changes in patient head orientation with respect to gravity suggested that less than 1 mm of the brain shift recorded intraoperatively could have resulted from the change in patient orientation between the time of imaging and the time of surgery. These results suggest that intraoperative brain deformation is an important source of error that needs to be considered when using neurosurgical navigation systems.

Bragg-peak proton-beam therapy for arteriovenous malformations of the brain.

Abstract: Patients with arteriovenous malformations of the brain, who are subject to disabling or fatal recurrent hemorrhage, seizures, severe headache, and progressive neurologic deficits, may be considered unsuitable for conventional therapies (craniotomy with excision or embolization), usually because of the location, size, or operative risk of the lesion. We have treated such patients with stereotactic Bragg-peak proton-beam therapy and report the follow-up of 74 of the first 75, 2 to 16 years after treatment. Proton-beam therapy is intended to induce subendothelial deposition of collagen and hyaline substance, which narrows the lumens of small vessels and thickens the walls of the malformation during the first 12 to 24 months after the procedure. Two deaths from hemorrhage occurred in the first 12 months after treatment, but no lethal or disabling hemorrhages occurred after this interval. Seizures, headaches, and progressive neurologic deficits were in most cases arrested or improved. Bragg-peak proton-beam therapy appears to be a useful technique for treatment of intracranial arteriovenous malformations, especially those that are unsuitable for treatment by other methods.