ABSTRACT 383

Abstract

Background and aims: Urgent craniotomy is often indicated in pediatric patients due to traumatic brain injury and occasionally for arterio-venous malformation and brain abscess. Aims: To discuss the perioperative management of urgent craniotomy in pediatric patients. Methods: Experience of our institute as well as the recently published articles in the same field. Results: Urgent craniotomy is indicated mainly to evacuate extra- or subdural hematoma causing intra-cranial mass effects. Less common indications include brain abscess and decompression after bleeding form AVM. The main perioperative goal is optimization of cerebral perfusion pressure (CPP), prevention and early management of secondary brain injury. Secondary brain injury may result from hypotension, hypovolemia, hypoxia, fever, high intra-cranial pressure (ICP), anemia, hypo- or hyperglycemia, acidosis and seizure. ICP should be monitored in patients with severe brain injury, CPP should be maintained according to the age (usually 40 -50 mmHg). Hyperosmolar therapy may be used if indicated. Hypothermia may be used in patients with TBI within 8 hours. Arterial carbon dioxide pressure should maintained within normal range and Prophylactic hyperventilation should be not be used. High ICP is managed initially with medical measures, but if it is failed or the patient has early signs of herniation decompression craniectomy should be done. Conclusions: The main therapeutic goals are limitation the effects of primary injury, prevention and aggressive management of factors which may cause secondary brain injury. Medical treatment of high ICP and maintenance of CPP are paramount. Early surgical intervention may limits the adverse effects of high ICP and mass occupying lesions.