Cranial Procedures Research Articles

Complications of subcutaneous low-dose heparin therapy in neurosurgical patients

BACKGROUND Venous thromboembolism is a major cause of postoperative morbidity and mortality in neurosurgery. The use of low-dose unfractionated heparin therapy perioperatively for prophylaxis against deep vein thromboses and pulmonary embolism has been well demonstrated in many other surgical specialties but is less commonly used in neurosurgery because of fears of devastating postoperative hematomas. METHODS The safety of such therapy has been analyzed in 950 patients undergoing an inpatient neurosurgical procedure. 872 patients (152 cranial procedures) completed treatment with 5000 U sodium heparin subcutaneously twice a day, commencing before surgery and continuing till patients were ambulatory. RESULTS There were three minor hemorrhagic complications—two superficial wound hematomas (one requiring treatment) and one gastrointestinal hemorrhage—identified. Three clinically significant major complications developed, two epidural hematomas after spinal surgery requiring evacuation and one intraventricular hemorrhage after brain biopsy. CONCLUSION This report, along with an analysis of previously published reports of low-dose perioperative heparin therapy in neurosurgical patients, suggests that such therapy is unlikely to be associated with increased morbidity. Given the known efficacy of low-dose heparin in reducing venous thromboembolism in other surgical patients, such therapy may reduce mortality and morbidity from thromboembolic complications in neurosurgical patients with minimal risk.

Early combined management of frontal sinus and orbital and facial fractures.

Historically, frontal sinus fractures and associated maxillofacial fractures were addressed at different times. We retrospectively reviewed our experience with a series of 79 consecutive patients with bitable frontal sinus fractures, most with associated facial fractures, who underwent early combined cranial and maxillofacial procedures. The operations were performed emergently for patients with open or depressed skull fractures and hematomas with mass effect, and electively within 2 weeks for those with closed fractures. The cranial procedures were performed first. The nasofrontal ducts were packed with "cigars" of bacitracin powder wrapped in Surgicel. All patients received antibiotics for 2 weeks. Postoperatively, good subjective cosmetic results were obtained except in one patient. Eight patients with lumbar drains had expected temporary cerebrospinal fluid (CSF) leaks of less than 72 hours duration. Six postoperative intracranial infections (four cases of meningitis, one epidural empyema, and one intracerebral abscess) were detected; five of these occurred in patients with open depressed fractures. Patients with preoperative CSF leaks (p = 0.0039, Fisher's exact test) and open fractures (p = 0.065, Fisher's exact test) were more likely to develop intracranial infections. The combined neurosurgical and maxillofacial repairs achieved good cosmetic outcomes, with relatively low morbidity. By combining the two-stage procedure into one stage, standard surgical and anesthetic risks could potentially be reduced. Preoperative CSF leaks and open fractures were associated with a higher incidence of postoperative central nervous system infection. Early operations did not appear to be associated with a higher complication rate.

Shaving the hair--is it always necessary for cranial neurosurgical procedures?

Shaving of the hair and neurosurgical procedures are almost inseparably connected issues. This may add an additional psychological stress to the patient. Those departments which abandoned pre-operative shaving did not see higher infection rates. From January 1993 to September 1994 we performed 57 cranial procedures without any shaving, among them 5 shunt procedures. We found no disturbances of wound healing or septic complications. Therefore neurosurgical procedures without shaving are recommended for all benign cranial processes if a rapid rehabilitation of the patient to his normal daily life is to be expected.

Shunts and shunt problems in childhood.

Extra cranial shunting procedures (Cone et al. 1949, Matson 1951) were used to treat hydrocephalus before the work of Nulsen and Spitz (1952) and before the introduction of the Holter valve in 1956. However in most cases they were inefficient or even dangerous; they overdrained because they could not close and rapidly blocked due to tissue reaction to the constituent material.

Neurodestructive procedures in the management of cancer pain.

Abstract The treatment of cancer pain varies widely, both from country to country and within a given country. In major western centers, all or almost all methods are available, but throughout each country, only one or two of the simplest methods may be widely available. This is due partly to lack of knowledge, partly to lack of training, and partly to fears of litigation. In third world countries, the situation is worse. This paper focuses on the simpler methods of pain relief—intrathecal phenol or alcohol, morphine, and celiac plexus blocks—since these are what most patients receive. The more complicated techniques, such as percutaneous cordotomy and epidural and subarachnoid morphine, are discussed in relation to their increased use in the future. Some methods, such as alcohol injection of the pituitary fossa, thalamotomy and other cranial procedures, will disappear as new ways of using morphine spread.

Self-inflicted transparietal intraventricular nail: case report and surgical technique

Background Deliberate self-harm with stone- or hammer-driven nail through the cranium is unusual. The need is stressed for comprehensive radiological evaluation with computed tomography (CT) scan, with or without angiography, and removal through an open cranial procedure under general anaesthesia, rather than extraction through a burrhole under local anesthetic infiltration. Methods We present here a 27-year old male who presented at our Teaching Hospital setting with a self-inflicted hand-driven intracranial nail to the left parietal region. He had a detailed neurological examination, was evaluated pre-operatively with computerised tomography of the brain and underwent an open cranial procedure under general anaesthesia for nail retrieval. Psychiatric unit evaluated and managed him for chronic depression. Results The transparietal, intraventricular 10cm long nail was retrieved and associated abscess evacuated by an open cranial procedure. Pre-operative neurological impairments regressed and his mood stabilized with anti-depressants. He was discharged without further deficits and has remained well for over four years Conclusion Self-inflicted hand-driven intracranial nail is a very rare form of penetrating cranio-cerebral trauma. Preoperative computerised tomography scan of the brain, meticulous open cranial removal under general anaesthesia and psychiatric management enable discharge without further injury or deficits. On the other hand, removal through a burrhole or just pulling out the nail would not allow intraoperative visualisation of associated lesions; the latter also predispose to further vascular and parenchymal brain injuries, worsening neurolological impairments.Key words: Intracranial Nail; Open Cranial Procedure; Psychiatric Evaluation.