Subgaleal Drain Research Articles

The Danish chronic subdural hematoma study-predicting recurrence of chronic subdural hematoma.

Anincreasing incidence of chronic subdural hematoma (CSDH) and an unchanging high recurrence rate of 10-20% call for individualized treatment. The aim of this study was to establish individualized prediction models for the risk of recurrence treating death as a competing risk. A retrospective national cohort of unilateral CSDH was included for analysis. Using competing risk survival analysis, we tested whether available covariates were associated with the risk of recurrence. We further established a pre- and a postoperative prediction model, where predictors were chosen using a LASSO approach. The models were visualized in nomograms. Predictive performance was evaluated by c index and calibrations plots. A total of 763 patients with surgically evacuated unilateral CSDH were included for analysis. The recurrence rate was 14% while 12% of patients died during follow-up (1year). In our association model, hematoma size, drain type, drainage time, presence of complications, and Glasgow Coma Score were significantly associated to recurrence. Subdural drain was associated with a lower recurrence risk than subgaleal drain. The preoperative model included hematoma size, hematoma density, and history of hypertension. The postoperative model included further drain type, drainage time, and surgical complications. The nomograms allow easy assessment of the recurrence risk for the individual patient, providing a better possibility for individual adjustment of treatment and follow-up. The predictive performance indicates that significant unaccounted or unknown factors still remain. The association test found passive subdural drain superior to passive subgaleal drain in minimizing the risk of CSDH recurrence.

Postoperative Drain Use in Cranial Vault Remodeling: A Survey of Craniofacial Surgeon Practices and a Review of the Literature.

The use of subgaleal drains following primary cranioplasty for craniosynostosis has undergone limited investigation. Proposed benefits include prevention of seroma, detection of postoperative bleeding, and cerebrospinal fluid leak. We conducted a systematic review of the literature and surveyed craniofacial surgeons to ascertain the current evidence pertaining to drain use following primary cranioplasty for craniosynostosis and to determine surgical practice patterns. PubMed and Embase databases were searched to identify relevant articles. Abstracts were reviewed by 2 investigators, and a Cohen κ statistic was calculated. Patient demographic and outcome data were extracted and compared. A 9-question survey was e-mailed to active and associate members of the American Society of Craniofacial Surgeons. A total of 7395 unique citations were identified. Only 2 retrospective chart reviews met inclusion criteria. All objective parameters demonstrated no difference between patients with and without drains. A subjective benefit of limiting facial swelling was proposed without objective analysis. Fifty (32.5%) of the 154 craniofacial surgeons responded to the survey. Forty-two percent used postoperative drains. A significant association (P = .01) was found between the belief that drains limited facial swelling and their use. The literature examining postoperative drain use in primary cranioplasty for craniosynostosis is restricted. The current studies show no definite benefit to drain use but are limited in their assessment of key outcomes. There is wide variability among surgeons regarding drain use, and this seems to be motivated by belief and tradition.

Excessive Hemostasis on the Scalp Increases Superficial Surgical Site Infection Rate in Cranioplasty

Cranioplasty is a routine procedure, but it carries a significantly higher complication rate over standard clean cranial surgery. Surgical site infection is the most common but severe complication. Risk factors for surgical site infection are still debated. A retrospective survey of 155 patients (≥16 years old) who exclusively underwent customized titanium cranioplasty from April 2014 to January 2017 was performed. Preoperative clinical parameters, surgeon's hemostasis technique, temporalis dissection, operative time, intraoperative blood loss, postoperative catheter duration and drainage, postoperative hemorrhage and extradural fluid collection (EDFC), and prophylactic antibiotics were recorded and compared between patients with superficial surgical site infection (sSSI) and patients with non-sSSI. Overall sSSI rate was 10.3%. Binary logistic analysis showed excessive hemostasis on scalp (odds ratio= 10.302, P= 0.000), presence of postoperative EDFC (odds ratio= 12.740, P= 0.003), and postoperative drainage >277 mL (odds ratio= 10.302, P= 0.000) were independent risk factors for sSSI. Patients who received excessive hemostasis had a longer operative time (P= 0.000). A flaccid cranial defect was a protective factor for postoperative EDFC (odds ratio= 0.130, P= 0.044), whereas presence of ventriculoperitoneal shunt could induce EDFC formation (odds ratio= 9.598, P= 0.020). Postoperative subgaleal drainage was correlated to the size of cranial defect (standardized β= 0.347, P= 0.000). Timing of cranioplasty and use of prophylactic antibiotics were not related to sSSI. Surgeons should lower the hemostasis standard for cranioplasty, as this would promote wound healing and reduce operative time, which subsequently decreases SSI rate.

(42) A Case of Recurrent Intracranial Bleeds in the Setting of Alagille Syndrome

Introduction: Alagille Syndrome (ALGS) is a complex multi-systemic disease that is simply defined as abnormalities of intrahepatic bile ducts. It is an autosomal disease that is commonly attributed to mutations of the JAG1 or NOTCH2 genes. Definitive diagnosis requires liver biopsy plus having three out of five characteristic clinical features: cholestasis, cardiac defect, skeletal abnormalities, ophthalmologic abnormalities and facial features. There has been discussion about how children with ALGS have an increased risk of complications in the setting of minor trauma. This case is about a 22- month old male who obtained an epidural hematoma after a low height fall and developed subsequent intracranial bleeds. Case: A 22- month old male with ALGS and history of pulmonary stenosis status post repair presented to the Emergency Department after falling from a chair onto tile floor. At presentation, he was found to have GCS of 6 and was immediately intubated. Initial work up included: Complete Blood Count with differential, Complete Metabolic Panel and a CT Head without contrast. Labs were within normal limits with the exception of: Hemoglobin of 8.8 gm/dl, hematocrit 26.7%, Alkaline Phosphatase 433, Aspartate Transaminase 81, Alanine Transaminase 88. CT showed: left epidural bleed with mass effect causing early uncal herniation as well as subdural bleed. He was taken for immediate craniectomy and evacuation, which revealed a temporal bone fracture that was not seen on CT. An intracranial monitor and subgaleal drain were placed. Repeat CT revealed new infratentorial subdural bleed and decrease in midline shift. His hospitalization was further complicated with obstructive hydrocephalous and eventually new parenchymal and intraventricular bleeds. His presentation and course were thought to be due to his predisposition for abnormal intracranial vasculature; rather than thrombocytopenia or coagulopathy, as he had normal liver function and coagulation factors. Discussion: Alagille Syndrome’s multi-systemic effects makes individuals susceptible to significant head injury even in the setting of minor mechanism of injury. There has been discussion about ALGS being associated with skeletal and vasculature fragility. Higher incidence of fractures has been reported in ALGS. This is thought to be due to malabsorption of fat soluble vitamins including Vitamin D, thus impeding bone formation and potentially resulting in: osteopenia, osteoporosis, rickets. The cranial temporal bone has been shown to be most vulnerable to this. Perhaps this poor mineralization and thin nature of the temporal bone was why the fracture was not visualized in our patient’s initial CT. Vasculature fragility has also been seen in post mortem autopsies and have shown:

Fibrinolytic Therapy Improves Outcomes in Patients with Epidural Hematomas Following Cranioplasty: A Pilot Study.

Cranioplasty is a cosmetic procedure utilized to reconstruct cranial defects in patients following decompressive craniectomy. Epidural hematomas are a common complication of cranioplasty and often require surgical drainage. However, repeated surgery compromises patient safety and delays recovery. We investigated the development of epidural hematomas among 131 patients who underwent cranioplasty. Then we explored the efficacy of urokinase (UK) injection for the noninvasive treatment of epidural hematomas. We observed that 15 patients presented with epidural hematoma following cranioplasty. UK (30,000 IU/3 mL) was injected into the hematoma cavity twice every 12 hours in the first postoperative day. Next we closed the subgaleal drain for 1.5 hours and connected it with a negative-pressure ball on full vacuum to allow drainage. Binary logistic regression analysis was used to evaluate the risk factors associated with the development of epidural hematomas. Our findings demonstrated that a sunken skin flap was a risk factor for epidural hematoma formation (p = 0.006). The decrease in epidural hematoma volume was 35.27 ± 7.27 mL in the first 12 hours on postoperative day 1 after UK treatment. All treated patients whose Glasgow Coma Scale score did not significantly change despite the epidural hematoma had an uneventful recovery without additional complications and were discharged from the hospital, except for one patient. Fibrinolytic therapy can be considered an optional treatment for postoperative epidural hematoma associated with cranioplasty, especially in patients who refused further operative treatment or who are not optimal candidates for a second surgery.

Subgaleal Drain for Chronic Subdural Hematoma

Subgaleal Drain for Chronic Subdural Hematoma

Assessment of drainage techniques for evacuation of chronic subdural hematoma: a consecutive population-based comparative cohort study.

OBJECTIVE Surgery for chronic subdural hematoma (CSDH) is one of the most common neurosurgical procedures. The benefit of postoperative passive subdural drainage compared with no drains has been established, but other drainage techniques are common, and their effectiveness compared with passive subdural drains remains unknown. METHODS In Scandinavian population-based cohorts the authors conducted a consecutive, parallel cohort study to compare different drainage techniques. The techniques used were continuous irrigation and drainage (CID cohort, n = 166), passive subdural drainage (PD cohort, n = 330), and active subgaleal drainage (AD cohort, n = 764). The primary end point was recurrence in need of reoperation within 6 months of index surgery. Secondary end points were complications, perioperative mortality, and overall survival. The analyses were based on direct regional comparison (i.e., surgical strategy). RESULTS Recurrence in need of surgery was observed in 18 patients (10.8%) in the CID cohort, in 66 patients (20.0%) in the PD cohort, and in 85 patients (11.1%) in the AD cohort (p < 0.001). Complications were more common in the CID cohort (14.5%) compared with the PD (7.3%) and AD (8.1%) cohorts (p = 0.019). Perioperative mortality rates were similar between cohorts (p = 0.621). There were some differences in baseline and treatment characteristics possibly interfering with the above-mentioned results. However, after adjusting for differences in baseline and treatment characteristics in a regression model, the drainage techniques were still significantly associated with clinical outcome (p < 0.001 for recurrence, p = 0.017 for complications). CONCLUSIONS Compared with the AD cohort, more recurrences were observed in the PD cohort and more complications in the CID cohort, also after adjustment for differences at baseline. Although the authors cannot exclude unmeasured confounding factors when comparing centers, AD appears superior to the more common PD. Clinical trial registration no.: NCT01930617 (clinicaltrials.gov).

The role of subgaleal suction drain placement in chronic subdural hematoma evacuation.

Introduction:There is lack of uniformity about the preferred surgical treatment, role of drain, and type of drain among various surgeons in chronic subdural hematoma (CSDH). The present study is aimed to evaluate role of subgaleal drain.Materials and Methods:This was a prospective study of 260 patients of CSDH treated surgically. Burr-hole irrigation with and without suction drain was done in 140 and 120 patients, respectively. Out of 120 patients without suction drain 60 each were managed by single and two burr holes. Pre- and postoperative GCS was recorded. Recurrent hematomas, CSDH secondary to tumor, due to intracranial hypotension, coagulopathy, children below 18 years, and patients treated by twist drill craniostomy or craniotomy were excluded. Subgaleal closed-system drainage with low negative pressure was used.Results:Age of the patients ranged from 18 to 75 years with mean age of 57 years. There were 9, 47, 204 patients in GCS of 3-8, 9-12, and 13-15, respectively. Both the groups were comparable in terms of age, etiology, gender, and neurological status. There was no difference in the mortality in both the group. The recurrence and postoperative pneumocephalus was significantly less in suction drain group as compared to without drain group. There was no infection or any other complication related to suction drainage.Conclusion:Subgaleal closed suction drainage was safe, simple, and effective in the management of CSDH. Recurrence rate was low in the suction drain group.

Antibiotic prophylaxis for subdural and subgaleal drains

OBJECTIVE The authors sought to determine the effects of eliminating the use of prolonged prophylactic systemic antibiotics (PPSAs) in patients with subdural and subgaleal drains. METHODS Using a retrospective database, the authors collected data for patients over the age of 17 years who had undergone cranial surgery at their institution between December 2013 and July 2014 (PPSAs period) or between December 2014 and July 2015 (non-PPSAs period) and had subdural or subgaleal drains left in place postoperatively. RESULTS One hundred five patients in the PPSAs period and 80 in the non-PPSAs period were identified. The discontinuation of PPSAs did not result in an increase in the frequency of surgical site infection (SSI). The frequency of Clostridium difficile (CDI) and the growth of resistant bacteria were reduced in the non-PPSAs period in comparison with the PPSAs period. In the 8 months after the drain prophylaxis protocol was changed, $93,194.63 were saved in the costs of antibiotics and complications related to antibiotics. CONCLUSIONS After discontinuing PPSAs for patients with subdural or subgaleal drains at their institution, the authors did not observe an increase in the frequency of SSI. They did, however, note a decrease in the frequency of CDI and the growth of resistant organisms. It appears that not only can patients in this population do without PPSAs, but also that complications are avoided when antibiotic use is limited to 24 hours after surgery.

頭蓋形成術直後の予期せぬ合併症について(Unexpected complications immediately after cranioplasty)

要旨頭蓋形成術直後に脳浮腫と脳出血を認めた症例を報告する。症例は84歳，男性。くも膜下出血に対し開頭クリッピング術，外減圧術が施行され，第58病日に頭蓋形成術が施行された。術中は問題なく手術が終了したが，術直後の頭部CTにて脳浮腫，脳出血を認めた。その後浮腫は進行したが追加手術を施行することなく，浮腫は改善し神経症状は術前と変わらないまで改善し安定した。手術前後でperfusion MRIを施行し，病側の脳血流量・脳血液量が健側比で上昇を認め，無症候性のsinking skin flap syndrome（SSFS）であったと考えられた。頭蓋形成術直後に脳浮腫や脳出血を呈する原因は再灌流，自動調整能の低下，SSFS，皮下ドレーンによる陰圧，静脈鬱滞，正中偏位からの復元による血管損傷，アレルギー反応が原因と考えられる。この合併症による致死率は高い。頭蓋形成術は比較的容易な手術であり，合併症の多くは痙攣，感染，硬膜外血腫であるが，脳浮腫や脳出血が生じることも念頭に置き，術前に十分な説明をする必要があると考えられた。

Sudden Death Following Cranioplasty.

I read with interest the recently published article by Lee et al12). The report details a case of severe postoperative cerebral oedema following a seizure in the recovery room. The procedure had otherwise been uneventful and the authors speculate that placing the epidural and subgaleal drains on active suction may have been a contributory factor. They also comment that there have only been five reported cases of unexpected massive cerebral oedema following cranioplasty. At the time of writing this may have indeed been the case, however examination of the recent cranioplasty literature reveals that this phenomenon may be more common than has previously been appreciated. Lee et al. would not have been able to include the findings of a recent article by Sviri15) in the Journal of Neurosurgery as they had already submitted their case report. However a further literature review confirmed that there have to date been sixteen such cases (Table 1). A literature search was performed in the MEDLINE database (1966-July 2015 2012). The following keywords were used : decompressive craniectomy, cranioplasty, complications and sudden death. The bibliographies of retrieved reports were searched for additional references. For those cases that were reported as part of a cohort series this represents an incidence ranging from 2.2% to 7%, which is extraordinarily high for what is essentially a technically straightforward elective procedure2,8,9,15). It may well be that these cases represent an unusual clinical occurrence that is both uncommon and unpredictable. Alternatively it may well be that this complication is just underreported. Indeed, a recent publication listed death following bone flap replacement on the outcome algorithm for patients who have had a decompressive craniectomy following ischemic stroke10). In addition, a recent article reported a mortality rate of 3.16% following cranioplasty (although in this particular study the actual cause of death was not documented18)). Notwithstanding these limitations, it would seem that death following cranioplasty is not entirely unexpected and in view of these findings care must be taken when counselling patients and their relatives prior to a cranioplasty procedure. Table 1 Characteristics of patients in previous studies who had died following cranioplasty Currently the precise pathophysiology has yet to be determined; however, a number of authors have suggested it may relate to the use of suction drains and loss of cerebral autoregulation2,8,16).

IMPROVED NEUROLOGICAL ASSESSMENT OF SEVERE INTRAVENTRICULARHEMORRHAGE IN NEWBORNS WITH VERY LOW AND EXTREMELY BIRTH WEIGHT

Neurological outcomes in severe intraventricular hemorrhage in infants with very prematurity de- termined by correctable and uncorrectable factors of bleeding. The aim of the study was to develop an optimal clinical diagnostic algorithm in selection of treatment of severe intraventricular hemorrhage in infants born with critical immaturity. During the period 2005-2010. He received treatment at the hospi- tal in 1150 infants with very low birth weight (VLBW), and extremely low birth weight (ELBW). We used clinical methods of evaluation: neurological examination, pediatric Glasgow Coma Scale / Saint Petersburg (Iova A.S. et al., 1999). Diagnostic methods: ulrasonografiya (US), computed tomography (CT), magnetic resonance imaging (MRI).Ways of improving diagnostic tactics depending on the risk factors and the dynamic clinical and ultrasonographic evaluation. Adoption subgaleal drainage when post-hemorrhagic ventriculodilatation improves early neurological outcomes in children.

Reducing surgical site infections following craniotomy: examination of the use of topical vancomycin

Although the use of topical vancomycin has been shown to be safe and effective for reducing postoperative infection rates in patients after spine surgery, its use in cranial wounds has not been studied systematically. The authors hypothesized that topical vancomycin, applied in powder form directly to the subgaleal space during closure, would reduce cranial wound infection rates. A cohort of 150 consecutive patients who underwent craniotomy was studied retrospectively. Seventy-five patients received 1 g of vancomycin powder applied in the subgaleal space at the time of closure. This group was compared with 75 matched-control patients who were accrued over the same time interval and did not receive vancomycin. The primary outcome measure was the presence of surgical site infection within 3 months. Secondary outcome measures included tissue pH from a subgaleal drain and vancomycin levels from the subgaleal space and serum. Vancomycin was associated with significantly fewer surgical site infections (1 of 75) than was standard antibiotic prophylaxis alone (5 of 75; p < 0.05). Cultures were positive for typical skin flora species. As expected, local measured vancomycin concentrations peaked immediately after surgery (mean ± SD 499 ± 37 μg/ml) and gradually decreased over 12 hours. Vancomycin in the circulating serum remained undetectable. Subgaleal topical vancomycin was associated with a lower incidence of surgical site infections after craniotomy. The authors attribute this reduction in the infection rate to local vancomycin concentrations well above the minimum inhibitory concentration for antimicrobial efficacy. Topical vancomycin is safe and effective for reducing surgical site infections after craniotomy. These data support the need for a prospective randomized examination of topical vancomycin in the setting of cranial surgery.

Optimizations and Nuances in Neurosurgical Technique for the Minimization of Complications in Subdural Electrode Placement for Epilepsy Surgery

Surgical intervention is an important therapeutic option for patients with intractable epilepsy and a well-characterized epileptogenic focus. Invasive monitoring with subdural electrodes is an effective technique for localizing epileptogenic foci. Previous studies reported varying complication rates, and these may deter more widespread adoption. We present potentially valuable technical nuances that may be associated with low complication rates. We assess the potential contribution of specific aspects of surgical technique to the reduction of complication rates. We retrospectively reviewed patients from the Rush University Surgical Epilepsy database who underwent craniotomies for invasive electroencephalography monitoring for medically intractable epilepsy using our technique. We analyzed and compared complication rates and techniques with those reported elsewhere. The sample group comprised 127 consecutive patients who underwent electrode implantation. The average monitoring period was 6 days. There were 5 complications (3.9%), including 1 subdural hematoma requiring surgery (0.8%), 1 infection (0.8%), 2 pulmonary emboli (1.6%), and 1 deep vein thrombosis (0.8%). There were no symptomatic cerebrospinal fluid leaks or permanent neurologic complications. These results compare favorably with published results. Analysis and comparison of our technique anecdotally suggest the importance of use of a subgaleal drain throughout the monitoring period, postoperative antibiotic coverage for 1 week, meticulous hemostasis, and secure suturing of the electrodes to the dura mater to minimize trauma to superficial vessels as potential contributors to improved complication rates. A very low incidence of major morbidity can be achieved in invasive electroencephalography monitoring with this protocol.

Comparison of Subgaleal and Subdural Closed Drainage System in Surgical Treatment of Chronic Subdural Hematoma

OBJECTIVE:One or two burr-hole craniostomies with subgaleal or subdural drainage system and irrigation are the most common methods for surgical treatment of CSDH. The aim of this study is to compare the advantages or disadvantages of these techniques used for CSDH.METHODS:Seventy patients were treated by burr-hole subdural drainage or subgaleal drainage system with irrigation. Our patients were classified into two groups according to the operative procedure as follows: Group I, one or two burr-hole craniostomy with subgaleal closed system drainage and irrigation (n=36), Group II, one or two burr-hole craniostomies with subdural closed drainage system and irrigation (n=38). We compared male and female ratios, complication rates, and age distribution between groups.RESULTS:There was no remarkable difference between recurrence rates of the two groups. Recurrence rate was 6.25% in Group I and 7.8% in Group II. Subdural empyema occurred in one of the patients in Group II. Symptomatic pneumocephalus did not develop in patients. Four patients were reoperated for recurrence at an average of 12–20 days after the operation with the same methods.CONCLUSION:Both of the techniques have a higher cure rate and a lower risk of recurrence. However, subgaleal drainage system is relatively less invasive, safe, and technically easy. So it is applicable for aged and higher risk patients.

Cardiac Arrest after Connecting Negative Pressure to the Subgaleal Drain during Craniotomy Closure.

A one-year-old child operated on for arachnoid cyst in right frontoparietotemporal region had sudden bradycardia followed by cardiac arrest leading to death after connecting negative pressure to the subgaleal drain during craniotomy closure. The surgical procedure was uneventful. It is a common practice to place epidural or subgaleal drains connected to a vacuum system towards the end of craniotomy to prevent accumulation of intracranial and extracranial blood. The phenomenon of bradycardia with hypotension is known to occur following negative pressure application to the epidural, epicranial, or subgaleal space after craniotomy closure. However cardiac arrest as a complication of negative pressure suction drain in neurosurgical patients is not described in the literature.

Chronic subdural hematoma: complication avoidance

Background and objectiveChronic subdural hematoma (CSDH) is defined as the presence of a typical neomembrane, typical liquefied blood within the hematoma cavity, and 3 weeks of more of acute subdural hematoma. It has been classified into separate, laminar, homogenous, and trabecular types. This study analyzed the complications after burr hole evacuation in CSDHs and the best methods to avoid or at least minimize them.Materials and MethodsA total of 28 patients who were suffering from complications after evacuation of CSDH were analyzed. Data on patients and treatment protocol were collected. Medical problems were also managed. Complications were studied as regards their causes and avoidance.ResultsThe highest incidence of complications is observed in the seventh decade of life. Recurrence was the most common complication especially in the separate type. The recurrence rate was higher among patients operated through a single burr hole. Extradural hematomas, although rare, were observed in three patients. Acute subdural hematoma and cerebral infarction had the worst prognosis.ConclusionSubgaleal dissection and insertion of a subgaleal drain are important for absorption and suction of the residual air and blood. In addition, intraoperative copious saline irrigation and postoperative meticulous follow-up are important for patients with a high risk of recurrence, especially those with hematomas of the separate type. During evacuation of the hematoma, we must avoid sudden decompression of the brain as it leads to cerebral infarction or intracranial hemorrhage. It is important to inform the anesthetist before performing the drainage that the blood pressure should be closely monitored and maintained at normal levels while infusing normal saline during surgery to avoid hypotension, which may lead to infarction. Any source of blood from the extradural space must be adequately dealt with.

Trigeminocardiac reflex in neurosurgical practice: Report of two new cases

Background:Systemic hypotension, cardiac dysrhythmia especially bradycardia, apnea, and gastric hypermotility occurring presumably after stimulation of any of the sensory branches of trigeminal nerve are coined as trigeminocardiac reflex (TCR). Neither enough is known about the predisposing factors in relation with the intraoperative occurrence of this life threatening reflex, nor about the exact pathophysiology of its brain stem pathway.Encountering two cases of bradycardia and hypotension during surgery encouraged the authors to: (1) report these two cases and review similar reports in the relevant literature, (2) discuss the suggested mechanisms for such an event, and (3) report the result of a prospective cohort of precisely checked cases in a sister article, to remind the younger neurosurgical community of a possible and bothering even mortal, but avoidable complication in their everyday practice.Case Description:The first case was a 71-year-old male who developed bradycardia and hypotension while packing his large sella tursica with autologous fat after removing a large nonfunctional pituitary adenoma transsphenoidally to prevent cerebrospinal fluid leakage. The changes in his vital signs were detected and controlled rapidly.The second case was a 52-year-old female who underwent right pterional craniotomy for right clinoidal meningioma. She developed severe bradycardia and hypotension after skin closure completed and just when the subgaleal drain was connected to the aspirating bag and negative pressure maintained in the subgaleal region.Both cases could be managed successfully after on time detection of such life threatening complication and proper management.Conclusion:We do not intend only to add two new cases of TCR occurring in the perioperative period in neurosurgical practice, but we wish to raise the question: (a) what could be the predisposing factors for development of such issue for better handling of the problem and (b) stress upon careful continuous mapping of the vital signs during surgery and even till very late after operation.

Asystole following craniotomy closure: Yet another complication of negative-pressure suctioning of subgaleal drain

Asystole following craniotomy closure: Yet another complication of negative-pressure suctioning of subgaleal drain

Chapter 10. Cerebrospinal fluid drainage

Chapter 10. Cerebrospinal fluid drainage