Value of Routine Preoperative Tests for Coagulation Before Elective Cranial Surgery. Results of an Institutional Audit and a Nationwide Survey of Neurosurgical Centers in Pakistan.

PubMed

Akhunzada, Naveed Zaman; Tariq, Muhammad Bilal; Khan, Saad Akhtar; Sattar, Sidra; Tariq, Wajeeha; Shamim, Muhammad Shahzad; Dogar, Samie Asghar

2018-05-03

Routine preoperative blood testing has become a dogma. The general practice is to order preoperative workup as a knee-jerk response rather than individualize it for each patient. The fact that the bleeding brain tends to swell, which coupled with limited options for proximal control, packing, and overall hemostasis, leads to an overemphasis on the preoperative coagulation profile. This is a retrospective review of the medical records of patients admitted at Aga Khan University Hospital from January 2010 to December 2015 for an elective craniotomy. The hospital registry was used to identify files for review. Data were collected on a predefined proforma. A nationwide survey was performed, and 30 neurosurgery centers were contacted across Pakistan to confirm the practice of preoperative workup. The survey revealed that all centers had a similar practice of preoperative workup. This included complete blood count, serum electrolytes, and coagulation profile, including prothrombin time, activated partial thromboplastin time (aPTT), and international normalized ratio (INR). A total of 1800 files were reviewed. Nine (0.5%) patients were found to have deranged clotting profile without any predictive history of clotting derangement; 56% were male and 44% were female. Median age was 32 years with an interquartile range of 27 years. Median aPTT was (40.8 with 20.8 IQR). Median INR was (1.59 with 0.48 IQR). Median blood loss was (400 with 50 IQR). No significant association between coagulation profile (aPTT, INR) and blood loss was found (P = 0.85, r = -0.07). We conclude that patients without a history of coagulopathy and normal physical examination do not require routine coagulation screening before elective craniotomy. Copyright © 2018 Elsevier Inc. All rights reserved.

Efficacy of continuous positive airway pressure and incentive spirometry on respiratory functions during the postoperative period following supratentorial craniotomy: A prospective randomized controlled study.

PubMed

Sah, Hulya Kahraman; Akcil, Eren Fatma; Tunali, Yusuf; Vehid, Hayriye; Dilmen, Ozlem Korkmaz

2017-11-01

Volume controlled ventilation with low PEEP is used in neuro-anesthesia to provide constant PaCO 2 levels and prevent raised intracranial pressure. Therefore, neurosurgery patients prone to atelectasis formation, however, we could not find any study that evaluates prevention of postoperative pulmonary complications in neurosurgery. A prospective, randomized controlled study. Intensive care unit in a university hospital in Istanbul. Seventy-nine ASAI-II patients aged between 18 and 70years scheduled for elective supratentorial craniotomy were included in the study. Patients randomized into 3 groups after surgery. The Group IS (n=20) was treated with incentive spirometry 5 times in 1min and 5min per hour, the Group CPAP (n=20) with continuous positive airway pressure 10 cmH 2 O pressure and 0.4 F i O 2 via an oronasal mask 5min per hour, and the Group Control (n=20) 4L·min -1 O 2 via mask; all during the first 6h postoperatively. Respiratory functions tests and arterial blood gases analysis were performed before the induction of anesthesia (Baseline), 30min, 6h, 24h postoperatively. The IS and CPAP applications have similar effects with respect to FVC values. The postoperative 30min FEV 1 values were statistically significantly reduced compared to the Baseline in all groups (p<0.0001). FEV 1 values were statistically significantly increased at the postoperative 24h compared to the postoperative 30min in the Groups IS and CPAP (p<0.0001). This increase, however, was not observed in the Group Control, and the postoperative 24h FEV 1 values were statistically significantly lower in the Group Control compared to the Group IS (p=0.015). Although this study is underpowered to detect differences in FEV 1 values, the postoperative 24h FEV 1 values were significantly higher in the IS group than the Control group and this difference was not observed between the CPAP and Control groups. It might be evaluate a favorable effect of IS in neurosurgery patients. But larger studies are needed to make a certain conclusion. Copyright © 2017 Elsevier Inc. All rights reserved.

Comparison of propofol pharmacokinetic and pharmacodynamic models for awake craniotomy: A prospective observational study.

PubMed

Soehle, Martin; Wolf, Christina F; Priston, Melanie J; Neuloh, Georg; Bien, Christian G; Hoeft, Andreas; Ellerkmann, Richard K

2015-08-01

Anaesthesia for awake craniotomy aims for an unconscious patient at the beginning and end of surgery but a rapidly awakening and responsive patient during the awake period. Therefore, an accurate pharmacokinetic/pharmacodynamic (PK/PD) model for propofol is required to tailor depth of anaesthesia. To compare the predictive performances of the Marsh and the Schnider PK/PD models during awake craniotomy. A prospective observational study. Single university hospital from February 2009 to May 2010. Twelve patients undergoing elective awake craniotomy for resection of brain tumour or epileptogenic areas. Arterial blood samples were drawn at intervals and the propofol plasma concentration was determined. The prediction error, bias [median prediction error (MDPE)] and inaccuracy [median absolute prediction error (MDAPE)] of the Marsh and the Schnider models were calculated. The secondary endpoint was the prediction probability PK, by which changes in the propofol effect-site concentration (as derived from simultaneous PK/PD modelling) predicted changes in anaesthetic depth (measured by the bispectral index). The Marsh model was associated with a significantly (P = 0.05) higher inaccuracy (MDAPE 28.9 ± 12.0%) than the Schnider model (MDAPE 21.5 ± 7.7%) and tended to reach a higher bias (MDPE Marsh -11.7 ± 14.3%, MDPE Schnider -5.4 ± 20.7%, P = 0.09). MDAPE was outside of accepted limits in six (Marsh model) and two (Schnider model) of 12 patients. The prediction probability was comparable between the Marsh (PK 0.798 ± 0.056) and the Schnider model (PK 0.787 ± 0.055), but after adjusting the models to each individual patient, the Schnider model achieved significantly higher prediction probabilities (PK 0.807 ± 0.056, P = 0.05). When using the 'asleep-awake-asleep' anaesthetic technique during awake craniotomy, we advocate using the PK/PD model proposed by Schnider. Due to considerable interindividual variation, additional monitoring of anaesthetic depth is recommended. ClinicalTrials.gov identifier: NCT 01128465.

Integrative Review: Post-Craniotomy Pain in the Brain Tumor Patient

PubMed Central

Guilkey, Rebecca Elizabeth; Von Ah, Diane; Carpenter, Janet S.; Stone, Cynthia; Draucker, Claire B.

2015-01-01

Aim To conduct an integrative review to examine evidence of pain and associated symptoms in adult (≥ 21 years of age), post-craniotomy, brain tumor patients hospitalized on intensive care units. Background Healthcare providers believe craniotomies are less painful than other surgical procedures. Understanding how post-craniotomy pain unfolds over time will help inform patient care and aid in future research and policy development. Design Systematic literature search to identify relevant literature. Information abstracted using the Theory of Unpleasant Symptoms’ concepts of influencing factors, symptom clusters and patient performance. Inclusion criteria were indexed, peer-reviewed, full-length, English-language articles. Keywords were ‘traumatic brain injury,’ ‘pain, post-operative,’ ‘brain injuries,’ ‘postoperative pain,’ ‘craniotomy,’ ‘decompressive craniectomy,’ and ‘trephining.’ Data sources Medline, OVID, PubMed and CINAHL databases from 2000 – 2014. Review Method Cooper’s five-stage integrative review method was used to assess and synthesize literature. Results The search yielded 115 manuscripts, with 26 meeting inclusion criteria. Most studies were randomized, controlled trials conducted outside of the United States. All tested pharmacological pain interventions. Post-craniotomy brain tumor pain was well-documented and associated with nausea, vomiting and changes in blood pressure and impacted patient length of hospital stay, but there was no consensus for how best to treat such pain. Conclusion The Theory of Unpleasant Symptoms provided structure to the search. Post-craniotomy pain is experienced by patients, but associated symptoms and impact on patient performance remain poorly understood. Further research is needed to improve understanding and management of post-craniotomy pain in this population. PMID:26734710

Surgical site infections following craniotomy focusing on possible post-operative acquisition of infection: prospective cohort study.

PubMed

Sneh-Arbib, O; Shiferstein, A; Dagan, N; Fein, S; Telem, L; Muchtar, E; Eliakim-Raz, N; Rubinovitch, B; Rubin, G; Rappaport, Z H; Paul, M

2013-12-01

Neurosurgery is characterized by a prolonged risk period for surgical site infection (SSI), mainly related to the presence of cerebrospinal fluid (CSF) drains. We aimed to examine factors associated with post-neurosurgical SSIs, focusing on post-operative factors. A prospective cohort study was conducted in a single center over a period of 18 months in Israel. Included were adult patients undergoing clean or clean-contaminated craniotomy, including craniotomies with external CSF drainage or shunts. SSIs were defined by the Centers for Disease Control and Prevention (CDC) criteria for healthcare-associated infections. All patients were followed up for 90 days and those with foreign body insertion for 1 year. We compared patients with and without SSI. A multivariable regression analysis for SSI was conducted including uncorrelated variables significantly associated with SSI. A total of 502 patients were included, with 138 (27.5%) undergoing emergent or urgent craniotomy. The overall SSI rate was 5.6% (28 patients), of which 3.2% (16 patients) were intracerebral. Non-elective surgery, external CSF drainage/monitoring devices, re-operation, and post-operative respiratory failure were independently associated with subsequent SSI. External CSF devices was the only significant risk factor for intracerebral SSIs (p < 0.001). Internal shunts or other foreign body insertions were not associated with SSIs. A phenotypically identical isolate to that causing the SSI was isolated from respiratory secretions prior to the SSI in 4/9 patients with microbiologically documented intracerebral SSIs. Patients with SSIs had longer hospital stay, poorer functional capacity on discharge, and higher 90-day mortality. We raise the possibility of post-operative infection acquisition through external CSF devices. Standard operating procedures for their maintenance are necessary.

Endoscope-Assisted Keyhole Technique for Hypertensive Cerebral Hemorrhage in Elderly Patients: A Randomized Controlled Study in 184 Patients.

PubMed

Feng, Yi; He, Jianqing; Liu, Bin; Yang, Likun; Wang, Yuhai

2016-01-01

Hypertensive cerebral hemorrhage (HCH) is a potentially life-threatening cerebrovascular disease with high mortality. In case of a massive hematoma, surgical drainage is a crucial treatment. The aim of the present study was to assess the efficacy of the endoscope-assisted keyhole technique in elderly patients with intracerebral hematoma who needed a flap craniotomy as traditional treatment. One hundred-eighty-four elderly patients with HCH, who had craniotomy indications after conservative treatment for 6-24 hours after onset, were randomly divided into two groups. In the craniotomy group, traditional hematoma drainage was performed. In the keyhole group, an endoscope-assisted keyhole technique was used. Anesthesia time, blood loss, hematoma drainage rate, and complications were compared. The clinical primary outcome was the six-month efficacy rate (defined by the activities of daily living (ADL) score). Anesthesia time was longer in the craniotomy group (3.43 ± 0.65 vs. 1.53 ± 0.52 h, P < 0.01), and blood losses were more important (256 ± 129 vs. 96 ± 39 ml P < 0.01). There was no difference in hematoma drainage rate between the two groups (77.25 ± 13.44 vs. 83.52 ± 27.51% P > 0.05). Complications, including tracheotomy (P < 0.01), pulmonary infection (P < 0.01) and hypoproteinemia (P < 0.05) were more frequent in the craniotomy group. There was no difference in the occurrence of other complications, including revision surgery digestive tract ulcer and epilepsy. Proportion of patients with good prognosis (ADL I-III) was larger in the keyhole group (P < 0.05). In elderly HCH patients with an indication for hematoma drainage, better outcomes were achieved using an endoscope-assisted keyhole technique.

One Small Randomly Blinking Dot in an Otherwise Dark Environment: Effects on Visual Cortical Neurons of Kittens.

DTIC Science & Technology

1982-06-23

back onto the tangent screen. A one centimeter oblong craniotomy was drilled, revealing the medial banks of both hemispheres, -2 mm posterior to A-P...zero. A one cm high plastic chamber was cemented to the skull around the craniotomy . After tungsten hooks were used to tear the dura over the medial...stimulus continuously for several weeks. If the kittens were awake for 10 hr per day average then each accumulated about 500 hr opportunity to view the

Intraoperative seizures and seizures outcome in patients underwent awake craniotomy.

PubMed

Yuan, Yang; Peizhi, Zhou; Xiang, Wang; Yanhui, Liu; Ruofei, Liang; Shu, Jiang; Qing, Mao

2016-11-25

Awake craniotomies (AC) could reduce neurological deficits compared with patients under general anesthesia, however, intraoperative seizure is a major reason causing awake surgery failure. The purpose of the study was to give a comprehensive overview the published articles focused on seizure incidence in awake craniotomy. Bibliographic searches of the EMBASE, MEDLINE,were performed to identify articles and conference abstracts that investigated the intraoperative seizure frequency of patients underwent AC. Twenty-five studies were included in this meta-analysis. Among the 25 included studies, one was randomized controlled trials and 5 of them were comparable studies. The pooled data suggested the general intraoperative seizure(IOS) rate for patients with AC was 8%(fixed effect model), sub-group analysis identified IOS rate for glioma patients was 8% and low grade patients was 10%. The pooled data showed early seizure rates of AC patients was 11% and late seizure rates was 35%. This systematic review and meta-analysis shows that awake craniotomy is a safe technique with relatively low intraoperative seizure occurrence. However, few RCTs were available, and the acquisition of further evidence through high-quality RCTs is highly recommended.

Comparison of dexmedetomidine and propofol for conscious sedation in awake craniotomy: a prospective, double-blind, randomized, and controlled clinical trial.

PubMed

Shen, She-liang; Zheng, Jia-yin; Zhang, Jun; Wang, Wen-yuan; Jin, Tao; Zhu, Jing; Zhang, Qi

2013-11-01

It has been reported that dexmedetomidine (DEX) can be used for conscious sedation in awake craniotomy, but few data exist to compare DEX versus propofol (PRO). To compare the efficacy and safety of DEX versus PRO for conscious sedation in awake craniotomy. Thirty patients of American Society of Anesthesiologists grade I-II scheduled for awake craniotomy, were randomized into 2 groups each containing 15 subjects. Group D received DEX and group P received PRO. Two minutes after tracheal intubation (T1), PRO (target plasma concentration) was titrated down to 1 to 4 µg/mL in group P. In group D, PRO was discontinued and DEX was administered 1.0 µg/kg followed by a maintenance dose of 0.2 to 0.7 µg/kg/h. The surgeon preset the anticipated awake point-in-time (T0) preoperatively. Ten minutes before T0 (T3), DEX was titrated down to 0.2 µg/kg/h in group D, PRO was discontinued and normal saline (placebo) 5 mL/h was infused in group P. Arousal time, quality of revival and adverse events during the awake period, degree of satisfaction from surgeons and patients were recorded. Arousal time was significantly shorter in group D than in group P (P < .001). The quality of revival during the awake period in group D was similar to that of group P (P = .68). The degree of satisfaction of surgeons was significantly higher in group D than in group P (P < .001), but no difference was found between the 2 groups with respect to patient satisfaction (P = .80). There was no difference between the 2 groups in the incidence of adverse events during the awake period (P > .05). Either DEX or PRO can be effectively and safely used for conscious sedation in awake craniotomy. Comparing the two, DEX produced a shorter arousal time and a higher degree of surgeon satisfaction.

A comparison study of immune-inflammatory response in electroacupuncture and transcutaneous electrical nerve stimulation for patients undergoing supratentorial craniotomy

PubMed Central

Li, Guoyan; Li, Shuqin; Sun, Lizhi; Lin, Fangcai; Wang, Baoguo

2015-01-01

Objective: The effect of transcutaneous electrical nerve stimulation (TENS) on immuno-inflammatory response was tested and the differences between electroacupuncture (EA) and TENS in immuno-inflammatory response in patients undergoing supratentorial craniotomy were explored. Methods: 51 patients received craniotomy were randomly divided into 3 groups: control (group C, n=18), EA (group A, n=19) and TENS (group T, n=14) groups. Blood samples were collected before anesthesia (T0) and 30 min (T1), 2 h (T2) and 4 h (T3) after induction of anesthesia to measure the levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-8, IL-10, IgM, IgA and IgG. Results: No significant difference existed between group A and group T during craniotomy. IgM and IgA decreased significantly in group C compared with groups A and T at T2 and T3 time points. Compared with group C, there were significant differences in TNF-α, IgM and IgA levels at T0 in groups A and T; no significant difference was found in the levels of IgG, IL-10 and IL-8. Conclusion: EA and TENS could reduce immunosuppression in patients undergoing supratentorial craniotomy and it has significance in choice of treatment in immunosuppressive therapy. PMID:25785107

A comparison study of immune-inflammatory response in electroacupuncture and transcutaneous electrical nerve stimulation for patients undergoing supratentorial craniotomy

PubMed Central

Li, Guoyan; Li, Shuqin; Sun, Lizhi; Lin, Fangcai; Wang, Baoguo

2015-01-01

Objective: The effect of transcutaneous electrical nerve stimulation (TENS) on immuno-inflammatory response was tested and the differences between electroacupuncture (EA) and TENS in immuno-inflammatory response in patients undergoing supratentorial craniotomy were explored. Methods: 51 patients received craniotomy were divided randomly into 3 groups: control (group C, n=18), EA (group A, n=19) and TENS (group T, n=14) groups. Blood samples were collected before anesthesia (T0) and 30 min (T1), 2 h (T2) and 4 h (T3) after induction of anesthesia to measure the levels of tumor necrosis factor-α (TNF-α), interleukin (IL)-8, IL-10, IgM, IgA and IgG.. Results: No significant difference existed between groups A and group T during craniotomy. IgM and IgA decreased significantly in group C compared with groups A and T at T2 and T3 time points. Compared with group C, there were significant difference in TNF-α, IgM and IgA level at T0 in groups A and T; no significant difference was found in the levels of IgG, IL-10 and IL-8. Conclusion: EA and TENS could reduce immunosuppression in patients undergoing supratentorial craniotomy and it has significance in choice of treatment in immunosuppressive therapy. PMID:25932216

Wound healing after craniotomy: a randomized trial comparing scalp clips to artery forceps for scalp hemostasis.

PubMed

Langford, Peter; Wolfe, Rory; Danks, R Andrew

2009-12-01

In this prospective randomized clinical trial, investigators looked at wound healing after craniotomy. The hypothesis was that the self-closing plastic scalp clips used for hemostasis on the skin edge might lead to localized microscopic tissue damage and subsequent delayed wound healing. The trial consisted of 2 arms in which different methods were used to secure scalp hemostasis: 1) the routinely used plastic clips (Scalpfix, Aesculap); and 2) the older method of artery forceps placed on the galea. Participants were restricted to those > 16 years of age undergoing craniotomies expected to last > 2 hours. Repeat operations were not included. One hundred fifty patients were enrolled. They were visited at 3 and 6 weeks postoperatively by an observer blinded to the method used, and the wounds were assessed for macroscopic epithelial closure, signs of infection, and hair regrowth by using a predefined assessment scale. The results showed no significant difference in wound healing between the 2 groups at either 3 weeks (OR 0.55, 95% CI 0.27-1.11; p = 0.09) or 6 weeks (OR 0.79, 95% CI 0.39-1.58; p = 0.50). The length of operation was found to be a significant factor affecting wound healing at 6 weeks (OR/hour 0.68, 95% CI 0.51-0.92; p = 0.01). The use of Aesculap Scalpfix self-retaining plastic scalp clips on the skin edge during craniotomy surgery does not appear to affect wound healing significantly to the postoperative 6-week mark.

Which one is more effective for analgesia in infratentorial craniotomy? The scalp block or local anesthetic infiltration.

PubMed

Akcil, Eren Fatma; Dilmen, Ozlem Korkmaz; Vehid, Hayriye; Ibısoglu, Lutfiye Serap; Tunali, Yusuf

2017-03-01

The most painful stages of craniotomy are the placement of the pin head holder and the skin incision. The primary aim of the present study is to compare the effects of the scalp block and the local anesthetic infiltration with bupivacaine 0.5% on the hemodynamic response during the pin head holder application and the skin incision in infratentorial craniotomies. The secondary aims are the effects on pain scores and morphine consumption during the postoperative 24h. This prospective, randomized and placebo controlled study included forty seven patients (ASA I, II and III). The scalp block was performed in the Group S, the local anesthetic infiltration was performed in the Group I and the control group (Group C) only received remifentanil as an analgesic during the intraoperative period. The hemodynamic response to the pin head holder application and the skin incision, as well as postoperative pain intensity, cumulative morphine consumption and opioid related side effects were compared. The scalp block reduced the hemodynamic response to the pin head holder application and the skin incision in infratentorial craniotomies. The local anesthetic infiltration reduced the hemodynamic response to the skin incision. As well as both scalp block and local anesthetic infiltration reduced the cumulative morphine consumption in postoperative 24h. Moreover, the pain intensity was lower after scalp block in the early postoperative period. The scalp block may provide better analgesia in infratentorial craniotomies than local anesthetic infiltration. Copyright © 2017 Elsevier B.V. All rights reserved.

Shampoo after craniotomy: a pilot study.

PubMed

Ireland, Sandra; Carlino, Karen; Gould, Linda; Frazier, Fran; Haycock, Patricia; Ilton, Suzin; Deptuck, Rachel; Bousfield, Brenda; Verge, Donna; Antoni, Karen; MacRae, Louise; Renshaw, Heather; Bialachowski, Ann; Chagnon, Carol; Reddy, Kesava

2007-01-01

The primary goal of this study was to assess the effect of postoperative hair-washing on incision infection and health-related quality of life (HRQOL) in craniotomy patients. The objectives of this study were to 1) determine the effect of postoperative hair-washing on incision infection and HRQOL, 2) provide evidence to support postoperative patient hygienic care, and 3) develop neurosurgical nursing research capacity Does hair-washing 72 hours after craniotomy and before suture or clip removal influence postoperative incision infection and postoperative HRQOL? A prospective cohort of 100 adult patients was randomized to hair-washing 72-hours postoperatively (n = 48), or no hair washing until suture or clip removal (n = 52). At five to -10 days postoperatively, sutures or clips were removed, incisions were assessed using the ASEPSIS Scale (n = 85) and participants were administered the SF-12 Health Survey (n = 71). At 30 days postoperatively, incisions (n = 70) were reassessed. No differences were found between hair-washing and no hair-washing groups for ASEPSIS scores at five to 10 days and 30 days, and total SF-12 scores at five to 10 days postoperatively (p > or = 0.05). Postoperative hair-washing resulted in no increase in incision infection scores or decrease in HRQOL scores when compared to no hair-washing in patients experiencing craniotomy.

Awake craniotomy anesthetic management using dexmedetomidine, propofol, and remifentanil

PubMed Central

Prontera, Andrea; Baroni, Stefano; Marudi, Andrea; Valzania, Franco; Feletti, Alberto; Benuzzi, Francesca; Bertellini, Elisabetta; Pavesi, Giacomo

2017-01-01

Introduction Awake craniotomy allows continuous monitoring of patients’ neurological functions during open surgery. Anesthesiologists have to sedate patients in a way so that they are compliant throughout the whole surgical procedure, nevertheless maintaining adequate analgesia and anxiolysis. Currently, the use of α2-receptor agonist dexmedetomidine as the primary hypnotic–sedative medication is increasing. Methods Nine patients undergoing awake craniotomy were treated with refined monitored anesthesia care (MAC) protocol consisting of a combination of local anesthesia without scalp block, low-dose infusion of dexmedetomidine, propofol, and remifentanil, without the need of airways management. Results The anesthetic protocol applied in our study has the advantage of decreasing the dose of each drug and thus reducing the occurrence of side effects. All patients had smooth and rapid awakenings. The brain remained relaxed during the entire procedure. Conclusion In our experience, this protocol is safe and effective during awake brain surgery. Nevertheless, prospective randomized trials are necessary to confirm the optimal anesthetic technique to be used. PMID:28424537

Awake craniotomy anesthetic management using dexmedetomidine, propofol, and remifentanil.

PubMed

Prontera, Andrea; Baroni, Stefano; Marudi, Andrea; Valzania, Franco; Feletti, Alberto; Benuzzi, Francesca; Bertellini, Elisabetta; Pavesi, Giacomo

2017-01-01

Awake craniotomy allows continuous monitoring of patients' neurological functions during open surgery. Anesthesiologists have to sedate patients in a way so that they are compliant throughout the whole surgical procedure, nevertheless maintaining adequate analgesia and anxiolysis. Currently, the use of α2-receptor agonist dexmedetomidine as the primary hypnotic-sedative medication is increasing. Nine patients undergoing awake craniotomy were treated with refined monitored anesthesia care (MAC) protocol consisting of a combination of local anesthesia without scalp block, low-dose infusion of dexmedetomidine, propofol, and remifentanil, without the need of airways management. The anesthetic protocol applied in our study has the advantage of decreasing the dose of each drug and thus reducing the occurrence of side effects. All patients had smooth and rapid awakenings. The brain remained relaxed during the entire procedure. In our experience, this protocol is safe and effective during awake brain surgery. Nevertheless, prospective randomized trials are necessary to confirm the optimal anesthetic technique to be used.

Evaluation of hyperglycaemic response to intra-operative dexamethasone administration in patients undergoing elective intracranial surgery: A randomised, prospective study.

PubMed

Sethi, Rakesh; Naqash, Imtiaz A; Bajwa, Sukhminder Jit Singh; Dutta, Vikas; Ramzan, Altaf Umar; Zahoor, Syed Amir

2016-01-01

The glucocorticoid dexamethasone in a bolus dose of 8-10 mg followed by quarterly dose of 4 mg is commonly used during intracranial surgery so as to reduce oedema and vascular permeability. However, the detrimental hyperglycaemic effects of dexamethasone may override its potentially beneficial effects. The present prospective, randomised study aimed at comparing the degree and magnitude of hyperglycaemia induced by prophylactic administration of dexamethasone in patients undergoing elective craniotomy. Sixty American Society of Anaesthesiologist (ASA) grade-I and II patients were randomly assigned to three groups of 20 patients each. Group-I received dexamethasone during surgery for the first time. Group-II received dexamethasone in addition to receiving it pre-operatively, whereas Group-III (control group) patients were administered normal saline as placebo. Baseline blood glucose (BG) was measured in all the three groups before induction of anaesthesia and thereafter after every hour for 4 h and then two-hourly. Besides intra- and intergroup comparison of BG, peak BG concentration was also recorded for each patient. Statistical analysis was carried out with analysis of variance (ANOVA) and Student's t-test and value of P < 0.05 was considered statistically significant. Baseline BG reading were higher and statistically significant in Group-II as compared with Group-I and Group-III (P < 0.05). However, peak BG levels were significantly higher in Group-I than in Group-II and III (P < 0.05). Similarly, the magnitude of change in peak BG was significantly higher in Group-I as compared to Group-II and III (P < 0.05). Peri-operative administration of dexamethasone during neurosurgical procedures can cause significant increase in BG concentration especially in patients who receive dexamethasone intra-operatively only.

Evaluation of hyperglycaemic response to intra-operative dexamethasone administration in patients undergoing elective intracranial surgery: A randomised, prospective study

PubMed Central

Sethi, Rakesh; Naqash, Imtiaz A.; Bajwa, Sukhminder Jit Singh; Dutta, Vikas; Ramzan, Altaf Umar; Zahoor, Syed Amir

2016-01-01

Background and Aim: The glucocorticoid dexamethasone in a bolus dose of 8-10 mg followed by quarterly dose of 4 mg is commonly used during intracranial surgery so as to reduce oedema and vascular permeability. However, the detrimental hyperglycaemic effects of dexamethasone may override its potentially beneficial effects. The present prospective, randomised study aimed at comparing the degree and magnitude of hyperglycaemia induced by prophylactic administration of dexamethasone in patients undergoing elective craniotomy. Materials and Methods: Sixty American Society of Anaesthesiologist (ASA) grade-I and II patients were randomly assigned to three groups of 20 patients each. Group-I received dexamethasone during surgery for the first time. Group-II received dexamethasone in addition to receiving it pre-operatively, whereas Group-III (control group) patients were administered normal saline as placebo. Baseline blood glucose (BG) was measured in all the three groups before induction of anaesthesia and thereafter after every hour for 4 h and then two-hourly. Besides intra- and intergroup comparison of BG, peak BG concentration was also recorded for each patient. Statistical analysis was carried out with analysis of variance (ANOVA) and Student's t-test and value of P < 0.05 was considered statistically significant. Results: Baseline BG reading were higher and statistically significant in Group-II as compared with Group-I and Group-III (P < 0.05). However, peak BG levels were significantly higher in Group-I than in Group-II and III (P < 0.05). Similarly, the magnitude of change in peak BG was significantly higher in Group-I as compared to Group-II and III (P < 0.05). Conclusion: Peri-operative administration of dexamethasone during neurosurgical procedures can cause significant increase in BG concentration especially in patients who receive dexamethasone intra-operatively only. PMID:27057213

A Prospective, Randomized, Double-Blinded, Double-Dummy Pilot Study to Assess the Preemptive Effect of Triple Therapy with Aprepitant, Dexamethasone, and Promethazine versus Ondansetron, Dexamethasone and Promethazine on Reducing the Incidence of Postoperative Nausea and Vomiting Experienced by Patients Undergoing Craniotomy Under General Anesthesia.

PubMed

Bergese, Sergio Daniel; Puente, Erika G; Antor, Maria A; Viloria, Adolfo L; Yildiz, Vedat; Kumar, Nicolas Alexander; Uribe, Alberto A

2016-01-01

Postoperative nausea and vomiting (PONV) is among the most common distressing complications of surgery under anesthesia. Previous studies have demonstrated that patients who undergo craniotomy have incidences of nausea and vomiting as high as 50-70%. The main purpose of this pilot study is to assess the incidence of PONV by using two different prophylactic regimens in subjects undergoing a craniotomy. Thus, we designed this study to assess the efficacy and safety of triple therapy with the combination of dexamethasone, promethazine, and aprepitant versus ondansetron to reduce the incidence of PONV in patients undergoing craniotomy. This is a prospective, single center, two-armed, randomized, double-dummy, double-blind, pilot study. Subjects were randomly assigned to one of the two treatment groups. Subjects received 40 mg of aprepitant pill (or matching placebo pill) 30-60 min before induction of anesthesia and 4 mg of ondansetron IV (or 2 ml of placebo saline solution) at induction of anesthesia. In addition, all subjects received 25 mg of promethazine IV and 10 mg of dexamethasone IV at induction of anesthesia. Assessments of PONV commenced for the first 24 h after surgery and were subsequently assessed for up to 5 days. The overall incidence of PONV during the first 24 h after surgery was 31.0% (n = 15) in the aprepitant group and 36.2% (n = 17) for the ondansetron group. The median times to first emetic and significant nausea episodes were 7.6 (2.9, 48.7) and 14.3 (4.4, 30.7) hours, respectively, for the aprepitant group and 6.0 (2.2, 29.5) and 9.6 (0.7, 35.2) hours, respectively, for the ondansetron group. There were no statistically significant differences between these groups. No adverse events directly related to study medications were found. This pilot study showed similar effectiveness when comparing the two PONV prophylaxis regimens. Our data showed that both treatments could be effective regimens to prevent PONV in patients undergoing craniotomy under general anesthesia. Future trials testing new PONV prophylaxis regimens in this surgical population should be performed to gain a better understanding of how to best provide prophylactic treatment.

Efficacy of Dexmedetomidine as an Adjuvant to Local Anesthetic Agent in Scalp Block and Scalp Infiltration to Control Postcraniotomy Pain: A Double-Blind Randomized Trial.

PubMed

Vallapu, Shankar; Panda, Nidhi Bidyut; Samagh, Navneh; Bharti, Neerja

2018-01-01

Scalp infiltration and scalp block are being used to manage postcraniotomy pain. Dexmedetomidine has been successfully used as an adjuvant in regional anesthesia. The study was intended to compare whether addition of dexmedetomidine prolonged the duration of analgesia as well as to compare the two techniques. The primary objective was to assess whether addition of dexmedetomidine to bupivacaine prolonged the duration of analgesia. The secondary objective was to compare between scalp nerve block and scalp infiltration as techniques for pain relief. The randomized control study was conducted in a tertiary care center from November 2013 to October 2014. A total of 150 American Society of Anesthesiologists Physical Status I-II patients, aged 18-70 years undergoing elective craniotomy were included. Patients were randomized into three groups of 50 patients, i.e., Group BI (bupivacaine infiltration), Group BDI (bupivacaine and dexmedetomidine infiltration), and Group BDNB (bupivacaine and dexmedetomidine scalp nerve block). Patient's pain score, pain-free interval, rescue analgesic requirement, and hemodynamic and respiratory parameters were noted for 48 h. Patients were followed up at 1 and 3 months to assess postcraniotomy pain. Pain-free period was significantly longer in Group BDNB than Groups BDI and BI ( P < 0.0001) and pain control was better in dexmedetomidine containing groups than in bupivacaine group (BI) ( P < 0.0001). The rescue analgesic requirement was significantly lower in Group BDNB and Group BDI compared to Group BI. The addition of dexmedetomidine (1 μg/kg) to bupivacaine prolonged the pain-free period. Scalp nerve block is a superior technique than scalp infiltration.

Effect of intravenous parecoxib on post-craniotomy pain.

PubMed

Williams, D L; Pemberton, E; Leslie, K

2011-09-01

Pain management in craniotomy patients is challenging, with mild-to-moderate pain intensity, moderate-to-high risk of postoperative nausea and vomiting (PONV), and potentially catastrophic consequences of analgesic-related side-effects. The aim of this study was to determine whether i.v. parecoxib administered at dural closure during craniotomy decreased total morphine consumption and morphine-related side-effects compared with placebo. One hundred adult patients presenting for supratentorial craniotomy under propofol/remifentanil anaesthesia were randomized to receive parecoxib, 40 mg i.v., or placebo in a double-blind manner. All patients received local anaesthetic scalp infiltration, regular i.v. paracetamol, nurse-administered morphine in the post-anaesthesia care unit (PACU) until verbal analogue pain scores were ≤4/10 and patient-controlled morphine thereafter. Morphine consumption, pain intensity, and analgesia-related side-effects were recorded during the first 24 h after operation. Ninety-six patients (49 control and 47 parecoxib) were included in the analyses. Fifty-nine (61%) patients received morphine in the PACU and only one patient (control) did not receive any morphine in the postoperative period. There were no significant differences between the two groups in morphine consumption [20 (range: 0-102) vs 16 (range: 1-92) mg; P=0.38], pain intensity [excellent/very good pain relief in 78% of parecoxib patients; 74% of control patients (P=0.72)] or analgesia-related side-effects (PONV in 51% of parecoxib patients; 56% of control patients; P=0.55) in the first 24 h after operation. No major morbidity was recorded. Our study demonstrated no clinical benefit to adding i.v. parecoxib to local anaesthetic scalp infiltration, i.v. paracetamol, and patient-controlled i.v. morphine after supratentorial craniotomy.

The Potential Benefits of Awake Craniotomy for Brain Tumor Resection: An Anesthesiologist's Perspective.

PubMed

Meng, Lingzhong; Berger, Mitchel S; Gelb, Adrian W

2015-10-01

Awake craniotomy for brain tumor resection is becoming a standard of care for lesions residing within or in close proximity to regions presumed to have language or sensorimotor function. Evidence shows an improved outcome including greater extent of resection, fewer late neurological deficits, shorter hospital stay, and longer survival after awake brain tumor resection compared with surgery under general anesthesia. The surgeon's ability to maximize tumor resection within the constraint of preserving neurological function by intraoperative stimulation mapping in an awake patient is credited for this advantageous result. It is possible that the care provided by anesthesiologists, especially the avoidance of certain components of general endotracheal anesthesia, may also be important in the outcome of awake brain tumor resection. We present our interpretation of the evidence that we believe substantiates this proposition. However, due to the lack of direct evidence based on randomized-controlled trials and the heterogeneity of anesthetic techniques used for awake craniotomy, our perspective is largely speculative and hypothesis generating that needs to be validated or refuted by future quality research.

Endoscopic Evacuation of Basal Ganglia Hemorrhage via Keyhole Approach Using an Adjustable Cannula in Comparison with Craniotomy

PubMed Central

Zhang, Heng-Zhu; Li, Yu-Ping; Yan, Zheng-cun; Wang, Xing-dong; She, Lei; Wang, Xiao-dong; Dong, Lun

2014-01-01

Neuroendoscopic (NE) surgery as a minimal invasive treatment for basal ganglia hemorrhage is a promising approach. The present study aims to evaluate the efficacy and safety of NE approach using an adjustable cannula to treat basal ganglia hemorrhage. In this study, we analysed the clinical and radiographic outcomes between NE group (21 cases) and craniotomy group (30 cases). The results indicated that NE surgery might be an effective and safe approach for basal ganglia haemorrhage, and it is also suggested that NE approach may improve good functional recovery. However, NE approach only suits the selected patient, and the usefulness of NE approach needs further randomized controlled trials (RCTs) to evaluate. PMID:24949476

Mini-craniotomy as the primary surgical intervention for the treatment of chronic subdural hematoma--a retrospective analysis.

PubMed

Van Der Veken, Jorn; Duerinck, Johnny; Buyl, Ronald; Van Rompaey, Katrijn; Herregodts, Patrick; D'Haens, Jean

2014-05-01

The incidence of chronic subdural hematoma (CSDH) is increasing, but optimal treatment remains controversial. Recent meta-analyses suggest burr hole (BH) drainage is the best treatment because it provides optimal balance between recurrence and morbidity. Mini-craniotomy may offer supplementary technical advantages while maintaining equal or better outcomes. This study investigates the outcome of mini-craniotomy as the sole treatment in patients with CSDH. We analyzed all patients operated on for CSDH with mini-craniotomy in our neurosurgical center between 2005-2010. Baseline patient characteristics (age, sex, comorbidities, imaging characteristics, known risk factors for development of CSDH and neurological examination at presentation) and outcomes (mortality, complications, recurrence and neurological examination at discharge) were recorded. One hundred twenty-six adult patients were included, mean age was 73.9 (range 18 to 95) years old, and the sex ratio (M:F) was 2:1. Eighty-four percent of the patients showed clinical improvement at discharge, as shown by a decrease in the Markwalder score postoperatively (with 57 % Markwalder 0 and 23 % Markwalder 1). Recurrence rate was 8.7 %. Overall complication rate was 34.1 % (27.8 % medical complications and 6.3 % surgical complications). In-hospital mortality was 13.5 % (8.7 % due to pulmonary infections and 1.6 % to surgical complications). Preoperative Markwalder grade correlated significantly with complication rate, as did the presence of a neurodegenerative disease (p = 0.018). Factors significantly related to mortality in univariate analysis were arterial hypertension (p = 0.038), heart failure (p = 0.02), renal failure (p = 0.017), neurodegenerative disease (p = 0.001), cerebrovascular accident (p = 0.008) and coagulopathy (p = 0.019). Multivariate analysis was not able to confirm any significant relationship. This is the first published series of CSDH in which all consecutive patients were operated on by mini-craniotomy. The invasiveness and complication rate of mini-craniotomy are equal to those of burr hole treatment, but visualization is superior, resulting in lower recurrences. A randomized controlled trial is indicated to identify the best surgical strategy for the treatment of CSDH.

Comparison of the clinical efficacy of craniotomy and craniopuncture therapy for the early stage of moderate volume spontaneous intracerebral haemorrhage in basal ganglia: Using the CTA spot sign as an entry criterion.

PubMed

Ge, Chunyan; Zhao, Wangmiao; Guo, Hong; Sun, Zhaosheng; Zhang, Wanzeng; Li, Xiaowei; Yang, Xuehui; Zhang, Jinrong; Wang, Dongxin; Xiang, Yi; Mao, Jianhui; Zhang, Wenchao; Guo, Hao; Zhang, Yazhao; Chen, Jianchao

2018-06-01

Surgical treatment is widely used for haematoma removal in spontaneous intracerebral haemorrhage (ICH) patients, but there is controversy about the selection of surgical methods. The CT angiography (CTA) spot sign has been proven to be a promising factor predicting haematoma expansion and is recommended as an entry criterion for haemostatic therapy in patients with ICH. This trial was designed to evaluate the clinical efficacy of two surgical methods (haematoma removal by craniotomy and craniopuncture combined with urokinase infusion) for patients in the early stage (≤6h from symptom onset) of spontaneous ICH with a moderate haematoma volume (30 ml - 60 ml). From January 2012 to July 2017, 196 eligible patients treated in our institution were enrolled according to the inclusion criteria. The patients were divided into the CTA spot sign positive type and CTA spot sign negative type according to the presence or absence of the CTA spot sign. For each type, the patients were randomly assigned to two groups, i.e., the craniotomy group, in which patients underwent craniotomy with haematoma removal, and the craniopuncture group, in which patients underwent minimally invasive craniopuncture combined with urokinase infusion therapy. Neurological function was evaluated with the Scandinavian Stroke Scale (SSS) at day 14. The disability level and the activities of daily living were assessed using a modified Rankin Scale (mRS) and Barthel Index (BI) at day 90. Case fatalities were recorded at day 14 and 90. Complications were recorded during hospitalization. For the CTA spot sign positive type, the craniotomy group had a higher SSS than that in the craniopuncture group (P < 0.05) at day 14. The rebleeding rate was higher in the craniopuncture group than that in the craniotomy group (P < 0.05) during hospitalization. The craniotomy group had a lower mRS than that in the craniopuncture group (P < 0.01) and had a higher BI than that in the craniopuncture group (P < 0.05) at day 90. There was no statistically significant difference in the fatality rate between the two groups. For the CTA spot sign negative type, there were no significant differences in the SSS, mRS, BI, fatality rate and complication rate between the two groups. ICH can be divided into the CTA spot sign positive and negative type according to the presence or absence of the CTA spot sign. For the CTA spot sign positive type, patients can benefit from craniotomy with haematoma removal, which can reduce the postoperative rebleeding rate and improve the prognosis. For the CTA spot sign negative type, both craniotomy and craniopuncture are applicable. Considering simple procedure and minor surgical injury, craniopuncture can be a more reasonable choice. Copyright © 2018 Elsevier B.V. All rights reserved.

A randomized, double-blinded comparison of ondansetron, granisetron, and placebo for prevention of postoperative nausea and vomiting after supratentorial craniotomy.

PubMed

Jain, Virendra; Mitra, Jayanta K; Rath, Girija P; Prabhakar, Hemanshu; Bithal, Parmod K; Dash, Hari H

2009-07-01

Postoperative nausea and vomiting (PONV) are frequent and distressing complications after neurosurgical procedures. We evaluated the efficacy of ondansetron and granisetron to prevent PONV after supratentorial craniotomy. In a randomized double-blind, placebo controlled trial, 90 adult American Society of Anesthesiologists I, II patients were included in the study. A standard anesthesia technique was followed. Patients were divided into 3 groups to receive either placebo (saline), ondansetron 4 mg, or granisetron 1 mg intravenously at the time of dural closure. After extubation, episodes of nausea and vomiting were noted for 24 hours postoperatively. Statistical analysis was performed using chi2 test and 1-way analysis of variance. Demographic data, duration of surgery, intraoperative fluids and analgesic requirement, and postoperative pain (visual analog scale) scores were comparable in all 3 groups. It was observed that the incidence of vomiting in 24 hours, severe emetic episodes, and requirement of rescue antiemetics were less in ondansetron and granisetron groups as compared with placebo (P<0.001). Both the study drugs had comparable effect on vomiting. However, the incidence of nausea was comparable in all 3 groups (P=0.46). A favorable influence on the patient satisfaction scores, and number needed to prevent emesis was seen in the 2 drug groups. No significant correlation was found between neurosurgical factors (presence of midline shift, mass effect, pathologic diagnosis of tumor, site of tumor) and the occurrence of PONV. We conclude that ondansetron 4 mg and granisetron 1 mg are comparably effective at preventing emesis after supratentorial craniotomy. However, neither drugs prevented nausea effectively.

Postoperative Intravenous Acetaminophen for Craniotomy Patients: A Randomized Controlled Trial.

PubMed

Greenberg, Steven; Murphy, Glenn S; Avram, Michael J; Shear, Torin; Benson, Jessica; Parikh, Kruti N; Patel, Aashka; Newmark, Rebecca; Patel, Vimal; Bailes, Julian; Szokol, Joseph W

2018-01-01

To determine whether opioids during the first 24 postoperative hours were significantly altered when receiving intravenous (IV) acetaminophen during that time compared with those receiving placebo (normal saline). One hundred forty patients undergoing any type of craniotomy were randomly assigned to receive either 1 g of IV acetaminophen or placebo upon surgical closure, and every 6 hours thereafter, up to 18 hours postoperatively. Analgesic requirements for the first 24 postoperative hours were recorded. Time to rescue medications in the postanesthesia care unit (PACU)/intensive care unit (ICU), amount of rescue medication, ICU and hospital lengths of stay, number of successful neurological examinations, sedation, delirium, satisfaction, and visual analog scale pain scores were also recorded. Compared with the placebo group, more patients in the IV acetaminophen group (10/66 [15.2%] vs. 4/65 [6.2%] in the placebo group) did not require opioids within the first 24 postoperative hours, but this did not reach significance (odds ratio, -9.0%, 95% confidence interval -20.5% to 1.8%; P = 0.166). Both groups had similar times to rescue medications, amounts of rescue medications, ICU and hospital lengths of stay, numbers of successful neurological examinations, sedation, delirium, satisfaction scores, visual analog scale pain scores, and temperatures within the first 24 postoperative hours. The opioid requirements within the first 24 postoperative hours were similar in the placebo and acetaminophen groups. This study is informative for the design and planning of future studies investigating the management of postoperative pain in patients undergoing craniotomies. Copyright © 2017 Elsevier Inc. All rights reserved.

Inflammatory Profile of Awake Function-Controlled Craniotomy and Craniotomy under General Anesthesia

PubMed Central

Klimek, Markus; Hol, Jaap W.; Wens, Stephan; Heijmans-Antonissen, Claudia; Niehof, Sjoerd; Vincent, Arnaud J.; Klein, Jan; Zijlstra, Freek J.

2009-01-01

Background. Surgical stress triggers an inflammatory response and releases mediators into human plasma such as interleukins (ILs). Awake craniotomy and craniotomy performed under general anesthesia may be associated with different levels of stress. Our aim was to investigate whether those procedures cause different inflammatory responses. Methods. Twenty patients undergoing craniotomy under general anesthesia and 20 patients undergoing awake function-controlled craniotomy were included in this prospective, observational, two-armed study. Circulating levels of IL-6, IL-8, and IL-10 were determined pre-, peri-, and postoperatively in both patient groups. VAS scores for pain, anxiety, and stress were taken at four moments pre- and postoperatively to evaluate physical pain and mental duress. Results. Plasma IL-6 level significantly increased with time similarly in both groups. No significant plasma IL-8 and IL-10 change was observed in both experimental groups. The VAS pain score was significantly lower in the awake group compared to the anesthesia group at 12 hours postoperative. Postoperative anxiety and stress declined similarly in both groups. Conclusion. This study suggests that awake function-controlled craniotomy does not cause a significantly different inflammatory response than craniotomy performed under general anesthesia. It is also likely that function-controlled craniotomy does not cause a greater emotional challenge than tumor resection under general anesthesia. PMID:19536349

Awake craniotomy induces fewer changes in the plasma amino acid profile than craniotomy under general anesthesia.

PubMed

Hol, Jaap W; Klimek, Markus; van der Heide-Mulder, Marieke; Stronks, Dirk; Vincent, Arnoud J; Klein, Jan; Zijlstra, Freek J; Fekkes, Durk

2009-04-01

In this prospective, observational, 2-armed study, we compared the plasma amino acid profiles of patients undergoing awake craniotomy to those undergoing craniotomy under general anesthesia. Both experimental groups were also compared with a healthy, age-matched and sex-matched reference group not undergoing surgery. It is our intention to investigate whether plasma amino acid levels provide information about physical and emotional stress, as well as pain during awake craniotomy versus craniotomy under general anesthesia. Both experimental groups received preoperative, perioperative, and postoperative dexamethasone. The plasma levels of 20 amino acids were determined preoperative, perioperative, and postoperatively in all groups and were correlated with subjective markers for pain, stress, and anxiety. In both craniotomy groups, preoperative levels of tryptophan and valine were significantly decreased whereas glutamate, alanine, and arginine were significantly increased relative to the reference group. Throughout time, tryptophan levels were significantly lower in the general anesthesia group versus the awake craniotomy group. The general anesthesia group had a significantly higher phenylalanine/tyrosine ratio, which may suggest higher oxidative stress, than the awake group throughout time. Between experimental groups, a significant increase in large neutral amino acids was found postoperatively in awake craniotomy patients, pain was also less and recovery was faster. A significant difference in mean hospitalization time was also found, with awake craniotomy patients leaving after 4.53+/-2.12 days and general anesthesia patients after 6.17+/-1.62 days; P=0.012. This study demonstrates that awake craniotomy is likely to be physically and emotionally less stressful than general anesthesia and that amino acid profiling holds promise for monitoring postoperative pain and recovery.

Brain surgery

MedlinePlus

Craniotomy; Surgery - brain; Neurosurgery; Craniectomy; Stereotactic craniotomy; Stereotactic brain biopsy; Endoscopic craniotomy ... cut depends on where the problem in the brain is located. The surgeon creates a hole in ...

Effects of music listening on anxiety and physiological responses in patients undergoing awake craniotomy.

PubMed

Wu, Pao-Yuan; Huang, Mei-Lin; Lee, Wen-Ping; Wang, Chi; Shih, Whei-Mei

2017-06-01

The purpose of this study was to explore the effects of music listening on the level of anxiety and physiological responses for awake craniotomy. An experimental design with randomization was applied in this study. Participants in experimental group (19 patients) selected and listened music at their preferences in the waiting room and throughout the entire surgical procedure in addition to usual care while control group (19 patients) only gave usual care. State-Trait Anxiety Inventory (STAI), heartbeat, breathing, and blood pressure were collected for analysis. The results of this study showed that after music listening, there was significant decrease in the level of anxiety (p<.001). The findings also showed that the music intervention significantly reduced heartbeat rate 84.5 (p<.004), systolic pressure 42 (p<.001), and diastolic pressure 38 (p<.001) over time. We concluded that music listening is associated with a decreased level of anxiety and distress after awake craniotomy patients. The results of this study can provide perioperative nursing care in providing music listening when patients were in the waiting room and during surgery to reduce the anxiety so as to reach the goal of human care and improve perioperative nursing care. Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Chronic Subdural Hematoma Treated by Small or Large Craniotomy with Membranectomy as the Initial Treatment

PubMed Central

Kim, Jae-Hong; Kim, Jung-Hee; Kong, Min-Ho; Song, Kwan-Young

2011-01-01

Objective There are few studies comparing small and large craniotomies for the initial treatment of chronic subdural hematoma (CSDH) which had non-liquefied hematoma, multilayer intrahematomal loculations, or organization/calcification on computed tomography and magnetic resonance imaging. These procedures were compared to determine which would produce superior postoperative results. Methods Between 2001 and 2009, 317 consecutive patients were surgically treated for CSDH at our institution. Of these, 16 patients underwent a small craniotomy with partial membranectomy and 42 patients underwent a large craniotomy with extended membranectomy as the initial treatment. A retrospective review was performed to compare the postoperative outcomes of these two techniques, focusing on improvement of neurological status, complications, reoperation rate, and days of post-operative hospitalization. Results The mean ages were 69.4±12.1 and 55.6±9.3 years in the small and large craniotomy groups, respectively. The recurrence of hematomas requiring reoperation occurred in 50% and 10% of the small and large craniotomy patients, respectively (p<0.001). There were no significant differences in postoperative neurological status, complications, or days of hospital stay between these two groups. Conclusion Among the cases of CSDH initially requiring craniotomy, the large craniotomy with extended membranectomy technique reduced the reoperation rate, compared to that of the small craniotomy with partial membranectomy technique. PMID:22053228

Comparison of endoscopic evacuation, stereotactic aspiration and craniotomy for the treatment of supratentorial hypertensive intracerebral haemorrhage: study protocol for a randomised controlled trial.

PubMed

Xu, Xinghua; Zheng, Yi; Chen, Xiaolei; Li, Fangye; Zhang, Huaping; Ge, Xin

2017-06-28

Hypertensive intracerebral haemorrhage (HICH) is the most common form of haemorrhagic stroke with the highest morbidity and mortality of all stroke types. The choice of surgical or conservative treatment for patients with HICH remains controversial. In recent years, minimally invasive surgeries, such as endoscopic evacuation and stereotactic aspiration, have been attempted for haematoma removal and offer promise. However, research evidence on the benefits of endoscopic evacuation or stereotactic aspiration is still insufficient. A multicentre, randomised controlled trial will be conducted to compare the efficacy of endoscopic evacuation, stereotactic aspiration and craniotomy in the treatment of supratentorial HICH. About 1350 eligible patients from 10 neurosurgical centres will be randomly assigned to an endoscopic group, a stereotactic group and a craniotomy group at a 1:1:1 ratio. Randomisation is undertaken using a 24-h randomisation service accessed by telephone or the Internet. All patients will receive the corresponding surgery based on their grouping. They will be followed-up at 1, 3 and 6 months after surgery. The primary outcome is the modified Rankin Scale at 6-month follow-up. Secondary outcomes include: haematoma clearance rate; Glasgow Coma Scale 7 days after surgery; rebleeding rate; intracranial infection rate; hospitalisation time; mortality at 1 month and 3 months after surgery; the Barthel Index and the WHO quality of life at 3 months and 6 months after surgery. The trial aims to investigate whether endoscopic evacuation and stereotactic aspiration could improve the outcome of supratentorial HICH compared with craniotomy. The trial will help to determine the best surgical method for the treatment of supratentorial HICH. ClinicalTrials.gov, ID: NCT02811614 . Registered on 20 June 2016.

Predicting sleepiness during an awake craniotomy.

PubMed

Itoi, Chihiro; Hiromitsu, Kentaro; Saito, Shoko; Yamada, Ryoji; Shinoura, Nobusada; Midorikawa, Akira

2015-12-01

An awake craniotomy is a safe neurological surgical technique that minimizes the risk of brain damage. During the course of this surgery, the patient is asked to perform motor or cognitive tasks, but some patients exhibit severe sleepiness. Thus, the present study investigated the predictive value of a patient's preoperative neuropsychological background in terms of sleepiness during an awake craniotomy. Thirty-seven patients with brain tumor who underwent awake craniotomy were included in this study. Prior to craniotomy, the patient evaluated cognitive status, and during the surgery, each patient's performance and attitude toward cognitive tasks were recorded by neuropsychologists. The present findings showed that the construction and calculation abilities of the patients were moderately correlated with their sleepiness. These results indicate that the preoperative cognitive functioning of patients was related to their sleepiness during the awake craniotomy procedure and that the patients who exhibited sleepiness during an awake craniotomy had previously experienced reduced functioning in the parietal lobe. Copyright © 2015 Elsevier B.V. All rights reserved.

Awake craniotomy for supratentorial gliomas: why, when and how?

PubMed

Ibrahim, George M; Bernstein, Mark

2012-09-01

Awake craniotomy has become an increasingly utilized procedure in the treatment of supratentorial intra-axial tumors. The popularity of this procedure is partially attributable to improvements in intraoperative technology and anesthetic techniques. The application of awake craniotomy to the field of neuro-oncology has decreased iatrogenic postoperative neurological deficits, allowed for safe maximal tumor resection and improved healthcare resource stewardship by permitting early patient discharge. In this article, we review recent evidence for the utility of awake craniotomy in the resection of gliomas and describe the senior author's experience in performing this procedure. Furthermore, we explore innovative applications of awake craniotomy to outpatient tumor resections and the conduct of neurosurgery in resource-poor settings. We conclude that awake craniotomy is an effective and versatile neurosurgical procedure with expanding applications in neuro-oncology.

Secure Cluster Head Sensor Elections Using Signal Strength Estimation and Ordered Transmissions

PubMed Central

Wang, Gicheol; Cho, Gihwan

2009-01-01

In clustered sensor networks, electing CHs (Cluster Heads) in a secure manner is very important because they collect data from sensors and send the aggregated data to the sink. If a compromised node is elected as a CH, it can illegally acquire data from all the members and even send forged data to the sink. Nevertheless, most of the existing CH election schemes have not treated the problem of the secure CH election. Recently, random value based protocols have been proposed to resolve the secure CH election problem. However, these schemes cannot prevent an attacker from suppressing its contribution for the change of CH election result and from selectively forwarding its contribution for the disagreement of CH election result. In this paper, we propose a modified random value scheme to prevent these disturbances. Our scheme dynamically adjusts the forwarding order of contributions and discards a received contribution when its signal strength is lower than the specified level to prevent these malicious actions. The simulation results have shown that our scheme effectively prevents attackers from changing and splitting an agreement of CH election result. Also, they have shown that our scheme is relatively energy-efficient than other schemes. PMID:22408550

[Awake craniotomy].

PubMed

2012-01-01

The article is a literature review on awake craniotomy. History of method, indications and contraindications, necessary conditions for successful application as well as complications and their prevention and correction are considered Outcomes in patients with neuro-oncological pathology and in patients with intractable epilepsy after awake craniotomy are also analyzed. It's also shown that awake craniotomy can make removal of tumors near eloquent cortex more radical and improve neurological outcome in such patients.

Failed awake craniotomy: a retrospective analysis in 424 patients undergoing craniotomy for brain tumor.

PubMed

Nossek, Erez; Matot, Idit; Shahar, Tal; Barzilai, Ori; Rapoport, Yoni; Gonen, Tal; Sela, Gal; Korn, Akiva; Hayat, Daniel; Ram, Zvi

2013-02-01

Awake craniotomy for removal of intraaxial tumors within or adjacent to eloquent brain regions is a well-established procedure. However, awake craniotomy failures have not been well characterized. In the present study, the authors aimed to analyze and assess the incidence and causes for failed awake craniotomy. The database of awake craniotomies performed at Tel Aviv Medical Center between 2003 and 2010 was reviewed. Awake craniotomy was considered a failure if conversion to general anesthesia was required, or if adequate mapping or monitoring could not have been achieved. Of 488 patients undergoing awake craniotomy, 424 were identified as having complete medical, operative, and anesthesiology records. The awake craniotomies performed in 27 (6.4%) of these 424 patients were considered failures. The main causes of failure were lack of intraoperative communication with the patient (n = 18 [4.2%]) and/or intraoperative seizures (n = 9 [2.1%]). Preoperative mixed dysphasia (p < 0.001) and treatment with phenytoin (p = 0.0019) were related to failure due to lack of communication. History of seizures (p = 0.03) and treatment with multiple antiepileptic drugs (p = 0.0012) were found to be related to failure due to intraoperative seizures. Compared with the successful awake craniotomy group, a significantly lower rate of gross-total resection was achieved (83% vs 54%, p = 0.008), there was a higher incidence of short-term speech deterioration postoperatively (6.1% vs 23.5%, p = 0.0017) as well as at 3 months postoperatively (2.3% vs 15.4%, p = 0.0002), and the hospitalization period was longer (4.9 ± 6.2 days vs 8.0 ± 10.1 days, p < 0.001). Significantly more major complications occurred in the failure group (4 [14.8%] of 27) than in the successful group (16 [4%] of 397) (p = 0.037). Failures of awake craniotomy were associated with a lower incidence of gross-total resection and increased postoperative morbidity. The majority of awake craniotomy failures were preventable by adequate patient selection and avoiding side effects of drugs administered during surgery.

Trans-lamina terminalis approach to third ventricle using supraorbital craniotomy: technique description and literature review for outcome comparison with anterior, lateral and trans-sphenoidal corridors.

PubMed

Krishna, V; Blaker, B; Kosnik, L; Patel, S; Vandergrift, W

2011-10-01

The trans-lamina terminalis approach has been described to remove third ventricular tumors. Various surgical corridors for this approach include anterior (via bifrontal craniotomy), anterolateral (via supra-orbital craniotomy), lateral (via pterional craniotomy) and trans-sphenoidal corridors. Supra-orbital craniotomy offers a minimally invasive access for resection of third ventricular tumors. The trans-lamina terminalis technique through a supra-orbital craniotomy is described. Also, a literature review of clinical outcome data was performed for the comparison of different surgical corridors (anterior, antero-lateral, lateral, and trans-sphenoidal). The operative steps and anatomic landmarks for supra-orbital craniotomy are discussed, along with 3 representative cases and respective outcomes. Gross total resection was achieved in 2 patients, and one patient required reoperation for recurrence. Based on the current literature, the clinical outcomes after supra-orbital craniotomy for trans-lamina terminalis approach are comparable to other surgical corridors. The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for third ventricular tumors. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long working distance is a major limitation. The clinical outcomes are comparable to other surgical corridors. Sound understanding of major strengths, limitations, and strategies for complication avoidance is necessary for its safe and effective application. © Georg Thieme Verlag KG Stuttgart · New York.

A case of loss of consciousness with contralateral acute subdural haematoma during awake craniotomy

PubMed Central

Kamata, Kotoe; Maruyama, Takashi; Nitta, Masayuki; Ozaki, Makoto; Muragaki, Yoshihiro; Okada, Yoshikazu

2014-01-01

We are reporting the case of a 56-year-old woman who developed loss of consciousness during awake craniotomy. A thin subdural haematoma in the contralateral side of the craniotomy was identified with intraoperative magnetic resonance imaging and subsequently removed. Our case indicates that contralateral acute subdural haematoma could be a cause of deterioration of the conscious level during awake craniotomy. PMID:25301378

Awake craniotomy for tumor resection.

PubMed

Attari, Mohammadali; Salimi, Sohrab

2013-01-01

Surgical treatment of brain tumors, especially those located in the eloquent areas such as anterior temporal, frontal lobes, language, memory areas, and near the motor cortex causes high risk of eloquent impairment. Awake craniotomy displays major rule for maximum resection of the tumor with minimum functional impairment of the Central Nervous System. These case reports discuss the use of awake craniotomy during the brain surgery in Alzahra Hospital, Isfahan, Iran. A 56-year-old woman with left-sided body hypoesthesia since last 3 months and a 25-year-old with severe headache of 1 month duration were operated under craniotomy for brain tumors resection. An awake craniotomy was planned to allow maximum tumor intraoperative testing for resection and neurologic morbidity avoidance. The method of anesthesia should offer sufficient analgesia, hemodynamic stability, sedation, respiratory function, and also awake and cooperative patient for different neurological test. Airway management is the most important part of anesthesia during awake craniotomy. Tumor surgery with awake craniotomy is a safe technique that allows maximal resection of lesions in close relationship to eloquent cortex and has a low risk of neurological deficit.

Awake craniotomy for tumor resection

PubMed Central

Attari, Mohammadali; Salimi, Sohrab

2013-01-01

Surgical treatment of brain tumors, especially those located in the eloquent areas such as anterior temporal, frontal lobes, language, memory areas, and near the motor cortex causes high risk of eloquent impairment. Awake craniotomy displays major rule for maximum resection of the tumor with minimum functional impairment of the Central Nervous System. These case reports discuss the use of awake craniotomy during the brain surgery in Alzahra Hospital, Isfahan, Iran. A 56-year-old woman with left-sided body hypoesthesia since last 3 months and a 25-year-old with severe headache of 1 month duration were operated under craniotomy for brain tumors resection. An awake craniotomy was planned to allow maximum tumor intraoperative testing for resection and neurologic morbidity avoidance. The method of anesthesia should offer sufficient analgesia, hemodynamic stability, sedation, respiratory function, and also awake and cooperative patient for different neurological test. Airway management is the most important part of anesthesia during awake craniotomy. Tumor surgery with awake craniotomy is a safe technique that allows maximal resection of lesions in close relationship to eloquent cortex and has a low risk of neurological deficit. PMID:24223378

Epidemiology of Moderate-to-Severe Penetrating Versus Closed Traumatic Brain Injury in the Iraq and Afghanistan Wars

DTIC Science & Technology

2012-01-01

Craniotomy 1.21 incision and drainage of cranial sinus 1.23 reopening of craniotomy site 1.24 other craniotomy 1.31 incision of cerebral meninges 1.39 other...Any intervention 401 (51.8) 102 (21.2) 503 (40.1) G0.0001 ICP monitoring 249 (32.2) 77 (16.0) 326 (26.0) G0.0001 Craniotomy 167 (21.6) 30 (6.2) 197

Awake craniotomy: improving the patient's experience.

PubMed

Potters, Jan-Willem; Klimek, Markus

2015-10-01

Awake craniotomy patients are exposed to various stressful stimuli while their attention and vigilance is important for the success of the surgery. We describe several recent findings on the perception of awake craniotomy patients and address nonpharmacological perioperative factors that enhance the experience of awake craniotomy patients. These factors could also be applicable to other surgical patients. Proper preoperative counseling gives higher patient satisfaction and should be individually tailored to the patient. Furthermore, there is a substantial proportion of patients who have significant pain or fear during an awake craniotomy procedure. There is a possibility that this could induce post-traumatic stress disorder or related symptoms. Preoperative preparation is of utmost importance in awake craniotomy patients, and a solid doctor-patient relationship is an important condition. Nonpharmacological intraoperative management should focus on reduction of fear and pain by adaptation of the environment and careful and well considered communication.

Cosmetic and functional reconstruction achieved using a split myofascial bone flap for pterional craniotomy. Technical note.

PubMed

Matsumoto, K; Akagi, K; Abekura, M; Ohkawa, M; Tasaki, O; Tomishima, T

2001-04-01

Cosmetic deformities that appear following pterional craniotomy are usually caused by temporal muscle atrophy, injury to the frontotemporal branch of the facial nerve, or bone pits in the craniotomy line. To resolve these problems during pterional craniotomy, an alternative method was developed in which a split myofascial bone flap and a free bone flap are used. The authors have used this method in the treatment of 40 patients over the last 3 years. Excellent cosmetic and functional results have been obtained. This method can provide wide exposure similar to that achieved using Yaşargil's interfascial pterional craniotomy, without limiting the operative field with a bulky temporal muscle flap.

Nonopioid anesthesia for awake craniotomy: a case report.

PubMed

Wolff, Diane L; Naruse, Robert; Gold, Michele

2010-02-01

Awake craniotomy is becoming more popular as a neurosurgical technique that allows for increased tumor resection and decreased postoperative neurologic morbidity. This technique, however, presents many challenges to both the neurosurgeon and anesthetist. An ASA class II, 37-year-old man with recurrent oligodendroglioma presented for repeated craniotomy. Prior craniotomy under general anesthesia resulted in residual neurologic deficits. An awake craniotomy was planned to allow for intraoperative testing for maximum tumor resection and avoidance of neurologic morbidity. The patient was sedated with propofol, and bupivacaine was infiltrated for placement of Mayfield tongs and skin incision. Following exposure of brain tissue, propofol infusion was discontinued to allow for patient cooperation during the procedure. Speech, motor, and sensory testing occurred during tumor resection until resection stopped after onset of weakness in the right arm. The propofol infusion was resumed while the cranium was closed and Mayfield tongs removed. The patient was awake, alert, oriented, and able to move all extremities but had residual weakness in the right forearm. Awake craniotomy requires appropriate patient selection, knowledge of the surgeon's skill, and a thorough anesthesia plan. This case report discusses the clinical and anesthetic management for awake craniotomy and reviews the literature.

Awake Craniotomy: First-Year Experiences and Patient Perception.

PubMed

Joswig, Holger; Bratelj, Denis; Brunner, Thomas; Jacomet, Alfred; Hildebrandt, Gerhard; Surbeck, Werner

2016-06-01

Awake craniotomy for brain lesions in or near eloquent brain regions enables neurosurgeons to assess neurologic functions of patients intraoperatively, reducing the risk of permanent neurologic deficits and increasing the extent of resection. A retrospective review was performed of a consecutive series of patients with awake craniotomies in the first year of their introduction to our tertiary non-university-affiliated neurosurgery department. Operation time, complications, and neurologic outcome were assessed, and patient perception of awake craniotomy was surveyed using a mailed questionnaire. There were 24 awake craniotomies performed in 22 patients for low-grade/high-grade gliomas, cavernomas, and metastases (average 2 cases per month). Mean operation time was 205 minutes. Failure of awake craniotomy because of intraoperative seizures with subsequent postictal impaired testing or limited cooperation occurred in 2 patients. Transient neurologic deficits occurred in 29% of patients; 1 patient sustained a permanent neurologic deficit. Of the 18 patients (82%) who returned the questionnaire, only 2 patients recalled significant fear during surgery. Introducing awake craniotomy to a tertiary non-university-affiliated neurosurgery department is feasible and resulted in reasonable operation times and complication rates and high patient satisfaction. Copyright © 2016 Elsevier Inc. All rights reserved.

Workload Trend Analysis for the Military Graduate Medical Education Program in San Antonio

DTIC Science & Technology

2005-05-25

Procedures 57 Introduction and Methodology 57 Results and Discussion 58 Craniotomy 61 Introduction and Methodology 61 Results and Discussion 62...distribution of major vascular procedures by age group for FY 00-04 36. WHMC and BAMC craniotomies for FY 00-04 by age group 37. WHMC and BAMC FY 00-04...average craniotomies by age group compared to required average based on RRC requirement 38. WHMC and BAMC distribution of craniotomies by age group for

The history of craniotomy for headache treatment.

PubMed

Assina, Rachid; Sarris, Christina E; Mammis, Antonios

2014-04-01

Both the history of headache and the practice of craniotomy can be traced to antiquity. From ancient times through the present day, numerous civilizations and scholars have performed craniotomy in attempts to treat headache. Today, surgical intervention for headache management is becoming increasingly more common due to improved technology and greater understanding of headache. By tracing the evolution of the understanding of headache alongside the practice of craniotomy, investigators can better evaluate the mechanisms of headache and the therapeutic treatments used today.

Teaching and sustainably implementing awake craniotomy in resource-poor settings.

PubMed

Howe, Kathryn L; Zhou, Guosheng; July, Julius; Totimeh, Teddy; Dakurah, Thomas; Malomo, Adefolarin O; Mahmud, Muhammad R; Ismail, Nasiru J; Bernstein, Mark A

2013-12-01

Awake craniotomy for brain tumor resection has the benefit of avoiding a general anesthetic and decreasing associated costs (e.g., intensive care unit beds and intravenous line insertion). In low- and middle-income countries, significant resource limitations for the system and individual make awake craniotomy an ideal tool, yet it is infrequently used. We sought to determine if awake craniotomy could be effectively taught and implemented safely and sustainably in low- and middle-income countries. A neurosurgeon experienced in the procedure taught awake craniotomy to colleagues in China, Indonesia, Ghana, and Nigeria during the period 2007-2012. Patients were selected on the basis of suspected intraaxial tumor, absence of major dysphasia or confusion, and ability to tolerate the positioning. Data were recorded by the local surgeons and included preoperative imaging, length of hospital admission, final pathology, postoperative morbidity, and mortality. Awake craniotomy was performed for 38 cases of suspected brain tumor; most procedures were completed independently. All patients underwent preoperative computed tomography or magnetic resonance imaging. In 64% of cases, patients remained in the hospital <10 days. The most common pathology was high-grade glioma, followed by meningioma, low-grade glioma, and metastasis. No deaths occurred, and no case required urgent intubation. The most common perioperative and postoperative issue was seizure, with 1 case of permanent postoperative deficit. Awake craniotomy was successfully taught and implemented in 6 neurosurgical centers in China, Indonesia, Ghana, and Nigeria. Awake craniotomy is safe, resource-sparing, and sustainable. The data suggest awake craniotomy has the potential to significantly improve access to neurosurgical care in resource-challenged settings. Copyright © 2013 Elsevier Inc. All rights reserved.

Using Elections as Teachable Moments: A Randomized Evaluation of the Student Voices Civic Education Program

ERIC Educational Resources Information Center

Syvertsen, Amy K.; Stout, Michael D.; Flanagan, Constance A.

2009-01-01

The recommitment of public education to its civic roots has revived discussion on how to engage younger generations of citizens in electoral politics and civic life. This randomized trial of 1,670 high school students in 80 social studies classrooms evaluates the impact of an election-based civics program on students' civic knowledge, skills, and…

Pediatric Awake Craniotomy for Brain Lesions.

PubMed

Akay, Ali; Rükşen, Mete; Çetin, H Yurday; Seval, H Özer; İşlekel, Sertaç

2016-01-01

Awake craniotomy is a special method to prevent motor deficits during the resection of lesions that are located in, or close to, functional areas. Although it is more commonly performed in adult patients, reports of pediatric cases undergoing awake craniotomy are limited in the literature. In our clinic, where we frequently use awake craniotomy in adult patients, we performed this method in 2 selected pediatric cases for lesion surgery. At an early age, these 2 cases diagnosed with epilepsy presented cerebral lesions, but since the lesions enclosed functional areas, surgical resection was not regarded as a treatment option at this time. In these 2 pediatric cases, we successfully completed lesion surgery with awake craniotomy. The method and the techniques employed during surgery are presented concomitant with other reports in the literature. © 2016 S. Karger AG, Basel.

Management of supratentorial cavernous malformations: craniotomy versus gammaknife radiosurgery.

PubMed

Shih, Yang-Hsin; Pan, David Hung-Chi

2005-02-01

Although craniotomy is the preferred treatment for symptomatic solitary supratentorial cavernous malformation (CM), radiosurgery is also an option. Our aim was to see which of these strategies was the most effective and under what circumstances. Of the 46 patients with solitary supratentorial CM that we retrospectively studied, 24 presented with seizures, 16 with focal neurological deficits due to intracerebral hemorrhage, and 6 with both seizures and bleeding. Sixteen were treated with craniotomy and 30 with gammaknife radiosurgery (GKRS). The main outcome measures for comparing craniotomy with GKRS were the proportion of postoperative seizure-free patients and the proportion of patients in whom no rebleeding occurred. Of patients presenting with seizures with/without bleeding, a significantly higher proportion of the craniotomy group than the GKRS group became and remained seizure-free (11/14 [79%] versus 4/16 [25%]; P < 0.002), and of those presenting with bleeding with/without seizures, a somewhat (though nonsignificantly) higher proportion did not rebleed (4/4 [100%] versus 12/18 [67%]) after surgery. The remaining 2 of the 16 craniotomy patients did not rebleed and had no residual tumor at follow up. Twelve of the 30 GKRS patients had evidence of tumor regression at follow up. In the clinical management of solitary supratentorial CM, craniotomy for lesionectomy resulted in better seizure control and rebleeding avoidance than GKRS.

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms.

PubMed

Deshaies, Eric M; Villwock, Mark R; Singla, Amit; Toshkezi, Gentian; Padalino, David J

2015-08-11

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average.

Effect of operating microscope light on brain temperature during craniotomy.

PubMed

Gayatri, Parthasarathi; Menon, Girish G; Suneel, Puthuvassery R

2013-07-01

Operating microscopes used during neurosurgery are fitted with xenon light. Burn injuries have been reported because of xenon microscope lighting as the intensity of xenon light is 300 W. We designed this study to find out if the light of operating microscope causes an increase in temperature of the brain tissue, which is exposed underneath. Twenty-one adult patients scheduled for elective craniotomies were enrolled. Distal esophageal temperature (T Eso), brain temperature under the microscope light (T Brain), and brain temperature under dura mater (T Dura) were measured continuously at 15-minute intervals during microscope use. The irrigation fluid temperature, room temperature, intensity of the microscope light, and the distance of the microscope from the brain surface were kept constant. The average age of the patients was 44±15 years (18 males and 3 females). The mean duration of microscope use was 140±39 minutes. There were no significant changes in T Brain and T Dura and T Eso over time. T Dura was significantly lower than T Brain both at time 0 and 60 minutes but not at 90 minutes. T Brain was significantly lower than T Eso both at time 0 and 60 minutes but not at 90 minutes. The T Dura remained significantly lower than T Eso at 0, 60, and 90 minutes. Our study shows that there is no significant rise in brain temperature under xenon microscope light up to 120 minutes duration, at intensity of 60% to 70%, from a distance of 20 to 25 cm from the brain surface.

How I do it: Awake craniotomy.

PubMed

Hill, Ciaran Scott; Severgnini, Flavio; McKintosh, Edward

2017-01-01

Awake craniotomy allows continuous assessment of a patient's clinical and neurological status during open brain surgery. This facilitates early detection of interference with eloquent cortex, and hence can allow a surgeon to maximize resection margins without compromising neurological function. Awake craniotomy requires an effective scalp blockade, intraoperative assessment, and a carefully co-ordinated theatre team. A variety of clinical and electrophysiological techniques can be used to assess cortical function. Effective scalp blockade and awake craniotomy provides the opportunity to intraoperatively assess cortical function in the awake patient, thus providing an important neurosurgical option for lesions near eloquent cortex.

Regional Anesthesia to Scalp for Craniotomy: Innovation With Innervation.

PubMed

Jayaram, Kavitha; Srilata, Moningi; Kulkarni, Dilipkumar; Ramachandran, Gopinath

2016-01-01

Effective management and pain prevention is of great importance to avoid postoperative complications such as hypertension, agitation, and vomiting. All these adverse events may lead to elevation in intracranial pressure and, in turn, unfavorable outcome and prolonged hospital stay. Development of multiple methods of analgesia may contribute to the alleviation of problems due to pain. We tested the effectiveness of bilateral maxillary block with greater and lesser occipital nerve block for providing analgesia to the scalp. This study was undertaken in 40 patients scheduled for craniotomy. Before skin incision, patients were assigned randomly to receive either bilateral maxillary (group M) or scalp block (group S). Data on intraoperative hemodynamics, postoperative analgesia, and sedation were collected and analyzed for statistical significance. The primary outcome was the visual analog pain score. It was similar between the 2 groups at 1, 2, and 4 hours after extubation. At 12 hours, the maxillary block group had better analgesia (mean visual analog score: 3.4 cm for group M and 4.1 cm for group S with P-value of 0.0002) and sedation scores. Intraoperatively, there was no difference in the heart rate, blood pressure, and the anesthetic requirements between both the groups. Three patients in group S required fentanyl supplementation in the intraoperative period. There were no adverse events noted in the perioperative period among both the groups. Maxillary block along with greater and lesser occipital nerve block is an effective alternative to scalp block for craniotomy and has longer duration of analgesia.

Patients' perspective on awake craniotomy for brain tumors-single center experience in Brazil.

PubMed

Leal, Rafael Teixeira Magalhaes; da Fonseca, Clovis Orlando; Landeiro, Jose Alberto

2017-04-01

Awake craniotomy with brain mapping is the gold standard for eloquent tissue localization. Patients' tolerability and satisfaction have been shown to be high; however, it is a matter of debate whether these findings could be generalized, since patients across the globe have their own cultural backgrounds and may perceive and accept this procedure differently. We conducted a prospective qualitative study about the perception and tolerability of awake craniotomy in a population of consecutive brain tumor patients in Brazil between January 2013 and April 2015. Seventeen patients were interviewed using a semi-structured model with open-ended questions. Patients' thoughts were grouped into five categories: (1) overall perception: no patient considered awake craniotomy a bad experience, and most understood the rationale behind it. They were positively surprised with the surgery; (2) memory: varied from nothing to the entire surgery; (3) negative sensations: in general, it was painless and comfortable. Remarks concerning discomfort on the operating table were made; (4) postoperative recovery: perception of the postoperative period was positive; (5) previous surgical experiences versus awake craniotomy: patients often preferred awake surgery over other surgery under general anesthesia, including craniotomies. Awake craniotomy for brain tumors was well tolerated and yielded high levels of satisfaction in a population of patients in Brazil. This technique should not be avoided under the pretext of compromising patients' well-being.

Chronic subdural hematoma management: a systematic review and meta-analysis of 34,829 patients.

PubMed

Almenawer, Saleh A; Farrokhyar, Forough; Hong, Chris; Alhazzani, Waleed; Manoranjan, Branavan; Yarascavitch, Blake; Arjmand, Parnian; Baronia, Benedicto; Reddy, Kesava; Murty, Naresh; Singh, Sheila

2014-03-01

To compare the efficacy and safety of multiple treatment modalities for the management of chronic subdural hematoma (CSDH) patients. Current management strategies of CSDHs remain widely controversial. Treatment options vary from medical therapy and bedside procedures to major operative techniques. We searched MEDLINE (PubMed and Ovid), EMBASE, CINAHL, Google scholar, and the Cochrane library from January 1970 through February 2013 for randomized and observational studies reporting one or more outcome following the management of symptomatic patients with CSDH. Independent reviewers evaluated the quality of studies and abstracted the data on the safety and efficacy of percutaneous bedside twist-drill drainage, single or multiple operating room burr holes, craniotomy, corticosteroids as a main or adjuvant therapy, use of drains, irrigation of the hematoma cavity, bed rest, and treatment of recurrences following CSDH management. Mortality, morbidity, cure, and recurrence rates were examined for each management option. Randomized, prospective, retrospective, and overall observational studies were analyzed separately. Pooled estimates, confidence intervals (CIs), and relative risks (RRs) were calculated for all outcomes using a random-effects model. A total of 34,829 patients from 250 studies met our eligibility criteria. Sixteen trials were randomized, and the remaining 234 were observational. We included our unpublished single center series of 834 patients. When comparing percutaneous bedside drainage to operating room burr hole evacuation, there was no significant difference in mortality (RR, 0.69; 95% CI, 0.46-1.05; P = 0.09), morbidity (RR, 0.45; 95% CI, 0.2-1.01; P = 0.05), cure (RR, 1.05; 95% CI, 0.98-1.11; P = 0.15), and recurrence rates (RR, 1; 95% CI, 0.66-1.52; P = 0.99). Higher morbidity was associated with the adjuvant use of corticosteroids (RR, 1.97; 95% CI, 1.54-2.45; P = 0.005), with no significant improvement in recurrence and cure rates. The use of drains following CSDH drainage resulted in a significant decrease in recurrences (RR, 0.46; 95% CI, 0.27-0.76; P = 0.002). Craniotomy was associated with higher complication rates if considered initially (RR, 1.39; 95% CI, 1.04-1.74; P = 0.01); however, craniotomy was superior to minimally invasive procedures in the management of recurrences (RR, 0.22; 95% CI, 0.05-0.85; P = 0.003). Percutaneous bedside twist-drill drainage is a relatively safe and effective first-line management option. These findings may result in potential health cost savings and eliminate perioperative risks related to general anesthetic.

Craniotomy with endoscopic assistance in the treatment of nasopharygeal fibroangioma.

PubMed

Fu, Ji-di; Liu, Hao-cheng; Zhao, Shang-feng; Zhang, Jia-liang; Li, Yong; Ni, Xin; Yu, Chun-jiang

2010-05-20

Nasopharygeal fibroangioma (NPF) can be approached through lateral rhinotomy, the middle skull fossa approach and the transcranial-facial combined approach. It is complicated and thus results in more insults, and when adopted, the total resection rate of tumor is still low. The nasal endoscope is minimally invasive, the dead angles of a craniotomy, such as sphenoid sinus, maxillary sinus, and nasopharynx are easily approached by an endoscope. Lateral rhinotomy have to make facial incision and affects maxillary bone development. We combined the craniotomy and endoscopic approach intending to take advantages of the two approaches. Twelve NPF patients who underwent craniotomy with endoscopic assistance from March 2002 to July 2008 at the Beijing Tongren Hospital were selected. All patients were male. Their ages ranged from 11 to 33 years. The main symptoms were visual deterioration, exophthalmos, nasal obstruction, epistaxis and pharynx nasalis neoplasm. The diagnosis was based on CT, MRI and digital subtraction angiography (DSA). All patients had intracranial encroachment and all underwent DSA and embolism treatment were taken before surgery. Seven patients had a pterional craniotomy, five had a frontal-temporal-orbital-zygomatic craniotomy. Most of the tumor was resected piecemeal, then removed through the sphenoidal sinus. Finally, using an endoscope in the nasal cavity, tumor in nasal cavity was resected and removed through the sphenoidal sinus, observing the dead angle of the craniotomy and confirming that sinus drainage was unobstructed. The tumor was removed completely in 11 patients and partially resected in one patient because of hemorrhage. One patient had an infection after the operation and one patient had cerebrospinal rhinorrhea 3 years after surgery that was remediated by endoscopic repair. Craniotomy with endoscopic assistance in the treatment of NPF was minimally invasive, safe and efficient, and avoided facial incision.

Patient response to awake craniotomy - a summary overview.

PubMed

Milian, Monika; Tatagiba, Marcos; Feigl, Guenther C

2014-06-01

Awake craniotomy is a valuable procedure since it allows brain mapping and live monitoring of eloquent brain functions. The advantage of minimizing resource utilization is also emphasized by some physicians in North America. Data on how well an awake craniotomy is tolerated by patients and how much stress it creates is available from different studies, but this topic has not consequently been summarized in a review of the available literature. Therefore, it is the purpose of this review to shed more light on the still controversially discussed aspect of an awake craniotomy. We reviewed the available English literature published until December 2013 searching for studies that investigated patients' responses to awake craniotomies. Twelve studies, published between 1998 and 2013, including 396 patients with awake surgery were identified. Eleven of these 12 studies set the focus on the perioperative time, one study focused on the later postoperative time. The vast majority of patients felt well prepared and overall satisfaction with the procedure was high. In the majority of studies up to 30 % of the patients recalled considerable pain and 10-14 % experienced strong anxiety during the procedure. The majority of patients reported that they would undergo an awake craniotomy again. A post traumatic stress disorder was present neither shortly nor years after surgery. However, a normal human response to such an exceptional situation can for instance be the delayed appearance of unintentional distressing recollections of the event despite the patients' satisfaction concerning the procedure. For selected patients, an awake craniotomy presents the best possible way to reduce the risk of surgery related neurological deficits. However, benefits and burdens of this type of procedure should be carefully considered when planning an awake craniotomy and the decision should serve the interests of the patient.

Patient acceptance of awake craniotomy.

PubMed

Wrede, Karsten H; Stieglitz, Lennart H; Fiferna, Antje; Karst, Matthias; Gerganov, Venelin M; Samii, Madjid; von Gösseln, Hans-Henning; Lüdemann, Wolf O

2011-12-01

The aim of this study was to objectively assess the patients' acceptance for awake craniotomy in a group of neurosurgical patients, who underwent this procedure for removal of lesions in or close to eloquent brain areas. Patients acceptance for awake craniotomy under local anesthesia and conscious sedation was assessed by a formal questionnaire (PPP33), initially developed for general surgery patients. The results are compared to a group of patients who had brain surgery under general anesthesia and to previously published data. The awake craniotomy (AC) group consisted of 37 male and 9 female patients (48 craniotomies) with age ranging from 18 to 71 years. The general anesthesia (GA) group consisted of 26 male and 15 female patients (43 craniotomies) with age ranging from 26 to 83 years. All patients in the study were included in the questionnaire analysis. In comparison to GA the overall PPP33 score for AC was higher (p=0.07), suggesting better overall acceptance for AC. The subscale scores for AC were also significantly better compared to GA for the two subscales "postoperative pain" (p=0.02) and "physical disorders" (p=0.01) and equal for the other 6 subscales. The results of the overall mean score and the scores for the subscales of the PPP33 questionnaire verify good patients' acceptance for AC. Previous studies have shown good patients' acceptance for awake craniotomy, but only a few times using formal approaches. By utilizing a formal questionnaire we could verify good patient acceptance for awake craniotomy for the treatment of brain tumors in or close to eloquent areas. This is a novel approach that substantiates previously published experiences. Copyright © 2011 Elsevier B.V. All rights reserved.

[Awake craniotomy: analysis of complicated cases].

PubMed

Kulikov, A S; Kobyakov, G L; Gavrilov, A G; Lubnin, A Yu

2015-01-01

Awake craniotomy is recognized as method that can decrease the frequency of neurological complications after surgery for gliomas located near eloquent brain regions. Unfortunately good neurological outcome can't be ensured even by using of this technique. This paper discusses reasons and possible ways of prevention of such complications. 162 awake craniotomies were performed in our clinic. 152 of patients were discharged from the clinic with good outcome. In 10 (6%) cases sustained severe neurological deficit was noted. These complications were associated with anatomic or ischemic injury of subcortical pathways and internal capsule. Awake craniotomy is effective instrument of brain language mapping and prevention of neurological deterioration. Severe neurological complications of awake craniotomy are associated with underestimate neurosurgical risks, especially in terms of blood vessel injury and depth of resection. The main way of prevention of such complications is meticulous planning of operation and adequate using of mapping facilities.

Pediatric awake craniotomy for seizure focus resection with dexmedetomidine sedation-a case report.

PubMed

Sheshadri, Veena; Chandramouli, B A

2016-08-01

Resection of lesions near the eloquent cortex of brain necessitates awake craniotomy to reduce the risk of permanent neurologic deficits during surgery. There are limited reports of anesthetic management of awake craniotomy in pediatric patients. This report is on use of dexmedetomidine sedation for awake craniotomy in a 11-year-old child, without any airway adjuncts throughout the procedure. Dexmedetomidine infusion administered at a dosage of 0.2 to 0.7μg kg(-1) h(-1) provided adequate sedation for the entire procedure. There were no untoward incidents or any interference with electrocorticography, intraoperative stimulation, and functional mapping. Adequate preoperative visits and counseling of patient and parents regarding course and nature of events along with well-planned intraoperative management are of utmost importance in a pediatric age group for successful intraoperative awake craniotomy. Copyright © 2016 Elsevier Inc. All rights reserved.

Combination of Continuous Dexmedetomidine Infusion with Titrated Ultra-Low-Dose Propofol-Fentanyl for an Awake Craniotomy

PubMed Central

Das, Samaresh; Al-Mashani, Ali; Suri, Neelam; Salhotra, Neeraj; Chatterjee, Nilay

2016-01-01

An awake craniotomy is a continuously evolving technique used for the resection of brain tumours from the eloquent cortex. We report a 29-year-old male patient who presented to the Khoula Hospital, Muscat, Oman, in 2016 with a two month history of headaches and convulsions due to a space-occupying brain lesion in close proximity with the left motor cortex. An awake craniotomy was conducted using a scalp block, continuous dexmedetomidine infusion and a titrated ultra-low-dose of propofolfentanyl. The patient remained comfortable throughout the procedure and the intraoperative neuropsychological tests, brain mapping and tumour resection were successful. This case report suggests that dexmedetomidine in combination with titrated ultra-low-dose propofolfentanyl are effective options during an awake craniotomy, ensuring optimum sedation, minimal disinhibition and a rapid recovery. To the best of the authors’ knowledge, this is the first awake craniotomy conducted successfully in Oman. PMID:27606116

Awake Craniotomy: A New Airway Approach.

PubMed

Sivasankar, Chitra; Schlichter, Rolf A; Baranov, Dimitry; Kofke, W Andrew

2016-02-01

Awake craniotomies have been performed regularly at the University of Pennsylvania since 2004. Varying approaches to airway management are described for this procedure, including intubation with an endotracheal tube and use of a laryngeal mask airway, simple facemask, or nasal cannula. In this case series, we describe the successful use (i.e., no need for endotracheal intubation related to inadequate gas exchange) of bilateral nasopharyngeal airways in 90 patients undergoing awake craniotomies. The use of nasopharyngeal airways can ease the transition between the asleep and awake phases of the craniotomy without the need to stimulate the airway. Our purpose was to describe our experience and report adverse events related to this technique.

Effective and safe mannitol administration in patients undergoing supratentorial tumor surgery: A prospective, randomized and double blind study.

PubMed

Akcil, Eren Fatma; Dilmen, Ozlem Korkmaz; Karabulut, Esra Sultan; Koksal, Serdar Selcuk; Altindas, Fatis; Tunali, Yusuf

2017-08-01

Although osmotic diuresis with mannitol is commonly used to provide brain relaxation, there is no consensus regarding its optimal dose and combination with loop diuretics. The aim of the present study is to evaluate the effects of mannitol and combination of furosemide with different doses of mannitol on brain relaxation and on blood electrolytes, lactate level, urine output, fluid balance and blood osmolarity in patients undergoing supratentorial tumor surgery. This prospective, randomized, double blind, placebo-controlled study included 51 patients (ASA I-III) scheduled for elective supratentorial craniotomy. Different doses and combinations of diuretics were administered after the bone flap removal. The Group 1 received mannitol at 0.5gkg -1 and furosemide at 0.5mgkg -1 , the Group 2 received mannitol at 1gkg -1 and furosemide at 0.5mgkg -1 , and the Group 3 received mannitol at 0.5gkg -1 and placebo. The primary end-point of the present study is to evaluate the effects of mannitol and combination of furosemide with different doses of mannitol on brain relaxation and the secondary end-points are to evaluate their effects on blood electrolytes, lactate level, urine output, fluid balance and blood osmolarity. This study shows that mannitol alone (0.5gkg -1 ), and the combinations of furosemide (0.5mgkg -1 ) with different doses of mannitol (0.5gkg -1 -1gkg -1 ) provides adequate brain relaxation. However, administration of furosemide with low or high doses of mannitol may cause reduction in the sodium and chloride levels as well as rise in the lactate level. Moreover it may cause high urine output and negative intra-operative fluid balance. Administration of 0.5gkg -1 mannitol provides adequate brain relaxation without causing systemic side effects in patients undergoing supratentorial tumor surgery. This study is registered to clinical trials (Clinical Trials.gov identifier NCT02712476). Copyright © 2017 Elsevier B.V. All rights reserved.

Diagnostic and prognostic value of procalcitonin for early intracranial infection after craniotomy

PubMed Central

Yu, Y.; Li, H.J.

2017-01-01

Intracranial infection is a common clinical complication after craniotomy. We aimed to explore the diagnostic and prognostic value of dynamic changing procalcitonin (PCT) in early intracranial infection after craniotomy. A prospective study was performed on 93 patients suspected of intracranial infection after craniotomy. Routine peripheral venous blood was collected on the day of admission, and C reactive protein (CRP) and PCT levels were measured. Cerebrospinal fluid (CSF) was collected for routine biochemical, PCT and culture assessment. Serum and CSF analysis continued on days 1, 2, 3, 5, 7, 9, and 11. The patients were divided into intracranial infection group and non-intracranial infection group; intracranial infection group was further divided into infection controlled group and infection uncontrolled group. Thirty-five patients were confirmed with intracranial infection after craniotomy according to the diagnostic criteria. The serum and cerebrospinal fluid PCT levels in the infected group were significantly higher than the non-infected group on day 1 (P<0.05, P<0.01). The area under curve of receiver operating characteristics was 0.803 for CSF PCT in diagnosing intracranial infection. The diagnostic sensitivity and specificity of CSF PCT was superior to other indicators. The serum and CSF PCT levels have potential value in the early diagnosis of intracranial infection after craniotomy. Since CSF PCT levels have higher sensitivity and specificity, dynamic changes in this parameter could be used for early detection of intracranial infection after craniotomy, combined with other biochemical indicators. PMID:28443989

Awake craniotomy and multilingualism: language testing during anaesthesia for awake craniotomy in a bilingual patient.

PubMed

Costello, T G

2014-08-01

An awake craniotomy for epilepsy surgery is presented where a bilingual patient post-operatively reported temporary aphasia of his first language (Spanish). This case report discusses the potential causes for this clinical presentation and methods to prevent the occurrence of this in future patients undergoing this form of surgery. Copyright © 2014 Elsevier Ltd. All rights reserved.

P10.05 Establishment of team work awake craniotomy: clinical experience in Taiwan

PubMed Central

Chen, P.; Chang, W.; Chao, Y.; Toh, C.; Wei, K.

2017-01-01

Abstract Introduction: Awake craniotomy provides the opportunity to maximize both extent of resection and preservation of neurological function. Serial preoperative and postoperative neurobehavial evaluation, magnetic resonance image examination and intraoperative task investigation need multidisciplinary experts to cooperate. Materials and Methods: From 2013, we gradually establish our team for awake craniotomy. Patient who had brain tumor with the symptom of aphasia or hemiparesis and are willing to cooperate would be entered the protocol of awake craniotomy. Patients would receive complete preoperative neurobehavial examination by psychologists and speech therapists and magnetic resonance image included diffuse tensor image. During operation, Patients went through asleep-awake-asleep anesthetic techniques. Direct electric stimulation was used for both cortical and subcortical mapping. Navigation included information of lesion and important fiber tract guided the direction of excision. Rehabilitation doctor performed the tasks and decided the positive response caused by stimulation or excisional procedure. After operation, post-operative image and neurobehavial examination would be performed within one week, 3 months, 6 months and one year later Results: We scheduled awake craniotomy on almost every Tuesday. In recent 89 patients who received awake craniotomy, Twenty-five participants with recurrent tumor underwent the operation. Seven patients received twice and one patient received three times of awake craniotomy. Two patients had controllable intraoperative seizure attack. Early termination of awake status was found in two patients due to general discomfort. Patients with modest preoperative performance status still benefit from the operation. Neurobehavioral functions improved over time and some specific feature correlate to certain aspect of quality of life. The grading of tumor and the extension of resection influence the recovery of neurobehavioral functions and progression free survival considerably. Conclusions: Awake craniotomy is a feasible and effective way to improve not only patient`s survival rate but also quality of life. A team with neurosurgeon, rehabilitation doctor, speech therapist, psychologist, anesthesiologist, nurses and other specialist is important to improve the quality of clinical care for patient who received awake craniotomy. This study is supported by Chang Gung Memorial Hospital with grant number: CMRPG3D0243

Awake craniotomy in a depressed and agitated patient

PubMed Central

Al Shuaibi, Khalid M.

2010-01-01

Depressed patients with brain tumors are often not referred to awake craniotomy because of concern of uncooperation which may increase the risk of perioperative complications. This report describes an interesting case of awake craniotomy for frontal lobe glioma in a 41-year-old woman undergoing language and motor mapping intraoperatively. As she was fearful and apprehensive and was on antidepressant therapy to control depression, the author adopted general anesthesia with laryngeal mask airway during initial stage of skull pinning and craniotomy procedures. Then, the patient reverted to awake state to continue the intended neurosurgical procedure. The patient tolerated the situation satisfactorily and was cooperative till the finish, without any event. PMID:25885087

Minimally Invasive Thumb-sized Pterional Craniotomy for Surgical Clip Ligation of Unruptured Anterior Circulation Aneurysms

PubMed Central

Deshaies, Eric M; Villwock, Mark R; Singla, Amit; Toshkezi, Gentian; Padalino, David J

2015-01-01

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowship-trained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average. PMID:26325337

Surgical Management of Dural Arteriovenous Fistula After Craniotomy: Case Report and Review of Literature.

PubMed

Pabaney, Aqueel H; Robin, Adam M; Basheer, Azam; Malik, Ghaus

2016-05-01

Development of dural arteriovenous fistula (dAVF) with cortical venous drainage at the site of previous craniotomy is a rare manifestation of nontraumatic subarachnoid hemorrhage (SAH). The authors present a case of postcraniotomy dAVF formation and discuss plausible underlying mechanisms of fistula formation and treatment options as well as review the literature. A 62-year-old man, who had undergone craniotomy 2 decades previously, presented with SAH. Workup revealed a low-flow dAVF with leptomeningeal venous drainage at the posterior margin of the craniotomy. Surgical resection of fistula was undertaken that resulted in cure. Spontaneous SAH in patients with a previous history of an intracranial procedure (e.g., craniotomy, ventriculostomy) should prompt detailed imaging evaluation. In the absence of vascular disease, meticulous review of the angiogram must be undertaken to rule out dAVF at the procedure site and it should be treated definitively. Copyright © 2016 Elsevier Inc. All rights reserved.

Immediate titanium mesh cranioplasty for treatment of post-craniotomy infections

PubMed Central

Wind, Joshua J.; Ohaegbulam, Chima; Iwamoto, Fabio M.; Black, Peter McL.; Park, John K.

2011-01-01

OBJECTIVE Post craniotomy infections have generally been treated by debridement of infected tissues, disposal of the bone flap, and delayed cranioplasty several months later to repair the resulting skull defect. Debridement followed by retention of the bone flap has also been advocated. Here we propose an alternative operative strategy for the treatment of post craniotomy infections. METHODS Two patients presenting with clinical and radiographic signs and symptoms of post craniotomy infections were treated by debridement, bone flap disposal, and immediate titanium mesh cranioplasty. The patients were subsequently administered antibiotics and their clinical courses were followed. RESULTS The patients treated in this fashion did not have recurrence of their infections during three-year follow-up periods. CONCLUSIONS Surgical debridement, bone flap disposal and immediate titanium mesh cranioplasty may be a suitable option for the treatment of post craniotomy infections. This treatment strategy facilitates the eradication of infectious sources and obviates the risks and costs associated with a second surgical procedure. PMID:22120410

Awake craniotomy

PubMed Central

Bajunaid, Khalid M.; Ajlan, Abdulrazag M.

2015-01-01

Objective: To report the personal experiences of patients undergoing awake craniotomy for brain tumor resection. Methods: We carried out a qualitative descriptive survey of patients’ experiences with awake craniotomies for brain tumor resection. The survey was conducted through a standard questionnaire form after the patient was discharged from the hospital. Results: Of the 9 patients who met the inclusion criteria and underwent awake craniotomy, 3 of those patients reported no recollection of the operation. Five patients had auditory recollections from the operation. Two-thirds (6/9) reported that they did not perceive pain. Five patients remembered the head clamp fixation, and 2 of those patients classified the pain from the clamp as moderate. None of the patients reported that the surgery was more difficult than anticipated. Conclusion: Awake craniotomy for surgical resection of brain tumors was well tolerated by patients. Most patients reported that they do not recall feeling pain during the operation. However, we feel that further work and exploration are needed in order to achieve better control of pain and discomfort during these types of operations. PMID:26166593

Scalp Block for Awake Craniotomy in a Patient With a Frontal Bone Mass: A Case Report

PubMed Central

Amiri, Hamid Reza; Kouhnavard, Marjan; Safari, Saeid

2012-01-01

“Anesthesia” for awake craniotomy is a unique clinical condition that requires the anesthesiologist to provide changing states of sedation and analgesia, to ensure optimal patient comfort without interfering with electrophysiologic monitoring and patient cooperation, and also to manipulate cerebral and systemic hemodynamics while guaranteeing adequate ventilation and patency of airways. Awake craniotomy is not as popular in developing countries as in European countries. This might be due to the lack of information regarding awake craniotomy and its benefits among the neurosurgeons and anesthetists in developing countries. From the economic perspective, this procedure may decrease resource utilization by reducing the use of invasive monitoring, the duration of the operation, and the length of postoperative hospital stay. All these reasons also favor its use in the developing world, where the availability of resources still remains a challenge. In this case report we presented a successful awake craniotomy in patient with a frontal bone mass. PMID:24904791

Awake craniotomy. A patient`s perspective.

PubMed

Bajunaid, Khalid M; Ajlan, Abdulrazag M

2015-07-01

To report the personal experiences of patients undergoing awake craniotomy for brain tumor resection. We carried out a qualitative descriptive survey of patients` experiences with awake craniotomies for brain tumor resection. The survey was conducted through a standard questionnaire form after the patient was discharged from the hospital. Of the 9 patients who met the inclusion criteria and underwent awake craniotomy, 3 of those patients reported no recollection of the operation. Five patients had auditory recollections from the operation. Two-thirds (6/9) reported that they did not perceive pain. Five patients remembered the head clamp fixation, and 2 of those patients classified the pain from the clamp as moderate. None of the patients reported that the surgery was more difficult than anticipated. Awake craniotomy for surgical resection of brain tumors was well tolerated by patients. Most patients reported that they do not recall feeling pain during the operation. However, we feel that further work and exploration are needed in order to achieve better control of pain and discomfort during these types of operations.

Spreading Depolarizations Have Prolonged Direct Current Shifts and Are Associated with Poor Outcome in Brain Trauma

DTIC Science & Technology

2011-01-01

prognosis. Keywords: cortical spreading depression; electroencephalography; craniotomy ; signal processing; acute brain injury Introduction Cortical...Mannheim, Germany). Inclusion criteria were the clinical decision for craniotomy for lesion evacuation and/or decompression and age ~ 18 years...externalized through a burr hole in the skull (if the bone flap was replaced) and tu nne lied beneath the scalp to exit 2-3 em from the craniotomy

Infections in patients undergoing craniotomy: risk factors associated with post-craniotomy meningitis.

PubMed

Kourbeti, Irene S; Vakis, Antonis F; Ziakas, Panayiotis; Karabetsos, Dimitris; Potolidis, Evangelos; Christou, Silvana; Samonis, George

2015-05-01

OBJECT The authors performed a prospective study to define the prevalence and microbiological characteristics of infections in patients undergoing craniotomy and to clarify the risk factors for post-craniotomy meningitis. METHODS Patients older than 18 years who underwent nonstereotactic craniotomies between January 2006 and December 2008 were included. Demographic, clinical, laboratory, and microbiological data were systemically recorded. Patient characteristics, craniotomy type, and pre- and postoperative variables were evaluated as risk factors for meningitis RESULTS Three hundred thirty-four procedures were analyzed (65.6% involving male patients). Traumatic brain injury was the most common reason for craniotomy. Almost 40% of the patients developed at least 1 infection. Ventilator-associated pneumonia (VAP) was the most common infection recorded (22.5%) and Acinetobacter spp. were isolated in 44% of the cases. Meningitis was encountered in 16 procedures (4.8%), and CSF cultures were positive for microbial growth in 100% of these cases. Gram-negative pathogens (Acinetobacter spp., Klebsiella spp., Pseudomonas aeruginosa, Enterobacter cloaceae, Proteus mirabilis) represented 88% of the pathogens. Acinetobacter and Klebsiella spp. demonstrated a high percentage of resistance in several antibiotic classes. In multivariate analysis, the risk for meningitis was independently associated with perioperative steroid use (OR 11.55, p = 0.005), CSF leak (OR 48.03, p < 0.001), and ventricular drainage (OR 70.52, p < 0.001). CONCLUSIONS Device-related postoperative communication between the CSF and the environment, CSF leak, and perioperative steroid use were defined as risk factors for meningitis in this study. Ventilator-associated pneumonia was the most common infection overall. The offending pathogens presented a high level of resistance to several antibiotics.

Craniotomy: true sham for traumatic brain injury, or a sham of a sham?

PubMed

Cole, Jeffrey T; Yarnell, Angela; Kean, William S; Gold, Eric; Lewis, Bobbi; Ren, Ming; McMullen, David C; Jacobowitz, David M; Pollard, Harvey B; O'Neill, J Timothy; Grunberg, Neil E; Dalgard, Clifton L; Frank, Joseph A; Watson, William D

2011-03-01

Abstract Neurological dysfunction after traumatic brain injury (TBI) is caused by both the primary injury and a secondary cascade of biochemical and metabolic events. Since TBI can be caused by a variety of mechanisms, numerous models have been developed to facilitate its study. The most prevalent models are controlled cortical impact and fluid percussion injury. Both typically use "sham" (craniotomy alone) animals as controls. However, the sham operation is objectively damaging, and we hypothesized that the craniotomy itself may cause a unique brain injury distinct from the impact injury. To test this hypothesis, 38 adult female rats were assigned to one of three groups: control (anesthesia only); craniotomy performed by manual trephine; or craniotomy performed by electric dental drill. The rats were then subjected to behavioral testing, imaging analysis, and quantification of cortical concentrations of cytokines. Both craniotomy methods generate visible MRI lesions that persist for 14 days. The initial lesion generated by the drill technique is significantly larger than that generated by the trephine. Behavioral data mirrored lesion volume. For example, drill rats have significantly impaired sensory and motor responses compared to trephine or naïve rats. Finally, of the seven tested cytokines, KC-GRO and IFN-γ showed significant increases in both craniotomy models compared to naïve rats. We conclude that the traditional sham operation as a control confers profound proinflammatory, morphological, and behavioral damage, which confounds interpretation of conventional experimental brain injury models. Any experimental design incorporating "sham" procedures should distinguish among sham, experimentally injured, and healthy/naïve animals, to help reduce confounding factors.

Technical Aspects of Awake Craniotomy with Mapping for Brain Tumors in a Limited Resource Setting.

PubMed

Leal, Rafael Teixeira Magalhaes; Barcellos, Bruno Mendonça; Landeiro, Jose Alberto

2018-05-01

Brain tumor surgery near or within eloquent regions is increasingly common and is associated with a high risk of neurologic injury. Awake craniotomy with mapping has been shown to be a valid method to preserve neurologic function and increase the extent of resection. However, the technique used varies greatly among centers. Most count on professionals such as neuropsychologists, speech therapists, neurophysiologists, or neurologists to help in intraoperative patient evaluation. We describe our technique with the sole participation of neurosurgeons and anesthesiologists. A retrospective review of 19 patients who underwent awake craniotomies for brain tumors between January 2013 and February 2017 at a tertiary university hospital was performed. We sought to identify and describe the most critical stages involved in this surgery as well as show the complications associated with our technique. Preoperative preparation, positioning, anesthesia, brain mapping, resection, and management of seizures and pain were stages deemed relevant to the accomplishment of an awake craniotomy. Sixteen percent of the patients developed new postoperative deficit. Seizures occurred in 24%. None led to awake craniotomy failure. We provide a thorough description of the technique used in awake craniotomies with mapping used in our institution, where the intraoperative patient evaluation is carried out solely by neurosurgeons and anesthesiologists. The absence of other specialized personnel and equipment does not necessarily preclude successful mapping during awake craniotomy. We hope to provide helpful information for those who wish to offer function-guided tumor resection in their own centers. Copyright © 2018 Elsevier Inc. All rights reserved.

Development of a safe and pragmatic awake craniotomy program at Maine Medical Center.

PubMed

Rughani, Anand I; Rintel, Theodor; Desai, Rajiv; Cushing, Deborah A; Florman, Jeffrey E

2011-01-01

Awake craniotomy offers an excellent means of performing intraoperative mapping and optimizing surgical resection of brain tumors. Awake craniotomy relies on a strong collaboration between anesthesiologists, neurosurgeons, and operating room staff. The authors recently introduced awake craniotomy for tumor resection at the Maine Medical Center and propose that it can be performed safely, effectively, and efficiently in a high-volume community hospital. We describe a practical approach to performing awake craniotomy involving streamlined anesthetic protocols and simplified intraoperative testing parameters in a carefully selected group of patients. Our first 25 patients are retrospectively reviewed with particular attention to the anesthetic protocol, the extent of resection, the operative time, post-operative complications, the length of hospitalization, and their functional status at follow-up. The authors established an anesthetic protocol based primarily on midazolam, fentanyl, propofol, and local anesthetic. The authors note that all but one patient was able to tolerate the awake procedure. Gross total resection was achieved in nearly 80% of patients with a glial tumor. Operative time was short, averaging 159 minutes of entire anesthesia care. Length of stay averaged 3.7 days. Persistent new post-operative deficits were noted in 2 of 25 patients. There was no substantial difference in total hospital charges for patients undergoing awake craniotomy when compared to a matched historical control. With attention focused on patient selection and a streamlined anesthetic protocol, the authors were able to successfully implement an awake craniotomy protocol in a community setting with satisfying results, including low operative morbidity, short operative times, low anesthetic complications, and excellent patient tolerance.

Short-term intravenous antimicrobial prophylaxis for elective rectal cancer surgery: results of a prospective randomized non-inferiority trial.

PubMed

Ishibashi, Keiichiro; Ishida, Hideyuki; Kuwabara, Kouki; Ohsawa, Tomonori; Okada, Norimichi; Yokoyama, Masaru; Kumamoto, Kensuke

2014-04-01

To investigate the non-inferiority of postoperative single-dose intravenous antimicrobial prophylaxis to multiple-dose intravenous antimicrobial prophylaxis in terms of the incidence of surgical site infections (SSIs) in patients undergoing elective rectal cancer surgery by a prospective randomized study. Patients undergoing elective surgery for rectal cancer were randomized to receive a single intravenous injection of flomoxef (group 1) or five additional doses (group 2) of flomoxef after the surgery. All the patients had received preoperative oral antibiotic prophylaxis (kanamycin and erythromycin) after mechanical cleansing within 24 h prior to surgery, and had received intravenous flomoxef during surgery. A total of 279 patients (including 139 patients in group 1 and 140 in group 2) were enrolled in the study. The incidence of SSIs was 13.7% in group 1 and 13.6% in group 2 (difference [95% confidence interval]: -0.2% [-0.9 to 0.7%]). The incidence of SSIs was not significantly different in patients undergoing elective rectal surgery who were treated using a single dose of postoperative antibiotics compared to those treated using multiple-dose antibiotics when preoperative mechanical and chemical bowel preparations were employed.

Anaesthesia for awake craniotomy: A retrospective study of 54 cases.

PubMed

Sokhal, Navdeep; Rath, Girija Prasad; Chaturvedi, Arvind; Dash, Hari Hara; Bithal, Parmod Kumar; Chandra, P Sarat

2015-05-01

The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre. Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded. Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1-14 days) and mean hospital stay was 7.0 ± 5.0 day (3-30 days). 'Conscious sedation' was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure.

Anaesthesia for awake craniotomy: A retrospective study of 54 cases

PubMed Central

Sokhal, Navdeep; Rath, Girija Prasad; Chaturvedi, Arvind; Dash, Hari Hara; Bithal, Parmod Kumar; Chandra, P Sarat

2015-01-01

Background and Aims: The anaesthetic challenge of awake craniotomy is to maintain adequate sedation, analgesia, respiratory and haemodynamic stability in an awake patient who should be able to co-operate during intraoperative neurological assessment. The current literature, sharing the experience on awake craniotomy, in Indian context, is minimal. Hence, we carried out a retrospective study with the aim to review and analyse the anaesthetic management and perioperative complications in patients undergoing awake craniotomy, at our centre. Methods: Medical records of 54 patients who underwent awake craniotomy for intracranial lesions over a period of 10 years were reviewed, retrospectively. Data regarding anaesthetic management, intraoperative complications and post-operative course were recorded. Results: Propofol (81.5%) and dexmedetomidine (18.5%) were the main agents used for providing conscious sedation to facilitate awake craniotomy. Hypertension (16.7%) was the most commonly encountered complication during intraoperative period, followed by seizures (9.3%), desaturation (7.4%), tight brain (7.4%), and shivering (5.6%). The procedure had to be converted to general anaesthesia in one of patients owing to refractory brain bulge. The incidence of respiratory and haemodynamic complications were comparable in the both groups (P > 0.05). There was less incidence of intraoperative seizures in patients who received propofol (P = 0.03). In post-operative period, 20% of patients developed new motor deficit. Mean intensive care unit stay was 2.8 ± 1.9 day (1–14 days) and mean hospital stay was 7.0 ± 5.0 day (3–30 days). Conclusions: ‘Conscious sedation’ was the technique of choice for awake craniotomy, at our institute. Fentanyl, propofol, and dexmedetomidine were the main agents used for this purpose. Patients receiving propofol had less incidence of intraoperative seizure. Appropriate selection of patients, understanding the procedure of surgery, and judicious use of sedatives or anaesthetic agents are key to the success for awake craniotomy as a procedure. PMID:26019355

Music is Beneficial for Awake Craniotomy Patients: A Qualitative Study.

PubMed

Jadavji-Mithani, Radhika; Venkatraghavan, Lashmi; Bernstein, Mark

2015-01-01

Patients undergoing awake craniotomy may experience high levels of stress. Minimizing anxiety benefits patients and surgeons. Music has many therapeutic effects in altering human mood and emotion. Tonality of music as conveyed by composition in major or minor keys can have an impact on patients' emotions and thoughts. Assessing the effects of listening to major and minor key musical pieces on patients undergoing awake craniotiomy could help in the design of interventions to alleviate anxiety, stress and tension. Twenty-nine patients who were undergoing awake craniotomy were recruited and randomly assigned into two groups: Group 1 subjects listened to major key music and Group 2 listened to minor key compositions. Subjects completed a demographics questionnaire, a pre- and post-operative Beck Anxiety Inventory (BAI) and a semi-structured open-ended interview. RESULTS were analyzed using modified thematic analysis through open and axial coding. Overall, patients enjoyed the music regardless of the key distinctions and stated they benefitted from listening to the music. No adverse reactions to the music were found. Subjects remarked that the music made them feel more at ease and less anxious before, during and after their procedure. Patients preferred either major key or minor key music but not a combination of both. Those who preferred major key pieces said it was on the basis of tonality while the individuals who selected minor key pieces stated that tempo of the music was the primary factor. Overall, listening to music selections was beneficial for the patients. Future work should further investigate the effects of audio interventions in awake surgery through narrative means.

Risk of brain herniation after craniotomy with lumbar spinal drainage: a propensity score analysis.

PubMed

Motoyama, Yasushi; Nakajima, Tsukasa; Takamura, Yoshiaki; Nakazawa, Tsutomu; Wajima, Daisuke; Takeshima, Yasuhiro; Matsuda, Ryosuke; Tamura, Kentaro; Yamada, Shuichi; Yokota, Hiroshi; Nakagawa, Ichiro; Nishimura, Fumihiko; Park, Young-Su; Nakamura, Mitsutoshi; Nakase, Hiroyuki

2018-06-08

OBJECTIVE Lumbar spinal drainage (LSD) during neurosurgery can have an important effect by facilitating a smooth procedure when needed. However, LSD is quite invasive, and the pathology of brain herniation associated with LSD has become known recently. The objective of this study was to determine the risk of postoperative brain herniation after craniotomy with LSD in neurosurgery overall. METHODS Included were 239 patients who underwent craniotomy with LSD for various types of neurological diseases between January 2007 and December 2016. The authors performed propensity score matching to establish a proper control group taken from among 1424 patients who underwent craniotomy and met the inclusion criteria during the same period. The incidences of postoperative brain herniation between the patients who underwent craniotomy with LSD (group A, n = 239) and the matched patients who underwent craniotomy without LSD (group B, n = 239) were compared. RESULTS Brain herniation was observed in 24 patients in group A and 8 patients in group B (OR 3.21, 95% CI 1.36-8.46, p = 0.005), but the rate of favorable outcomes was higher in group A (OR 1.79, 95% CI 1.18-2.76, p = 0.005). Of the 24 patients, 18 had uncal herniation, 5 had central herniation, and 1 had uncal and subfalcine herniation; 8 patients with other than subarachnoid hemorrhage were included. Significant differences in the rates of deep approach (OR 5.12, 95% CI 1.8-14.5, p = 0.002) and temporal craniotomy (OR 10.2, 95% CI 2.3-44.8, p = 0.002) were found between the 2 subgroups (those with and those without herniation) in group A. In 5 patients, brain herniation proceeded even after external decompression (ED). Cox regression analysis revealed that the risk of brain herniation related to LSD increased with ED (hazard ratio 3.326, 95% CI 1.491-7.422, p < 0.001). Among all 1424 patients, ED resulted in progression or deterioration of brain herniation more frequently in those who underwent LSD than it did in those who did not undergo LSD (OR 9.127, 95% CI 1.82-62.1, p = 0.004). CONCLUSIONS Brain herniation downward to the tentorial hiatus is more likely to occur after craniotomy with LSD than after craniotomy without LSD. Using a deep approach and craniotomy involving the temporal areas are risk factors for brain herniation related to LSD. Additional ED would aggravate brain herniation after LSD. The risk of brain herniation after placement of a lumbar spinal drain during neurosurgery must be considered even when LSD is essential.

Clamp-Crushing versus stapler hepatectomy for transection of the parenchyma in elective hepatic resection (CRUNSH) - A randomized controlled trial (NCT01049607)

PubMed Central

2011-01-01

Background Hepatic resection is still associated with significant morbidity. Although the period of parenchymal transection presents a crucial step during the operation, uncertainty persists regarding the optimal technique of transection. It was the aim of the present randomized controlled trial to evaluate the efficacy and safety of hepatic resection using the technique of stapler hepatectomy compared to the simple clamp-crushing technique. Methods/Design The CRUNSH Trial is a prospective randomized controlled single-center trial with a two-group parallel design. Patients scheduled for elective hepatic resection without extrahepatic resection at the Department of General-, Visceral- and Transplantation Surgery, University of Heidelberg are enrolled into the trial and randomized intraoperatively to hepatic resection by the clamp-crushing technique and stapler hepatectomy, respectively. The primary endpoint is total intraoperative blood loss. A set of general and surgical variables are documented as secondary endpoints. Patients and outcome-assessors are blinded for the treatment intervention. Discussion The CRUNSH Trial is the first randomized controlled trial to evaluate efficacy and safety of stapler hepatectomy compared to the clamp-crushing technique for parenchymal transection during elective hepatic resection. Trial Registration ClinicalTrials.gov: NCT01049607 PMID:21888669

Using Elicited Choice Probabilities in Hypothetical Elections to Study Decisions to Vote

PubMed Central

Delavande, Adeline; Manski, Charles F.

2015-01-01

This paper demonstrates the feasibility and usefulness of survey research asking respondents to report voting probabilities in hypothetical election scenarios. Posing scenarios enriches the data available for studies of voting decisions, as a researcher can pose many more and varied scenarios than the elections that persons actually face. Multiple scenarios were presented to over 4,000 participants in the American Life Panel (ALP). Each described a hypothetical presidential election, giving characteristics measuring candidate preference, closeness of the election, and the time cost of voting. Persons were asked the probability that they would vote in this election and were willing and able to respond. We analyzed the data through direct study of the variation of voting probabilities with election characteristics and through estimation of a random utility model of voting. Voting time and election closeness were notable determinants of decisions to vote, but not candidate preference. Most findings were corroborated through estimation of a model fit to ALP data on respondents' actual voting behavior in the 2012 election. PMID:25705068

Miscarriage with a History of Elective Abortion: A Comparison Study of the Miscarriage Experience - Women with a History of Elective Abortion Versus Women Without a History of Elective Abortion

DTIC Science & Technology

1990-01-01

1974). Loss and Change. Pantheon Books, Random House: New York. McDonnell, K. (1986). Not an easy choice, a feminist reexamines abortion. Whole Earth...Boston: Little, Brown and Company. Worden, J. W. (1982). Grief Counseling and Grief Therapy . New York: Springer Publishing Company. APPENDIX A--Meaning of

The Air Force Critical Care Air Transport Team (CCATT): Using the Estimating Supplies Program (ESP) to Validate Clinical Requirements

DTIC Science & Technology

2005-04-05

categories are postsurgical cases, and represent thoracic, staged exploratory laparotomy, vascular/amputation, and craniotomy PCs for which surgical...Post Surgical Craniotomy J – Environmental Emergency E – Burns > 20% BSA K – Medical, Anaphylaxis/Asthma F – Class III and IV Hemorrhagic Shock...Amputation G – Crush/Blunt Injury K – Med, Anaphylaxis Asthma D – Post Surgical Craniotomy H – Head Injury

Spreading Depressions as Secondary Insults after Traumatic Injury to the Human Brain

DTIC Science & Technology

2012-09-01

earlier and larger craniotomies and better outcomes, despite being similar in initial injury characteristics compared to KCH patients. VCU patients also...enrolled patients with acute TBI who met the following inclusion criteria: clinical decision for craniotomy for lesion evacuation, de compression, or... craniotomies for evacuation of intracranial mass lesions or cerebral decompression, a median of 9·9 h (IQR 4·5–26·3) after trauma

The Air Force Mobile Forward Surgical Team (MFST): Using the Estimating Supplies Program to Validate Clinical Requirement

DTIC Science & Technology

2004-12-01

conducted in an abbreviated, staged manner, such as laparotomies, decompression craniotomies , vascular shunts, or amputations. The FRSS provides...Performed at MFST Abbreviated laparotomy 36.29 Vascular shunt/ligate 32.84 Amputation 12.32 Decompression craniotomy 8.98 Thoracotomy 6.35...Vascular shunt/ligations 6 33 Abbreviated laparotomy 4 22 Amputation 3 16 Decompression craniotomy 3 16 Thoracotomy 2 10 Other 3 Total 18 100

Quantifying surgical access in eyebrow craniotomy with and without orbital bar removal: cadaver and surgical phantom studies.

PubMed

Zador, Zsolt; Coope, David J; Gnanalingham, Kanna; Lawton, Michael T

2014-04-01

Eyebrow craniotomy is a recently described minimally invasive approach for tackling primarily pathology of the anterior skull base. The removal of the orbital bar may further expand the surgical corridor of this exposure, but the extent of benefit is poorly quantified. We assessed the effect of orbital bar removal with regards to surgical access in the eyebrow craniotomy using classic morphometric measurements in cadaver heads. Using surgical phantoms and neuronavigation, we also measured the 'working volume', a new parameter for characterising the volume of surgical access in these approaches. Silicon injected cadaver heads (n = 5) were used for morphometric analysis of the eyebrow craniotomy with and without orbital bar removal. Working depths and 'working areas' of surgical access were measured as defined by key anatomical landmarks. The eyebrow craniotomy with or without orbital bar removal was also simulated using surgical phantoms (n = 3, 90-120 points per trial), calibrated against a frameless neuronavigation system. Working volume was derived from reference coordinates recorded along the anatomical borders of the eyebrow craniotomy using the "α-shape algorithm" in R statistics. In cadaver heads, eyebrow craniotomy with removal of the orbital bar reduced the working depth to the ipsilateral anterior clinoid process (42 ± 2 versus 33 ± 3 mm; p < 0.05), but the working areas as defined by deep neurovascular and bony landmarks was statistically unchanged (total working areas of 418 ± 80 cm(2) versus 334 ± 48 cm(2); p = 0.4). In surgical phantom studies, however, working-volume for the simulated eyebrow craniotomies was increased with orbital bar removal (16 ± 1 cm(3) versus 21 ± 1 cm(3); p < 0.01). In laboratory studies, orbital bar removal in eyebrow craniotomy provides a modest reduction in working depth and increase in the working volume. But this must be weighed up against the added morbidity of the procedure. Working volume, a newly developed parameter may provide a more meaningful endpoint for characterising the surgical access for different surgical approaches and it could be applied to other operative cases undertaken with frameless neuronavigation.

Awake craniotomy, electrophysiologic mapping, and tumor resection with high-field intraoperative MRI.

PubMed

Parney, Ian F; Goerss, Stephan J; McGee, Kiaran; Huston, John; Perkins, William J; Meyer, Frederic B

2010-05-01

Awake craniotomy and electrophysiologic mapping (EPM) is an established technique to facilitate the resection of near eloquent cortex. Intraoperative magnetic resonance imaging (iMRI) is increasingly used to aid in the resection of intracranial lesions. Standard draping protocols in high-field iMRI units make awake craniotomies challenging, and only two groups have previously reported combined EPM and high-field iMRI. We present an illustrative case describing a simple technique for combining awake craniotomy and EPM with high-field iMRI. A movable platter is used to transfer the patient from the operating table to a transport trolley and into the adjacent MRI and still maintaining the patient's surgical position. This system allows excess drapes to be removed, facilitating awake craniotomy. A 57-year-old right-handed man presented with new onset seizures. Magnetic resonance imaging demonstrated a large left temporal mass. The patient underwent an awake, left frontotemporal craniotomy. The EPM demonstrated a single critical area for speech in his inferior frontal gyrus. After an initial tumor debulking, the scalp flap was loosely approximated, the wound was covered with additional drapes, and the excess surrounding drapes were trimmed. An iMRI was obtained. The image-guidance system was re-registered and the patient was redraped. Additional resection was performed, allowing extensive removal of what proved to be an anaplastic astrocytoma. The patient tolerated this well without any new neurological deficits. Standard protocols for positioning and draping in high-field iMRI units make awake craniotomies problematic. This straightforward technique for combined awake EPM and iMRI may facilitate safe removal of large lesions in eloquent cortex. Copyright © 2010 Elsevier Inc. All rights reserved.

Spreading Depolarizations of Cerebral Cortex After Brain Injury: Mechanism of Injury Progression and Relevance to Military Neurotrauma

DTIC Science & Technology

2006-11-01

sustained penetrating brain injury (PBI). Emergency craniotomies are performed to treat these severe injuries in theater, sometimes on a daily...after craniotomy surgery. ECoG recordings were made subsequently for 1-10 days. CSD was identified by rapidly developing depression of ECoG amplitude...treat patients with moderate-to-severe TBI provides the opportunity to monitor for CSD by ECoG recordings. In these cases, craniotomy is performed as

Emergency Interventions After Severe Traumatic Brain Injury in Rats: Effect on Neuropathology and Functional Outcome

DTIC Science & Technology

2000-01-01

placed in a stereotaxic frame and a left parietal craniotomy was performed. The dura and bone flap were left in place until immediately before CCI. A...microtransducer) was inserted through a burr hole in the frontal bone into the contralateral (right) frontal cortex at the time of craniotomy ...immediately after injury) or vehicle. A separate sham group (all surgery including craniotomy , but no TBI was also studied. Brain temperature maintained at

Total Intravenous Anesthesia Including Ketamine versus Volatile Gas Anesthesia for Combat-related Operative Traumatic Brain Injury

DTIC Science & Technology

2008-07-01

receiving VGA with regard to Injury Severity Score, Glasgow Coma Scale score, base deficit, Head Abbreviated Injury Score, and craniectomy or craniotomy ...1, 2, or 3. Craniectomy or craniotomy was performed at the discretion of the neurosurgeon based on type of skull injury, severity of injury, and...perfectly on GCS ( 8, 8), base deficit ( 6, 6), Head Abbreviated Injury Score ( 3, 3) and craniectomy versus craniotomy . From these, subsets

Accuracy of frame-based stereotactic depth electrode implantation during craniotomy for subdural grid placement.

PubMed

Munyon, Charles N; Koubeissi, Mohamad Z; Syed, Tanvir U; Lüders, Hans O; Miller, Jonathan P

2013-01-01

Frame-based stereotaxy and open craniotomy may seem mutually exclusive, but invasive electrophysiological monitoring can require broad sampling of the cortex and precise targeting of deeper structures. The purpose of this study is to describe simultaneous frame-based insertion of depth electrodes and craniotomy for placement of subdural grids through a single surgical field and to determine the accuracy of depth electrodes placed using this technique. A total of 6 patients with intractable epilepsy underwent placement of a stereotactic frame with the center of the planned cranial flap equidistant from the fixation posts. After volumetric imaging, craniotomy for placement of subdural grids was performed. Depth electrodes were placed using frame-based stereotaxy. Postoperative CT determined the accuracy of electrode placement. A total of 31 depth electrodes were placed. Mean distance of distal electrode contact from the target was 1.0 ± 0.15 mm. Error was correlated to distance to target, with an additional 0.35 mm error for each centimeter (r = 0.635, p < 0.001); when corrected, there was no difference in accuracy based on target structure or method of placement (prior to craniotomy vs. through grid, p = 0.23). The described technique for craniotomy through a stereotactic frame allows placement of subdural grids and depth electrodes without sacrificing the accuracy of a frame or requiring staged procedures.

The floating anchored craniotomy

PubMed Central

Gutman, Matthew J.; How, Elena; Withers, Teresa

2017-01-01

Background: The “floating anchored” craniotomy is a technique utilized at our tertiary neurosurgery institution in which a traditional decompressive craniectomy has been substituted for a floating craniotomy. The hypothesized advantages of this technique include adequate decompression, reduction in the intracranial pressure, obviating the need for a secondary cranioplasty, maintained bone protection, preventing the syndrome of the trephined, and a potential reduction in axonal stretching. Methods: The bone plate is re-attached via multiple loosely affixed vicryl sutures, enabling decompression, but then ensuring the bone returns to its anatomical position once cerebral edema has subsided. Results: From the analysis of 57 consecutive patients analyzed at our institution, we have found that the floating anchored craniotomy is comparable to decompressive craniectomy for intracranial pressure reduction and has some significant theoretical advantages. Conclusions: Despite the potential advantages of techniques that avoid the need for a second cranioplasty, they have not been widely adopted and have been omitted from trials examining the utility of decompressive surgery. This retrospective analysis of prospectively collected data suggests that the floating anchored craniotomy may be applicable instead of decompressive craniectomy. PMID:28713633

Coagulation management in patients undergoing neurosurgical procedures.

PubMed

Robba, Chiara; Bertuetti, Rita; Rasulo, Frank; Bertuccio, Alessando; Matta, Basil

2017-10-01

Management of coagulation in neurosurgical procedures is challenging. In this contest, it is imperative to avoid further intracranial bleeding. Perioperative bleeding can be associated with a number of factors, including anticoagulant drugs and coagulation status but is also linked to the characteristic and the site of the intracranial disorder. The aim of this review will be to focus primarily on the new evidence regarding the management of coagulation in patients undergoing craniotomy for neurosurgical procedures. Antihemostatic and anticoagulant drugs have shown to be associated with perioperative bleeding. On the other hand, an increased risk of venous thromboembolism and hypercoagulative state after elective and emergency neurosurgery, in particular after brain tumor surgery, has been described in several patients. To balance the risk between thrombosis and bleeding, it is important to be familiar with the perioperative changes in coagulation and with the recent management guidelines for anticoagulated patients undergoing neurosurgical procedures, in particular for those taking new direct anticoagulants. We have considered the current clinical trials and literature regarding both safety and efficacy of deep venous thrombosis prophylaxis in the neurosurgical population. These were mainly trials concerning both elective surgical and intensive care patients with a poor grade intracranial bleed or multiple traumas with an associated severe traumatic brain injury (TBI). Coagulation management remains a major issue in patients undergoing neurosurgical procedures. However, in this field of research, literature quality is poor and further studies are necessary to identify the best strategies to minimize risks in this group of patients.

The legacy of Hephaestus: the first craniotomy.

PubMed

Brasiliense, Leonardo Bc; Safavi-Abbasi, Sam; Crawford, Neil R; Spetzler, Robert F; Theodore, Nicholas

2010-10-01

Hephaestus is best known as the Greek god of metalworking, fire, and fine arts. As the only Olympian deity not endowed with physical perfection, he has been considered misfortunate among the Olympians. However, textual analysis of his myths reveals that Hephaestus was highly regarded by Greeks for his manual skills and intelligence. Furthermore, one of the myths about Hephaestus indicates that he performed the first recorded craniotomy. This text asserts that Hephaestus intentionally performed the craniotomy to remove a mass growing inside Zeus' head, thereby relieving him of an excruciating headache. The successful craniotomy resulted in the birth of the goddess Athena. From a neurosurgical perspective, the story is allegorical. Nonetheless, it represents the surgical management of intracranial ailments, which is thought to have been reported in Greece centuries later by Hippocrates.

The sampling characteristics of electivity indices.

PubMed

Lechowicz, Martin J

1982-01-01

Electivity indices measure the utilization of food types (r) in relation to their abundance or availability in the environment (p). Foods that constitute a larger proportion of the diet than of the available foods are considered preferred; conversely those proportionately underrepresented in the diet are avoided. A food is eaten at random if its proportion in the diet equals its proportion in the environment. A family of electivity indices stemming from Ivlev's (1961) classic monograph exist and differ only in the particular algorithm used to calculate electivity from r and p.For each available index I graphed the values of electivity as contours for all combinations of r and p. These graphs are compared to illustrate the strengths and weaknesses of each index on the basis of the following criteria: 1) the value of the index when r=p for a food, 2) the symmetry of the electivity value as feeding deviates from random, 3) the possible range of index values, 4) the linearity of changes in electivity over the full range of r and p, 5) the sensitivity of the index to sampling errors, 6) the statistical testability of the electivity, and 7) the stability of the electivity value for a food type that changes relative abundance or occurs in combination with different food types. No one index ideally satisfies all the criteria.The host preferences of gypsy moth, Lymantria dispar, feeding on tree foliage in an undisturbed deciduous forest in southwestern Quebec, Canada were used to compare the available indices: Ivlev's electivity, E; Ivlev's forage ratio, E'; Jacob's modified electivity, D; Jacob's modified forage ratio, log Q; Chesson's alpha; Strauss' linear index, L; and Vanderploeg and Scavia's relativized electivity, E * . The electivity values calculated by each index differ one from another; host trees shown as preferred by one index will frequently appear avoided according to an alternative index. The rank order electivities for the 19 available host trees, however, are remarkably similar for all but Strauss' linear index, L. Populus grandidentata, Quercus rubra, Ostrya virginiana, and Amelanchier were the most preferred host trees in the sampled forest; Prunus serotina, Acer pensylvanicum, A. rubrum, Betula lutea, and Fraxinus americana were most avoided. The use of Vanderploeg and Scavia's E * index is recommended.

[Awake craniotomy].

PubMed

Kobyakov, G L; Lubnin, A Yu; Kulikov, A S; Gavrilov, A G; Goryaynov, S A; Poddubskiy, A A; Lodygina, K S

2016-01-01

Awake craniotomy is a neurosurgical intervention aimed at identifying and preserving the eloquent functional brain areas during resection of tumors located near the cortical and subcortical language centers. This article provides a review of the modern literature devoted to the issue. The anatomical rationale and data of preoperative functional neuroimaging, intraoperative electrophysiological monitoring, and neuropsychological tests as well as the strategy of active surgical intervention are presented. Awake craniotomy is a rapidly developing technique aimed at both preserving speech and motor functions and improving our knowledge in the field of speech psychophysiology.

A randomized placebo-controlled trial of preoperative tranexamic acid among women undergoing elective cesarean delivery.

PubMed

Maged, Ahmed M; Helal, Omneya M; Elsherbini, Moutaz M; Eid, Marwa M; Elkomy, Rasha O; Dahab, Sherif; Elsissy, Maha H

2015-12-01

To study the efficacy and safety of preoperative intravenous tranexamic acid to reduce blood loss during and after elective lower-segment cesarean delivery. A single-blind, randomized placebo-controlled study was undertaken of women undergoing elective lower-segment cesarean delivery of a full-term singleton pregnancy at a center in Cairo, Egypt, between November 2013 and November 2014. Patients were randomly assigned (1:1) using computer-generated random numbers to receive either 1g tranexamic acid or 5% glucose 15 minutes before surgery. Preoperative and postoperative complete blood count, hematocrit values, and maternal weight were used to calculate the estimated blood loss (EBL) during cesarean, which was the primary outcome. Analyses included women who received their assigned treatment, whose surgery was 90 minutes or less, and who completed follow-up. Analyses included 100 women in each group. Mean EBL was significantly higher in the placebo group (700.3 ± 143.9 mL) than in the tranexamic acid group (459.4 ±7 5.4 mL; P<0.001). Only six women, all in the placebo group, experienced an EBL of more than 1000 mL. There were no reports of thromboembolic events up to 4 weeks postoperatively. Preoperative administration of tranexamic acid safely reduces blood loss during elective lower-segment cesarean delivery. Australian New Zealand Clinical Trials Registry:ACTRN12615000312549. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Effect of tranexamic acid on intraoperative blood loss and transfusion requirements in patients undergoing excision of intracranial meningioma.

PubMed

Hooda, Bhavna; Chouhan, Rajendra Singh; Rath, Girija Prasad; Bithal, Parmod Kumar; Suri, Ashish; Lamsal, Ritesh

2017-07-01

Surgical excision of meningioma is often complicated by significant blood loss requiring blood transfusion with its attendant risks. Although tranexamic acid is used to reduce perioperative blood loss, its blood conservation effect is uncertain in neurosurgery. Sixty adults undergoing elective craniotomy for meningioma excision were randomized to receive either tranexamic acid or placebo, initiated prior to skin incision. Patients in the tranexamic acid group received intravenous bolus of 20mg/kg over 20min followed by an infusion of 1mg/kg/h till the conclusion of surgery. Intraoperative blood loss, transfusion requirements and estimation of surgical hemostasis using a 5-grade scale were noted. Postoperatively, the extent of tumor excision on CT scan and complications were observed. Demographics, tumor characteristics, amount of fluid infusion, and duration of surgery and anesthesia were comparable between the two groups. The amount of blood loss was significantly less in tranexamic acid group compared to placebo (830mlvs 1124ml; p=0.03). The transfusion requirement was less in tranexamic acid group (p>0.05). The patients in tranexamic acid group fared better on a 5-grade surgical hemostasis scale with more patients showing good hemostasis (p=0.007). There were no significant differences between the groups with regards to extent of tumor removal, perioperative complications, hospital stay or neurologic outcome. To conclude, administration of tranexamic acid significantly reduced blood loss in patients undergoing excision of meningioma. Fewer patients in the tranexamic acid group received blood transfusions. Surgical field hemostasis was better achieved in patients who received tranexamic acid. Copyright © 2017 Elsevier Ltd. All rights reserved.

Surgical Evacuation of Spontaneous Supratentorial Lobar Intracerebral Hemorrhage: Comparison of Safety and Efficacy of Stereotactic Aspiration, Endoscopic Surgery, and Craniotomy.

PubMed

Li, Yuqian; Yang, Ruixin; Li, Zhihong; Yang, Yanping; Tian, Bo; Zhang, Xingye; Wang, Bao; Lu, Dan; Guo, Shaochun; Man, Minghao; Yang, Yang; Luo, Tao; Gao, Guodong; Li, Lihong

2017-09-01

The safety and efficacy of craniotomy, endoscopic surgery, and stereotactic aspiration for surgical evacuation of spontaneous supratentorial lobar intracerebral hemorrhage (ICH) is yet uncertain. The present study analyzed the clinical and radiographic data from 99 patients with spontaneous supratentorial lobar ICH, retrospectively, to address this issue. Patients who underwent craniotomy, endoscopy surgery, or stereotactic aspiration were assigned to the craniotomy group (n = 31), endoscopy surgery group (n = 32), or stereotactic aspiration group (n = 36), respectively. The characteristics of all the enrolled patients at the time of admission were assimilated. Also, the therapeutic effects of the three surgical procedures were evaluated based on short-term outcomes within 30 days and long-term outcomes at 6 months after the ictus. The results showed that stereotactic aspiration and endoscopic surgery were associated with a superior clinical therapeutic effect in both short-term and long-term outcomes than craniotomy for the treatment of spontaneous supratentorial lobar ICH. Notably, severely affected patients with hematoma volume > 60 mL or Glasgow Coma Scale score 4-8 may benefit more from endoscopic surgery than the two other surgical procedures. The current findings demonstrate that both stereotactic aspiration and endoscopic surgery possess an apparent advantage over craniotomy for the evacuation of spontaneous supratentorial lobar ICH. The endoscopic surgery might be more safe and effective with higher evacuation rate, better functional neurological outcomes, and lower complication and mortality rates. Copyright © 2017 Elsevier Inc. All rights reserved.

Pain during awake craniotomy for brain tumor resection. Incidence, causes, consequences and management.

PubMed

Fontaine, D; Almairac, F

2017-06-01

Awake craniotomy for brain tumor resection is usually well-tolerated and most of the patients are satisfied. However, in studies reporting the patients' postoperative perception of the awake craniotomy procedure, about half of them have experienced some degree of intraoperative pain. Pain was mild (intensity between 1 and 2 on the visual analogical score) short lasting in most cases, and did not challenge the procedure. Pain was reported as moderate in about 25% and exceptionally severe. We conducted a preliminary survey among French centers (n=9) routinely performing awake craniotomy. Neurosurgeons' opinions were concordant with patient's reports. Intraoperative pain exceptionally challenged the awake craniotomy procedure or led to changes in the resection strategy. For neurosurgeons, the most challenging causes of intraoperative pain were the patient's inadequate installation, the contact of surgical tools with pain-sensitive intracranial structures, especially the dura mater of the skull base, falx cerebri, and the leptomeninges of the lateral fissure and neighboring sulci. Strategies to deal with these causes included focusing the patient on the intraoperative functional tests to distract their attention away from the pain, and avoiding contacts with the pain-sensitive intracranial structures during the awake phase. Adequate preoperative patient information and preparation, trained anesthesiologists and application of recommendations for awake craniotomy procedures as well as adaptation of surgical technique to avoid contact with pain-sensitive intracranial structures are key factors to prevent intraoperative pain and ensure patient's postoperative satisfaction. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Asleep-awake-asleep craniotomy: a comparison with general anesthesia for resection of supratentorial tumors.

PubMed

Rajan, Shobana; Cata, Juan P; Nada, Eman; Weil, Robert; Pal, Rakhi; Avitsian, Rafi

2013-08-01

The anesthetic plan for patients undergoing awake craniotomy, when compared to craniotomy under general anesthesia, is different, in that it requires changes in states of consciousness during the procedure. This retrospective review compares patients undergoing an asleep-awake-asleep technique for craniotomy (group AW: n = 101) to patients undergoing craniotomy under general anesthesia (group AS: n = 77). Episodes of desaturation (AW = 31% versus AS = 1%, p < 0.0001), although temporary, and hypercarbia (AW = 43.75 mmHg versus AS = 32.75 mmHg, p < 0.001) were more common in the AW group. The mean arterial pressure during application of head clamp pins and emergence was significantly lower in AW patients compared to AS patients (pinning 91.47 mmHg versus 102.9 mmHg, p < 0.05 and emergence 84.85 mmHg versus 105 mmHg, p < 0.05). Patients in the AW group required less vasopressors intraoperatively (AW = 43% versus AS = 69%, p < 0.01). Intraoperative fluids were comparable between the two groups. The post anesthesia care unit (PACU) administered significantly fewer intravenous opioids in the AW group. The length of stay in the PACU and hospital was comparable in both groups. Thus, asleep-awake-asleep craniotomies with propofol-dexmedetomidine infusion had less hemodynamic response to pinning and emergence, and less overall narcotic use compared to general anesthesia. Despite a higher incidence of temporary episodes of desaturation and hypoventilation, no adverse clinical consequences were seen. Copyright © 2013 Elsevier Ltd. All rights reserved.

Comparison of Dexmedetomidine and Remifentanil on Airway Reflex and Hemodynamic Changes during Recovery after Craniotomy

PubMed Central

Kim, Hyunzu; Min, Kyeong Tae; Lee, Jeong Rim; Ha, Sang Hee; Lee, Woo Kyung; Seo, Jae Hee

2016-01-01

Purpose During emergence from anesthesia for a craniotomy, maintenance of hemodynamic stability and prompt evaluation of neurological status is mandatory. The aim of this prospective, randomized, double-blind study was to compare the effects of dexmedetomidine and remifentanil on airway reflex and hemodynamic change in patients undergoing craniotomy. Materials and Methods Seventy-four patients undergoing clipping of unruptured cerebral aneurysm were recruited. In the dexmedetomidine group, patients were administered dexmedetomidine (0.5 µg/kg) for 5 minutes, while the patients of the remifentanil group were administered remifentanil with an effect site concentration of 1.5 ng/mL until endotracheal extubation. The incidence and severity of cough and hemodynamic variables were measured during the recovery period. Hemodynamic variables, respiration rate, and sedation scale were measured after extubation and in the post-anesthetic care unit (PACU). Results The incidence of grade 2 and 3 cough at the point of extubation was 62.5% in the dexmedetomidine group and 53.1% in the remifentanil group (p=0.39). Mean arterial pressure (p=0.01) at admission to the PACU and heart rate (p=0.04 and 0.01, respectively) at admission and at 10 minutes in the PACU were significantly lower in the dexmedetomidine group. Respiration rate was significantly lower in the remifentanil group at 2 minutes (p<0.01) and 5 minutes (p<0.01) after extubation. Conclusion We concluded that a single bolus of dexmedetomidine (0.5 µg/kg) and remifentanil infusion have equal effectiveness in attenuating coughing and hemodynamic changes in patients undergoing cerebral aneurysm clipping; however, dexmedetomidine leads to better preservation of respiration. PMID:27189295

A multicenter, randomized controlled trial comparing the identification rate of stigmata of recent hemorrhage and rebleeding rate between early and elective colonoscopy in outpatient-onset acute lower gastrointestinal bleeding: study protocol for a randomized controlled trial.

PubMed

Niikura, Ryota; Nagata, Naoyoshi; Yamada, Atsuo; Doyama, Hisashi; Shiratori, Yasutoshi; Nishida, Tsutomu; Kiyotoki, Shu; Yada, Tomoyuki; Fujita, Tomoki; Sumiyoshi, Tetsuya; Hasatani, Kenkei; Mikami, Tatsuya; Honda, Tetsuro; Mabe, Katsuhiro; Hara, Kazuo; Yamamoto, Katsumi; Takeda, Mariko; Takata, Munenori; Tanaka, Mototsugu; Shinozaki, Tomohiro; Fujishiro, Mitsuhiro; Koike, Kazuhiko

2018-04-03

The clinical benefit of early colonoscopy within 24 h of arrival in patients with severe acute lower gastrointestinal bleeding (ALGIB) remains controversial. This trial will compare early colonoscopy (performed within 24 h) versus elective colonoscopy (performed between 24 and 96 h) to examine the identification rate of stigmata of recent hemorrhage (SRH) in ALGIB patients. We hypothesize that, compared with elective colonoscopy, early colonoscopy increases the identification of SRH and subsequently improves clinical outcomes. This trial is an investigator-initiated, multicenter, randomized, open-label, parallel-group trial examining the superiority of early colonoscopy over elective colonoscopy (standard therapy) in ALGIB patients. The primary outcome measure is the identification of SRH. Secondary outcomes include 30-day rebleeding, success of endoscopic treatment, need for additional endoscopic examination, need for interventional radiology, need for surgery, need for transfusion during hospitalization, length of stay, 30-day thrombotic events, 30-day mortality, preparation-related adverse events, and colonoscopy-related adverse events. The sample size will enable detection of a 9% SRH rate in elective colonoscopy patients and a SRH rate of ≥ 26% in early colonoscopy patients with a risk of type I error of 5% and a power of 80%. This trial will provide high-quality data on the benefits and risks of early colonoscopy in ALGIB patients. UMIN-CTR Identifier, UMIN000021129 . Registered on 21 February 2016; ClinicalTrials.gov Identifier, NCT03098173 . Registered on 24 March 2017.

Awake craniotomy for assisting placement of auditory brainstem implant in NF2 patients.

PubMed

Zhou, Qiangyi; Yang, Zhijun; Wang, Zhenmin; Wang, Bo; Wang, Xingchao; Zhao, Chi; Zhang, Shun; Wu, Tao; Li, Peng; Li, Shiwei; Zhao, Fu; Liu, Pinan

2018-06-01

Auditory brainstem implants (ABIs) may be the only opportunity for patients with NF2 to regain some sense of hearing sensation. However, only a very small number of individuals achieved open-set speech understanding and high sentence scores. Suboptimal placement of the ABI electrode array over the cochlear nucleus may be one of main factors for poor auditory performance. In the current study, we present a method of awake craniotomy to assist with ABI placement. Awake surgery and hearing test via the retrosigmoid approach were performed for vestibular schwannoma resections and auditory brainstem implantations in four patients with NF2. Auditory outcomes and complications were assessed postoperatively. Three of 4 patients who underwent awake craniotomy during ABI surgery received reproducible auditory sensations intraoperatively. Satisfactory numbers of effective electrodes, threshold levels and distinct pitches were achieved in the wake-up hearing test. In addition, relatively few electrodes produced non-auditory percepts. There was no serious complication attributable to the ABI or awake craniotomy. It is safe and well tolerated for neurofibromatosis type 2 (NF2) patients using awake craniotomy during auditory brainstem implantation. This method can potentially improve the localization accuracy of the cochlear nucleus during surgery.

Reconciling Air Force Physicians’ Peacetime and Wartime Capabilities, Demonstration of a Work Force Design Methodology.

DTIC Science & Technology

1985-08-01

training would again be required, include work on peripheral nerves, craniotomy and craniectomy (although approximately one-fifth of the -general surgeons...said never to craniotomy and craniectomy), and closed and open reductions of fractures of facial bones. Surgical subspecialty examinations can be...0 0 0 0 0 0 Free skin grfts-sites exc face 100 0 0 0 0 0 0 Free skin grafts to face 81 16 4 0 0 0 0 Craniotomy /craniectomy 7 25 11 12 11 15 19 Burr

Burr Hole Washout versus Craniotomy for Chronic Subdural Hematoma: Patient Outcome and Cost Analysis

PubMed Central

Regan, Jacqueline M.; Worley, Emmagene; Shelburne, Christopher; Pullarkat, Ranjit; Watson, Joseph C.

2015-01-01

Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients’ clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings. PMID:25611468

Burr hole washout versus craniotomy for chronic subdural hematoma: patient outcome and cost analysis.

PubMed

Regan, Jacqueline M; Worley, Emmagene; Shelburne, Christopher; Pullarkat, Ranjit; Watson, Joseph C

2015-01-01

Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients' clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings.

Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study.

PubMed

Mahajan, Charu; Rath, Girija Prasad; Singh, Gyaninder Pal; Mishra, Nitasha; Sokhal, Suman; Bithal, Parmod Kumar

2018-01-01

The goal of awake craniotomy is to maintain adequate sedation, analgesia, respiratory, and hemodynamic stability and also to provide a cooperative patient for neurologic testing. An observational study carried out to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy. Adult patients with age >18 year who underwent awake craniotomy for intracranial tumor surgery were enrolled. Those who were uncooperative and had difficult airway were excluded from the study. In the operating room, the patients received a bolus dose of dexmedetomidine 1 μg/kg followed by an infusion of 0.2-0.7 μg/kg/h (bispectral index target 60-80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various stages of the procedure, intraoperative complications, total amount of fentanyl used, intravenous fluids required, blood loss and transfusion, duration of surgery, Intensive Care Unit (ICU), and hospital stay were collected. The patients were assessed for Glasgow outcome scale (GOS) score and patient satisfaction score (PSS). A total of 27 patients underwent awake craniotomy during a period of 2 years. Most common intraoperative complication was seizures; observed in five patients (18.5%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5 ± 85.0 μg. The duration of surgery, ICU, and hospital stays were 231.5 ± 90.5 min, 14.5 ± 3.5 h, and 4.7 ± 1.5 days, respectively. The overall PSS was 8 and GOS was good in all the patients. The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. The absence of major complications and higher PSS makes it close to an ideal agent for craniotomy in awake state.

Efficacy and safety of dexmedetomidine infusion for patients undergoing awake craniotomy: An observational study

PubMed Central

Mahajan, Charu; Rath, Girija Prasad; Singh, Gyaninder Pal; Mishra, Nitasha; Sokhal, Suman; Bithal, Parmod Kumar

2018-01-01

Background: The goal of awake craniotomy is to maintain adequate sedation, analgesia, respiratory, and hemodynamic stability and also to provide a cooperative patient for neurologic testing. An observational study carried out to evaluate the efficacy of dexmedetomidine sedation for awake craniotomy. Materials and Methods: Adult patients with age >18 year who underwent awake craniotomy for intracranial tumor surgery were enrolled. Those who were uncooperative and had difficult airway were excluded from the study. In the operating room, the patients received a bolus dose of dexmedetomidine 1 μg/kg followed by an infusion of 0.2–0.7 μg/kg/h (bispectral index target 60–80). Once the patients were sedated, scalp block was given with bupivacaine 0.25%. The data on hemodynamics at various stages of the procedure, intraoperative complications, total amount of fentanyl used, intravenous fluids required, blood loss and transfusion, duration of surgery, Intensive Care Unit (ICU), and hospital stay were collected. The patients were assessed for Glasgow outcome scale (GOS) score and patient satisfaction score (PSS). Results: A total of 27 patients underwent awake craniotomy during a period of 2 years. Most common intraoperative complication was seizures; observed in five patients (18.5%). None of these patients experienced any episode of desaturation. Two patients had tight brain for which propofol boluses were administered. The average fentanyl consumption was 161.5 ± 85.0 μg. The duration of surgery, ICU, and hospital stays were 231.5 ± 90.5 min, 14.5 ± 3.5 h, and 4.7 ± 1.5 days, respectively. The overall PSS was 8 and GOS was good in all the patients. Conclusion: The use of dexmedetomidine infusion with regional scalp block in patients undergoing awake craniotomy is safe and efficacious. The absence of major complications and higher PSS makes it close to an ideal agent for craniotomy in awake state. PMID:29628833

Incidence of Postoperative Hematomas Requiring Surgical Treatment in Neurosurgery: A Retrospective Observational Study.

PubMed

Lillemäe, Kadri; Järviö, Johanna Annika; Silvasti-Lundell, Marja Kaarina; Antinheimo, Jussi Juha-Pekka; Hernesniemi, Juha Antero; Niemi, Tomi Tapio

2017-12-01

We aimed to characterize the occurrence of postoperative hematoma (POH) after neurosurgery overall and according to procedure type and describe the prevalence of possible confounders. Patient data between 2010 and 2012 at the Department of Neurosurgery in Helsinki University Hospital were retrospectively analyzed. A data search was performed according to the type of surgery including craniotomies; shunt procedures, spine surgery, and spinal cord stimulator implantation. We analyzed basic preoperative characteristics, as well as data about the initial intervention, perioperative period, revision operation and neurologic recovery (after craniotomy only). The overall incidence of POH requiring reoperation was 0.6% (n = 56/8783) to 0.6% (n = 26/4726) after craniotomy, 0% (n = 0/928) after shunting procedure, 1.1% (n = 30/2870) after spine surgery, and 0% (n = 0/259) after implantation of a spinal cord stimulator. Craniotomy types with higher POH incidence were decompressive craniectomy (7.9%, n = 7/89), cranioplasty (3.6%, n = 4/112), bypass surgery (1.7%, n = 1/60), and epidural hematoma evacuation (1.6%, n = 1/64). After spinal surgery, POH was observed in 1.1% of cervical and 2.1% of thoracolumbar operations, whereas 46.7% were multilevel procedures. 64.3% of patients with POH and 84.6% of patients undergoing craniotomy had postoperative hypertension (systolic blood pressure >160 mm Hg or lower if indicated). Poor outcome (Glasgow Outcome Scale score 1-3), whereas death at 6 months after craniotomy was detected in 40.9% and 21.7%. respectively, of patients with POH who underwent craniotomy. POH after neurosurgery was rare in this series but was associated with poor outcome. Identification of risk factors of bleeding, and avoiding them, if possible, might decrease the incidence of POH. Copyright © 2017 Elsevier Inc. All rights reserved.

Anesthetic management with scalp nerve block and propofol/remifentanil infusion during awake craniotomy in an adolescent patient -A case report-

PubMed Central

Sung, Bohyun; Park, Jin-Woo; Byon, Hyo-Jin; Kim, Jin-Tae; Kim, Chong Sung

2010-01-01

Despite of various neurophysiologic monitoring methods under general anesthesia, functional mapping at awake state during brain surgery is helpful for conservation of speech and motor function. But, awake craniotomy in children or adolescents is worrisome considering their emotional friabilities. We present our experience on anesthetic management for awake craniotomy in an adolescent patient. The patient was 16 years old male who would undergo awake craniotomy for removal of brain tumor. Scalp nerve block was done with local anesthetics and we infused propofol and remifentanil with target controlled infusion. The patient endured well and was cooperative before scalp suture, but when surgeon sutured scalp, he complained of pain and was suddenly agitated. We decided change to general anesthesia. Neurosurgeon did full neurologic examinations and there was no neurologic deficit except facial palsy of right side. Facial palsy had improved with time. PMID:21286435

[AWAKE CRANIOTOMY: IN SEARCH FOR OPTIMAL SEDATION].

PubMed

Kulikova, A S; Sel'kov, D A; Kobyakov, G L; Shmigel'skiy, A V; Lubnin, A Yu

2015-01-01

Awake craniotomy is a "gold standard"for intraoperative brain language mapping. One of the main anesthetic challenge of awake craniotomy is providing of optimal sedation for initial stages of intervention. The goal of this study was comparison of different technics of anesthesia for awake craniotomy. Materials and methods: 162 operations were divided in 4 groups: 76 cases with propofol sedation (2-4mg/kg/h) without airway protection; 11 cases with propofol sedation (4-5 mg/kg/h) with MV via LMA; 36 cases of xenon anesthesia; and 39 cases with dexmedetomidine sedation without airway protection. Results and discussion: brain language mapping was successful in 90% of cases. There was no difference between groups in successfulness of brain mapping. However in the first group respiratory complications were more frequent. Three other technics were more safer Xenon anesthesia was associated with ultrafast awakening for mapping (5±1 min). Dexmedetomidine sedation provided high hemodynamic and respiratory stability during the procedure.

Resting state functional connectivity magnetic resonance imaging integrated with intraoperative neuronavigation for functional mapping after aborted awake craniotomy

PubMed Central

Batra, Prag; Bandt, S. Kathleen; Leuthardt, Eric C.

2016-01-01

Background: Awake craniotomy is currently the gold standard for aggressive tumor resections in eloquent cortex. However, a significant subset of patients is unable to tolerate this procedure, particularly the very young or old or those with psychiatric comorbidities, cardiopulmonary comorbidities, or obesity, among other conditions. In these cases, typical alternative procedures include biopsy alone or subtotal resection, both of which are associated with diminished surgical outcomes. Case Description: Here, we report the successful use of a preoperatively obtained resting state functional connectivity magnetic resonance imaging (MRI) integrated with intraoperative neuronavigation software in order to perform functional cortical mapping in the setting of an aborted awake craniotomy due to loss of airway. Conclusion: Resting state functional connectivity MRI integrated with intraoperative neuronavigation software can provide an alternative option for functional cortical mapping in the setting of an aborted awake craniotomy. PMID:26958419

Use of Subdural Evacuating Port System Following Open Craniotomy with Excision of Native Dura and Membranes for Management of Chronic Subdural Hematoma.

PubMed

Cage, Tene; Bach, Ashley; McDermott, Michael W

2017-04-26

An 86-year-old woman was admitted to the intensive care unit with a chronic subdural hematoma (CSDH) and rapid onset of worsening neurological symptoms. She was taken to the operating room for a mini-craniotomy for evacuation of the CSDH including excision of the dura and CSDH membrane. Postoperatively, a subdural evacuation port system (SEPS) was integrated into the craniotomy site and left in place rather than a traditional subdural catheter drain to evacuate the subdural space postoperatively. The patient had a good recovery and improvement of symptoms after evacuation and remained clinically well after the SEPS was removed. We offer the technique of dura and CSDH membrane excision plus SEPS drain as an effective postoperative alternative to the standard craniotomy leaving the native dura intact with traditional subdural drain that overlies the cortical surface of the brain in treating patients with CSDH.

Perioperative Factors Contributing the Post-Craniotomy Pain: A Synthesis of Concepts.

PubMed

Chowdhury, Tumul; Garg, Rakesh; Sheshadri, Veena; Venkatraghavan, Lakshmi; Bergese, Sergio Daniel; Cappellani, Ronald B; Schaller, Bernhard

2017-01-01

The perioperative management of post-craniotomy pain is controversial. Although the concept of pain control in non-neurosurgical fields has grown substantially, the understanding of neurosurgical pain and its causative factors in such a population is inconclusive. In fact, the organ that is the center of pain and its related mechanisms receives little attention to alleviate distress during neurosurgical procedures. In contrast to the old belief that pain following intracranial surgery is minimal, recent data suggest the exact opposite. Despite the evolution of various multimodal analgesic techniques for optimal pain control, the concern of post-craniotomy pain remains. This paradox could be due to the lack of thorough understanding of different perioperative factors that can influence the incidence and intensity of pain in post-craniotomy population. Therefore, this review aims to give an in-depth insight into the various aspects of pain and its related factors in adult neurosurgical patients.

Perioperative Factors Contributing the Post-Craniotomy Pain: A Synthesis of Concepts

PubMed Central

Chowdhury, Tumul; Garg, Rakesh; Sheshadri, Veena; Venkatraghavan, Lakshmi; Bergese, Sergio Daniel; Cappellani, Ronald B.; Schaller, Bernhard

2017-01-01

The perioperative management of post-craniotomy pain is controversial. Although the concept of pain control in non-neurosurgical fields has grown substantially, the understanding of neurosurgical pain and its causative factors in such a population is inconclusive. In fact, the organ that is the center of pain and its related mechanisms receives little attention to alleviate distress during neurosurgical procedures. In contrast to the old belief that pain following intracranial surgery is minimal, recent data suggest the exact opposite. Despite the evolution of various multimodal analgesic techniques for optimal pain control, the concern of post-craniotomy pain remains. This paradox could be due to the lack of thorough understanding of different perioperative factors that can influence the incidence and intensity of pain in post-craniotomy population. Therefore, this review aims to give an in-depth insight into the various aspects of pain and its related factors in adult neurosurgical patients. PMID:28299313

Keyhole concept in cerebral aneurysm clipping and tumor removal by the supraciliary lateral supraorbital approach

PubMed Central

Mori, Kentaro

2014-01-01

The keyhole concept in neurosurgery is designed to minimize the craniotomy needed for the access route to deep intracranial pathologies. Such keyhole surgeries cause less trauma and can be less invasive than conventional surgical techniques. Among the various types of keyhole mini-craniotomy, supraorbital or lateral supraorbital mini-craniotomy is the standard and basic keyhole approaches. The lateral supraorbital keyhole provides adequate working space in the suprasellar to parasellar areas and planum sphenoidale area including the anterior communicating artery complex. Despite the development of neuro-endoscopic techniques and intra-operative assistant methods, the limited working angle to manipulate and observe deeply situated pathologies is a major disadvantage of the keyhole approaches. Neurosurgeons should understand that keyhole mini-craniotomy surgeries aim at “minimally invasive neurosurgery” but still carry the risks of malpractice unless we understand the advantages and disadvantages of these keyhole concepts and strategies. PMID:24891885

The Impact of Property Wealth and Income Wealth on School Bond Elections.

ERIC Educational Resources Information Center

Jacobson, Thomas

1997-01-01

Examines the linkage between facility bond elections and the indicators of wealth (property valuation and income) and the appropriateness of relying on property valuations as the primary indicator of school district wealth. Results from 31 randomly selected schools in Nebraska show an unclear relationship between wealth factors and success in…

Advances in open microsurgery for cerebral aneurysms.

PubMed

Davies, Jason M; Lawton, Michael T

2014-02-01

Endovascular techniques introduced strong extrinsic forces that provoked reactive changes in aneurysm surgery. Microsurgery has become less invasive, more appealing to patients, lower risk, and efficacious for complex aneurysms, particularly those unfavorable for or failing endovascular therapy. To review specific advances in open microsurgery for aneurysms. A university-based, single-surgeon practice was examined for the use of minimally invasive craniotomies, surgical management of recurrence after coiling, the use of intracranial-intracranial bypass techniques, and cerebrovascular volume-outcome relationships. The mini-pterional, lateral supraorbital, and orbital-pterional craniotomies are minimally invasive alternatives to standard craniotomies. Mini-pterional and lateral supraorbital craniotomies were used in one-fourth of unruptured patients, increasing from 22% to 28%, whereas 15% of patients underwent orbital-pterional craniotomies and trended upward from 11% to 20%. Seventy-four patients were treated for coil recurrences (2.3% of all aneurysms) with direct clip occlusion (77%), clip occlusion after coil extraction (7%), or parent artery occlusion with bypass (16%). Intracranial-intracranial bypass (in situ bypass, reimplantation, reanastomosis, and intracranial grafts) transformed the management of giant aneurysms and made the surgical treatment of posterior inferior cerebellar artery aneurysms competitive with endovascular therapy. Centralization maximized the volume-outcome relationships observed with clipping. Aneurysm microsurgery has embraced minimalism, tailoring the exposure to the patient's anatomy with the smallest possible craniotomy that provides adequate exposure. The development of intracranial-intracranial bypasses is an important advancement that makes microsurgery a competitive option for complex and recurrent aneurysms. Trends toward centralizing aneurysm surgery in tertiary centers optimize results achievable with open microsurgery.

Anesthetic approach to high-risk patients and prolonged awake craniotomy using dexmedetomidine and scalp block.

PubMed

Garavaglia, Marco M; Das, Sunit; Cusimano, Michael D; Crescini, Charmagne; Mazer, C David; Hare, Gregory M T; Rigamonti, Andrea

2014-07-01

Awake craniotomy with intraoperative speech or motor testing is relatively contraindicated in cases requiring prolonged operative times and in patients with severe medical comorbidities including anxiety, anticipated difficult airway, obesity, large tumors, and intracranial hypertension. The anesthetic management of neurosurgical patients who possess these contraindications but would be optimally treated by an awake procedure remains unclear. We describe a new anesthetic approach for awake craniotomy that did not require any airway manipulation, utilizing a bupivacaine-based scalp nerve block, and dexmedetomidine as the primary hypnotic-sedative agent. Using this technique, we provided optimal operative conditions to perform awake craniotomy facilitating safe tumor resection, while utilizing intraoperative electrocorticography for motor and speech mapping in a cohort of 10 patients at a high risk for airway compromise and complications associated with patient comorbidities. All patients underwent successful awake craniotomy, intraoperative mapping, and tumor resection with adequate sedation for up to 9 hours (median 3.5 h, range 3 to 9 h) without any loss of neurological function, airway competency, or the need to provide any active rescue airway management. We report 4 of these cases that highlight our experience: 1 case required prolonged surgery because of the complexity of tumor resection and 3 patients had important medical comorbidities and/or relative contraindication for an awake procedure. Dexmedetomidine, with concurrent scalp block, is an effective and safe anesthetic approach for awake craniotomy. Dexmedetomidine facilitates the extension procedure complexity and duration in patients who might traditionally not be considered to be candidates for this procedure.

Prospective study of awake craniotomy used routinely and nonselectively for supratentorial tumors.

PubMed

Serletis, Demitre; Bernstein, Mark

2007-07-01

The authors prospectively assessed the value of awake craniotomy used nonselectively in patients undergoing resection of supratentorial tumors. The demographic features, presenting symptoms, tumor location, histological diagnosis, outcomes, and complications were documented for 610 patients who underwent awake craniotomy for supratentorial tumor resection. Intraoperative brain mapping was used in 511 cases (83.8%). Mapping identified eloquent cortex in 115 patients (22.5%) and no eloquent cortex in 396 patients (77.5%). Neurological deficits occurred in 89 patients (14.6%). In the subset of 511 patients in whom brain mapping was performed, 78 (15.3%) experienced postoperative neurological worsening. This phenomenon was more common in patients with preoperative neurological deficits or in those individuals in whom mapping successfully identified eloquent tissue. Twenty-five (4.9%) of the 511 patients suffered intraoperative seizures, and two of these individuals required intubation and induction of general anesthesia after generalized seizures occurred. Four (0.7%) of the 610 patients developed wound complications. Postoperative hematomas developed in seven patients (1.1%), four of whom urgently required a repeated craniotomy to allow evacuation of the clot. Two patients (0.3%) required readmission to the hospital soon after being discharged. There were three deaths (0.5%). Awake craniotomy is safe, practical, and effective during resection of supratentorial lesions of diverse pathological range and location. It allows for intraoperative brain mapping that helps identify and protect functional cortex. It also avoids the complications inherent in the induction of general anesthesia. Awake craniotomy provides an excellent alternative to surgery of supratentorial brain lesions in patients in whom general anesthesia has been induced.

Health care issues in Croatian elections 2005-2010: series of public opinion surveys.

PubMed

Radin, Dagmar; Dzakula, Aleksandar; Benkovic, Vanesa

2011-10-15

To compare the results of a series of public opinion surveys on experiences with the health care sector in Croatia conducted in the time of elections and to analyze whether political party affiliation had any influence on issues of priority ranking. The surveys were conducted during 2005, 2007, and 2009. They were administered through a Computer Assisted Telephone Interviewing method to representative samples of Croatian population and were statistically weighted according to sex, age, level of education, and political party affiliation. The random sampling of the person within the household was done using the table of random numbers. Health and health care system was the most important issue (58%) during the 2007 parliamentary election and the second most important issue during the 2005 and 2009 elections (46% and 28%). In the 2007 election, health care was viewed as most important by women, respondents with lower education levels, and respondents with lower income. In 2005, the most important health care issues were corruption and lack of funding (45% and 43%, respectively), in 2007 poor organization and lack of funding (43% and 42%, respectively), and in 2009 lack of funding and corruption (51% and 45%, respectively). Health and health care system were consistently among the top two issues in all elections from 2005 to 2009. The top three most important health care sector issues were corruption, poor organization, and lack of funding. This indicates that political parties should include solutions to these issues in their health care policymaking.

Instrumental delivery of the fetal head at the time of elective repeat cesarean: a randomized pilot study.

PubMed

Bofill, J A; Lencki, S G; Barhan, S; Ezenagu, L C

2000-01-01

We sought to ascertain whether the routine use of instruments, forceps or vacuum, at the time of elective repeat cesarean delivery, permits a delivery that is as safe for mother and infant and as easy for mother and physician as traditional manual delivery of the fetal head. In this prospective study 44 women undergoing elective repeat cesarean were randomized to deliver by Vacuum (V), Forceps (F), or by Manual (M) means. Groups were compared with regard to demographic variables and maternal and neonatal outcomes. Deliveries were timed from entry into the uterus until full delivery of the infant. Maternal pain scores were assessed using a 10-cm visual analog scale. There were no differences in demographic variables except that the M group had fewer women with up to two cesareans. A large percentage of women in each group were delivered with the randomized instrument. Use of the V did not demonstrate fewer extensions of the uterine incision or lesser amounts of blood loss as measured by serial hemoglobin determinations. There was a trend for the F group to require a longer period of time for delivery (p = 0.061). Women in the V group reported significantly lower pain scores (p = 0.015). There were no serious neonatal injuries. The routine use of instruments at the time of elective repeat cesarean delivery appears safe and effective.

Post-craniotomy intracranial infection in patients with brain tumors: a retrospective analysis of 5723 consecutive patients.

PubMed

Shi, Zhong-Hua; Xu, Ming; Wang, Yong-Zhi; Luo, Xu-Ying; Chen, Guang-Qiang; Wang, Xin; Wang, Tao; Tang, Ming-Zhong; Zhou, Jian-Xin

2017-02-01

To determine the risk factors for and the incidence, outcomes, and causative pathogens of post-craniotomy intracranial infection (PCII) in patients with brain tumors. A retrospective study was performed of 5723 patients with brain tumors who were surgically treated between January 2012 and December 2013 in Beijing Tiantan Hospital. The patients' demographics, pathohistological diagnoses, surgical procedures, postoperative variables, causative pathogens, and outcomes were evaluated. The overall incidence of PCII was 6.8%, and 82.1% of all cases were diagnosed within two weeks after the craniotomy. Postoperative administration of antibiotics reduced the incidence of PCII. Independent risk factors included clean-contaminated craniotomy, prolonged operation (> 7 h), external cerebrospinal fluid (CSF) drainage/monitoring device placement, and postoperative CSF leakage. Patients ≤ 45 years old were more susceptible to infection. Compared with supratentorial tumors, tumors located in the infratentorial or intraventricular regions were more vulnerable to PCII. Gram-positive bacteria were the most common causative pathogens isolated from the CSF samples, accounting for 82.0% of the PCII cases. Risk factors for PCII can be identified early in the perioperative period. These findings raise the possibility of improving the clinical outcomes of patients with brain tumors who undergo craniotomy.

Application of COMPONT Medical Adhesive Glue for Tension-Reduced Duraplasty in Decompressive Craniotomy

PubMed Central

Zhou, Yujia; Wang, Gesheng; Liu, Jialin; Du, Yong; Wang, Lei; Wang, Xiaoyong

2016-01-01

Background The aim of this study was to evaluate the application of medical adhesive glue for tension-reduced duraplasty in decompressive craniotomy. Material/Methods A total of 56 cases were enrolled for this study from Jan 2013 to May 2015. All patients underwent decompressive craniotomy and the dura was repaired in all of them with tension-reduced duraplasty using the COMPONT medical adhesive to glue artificial dura together. The postoperative complications and the healing of dura mater were observed and recorded. Results No wound infection, epidural or subdural hematoma, cerebrospinal fluid leakage, or other complications associated with the procedure occurred, and there were no allergic reactions to the COMPONT medical adhesive glue. The second-phase surgery of cranioplasty was performed at 3 to 6 months after the decompressive craniotomy in 32 out of the 56 cases. During the cranioplasty we observed no adherence of the artificial dura mater patch to the skin flap, no residual COMPONT glue, or hydropic or contracture change of tissue at the surgical sites. Additionally, no defect or weakening of the adherence between the artificial dura mater patch and the self dura matter occurred. Conclusions COMPONT medical adhesive glue is a safe and reliable tool for tension-reduced duraplasty in decompressive craniotomy. PMID:27752035

Intraoperative seizures during craniotomy under general anesthesia.

PubMed

Howe, John; Lu, Xiaoying; Thompson, Zoe; Peterson, Gordon W; Losey, Travis E

2016-05-01

An acute symptomatic seizure is a clinical seizure occurring at the time of or in close temporal association with a brain insult. We report an acute symptomatic seizure occurring during a surgical procedure in a patient who did not have a prior history of epilepsy and who did not have a lesion associated with an increased risk of epilepsy. To characterize the incidence and clinical features of intraoperative seizures during craniotomy under general anesthesia, we reviewed cases where continuous EEG was acquired during craniotomy. Records of 400 consecutive cases with propofol as general anesthesia during craniotomy were reviewed. Demographic data, indication for surgery, clinical history, history of prior seizures, duration of surgery and duration of burst suppression were recorded. Cases where seizures were observed were analyzed in detail. Two out of 400 patients experienced intraoperative seizures, including one patient who appeared to have an acute symptomatic seizure related to the surgical procedure itself and a second patient who experienced two seizures likely related to an underlying diagnosis of epilepsy. This is the first report of an acute symptomatic seizure secondary to a neurosurgical procedure. Overall, 0.5% of patients monitored experienced seizures, indicating that intraoperative seizures are rare, and EEG monitoring during craniotomies is of low yield in detecting seizures. Copyright © 2016. Published by Elsevier Ltd.

Feasibility of Piezoelectric Endoscopic Transsphenoidal Craniotomy: A Cadaveric Study

PubMed Central

Tomazic, Peter Valentin; Gellner, Verena; Koele, Wolfgang; Hammer, Georg Philipp; Braun, Eva Maria; Gerstenberger, Claus; Clarici, Georg; Holl, Etienne; Braun, Hannes; Stammberger, Heinz; Mokry, Michael

2014-01-01

Objective. Endoscopic transsphenoidal approach has become the gold standard for surgical treatment of treating pituitary adenomas or other lesions in that area. Opening of bony skull base has been performed with burrs, chisels, and hammers or standard instruments like punches and circular top knives. The creation of primary bone flaps—as in external craniotomies—is difficult.The piezoelectric osteotomes used in the present study allows creating a bone flap for endoscopic transnasal approaches in certain areas. The aim of this study was to prove the feasibility of piezoelectric endoscopic transnasal craniotomies. Study Design. Cadaveric study. Methods. On cadaveric specimens (N = 5), a piezoelectric system with specially designed hardware for endonasal application was applied and endoscopic transsphenoidal craniotomies at the sellar floor, tuberculum sellae, and planum sphenoidale were performed up to a size of 3–5 cm2. Results. Bone flaps could be created without fracturing with the piezoosteotome and could be reimplanted. Endoscopic handling was unproblematic and time required was not exceeding standard procedures. Conclusion. In a cadaveric model, the piezoelectric endoscopic transsphenoidal craniotomy (PETC) is technically feasible. This technique allows the surgeon to create a bone flap in endoscopic transnasal approaches similar to existing standard transcranial craniotomies. Future trials will focus on skull base reconstruction using this bone flap. PMID:24689037

The cost effectiveness of elective laparoscopic sigmoid resection for symptomatic diverticular disease: financial outcome of the randomized control Sigma trial.

PubMed

Klarenbeek, Bastiaan R; Coupé, Veerle M H; van der Peet, Donald L; Cuesta, Miguel A

2011-03-01

Direct healthcare costs of patients with symptomatic diverticular disease randomized for either laparoscopic or open elective sigmoid resection are compared. Cost-effectiveness analysis of the laparoscopic approach compared with open sigmoid resections is presented. An economic evaluation of the randomized control Sigma trial was conducted, comparing elective laparoscopic sigmoid resection (LSR) to open sigmoid resection (OSR) in patients with symptomatic diverticulitis. Prospective registration of detailed intervention units per patient resulted in actual resource use per individual patient. To avoid distributional assumptions, the nonparametric bootstrap was applied. For the cost-effectiveness analysis, differences in total cost between LSR and OSR were compared with the differences in VAS pain score, SF-36 values for general health, and complication rate. The difference in total healthcare costs between the group that received LSR (euro 9969) and the group that received OSR (euro 9366) was not statistically significant. The slight increase in total costs was determined mainly by the significantly higher operation costs of LSR (euro 6663 vs. euro 5306). Lower costs for hospitalization (euro 2983 vs. euro 3598), blood products (euro 87 vs. euro 240), paramedical services (euro 157 vs. euro 278), and emergency attendance (euro 72 vs. euro 115) in the LSR group partially compensated these increased operation costs. The incremental cost-effectiveness ratios (ICER) indicate that improvements in pain, quality of life, and complication rate could be achieved at limited costs. Total healthcare costs of laparoscopic and open elective sigmoid resections for symptomatic diverticular disease are similar. As the clinical outcomes are in favor of the LSR group, candidates for an elective sigmoid resection should preferably be approached laparoscopically.

Intraoperative language localization in multilingual patients with gliomas.

PubMed

Bello, Lorenzo; Acerbi, Francesco; Giussani, Carlo; Baratta, Pietro; Taccone, Paolo; Songa, Valeria; Fava, Marica; Stocchetti, Nino; Papagno, Costanza; Gaini, Sergio M

2006-07-01

Intraoperative localization of speech is problematic in patients who are fluent in different languages. Previous studies have generated various results depending on the series of patients studied, the type of language, and the sensitivity of the tasks applied. It is not clear whether languages are mediated by multiple and separate cortical areas or shared by common areas. Globally considered, previous studies recommended performing a multiple intraoperative mapping for all the languages in which the patient is fluent. The aim of this work was to study the feasibility of performing an intraoperative multiple language mapping in a group of multilingual patients with a glioma undergoing awake craniotomy for tumor removal and to describe the intraoperative cortical and subcortical findings in the area of craniotomy, with the final goal to maximally preserve patients' functional language. Seven late, highly proficient multilingual patients with a left frontal glioma were submitted preoperatively to a battery of tests to evaluate oral language production, comprehension, and repetition. Each language was tested serially starting from the first acquired language. Items that were correctly named during these tests were used to build personalized blocks to be used intraoperatively. Language mapping was undertaken during awake craniotomies by the use of an Ojemann cortical stimulator during counting and oral naming tasks. Subcortical stimulation by using the same current threshold was applied during tumor resection, in a back and forth fashion, and the same tests. Cortical sites essential for oral naming were found in 87.5% of patients, those for the first acquired language in one to four sites, those for the other languages in one to three sites. Sites for each language were distinct and separate. Number and location of sites were not predictable, being randomly and widely distributed in the cortex around or less frequently over the tumor area. Subcortical stimulations found tracts for the first acquired language in four patients and for the other languages in three patients. Three of these patients decreased their fluency immediately after surgery, affecting the first acquired language, which fully recovered in two patients and partially in one. The procedure was agile and well tolerated by the patients. These findings show that multiple cortical and subcortical language mapping during awake craniotomy for tumor removal is a feasible procedure. They support the concept that intraoperative mapping should be performed for all the languages in which the patient is fluent in to preserve functional integrity.

The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review.

PubMed

de Almeida, Cesar Cimonari; Boone, M Dustin; Laviv, Yosef; Kasper, Burkhard S; Chen, Clark C; Kasper, Ekkehard M

2018-02-01

Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.

Mini-Craniotomy Under Local Anesthesia for Chronic Subdural Hematoma: An Effective Choice for Elderly Patients and for Patients in a Resource-Strained Environment.

PubMed

Mahmood, Shaikh Danish; Waqas, Muhammad; Baig, Mirza Zain; Darbar, Aneela

2017-10-01

Mini-craniotomy for chronic subdural hematoma (CSDH) is associated with lower rates of recurrence. However, the procedure is performed mostly with the patient under general anesthesia (GA) and therefore frequently requires an intensive care unit (ICU) facility, especially in the elderly population. Because of the unavailability of ICU beds, and to avoid GA, we started to perform this procedure with the patient under local anesthesia (LA). This was a retrospective medical chart review conducted in the section of Neurosurgery at the Aga Khan Hospital in Karachi, Pakistan. The study duration was 1 year. We included patients aged 55 years or older undergoing surgery for CSDH. Clinical characteristics, hospital stay, and recurrence rates were compared between 2 groups, local versus general anesthesia. Thirty-five patients underwent mini-craniotomy for CSDH in the study period. Sixteen patients underwent mini-craniotomy under LA versus 19 patients for GA. Median age for the LA group was 67 years compared with 70 years in the GA group. Four patients from the LA group experienced postoperative complications versus 7 from the GA group. Only one patient in the LA group required an ICU bed in the postoperative period. There was no recurrence in LA group. The overall recurrence was 2.86%. Mini-craniotomy for CSDH under LA is an equally effective procedure compared with mini-craniotomy under GA. In addition, it minimizes the risks of GA in the elderly population and obviates the need of a postoperative ICU bed. It also reduces operative time and hospital stay as compared with GA. Copyright © 2017 Elsevier Inc. All rights reserved.

Outcome of elderly patients undergoing awake-craniotomy for tumor resection.

PubMed

Grossman, Rachel; Nossek, Erez; Sitt, Razi; Hayat, Daniel; Shahar, Tal; Barzilai, Ori; Gonen, Tal; Korn, Akiva; Sela, Gal; Ram, Zvi

2013-05-01

Awake-craniotomy allows maximal tumor resection, which has been associated with extended survival. The feasibility and safety of awake-craniotomy and the effect of extent of resection on survival in the elderly population has not been established. The aim of this study was to compare surgical outcome of elderly patients undergoing awake-craniotomy to that of younger patients. Outcomes of consecutive patients younger and older than 65 years who underwent awake-craniotomy at a single institution between 2003 and 2010 were retrospectively reviewed. The groups were compared for clinical variables and surgical outcome parameters, as well as overall survival. A total of 334 young (45.4 ± 13.2 years, mean ± SD) and 90 elderly (71.7 ± 5.1 years) patients were studied. Distribution of gender, mannitol treatment, hemodynamic stability, and extent of tumor resection were similar. Significantly more younger patients had a better preoperative Karnofsky Performance Scale score (>70) than elderly patients (P = 0.0012). Older patients harbored significantly more high-grade gliomas (HGG) and brain metastases, and fewer low-grade gliomas (P < 0.0001). No significantly higher rate of mortality, or complications were observed in the elderly group. Age was associated with increased length of stay (4.9 ± 6.3 vs. 6.6 ± 7.5 days, P = 0.01). Maximal extent of tumor resection in patients with HGG was associated with prolonged survival in the elderly patients. Awake-craniotomy is a well-tolerated and safe procedure, even in elderly patients. Gross total tumor resection in elderly patients with HGG was associated with prolonged survival. The data suggest that favorable prognostic factors for patients with malignant brain tumors are also valid in elderly patients.

Classifying multiple types of hand motions using electrocorticography during intraoperative awake craniotomy and seizure monitoring processes—case studies

PubMed Central

Xie, Tao; Zhang, Dingguo; Wu, Zehan; Chen, Liang; Zhu, Xiangyang

2015-01-01

In this work, some case studies were conducted to classify several kinds of hand motions from electrocorticography (ECoG) signals during intraoperative awake craniotomy & extraoperative seizure monitoring processes. Four subjects (P1, P2 with intractable epilepsy during seizure monitoring and P3, P4 with brain tumor during awake craniotomy) participated in the experiments. Subjects performed three types of hand motions (Grasp, Thumb-finger motion and Index-finger motion) contralateral to the motor cortex covered with ECoG electrodes. Two methods were used for signal processing. Method I: autoregressive (AR) model with burg method was applied to extract features, and additional waveform length (WL) feature has been considered, finally the linear discriminative analysis (LDA) was used as the classifier. Method II: stationary subspace analysis (SSA) was applied for data preprocessing, and the common spatial pattern (CSP) was used for feature extraction before LDA decoding process. Applying method I, the three-class accuracy of P1~P4 were 90.17, 96.00, 91.77, and 92.95% respectively. For method II, the three-class accuracy of P1~P4 were 72.00, 93.17, 95.22, and 90.36% respectively. This study verified the possibility of decoding multiple hand motion types during an awake craniotomy, which is the first step toward dexterous neuroprosthetic control during surgical implantation, in order to verify the optimal placement of electrodes. The accuracy during awake craniotomy was comparable to results during seizure monitoring. This study also indicated that ECoG was a promising approach for precise identification of eloquent cortex during awake craniotomy, and might form a promising BCI system that could benefit both patients and neurosurgeons. PMID:26483627

Pediatric awake craniotomy and intra-operative stimulation mapping.

PubMed

Balogun, James A; Khan, Osaama H; Taylor, Michael; Dirks, Peter; Der, Tara; Carter Snead Iii, O; Weiss, Shelly; Ochi, Ayako; Drake, James; Rutka, James T

2014-11-01

The indications for operating on lesions in or near areas of cortical eloquence balance the benefit of resection with the risk of permanent neurological deficit. In adults, awake craniotomy has become a versatile tool in tumor, epilepsy and functional neurosurgery, permitting intra-operative stimulation mapping particularly for language, sensory and motor cortical pathways. This allows for maximal tumor resection with considerable reduction in the risk of post-operative speech and motor deficits. We report our experience of awake craniotomy and cortical stimulation for epilepsy and supratentorial tumors located in and around eloquent areas in a pediatric population (n=10, five females). The presenting symptom was mainly seizures and all children had normal neurological examinations. Neuroimaging showed lesions in the left opercular (n=4) and precentral or peri-sylvian regions (n=6). Three right-sided and seven left-sided awake craniotomies were performed. Two patients had a history of prior craniotomy. All patients had intra-operative mapping for either speech or motor or both using cortical stimulation. The surgical goal for tumor patients was gross total resection, while for all epilepsy procedures, focal cortical resections were completed without any difficulty. None of the patients had permanent post-operative neurologic deficits. The patient with an epileptic focus over the speech area in the left frontal lobe had a mild word finding difficulty post-operatively but this improved progressively. Follow-up ranged from 6 to 27 months. Pediatric awake craniotomy with intra-operative mapping is a precise, safe and reliable method allowing for resection of lesions in eloquent areas. Further validations on larger number of patients will be needed to verify the utility of this technique in the pediatric population. Copyright © 2014 Elsevier Ltd. All rights reserved.

Supraorbital Versus Endoscopic Endonasal Approaches for Olfactory Groove Meningiomas: A Cost-Minimization Study.

PubMed

Gandhoke, Gurpreet S; Pease, Matthew; Smith, Kenneth J; Sekula, Raymond F

2017-09-01

To perform a cost-minimization study comparing the supraorbital and endoscopic endonasal (EEA) approach with or without craniotomy for the resection of olfactory groove meningiomas (OGMs). We built a decision tree using probabilities of gross total resection (GTR) and cerebrospinal fluid (CSF) leak rates with the supraorbital approach versus EEA with and without additional craniotomy. The cost (not charge or reimbursement) at each "stem" of this decision tree for both surgical options was obtained from our hospital's finance department. After a base case calculation, we applied plausible ranges to all parameters and carried out multiple 1-way sensitivity analyses. Probabilistic sensitivity analyses confirmed our results. The probabilities of GTR (0.8) and CSF leak (0.2) for the supraorbital craniotomy were obtained from our series of 5 patients who underwent a supraorbital approach for the resection of an OGM. The mean tumor volume was 54.6 cm 3 (range, 17-94.2 cm 3 ). Literature-reported rates of GTR (0.6) and CSF leak (0.3) with EEA were applied to our economic analysis. Supraorbital craniotomy was the preferred strategy, with an expected value of $29,423, compared with an EEA cost of $83,838. On multiple 1-way sensitivity analyses, supraorbital craniotomy remained the preferred strategy, with a minimum cost savings of $46,000 and a maximum savings of $64,000. Probabilistic sensitivity analysis found the lowest cost difference between the 2 surgical options to be $37,431. Compared with EEA, supraorbital craniotomy provides substantial cost savings in the treatment of OGMs. Given the potential differences in effectiveness between approaches, a cost-effectiveness analysis should be undertaken. Copyright © 2017 Elsevier Inc. All rights reserved.

[The treatment principles of frontal sinus tract after the frontal approach craniotomy].

PubMed

Yu, Huanxin; Li, Haiyan; Liu, Gang

2015-12-01

To investigate the causes, clinical manifestation and treatment principles of frontal sinus tract after the frontal approach craniotomy. The clinic data of 13 patients with frontal skin sinus tract after the frontal approach craniotomy were retrospectively analyzed. All of them were described in the clinical record to have undergone frontal sinus mucosa pushing down or shaving and bone wax filling in the frontal sinus during the surgery, of whom 3 cases had history of frontal abscess incision drainage. All patients were performed endoscopic frontal sinus surgery and forehead skin sinus tract excision and suture. All of the patients successfully recovered after one-stage operation, and the frontal skin sinus tract was healed. The frontal approach craniotomy with postoperative frontal sinus tract was related with the improper use of bone wax tamponade and sealing of frontal sinus. The treatment principles were to remove bone wax, remove inflammatory granulation tissue around the sinus tract, and to open frontal sinus and promote frontal sinus drainage.

Ethical challenges with awake craniotomy for tumor.

PubMed

Kirsch, Brandon; Bernstein, Mark

2012-01-01

Awake brain surgery is useful for the treatment of a number of conditions such as epilepsy and brain tumor, as well as in functional neurosurgery. Several studies have been published regarding clinical results and outcomes of patients who have undergone awake craniotomy but few have dealt with related ethical issues. The authors undertake to explore broadly the ethical issues surrounding awake brain surgery for tumor resection to encourage further consideration and discussion. Based on a review of the literature related to awake craniotomy and in part from the personal experience of the senior author, we conducted an assessment of the ethical issues associated with awake brain tumor surgery. The major ethical issues identified relate to: (1) lack of data; (2) utilization; (3) conflict of interest; (4) informed consent; (5) surgical innovation; and (6) surgical training. The authors respectfully suggest that the selection of patients for awake craniotomy needs to be monitored according to more consistent, objective standards in order to avoid conflicts of interest and potential harm to patients.

Anaesthetic management for awake craniotomy in brain glioma resection: initial experience in Military Hospital Mohamed V of Rabat.

PubMed

Meziane, Mohammed; Elkoundi, Abdelghafour; Ahtil, Redouane; Guazaz, Miloudi; Mustapha, Bensghir; Haimeur, Charki

2017-01-01

The awake brain surgery is an innovative approach in the treatment of tumors in the functional areas of the brain. There are various anesthetic techniques for awake craniotomy (AC), including asleep-awake-asleep technique, monitored anesthesia care, and the recent introduced awake-awake-awake method. We describe our first experience with anesthetic management for awake craniotomy, which was a combination of these techniques with scalp nerve block, and propofol/rémifentanil target controlled infusion. A 28-year-oldmale underwent an awake craniotomy for brain glioma resection. The scalp nerve block was performed and a low sedative state was maintained until removal of bone flap. During brain glioma resection, the patient awake state was maintained without any complications. Once, the tumorectomy was completed, the level of anesthesia was deepened and a laryngeal mask airway was inserted. A well psychological preparation, a reasonable choice of anesthetic techniques and agents, and continuous team communication were some of the key challenges for successful outcome in our patient.

[Difficult Ventilation Requiring Emergency Endotracheal Intubation during Awake Craniotomy Managed by Laryngeal Mask Airway].

PubMed

Matsuda, Asako; Mizota, Toshiyuki; Tanaka, Tomoharu; Segawa, Hajime; Fukuda, Kazuhiko

2016-04-01

We report a case of difficult ventilation requiring emergency endotracheal intubation during awake craniotomy managed by laryngeal mask airway (LMA). A 45-year-old woman was scheduled to receive awake craniotomy for brain tumor in the frontal lobe. After anesthetic induction, airway was secured using ProSeal LMA and patient was mechanically ventilated in pressure-control mode. Patient's head was fixed with head-pins at anteflex position, and the operation started. About one hour after the start of the operation, tidal volume suddenly decreased. We immediately started manual ventilation, but the airway resistance was extremely high and we could not adequately ventilate the patient. We administered muscle relaxant for suspected laryngospasm, but ventilatory status did not improve; so we decided to conduct emergency endotracheal intubation. We tried to intubate using Airwayscope or LMA-Fastrach, but they were not effective in our case. Finally trachea was intubated using transnasal fiberoptic bronchoscopy. We discuss airway management during awake craniotomy, focusing on emergency endotracheal intubation during surgery.

Use of Subdural Evacuating Port System Following Open Craniotomy with Excision of Native Dura and Membranes for Management of Chronic Subdural Hematoma

PubMed Central

Bach, Ashley; McDermott, Michael W.

2017-01-01

An 86-year-old woman was admitted to the intensive care unit with a chronic subdural hematoma (CSDH) and rapid onset of worsening neurological symptoms. She was taken to the operating room for a mini-craniotomy for evacuation of the CSDH including excision of the dura and CSDH membrane. Postoperatively, a subdural evacuation port system (SEPS) was integrated into the craniotomy site and left in place rather than a traditional subdural catheter drain to evacuate the subdural space postoperatively. The patient had a good recovery and improvement of symptoms after evacuation and remained clinically well after the SEPS was removed. We offer the technique of dura and CSDH membrane excision plus SEPS drain as an effective postoperative alternative to the standard craniotomy leaving the native dura intact with traditional subdural drain that overlies the cortical surface of the brain in treating patients with CSDH. PMID:28560123

Comparative analysis of monotherapy versus duotherapy antiseizure drug management for postoperative seizure control in patients undergoing an awake craniotomy.

PubMed

Eseonu, Chikezie I; Eguia, Francisco; Garcia, Oscar; Kaplan, Peter W; Quiñones-Hinojosa, Alfredo

2018-06-01

OBJECTIVE Postoperative seizures are a common complication in patients undergoing an awake craniotomy, given the cortical manipulation during tumor resection and the electrical cortical stimulation for brain mapping. However, little evidence exists about the efficacy of postoperative seizure prophylaxis. This study aims to determine the most appropriate antiseizure drug (ASD) management regimen following an awake craniotomy. METHODS The authors performed a retrospective analysis of data pertaining to patients who underwent an awake craniotomy for brain tumor from 2007 to 2015 performed by a single surgeon. Patients were divided into 2 groups, those who received a single ASD (the monotherapy group) and those who received 2 types of ASDs (the duotherapy group). Patient demographics, symptoms, tumor characteristics, hospitalization details, and seizure outcome were evaluated. Multivariable logistic regression was used to evaluate numerous clinical variables associated with postoperative seizures. RESULTS A total of 81 patients underwent an awake craniotomy for tumor resection of an eloquent brain lesion. Preoperative baseline characteristics were comparable between the 2 groups. The postoperative seizure rate was 21.7% in the monotherapy group and 5.7% in the duotherapy group (p = 0.044). Seizure outcome at 6 months' follow-up was assessed with the Engel classification scale. The duotherapy group had a significantly higher proportion of seizure-free (Engel Class I) patients than the monotherapy group (90% vs 60%, p = 0.027). The length of stay was similar, 4.02 days in the monotherapy group and 4.51 days in the duotherapy group (p = 0.193). The 90-day readmission rate was higher for the monotherapy group (26.1% vs 8.5% in the duotherapy group, p = 0.044). Multivariate logistic regression showed that preoperative seizure history was a significant predictor for postoperative seizures following an awake craniotomy (OR 2.08, 95% CI 0.56-0.90, p < 0.001). CONCLUSIONS Patients with a preoperative seizure history may be at a higher risk for postoperative seizures following an awake craniotomy and may benefit from better postoperative seizure control with postoperative ASD duotherapy.

Health care issues in Croatian elections 2005-2009: series of public opinion surveys

PubMed Central

Radin, Dagmar; Džakula, Aleksandar; Benković, Vanesa

2011-01-01

Aim To compare the results of a series of public opinion surveys on experiences with the health care sector in Croatia conducted in the time of elections and to analyze whether political party affiliation had any influence on issues of priority ranking. Methods The surveys were conducted during 2005, 2007, and 2009. They were administered through a Computer Assisted Telephone Interviewing method to representative samples of Croatian population and were statistically weighted according to sex, age, level of education, and political party affiliation. The random sampling of the person within the household was done using the table of random numbers. Results Health and health care system was the most important issue (58%) during the 2007 parliamentary election and the second most important issue during the 2005 and 2009 elections (46% and 28%). In the 2007 election, health care was viewed as most important by women, respondents with lower education levels, and respondents with lower income. In 2005, the most important health care issues were corruption and lack of funding (45% and 43%, respectively), in 2007 poor organization and lack of funding (43% and 42%, respectively), and in 2009 lack of funding and corruption (51% and 45%, respectively). Conclusion Health and health care system were consistently among the top two issues in all elections from 2005 to 2009. The top three most important health care sector issues were corruption, poor organization, and lack of funding. This indicates that political parties should include solutions to these issues in their health care policymaking. PMID:21990075

A removable silicone elastomer seal reduces granulation tissue growth and maintains the sterility of recording chambers for primate neurophysiology

PubMed Central

Spitler, Kevin M.; Gothard, Katalin M.

2008-01-01

The maintenance of the sterility of craniotomies for serial acute neurophysiological recordings is exacting and time consuming yet is vital to the health of valuable experimental animals. We have developed a method to seal the craniotomy with surgical grade silicone elastomer (Silastic®) in a hermetically sealed chamber. Under these conditions the tissues in the craniotomy and the inside surface of the chamber remain unpopulated by bacteria. The silicone elastomer sealant retarded the growth of granulation tissue on the dura and reduced the procedures required to maintain ideal conditions for neurophysiological recordings. PMID:18241928

Unnecessary gastric decompression in distal elective bowel anastomoses in children: a randomized study.

PubMed

Davila-Perez, Roberto; Bracho-Blanchet, Eduardo; Tovilla-Mercado, Jose Manuel; Hernandez-Plata, Jose Alejandro; Reyes-Lopez, Alfonso; Nieto-Zermeño, Jaime

2010-05-01

The goal of this study was to investigate the role of nasogastric drainage in preventing postoperative complications in children with distal elective bowel anastomosis. Nasogastric drainage has been used as a routine measure after gastrointestinal surgery in children and adults to hasten bowel function, prevent postoperative complications, and shorten hospital stay. However, there has been no study that shows in a scientific manner the benefit of nasogastric drainage in children. We performed a clinical, controlled, randomized trial comprising 60 children who underwent distal elective bowel anastomoses and compared postoperative complications between a group with nasogastric tube in place (n = 29) and one without it (n = 31). Demographic data and diagnoses were comparable in both groups (P = NS). No anastomotic leaks or enterocutaneous fistulae were found in any patient. There were no significant differences between the two groups with respect to abdominal distension, infection, or hospital stay. Only one patient in the experimental group required placement of the nasogastric tube due to persistent abdominal distension (3.2%). The routine use of nasogastric drainage after distal elective intestinal surgery in children can be eliminated. Its use should depend on the individual patient's situation.

Patients' perceptions of awake and outpatient craniotomy for brain tumor: a qualitative study.

PubMed

Khu, Kathleen Joy; Doglietto, Francesco; Radovanovic, Ivan; Taleb, Faisal; Mendelsohn, Daniel; Zadeh, Gelareh; Bernstein, Mark

2010-05-01

Routine and nonselective use of awake and outpatient craniotomy for supratentorial tumors has been shown to be safe and effective from a medical standpoint. In this study the authors aim was to explore patients' perceptions about awake and outpatient craniotomy. Qualitative research methodology was used. Two semistructured, open-ended interviews were conducted with 27 participants, who were ambulatory adult patients who underwent craniotomy for brain tumor excision between October 2008 and April 2009. The participants were each assigned to one of the following categories: 1) awake outpatient; 2) awake inpatient; 3) outpatient under general anesthesia; and 4) inpatient under general anesthesia. Interviews were audiotaped and transcribed, and the data were subjected to thematic analysis. The following 6 overarching themes emerged from the data: 1) patients had a positive experience with awake craniotomy; 2) patient satisfaction with outpatient surgery was high; 3) patients understood the rationale behind awake surgery; 4) patients were surprised that brain surgery can be done on an outpatient basis; 5) trust in one's surgeon was important; and 6) patients were more concerned about the disease than the procedure. The results reflected positively on the patients' awake and outpatient surgery experience, but there were some areas that require improvement, specifically perioperative pain control and postoperative care. These insights on patients' perspectives can lead to better delivery of care, and ultimately, improved health outcomes.

Evaluation of Language Function under Awake Craniotomy

PubMed Central

KANNO, Aya; MIKUNI, Nobuhiro

2015-01-01

Awake craniotomy is the only established way to assess patients’ language functions intraoperatively and to contribute to their preservation, if necessary. Recent guidelines have enabled the approach to be used widely, effectively, and safely. Non-invasive brain functional imaging techniques, including functional magnetic resonance imaging and diffusion tensor imaging, have been used preoperatively to identify brain functional regions corresponding to language, and their accuracy has increased year by year. In addition, the use of neuronavigation that incorporates this preoperative information has made it possible to identify the positional relationships between the lesion and functional regions involved in language, conduct functional brain mapping in the awake state with electrical stimulation, and intraoperatively assess nerve function in real time when resecting the lesion. This article outlines the history of awake craniotomy, the current state of pre- and intraoperative evaluation of language function, and the clinical usefulness of such functional evaluation. When evaluating patients’ language functions during awake craniotomy, given the various intraoperative stresses involved, it is necessary to carefully select the tasks to be undertaken, quickly perform all examinations, and promptly evaluate the results. As language functions involve both input and output, they are strongly affected by patients’ preoperative cognitive function, degree of intraoperative wakefulness and fatigue, the ability to produce verbal articulations and utterances, as well as perform synergic movement. Therefore, it is essential to appropriately assess the reproducibility of language function evaluation using awake craniotomy techniques. PMID:25925758

Impact of preoperative functional magnetic resonance imaging during awake craniotomy procedures for intraoperative guidance and complication avoidance.

PubMed

Trinh, Victoria T; Fahim, Daniel K; Maldaun, Marcos V C; Shah, Komal; McCutcheon, Ian E; Rao, Ganesh; Lang, Frederick; Weinberg, Jeffrey; Sawaya, Raymond; Suki, Dima; Prabhu, Sujit S

2014-01-01

We wanted to study the role of functional MRI (fMRI) in preventing neurological injury in awake craniotomy patients as this has not been previously studied. To examine the role of fMRI as an intraoperative adjunct during awake craniotomy procedures. Preoperative fMRI was carried out routinely in 214 patients undergoing awake craniotomy with direct cortical stimulation (DCS). In 40% of our cases (n = 85) fMRI was utilized for the intraoperative localization of the eloquent cortex. In the other 129 cases significant noise distortion, poor task performance and nonspecific BOLD activation precluded the surgeon from using the fMRI data. Compared with DCS, fMRI had a sensitivity and specificity, respectively, of 91 and 64% in Broca's area, 93 and 18% in Wernicke's area and 100 and 100% in motor areas. A new intraoperative neurological deficit during subcortical dissection was predictive of a worsened deficit following surgery (p < 0.001). The use of fMRI for intraoperative localization was, however, not significant in preventing worsened neurological deficits, both in the immediate postoperative period (p = 1.00) and at the 3-month follow-up (p = 0.42). The routine use of fMRI was not useful in identifying language sites as performed and, more importantly, practiced tasks failed to prevent neurological deficits following awake craniotomy procedures. © 2014 S. Karger AG, Basel.

Evaluation of Language Function under Awake Craniotomy.

PubMed

Kanno, Aya; Mikuni, Nobuhiro

2015-01-01

Awake craniotomy is the only established way to assess patients' language functions intraoperatively and to contribute to their preservation, if necessary. Recent guidelines have enabled the approach to be used widely, effectively, and safely. Non-invasive brain functional imaging techniques, including functional magnetic resonance imaging and diffusion tensor imaging, have been used preoperatively to identify brain functional regions corresponding to language, and their accuracy has increased year by year. In addition, the use of neuronavigation that incorporates this preoperative information has made it possible to identify the positional relationships between the lesion and functional regions involved in language, conduct functional brain mapping in the awake state with electrical stimulation, and intraoperatively assess nerve function in real time when resecting the lesion. This article outlines the history of awake craniotomy, the current state of pre- and intraoperative evaluation of language function, and the clinical usefulness of such functional evaluation. When evaluating patients' language functions during awake craniotomy, given the various intraoperative stresses involved, it is necessary to carefully select the tasks to be undertaken, quickly perform all examinations, and promptly evaluate the results. As language functions involve both input and output, they are strongly affected by patients' preoperative cognitive function, degree of intraoperative wakefulness and fatigue, the ability to produce verbal articulations and utterances, as well as perform synergic movement. Therefore, it is essential to appropriately assess the reproducibility of language function evaluation using awake craniotomy techniques.

[Comparison of extent of postoperative hydrocephalus in patients between intervertional therapy with embolism and craniotomy occlusion in Hunt-Hess III-IV level aneurysm induced subarachnoid hemorrhage and their prognosis].

PubMed

Liu, Yang; Sun, Shengkai; Chen, Xuyi; Cheng, Shixiang; Qin, Zhizhen; Liu, Xiu; Chen, Xiaochu; Ning, Lili; Wang, Zhihong

2015-02-01

To analyze and compare the difference and prognosis between vascular embolization and craniotomy occlusion in patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) with Hunt-Hess level III-IV, and acute postoperative hydrocephalus. A retrospective study was conducted on 767 patients who had undergone vascular embolization (vascular embolization group, n = 403) or craniotomy occlusion operation (craniotomy occlusion operation group, n = 364), and the patients with postoperative acute hydrocephalus were screened. The clinical data of patients of both groups was analyzed. By judging short-term prognosis in patients with hydrocephalus with Glasgow outcome scale (GOS) score estimated at discharge, the advantages and disadvantages of two surgical procedures were compared. The number of cases with postoperative hydrocephalus in vascular embolization group was 56 (13.90%), while that in craniotomy occlusion group was 33 (9.07%). The difference between the two groups of incidence of hydrocephalus was statistically significant (χ (2) = 4.350, P = 0.037). In 767 patients with aSAH, the incidence of hydrocephalus among the patients after the hematoma removal operation was significantly lower than that of patients without hematoma removal [3.07% (11/358) vs. 19.07% (78/409), χ (2) = 47.635, P = 0.000]. The incidence of hydrocephalus among the patients after ventricular drainage was significantly lower than that of patients without the drainage [2.77% (19/685) vs. 85.37% (70/82), χ (2) = 487.032, P = 0.000]. In 403 cases of vascular embolization group, the incidence of hydrocephalus in the patients after the hematoma removal operation was lower than that of patients without it [8.06% (5/62) vs. 14.96% (51/341), χ (2) = 2.082, P = 0.168]. The incidence of hydrocephalus in the patients after the ventricular drainage was lower than that of patients without drainage [2.59% (9/347) vs. 83.93% (47/56), χ (2) = 266.599, P = 0.000]. In 364 cases of craniotomy occlusion operation group, the incidence of hydrocephalus in the patients after hematoma removal operation was significantly lower than that of patients did not receive [2.03% (6/296) vs. 39.71% (27/68), χ (2) = 95.226, P = 0.000]. The incidence of hydrocephalus among the patients after the ventricular drainage was significantly lower than that of patients without drainage [2.96% (10/338) vs. 88.46% (23/26), χ (2) = 203.852, P = 0.000]. The difference in incidence of hydrocephalus between the patients who had hematoma removal surgery between vascular embolization group and craniotomy occlusion operation group was statistically significant [8.06% (5/62) vs. 2.03% (6/296), χ (2) = 4.411, P = 0.027], while no statistically difference was present in ventricular drainage patients [2.59% (9/347) vs. 2.96% (10/338), χ (2) = 0.085, P = 0.819]. There were 23 patients (41.07%) with good outcome (GOS score 4-5), while 33 (58.93%) with poor outcome (GOS score 1-3) in 56 patients undergone vascular embolization operation. Good result (GOS score 4-5) was shown in 21 (63.64%) and 12 (36.36%) with poor outcome (GOS score 1-3) among 33 patients with hydrocephalus after craniotomy occlusion operation, and the difference was statistically significant (χ (2) = 4.230, P = 0.039). Hematoma is one of the main factor contributing to the differences in the incidence of postoperative hydrocephalus of Hunt-Hess grade III-IV patients either receiving vascular embolization or craniotomy occlusion operation. Lateral ventricle drainage may not be the factor that contributes to the difference in incidence of hydrocephalus formation between the vascular embolization and craniotomy occlusion operation groups in Hunt-Hess level III-IV patients. The short term prognosis in the craniotomy occlusion operation group is superior to that of endovascular intervention embolization group.

Severe bradycardia and hypotension after connecting negative pressure to the subgaleal drain during craniotomy closure.

PubMed

Karamchandani, K; Chouhan, R S; Bithal, P K; Dash, H H

2006-05-01

Negative pressure drainage systems are often used after craniotomy for evacuation of potential bleeding. There are several reports of haemodynamic disturbances with epidural negative pressure drainage, but such reports are very few for subgaleal drains placed over the bone flap. We report a case in which a patient developed severe cardiovascular disturbances after the vacuum drainage was connected to a subgaleal drain after craniotomy for aneurysm clipping. The patient had no significant cardiac history, had an uneventful intra-operative course and yet developed bradycardia and hypotension, which were reproducible and severe enough to require atropine administration. Anaesthetists must be aware of these effects, so that they can anticipate and treat such complications.

High-Flow Nasal Oxygen in Patient With Obstructive Sleep Apnea Undergoing Awake Craniotomy: A Case Report.

PubMed

Wong, Jaclyn W M; Kong, Amy H S; Lam, Sau Yee; Woo, Peter Y M

2017-12-15

Patients with obstructive sleep apnea are frequently considered unsuitable candidates for awake craniotomy due to anticipated problems with oxygenation, ventilation, and a potentially difficult airway. At present, only a handful of such accounts exist in the literature. Our report describes the novel use of high-flow nasal oxygen therapy for a patient with moderate obstructive sleep apnea who underwent an awake craniotomy under deep sedation. The intraoperative application of high-flow nasal oxygen therapy achieved satisfactory oxygenation, maintained the partial carbon dioxide pressure within a reasonable range even during periods of deep sedation, permitted responsive patient monitoring during mapping, and provided excellent patient and surgeon satisfaction.

Mild intraoperative hypothermia during surgery for intracranial aneurysm.

PubMed

Todd, Michael M; Hindman, Bradley J; Clarke, William R; Torner, James C

2005-01-13

Surgery for intracranial aneurysm often results in postoperative neurologic deficits. We conducted a randomized trial at 30 centers to determine whether intraoperative cooling during open craniotomy would improve the outcome among patients with acute aneurysmal subarachnoid hemorrhage. A total of 1001 patients with a preoperative World Federation of Neurological Surgeons score of I, II, or III ("good-grade patients"), who had had a subarachnoid hemorrhage no more than 14 days before planned surgical aneurysm clipping, were randomly assigned to intraoperative hypothermia (target temperature, 33 degrees C, with the use of surface cooling techniques) or normothermia (target temperature, 36.5 degrees C). Patients were followed closely postoperatively and examined approximately 90 days after surgery, at which time a Glasgow Outcome Score was assigned. There were no significant differences between the group assigned to intraoperative hypothermia and the group assigned to normothermia in the duration of stay in the intensive care unit, the total length of hospitalization, the rates of death at follow-up (6 percent in both groups), or the destination at discharge (home or another hospital, among surviving patients). At the final follow-up, 329 of 499 patients in the hypothermia group had a Glasgow Outcome Score of 1 (good outcome), as compared with 314 of 501 patients in the normothermia group (66 percent vs. 63 percent; odds ratio, 1.14; 95 percent confidence interval, 0.88 to 1.48; P=0.32). Postoperative bacteremia was more common in the hypothermia group than in the normothermia group (5 percent vs. 3 percent, P=0.05). Intraoperative hypothermia did not improve the neurologic outcome after craniotomy among good-grade patients with aneurysmal subarachnoid hemorrhage. Copyright 2005 Massachusetts Medical Society.

Opening the Internal Hematoma Membrane Does Not Alter the Recurrence Rate of Chronic Subdural Hematomas: A Prospective Randomized Trial.

PubMed

Unterhofer, Claudia; Freyschlag, Christian F; Thomé, Claudius; Ortler, Martin

2016-08-01

Factors determining the recurrence of chronic subdural hematomas (CSDHs) are not clear. Whether opening the so-called internal hematoma membrane is useful has not been investigated. To investigate whether splitting the inner hematoma membrane influences the recurrence rate in patients undergoing burr-hole craniotomy for CSDH. Fifty-two awake patients undergoing surgery for 57 CSDHs were prospectively randomized to either partial opening of the inner hematoma membrane (group A) or not (group B) after enlarged burr-hole craniotomy and hematoma evacuation. Drainage was left in situ for several days postoperatively. Groups were comparable with regard to demographic, clinical, and imaging variables. Outcome was assessed after 3-6 weeks for the combined outcome variable of reoperation or residual hematoma of one third or more of the original hematoma thickness. Fourteen patients underwent reoperation for clinical deterioration or residual hematoma during follow-up (n = 6 in group A, 21%; n = 8 in group B, 28 %) (P = 0.537). Residual hematoma of ≥ one third not requiring surgery was present in 7 patients in group A (25%) and 10 patients in group B (36%) (P = 0.383). The overall cumulative failure rate (reoperation or hematoma thickness ≥ one third) was 13/28 (46%) in group A and 18/28 in group B (P = 0.178; relative risk, 0.722 [95% confidence interval, 0.445-1.172]; absolute risk reduction -16% [95% confidence interval, -38% to 8%]). Opening the internal hematoma membrane does not alter the rate of patients requiring revision surgery and the number of patients showing a marked residual hematoma 6 weeks after evacuation of a CSDH. Copyright © 2016 Elsevier Inc. All rights reserved.

On the likelihood of single-peaked preferences.

PubMed

Lackner, Marie-Louise; Lackner, Martin

2017-01-01

This paper contains an extensive combinatorial analysis of the single-peaked domain restriction and investigates the likelihood that an election is single-peaked. We provide a very general upper bound result for domain restrictions that can be defined by certain forbidden configurations. This upper bound implies that many domain restrictions (including the single-peaked restriction) are very unlikely to appear in a random election chosen according to the Impartial Culture assumption. For single-peaked elections, this upper bound can be refined and complemented by a lower bound that is asymptotically tight. In addition, we provide exact results for elections with few voters or candidates. Moreover, we consider the Pólya urn model and the Mallows model and obtain lower bounds showing that single-peakedness is considerably more likely to appear for certain parameterizations.

Subdural Hematoma

DTIC Science & Technology

2006-07-01

characterization of more subtle associated CNS injuries. Treatment of nonacute subdural hematoma may involve craniotomy -guided hematoma evacuation...nature of this process. Note the ventricular shunt (arrow) in place for drainage of hydrocephalus, caused by significant mass effect on the...collections may require craniotomy . Because SDH may be under high intracranial pressure resultant from associated injuries, patients with the acute form

Burr-hole drainage for the treatment of acute epidural hematoma in coagulopathic patients: a report of eight cases.

PubMed

Habibi, Zohreh; Meybodi, Ali Tayebi; Haji Mirsadeghi, Seyed Mohammad; Miri, Seyed Mojtaba

2012-07-20

Craniotomy has been accepted as the treatment of choice for the management of acute epidural hematomas (AEDH). However, in practice, it seems possible to evacuate AEDH via a single burr hole instead of the traditional craniotomy in certain circumstances. Among 160 patients with AEDH meeting criteria for evacuation admitted to the emergency and accident division of our center between 2006 and 2009, we found 8 cases of hematoma appearing isodense to brain parenchyma on computed tomography (CT), who had concomitant coagulopathy. These patients were managed by burr-hole drainage for treatment of the liquefied AEDH. A closed drainage system was then kept in the epidural space for 3 days. In all 8 patients, AEDH was evacuated successfully via burr-hole placement over the site of hematoma. The level of consciousness and other symptoms improved within the first day, and no patient required an additional routine craniotomy. For patients with slowly-developing AEDH in the context of impaired coagulation, burr-hole evacuation and drainage might be a less invasive method of treatment compared to conventional craniotomy.

Awake craniotomy using electromagnetic navigation technology without rigid pin fixation.

PubMed

Morsy, Ahmed A; Ng, Wai Hoe

2015-11-01

We report our institutional experience using an electromagnetic navigation system, without rigid head fixation, for awake craniotomy patients. The StealthStation® S7 AxiEM™ navigation system (Medtronic, Inc.) was used for this technique. Detailed preoperative clinical and neuropsychological evaluations, patient education and contrast-enhanced MRI (thickness 1.5mm) were performed for each patient. The AxiEM Mobile Emitter was typically placed in a holder, which was mounted to the operating room table, and a non-invasive patient tracker was used as the patient reference device. A monitored conscious sedation technique was used in all awake craniotomy patients, and the AxiEM Navigation Pointer was used for navigation during the procedure. This offers the same accuracy as optical navigation, but without head pin fixation or interference with intraoperative neurophysiological techniques and surgical instruments. The application of the electromagnetic neuronavigation technology without rigid head fixation during an awake craniotomy is accurate, and offers superior patient comfort. It is recommended as an effective adjunctive technique for the conduct of awake surgery. Copyright © 2015 Elsevier Ltd. All rights reserved.

Anaesthetic management for awake craniotomy in brain glioma resection: initial experience in Military Hospital Mohamed V of Rabat

PubMed Central

Meziane, Mohammed; Elkoundi, Abdelghafour; Ahtil, Redouane; Guazaz, Miloudi; Mustapha, Bensghir; Haimeur, Charki

2017-01-01

The awake brain surgery is an innovative approach in the treatment of tumors in the functional areas of the brain. There are various anesthetic techniques for awake craniotomy (AC), including asleep-awake-asleep technique, monitored anesthesia care, and the recent introduced awake-awake-awake method. We describe our first experience with anesthetic management for awake craniotomy, which was a combination of these techniques with scalp nerve block, and propofol/rémifentanil target controlled infusion. A 28-year-oldmale underwent an awake craniotomy for brain glioma resection. The scalp nerve block was performed and a low sedative state was maintained until removal of bone flap. During brain glioma resection, the patient awake state was maintained without any complications. Once, the tumorectomy was completed, the level of anesthesia was deepened and a laryngeal mask airway was inserted. A well psychological preparation, a reasonable choice of anesthetic techniques and agents, and continuous team communication were some of the key challenges for successful outcome in our patient. PMID:28904684

Wechsler Adult Intelligence Scale-Revised Block Design broken configuration errors in nonpenetrating traumatic brain injury.

PubMed

Wilde, M C; Boake, C; Sherer, M

2000-01-01

Final broken configuration errors on the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981) Block Design subtest were examined in 50 moderate and severe nonpenetrating traumatically brain injured adults. Patients were divided into left (n = 15) and right hemisphere (n = 19) groups based on a history of unilateral craniotomy for treatment of an intracranial lesion and were compared to a group with diffuse or negative brain CT scan findings and no history of neurosurgery (n = 16). The percentage of final broken configuration errors was related to injury severity, Benton Visual Form Discrimination Test (VFD; Benton, Hamsher, Varney, & Spreen, 1983) total score and the number of VFD rotation and peripheral errors. The percentage of final broken configuration errors was higher in the patients with right craniotomies than in the left or no craniotomy groups, which did not differ. Broken configuration errors did not occur more frequently on designs without an embedded grid pattern. Right craniotomy patients did not show a greater percentage of broken configuration errors on nongrid designs as compared to grid designs.

MRimaging findings after ventricular puncture in patients with SAH.

PubMed

Tominaga, J; Shimoda, M; Oda, S; Kumasaka, A; Yamazaki, K; Tsugane, R

2001-11-01

Using magnetic resonance (MR) imaging, we studied brain injury from ventricular puncture performed during craniotomy in the acute stage of subarachnoid hemorrhage (SAH). 80 patients underwent craniotomy for aneurysm obliteration within 48 hr after SAH, ventricular puncture for drainage of cerebrospinal fluid (CSF) was performed to reduce intracranial pressure. MR imaging was performed within 3 days following surgery to measure the size of the lesion, and was repeated on postoperative days 14 and 30. Of the 80 patients with ventricular puncture preceding craniotomy, 65 (81%) showed MR evidence of brain injury from the puncture. Overall, 149 lesions were detected. According to coronal images, cortical injuries (54 cases), penetrating injury to tracts along the ventricular tube (55 cases), caudate injury (25 cases), and corpus callosum injury (15 cases). Brain injuries from ventricular puncture did not correlate significantly to patient outcome. While ventricular puncture and drainage of CSF can readily be performed to decrease brain volume at the time of craniotomy in acute-stage SAH, neurosurgeons should be aware of a surprisingly high incidence of brain injury complicating puncture.

Berengario's drill: origin and inspiration.

PubMed

Chorney, Michael A; Gandhi, Chirag D; Prestigiacomo, Charles J

2014-04-01

Craniotomies are among the oldest neurosurgical procedures, as evidenced by early human skulls discovered with holes in the calvaria. Though devices change, the principles to safely transgress the skull are identical. Modern neurosurgeons regularly use electric power drills in the operating theater; however, nonelectric trephining instruments remain trusted by professionals in certain emergent settings in the rare instance that an electric drill is unavailable. Until the late Middle Ages, innovation in craniotomy instrumentation remained stunted without much documented redesign. Jacopo Berengario da Carpi's (c. 1457-1530 CE) text Tractatus de Fractura Calvae sive Cranei depicts a drill previously unseen in a medical volume. Written in 1518 CE, the book was motivated by defeat over the course of Lorenzo II de'Medici's medical care. Berengario's interchangeable bit with a compound brace ("vertibulum"), known today as the Hudson brace, symbolizes a pivotal device in neurosurgery and medical tool design. This drill permitted surgeons to stock multiple bits, perform the craniotomy faster, and decrease equipment costs during a period of increased incidence of cranial fractures, and thus the need for craniotomies, which was attributable to the introduction of gunpowder. The inspiration stemmed from a school of thought growing within a population of physicians trained as mathematicians, engineers, and astrologers prior to entering the medical profession. Berengario may have been the first to record the use of such a unique drill, but whether he invented this instrument or merely adapted its use for the craniotomy remains clouded.

Awake craniotomy for microsurgical obliteration of mycotic aneurysms: technical report of three cases.

PubMed

Lüders, Jürgen C; Steinmetz, Michael P; Mayberg, Marc R

2005-01-01

Infectious (mycotic) aneurysms that do not resolve with medical treatment require surgical obliteration, usually requiring sacrifice of the parent artery. In addition, patients with mycotic aneurysms frequently need subsequent cardiac valve repair, which often necessitates anticoagulation. Three cases of awake craniotomy for microsurgical clipping of mycotic aneurysms are presented. Awake minimally invasive craniotomy using frameless stereotactic guidance on the basis of computed tomographic angiography enables temporary occlusion of the parent artery with neurological assessment before obliteration of the aneurysm. A 56-year-old woman presented with progressively worsening mitral valve disease and a history of subacute bacterial endocarditis and subarachnoid hemorrhage 30 years previously. A cerebral angiogram revealed a 4-mm left middle cerebral artery (MCA) angular branch aneurysm, which required obliteration before mitral valve replacement. The second patient, a 64-year-old woman with a history of rheumatic fever, had an 8-mm right distal MCA aneurysm diagnosed in the setting of pulmonary abscess and worsening cardiac function as a result of mitral valve disease. The third patient, a 57-year-old man with a history of fevers, night sweats, and progressive mitral valve disease, had an enlarging left MCA angular branch aneurysm despite the administration of antibiotics. Because of their location on distal MCA branches, none of the aneurysms were amenable to preoperative test balloon occlusion. After undergoing stereotactic computed tomographic angiography with fiducial markers, the patients underwent a minimally invasive awake craniotomy with frameless stereotactic navigation. In all cases, the results of the neurological examination were unchanged during temporary parent artery occlusion and the aneurysms were successfully obliterated. Awake minimally invasive craniotomy for an infectious aneurysm located in eloquent brain enables awake testing before permanent clipping or vessel sacrifice. Combining frameless stereotactic navigation with computed tomographic angiography allowed us to perform the operation quickly through a small craniotomy with minimal exploration.

Past history of skin infection and risk of surgical site infection after elective surgery.

PubMed

Faraday, Nauder; Rock, Peter; Lin, Elaina E; Perl, Trish M; Carroll, Karen; Stierer, Tracey; Robarts, Polly; McFillin, Angela; Ross, Tracy; Shah, Ashish S; Riley, Lee H; Tamargo, Rafael J; Black, James H; Blasco-Colmenares, Elena; Guallar, Eliseo

2013-01-01

To identify baseline patient characteristics associated with increased susceptibility to surgical site infection (SSI) after elective surgery. The Center for Medicare and Medicaid Services considers SSI to be preventable through adherence to current infection control practices; however, the etiology of wound infection is incompletely understood. Prospective cohort study involving patients undergoing cardiac, vascular, craniotomy, and spinal surgery at 2 academic medical centers in Baltimore, MD. A comprehensive medical history was obtained at baseline, and participants were followed for 6 months using active inpatient and outpatient surveillance for deep SSI and infectious death. Infection control best practices were monitored perioperatively. The relative risk of SSI/infectious death was determined comparing those with versus those without a past medical history of skin infection using Cox proportional hazards models. Of 613 patients (mean [SD] = 62.3 [11.5] years; 42.1% women), 22.0% reported a history of skin infection. The cumulative incidence of deep SSI/infectious death was 6.7% versus 3.1% for those with and without a history of skin infection, respectively (unadjusted hazard ratio (HR) = 2.25; 95% confidence interval (95% CI), 0.98-5.14; P = 0.055). Risk estimates increased after adjustments for demographic and socioeconomic variables (HR = 2.82; 95% CI, 1.18-6.74; P = 0.019) and after propensity score adjustment for all potential confounders (HR = 3.41; 95% CI, 1.36-8.59; P = 0.009). Adjustments for intraoperative infection risk factors and adherence to infection control best practice metrics had no impact on risk estimates. A history of skin infection identified a state of enhanced susceptibility to SSI at baseline that is independent of traditional SSI risk factors and adherence to current infection control practices.

Involved-Field Radiotherapy versus Elective Nodal Irradiation in Combination with Concurrent Chemotherapy for Locally Advanced Non-Small Cell Lung Cancer: A Prospective Randomized Study

PubMed Central

Chen, Ming; Bao, Yong; Ma, Hong-Lian; Wang, Jin; Wang, Yan; Peng, Fang; Zhou, Qi-Chao; Xie, Cong-Hua

2013-01-01

This prospective randomized study is to evaluate the locoregional failure and its impact on survival by comparing involved field radiotherapy (IFRT) with elective nodal irradiation (ENI) in combination with concurrent chemotherapy for locally advanced non-small cell lung cancer. It appears that higher dose could be delivered in IFRT arm than that in ENI arm, and IFRT did not increase the risk of initially uninvolved or isolated nodal failures. Both a tendency of improved locoregional progression-free survival and a significant increased overall survival rate are in favor of IFRT arm in this study. PMID:23762840

Epidural abscess treated with a medial supraorbital craniotomy through an incision in the eyebrow. Case report.

PubMed

Rosen, David S; Shafizadeh, Stephen; Baroody, Fuad M; Yamini, Bakhtiar

2008-02-01

The authors describe a medial supraorbital craniotomy performed through a medial eyebrow skin incision to approach an epidural abscess located in the medial anterior fossa of the skull. An 8-year-old boy presented with fevers and facial swelling. Imaging demonstrated pansinusitis and an epidural fluid collection adjacent to the frontal sinus. A medial supraorbital craniotomy was performed to access and drain the epidural abscess. The supraorbital nerve laterally and the supratrochlear nerve medially were preserved by incising the frontalis muscle vertically, parallel to the course of the nerves, and dissecting the subperiosteal plane to mobilize the nerves. This approach may be a useful access corridor for other lesions located near the medial anterior fossa.

Conscious sedation for awake craniotomy in intraoperative magnetic resonance imaging operating theater

PubMed Central

Takrouri, Mohamad Said Maani; Shubbak, Firas A.; Al Hajjaj, Aisha; Maestro, Rolando F. Del; Soualmi, Lahbib; Alkhodair, Mashael H.; Alduraiby, Abrar M.; Ghanem, Najeeb

2010-01-01

This case report describes the first case in intraoperative magnetic resonance imaging operating theater (iMRI OT) (BrainSuite®) of awake craniotomy for frontal lobe glioma excision in a 24-year-old man undergoing eloquent cortex language mapping intraoperatively. As he was very motivated to take pictures of him while being operated upon, the authors adapted conscious sedation technique with variable depth according to Ramsey's scale, in order to revert to awake state to perform the intended neurosurgical procedure. The patient tolerated the situation satisfactorily and was cooperative till the finish, without any event. We elicit in this report the special environment of iMRI OT for lengthy operation in pinned fixed patient having craniotomy. PMID:25885085

The History of Awake Craniotomy in Hospital Universiti Sains Malaysia

PubMed Central

WAN HASSAN, Wan Mohd Nazaruddin

2013-01-01

Awake craniotomy is a brain surgery performed on awake patients and is indicated for certain intracranial pathologies. These include procedures that require an awake patient for electrocorticographic mapping or precise electrophysiological recordings, resection of lesions located close to or in the motor and speech of the brain, or minor intracranial procedures that aim to avoid general anaesthesia for faster recovery and earlier discharge. This type of brain surgery is quite new and has only recently begun to be performed in a few neurosurgical centres in Malaysia. The success of the surgery requires exceptional teamwork from the neurosurgeon, neuroanaesthesiologist, and neurologist. The aim of this article is to briefly describe the history of awake craniotomy procedures at our institution. PMID:24643321

The effects of arterial carbon dioxide partial pressure and sevoflurane on capillary venous cerebral blood flow and oxygen saturation during craniotomy.

PubMed

Klein, Klaus Ulrich; Glaser, Martin; Reisch, Robert; Tresch, Achim; Werner, Christian; Engelhard, Kristin

2009-07-01

Intraoperative routine monitoring of cerebral blood flow and oxygenation remains a technological challenge. Using the physiological principle of carbon dioxide reactivity of cerebral vasculature, we investigated a recently developed neuromonitoring device (oxygen-to-see, O2C device) for simultaneous measurements of regional cerebral blood flow (rvCBF), blood flow velocity (rvVelo), oxygen saturation (srvO2), and hemoglobin amount (rvHb) at the capillary venous level in patients subjected to craniotomy. Twenty-six neurosurgical patients were randomly assigned to anesthesia with 1.4% or 2.0% sevoflurane end-tidal concentration. After craniotomy, a fiberoptic probe was applied on a macroscopically healthy surface of cerebral tissue next to the site of surgery. Simultaneous measurements in 2 and 8 mm cerebral depth were performed in each patient during lower (35 mm Hg) and higher (45 mm Hg) levels (random order) of arterial carbon dioxide partial pressure (PaCO2). The principle of these measurements relies on the combination of laser-Doppler flowmetry (rvCBF, rvVelo) and photo-spectrometry (srvO2, rvHb). Linear models were fitted to test changes of end points (rvCBF, rvVelo, srvO2, rvHb) in response to lower and higher levels of PaCO2, 1.4% and 2.0% sevoflurane end-tidal concentration, and 2 and 8 mm cerebral depth. RvCBF and rvVelo were elevated by PaCO2 independent of sevoflurane concentration in 2 and 8 mm depth of cerebral tissue (P < 0.001). Higher PaCO2 induced an increase in mean srvO2 from 50% to 68% (P < 0.001). RvVelo (P < 0.001) and srvO2 (P = 0.007) were higher in 8 compared with 2 mm cerebral depth. RvHb was not influenced by alterations in PaCO2 but positively correlated to sevoflurane concentration (P = 0.005). Increases in rvCBF and rvVelo by PaCO2 suggest preserved hypercapnic vasodilation under anesthesia with sevoflurane 1.4% and 2.0% end-tidal concentration. A consecutive increase in srvO2 implies that cerebral arteriovenous difference in oxygen was decreased by elevated PaCO2. Unchanged levels of rvHb signify that there was no blood loss during measurements. Data suggest that the device allows detection of local changes in blood flow and oxygen saturation in response to different PaCO2 levels in predominant venous cerebral microvessels.

Neurologic Deterioration Due to Brain Sag After Bilateral Craniotomy for Subdural Hematoma Evacuation.

PubMed

Liu, James K C

2018-06-01

Intracranial hypotension from cerebrospinal fluid (CSF) hypovolemia resulting in cerebral herniation is a rare but known complication that can occur after neurosurgical procedures, usually encountered in correlation with perioperative placement of a lumbar subarachnoid drain. Decrease in CSF volume resulting in loss of buoyancy results in downward herniation of the brain without contributing mass effect, causing a phenomenon known as brain sag. Unreported previously is brain sag occurring without concomitant occult CSF leak or lumbar drainage. This case report describes a patient who underwent bilateral craniotomies for subacute on chronic subdural hematoma with successful decompression but experienced acute neurologic deterioration secondary to brain sag. Despite an initial improvement in neurologic function, he subsequently experienced progressive neurologic deterioration with evidence of cerebral herniation on neuroimaging, without evidence of continued mass effect on the brain parenchyma. After a diagnosis of brain sag was determined based on imaging criteria, the patient was placed in a flat position, which resulted in rapid improvement in his neurologic function without any further intervention. This case is unique in comparison with previous reports of intracranial hypotension after craniotomy in that the symptoms were completely reversed with positioning alone, without any evidence of active or occult CSF drainage. This report emphasizes that the diagnosis of brain sag should be taken into consideration when there is an unknown reason for neurologic decline after craniotomy, particularly bilateral craniotomies, if the imaging indicates herniation with imaging findings consistent with intracranial hypotension, without evidence of overlying mass effect. Copyright © 2018 Elsevier Inc. All rights reserved.

The effect of single low-dose dexamethasone on vomiting during awake craniotomy.

PubMed

Kamata, Kotoe; Morioka, Nobutada; Maruyama, Takashi; Komayama, Noriaki; Nitta, Masayuki; Muragaki, Yoshihiro; Kawamata, Takakazu; Ozaki, Makoto

2016-12-01

Intraoperative vomiting leads to serious respiratory complications that could influence the surgical decision-making process for awake craniotomy. However, the use of antiemetics is still limited in Japan. The aim of this study was to investigate the effect of prophylactically administered single low-dose dexamethasone on the incidence of vomiting during awake craniotomy. The frequency of hyperglycemia was also examined. We conducted a retrospective case review of awake craniotomy for glioma resection between 2012 and 2015. Of the 124 patients, 91 were included in the analysis. Dexamethasone was not used in 43 patients and the 48 remaining patients received an intravenous bolus of 4.95 mg dexamethasone at anesthetic induction. Because of stable operating conditions, no one required conscious sedation throughout functional mapping and tumor resection. Although dexamethasone pretreatment reduced the incidence of intraoperative vomiting (P = 0.027), the number of patients who complained of nausea was comparable (P = 0.969). No adverse events related to vomiting occurred intraoperatively. Baseline blood glucose concentration did not differ between each group (P = 0.143), but the samples withdrawn before emergence (P = 0.018), during the awake period (P < 0.0001) and at the end of surgery (P < 0.0001) showed significantly higher glucose levels in the dexamethasone group. Impaired wound healing was not observed in either group. A single low-dose of dexamethasone prevents intraoperative vomiting for awake craniotomy cases. However, as even a small dose of dexamethasone increases the risk for hyperglycemia, antiemetic prophylaxis with dexamethasone should be administered after careful consideration. Monitoring of perioperative blood glucose concentration is also necessary.

Conference Support - Surgery in Extreme Environments - Center for Surgical Innovation

DTIC Science & Technology

2007-01-01

flights. During this 16-day mission in April 1998, surgical procedures, including thoracotomies, laparotomies, craniotomies , laminectomies, and...fixation, craniotomy , laminectomy, and leg dissection. These experiments also permitted the evaluation of IV insertion using the autonomic protocol and...missions will be required to address: Repair of lacerations; wound cement, layered closure Incision and drainage of abscess Needle aspiration of

Awake craniotomy in a patient with ejection fraction of 10%: considerations of cerebrovascular and cardiovascular physiology.

PubMed

Meng, Lingzhong; Weston, Stephen D; Chang, Edward F; Gelb, Adrian W

2015-05-01

A 37-year-old man with nonischemic 4-chamber dilated cardiomyopathy and low-output cardiac failure (estimated ejection fraction of 10%) underwent awake craniotomy for a low-grade oligodendroglioma resection under monitored anesthesia care. The cerebrovascular and cardiovascular physiologic challenges and our management of this patient are discussed. Published by Elsevier Inc.

Delayed intracranial subdural empyema following burr hole drainage: Case series and literature review.

PubMed

Kim, You-Sub; Joo, Sung-Pil; Song, Dong-Jun; Kim, Sung-Hyun; Kim, Tae-Sun

2018-05-01

A subdural empyema (SDE) following burr hole drainage of a chronic subdural hematoma (CSDH) can be difficult to distinguish from a recurrence of the CSDH, especially when imaging data is limited to a computed tomography (CT) scan. All patients underwent burr hole drainage of the CSDH at first, and the appearance of the SDE occurred within one month. A contrast-enhanced magnetic resonance imaging (MRI) scan, with diffusion-weighted imaging (DWI), revealed both the SDE and diffuse meningitis in all patients. In Case 1, because the patient was very young, burr hole drainage of the SDE, rather than craniotomy, was performed. However, subsequent craniotomy was required due to recurrence of the SDE. In Cases 2 and 3, an initial craniotomy was performed without burr hole drainage. Symptoms improved for all patients, and each was discharged without any neurologic deficits or subsequent recurrence. Neurosurgeons should consider the possibility of infection if recurrence of CSDH occurs within 1 month following drainage of a subdural hematoma. A contrast-enhanced MRI with DWI should be performed to differentiate SDE from CSDH. In addition, surgical evacuation of the empyema via wide craniotomy is preferred to burr hole drainage.

Post-operative orofacial pain, temporomandibular dysfunction and trigeminal sensitivity after recent pterional craniotomy: preliminary study.

PubMed

Brazoloto, Thiago Medina; de Siqueira, Silvia Regina Dowgan Tesseroli; Rocha-Filho, Pedro Augusto Sampaio; Figueiredo, Eberval Gadelha; Teixeira, Manoel Jacobsen; de Siqueira, José Tadeu Tesseroli

2017-05-01

Surgical trauma at the temporalis muscle is a potential cause of post-craniotomy headache and temporomandibular disorders (TMD). The aim of this study was to evaluate the prevalence of pain, masticatory dysfunction and trigeminal somatosensory abnormalities in patients who acquired aneurysms following pterional craniotomy. Fifteen patients were evaluated before and after the surgical procedure by a trained dentist. The evaluation consisted of the (1) research diagnostic criteria for TMD, (2) a standardized orofacial pain questionnaire and (3) a systematic protocol for quantitative sensory testing (QST) for the trigeminal nerve. After pterional craniotomy, 80% of the subjects, 12 patients, developed orofacial pain triggered by mandibular function. The pain intensity was measured by using the visual analog scale (VAS), and the mean pain intensity was 3.7. The prevalence of masticatory dysfunction was 86.7%, and there was a significant reduction of the maximum mouth opening. The sensory evaluation showed tactile and thermal hypoesthesia in the area of pterional access in all patients. There was a high frequency of temporomandibular dysfunction, postoperative orofacial pain and trigeminal sensory abnormalities. These findings can help to understand several abnormalities that can contribute to postoperative headache or orofacial pain complaints after pterional surgeries.

[A Case of Psychogenic Tremor during Awake Craniotomy].

PubMed

Kujirai, Kazumasa; Kamata, Kotoe; Uno, Toshihiro; Hamada, Keiko; Ozaki, Makoto

2016-01-01

A 31-year-old woman with a left frontal and parietal brain tumor underwent awake craniotomy. Propofol/remifentanil general anesthesia was induced. Following craniotomy, anesthetic administrations ceased. The level of consciousness was sufficient and she was not agitated. However, the patient complained of nausea 70 minutes into the awake phase. Considering the adverse effects of antiemetics and the upcoming surgical strategy, we did not give any medications. Nausea disappeared spontaneously while the operation was suspended. When surgical intervention extended to the left caudate nucleus, involuntary movement, classified as a tremor, with 5-6 Hz frequency, abruptly occurred on her left forearm. The patient showed emotional distress. Tremor appeared on her right forearm and subsequently spread to her lower extremities. Intravenous midazolam and fentanyl could not reduce her psychological stress. Since the tremor disturbed microscopic observation, general anesthesia was induced. Consequently, the tremor disappeared and did not recur. Based on the anatomical ground and the medication status, her involuntary movement was diagnosed as psychogenic tremor. Various factors can induce involuntary movements. In fact, intraoperative management of nausea and vomiting takes priority during awake craniotomy, but we should be reminded that some antiemetics potentially induce involuntary movement that could be caused by surgery around basal ganglia.

Ammonia encephalopathy and awake craniotomy for brain language mapping: cause of failed awake craniotomy.

PubMed

Villalba Martínez, G; Fernández-Candil, J L; Vivanco-Hidalgo, R M; Pacreu Terradas, S; León Jorba, A; Arroyo Pérez, R

2015-05-01

We report the case of an aborted awake craniotomy for a left frontotemporoinsular glioma due to ammonia encephalopathy on a patient taking Levetiracetam, valproic acid and clobazam. This awake mapping surgery was scheduled as a second-stage procedure following partial resection eight days earlier under general anesthesia. We planned to perform the surgery with local anesthesia and sedation with remifentanil and propofol. After removal of the bone flap all sedation was stopped and we noticed slow mentation and excessive drowsiness prompting us to stop and control the airway and proceed with general anesthesia. There were no post-operative complications but the patient continued to exhibit bradypsychia and hand tremor. His ammonia level was found to be elevated and was treated with an infusion of l-carnitine after discontinuation of the valproic acid with vast improvement. Ammonia encephalopathy should be considered in patients treated with valproic acid and mental status changes who require an awake craniotomy with patient collaboration. Copyright © 2014 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Scalp marking for a craniotomy using a laser pointer during preoperative computed tomographic imaging: technical note.

PubMed

Kubo, S; Nakata, H; Sugauchi, Y; Yokota, N; Yoshimine, T

2000-05-01

The preoperative localization of superficial intracranial lesions is often necessary for accurate burr hole placement or craniotomy siting. It is not always easy, however, to localize the lesions over the scalp working only from computed tomographic images. We developed a simple method for such localization using a laser pointer during the preoperative computed tomographic examination. The angle of incidence, extending from a point on the scalp to the center of the computed tomographic image, is measured by the software included with the scanner. In the gantry, at the same angle as on the image, a laser is beamed from a handmade projector onto the patient's scalp toward the center of the gantry. The point illuminated on the patient's head corresponds to that on the image. The device and the method are described in detail herein. We applied this technique to mark the area for the craniotomy before surgery in five patients with superficial brain tumors. At the time of surgery, it was confirmed that the tumors were circumscribed precisely. The technique is easy to perform and useful in the preoperative planning for a craniotomy. In addition, the device is easily constructed and inexpensive.

Cortical spreading depression occurs during elective neurosurgical procedures.

PubMed

Carlson, Andrew P; William Shuttleworth, C; Mead, Brittany; Burlbaw, Brittany; Krasberg, Mark; Yonas, Howard

2017-01-01

OBJECTIVE Cortical spreading depression (CSD) has been observed with relatively high frequency in the period following human brain injury, including traumatic brain injury and ischemic/hemorrhagic stroke. These events are characterized by loss of ionic gradients through massive cellular depolarization, neuronal dysfunction (depression of electrocorticographic [ECoG] activity) and slow spread (2-5 mm/min) across the cortical surface. Previous data obtained in animals have suggested that even in the absence of underlying injury, neurosurgical manipulation can induce CSD and could potentially be a modifiable factor in neurosurgical injury. The authors report their initial experience with direct intraoperative ECoG monitoring for CSD. METHODS The authors prospectively enrolled patients undergoing elective craniotomy for supratentorial lesions in cases in which the surgical procedure was expected to last > 2 hours. These patients were monitored for CSD from the time of dural opening through the time of dural closure, using a standard 1 × 6 platinum electrode coupled with an AC or full-spectrum DC amplifier. The data were processed using standard techniques to evaluate for slow potential changes coupled with suppression of high-frequency ECoG propagating across the electrodes. Data were compared with CSD validated in previous intensive care unit (ICU) studies, to evaluate recording conditions most likely to permit CSD detection, and identify likely events during the course of neurosurgical procedures using standard criteria. RESULTS Eleven patients underwent ECoG monitoring during elective neurosurgical procedures. During the periods of monitoring, 2 definite CSDs were observed to occur in 1 patient and 8 suspicious events were detected in 4 patients. In other patients, either no events were observed or artifact limited interpretation of the data. The DC-coupled amplifier system represented an improvement in stability of data compared with AC-coupled systems. Compared with more widely used postoperative ICU monitoring, there were additional challenges with artifact from saturation during bipolar cautery as well as additional noise peaks detected. CONCLUSIONS CSD can occur during elective neurosurgical procedures even in brain regions distant from the immediate operative site. ECoG monitoring with a DC-coupled full-spectrum amplifier seemed to provide the most stable signal despite significant challenges to the operating room environment. CSD may be responsible for some cases of secondary surgical injury. Though further studies on outcome related to the occurrence of these events is needed, efforts to decrease the occurrence of CSD by modification of anesthetic regimen may represent a novel target for study to increase the safety of neurosurgical procedures.

Chronic subdural haematoma treated by craniotomy, durectomy, outer membranectomy and subgaleal suction drainage. Personal experience in 39 patients.

PubMed

Mohamed, E E H Hussein

2003-06-01

According to the CT and MRI appearances, 39 chronic subdural haematoma (CSDH) patients were suspected of having solid clots and/or a high likelihood of loculation. Craniotomy was planned from the start. Beside the better exposure, excision of the dura and outer membrane, assumed to be the source of haematoma fluid, this is an additional step to minimize the incidence of significant recollection. There were no additional operative or postoperative cranial and/or systemic complications when compared with other minor procedures. Two patients (5%) required once percutaneous tapping and aspiration. Accordingly, if a case is considered to be better managed with craniotomy, durectomy and outer membranectomy this is an easy and safe technique with minimal incidence of recollection, morbidity and mortality.

[Successful airway management using i-gel in 7 patients undergoing awake craniotomy].

PubMed

Matsunami, Katsuaki; Sanuki, Michiyoshi; Yasuuji, Masakazu; Nakanuno, Ryuichi; Kato, Takahiro; Kawamoto, Masashi

2014-07-01

In order to secure airway during awake craniotomy, we used i-gel to perform positive-pressure ventilation in 7 patients for their anesthetic management. During removal of a tumor around the motor speech center, anesthetic management including asleep-awake-asleep technique was applied for speech testing. The technique, insertion and re-insertion of i-gel, was needed and it was easy in all the patients. During positive-pressure ventilation, peak pressure, tidal volume both for inspiration and expiration, and endtidal-CO2 were not markedly altered. Leakage around i-gel, and its differences between inspiration and expiration were negligible, while the tidal volume was adequate. We conclude that i-gel is useful for anesthetic management for awake craniotomy procedure for both securing airway and ventilation.

Dynamic subcellular imaging of cancer cell mitosis in the brain of live mice.

PubMed

Momiyama, Masashi; Suetsugu, Atsushi; Kimura, Hiroaki; Chishima, Takashi; Bouvet, Michael; Endo, Itaru; Hoffman, Robert M

2013-04-01

The ability to visualize cancer cell mitosis and apoptosis in the brain in real time would be of great utility in testing novel therapies. In order to achieve this goal, the cancer cells were labeled with green fluorescent protein (GFP) in the nucleus and red fluorescent protein (RFP) in the cytoplasm, such that mitosis and apoptosis could be clearly imaged. A craniotomy open window was made in athymic nude mice for real-time fluorescence imaging of implanted cancer cells growing in the brain. The craniotomy window was reversibly closed with a skin flap. Mitosis of the individual cancer cells were imaged dynamically in real time through the craniotomy-open window. This model can be used to evaluate brain metastasis and brain cancer at the subcellular level.

Moral absolutism and abortion: Alan Donagan on the hysterectomy and craniotomy cases.

PubMed

Reynolds, Terrence

1985-07-01

Reynolds argues that the nonconsequentialist moral theory proposed by Alan Donagan in his book The Theory of Morality (University of Chicago Press; 1977) does not resolve the cases in which craniotomy or removal of a cancerous uterus appears necessary to save the life of a pregnant woman. Donagan's absolute prohibition against the murder of the innocent and his rejection of the principle of double effect have led him to view the fetus as a pursuer or assailant or to assert the theory of proleptic agreement--that in risk taking ventures the parties may agree that killing one person to save the lives of the others will be accepted. Reynolds holds these arguments to be inapplicable in therapeutic abortions involving craniotomy or hysterectomy and concludes that Donagan's absolutist theory must be reexamined.

[Scalp neuralgia and headache elicited by cranial superficial anatomical causes: supraorbital neuralgia, occipital neuralgia, and post-craniotomy headache].

PubMed

Shimizu, Satoru

2014-01-01

Most scalp neuralgias are supraorbital or occipital. Although they have been considered idiopathic, recent studies revealed that some were attributable to mechanical irritation with the peripheral nerve of the scalp by superficial anatomical cranial structures. Supraorbital neuralgia involves entrapment of the supraorbital nerve by the facial muscle, and occipital neuralgia involves entrapment of occipital nerves, mainly the greater occipital nerve, by the semispinalis capitis muscle. Contact between the occipital artery and the greater occipital nerve in the scalp may also be causative. Decompression surgery to address these neuralgias has been reported. As headache after craniotomy is the result of iatrogenic injury to the peripheral nerve of the scalp, post-craniotomy headache should be considered as a differential diagnosis.

Enhanced recovery after elective coronary revascularization surgery with minimal versus conventional extracorporeal circulation: a prospective randomized study.

PubMed

Anastasiadis, Kyriakos; Asteriou, Christos; Antonitsis, Polychronis; Argiriadou, Helena; Grosomanidis, Vassilios; Kyparissa, Magdalena; Deliopoulos, Apostolos; Konstantinou, Dimitrios; Tossios, Paschalis

2013-10-01

A minimal extracorporeal circulation (MECC) circuit integrates the advances in cardiopulmonary bypass (CPB) technology into a single circuit and is associated with improved short-term outcome. The aim of this study was to prospectively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures. Prospective randomized study. All patients scheduled for elective coronary artery surgery were evaluated, excluding those considered particularly high risk for fast-track failure. The fast-track protocol included careful preoperative patient selection, a fast-track anesthetic technique based on minimal administration of fentanyl, surgery at normothermia, early postoperative extubation in the cardiac recovery unit, and admission to the cardiothoracic ward within the first 24 hours postoperatively. One hundred twenty patients were assigned randomly into 2 groups (60 in each group). Group A included patients who were operated on using the MECC circuit, whereas patients in Group B underwent surgery on conventional CPB. Incidence of fast-track recovery was significantly higher in patients undergoing MECC (25% v 6.7%, p = 0.006). MECC also was recognized as a strong independent predictor of early recovery, with an odds ratio of 3.8 (p = 0.011). Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion, duration of inotropic support, need for an intra-aortic balloon pump, and development of postoperative atrial fibrillation and renal failure. MECC promotes successful early recovery after elective coronary revascularization procedures, even in a nondedicated cardiac intensive care unit setting. Copyright © 2013 Elsevier Inc. All rights reserved.

Effect of Structured Touch and Guided Imagery for Pain and Anxiety in Elective Joint Replacement Patients--A Randomized Controlled Trial: M-TIJRP.

PubMed

Forward, John Brent; Greuter, Nancy Elizabeth; Crisall, Santa J; Lester, Houston F

2015-01-01

Postoperative management of pain after total joint arthroplasty remains a challenge despite advancements in analgesics. Evidence shows that complementary modalities with mind-body and tactile-based approaches are valid and effective adjuncts to reduce pain and anxiety postoperatively. To investigate the effectiveness of the "M" Technique (M), a registered method of structured touch using a set sequence and number of strokes, and a consistent level of pressure on hands and feet, compared with guided imagery and usual care, for the reduction of pain and anxiety in patients undergoing elective total knee or hip replacement surgery. Randomized controlled trial: M-TIJRP (MiTechnique and guided Imagery in Joint Replacement Patients [Mighty Junior P]). At a community hospital, 225 male and female patients, aged 38 to 90 years, undergoing elective total hip or knee replacement were randomly assigned to 1 of 3 groups (75 patients in each): M, guided imagery, or usual care. They were blinded to their assignment until the intervention. Reduction of pain and anxiety postoperatively. Secondary outcomes measured use of pain medication and patient satisfaction. This study yielded positive findings for the management of pain and anxiety in patients undergoing elective joint replacement using M and guided imagery for 18 to 20 minutes compared with usual care. M showed the largest predicted decreases in both pain and anxiety between groups. There was no significant difference in narcotic pain medication use between groups. Patient satisfaction survey ratings were highest for M, followed by guided imagery. The benefit of M may be because of the specifically structured sequence of touch by competent caring, trained providers.

Effect of Structured Touch and Guided Imagery for Pain and Anxiety in Elective Joint Replacement Patients—A Randomized Controlled Trial: M-TIJRP

PubMed Central

Forward, John Brent; Greuter, Nancy Elizabeth; Crisall, Santa J; Lester, Houston F

2015-01-01

Context: Postoperative management of pain after total joint arthroplasty remains a challenge despite advancements in analgesics. Evidence shows that complementary modalities with mind-body and tactile-based approaches are valid and effective adjuncts to reduce pain and anxiety postoperatively. Objective: To investigate the effectiveness of the “M” Technique (M), a registered method of structured touch using a set sequence and number of strokes, and a consistent level of pressure on hands and feet, compared with guided imagery and usual care, for the reduction of pain and anxiety in patients undergoing elective total knee or hip replacement surgery. Methods: Randomized controlled trial: M-TIJRP (MiTechnique and guided Imagery in Joint Replacement Patients [Mighty Junior P]). At a community hospital, 225 male and female patients, aged 38 to 90 years, undergoing elective total hip or knee replacement were randomly assigned to 1 of 3 groups (75 patients in each): M, guided imagery, or usual care. They were blinded to their assignment until the intervention. Main Outcome Measures: Reduction of pain and anxiety postoperatively. Secondary outcomes measured use of pain medication and patient satisfaction. Results: This study yielded positive findings for the management of pain and anxiety in patients undergoing elective joint replacement using M and guided imagery for 18 to 20 minutes compared with usual care. M showed the largest predicted decreases in both pain and anxiety between groups. There was no significant difference in narcotic pain medication use between groups. Patient satisfaction survey ratings were highest for M, followed by guided imagery. Conclusion: The benefit of M may be because of the specifically structured sequence of touch by competent caring, trained providers. PMID:26222093

Comparison between oral antibiotics and probiotics as bowel preparation for elective colon cancer surgery to prevent infection: prospective randomized trial.

PubMed

Sadahiro, Sotaro; Suzuki, Toshiyuki; Tanaka, Akira; Okada, Kazutake; Kamata, Hiroko; Ozaki, Toru; Koga, Yasuhiro

2014-03-01

We have already reported that, for patients undergoing elective colon cancer operations, perioperative infection can be prevented by a single intravenous dose of an antibiotic given immediately beforehand if mechanical bowel preparation and the administration of oral antibiotics are implemented. Synbiotics has been reported to reduce the rate of infection in patients after pancreatic cancer operations. The effectiveness of oral antibiotics and probiotics in preventing postoperative infection in elective colon cancer procedures was examined in a randomized controlled trial. Three hundred ten patients with colon cancer randomly were assigned to one of three groups. All patients underwent mechanical bowel preparation and received a single intravenous dose of flomoxef immediately before operation. Probiotics were administered in Group A; oral antibiotics were administered in Group B; and neither probiotics nor oral antibiotics were administered in Group C. Stool samples were collected 9 and 2 days before and 7 and 14 days after the procedure. Clostridium difficile toxin and the number of bacteria in the intestine were determined. The rates of incisional surgical-site infection were 18.0%, 6.1%, and 17.9% in Groups A, B, and C, and the rates of leakage were 12.0%, 1.0%, and 7.4% in Groups A, B, and C, respectively, indicating that both rates were lesser in Group B than in Groups A and C (P = .014 and P = .004, respectively). The detection rates of C. difficile toxin were not changed among the three groups. We recommend oral antibiotics, rather than probiotics, as bowel preparation for elective colon cancer procedures to prevent surgical-site infections. Copyright © 2014 Mosby, Inc. All rights reserved.

Nociceptive Neuropeptide Increases and Periorbital Allodynia in a Model of Traumatic Brain Injury

PubMed Central

Elliott, Melanie B.; Oshinsky, Michael L.; Amenta, Peter S.; Awe, Olatilewa O.; Jallo, Jack I.

2014-01-01

Objective This study tests the hypothesis that injury to the somatosensory cortex is associated with periorbital allodynia and increases in nociceptive neuropeptides in the brainstem in a mouse model of controlled cortical impact (CCI) injury. Methods Male C57BL/6 mice received either CCI or craniotomy-only followed by weekly periorbital von Frey (mechanical) sensory testing for up to 28 days post-injury. Mice receiving an incision only and naïve mice were included as control groups. Changes in calcitonin gene-related peptide (CGRP) and substance P (SP) within the brainstem were determined using enzyme-linked immunosorbent assay and immunohistochemistry, respectively. Activation of ionized calcium-binding adaptor molecule-1–labeled macrophages/microglia and glial fibrillary acidic protein (GFAP)-positive astrocytes were evaluated using immunohistochemistry because of their potential involvement in nociceptor sensitization. Results Incision-only control mice showed no changes from baseline periorbital von Frey mechanical thresholds. CCI significantly reduced mean periorbital von Frey thresholds (periorbital allodynia) compared with baseline and craniotomy-only at each endpoint, analysis of variance P < .0001. Craniotomy significantly reduced periorbital threshold at 14 days but not 7, 21, or 28 days compared with baseline threshold, P < .01. CCI significantly increased SP immunoreactivity in the brainstem at 7 and 14 days but not 28 days compared with craniotomy-only and controls, P < .001. CGRP levels in brainstem tissues were significantly increased in CCI groups compared with controls (incision-only and naïve mice) or craniotomy-only mice at each endpoint examined, P < .0001. There was a significant correlation between CGRP and periorbital allodynia (P < .0001, r = −0.65) but not for SP (r = 0.20). CCI significantly increased the number of macrophage/microglia in the injured cortex at each endpoint up to 28 days, although cell numbers declined over weeks post-injury, P < .001. GFAP+ immunoreactivity was significantly increased at 7 but not 14 or 28 days after CCI, P < .001. Craniotomy resulted in transient periorbital allodynia accompanied by transient increases in SP, CGRP, and GFAP immunoreactivity compared with control mice. There was no increase in the number of macrophage/microglia cells compared with controls after craniotomy. Conclusion Injury to the somatosensory cortex results in persistent periorbital allodynia and increases in brainstem nociceptive neuropeptides. Findings suggest that persistent allodynia and increased neuropeptides are maintained by mechanisms other than activation of macrophage/microglia or astrocyte in the injured somatosensory cortex. PMID:22568499

Modified irrigation hose placement in draping for craniotomy: provision of a free foot space for surgeons: technical note.

PubMed

Shimizu, S; Utsuki, S; Suzuki, S; Oka, H; Yamada, M; Fujii, K

2008-04-01

Sterility and utility are essential in surgical draping. For craniotomy, we modified the course of the irrigation hose to maintain a free foot space for the surgeon by connection with a suction bottle placed beside the patient's body through a slit made in the linen. This minor modification provides convenience to the surgeon during operations.

Potential for thermal damage to the blood–brain barrier during craniotomy: implications for intracortical recording microelectrodes

NASA Astrophysics Data System (ADS)

Shoffstall, Andrew J.; Paiz, Jen E.; Miller, David M.; Rial, Griffin M.; Willis, Mitchell T.; Menendez, Dhariyat M.; Hostler, Stephen R.; Capadona, Jeffrey R.

2018-06-01

Objective. Our objective was to determine how readily disruption of the blood–brain barrier (BBB) occurred as a result of bone drilling during a craniotomy to implant microelectrodes in rat cortex. While the phenomenon of heat production during bone drilling is well known, practices to evade damage to the underlying brain tissue are inconsistently practiced and reported in the literature. Approach. We conducted a review of the intracortical microelectrode literature to summarize typical approaches to mitigate drill heating during rodent craniotomies. Post mortem skull-surface and transient brain-surface temperatures were experimentally recorded using an infrared camera and thermocouple, respectively. A number of drilling conditions were tested, including varying drill speed and continuous versus intermittent contact. In vivo BBB permeability was assayed 1 h after the craniotomy procedure using Evans blue dye. Main results. Of the reviewed papers that mentioned methods to mitigate thermal damage during craniotomy, saline irrigation was the most frequently cited (in six of seven papers). In post mortem tissues, we observed increases in skull-surface temperature ranging from  +3 °C to  +21 °C, dependent on drill speed. In vivo, pulsed-drilling (2 s-on/2 s-off) and slow-drilling speeds (1000 r.p.m.) were the most effective methods we studied to mitigate heating effects from drilling, while inconclusive results were obtained with saline irrigation. Significance. Neuroinflammation, initiated by damage to the BBB and perpetuated by the foreign body response, is thought to play a key role in premature failure of intracortical recording microelectrodes. This study demonstrates the extreme sensitivity of the BBB to overheating caused by bone drilling. To avoid damage to the BBB, the authors recommend that craniotomies be drilled with slow speeds and/or with intermittent drilling with complete removal of the drill from the skull during ‘off’ periods. While saline alone was ineffective at preventing overheating, its use is still recommended to remove bone dust from the surgical site and to augment other cooling methods.

Organized Chronic Subdural Hematomas Treated by Large Craniotomy with Extended Membranectomy as the Initial Treatment

PubMed Central

Balevi, Mustafa

2017-01-01

Objective: The aim of this retrospective study is to evaluate the efficacy and incidence of complications of craniotomy and membranectomy in elderly patients for the treatment of organized chronic subdural hematoma (OCSH). Materials and Methods: We retrospectively reviewed a series of 28 consecutive patients suffering from OCSH, diagnosed by magnetic resonance imaging (MRI) or computer tomography (CT) to establish the degree of organization and determine the intrahematomal architecture including inner membrane ossification. The indication to perform a primary enlarged craniotomy as initial treatment for nonliquefied OCSH with multilayer loculations was based on the hematoma MRI appearance – mostly hyperintense in both T1- and T2-weighted images with a hypointense web- or net-like structure within the hematoma cavity or inner membrane calcification CT appearance - hyperdense. These cases have been treated by a large craniotomy with extended membranectomy as the initial treatment. However, the technique of a burr hole with closed system drainage for 24–72 h was chosen for cases of nonseptated and mostly liquefied Chronic Subdural Hematoma (CSDH). Results: Between 1998 and 2015, 148 consecutive patients were surgically treated for CSDH at our institution. Of these, 28 patients which have OSDH underwent a large craniotomy with extended membranectomy as the initial treatment. The average age of the patients was 69 (69.4 ± 12.1). Tension pneumocephalus (TP) has occurred in 22.8% of these patients (n = 28). Recurring subdural hemorrhage (RSH) in the operation area has occurred in 11.9% of these patients in the first 24 h. TP with RSH was seen in 4 of 8 TP patients (50%). Large epidural air was seen in one case. Postoperative seizures requiring medical therapy occurred in 25% of our patients. The average stay in the department of neurosurgery was 11 days, ranging from 7 to 28 days. Four patients died within 28 days after surgery; mortality rate was 14.28%. Conclusion: Large craniotomy and extended membrane excision for OSDH still carry a high rate of mortality and morbidity in elderly patients. TP, RSH, and postoperative seizures are frequently seen complications in elderly patients. PMID:29114271

Organized Chronic Subdural Hematomas Treated by Large Craniotomy with Extended Membranectomy as the Initial Treatment.

PubMed

Balevi, Mustafa

2017-01-01

The aim of this retrospective study is to evaluate the efficacy and incidence of complications of craniotomy and membranectomy in elderly patients for the treatment of organized chronic subdural hematoma (OCSH). We retrospectively reviewed a series of 28 consecutive patients suffering from OCSH, diagnosed by magnetic resonance imaging (MRI) or computer tomography (CT) to establish the degree of organization and determine the intrahematomal architecture including inner membrane ossification. The indication to perform a primary enlarged craniotomy as initial treatment for nonliquefied OCSH with multilayer loculations was based on the hematoma MRI appearance - mostly hyperintense in both T1- and T2-weighted images with a hypointense web- or net-like structure within the hematoma cavity or inner membrane calcification CT appearance - hyperdense. These cases have been treated by a large craniotomy with extended membranectomy as the initial treatment. However, the technique of a burr hole with closed system drainage for 24-72 h was chosen for cases of nonseptated and mostly liquefied Chronic Subdural Hematoma (CSDH). Between 1998 and 2015, 148 consecutive patients were surgically treated for CSDH at our institution. Of these, 28 patients which have OSDH underwent a large craniotomy with extended membranectomy as the initial treatment. The average age of the patients was 69 (69.4 ± 12.1). Tension pneumocephalus (TP) has occurred in 22.8% of these patients ( n = 28). Recurring subdural hemorrhage (RSH) in the operation area has occurred in 11.9% of these patients in the first 24 h. TP with RSH was seen in 4 of 8 TP patients (50%). Large epidural air was seen in one case. Postoperative seizures requiring medical therapy occurred in 25% of our patients. The average stay in the department of neurosurgery was 11 days, ranging from 7 to 28 days. Four patients died within 28 days after surgery; mortality rate was 14.28%. Large craniotomy and extended membrane excision for OSDH still carry a high rate of mortality and morbidity in elderly patients. TP, RSH, and postoperative seizures are frequently seen complications in elderly patients.

Awake craniotomy and electrophysiological mapping for eloquent area tumours.

PubMed

Chacko, Ari George; Thomas, Santhosh George; Babu, K Srinivasa; Daniel, Roy Thomas; Chacko, Geeta; Prabhu, Krishna; Cherian, Varghese; Korula, Grace

2013-03-01

An awake craniotomy facilitates radical excision of eloquent area gliomas and ensures neural integrity during the excision. The study describes our experience with 67 consecutive awake craniotomies for the excision of such tumours. Sixty-seven patients with gliomas in or adjacent to eloquent areas were included in this study. The patient was awake during the procedure and intraoperative cortical and white matter stimulation was performed to safely maximize the extent of surgical resection. Of the 883 patients who underwent craniotomies for supratentorial intraaxial tumours during the study period, 84 were chosen for an awake craniotomy. Sixty-seven with a histological diagnosis of glioma were included in this study. There were 55 men and 12 women with a median age of 34.6 years. Forty-two (62.6%) patients had positive localization on cortical stimulation. In 6 (8.9%) patients white matter stimulation was positive, five of whom had responses at the end of a radical excision. In 3 patients who developed a neurological deficit during tumour removal, white matter stimulation was negative and cessation of the surgery did not result in neurological improvement. Sixteen patients (24.6%) had intraoperative neurological deficits at the time of wound closure, 9 (13.4%) of whom had persistent mild neurological deficits at discharge, while the remaining 7 improved to normal. At a mean follow-up of 40.8 months, only 4 (5.9%) of these 9 patients had persistent neurological deficits. Awake craniotomy for excision of eloquent area gliomas enable accurate mapping of motor and language areas as well as continuous neurological monitoring during tumour removal. Furthermore, positive responses on white matter stimulation indicate close proximity of eloquent cortex and projection fibres. This should alert the surgeon to the possibility of postoperative deficits to change the surgical strategy. Thus the surgeon can resect tumour safely, with the knowledge that he has not damaged neurological function up to that point in time thus maximizing the tumour resection and minimizing neurological deficits. Copyright © 2012 Elsevier B.V. All rights reserved.

Coconut Model for Learning First Steps of Craniotomy Techniques and Cerebrospinal Fluid Leak Avoidance.

PubMed

Drummond-Braga, Bernardo; Peleja, Sebastião Berquó; Macedo, Guaracy; Drummond, Carlos Roberto S A; Costa, Pollyana H V; Garcia-Zapata, Marco T; Oliveira, Marcelo Magaldi

2016-12-01

Neurosurgery simulation has gained attention recently due to changes in the medical system. First-year neurosurgical residents in low-income countries usually perform their first craniotomy on a real subject. Development of high-fidelity, cheap, and largely available simulators is a challenge in residency training. An original model for the first steps of craniotomy with cerebrospinal fluid leak avoidance practice using a coconut is described. The coconut is a drupe from Cocos nucifera L. (coconut tree). The green coconut has 4 layers, and some similarity can be seen between these layers and the human skull. The materials used in the simulation are the same as those used in the operating room. The coconut is placed on the head holder support with the face up. The burr holes are made until endocarp is reached. The mesocarp is dissected, and the conductor is passed from one hole to the other with the Gigli saw. The hook handle for the wire saw is positioned, and the mesocarp and endocarp are cut. After sawing the 4 margins, mesocarp is detached from endocarp. Four burr holes are made from endocarp to endosperm. Careful dissection of the endosperm is done, avoiding liquid albumen leak. The Gigli saw is passed through the trephine holes. Hooks are placed, and the endocarp is cut. After cutting the 4 margins, it is dissected from the endosperm and removed. The main goal of the procedure is to remove the endocarp without fluid leakage. The coconut model for learning the first steps of craniotomy and cerebrospinal fluid leak avoidance has some limitations. It is more realistic while trying to remove the endocarp without damage to the endosperm. It is also cheap and can be widely used in low-income countries. However, the coconut does not have anatomic landmarks. The mesocarp makes the model less realistic because it has fibers that make the procedure more difficult and different from a real craniotomy. The model has a potential pedagogic neurosurgical application for freshman residents before they perform a real craniotomy for the first time. Further validity is necessary to confirm this hypothesis. Copyright © 2016 Elsevier Inc. All rights reserved.

A pilot randomized trial of pentoxifylline for the reduction of periprocedural myocardial injury in patients undergoing elective percutaneous coronary intervention.

PubMed

Aslanabadi, Naser; Shirzadi, Hamid Reza; Asghari-Soufi, Hossein; Dousti, Samaneh; Ghaffari, Samad; Sohrabi, Bahram; Mashayekhi, Simin Ozar; Hamishehkar, Hadi; Entezari-Maleki, Taher

2015-02-01

Periprocedural myocardial injury (PMI) following percutaneous coronary intervention (PCI) has received great attention due to its significant association with mortality and morbidity. Accordingly, cardioprotection during PCI is one of the important therapeutic concerns. Regarding the potential cardiovascular benefits of pentoxifylline this study was performed to evaluate whether the pretreatment pentoxifylline could reduce PMI in patients who are undergoing elective PCI. A randomized clinical trial on 85 patients undergoing elective PCI was performed. The intervention group (n = 41) received 1200 mg pentoxifylline in divided doses plus the standard treatment before PCI, while the control group (n = 44) received the standard treatment. For assessing myocardial damage during PCI, the levels of CK-MB and troponin-I were measured at baseline, 8, and 24 h after the procedure. Then, patients were followed up for a 1-month period regarding the major adverse cardiac effect. Comparing with the control group, no significant change of CK-MB at 8 (p = 0.315) and 24 h (p = 0.896) after PCI was documented in pentoxifylline group. Similarly, no significant change was found in troponin-I at 8 (p = 0.141) and 24 h (p = 0.256) after PCI. This study could not support the pretreatment with pentoxifylline in the prevention of PMI in patients undergoing elective PCI. However, the trend was toward the potential benefit of pentoxifylline.

[Causes and management of frontal sinusitis after transfrontal craniotomy].

PubMed

Liu, T C; Yu, X F; Gu, Z W; Bai, W L; Wang, Z H; Cao, Z W

2018-02-01

Objective: The aim of this study is to investigate the causes and the strategy of frontal sinusitis after transfrontal craniotomy by endoscopic frontal sinus surgery and traditional surgery with facial incision. Method: A total of thirty-four patients with frontal sinusitis after transfrontal craniotomy were admitted, with the symptom of purulence stuff, headache and upper eyelid discharging. The onset time was 2.6 years on average. The frontal sinus CT and MRI images showed frontal sinusitis. Twenty-seven patients were treated with endoscopic frontal sinus surgery, and seven patient was treated with combined endoscopic and traditional frontal sinus surgery. In the revision surgery, the bone wax and inflammatory granulation tissue were cleaned out in both operational methods. The cure standard was that the postoperative frontal sinus inflammation disappeared and the drainage of the volume recess was unobstructed. Result: Thirty-four patients had a history of transfrontal craniotomy, and there was a record of bone wax packing in every operation. Among twenty-seven patients with endoscopic frontal sinus surgery, Twenty-five cases cured and two cases were operated twice. Seven patients were cured with combined endoscopic and traditional frontal sinus surgery. Conclusion: The frontal sinusitis after transfrontal craniotomy may be related to the inadequate sinus management, especially bone wax to be addressed to the frontal sinus ramming leading to frontal sinus mucosa secretion obstruction and poor drainage. Endoscopic frontal sinus surgery is a way of minimally invasive surgery. The satisfying curative effect can be obtained by endoscopic removal of bone wax, inflammatory granulation tissue, and the enlargement of frontal sinus aperture after exposure to the frontal sinus, and some cases was treated with both operation method.

The efficacy and safety of burr-hole craniotomy without continuous drainage for chronic subdural hematoma and subdural hygroma in children under 2 years of age.

PubMed

Matsuo, Kazuya; Akutsu, Nobuyuki; Otsuka, Kunitoshi; Yamamoto, Kazuki; Kawamura, Atsufumi; Nagashima, Tatsuya

2016-12-01

Various treatment modalities have been used in the management of chronic subdural hematoma and subdural hygroma (CSDH/SDHy) in children. However, few studies have examined burr-hole craniotomy without continuous drainage in such cases. Here, we retrospectively evaluated the efficacy and safety of burr-hole craniotomy without continuous drainage for CSDH/SDHy in children under 2 years old. We also aimed to determine the predictors of CSDH/SDHy recurrence. We conducted a retrospective chart review of 25 children under 2 years old who underwent burr-hole craniotomy without continuous drainage for CSDH/SDHy at a pediatric teaching hospital over a 10-year period. We analyzed the relationship between CSDH/SDHy recurrence and factors such as abusive head trauma, laterality of CSDH/SDHy, and subdural fluid collection type (hematoma or hygroma). CSDH/SDHy recurred in 5 of the 25 patients (20 %), requiring a second operation at an average of 0.92 ± 1.12 months after the initial procedure. The mean follow-up period was 25.1 ± 28.6 months. There were no complications related to either operation. None of the assessed factors were statistically associated with recurrence. Burr-hole craniotomy without continuous drainage for CSDH/SDHy appears safe in children aged under 2 years and results in a relatively low recurrence rate. No predictors of CSDH/SDHy recurrence were identified. Advantages of this method include avoiding external subdural drainage-related complications. However, burr-hole drainage may be more effective for CSDH, which our data suggests is more likely to recur than SDHy, providing the procedure is performed with specific efforts to reduce complications.

Assessment of molecular markers demonstrates concordance between samples acquired via stereotactic biopsy and open craniotomy in both anaplastic astrocytomas and glioblastomas.

PubMed

Gessler, Florian; Baumgarten, Peter; Bernstock, Joshua D; Harter, Patrick; Lescher, Stephanie; Senft, Christian; Seifert, Volker; Marquardt, Gerhard; Weise, Lutz

2017-06-01

The classification, treatment and prognosis of high-grade gliomas has been shown to correlate with the expression of molecular markers (e.g. MGMT promotor methylation and IDH1 mutations). Acquisition of tumor samples may be obtained via stereotactic biopsy or open craniotomy. Between the years 2009 and 2013, 22 patients initially diagnosed with HGGs via stereotactic biopsy, that ultimately underwent open craniotomy for resection of their tumor were prospectively included in an institutional glioma database. MGMT promotor analysis was performed using methylation-specific (MS)-PCR and IDH1R132H mutation analysis was performed using immunohistochemistry. Three patients (13.7%) exhibited IDH1R132H mutations in samples obtained via stereotactic biopsy. Tissue derived from stereotaxic biopsy was demonstrated to have MGMT promotor methylation in ten patients (45.5%), while a non-methylated MGMT promotor was demonstrated in ten patients (45.5%); inconclusive results were obtained for the remaining two patients (9%) within our cohort. The initial histologic grading, IDH1R132H mutation and MGMT promotor methylation results were confirmed using samples obtained during open craniotomy in all but one patient; here inconclusive MGMT promotor analysis was obtained in contrast to that which was obtained via stereotactic biopsy. Tumor samples acquired via stereotactic biopsy provide accurate information with regard to clinically relevant molecular markers that have been shown to impact patient care decisions. The profile of markers analyzed in our cohort was nearly concordant between those samples obtained via stereotactic biopsy or open craniotomy thereby suggesting that clinical decisions may be based on the molecular profile of the tumor samples obtained via stereotactic biopsy.

Surgery-Independent Language Function Decline in Patients Undergoing Awake Craniotomy.

PubMed

Gonen, Tal; Sela, Gal; Yanakee, Ranin; Ram, Zvi; Grossman, Rachel

2017-03-01

Despite selection process before awake-craniotomy, some patients experience an unexpected decline in language functions in the operating room (OR), compared with their baseline evaluation, which may impair their functional monitoring. To investigate this phenomenon we prospectively compared language function the day before surgery and on entrance to the OR. Data were collected prospectively from consecutive patients undergoing awake-craniotomy with intraoperative cortical mapping for resection of gliomas affecting language areas. Language functions of 79 patients were evaluated and compared 1-2 days before surgery and after entering the OR. Changes in functional linguistic performance were analyzed with respect to demographic, clinical, and pathologic characteristics. There was a significant decline in language function, beyond sedation effect, after entering the OR, (from median/interquartile range: 0.94/0.72-0.98 to median/interquartile range: 0.86/0.51-0.94; Z = -7.19, P < 0.001). Univariate analyses revealed that this decline was related to age, preoperative Karnofsky Performance Scale, tumor location, tumor pathology, and preexisting language deficits. Multivariate stepwise regression identified tumor pathology and the presence of preoperative language deficit as significant independent predictors for this functional decline. Patients undergoing awake-craniotomy may experience a substantial decline in language functioning after entering the OR. Tumor grade and the presence of preoperative language deficits were significant risk factors for this phenomenon, suggesting a possible relation between cognitive reserve, psychobehavioral coping abilities and histologic features of a tumor involving language areas. Capturing and identifying this unique population of patients who are prone to experience such language decline may improve our ability in the future to select patients eligible for awake-craniotomy. Copyright © 2016 Elsevier Inc. All rights reserved.

[Functional mapping using subdural electrodes combined with monitoring during awake craniotomy enabled preservation of function and extensive resection of a glioma adjacent to the parietal lobe language sites: a case report].

PubMed

Takebayashi, Kento; Saito, Taiichi; Nitta, Masayuki; Tamura, Manabu; Maruyama, Takashi; Muragaki, Yoshihiro; Okada, Yoshikazu

2015-01-01

Surgical resection of gliomas located in the dominant parietal lobe is difficult because this lesion is surrounded by multiple functional areas. Although functional mapping during awake craniotomy is very useful for resection of gliomas adjacent to eloquent areas, the limited time available makes it difficult to sufficiently evaluate multiple functions, such as language, calculative ability, distinction of right and left sides, and finger recognition. Here, we report a case of anaplastic oligodendroglioma, which was successfully treated with a combination of functional mapping using subdural electrodes and monitoring under awake craniotomy for glioma. A 32-year-old man presented with generalized seizure. Magnetic resonance imaging revealed a non-enhanced tumor in the left angular and supramarginal gyri. In addition, the tumor showed high accumulation on 11C-methionine positron emission tomography(PET)(tumor/normal brain tissue ratio=3.20). Preparatory mapping using subdural electrodes showed absence of brain function on the tumor lesion. Surgical removal was performed using cortical mapping during awake craniotomy with an updated navigation system using intraoperative magnetic resonance imaging(MRI). The tumor was resected until aphasia was detected by functional monitoring, and the extent of tumor resection was 93%. The patient showed transient transcortical aphasia and Gerstmann's syndrome after surgery but eventually recovered. The pathological diagnosis was anaplastic oligodendroglioma, and the patient was administered chemo-radiotherapy. The patient has been progression free for more than 2 years. The combination of subdural electrode mapping and monitoring during awake craniotomy is useful in order to achieve preservation of function and extensive resection for gliomas in the dominant parietal lobe.

Out-of-Body Experience During Awake Craniotomy.

PubMed

Bos, Eelke M; Spoor, Jochem K H; Smits, Marion; Schouten, Joost W; Vincent, Arnaud J P E

2016-08-01

The out-of-body experience (OBE), during which a person feels as if he or she is spatially removed from the physical body, is a mystical phenomenon because of its association with near-death experiences. Literature implicates the cortex at the temporoparietal junction (TPJ) as the possible anatomic substrate for OBE. We present a patient who had an out-of-body experience during an awake craniotomy for resection of low-grade glioma. During surgery, stimulation of subcortical white matter in the left TPJ repetitively induced OBEs, in which the patient felt as if she was floating above the operating table looking down on herself. We repetitively induced OBE by subcortical stimulation near the left TPJ during awake craniotomy. Diffusion tensor imaging tractography implicated the posterior thalamic radiation as a possible substrate for autoscopic phenomena. Copyright © 2016 Elsevier Inc. All rights reserved.

System design of a hand-held mobile robot for craniotomy.

PubMed

Kane, Gavin; Eggers, Georg; Boesecke, Robert; Raczkowsky, Jörg; Wörn, Heinz; Marmulla, Rüdiger; Mühling, Joachim

2009-01-01

This contribution reports the development and initial testing of a Mobile Robot System for Surgical Craniotomy, the Craniostar. A kinematic system based on a unicycle robot is analysed to provide local positioning through two spiked wheels gripping directly onto a patients skull. A control system based on a shared control system between both the Surgeon and Robot is employed in a hand-held design that is tested initially on plastic phantom and swine skulls. Results indicate that the system has substantially lower risk than present robotically assisted craniotomies, and despite being a hand-held mobile robot, the Craniostar is still capable of sub-millimetre accuracy in tracking along a trajectory and thus achieving an accurate transfer of pre-surgical plan to the operating room procedure, without the large impact of current medical robots based on modified industrial robots.

Effect of Head Insulation on the Total Time Required to Rewarm Postoperative Cardiac Surgery Patients.

DTIC Science & Technology

1992-05-01

two-hour period in the recovery room. Individuals were excluded from the study if they had cardiac surgery, craniotomies , surgeries precluding the use...years). Patients were excluded if they had: craniotomies , cardiac surgery, coagulation defects, 34 preoperative hyperthermia, or previous tympanoplasty...intraoperatively. 3. Postoperative mediastinal/chest tube drainage > 100 ml/hour for four hours. 4. Postoperative cardiac arrest during data collection period

Bioacoustic Signal Classification in Cat Auditory Cortex

DTIC Science & Technology

1991-06-14

Studies Preparations for the setup to record from awake animals in a behavioral setting were initiated with the help of Dr. William Jenkins, our...temporal muscle over the right hemisphere was then retracted and the lateral cortex exposed by a craniotomy . The dura overlaying the middle ectosylvian...sites. For recording topographically identified single neurons, a wire mesh was placed over the craniotomy and the space between the grid and cortex was

Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm.

PubMed

Schievink, Wouter I; Palestrant, David; Maya, M Marcel; Rappard, George

2009-03-01

Spontaneous spinal CSF leaks are best known as a cause of orthostatic headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray-white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvement in her level of consciousness. A CT myelogram demonstrated an upper thoracic CSF leak that eventually required surgical correction. The patient made a complete neurological recovery. Neurological deterioration after craniotomy may be caused by brain sagging caused by a spontaneous spinal CSF leak, similar to intracranial hypotension due to intraoperative lumbar CSF drainage.

Awake craniotomy in a developmentally delayed blind man with cognitive deficits.

PubMed

Burbridge, Mark; Raazi, Mateen

2013-04-01

To describe the complex perioperative considerations and anesthetic management of a cognitively delayed blind adult male who underwent awake craniotomy to remove a left anterior temporal lobe epileptic focus. A 28-yr-old left-handed blind cognitively delayed man was scheduled for awake craniotomy to resect a left anterior temporal lobe epileptic focus due to intractable epilepsy despite multiple medications. His medical history was also significant for retinopathy of prematurity that rendered him legally blind in both eyes and an intracerebral hemorrhage shortly after birth that resulted in a chronic brain injury and developmental delay. His cognitive capacity was comparable with that of an eight year old. Since patient cooperation was the primary concern during the awake electrocorticography phase of surgery, careful assessment of the patient's ability to tolerate the procedure was undertaken. There was extensive planning between surgeons and anesthesiologists, and a patient-specific pharmacological strategy was devised to facilitate surgery. The operation proceeded without complication, the patient has remained seizure-free since the procedure, and his quality of life has improved dramatically. This case shows that careful patient assessment, effective interdisciplinary communication, and a carefully tailored anesthetic strategy can facilitate an awake craniotomy in a potentially uncooperative adult patient with diminished mental capacity and sensory deficits.

Factors affecting profitability for craniotomy.

PubMed

Popp, A John; Scrime, Todd; Cohen, Benjamin R; Feustel, Paul J; Petronis, Karen; Habiniak, Sharon; Waldman, John B; Vosburgh, Margaret M

2002-04-15

The authors studied factors influencing hospital profitability after craniotomy in patients who underwent craniotomy coded as diagnosis-related group (DRG) 1 (17 years of age with nontraumatic disease without complication) and who met their hospital's craniotomy pathway criteria and had a hospital length of stay 4 days or less during a 20-month period. Data in all patients meeting these criteria (76 cases) were collected and collated from various hospital databases. Twenty-one cases were profitable and 55 were not. Variables traditionally influencing cost of care, such as surgeon, procedure, length of operation, and pharmacy use had no significant effect on whether a patient was profitable. The most important influence on profitability was the individual payor. Cases in which care was reimbursed under the prospective payment system based on DRGs were nearly always profitable whereas those covered by per diem plans were nearly always nonprofitable. 1) Hospital information systems should be customized to deliver consolidated data for timely analysis of cost of care for individual patients. This information may be useful in negotiating profitable contracts. 2) A clinical pathway was successful in reducing the difference in cost of care between profitable and nonprofitable postcraniotomy cases. 3) In today's health care environment both cost containment and revenue assume importance in determining profitability.

A randomized study comparing skin closure in cesarean sections: staples vs subcuticular sutures.

PubMed

Rousseau, Julie-Anne; Girard, Karine; Turcot-Lemay, Lucile; Thomas, Nancy

2009-03-01

We sought to compare postoperative pain according to the skin closure method (subcuticular sutures vs staples) after an elective term cesarean section. A randomized controlled trial of 101 women was performed. Women were randomly assigned to subcuticular sutures or staples. Operative technique and postoperative analgesia were standardized. Stratification was used for primary vs repeat cesareans. Analog pain and satisfaction scales ranging from 0-10 were completed at postoperative days 1 and 3, and at 6 weeks postoperatively. A digital photograph of the incision was taken at 6 weeks postoperatively and evaluated by 3 independent blinded observers. Pain at 6 weeks postoperatively was significantly less in the staple group (0.17 vs 0.51; P = .04). Operative time was shorter in that group (24.6 vs 32.9 minutes; P < .0001). No difference was noted for incision appearance and women's satisfaction. Staples are the method of choice for skin closure for elective term cesareans in our population.

A Tortuous Process of Surgical Treatment for a Large Calcified Chronic Subdural Hematoma.

PubMed

Li, Huan; Mao, Xiang; Tao, Xiao-Gang; Li, Jing-Sheng; Liu, Bai-Yun; Wu, Zhen

2017-12-01

Calcified chronic subdural hematoma (CCSDH) is a rare disease for which no standard approach to treatment has been established. Reports covering both burr hole trepanation and craniotomy for CCSDH are rare. Furthermore, infection of CCSDH after the burr hole trepanation has not been reported in the literature. A 61-year-old man presented with left frontotemporoparietal CCSDH demonstrated on computed tomography (CT) scan. The patient underwent 2 separate burr hole trepanations with intraoperative irrigation and postoperative drainage. These procedures led to infection of the CCSDH. The patient eventually underwent an open craniotomy to provide complete removal of the hematoma. Owing to the complex contents of a CCSDH, burr hole trepanation cannot adequately drain the hematoma or relieve the mass effect. Craniotomy is a much more reliable approach for achieving complete resection of a CCSDH. Copyright © 2017 Elsevier Inc. All rights reserved.

Epidural Hematoma Complication after Rapid Chronic Subdural Hematoma Evacuation: A Case Report.

PubMed

Akpinar, Aykut; Ucler, Necati; Erdogan, Uzay; Yucetas, Cem Seyho

2015-07-06

Chronic subdural hematoma generally occurs in the elderly. After chronic subdural hematoma evacuation surgery, the development of epidural hematoma is a very rare entity. We report the case of a 41-year-old man with an epidural hematoma complication after chronic subdural hematoma evacuation. Under general anesthesia, the patient underwent a large craniotomy with closed system drainage performed to treat the chronic subdural hematoma. After chronic subdural hematoma evacuation, there was epidural leakage on the following day. Although trauma is the most common risk factor in young CSDH patients, some other predisposing factors may exist. Intracranial hypotension can cause EDH. Craniotomy and drainage surgery can usually resolve the problem. Because of rapid dynamic intracranial changes, epidural leakages can occur. A large craniotomy flap and silicone drainage in the operation area are key safety points for neurosurgeons and hydration is essential.

Social influence and political mobilization: Further evidence from a randomized experiment in the 2012 U.S. presidential election

PubMed Central

Bond, Robert M.; Bakshy, Eytan; Eckles, Dean; Fowler, James H.

2017-01-01

A large-scale experiment during the 2010 U.S. Congressional Election demonstrated a positive effect of an online get-out-the-vote message on real world voting behavior. Here, we report results from a replication of the experiment conducted during the U.S. Presidential Election in 2012. In spite of the fact that get-out-the-vote messages typically yield smaller effects during high-stakes elections due to saturation of mobilization efforts from many sources, a significant increase in voting was again observed. Voting also increased significantly among the close friends of those who received the message to go to the polls, and the total effect on the friends was likely larger than the direct effect, suggesting that understanding social influence effects is potentially even more important than understanding the direct effects of messaging. These results replicate earlier work and they add to growing evidence that online social networks can be instrumental for spreading offline behaviors. PMID:28445476

Social influence and political mobilization: Further evidence from a randomized experiment in the 2012 U.S. presidential election.

PubMed

Jones, Jason J; Bond, Robert M; Bakshy, Eytan; Eckles, Dean; Fowler, James H

2017-01-01

A large-scale experiment during the 2010 U.S. Congressional Election demonstrated a positive effect of an online get-out-the-vote message on real world voting behavior. Here, we report results from a replication of the experiment conducted during the U.S. Presidential Election in 2012. In spite of the fact that get-out-the-vote messages typically yield smaller effects during high-stakes elections due to saturation of mobilization efforts from many sources, a significant increase in voting was again observed. Voting also increased significantly among the close friends of those who received the message to go to the polls, and the total effect on the friends was likely larger than the direct effect, suggesting that understanding social influence effects is potentially even more important than understanding the direct effects of messaging. These results replicate earlier work and they add to growing evidence that online social networks can be instrumental for spreading offline behaviors.

Care of Pediatric Neurosurgical Patients in Iraq in 2007: Clinical and Ethical Experience of a Field Hospital

DTIC Science & Technology

2010-09-01

epidural abscess from a prior craniotomy for trauma at our facility. Patient Care Of the 42 pediatric patients seen in consultation, 28 required surgical...bifrontal craniotomy for the repair of an anterior skull base inju- ry (3 cases), decompressive craniectomy (5 cases), local debridement and wound closure...for PHI (10 cases), ICP monitoring only (4 cases), spinal instrumentation (1 case), spinal exploration/debridement with lumbar drainage for

Von Hippel-Lindau Disease: A Rare Familiar Multi-System Disorder and the Impact of the Clinical Nurse Specialist

DTIC Science & Technology

1993-01-01

would undergo removal of both adrenal glands, the renal cell carcinomas, a cholecystectomy and a choledochoduodenostomy for biliary drainage . The...bleeding, renal failure, and pancreatitis. After recovery, a craniotomy would be done to remove the hemangioblastoma that had been bleeding. The...analgesia. After a three month convalescence, the patient had a craniotomy and was home within a week. The patient’s siblings have all had negative eye

Use of the Abdominal Aortic Tourniquet for Hemorrhage Control

DTIC Science & Technology

2013-10-01

simulate an epidural hematoma) using a bone drill to access the epidural space via a craniotomy and then use a small bladder and fill with fluid. We would...external pressure transducer and CSF drainage system. The catheter will be sutured in place and a nonocclusive dressing applied. The catheter will...diameter in relation to ICP. Craniotomy . A midline incision from the level of lateral canthi to 4-7cm past the external occipital protuberance will be

Evaluation of SOCOM Wireless Monitor in Trauma Patients

DTIC Science & Technology

2016-02-01

the need for craniotomy in the absence of neurologic change. J Trauma Acute Care Surg 2013 Apr;74(4):967-75. 35) Thorson CM, Van Haren RM, Ryan...Guarch GA, Hanna M, Allen CJ, Ray JJ, Schulman CI, Proctor KG, Sleeman D, Namias N: Need for percutaneous drainage after cholecystectomy is higher in...Repeat head CT after minimal brain injury predicts need for craniotomy in absence of neurologic change. a. Presented at 71rst Annual Meeting of

Should epidural drain be recommended after supratentorial craniotomy for epileptic patients?

PubMed

Guangming, Zhang; Huancong, Zuo; Wenjing, Zhou; Guoqiang, Chen; Xiaosong, Wang

2009-08-01

ED was once and is still commonly applied to prevent mainly EH and subgaleal CSF collection. We designed this study to observe if ED could decrease the incidence and volume of EH and subgaleal CSF collection after supratentorial craniotomy in epileptic patients. Three hundred forty-two epileptic patients were divided into 2 groups according to their first craniotomy date (group 1 in odd date and group 2 in even date). Patients in group 1 had ED and those in group 2 had no ED. The patient numbers and volumes of EH and subgaleal CSF collections in both groups were recorded and statistically analyzed. There were 22 EHs in group 1 and 20 EHs in group 2. There were 11 and 10 subgaleal CSF collections in groups 1 and 2, respectively. The average volume of EH was 13.5 +/- 8.12 and 14.65 +/- 7.72 mL in groups 1 and 2, respectively. The average volume of subgaleal CSF collection was 42.76 +/- 12.09 and 43.75 +/- 11.44 mL in groups 1 and 2, respectively. There were no statistical differences in the incidence and average volume of EH and subgaleal CSF collection between the 2 groups. ED cannot decrease the incidence and volume of EH and subgaleal CSF collection. ED should not be recommended after supratentorial epileptic craniotomy.

[Risk factors for surgical site infections in patients undergoing craniotomy].

PubMed

Cha, Kyeong-Sook; Cho, Ok-Hee; Yoo, So-Yeon

2010-04-01

The objectives of this study were to determine the prevalence, incidence, and risk factors for postoperative surgical site infections (SSIs) after craniotomy. This study was a retrospective case-control study of 103 patients who had craniotomies between March 2007 and December 2008. A retrospective review of prospectively collected databases of consecutive patients who underwent craniotomy was done. SSIs were defined by using the Centers for Disease Control criteria. Twenty-six cases (infection) and 77 controls (no infection) were matched for age, gender and time of surgery. Descriptive analysis, t-test, X(2)-test and logistic regression analyses were used for data analysis. The statistical difference between cases and controls was significant for hospital length of stay (>14 days), intensive care unit stay more than 15 days, Glasgrow Coma Scale (GCS) score (< or = 7 days), extra-ventricular drainage and coexistent infection. Risk factors were identified by logistic regression and included hospital length of stay of more than 14 days (odds ratio [OR]=23.39, 95% confidence interval [CI]=2.53-216.11) and GCS score (< or = 7 scores) (OR=4.71, 95% CI=1.64-13.50). The results of this study show that patients are at high risk for infection when they have a low level of consciousness or their length hospital stay is long term. Nurses have to take an active and continuous approach to infection control to help with patients having these risk factors.

Efficacy and safety of key hole craniotomy for the evacuation of spontaneous cerebellar hemorrhage.

PubMed

Tokimura, Hiroshi; Tajitsu, Kenichiro; Taniguchi, Ayumi; Yamahata, Hitoshi; Tsuchiya, Masahiro; Takayama, Kenji; Shinsato, Tomomi; Arita, Kazunori

2010-01-01

The efficacy and safety of cerebellar hemorrhage evacuation by key hole craniotomy and the importance of thorough evacuation and irrigation of the hematoma in the fourth ventricle to resolve obstructive hydrocephalus were assessed in 23 patients with spontaneous cerebellar hemorrhage (SCH) greater than 3 cm or with brainstem compression and hydrocephalus. A 5-cm elongated S-shaped scalp incision was made, and a 3-cm key hole craniotomy was performed over a cerebellar convexity area. The hematoma was immediately evacuated through a small corticotomy. The hematoma in the fourth ventricle was gently removed through the hematoma cavity, followed by thorough saline irrigation to release obstructive hydrocephalus. Patients classified retrospectively into favorable and poor outcome groups using the Glasgow Outcome Scale (GOS) scores of 4-5 vs. 1-3 showed significant differences with respect to the preoperative Glasgow Coma Scale, hematoma size and volume, and brainstem compression. Only 2 of the 23 patients required ventricular drainage and no postoperative complications were recorded. Patients treated by experienced and inexperienced surgeons showed no significant differences in the hematoma evacuation rate, postoperative GOS, and interval from skin incision to start of hematoma evacuation. Our simplified method of key hole craniotomy to treat SCH was less invasive but easy to perform, as even inexperienced neurosurgeons could obtain good surgical results. Thorough cleaning of the fourth ventricle minimized the necessity for ventricular drainage.

Successful Insular Glioma Removal in a Deaf Signer Patient During an Awake Craniotomy Procedure.

PubMed

Metellus, Philippe; Boussen, Salah; Guye, Maxime; Trebuchon, Agnes

2017-02-01

Resection of tumors located within the insula of the dominant hemisphere represents a technical challenge because of the complex anatomy, including the surrounding vasculature, and the relationship to functional (motor and language) structures. We report here the case of a successful resection of a left insular glioma in a native deaf signer during an awake craniotomy. The patient, a congenitally deaf right-handed patient who is a native user of sign language, presented with a seizure 1 week before he was referred to our department. Magnetic resonance imaging revealed a left heterogeneous insular tumor enhanced after intravenous gadolinium infusion. Because of its deep and dominant hemisphere location, an awake craniotomy was decided. The patient was evaluated intraoperatively using object naming, text reading, and sign repetition tasks. An isolated inferior frontal gyrus site evoked repeated object naming errors. A transopercular parietal approach was performed and allowed the successful removal of the tumor under direct electric stimulation and electrocorticography. To our knowledge, this is the first report of successful removal of a left insular tumor without any functional sequelae in a native deaf signer using intraoperative direct cerebral stimulation during an awake craniotomy. The methodology used also provides the first evidence of the actual anatomo-functional organization of language in deaf signers. Copyright © 2016 Elsevier Inc. All rights reserved.

Orbitopterional Craniotomy Resection of Pediatric Suprasellar Craniopharyngioma.

PubMed

LeFever, Devon; Storey, Chris; Guthikonda, Bharat

2018-04-01

The orbitopterional approach provides an excellent combination of basal access and suprasellar access. This approach also allows for less brain retraction when resecting larger suprasellar tumors that are more superiorly projecting due to a more frontal and inferior trajectory. In this operative video, the authors thoroughly detail an orbitopterional craniotomy utilizing a one-piece modified orbitozygomatic technique. This technique involves opening the craniotomy through a standard pterional incision. The craniotomy is performed using the standard three burr holes of a pterional approach; however, the osteotomy is extended anteriorly through the frontal process of the zygomatic bone as well as through the supraorbital rim. In this operative video atlas, the authors illustrate the operative anatomy, as well as surgical strategy and techniques to resect a large suprasellar craniopharyngioma in a 4-year-old male. Other reasonable approach options for a lesion of this size would include a standard pterional approach, a supraorbital approach, or expanded endoscopic transsphenoidal approach. The lesion was quite high and thus, the supraorbital approach may confine access to the superior portion of the tumor. While recognizing that some groups may have chosen the endoscopic expanded transsphenoidal approach for this lesion, the authors describe more confidence in achieving the goal of a safe and maximal resection with the orbitopterional approach. The link to the video can be found at: https://youtu.be/eznsK16BzR8 .

Chronic Subdural Hematoma Infected by Propionibacterium Acnes: A Case Report

PubMed Central

Yamamoto, Shusuke; Asahi, Takashi; Akioka, Naoki; Kashiwazaki, Daina; Kuwayama, Naoya; Kuroda, Satoshi

2015-01-01

We present a very rare case of a patient with an infected subdural hematoma due to Propionibacterium acnes. A 63-year-old male complained of dizziness and was admitted to our hospital. He had a history of left chronic subdural hematoma due to a traffic accident, which had been conservatively treated. Physical, neurological and laboratory examinations revealed no definite abnormality. Plain CT scan demonstrated a hypodense crescentic fluid collection over the surface of the left cerebral hemisphere. The patient was diagnosed with chronic subdural hematoma and underwent burr hole surgery three times and selective embolization of the middle meningeal artery, but the lesion easily recurred. Repeated culture examinations of white sedimentation detected P. acnes. Therefore, he underwent craniotomy surgery followed by intravenous administration of antibiotics. The infected subdural hematoma was covered with a thick, yellowish outer membrane, and the large volume of pus and hematoma was removed. However, the lesion recurred again and a low-density area developed in the left frontal lobe. Craniotomy surgery was performed a second time, and two Penrose drainages were put in both the epidural and subdural spaces. Subsequently, the lesions completely resolved and he was discharged without any neurological deficits. Infected subdural hematoma may be refractory to burr hole surgery or craniotomy alone, in which case aggressive treatment with craniotomy and continuous drainage should be indicated before the brain parenchyma suffers irreversible damage. PMID:25759659

Usefulness of an Osteotomy Template for Skull Tumorectomy and Simultaneous Skull Reconstruction.

PubMed

Oji, Tomito; Sakamoto, Yoshiaki; Miwa, Tomoru; Nakagawa, Yu; Yoshida, Kazunari; Kishi, Kazuo

2016-09-01

Simultaneous tumor resection and cranioplasty with hydroxyapatite osteosynthesis are sometimes necessary in patients of skull neoplasms or skull-invasive tumors. However, the disadvantage of simultaneous surgery is that mismatches often occur between the skull defect and the hydroxyapatite implant. To solve this problem, the authors developed a customized template for designing the craniotomy line. Before each operation, the craniotomy design was discussed with a neurosurgeon. Based on the discussion, 2 hydroxyapatite implants were customized for each patient on the basis of models prepared using computed tomography data. The first implant was an onlay template for the preoperative cranium, which was customized for designing the osteotomy line. The other implant was used for the skull defect. Using the template, the osteotomy line was drawn along the template edge, osteotomy was performed along this line, and the implant was placed in the skull defect. This technique was performed in 3 patients. No implant or defect trimming was required in any patient, good cosmetic outcomes were noted in all patients, and no complications occurred. Use of predesigned hydroxyapatite templates for craniotomy during simultaneous skull tumor resection and cranioplasty has some clinical advantages: the precise craniotomy line can be designed, the implant and skull defect fit better and show effective osteoconduction, trimming of the implant or defect is minimized, and the operation time is shortened.

Surgical site infections following colorectal cancer surgery: a randomized prospective trial comparing common and advanced antimicrobial dressing containing ionic silver.

PubMed

Biffi, Roberto; Fattori, Luca; Bertani, Emilio; Radice, Davide; Rotmensz, Nicole; Misitano, Pasquale; Cenciarelli, Sabine; Chiappa, Antonio; Tadini, Liliana; Mancini, Marina; Pesenti, Giovanni; Andreoni, Bruno; Nespoli, Angelo

2012-05-23

An antimicrobial dressing containing ionic silver was found effective in reducing surgical-site infection in a preliminary study of colorectal cancer elective surgery. We decided to test this finding in a randomized, double-blind trial. Adults undergoing elective colorectal cancer surgery at two university-affiliated hospitals were randomly assigned to have the surgical incision dressed with Aquacel Ag Hydrofiber dressing or a common dressing. To blind the patient and the nursing and medical staff to the nature of the dressing used, scrub nurses covered Aquacel Ag Hydrofiber with a common wound dressing in the experimental arm, whereas a double common dressing was applied to patients of control group. The primary end-point of the study was the occurrence of any surgical-site infection within 30 days of surgery. A total of 112 patients (58 in the experimental arm and 54 in the control group) qualified for primary end-point analysis. The characteristics of the patient population and their surgical procedures were similar. The overall rate of surgical-site infection was lower in the experimental group (11.1% center 1, 17.5% center 2; overall 15.5%) than in controls (14.3% center 1, 24.2% center 2, overall 20.4%), but the observed difference was not statistically significant (P = 0.451), even with respect to surgical-site infection grade 1 (superficial) versus grades 2 and 3, or grade 1 and 2 versus grade 3. This randomized trial did not confirm a statistically significant superiority of Aquacel Ag Hydrofiber dressing in reducing surgical-site infection after elective colorectal cancer surgery. Clinicaltrials.gov: NCT00981110.

Efficacy of a single 40-mg intravenous dose of parecoxib for postoperative pain control after elective cesarean delivery: A double-blind randomized placebo-controlled trial.

PubMed

Inthigood, Nittaya; Lertbunnaphong, Tripop; Jaishuen, Atthapon

2017-01-01

The aim of this study was to determine the efficacy of a single 40-mg intravenous (i.v.) dose of parecoxib as an adjunctive analgesia to intrathecal morphine after elective cesarean delivery (CD). A total of 82 low-risk term pregnant women who were scheduled for elective CD during the June 2014-June 2015 study period were enrolled. Two hours after surgery, subjects were randomly assigned to receive either i.v. injection of 2 mL (40 mg) parecoxib (study group; n = 41) or 2 mL normal saline solution (control group; n = 41). Patient randomization into groups was determined by the hospital's central computer system. Outcome measurements included total postoperative supplemental meperidine consumption, recorded pain score by numeric pain rating scale at 6, 12, 18, and 24 h, postoperatively, and patient satisfaction. Patient characteristics and pregnancy outcomes were comparable between groups. Total postoperative meperidine consumption was not significantly different between groups (12.7 ± 18.8 mg vs 8.3 ± 16.7 mg; P > 0.05). Compared with control, the study group was significantly less likely to experience moderate to severe postoperative pain (score ≥ 4) at 6 h (0% vs 21.9%; P = 0.002). Study group patients reported higher satisfaction than control group patients (median score: 8 vs 6; P < 0.01). No patients in either group reported adverse effects from their assigned intervention. Parecoxib did not demonstrate effectiveness in reducing patient requirement for supplementary meperidine after CD. However, administration of a single 40-mg dose of i.v. parecoxib after elective CD demonstrated effectiveness in reducing pain scores, with a resulting increase in patient satisfaction. © 2016 Japan Society of Obstetrics and Gynecology.

Awake craniotomy for gliomas in a high-field intraoperative magnetic resonance imaging suite: analysis of 42 cases.

PubMed

Maldaun, Marcos V C; Khawja, Shumaila N; Levine, Nicholas B; Rao, Ganesh; Lang, Frederick F; Weinberg, Jeffrey S; Tummala, Sudhakar; Cowles, Charles E; Ferson, David; Nguyen, Anh-Thuy; Sawaya, Raymond; Suki, Dima; Prabhu, Sujit S

2014-10-01

The object of this study was to describe the experience of combining awake craniotomy techniques with high-field (1.5 T) intraoperative MRI (iMRI) for tumors adjacent to eloquent cortex. From a prospective database the authors obtained and evaluated the records of all patients who had undergone awake craniotomy procedures with cortical and subcortical mapping in the iMRI suite. The integration of these two modalities was assessed with respect to safety, operative times, workflow, extent of resection (EOR), and neurological outcome. Between February 2010 and December 2011, 42 awake craniotomy procedures using iMRI were performed in 41 patients for the removal of intraaxial tumors. There were 31 left-sided and 11 right-sided tumors. In half of the cases (21 [50%] of 42), the patient was kept awake for both motor and speech mapping. The mean duration of surgery overall was 7.3 hours (range 4.0-13.9 hours). The median EOR overall was 90%, and gross-total resection (EOR ≥ 95%) was achieved in 17 cases (40.5%). After viewing the first MR images after initial resection, further resection was performed in 17 cases (40.5%); the mean EOR in these cases increased from 56% to 67% after further resection. No deficits were observed preoperatively in 33 cases (78.5%), and worsening neurological deficits were noted immediately after surgery in 11 cases (26.2%). At 1 month after surgery, however, worsened neurological function was observed in only 1 case (2.3%). There was a learning curve with regard to patient positioning and setup times, although it did not adversely affect patient outcomes. Awake craniotomy can be safely performed in a high-field (1.5 T) iMRI suite to maximize tumor resection in eloquent brain areas with an acceptable morbidity profile at 1 month.

Incidence of intraoperative seizures during motor evoked potential monitoring in a large cohort of patients undergoing different surgical procedures.

PubMed

Ulkatan, Sedat; Jaramillo, Ana Maria; Téllez, Maria J; Kim, Jinu; Deletis, Vedran; Seidel, Kathleen

2017-04-01

OBJECTIVE The purpose of this study was to investigate the incidence of seizures during the intraoperative monitoring of motor evoked potentials (MEPs) elicited by electrical brain stimulation in a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. METHODS The authors retrospectively analyzed data from 4179 consecutive patients who underwent surgery or an interventional radiology procedure with MEP monitoring. RESULTS Of 4179 patients, only 32 (0.8%) had 1 or more intraoperative seizures. The incidence of seizures in cranial procedures, including craniotomies and interventional neuroradiology, was 1.8%. In craniotomies in which transcranial electrical stimulation (TES) was applied to elicit MEPs, the incidence of seizures was 0.7% (6/850). When direct cortical stimulation was additionally applied, the incidence of seizures increased to 5.4% (23/422). Patients undergoing craniotomies for the excision of extraaxial brain tumors, particularly meningiomas (15 patients), exhibited the highest risk of developing an intraoperative seizure (16 patients). The incidence of seizures in orthopedic spine surgeries was 0.2% (3/1664). None of the patients who underwent surgery for conditions of the spinal cord, neck, or peripheral nerves or who underwent cranial or noncranial interventional radiology procedures had intraoperative seizures elicited by TES during MEP monitoring. CONCLUSIONS In this largest such study to date, the authors report the incidence of intraoperative seizures in patients who underwent MEP monitoring during a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. The low incidence of seizures induced by electrical brain stimulation, particularly short-train TES, demonstrates that MEP monitoring is a safe technique that should not be avoided due to the risk of inducing seizures.

Use of Performance Measures to Evaluate, Document Competence and Deterioration of Advanced Surgical Skills Exposure for Trauma (ASSET) Surgical Skills

DTIC Science & Technology

2015-03-01

71(2):193- 7. 13. Lobel DA, Elder JB, Schirmer CM, Bowyer MW, Rezai AR. A novel craniotomy simulator provides a validated method to enhance...MW, Rezai AR. A novel craniotomy simulator provides a validated method to enhance education in the management of traumatic brain injury...comparisons are significant at pɘ.05 - Wilcoxon matched pairs) A Specialty 0 5 10 15 20 Thoracotomy in ED Repair/ Drainage Hapatic Lacs- Open Neck exploration

Current US Military Operations and Implications for Military Surgical Training

DTIC Science & Technology

2010-11-01

with most procedures encountered except nephrectomy (1.5 proce- dures per resident [PPR]), craniotomy (1.1 PPRs), inferior vena cava injury (1.1 PPRs... craniotomy , IVC injury, duodenal injury, and bladder re- pair. Residents had minimal experience with external fixa- tion of skeletal injury and...vascular injury 3.5 NR Nephrectomy 3.5 1.5 Pancreatic drainage 2.8 1.9 IVC injury 2.4 1.1 Duodenal injury 2.2 0.6 NR, procedure frequency not captured

[Osteomyelitis due to Yokenella regensburgei following craniotomy in an immunocompetent patient].

PubMed

Penagos, Sara Catalina; Gómez, Sebastián; Villa, Pablo; Estrada, Santiago; Agudelo, Carlos Andrés

2015-01-01

The gram-negative bacillus Yokenella regensburgei (of the Enterobacteriaceae family) can be found in groundwater and foodstuffs, as well as the digestive tracts of insects and reptiles. Although it has been isolated from humans since its original description, it has rarely been reported as a cause of infection, and then, only in immunosuppressed patients. We report the first case of post-surgical secondary osteomyelitis due to Y. regensburgei in an immunocompetent woman who had undergone a craniotomy.

OsiriX software as a preoperative planning tool in cranial neurosurgery: A step-by-step guide for neurosurgical residents

PubMed Central

Spiriev, Toma; Nakov, Vladimir; Laleva, Lili; Tzekov, Christo

2017-01-01

Background: OsiriX (Pixmeo, Switzerland) is an open-source Digital Imaging and Communications in Medicine (DICOM) viewer that is gaining more and more attention in the neurosurgical community because of its user-friendly interface, powerful three-dimensional (3D) volumetric rendering capabilities, and various options for data integration. This paper presents in detail the use of OsiriX software as a preoperative planning tool in cranial neurosurgery. Methods: In January 2013, OsiriX software was introduced into our clinical practice as a preoperative planning tool. Its capabilities are being evaluated on an ongoing basis in routine elective cranial cases. Results: The program has proven to be highly effective at volumetrically representing data from radiological examinations in 3D. Among its benefits in preoperative planning are simulating the position and exact location of the lesion in 3D, tailoring the skin incision and craniotomy bone flap, enhancing the representation of normal and pathological anatomy, and aiding in planning the reconstruction of the affected area. Conclusion: OsiriX is a useful tool for preoperative planning and visualization in neurosurgery. The software greatly facilitates the surgeon's understanding of the relationship between normal and pathological anatomy and can be used as a teaching tool. PMID:29119039

Epidural Hematoma Complication after Rapid Chronic Subdural Hematoma Evacuation: A Case Report

PubMed Central

Akpinar, Aykut; Ucler, Necati; Erdogan, Uzay; Yucetas, Cem Seyho

2015-01-01

Patient: Male, 41 Final Diagnosis: Healty Symptoms: Headache Medication: — Clinical Procedure: Chronic subdural hematoma Specialty: Neurosurgery Objective: Diagnostic/therapeutic accidents Background: Chronic subdural hematoma generally occurs in the elderly. After chronic subdural hematoma evacuation surgery, the development of epidural hematoma is a very rare entity. Case Report: We report the case of a 41-year-old man with an epidural hematoma complication after chronic subdural hematoma evacuation. Under general anesthesia, the patient underwent a large craniotomy with closed system drainage performed to treat the chronic subdural hematoma. After chronic subdural hematoma evacuation, there was epidural leakage on the following day. Conclusions: Although trauma is the most common risk factor in young CSDH patients, some other predisposing factors may exist. Intracranial hypotension can cause EDH. Craniotomy and drainage surgery can usually resolve the problem. Because of rapid dynamic intracranial changes, epidural leakages can occur. A large craniotomy flap and silicone drainage in the operation area are key safety points for neurosurgeons and hydration is essential. PMID:26147957

[Awake craniotomy. Considerations in special situations].

PubMed

Solera Ruiz, I; Uña Orejón, R; Valero, I; Laroche, F

2013-01-01

Awake craniotomy was the earliest surgical procedure known, and it has become fashionable again. In the past it was used for the surgical management of intractable epilepsy, but nowadays, its indications are increasing, and it is a widely recognized technique for the resection of mass lesions involving the eloquent cortex, and for deep brain stimulation. The procedure is safe, provides excellent results, and saves money and resources. The anesthesiologist should know the principles underlying neuroanesthesia, the technique of scalp blockade, and the sedation protocols, as well as feeling comfortable with advanced airway management. The main anesthetic aim is to keep patients cooperating when required (analgesia-based anesthesia). This review attempts to summarize the most recent evidence from the clinical literature, a long as the number of patients undergoing craniotomies in the awake state are increasing, specifically in the pediatric population. Copyright © 2011 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.

Tumefactive multiple sclerosis requiring emergency craniotomy: case report and literature review.

PubMed

Munarriz, Pablo M; Castaño-Leon, Ana M; Martinez-Perez, Rafael; Hernandez-Lain, Aurelio; Ramos, Ana; Lagares, Alfonso

2013-01-01

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system, characterized by focal neurological dysfunction with a relapsing and remitting course. Tumor-like presentation of MS (or "tumefactive"/"pseudotumoral" presentation) has been described before with a certain frequency; it consists of a large single plaque (>2cm) with presence of edema and mass effect and it is hard to distinguish from a brain tumor. However, we present a very rare case of a 53-year-old woman with a right temporal mass that turned out to be a MS plaque, who deteriorated within hours (brain herniation with loss of consciousness and unilateral mydriasis) and required an emergency craniotomy. We also present a review of the literature. It appears that only 4 cases of emergency craniotomy/craniectomy required in a patient with a tumor-like MS plaque have been reported before. Copyright © 2012 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.

Oral hydration for prevention of contrast-induced acute kidney injury in elective radiological procedures: a systematic review and meta-analysis of randomized controlled trials.

PubMed

Cheungpasitporn, Wisit; Thongprayoon, Charat; Brabec, Brady A; Edmonds, Peter J; O'Corragain, Oisin A; Erickson, Stephen B

2014-12-01

The reports on efficacy of oral hydration treatment for the prevention of contrast-induced acute kidney injury (CIAKI) in elective radiological procedures and cardiac catheterization remain controversial. The objective of this meta-analysis was to assess the use of oral hydration regimen for prevention of CIAKI. Comprehensive literature searches for randomized controlled trials (RCTs) of outpatient oral hydration treatment was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials Systematic Reviews, and clinicaltrials.gov from inception until July 4(th), 2014. Primary outcome was the incidence of CIAKI. Six prospective RCTs were included in our analysis. Of 513patients undergoing elective procedures with contrast exposures,45 patients (8.8%) had CIAKI. Of 241 patients with oral hydration regimen, 23 (9.5%) developed CIAKI. Of 272 patients with intravenous (IV) fluid regimen, 22 (8.1%) had CIAKI. Study populations in all included studies had relatively normal kidney function to chronic kidney disease (CKD) stage 3. There was no significant increased risk of CIAKI in oral fluid regimen group compared toIV fluid regimen group (RR = 0.94, 95% confidence interval, CI = 0.38-2.31). According to our analysis,there is no evidence that oral fluid regimen is associated with more risk of CIAKI in patients undergoing elective procedures with contrast exposures compared to IV fluid regimen. This finding suggests that the oral fluid regimen might be considered as a possible outpatient treatment option for CIAKI prevention in patients with normal to moderately reduced kidney function.

Increasing the Elective Endovascular to Open Repair Ratio of Popliteal Artery Aneurysm.

PubMed

Wrede, Axel; Wiberg, Frans; Acosta, Stefan

2018-02-01

Open repair (OR) for popliteal artery aneurysm (PAA) has recently been challenged by endovascular repair (ER) as the primary choice of treatment. The aim of the present study was to evaluate time trends in treatment modality and compare outcomes between OR and ER among electively operated patients after start of screening in 2010 for abdominal aortic aneurysm (AAA), a disease highly associated with PAA. Between January 1, 2009, and April 30, 2017, 102 procedures and 36 acute and 66 elective repairs for PAA were identified. Over time, a trend ( P = .089) for an increasing elective to acute repair ratio of PAA and an increase in elective ER to OR ratio ( P = .003) was found. Among electively repaired PAAs, the ER group was older ( P = .047) and had a higher ankle-brachial index (ABI; P = .044). The ER group had fewer wound infections ( P = .003), fewer major bleeding complications ( P = .046), and shorter in-hospital stay ( P < .001). After 1 year of follow-up, the ER group had a higher rate of major amputations ( P = .037). Amputation-free survival at the end of follow-up did not differ between groups ( P = .68). Among the 17 patients with PAA eligible for AAA screening, 4 (24%) were diagnosed with PAA through the screening program of AAA. The epidemiology of elective repair of PAA has changed toward increased ER, although ER showed a higher rate of major amputations at 1 year. Confounding was considerable and a randomized trial is needed for evaluation of the best therapeutic option.

High School Students with Reading Comprehension Difficulties: Results of a Randomized Control Trial of a Two-Year Reading Intervention

ERIC Educational Resources Information Center

Vaughn, Sharon; Roberts, Greg; Wexler, Jade; Vaughn, Michael G.; Fall, Anna-Mária; Schnakenberg, Jennifer B.

2015-01-01

A 2-year, randomized control trial with 9th to 10th grade students with significant reading problems was provided for 50 minutes a day in small groups. Comparison students were provided an elective class and treatment students the reading intervention. Students were identified as demonstrating reading difficulties through failure on their state…

Primary Enlarged Craniotomy in Organized Chronic Subdural Hematomas

PubMed Central

CALLOVINI, Giorgio Maria; BOLOGNINI, Andrea; CALLOVINI, Gemma; GAMMONE, Vincenzo

2014-01-01

The aim of the study is to evaluate the efficacy of craniotomy and membranectomy as initial treatment of organized chronic subdural hematoma (OCSH). We retrospectively reviewed a series of 34 consecutive patients suffering from OCSH, diagnosed by magnetic resonance imaging (MRI) or contrast computer tomography (CCT) in order to establish the degree of organization and determine the intrahematomal architecture. The indication to perform a primary enlarged craniotomy as initial treatment for non-liquefied chronic subdural hematoma (CSDH) with multilayer loculations was based on the hematoma MRI appearance—mostly hyperintense in both T1- and T2-weighted images with a hypointense web- or net-like structure within the hematoma cavity. The reason why some hematomas evolve towards a complex and organized architecture remains unclear; the most common aspect to come to light was the “long standing” of the CSDHs which, in our series, had an average interval of 10 weeks between head injury and initial scan. Recurrence was found to have occurred in 2 patients (6% of cases) in the form of acute subdural hematoma. One patient died as the result of an intraventricular and subarachnoid haemorrhage, while 2 patients (6%) suffered an haemorrhagic stroke ipsilateral to the OCSH. Eighty-nine percent of cases had a good recovery, while 11% remained unchanged or worsened. In select cases, based on the MRI appearance, primary enlarged craniotomy seems to be the treatment of choice for achieving a complete recovery and a reduced recurrence rate in OCSH. PMID:24305027

Training anesthesiology residents in providing anesthesia for awake craniotomy: learning curves and estimate of needed case load.

PubMed

Bilotta, Federico; Titi, Luca; Lanni, Fabiana; Stazi, Elisabetta; Rosa, Giovanni

2013-08-01

To measure the learning curves of residents in anesthesiology in providing anesthesia for awake craniotomy, and to estimate the case load needed to achieve a "good-excellent" level of competence. Prospective study. Operating room of a university hospital. 7 volunteer residents in anesthesiology. Residents underwent a dedicated training program of clinical characteristics of anesthesia for awake craniotomy. The program was divided into three tasks: local anesthesia, sedation-analgesia, and intraoperative hemodynamic management. The learning curve for each resident for each task was recorded over 10 procedures. Quantitative assessment of the individual's ability was based on the resident's self-assessment score and the attending anesthesiologist's judgment, and rated by modified 12 mm Likert scale, reported ability score visual analog scale (VAS). This ability VAS score ranged from 1 to 12 (ie, very poor, mild, moderate, sufficient, good, excellent). The number of requests for advice also was recorded (ie, resident requests for practical help and theoretical notions to accomplish the procedures). Each task had a specific learning rate; the number of procedures necessary to achieve "good-excellent" ability with confidence, as determined by the recorded results, were 10 procedures for local anesthesia, 15 to 25 procedures for sedation-analgesia, and 20 to 30 procedures for intraoperative hemodynamic management. Awake craniotomy is an approach used increasingly in neuroanesthesia. A dedicated training program based on learning specific tasks and building confidence with essential features provides "good-excellent" ability. © 2013 Elsevier Inc. All rights reserved.

Specificities of Awake Craniotomy and Brain Mapping in Children for Resection of Supratentorial Tumors in the Language Area.

PubMed

Delion, Matthieu; Terminassian, Aram; Lehousse, Thierry; Aubin, Ghislaine; Malka, Jean; N'Guyen, Sylvie; Mercier, Philippe; Menei, Philippe

2015-12-01

In the pediatric population, awake craniotomy began to be used for the resection of brain tumor located close to eloquent areas. Some specificities must be taken into account to adapt this method to children. The aim of this clinical study is to not only confirm the feasibility of awake craniotomy and language brain mapping in the pediatric population but also identify the specificities and necessary adaptations of the procedure. Six children aged 11 to 16 were operated on while awake under local anesthesia with language brain mapping for supratentorial brain lesions (tumor and cavernoma). The preoperative planning comprised functional magnetic resonance imaging (MRI) and neuropsychologic and psychologic assessment. The specific preoperative preparation is clearly explained including hypnosis conditioning and psychiatric evaluation. The success of the procedure was based on the ability to perform the language brain mapping and the tumor removal without putting the patient to sleep. We investigated the pediatric specificities, psychological experience, and neuropsychologic follow-up. The children experienced little anxiety, probably in large part due to the use of hypnosis. We succeeded in doing the cortical-subcortical mapping and removing the tumor without putting the patient to sleep in all cases. The psychological experience was good, and the neuropsychologic follow-up showed a favorable evolution. Preoperative preparation and hypnosis in children seemed important for performing awake craniotomy and contributing language brain mapping with the best possible psychological experience. The pediatrics specificities are discussed. Copyright © 2015 Elsevier Inc. All rights reserved.

Diagnostic work up for language testing in patients undergoing awake craniotomy for brain lesions in language areas.

PubMed

Bilotta, Federico; Stazi, Elisabetta; Titi, Luca; Lalli, Diana; Delfini, Roberto; Santoro, Antonio; Rosa, Giovanni

2014-06-01

Awake craniotomy is the technique of choice in patients with brain tumours adjacent to primary and accessory language areas (Broca's and Wernicke's areas). Language testing should be aimed to detect preoperative deficits, to promptly identify the occurrence of new intraoperative impairments and to establish the course of postoperative language status. Aim of this case series is to describe our experience with a dedicated language testing work up to evaluate patients with or at risk for language disturbances undergoing awake craniotomy for brain tumour resection. Pre- and intra operative testing was accomplished with 8 tests. Intraoperative evaluation was accomplished when patients were fully cooperative (Ramsey < 3). Postoperative evaluation was scheduled at early (within 21 days) and long-term follow-up (3-6 months). Twenty consecutive patients were prospectively recruited. Preoperative language testings were normal in 9 patients (45%), showed mild to moderate language deficit in 8 (40%) and severe language deficit or aphasic disorders in 3 (15%). Broca's area was identified in 15 patients, in all cases by counting arrest during stimulation and in 12 cases by naming arrest. In this article we describe our experience using a language testing work up to evaluate - pre, intra and postoperatively - patients undergoing awake craniotomy for brain tumour resection with preoperative language disturbances or at risk for postoperative language deficits. This approach allows a systematic evaluation and recording of language function status and can be accomplished even when a neuropsychologist or speech therapist are not involved in the operation crew.

Awake right hemisphere brain surgery.

PubMed

Hulou, M Maher; Cote, David J; Olubiyi, Olutayo I; Smith, Timothy R; Chiocca, E Antonio; Johnson, Mark D

2015-12-01

We report the indications and outcomes of awake right hemispheric brain surgery, as well as a rare patient with crossed aphasia. Awake craniotomies are often performed to protect eloquent cortex. We reviewed the medical records for 35 of 96 patients, in detail, who had awake right hemisphere brain operations. Intraoperative cortical mapping of motor and/or language function was performed in 29 of the 35 patients. A preoperative speech impairment and left hand dominance were the main indicators for awake right-sided craniotomies in patients with right hemisphere lesions. Four patients with lesion proximity to eloquent areas underwent awake craniotomies without cortical mapping. In addition, one patient had a broncho-pulmonary fistula, and another had a recent major cardiac procedure that precluded awake surgery. An eloquent cortex representation was identified in 14 patients (48.3%). Postoperatively, seven of 17 patients (41.1%) who presented with weakness, experienced improvements in their motor functions, 11 of 16 (68.7%) with seizures became seizure-free, and seven of nine (77.7%) with moderate to severe headaches and one of two with a visual field deficit improved significantly. There were also improvements in speech and language functions in all patients who presented with speech difficulties. A right sided awake craniotomy is an excellent option for left handed patients, or those with right sided cortical lesions that result in preoperative speech impairments. When combined with intraoperative cortical mapping, both speech and motor function can be well preserved. Copyright © 2015 Elsevier Ltd. All rights reserved.

Incidence of chronic groin pain following open mesh inguinal hernia repair, and effect of elective division of the ilioinguinal nerve: meta-analysis of randomized controlled trials.

PubMed

Charalambous, M P; Charalambous, C P

2018-06-01

Chronic post-operative groin pain is a substantial complication following open mesh inguinal hernia repair. The exact cause of this pain is still unclear, but entrapment or trauma of the ilioinguinal nerve may have a role to play. Elective division of this nerve during hernia repair has been proposed in an attempt to reduce the incidence of chronic groin pain. We performed a meta-analysis of nine randomized controlled trials comparing preservation versus elective division of the ilioinguinal nerve during this operation. A substantial proportion of patients having open mesh inguinal hernia repair experience chronic groin pain when the ilioinguinal nerve is preserved (estimated rate of 9.4% at 6 months and 4.8% at 1 year). Elective division of the nerve resulted in a significant reduction of groin pain at 6-months post-surgery (RR 0.47, p = 0.02), including moderate/severe pain (RR 0.57, p = 0.01). However, division of the nerve also resulted in an increase of subjective groin numbness at this time point (RR 1.55, p = 0.06). At 12-month post-surgery, the beneficial effect of nerve division on chronic pain was reduced, with no significant difference in the rates of overall groin pain (RR 0.69, p = 0.38), or of moderate-to-severe groin pain (RR 0.99, p = 0.98) between the two groups. The prevalence of groin numbness was also similar between the two groups at 12-month post-surgery (RR 0.79, p = 0.48). Routine elective division of the ilioinguinal nerve during open mesh inguinal hernia repair does not significantly reduce chronic groin pain beyond 6 months, and may result in increased rates of groin numbness, especially in the first 6-months post-surgery.

Atypia in random periareolar fine-needle aspiration affects the decision of women at high risk to take tamoxifen for breast cancer chemoprevention.

PubMed

Goldenberg, Vanessa K; Seewaldt, Victoria L; Scott, Victoria; Bean, Gregory R; Broadwater, Gloria; Fabian, Carol; Kimler, Bruce; Zalles, Carola; Lipkus, Isaac M

2007-05-01

Random periareolar fine-needle aspiration (RPFNA) is a research procedure designed to (a) evaluate short-term breast cancer risk in women at high risk for developing breast cancer, and (b) track response to chemoprevention. Of import, cellular atypia in breast RPFNA is prospectively associated with a 5.6-fold increase in breast cancer risk in women at high risk. Among 99 women attending a clinic for high-risk breast cancer, we explored the effects of RPFNA cytology results on decision making pertaining to the use of tamoxifen for breast cancer chemoprevention. No patient with nonproliferative or hyperplastic cytology subsequently elected to take tamoxifen. Only 7% of subjects with borderline atypia elected to take tamoxifen. In contrast, 50% with atypia elected to take tamoxifen. These results suggest that the provision of a biomarker of short-term risk can affect the motivation to take tamoxifen for chemoprevention. This conclusion is informative given that tamoxifen, due to its side effects, is often underused by women at high risk of developing breast cancer. Further research is needed to determine the mechanisms through which RPFNA results affect the decision to use tamoxifen, or any other breast cancer chemopreventive agent.

Randomized Controlled Trial of Use of the Peanut Ball During Labor.

PubMed

Roth, Cheryl; Dent, Sarah A; Parfitt, Sheryl E; Hering, Sandra L; Bay, R Curtis

2016-01-01

The purpose of this study was to evaluate the efficacy of peanut ball use on duration of first stage labor and pushing time in women who were scheduled for elective induction of labor at ≥39 weeks gestation and planning an epidural. In this randomized controlled trial, women having labor induction and planning a labor epidural were assigned (1:1) to one of two groups: one group used a peanut ball and one group did not. Outcome variables were time spent in first stage labor and time spent pushing. Factors included group assignment (peanut ball, no peanut ball), parity (primiparous, multiparous), and race. Age and maximum oxytocin dose served as covariates. Among women having elective induction with epidural analgesia, use of a peanut ball reduced first stage labor duration for primiparous patients significantly more than multiparous patients, p = 0.018. There was no significant difference in the reduction of length of first stage labor for multiparous women, p = 0.057 with use of the peanut ball. Peanut ball use did not alter length of pushing time for either group, p > 0.05. Use of peanut balls may reduce total labor time to a greater degree in primiparous patients than multiparous patients having elective induction at ≥39 weeks with epidural analgesia.

SMS texts on corruption help Ugandan voters hold elected councillors accountable at the polls.

PubMed

Buntaine, Mark T; Jablonski, Ryan; Nielson, Daniel L; Pickering, Paula M

2018-06-11

Many politicians manipulate information to prevent voters from holding them accountable; however, mobile text messages may make it easier for nongovernmental organizations to credibly share information on official corruption that is difficult for politicians to counter directly. We test the potential for texts on budget management to improve democratic accountability by conducting a large ( n = 16,083) randomized controlled trial during the 2016 Ugandan district elections. In cooperation with a local partner, we compiled, simplified, and text-messaged official information on irregularities in local government budgets. Verified recipients of messages that described more irregularities than expected reported voting for incumbent councillors 6% less often; verified recipients of messages conveying fewer irregularities than expected reported voting for incumbent councillors 5% more often. The messages had no observable effect on votes for incumbent council chairs, potentially due to voters' greater reliance on other sources of information for higher profile elections. These mixed results suggest that text messages on budget corruption help voters hold some politicians accountable in settings where elections are not free and fair. Copyright © 2018 the Author(s). Published by PNAS.

Cranberry juice capsules and urinary tract infection post surgery: Results of a randomized trial

PubMed Central

Foxman, Betsy; Cronenwett, Ms. Anna E.W.; Spino, Cathie; Berger, Mitchell B.; Morgan, Daniel M.

2015-01-01

Objective The risk of urinary tract infection (UTI) among women undergoing elective gynecologic surgery where a catheter is placed is high: 10 to 64% following catheter removal. We conducted the first randomized, double-blind, placebo-controlled trial of the therapeutic efficacy of cranberry juice capsules in preventing UTI post surgery. Study Design We recruited patients from a single hospital between August 2011 and January 2013. Eligible participants were undergoing elective gynecologic surgery that did not involve a fistula repair or vaginal mesh removal. 160 patients were randomized and received two cranberry juice capsules two times a day, equivalent to two 8-ounce servings of cranberry juice, for 6 weeks after surgery, or matching placebo. The primary endpoint was the proportion of participants who experienced clinically-diagnosed and treated UTI with or without positive urine culture. Kaplan-Meier plots and logrank tests compared the two treatment groups. Results The occurrence of UTI was significantly lower in the cranberry treatment group compared to the placebo group (15/80 (19%) versus 30/80 (38%); OR=0.38; 95% CI: 0.19, 0.79; p=0.008). After adjustment for known confounders, including frequency of intermittent self-catheterization in the post- operative period, the protective effects of cranberry remained (OR=0.42; 95% CI: 0.18, 0.94). There were no treatment differences in the incidence of adverse events; including gastrointestinal upset (56% vs. 61% for cranberry vs. placebo). Conclusions Among women undergoing elective benign gynecologic surgery involving urinary catheterization, use of cranberry extract tablets during the postoperative period reduced the rate of UTI by half. PMID:25882919

Colonic stenting as bridge to surgery versus emergency surgery for management of acute left-sided malignant colonic obstruction: a multicenter randomized trial (Stent-in 2 study)

PubMed Central

van Hooft, Jeanin E; Bemelman, Willem A; Breumelhof, Ronald; Siersema, Peter D; Kruyt, Philip M; van der Linde, Klaas; Veenendaal, Roeland A; Verhulst, Marie-Louise; Marinelli, Andreas W; Gerritsen, Josephus JGM; van Berkel, Anne-Marie; Timmer, Robin; Grubben, Marina JAL; Scholten, Pieter; Geraedts, Alfons AM; Oldenburg, Bas; Sprangers, Mirjam AG; Bossuyt, Patrick MM; Fockens, Paul

2007-01-01

Background Acute left-sided colonic obstruction is most often caused by malignancy and the surgical treatment is associated with a high mortality and morbidity rate. Moreover, these operated patients end up with a temporary or permanent stoma. Initial insertion of an enteral stent to decompress the obstructed colon, allowing for surgery to be performed electively, is gaining popularity. In uncontrolled studies stent placement before elective surgery has been suggested to decrease mortality, morbidity and number of colostomies. However stent perforation can lead to peritoneal tumor spill, changing a potentially curable disease in an incurable one. Therefore it is of paramount importance to compare the outcomes of colonic stenting followed by elective surgery with emergency surgery for the management of acute left-sided malignant colonic obstruction in a randomized multicenter fashion. Methods/design Patients with acute left-sided malignant colonic obstruction eligible for this study will be randomized to either emergency surgery (current standard treatment) or colonic stenting as bridge to elective surgery. Outcome measurements are effectiveness and costs of both strategies. Effectiveness will be evaluated in terms of quality of life, morbidity and mortality. Quality of life will be measured with standardized questionnaires (EORTC QLQ-C30, EORTC QLQ-CR38, EQ-5D and EQ-VAS). Morbidity is defined as every event leading to hospital admission or prolonging hospital stay. Mortality will be analyzed as total mortality as well as procedure-related mortality. The total costs of treatment will be evaluated by counting volumes and calculating unit prices. Including 120 patients on a 1:1 basis will have 80% power to detect an effect size of 0.5 on the EORTC QLQ-C30 global health scale, using a two group t-test with a 0.05 two-sided significance level. Differences in quality of life and morbidity will be analyzed using mixed-models repeated measures analysis of variance. Mortality will be compared using Kaplan-Meier curves and log-rank statistics. Discussion The Stent-in 2 study is a randomized controlled multicenter trial that will provide evidence whether or not colonic stenting as bridge to surgery is to be performed in patients with acute left-sided colonic obstruction. Trial registration Current Controlled Trials ISRCTN46462267. PMID:17608947

[Effect of epidural drainage and dural tenting suture on epidural hematoma in 145 cases of craniotomy].

PubMed

Zhao, Jie; Liu, Zhixiong; Liu, Yunsheng; Liu, Jinfang; Fang, Wenhua; Rao, Yihua; Yang, Liang; Yuan, Xianrui

2010-03-01

To evaluate the efficacy of dural tenting suture and epidural drainage in craniotomy. In 145 cases of intracranial lesions, dural tenting suture and epidural drainage were performed to prevent epidural hematoma. Postoperative computed tomography (CT) showed no epidural hematoma required surgery in both groups. Both dural tenting suture and epidural drainage are effective in preventing epidural hematoma. Hemostasis is the key step. Dural tenting suture without epidural drainage relieves psychological stress. It decreases the risk of intracranial infection and avoids some unusual complications.

The Critical Size Defect as an Experimental Model for Craniomaxillofacial Nonunions,

DTIC Science & Technology

1985-01-01

union evident at two months. The wider defects of 12 m, 15 m, and 18 mm in length exhibited bony union in four months but exhibited drainage either...Prolo, D.J., (-btierrez, R.V., DeVine, J.S., and (*und, R.A.: Clinical l1tility of Alloqeneic Skull Discs in Human Craniotomy . Neurosurgery. 14:1R3, 1984...1. R rm craniotomy defect prepared in dried rat skull. Piq. 2. 15 rm craniotamy defect in dried rabbit skull. Fig. 3. r-ied dog mandible qhowing

Systematic review: elective induction of labor versus expectant management of pregnancy.

PubMed

Caughey, Aaron B; Sundaram, Vandana; Kaimal, Anjali J; Gienger, Allison; Cheng, Yvonne W; McDonald, Kathryn M; Shaffer, Brian L; Owens, Douglas K; Bravata, Dena M

2009-08-18

The rates of induction of labor and elective induction of labor are increasing. Whether elective induction of labor improves outcomes or simply leads to greater complications and health care costs is commonly debated in the literature. To compare the benefits and harms of elective induction of labor and expectant management of pregnancy. MEDLINE (through February 2009), Web of Science, CINAHL, Cochrane Central Register of Controlled Trials (through March 2009), bibliographies of included studies, and previous systematic reviews. Experimental and observational studies of elective induction of labor reported in English. Two authors abstracted study design; patient characteristics; quality criteria; and outcomes, including cesarean delivery and maternal and neonatal morbidity. Of 6117 potentially relevant articles, 36 met inclusion criteria: 11 randomized, controlled trials (RCTs) and 25 observational studies. Overall, expectant management of pregnancy was associated with a higher odds ratio (OR) of cesarean delivery than was elective induction of labor (OR, 1.22 [95% CI, 1.07 to 1.39]; absolute risk difference, 1.9 percentage points [CI, 0.2 to 3.7 percentage points]) in 9 RCTs. Women at or beyond 41 completed weeks of gestation who were managed expectantly had a higher risk for cesarean delivery (OR, 1.21 [CI, 1.01 to 1.46]), but this difference was not statistically significant in women at less than 41 completed weeks of gestation (OR, 1.73 [CI, 0.67 to 4.5]). Women who were expectantly managed were more likely to have meconium-stained amniotic fluid than those who were electively induced (OR, 2.04 [CI, 1.34 to 3.09]). There were no recent RCTs of elective induction of labor at less than 41 weeks of gestation. The 2 studies conducted at less than 41 weeks of gestation were of poor quality and were not generalizable to current practice. RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid. There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided.

Field experiment estimate of electoral fraud in Russian parliamentary elections

PubMed Central

Enikolopov, Ruben; Korovkin, Vasily; Petrova, Maria; Sonin, Konstantin; Zakharov, Alexei

2013-01-01

Electoral fraud is a widespread phenomenon, especially outside the developed world. Despite abundant qualitative and anecdotal evidence on its existence from around the world, there is very limited quantitative evidence on the extent of electoral fraud. We exploit random assignment of independent observers to 156 of 3,164 polling stations in the city of Moscow to estimate the effect of electoral fraud on the outcome of the Russian parliamentary elections held on December 4, 2011. We estimate the actual share of votes for the incumbent United Russia party to be at least 11 percentage points lower than the official count (36% instead of 47%). Our results suggest that the extent of the fraud was sufficient to have had a substantial impact on the outcome of the elections; they also confirm that the presence of observers is an important factor in ensuring the integrity of the procedure. PMID:23267093

Tumor location and IDH1 mutation may predict intraoperative seizures during awake craniotomy.

PubMed

Gonen, Tal; Grossman, Rachel; Sitt, Razi; Nossek, Erez; Yanaki, Raneen; Cagnano, Emanuela; Korn, Akiva; Hayat, Daniel; Ram, Zvi

2014-11-01

Intraoperative seizures during awake craniotomy may interfere with patients' ability to cooperate throughout the procedure, and it may affect their outcome. The authors have assessed the occurrence of intraoperative seizures during awake craniotomy in regard to tumor location and the isocitrate dehydrogenase 1 (IDH1) status of the tumor. Data were collected in 137 consecutive patients who underwent awake craniotomy for removal of a brain tumor. The authors performed a retrospective analysis of the incidence of seizures based on the tumor location and its IDH1 mutation status, and then compared the groups for clinical variables and surgical outcome parameters. Tumor location was strongly associated with the occurrence of intraoperative seizures. Eleven patients (73%) with tumor located in the supplementary motor area (SMA) experienced intraoperative seizures, compared with 17 (13.9%) with tumors in the other three non-SMA brain regions (p < 0.0001). Interestingly, there was no significant association between history of seizures and tumor location (p = 0.44). Most of the patients (63.6%) with tumor in the SMA region harbored an IDH1 mutation compared with those who had tumors in non-SMA regions. Thirty-one of 52 patients (60%) with a preoperative history of seizures had an IDH1 mutation (p = 0.02), and 15 of 22 patients (68.2%) who experienced intraoperative seizures had an IDH1 mutation (p = 0.03). In a multivariate analysis, tumor location was found as a significant predictor of intraoperative seizures (p = 0.002), and a trend toward IDH1 mutation as such a predictor was found as well (p = 0.06). Intraoperative seizures were not associated with worse outcome. Patients with tumors located in the SMA are more prone to develop intraoperative seizures during awake craniotomy compared with patients who have a tumor in non-SMA frontal areas and other brain regions. The IDH1 mutation was more common in SMA region tumors compared with other brain regions, and may be an additional risk factor for the occurrence of intraoperative seizures.

Necessity of Surgical Site Closed Suction Drain for Pterional Craniotomy

PubMed Central

Choi, Su Yong; Yoon, Sung Min; Yoo, Chan Jong; Kim, Young Bo; Kim, Woo Kyung

2015-01-01

Objective The aim of this study was to assess the benefit of using a prophylactic surgical site closed suction drain in pterional craniotomy. Materials and Methods A retrospective review was conducted on 607 consecutive patients who underwent a pterional craniotomy for treatment of intracranial anterior circulation aneurysms over a 5-year period. Between January 2000 and December 2004, 607 patients were divided into two groups, those who had a prophylactic suction drain during closure of the surgical site (drain group, DG) and those who did not (non-drain group, NDG). Head computed tomography (CT) was taken routinely on postoperative day (POD) 1, 7, and 14. Patients' demographics, incidence of surgical site complications, and courses of surgical site healing which were evaluated radiologically by the thickness of the surgical site myocutaneous layer, were analyzed between DG and NDG. Results Patients' demographics and characteristics did not differ significantly between the two groups. The head CT showed that the degree of changes in the postoperative surgical site thickness was 148% at POD 1, 209% at POD 7, and 198% at POD 14 in DG, and 118% at POD 1, 152% at POD 7, and 158% at POD 14 in NDG compared to the preoperative value. Postoperative surgical site hematoma was 7.9% (22/274) in DG and 2.4% (8/333) in NDG. Conclusion Prophylactic use of an epidural and/or subgaleal closed suction drain does not appear to be necessary for prevention of postoperative surgical site hematoma as well as for promotion of surgical site healing in pterional craniotomy. PMID:26523255

Acute Monocular Blindness Due to Orbital Compartment Syndrome Following Pterional Craniotomy.

PubMed

Habets, Jeroen G V; Haeren, Roel H L; Lie, Suen A N; Bauer, Noel J C; Dings, Jim T A

2018-06-01

We present a case of orbital compartment syndrome (OCS) leading to monocular irreversible blindness following a pterional craniotomy for clipping of an anterior communicating artery aneurysm. OCS is an uncommon but vision-threatening entity requiring urgent decompression to reduce the risk of permanent visual loss. Iatrogenic orbital roof defects are a common finding following pterional craniotomies. However, complications related to these defects are rarely reported. A 65-year-old female who underwent an anterior communicating artery clipping via a pterional approach 4 days before developed proptosis, ocular movement paresis, and irreversible visual impairment following an orthopedic surgery. Computed tomography images revealed an intraorbital cerebrospinal fluid (CSF) collection, which was evacuated via an acute recraniotomy. The next day, proptosis and intraorbital CSF collection on computed tomography images reoccurred and an oral and maxillofacial surgeon evacuated the collection via a blepharoplasty incision and blunt dissection. In addition, the patient was treated with acetazolamide and an external lumbar CSF drainage during 12 days. Hereafter, the CSF collection did not reoccur. Unfortunately, monocular blindness was persistent. We hypothesize the CSF collection occurred due to the combination of a postoperative orbital roof defect and a temporarily increased intracranial pressure during the orthopedic surgery. We plead for more awareness of this severe complication after pterional surgeries and emphasize the importance of 1) strict ophthalmologic examination after pterional craniotomies in case of intracranial pressure increasing events, 2) immediate consultation of an oral and maxillofacial surgeon, and 3) consideration of CSF-draining interventions since symptoms are severely invalidating and irreversible within a couple of hours. Copyright © 2018 Elsevier Inc. All rights reserved.

Awake craniotomy may further improve neurological outcome of intraoperative MRI-guided brain tumor surgery.

PubMed

Tuominen, Juho; Yrjänä, Sanna; Ukkonen, Anssi; Koivukangas, John

2013-10-01

Results of awake craniotomy are compared to results of resections done under general anesthesia in patients operated with IMRI control. We hypothesized that stimulation of the cortex and white matter during awake surgery supplements IMRI control allowing for safer resection of eloquent brain area tumors. The study group consisted of 20 consecutive patients undergoing awake craniotomy with IMRI control. Resection outcome of these patients was compared to a control group of 20 patients operated in the same IMRI suite but under general anesthesia without cortical stimulation. The control group was composed of those patients whose age, sex, tumor location, recurrence and histology best matched to patients in study group. Cortical stimulation identified functional cortex in eight patients (40 %). Postoperatively the neurological condition in 16 patients (80 %) in the study group was unchanged or improved compared with 13 patients (65 %) in the control group. In both groups, three patients (15 %) had transient impairment symptoms. There was one patient (5 %) with permanent neurological impairment in the study group compared to four patients (20 %) in the control group. These differences between groups were not statistically significant. There was no surgical mortality in either group and the overall infection rate was 5 %. Mean operation time was 4 h 45 min in the study group and 3 h 15 min in the control group. The study consisted of a limited patient series, but it implies that awake craniotomy with bipolar cortical stimulation may help to reduce the risk of postoperative impairment following resection of tumors located in or near speech and motor areas also under IMRI control.

The Cost of Brain Surgery: Awake vs Asleep Craniotomy for Perirolandic Region Tumors.

PubMed

Eseonu, Chikezie I; Rincon-Torroella, Jordina; ReFaey, Karim; Quiñones-Hinojosa, Alfredo

2017-08-01

Cost effectiveness has become an important factor in the health care system, requiring surgeons to improve efficacy of procedures while reducing costs. An awake craniotomy (AC) with direct cortical stimulation (DCS) presents one method to resect eloquent region tumors; however, some authors assert that this procedure is an expensive alternative to surgery under general anesthesia (GA) with neuromonitoring. To evaluate the cost effectiveness and clinical outcomes between AC and GA patients. Retrospective analysis of a cohort of 17 patients with perirolandic gliomas who underwent an AC with DCS were case-control matched with 23 patients with perirolandic gliomas who underwent surgery under GA with neuromonitoring (ie, motor-evoked potentials, somatosensory-evoked potentials, phase reversal). Inpatient costs, quality-adjusted life years (QALY), extent of resection, and neurological outcome were compared between the groups. Total inpatient expense per patient was $34 804 in the AC group and $46 798 in the GA group ( P = .046). QALY score for the AC group was 0.97 and 0.47 for the GA group ( P = .041). The incremental cost per QALY for the AC group was $82 720 less than the GA group. Postoperative Karnofsky performance status was 91.8 in the AC group and 81.3 in the GA group (P = .047). Length of hospitalization was 4.12 days in the AC group and 7.61 days in the GA group ( P = .049). The total inpatient costs for awake craniotomies were lower than surgery under GA. This study suggests better cost effectiveness and neurological outcome with awake craniotomies for perirolandic gliomas. Copyright © 2017 by the Congress of Neurological Surgeons

Clinical outcomes from maximum-safe resection of primary and metastatic brain tumors using awake craniotomy.

PubMed

Groshev, Anastasia; Padalia, Devang; Patel, Sephalie; Garcia-Getting, Rosemarie; Sahebjam, Solmaz; Forsyth, Peter A; Vrionis, Frank D; Etame, Arnold B

2017-06-01

To retrospectively analyze outcomes in patients undergoing awake craniotomies for tumor resection at our institution in terms of extent of resection, functional preservation and length of hospital stay. All cases of adults undergoing awake-craniotomy from September 2012-February 2015 were retrospectively reviewed based on an IRB approved protocol. Information regarding patient age, sex, cancer type, procedure type, location, hospital stay, extent of resection, and postoperative complications was extracted. 76 patient charts were analyzed. Resected cancer types included metastasis to the brain (41%), glioblastoma (34%), WHO grade III anaplastic astrocytoma (18%), WHO grade II glioma (4%), WHO grade I glioma (1%), and meningioma (1%). Over a half of procedures were performed in the frontal lobes, followed by temporal, and occipital locations. The most common indication was for motor cortex and primary somatosensory area lesions followed by speech. Extent of resection was gross total for 59% patients, near-gross total for 34%, and subtotal for 7%. Average hospital stay for the cohort was 1.7days with 75% of patients staying at the hospital for only 24h or less post surgery. In the postoperative period, 67% of patients experienced improvement in neurological status, 21% of patients experienced no change, 7% experienced transient neurological deficits, which resolved within two months post op, 1% experienced transient speech deficit, and 3% experienced permanent weakness. In a consecutive series of 76 patients undergoing maximum-safe resection for primary and metastatic brain tumors, awake-craniotomy was associated with a short hospital stay and low postoperative complications rate. Copyright © 2017 Elsevier B.V. All rights reserved.

Efficacy and Safety of a Lidocaine and Ropivacaine Mixture for Scalp Nerve Block and Local Infiltration Anesthesia in Patients Undergoing Awake Craniotomy.

PubMed

Chaki, Tomohiro; Sugino, Shigekazu; Janicki, Piotr K; Ishioka, Yoshiya; Hatakeyama, Yosuke; Hayase, Tomo; Kaneuchi-Yamashita, Miki; Kohri, Naonori; Yamakage, Michiaki

2016-01-01

Mixtures of various local anesthetics, such as lidocaine and ropivacaine, have been widely used. However, their efficacy and safety for scalp nerve blocks and local infiltration during awake craniotomy have not been fully elucidated. We prospectively investigated 53 patients who underwent awake craniotomy. Scalp block was performed for the blockade of the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, greater occipital, and lesser occipital nerves with a mixture containing equal volumes of 2% lidocaine and 0.75% ropivacaine, including 5 μg/mL of epinephrine. Infiltration anesthesia was applied at the site of skin incision using the same mixture. The study outcomes included changes in heart rate and blood pressure after head pinning and skin incision, and incidence of severe pain on emergence from anesthesia. Total doses and plasma concentrations of lidocaine and ropivacaine were measured at different time points after performing the block. The heart rate and blood pressure after head pinning were marginally, but significantly, increased when compared with baseline values. There were no significant differences in heart rate and blood pressure before and after the skin incision. Nineteen percent of the patients (10/53) complained of incisional pain at emergence from anesthesia. The highest observed blood concentrations of lidocaine and ropivacaine were 1.9±0.9 and 1.1±0.4 μg/mL, respectively. No acute anesthetic toxicity symptom was observed. Scalp block with a mixture of lidocaine and ropivacaine seems to provide effective and safe anesthetic management in patients undergoing awake craniotomy.

Using a Virtual Reality Social Network During Awake Craniotomy to Map Social Cognition: Prospective Trial.

PubMed

Bernard, Florian; Lemée, Jean-Michel; Aubin, Ghislaine; Ter Minassian, Aram; Menei, Philippe

2018-06-26

In awake craniotomy, it is possible to temporarily inactivate regions of the brain using direct electrical stimulation, while the patient performs neuropsychological tasks. If the patient shows decreased performance in a given task, the neurosurgeon will not remove these regions, so as to maintain all brain functions. The objective of our study was to describe our experience of using a virtual reality (VR) social network during awake craniotomy and discuss its future applications for perioperative mapping of nonverbal language, empathy, and theory of mind. This was a single-center, prospective, unblinded trial. During wound closure, different VR experiences with a VR headset were proposed to the patient. This project sought to explore interactions with the neuropsychologist's avatar in virtual locations using a VR social network as an available experience. Three patients experienced VR. Despite some limitations due to patient positioning during the operation and the limitation of nonverbal cues inherent to the app, the neuropsychologist, as an avatar, could communicate with the patient and explore gesture communication while wearing a VR headset. With some improvements, VR social networks can be used in the near future to map social cognition during awake craniotomy. ClinicalTrials.gov NCT03010943; https://clinicaltrials.gov/ct2/show/NCT03010943 (Archived at WebCite at http://www.webcitation.org/70CYDil0P). ©Florian Bernard, Jean-Michel Lemée, Ghislaine Aubin, Aram Ter Minassian, Philippe Menei. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 26.06.2018.

[How much pressure is applied on the eye balls during craniotomy?: Measurement with FlexiForce contact surface force sensor].

PubMed

Okada, Takeshi; Ishikawa, Tatsuya; Nishimura, Hiromi; Suzuki, Akifumi

2012-12-01

Visual loss following craniotomy is a serious postoperative complication in which elevation of ocular pressure during retraction of the skin flap may cause retinal ischemia. We reported that continuous monitoring of extraocular pressure with the FlexiForce sensor may avoid excessive skin flap retraction during craniotomy and thus prevent ocular complications. Between January 2008 and December 2011, we analyzed data from 46 consecutive patients for whom continuous monitoring of extraocular pressure with FlexiForce sensor was performed. This sensor continuously displays the compressive force, allowing surgeons to check values on the monitor at any time. An alarm sounds if 50 gf is exceeded. We analyzed the temporal course of extraocular pressure and the relationship with patient characteristics. No visual complications were encountered in this patient series. Maximum compressive force during craniotomy was 35.8±27.2 gf, with increases typically seen when surgeons used hooks or drills. However, due to the alarm, no prolonged periods of high force were noted in any patient. Effective methods for reducing force were: (1) taking off hooks on the compressive side; (2) changing the direction of hook tension; and (3) placing cushions such as gauze under the side of the skin flap. Maximum compressive force during microsurgery was 21.8±18.4 gf, and correlated with the beginning force of microsurgery. Compressive force was greatly reduced compared to the force reported previously. The etiologies of visual disability are not fully understood, but this sensor may be helpful in reducing extraocular compression.

Oral Hydration for Prevention of Contrast-Induced Acute Kidney Injury in Elective Radiological Procedures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

PubMed Central

Cheungpasitporn, Wisit; Thongprayoon, Charat; Brabec, Brady A.; Edmonds, Peter J.; O'Corragain, Oisin A.; Erickson, Stephen B.

2014-01-01

Background: The reports on efficacy of oral hydration treatment for the prevention of contrast-induced acute kidney injury (CIAKI) in elective radiological procedures and cardiac catheterization remain controversial. Aims: The objective of this meta-analysis was to assess the use of oral hydration regimen for prevention of CIAKI. Materials and Methods: Comprehensive literature searches for randomized controlled trials (RCTs) of outpatient oral hydration treatment was performed using MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials Systematic Reviews, and clinicaltrials.gov from inception until July 4th, 2014. Primary outcome was the incidence of CIAKI. Results: Six prospective RCTs were included in our analysis. Of 513patients undergoing elective procedures with contrast exposures,45 patients (8.8%) had CIAKI. Of 241 patients with oral hydration regimen, 23 (9.5%) developed CIAKI. Of 272 patients with intravenous (IV) fluid regimen, 22 (8.1%) had CIAKI. Study populations in all included studies had relatively normal kidney function to chronic kidney disease (CKD) stage 3. There was no significant increased risk of CIAKI in oral fluid regimen group compared toIV fluid regimen group (RR = 0.94, 95% confidence interval, CI = 0.38-2.31). Conclusions: According to our analysis,there is no evidence that oral fluid regimen is associated with more risk of CIAKI in patients undergoing elective procedures with contrast exposures compared to IV fluid regimen. This finding suggests that the oral fluid regimen might be considered as a possible outpatient treatment option for CIAKI prevention in patients with normal to moderately reduced kidney function. PMID:25599049

Surgical Management of Supratentorial Intracerebral Hemorrhages: Endoscopic Versus Open Surgery.

PubMed

Eroglu, Umit; Kahilogullari, Gokmen; Dogan, Ihsan; Yakar, Fatih; Al-Beyati, Eyyub S M; Ozgural, Onur; Cohen-Gadol, Aaron A; Ugur, Hasan Caglar

2018-06-01

Intracerebral hemorrhage continues to be a major global problem. No standard treatment or surgical procedure has been identified for intracerebral hemorrhages. High morbidity and mortality rates caused by conventional approaches and the disease itself have necessitated more-invasive treatment methods. The endoscopic approach is a more minimally invasive method than craniotomy, which is another alternative surgical treatment. We compared intracerebral hematoma drainage in 2 groups of 17 patients each, treated with minimally invasive endoscopic method versus craniotomy. All the patients were treated for supratentorial spontaneous hemorrhage between December 2013 and February 2017 at the Neurosurgery Clinic of Ankara University Faculty of Medicine. We retrospectively evaluated 34 patients surgically treated between December 2013 and February 2017. All patients underwent surgery within the first 24 hours. Patients in the early surgery group had better surgical outcomes. In the neuroendoscopic group, Glasgow Coma Scale increased from 6 to 11 at 1 week postoperatively compared with 5 to 9 in the craniotomy group. Minimally invasive endoscopic hematoma evacuation may be a good alternative surgical method for treating supratentorial spontaneous cerebral hematomas. Copyright © 2018 Elsevier Inc. All rights reserved.

Challenges in pediatric neuroanesthesia: awake craniotomy, intraoperative magnetic resonance imaging, and interventional neuroradiology.

PubMed

McClain, Craig D; Landrigan-Ossar, Mary

2014-03-01

This article gives a review of 3 challenges in caring for children undergoing neurosurgical and neurointerventional procedures. Anesthesiologists may have experience with certain aspects of these situations but may not have extensive experience with each clinical setting. This review addresses issues with awake craniotomy, intraoperative magnetic resonance imaging, and neurointerventional procedures in children with neurologic disease. Familiarization with these complex clinical scenarios and their unique considerations allows the anesthesiologist to deliver optimal care and helps facilitate the best possible outcome for these patients. Copyright © 2014 Elsevier Inc. All rights reserved.

How I do it: surgical ligation of craniocervical junction dural AV fistulas.

PubMed

Sorenson, Thomas J; La Pira, Biagia; Hughes, Joshua; Lanzino, Giuseppe

2017-08-01

Dural arteriovenous fistulas (DAVFs) of the craniocervical junction are uncommon vascular lesions, which often require surgical treatment even in the endovascular era. Most commonly, the fistula is placed laterally, and surgical ligation is performed through a lateral suboccipital craniotomy. After dural opening, the area is inspected, and the arterialized vein is identified emerging from the dura, often adjacent to the entry point of the vertebral artery, and ligated. A far lateral craniotomy is the authors' preferred surgical approach for accessing and treating dural arteriovenous fistulas of the craniocervical junction that cannot be reached endovascularly.

[Craniotomy without trichotomy: analysis of 640 cases].

PubMed

Dvilevicius, Amylcar E; Machado, Silvio; do Rêgo, José Iram M; Santos, Daniel Souza; Pietrowski, Fábio; Reis, Arnaldo Dias

2004-03-01

The hair shaving in preparation for neurosurgery is frequently used in most of neurosurgical centers to perform craniotomy. We question about its necessity after our retrospective analysis of 640 patients undergoing cranial procedures without previous hair shaving. We had the overall surgical wound infection rate of 1.09%, not higher than tricotomy in the review of the literature. In 7 cases with infection, 3 patients were undergoing to CSF shunts, 3 patients had head injury, and one had brain tumor. The technique for preparing skin and hair for cranial procedures, its advantages and disadvantages are described and discussed.

Cranberry juice capsules and urinary tract infection after surgery: results of a randomized trial.

PubMed

Foxman, Betsy; Cronenwett, Anna E W; Spino, Cathie; Berger, Mitchell B; Morgan, Daniel M

2015-08-01

The risk of urinary tract infection (UTI) among women undergoing elective gynecological surgery during which a catheter is placed is high: 10-64% following catheter removal. We conducted the first randomized, double-blind, placebo-controlled trial of the therapeutic efficacy of cranberry juice capsules in preventing UTI after surgery. We recruited patients from a single hospital between August 2011 and January 2013. Eligible participants were undergoing elective gynecological surgery that did not involve a fistula repair or vaginal mesh removal. One hundred sixty patients were randomized and received 2 cranberry juice capsules 2 times a day, equivalent to 2 8 ounce servings of cranberry juice, for 6 weeks after surgery or matching placebo. The primary endpoint was the proportion of participants who experienced clinically diagnosed and treated UTI with or without positive urine culture. Kaplan-Meier plots and log rank tests compared the 2 treatment groups. The occurrence of UTI was significantly lower in the cranberry treatment group compared with the placebo group (15 of 80 [19%] vs 30 of 80 [38%]; odds ratio, 0.38; 95% confidence interval, 0.19-0.79; P = .008). After adjustment for known confounders, including the frequency of intermittent self-catheterization in the postoperative period, the protective effects of cranberry remained (odds ratio, 0.42; 95% confidence interval, 0.18-0.94). There were no treatment differences in the incidence of adverse events, including gastrointestinal upset (56% vs 61% for cranberry vs placebo). Among women undergoing elective benign gynecological surgery involving urinary catheterization, the use of cranberry extract capsules during the postoperative period reduced the rate of UTI by half. Copyright © 2015 Elsevier Inc. All rights reserved.

A Double-Blinded Randomized Clinical Study on the Therapeutic Effect of Gastrografin in Prolonged Postoperative Ileus After Elective Colorectal Surgery.

PubMed

Biondo, Sebastiano; Miquel, Jordi; Espin-Basany, Eloy; Sanchez, Jose Luis; Golda, Thomas; Ferrer-Artola, Ana Maria; Codina-Cazador, Antonio; Frago, Ricardo; Kreisler, Esther

2016-01-01

Postoperative ileus is a common problem with significant clinical and economic consequences. We hypothesized that Gastrografin may have therapeutic utility by accelerating the recovery of postoperative ileus after colorectal surgery. The aim of this trial was to study the impact of oral Gastrografin administration on postoperative prolonged ileus (PPI) after elective colorectal surgery. The main endpoint of this randomized, double-blinded, controlled trial was time of resolution of PPI. The secondary endpoints were overall hospital length of stay, time to start oral intake, time to first passage of flatus or stools, time of need of nasogastric tube, and need of parenteral nutrition. Included criteria were patients older than 18 years, operated for colonic neoplasia, inflammatory bowel disease, or diverticular disease. There were two treatments: Gastrografin administration and placebo. The sample size was calculated taking into account the average length of postoperative ileus after colorectal resection until tolerance to oral intake. Statistical analysis showed that 29 subjects in each group were needed. Twenty-nine patients per group were randomized. Groups were comparable for age, gender, ASA Physical Status Classification System, stoma construction, and surgical technique. No statistical differences were observed in mean time to resolution between the two groups, 9.1 days (CI 95%, 6.51-11.68) in Gastrografin group versus 10.3 days (CI 6.96-10.29) in Placebo group (P = 0.878). Even if not statistically significant, time of resolution of PPI, overall length of stay, time of need of nasogastric tube, and time to tolerance of oral intake were shorter in the G group. Gastrografin does not accelerate significantly the recovery of prolonged postoperative ileus after elective colorectal resection when compared with placebo. However, it seems to clinically improve all the analyzed variables.

Randomized clinical trial of stapler versus clamp-crushing transection in elective liver resection.

PubMed

Rahbari, N N; Elbers, H; Koch, M; Vogler, P; Striebel, F; Bruckner, T; Mehrabi, A; Schemmer, P; Büchler, M W; Weitz, J

2014-02-01

Various devices have been developed to facilitate liver transection and reduce blood loss in liver resections. None of these has proven superiority compared with the classical clamp-crushing technique. This randomized clinical trial compared the effectiveness and safety of stapler transection with that of clamp-crushing during open liver resection. Patients admitted for elective open liver resection between January 2010 and October 2011 were assigned randomly to stapler transection or the clamp-crushing technique. The primary endpoint was the total amount of intraoperative blood loss. Secondary endpoints included transection time, duration of operation, complication rates and resection margins. A total of 130 patients were enrolled, 65 to clamp-crushing and 65 to stapler transection. There was no difference between groups in total intraoperative blood loss: median (i.q.r.) 1050 (525-1650) versus 925 (450-1425) ml respectively (P = 0·279). The difference in total intraoperative blood loss normalized to the transection surface area was not statistically significant (P = 0·092). Blood loss during parenchymal transection was significantly lower in the stapler transection group (P = 0·002), as were the parenchymal transection time (mean(s.d.) 30(21) versus 9(7) min for clamp-crushing and stapler transection groups respectively; P < 0·001) and total duration of operation (mean(s.d.) 221(86) versus 190(85) min; P = 0·047). There were no significant differences in postoperative morbidity (P = 0·863) or mortality (P = 0·684) between groups. Stapler transection is a safe technique but does not reduce intraoperative blood loss in elective liver resection compared with the clamp-crushing technique. NCT01049607 (http://www.clinicaltrials.gov). © 2014 BJS Society Ltd. Published by John Wiley & Sons Ltd.

A meta-analysis of the efficacy of prophylactic alpha-blockade for the prevention of urinary retention following primary unilateral inguinal hernia repair.

PubMed

Clancy, C; Coffey, J C; O'Riordain, M G; Burke, J P

2017-03-14

Urinary retention following inguinal hernia surgery is common and is believed to be associated with adrenergic over-stimulation of the smooth muscle in the bladder neck and prostate. The efficacy of prophylactic alpha-blockade in the prevention of urinary retention following elective inguinal hernia repair in males is unknown. A comprehensive literature search was performed adhering to PRISMA guidelines. Each study was reviewed and data were extracted. Random-effects models were used to combine data. Five randomized studies describing 456 patients were identified. General or spinal anaesthetic were used. Prophylactic alpha-blockade decreases the risk of urinary retention requiring catheterisation following elective unilateral inguinal hernia repair compared to control groups (OR:0.179, 95% CI:0.043-0.747, p:0.018). Rates of urinary retention between treatment and control groups are reduced by 20.6%. No serious complications relating to alpha blockade occurred. Prophylactic alpha-blockade reduces urinary retention following elective inguinal hernia surgery under general or spinal anaesthetic. Urinary retention is common following inguinal hernia surgery. It is believed to be associated with adrenergic over-stimulation of the smooth muscle in the bladder neck and prostate. Prophylactic alpha-blockade reduces the rates of urinary retention by 20.6% in adult males undergoing general or spinal anaesthetic with minimal associated side effects. Copyright © 2017. Published by Elsevier Inc.

Elective decompression of the left ventricle in pediatric patients may reduce the duration of venoarterial extracorporeal membrane oxygenation.

PubMed

Hacking, Douglas F; Best, Derek; d'Udekem, Yves; Brizard, Christian P; Konstantinov, Igor E; Millar, Johnny; Butt, Warwick

2015-04-01

We aimed to determine the effect of elective left heart decompression at the time of initiation of central venoarterial extracorporeal membrane oxygenation (VA ECMO) on VA ECMO duration and clinical outcomes in children in a single tertiary ECMO referral center with a large pediatric population from a national referral center for pediatric cardiac surgery. We studied 51 episodes of VA ECMO in a historical cohort of 49 pediatric patients treated between the years 1990 and 2013 in the Paediatric Intensive Care Unit (PICU) of the Royal Children's Hospital, Melbourne. The cases had a variety of diagnoses including congenital cardiac abnormalities, sepsis, myocarditis, and cardiomyopathy. Left heart decompression as an elective treatment or an emergency intervention for left heart distension was effectively achieved by a number of methods, including left atrial venting, blade atrial septostomy, and left ventricular cannulation. Elective left heart decompression was associated with a reduction in time on ECMO (128 h) when compared with emergency decompression (236 h) (P = 0.013). Subgroup analysis showed that ECMO duration was greatest in noncardiac patients (elective 138 h, emergency 295 h; P = 0.02) and in patients who died despite both emergency decompression and ECMO (elective 133 h, emergency 354 h; P = 0.002). As the emergency cases had a lower pH, a higher PaCO2 , and a lower oxygenation index and were treated with a higher mean airway pressure, positive end-expiratory pressure, and respiratory rate prior to receiving VA ECMO, we undertook multivariate linear regression modeling to show that only PaCO2 and the timing of left heart decompression were associated with ECMO duration. However, elective left heart decompression was not associated with a reduction in length of PICU stay, duration of mechanical ventilation, or duration of oxygen therapy. Elective left heart decompression was not associated with improved ECMO survival or survival to PICU discharge. Elective left heart decompression may reduce ECMO duration and has therefore the potential to reduce ECMO-related complications. A prospective, randomized controlled trial is indicated to study this intervention further. Copyright © 2014 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Evaluating Pictures of Nature and Soft Music on Anxiety and Well-Being During Elective Surgery.

PubMed

Nielsen, Elinor; Wåhlin, Ingrid; Frisman, Gunilla Hollman

2018-01-01

Patients going through surgery being awake often have a sense of anxiety and need support to relax. The aim of this study was to investigate whether looking at pictures of natural scenery could reduce anxiety and pain and increase relaxation and well-being being awake during the elective surgery. This three-arm, randomized intervention study consisted of one group viewing pictures of natural scenery, one group listening to soft instrumental music, and one control group without distraction, all adult patients (n=174). The State Trait Anxiety Inventory short form and a visual analogue scale on well-being were used as well as sedation treatment if necessary. No differences related to anxiety after surgery were found among the three groups. When controlling for the effect of sedative treatment, however, patients without sedation had a lower degree of anxiety postoperatively (p=0.014). Younger patients had a higher degree of anxiety and lower degree of postoperative relaxation and well-being. Viewing pictures of natural scenery while being awake during elective surgery is as relaxing as listening to soft instrumental music. Offering nature scenery pictures for patients to view could be relaxing during the elective surgery.

Comparison of Online Versus Classroom Delivery of an Immunization Elective Course

PubMed Central

Pitterle, Michael E.; Hayney, Mary S.

2014-01-01

Objective. To compare performance and preferences of students who were randomly allocated to classroom or online sections of an elective course on immunization. Methods. Students were randomly assigned to either the classroom or online section. All course activities (lectures, quizzes, case discussions, vaccine administration, and final examination) were the same for both sections, except for the delivery of lecture material. Assessment. Students were surveyed on their preferences at the beginning and end of the semester. At the end of the semester, the majority of students in the classroom group preferred classroom or blended delivery while the majority of students in the online group preferred blended or online delivery (p<0.01). Student performance was compared at the end of the semester. There was no significant difference for any of the grades in the course between the 2 sections. Conclusion. There was no difference in student performance between the classroom and online sections, suggesting that online delivery is an effective way to teach students about immunization. PMID:24954936

Adequate margins for random setup uncertainties in head-and-neck IMRT

DOE Office of Scientific and Technical Information (OSTI.GOV)

Astreinidou, Eleftheria; Bel, Arjan; Raaijmakers, Cornelis P.J.

2005-03-01

Purpose: To investigate the effect of random setup uncertainties on the highly conformal dose distributions produced by intensity-modulated radiotherapy (IMRT) for clinical head-and-neck cancer patients and to determine adequate margins to account for those uncertainties. Methods and materials: We have implemented in our clinical treatment planning system the possibility of simulating normally distributed patient setup displacements, translations, and rotations. The planning CT data of 8 patients with Stage T1-T3N0M0 oropharyngeal cancer were used. The clinical target volumes of the primary tumor (CTV{sub primary}) and of the lymph nodes (CTV{sub elective}) were expanded by 0.0, 1.5, 3.0, and 5.0 mm inmore » all directions, creating the planning target volumes (PTVs). We performed IMRT dose calculation using our class solution for each PTV margin, resulting in the conventional static plans. Then, the system recalculated the plan for each positioning displacement derived from a normal distribution with {sigma} = 2 mm and {sigma} = 4 mm (standard deviation) for translational deviations and {sigma} = 1 deg for rotational deviations. The dose distributions of the 30 fractions were summed, resulting in the actual plan. The CTV dose coverage of the actual plans was compared with that of the static plans. Results: Random translational deviations of {sigma} = 2 mm and rotational deviations of {sigma} = 1 deg did not affect the CTV{sub primary} volume receiving 95% of the prescribed dose (V{sub 95}) regardless of the PTV margin used. A V{sub 95} reduction of 3% and 1% for a 0.0-mm and 1.5-mm PTV margin, respectively, was observed for {sigma} = 4 mm. The V{sub 95} of the CTV{sub elective} contralateral was approximately 1% and 5% lower than that of the static plan for {sigma} = 2 mm and {sigma} = 4 mm, respectively, and for PTV margins < 5.0 mm. An additional reduction of 1% was observed when rotational deviations were included. The same effect was observed for the CTV{sub elective} ipsilateral but with smaller dose differences than those for the contralateral side. The effect of the random uncertainties on the mean dose to the parotid glands was not significant. The maximal dose to the spinal cord increased by a maximum of 3 Gy. Conclusions: The margins to account for random setup uncertainties, in our clinical IMRT solution, should be 1.5 mm and 3.0 mm in the case of {sigma} = 2 mm and {sigma} = 4 mm, respectively, for the CTV{sub primary}. Larger margins (5.0 mm), however, should be applied to the CTV{sub elective}, if the goal of treatment is a V{sub 95} value of at least 99%.« less

Minimally Invasive Alternative Approaches to Pterional Craniotomy: A Systematic Review of the Literature.

PubMed

Rychen, Jonathan; Croci, Davide; Roethlisberger, Michel; Nossek, Erez; Potts, Matthew; Radovanovic, Ivan; Riina, Howard; Mariani, Luigi; Guzman, Raphael; Zumofen, Daniel W

2018-05-01

Minimally invasive alternatives to the pterional craniotomy include the minipterional and the supraorbital craniotomy (SOC). The latter is performed via either an eyebrow or an eyelid skin incision. The purpose of this systematic review was to analyze the type and the incidence of approach-related complications of these so-called "keyhole craniotomies". We review pertinent articles retrieved by search in the PubMed/Medline database. Inclusion criteria were all full-text articles, abstracts, and posters in English, up to 2016, reporting clinical results. A total of 105 articles containing data on 5837 surgeries performed via a minipterional or either of the 2 variants of the SOC met the eligibility criteria. Pain on mastication was the most commonly reported approach-related complication of the minipterional approach, and occurred in 7.5% of cases. Temporary palsy of the frontal branch of the facial nerve and temporary supraorbital hypesthesia were associated with the SOC eyebrow variant, and occurred in 6.5%, respectively in 3.6% of cases. Transient postoperative periorbital edema and transient ophthalmoparesis occurred in 36.8% and 17.4% of cases, respectively, when the SOC was performed via an eyelid skin incision. The risk of occurrence of the latter 2 complications was related to the removal of the orbital rim, which is an obligatory part of the SOC approach through the eyelid but optional with the SOC eyebrow variant. Each of the 3 keyhole approaches has a specific set and incidence of approach-related complications. It is essential to be aware of these complications to make the safest individual choice. Copyright © 2018 Elsevier Inc. All rights reserved.

Comparative Analysis of the Mini-pterional and Supraorbital Keyhole Craniotomies for Unruptured Aneurysms with Numeric Measurements of Their Geometric Configurations.

PubMed

Kang, Ho-Jun; Lee, Yoon-Soo; Suh, Sang-Jun; Lee, Jeong-Ho; Ryu, Kee-Young; Kang, Dong-Gee

2013-03-01

Keyhole craniotomy is a modification of pterional craniotomy that allows for use of a minimally invasive approach toward cerebral aneurysms. Currently, mini-pterional (MPKC) and supraorbital keyhole craniotomies (SOKC) are commonly used. In this study, we measured and compared the geometric configurations of surgical exposure provided by MPKC and SOKC. Nine patients underwent MPKC and four underwent SOKC. Their postoperative contrast-enhanced brain computed tomographic scans were evaluated. The transverse and longitudinal diameters and areas of exposure were measured. The locations of the anterior communicating artery, bifurcation of the middle cerebral artery (MCAB), and the internal carotid artery (ICA) terminal were identified, and the working angles and depths for these targets were measured. No significant differences in the transverse diameters of exposure were observed between MPKC and SOKC. However, the longitudinal diameters and the areas were significantly larger, by 1.5 times in MPKC. MPKC provided larger operable working angles for the targets. The angles by MPKC, particularly for the MCAB, reached up to 1.9-fold of those by SOKC. Greater working depths were required in order to reach the targets by SOKC, and the differences were the greatest in the MCAB by 1.6-fold. MPKC provides larger exposure than SOKC with a similar length of skin incision. MPKC allows for use of a direct transsylvian approach, and exposes the target in a wide working angle within a short distance. Despite some limitations in exposure, SOKC is suitable for a direct subfrontal approach, and provides a more anteromedial and basal view. MCAB and posteriorly directing ICA terminal aneurysms can be good candidates for MPKC.

Tension pneumocephalus following suboccipital sitting craniotomy in the pediatric population.

PubMed

Daszkiewicz, P; Dziedzic, D

Sitting craniotomy often results in entrapment of air in fluid-filled intracranial cavities. Gas under pressure exerts a deleterious effect on adjacent nervous tissue, resulting in clinical deterioration. To assess the incidence of tension pneumocephalus (TP) and to define risk factors associated therewith. Analysis included 100 consecutive patients (57 boys, 43 girls, mean age 9.7 y) undergoing suboccipital sitting craniotomy since 2012 to 2014. In our material (n=100) TP was seen in 7 cases, asymptomatic pneumocephalus (AP) in 77 and no pneumocephalus (NP) in 16. Tumor types encountered were typical for pediatric population. In the TP group (n=7) the ratio of low-grade to high-grade tumors was 5:2, in the AP group (n=77) 2:1 and in the NP group (n=16) 1:1. Preoperative hydrocephalus was present in 21 cases (21%, mean incidence), thereof 3 in the TP group (3/7; 42.8%), 12 in AP group (12/77; 15.5%) and 6 in the NP group (6/16; 37.5%). All TP patients received an emergency external drainage, thereof 4 required a permanent ventriculo-peritoneal shunt (57.1%), while AP and NP patients combined (n=93) required a permanent shunt in 4 cases only (4.3%). TP-associated morbidity (n=2) consisted in a significant deterioration of neurological condition. TP is a relatively rare but potentially serious complication of suboccipital sitting craniotomy. Risk factors for TP are low-grade tumor and pre-existing long-standing hydrocephalus. TP requires emergency decompression by temporary external drainage. TP patients significantly more often require a permanent CSF shunt. Copyright © 2017. Published by Elsevier Urban & Partner Sp. z o.o.

Rapid and minimum invasive functional brain mapping by real-time visualization of high gamma activity during awake craniotomy.

PubMed

Ogawa, Hiroshi; Kamada, Kyousuke; Kapeller, Christoph; Hiroshima, Satoru; Prueckl, Robert; Guger, Christoph

2014-11-01

Electrocortical stimulation (ECS) is the gold standard for functional brain mapping during an awake craniotomy. The critical issue is to set aside enough time to identify eloquent cortices by ECS. High gamma activity (HGA) ranging between 80 and 120 Hz on electrocorticogram is assumed to reflect localized cortical processing. In this report, we used real-time HGA mapping and functional neuronavigation integrated with functional magnetic resonance imaging (fMRI) for rapid and reliable identification of motor and language functions. Four patients with intra-axial tumors in their dominant hemisphere underwent preoperative fMRI and lesion resection with an awake craniotomy. All patients showed significant fMRI activation evoked by motor and language tasks. During the craniotomy, we recorded electrocorticogram activity by placing subdural grids directly on the exposed brain surface. Each patient performed motor and language tasks and demonstrated real-time HGA dynamics in hand motor areas and parts of the inferior frontal gyrus. Sensitivity and specificity of HGA mapping were 100% compared with ECS mapping in the frontal lobe, which suggested HGA mapping precisely indicated eloquent cortices. We found different HGA dynamics of language tasks in frontal and temporal regions. Specificities of the motor and language-fMRI did not reach 85%. The results of HGA mapping was mostly consistent with those of ECS mapping, although fMRI tended to overestimate functional areas. This novel technique enables rapid and accurate identification of motor and frontal language areas. Furthermore, real-time HGA mapping sheds light on underlying physiological mechanisms related to human brain functions. Copyright © 2014 Elsevier Inc. All rights reserved.

Awake Craniotomy Anesthesia: A Comparison of the Monitored Anesthesia Care and Asleep-Awake-Asleep Techniques.

PubMed

Eseonu, Chikezie I; ReFaey, Karim; Garcia, Oscar; John, Amballur; Quiñones-Hinojosa, Alfredo; Tripathi, Punita

2017-08-01

Commonly used sedation techniques for an awake craniotomy include monitored anesthesia care (MAC), using an unprotected airway, and the asleep-awake-asleep (AAA) technique, using a partially or totally protected airway. We present a comparative analysis of the MAC and AAA techniques, evaluating anesthetic management, perioperative outcomes, and complications in a consecutive series of patients undergoing the removal of an eloquent brain lesion. Eighty-one patients underwent awake craniotomy for an intracranial lesion over a 9-year period performed by a single-surgeon and a team of anesthesiologists. Fifty patients were treated using the MAC technique, and 31 were treated using the AAA technique. A retrospective analysis evaluated anesthetic management, intraoperative complications, postoperative outcomes, pain management, and complications. The MAC and AAA groups had similar preoperative patient and tumor characteristics. Mean operative time was shorter in the MAC group (283.5 minutes vs. 313.3 minutes; P = 0.038). Hypertension was the most common intraoperative complication seen (8% in the MAC group vs. 9.7% in the AAA group; P = 0.794). Intraoperative seizure occurred at a rate of 4% in the MAC group and 3.2% in the AAA group (P = 0.858). Awake cases were converted to general anesthesia in no patients in the MAC group and in 1 patient (3.2%) in the AAA group (P = 0.201). No cases were aborted in either group. The mean hospital length of stay was 3.98 days in the MAC group and 3.84 days in the AAA group (P = 0.833). Both the MAC and AAA sedation techniques provide an efficacious and safe method for managing awake craniotomy cases and produce similar perioperative outcomes, with the MAC technique associated with shorter operative time. Copyright © 2017 Elsevier Inc. All rights reserved.

Electrocorticographic Frequency Alteration Mapping of Speech Cortex during an Awake Craniotomy: Case Report

PubMed Central

Breshears, J.; Sharma, M.; Anderson, N.R.; Rashid, S.; Leuthardt, E.C.

2010-01-01

Objective Traditional electrocortical stimulation (ECS) mapping is limited by the lengthy serial investigation (one location at a time) and the risk of afterdischarges in localizing eloquent cortex. Electrocorticographic frequency alteration mapping (EFAM) allows the parallel investigation of many cortical sites in much less time and with no risk of afterdischarges because of its passive nature. We examined its use with ECS in the context of language mapping during an awake craniotomy for a tumor resection. Clinical Presentation The patient was a 61-year-old right-handed Caucasian male who presented with headache and mild aphasia. Imaging demonstrated a 3-cm cystic mass in the posterior temporal-parietal lobe. The patient underwent an awake craniotomy for the mapping of his speech cortex and resection of the mass. Intervention Using a 32-contact electrode array, electrocorticographic signals were recorded from the exposed cortex as the patient participated in a 3-min screening task involving active (patient naming visually presented words) and rest (patient silent) conditions. A spectral comparison of the 2 conditions revealed specific cortical locations associated with activation during speech. The patient was then widely mapped using ECS. Three of 4 sites identified by ECS were also identified passively and in parallel by EFAM, 2 with statistical significance and the third by qualitative inspection. Conclusion EFAM was technically achieved in an awake craniotomy patient and had good concordance with ECS mapping. Because it poses no risk of afterdischarges and offers substantial time savings, EFAM holds promise for future development as an adjunct intraoperative mapping tool. Additionally, the cortical signals obtained by this modality can be utilized for localization in the presence of a tumor adjacent to the eloquent regions. PMID:19940544

“Awake” intraoperative functional MRI (ai-fMRI) for mapping the eloquent cortex: Is it possible in awake craniotomy?☆

PubMed Central

Lu, Jun-Feng; Zhang, Han; Wu, Jin-Song; Yao, Cheng-Jun; Zhuang, Dong-Xiao; Qiu, Tian-Ming; Jia, Wen-Bin; Mao, Ying; Zhou, Liang-Fu

2012-01-01

As a promising noninvasive imaging technique, functional MRI (fMRI) has been extensively adopted as a functional localization procedure for surgical planning. However, the information provided by preoperative fMRI (pre-fMRI) is hampered by the brain deformation that is secondary to surgical procedures. Therefore, intraoperative fMRI (i-fMRI) becomes a potential alternative that can compensate for brain shifts by updating the functional localization information during craniotomy. However, previous i-fMRI studies required that patients be under general anesthesia, preventing the wider application of such a technique as the patients cannot perform tasks unless they are awake. In this study, we propose a new technique that combines awake surgery and i-fMRI, named “awake” i-fMRI (ai-fMRI). We introduced ai-fMRI to the real-time localization of sensorimotor areas during awake craniotomy in seven patients. The results showed that ai-fMRI could successfully detect activations in the bilateral primary sensorimotor areas and supplementary motor areas for all patients, indicating the feasibility of this technique in eloquent area localization. The reliability of ai-fMRI was further validated using intraoperative stimulation mapping (ISM) in two of the seven patients. Comparisons between the pre-fMRI-derived localization result and the ai-fMRI derived result showed that the former was subject to a heavy brain shift and led to incorrect localization, while the latter solved that problem. Additionally, the approaches for the acquisition and processing of the ai-fMRI data were fully illustrated and described. Some practical issues on employing ai-fMRI in awake craniotomy were systemically discussed, and guidelines were provided. PMID:24179766

"Imagine your neighbor mows the lawn": a pilot study of psychological sequelae due to awake craniotomy: clinical article.

PubMed

Milian, Monika; Luerding, Ralf; Ploppa, Annette; Decker, Karlheinz; Psaras, Tsambika; Tatagiba, Marcos; Gharabaghi, Alireza; Feigl, Guenther C

2013-06-01

Although it has been reported that awake neurosurgical procedures are well tolerated, the long-term occurrence of general psychological sequelae has not yet been investigated. This study assessed the frequency and effects of psychological symptoms after an awake craniotomy on health-related quality of life (HRQOL). Sixteen patients undergoing an awake surgery were surveyed with a self-developed questionnaire, the Posttraumatic Stress Disorder Inventory For Awake Surgery Patients, which adopts the core components of the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) posttraumatic stress disorder (PTSD) criteria. The mean time between surgery and data collection was 97.3 ± 93.2 weeks. Health-related quality of life was assessed with the 36-Item Short Form Health Survey. Forty-four percent of the patients stated that they had experienced either repetitive distressing recollections or dreams related to the awake surgery, 18.8% stated persistent avoidance of stimuli associated with the awake surgery, and symptoms of increased arousal occurred in 62.5%. Two patients presented with postoperative psychological sequelae resembling PTSD symptoms. Younger age at surgery and female sex were risk factors for symptoms of increased arousal. The experience of intense anxiety during awake surgery appears to favor the development of postsurgical PTSD symptoms, while recurrent distressing recollections particularly affect HRQOL negatively. In many cases awake craniotomy is necessary to preserve language and motor function. However, in some cases awake craniotomy can lead to postoperative psychological sequelae resembling PTSD symptoms. Therefore, possible long-term effects of an awake surgery should be considered and discussed with the patient when planning this type of surgery.

Awake Craniotomy vs Craniotomy Under General Anesthesia for Perirolandic Gliomas: Evaluating Perioperative Complications and Extent of Resection.

PubMed

Eseonu, Chikezie I; Rincon-Torroella, Jordina; ReFaey, Karim; Lee, Young M; Nangiana, Jasvinder; Vivas-Buitrago, Tito; Quiñones-Hinojosa, Alfredo

2017-09-01

A craniotomy with direct cortical/subcortical stimulation either awake or under general anesthesia (GA) present 2 approaches for removing eloquent region tumors. With a reported higher prevalence of intraoperative seizures occurring during awake resections of perirolandic lesions, oftentimes, surgery under GA is chosen for these lesions. To evaluate a single-surgeon's experience with awake craniotomies (AC) vs surgery under GA for resecting perirolandic, eloquent, motor-region gliomas. Between 2005 and 2015, a retrospective analysis of 27 patients with perirolandic, eloquent, motor-area gliomas that underwent an AC were case-control matched with 31 patients who underwent surgery under GA for gliomas in the same location. All patients underwent direct brain stimulation with neuromonitoring and perioperative risk factors, extent of resection, complications, and discharge status were assessed. The postoperative Karnofsky Performance Score (KPS) was significantly lower for the GA patients at 81.1 compared to the AC patients at 93.3 ( P = .040). The extent of resection for GA patients was 79.6% while the AC patients had an 86.3% resection ( P = .136). There were significantly more 100% total resections in the AC patients 25.9% compared to the GA group (6.5%; P = .041). Patients in the GA group had a longer mean length of hospitalization of 7.9 days compared to the AC group at 4.2 days ( P = .049). We show that AC can be performed with more frequent total resections, better postoperative KPS, shorter hospitalizations, as well as similar perioperative complication rates compared to surgery under GA for perirolandic, eloquent motor-region glioma. Copyright © 2017 by the Congress of Neurological Surgeons

A pilot microdialysis study in brain tumor patients to assess changes in intracerebral cytokine levels after craniotomy and in response to treatment with a targeted anti-cancer agent.

PubMed

Portnow, Jana; Badie, Behnam; Liu, Xueli; Frankel, Paul; Mi, Shu; Chen, Mike; Synold, Timothy W

2014-05-01

Intracerebral microdialysis enables continuous measurement of changes in brain biochemistry. In this study intracerebral microdialysis was used to assess changes in cytokine levels after tumor resection and in response to treatment with temsirolimus. Brain tumor patients undergoing craniotomy participated in this non-therapeutic study. A 100 kDa molecular weight cut-off microdialysis catheter was placed in peritumoral tissue at the time of resection. Cohort 1 underwent craniotomy only. Cohort 2 received a 200 mg dose of intravenous temsirolimus 48 h after surgery. Dialysate samples were collected continuously for 96 h and analyzed for the presence of 30 cytokines. Serial blood samples were collected to measure systemic cytokine levels. Dialysate samples were obtained from six patients in cohort 1 and 4 in cohort 2. Seventeen cytokines could be recovered in dialysate samples from at least 8 of 10 patients. Concentrations of interleukins and chemokines were markedly elevated in peritumoral tissue, and most declined over time, with IL-8, IP-10, MCP-1, MIP1β, IL-6, IL-12p40/p70, MIP1α, IFN-α, G-CSF, IL-2R, and vascular endothelial growth factor significantly (p < 0.05) decreasing over 96 h following surgery. No qualitative changes in intracerebral or serum cytokine concentrations were detected after temsirolimus administration. This is the first intracerebral microdialysis study to evaluate the time course of changes in macromolecule levels in the peritumoral microenvironment after a debulking craniotomy. Initial elevations of peritumoral interleukins and chemokines most likely reflected an inflammatory response to both tumor and surgical trauma. These findings have implications for development of cellular therapies that are administered intracranially at the time of surgery.

Population Pharmacokinetics of Phenytoin Based on NONMEM in Patients with Intracranial Tumor During the First Week of Post-Craniotomy.

PubMed

Li, Zhong-Dong; Liu, Meng; Li, Liang; Wan, Jing-Hai; Lei, Zhaojin; Huang, Yong-An

2016-01-01

It was reported that phenytoin can prevent early post traumatic seizures. The present study aims to establish a population pharmacokinetic (PPK) model of oral phenytoin in patients with intracranial tumor during the early periods, the first week, of post-craniotomy to optimize phenytoin dosage regimen. Sixty-two patients with intracranial tumor were genotyped for CYP2C9 and CYP2C19 by real time PCR (TaqMan probe), and subsequently their phenytoin dosage regimens were designed according to the results of previous literature. A total of 123 plasma concentrations of oral phenytoin during the early periods of post-craniotomy, patient demographics, clinical biochemical indicators and drug combination were collected. A PPK model was performed using the nonlinear mixed effects model (NONMEM) program. The final PPK model equations of oral phenytoin were found to be as follows: for patients with CYP2C9 *1/*1, Vmax=22.66.(BWT/60.96)0.454(mg/h) and Km; =4.03 (mg/L); for patients with CYP2C9*1/*3, Vmax = 16.65.(BWT / 60.96 )0.454(mg/h) and Km =5.96 (mg/L). The PPK model was proved to be stable and effective by bootstrap method. Clinical individualized dosage regimens of additional 50 patients were designed by above PPK model. Concentrations on the morning of Day 7 (D7 concentrations) of 56% (28/50) of these patients were within the therapeutic range (10.20mg/L), which demonstrated better improvement than that of 37.1% of above 62 patients. The final PPK model of oral phenytoin may be helpful to design phenytoin individualized dosage regimen at the early stage of post-craniotomy when characteristics of patients meet these of subpopulation in the study.

Continuous physical examination during subcortical resection in awake craniotomy patients: Its usefulness and surgical outcome.

PubMed

Bunyaratavej, Krishnapundha; Sangtongjaraskul, Sunisa; Lerdsirisopon, Surunchana; Tuchinda, Lawan

2016-08-01

To evaluate the value of physical examination as a monitoring tool during subcortical resection in awake craniotomy patients and surgical outcomes. Authors reviewed medical records of patients underwent awake craniotomy with continuous physical examination for pathology adjacent to the eloquent area. Between January 2006 and August 2015, there were 37 patients underwent awake craniotomy with continuous physical examination. Pathology was located in the left cerebral hemisphere in 28 patients (75.7%). Thirty patients (81.1%) had neuroepithelial tumors. Degree of resections were defined as total, subtotal, and partial in 16 (43.2%), 11 (29.7%) and 10 (27.0%) patients, respectively. Median follow up duration was 14 months. The reasons for termination of subcortical resection were divided into 3 groups as follows: 1) by anatomical landmark with the aid of neuronavigation in 20 patients (54%), 2) by reaching subcortical stimulation threshold in 8 patients (21.6%), and 3) by abnormal physical examination in 9 patients (24.3%). Among these 3 groups, there were statistically significant differences in the intraoperative (p=0.002) and early postoperative neurological deficit (p=0.005) with the lowest deficit in neuronavigation group. However, there were no differences in neurological outcome at later follow up (3-months p=0.103; 6-months p=0.285). There were no differences in the degree of resection among the groups. Continuous physical examination has shown to be of value as an additional layer of monitoring of subcortical white matter during resection and combining several methods may help increase the efficacy of mapping and monitoring of subcortical functions. Copyright © 2016 Elsevier B.V. All rights reserved.

A Case Report of Onyx Pulmonary Arterial Embolism Contributing to Hypoxemia During Awake Craniotomy for Arteriovenous Malformation Resection.

PubMed

Tolly, Brian T; Kosky, Jenna L; Koht, Antoun; Hemmer, Laura B

2017-02-15

A healthy 26-year-old man with cerebral arteriovenous malformation underwent staged endovascular embolization with Onyx followed by awake craniotomy for resection. The perioperative course was complicated by tachycardia and severe intraoperative hypoxemia requiring significant oxygen supplementation. Postoperative chest computed tomography (CT) revealed hyperattenuating Onyx embolization material within the pulmonary vasculature, and an electrocardiogram indicated possible right heart strain, supporting clinically significant embolism. With awake arteriovenous malformation resection following adjunctive Onyx embolization becoming increasingly employed for lesions involving the eloquent cortex, anesthesiologists need to be aware of pulmonary migration of Onyx material as a potential contributor to significant perioperative hypoxemia.

Anaesthetic Management of Supratentorial Tumor Craniotomy Using Awake-Throughout Approach.

PubMed

Shafiq, Faraz; Salim, Fahad; Enam, Ather; Parkash, Jai; Faheem, Mohammad

2017-12-01

The authors are reporting an anaesthetic management of patient presenting with left parietal lobe space occupying lesion and scheduled for Awake-craniotomy. Awake-throughout approach using scalp block was planned. Among techniques reported for keeping patient awake during the surgery, this one is really underutilized. The successful conduct requires thorough preoperative assessment and psychological preparation. We used powerpoint presentation as a preoperative teaching tool. The anatomical landmark technique was used to institute scalp block, where individual nerves were targeted bilaterally. Patient remained stable throughout and participated actively in intraoperative neurological monitoring. Postoperative period showed remarkable recovery, better pain control, and shorter length of stay in hospital.

Awake craniotomy for brain tumor: indications, technique and benefits.

PubMed

Dziedzic, Tomasz; Bernstein, Mark

2014-12-01

Increasing interest in the quality of life of patients after treatment of brain tumors has led to the exploration of methods that can improve intraoperative assessment of neurological status to avoid neurological deficits. The only method that can provide assessment of all eloquent areas of cerebral cortex and white matter is brain mapping during awake craniotomy. This method helps ensure that the quality of life and the neuro-oncological result of treatment are not compromised. Apart from the medical aspects of awake surgery, its economic issues are also favorable. Here, we review the main aspects of awake brain tumor surgery. Neurosurgical, neuropsychological, neurophysiological and anesthetic issues are briefly discussed.

Dexmedetomidine and Mannitol for Awake Craniotomy in a Pregnant Patient.

PubMed

Handlogten, Kathryn S; Sharpe, Emily E; Brost, Brian C; Parney, Ian F; Pasternak, Jeffrey J

2015-05-01

We describe the use of dexmedetomidine for an awake neurosurgical procedure in a pregnant patient and quantify the effect of mannitol on intrauterine volume. A 27-year-old woman underwent a craniotomy, with intraprocedural motor and speech mapping, at 20 weeks of gestation. Sedation was maintained with dexmedetomidine. Mannitol at 0.25 g/kg IV was administered to control brain volume during surgery. Internal uterine volume was estimated at 1092 cm before surgery and decreased to 770 and 953 cm at 9 and 48 hours, respectively, after baseline assessment. No adverse maternal or fetal effects were noted during the intraoperative period or up to 48 hours postoperatively.

Investigating bone chip formation in craniotomy.

PubMed

Huiyu, He; Chengyong, Wang; Yue, Zhang; Yanbin, Zheng; Linlin, Xu; Guoneng, Xie; Danna, Zhao; Bin, Chen; Haoan, Chen

2017-10-01

In a craniotomy, the milling cutter is one of the most important cutting tools. The operating performance, tool durability and cutting damage to patients are influenced by the tool's sharpness, intensity and structure, whereas the cutting characteristics rely on interactions between the tool and the skull. In this study, an orthogonal cutting experiment during a craniotomy of fresh pig skulls was performed to investigate chip formation on the side cutting and face cutting of the skull using a high-speed camera. The cutting forces with different combinations of cutting parameters, such as the rake angle, clearance angle, depth of cut and cutting speed, were measured. The skull bone microstructure and cutting damage were observed by scanning electron microscope. Cutting models for different cutting approaches and various depths of cut were constructed and analyzed. The study demonstrated that the effects of shearing, tension and extrusion occur during chip formation. Various chip types, such as unit chips, splintering chips and continuous chips, were generated. Continuous pieces of chips, which are advisable for easy removal from the field of operation, were formed at greater depths of cut and tool rake angles greater than 10°. Cutting damage could be relieved with a faster recovery with clearance angles greater than 20°.

Surgical and anesthesiological considerations of awake craniotomy: Cerrahpasa experience.

PubMed

Sanus, Galip Zihni; Yuksel, Odhan; Tunali, Yusuf; Ozkara, Cigdem; Yeni, Naz; Ozlen, Fatma; Tanriverdi, Taner; Ozyurt, Emin; Uzan, Mustafa

2015-01-01

Awake craniotomy (AC) with electrical cortical stimulation has become popular during the last ten years although the basic principles were introduced almost 50 years ago. The aim of this paper is to share with the readers our experience in 25 patients who underwent AC with electrical stimulation. Twenty-five patients who underwent AC between 2010 and 2013 are the subjects of this paper. All patients were diagnosed with intraaxial lesions involving the functional area itself or very close to it by preoperative imaging. During surgery, the functional area was demonstrated by cortical electrical stimulation and resection aimed to preserve it in order to avoid an irreversible functional deficit. Total resection was possible in 80% while in 20% subtotal resection had to be performed because of involvement of the functional area itself. The neurological complication rate was found to be 16% (4 patients) and all were transient. No complication regarding anesthesia was noted. Awake craniotomy in selected patients is very effective, safe and practical for supratentorial lesions close to the eloquent area. Complications related to the surgery itself are uncommon and general anesthesia is avoided. The hospital stay including the intensive care unit is short which makes it very economical surgical procedure.

da Vinci robot-assisted keyhole neurosurgery: a cadaver study on feasibility and safety.

PubMed

Marcus, Hani J; Hughes-Hallett, Archie; Cundy, Thomas P; Yang, Guang-Zhong; Darzi, Ara; Nandi, Dipankar

2015-04-01

The goal of this cadaver study was to evaluate the feasibility and safety of da Vinci robot-assisted keyhole neurosurgery. Several keyhole craniotomies were fashioned including supraorbital subfrontal, retrosigmoid and supracerebellar infratentorial. In each case, a simple durotomy was performed, and the flap was retracted. The da Vinci surgical system was then used to perform arachnoid dissection towards the deep-seated intracranial cisterns. It was not possible to simultaneously pass the 12-mm endoscope and instruments through the keyhole craniotomy in any of the approaches performed, limiting visualization. The articulated instruments provided greater dexterity than existing tools, but the instrument arms could not be placed in parallel through the keyhole craniotomy and, therefore, could not be advanced to the deep cisterns without significant clashing. The da Vinci console offered considerable ergonomic advantages over the existing operating room arrangement, allowing the operating surgeon to remain non-sterile and seated comfortably throughout the procedure. However, the lack of haptic feedback was a notable limitation. In conclusion, while robotic platforms have the potential to greatly enhance the performance of transcranial approaches, there is strong justification for research into next-generation robots, better suited to keyhole neurosurgery.

Membranectomy in Chronic Subdural Hematoma: Meta-Analysis.

PubMed

Sahyouni, Ronald; Mahboubi, Hossein; Tran, Peter; Roufail, John S; Chen, Jefferson W

2017-08-01

Initial management strategies of chronic subdural hematoma (cSDH) are controversial and range from bedside twist-drill or burr-hole drainage to craniotomy with membranectomy (CWM). We aim to 1) perform a meta-analysis of the available data on the outcomes of CWM for treatment of cSDH in published English-language literature and 2) evaluate collective outcomes of CWM with respect to morbidity, mortality, and recurrence rates. A search of English-language literature performed in PubMed, Ovid, and Cochrane databases using key words ("subdural hematoma" or "chronic subdural hematoma") and ("membrane" or "membranectomy") from inception to December 2016 was conducted. Studies reporting outcomes of CWM in cSDH were included. Mortality, morbidity, follow-up duration, and recurrence rate data were extracted and analyzed. Pooled estimates and confidence intervals (CIs) were calculated for all outcomes using a random-effects model. Of 301 articles found, 17 articles containing 5369 patients met our eligibility criteria. Mean follow-up duration ranged from 1-30.8 months. Collective mean mortality and morbidity rates were 3.7% and 6.9%, respectively (95% CI 2-5.4% and 2.1-11.6%; P < 0.001 and P = 0.004). The collective mean recurrence rate was 7.6% (95% CI: 5%-10.2%; P < 0.001). Clinical data on outcomes of CWM in cSDH are limited to single institutional analyses, with considerable variation in recurrence rates and follow-up time. The rates we reported are comparable with the 5% mortality and 3%-12% morbidity rates and lower than the 10%-21% recurrence rate in the literature for burr holes or craniotomy without membranectomy. This meta-analysis provides an in-depth analysis of available data and reviews reported outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

Impact of mechanical bowel preparation in elective colorectal surgery: A meta-analysis.

PubMed

Rollins, Katie E; Javanmard-Emamghissi, Hannah; Lobo, Dileep N

2018-01-28

To analyse the effect of mechanical bowel preparation vs no mechanical bowel preparation on outcome in patients undergoing elective colorectal surgery. Meta-analysis of randomised controlled trials and observational studies comparing adult patients receiving mechanical bowel preparation with those receiving no mechanical bowel preparation, subdivided into those receiving a single rectal enema and those who received no preparation at all prior to elective colorectal surgery. A total of 36 studies (23 randomised controlled trials and 13 observational studies) including 21568 patients undergoing elective colorectal surgery were included. When all studies were considered, mechanical bowel preparation was not associated with any significant difference in anastomotic leak rates (OR = 0.90, 95%CI: 0.74 to 1.10, P = 0.32), surgical site infection (OR = 0.99, 95%CI: 0.80 to 1.24, P = 0.96), intra-abdominal collection (OR = 0.86, 95%CI: 0.63 to 1.17, P = 0.34), mortality (OR = 0.85, 95%CI: 0.57 to 1.27, P = 0.43), reoperation (OR = 0.91, 95%CI: 0.75 to 1.12, P = 0.38) or hospital length of stay (overall mean difference 0.11 d, 95%CI: -0.51 to 0.73, P = 0.72), when compared with no mechanical bowel preparation, nor when evidence from just randomized controlled trials was analysed. A sub-analysis of mechanical bowel preparation vs absolutely no preparation or a single rectal enema similarly revealed no differences in clinical outcome measures. In the most comprehensive meta-analysis of mechanical bowel preparation in elective colorectal surgery to date, this study has suggested that the use of mechanical bowel preparation does not affect the incidence of postoperative complications when compared with no preparation. Hence, mechanical bowel preparation should not be administered routinely prior to elective colorectal surgery.

The search engine manipulation effect (SEME) and its possible impact on the outcomes of elections

PubMed Central

Epstein, Robert; Robertson, Ronald E.

2015-01-01

Internet search rankings have a significant impact on consumer choices, mainly because users trust and choose higher-ranked results more than lower-ranked results. Given the apparent power of search rankings, we asked whether they could be manipulated to alter the preferences of undecided voters in democratic elections. Here we report the results of five relevant double-blind, randomized controlled experiments, using a total of 4,556 undecided voters representing diverse demographic characteristics of the voting populations of the United States and India. The fifth experiment is especially notable in that it was conducted with eligible voters throughout India in the midst of India’s 2014 Lok Sabha elections just before the final votes were cast. The results of these experiments demonstrate that (i) biased search rankings can shift the voting preferences of undecided voters by 20% or more, (ii) the shift can be much higher in some demographic groups, and (iii) search ranking bias can be masked so that people show no awareness of the manipulation. We call this type of influence, which might be applicable to a variety of attitudes and beliefs, the search engine manipulation effect. Given that many elections are won by small margins, our results suggest that a search engine company has the power to influence the results of a substantial number of elections with impunity. The impact of such manipulations would be especially large in countries dominated by a single search engine company. PMID:26243876

The search engine manipulation effect (SEME) and its possible impact on the outcomes of elections.

PubMed

Epstein, Robert; Robertson, Ronald E

2015-08-18

Internet search rankings have a significant impact on consumer choices, mainly because users trust and choose higher-ranked results more than lower-ranked results. Given the apparent power of search rankings, we asked whether they could be manipulated to alter the preferences of undecided voters in democratic elections. Here we report the results of five relevant double-blind, randomized controlled experiments, using a total of 4,556 undecided voters representing diverse demographic characteristics of the voting populations of the United States and India. The fifth experiment is especially notable in that it was conducted with eligible voters throughout India in the midst of India's 2014 Lok Sabha elections just before the final votes were cast. The results of these experiments demonstrate that (i) biased search rankings can shift the voting preferences of undecided voters by 20% or more, (ii) the shift can be much higher in some demographic groups, and (iii) search ranking bias can be masked so that people show no awareness of the manipulation. We call this type of influence, which might be applicable to a variety of attitudes and beliefs, the search engine manipulation effect. Given that many elections are won by small margins, our results suggest that a search engine company has the power to influence the results of a substantial number of elections with impunity. The impact of such manipulations would be especially large in countries dominated by a single search engine company.

Cost-Effectiveness Analysis of Elective Neck Dissection in Patients With Clinically Node-Negative Oral Cavity Cancer.

PubMed

Acevedo, Joseph R; Fero, Katherine E; Wilson, Bayard; Sacco, Assuntina G; Mell, Loren K; Coffey, Charles S; Murphy, James D

2016-11-10

Purpose Recently, a large randomized trial found a survival advantage among patients who received elective neck dissection in conjunction with primary surgery for clinically node-negative oral cavity cancer compared with those receiving primary surgery alone. However, elective neck dissection comes with greater upfront cost and patient morbidity. We present a cost-effectiveness analysis of elective neck dissection for the initial surgical management of early-stage oral cavity cancer. Methods We constructed a Markov model to simulate primary, adjuvant, and salvage therapy; disease recurrence; and survival in patients with T1/T2 clinically node-negative oral cavity squamous cell carcinoma. Transition probabilities were derived from clinical trial data; costs (in 2015 US dollars) and health utilities were estimated from the literature. Incremental cost-effectiveness ratios, expressed as dollar per quality-adjusted life-year (QALY), were calculated with incremental cost-effectiveness ratios less than $100,000/QALY considered cost effective. We conducted one-way and probabilistic sensitivity analyses to examine model uncertainty. Results Our base-case model found that over a lifetime the addition of elective neck dissection to primary surgery reduced overall costs by $6,000 and improved effectiveness by 0.42 QALYs compared with primary surgery alone. The decrease in overall cost despite the added neck dissection was a result of less use of salvage therapy. On one-way sensitivity analysis, the model was most sensitive to assumptions about disease recurrence, survival, and the health utility reduction from a neck dissection. Probabilistic sensitivity analysis found that treatment with elective neck dissection was cost effective 76% of the time at a willingness-to-pay threshold of $100,000/QALY. Conclusion Our study found that the addition of elective neck dissection reduces costs and improves health outcomes, making this a cost-effective treatment strategy for patients with early-stage oral cavity cancer.

Delivery at Term: When, How, and Why.

PubMed

Walker, Kate F; Thornton, Jim G

2018-06-01

There is growing evidence from randomized trials that induction of labor at or near term does not increase cesarean delivery; observational data show that the optimal gestation for spontaneous delivery for the baby is 39 weeks. Elective cesarean at these gestations is also sometimes considered, but evaluating the associated risks is complex. For the baby, although cesarean obviates the risks of labor, it carries a risk of respiratory problems, which may be severe. For the mother, cesarean is more dangerous than vaginal and emergency cesarean is more dangerous than elective. The authors consider the evidence base for near-term induction of labor and cesarean for a range of scenarios. Copyright © 2018 Elsevier Inc. All rights reserved.

[Psychoprophylaxis in elective paediatric general surgery: does audiovisual tools improve the perioperative anxiety in children and their families?

PubMed

Álvarez García, N; Gómez Palacio, V; Siles Hinojosa, A; Gracia Romero, J

2017-10-25

Surgery is considered a stressful experience for children and their families who undergo elective procedures. Different tools have been developed to improve perioperative anxiety. Our objective is to demonstrate if the audiovisual psychoprophylaxis reduces anxiety linked to paediatric surgery. A randomized prospective case-control study was carried out in children aged 4-15 who underwent surgery in a Paediatric Surgery Department. We excluded patients with surgical backgrounds, sever illness or non-elective procedures. Simple randomization was performed and cases watched a video before being admitted, under medical supervision. Trait and state anxiety levels were measured using the STAI-Y2, STAI-Y2, STAI-C tests and VAS in children under 6-years-old, at admission and discharge. 100 patients (50 cases/50 controls) were included, mean age at diagnosis was 7.98 and 7.32 respectively. Orchiopexy was the most frequent surgery performed in both groups. Anxiety state levels from parents were lower in the Cases Group (36.06 vs 39.93 p= 0.09 in fathers, 38.78 vs 40.34 p= 0.43 in mothers). At discharge, anxiety levels in children aged > 6 were statistically significant among cases (26.84 vs 32.96, p< 0.05). The use of audiovisual psychoprophylaxis tools shows a clinically relevant improvement in perioperative anxiety, both in children and their parents. Our results are similar to those reported by other authors supporting these tools as beneficial strategy for the family.

Effect of the application of a bundle of three measures (intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples) on the surgical site infection after elective laparoscopic colorectal cancer surgery.

PubMed

Ruiz-Tovar, Jaime; Llavero, Carolina; Morales, Vicente; Gamallo, Carlos

2018-01-18

Surgical site infection (SSI) prevention bundles include the simultaneous use of different measures, which individually have demonstrated an effect on prevention of SSI. The implementation of bundles can yield superior results to the implementation of individual measures. The aim of this study was to address the effect of the application of a bundle including intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, on the surgical site infection after elective laparoscopic colorectal cancer surgery. A prospective, randomized study was performed, including patients with diagnosis of colorectal neoplasms and plans to undergo an elective laparoscopic surgery. The patients were randomized into two groups: those patients following standard bundles (Group 1) and those ones following the experimental bundle with three additional measures, added to the standard bundle. Incisional and organ space SSI were investigated. The study was assessor-blinded. A total of 198 patients were included in the study, 99 in each group. The incisional SSI rate was 16% in Group 1 and 2% in Group 2 [p = 0.007; RR = 5.6; CI 95% (1.4-17.8)]. The organ-space SSI rate was 4% in Group 1 and 0% in Group 2 [p = 0.039; RR = 1.7; CI 95% (1.1-11.6)]. Median hospital stay was 5.5 days in Group 1 and 4 days in Group 2 (p = 0.028). The addition of intraperitoneal lavage with antibiotic solution, fascial closure with Triclosan-coated sutures and Mupirocin ointment application on the skin staples, to a standard bundle of SSI prevention, reduces the incisional and organ-space SSI and consequently the hospital stay, after elective laparoscopic colorectal cancer surgery (ClinicalTrials.gov Identifier: NCT03081962).

Impact of Music Therapy on Hospitalized Patients Post-Elective Orthopaedic Surgery: A Randomized Controlled Trial.

PubMed

Gallagher, Lisa M; Gardner, Vickie; Bates, Debbie; Mason, Shelley; Nemecek, Jeanine; DiFiore, Jacquelyn Baker; Bena, James; Li, Manshi; Bethoux, Francois

Music therapy (MT) research has demonstrated positive effects on fatigue, depressed mood, anxiety, and pain in perioperative care areas. However, there has been limited research on the effects of MT for surgical patients on orthopaedic units. The purpose of this study was to understand the impact of MT sessions on post-elective orthopaedic surgery patients' pain, mood, nausea, anxiety, use of narcotics and antiemetics, and length of stay. This was a randomized controlled study with an experimental arm (MT sessions) and a control arm (standard medical care). Patients received MT within 24 hours of admission to the unit, as well as every day of their stay. Same-day pre- and postdata were collected 30 minutes apart for both arms, including patient self-reported mood, pain, anxiety, and nausea. Use of medications and length of stay were gleaned from the electronic medical record. Data were obtained for 163 patients, age 60.5 ± 11.1 years, 56% of whom were male. Joints targeted by surgeries were hips (54%), knees (42%), and shoulders (4%). There were significantly greater changes favoring the MT group on Day 1 (pain, anxiety, and mood), Day 2 (pain, anxiety, mood, and nausea), and Day 3 (pain, anxiety, and mood). Among participants with a pre-pain score of 2 or more on Day 1, a decrease of at least 2 points was noted in 36% of the MT group and 10% of the control group (P < .001). Overall, 73% of MT patients versus 41% of control patients reported improved pain (P < .001). No significant between-group differences in medications or length of stay were noted. We observed greater same-day improvements of pain, emotional status, and nausea with MT sessions, compared to usual care, in patients hospitalized after elective orthopaedic surgeries. Effects on narcotic and antiemetic usage, as well as length of stay, were not observed. More research needs to be conducted to better understand the benefits of MT pre- and post-elective orthopaedic surgery.

Glycoprotein IIB/IIIA inhibitor to reduce postpercutaneous coronary intervention myonecrosis and improve coronary flow in diabetics: the 'OPTIMIZE-IT' pilot randomized study.

PubMed

Talarico, Giovanni Paolo; Brancati, Marta; Burzotta, Francesco; Porto, Italo; Trani, Carlo; De Vita, Maria; Todaro, Daniel; Giammarinaro, Maura; Leone, Antonio Maria; Niccoli, Giampaolo; Andreotti, Felicita; Mazzari, Mario Attilio; Schiavoni, Giovanni; Crea, Filippo

2009-03-01

Subgroup analyses of trials enrolling acute coronary syndrome patients suggest that inhibition of glycoprotein IIb/IIIa can improve the outcome of diabetic patients undergoing percutaneous coronary interventions (PCIs), possibly by improving microvascular perfusion. However, the efficacy of small-molecule IIb/IIIa receptor inhibitors to improve microvascular perfusion in stable diabetic patients undergoing elective PCI has not been specifically investigated. We randomized consecutive stable diabetic patients, undergoing elective PCI, to tirofiban or placebo groups along with double antiplatelet therapy. High-dose bolus (25 microg/kg per 3 min) of tirofiban was administered immediately before PCI followed by 8 h continuous infusion (0.15 microg/kg per min). Postprocedural myonecrosis was assessed prospectively by measurement of cardiac troponin T (cTnT) at 6 and 24 h after PCI. The primary end-points were post-PCI coronary flow estimated by corrected thrombolysis in myocardial infarction frame count and post-PCI myocardial infarction. Platelet aggregation was measured by platelet function analyser-100 values. Forty-six patients entered the study (22 randomized to placebo and 24 randomized to tirofiban). The study drug was associated with a significant increase of platelet function analyser-100 values that peaked immediately after PCI and was maintained at 6 h (pre-PCI: 131 +/- 65 s; post-PCI: 222 +/- 49 s; after 6 h: 219 +/- 55 s).Post-PCI corrected thrombolysis in myocardial infarction frame count was similar in tirofiban and in placebo groups (10.2 +/- 3.6 vs. 12.0 +/- 7.6, P = 0.30, respectively). The prevalence of raised cTnT levels was similar in the two groups (25 vs. 30%, P = 0.56, respectively). At multivariate analysis, direct stenting (associated with reduced myonecrosis) and postdilatation (associated with increased myonecrosis) predicted cTnT elevation. A high-dose bolus of tirofiban in stable diabetic patients undergoing elective PCI, along with double antiplatelet therapy, was associated with a significant further inhibition of platelet aggregation which, however, did not translate in a lower incidence of post-PCI distal embolization.

Cosmetic reconstruction of temporal defect following pterional [corrected] craniotomy.

PubMed

Badie, B

1996-04-01

Depression of the temporal fossa that is often caused by atrophy of the temporalis muscle or superficial temporal fat pad may be an unavoidable defect following pterional craniotomy. Various techniques have been previously described to correct this disfiguring defect. Most techniques, however, require drilling holes into the cranium or the synthetic grafts for attachment of the temporalis muscle. A simple method is described by which a temporal fossa depression is repaired with methylmethacrylate bone cement and a new superior temporal line is created for attachment of the temporalis muscle without the need to drill suture holes into the acrylic or the cranium. The technique described has been used on several patients with excellent cosmetic outcome.

The minimally invasive endoscopic management of septated chronic subdural hematomas: surgical technique.

PubMed

Berhouma, M; Jacquesson, T; Jouanneau, E

2014-12-01

Fibrin membranes and compartmentalization within the subdural space are a frequent cause of failure in the treatment of chronic subdural hematomas (CSH). This specific subtype of CSH classically requires craniotomy, which carries significant morbidity and mortality rates, particularly in elderly patients. In this work, we describe a minimally invasive endoscopic alternative. Under local scalp anesthesia, a rigid endoscope is inserted through a parietal burr hole in the subdural space to collapse fibrin septa and cut the internal membrane. It also allows cauterization of active bleedings and the placement of a drain under direct visualization. The endoscopic treatment of septated CSH represents a minimally invasive alternative to craniotomy especially for the internal membranectomy.

How Do Minnesota School Board Members Learn to Do Their Jobs?

ERIC Educational Resources Information Center

Conlon, Thomas Julius

2009-01-01

School boards in Minnesota largely function as volunteer or lowly-compensated elected bodies whose members are not professionally trained for their jobs, yet the public demands accountability and results from their local public school districts. This descriptive study examined how a random sample of 322 Minnesota school board members learned to do…

Metal Detectors in Public Schools: A Policy Perspective.

ERIC Educational Resources Information Center

Johnson, Robert S.

1993-01-01

Before electing to utilize metal-detection devices for random weapons searches of students, school districts should be prepared for the possibility of having to litigate the legality of their policies. Reviews the limited case law on the subject, and offers recommendations to districts that decide to proceed with the development of such a policy.…

Does preoperative oral carbohydrate reduce hospital stay? A randomized trial.

PubMed

Webster, Joan; Osborne, Sonya Ranee; Gill, Richard; Chow, Carina Faran Kalan; Wallin, Siobhan; Jones, Lee; Tang, Annie

2014-02-01

Oral carbohydrate-rich fluids are used preoperatively to improve postoperative recovery, but their effectiveness for reducing length of hospital stay is uncertain. We assessed the effectiveness of preoperative loading with carbohydrates on the postoperative outcomes of 44 patients scheduled for elective colorectal surgery who were randomly allocated to a carbohydrate-rich fluid group or a usual care group during their preadmission clinic visit. Our primary outcome was the time patients required to be ready for discharge. Patients in the control group spent an average of 4.3 days (95% confidence interval [CI], 3.2-5.7) in the hospital and patients in the carbohydrate-rich fluid group spent 4.1 days (95% CI, 3.2-5.4) in the hospital until they met discharge criteria (P = .824). We found that the safety of administering preoperative oral carbohydrate-rich fluids is supported, but we were unable to confirm or refute the benefit of this treatment regimen for contributing to shorter hospital stays after elective colorectal surgery. Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.

[Extendable Cords to Prevent Tumbling of a Suction Device during Craniotomy].

PubMed

Shimizu, Satoru; Mochizuki, Takahiro; Osawa, Shigeyuki; Sekiguchi, Tomoko; Koizumi, Hiroyuki; Kumabe, Toshihiro

2016-02-01

Suction is necessary during craniotomy, and intraoperative tumbling of the suction device interrupts operative procedures. To avoid this, we developed a technique that would fasten the device to an extendable cord as is used to secure cell phones. We used this technique in more than 300 craniotomies at the specific point of time when the suction device tends to tumble, i. e., during the opening and closure of a wound, which requires frequent instrument exchanges. Extendable cords fastened to the tip of the suction hose using a gift tie were attached to the drapes to secure the suction device next to the operative field. During the operation, the extendable cord followed the suction device manipulations. Consequently, although there was some tension in the cord during its extension, the maneuverability of the suction device was maintained. As the hanging suction device was closer to the operative field than devices stored in conventional pockets, its manipulation was easier and quicker. Upon release, the suction device automatically returned to its original position without distracting the surgeon. Tumbling of the device was prevented, and there were no procedure-related complications. Our simple modification using extendable cords prevented tumbling, avoided unnecessary replacements, and eased the manipulation of a suction device.

Awake Craniotomy for Tumor Resection: Further Optimizing Therapy of Brain Tumors.

PubMed

Mehdorn, H Maximilian; Schwartz, Felix; Becker, Juliane

2017-01-01

In recent years more and more data have emerged linking the most radical resection to prolonged survival in patients harboring brain tumors. Since total tumor resection could increase postoperative morbidity, many methods have been suggested to reduce the risk of postoperative neurological deficits: awake craniotomy with the possibility of continuous patient-surgeon communication is one of the possibilities of finding out how radical a tumor resection can possibly be without causing permanent harm to the patient.In 1994 we started to perform awake craniotomy for glioma resection. In 2005 the use of intraoperative high-field magnetic resonance imaging (MRI) was included in the standard tumor therapy protocol. Here we review our experience in performing awake surgery for gliomas, gained in 219 patients.Patient selection by the operating surgeon and a neuropsychologist is of primary importance: the patient should feel as if they are part of the surgical team fighting against the tumor. The patient will undergo extensive neuropsychological testing, functional MRI, and fiber tractography in order to define the relationship between the tumor and the functionally relevant brain areas. Attention needs to be given at which particular time during surgery the intraoperative MRI is performed. Results from part of our series (without and with ioMRI scan) are presented.

A novel tablet computer platform for advanced language mapping during awake craniotomy procedures.

PubMed

Morrison, Melanie A; Tam, Fred; Garavaglia, Marco M; Golestanirad, Laleh; Hare, Gregory M T; Cusimano, Michael D; Schweizer, Tom A; Das, Sunit; Graham, Simon J

2016-04-01

A computerized platform has been developed to enhance behavioral testing during intraoperative language mapping in awake craniotomy procedures. The system is uniquely compatible with the environmental demands of both the operating room and preoperative functional MRI (fMRI), thus providing standardized testing toward improving spatial agreement between the 2 brain mapping techniques. Details of the platform architecture, its advantages over traditional testing methods, and its use for language mapping are described. Four illustrative cases demonstrate the efficacy of using the testing platform to administer sophisticated language paradigms, and the spatial agreement between intraoperative mapping and preoperative fMRI results. The testing platform substantially improved the ability of the surgeon to detect and characterize language deficits. Use of a written word generation task to assess language production helped confirm areas of speech apraxia and speech arrest that were inadequately characterized or missed with the use of traditional paradigms, respectively. Preoperative fMRI of the analogous writing task was also assistive, displaying excellent spatial agreement with intraoperative mapping in all 4 cases. Sole use of traditional testing paradigms can be limiting during awake craniotomy procedures. Comprehensive assessment of language function will require additional use of more sophisticated and ecologically valid testing paradigms. The platform presented here provides a means to do so.

Intraoperative Subcortical Electrical Mapping of the Optic Tract in Awake Surgery Using a Virtual Reality Headset.

PubMed

Mazerand, Edouard; Le Renard, Marc; Hue, Sophie; Lemée, Jean-Michel; Klinger, Evelyne; Menei, Philippe

2017-01-01

Brain mapping during awake craniotomy is a well-known technique to preserve neurological functions, especially the language. It is still challenging to map the optic radiations due to the difficulty to test the visual field intraoperatively. To assess the visual field during awake craniotomy, we developed the Functions' Explorer based on a virtual reality headset (FEX-VRH). The impaired visual field of 10 patients was tested with automated perimetry (the gold standard examination) and the FEX-VRH. The proof-of-concept test was done during the surgery performed on a patient who was blind in his right eye and presenting with a left parietotemporal glioblastoma. The FEX-VRH was used intraoperatively, simultaneously with direct subcortical electrostimulation, allowing identification and preservation of the optic radiations. The FEX-VRH detected 9 of the 10 visual field defects found by automated perimetry. The patient who underwent an awake craniotomy with intraoperative mapping of the optic tract using the FEX-VRH had no permanent postoperative visual field defect. Intraoperative visual field assessment with the FEX-VRH during direct subcortical electrostimulation is a promising approach to mapping the optical radiations and preventing a permanent visual field defect during awake surgery for epilepsy or tumor. Copyright © 2016 Elsevier Inc. All rights reserved.

Intra-operative fluid warming in elective caesarean section: a blinded randomised controlled trial.

PubMed

Woolnough, M; Allam, J; Hemingway, C; Cox, M; Yentis, S M

2009-10-01

We assessed the effect of warming intravenous fluids during elective caesarean section under combined spinal-epidural anaesthesia in a blinded, randomised controlled trial. Seventy-five women having elective caesarean section were randomly assigned to receive all intravenous fluids at room temperature, or heated in a cabinet set at 45 degrees C or via a Hotline fluid warmer (Smiths Medical International Ltd, Watford, Herts, UK). After 10 mL/kg crystalloid preload, combined spinal-epidural anaesthesia was performed. Core and ambient temperatures, thermal comfort and shivering were measured every 15 min thereafter. The primary outcome was the temperature at 60 min. Temperature decreased in all groups. Although the temperature decrease at 60 min was similar in the heated cabinet and Hotline groups, the room temperature group exhibited a greater decrease [difference 0.4 degrees C (95% CI 0.2-0.6 degrees C); P=0.015]. More women felt cold in the room temperature group (8: 32%) than in the heated cabinet set (3: 12%) and Hotline (1: 4%) groups (P=0.02), but the incidence of shivering was similar: 11 (44%), 9 (36%) and 7 (28%) respectively. Apgar scores and neonatal cord gases were similar. Warming intravenous fluids mitigates the decrease in maternal temperature during elective caesarean section under combined spinal-epidural anaesthesia and improves thermal comfort, but does not affect shivering. Intravenous fluids should be warmed routinely in elective caesarean section, especially for cases of expected long duration, but the use of pre-warmed fluids is as efficient and cheaper than using a Hotline fluid warmer.

Short-Term High-Dose Vitamin E to Prevent Contrast Medium-Induced Acute Kidney Injury in Patients With Chronic Kidney Disease Undergoing Elective Coronary Angiography: A Randomized Placebo-Controlled Trial.

PubMed

Rezaei, Yousef; Khademvatani, Kamal; Rahimi, Behzad; Khoshfetrat, Mehran; Arjmand, Nasim; Seyyed-Mohammadzad, Mir-Hossein

2016-03-15

Contrast medium-induced acute kidney injury (CIAKI) is a leading cause of acquired renal impairment. The effects of antioxidants have been conflicting regarding the prevention of CIAKI. We performed a study of vitamin E use to decrease CIAKI in patients undergoing elective coronary angiography. In a placebo-controlled randomized trial at 2 centers in Iran, 300 patients with chronic kidney disease-defined as estimated glomerular filtration rate <60 mL/min per 1.73 m(2)-were randomized 1:1 to receive 0.9% saline infusion 12 hours prior to and after intervention combined with 600 mg vitamin E 12 hours before plus 400 mg vitamin E 2 hours before coronary angiography or to receive placebo. The primary end point was the development of CIAKI, defined as an increase ≥0.5 mg/dL or ≥25% in serum creatinine that peaked within 72 hours. Based on an intention-to-treat analysis, CIAKI developed in 10 (6.7%) and 21 (14.1%) patients in the vitamin E and placebo groups, respectively (P=0.037). Change in white blood cell count from baseline to peak value was greater in the vitamin E group compared with the placebo group (-500 [-1500 to 200] versus 100 [-900 to 600]×10(3)/mL, P=0.001). In multivariate analysis, vitamin E (odds ratio 0.408, 95% CI 0.170-0.982, P=0.045) and baseline Mehran score (odds ratio 1.257, 95% CI 1.007-1.569; P=0.043) predicted CIAKI. Prophylactic short-term high-dose vitamin E combined with 0.9% saline infusion is superior to placebo for prevention of CIAKI in patients undergoing elective coronary angiography. URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02070679. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Surgical Craniotomy for Intracerebral Haemorrhage.

PubMed

Mendelow, A David

2015-01-01

Craniotomy is probably indicated for patients with superficial spontaneous lobar supratentorial intracerebral haemorrhage (ICH) when the level of consciousness drops below 13 within the first 8 h of the onset of the haemorrhage. Once the level drops below 9, it is probably too late to consider craniotomy for these patients, so clinical vigilance is paramount. While this statement is only backed up by evidence that is moderately strong, meta-analysis of available data suggests that it is true in the rather limited number of patients with ICH. Meta-analyses like this can often predict the results of future prospective randomised controlled trials a decade or more before the trials are completed and published. Countless such examples exist in the literature, as is the case for thrombolysis in patients with myocardial infarction in the last millennium: meta-analysis determined the efficacy more than a decade BEFORE the last trial (ISIS-2) confirmed the benefit of thrombolysis for myocardial infarction. Careful examination of the meta-analysis' Forest plots in this chapter will demonstrate why this statement is made at the outset. Other meta-analyses of surgery for ICH have also indicated that minimal interventional techniques using topical thrombolysis or endoscopy via burrholes or even twist drill aspiration may be particularly successful for the treatment of supratentorial ICH, especially when the clot is deep seated. Ongoing clinical trials (CLEAR III and MISTIE III) should confirm this in the fullness of time. There are 2 exceptions to these generalisations. First, based on trial evidence, aneurysmal ICH is best treated with surgery. Second, cerebellar ICH represents a special case because of the development of hydrocephalus, which may require expeditious drainage as the intracranial pressure rises. The cerebellar clot will then require evacuation, usually via posterior fossa craniectomy, rather than craniotomy. Technical advances suggest that image-guided surgery may improve the completeness of surgical evacuation and outcomes, regardless of which surgical technique is employed. © 2016 S. Karger AG, Basel.

Clinical study on minimally invasive liquefaction and drainage of intracerebral hematoma in the treatment of hypertensive putamen hemorrhage.

PubMed

Liang, Ke-Shan; Ding, Jian; Yin, Cheng-Bin; Peng, Li-Jing; Liu, Zhen-Chuan; Guo, Xiao; Liang, Shu-Yu; Zhang, Yong; Zhou, Sheng-Nian

2017-12-04

This study aims to compare the curative effect of different treatment methods of hypertensive putamen hemorrhage, in order to determine an ideal method of treatment; and to explore the curative effect of the application of soft channel technology-minimally invasive liquefaction and drainage of intracerebral hematoma in the treatment of hypertensive putamen hemorrhage. Patients with hypertensive cerebral hemorrhage, who were treated in our hospital from January 2015 to January 2016, were included into this study. Patients were divided into three groups: minimally invasive drainage group, internal medical treatment group and craniotomy group. In the minimally invasive drainage group, puncture aspiration and drainage were performed according to different hematoma conditions detected in brain CT, the frontal approach was selected for putamen and intracerebral hemorrhage, and drainage was reserved until the hematoma disappeared in CT detection. Drug therapy was dominated in the internal medical treatment group, while surgery under general anesthesia was performed to remove the hematoma in the craniotomy group. Post-treatment neurological function defect scores in minimally invasive drainage group and internal medical group were 16.14 ± 11.27 and 31.43 ± 10.42, respectively; and the difference was remarkably significant (P< 0.01). Post-treatment neurological function defect scores in the minimally invasive drainage group and craniotomy group were 16.14 ± 11.27 and 24.20 ± 12.23, respectively; and the difference was statistically significant (P< 0.05). There was a remarkable significant difference in ADL1-2 level during followed-up in survival patients between the minimally invasive drainage group and internal medical treatment group (P< 0.01), and there was a significant difference in followed-up mortality between these two groups (P< 0.01). Clinical observation and following-up results revealed that minimally invasive drainage treatment was superior to internal medical treatment and craniotomy.

Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study

PubMed Central

Carroli, Guillermo; Zavaleta, Nelly; Donner, Allan; Wojdyla, Daniel; Faundes, Anibal; Velazco, Alejandro; Bataglia, Vicente; Langer, Ana; Narváez, Alberto; Valladares, Eliette; Shah, Archana; Campodónico, Liana; Romero, Mariana; Reynoso, Sofia; de Pádua, Karla Simônia; Giordano, Daniel; Kublickas, Marius; Acosta, Arnaldo

2007-01-01

Objective To assess the risks and benefits associated with caesarean delivery compared with vaginal delivery. Design Prospective cohort study within the 2005 WHO global survey on maternal and perinatal health. Setting 410 health facilities in 24 areas in eight randomly selected Latin American countries; 123 were randomly selected and 120 participated and provided data Participants 106 546 deliveries reported during the three month study period, with data available for 97 095 (91% coverage). Main outcome measures Maternal, fetal, and neonatal morbidity and mortality associated with intrapartum or elective caesarean delivery, adjusted for clinical, demographic, pregnancy, and institutional characteristics. Results Women undergoing caesarean delivery had an increased risk of severe maternal morbidity compared with women undergoing vaginal delivery (odds ratio 2.0 (95% confidence interval 1.6 to 2.5) for intrapartum caesarean and 2.3 (1.7 to 3.1) for elective caesarean). The risk of antibiotic treatment after delivery for women having either type of caesarean was five times that of women having vaginal deliveries. With cephalic presentation, there was a trend towards a reduced odds ratio for fetal death with elective caesarean, after adjustment for possible confounding variables and gestational age (0.7, 0.4 to 1.0). With breech presentation, caesarean delivery had a large protective effect for fetal death. With cephalic presentation, however, independent of possible confounding variables and gestational age, intrapartum and elective caesarean increased the risk for a stay of seven or more days in neonatal intensive care (2.1 (1.8 to 2.6) and 1.9 (1.6 to 2.3), respectively) and the risk of neonatal mortality up to hospital discharge (1.7 (1.3 to 2.2) and 1.9 (1.5 to 2.6), respectively), which remained higher even after exclusion of all caesarean deliveries for fetal distress. Such increased risk was not seen for breech presentation. Lack of labour was a risk factor for a stay of seven or more days in neonatal intensive care and neonatal mortality up to hospital discharge for babies delivered by elective caesarean delivery, but rupturing of membranes may be protective. Conclusions Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations. PMID:17977819

Effects of scalp block with bupivacaine versus levobupivacaine on haemodynamic response to head pinning and comparative efficacies in postoperative analgesia: A randomized controlled trial.

PubMed

Can, Banu O; Bilgin, Hülya

2017-04-01

Objective This study was performed to determine the effects of scalp blocks with bupivacaine versus levobupivacaine on the haemodynamic response during craniotomy and the efficacies and analgesic requirements of these drugs postoperatively. Methods This randomized, prospective, placebo-controlled, double-blind study included 90 patients (age, 18-85 years; American Society of Anesthesiologists physical status, I or II). The patients were randomly divided into three groups: those who received 20 mL of 0.5% bupivacaine (Group B, n = 30), 20 mL of 0.5% levobupivacaine (Group L, n = 30), or saline as a placebo (Group C, n = 30). Scalp blocks were performed 5 min before head pinning. The primary outcome was the mean arterial pressure (MAP), and the secondary outcomes were the heart rate (HR), visual analogue scale (VAS) scores, and additional intraoperative and postoperative drug use. Postoperative pain was evaluated using a 10-cm VAS. Results During head pinning and incision, the MAP and HR were significantly higher in Group C. The additional drug requirement for intraoperative hypertension and tachycardia was significantly higher in Group C. There were no significant differences in MAP, HR, or VAS scores between Groups B and L. Conclusion Both bupivacaine and levobupivacaine can be effectively and safely used for scalp blocks to control haemodynamic responses and postoperative pain.

Dexmedetomidine and general anesthesia: a narrative literature review of its major indications for use in adults undergoing non-cardiac surgery.

PubMed

Davy, Arthur; Fessler, Julien; Fischler, Marc; LE Guen, Morgan

2017-12-01

In Europe, dexmedetomidine has marketing approval only for sedation in intensive care units. However, its use during general anesthesia has been widely reported. The aim of this narrative review is to draw a picture of potential indications in anesthesia. We searched in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials using the keywords "Dexmedetomidine, Dexdor, Precedex and Dexdomitor." The research ended in December 2016. Studies were eligible for inclusion if they reported the use of dexmedetomidine in adults receiving general anesthesia. We excluded studies related to cardiac surgery and studies reporting the use of dexmedetomidine as an adjuvant of locoregional anesthesia. Several potential uses for dexmedetomidine during general anesthesia are described, especially: awake fiber optic intubation, the sparing effect of dexmedetomidine on hypnotic and opioid drugs, prevention of postoperative pain, nausea and vomiting and shivering, improvement of postoperative sleep and postoperative recovery, opioid-free anesthesia, use in craniotomy, endovascular stroke treatment and drug-induced sleep endoscopy. A protective effect against cardiac complications, an anti-inflammatory effect, and side effects, particularly bradycardia, are also described. The properties of dexmedetomidine lead to its use for elective indications such as awake fiberoptic intubation and neurosurgical anesthesia. New topics are under debate. These subjects must be studied thoroughly because of their implication in the patients' surgical course. These advantages must be weighed against the major drawback of dexmedetomidine administration which is the potential for hemodynamic abnormalities.

Decision Aid for Cigarette Smokers Scheduled for Elective Surgery.

PubMed

Warner, David O; LeBlanc, Annie; Kadimpati, Sandeep; Vickers, Kristin S; Shi, Yu; Montori, Victor M

2015-07-01

Decision aids can increase patient involvement in decision-making about health care. The study goal was to develop and test a decision aid for use by clinicians in discussion options for changing smoking behavior before and after elective surgery. In formative work, a decision aid was designed to facilitate patient-clinician discussion regarding three options: continue smoking, attempt a period of temporary abstinence, and attempt to quit smoking for good. A randomized, two-group pilot study was then conducted in smokers evaluated in preparation for elective surgery in a preoperative clinic to test the hypothesis that the decision aid would improve measures of decisional quality compared with usual care. The final decision aid consisted of three laminated cards. The front of each card included a colorful graphic describing each choice; the reverse including two to three pros and cons for each decision, a simple graphic illustrating the effects of smoking on the body, and a motivational phrase. In the randomized trial of 130 patients, the decision aid significantly (P < 0.05) improved measures of decisional quality and patient involvement in decision making (Cohen's d effect sizes of 0.76 and 1.20 for the Decisional Conflict Scale and Observing PatienT involvement In decisiON-making scale, respectively). However, the decision aid did not affect any aspect of perioperative smoking behavior, including the distribution of or adherence to choices. Although the use of a decision aid to facilitate clinician-patient discussions regarding tobacco use around the time of surgery substantially improved measures of decisional quality, it alone did not change perioperative tobacco use behavior.

Two occurrences of delayed epidural hematoma in different areas following decompressive craniectomy for acute subdural hematoma in a single patient: a case report.

PubMed

Wu, Ruhong; Shi, Jia; Cao, Jiachao; Mao, Yumin; Dong, Bo

2017-12-04

Delayed epidural hematoma (DEH) following evacuation of traumatic acute subdural hematoma (ASDH) or acute epidural hematoma (EDH) is a rare but devastating complication, especially when it occurs sequentially in a single patient. A 19-year-old man who developed contralateral DEH following craniotomy for evacuation of a traumatic right-side ASDH and then developed a left-side DEH of the posterior cranial fossa after craniotomy for evacuation of the contralateral DEH. He was immediately returned to the operating room for additional surgeries and his neurological outcome was satisfactory. Although DEH occurring after evacuation of ASDH or acute EDH is a rare event, timely recognition is critical to prognosis.

Linear undisplaced fracture of temporoparietal bone acting as spontaneous early decompressive craniotomy in a neonate

PubMed Central

Vankipuram, Siddharth; Balasubramanium, Srikant; Tyagi, Devendra K.; Savant, H. V.

2015-01-01

Decompressive craniotomy (DC) is used to treat intracranial hypertension associated with traumatic brain injury. Early DC is associated with better outcomes. We present a neonate with a history of fall with computed tomography scan showing a large frontoparietal contusion and associated parietal and temporal bone fracture. This acted as a spontaneous DC causing bony segment to separate due to which the edematous brain could be accommodated. Despite the presence of a large contusion, the child was neurologically intact and medically managed. The neonate presented with a posttraumatic leptomeningeal cyst 2 months later, which had to be repaired surgically. We discuss how a linear undisplaced fracture acts as spontaneous DC and the role of early DC in improving outcomes. PMID:26557171

Comments on "Getting out the Vote with Evaluative Thinking"

ERIC Educational Resources Information Center

Henry, Gary T.

2015-01-01

In this commentary, Gary Henry explains that the Danes have got it right, again. Not only is their voter turnout high to begin with, but they are evaluating ways to increase voter turnout with "random variation" to accurately assess the effects of the innovations. In the Danish 2009 municipal elections, 65.8% turned out to vote, which…

Selective Exposure and Retention of Political Advertising: A Regional Comparison.

ERIC Educational Resources Information Center

Surlin, Stuart H.; Gordon, Thomas F.

The results presented in this article are but a portion of the information gathered in a larger survey examining the relative roles of "selective exposure" to and "selective retention" of political advertising during the 1972 presidential election. Random samples in two metropolitan areas in different regions of the country (Atlanta, Ga., n=281;…

Foreign Policy News in the 1980 Presidential Election Campaign.

ERIC Educational Resources Information Center

Stovall, James Glen

A survey was conducted to determine the extent and content of newspaper coverage of foreign policy issues in the 1980 United States presidential campaign. Fifty daily newspapers from every region of the country were selected randomly based on circulation. A list of 757 news events was divided into party and nonparty events, and the party events…

40 CFR 1054.310 - How must I select engines for production-line testing?

Code of Federal Regulations, 2010 CFR

2010-07-01

... remedial steps required under § 1054.320. (i) You may elect to test more randomly chosen engines than we... 40 Protection of Environment 32 2010-07-01 2010-07-01 false How must I select engines for... (CONTINUED) AIR POLLUTION CONTROLS CONTROL OF EMISSIONS FROM NEW, SMALL NONROAD SPARK-IGNITION ENGINES AND...

Voter Learning and Interest in the 2000 Presidential Election: Did the Media Matter?

ERIC Educational Resources Information Center

Weaver, David; Drew, Dan

2001-01-01

Examines the relationships of exposure and attention to various news media, including the Internet, with information learned about the issue positions of George Bush and Al Gore, Jr., and intention to vote among a random sample of adult residents of Indiana. Compares results to earlier studies. Confirms the importance of television news and…

The effect of early education on patient anxiety while waiting for elective cardiac catheterization.

PubMed

Harkness, Karen; Morrow, Lydia; Smith, Kelly; Kiczula, Michele; Arthur, Heather M

2003-07-01

A supply-demand mismatch with respect to cardiac catheterization (CATH) often results in patients experiencing waiting times that vary from a few weeks to several months. Long delays can impose both physical and psychological distress for patients. The purpose of this study was to examine the effect of a psychoeducational nursing intervention at the beginning of the waiting period on patient anxiety during the waiting time for elective CATH. This was a 2-group randomized controlled trial. Intervention patients received a nurse-delivered, detailed information/education session within 2 weeks of being placed on the waiting list for elective CATH. Control group patients received usual care. The mean waiting time for CATH was 13.4+/-7.2 weeks, which did not differ between groups (P=0.509). Anxiety increased in both groups over the waiting time (P=0.028). Health-related quality of life deteriorated over the waiting time in both groups (P<0.05). On a visual analogue scale, there was a significant difference (P=0.002) between the intervention (4.0+/-2.7) and control (5.2+/-3.0) groups in self-reported anxiety 2 weeks prior to CATH. The waiting period prior to elective CATH has a negative impact on patients' perceived anxiety and quality of life and a simple intervention, provided at the beginning of the waiting period, may positively affect the experience of waiting.

Homeopathic arnica for prevention of pain and bruising: randomized placebo-controlled trial in hand surgery

PubMed Central

Stevinson, C; Devaraj, V S; Fountain-Barber, A; Hawkins, S; Ernst, E

2003-01-01

Homeopathic arnica is widely believed to control bruising, reduce swelling and promote recovery after local trauma; many patients therefore take it perioperatively. To determine whether this treatment has any effect, we conducted a double-blind, placebo-controlled, randomized trial with three parallel arms. 64 adults undergoing elective surgery for carpal tunnel syndrome were randomized to take three tablets daily of homeopathic arnica 30C or 6C or placebo for seven days before surgery and fourteen days after surgery. Primary outcome measures were pain (short form McGill Pain Questionnaire) and bruising (colour separation analysis) at four days after surgery. Secondary outcome measures were swelling (wrist circumference) and use of analgesic medication (patient diary). 62 patients could be included in the intention-to-treat analysis. There were no group differences on the primary outcome measures of pain (P=0.79) and bruising (P=0.45) at day four. Swelling and use of analgesic medication also did not differ between arnica and placebo groups. Adverse events were reported by 2 patients in the arnica 6C group, 3 in the placebo group and 4 in the arnica 30C group. The results of this trial do not suggest that homeopathic arnica has an advantage over placebo in reducing postoperative pain, bruising and swelling in patients undergoing elective hand surgery. PMID:12562974

Homeopathic arnica for prevention of pain and bruising: randomized placebo-controlled trial in hand surgery.

PubMed

Stevinson, C; Devaraj, V S; Fountain-Barber, A; Hawkins, S; Ernst, E

2003-02-01

Homeopathic arnica is widely believed to control bruising, reduce swelling and promote recovery after local trauma; many patients therefore take it perioperatively. To determine whether this treatment has any effect, we conducted a double-blind, placebo-controlled, randomized trial with three parallel arms. 64 adults undergoing elective surgery for carpal tunnel syndrome were randomized to take three tablets daily of homeopathic arnica 30C or 6C or placebo for seven days before surgery and fourteen days after surgery. Primary outcome measures were pain (short form McGill Pain Questionnaire) and bruising (colour separation analysis) at four days after surgery. Secondary outcome measures were swelling (wrist circumference) and use of analgesic medication (patient diary). 62 patients could be included in the intention-to-treat analysis. There were no group differences on the primary outcome measures of pain (P=0.79) and bruising (P=0.45) at day four. Swelling and use of analgesic medication also did not differ between arnica and placebo groups. Adverse events were reported by 2 patients in the arnica 6C group, 3 in the placebo group and 4 in the arnica 30C group. The results of this trial do not suggest that homeopathic arnica has an advantage over placebo in reducing postoperative pain, bruising and swelling in patients undergoing elective hand surgery.

Randomized clinical trial of peritoneal lavage for preventing surgical site infection in elective liver surgery.

PubMed

Tanaka, Kuniya; Matsuo, Kenichi; Kawaguchi, Daisuke; Murakami, Takashi; Hiroshima, Yukihiko; Hirano, Atsushi; Sato, Sho; Endo, Itaru; Taguri, Masataka; Koda, Keiji

2015-06-01

Although intraoperative peritoneal lavage is often performed routinely with the aim of reducing peritoneal contamination, little evidence of lavage benefits in elective liver resection without bile duct resection is available. We addressed the issue with a randomized clinical trial. We prospectively and randomly assigned consecutive patients undergoing liver resection to a lavage group or a non-lavage group. Peritoneal lavage was performed at the end of operation for patients in the lavage group. The primary endpoint was the rate of surgical site infection. Ninety-six patients were assigned to the lavage group and 97 to the non-lavage group. When superficial/deep incisional infection and organ/space infection were considered together, no significant difference in surgical site infection rate was evident between lavage (21.9%) and non-lavage groups (13.4%, P = 0.135). However, organ/space infection was significantly more frequent in the lavage group (16.7%) than the non-lavage group (7.2%, P = 0.048). Peritoneal lavage was identified as a risk factor for organ/space infection by multivariate analysis (relative risk, 2.977; confidence interval, 1.094 to 8.100; P = 0.033). Intraoperative peritoneal lavage does not reduce overall incidence of surgical site infection and may increase risk of organ/space infection. © 2015 Japanese Society of Hepato-Biliary-Pancreatic Surgery.

Craniotomy - slideshow

MedlinePlus

... Duplication for commercial use must be authorized in writing by ADAM Health Solutions. About MedlinePlus Site Map FAQs Customer Support Get email updates Subscribe to RSS Follow us Disclaimers Copyright ...

The Effect of High Dose Cilostazol and Rosuvastatin on Periprocedural Myocardial Injury in Patients with Elective Percutaneous Coronary Intervention

PubMed Central

H., Ari; N., Emlek; S., Ari; S., Coşar; K., Doğanay; C., Aydin; E., Tenekecioğlu; A., Tütüncü; O.C., Yontar; M., Gürdoğan; T., Bozat; M., Melek

2015-01-01

Background The aim of our study was to assess the effect of pretreatment with cilostazol and rosuvastatin combination before elective percutaneous coronary intervention (PCI) on peri-procedural myocardial injury (PPMIJ). Methods We randomly assigned 172 patients with stable angina pectoris scheduled for elective PCI to pre- treatment with Cilostazol 200mg and Rosuvastatin 40 mg (group 1), or to pretreatment with Rosuvastatin 40 mg group (group 2). The primary end-point was the occurrence of PPMIJ defined as any cardiac troponin I (Tn I) level elevated above the upper normal limit (UNL). The occurrence of peri-procedural myocardial infarction (PPMIN) was defined as a post-procedural increase in cTnI level ≥ 5 times above the UNL. Results There was no significant difference in baseline characteristics between group 1 (n = 86) and group 2 (n = 86). The rate of PPMIJ (21% vs. 24%, p = 0.58) and PPMIN (2.3% vs. 7%, p = 0.27) were similar between the two study groups. Subgroup analysis performed on those patients without statin therapy before PCI (53 patients in group 1 and 50 patients in group 2) showed that the incidence of PPMIJ was significantly lower in the group 1 patients without chronic statin treatment [17% (9/53) versus 34% (17/50); p = 0.04], but the rate of PPMIN was similar between the two groups for those patients without chronic statin treatment [1.9% (1/53) versus 10% (5/50); p = 0.07]. Conclusions We found that adjunct cilostazol and rosuvastatin pre-treatment did not significantly reduce PPMIJ after elective PCI in patients with stable angina pectoris. However, adjunct cilostazol pre-treatment could reduce PPMIJ in patients without chronic statin therapy before elective PCI. PMID:27122885

Postoperative Mortality Among Patients With Inflammatory Bowel Diseases: A Systematic Review and Meta-analysis of Population-Based Studies.

PubMed

Singh, Sunny; Al-Darmaki, Ahmed; Frolkis, Alexandra D; Seow, Cynthia H; Leung, Yvette; Novak, Kerri L; Ghosh, Subrata; Eksteen, Bertus; Panaccione, Remo; Kaplan, Gilaad G

2015-10-01

There have been varying reports of mortality after intestinal resection for the inflammatory bowel diseases (IBDs). We performed a systematic review and meta-analysis of population-based studies to determine postoperative mortality after intestinal resection in patients with IBD. We searched Medline, EMBASE, and PubMed, from 1990 through 2015, to identify 18 articles and 3 abstracts reporting postoperative mortality among patients with IBD. The studies included 67,057 patients with ulcerative colitis (UC) and 75,971 patients with Crohn's disease (CD), from 15 countries. Mortality estimates stratified by emergent and elective surgeries were pooled separately for CD and UC using a random-effects model. To assess changes over time, the start year of the study was included as a continuous variable in a meta-regression model. In patients with UC, postoperative mortality was significantly lower among patients who underwent elective (0.7%; 95% confidence interval [CI], 0.6%-0.9%) vs emergent surgery (5.3%; 95% CI, 3.8%-7.4%). In patients with CD, postoperative mortality was significantly lower among patients who underwent elective (0.6%; 95% CI, 0.2%-1.7%) vs emergent surgery (3.6%; 95% CI, 1.8%-6.9%). Postoperative mortality did not differ for elective (P = .78) or emergent (P = .31) surgeries when patients with UC were compared with patients with CD. Postoperative mortality decreased significantly over time for patients with CD (P < .05) but not UC (P = .21). Based on a systematic review and meta-analysis, postoperative mortality was high after emergent, but not elective, intestinal resection in patients with UC or CD. Optimization of management strategies and more effective therapies are necessary to avoid emergent surgeries. Copyright © 2015 AGA Institute. Published by Elsevier Inc. All rights reserved.

The Effect of High Dose Cilostazol and Rosuvastatin on Periprocedural Myocardial Injury in Patients with Elective Percutaneous Coronary Intervention.

PubMed

H, Ari; N, Emlek; S, Ari; S, Coşar; K, Doğanay; C, Aydin; E, Tenekecioğlu; A, Tütüncü; O C, Yontar; M, Gürdoğan; T, Bozat; M, Melek

2015-07-01

The aim of our study was to assess the effect of pretreatment with cilostazol and rosuvastatin combination before elective percutaneous coronary intervention (PCI) on peri-procedural myocardial injury (PPMIJ). We randomly assigned 172 patients with stable angina pectoris scheduled for elective PCI to pre- treatment with Cilostazol 200mg and Rosuvastatin 40 mg (group 1), or to pretreatment with Rosuvastatin 40 mg group (group 2). The primary end-point was the occurrence of PPMIJ defined as any cardiac troponin I (Tn I) level elevated above the upper normal limit (UNL). The occurrence of peri-procedural myocardial infarction (PPMIN) was defined as a post-procedural increase in cTnI level ≥ 5 times above the UNL. There was no significant difference in baseline characteristics between group 1 (n = 86) and group 2 (n = 86). The rate of PPMIJ (21% vs. 24%, p = 0.58) and PPMIN (2.3% vs. 7%, p = 0.27) were similar between the two study groups. Subgroup analysis performed on those patients without statin therapy before PCI (53 patients in group 1 and 50 patients in group 2) showed that the incidence of PPMIJ was significantly lower in the group 1 patients without chronic statin treatment [17% (9/53) versus 34% (17/50); p = 0.04], but the rate of PPMIN was similar between the two groups for those patients without chronic statin treatment [1.9% (1/53) versus 10% (5/50); p = 0.07]. We found that adjunct cilostazol and rosuvastatin pre-treatment did not significantly reduce PPMIJ after elective PCI in patients with stable angina pectoris. However, adjunct cilostazol pre-treatment could reduce PPMIJ in patients without chronic statin therapy before elective PCI. Cilostazol; Myocardial injury; Percutaneous coronary intervention; Statin.

Designing a pain management protocol for craniotomy: A narrative review and consideration of promising practices

PubMed Central

Vacas, Susana; Van de Wiele, Barbara

2017-01-01

Background: Craniotomy is a relatively common surgical procedure with a high incidence of postoperative pain. Development of standardized pain management and enhanced recovery after surgery (ERAS) protocols are necessary and crucial to optimize outcomes and patient satisfaction and reduce health care costs. Methods: This work is based upon a literature search of published manuscripts (between 1996 and 2017) from Pubmed, Cochrane Central Register, and Google Scholar. It seeks to both synthesize and review our current scientific understanding of postcraniotomy pain and its part in neurosurgical ERAS protocols. Results: Strategies to ameliorate craniotomy pain demand interventions during all phases of patient care: preoperative, intraoperative, and postoperative interventions. Pain management should begin in the perioperative period with risk assessment, patient education, and premedication. In the intraoperative period, modifications in anesthesia technique, choice of opioids, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), regional techniques, dexmedetomidine, ketamine, lidocaine, corticosteroids, and interdisciplinary communication are all strategies to consider and possibly deploy. Opioids remain the mainstay for pain relief, but patient-controlled analgesia, NSAIDs, standardization of pain management, bio/behavioral interventions, modification of head dressings as well as patient-centric management are useful opportunities that potentially improve patient care. Conclusions: Future research on mechanisms, predictors, treatments, and pain management pathways will help define the combinations of interventions that optimize pain outcomes. PMID:29285407

Preferences and Utilities for Health States after Treatment of Olfactory Groove Meningioma: Endoscopic versus Open.

PubMed

Yao, Christopher M; Kahane, Alyssa; Monteiro, Eric; Gentili, Fred; Zadeh, Gelareh; de Almeida, John R

2017-08-01

Objectives  The purpose of this study is to report health utility scores for patients with olfactory groove meningiomas (OGM) treated with either the standard transcranial approach, or the expanded endonasal endoscopic approach. Design  The time trade-off technique was used to derive health utility scores. Setting  Healthy individuals without skull base tumors were surveyed. Main Outcome Measures  Participants reviewed and rated scenarios describing treatment (endoscopic, open, stereotactic radiation, watchful waiting), remission, recurrence, and complications associated with the management of OGMs. Results  There were 51 participants. The endoscopic approach was associated with higher utility scores compared with an open craniotomy approach (0.88 vs. 0.74; p  < 0.001) and watchful waiting (0.88 vs.0.74; p  = 0.002). If recurrence occurred, revision endoscopic resection continued to have a higher utility score compared with revision open craniotomy (0.68; p  = 0.008). On multivariate analysis, older individuals were more likely to opt for watchful waiting ( p  = 0.001), whereas participants from higher income brackets were more likely to rate stereotactic radiosurgery with higher utility scores ( p  = 0.017). Conclusion  The endoscopic approach was associated with higher utility scores than craniotomy for primary and revision cases. The present utilities can be used for future cost-utility analyses.

Election Verifiability: Cryptographic Definitions and an Analysis of Helios and JCJ

DTIC Science & Technology

2015-08-06

SHA - 256 [98], we assume that H is a random oracle to prove Theorem 2. Moreover, we assume the sigma protocols used by Helios 4.0 satisfy the...Aspects in Security and Trust, volume 5491 of LNCS, pages 242– 256 . Springer, 2008. [68] Martin Hirt. Receipt-Free K-out-of-L Voting Based on ElGamal

Pain following Craniotomy: Reassessment of the Available Options

PubMed Central

Haldar, Rudrashish; Kaushal, Ashutosh; Gupta, Devendra; Srivastava, Shashi; Singh, Prabhat K.

2015-01-01

Pain following craniotomy has frequently been neglected because of the notion that postcraniotomy patients do not experience severe pain. However a gradual change in this outlook is observed because of increased sensitivity of neuroanaesthesiologists and neurosurgeons toward acute postcraniotomy pain. Multiple modalities exist for treating this variety of pain each with its own share of advantages and disadvantages. However, individually none of these modalities has been proclaimed as the best and applicable universally. A considerable amount of dispute remains to ascertain the appropriate therapeutic regimen for treating postcraniotomy pain in spite of numerous trials using different drugs and their combinations. This review aims to highlight the genesis, characteristics, and different strategies that are undertaken for management of acute postcraniotomy pain. Chronic postcraniotomy pain which can be debilitating sequelae is also discussed concisely. PMID:26495298

Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients.

PubMed

Maltby, J Roger; Pytka, Saul; Watson, Neil C; Cowan, Robert A McTaggart; Fick, Gordon H

2004-02-01

To determine whether, in obese [body mass index (BMI) > 30 kg.m(2)] patients, oral intake of 300 mL clear liquid two hours before elective surgery affects the volume and pH of gastric contents at induction of anesthesia. A single-blind, randomized study of 126 adult patients, age > or = 18 yr, ASA physical status I or II, BMI > 30 kg.m(2) who were scheduled for elective surgery under general anesthesia. Patients were excluded if they had diabetes mellitus, symptoms of gastroesophageal reflux, or had taken medication within 24 hr that affects gastric secretion, gastric fluid pH or gastric emptying. All patients fasted from midnight and were randomly assigned to fasting or fluid group. Two hours before their scheduled time of surgery, all patients drank 10 mL of water containing phenol red 50 mg. Those in the fluid group followed with 300 mL clear liquid of their choice. Immediately following induction of general anesthesia and tracheal intubation, gastric contents were aspirated through a multiorifice Salem sump tube. The fluid volume, pH and phenol red concentration were recorded. Median (range) values in fasting vs fluid groups were: gastric fluid volume 26 (3-107) mL vs 30 (3-187) mL, pH 1.78 (1.31-7.08) vs 1.77 (1.27-7.34) and phenol red retrieval 0.1 (0-30)% vs 0.2 (0-15)%. Differences between groups were not statistically significant. Obese patients without comorbid conditions should follow the same fasting guidelines as non-obese patients and be allowed to drink clear liquid until two hours before elective surgery, inasmuch as obesity per se is not considered a risk factor for pulmonary aspiration.

Vascular access site complication in transfemoral coronary angiography between uninterrupted warfarin and heparin bridging.

PubMed

Wongcharoen, Wanwarang; Pinyosamosorn, Kittipong; Gunaparn, Siriluck; Boonnayhun, Suchada; Thonghong, Tasalak; Suwannasom, Pannipa; Phrommintikul, Arintaya

2017-08-01

Warfarin discontinuation with heparin bridging is a common practice in patients receiving warfarin prior to elective coronary angiography (CAG). The uninterrupted warfarin strategy has been suggested to be alternative option for patients with high thromboembolic risk. Therefore, we aimed to assess the safety of elective transfemoral CAG during uninterrupted warfarin therapy compared to heparin bridging. This study was a randomized open-label design with blinded event evaluation. The 110 consecutive patients (age ≥ 18 years) receiving warfarin before the planned transfemoral CAG were randomly assigned to either heparin bridging or uninterrupted warfarin with targeted INR (2.0-3.0). The primary outcome was the incidence of major vascular access site complications. The baseline characteristics were comparable between two groups (mean age was 60.1 ± 7.8 years, 49 males). The mean INR on the day of CAG of heparin bridging and uninterrupted warfarin groups was 1.2 ± 0.3 and 2.2 ± 0.5 (P < 0.001). The major vascular access site complications occurred in 3 of 55 (5.5%) heparin-bridging patients and in none of 55 uninterrupted warfarin patients (P = 0.243). The total vascular access site complications occurred in 6 (10.9%) heparin-bridging and one (1.8%) uninterrupted warfarin patients (P = 0.113). No patient developed either other bleeding or thromboembolic events during 7 days after CAG. We demonstrated that an uninterrupted warfarin strategy did not increase vascular access site complications in patients undergoing transfemoral CAG compared to heparin bridging therapy. Due to the safety and the ease of uninterrupted warfarin strategy, this approach should be encouraged in patients receiving long-term warfarin who undergo elective transfemoral CAG. © 2017, Wiley Periodicals, Inc.

High-dose senna compared with conventional PEG-ES lavage as bowel preparation for elective colonoscopy: a prospective, randomized, investigator-blinded trial.

PubMed

Radaelli, Franco; Meucci, Gianmichele; Imperiali, Gianni; Spinzi, Giancarlo; Strocchi, Enrico; Terruzzi, Vittorio; Minoli, Giorgio

2005-12-01

To compare the efficacy and patient acceptance of an oral high dose of senna to conventional polyethylene glycol-electrolyte lavage solution (PEG-ES) in adults undergoing elective colonoscopy. Consecutive outpatients referred for elective colonoscopy were prospectively randomly assigned to receive, the day before the procedure, either 24 tablets of 12 mg senna, divided into two doses at 1 p.m. and 9 p.m. (senna group, n=191), or standard 4-L PEG-ES (PEG-ES group, n=92). The overall quality of colon cleansing (primary outcome measure) and cleansing in the right colon were evaluated using the Aronchick scoring scale (1=excellent to 4=inadequate) by the investigator/endoscopist who was blinded to the treatment assignment. Patient acceptance and the safety of the preparation were assessed by a nurse, using a structured questionnaire covering compliance with the dosing, overall tolerance of the preparation (1=none or mild discomfort to 4=severely distressing), and adverse events. The quality of colon cleansing, overall tolerance of the preparation, and compliance were significantly better with senna; overall cleansing was excellent or good in 90.6% of patients in the senna group and in 79.7% in the PEG-ES group (p= 0.003). The percentage of procedures rescheduled because of insufficient colon cleansing was 7.3% in the PEG-ES group and 2.6% in the senna group (p=0.035). Multivariate logistic regression modeling showed the PEG-ES preparation as negative independent predictor of unsuccessful bowel cleansing. The incidence of adverse reactions was similar in the two groups; patients who received senna experienced significantly less nausea and vomiting, but more abdominal pain. An oral high dose of senna is a valid alternative to standard PEG-ES for outpatient colonoscopy preparation.

Aneurysm in the brain

MedlinePlus

... ruptured: Clipping is done during open brain surgery (craniotomy) . Endovascular repair is most often done. It usually ... unit (ICU) Complete bed rest and activity restrictions Drainage of blood from the brain area (cerebral ventricular ...

Impact of Prophylactic Continuous Positive Airway Pressure on Transient Tachypnea of the Newborn and Neonatal Intensive Care Admission in Newborns Delivered by Elective Cesarean Section.

PubMed

Celebi, Miray Yilmaz; Alan, Serdar; Kahvecioglu, Dilek; Cakir, Ufuk; Yildiz, Duran; Erdeve, Omer; Arsan, Saadet; Atasay, Begum

2016-01-01

This study aims to evaluate the effect of the prophylactic continuous positive airway pressure (CPAP) administration in the delivery room to newborns who were delivered by elective cesarean section (CS). Inborn infants with gestational age between 34(0/7) to 38(6/7) and born by elective CS were prospectively randomized to receive either prophylactic CPAP for 20 minutes via face mask or standardized care without CPAP in the delivery room. Primary outcomes were the incidence of transient tachypnea of the newborn (TTN) and neonatal intensive care unit (NICU) admission due to respiratory distress. A total of 259 infants with a mean gestational age of 37.7 ± 0.8 weeks and birth weight of 3,244 ± 477 g were included. A total of 134 infants received prophylactic CPAP and 125 received control standard care. The rate of NICU admission was significantly lower in prophylactic CPAP group (p = 0.045). Although the rate of TTN was lower in the prophylactic CPAP group, the difference was not statistically significant (p = 0.059). The rate of NICU admission due to respiratory distress was significantly higher in late-preterm cohort than early-term cohort (p < 0.0001). Prophylactic CPAP administration decreases the rate of NICU admission without any side effect in late-preterm and early-term infants delivered by elective CS. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Dexmedetomidine in the Supratentorial Craniotomy

PubMed Central

Ilhan, Osman; Koruk, Senem; Serin, Gokcen; Erkutlu, Ibrahim; Oner, Unsal

2010-01-01

Objective: In this double-blind prospective clinical study, we investigated the effects of fentanyl and dexmedetomidine as adjuvant agents in supratentorial craniotomies on the following: hemodynamic changes during perioperative and recovery periods, brain edema perioperatively, recovery times and side effects, such as hypertension, shivering, nausea and vomiting. Materials and Methods: Thirty consenting ASA physical status I–II patients undergoing intracranial tumor surgery were randomly divided in two groups. In group D (n=15), dexmedetomidine was infused as a 1 μg/kg bolus dose 10 minutes before induction of anesthesia and maintained with 0.4–0.5 μg/kg/min during the operation. In group F (n=15), animals were given fentanyl 0.02 μg/kg/min as an infusion for anesthesia maintenance. At induction, fentanyl was given as a 2 μg/kg dose in group D and as a 4 μg/kg dose in group F. Hemodynamic changes, recovery times and postoperative side effects were recorded before induction, during the perioperative period and 24 hours postoperatively. Results: In group D; MAP and HR values after intubation, after skull clamp insertion and after extubation were lower than in group F (p<0.05). In group D, cerebral relaxation scores were also significantly lower. Recovery times were found to be shorter in group D as compared to group F; the same trend was observed for the supplemental opioid requirement. During the postoperative period, there was no shivering, nausea or vomiting in group D, but in group F, 3 patients complained of shivering, and 2 patients experienced nausea and vomiting. Conclusion: In our study, we found that dexmedetomidine controlled the hemodynamic changes better than fentanyl perioperatively, after extubation and during the early postoperative period. Our results suggest that that dexmedetomidine is safer and more effective in controlling hemodynamic changes during surgical stimulation than the standard agents used in neuroanesthesia. PMID:25610125

Awake Craniotomy with Noninvasive Brain Mapping by 3-Tesla Functional Magnetic Resonance Imaging for Excision of Low-grade Glioma: A Case of a Young Patient from Pakistan.

PubMed

Aleem Bhatti, Atta Ul; Jakhrani, Nasir Khan; Parekh, Maria Adnan

2018-01-01

The past few years have seen increasing support for gross total resection in the management of low-grade gliomas (LGGs), with a greater extent of resection correlated with better overall survival, progression-free survival, and time to malignant transformation. There is consistent evidence in literature supporting extent of safe resection as a good prognostic indicator as well as positively affecting seizure control, symptomatic relief in pressure symptoms, and longer progression-free and total survival. The operative goal in most LGG cases is to maximize the extent of resection for these benefits while avoiding postoperative neurologic deficits. Several advanced invasive and noninvasive surgical techniques such as intraoperative magnetic resonance imaging (MRI), fluorescence-guided surgery, intraoperative functional pathway mapping, and neuronavigation have been developed in an attempt to better achieve maximal safe resection. We present a case of LGG in a young patient with a 5-year history of refractory seizures and gradual onset walking difficulty. Serial MRI brain scans revealed a progressive increase in right frontal tumor size with substantial edema and parafalcine herniation. Noninvasive brain mapping by functional MRI (fMRI) and sleep-awake-sleep type of anesthesia with endotracheal tube insertion was utilized during an awake craniotomy. Histopathology confirmed a Grade II oligodendroglioma, and genetic analysis revealed no codeletion at 1p/19q. Neurological improvement was remarkable in terms of immediate motor improvement, and the patient remained completely seizure free on a single antiepileptic drug. There is no radiologic or clinical evidence of recurrence 6 months postoperatively. This is the first published report of an awake craniotomy for LGG in Pakistan. The contemporary concept of supratotal resection in LGGs advocates generous functional resection even beyond MRI findings rather than mere excision of oncological boundaries. This relatively aggressive approach is only possible with an awake craniotomy, which ensures preservation of functional status and thus less postoperative morbidity and better outcomes. Noninvasive mapping for intracranial space-occupying lesions, including fMRI and blood-oxygen-level dependent (BOLD) imaging modality, is an essential tool in a resource-limited setting such as Pakistan.

Current trends and progress in clinical applications of oocyte cryopreservation.

PubMed

Cil, Aylin P; Seli, Emre

2013-06-01

To delineate the current trends in the clinical application of oocyte cryopreservation. Although the first live birth from oocyte cryopreservation was reported approximately three decades ago, significant improvement in the clinical application of oocyte cryopreservation took place only over the past decade. On the basis of the available evidence suggesting that success rates with donor oocyte vitrification are similar to that of IVF with fresh donor oocytes, the American Society of Reproductive Medicine has recently stated that oocyte cryopreservation should no longer be considered experimental for medical indications, outlying elective oocyte cryopreservation. Meanwhile, a few surveys on the attitudes toward oocyte cryopreservation revealed that elective use for the postponement of fertility is currently the most common indication for oocyte cryopreservation. Most recently, a randomized controlled trial revealed important evidence on the safety of nondonor oocyte cryopreservation, and confirmed that the clinical success of vitrification is comparable to that of IVF with fresh oocytes. The evidence suggesting similar IVF success rates with both donor and nondonor cryopreserved oocytes compared with fresh oocytes will increase the utilization of elective oocyte cryopreservation. Appropriate counseling of women for oocyte cryopreservation requires the establishment of age-based clinical success rates with cryopreserved oocytes for various indications.

Motives for cosmetic procedures in Saudi women.

PubMed

Al-Natour, Sahar H

2014-01-01

The media-fuelled obsession with beauty in modern society has led more women to seek elective cosmetic procedures to meet the portrayed ideals of beauty in different cultures. This study gives insights into incentives and desires to undergo cosmetic procedures in a conservative society with strict religious practices where women are veiled. Questionnaire data were obtained from 509 Saudi women who responded to a survey distributed randomly to a sample of Saudi women aged 17 to 72 years. At least 1 elective cosmetic procedure was performed in 42% of the women, of whom 77.8% wore a veil. Another 33% considered having a procedure. The motives for seeking a cosmetic procedure were to improve self-esteem in 83.7%, attract a husband in 63.3%, or prevent a husband from seeking another wife in 36.2%. The decision to seek a procedure was affected by the media, with high peer influence. Motivation for elective cosmetic procedures in Saudi women is influenced by a combination of emotional and cultural factors, level of education, marital status, and religious beliefs. The veil is not an impediment for seeking such procedures. The limitation of the study was missing data analysis as some items in the questionnaire were completed inaccurately or left unanswered.

Persuading girls to take elective physical science courses in high school: Who are the credible communicators?

NASA Astrophysics Data System (ADS)

Koballa, Thomas R., Jr.

Eighth-grade girls (N=257) randomly selected from nine different public junior high schools in central Texas were questioned in order to identify the communicators whom they perceive as highly credible regarding reasons for taking elective physical science courses in high school and the attributes associated with these communicators. Four persons were each identified by better than 10 percent of the sample as the best person to try to convince junior high school girls to take elective physical science courses in high school. In order of perceived credibility, these persons are father, woman science teacher, mother, and boy high school student. Slight variations in the order of perceived credibility were found when the responses from girls of the different ethnic groups represented in the sample (Caucasian, Hispanic, Black, and Asian) were examined separately. Attributes listed by the respondents for father, woman science teacher, mother, and boy high school student were examined and classified into the categories of prestige, trustworthiness, similarity, attractiveness, and power. Prestige and trustworthiness are the attributes associates most frequently with communicators identified as highly credible. Implications of the present study and suggestions for further research are discussed.

Risk of intraoperative hypotension with loop diuretics: a randomized controlled trial.

PubMed

Khan, Nadia A; Campbell, Norman R; Frost, Shaun D; Gilbert, Ken; Michota, Frank A; Usmani, Ali; Seal, Doug; Ghali, William A

2010-11-01

There is growing concern regarding the safety of blood pressure-lowering medications administered during the perioperative period. Whether loop diuretics also induce intraoperative hypotension is uncertain. Our objective was to compare the effects of continuing or withholding furosemide on the day of noncardiac elective surgery on intraoperative hypotension among chronic users of furosemide. A double blind, randomized, placebo controlled trial was conducted at 3 North American university centers between September 2000 and December 2006. Participants were randomly assigned in a 1:1 ratio to receive either furosemide or placebo on the day of surgery. The primary outcome was risk of developing intraoperative hypotension. A priori secondary outcomes included risk of heart failure; composite cardiovascular event (myocardial infarction, arrhythmia, stroke or transient ischemic attack, or death); and change in renal function and electrolytes. Of the 212 patients enrolled, 193 patients underwent surgery. There was no significant difference in risk of developing intraoperative hypotension between the furosemide (49%) and placebo (51.9%) groups (relative risk [RR], 0.95; 95% confidence interval [CI], 0.72-1.24; P = .78). The intraoperative administration of vasopressors and fluids were similar between both groups. The risk of developing postoperative cardiovascular events was not significantly different between those randomized to furosemide (4.8%) or placebo (2.8%) (RR, 1.73; 95% CI, 0.42-7.06; P = .49). There was no significant difference in renal function or electrolytes between the 2 groups. Among elective, noncardiac surgeries in patients chronically treated with furosemide, the administration of furosemide on the day of surgery did not significantly increase the risk for intraoperative hypotension. Copyright © 2010 Elsevier Inc. All rights reserved.

Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis.

PubMed

Watt, Jennifer; Tricco, Andrea C; Talbot-Hamon, Catherine; Pham, Ba'; Rios, Patricia; Grudniewicz, Agnes; Wong, Camilla; Sinclair, Douglas; Straus, Sharon E

2018-04-01

Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery. Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates. Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3-23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2-17.9), frailty (OR 4.1, 95% CI 1.4-11.7), cognitive impairment (OR 2.7, 95% CI 1.9-3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6-2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3-2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4-3.6) and smoking status (OR 1.8 95% CI 1.3-2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52-0.91). Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care.

Predictors of outcome after elective endovascular abdominal aortic aneurysm repair and external validation of a risk prediction model.

PubMed

Wisniowski, Brendan; Barnes, Mary; Jenkins, Jason; Boyne, Nicholas; Kruger, Allan; Walker, Philip J

2011-09-01

Endovascular abdominal aortic aneurysm (AAA) repair (EVAR) has been associated with lower operative mortality and morbidity than open surgery but comparable long-term mortality and higher delayed complication and reintervention rates. Attention has therefore been directed to identifying preoperative and operative variables that influence outcomes after EVAR. Risk-prediction models, such as the EVAR Risk Assessment (ERA) model, have also been developed to help surgeons plan EVAR procedures. The aims of this study were (1) to describe outcomes of elective EVAR at the Royal Brisbane and Women's Hospital (RBWH), (2) to identify preoperative and operative variables predictive of outcomes after EVAR, and (3) to externally validate the ERA model. All elective EVAR procedures at the RBWH before July 1, 2009, were reviewed. Descriptive analyses were performed to determine the outcomes. Univariate and multivariate analyses were performed to identify preoperative and operative variables predictive of outcomes after EVAR. Binomial logistic regression analyses were used to externally validate the ERA model. Before July 1, 2009, 197 patients (172 men), who were a mean age of 72.8 years, underwent elective EVAR at the RBWH. Operative mortality was 1.0%. Survival was 81.1% at 3 years and 63.2% at 5 years. Multivariate analysis showed predictors of survival were age (P = .0126), American Society of Anesthesiologists (ASA) score (P = .0180), and chronic obstructive pulmonary disease (P = .0348) at 3 years and age (P = .0103), ASA score (P = .0006), renal failure (P = .0048), and serum creatinine (P = .0022) at 5 years. Aortic branch vessel score was predictive of initial (30-day) type II endoleak (P = .0015). AAA tortuosity was predictive of midterm type I endoleak (P = .0251). Female sex was associated with lower rates of initial clinical success (P = .0406). The ERA model fitted RBWH data well for early death (C statistic = .906), 3-year survival (C statistic = .735), 5-year survival (C statistic = .800), and initial type I endoleak (C statistic = .850). The outcomes of elective EVAR at the RBWH are broadly consistent with those of a nationwide Australian audit and recent randomized trials. Age and ASA score are independent predictors of midterm survival after elective EVAR. The ERA model predicts mortality-related outcomes and initial type I endoleak well for RBWH elective EVAR patients. Copyright © 2011 Society for Vascular Surgery. All rights reserved.

Pathologic Progression, Possible Origin, and Management of Multiple Primary Intracranial Neuroendocrine Carcinomas.

PubMed

Cao, Jingwei; Xu, Wenzhe; Du, Zhenhui; Sun, Bin; Li, Feng; Liu, Yuguang

2017-10-01

Primary intracranial neuroendocrine carcinomas (NECs) are extremely rare malignant tumors with no previous reports of multiple ones in the literatures. The clinical presentation, preoperative and reexamined magnetic resonance imaging findings, as well as histopathologic studies of a 56-year-old female subject with multiple intracranial NECs mimicking multiple intracranial meningiomas, who underwent 3 operations with left parietal craniotomy, right occipital parietal craniotomy, and left frontal craniotomy, separately and chronologically, are presented in this article. Noteworthy, the first and second tumors were confirmed as NECs exhibiting histologic characteristics of typical anaplastic meningiomas with features of whorl formation, while the third tumor was a typical NEC with features of organoid cancer nests. In other words, the first 2 lesions were diagnosed as meningioma as opposed to NEC. It was only after the third surgery that the pathology for the first 2 cases was reviewed and had a revised diagnosis. After the third surgical resection, the patient further received whole brain radiotherapy and systemic chemotherapy (temozolomide combined with YH-16). At her 10-month follow-up, the patient achieved a good outcome. Multiple primary intracranial NECs are extremely rare. The tumor might be of arachnoidal or leptomeningeal origin, with histologic patterns that might lead to transformation and/or progression. Maximal surgical resection is warranted for symptomatic mass effect. Postoperative adjuvant treatments including radiotherapy and chemotherapy should be a recommended therapeutic modality. Copyright © 2017 Elsevier Inc. All rights reserved.

Vaccum drainage system application in the management of operation-related non-regional epidural hematoma

PubMed Central

2013-01-01

Background Epidural intracranial hematoma is one of the most common complications of surgeries for intracranial tumors. The non-regional epidural hematoma is related to severe fluctuation of the intracranial pressure during the operation. The traditional management of hematoma evacuation through craniotomy is time-consuming and may aggravate intracranial pressure imbalance, which causes further complications. We designed a method using vaccum epidural drainage system, and tried to evaluate advantage and the disadvantage of this new technique. Methods Seven patients of intracranial tumors were selected. All of the patients received tumor resection and intra-operative non-regional epidural hematoma was confirmed through intra-operative ultrasound or CT scan. The vaccum drainage system was applied. Another ten patients who received craniotomy for intra-operative non-regional epidural hematoma evacuation were selected as comparison. Regular tests, like serial CT scan, were performed afterward to evaluate the effectiveness and to help deciding when to remove the drainage system. Results The vaccum drainage method was effective in epidual hemotoma clearance and prevented recurrent epidural hemorrhage. The drainage systems were removed within 4 days. All of the patients recovered well. No complications related to the drainage system were observed. Conclusions Compared to the traditional craniotomy, the new method of epidural hemoatoma management using vaccum epidural drainage system proved to be as effective in hematoma clearance, and was less-invasive and easier to perform, with less complication, shorter hospitalization, less economic burden, and better prognosis. PMID:23842198

The incidence and risk factors of meningitis after major craniotomy in China: a retrospective cohort study.

PubMed

Chen, Chen; Zhang, Bingyan; Yu, Shenglei; Sun, Feng; Ruan, Qiaoling; Zhang, Wenhong; Shao, Lingyun; Chen, Shu

2014-01-01

Meningitis after neurosurgery can result in severe morbidity and high mortality. Incidence varies among regions and limited data are focused on meningitis after major craniotomy. This retrospective cohort study aimed to determine the incidence, risk factors and microbiological spectrum of postcraniotomy meningitis in a large clinical center of Neurosurgery in China. Patients who underwent neurosurgeries at the Department of Neurosurgery in Huashan Hospital, the largest neurosurgery center in Asia and the Pacific, between 1st January and 31st December, 2008 were selected. Individuals with only shunts, burr holes, stereotactic surgery, transsphenoidal or spinal surgery were excluded. The complete medical records of each case were reviewed, and data on risk factors were extracted and evaluated for meningitis. A total of 65 meningitides were identified among 755 cases in the study, with an incidence of 8.60%. The risk of meningitis was increased by the presence of diabetes mellitus (odds ratio [OR], 6.27; P = 0.009), the use of external ventricular drainage (OR, 4.30; P = 0.003) and the use of lumbar drainage (OR, 17.23; P<0.001). The isolated microorganisms included Acinetobacter baumannii, Enterococcus sp, Streptococcus intermedius and Klebsiella pneumonia. Meningitis remains an important source of morbidity and mortality after major craniotomy. Diabetic patients or those with cerebral spinal fluid shunts carry significant high risk of infection. Thus, identification of the risk factors as soon as possible will help physicians to improve patient care.

The Incidence and Risk Factors of Meningitis after Major Craniotomy in China: A Retrospective Cohort Study

PubMed Central

Yu, Shenglei; Sun, Feng; Ruan, Qiaoling; Zhang, Wenhong; Shao, Lingyun; Chen, Shu

2014-01-01

Background Meningitis after neurosurgery can result in severe morbidity and high mortality. Incidence varies among regions and limited data are focused on meningitis after major craniotomy. Aim This retrospective cohort study aimed to determine the incidence, risk factors and microbiological spectrum of postcraniotomy meningitis in a large clinical center of Neurosurgery in China. Methods Patients who underwent neurosurgeries at the Department of Neurosurgery in Huashan Hospital, the largest neurosurgery center in Asia and the Pacific, between 1stJanuary and 31st December, 2008 were selected. Individuals with only shunts, burr holes, stereotactic surgery, transsphenoidal or spinal surgery were excluded. The complete medical records of each case were reviewed, and data on risk factors were extracted and evaluated for meningitis. Results A total of 65 meningitides were identified among 755 cases in the study, with an incidence of 8.60%. The risk of meningitis was increased by the presence of diabetes mellitus (odds ratio [OR], 6.27; P = 0.009), the use of external ventricular drainage (OR, 4.30; P = 0.003) and the use of lumbar drainage (OR, 17.23; P<0.001). The isolated microorganisms included Acinetobacter baumannii, Enterococcus sp, Streptococcus intermedius and Klebsiella pneumonia. Conclusions Meningitis remains an important source of morbidity and mortality after major craniotomy. Diabetic patients or those with cerebral spinal fluid shunts carry significant high risk of infection. Thus, identification of the risk factors as soon as possible will help physicians to improve patient care. PMID:25003204

Remote cerebellar hemorrhage following supratentorial craniotomy.

PubMed

Huang, Chih-Yuan; Lee, Po-Hsuan; Lin, Sheng-Hsiang; Chuang, Ming-Tsung; Sun, Yuan-Ting; Hung, Yu-Chang; Lee, E-Jian

2012-06-01

Cerebellar hemorrhage remote from the site of surgery may complicate neurosurgical procedure. The exact pathophysiology of this type of hemorrhage is poorly understood. We retrospectively compared 16 patients who had remote cerebellar hemorrhage (RCH) with a case-matched control cohort, to determine the significance of perisurgical and surgical factors that may predispose patients to such bleeding events. From 1 June 2005 to 31 December 2008, postoperative routine head computed tomographic (CT) scan was performed in our institution and 16 patients with RCH after supratentorial neurosurgical procedure were identified. The medical charts of these 16 cases and a control cohort of 64 patients were recorded. All parameters were analyzed with regards to various variables. The incidence RCH after supratentorial craniotomy increased after postoperative computed tomographic scan. The mechanism of cerebellar hemorrhage in this series of patients is most likely multifactorial. Several variables showed a significant association with the occurrence of RCH. Multivariate analysis indicated that the following two factors independently correlated with occurrence of RCH: (1) postoperative epidural drainage amount; and (2) history of previous cerebrovascular accident (CVA) with cerebral atrophy. All cases with RCH underwent medical treatment and no neurological sequelae associated with RCH. Postoperative epidural drainage amount and history of previous CVA with cerebral atrophy can reliably predict the occurrence of cerebellar hemorrhage after supratentorial craniotomy. One of the most important strategies to minimize hazardous complications is to be aware of these potential risk factors and to take action to prevent them.

Awake craniotomy for brain lesions within and near the primary motor area: A retrospective analysis of factors associated with worsened paresis in 102 consecutive patients

PubMed Central

Shinoura, Nobusada; Midorikawa, Akira; Yamada, Ryoji; Hana, Taijun; Saito, Akira; Hiromitsu, Kentaro; Itoi, Chisato; Saito, Syoko; Yagi, Kazuo

2013-01-01

Background: We analyzed factors associated with worsened paresis in a large series of patients with brain lesions located within or near the primary motor area (M1) to establish protocols for safe, awake craniotomy of eloquent lesions. Methods: We studied patients with brain lesions involving M1, the premotor area (PMA) and the primary sensory area (S1), who underwent awake craniotomy (n = 102). In addition to evaluating paresis before, during, and one month after surgery, the following parameters were analyzed: Intraoperative complications; success or failure of awake surgery; tumor type (A or B), tumor location, tumor histology, tumor size, and completeness of resection. Results: Worsened paresis at one month of follow-up was significantly associated with failure of awake surgery, intraoperative complications and worsened paresis immediately after surgery, which in turn was significantly associated with intraoperative worsening of paresis. Intraoperative worsening of paresis was significantly related to preoperative paresis, type A tumor (motor tract running in close proximity to and compressed by the tumor), tumor location within or including M1 and partial removal (PR) of the tumor. Conclusions: Successful awake surgery and prevention of deterioration of paresis immediately after surgery without intraoperative complications may help prevent worsening of paresis at one month. Factors associated with intraoperative worsening of paresis were preoperative motor deficit, type A and tumor location in M1, possibly leading to PR of the tumor. PMID:24381792

Occipital Artery to Middle Cerebral Artery Bypass in Cases of Unavailable Superficial Temporal Artery.

PubMed

Hirano, Tsukasa; Mikami, Takeshi; Suzuki, Hime; Hirano, Toru; Kimura, Yusuke; Komatsu, Katusya; Akiyama, Yukinori; Wanibuchi, Masahiko; Mikuni, Nobuhiro

2018-04-01

In neurosurgery, extracranial-to-intracranial (EC-IC) bypass surgery is necessary for patients who have undergone surgery in which the superficial temporal artery (STA) was already used for a different bypass procedure or was damaged. Here we report our experience with EC-IC bypass using the occipital artery (OA) in patients in whom the STA was unavailable, and discuss the technical considerations and pitfalls. Five patients with ischemic-onset moyamoya disease and atherosclerotic disease were included. Two patterns of skin incisions were planned according to the OA pathway and recipient artery location. In one of these methods, a skin incision is made above the OA, and a craniotomy is performed under this incision after OA dissection. In the other method, a skin incision is made above the OA to enable its dissection, and a craniotomy is performed via a separate skin incision. No major perioperative complications developed in any of the 5 cases, and bypass patency was confirmed in all patients. There was a significant difference between the preoperative and postoperative asymmetry ratios of the mean transit time values. Our findings suggest that OA-to-middle cerebral artery (MCA) bypass is a simple and effective technique in patients in whom the STA was already used or was damaged by previous intracranial revascularization or craniotomy. This procedure could be an alternative to STA-MCA bypass in patients without an available STA. Copyright © 2018 Elsevier Inc. All rights reserved.

Novel techniques of real-time blood flow and functional mapping: technical note.

PubMed

Kamada, Kyousuke; Ogawa, Hiroshi; Saito, Masato; Tamura, Yukie; Anei, Ryogo; Kapeller, Christoph; Hayashi, Hideaki; Prueckl, Robert; Guger, Christoph

2014-01-01

There are two main approaches to intraoperative monitoring in neurosurgery. One approach is related to fluorescent phenomena and the other is related to oscillatory neuronal activity. We developed novel techniques to visualize blood flow (BF) conditions in real time, based on indocyanine green videography (ICG-VG) and the electrophysiological phenomenon of high gamma activity (HGA). We investigated the use of ICG-VG in four patients with moyamoya disease and two with arteriovenous malformation (AVM), and we investigated the use of real-time HGA mapping in four patients with brain tumors who underwent lesion resection with awake craniotomy. Real-time data processing of ICG-VG was based on perfusion imaging, which generated parameters including arrival time (AT), mean transit time (MTT), and BF of brain surface vessels. During awake craniotomy, we analyzed the frequency components of brain oscillation and performed real-time HGA mapping to identify functional areas. Processed results were projected on a wireless monitor linked to the operating microscope. After revascularization for moyamoya disease, AT and BF were significantly shortened and increased, respectively, suggesting hyperperfusion. Real-time fusion images on the wireless monitor provided anatomical, BF, and functional information simultaneously, and allowed the resection of AVMs under the microscope. Real-time HGA mapping during awake craniotomy rapidly indicated the eloquent areas of motor and language function and significantly shortened the operation time. These novel techniques, which we introduced might improve the reliability of intraoperative monitoring and enable the development of rational and objective surgical strategies.

Novel Techniques of Real-time Blood Flow and Functional Mapping: Technical Note

PubMed Central

KAMADA, Kyousuke; OGAWA, Hiroshi; SAITO, Masato; TAMURA, Yukie; ANEI, Ryogo; KAPELLER, Christoph; HAYASHI, Hideaki; PRUECKL, Robert; GUGER, Christoph

2014-01-01

There are two main approaches to intraoperative monitoring in neurosurgery. One approach is related to fluorescent phenomena and the other is related to oscillatory neuronal activity. We developed novel techniques to visualize blood flow (BF) conditions in real time, based on indocyanine green videography (ICG-VG) and the electrophysiological phenomenon of high gamma activity (HGA). We investigated the use of ICG-VG in four patients with moyamoya disease and two with arteriovenous malformation (AVM), and we investigated the use of real-time HGA mapping in four patients with brain tumors who underwent lesion resection with awake craniotomy. Real-time data processing of ICG-VG was based on perfusion imaging, which generated parameters including arrival time (AT), mean transit time (MTT), and BF of brain surface vessels. During awake craniotomy, we analyzed the frequency components of brain oscillation and performed real-time HGA mapping to identify functional areas. Processed results were projected on a wireless monitor linked to the operating microscope. After revascularization for moyamoya disease, AT and BF were significantly shortened and increased, respectively, suggesting hyperperfusion. Real-time fusion images on the wireless monitor provided anatomical, BF, and functional information simultaneously, and allowed the resection of AVMs under the microscope. Real-time HGA mapping during awake craniotomy rapidly indicated the eloquent areas of motor and language function and significantly shortened the operation time. These novel techniques, which we introduced might improve the reliability of intraoperative monitoring and enable the development of rational and objective surgical strategies. PMID:25263624

Determination of surgical variables for a brain shift correction pipeline using an Android application

NASA Astrophysics Data System (ADS)

Vijayan, Rohan; Conley, Rebekah H.; Thompson, Reid C.; Clements, Logan W.; Miga, Michael I.

2016-03-01

Brain shift describes the deformation that the brain undergoes from mechanical and physiological effects typically during a neurosurgical or neurointerventional procedure. With respect to image guidance techniques, brain shift has been shown to compromise the fidelity of these approaches. In recent work, a computational pipeline has been developed to predict "brain shift" based on preoperatively determined surgical variables (such as head orientation), and subsequently correct preoperative images to more closely match the intraoperative state of the brain. However, a clinical workflow difficulty in the execution of this pipeline has been acquiring the surgical variables by the neurosurgeon prior to surgery. In order to simplify and expedite this process, an Android, Java-based application designed for tablets was developed to provide the neurosurgeon with the ability to orient 3D computer graphic models of the patient's head, determine expected location and size of the craniotomy, and provide the trajectory into the tumor. These variables are exported for use as inputs for the biomechanical models of the preoperative computing phase for the brain shift correction pipeline. The accuracy of the application's exported data was determined by comparing it to data acquired from the physical execution of the surgeon's plan on a phantom head. Results indicated good overlap of craniotomy predictions, craniotomy centroid locations, and estimates of patient's head orientation with respect to gravity. However, improvements in the app interface and mock surgical setup are needed to minimize error.

Rigidity of the far-right? Motivated social cognition in a nationally representative sample of Hungarians on the eve of the far-right breakthrough in the 2010 elections.

PubMed

Lönnqvist, Jan-Erik; Szabó, Zsolt Péter; Kelemen, Laszlo

2018-04-26

We investigated the "rigidity of the right" hypothesis in the context of the far-right breakthrough in the 2010 Hungarian parliamentary elections. This hypothesis suggests that psychological characteristics having to do with need for security and certainty attract people to a broad-based right-wing ideology. A nationally representative sample (N = 1000) in terms of age, gender and place of residence was collected by means of the random walking method and face-to-face interviews. Voters of JOBBIK (n = 124), the radically nationalist conservative far-right party, scored lower on System Justifying Belief, Belief in a Just World (Global) and higher on Need for Cognition than other voters. Our results contradict the "rigidity of the right" hypothesis: JOBBIK voters scored, on many measures, opposite to what the hypothesis would predict. © 2018 International Union of Psychological Science.

More Tweets, More Votes: Social Media as a Quantitative Indicator of Political Behavior

PubMed Central

DiGrazia, Joseph; McKelvey, Karissa; Bollen, Johan; Rojas, Fabio

2013-01-01

Is social media a valid indicator of political behavior? There is considerable debate about the validity of data extracted from social media for studying offline behavior. To address this issue, we show that there is a statistically significant association between tweets that mention a candidate for the U.S. House of Representatives and his or her subsequent electoral performance. We demonstrate this result with an analysis of 542,969 tweets mentioning candidates selected from a random sample of 3,570,054,618, as well as Federal Election Commission data from 795 competitive races in the 2010 and 2012 U.S. congressional elections. This finding persists even when controlling for incumbency, district partisanship, media coverage of the race, time, and demographic variables such as the district's racial and gender composition. Our findings show that reliable data about political behavior can be extracted from social media. PMID:24312181

Conditions for exercising residents' voting rights in long-term care residences: a prospective multicenter study.

PubMed

Bosquet, Antoine; El Massioui, Farid; Mahé, Isabelle

2015-01-01

To assess voting conditions in long-term care settings, we conducted a multicenter survey after the 2009 European elections in France. A questionnaire about voting procedures and European elections was proposed in 146 out of 884 randomized facilities. Sixty-four percent of facilities answered the questionnaire. Four percent of residents voted (national turnout: 40%), by proxy (58%) or at polling places (42%). Abstention related to procedural issues was reported in 32% of facilities. Sixty-seven percent of establishments had voting procedures, and 53% declared that they assessed residents' capacity to vote. Assistance was proposed to residents for voter registration, for proxy voting, and for voting at polling places, respectively, in 33%, 87%, and 80% of facilities. This survey suggests that residents may be disenfranchised and that more progress should be made to protect the voting rights of residents in long-term care facilities.

Antibiotic prophylaxis in open inguinal hernia repair: a literature review and summary of current knowledge

PubMed Central

Makarewicz, Wojciech; Ropel, Jerzy; Bobowicz, Maciej; Kąkol, Michał; Śmietański, Maciej

2016-01-01

More than 1 million inguinal hernia repairs are performed in Europe and the US annually. Although antibiotic prophylaxis is not required in clean, elective procedures, the routine use of implants (90% of inguinal hernia repairs are performed with mesh) makes the topic controversial. The European Hernia Society does not recommend routine antibiotic prophylaxis for elective inguinal hernia repairs. However, the latest randomized controlled trial, published by Mazaki et al., indicates that the use of prophylaxis is effective for the prevention of surgical site infection. Unnecessary prophylaxis contributes to the development of bacterial resistance and significantly increases healthcare costs. This review documents clinical trials on inguinal hernia repairs with mesh and summarizes the current knowledge. It also tries to solve certain problems, namely: what constitutes a real risk factor, late-onset infection, and how the “surgical environment” impacts on the need to use antibiotic prophylaxis. PMID:27829934

Eighteen-month Clinical Study of Universal Adhesives in Noncarious Cervical Lesions.

PubMed

Ruschel, V C; Shibata, S; Stolf, S C; Chung, Y; Baratieri, L N; Heymann, H O; Walter, R

To evaluate the clinical performance of Scotchbond Universal (3M Oral Care) and Prime & Bond Elect (Dentsply Sirona) in the restoration of noncarious cervical lesions (NCCLs). This was a randomized controlled clinical trial involving 63 subjects. Two hundred and three NCCLs were restored using Scotchbond Universal and Prime & Bond Elect using both an etch-and-rinse and a self-etch technique. Lesions were notch-shaped NCCLs, and the restorations were placed without any mechanical retention. Restorations were finished immediately after placement and scored with regard to retention, marginal discoloration, marginal adaptation, and secondary caries. Similar assessment of the restorations was performed 18 months after placement. Logistic regression was performed for each outcome separately with a compound symmetric variance-covariance structure assumed to consider a correlation of restorations within subjects. All analyses were conducted using SAS version 9.4 (SAS Inc). One hundred and fifty-eight teeth (77.8% of the restorations placed) in 46 subjects (73% of subjects enrolled) were available for the 18-month follow-up. A statistically significant difference was reached only for the comparison Scotchbond Universal/self-etch (SU_SE) and Prime & Bond Elect/etch-and-rinse (PBE_E&R) groups ( p=0.01), where a restoration with SU_SE was 66% less likely to maintain a score of Alpha for marginal discoloration than a restoration performed with PBE_E&R. Scotchbond Universal and Prime & Bond Elect presented acceptable clinical performance after 18 months of clinical service. However, Scotchbond Universal, when applied with a self-etch approach, did demonstrate a relatively high level of marginal discoloration when compared to the other groups.

Risk models for mortality following elective open and endovascular abdominal aortic aneurysm repair: a single institution experience.

PubMed

Choke, E; Lee, K; McCarthy, M; Nasim, A; Naylor, A R; Bown, M; Sayers, R

2012-12-01

To develop and validate an "in house" risk model for predicting perioperative mortality following elective AAA repair and to compare this with other models. Multivariate logistics regression analysis was used to identify risk factors for perioperative-day mortality from one tertiary institution's prospectively maintained database. Consecutive elective open (564) and endovascular (589) AAA repairs (2000-2010) were split randomly into development (810) and validation (343) data sets. The resultant model was compared to Glasgow Aneurysm Score (GAS), Modified Customised Probability Index (m-CPI), CPI, the Vascular Governance North West (VGNW) model and the Medicare model. Variables associated with perioperative mortality included: increasing age (P = 0.034), myocardial infarct within last 10 years (P = 0.0008), raised serum creatinine (P = 0.005) and open surgery (P = 0.0001). The areas under the receiver operating characteristic curve (AUC) for predicted probability of 30-day mortality in development and validation data sets were 0.79 and 0.82 respectively. AUCs for GAS, m-CPI and CPI were poor (0.63, 0.58 and 0.58 respectively), whilst VGNW and Medicare model were fair (0.73 and 0.79 respectively). In this study, an "in-house" developed and validated risk model has the most accurate discriminative value in predicting perioperative mortality after elective AAA repair. For purposes of comparative audit with case mix adjustments, national models such as the VGNW or Medicare models should be used. Copyright © 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.

Assessment of the urgency and deferability of transfusion to inform emergency blood planning and triage: the Bloodhound prospective audit of red blood cell use.

PubMed

Shortt, Jake; Polizzotto, Mark N; Waters, Neil; Borosak, Marija; Moran, Martine; Comande, Mary; Devine, Alexandra; Jolley, Damien J; Wood, Erica M

2009-11-01

Careful planning is essential to ensure blood availability during shortages. Triaging supply is one proposed strategy; however, few data concerning the urgency of transfusion are available to inform planning. This study sought to determine the proportion of red blood cells (RBCs) used for clinically urgent indications. A total of 5132 RBC units were randomly selected at point of production and distributed into general statewide inventory over a 9-month period. These selected units carried case report forms, for completion at the point of hospital issue for transfusion. Completed forms were returned to the blood service for collation and analysis, capturing information on indication and clinical urgency of supply, including use for potentially deferrable elective surgery. Data from 5052 RBC units indicated that 95.6% were transfused. Approximately one-third of transfused units were used to support surgery, one-third for hematology/oncology, and one-third for other medical and miscellaneous indications. Where used for surgery, 25.7% (95% confidence interval [CI], 23.4%-28.0%) were for elective procedures, although urgency of surgery was unknown in 17.1% (95% CI, 15.2%-19.2%) of cases. Supply for nonurgent medical indications and elective surgery only accounted for 9.8% (95% CI, 9.0%-10.6%) of use, with 53.4% (95% CI, 52.0%-54.8%) of RBCs required within 24 hours. The majority of RBCs are transfused with a high degree of clinical urgency, with only a minor proportion required to support elective surgery.

Vasopressor choice for hypotension in elective Cesarean section: ephedrine or phenylephrine?

PubMed Central

Gunda, Chandrakala P.; Malinowski, Jennifer; Tegginmath, Aruna; Suryanarayana, Venkatesh G.

2010-01-01

Introduction Hypotensive episodes are a common complication of spinal anesthesia during Cesarean section. The purpose of this study was to compare the effectiveness and the side effects of vasopressors, ephedrine and phenylephrine, administered for hypotension during elective Cesarean section under spinal anesthesia. Material and methods The study consisted of 100 selected ASA I/II females scheduled for elective Cesarean section under spinal anesthesia. Each patient was randomly assigned to one of the two double-blind study groups. Group E received 1 ml ephedrine (5 mg/ml) with normal saline if hypotension was present (n=50). Group P received 1 ml phenylephrine (100 µg/ml) with normal saline if hypotension developed (n=50). Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP) were compared within and between groups to basal levels at time increments of 0, 2, 4, 6, 8, 10, 15, 20, 25, 30, 45, and 60 min from start of surgery. Incidence of side effects and neonatal outcomes were studied between groups. Results All patients required vasopressor therapy for hypotension. Administration of phenylephrine was associated with significant drop in HR. Changes in SBP, DBP, and MAP were similar in both groups for most observed times. The incidences of nausea/vomiting and tachycardia were significantly higher in the ephedrine group. Conclusions Phenylephrine and ephedrine are acceptable choices to combat maternal hypotension related to spinal anesthesia in elective Cesarean section. Complications of intra-operative nausea and vomiting, tachycardia and bradycardia should be considered when choosing a vasopressor, suggesting phenylephrine may be more appropriate when considering maternal well-being. PMID:22371756

Restoration of small bone defects at craniotomy using autologous bone dust and fibrin glue.

PubMed

Matsumoto, K; Kohmura, E; Kato, A; Hayakawa, T

1998-10-01

Bone gaps or burr holes often result in small but undesirable scalp or skin depressions after craniotomy. Whereas a number of reports have discussed cranioplasties to avoid large bone defects, little has been written about the problem of small bone defects which, despite their minor size, could result in bothersome cosmetic problems. This study was designed to assess a simple method to repair burr hole defects and bridge bone gaps with autologous bone dust and fibrin glue. Bone dust was collected when burr holes were created or craniectomy was performed. After replacement of the bone flap, the burr holes or bone gap were filled with a mixture of bone dust and fibrin glue. The mixture of bone dust and fibrin glue was easily shaped to fit bone defects, resulting in favorable cosmetic outcomes 1 to 5 years after operation.

The Supraorbital Keyhole Craniotomy through an Eyebrow Incision: Its Origins and Evolution

PubMed Central

Ormond, D. Ryan; Hadjipanayis, Costas G.

2013-01-01

In the modern era of neurosurgery, the use of the operative microscope, rigid rod-lens endoscope, and neuronavigation has helped to overcome some of the previous limitations of surgery due to poor lighting and anatomic localization available to the surgeon. Over the last thirty years, the supraorbital craniotomy and subfrontal approach through an eyebrow incision have been developed and refined to play a legitimate role in the armamentarium of the modern skull base neurosurgeon. With careful patient selection, the supraorbital “keyhole” approach offers a less invasive but still efficacious approach to a number of lesions along the subfrontal corridor. Well over 1000 cases have been reported in the literature utilizing this approach establishing its safety and efficacy. This paper discusses the nuances of this approach, including the benefits and limitations of its use described through our technique, review of the literature, and case illustration. PMID:23936644

Simultaneous determination of vancomycin and ceftazidime in cerebrospinal fluid in craniotomy patients by high-performance liquid chromatography.

PubMed

Ye, Guangming; Cai, Xuejian; Wang, Biao; Zhou, Zhongxian; Yu, Xiaohua; Wang, Weibin; Zhang, Jiandong; Wang, Yuhai; Dong, Jierong; Jiang, Yunyun

2008-11-04

A simple, accurate and rapid method for simultaneous analysis of vancomycin and ceftazidime in cerebrospinal fluid (CSF), utilizing high-performance liquid chromatography (HPLC), has been developed and thoroughly validated to satisfy strict FDA guidelines for bioanalytical methods. Protein precipitation was used as the sample pretreatment method. In order to increase the accuracy, tinidazole was chosen as the internal standard. Separation was achieved on a Diamonsil C18 column (200 mm x 4.6mm I.D., 5 microm) using a mobile phase composed of acetonitrile and acetate buffer (pH 3.5) (8:92, v/v) at room temperature (25 degrees C), and the detection wavelength was 240 nm. All the validation data, such as accuracy, precision, and inter-day repeatability, were within the required limits. The method was applied to determine vancomycin and ceftazidime concentrations in CSF in five craniotomy patients.

[Awake craniotomy for brain tumours].

PubMed

Milos, Peter; Metcalf, Kerstin; Vigren, Patrick; Lindehammar, Hans; Nilsson, Malin; Boström, Sverre

2016-10-11

Awake craniotomy for brain tumours  Awake neurosurgery is a useful method in lesions near eloquent brain areas, particularly low-grade gliomas.The aim is to maximise tumour resection and preserve neurological function. We performed 40 primary awake surgeries and 8 residual surgeries. Patients were operated awake throughout the procedure or with a laryngeal mask and general anaesthesia during the opening stage and then awake during intracerebral surgery. Language and motor function were mapped with direct cortical stimulation, motor evoked potential and standardised neurological testing. Radiologically, complete resection was achieved in 18 out of 40 patients in the primary surgeries. Full neurological recovery at three months was observed in 29 patients. Of the 11 patients with persisting neurological deficits at three months, symptoms were present preoperatively in 9 patients. We conclude that awake surgery, combined with intraoperative neurophysiological methods, is a safe method to improve treatment for low-grade gliomas.

[Usefulness of volume rendering stereo-movie in neurosurgical craniotomies].

PubMed

Fukunaga, Tateya; Mokudai, Toshihiko; Fukuoka, Masaaki; Maeda, Tomonori; Yamamoto, Kouji; Yamanaka, Kozue; Minakuchi, Kiyomi; Miyake, Hirohisa; Moriki, Akihito; Uchida, Yasufumi

2007-12-20

In recent years, the advancements in MR technology combined with the development of the multi-channel coil have resulted in substantially shortened inspection times. In addition, rapid improvement in functional performance in the workstation has produced a more simplified imaging-making process. Consequently, graphical images of intra-cranial lesions can be easily created. For example, the use of three-dimensional spoiled gradient echo (3D-SPGR) volume rendering (VR) after injection of a contrast medium is applied clinically as a preoperative reference image. Recently, improvements in 3D-SPGR VR high-resolution have enabled accurate surface images of the brain to be obtained. We used stereo-imaging created by weighted maximum intensity projection (Weighted MIP) to determine the skin incision line. Furthermore, the stereo imaging technique utilizing 3D-SPGR VR was actually used in cases presented here. The techniques we report here seemed to be very useful in the pre-operative simulation of neurosurgical craniotomy.

[Long-Term Survival of a Patient with Sigmoid Colon Cancer with Multiple Visceral Metastases].

PubMed

Sasaki, Yoshiyuki; Nishigori, Naoto; Koyama, Fumikazu; Ueda, Takeshi; Inoue, Takashi; Kawasaki, Keijirou; Obara, Shinsaku; Nakamoto, Takayuki; Nakamura, Yasuyuki; Fujii, Hisao; Nakajima, Yoshiyuki

2016-11-01

A 66-year-old woman underwent total pelvic exenteration for a pelvic tumor. The pathological diagnosis was sigmoid colon cancer T4b(in the small intestine, uterus, and vagina), N0, M0, Stage II . The patient was treated with XELOX for 6 months as adjuvant chemotherapy and was then treated with IRIS for another 6 months. Brain metastasis developed in the left occipital lobe after 12 months, and she underwent craniotomy and enucleation of the tumor. Liver metastasis and peritoneal dissemination metastasis developed 16 months after her initial diagnosis. The patient underwent re-craniotomy and radiotherapy for recurrence of the brain metastasis 18 months after diagnosis and started taking TAS-102 3 months later. She began treatment with CPT-11 plus panitumumab 24 months after diagnosis, and the dose was increased 9 months later(ie, 35 months after the initial diagnosis). The patient remains alive 42 months after surgery.

Aspirin reload before elective percutaneous coronary intervention: impact on serum thromboxane b2 and myocardial reperfusion indexes.

PubMed

Basili, Stefania; Tanzilli, Gaetano; Raparelli, Valeria; Calvieri, Camilla; Pignatelli, Pasquale; Carnevale, Roberto; Dominici, Marcello; Placanica, Attilio; Arrivi, Alessio; Farcomeni, Alessio; Barillà, Francesco; Mangieri, Enrico; Violi, Francesco

2014-08-01

Microvascular obstruction seems to predict poor outcome in patients undergoing elective percutaneous coronary intervention (PCI), but the underlying mechanism is still unclear. We analyzed whether serum thromboxane B2, a stable metabolite of thromboxane A2, may be implicated in post-PCI microvascular obstruction. We enrolled 91 patients (74 males, 66±10 years) on chronic low-dose aspirin therapy (aspirin, 100 mg daily) scheduled for elective PCI and randomly assigned to receive aspirin reload (325 mg orally, n=46) or no reload (control group, n=45) ≥1 hour before elective PCI. Serum levels of thromboxane B2, reperfusion indexes (corrected Thrombolysis In Myocardial Infarction frame count and myocardial blush grade), and serum cardiac troponin I were assessed before and after PCI. Serum thromboxane B2 significantly increased after 120 minutes (P=0.0447) from PCI in control but not in aspirin reload group. After PCI, both groups showed a statistically significant reduction in corrected Thrombolysis In Myocardial Infarction frame count more evident in aspirin reload group (P=0.0023). Moreover, after PCI, 61% of patients allocated to aspirin reload and only 32% of patients allocated to control group reached normal microcirculatory reperfusion (myocardial blush grade=3); patients with myocardial blush grade=3 exhibited lower values of serum thromboxane B2 compared with those with myocardial blush grade <3 (P=0.05). Periprocedural cardiac troponin I significantly increased (F=3.64; P=0.01334) and correlated with serum thromboxane B2 (ρ=0.31; P=0.0413) in control but not in aspirin reload group. In addition, left ventricular ejection fraction significantly increased after PCI only in the aspirin reload group (P=0.0005). Aspirin loading dose before elective PCI improves myocardial reperfusion and injury indexes, suggesting a possible role of platelet thromboxane A2 in microvascular occlusion. http://www.clinicaltrials.gov. Unique identifier: NCT01374698. © 2014 American Heart Association, Inc.

Impact of preoperative patient education on the prevention of postoperative complications after major visceral surgery: the cluster randomized controlled PEDUCAT trial.

PubMed

Klaiber, Ulla; Stephan-Paulsen, Lisa M; Bruckner, Thomas; Müller, Gisela; Auer, Silke; Farrenkopf, Ingrid; Fink, Christine; Dörr-Harim, Colette; Diener, Markus K; Büchler, Markus W; Knebel, Phillip

2018-05-24

The prevention of postoperative complications is of prime importance after complex elective abdominal operations. Preoperative patient education may prevent postoperative complications and improve patients' wellbeing, but evidence for its efficacy is poor. The aims of the PEDUCAT trial were (a) to assess the impact of preoperative patient education on postoperative complications and patient-reported outcomes in patients scheduled for elective complex visceral surgery and (b) to evaluate the feasibility of cluster randomization in this setting. Adult patients (age ≥ 18 years) scheduled for elective major visceral surgery were randomly assigned in clusters to attend a preoperative education seminar or to the control group receiving the department's standard care. Outcome measures were the postoperative complications pneumonia, deep vein thrombosis (DVT), pulmonary embolism, burst abdomen, and in-hospital fall, together with patient-reported outcomes (postoperative pain, anxiety and depression, patient satisfaction, quality of life), length of hospital stay (LOS), and postoperative mortality within 30 days after the index operation. Statistical analysis was primarily by intention to treat. In total 244 patients (60 clusters) were finally included (intervention group 138 patients; control group 106 patients). Allocation of hospital wards instead of individual patients facilitated study conduct and reduced confusion about group assignment. In the intervention and control groups respectively, pneumonia occurred in 7.4% versus 8.3% (p = 0.807), pulmonary embolism in 1.6% versus 1.0% (p = 0.707), burst abdomen in 4.2% versus 1.0% (p = 0.165), and in-hospital falls in 0.0% versus 4.2% of patients (p = 0.024). DVT did not occur in any of the patients. Mortality rates (1.4% versus 1.9%, p = 0.790) and LOS (14.2 (+/- 12.0) days versus 16.1 (+/- 15.0) days, p = 0.285) were also similar in the intervention and control groups. Cluster randomization was feasible in the setting of preoperative patient education and reduced the risk of contamination effects. The results of this trial indicate good postoperative outcomes in patients undergoing major visceral surgery without superiority of preoperative patient education compared to standard patient care at a high-volume center. However, preoperative patient education is a helpful instrument not only for teaching patients but also for training the nursing staff. German Clinical Trials Registry, DRKS00004226 . Registered on 23 October 2012. Registered 8 days after the first enrollment.

When Is It Appropriate to Use Glutamine in Critical Illness?

PubMed

Mundi, Manpreet S; Shah, Meera; Hurt, Ryan T

2016-08-01

Glutamine is a nonessential amino acid, which under trauma or critical illness can become essential. A number of historic small single-center randomized controlled trials (RCTs) have demonstrated positive treatment effects on clinical outcomes with glutamine supplementation. Meta-analyses based on these trials demonstrated a significant reduction in hospital mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS with intravenous (IV) glutamine. Similar results were not noted in 2 large multicenter RCTs (REDOXS and MetaPlus) assessing the efficacy of glutamine supplementation in ventilated ICU patients. The REDOXS trial of 40 ICUs randomized 1223 ventilated ICU patients to glutamine (IV and enteral), antioxidants, both glutamine and antioxidants, or placebo. The main conclusions were a trend toward increased 28-day mortality and significant increased hospital and 6-month mortality in those who received glutamine. The MetaPlus trial of 14 ICUs, which randomized 301 ventilated ICU patients to glutamine-enriched enteral vs an isocaloric diet, noted increased 6-month mortality in the glutamine-supplemented group. Newer RCTs have focused on specific populations and have demonstrated benefits in burn and elective surgery patients with glutamine supplementation. Whether larger studies will confirm these findings is yet to be determined. Recent American Society for Parenteral and Enteral Nutrition guidelines recommend that IV and enteral glutamine should not be used in the critical care setting based on the moderate quality of evidence available. We agree with these recommendations and would encourage larger multicenter studies to evaluate the risks and benefits of glutamine in burn and elective surgery patients. © 2016 American Society for Parenteral and Enteral Nutrition.

Prospective randomized clinical trial comparing laparoscopic cholecystectomy and hybrid natural orifice transluminal endoscopic surgery (NOTES) (NCT00835250).

PubMed

Noguera, José F; Cuadrado, Angel; Dolz, Carlos; Olea, José M; García, Juan C

2012-12-01

Natural orifice transluminal endoscopic surgery (NOTES) is a technique still in experimental development whose safety and effectiveness call for assessment through clinical trials. In this paper we present a three-arm, noninferiority, prospective randomized clinical trial of 1 year duration comparing the vaginal and transumbilical approaches for transluminal endoscopic surgery with the conventional laparoscopic approach for elective cholecystectomy. Sixty female patients between the ages of 18 and 65 years who were eligible for elective cholecystectomy were randomized in a ratio of 1:1:1 to receive hybrid transvaginal NOTES (TV group), hybrid transumbilical NOTES (TU group) or conventional laparoscopy (CL group). The main study variable was parietal complications (wound infection, bleeding, and eventration). The analysis was by intention to treat, and losses were not replaced. Cholecystectomy was successfully performed on 94% of the patients. One patient in the TU group was reconverted to CL owing to difficulty in maneuvering the endoscope. After a minimum follow-up period of 1 year, no differences were noted in the rate of parietal complications. Postoperative pain, length of hospital stay, and time off from work were similar in the three groups. No patient developed dyspareunia. Surgical time was longer among cases in which a flexible endoscope was used (CL, 47.04 min; TV, 64.85 min; TU, 59.80 min). NOTES approaches using the flexible endoscope are not inferior in safety or effectiveness to conventional laparoscopy. The transumbilical approach with flexible endoscope is as effective and safe as the transvaginal approach and is a promising, single-incision approach.

Comparing GlideScope Video Laryngoscope and Macintosh Laryngoscope Regarding Hemodynamic Responses During Orotracheal Intubation: A Randomized Controlled Trial

PubMed Central

Pournajafian, Ali Reza; Ghodraty, Mohammad Reza; Faiz, Seyed Hamid Reza; Rahimzadeh, Poupak; Goodarzynejad, Hamidreza; Dogmehchi, Enseyeh

2014-01-01

Background: To determine if the GlideScope® videolaryngoscope (GVL) could attenuate the hemodynamic responses to orotracheal intubation compared with conventional Macintosh laryngoscope. Objectives: The aim of this relatively large randomized trial was to compare the hemodynamic stress responses during laryngoscopy and tracheal intubation using GVL versus MCL amongst healthy adult individuals receiving general anesthesia for elective surgeries. Patients and Methods: Ninety five healthy adult patients with American Society of Anesthesiologists physical status class I or II that were scheduled for elective surgery under general anesthesia were randomly allocated to either Macintosh or GlideScope arms. All patients received a standardized protocol of general anesthesia. Hemodynamic changes associated with intubation were recorded before and at 1, 3 and 5 minutes after the intubation. The time taken to perform endotracheal intubation was also noted in both groups. Results: Immediately before laryngoscopy (pre-laryngoscopy), the values of all hemodynamic variables did not differ significantly between the two groups (All P values > 0.05). Blood pressures and HR values changed significantly over time within the groups. Time to intubation was significantly longer in the GlideScope (15.9 ± 6.7 seconds) than in the Macintosh group (7.8 ± 3.7 sec) (P< 0.001). However, there were no significant differences between the two groups in hemodynamic responses at all time points. Conclusions: The longer intubation time using GVL suggests that the benefit of GVL could become apparent if the time taken for orotracheal intubation could be decreased in GlideScope group. PMID:24910788

Current trends and progress in clinical applications of oocyte cryopreservation

PubMed Central

Cil, Aylin P.; Seli, Emre

2013-01-01

Purpose of review To delineate the current trends in the clinical application of oocyte cryopreservation. Recent findings Although the first live birth from oocyte cryopreservation was reported approximately three decades ago, significant improvement in the clinical application of oocyte cryopreservation took place only over the past decade. On the basis of the available evidence suggesting that success rates with donor oocyte vitrification are similar to that of IVF with fresh donor oocytes, the American Society of Reproductive Medicine has recently stated that oocyte cryopreservation should no longer be considered experimental for medical indications, outlying elective oocyte cryopreservation. Meanwhile, a few surveys on the attitudes toward oocyte cryopreservation revealed that elective use for the postponement of fertility is currently the most common indication for oocyte cryopreservation. Most recently, a randomized controlled trial revealed important evidence on the safety of nondonor oocyte cryopreservation, and confirmed that the clinical success of vitrification is comparable to that of IVF with fresh oocytes. Summary The evidence suggesting similar IVF success rates with both donor and nondonor cryopreserved oocytes compared with fresh oocytes will increase the utilization of elective oocyte cryopreservation. Appropriate counseling of women for oocyte cryopreservation requires the establishment of age-based clinical success rates with cryopreserved oocytes for various indications. PMID:23562954

FACTORS CONTRIBUTING TO ELECTIVE THEATRE CANCELLATIONS IN THE DEPARTMENT OF SURGERY AT CHBAH.

PubMed

Mulira, M; Smith, M D; Moorman, J

2017-06-01

Elective theatre cancellations is a common experience the world over that impacts on theatre efficiency with undesirable consequences on the health care system, the patients and their families. It increases costs of running theatres, is a financial burden and emotional strain on patients and their families. A retrospective study where 300 cancellations in the Department of Surgery were randomly selected and analysed from the Morbidity and Mortality meetings held at Chris Hani Baragwanath Academic Hospital from November 2015. Of the 1554 elective cases booked during the period under review, there were 294 cancellations resulting in a cancellation rate of 18.9%. Laparoscopic Cholecystectomy was the most common procedure (31.8%) cancelled. The most common reason for cancellation (50%) was time constraints. Administrative related reasons for cancellation were the most common (85%) encountered. The majority of cancellations were judged to be the event of an Unavoidable reason. The majority of the patients cancelled were ASA II and ASA III (77%). The ASA score had no significance on medical related cancellations. We reported a comparatively high cancellation rate. Further prospective studies need to be conducted to critically evaluate the reasons behind lack of operative time as the majority of the reasons for cancellation could be potentially avoidable.

The effect of a multimedia health educational program on the postoperative recovery of patients undergoing laparoscopic cholecystectomy.

PubMed

Stergiopoulou, Antonia; Birbas, Konstantinos; Katostaras, Theophanis; Diomidous, Mariana; Mantas, John

2006-01-01

Aim of this study is the evaluation of the impact of preoperative informative session using a Multimedia Health Educational Program (MHEP) on patients undergoing elective Laparoscopic Cholecystectomy (LC) for cholelithiasis, preoperative anxiety and postoperative pain and nausea. Sixty consecutive patients scheduled for elective LC were considered for enrollment in the trial. Patients were assigned randomly to four groups: Group A included 15 patients, preoperatively informed regarding LC through the MHEP presented by a Registered Nurse (RN). Group B included 15 patients preoperatively informed through a leaflet (designed and developed using the exact contents of the MHEP). In Group C, there were 15 patients who were being informed verbally from the RN. Finally, the control Group D included 15 patients, who had the conventional preoperative information about the operation and postoperative course by the attending surgeon and anesthesiologist, as every other patient included in groups A, B, C. Preoperative assessment of patient's knowledge about cholelithiasis and LC was performed after informative session, and was based on a specifically developed "closed, true-false" questionnaire. Preliminary results suggest that conventional information provided by the attending surgeon (Group D) is inadequate. Specifically developed informative sessions with the contribution of MHEP seems to be effective on reducing preoperative anxiety and postoperative pain, in patients undergoing elective LC.

Preoperative carbohydrate loading for elective surgery: a systematic review and meta-analysis.

PubMed

Li, Lun; Wang, Zehao; Ying, Xiangji; Tian, Jinhui; Sun, Tiantian; Yi, Kang; Zhang, Peng; Jing, Zhang; Yang, Kehu

2012-07-01

It is unclear whether the preoperative administration of oral carbohydrates (CHO) is safe and effective, and therefore we herein evaluated the efficacy and adverse events associated with CHO for elective surgery. Comprehensive searches were conducted to identify randomized controlled trials (RCTs), which evaluated preoperative CHO for elective surgery. Two reviewers independently selected the trials, extracted data, and assessed the methodological qualities and evidence levels. The data were analyzed by the RevMan 5.0 software program. CHO increased the insulin and glucose levels on the first day after surgery higher than those in overnight fasting group (fifteen RCTs) and i.v. glucose infusion group (three RCTs). The pooled results of thirteen RCTs showed greater declines in the insulin level at the induction of anesthesia and a smaller increase in the glucose level at the end of surgery, and fewer decreases in the postoperative insulin sensitivity index in the CHO group were observed as compared to the placebo group. No aspiration was observed in any of the included studies. CHO appears to be safe, and may attenuate postoperative insulin resistance as compared to placebo. However, the quality of most of the published trials has been poor, and the evidence levels for most outcomes were low, so rigorous and larger RCTs are needed in the future.

Sophisticated approval voting, ignorance priors, and plurality heuristics: a behavioral social choice analysis in a Thurstonian framework.

PubMed

Regenwetter, Michel; Ho, Moon-Ho R; Tsetlin, Ilia

2007-10-01

This project reconciles historically distinct paradigms at the interface between individual and social choice theory, as well as between rational and behavioral decision theory. The authors combine a utility-maximizing prescriptive rule for sophisticated approval voting with the ignorance prior heuristic from behavioral decision research and two types of plurality heuristics to model approval voting behavior. When using a sincere plurality heuristic, voters simplify their decision process by voting for their single favorite candidate. When using a strategic plurality heuristic, voters strategically focus their attention on the 2 front-runners and vote for their preferred candidate among these 2. Using a hierarchy of Thurstonian random utility models, the authors implemented these different decision rules and tested them statistically on 7 real world approval voting elections. They cross-validated their key findings via a psychological Internet experiment. Although a substantial number of voters used the plurality heuristic in the real elections, they did so sincerely, not strategically. Moreover, even though Thurstonian models do not force such agreement, the results show, in contrast to common wisdom about social choice rules, that the sincere social orders by Condorcet, Borda, plurality, and approval voting are identical in all 7 elections and in the Internet experiment. PsycINFO Database Record (c) 2007 APA, all rights reserved.

A qualitative assessment of the supportive care and resource needs of patients undergoing craniotomy for benign brain tumours.

PubMed

Wong, Janice; Mendelsohn, Daniel; Nyhof-Young, Joyce; Bernstein, Mark

2011-11-01

As past literature has focused on support needs of patients with malignant brain tumours, the support needs of patients with benign brain tumours have largely been overlooked. The purpose of this study was to evaluate the supportive care and resource needs of patients undergoing craniotomy for benign brain tumours. Individual, semi-structured interviews were conducted with patients who had undergone craniotomy for a benign brain tumour within the past 2 years. Interviews were audio-recorded, transcribed, anonymized and subjected to descriptive thematic analysis by multiple investigators in the grounded theory tradition. Twenty-nine patients (20 women, 20-88 years of age) with World Health Organization grade I brain tumours (25 meningioma) were interviewed. Five overarching themes emerged: (1) need for formal support from diagnosis onwards; (2) complexity of supportive needs during postoperative recovery; (3) importance of regular long-term monitoring by physicians; (4) influence of psychosocial factors on supportive needs; and (5) existence of barriers to equal access to available supports. Patients' supportive care needs are temporally dependent on disease course and treatment, and modifiable by demographic and psychosocial factors. Findings of this study show that patients with benign tumours lacked but needed many supportive care resources currently available to cancer patients. Many of the potential solutions to this current gap in supportive care involve extending support resources already available for cancer patients to patients with benign brain tumours. We thus suggest recommendations to improve service gaps and reduce disparities in supportive care for patients with benign brain tumours.

Preservation of the Myofascial Cuff During Posterior Fossa Surgery to Reduce the Rate of Pseudomeningocele Formation and Cerebrospinal Fluid Leak: A Technical Note.

PubMed

Felbaum, Daniel R; Mueller, Kyle; Anaizi, Amjad; Mason, Robert B; Jean, Walter C; Voyadzis, Jean M

2016-12-28

 Suboccipital craniotomy is a workhorse neurosurgical operation for approaching the posterior fossa but carries a high risk of pseudomeningocele and cerebrospinal fluid (CSF) leak. We describe our experience with a simple T-shaped fascial opening that preserves the occipital myofascial cuff as compared to traditional methods to reduce this risk.  A single institution, retrospective review of prospectively collected database was performed of patients that underwent a suboccipital craniectomy or craniotomy. Patient data was reviewed for craniotomy or craniectomy, dural graft, and/or sealant use as well as CSF complications. A pseudomeningocele was defined as a subcutaneous collection of cerebrospinal fluid palpable clinically and confirmed on imaging. A CSF leak was defined as a CSF-cutaneous fistula manifested by CSF leaking through the wound. All patients underwent regular postoperative visits of two weeks, one month, and three months.  Our retrospective review identified 33 patients matching the inclusion criteria. Overall, our cohort had a 21% (7/33) rate of clinical and radiographic pseudomeningocele formation with 9% (3/33) requiring surgical revision or a separate procedure. The rate of clinical and radiographic pseudomeningocele formation in the myofascial cuff preservation technique was less than standard techniques (12% and 31%, respectively). Revision or further surgical procedures were also reduced in the myofascial cuff preservation technique vs. the standard technique (6% vs 13%).  Preservation of the myofascial cuff during posterior fossa surgery is a simple and adoptable technique that reduces the rate of pseudomeningocele formation and CSF leak as compared with standard techniques.

The effect of electroacupuncture on postoperative immunoinflammatory response in patients undergoing supratentorial craniotomy

PubMed Central

LI, GUOYAN; LI, SHUQIN; WANG, BAOGUO; AN, LIXIN

2013-01-01

The aim of this study was to explore the effect of electroacupuncture (EA) on immune function in patients undergoing supratentorial craniotomy. We also examined whether point specificity in EA was present. The study involved 29 patients undergoing craniotomy. The patients were divided into three groups: a control (C, n=10), an EA (A, n=9) and a sham acupoints group (S, n=10). Blood samples were collected at the following time points: before anesthesia (T0), 4 h after the induction of anesthesia (T1), 1 day post-surgery (T2) and 2 days post-surgery (T3) to determine the levels of tumor necrosis factor-α (TNF-α), interleukin-8 (IL-8), interleukin-10 (IL-10), immunoglobulin M (IgM), IgA and IgG. Data were analyzed using SPSS 13.0 software. When comparing the levels of cytokines following surgery, we observed that the peripheral blood IL-8 levels in groups A and S were increased significantly compared with those of group C at 1 and 2 days after surgery. When comparing immunoglobulin levels after surgery, we established that the peripheral blood IgA levels in group C had decreased significantly compared to those of group A and group S 4 h after induction of anesthesia and 1 day after surgery. However, there was no significant difference between group A and group S. Compared with simple general anesthesia, acupuncture combined with anesthesia partially reduces immune suppression in the perioperative periods under the same conditions as the simple general anesthesia. Point specificity in EA was not present. PMID:24137250

Surgical resection of skull-base chordomas: experience in case selection for surgical approach according to anatomical compartments and review of the literature.

PubMed

Shimony, Nir; Gonen, Lior; Shofty, Ben; Abergel, Avraham; Fliss, Dan M; Margalit, Nevo

2017-10-01

Chordoma is a rare bony malignancy known to have a high rate of local recurrence after surgery. The best treatment paradigm is still being evaluated. We report our experience and review the literature. We emphasize on the difference between endoscopic and open craniotomy in regard to the anatomical compartment harboring the tumor, the limitations of the approaches and the rate of surgical resection. We retrospectively collected all patients with skull-base chordomas operated on between 2004 and 2014. Detailed radiological description of the compartments being occupied by the tumor and the degree of surgical resection is discussed. Eighteen patients were operated on in our facility for skull-base chordoma. Seventeen endoscopic surgeries were done in 15 patients, and 7 craniotomies were done in 5 patients. The mean age was 48.9 years (±19.8 years). When reviewing the anatomical compartments, we found that the most common were the upper clivus (95.6%) and lower clivus (58.3%), left cavernous sinus (66.7%) and petrous apex (∼60%). Most of the patients had intradural tumor involvement (70.8%). In all craniotomy cases, there was residual tumor in multiple compartments. In the endoscopic cases, the most difficult compartments for total resection were the lower clivus, and lateral extensions to the petrous apex or cavernous sinus. Our experience shows that the endoscopic approach is a good option for midline tumors without significant lateral extension. In cases with very lateral or lower extensions, additional approaches should be added trying to achieve complete resection.

Feasibility of Telementoring for Microneurosurgical Procedures Using a Microscope: A Proof-of-Concept Study.

PubMed

Ladd, Bryan M; Tackla, Ryan D; Gupte, Akshay; Darrow, David; Sorenson, Jeffery; Zuccarello, Mario; Grande, Andrew W

2017-03-01

Our pilot study evaluated the effectiveness of our telementoring-telescripting model to facilitate seamless communication between surgeons while the operating surgeon is using a microscope. As a first proof of concept, 4 students identified 20 anatomic landmarks on a dry human skull with or without telementoring guidance. To assess the ability to communicate operative information, a senior neurosurgery resident evaluated the student's ability and timing to complete a stepwise craniotomy on a cadaveric head, with and without telementoring guidance; a second portion included exposure of the anterior circulation. The mentor was able to annotate directly onto the operator's visual field, which was visible to the operator without looking away from the binocular view. The students showed that they were familiar with half (50% ± 10%) of the structures for identification and none was familiar with the steps to complete a craniotomy before using our system. With the guidance of a remote surgeon projected into the visual field of the microscope, the students were able to correctly identify 100% of the structures and complete a craniotomy. Our system also proved effective in guiding a more experienced neurosurgery resident through complex operative steps associated with exposure of the anterior circulation. Our pilot study showed a platform feasible in providing effective operative direction to inexperienced operators while operating using a microscope. A remote mentor was able to view the visual field of the microscope, annotate on the visual stream, and have the annotated stream appear in the binocular view for the operating mentee. Copyright © 2016 Elsevier Inc. All rights reserved.

Enhancement of matrix metalloproteinases 2 and 9 accompanied with neurogenesis following collagen glycosaminoglycan matrix implantation after surgical brain injury.

PubMed

Hsu, Wei-Cherng; Yu, Chun-Hsien; Kung, Woon-Man; Huang, Kuo-Feng

2018-06-01

Surgical brain injury may result in irreversible neurological deficits. Our previous report showed that partial regeneration of a traumatic brain lesion is achieved by implantation of collagen glycosaminoglycan (CGM). Matrix metalloproteinases (MMPs) may play an important role in neurogenesis but there is currently a lack of studies displaying the relationship between the stimulation of MMPs and neurogenesis after collagen glycosaminoglycan implantation following surgical brain trauma. The present study was carried out to further examine the expression of MMP2 and MMP9 after implantation of collagen glycosaminoglycan (CGM) following surgical brain trauma. Using the animal model of surgically induced brain lesion, we implanted CGM into the surgical trauma. Rats were thus divided into three groups: (1) sham operation group: craniotomy only; (2) lesion (L) group: craniotomy + surgical trauma lesion; (3) lesion + CGM (L + CGM) group: CGM implanted following craniotomy and surgical trauma lesion. Cells positive for SOX2 (marker of proliferating neural progenitor cells) and matrix metalloproteinases (MMP2 and MMP9) in the lesion boundary zone were assayed and analyzed by immunofluorescence and ELISA commercial kits, respectively. Our results demonstrated that following implantation of CGM after surgical brain trauma, significant increases in MMP2 + /SOX2 + cells and MMP9 + /SOX2 + cells were seen within the lesion boundary zone in the L + CGM group. Tissue protein concentrations of MMP2 and MMP9 also increased after CGM scaffold implantation. These findings suggest that implantation of a CGM scaffold alone after surgical brain trauma can enhance the expression of MMP2 and MMP9 accompanied by neurogenesis.

Pattern of Corticospinal Projections Defined by Brain Mapping During Resective Epilepsy Surgery in a Patient with Congenital Hemiparesis and Intractable Epilepsy.

PubMed

Yang, Chen-Ya; Chen, Hsin-Hung; Chen, Chien; Chiu, Jan-Wei; Chou, Chen-Liang; Yang, Tsui-Fen

2017-11-01

Congenital or early-onset brain structural lesions often cause contralateral hemiparesis, cognitive deficits, developmental delays, and seizures. Seizure is the most debilitating condition, as it greatly impairs quality of life in both the affected individuals and their caregivers and prevents them from active social participation. A 34-year-old man with hemiparesis and early-onset seizures since childhood owing to a congenital brain lesion developed intractable seizures in the last 2 years and was subsequently admitted for resective epileptic surgery. During the operation, we employed an innovative intraoperative neurophysiologic monitoring technique. In contrast to routine application for transcranial stimulation, we recorded compound muscle action potentials over the bilateral limb muscles simultaneously, instead of over the contralateral muscles only, to determine the patterns of the corticospinal projections. Transcranial stimulation over the bilateral hemispheres was applied before craniotomy, and direct cortical stimulation over the lesioned hemisphere was applied after craniotomy. By integrating both approaches, we could first identify the pattern of corticospinal projections before craniotomy and then accurately define the noneloquent area, which guided the resection to successfully accomplish the surgical goal. This technique is simple because no patient participation is required. We believe that it has the potential to replace conventional preoperative functional magnetic resonance imaging and transcranial magnetic stimulation in resective epilepsy surgery, particularly for young patients. Not only can it improve the safety of surgical procedures, but also it can help predict functional outcome. Copyright © 2017 Elsevier Inc. All rights reserved.

Supraorbital keyhole surgery for optic nerve decompression and dura repair.

PubMed

Chen, Yuan-Hao; Lin, Shinn-Zong; Chiang, Yung-Hsiao; Ju, Da-Tong; Liu, Ming-Ying; Chen, Guann-Juh

2004-07-01

Supraorbital keyhole surgery is a limited surgical procedure with reduced traumatic manipulation of tissue and entailing little time in the opening and closing of wounds. We utilized the approach to treat head injury patients complicated with optic nerve compression and cerebrospinal fluid leakage (CSF). Eleven cases of basal skull fracture complicated with either optic nerve compression and/or CSF leakage were surgically treated at our department from February 1995 to June 1999. Six cases had primary optic nerve compression, four had CSF leakage and one case involved both injuries. Supraorbital craniotomy was carried out using a keyhole-sized burr hole plus a small craniotomy. The size of craniotomy approximated 2 x 3 cm2. The optic nerve was decompressed via removal of the optic canal roof and anterior clinoid process with high-speed drills. The defect of dura was repaired with two pieces of tensa fascia lata that were attached on both sides of the torn dural defect with tissue glue. Seven cases with optic nerve injury included five cases of total blindness and two cases of light perception before operation. Vision improved in four cases. The CSF leakage was stopped successfully in all four cases without complication. As optic nerve compression and CSF leakage are skull base lesions, the supraorbital keyhole surgery constitutes a suitable approach. The supraorbital keyhole surgery allows for an anterior approach to the skull base. This approach also allows the treatment of both CSF leakage and optic nerve compression. Our results indicate that supraorbital keyhole operation is a safe and effective method for preserving or improving vision and attenuating CSF leakage following injury.

Submission Manual.

DTIC Science & Technology

1985-06-01

SURGICAL BLOOD ORDERING SCHEDULE # UNITS CROSSMATCHED OR PROCEDURE TYPE AND SCREEN (T/S) * Abdominal abscess drainage ....... ................ T/S...Abdominal paracentesis ...... .................. .. T/S Abdominoperineal resection ........ ................ 5 Abscess - drainage of abdominal, liver, lung...triple)o . o . 6 Craniofacial reconstruction .. ...... ......... 2 Craniplast...................... . . . . 2 Craniotomy and excision of mass

Periprocedural use of tirofiban in elective percutaneous coronary intervention for long coronary lesions in stable patients with overlapping drug-eluting stents--the PETITION study: a prospective, randomized, multicenter study.

PubMed

Zhang, Qi; Wang, Xiao Long; Liao, Min Lei; Hu, Jian; Yang, Zhen Kun; Ding, Feng Hua; Zhang, Jian Sheng; Du, Run; Zhu, Tian Qi; Shen, Wei Feng; Zhang, Rui Yan

2015-03-01

Patients are at risk of developing periprocedural myonecrosis after percutaneous coronary intervention (PCI). We investigated whether the use of the platelet glycoprotein (GP) IIb/IIIa receptor inhibitor tirofiban could reduce periprocedural myocardial infarction (PMI) in patients with stable coronary artery disease undergoing elective PCI with overlapping stent implantation for long lesions. A total of 748 stable angina patients with long lesions (≥ 40 mm in length) treated with overlapping stent implantation were randomly assigned to receive tirofiban (tirofiban group; n = 373) or conventional therapy (control group; n = 375). Intravenous tirofiban was initiated before PCI and maintained for 12 hr after the procedure. The primary endpoint was PMI, defined as an elevation in CK-MB > 3 times the upper limit of normal 12 hr after the index procedure. The secondary endpoint was major adverse cardiac events (MACE), including cardiac death, target vessel revascularization, and recurrent MI (re-MI), at one-year of clinical follow-up. The safety end-points included Thrombolysis in Myocardial Infarction (TIMI) major bleeding and stent thrombosis. Despite comparable angiographic and procedural characteristics, in the intention-to-treatment analysis, the primary endpoint was significantly reduced in the tirofiban group (4.0% vs. 11.5%, P < 0.001). Multivariate analysis revealed that the adjunctive use of tirofiban was the only negative predictor of PMI (OR 0.41, 95% CI 0.28-0.81, P < 0.01). At one-year of clinical follow-up, the overall occurrence of MACE was significantly lower in the tirofiban group (13.4% vs. 22.7%, P = 0.001). The rate of TIMI major bleeding and stent thrombosis did not differ significantly between the two groups. Our results show that the adjunctive use of tirofiban reduces the occurrence of PMI and MACE at one year in stable coronary artery disease patients undergoing elective PCI for long lesions with overlapping stent implantation. © 2015 Wiley Periodicals, Inc.

The interplay of self-reflection, social interaction and random events in the dynamics of opinion flow in two-party democracies

NASA Astrophysics Data System (ADS)

Lichtenegger, Klaus; Hadzibeganovic, Tarik

2016-01-01

We propose a continuous process opinion formation model to study the dynamics of a multi-level relationship between voters, political parties, and facts in two-party democratic elections. In our model, opinions can take any real value between two extremes and an unaligned, moderate opinion state without a preference. Starting with a random opinion configuration, individual voter opinions evolve and change over time due to self-reflection, inter-personal communication, external media influence, and noise. Parties are influenced by their own ideologies, facts, and voters’ opinions. Elections are held periodically and the party that is closer in opinion to the majority of voters forms the new government. The government policy is then expected to be in proximity to the voter opinions and the policies of the currently ruling political party. We analyze the tension of opinions as a measure of how dramatically opinions can disagree within a given sample of voters and the success of the government and parties as the degree of coincidence between the policies and facts. Our model generates realistic quasi-periodic alternations between incumbents and challengers that are typical for two-party systems. Moreover, our model shows that relative to other voters’ strategies, conscious voting can lead to more successful governments of not only fact-oriented but also pragmatic and balanced political parties, irrespective of the strategies of the competing opposition parties. In addition, our simulations uncover several interesting features including less victories for strictly ideological or fact-oriented parties unless they include some aspects of populism or pragmatism. In this sense, our model can also describe situations where election outcomes are not necessarily based on votes for the current programs of competing parties and their placement on relevant issues, but instead result from voters’ dissatisfaction with the previous government and the votes against it.

Site-directed topical lidocaine spray attenuates perioperative respiratory adverse events in children undergoing elective surgery.

PubMed

Li, Li-Wei; He, Long; Ai, Yanqiu; Chu, Qinjun; Zhang, Wei

2016-06-01

Perioperative respiratory adverse events (PRAEs) are a major cause of morbidity and mortality associated with pediatric anesthesia. Topical lidocaine administration reduces risk of PRAE in children undergoing elective endotracheal intubation. However, definitive evidence of its efficacy remains elusive, due, in part, to the wide variability in the methodology for spraying topical lidocaine. In this randomized controlled double-blind clinical trial, we sought to evaluate the effect of site-directed topical airway lidocaine, sprayed directly onto supraglottic, glottis, and subglottic areas, on the incidence of PRAE. The study population consisted of 322 children (age range, 6 mo-12 y), who were scheduled for an elective surgical procedure under general anesthesia with endotracheal intubation. Patients were randomly assigned to receive topical spray of lidocaine (group L) or saline (group S) over the supraglottic, glottis and subglottic areas under direct vision before tracheal intubation. Incidence of PRAE and time to extubation was recorded. There were no statistically significant intergroup differences with regard to baseline demographics, patient characteristics, and surgical parameters. Group L was associated with a significantly lower incidence of PRAE as compared with group S (12.80% versus 38.13%, respectively; P < 0.001). Similarly, the incidence of laryngospasm (1.7% versus 8.1%; P = 0.01), excessive coughing (4.3% versus 13.2%; P = 0.005), and oxygen desaturation <95% (6.8% versus 16.9%; P = 0.005), respectively, was significantly lower in group L. However, time to extubation was longer in group L as compared with that in group S (18.6 ± 7.7 min versus 21.3 ± 8.9 min; P = 0.03). Site-directed topical spray of lidocaine over supraglottic, glottis, and subglottic areas before tracheal intubation significantly reduced the incidence of PRAE and a prolongation of extubation time in children. Copyright © 2016 Elsevier Inc. All rights reserved.

Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials.

PubMed

Rollins, Katie E; Lobo, Dileep N

2016-03-01

To compare the effects of intraoperative goal-directed fluid therapy (GDFT) with conventional fluid therapy, and determine whether there was a difference in outcome between studies that did and did not use Enhanced Recovery After Surgery (ERAS) protocols. Meta-analysis of randomized controlled trials of adult patients undergoing elective major abdominal surgery comparing intraoperative GDFT versus conventional fluid therapy. The outcome measures were postoperative morbidity, length of stay, gastrointestinal function and 30-day mortality. A total of 23 studies were included with 2099 patients: 1040 who underwent GDFT and 1059 who received conventional fluid therapy. GDFT was associated with a significant reduction in morbidity (risk ratio [RR] 0.76, 95% confidence interval [CI] 0.66-0.89, P = 0.0007), hospital length of stay (LOS; mean difference -1.55 days, 95% CI -2.73 to -0.36, P = 0.01), intensive care LOS (mean difference -0.63 days, 95% CI -1.18 to -0.09, P = 0.02), and time to passage of feces (mean difference -0.90 days, 95% CI -1.48 to -0.32 days, P = 0.002). However, no difference was seen in mortality, return of flatus, or risk of paralytic ileus. If patients were managed in an ERAS pathway, the only significant reductions were in intensive care LOS (mean difference -0.63 days, 95% CI -0.94 to -0.32, P < 0.0001) and time to passage of feces (mean difference -1.09 days, 95% CI -2.03 to -0.15, P = 0.02). If managed in a traditional care setting, a significant reduction was seen in both overall morbidity (RR 0.69, 95% CI 0.57 to -0.84, P = 0.0002) and total hospital LOS (mean difference -2.14, 95% CI -4.15 to -0.13, P = 0.04). GDFT may not be of benefit to all elective patients undergoing major abdominal surgery, particularly those managed in an ERAS setting.

Chewing Xylitol Gum could Accelerate Bowel motility Recovery after Elective Open Proctectomy for Rectal Cancer.

PubMed

Yang, Ping; Long, Wu Jun; Wei, Li

2018-01-01

A number of studies with conflicting results have evaluated the effect of chewing gum on post-operative gastrointestinal recovery in patients after major colorectal surgery. The objective of the study was to study the efficacy of chewing gum in patients with rectal cancer after elective open proctectomy only. A randomized controlled clinical trial was performed. We recruited patients who would undergo elective open proctectomy for rectal cancer in Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital. Patients in the intervention arm received chewing gum 3 times a day postoperatively. All patients in the trial were placed on the same perioperative management and standardized post-operative care plans. The primary outcome was time to the first peristalsis sounds, time to first flatus and the first defecation. A total of 89 patients were recruited. The time to the first flatus was 42.33 ± 3.46 h in the gum group and 49.20 ± 1.42 h in the control group (p < 0.05). The time to the first defecation was significantly shorter in the gum-chewing group than in the control group (66.07 ± 2.36 vs. 78.37 ± 1.62 h; p < 0.05). Post-operative ileus (POI) was confirmed in 2 patients in the gum-chewing group and in 7 in the control group (7.0% vs. 23.9%; p = 0.028). The present study suggests that chewing gum is a method to reduce the time to first flatus, time to first defecation and POI in patients undergoing elective open proctectomy for rectal cancer. Copyright: © 2017 SecretarÍa de Salud.

Comparison of 7.2% hypertonic saline - 6% hydroxyethyl starch solution and 6% hydroxyethyl starch solution after the induction of anesthesia in patients undergoing elective neurosurgical procedures.

PubMed

Shao, Liujiazi; Wang, Baoguo; Wang, Shuangyan; Mu, Feng; Gu, Ke

2013-01-01

The ideal solution for fluid management during neurosurgical procedures remains controversial. The aim of this study was to compare the effects of a 7.2% hypertonic saline - 6% hydroxyethyl starch (HS-HES) solution and a 6% hydroxyethyl starch (HES) solution on clinical, hemodynamic and laboratory variables during elective neurosurgical procedures. Forty patients scheduled for elective neurosurgical procedures were randomly assigned to the HS-HES group orthe HES group. Afterthe induction of anesthesia, patients in the HS-HES group received 250 mL of HS-HES (500 mL/h), whereas the patients in the HES group received 1,000 mL of HES (1000 mL/h). The monitored variables included clinical, hemodynamic and laboratory parameters. Chictr.org: ChiCTR-TRC-12002357 The patients who received the HS-HES solution had a significant decrease in the intraoperative total fluid input (p<0.01), the volume of Ringer's solution required (p<0.05), the fluid balance (p<0.01) and their dural tension scores (p<0.05). The total urine output, blood loss, bleeding severity scores, operation duration and hemodynamic variables were similar in both groups (p>0.05). Moreover, compared with the HES group, the HS-HES group had significantly higher plasma concentrations of sodium and chloride, increasing the osmolality (p<0.01). Our results suggest that HS-HES reduced the volume of intraoperative fluid required to maintain the patients undergoing surgery and led to a decrease in the intraoperative fluid balance. Moreover, HS-HES improved the dural tension scores and provided satisfactory brain relaxation. Our results indicate that HS-HES may represent a new avenue for volume therapy during elective neurosurgical procedures.

Comparison of 7.2% hypertonic saline - 6% hydroxyethyl starch solution and 6% hydroxyethyl starch solution after the induction of anesthesia in patients undergoing elective neurosurgical procedures

PubMed Central

Shao, Liujiazi; Wang, Baoguo; Wang, Shuangyan; Mu, Feng; Gu, Ke

2013-01-01

OBJECTIVE: The ideal solution for fluid management during neurosurgical procedures remains controversial. The aim of this study was to compare the effects of a 7.2% hypertonic saline - 6% hydroxyethyl starch (HS-HES) solution and a 6% hydroxyethyl starch (HES) solution on clinical, hemodynamic and laboratory variables during elective neurosurgical procedures. METHODS: Forty patients scheduled for elective neurosurgical procedures were randomly assigned to the HS-HES group or the HES group. After the induction of anesthesia, patients in the HS-HES group received 250 mL of HS-HES (500 mL/h), whereas the patients in the HES group received 1,000 mL of HES (1000 mL/h). The monitored variables included clinical, hemodynamic and laboratory parameters. Chictr.org: ChiCTR-TRC-12002357 RESULTS: The patients who received the HS-HES solution had a significant decrease in the intraoperative total fluid input (p<0.01), the volume of Ringer's solution required (p<0.05), the fluid balance (p<0.01) and their dural tension scores (p<0.05). The total urine output, blood loss, bleeding severity scores, operation duration and hemodynamic variables were similar in both groups (p>0.05). Moreover, compared with the HES group, the HS-HES group had significantly higher plasma concentrations of sodium and chloride, increasing the osmolality (p<0.01). CONCLUSION: Our results suggest that HS-HES reduced the volume of intraoperative fluid required to maintain the patients undergoing surgery and led to a decrease in the intraoperative fluid balance. Moreover, HS-HES improved the dural tension scores and provided satisfactory brain relaxation. Our results indicate that HS-HES may represent a new avenue for volume therapy during elective neurosurgical procedures. PMID:23644851

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.

PubMed

Childers, Christopher P; Siletz, Anaar E; Singer, Emily S; Faltermeier, Claire; Hu, Q Lina; Ko, Clifford Y; Golladay, Gregory J; Kates, Stephen L; Wick, Elizabeth C; Maggard-Gibbons, Melinda

2018-01-01

Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery-a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/ Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

Suture versus preperitoneal polypropylene mesh for elective umbilical hernia repairs.

PubMed

Berger, Rachel L; Li, Linda T; Hicks, Stephanie C; Liang, Mike K

2014-12-01

Repair of primary ventral hernias (PVH) such as umbilical hernias is a common surgical procedure. There is a paucity of risk-adjusted data comparing suture versus mesh repair of these hernias. We compared preperitoneal polypropylene (PP) repair versus suture repair for elective umbilical hernia repair. A retrospective review of all elective open PVH repairs at a single institution from 2000-2010 was performed. Only patients with suture or PP repair of umbilical hernias were included. Univariate analysis was conducted and propensity for treatment-adjusted multivariate logistic regression. There were 442 elective open PVH repairs performed; 392 met our inclusion criteria. Of these patients, 126 (32.1%) had a PP repair and 266 (67.9%) underwent suture repair. Median (range) follow-up was 60 mo (1-143). Patients who underwent PP repair had more surgical site infections (SSIs; 19.8% versus 7.9%, P < 0.01) and seromas (14.3% versus 4.1%, P < 0.01). There was no difference in recurrence (5.6% versus 7.5%, P = 0.53). On propensity score-adjusted multivariate analysis, we found that body mass index (odds ratio [OR], 1.10) and smoking status (OR, 2.3) were associated with recurrence. Mesh (OR, 2.34) and American Society of Anesthesiologists (OR, 1.95) were associated with SSI. Only mesh (OR, 3.41) was associated with seroma formation. Although there was a trend toward more recurrence with suture repair in our study, this was not statistically significant. Mesh repair was associated with more SSI and seromas. Further prospective randomized controlled trial is needed to clarify the role of suture and mesh repair in PVH. Copyright © 2014 Elsevier Inc. All rights reserved.

Intraoperative Infusion of Dexmedetomidine for Prevention of Postoperative Delirium and Cognitive Dysfunction in Elderly Patients Undergoing Major Elective Noncardiac Surgery: A Randomized Clinical Trial.

PubMed

Deiner, Stacie; Luo, Xiaodong; Lin, Hung-Mo; Sessler, Daniel I; Saager, Leif; Sieber, Frederick E; Lee, Hochang B; Sano, Mary; Jankowski, Christopher; Bergese, Sergio D; Candiotti, Keith; Flaherty, Joseph H; Arora, Harendra; Shander, Aryeh; Rock, Peter

2017-08-16

Postoperative delirium occurs in 10% to 60% of elderly patients having major surgery and is associated with longer hospital stays, increased hospital costs, and 1-year mortality. Emerging literature suggests that dexmedetomidine sedation in critical care units is associated with reduced incidence of delirium. However, intraoperative use of dexmedetomidine for prevention of delirium has not been well studied. To evaluate whether an intraoperative infusion of dexmedetomidine reduces postoperative delirium. This study was a multicenter, double-blind, randomized, placebo-controlled trial that randomly assigned patients to dexmedetomidine or saline placebo infused during surgery and for 2 hours in the recovery room. Patients were assessed daily for postoperative delirium (primary outcome) and secondarily for postoperative cognitive decline. Participants were elderly (>68 years) patients undergoing major elective noncardiac surgery. The study dates were February 2008 to May 2014. Dexmedetomidine infusion (0.5 µg/kg/h) during surgery and up to 2 hours in the recovery room. The primary hypothesis tested was that intraoperative dexmedetomidine administration would reduce postoperative delirium. Secondarily, the study examined the correlation between dexmedetomidine use and postoperative cognitive change. In total, 404 patients were randomized; 390 completed in-hospital delirium assessments (median [interquartile range] age, 74.0 [71.0-78.0] years; 51.3% [200 of 390] female). There was no difference in postoperative delirium between the dexmedetomidine and placebo groups (12.2% [23 of 189] vs 11.4% [23 of 201], P = .94). After adjustment for age and educational level, there was no difference in the postoperative cognitive performance between treatment groups at 3 months and 6 months. Adverse events were comparably distributed in the treatment groups. Intraoperative dexmedetomidine does not prevent postoperative delirium. The reduction in delirium previously demonstrated in numerous surgical intensive care unit studies was not observed, which underscores the importance of timing when administering the drug to prevent delirium. clinicaltrials.gov Identifier NCT00561678.

[Balanced postoperative analgesia in abdominal surgery: efficiency of the combined use of epidural block and non-opioid analgesics].

PubMed

Borisov, D B; Levin, A V; Uvarov, D N; Kapanadze, L G; Nedashkovskiĭ, E V

2009-01-01

One hundred patients who had undergone elective surgery for abdominal malignancy were enrolled in the randomized, controlled study. Postoperative analgesia included only continuous epidural analgesia (PEA) or PEA with intramuscular ketorolac, or PEA with intramuscular ketorolac and intravenous paracetamol. The systemic use of ketorolac and paracetamol in addition to continuous epidural anesthesia can reduce a need for a local anesthetic and the intensity of postoperative movement pain.

Cost Transparency in Neurosurgery: A Single-Institution Analysis of Patient Out-of-Pocket Spending in 13 673 Consecutive Neurosurgery Cases.

PubMed

Mooney, Michael A; Yoon, Seungwon; Cole, Tyler; Sheehy, John P; Bohl, Michael A; Barranco, F David; Nakaji, Peter; Little, Andrew S; Lawton, Michael T

2018-05-15

Patient out-of-pocket (OOP) spending is an increasingly discussed topic; however, there is minimal data available on the patient financial burden of surgical procedures. To analyze hospital and surgeon expected payment data and patient OOP spending in neurosurgery. This is a retrospective cohort study of neurosurgical patients at a tertiary-referral center from 2013 to 2016. Expected payments, reflecting negotiated costs-of-care, as well as actual patient OOP payments for hospital care and surgeon professional fees were analyzed. A 4-tiered model of patient OOP cost sharing and a multivariate model of patient expected payments were created. A total of 13 673 consecutive neurosurgical cases were analyzed. Patient age, insurance type, case category, severity of illness, length of stay (LOS), and elective case status were significant predictors of increased expected payments (P < .05). Craniotomy ($53 397 ± 811) and posterior spinal fusion ($48 329 ± 864) were associated with the highest expected payments. In a model of patient OOP cost sharing, nearly all neurosurgical procedures exceeded yearly OOP maximums for Healthcare Marketplace plans. Mean patient payments for hospital care and surgeon professional fees were the highest for anterior/lateral spinal fusion cases for commercially insured patients ($1662 ± 165). Mean expected payments and mean patient payments for commercially insured patients increased significantly from 2013 to 2016 (P < .05). Expected payments and patient OOP spending for commercially insured patients significantly increased from 2013 to 2016, representing increased healthcare costs and patient cost sharing in an evolving healthcare environment. Patients and providers can consider this information prior to surgery to better anticipate the individual financial burden for neurosurgical care.

The effect of English language proficiency on length of stay and in-hospital mortality.

PubMed

John-Baptiste, Ava; Naglie, Gary; Tomlinson, George; Alibhai, Shabbir M H; Etchells, Edward; Cheung, Angela; Kapral, Moira; Gold, Wayne L; Abrams, Howard; Bacchus, Maria; Krahn, Murray

2004-03-01

In ambulatory care settings, patients with limited English proficiency receive lower quality of care. Limited information is available describing outcomes for inpatients. To investigate the effect of English proficiency on length of stay (LOS) and in-hospital mortality. Retrospective analysis of administrative data at 3 tertiary care teaching hospitals (University Health Network) in Toronto, Canada. Consecutive inpatient admissions from April 1993 to December 1999 were analyzed for LOS differences first by looking at 23 medical and surgical conditions (59,547 records) and then by a meta-analysis of 220 case mix groups (189,119 records). We performed a similar analysis for in-hospital mortality. LOS and odds of in-hospital death for limited English-proficient (LEP) patients relative to English-proficient (EP) patients. LEP patients stayed in hospital longer for 7 of 23 conditions (unstable coronary syndromes and chest pain, coronary artery bypass grafting, stroke, craniotomy procedures, diabetes mellitus, major intestinal and rectal procedures, and elective hip replacement), with LOS differences ranging from approximately 0.7 to 4.3 days. A meta-analysis using all admission data demonstrated that LEP patients stayed 6% (approximately 0.5 days) longer overall than EP patients (95% confidence interval, 0.04 to 0.07). LEP patients were not at increased risk of in-hospital death (relative odds, 1.0; 95% confidence interval, 0.9 to 1.1). Patients with limited English proficiency have longer hospital stays for some medical and surgical conditions. Limited English proficiency does not affect in-hospital mortality. The effect of communication barriers on outcomes of care in the inpatient setting requires further exploration, particularly for selected conditions in which length of stay is significantly prolonged.

Preservation of the Myofascial Cuff During Posterior Fossa Surgery to Reduce the Rate of Pseudomeningocele Formation and Cerebrospinal Fluid Leak: A Technical Note

PubMed Central

Felbaum, Daniel R; Anaizi, Amjad; Mason, Robert B; Jean, Walter C; Voyadzis, Jean M

2016-01-01

Introduction: Suboccipital craniotomy is a workhorse neurosurgical operation for approaching the posterior fossa but carries a high risk of pseudomeningocele and cerebrospinal fluid (CSF) leak. We describe our experience with a simple T-shaped fascial opening that preserves the occipital myofascial cuff as compared to traditional methods to reduce this risk. Methods: A single institution, retrospective review of prospectively collected database was performed of patients that underwent a suboccipital craniectomy or craniotomy. Patient data was reviewed for craniotomy or craniectomy, dural graft, and/or sealant use as well as CSF complications. A pseudomeningocele was defined as a subcutaneous collection of cerebrospinal fluid palpable clinically and confirmed on imaging. A CSF leak was defined as a CSF-cutaneous fistula manifested by CSF leaking through the wound. All patients underwent regular postoperative visits of two weeks, one month, and three months. Results: Our retrospective review identified 33 patients matching the inclusion criteria. Overall, our cohort had a 21% (7/33) rate of clinical and radiographic pseudomeningocele formation with 9% (3/33) requiring surgical revision or a separate procedure. The rate of clinical and radiographic pseudomeningocele formation in the myofascial cuff preservation technique was less than standard techniques (12% and 31%, respectively). Revision or further surgical procedures were also reduced in the myofascial cuff preservation technique vs. the standard technique (6% vs 13%). Conclusions: Preservation of the myofascial cuff during posterior fossa surgery is a simple and adoptable technique that reduces the rate of pseudomeningocele formation and CSF leak as compared with standard techniques.   PMID:28133584

Factors Influencing Norvancomycin Concentration in Plasma and Cerebrospinal Fluid in Patients After Craniotomy and Dosing Guideline: A Population Approach.

PubMed

Li, Xingang; Wu, Yuanxing; Sun, Shusen; Wang, Qiang; Zhao, Zhigang

2018-01-01

Antibacterial spectrum and activity of norvancomycin are comparable with vancomycin, and it has been widely used in China. Norvancomycin can penetrate into the cerebrospinal fluid (CSF) through the damaged blood-brain barrier in patients after craniotomy. Because higher inter-individual variability was observed, we aimed to identify factors related to drug concentration to guide clinicians with norvancomycin dosing. After craniotomy, patients with an indwelling catheter in the operational area/ventricle were intravenously administered norvancomycin. Venous blood and CSF specimens were collected at a scheduled time for measuring drug concentrations. Blood and CSF data were fitted simultaneously with the use of the nonlinear fixed-effects modeling method to develop the population pharmacokinetic model. Covariate analysis was applied to select candidate factors associated with pharmacokinetic parameters. A model-based simulation was performed to find optimized regimens for different subgroups of patients. A 3-compartmental model (central, peripheral, and CSF compartments) with 2 elimination pathways (drug elimination from the kidney and CSF outflow) was developed to characterize the in vivo process of norvancomycin. The covariate analysis identified that weight and drainage amount were strongly associated with the central volume and the drug clearance from CSF, respectively. Goodness-of-fit and model validation suggested that the proposed model was acceptable. A dosage regimen table was created for specific patient populations with different weights and drainage amounts to facilitate clinical application. We identified 2 clinical markers associated with plasma and CSF concentrations. The proposed simulation may be useful to clinicians for norvancomycin dosing in this specific population with normal kidney function. Copyright © 2018. Published by Elsevier Inc.

[Anesthesiological management of awake craniotomy : Asleep-awake-asleep technique or without sedation].

PubMed

Seemann, M; Zech, N; Graf, B; Hansen, E

2015-02-01

Awake craniotomy is indicated in deep brain stimulation (DBS) for treatment of certain movement disorders, such as in Parkinson disease patients or in the surgery of brain tumors in close vicinity to the language area. The standard procedure is the asleep-awake-asleep technique where general anesthesia or analgosedation is intermittently interrupted for neurological testing. In DBS the intraoperative improvement of symptoms, stereotactic navigation and microelectrode reading guide to the optimal position. In brain tumor resection, reversible functional impairments during electrical stimulation on the brain surface (brain mapping) show the exact individual position of eloquent or motoric areas that should be protected.The anesthesiology procedures used are very variable. It is a balancing act between overdosing of anesthetics with impairment of respiration and alertness and underdosing with pain, strain and stress for the patient. For the asleep-awake-asleep technique high acceptance but also frequent and partly severe complications have been reported. The psychological stress for the patient can be immense. Obviously, a feeling of being left alone and being at someone's mercy is not adequately treated by drugs and performance of the neurological tests is undoubtedly better and more reliable with less pharmacological impairment. Cranial nerve blocks can reduce the amount of anesthetics as they provide analgesia of the scalp more efficiently than local infiltration. With these nerve blocks, a strong therapeutic relationship and a specific communication, sedatives can be avoided and the need for opioids markedly reduced or abolished. The suggestive communication promotes for instance dissociation to an inner safe refuge, as well as reframing of disturbing noises and sensations. Each of the methods applied for awake craniotomy can profit from the principles of this awake-awake-awake technique.

Reliability of functional MR imaging with word-generation tasks for mapping Broca's area.

PubMed

Brannen, J H; Badie, B; Moritz, C H; Quigley, M; Meyerand, M E; Haughton, V M

2001-10-01

Functional MR (fMR) imaging of word generation has been used to map Broca's area in some patients selected for craniotomy. The purpose of this study was to measure the reliability, precision, and accuracy of word-generation tasks to identify Broca's area. The Brodmann areas activated during performance of word-generation tasks were tabulated in 34 consecutive patients referred for fMR imaging mapping of language areas. In patients performing two iterations of the letter word-generation tasks, test-retest reliability was quantified by using the concurrence ratio (CR), or the number of voxels activated by each iteration in proportion to the average number of voxels activated from both iterations of the task. Among patients who also underwent category or antonym word generation or both, the similarity of the activation from each task was assessed with the CR. In patients who underwent electrocortical stimulation (ECS) mapping of speech function during craniotomy while awake, the sites with speech function were compared with the locations of activation found during fMR imaging of word generation. In 31 of 34 patients, activation was identified in the inferior frontal gyri or middle frontal gyri or both in Brodmann areas 9, 44, 45, or 46, unilaterally or bilaterally, with one or more of the tasks. Activation was noted in the same gyri when the patient performed a second iteration of the letter word-generation task or second task. The CR for pixel precision in a single section averaged 49%. In patients who underwent craniotomy while awake, speech areas located with ECS coincided with areas of the brain activated during a word-generation task. fMR imaging with word-generation tasks produces technically satisfactory maps of Broca's area, which localize the area accurately and reliably.

Planum Sphenoidale and Tuberculum Sellae Meningiomas: Operative Nuances of a Modern Surgical Technique with Outcome and Proposal of a New Classification System.

PubMed

Mortazavi, Martin M; Brito da Silva, Harley; Ferreira, Manuel; Barber, Jason K; Pridgeon, James S; Sekhar, Laligam N

2016-02-01

The resection of planum sphenoidale and tuberculum sellae meningiomas is challenging. A universally accepted classification system predicting surgical risk and outcome is still lacking. We report a modern surgical technique specific for planum sphenoidale and tuberculum sellae meningiomas with associated outcome. A new classification system that can guide the surgical approach and may predict surgical risk is proposed. We conducted a retrospective review of the patients who between 2005 and March 2015 underwent a craniotomy or endoscopic surgery for the resection of meningiomas involving the suprasellar region. Operative nuances of a modified frontotemporal craniotomy and orbital osteotomy technique for meningioma removal and reconstruction are described. Twenty-seven patients were found to have tumors arising mainly from the planum sphenoidale or the tuberculum sellae; 25 underwent frontotemporal craniotomy and tumor removal with orbital osteotomy and bilateral optic canal decompression, and 2 patients underwent endonasal transphenoidal resection. The most common presenting symptom was visual disturbance (77%). Vision improved in 90% of those who presented with visual decline, and there was no permanent visual deterioration. Cerebrospinal fluid leak occurred in one of the 25 cranial cases (4%) and in 1 of 2 transphenoidal cases (50%), and in both cases it resolved with treatment. There was no surgical mortality. An orbitotomy and early decompression of the involved optic canal are important for achieving gross total resection, maximizing visual improvement, and avoiding recurrence. The visual outcomes were excellent. A new classification system that can allow the comparison of different series and approaches and indicate cases that are more suitable for an endoscopic transsphenoidal approach is presented. Copyright © 2016 Elsevier Inc. All rights reserved.

Development of a multi-exposure speckle imaging for mice brain imaging

NASA Astrophysics Data System (ADS)

Soleimanzad, Haleh; Gurden, Hirac; Pain, Frédéric

2017-02-01

In the last decade, Laser Speckle Contrast Imaging (LSCI) has been proposed and validated for imaging cerebral blood flow at the rodent brain surface in vivo. The technique relies on the calculation of the spatial speckle contrast, which is related to the velocity of scatterers (red blood cells). The implementation of the technique requires a partial craniotomy so that the brain tissues of interest can be illuminated with a laser diode. However, the studies of changes in the microcirculation during disease progression or treatment require longitudinal studies (i.e. imaging is done repeatedly over weeks or even months). Practically, the less invasive way to obtain such data is to image through the thinned skull without a craniotomy. However the presence of static scatterers (skull) will affect the speckle calculation and produce a bias in the estimation of the microcirculation changes. An extension to LSCI, termed Multi-Exposure Speckle Imaging (MESI) was proposed and validated a few years ago that address these limitations. It relies on a model of the speckle contrast as a function of the exposure time and the proportion of static scatterers. Here, we used MESI with the aim of repeatedly imaging the olfactory bulb of mice models of obesity. First, we have developed a MESI set up which was characterized on microfluidic flow phantoms with different flow-rates and channel diameters to simulate blood flow in animal model characteristics. Second, we show that MESI can discriminate flows in the presence of static scatterers and it can measure flow changes consistently. Finally we provide an in vivo validation of the technique in mice with and without a craniotomy.

Risk for intracranial pressure increase related to enclosed air in post-craniotomy patients during air ambulance transport: a retrospective cohort study with simulation.

PubMed

Brändström, Helge; Sundelin, Anna; Hoseason, Daniela; Sundström, Nina; Birgander, Richard; Johansson, Göran; Winsö, Ola; Koskinen, Lars-Owe; Haney, Michael

2017-05-12

Post-craniotomy intracranial air can be present in patients scheduled for air ambulance transport to their home hospital. We aimed to assess risk for in-flight intracranial pressure (ICP) increases related to observed intracranial air volumes, hypothetical sea level pre-transport ICP, and different potential flight levels and cabin pressures. A cohort of consecutive subdural hematoma evacuation patients from one University Medical Centre was assessed with post-operative intracranial air volume measurements by computed tomography. Intracranial pressure changes related to estimated intracranial air volume effects of changing atmospheric pressure (simulating flight and cabin pressure changes up to 8000 ft) were simulated using an established model for intracranial pressure and volume relations. Approximately one third of the cohort had post-operative intracranial air. Of these, approximately one third had intracranial air volumes less than 11 ml. The simulation estimated that the expected changes in intracranial pressure during 'flight' would not result in intracranial hypertension. For intracranial air volumes above 11 ml, the simulation suggested that it was possible that intracranial hypertension could develop 'inflight' related to cabin pressure drop. Depending on the pre-flight intracranial pressure and air volume, this could occur quite early during the assent phase in the flight profile. DISCUSSION: These findings support the idea that there should be radiographic verification of the presence or absence of intracranial air after craniotomy for patients planned for long distance air transport. Very small amounts of air are clinically inconsequential. Otherwise, air transport with maintained ground-level cabin pressure should be a priority for these patients.

Postoperative Neurosurgical Infection Rates After Shared-Resource Intraoperative Magnetic Resonance Imaging: A Single-Center Experience with 195 Cases.

PubMed

Dinevski, Nikolaj; Sarnthein, Johannes; Vasella, Flavio; Fierstra, Jorn; Pangalu, Athina; Holzmann, David; Regli, Luca; Bozinov, Oliver

2017-07-01

To determine the rate of surgical-site infections (SSI) in neurosurgical procedures involving a shared-resource intraoperative magnetic resonance imaging (ioMRI) scanner at a single institution derived from a prospective clinical quality management database. All consecutive neurosurgical procedures that were performed with a high-field, 2-room ioMRI between April 2013 and June 2016 were included (N = 195; 109 craniotomies and 86 endoscopic transsphenoidal procedures). The incidence of SSIs within 3 months after surgery was assessed for both operative groups (craniotomies vs. transsphenoidal approach). Of the 109 craniotomies, 6 patients developed an SSI (5.5%, 95% confidence interval [CI] 1.2-9.8%), including 1 superficial SSI, 2 cases of bone flap osteitis, 1 intracranial abscess, and 2 cases of meningitis/ventriculitis. Wound revision surgery due to infection was necessary in 4 patients (4%). Of the 86 transsphenoidal skull base surgeries, 6 patients (7.0%, 95% CI 1.5-12.4%) developed an infection, including 2 non-central nervous system intranasal SSIs (3%) and 4 cases of meningitis (5%). Logistic regression analysis revealed that the likelihood of infection significantly decreased with the number of operations in the new operational setting (odds ratio 0.982, 95% CI 0.969-0.995, P = 0.008). The use of a shared-resource ioMRI in neurosurgery did not demonstrate increased rates of infection compared with the current available literature. The likelihood of infection decreased with the accumulating number of operations, underlining the importance of surgical staff training after the introduction of a shared-resource ioMRI. Copyright © 2017 Elsevier Inc. All rights reserved.

Low-Level Laser Light Therapy Improves Cognitive Deficits and Inhibits Microglial Activation after Controlled Cortical Impact in Mice

PubMed Central

Khuman, Jugta; Zhang, Jimmy; Park, Juyeon; Carroll, James D.; Donahue, Chad

2012-01-01

Abstract Low-level laser light therapy (LLLT) exerts beneficial effects on motor and histopathological outcomes after experimental traumatic brain injury (TBI), and coherent near-infrared light has been reported to improve cognitive function in patients with chronic TBI. However, the effects of LLLT on cognitive recovery in experimental TBI are unknown. We hypothesized that LLLT administered after controlled cortical impact (CCI) would improve post-injury Morris water maze (MWM) performance. Low-level laser light (800 nm) was applied directly to the contused parenchyma or transcranially in mice beginning 60–80 min after CCI. Injured mice treated with 60 J/cm2 (500 mW/cm2×2 min) either transcranially or via an open craniotomy had modestly improved latency to the hidden platform (p<0.05 for group), and probe trial performance (p<0.01) compared to non-treated controls. The beneficial effects of LLLT in open craniotomy mice were associated with reduced microgliosis at 48 h (21.8±2.3 versus 39.2±4.2 IbA-1+ cells/200×field, p<0.05). Little or no effect of LLLT on post-injury cognitive function was observed using the other doses, a 4-h administration time point and 7-day administration of 60 J/cm2. No effect of LLLT (60 J/cm2 open craniotomy) was observed on post-injury motor function (days 1–7), brain edema (24 h), nitrosative stress (24 h), or lesion volume (14 days). Although further dose optimization and mechanism studies are needed, the data suggest that LLLT might be a therapeutic option to improve cognitive recovery and limit inflammation after TBI. PMID:21851183

Application of Awake Craniotomy and Intraoperative Brain Mapping for Surgical Resection of Insular Gliomas of the Dominant Hemisphere.

PubMed

Alimohamadi, Maysam; Shirani, Mohammad; Shariat Moharari, Reza; Pour-Rashidi, Ahmad; Ketabchi, Mehdi; Khajavi, Mohammadreza; Arami, Mohamadali; Amirjamshidi, Abbas

2016-08-01

Radical resection of dominant insular gliomas is difficult because of their close vicinity with internal capsule, basal ganglia, and speech centers. Brain mapping techniques can be used to maximize the extent of tumor removal and to minimize postoperative morbidities by precise localization of eloquent cortical and subcortical areas. Patients with newly diagnosed gliomas of dominant insula were enrolled. The exclusion criteria were severe cognitive disturbances, communication difficulty, age greater than 75 years, severe obesity, difficult airways for intubation and severe cardiopulmonary diseases. All were evaluated preoperatively with contrast-enhanced brain magnetic resonance imaging (MRI), functional brain MRI, and diffusion tensor tractography of language and motor systems. All underwent awake craniotomy with the same anesthesiology protocol. Intraoperative monitoring included continuous motor-evoked potential, electromyography, electrocorticography, direct electrical stimulation of cortex, and subcortical tracts. The patients were followed with serial neurologic examination and imaging. Ten patients were enrolled (4 men, 6 women) with a mean age of 43.6 years. Seven patients suffered from low-grade glioma, and 3 patients had high-grade glioma. The most common clinical presentation was seizure followed by speech disturbance, hemiparesis, and memory loss. Extent of tumor resection ranged from 73% to 100%. No mortality or new major postoperative neurologic deficit was encountered. Seizure control improved in three fourths of patients with medical refractory epilepsy. In one patient with speech disorder at presentation, the speech problem became worse after surgery. Brain mapping during awake craniotomy helps to maximize extent of tumor resection while preserving neurologic function in patients with dominant insular lobe glioma. Copyright © 2016. Published by Elsevier Inc.

Modified skin incision for avoiding the lesser occipital nerve and occipital artery during retrosigmoid craniotomy: potential applications for enhancing operative working distance and angles while minimizing the risk of postoperative neuralgias and intraoperative hemorrhage.

PubMed

Tubbs, R Shane; Fries, Fabian N; Kulwin, Charles; Mortazavi, Martin M; Loukas, Marios; Cohen-Gadol, Aaron A

2016-10-01

Chronic postoperative neuralgias and headache following retrosigmoid craniotomy can be uncomfortable for the patient. We aimed to better elucidate the regional nerve anatomy in an effort to minimize this postoperative complication. Ten adult cadaveric heads (20 sides) were dissected to observe the relationship between the lesser occipital nerve and a traditional linear versus modified U incision during retrosigmoid craniotomy. Additionally, the relationship between these incisions and the occipital artery were observed. The lesser occipital nerve was found to have two types of course. Type I nerves (60%) remained close to the posterior border of the sternocleidomastoid muscle and some crossed anteriorly over the sternocleidomastoid muscle near the mastoid process. Type II nerves (40%) left the posterior border of the sternocleidomastoid muscle and swung medially (up to 4.5cm posterior to the posterior border of the sternocleidomastoid muscle) as they ascended over the occiput. The lesser occipital nerve was near a midpoint of a line between the external occipital protuberance and mastoid process in all specimens with the type II nerve configuration. Based on our findings, the inverted U incision would be less likely to injure the type II nerves but would necessarily cross over type I nerves, especially more cranially on the nerve at the apex of the incision. As the more traditional linear incision would most likely transect the type I nerves and more so near their trunk, the U incision may be the overall better choice in avoiding neural and occipital artery injury during retrosigmoid approaches. Copyright © 2016 Elsevier Ltd. All rights reserved.

Hyperammonemic coma after craniotomy: Hepatic encephalopathy from upper gastrointestinal hemorrhage or valproate side effect?: Case report and literature review.

PubMed

Guo, Xiaopeng; Wei, Junji; Gao, Lu; Xing, Bing; Xu, Zhiqin

2017-04-01

Postoperative coma is not uncommon in patients after craniotomy. It generally presents as mental state changes and is usually caused by intracranial hematoma, brain edema, or swelling. Hyperammonemia can also result in postoperative coma; however, it is rarely recognized as a potential cause in coma patients. Hyperammonemic coma is determined through a complicated differential diagnosis, and although it can also be induced as a side effect of valproate (VPA), this cause is frequently unrecognized or confused with upper gastrointestinal hemorrhage (UGH)-induced hepatic encephalopathy. We herein present a case of valproate-induced hyperammonemic encephalopathy (VHE) to illustrate the rarity of such cases and emphasize the importance of correct diagnosis and proper treatment. A 61-year-old woman with meningioma was admitted into our hospital. Radical resection of the tumor was performed, and the patient recovered well as expected. After administration of valproate for 7 days, the patient was suddenly found in a deep coma, and her mental state deteriorated rapidly. The diagnoses of hepatic encephalopathy was confirmed. However, whether it origins from upper gastrointestinal hemorrhage or valproate side effect is uncertain. The patient's condition fluctuated without improvement during the subsequent 3 days under the treatment of reducing ammonia. With the discontinuation of valproate treatment, the patient regained complete consciousness within 48 hours, and her blood ammonia decreased to the normal range within 4 days. VHE is a rare but serious complication in patients after craniotomy and is diagnosed by mental state changes and elevated blood ammonia. Thus, the regular perioperative administration of VPA, which is frequently neglected as a cause of VHE, should be emphasized. In addition, excluding UGH prior to providing a diagnosis and immediately discontinuing VPA administration are recommended.

Prevention of atrial fibrillation and inflammatory response after on-pump coronary artery bypass using different statin dosages: a randomized, controlled trial.

PubMed

Pierri, Michele Danilo; Crescenzi, Giuseppe; Zingaro, Carlo; D'Alfonso, Alessandro; Capestro, Filippo; Scocco, Vitangelo; Brugia, Marina; Torracca, Lucia

2016-07-01

This randomized controlled trial aimed to evaluate the effects of seven-day preoperative treatment with two different dosages of atorvastatin on the incidence of postoperative atrial fibrillation (POAF) and release of inflammatory markers such as high-sensitive C-reactive protein (hsCRP) and interleukin-6 in patients undergoing elective first-time on-pump coronary artery bypass grafting (CABG). The cohort study comprised 212 consecutive patients, already taking statins, who underwent elective first-time CABG with cardiopulmonary bypass without history of atrial fibrillation (AF). Patients were randomly divided into two groups: those who received atorvastatin 40 mg (TOR40 group, 111 patients) and those who received 80 mg (TOR80 group, 101 patients) once a day for 7 days before the planned operation. The primary endpoint was the incidence of AF. The secondary endpoints were the postoperative variations of inflammatory markers, hospital length of stay, and the incidence of major adverse cardiac and clinical events. A total of 26 patients (23.6 %) pretreated with atorvastatin 40 mg and 16 (15.8 %) patients pretreated with atorvastatin 80 mg had postoperative AF but the difference did not reach the statistical significance (p = 0.157). Median values of interleukin-6 and hsCRP at 12 and 24 h did not have differences between the two groups. No statistically significant differences in the other secondary endpoints were detected. According to our result, 7-day preoperative treatment with a high dose of atorvastatin is associated with a trend to a decrease in the incidence of POAF compared with treatment at a lower dose, although it does not impact on the level of inflammatory markers. European Clinical Trials Database (EudraCT: 2006-005757-30).

Patient blood management in elective total hip- and knee-replacement surgery (part 2): a randomized controlled trial on blood salvage as transfusion alternative using a restrictive transfusion policy in patients with a preoperative hemoglobin above 13 g/dl.

PubMed

So-Osman, Cynthia; Nelissen, Rob G H H; Koopman-van Gemert, Ankie W M M; Kluyver, Ewoud; Pöll, Ruud G; Onstenk, Ron; Van Hilten, Joost A; Jansen-Werkhoven, Thekla M; van den Hout, Wilbert B; Brand, Ronald; Brand, Anneke

2014-04-01

Patient blood management is introduced as a new concept that involves the combined use of transfusion alternatives. In elective adult total hip- or knee-replacement surgery patients, the authors conducted a large randomized study on the integrated use of erythropoietin, cell saver, and/or postoperative drain reinfusion devices (DRAIN) to evaluate allogeneic erythrocyte use, while applying a restrictive transfusion threshold. Patients with a preoperative hemoglobin level greater than 13 g/dl were ineligible for erythropoietin and evaluated for the effect of autologous blood reinfusion. Patients were randomized between autologous reinfusion by cell saver or DRAIN or no blood salvage device. Primary outcomes were mean intra- and postoperative erythrocyte use and proportion of transfused patients (transfusion rate). Secondary outcome was cost-effectiveness. In 1,759 evaluated total hip- and knee-replacement surgery patients, the mean erythrocyte use was 0.19 (SD, 0.9) erythrocyte units/patient in the autologous group (n = 1,061) and 0.22 (0.9) erythrocyte units/patient in the control group (n = 698) (P = 0.64). The transfusion rate was 7.7% in the autologous group compared with 8.3% in the control group (P = 0.19). No difference in erythrocyte use was found between cell saver and DRAIN groups. Costs were increased by €298 per patient (95% CI, 76 to 520). In patients with preoperative hemoglobin levels greater than 13 g/dl, autologous intra- and postoperative blood salvage devices were not effective as transfusion alternatives: use of these devices did not reduce erythrocyte use and increased costs.

The Effect of Intraoperative Use of High-Dose Remifentanil on Postoperative Insulin Resistance and Muscle Protein Catabolism: A Randomized Controlled Study

PubMed Central

Taniguchi, Hideki; Sasaki, Toshio; Fujita, Hisae; Takano, Osami; Hayashi, Tsutomu; Cho, Haruhiko; Yoshikawa, Takaki; Tsuburaya, Akira

2013-01-01

Objective: We investigated the effect of the intraoperative use of a high dose remifentanil on insulin resistance and muscle protein catabolism. Design: Randomized controlled study. Patients and Intervention: Thirty-seven patients undergoing elective gastrectomy were randomly assigned to 2 groups that received remifentanil at infusion rates of 0.1 μg·kg-1·min-1 (Group L) and 0.5 μg·kg-1·min-1 (Group H). Main outcome measures: Primary efficacy parameters were changes in homeostasis model assessment as an index of insulin resistance (HOMA-IR) and 3-methylhistidine/creatinine (3-MH/Cr). HOMA-IR was used to evaluate insulin resistance, and 3-MH/Cr was used to evaluate the progress of muscle protein catabolism. Intraoperative stress hormones, insulin, and blood glucose were assessed as secondary endpoints. Results: Eighteen patients in Group L and 19 in Group H were examined. HOMA-IR values varied within normal limits in both groups during surgery, exceeding normal limits at 12 h after surgery and being significantly elevated in Group L. There were no significant differences in the 3-MH/Cr values between the 2 groups at any time point. The stress hormones (adrenocorticotropic hormone, cortisol, and adrenaline) were significantly elevated in Group L at 60 min after the start of surgery and at the initiation of skin closure. There were no significant differences in insulin values, but blood glucose was significantly elevated in Group L at 60 min after the start of surgery and at the start of skin closure. Conclusion: Use of high-dose remifentanil as intraoperative analgesia during elective gastrectomy reduced postoperative insulin resistance, although it did not reduce postoperative muscle protein catabolism. PMID:23869185

Human rights abuse and other criminal violations in Port-au-Prince, Haiti: a random survey of households.

PubMed

Kolbe, Athena R; Hutson, Royce A

2006-09-02

Reliable evidence of the frequency and severity of human rights abuses in Haiti after the departure of the elected president in 2004 was scarce. We assessed data from a random survey of households in the greater Port-au-Prince area. Using random Global Positioning System (GPS) coordinate sampling, 1260 households (5720 individuals) were sampled. They were interviewed with a structured questionnaire by trained interviewers about their experiences after the departure of President Jean-Bertrand Aristide. The response rate was 90.7%. Information on demographic characteristics, crime, and human rights violations was obtained. Our findings suggested that 8000 individuals were murdered in the greater Port-au-Prince area during the 22-month period assessed. Almost half of the identified perpetrators were government forces or outside political actors. Sexual assault of women and girls was common, with findings suggesting that 35,000 women were victimised in the area; more than half of all female victims were younger than 18 years. Criminals were the most identified perpetrators, but officers from the Haitian National Police accounted for 13.8% and armed anti-Lavalas groups accounted for 10.6% of identified perpetrators of sexual assault. Kidnappings and extrajudicial detentions, physical assaults, death threats, physical threats, and threats of sexual violence were also common. Our results indicate that crime and systematic abuse of human rights were common in Port-au-Prince. Although criminals were the most identified perpetrators of violations, political actors and UN soldiers were also frequently identified. These findings suggest the need for a systematic response from the newly elected Haitian government, the UN, and social service organisations to address the legal, medical, psychological, and economic consequences of widespread human rights abuses and crime.

The evaluation of clopidogrel use in perioperative general surgery patients: a prospective randomized controlled trial.

PubMed

Chu, Edward W; Chernoguz, Artur; Divino, Celia M

2016-06-01

The perioperative safety profile of clopidogrel, a potent antiplatelet agent used in the management of cardiovascular disease, is unknown, and there are no evidence-based guidelines recommending for either its interruption or continuation at this time. The aim of this study was to determine whether patients who are maintained on clopidogrel before general surgical procedures are at increased risk of perioperative bleeding complications. Patients receiving clopidogrel at the time of elective general surgery were randomized to either discontinue clopidogrel 1 week before surgery (group A) or continue clopidogrel into surgery (group B). All other antiplatelet and anticoagulant agents were discontinued before surgery. The primary end points were perioperative bleeding requiring intraoperative or postoperative transfusion of blood or blood components and bleeding-related readmission, reoperation, or mortality within 90 days of surgery. The secondary end points were perioperative myocardial infarction or cerebrovascular accidents within 90 days of surgery. Thirty-nine patients were enrolled and underwent 43 general surgical operations. Twenty-one procedures were randomized to group A and 22 to group B. The most commonly performed individual procedures were open inguinal hernia repair (23%), laparoscopic cholecystectomy (21%), open ventral hernia repair (15%), laparoscopic ventral hernia repair (11%), and laparoscopic inguinal hernia repair (9%). No perioperative mortalities, bleeding events requiring blood transfusion, or reoperations occurred. One readmission for intra-abdominal hematoma requiring percutaneous drainage occurred in each group (group A: 4.8% vs group B: 4.5%; P = 1.0). No myocardial infarctions or cerebrovascular accidents were observed or reported. The outcomes from this prospective study suggest that, patients undergoing commonly performed elective general surgical procedures can be safely maintained on clopidogrel without increased perioperative bleeding risk. Copyright © 2016 Elsevier Inc. All rights reserved.

Prevention of catheter-related bladder discomfort - pudendal nerve block with ropivacaine versus intravenous tramadol: study protocol for a randomized controlled trial.

PubMed

Li, Jing-Yi; Liao, Ren

2016-09-13

Catheter-related bladder discomfort (CRBD) is a common distressing symptom complex during the postoperative period, especially after urologic procedures with a relatively greater size urinary catheter. In this study, we will enroll male patients undergoing elective prostate surgery with urinary catheterization under general anesthesia, and we will compare the efficacy of pudendal nerve block (PNB) and intravenous tramadol in CRBD prevention. This trial is a prospective, randomized controlled trial that will test the superiority of bilateral PNB with 0.33 % ropivacaine compared with intravenous tramadol 1.5 mg/kg for CRBD prevention. A total of 94 male patients undergoing elective prostate surgery with urinary catheterization after anesthesia induction will be randomized to receive either bilateral PNB with 0.33 % ropivacaine (the PNB group) or intravenous tramadol 1.5 mg/kg (the tramadol group) after the completion of surgery. The primary outcome is the incidence of CRBD. The most important secondary outcome is the severity of postoperative CRBD, and other secondary outcomes include Numeric Rating Scale (NRS) score for postoperative pain; incidence of postoperative side effects such as postoperative nausea/vomiting, sedation, dizziness, and dry mouth; postoperative requirement for tramadol as a rescue treatment for CRBD and sufentanil as a rescue analgesic for postoperative pain; and NRS score for acceptance of an indwelling urinary catheter. This trial is planned to test the superiority of PNB with 0.33 % ropivacaine compared with intravenous tramadol 1.5 mg/kg. It may provide a basis for a new clinical practice for the prevention of CRBD. ClinicalTrials.gov identifier NCT02683070 . Registered on 11 February 2016.

Semuloparin for prevention of venous thromboembolism after major orthopedic surgery: results from three randomized clinical trials, SAVE-HIP1, SAVE-HIP2 and SAVE-KNEE.

PubMed

Lassen, M R; Fisher, W; Mouret, P; Agnelli, G; George, D; Kakkar, A; Mismetti, P; Turpie, A G G

2012-05-01

Semuloparin is a novel ultra-low-molecular-weight heparin under development for venous thromboembolism (VTE) prevention in patients at increased risk, such as surgical and cancer patients. Three Phase III studies compared semuloparin and enoxaparin after major orthopedic surgery: elective knee replacement (SAVE-KNEE), elective hip replacement (SAVE-HIP1) and hip fracture surgery (SAVE-HIP2). All studies were multinational, randomized and double-blind. Semuloparin and enoxaparin were administered for 7-10 days after surgery. Mandatory bilateral venography was to be performed between days 7 and 11. The primary efficacy endpoint was a composite of any deep vein thrombosis, non-fatal pulmonary embolism or all-cause death. Safety outcomes included major bleeding, clinically relevant non-major (CRNM) bleeding, and any clinically relevant bleeding (major bleeding plus CRNM). In total, 1150, 2326 and 1003 patients were randomized in SAVE-KNEE, SAVE-HIP1 and SAVE-HIP2, respectively. In all studies, the incidences of the primary efficacy endpoint were numerically lower in the semuloparin group vs. the enoxaparin group, but the difference was statistically significant only in SAVE-HIP1. In SAVE-HIP1, clinically relevant bleeding and major bleeding were significantly lower in the semuloparin vs. the enoxaparin group. In SAVE-KNEE and SAVE-HIP2, clinically relevant bleeding tended to be higher in the semuloparin group, but rates of major bleeding were similar in the two groups. Other safety parameters were generally similar between treatment groups. Semuloparin was superior to enoxaparin for VTE prevention after hip replacement surgery, but failed to demonstrate superiority after knee replacement surgery and hip fracture surgery. Semuloparin and enoxaparin exhibited generally similar safety profiles. © 2012 International Society on Thrombosis and Haemostasis.

Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis

PubMed Central

Rossaint, Rolf; Veldeman, Michael

2016-01-01

Background Awake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques. Methods Two authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI]. Results We have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1–3], 8% [95%CI:6–11], 17% [95%CI:12–23] and 2% [95%CI:2–3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36–2.69], 1.01 [95%CI:0.52–1.88] for seizures, 1.66 [95%CI:1.35–3.70] for new neurological dysfunction and 2.17 [95%CI:1.22–3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies. Conclusion SAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC. PMID:27228013

Anaesthesia Management for Awake Craniotomy: Systematic Review and Meta-Analysis.

PubMed

Stevanovic, Ana; Rossaint, Rolf; Veldeman, Michael; Bilotta, Federico; Coburn, Mark

2016-01-01

Awake craniotomy (AC) renders an expanded role in functional neurosurgery. Yet, evidence for optimal anaesthesia management remains limited. We aimed to summarise the latest clinical evidence of AC anaesthesia management and explore the relationship of AC failures on the used anaesthesia techniques. Two authors performed independently a systematic search of English articles in PubMed and EMBASE database 1/2007-12/2015. Search included randomised controlled trials (RCTs), observational trials, and case reports (n>4 cases), which reported anaesthetic approach for AC and at least one of our pre-specified outcomes: intraoperative seizures, hypoxia, arterial hypertension, nausea and vomiting, neurological dysfunction, conversion into general anaesthesia and failure of AC. Random effects meta-analysis was used to estimate event rates for four outcomes. Relationship with anaesthesia technique was explored using logistic meta-regression, calculating the odds ratios (OR) and 95% confidence intervals [95%CI]. We have included forty-seven studies. Eighteen reported asleep-awake-asleep technique (SAS), twenty-seven monitored anaesthesia care (MAC), one reported both and one used the awake-awake-awake technique (AAA). Proportions of AC failures, intraoperative seizures, new neurological dysfunction and conversion into general anaesthesia (GA) were 2% [95%CI:1-3], 8% [95%CI:6-11], 17% [95%CI:12-23] and 2% [95%CI:2-3], respectively. Meta-regression of SAS and MAC technique did not reveal any relevant differences between outcomes explained by the technique, except for conversion into GA. Estimated OR comparing SAS to MAC for AC failures was 0.98 [95%CI:0.36-2.69], 1.01 [95%CI:0.52-1.88] for seizures, 1.66 [95%CI:1.35-3.70] for new neurological dysfunction and 2.17 [95%CI:1.22-3.85] for conversion into GA. The latter result has to be interpreted cautiously. It is based on one retrospective high-risk of bias study and significance was abolished in a sensitivity analysis of only prospectively conducted studies. SAS and MAC techniques were feasible and safe, whereas data for AAA technique are limited. Large RCTs are required to prove superiority of one anaesthetic regime for AC.

Triple Therapy with Scopolamine, Ondansetron, and Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Moderate to High-Risk Patients Undergoing Craniotomy Under General Anesthesia: A Pilot Study.

PubMed

Bergese, Sergio D; Antor, Maria A; Uribe, Alberto A; Yildiz, Vedat; Werner, Joseph

2015-01-01

Postoperative nausea and vomiting (PONV) is one of the most common complaints from patients and clinicians after a surgical procedure. According to the current Society of Ambulatory Anesthesia Consensus Guidelines, the general incidence of vomiting and nausea is around 30 and 50%, respectively; and up to 80% in high-risk patients. In previous studies, the reported incidence of PONV at 24 h after craniotomy was 43-70%. The transdermal scopolamine (TDS) delivery system contains a 1.5-mg drug reservoir, which is designed to deliver a continuous slow release of scopolamine through intact skin during the first 72 h of patch application. Therefore, we designed this single arm, non-randomized, pilot study to assess the efficacy and safety of triple therapy with scopolamine, ondansetron, and dexamethasone to prevent PONV. In the preoperative area, subjects received an active TDS 1.5 mg that was applied to a hairless patch of skin in the mastoid area approximately 2 h prior to the operation. Immediately after anesthesia induction, all patients received a single 4 mg dose of ondansetron IV and a single 10 mg dose of dexamethasone IV. Patients who experienced nausea and/or vomiting received ondansetron 4 mg IV as the initial rescue medication. Postoperative nausea and vomiting assessments were performed for up to 120 h after surgery. A total of 36 subjects were analyzed. The overall incidence of PONV during the first 24 h after neurological surgery was 33% (n = 12). The incidence of nausea and emesis during the first 24 h after surgery was recorded as 33% (n = 12) and 16% (n = 6), respectively. Our data showed that this triple therapy regimen may be an efficient alternative regimen for PONV prophylaxis in patients undergoing neurological surgery with general anesthesia. Further studies using regimens affecting different receptor pathways should be performed to better prove the efficacy and safety in the prevention or delay of PONV.

A randomized trial for the study of the elective surgical treatment of portal hypertension in mansonic schistosomiasis.

PubMed Central

da Silva, L C; Strauss, E; Gayotto, L C; Mies, S; Macedo, A L; da Silva, A T; Silva, E F; Lacet, C M; Antonelli, R H; Fermanian, J

1986-01-01

From 1977 to 1983, 94 patients with esophageal varices and gastrointestinal bleeding secondary to mansonic schistosomiasis were entered into a prospective randomized trial comparing the three operations mainly used in Brazil: esophagogastric devascularization associated with splenectomy (EGDS, 32 patients), classical splenorenal shunt (SRS, 32 patients), and distal splenorenal shunt (DSRS, 30 patients). The randomization was interrupted because of a significant incidence of portosystemic encephalopathy (PSE) in the SRS group (26%), as compared to the DSRS (7%) and EGDS (0%) groups. The rate of rebleeding was the same in the three groups, but the rate of failure, as defined by the presence of technical problems, postoperative complications, or death, was significantly higher in the SRS group. This 2-year follow-up shows that SRS should be abandoned in hepatosplenic schistosomiasis and that a comparison between DSRS and EGDS with a longer follow-up is urgently needed. PMID:3090954

26 CFR 15.1-1 - Elections to deduct.

Code of Federal Regulations, 2010 CFR

2010-04-01

.... (2) Election to deduct under section 615—(i) General rule. The election to deduct exploration... 26 Internal Revenue 14 2010-04-01 2010-04-01 false Elections to deduct. 15.1-1 Section 15.1-1... Elections to deduct. (a) Manner of making election—(1) Election to deduct under section 617(a). The election...

Operation Brain Trauma Therapy Extended Studies

DTIC Science & Technology

2015-05-01

peaks in the TBI models. It is also possible that the use of a craniotomy in all 3 models results in an under- estimation of the potential benefit of...traditional strategies, namely, osmolar therapy (mannitol or hypertonic saline administration), CSF drainage , craniectomy, limitation of fluid administration

Post craniotomy extra-ventricular drain (EVD) associated nosocomial meningitis: CSF diagnostic criteria.

PubMed

Muñoz-Gómez, Sigridh; Wirkowski, Elizabeth; Cunha, Burke A

2015-01-01

Because external ventricular drains (EVDs) provide access to cerebrospinal fluid (CSF), there is potential for EVD associated acute bacterial meningitis (EVD-AM). Post-craniotomy, in patients with EVDs, one or more CSF abnormalities are commonly present making the diagnosis of EVD-AM problematic. EVD-AM was defined as elevated CSF lactic acid (>6 nmol/L), plus CSF marked pleocytosis (>50 WBCs/mm(3)), plus a positive Gram stain (same morphology as CSF isolate), plus a positive CSF culture of neuropathogen (same morphology as Gram stained organism). We reviewed 22 adults with EVDs to determine if our four CSF parameters combined accurately identified EVD-AM. No single or combination of <4 CSF parameters correctly diagnosed or ruled out EVD-AM. Combined our four CSF parameters clearly differentiated EVD-AM from one case of pseudomeningitis due to E. cloacae. We conclude that our four CSF criteria combined are useful in diagnosing EVD-AM in adults. Copyright © 2015 Elsevier Inc. All rights reserved.

In situ free-floating craniectomy: an unusual cause of chronic post-traumatic cephalalgia

PubMed Central

Kaliaperumal, Chandrasekaran; Raveendran, Savitha

2012-01-01

We describe a case of post-traumatic cephalalgia in a 54-year-old man with chronic right parieto-occipital headache 3 years posthead injury. At the initial presentation, his Glasgow Coma Scale (GCS) was 13/15 and CT brain revealed an acute subdural haematoma with fronto-temporal contusions. After 24 h his GCS dropped to 8/15 and subsequently he underwent a right-sided craniotomy and evacuation of the subdural haematoma and contusionectomy and intracranial pressure monitoring. To manage the cerebral oedema, the cranial bone flap was left in situ free-floating and was managed in an intensive care setting. He made good clinical recovery and 3 months postoperatively he complained of right-sided headache not relieved with medication and occipital nerve block. Three years later he underwent an exploration of the previous craniotomy scalp wound and the free-floating bone flap under the scalp was immobilised. The headache completely resolved following the procedure and is currently asymptomatic. PMID:22891026

A novel combination of two minimally invasive surgical techniques in the management of refractory radiation necrosis: Technical note.

PubMed

Habboub, Ghaith; Sharma, Mayur; Barnett, Gene H; Mohammadi, Alireza M

2017-01-01

Minimally-invasive approaches are attractive alternative to standard craniotomy for large intracranial tumors with potentially lesser morbidity. In this report, we describe a sequential combination of two minimally-invasive surgical techniques to treat a large intracranial tumor. A 49year-old woman presented with a history of breast cancer and large left parietal metastasis with significant perilesional edema. This was initially managed by whole brain radiation therapy and stereotactic radiosurgery. The patient underwent laser ablation of the tumor followed by internal tumor debulking using an exoscopic-assisted tubular retractor system. Post-operative MRI showed gross total coverage of the tumor by laser ablation and alleviation of mass effect. The patient recovered well and discharged on second postoperative day. The minimally-invasive combination of laser ablation followed by internal debulking using a tubular retractor device could be done safely and effectively as a minimally invasive alternative to standard craniotomy for large intracranial tumors. Copyright © 2016 Elsevier Ltd. All rights reserved.

Use of the Draeger Apollo to Deliver Bilevel Positive Pressure Ventilation During Awake Frontal Craniotomy for a Patient with Severe Chronic Obstructive Pulmonary Disease.

PubMed

Lee, Susie So-Hyun; Berman, Mitchell F

2015-12-01

In this case report, we describe the use of the Draeger Apollo anesthesia machine to deliver bilevel positive airway pressure (BiPAP) to a patient with severe chronic obstructive pulmonary disease and a history of lung resection undergoing frontal craniotomy for the removal of a brain tumor under moderate to deep sedation. BiPAP in the perioperative period has been described for purposes of preoxygenation and postextubation recruitment. Although its utility as a mode of ventilation during moderate to deep sedation has been demonstrated, it has not come into widespread use. We describe the intraoperative use of pressure support mode on the anesthesia machine to deliver noninvasive positive pressure ventilation through a standard anesthesia mask. Given its ease of access and effectiveness, it is our belief that intraoperative BiPAP may reduce hypoxemia and/or hypercarbia in patients with chronic obstructive pulmonary disease and obstructive sleep apnea undergoing moderate to deep sedation.

Systematic Review: Audiovisual Interventions for Reducing Preoperative Anxiety in Children Undergoing Elective Surgery

PubMed Central

Van Lieshout, Ryan J.; Schmidt, Louis A.; Dobson, Kathleen G.; Buckley, Norman

2016-01-01

Objective To examine the effectiveness of Audiovisual (AV) interventions at reducing preoperative anxiety and its associated outcomes in children undergoing elective surgery. Methods A systematic review of randomized controlled trials (RCTs) and nonrandomized studies where the primary outcome was children’s preoperative anxiety was conducted. Secondary outcomes included postoperative pain, behavioral changes, recovery, induction compliance, satisfaction, and cost-effectiveness. The risk of bias of each study was assessed. Results In all, 18 studies were identified. A meta-analytic approach and narrative synthesis of findings were used to summarize the results of the studies. Conclusions This systematic review suggests that AV interventions can be effective in reducing children’s preoperative anxiety. Videos, multi-faceted programs, and interactive games appear to be most effective, whereas music therapy and Internet programs are less effective. While AV interventions appear potentially useful, adequately powered RCTs are required to conclusively pinpoint the components and mechanisms of the most effective AV interventions and guide practice. PMID:26476281

The use of novel oral anticoagulants for thromboprophylaxis after elective major orthopedic surgery

PubMed Central

Rachidi, Saleh; Aldin, Ehab Saad; Greenberg, Charles; Sachs, Barton; Streiff, Michael; Zeidan, Amer M

2014-01-01

Venous thromboembolism is a common cause of morbidity and mortality among patients undergoing elective orthopedic surgery. Due to the high incidence of venous thromboembolism in this setting, perioperative anticoagulation is the recommended approach for thromboprophylaxis. Low molecular weight heparin (LMWH), fondaparinux and warfarin are the agents commonly used for thromboprophylaxis. The well-recognized limitations of warfarin and the inconvenience and discomfort associated with the subcutaneous administration of low molecular weight heparin and fondaparinux inspired intense investigation to develop novel oral anticoagulants (NOACs) with more predictable pharmacokinetics, fewer drug interactions and no need for regular laboratory monitoring. Three NOACs have been demonstrated to be effective for thromboprophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in large randomized controlled trials. Here we review the pharmacology of rivaroxaban, dabigatran, and apixaban, summarize the major clinical trials of these agents in thromboprophylaxis after THA and TKA, and discuss the clinical factors to be considered by providers when selecting a NOAC for their patients. PMID:24219550

Short-term forecasting of emergency inpatient flow.

PubMed

Abraham, Gad; Byrnes, Graham B; Bain, Christopher A

2009-05-01

Hospital managers have to manage resources effectively, while maintaining a high quality of care. For hospitals where admissions from the emergency department to the wards represent a large proportion of admissions, the ability to forecast these admissions and the resultant ward occupancy is especially useful for resource planning purposes. Since emergency admissions often compete with planned elective admissions, modeling emergency demand may result in improved elective planning as well. We compare several models for forecasting daily emergency inpatient admissions and occupancy. The models are applied to three years of daily data. By measuring their mean square error in a cross-validation framework, we find that emergency admissions are largely random, and hence, unpredictable, whereas emergency occupancy can be forecasted using a model combining regression and autoregressive integrated moving average (ARIMA) model, or a seasonal ARIMA model, for up to one week ahead. Faced with variable admissions and occupancy, hospitals must prepare a reserve capacity of beds and staff. Our approach allows estimation of the required reserve capacity.

Surgical approach to gallbladder disease in rural Guatemala.

PubMed

Imran, Jonathan B; Ochoa-Hernandez, Annie; Herrejon, Juan; Madni, Tarik D; Clark, Audra T; Huerta, Sergio

2017-10-01

In this article, we report the current surgical approach to gallbladder disease at a major referral hospital in rural Guatemala. Complications in a cohort of patients undergoing open versus laparoscopic cholecystectomy were catalogued. We reviewed cholecystectomies performed by surgeons at the Hospital Nacional de San Benito in El Peten, Guatemala, after the adoption of the laparoscopic approach. Laparoscopic cholecystectomies (LCs) between 2014 and 2015 (n = 42) were reviewed and matched by 58 randomly selected open cholecystectomies (OCs) during the same period. Patient demographics were similar in the LC and OC groups. Of the 63 patients who had elective surgery, 43 (68%) underwent OC. Conversion rate, hospital length of stay, and readmission rate were 4%, 4.8 days, and 5%, respectively. Complications were similar between groups. Despite the low number of LCs, their complications were not different from that of OCs. During the study period, a large number of cholecystectomies continued to be open, even in the elective setting. Published by Elsevier Inc.

Limited effects of micronutrient supplementation on strength and physical function after abdominal aortic aneurysmectomy.

PubMed

Watters, James M; Vallerand, Andrew; Kirkpatrick, Susan M; Abbott, Heather E; Norris, Sonya; Wells, George; Barber, Graeme G

2002-08-01

Tissue injury following ischemia-reperfusion is mediated in part by free oxygen radicals. We hypothesized that perioperative micronutrient supplementation would augment antioxidant defenses, minimize muscle injury, and minimize postoperative decreases in muscle strength and physical function following abdominal aortic aneurysmectomy. A university-affiliated hospital and regional referral center. A randomized, double-blind, placebo-controlled trial of supplementation with beta-carotene, vitamins C and E, zinc, and selenium for a period of 2-3 weeks prior to surgery and 1 week thereafter. Patients undergoing elective abdominal aortic aneurysmectomy (n=18 per group). Handgrip and other measures of strength and physical function. Handgrip and quadriceps strength decreased following surgery, but not to a significantly different extent in the placebo and supplemented groups. Self-rated physical function decreased following surgery in the placebo group and was preserved in the supplemented group. Perioperative supplementation with micronutrients with antioxidant properties has limited effects on strength and physical function following major elective surgery.

5 CFR 891.201 - Election.

Code of Federal Regulations, 2011 CFR

2011-01-01

... Administrative Personnel OFFICE OF PERSONNEL MANAGEMENT (CONTINUED) CIVIL SERVICE REGULATIONS (CONTINUED) RETIRED FEDERAL EMPLOYEES HEALTH BENEFITS Election and Change of Election § 891.201 Election. (a) The original... election. For any other retired employee receiving compensation, changes of election made under this...

29 CFR 452.103 - Primary elections.

Code of Federal Regulations, 2010 CFR

2010-07-01

... fifteen-day election notice requirement applies to any runoff election which may be held after an... election advises the members of the possibility of a runoff election and specifies such details as the time and place of such runoff election as may be necessary. ...

Responsiveness in Behaving Monkeys and Human Subjects

DTIC Science & Technology

1993-07-31

Status of Current Research - Statement of Work Each study involving awake , behaving monkey neurophysiological recording used a behavioral paradigm that...anesthesia. A craniotomy was performed at approximately A+ 14.5mm. The recording chamber then was fixed to the skull at a lateral angle of 8’ from

Risk factors for meningitis after craniotomy in patients with subarachnoid hemorrhage due to anterior circulation aneurysms rupture.

PubMed

Inoue, Takashi; Shimizu, Hiroaki; Fujimura, Miki; Sato, Kenichi; Endo, Hidenori; Niizuma, Kuniyasu; Sakata, Hiroyuki; Tominaga, Teiji

2015-12-01

Postoperative meningitis is a serious complication occurring after neurosurgical interventions. However, few investigations have focused specifically on the risk factors that predispose patients to meningitis after major craniotomy. This study identified the risk factors for postoperative meningitis after neurovascular surgery, and investigated the relationship between postoperative meningitis and clinical outcome. A total of 148 consecutive patients with subarachnoid hemorrhage (SAH) who underwent clipping surgery through a pterional approach within 72 h between January 2007 and September 2011 were retrospectively analyzed. The treatment strategy of our hospital for patients with SAH was based on the findings of digital subtraction angiography in the acute phase. Coil embolization was firstly considered, and clipping through craniotomy if indicated was performed as soon as possible. Prophylactic antibiotics were administered before beginning craniotomy and for at least 3 days after. Hydrocortisone was used to prevent hyponatremia if allowed by the medical condition of the patient. Intrathecal administration of nicardipine hydrochloride was given if required for vasospasm treatment. Meningitis was clinically diagnosed from the blood samplings and cerebrospinal fluid (CSF) examinations. Data were collected from the electronic and paper charts. The status of modified Rankin scale (mRS) 0-2 at discharge was defined as favorable outcome. A total of 14 patients (9.5%) had meningitis during this study period. Symptomatic vasospasm was detected in 33 patients (22.3%), and 12 patients (8.1%) had permanent neurological deficits caused by vasospasm. Overall, 109 patients (73.6%) had favorable outcome. The longer duration of drainage placement, presence of CSF leakage, and intrathecal administration of vasodilatory agent showed significantly higher incidence of postoperative meningitis in univariate analysis (p=0.0093, 0.0017, and 0.0090, respectively). The proportion of favorable outcome patients at discharge (mRS 0-2) was significantly lower in patients with postoperative meningitis (35.7%) than in patients without it (77.6%) (p=0.0004). The duration of in-hospital stay was significantly longer in patients with postoperative meningitis (median 58.5, range 28-115 days) than in patients without it (median 38.5, range 19-149 days) (p<0.001). Multivariate logistic regression analysis showed that only presence of CSF leakage was associated with postoperative meningitis (p=0.0299). Meningitis after surgery is still a serious complication that requires preventative intervention. The clinical outcome of patients with postoperative meningitis after neurovascular surgery is not still satisfactory. Copyright © 2015 Elsevier B.V. All rights reserved.

Awake Craniotomy in Arteriovenous Malformation Surgery: The Usefulness of Cortical and Subcortical Mapping of Language Function in Selected Patients.

PubMed

Gamble, Alexander J; Schaffer, Sarah G; Nardi, Dominic J; Chalif, David J; Katz, Jeffery; Dehdashti, Amir R

2015-11-01

Awake craniotomy for removal of intra-axial lesions is a well-established procedure. Few studies, however, have investigated the usefulness of this approach for resection of arteriovenous malformations adjacent to eloquent language areas. We demonstrate our experience by using cortical stimulation mapping and report for the first time on the usefulness of subcortical stimulation with interrogation of language function during resection of arteriovenous malformations (AVMs) located near language zones. Patients undergoing awake craniotomy for AVMs located in language zones and at least 5 mm away from the closest functional magnetic resonance imaging activation were analyzed. During surgery, cortical bipolar stimulation at 50 Hz, with an intensity of 2 mA, increased to a maximum of 10 mA was performed in the region around the AVM before claiming it negative for language function. In positive language site, the area was restimulated 3 times to confirm the functional deficit. The AVM resection was started based on cortical mapping findings. Further subcortical stimulation performed in concert with speech interrogation by the neuropsychologist continued at key points throughout the resection as feasible. The usefulness of cortical and subcortical stimulation in addition to patient outcomes was analyzed. Between March 2009 and September 2014, 42 brain AVM resections were performed. Four patients with left-sided language zone AVMs underwent awake craniotomy. The AVM locations were fronto-opercular in 2 patients and posterior temporal in 2. The AVM Spetzler-Martin grades were II (2 patients) and III (2 patients). In 1 patient, complete speech arrest was noticed during mapping of the peri-malformation zone, which was not breached during resection. In a second patient who initially demonstrated negative cortical mapping, a speech deficit was noticed during resection and subcortical stimulation. This guided the approach to protect and avoid the sensitive zone. This patient experienced mild postoperative expressive dysphasia that improved to normal within 6 weeks. Complete resection was achieved in all 4 patients. There were no other complications and no permanent neurological morbidity, resulting in good outcome in all 4 patients. Language mapping, both cortical and subcortical during AVM resection, may be valuable in a very select group of AVMs in language zones. Defining safe margins and feedback to the surgeon may provide the highest chances of a surgical cure while minimizing the risk of incurring a language deficit. Copyright © 2015 Elsevier Inc. All rights reserved.

An Open-Label, Analgesic Efficacy and Safety of Pituitary Radiosurgery for Patients With Opioid-Refractory Pain: Study Protocol for a Randomized Controlled Trial.

PubMed

Borius, Pierre-Yves; Garnier, Stéphanie Ranque; Baumstarck, Karine; Castinetti, Frédéric; Donnet, Anne; Guedj, Eric; Cornu, Philippe; Blond, Serge; Salas, Sébastien; Régis, Jean

2017-08-02

Hypophysectomy performed by craniotomy or percutaneous techniques leads to complete pain relief in more than 70% to 80% of cases for opioid refractory cancer pain. Radiosurgery could be an interesting alternative approach to reduce complications. To assess the analgesic efficacy compared with standard of care is the primary goal. The secondary objectives are to assess ophthalmic and endocrine tolerance, drug consumption, quality of life, and mechanisms of analgesic action. The trial is multicenter, randomized, prospective, and open-label with 2 parallel groups. This concerns patients in palliative care suffering from nociceptive or mixed cancer pain, refractory to standard opioid therapy. Participants will be randomly assigned to the control group receiving standards of care for pain according to recommendations, or to the experimental group receiving a pituitary GammaKnife (Elekta, Stockholm, Sweden) radiosurgery (160 Gy delivered in pituitary gland) associated with standards of care. Evaluation assessments will be taken at baseline, day0, day4, day7, day14, day28, day45, month3, and month6. We could expect pain improvement in 70% to 90% of cases at day4. In addition we will assess the safety of pituitary radiosurgery in a vulnerable population. The secondary endpoints could show decay of opioid consumption, good patient satisfaction, and improvement of the quality of life. The design of this study is potentially the most appropriate to demonstrate the efficacy and safety of radiosurgery for this new indication. New recommendations could be obtained in order to improve pain relief and quality of life. Copyright © 2017 by the Congress of Neurological Surgeons

Reoperation and readmission after clipping of an unruptured intracranial aneurysm: a National Surgical Quality Improvement Program analysis.

PubMed

Dasenbrock, Hormuzdiyar H; Smith, Timothy R; Rudy, Robert F; Gormley, William B; Aziz-Sultan, M Ali; Du, Rose

2018-03-01

OBJECTIVE Although reoperation and readmission have been used as quality metrics, there are limited data evaluating the rate of, reasons for, and predictors of reoperation and readmission after microsurgical clipping of unruptured aneurysms. METHODS Adult patients who underwent craniotomy for clipping of an unruptured aneurysm electively were extracted from the prospective National Surgical Quality Improvement Program registry (2011-2014). Multivariable logistic regression and recursive partitioning analysis evaluated the independent predictors of nonroutine hospital discharge, unplanned 30-day reoperation, and readmission. Predictors screened included patient age, sex, comorbidities, American Society of Anesthesiologists (ASA) classification, functional status, aneurysm location, preoperative laboratory values, operative time, and postoperative complications. RESULTS Among the 460 patients evaluated, 4.2% underwent any reoperation at a median of 7 days (interquartile range [IQR] 2-17 days) postoperatively, and 1.1% required a cranial reoperation. The most common reoperation was ventricular shunt placement (23.5%); other reoperations were tracheostomy, craniotomy for hematoma evacuation, and decompressive hemicraniectomy. Independent predictors of any unplanned reoperation were age greater than 51 years and longer operative time (p ≤ 0.04). Readmission occurred in 6.3% of patients at a median of 6 days (IQR 5-13 days) after discharge from the surgical hospitalization; 59.1% of patients were readmitted within 1 week and 86.4% within 2 weeks of discharge. The most common reason for readmission was seizure (26.7%); other causes of readmission included hydrocephalus, cerebrovascular accidents, and headache. Unplanned readmission was independently associated with age greater than 65 years, Class II or III obesity (body mass index > 35 kg/m 2 ), preoperative hyponatremia, and preoperative anemia (p ≤ 0.04). Readmission was not associated with operative time, complications during the surgical hospitalization, length of stay, or discharge disposition. Recursive partitioning analysis identified the same 4 variables, as well as ASA classification, as associated with unplanned readmission. The most potent predictors of nonroutine hospital discharge (16.7%) were postoperative neurological and cardiopulmonary complications; other predictors were age greater than 51 years, preoperative hyponatremia, African American and Asian race, and a complex vertebrobasilar circulation aneurysm. CONCLUSIONS In this national analysis, patient age greater than 65 years, Class II or III obesity, preoperative hyponatremia, and anemia were associated with adverse events, highlighting patients who may be at risk for complications after clipping of unruptured cerebral aneurysms. The preponderance of early readmissions highlights the importance of early surveillance and follow-up after discharge; the frequency of readmission for seizure emphasizes the need for additional data evaluating the utility and duration of postcraniotomy seizure prophylaxis. Moreover, readmission was primarily associated with preoperative characteristics rather than metrics of perioperative care, suggesting that readmission may be a suboptimal indicator of the quality of care received during the surgical hospitalization in this patient population.

11 CFR 9002.5 - Fund.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 11 Federal Elections 1 2011-01-01 2011-01-01 false Fund. 9002.5 Section 9002.5 Federal Elections FEDERAL ELECTION COMMISSION PRESIDENTIAL ELECTION CAMPAIGN FUND: GENERAL ELECTION FINANCING DEFINITIONS § 9002.5 Fund. Fund means the Presidential Election Campaign Fund established by 26 U.S.C. 9006(a). ...

11 CFR 9002.5 - Fund.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 11 Federal Elections 1 2010-01-01 2010-01-01 false Fund. 9002.5 Section 9002.5 Federal Elections FEDERAL ELECTION COMMISSION PRESIDENTIAL ELECTION CAMPAIGN FUND: GENERAL ELECTION FINANCING DEFINITIONS § 9002.5 Fund. Fund means the Presidential Election Campaign Fund established by 26 U.S.C. 9006(a). ...

Are elected health boards an effective mechanism for public participation in health service governance?

PubMed Central

Gauld, Robin

2010-01-01

Abstract Background  There is growing interest in the idea of elected members on health service governing boards as a means to induce public participation in planning and decision making, yet studies of elected boards are limited. Whether elected boards are an effective mechanism for public participation remains unclear. Setting and participants  This article discusses the experiences of New Zealand where, since 2001, there have been three sets of elections for District Health Boards. Information on candidates and election results is presented along with data gathered via post‐election voter surveys. The article also considers the broader regulatory context within which the elected boards must operate. Discussion and conclusions  The New Zealand experience illustrates that elected health boards may not be an effective mechanism for public participation. Voter turnout has declined since the inaugural elections of 2001, and non‐voters form the majority. Reasons for not voting include failure to receive voting papers, a lack of interest, or no knowledge of elections. The elections have also failed to produce minority representation, while the capacity for elected members to represent their communities is subject to constraints. On the upside, elections have enabled public involvement in various dimensions of participation, including oversight and processes of governance. New Zealand’s mixed performance suggests that elected boards may need to be complemented with other participatory channels, if increased public participation is the goal. PMID:20579118

Are elected health boards an effective mechanism for public participation in health service governance?

PubMed

Gauld, Robin

2010-12-01

There is growing interest in the idea of elected members on health service governing boards as a means to induce public participation in planning and decision making, yet studies of elected boards are limited. Whether elected boards are an effective mechanism for public participation remains unclear. This article discusses the experiences of New Zealand where, since 2001, there have been three sets of elections for District Health Boards. Information on candidates and election results is presented along with data gathered via post-election voter surveys. The article also considers the broader regulatory context within which the elected boards must operate. The New Zealand experience illustrates that elected health boards may not be an effective mechanism for public participation. Voter turnout has declined since the inaugural elections of 2001, and non-voters form the majority. Reasons for not voting include failure to receive voting papers, a lack of interest, or no knowledge of elections. The elections have also failed to produce minority representation, while the capacity for elected members to represent their communities is subject to constraints. On the upside, elections have enabled public involvement in various dimensions of participation, including oversight and processes of governance. New Zealand's mixed performance suggests that elected boards may need to be complemented with other participatory channels, if increased public participation is the goal. © 2010 Blackwell Publishing Ltd.

26 CFR 1.4-2 - Elections.

Code of Federal Regulations, 2010 CFR

2010-04-01

... INTERNAL REVENUE SERVICE, DEPARTMENT OF THE TREASURY INCOME TAX INCOME TAXES Normal Taxes and Surtaxes § 1.4-2 Elections. (a) Making of election. The election to pay the optional tax imposed under section 3... tax under section 3 as an election to take the standard deduction, and for treating an election to...

Annual Research Progress Report. 1 October 1977-30 September 1978.

DTIC Science & Technology

1978-09-30

requiring craniotomy , one open skull frac- ture, one cervical spine fracture, two quadraplegic patients and seven patients with an acute brain...attempt of aspiration is made. Although the blood is available by gravity drainage , this is not ideal for short collections periods. Further work on the

Intracortical Interactions in Visual Processing

DTIC Science & Technology

1986-05-01

demonstrated tolerance. End-tidal CO- was then brought below 3’S% and a craniotomy and durectomy performed over each nemisphere. Halothane was discontinued...Kanizsa, 1976) reported by von der Heydt, Peterhans £ Baumgartner (I98A) in awake monkey Area I8. The existence of such facilitation had been suggested

Effect of EEG Biofeedback on Convulsive Response to Monomethylhydrazine in the Rhesus Monkey

DTIC Science & Technology

1978-06-01

and sterile surgical procedures. A bilateral frontal- parietal craniotomy was performed and the dura opened to identify cortical anatomy. The location...conditioning of electroencephalographic activity while awake . Science 167: 1146-1148. Sterman, M. B., LoPresti, R. W. and Fairchild, M. D., June

Real-time Seizure Detection System Using Multiple Single-Neuron Recordings

DTIC Science & Technology

2001-10-25

electrodes were implanted bilaterally into the temporal lobe of each rat. The rats were anesthetized with nebutal (50mg/kg). Small craniotomies were...1997. [9] Fanselow, E.E., Reid, A.P., Nicolelis, M.A.L., Reduction of pentylenetetrazole-induced seizure activity in awake rats by seizure-triggered

5 CFR 839.621 - Can I cancel my FERS election if I was in the wrong retirement plan at the time I elected FERS...

Code of Federal Regulations, 2010 CFR

2010-01-01

... 5 Administrative Personnel 2 2010-01-01 2010-01-01 false Can I cancel my FERS election if I was in the wrong retirement plan at the time I elected FERS coverage and I have an election opportunity under... ERRONEOUS RETIREMENT COVERAGE CORRECTIONS ACT Making an Election Fers Elections § 839.621 Can I cancel my...

78 FR 51189 - Filing Dates for the Alabama Special Elections in the 1st Congressional District

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-20

... 1st Congressional District AGENCY: Federal Election Commission. ACTION: Notice of filing dates for... Congressional District vacated by Representative Jo Bonner. There are three possible special elections, but only... Election, the top two vote-getters will participate in a Special Runoff Election. General Election...

4 CFR 28.116 - Conduct of elections.

Code of Federal Regulations, 2010 CFR

2010-01-01

... collective bargaining agent, or withdraw such a designation; (3) Order a runoff or an additional election, if... runoff election may be held. (i) Runoff election. The Board may order a runoff election where one or more... employees eligible to vote, but none has gained a majority of the votes cast. The runoff election will be...

77 FR 56208 - Filing Dates for the Kentucky Special Election in the 4th Congressional District

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-12

... FEDERAL ELECTION COMMISSION [Notice 2012-06] Filing Dates for the Kentucky Special Election in the 4th Congressional District AGENCY: Federal Election Commission. ACTION: Notice of filing dates for special election. SUMMARY: Kentucky has scheduled a general election on November 6, 2012, to fill the U.S...

11 CFR 102.9 - Accounting for contributions and expenditures (2 U.S.C. 432(c)).

Code of Federal Regulations, 2010 CFR

2010-01-01

... (2 U.S.C. 432(c)). 102.9 Section 102.9 Federal Elections FEDERAL ELECTION COMMISSION GENERAL... general election pursuant to 11 CFR 110.1(b) prior to the date of the primary election, such candidate or... received for the primary election and contributions received for the general election. Acceptable...

26 CFR 1.1335-1 - Elective method; time and manner of making election and effect thereof.

Code of Federal Regulations, 2010 CFR

2010-04-01

... Elective method; time and manner of making election and effect thereof. (a) In general. If the taxpayer... election and effect thereof. 1.1335-1 Section 1.1335-1 Internal Revenue INTERNAL REVENUE SERVICE... election to all taxable years of the taxpayer beginning after December 31, 1941. Thus, the taxpayer need...

78 FR 7781 - Filing Dates for the South Carolina Special Elections in the 1st Congressional District

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-04

... in the 1st Congressional District AGENCY: Federal Election Commission. ACTION: Notice of filing dates... Primary Election, the top two vote-getters will participate in a Special Runoff Election. General Election... participating in the South Carolina Special Primary and Special General Elections shall file a 12-day Pre...

26 CFR 1.1291-10 - Deemed sale election.

Code of Federal Regulations, 2013 CFR

2013-04-01

... 26 Internal Revenue 11 2013-04-01 2013-04-01 false Deemed sale election. 1.1291-10 Section 1.1291... Deemed sale election. (a) Deemed sale election. This section provides rules for making the election under section 1291(d)(2)(A) (deemed sale election). Under that section, a shareholder (as defined in § 1.1291-9...

26 CFR 1.1291-10 - Deemed sale election.

Code of Federal Regulations, 2012 CFR

2012-04-01

... 26 Internal Revenue 11 2012-04-01 2012-04-01 false Deemed sale election. 1.1291-10 Section 1.1291... Deemed sale election. (a) Deemed sale election. This section provides rules for making the election under section 1291(d)(2)(A) (deemed sale election). Under that section, a shareholder (as defined in § 1.1291-9...

42 CFR 422.62 - Election of coverage under an MA plan.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 42 Public Health 3 2013-10-01 2013-10-01 false Election of coverage under an MA plan. 422.62... Enrollment § 422.62 Election of coverage under an MA plan. (a) General: Coverage election periods—(1) Initial coverage election period for MA. The initial coverage election period is the period during which a newly MA...

42 CFR 422.62 - Election of coverage under an MA plan.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 42 Public Health 3 2010-10-01 2010-10-01 false Election of coverage under an MA plan. 422.62... § 422.62 Election of coverage under an MA plan. (a) General: Coverage election periods—(1) Initial coverage election period for MA. The initial coverage election period is the period during which a newly MA...

42 CFR 422.62 - Election of coverage under an MA plan.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 42 Public Health 3 2011-10-01 2011-10-01 false Election of coverage under an MA plan. 422.62... § 422.62 Election of coverage under an MA plan. (a) General: Coverage election periods—(1) Initial coverage election period for MA. The initial coverage election period is the period during which a newly MA...

42 CFR 422.62 - Election of coverage under an MA plan.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 42 Public Health 3 2014-10-01 2014-10-01 false Election of coverage under an MA plan. 422.62... Enrollment § 422.62 Election of coverage under an MA plan. (a) General: Coverage election periods—(1) Initial coverage election period for MA. The initial coverage election period is the period during which a newly MA...

42 CFR 422.62 - Election of coverage under an MA plan.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 42 Public Health 3 2012-10-01 2012-10-01 false Election of coverage under an MA plan. 422.62... Enrollment § 422.62 Election of coverage under an MA plan. (a) General: Coverage election periods—(1) Initial coverage election period for MA. The initial coverage election period is the period during which a newly MA...