atlas of emergency neurosurgery
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Atlas of Emergency Neurosurgery
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Atlas of Emergency Neurosurgery
Jam ie S. Ullm an , MD, FAANS, FACS
Associate Professor, Depart m en t of Neu rosur geryHofstra Nor th Shore- LIJ School of Med icineDirector of Neurot raum aNorth Shore University Hosp it al
Manh asset, New York
P.B. Raks in , MD, FAANS
Assistan t Professor, Dep art m en t of Neurosu rgeryRush University Medical Cen terDirect or, Neurosu rger y ICU
Chief, Section Neurotrauma & Neurocritical CareJohn H. Stroger Jr Hosp ital of Cook Count y
(form erly Cook Coun ty Hospital)Chicago, Illino is
Medical Illustrator: Jen nife r Pryll
Thieme
New York Stut tgart Deh li Rio de Janeiro
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Executive Editor: Timothy HiscockManaging Editor: Elizabeth Palum bo
Director, Editorial Services: Mary Jo CaseyEditorial Assistant: Haley Paskalides
Production Editor: Heidi GrauelInternational Production Director: Andreas Schabert
Vice President, Editorial and E-Product Developme nt: Vera SpillnerInternational Marketing Director: Fiona Henderson
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Senior Vice President an d Chief Operat ing O cer: Sarah Vande rbiltPresident: Brian D. Scanlan
Print er: Asia Paci c O set
Library of Congress Cataloging-in-Publication Data
Atlas of em ergency n eurosu rgery / [edited by] Jam ie Ullman, P.B. Raksin.
p. ; cm. Includes bibliographical references and index.
ISBN 978 -1-6 040 6-36 8-4 ISBN 978 -1- 604 06-3 69- 1 (eISBN) I. Ullman , Jam ie, edit or. II. Raksin , P. B. (Patr icia B.), ed ito r.
[DNLM: 1. Em ergen ciesAtlas es. 2. Neuros urgica l Proced ure sm eth odsAtlase s. 3. Cen tra l Ner vous System surge ryAtlas es.4. Cen tra l Nervou s System Diseasessur geryAtlase s. 5. Cran iocereb ral Trau m asurge ryAtlas es.
6. Spina l Cord Injur iessurge ryAtlas es. 7. Spin al Injur iessur geryAtlase s. WL 17] RD593
617 .48dc2 32015005194
2015 Thiem e Medical Publishers, Inc.
Thieme Publishers New York333 Seven th Avenu e, New York, NY 100 01 USA, 1-8 00- 782 -348 8custom erservice@thiem e.com
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Printed in China
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ISBN 978-1 -60406 -368-4
Also available as an e- book:
eISBN 978-1- 60406-3 69-1
Important note:Medicine is an ever-changing science un dergoing continu al developmen t. Research and clinical experience are contin uallyexpanding our knowledge, in par ticular our knowledge of proper treatm ent and d rug therapy. Insofar as th is book ment ions any dosage or
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Contents
Forew ord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Acknowledgm ents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi i
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi ii
Contributo rs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
I Cerebral Traum a and Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapte r 1:Surgery for Epidural and Subdu ral Hematom as
Shelly D. Timm ons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Chapte r 2:Chron ic Subdu ral Hematom as
Branko Skovrlj, Jonathan Rasouli, A. Stew art Levy,
P. B. Rak sin , and Jam ie S. Ullman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16
Chapte r 3:Surger y for Cerebra l Cont usion s of the Front al and
Tem po ral Lobe s, Including Loba r Resection s
Pal S. Ran dhaw a and Craig Rabb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
Chapte r 4:Decompressive Craniectomy for Intracranial Hypertension and
Str oke, Includ ing Bon e Flap Stor age in Abdom ina l Fat LayerRoberto Rey -Dios and Dom enic P. Esposit o . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Chapte r 5:Surgery for Cerebellar Stroke an d Subo ccipital Trau m a
Faiz U. Ahm ad an d Ross Bullock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
Chapte r 6:Elevation of Depressed Skull Fractu res
Anan d Veeravagu , Bowen Jiang, an d Odet te A. Harris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
Chapte r 7:Invasive Neurom onitor ing Techn iques
Math ieu Laroche, Michael C. Huang, and Geo rey T. Manley . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Chapte r 8:Surgical Debride m en t of Penet rating InjuriesRolan d A. Torres an d P. B. Rak sin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Chapte r 9:Managem en t of Traum atic Neur ovascular Injur ies
Boyd F. Richards and Mark R. Harrigan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Chapte r 10:Managem en t of Veno us Sinu s Injur ies
Laurence Dav idson an d Rocco A. Arm on da . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
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II Spinal Em ergency Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chapte r 11:App lication o f Closed Spin al Tract ion
Nirit Weiss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Chapte r 12:Em ergency Managemen t of Odontoid Fractures
Sanjay Yad la, Benjam in M. Zussm an , and Jam es S. Harrop . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Chapte r 13:Cervical Burst Fractures
Teresa S. Purzn er, Jam es G. Purzner, and Michael G. Fehlin gs . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Chapte r 14:Cer vical Facet Dislocat ion
Daniel Resn ick an d Casey Madu ra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
Chapte r 15:Classi cation an d Treatm ent o f Thor acic Fract ures
Joseph Hsieh , Doniel Draz in, Michael Turner, Ali Shirzadi,
Kee Kim , and J. Pat rick Johnson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Chapte r 16:Thoracolumbar Fractures
Michael Y. Wang and Brian Hood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Chapte r 17:Spinal Epidu ral Com pression
Asha Iyer and Arth ur Jenkins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
Chapte r 18:Treatm ent of Acute Caud a Equina Synd rom e
Harel Deu tsch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
III Nontraum atic Em ergencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Chapte r 19:Removal of Spontaneous Intracerebral Hemorrhages
Just in Ma scitelli, Yakov Gologorsky, an d Josh ua Bederson . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
Chapte r 20:Surgery for Acute Int racran ial Infection
P. B. Rak sin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330
Chapte r 21:Ven tr icular Shu nt Malfunct ion
Sergey Abeshaus, Sam uel R. Browd, and Richard G. Ellenbogen . . . . . . . . . . . . . . . . . . . . . . . . 349
Chapte r 22:Pitu itary Apop lexy
Kalm on D. Post an d Soriaya Motiva la . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
IV Em ergency Operatio ns in Co mbat . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
Chapte r 23:Com bat Cranial Oper ationsLeon E. Moores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 386
Chapte r 24:Com bat-Associated Penetr ating Spine Injur y
Corey M. Mossop, Christopher J. Neal, Michael K. Rosner, and
Pau l Klimo Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
V Reconstructive Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
Chapte r 25:Replacem en t of Cran ial Bone Flap
Jam ie S. Ullm an . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412Chapte r 26:Techniques of Alloplastic Cranioplasty
Erin N. Kiehn a and John A. Jan e Jr. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
Chapte r 27:Surgery for Fronta l Sinus Injuries
Abilash Harida s and Peter J. Tau b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
vi
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VI Special Considerations in Pediatric Emergency Neurosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457
Chapte r 28:Special Cons iderat ions in th e Surgical Managem en t of
Pediatric Trau m atic Brain Injur yAnt hony Figaji and P. David Adelson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .458
Chapte r 29:Special Cons iderat ions in Pediatric Cer vical Spine Injur y
Pau l Klimo Jr., Nelson Ast ur Neto, W illiam C. Warner Jr., and
Michael S. Muhlbauer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .470Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 491
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Continuing Medical Education CreditInformation and Objectives
Objectives
1. Identify neurosu rgical conditions wh ich require em ergent or urgent intervention
2. Evaluate the various options for man aging spine traum a in the cervical, thoracic, and thora colum bar regions.
3. Apply provided techniques when per form ing urgent interventions for the brain and spine
4. Recognize key issues of applying brain and spinal traum a surgical techniques to military and pediatric populations.
Accreditation and Designation
The AANS is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical
education for physicians.
The AANS designates this endu ring m aterial for a m aximum of 15AMA PRA Category 1 creditsTM.Physicians should claim only the
credits comm ensurate w ith the extent of their part icipation in the activity.
Method of physician p articipation in th e learning process for this text book: The Hom e Study Examination is online on the AANS
website at: http://www.aans.org/education/books/aonemergency.asp
Estimated time to complete th is activity varies by learner, and activity equa led up to 15AMA PRA Category 1 cred itsTM.
Release and Termination Dates
Original Release Date: 0 5/2/2 015
CME Term ination Date: 05 /2/2 018
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Disclosure Information
The AANS controls the content and production of this CME activity an d at temp ts to ensure the present ation of balanced, objective
inform ation. In accordance with the Standard s for Comm ercial Suppor t e stablished by t he Accreditation Council for Continuing
Medical Education, authors, planning comm ittee m em bers, sta , and any others involved in planning in education content an d the
signi cant others of those men tioned m ust disclose any relationship they or their co-authors have with comm ercial interests wh ich
m ay be related to the ir conten t. The ACCME de nes, relevant nan cial relationsh ips as nan cial relationsh ips in any am oun t oc-
curring within the past 12 mont hs that create a con ict of interest.
Those (and the signi cant others of those m ention ed) who have disclosed a relationship* with com me rcial interests are
listed below.
Samuel R. Browd, MD, PhD, FAANS Aqueduct Neurosciences, Inc.,
Navison ics, Inc.
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Richard G. Ellenbogen , MD, FAANS NIH/NCI
NFL
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Abilash Haridas, MD Uptodate, Hydrocephalus Pediatric Honorarium
James S. Harrop, MD, FAANS Depuy Spine
Tejin, Globus Spine, AO SPine
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Kee D. Kim, MD, FAANS Stryker
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Shelly D. Timmons, MD, PhD, FAANS AO Neuro Resident Neurotrauma Course Honorarium
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*Relationsh ip refers to receipt of royalties, consultan tship, fu nding by research grant , receiving honoraria for edu cational serv ices else-
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Those (and the signi cant others of those me ntione d) who have reported they do not have any relationship w ith comm ercial
interests:
Name:
Sergey Abesha us, MD
P. David Adelson, MD, FAANS
Faiz U. Ahm ad, MD
Rocco A. Arm on da , MD, FAANS
Nels on Astur, MD
Joshua B. Bederson, MD, FAANS
M. Ross Bullock, MD, PhD
Lau re nce Davidson , MD, FAANS
Doniel Gabriel Drazin, MD
Yakov Gologo rsk y, MD
Mark R. Harrigan, MD, FAANS
Odet te Alth ea Harr is, MD, MPH, FAANS
Brian Jam es Hood, MD
Jose ph C. Hsieh, MD
Michael C. Huang, MDAsha Mu thuram an Iyer, MD
John A. Jane, Jr., MD, FAANS
Arth ur L. Jen kin s III, MD, FAANS
Bowe n Jiang, MD
J. Patrick Johnson, MD, FAANS
Erin Kiehna, MD
Pau l Klimo, Jr., MD, FAANS
Math ieu Laroche , MD
And rew Stew ard Levy, MD
Just in Robert Mascitelli, MD
Leo n E. Moores, MD, FAANS
Corey Micha el Mossop
Soriaya Motivala, MD
Michae l S. Muhlb au er, MD, FAANS
Christopher J. Neal, MD FAANS
Kalm on D. Post, MD, FAANS
Craig H. Rabb, MD, FAANS
Pat ric ia B. Raksin , MD, FAANS#
Pal Rand haw a, MD
Jonat han Rasouli, MD
Dan iel K. Resn ick, MD, FAANS
Roberto Rey-Dios, MD
Boyd Richar ds, DO
Mich ae l K. Rosn er, MD, FAANS
Ali Shirzad i, MDBran ko Skorvlj, MD
Pet er J. Tau b, M D, FACS, FAAP
Roland A. Tor re s, MD, FAANS
Jam ie S. Ullma n, MD, FAANS#
Anan d Veer avagu, MD
William C. Warn er, Jr., MD
Nir it Weiss , MD, FAANS
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Foreword
Simp licity is the ultim ate sophistication.
Leonard o da Vin ci, circa 1 519
This atlas e dited by Drs. Ullman and Raksin is clearly a very
valuable contribution to the neurosurgical literature and
may be best described as a quick reference atlas. Both ofthe editors are experienced neurosurgeons who have had
decades of experience in treating patients with head and
spinal injury. In this volume, they have brought together
many experts in the eld to describe their approach to the
spectrum of traum atic disorders that a ict the brain and
spine.
The illustrations are magni cent and th e text is direct and
easy to follow. This st yle ensures that this book w ill be a valu-
able guide for both residents as well as for m ore experienced
neurosurgeons. It will serve as a quick reference before one
embarks on treating a patient with a traumatic neurosurgi-cal disorder, or in preparing to t ake an exam ination.
Although th ere are other texts that deal w ith neurotrauma,
none of th em are as digestible as this one. I could wax elo-
quent on th e m any me rits of this book. I dont n eed to. As
you simply ip through its pages, you will see for yourself
that this is a book w orth havingnot just to display on your
bo oksh elf, but to keep han dy an d t o u se on an eve ryday ba -
sis. You w ill have no tr ouble pu tt ing it to good use.
Raj K. Narayan, MD, FACS, FAANS
Professor an d Chairm an
Department of NeurosurgeryHofstra North Shore LIJ School of Me dicine and
Director, Cushing Neuroscience Institute
Manh asset , New York
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xii
We would like to acknowledge and thank the a uthorskind
colleagues, m ent ors, and dedicate d residen ts and fellowsfor
lending their extraordinary expertise and experience to this
project .
We w ould like to t han k Dr. Mark Linskey, past chair of th e AANSPublications Comm ittee, for supp orting th e concept of th is at-
las, and Dr. James Rutka, then AANS secretary, for champion-
ing this at las to th e AANS Board of Director s. We are grat eful to
th e AANS for its generou s grant m atched by Thiem e Publish-
ers (to w hom we are also grateful)to fund t he illustrations.
Thanks also go to the Executive Committee of the AANS/CNS
Section on Neurotrauma and Critical Care for its support and
from wh ich m any of the aut hors were selected. We are grateful
to Dr. Michael Fehlings for his review an d coun sel regarding th e
spine topics. We acknowledge and th ank th e Thieme ed itorial
sta , past and presen t, for their hard work and dedication to
this project.
Illustrations form the backbone of this book an d, so, a special
th ank you goes to Jenn ifer Pryll, our ne illustrator, for her
tireless e orts in producing high-quality artwork. Ms. Pryll
demonstrated an extraordinary level of attention to detail and
responsiveness to the editors and au thors.
I (JSU) want to, personally, dedicate this book to my daughter
Sara (future singer/dancer, pediatrician, and/or neurosur geon)
and my husband Mark for their love and patience; my dear
family; and to t he AANS/CNS Section on Neur otra um a and Crit-
ical Care, of which I have been an Executive Com mitt ee m em ber
for m ore tha n 16 years and proud to b e its Chair (2014-2016).I would also like to thank my co-editor, P.B. Raksin, for her
collaboration, patience, and diligence throughout the books
pr od uct ion a pe rfec t m eld of m ind an d sp ir it . Finally, I w ou ld
like to thank my colleagues and residents at the Icahn School
of Medicine at Mount Sinai for the ir support and cont ributions
to this atlas and over the years; and the ne attending and
residen t sta of th e Hofstra North Shore-LIJ School of Medicine
wh o spend long nights on call treating emergency neu rosurgi-
cal patients.
I (PBR) would like to acknowledge the many patients whose
adversity has informed and enhanced my clinical experience
(and d igital image collection) in acute care ne urosurgery over
the p ast tw o decades. I would also like to thank m y co-editor,
Jam ie Ullm an, for inviting me to part ner w ith her in t his project
and en tru sting me t o help execute her vision. And, to my w ife
Lisawh o held down the fort wh ile I pored over m anuscripts
my eternal gratitude and a ection (and a prom ise to clean the
o ce now that this task is complete).
Jam ie S. Ullm an , MD, FAANS, FACS
P.B. Rak sin , MD, FAANS
Acknowledgments
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xiii
Preface
Neu ro su rge ry is not so sim ple. Dri llin g bu r hole s in th e em er -
gency department may relieve pressure from an expand-
ing epidural hematoma, but the ensuing uncontrolled arte-
rial bleeding may result in signi cant blood loss, hypoten sion,
and death if one is not skilled in handling this situation. And,
although trauma may be one of the more common reasonsfor emergent neurosurgical intervention, acute care for neu-
rosurgical diseases is as widely varied as the discipline itself.
The very eclectic nature of these emergent and urgent condi-
tions continually challenges the skills obtained during th e long
neurosurgery residency training period, demanding not only
br oa d kn ow ledge an d evo lvin g t echn ica l skills, bu t pre -, in tra -,
and p ostoperative clinical judgmen t th at can t ake a lifetime to
m aster all for the goal of imp roving patient ou tcom es.
Appreciation of this weighty t ask must be coupled with the idea
that learning in neurosurgery is a decidedly visual pursuit.
Neu rosu rgeo ns -in -t ra in ing st udy an atom ic re pre se ntat ion s,
dissect cadavers, and observe their mentors in the operating
room. With clinical experience and knowledge acquisition,
there eventually comes the ability to translate the written
words in a textbook into mental images, or to imagine ones
waystep-by-step and with variationsthrough a p rocedure
be fore en te ring t he o pe ra t ing t hea te r.
The t rue value of a surgical atlas, then , lies in the pr esent ation: th e
telling of a procedure in pictu res. Historically, atlases have bee n
designed to guide the learner through interventions in a step-
wise fashion. In 19 60, Jam es Leonar d Poppen , MD, published h is
famed atlas entitled, An Atlas of Neurosurgical Techn iques. This
tom e present ed procedu res in diagram m atic fashionuseful
to any neurosurgeon beginning to hone his or her craft. In that
spirit, and in th e spirit of great sur gical atlases such as Zollingers
Atlas of Surgical Operat ions , we have set out to create a similar
volum e devoted to emer gency neurosurgical procedures.
This book was written for neurosurgeons-in-training, as well
as for those already in practice who desire to meet the chal-
lenge of whatever comes into the emergency department.
Critical care practitioners may also nd this book bene -
cial to understanding the surgical management of neurologic
conditions that will demand their medical expertise in the
post op er at ive per iod .
The book is divided into six sect ions. Sect ion I (Chap ter s 110)
covers the basic procedures that form the bread and butter of
cranial neurosurgery for trauma and stroke, including crani-
otomies for intra- and extra-axial hematoma, management of
pe net ra t ing injur ies, an d d ecom pre ss ive cr an iect om y. Excel lent ,
comprehensive reviews of neuromonitoring and managementof neurovascular injuries compleme nt th ese chapters.
Section II (Chapter s 1118) focuses on spinal em ergency pro-
ceduresboth trau m atic and nontrau mat ic. The import ant role
of early surgery for acute traumatic spine and spinal cord in-
ju ries is increa sin gly re cognize d; severa l chap te rs ar e de vot ed
to operative management of these injuries. While open proce-
dures still predominate in the emergency management of these
entities, the increasing application of m inimally invasive tech-
niques in this setting cannot be ignored. Chapter 16 outlines
the minimally invasive approach to thoracolumbar trauma.
Non t ra um at ic e m er gencies, in clu ding ep idura l sp inal com pr es -
sion and cauda equina syndr ome, are also addressed.
Section III (Chapters 1922) discusses the surgical managem ent
of nontraumatic emergencies including spontaneous intracra-
nial hem orrhage, intracranial infection, pituitary a poplexy, and
the ever-haunting ventricular shunt malfunction. While the
sequelae of aneurysmal ruptu re sometimes require em ergent
surgical intervention, de nitive management often is under-
taken m ore electively within a 12- to 72-h our per iod. The tech-
nique of aneur ysm clipping is the subject of several imp ortan t
tomes and is beyond the general scope of this atlas. Similarly,
while surgery for ruptured arteriovenous malformations is of-
ten deferred for a period of time to per mit resorpt ion of hem or-
rhage, patients may present with life-threatening acute bleeds
that necessitate eme rgent intervent ion for relief of m ass e ect.These clinical scenarios are addressed in Chapter 19.
While only a select few neur osurgeons have participated in the
theater of war, we felt it would be valuable to include a section
addressing eme rgency intervent ions for ne urologic injuries in
comb at (Section IV, Chapt ers 23 and 24). Key lessons lear ned
over the pa st two de cades of con ict have led to increased sur-
vival from th ese devastating injuries. With th e looming th reat
of terrorism , we m ust be prepared to app ly these techniques in
civilian populations should the need arise.
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Section V (Chapters 2527) encompasses basic tenets of re-
constructive surgery. The management of frontal sinus inju-
ries requires a combination of acute care and reconstructive
approaches. Any consideration of decompre ssive craniectomy
would not be comp lete without a discussion of its natu ral con-
sequence: the need for additional, mostly elective, surgery
to restore the cranium to its original protective purpose. The
inform ation provided is designed to help the surgeon nish
the job.
Finally, Sect ion VI (Chap ters 2 8 and 29) consider s concern s spe-
ci c to the treat me nt of head and spinal injuries in the pediatric
pop ulat ion , inclu ding st ep s for t he re con st ruct ive re pair of le p -
tom eningeal cysts. These chapters are designed to highlight key
di erences in the acute, and delayed, managem ent of injuries in
children as compare d with ad ults.
The chapters follow a standardized format. Introductory
commentary for each topic is followed by an accounting of
indications for neurosurgical intervention and preprocedural
considerations. The operative procedure forms the core of each
section. For th e read ers convenience, we designed this book to
keep illustrations and procedural steps in close proximity. In
addition, many steps are repeated across chapters (with varia-
tion) to keep m ost of the chapte rs self-contained. Many of the
pr oce du ra l st ep s ar e accom pan ied by pe ar lsa dd it ion al w is-
dom from the subject experts, geared toward enhancing an
operations success and avoiding complications. Each chapter
concludes w ith a discussion of postoperative m anageme nt an d
special conside ration s relevant to that top ic. References are kept
to a minimum.
As the practice of neurosurgery is as m uch an ar t as it is a sci-
ence, there will be nuances and approaches preferable to each
individual surgeon, and there are often several ways to ac-
complish the sam e goal. The p rocedures outlined in t his book
represent the best practices of the various authors and can be
mod i ed based on surgeon experience, preference, and patient
characteristics. And, although we have made every attempt
to provide a comprehensive overview of the most commonly
encountered emergency procedures, it is inevitable that other
emergency conditions will arise that fall outside the scope of
this project. It is our hope that the information presented in
this book will serve as a platform upon which to build strat-
egies for treating more complex or less common emergency
pr esen tat ion s.
Jam ie S. Ullm an , MD, FAANS, FACS
P.B. Rak sin , MD, FAANS
Prefacexiv
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xv
Contributors
Sergey Abesh aus, MD
Department of Neurosurgery
Seattle Children s Hospit al
Seattle, Washington
P. David Adelson, MD, FACS, FAAP
DirectorDiane and Bruce Halle Endowed Chair in
Pediatric Neurosciences
Chief, Pediatric Neuro surger y
Barrow Neurological Institute at Phoenix
Children s Hospital
Phoenix, Arizona
Faiz U. Ahm ad, MD, MCh
Assistant Professor of Neurosurgery
Emo ry Universit y
Grady Memorial Hospital
Atlant a, Georgia
Rocco A. Armonda, MD
Division of Neur osurger y
Walter Reed National Military Medical Cent er
Bethesda, Maryland
Nelson Astu r Neto, MD
Departm ent of Orth opedic Surgery
Cam pbell Clinic Ort hop aed ics
Mem phis, Tenn essee
Josh ua Bederso n, MD
Professor a nd Chair
Department of Neurosurgery
Icahn School of Medicine at Mou nt Sinai
New York, New York
Samuel R. Browd, MD, PhDDirector
Departm ent of Neurosurgery an d Oncology
Cent er for Inte grative Brain Research
Seattle Children s Hospit al
Harborview Medical Center
University of Washington Medical Center
Seattle, Washington
Ross Bullock, MD, PhD
Professor of Neurosurgery
Universit y of Miami
Director, Clinical Neurotra um a
Jackson Hospit al
Miami, FloridaLauren ce Davidso n, MD
Sta Neurosurgeon
Division of Neuro surger y
Walter Reed National Military Medical Cent er
Bethesda, Maryland
Harel Deu tsch, MD
Associate Professor of Neurosu rgery
Rush Universit y Medical Cent er
Chicago, Illinois
Doniel Drazin, MD
Department of Neurosurgery
Cedar s Sinai Me dical Cent er
Los Angeles, California
Rich ard G. Elle nbo ge n, MD, FACS
Professor and Chairman
Departm ent of Neurological Surgery
University of Washington
Atten ding Neurosurgery
Harborview Medical Center
Seattle Childrens Hospit al
Seattle, Washington
Dom en ic P. Espo si to , MD, FACS, FAANS
Professor of Neurosur gery (Ret.)
Universit y of Mississippi
Neu ro su rgica l Cons ult an ts, LLCJackson, Mississippi
Michael G. Feh lin gs , MD, PhD, FRCSC
Neu ro su rgeo n
Division of Neuro surger y
Toront o Western Hospital
Toront o, Ontar io, Cana da
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Anthony Figaji, MD
Professor and Head
Pediatric Neurosurgery
University of Cape Town
Institu te for Child Health
Red Cross Childre ns Hospit al Cape Town
Cap e Town, South Africa
Yakov Golog orsk y, MD
Atten ding in NeurosurgeryMoun t Sinai Med ical Cent er
New York, New Yor k
Abilash Haridas, MD
Assistant Professor of Neurosurgery
Wayne State Universit y School of Medicine
Pediatric Neurosurgery
Cerebrovascular Neurosurgery
Childrens Hospital of Michigan
Detroit, Michigan
Mark R. Harrigan, MD
Associate Professor
Universit y of Alabam a Medical Cent er
Birmingham, Alabama
Odette A. Harris, MD, MPH
Associate Professor of Neuro surger y
Director of Brain Injury
Stan ford School of Medicine Hospital an d Clinics
Stanford, California
Jam es S. Harrop, MD
Professor of Orthopedic and Neurological Surgery
Director, Spine and Perip her al Ner ve Surger y
Thom as Je erson University
Philadelphia, Pennsylvania
Brian Hood, MD
Major USAF, MCAssistan t Professor of Clinical Medicine
Uniform ed University of Health Sciences
San Anto nio Military Med ical Cent er
San Anton io, Texas
Jos eph Hsieh, MD
Assistan t Professor
The Vivian L. Smith Department of Neurosurgery
The Universit y of Texas Hea lth Cent er
Houston , Texas
Michae l C. Huang , MD
Assistan t Clinical Professor of Neurological Surgery
University of California, San Francisco
San Francisco Genera l Hospital and Traum a Cent er
San Francisco, Californ ia
Asha Iyer, MD
Resident in Neurosurgery
Icahn School of Medicine at Mou nt Sinai
New York, New Yor k
John A. Jan e Jr., MD
Associate Professor of Neurosur gery an d Pediatr ics
Pediatrics Division Director
University of Virginia
Charlottesville, Virginia
Arthu r Jen kins , MD, FACS
Associate Professor of Neur osurger y
Icahn School of Medicine at Moun t Sinai
New York, New York
Bow en Jiang , MD
Resident in Neurosurgery
Johns Hopkins Hospital
Baltimore, Maryland
J. Patrick Johnson, MD, MS, FACS
Director of Spine Education and Neurosurgery Spine
Fellowship Program
Department of Neurosurgery
Cedar s Sinai Me dical Cent er
The Spine Institu te Foundat ion
Los Angeles, California
Professor of Neurosurgery
UC Davis Medica l Cen te r
Sacramen to, CA
Erin N. Kiehn a, MD
Assistant Professor of Neurosurgery
Child ren s Hosp ita l Los Angeles
Los Angeles, California
Kee Kim , MD
Associate Professor a nd Chief
Departm ent of Spinal Neurosurgery
Co-d irector, Spine Cent er
University of California, Davis School of Medicine
Sacramen to, California
Paul Klim o Jr., MD, MPHAssociate Professor of Neur osurger y
Universit y of Tenn essee
Associate, Sem m es-Mur ph ey Neurologic & Spine Inst itut e
Mem phis, Tenn essee
Mathie u Laroche, MD, MSc, FRCSC
Assistant Professor of Neurosurgery
University of Montral
Neu ro su rgeo n
Hpital du Sacr-Coeur d e Mont ral
Mont ral, Qube c, Cana da
A. Stew art Lev y, MD
Neu ro su rgeo n
St. Ant hony Hospit al
Chief of Neur osurger y
Cent ura Neuroscience & Spine
Lakewood, Colorado
Case y Madura, MD
Resident in Neurosurgery
Universit y of Wisconsin Hospital an d Clinics
Madison, Wisconsin
Contributorsxvi
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Geo rey T. Manley, MD, PhD,
Professor in Residence a nd Vice Chair ma n
Departm ent of Neurological Surgery
Co-Director a nd Principal Investigator
Brain an d Spin al Injur y Cen te r (BASIC)
Chief of Neur osurger y
San Francisco Genera l Hospital
University of California, San Francisco
San Francisco , Californ iaJus tin Masc itell i, MD
Resident in Neurosurgery
Icahn School of Medicine at Mou nt Sinai
New York, New York
Leo n E. Moo res, MD, MS
Professor of Neurosurgery
Virginia Commonwealth University
Professor of Surger y and Ped iatrics
Uniform ed Services Universit y
CEO, Ped iatr ic Specialist s o f Virginia
Director of Pediatr ic Neuro sciences
Inova Healt h System
Fairfax,Virginia
Core y M. Mosso p, MD
Neu ro su rge ry Ser vice
Walter Reed National Military Medical Cent er
Silver Spring, Marylan d
Soriaya Motivala, MD
Assistant Professor of Neurosurgery
Icahn School of Medicine at Mou nt Sinai
New York, New York
Michael S. Muhlbauer, MD
Departm ent of Pediatric Neurosurgery
Sem mes-Mur phey Neurologic & Spine Institu te
Clinical Assistant ProfessorUniversit y of Tenn essee
Le Bonh eur Children s Hosp ital
Mem phis, Tenn essee
Chris topher J. Neal, MD
Neu ro su rge ry Ser vice
Walter Reed National Military Medical Cent er
Bethesda, Maryland
Kalm on D. Pos t, MD
Professor and Chairm an-Emeritus
Depart me nt s of Neurosu rgery, Oncological Sciences,
Medicine, Endocrinology, Diabetes, an d Bone Disease
Icahn School of Medicine at Mou nt Sinai
New York, New York
Jam es G. Purzn er, MD
Resident in Neurosurgery
Universit y of Toront o
Toront o Western Hospital
Toront o, Ontar io, Cana da
Tere sa S. Purzne r, MD
Resident in Neurosurgery
Universit y o f Toront o
Toront o Western Hospital
Toront o, Ontar io, Cana da
Craig Rabb, MD
Professor of Neurosurgery
Director
Neu ro tra um a Pr ogr amOU Physicians Neuro surger y
Oklahom a City, Oklahom a
P.B. Raksin, MD, FAANS
Assistant Professor, Depart me nt of Neurosurgery
Rush Universit y Medical Cent er
Director, Neu rosur gery ICU
Chief, Section Neur otrau m a & Neurocrit ical Care
John H. Stroger Jr Hospital of Cook County (formerly Cook
County Hospital)
Chicago, Illinois
Pal S. Randhawa , MD
Resident in Neurosurgery
Universit y of Colorado
Aurora, Colorado
Jon athan Raso uli, MD
Resident in Neurosurgery
Icahn School of Medicine at Mou nt Sinai
New York, New York
Daniel Resnick , MD, MS
Professor a nd Vice Chairm an
Residency Program Director
Co-Director, Spinal Surger y Program
Departm ent of Neurological Surgery
Universit y of Wisconsin School of Medicine a nd Public
HealthMadison, Wisconsin
Roberto Rey-Dios, MD
Assistant Professor of Neurosurgery
Universit y of Mississippi Medical Cent er
Jackson, Mississippi
Boyd F. Richards, DO
Departm ent of Neurological Surgery
St. John Providence Healt h System
Michigan Spine an d Brain Surgeon s
South eld, Michigan
Michae l K. Ros ne r, MD
Chief of Neuro surger y Integrate d Service
Assistan t Professor
Uniform ed Services Universit y
Walter Reed National Military Medical Cent er
Washington, DC
Ali Shirzadi, MD
Neu ro su rgeo n
South Bay Brain a nd Spine
San Jose, Califor nia
Contributors x
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Branko Skovrlj, MD
Resident in Neurosurgery
Icahn School of Medicine at Mou nt Sinai
New York, New Yor k
Pete r J. Tau b, MD, FACS, FAAP
Professor of Surger y and Pediat rics
Associate Director, Residency Training Program
Chief, Craniomaxillofacial Surgery
Co-Director, Cleft and Craniofacial CenterMoun t Sinai Med ical Cent er
New York, New Yor k
Shelly D. Tim mons, MD, PhD, FACS, FAANS
Clinical Associate Professor of Neurosurgery
Tem ple University
Director of Neurotraum a
Associate Director for Neurosciences Adult ICU, GMC
Residen cy Program Director
Geisinger Health System
Danville, Pennsylvania
Roland A. Torres , MD
Chairm an of Neurosurgery
Alaska Native Med ical Cent er
Anch orage , Alaska
Michae l Turn er, MD, PhD
Neu ro su rge on
Frisco Spine
Frisco, Texas
Jam ie S. Ullm an , MD, FAANS, FACS
Associate Professor, Department of Neurosurgery
Hofstra North Shore-LIJ School of Medicine
Director of Neurotraum a
Nor th Shore Unive rs it y Hosp it al
Manh asset , New York
Anand Veeravagu, MD
Chief Residen t in Neuro surger y
Stan ford Universit y
Stanford, California
Michael Y. Wang, MD
Departments of Neurological Surgery & Rehabilitation
Medicine
Universit y of Miam i
Miller School of Med icineMiami, Florida
Will iam C. Warner Jr., MD
Department of Orthopaedics
Camp bell Clinic Ort hop aed ics
Mem phis, Tenn essee
Nirit Weiss, MD
Assistant Professor of Neurosurgery
Icahn School of Medicine at Moun t Sinai
New York, New York
Sanjay Yadla, MD, MPH
Department of Neurosurgery
Alexian Brothers Neurosciences InstituteElk Grove Village, Illinois
Benjamin M. Zussm an, MD
Resident in Neurosurgery
University of Pittsburgh
Pittsburgh, Pennsylvania
Contributorsxviii
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I Cerebral Trauma and Stroke
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2
Preprocedure Considerations
Radiographic Imaging Comp ute d tom ograph y (CT) is essential to evaluate for:! The presence and size of extra-a xial hematom a! Degree of m idline shift! Appearan ce of perim esencephalic cisterns! Presence of other space-occupying lesions
Preoperat ive imaging (Fig. 1.1).
Medications Preoperative antibiotics: either a cephalosporin or vancomy-
cin (if penicillin allergic) shou ld be given.
The patient should be given seizure prophylaxis at earliestopportunity after arrival to the hospital. Evidence-based
guidelines support the utilization of anticonvulsants for
7 days in patient s following traum atic brain injury.4
Fresh frozen plasma and/or other blood products/factorsshould be administered preoperatively and intraoperatively
as need ed to correct coagulopathy.
Operative Field Preparation The head may be positioned on a doughnut or horseshoe
head holder, rather than a thre e-pinion head holder, to facili-
tate m ore rapid progression to brain decompression.
The operat ive eld should be prepa red using an iodine-ba sedsterile prep solution, provided the patien t has no iodine allergies.
The use of chlorhexidine is controversial; produ ct insert in-formation bars th e use for procedures exposing the cerebral
m eninges. In cases with know n bet adine or iodine allergies,
chlorhexidine or alcohol prep can be used.
The incisions are marked and, after nal sterile draping, in l-trated w ith 1%lidocaine w ith epinephr ine 1:100,000.
Introduction
Rapid evacuation of extra-axial hematomas after trauma can
be a life -saving in te rven t ion . While th er e is no ab solu te cu t-
o time after which patients fare worse, m any studies have
demonstrated better outcomes with earlier evacuation. Surgi-
cal planning mu st take into consideration th e presence of other
intracranial lesions an d t he patients clinical status. The pres-
ence of polytraum a, the patients hem odynam ic status,1and the
pre se nce of coa gu lop at hy m ust be con sid er ed an d ad dr esse d
wh ile not delaying surgical inter vention.
Indications
Surgical intervention is appropr iate for epidural hematomas(EDH) with the following characteristics2
! Glasgow Com a Scale (GCS) score 8 and anisocoria "operating room as soon as possible
! Hematom a volum e 30 cm 3
! Hematoma volume , 30 cm3but accompan ied by:# Thickness 15 m m
# Midline shift 5 mm# GCS 8# Focal m otor de cit
! E aced cistern s! Deteriorating neurologic status
Surgical intervention is appropr iate forsubdura l h em atom as(SDH) with the following characteristics3
! Thickness 10 mm! Midline shift 5 mm! Thickness , 10 mm and m idl ine sh ift , 5 mm but accom-pa nied b y:
# Neurologic worsening by 2 or m ore points on the GCS# Asymm etric pupils# Fixed and dilated pupils# Intracranial pressure (ICP) 20 mm Hg
Surgery for Epidural and SubduralHematomasShelly D. Tim m ons
1
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1 Surgery for Epidural and Subdu ral Hemato mas
3
Fig. 1 .1ad CT scan is the modality most commonly utilized in the perioperative setting. (a) Epidural hematomas demonstrate a characteristic
convex shape (due to ad herence of t he dura at the suture lines) and are t ypically accompa nied by a (b) fracture (arrow). (c) Subdural hematomas
by co nt rast , are not bound by sut ure s a nd assume a crescentic appea rance, layering over the conve xity. (d) A small subdural hematoma may be
accompanied by disproportionate mass e ect and midline shift.
c
a b
d
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I Cereb ral Traum a and Stro ke
4
Operative Procedure
Positioning (Fig. 1.2a, b)
Figure Procedural Steps Pearls
Fig. 1.2 (a, b) The head is turned so
as to expose the operative
hemicranium. The patient
whose neck has not yet been
cleared can be po sitioned
in the cervical collar byplacing a bolster under the
ipsilateral shoulder and the
ipsilateral arm across the
chest. Pressure points should
be padded appropriately.
The he ad may be placed on
a foam or gel doughnut to
expedite positioning.
Discuss positioning with t he a nesth esiology tea m. The e ndot racheal tube (ETT) shouldexit t he cont ralateral side of t he m outh if placed orally, and shou ld be secured in place
using tap e, ETT collar, etc. The e yes should be prote cte d from corneal abrasion by placing
ointment under each lid and taping the lids shut.
Allowance for central venous cathe ters, pe ripheral intravenous cathet ers, and a rterial
lines should be m ade, with the se positioned toward t he ane sthesiology team if possible.Foley cathe ters shou ld always be placed an d should be accessible to t he ane sthesia team .
Pin xation may also be used, but positioning on a doughnut or horseshoe he ad holdermay expedite decompression of the brain.
The hea d should be positioned just at or slightly overhanging the end of the table and t hesterile craniotomy drape placed so that it hangs vertically to facilitate drainage of irrigation
by gravity. Final draping sho uld exclude t he a nesth esia se tup, using a vert ical drape.
An exit site for a subgaleal drain should be included in the area e xposed by the sterile d raping. Reverse Trende lenburg positioning m ay be used t o provide e levation of the head to he lp
reduce cerebral edem a.
a
b
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1 Surgery for Epidural and Subdu ral Hemato mas
5
Skin Incision (Fig. 1.3)
Figure Procedural Steps Pearls
Fig. 1.3 The skin incision
should be planned to
create a cranioto my
su cient to accessthe entire hematoma.
The question mark
or reverse question
mark incision
(illustrated he re)
is used comm only
to access large
traumatic extra-axial
hematomas.
Other skin incisions m ay be ut ilized t o evacuate smaller hematom as. However, beforecommitting to a more limited exposure, consideration should be given to the degree of brain
swelling anticipated.
When using a quest ion mark incision, care sho uld be t aken not t o place the incision too close tothe pinna of the ear. A margin of at least 1 cm should be used. Likewise, the vertical limb of t he
incision should be placed at least 1 cm anterior to the trag us. The scalp may be elevated o of
the underlying bone and retracted out of the way.
Scalp clips may be app lied t o the scalp edges t o aid in hemo stasis. Prior to ope ning the scalp over the te mp oralis muscle, an instrum ent may be passed over
the muscle fascia and t he skin divided down to the level of the instrument with a scalpel. The
tem poralis m ay the n b e divided in pa rallel with th e incision using Bovie caute ry.
Branches of the super cial and middle tem poral arteries may be encounte red and ma y beligate d an d divided sharply, or ca ute rized with t he bipolar cautery.
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I Cereb ral Traum a and Stro ke
6
Subcutaneous Dissection (Fig. 1.4)
Figure Procedural Steps Pearls
Fig. 1.4 For rapid opening, the
temporalis muscle may be
elevated simultaneously
with the scalp ap.
The tem poralis muscle may be elevated o of the underlying bone using a sharppe riostea l elevator, such as a Langenbeck, o r using th e Bovie caute ry.
The musculocutane ous ap should be protect ed from strangulation by placing drysponges (counted) behind the ap, which is the n secured using shhooks. A sponge
soaked with irrigation infused with epinep hrine may be placed on t he und ersurface of the
galea and muscle to aid in hem ostasis.
Bipolar caut ery ma y be used sparingly on scalp and m uscle vessels, taking care not toshrink the galea.
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1 Surgery for Epidural and Subdu ral Hemato mas
7
Cranioto my (Fig. 1.5a, b)
Figure Procedural Steps Pearls
Fig. 1.5 (a) Bur holes are placed at the pe rimet er of the planned
bone ap, leaving su cient bony margins so that the plating
hardware is not located imm ediately under the skin incision
at closure.
A no. 3 Pen eld dissec tor is used to strip the dura o of the
undersurface of the bone at e ach bur hole. If possible, the
Pen eld should be used to make a communication, in this
same plane, be tw ee n adjacent bur holes. The high-spe ed drill
attachment is converted to a cutting bit with a footplate and
used t o conne ct e ach pair of bur holes circumferentially.
The bone ap should be secured in place with a nge r prior to
making the nal cut.
(b) As the bone ap is elevate d o of the center dura, again
using a no. 3 Pen eld, the edge o f the ap should be securely
grasped and eventually removed from the exposure.
After creat ion of the bu r holes using a high-spee ddrill, bone wax is applied to t he raw bon e e dges
where necessary. Excess wax is removed, along with
any obstructive bone e dges dee p in the bur holes,
with a cup curett e.
A larger instrumen t, such a s a Lange nbeck periostea lelevator, may be used to elevate the ap, as long
as the underlying dura is protected from the sharp
edge of the instrume nt. The explanted bone apshould be cleared of hematom a and blood and
place d in irrigat ion infused with a nt ibiot ics on t he
back ta ble u nt il ready to be re place d.
Center holes may be made later in the bone ap forepidural tack-up sutures.
a b
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Evacuation o f Epidural Hemato ma (Fig. 1.6)
Figure Procedural Steps Pearls
Fig. 1.6 As the bone ap is elevated, an epiduralhemato ma will be appreciated imme diately
in the extradural space. This may be
removed using irrigation and suction.
The so urce o f bleeding sho uld be
addressed as quickly as po ssible, utilizing
bipolar cautery on the vesse l itself, and/or
bone w ax on the foramen spinosum where
the vessel enters the cranium.
Evacuation of an ep idural hem atom a will often yield bot h organizedhemat oma and liquid blood. The hem atoma is often adherent to the
blee ding vessel, commonly the middle m en ingeal arte ry in the ante rior
tem poral area. This, in turn, may be associated with a fracture of the
squamous portion of the tem poral bone.
Other sou rces of epidural hema tom as ma y be han dled similarly. Venousepidural hematomas sometimes require application of gel foam soaked
in thrombin and ge ntle pressure, or Bovie caute ry or bone wax to
blee ding bone ed ges.
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Dural Opening (Fig. 1.7)
Figure Procedural Steps Pearls
Fig. 1.7 The dura is opene d widely eno ugh to allow
access to as m uch of the subdural space as
possible in the craniotomy exposure.
The initial dural ope ning may be made
with a no . 11 scalpel. The dural edge s
may then be grasped with ne-toothed
forceps, elevated, and the remainder of the
opening performed with ne Metzenbaum
or teno tomy scissors. Occasionally, if the
brain is very edematous, the opening
may be made with a no. 1 1 scalpel over a
groove directo r.
For curvilinear incisions, at least 1 cm of dura should be left bet ween t hedurotomy and the bone edge to prevent retraction, causing di culty
with closure. If the brain is signi cantly edematou s and the dura is taut,
relaxing incisions may be ma de in the perimet er of a curvilinear incisionto prevent strangulation of the un derlying brain by the dural edge.
The dural edge s should be secured with 4-0 braided nylon sutures, andheld in place with mosquito hemostats, either to gravity or secured to
the drapes without undue t ension.
The dural ap or aps should be weighte d with hem ostat s in order topre vent shrinkage during t he pro ced ure as m uch as possible .
Dural vessels may be coagulated with th e bipolar at the e dges of the cutdura.
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Evacuation of Subdural Hematoma (Fig. 1.8)
Figure Procedural Steps Pearls
Fig. 1.8 The subdural
hem atoma (SDH) isseen overlying the
surface of the brain
and is evacuated with
irrigation and suct ion.
The sou rce of any SDH should be sough t. The source is ofte n a cor tical surface vein or arte ry.
SDHs occasionally may em anate directly from a surface contusion. Gent le irrigation with sterile saline shou ld be used and t he en tire perimet er of the
dural exposure explored with adequate lighting to ensure t hat t he hem atoma has been
completely evacuated. A brain retractor blade may be used to gently depress the brain
during this phase. Well-formed he mat omas may be grasped with biopsy forceps and ge ntly
elevated from t he brain surface while ushing the area with ample irrigation.
If an act ive b leeding source is ident i ed (which is not always possible), th e bleed ing shouldbe sto pped with b ipolar e lect roca ut er y, gelat in sponge so aked in th rom bin, a nd gent le
pre ssure with a cot to n pa t tie. The site sh ould be irrigated again to ensu re n o ac tive b leeding
prior t o dura l closure.
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Dural Closure (Fig. 1 .9)
Figure Procedural Steps Pearls
Fig. 1.9 After adequate evacuation of
the he matoma, the dura is
closed w ith 4-0 braided nylon
suture.
Epidural tack-up sutures are
placed through small drill
holes placed around the
perimeter of the craniotomy.
A central epidural tacking
stitch may be brought out
through tw o hole s drilled in
the bone ap.
Closure of the dura should be a ecte d in a watertight fashion if possible. Over theconvexity, water tight closure is not impe rative. The dura m ay be closed with simple
running, running-locking, or interrupt ed sut ures.
For large dural defects not amenable to primary closure due to shrunken dura, tornor adhe rent dura (comm on in the elderly), and/o r brain swelling, a variety of dural
substitute ma terials are available. The dura m ay be patche d with suturable graft
mat erials or autog raft from t he pa tients own galea or muscle fascia, or closed with
graft m ate rials alone.
Prior to placing the nal few sutures, the subdural space should be irrigated a naltime. When a large subdural poten tial space re ma ins (as in the case o f an elderly
patient and/ or one with a slack b rain), a sm all amount of irrigat ion m ay be left in the
subdural space to lessen the risk of extensive post operat ive pne umo cephalus.
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Bone Flap Replacement (Fig. 1.10)
Figure Procedural Steps Pearls
Fig. 1.10 Following evacuation of e ither an
epidural or subdural hematom a, the
bone ap is replaced in its anatomic
position, using a cranial plating
system . The central epidural tacking
stitch is secured.
Many types of cranial plating systems, with a variety of plate shapesand sizes, are available. These are gene rally made of titanium, which is
nonm agnet ic, allowing for later mag net ic resonance ima ging.
Resorbable plates and screws are available for children. Alternatively, thebone ap may be replace d with silk suture to avoid rigid xation in the
growing skull.
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Drain Placement (Fig. 1 .11)
Figure Procedural Steps Pearls
Fig. 1.11 For large aps, a subg aleal drain
may be used to lessen the risk of
postoperative subgaleal hematoma.
The drain should exit from a sepa rate st ab incision, forme d with a trocar o rno. 11 knife, and should be secured at its skin exit site with a nylon stitch.
The drain is att ached t o bulb suction.
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Patients with severe injuries will likely have additional in-vasive neuromonitoring (an ICP, external ventricular drain,
br ain t issue oxygen m on itor, or a com bina t ion th er eo f) to
guide management. Invasive hemodynamic monitoring (ar-
terial line, central venous line, Swan- Ganz cathe ter) m ay be
indicated to assist m anagem ent in critically ill patients.
Drains should be mon itored for outpu t every 4 hours for therst 8 hours and then every 8-hour sh ift.
The incision and /or dressing should be m onitored for bleed-ing initially, and for eryth em a, exudate, and/or edem a subse-
quent t o the initial postoperative period.
Medication Postoperative antibiotics are continued for 24 hours unless
there w as gross contam ination present at th e time of surgery,
in which case this period may be extended .
Seizure prophylaxis should be continued for a total of 7 daysfor pat ients w ith EDH or SDH. The presence of docum ented
seizures may provide an indication to continue therapy be-
yond this window.
Hyperosmolar the rapym annitol and/or hyperton ic salinemay be indicated for ICP control depending on the clinical
pict ur e.
Sedation and/or neuromuscular paralytics may be indicatedto assist ICP cont rol depe ndin g on the clinical picture .
Pressor support may be necessary to maintain adequate cra-nial perfusion pressure depe nding on th e clinical picture.
Ongoing coagulopathy should be corrected w ith fresh frozenplas m a o r ot he r a pp ro pr iat e b loo d p ro du ct s/ facto rs .
Radiographic Imaging Postoperative imaging (Fig. 1.12 ).
Further Management Drains are removed on the rst postoperative day, provided
input has slowed su ciently. If there is signi cant output , re-
moval may be delayed another 1 to 2 days.
The dressing is removed and the wound is cleansed withwarm water and m ild soap or shampoo after 24 hours.
Skin sutures or staples are removed on or about postopera-tive day 10 to 14.
Closing
If m ass e ect has been r elieved adequately and th e brain isslack (creating dead space in which blood may accumulate
po stop er at ively ), the pa t ients en d-t idal CO2 level should be
allowed to rise gradually to 30 to 35 m m Hg (roughly equiva-
lent t o pCO2of 35 to 40 m m Hg) during closure.
If ongoing coagulopathy is observed, measure s should be t ak-en to correct clotting param eters intraop eratively.
Sterile saline irrigation is utilized in the intradur al space. After du ral closure, copious am ounts of sterile saline infused
with antibiotic solution (e.g., bacitracin) are u sed t o irrigate
the wound.
Temp oralis m uscle and fascia are reapproximated with 0-gaugebraided absorbable su tu re. The galea is closed with int er ru pted ,
inverted, 2-0 braided absorbable suture. As the scalp closure
proceed s, th e scalp clips may be removed success ively, by
spreading with th e scalp clip applier or a hem ostat.
The skin may be closed with nylon or other nonbraided su-ture, or w ith staples. External sut ure is required on t he scalp,
as the re is not a well-developed su bcuticular layer.
The w ound m ay be dressed in a variety of ways. The aut horpr efe rs t o app ly a st rip of nonad he re nt p et ro lat um gauze over
sutures or stap les to prevent pulling. This base dressing, in
tur n, is covered with n arrow gauze ban dages to absorb m inor
oozing postoperatively. The dressing is secured with stretchy
dressing tape, applied un der slight tension to assist incisional
hem ostasis. Strips of dressing tape m ay be used to follow t he
curvature of th e head parallel to the incision for close adher -
ence. The dressing is removed after 24 hours, and the patient
is allowed to cleanse the wound w ith mild soap and wate r.
Postoperative ManagementMonitoring The patient should be monitored in the post-anesthesia care
unit (recovery room), progressive care unit, or intensive
care unit with frequent n eurologic checks, occurring at least
hourly initially. The patient s pre operative statu s and post-
operative course will dictate the t iming of transition to less
intensive monitoring.
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References
1. Bullock MR, Chesnut RM, Clifton GL, et al. Management and
pr ogn os is o f seve re t ra um at ic b ra in injur y. J Neur ot ra um a 2 00 0;
17:449597
2. Bullock MR, Chesnu t R, Ghajar J, et al. Surgical man agem ent of
acute ep idural hem atomas. Neurosurgery 2006;58:S7S15
3. Bullock MR, Chesnu t R, Ghajar J, et al. Surgical man agem ent of
acute subdu ral hem atomas. Neurosurgery 2006;58:S1624
4. Bullock et al. Ant iseizure prophylaxis . In: Guidelines for the
Management of Severe Traumatic Brain Injury, 3rd ed. J Neu-rotrauma 2007;24: S8386
Special Considerations
Preoperative planning is impor tant in the m anageme nt of trau-
matic SDHs. Planning for possible decompressive craniectomy
must often be incorporated into the positioning, incision, and
bo ne ap crea t ion (se e Chapt er 4) . Pat ients w ho ar e likely to
require the bone ap to be left out include those with midline
shift out of proport ion to the thickness of the SDH, those w ith
e aced cisterns, those with blunt vascular injury or ischemia to
the a ected hemisphere , or those with a signi cant amount ofunde rlying contusion.
Fig. 1.1 2a, b Axial CT images demonstrating resolution of (a) epidural hematoma and (b) subdural hematoma.
a b
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Chronic Subdural HematomasBranko Skovrlj, Jonathan Rasou li, A. Stewart Lev y, P.B. Raksin , and Jam ie S. Ullman2
Introduction
Chronic subdural hematoma (CSDH) is one of the most com-
monly treated neurosurgical disorders in the world. The 2006
Am erican Associat ion of Neu rological Surgeons procedural sur-
vey reported over 43,000 bur holes performed for the evacua-
tion of extra-axial (subdural/epidural) hematomas.1The most
comm on patient characteristics are elderly males with or with-
out a history of head trauma.2,3 Addit ional risk factors include a
history of alcoholism, the p resence of an inte rnal cerebrospinal
uid (CSF) shun t, and acquired or congenital bleeding diathe-
sis.4CSDHs are often un ilateral, but p resent as bilateral in ap-
proxim at ely 1 6 to 25%o f cases.3,5The most comm on presenting
symptoms include headache, ataxic gait, confusion, aphasia,
and var ious non speci c complaint s. If the CSDH is large and
causes signi cant m ass e ect, paresis, seizure, and coma m ay
ensue. Mortality statistics vary am ong institutions, but gener-
ally range from 5 to 16%.6,7
Several theories exist to explain the pathogenesis of CSDH.
The prevailing hypothesis is that most start as acute subdural
blee ds th at t r igge r a loc al in am m at or y re sp on se in the su r-
rounding me ninges. In am m ation triggers the migration of -
br ob last s, w hich th en crea te m em br an es that or ganize the clot
and secrete vascular endothelial growth factor (VEGF) that, in
turn, promotes the formation of capillaries within these mem-
br an es .
8
Over tim e, these mem brane capillaries bleed and pre-vent th e blood from being reabsorbed. Hem oglobin eventually
is broken dow n into hem osiderin, leading to the characteristic
appeara nce of CSDH on compu ted tomography (CT)/magnet ic
reson ance (MR) imaging (Fig. 2.1).
Management of CSDH typically involves surgical evacuation
of the clot and placemen t of postsurgical drains to prevent reac-
cum ulation of blood in the subdural space. In par ticular, the use
of drains after bur hole evacuation of CSDH has been show n to
reduce both recurrence and m ortality at 6 m onths.9Several op -
erative approaches are available. Bur h ole drainage is perform ed
m ost comm only. A mini-craniotomy m ay augmen t visualiza-
tion of the subdural space. When the radiographic appearance
is favorable, bedside p rocedu ressuch as m inima lly invasive
tw ist drill catheter placem ent or suction evacuationcan beused to good e ect. In addition to th ese surgical techniques,
several small studies have suggested that dexamethasone
thera py might show some prom ise in treating CSDH.10,11Newer
pha rm acologica l t re at m en t , su ch as th e us e of t ra nexam ic acid
(an antithrombolytic agent), is investigational.12 CSDH recur-
rence rates vary among institutions, but generally range from
8 t o 16 %.13,14Several studies have suggested that CSDH recur-
rence rates are higher with bilateral CSDH, with large volum es
of pneumocephalus after evacuation, and with use of antico-
agulation therapy.13,14
Indications
All Procedures Subacute or chronic subdural hematoma with maximum
thickness . 10 mm and/or midline sh ift . 7 mm
Subacute or chronic subdu ral of any thickness causing masse ect, midline shift, or neurologic signs and symptom s.
Minimally Invasive
Favorable CT imaging cha racte risticsa un iform ly isodenseor hypoden se collection in t he subd ural spaceare p resent.
This suggests the subdural hematom a is su ciently lique ed
to perm it drainage via a ventriculostomy catheter.
The presence of an isodense, or even slightly hyperdense,ground glass appearance is not necessarily a contraindication
to catheter drainage. This phenom enon is seen sometimes in
the set ting of a subacute or acute on chronic subdur al hem a-
toma, often w ith a gradual gradient from an terior hypodensity
to posterior hyperdensity (re ecting dependent acute blood
mixed with the predominantly chronic hematoma). These
usually can be drained e ectively with a bedside catheter or
suction evacuation procedure.
A small amou nt of acute, hyperdense subdur al blood with in alarger, mostly chronic, hypodense collection is not necessar-ily a contraindication.
While adequate drainage can be achieved even in the pres-ence of a few subdural membranes, extensive membranes
and m ultiple layers of subdural hem atoma (SDH) of di erent
ages or densities m ay pose a challenge. Bur h ole drainage or
craniotomy should be considered in this setting.
Preprocedure Considerations
Radiog raphic Imaging (Figs. 2 .1,2.2, and 2.3) X-ray: In general, X-ray is a poor diagnostic tool for CSDH.
Occasionally, a plain lm of the skull may reveal a calci ed
CSDH.15
CT:CT is the gold-sta nda rd im aging moda lity for diagnosingCSDH. SDHs classically dem onst rate a crescen tic con gura-
tion, as their distribution over th e cortical convexity is not
bou nded by su t ure lin es (in con t ras t to epid u ral b leeds) .
Mass e ect, cortical buckling, and midline shift may also
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appear d epen ding on the th ickness and size of the clot. The
appearan ce of blood on CT scan w ill change over t ime as
the blood product s age (Table 2.1 ); subacute blood appears
isodense and chronic blood, hypodense relative to brain.
The d egree of m idline sh ift an d th ickness of subdural blood
are useful radiographic m arkers to assist clinical decision
Fig. 2.1 Patient with subacute subdural hematoma with a so-calledhematocrit e ect with blood of di erent densities layering in a
dependent fashion. There is mass e ect causing mild shift and left
ventricular e acemen t. This patient was deem ed a good candidate for
bur hole dra inage .
m aking regarding operative inter vention. Noncontrast CT
usually is adequate to assess the age of the blood pr esent,
and therefore, the likelihood t hat it w ill be drained success-
fully via minimally invasive or open means. Contrast-en-
hanced imaging should be considered if there is concern for
subdura l empyema or for clarity in th e setting of a subacute
subdural hematoma that is isodense with respect to the
bra in t iss ue. Enhan ce m en t of co r t ical ve in s help s to de ne
the boundary between cortex and hematom a. Contras t mayalso dem onstrate the presence of membranes .
MRI:Magnetic reson ance im aging (MRI) is similarly sensi-tive an d speci c for diagno sing CSDH as CT scan; it is po-
tentially more sensitive in determining size and internal
structure.16 CT generally is preferred due to the high cost
of MR imaging as well as the time required to perform the
study. Similarly to CT scanning, the appe arance of subdura l
bloo d w ill also ch an ge ove r t im e (Table 2.2 ). MRI may be
considered for m ore detailed evaluation of mem branes and
layers if there is concern regarding t he feasibility of catheter
drainage.
Medications Intravenous (IV) antibiotics should be given within 1 hour
prior to incis ion . The u se of p ro ph yla xis in th e set t ing of m in -
imally invasive bed side procedures is left t o th e d iscretion of
the surgeon.
Antiepileptic drug proph ylaxis should be a dm inistered. Sedation for bedside procedures should be adm inistered with
caut ion. Minimize dosing or avoid sedat ion, if possible, as pa-
tients w ith CSDH may be par ticularly sensitive to its e ects.
One of the ben e ts of the bedside SDH drainage procedure
is the possibility to witness rapid neurologic improvement
a b
Fig. 2.2a, b Large right frontoparietal subdural hemat oma causing mass e ect and right ventricular e acement . There are some sept ations within
the mixed d ensity subdural. A small craniotom y was chosen to evacuate t he collection.
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when minimal or no sedating medications are used. This
stands in contrast to the delayed emergence some (often
elderly) patients experience after bur hole drainage under
general anesthesia. Bur hole procedures in the operating
room can be performed under conscious sedation or gen-
eral anesthesia as per surgeon preference or patient toler-
ance. Craniotomies typically are performed under general
anesthesia.
Operative Field Preparation The hair overlying the a ected hem isphere is clipped w ith
electric clippers.
Sterile skin preparation is performed with povidone iodineor chlorhexidine.
The planned incision sites are in ltrated w ith 1% lidocainewith 1:100,000 epinephrine.
Available imaging should be studied carefully to determinethe ideal entry point for the twist drill craniostomy. The
target is almost always more lateral than the typical inser-
tion site for a ventr iculostomy or intracranial pressure (ICP)monitor.
Fig. 2 .3 CT scan of a patients head with a homoge nous right hemispheric
subdural hematom a and right to left m idline shift. This case was selected
for twist drill craniostomy.
Table 2.1 CT appe arance of subdural blood over time 17
Time
Appearance relative
to brain parenchyma
Hyperacute (, 24 hours)
Acute (12 days)
Subacut e (213 days)
Chronic (. 14 days)
Hypo-/isodense
Hyperdense
Isodense
Hypodense
Table 2.2 MR appe arance of subdural blood ove r time 18
Time T1 T2
Hyperacute (, 24 hours)
Acute (13 days)
Early subacute (37 days)
Late sub acute (813 days)
Chronic (. 14 days)
Hypo-/isointense
Hypo-/isointense
Hyperintense
Hyperintense
Hypointense
Hyperintense
Hypointense
Hypointense
Hyperintense
Hyptointense
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Operative Procedure
Bur Hole Drainage
Positioning and Skin Incision (Fig. 2.4a, b)
a
b
Figure Procedural Steps Pearls
Fig. 2.4 The patient is positioned supine on a donut or a horseshoe, with
the head rotated approximately 30 degrees to the contralateral
side. A shoulder roll is placed lo ngitudinally bene ath the ipsilateral
shoulder. The back of the bed is e levated slightly.
Bur Holes (Right)
Two incisionseach approximate ly 3 cm in leng thare planned along
a line that bisect s the inte rval betwe en midline and superior tem poral
line. The anterior incision is positione d just ante rior to coronal suture
and the pos terior incision, over the parietal em inence.
Small Craniotom y (Left )
A lazy S incision is be gun from approximately 1 cm be low the
superior tempo ral line e xtending superiorly approximate ly 2 cm
lateral to the m idline in the parietal reg ion approximate ly 1 cm
poste rior to the co ronal suture. The incision can be further tailored to
the location and size of the hematoma.
For bilate ral procedures, t he h ead is kept ina neut ral position.
Trace out a reverse question marktypeincision over the a ect ed hem isphere. This
will facilitate a more extensive opening, if
necessary. The planned bur ho le incision
sites should fall along th e sup erior limb of
the que stion mark. If the CT appe arance of the extra-axial uid
is both hypodense and homogene ous, it
may be possible t o drain the collect ion
throug h a single bu r hole.
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Incisions and Bur Holes/Craniotomy (Fig. 2.5)
Figure Procedural Steps Pearls
Fig. 2.5 A no. 10 blade is used to o pen e ach incision to the leve l of pericranium. The
pericranium is opened with Bovie electrocautery and swept to either side
with a periosteal e levator. For the craniotomy, scalp clips are applied to the
scalp edge s. The te mporalis is incised and is re ected w ith the skin incision.
Self-retaining retractors are placed.
Bur Holes (Right)
Place a single bur hole at e ach incision site , using a round o r matchstick bur,
perforator, or acorn drill. Apply bone wax to the bo ny edg es as nece ssary.
Small Craniotom y (Left )
Place bur holes at the apices of the expo sed calvarium. A footplate
attachme nt, dental tool, or Pen eld no. 3 is used to free the underlying
dura from the bone . Use the craniotom e to create a small bone ap,
limited to the size o f the ope ning.
The craniotom e is used to create a roughly ovoid ap. The bone is
elevate dusing a blunt surgical tool to dissect any remaining dural
attachme nts to the unde rsurface of the bo neand set aside in antibiotic
solution.
Bur Holes
! Bur holes should be 1.5 t o 2 cmin diamete r.
Craniotomy! Resistance may be encountered
at t he level of coronal suture,
where the dura is more rmly
adherent to bone.
! The bone ap will be 4 to 5 cm indiameter.
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Dural Opening (Fig. 2.6)
Figure Procedural Steps Pearls
Fig. 2.6 Bur Holes (Right)
Coagulate the e xpose d dura with bipolar electrocautery at each bur hole site.
Open the dura in a cruciate fashion with a no. 11 blade. Coagulate the dural
lea ets w ith bipolar electrocautery to prevent bleeding into the subdural space
and to e nsure opening o f the dura across the full surface area of the bur hole.
Upon opening the dura, there m ay be imme diate expulsion of liquid
hem atoma. If not, a me mbrane is likely prese nt. The m em brane sho uld
be coagulated with bipolar electrocautery and opened sharply with a
no. 11 blade.
Small Craniotom y (Left )
Drill holes circumferentially at the periphery of the craniotomy site.
Line the e dge s of the cranioto my site with thin strips of ge latin spong esoaked in thrombin. Place epidural tacking stitches circumferentially with
4-0 braided nylon sutures.
Open the dura in a cruciate fashion, w ith a no. 11 blade, followe d by
tenotomy scissors.
An oute r membrane may be present upo n ope ning of the dura. Usually, it is
possible to develop a distinct plane between the undersurface of the dura and
the m embrane, using a dissector and cotton patties.
Re ect the resulting dural aps to each quadrant and secure them with4-0 braided nylon sutures.
Bur Holes! The p osterior site should be
opened rst to encourage
gravitat ional drainage.
! Attach one suction unit to aLukens trap prior to op en ing
the d ura in order to facilitat e
collect ion of a specime n for
path ology.
Craniotomy! When subdural hemat oma is
pre sent , the dura will have abluish hue.
! A 4-0 silk suture, passedthrough the periosteal dural
layer, may be used t o lift
the dura away from the
underlying structures to
facilitat e open ing.
! The subdural mem braneoften has a brown-green hue.
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Hem atoma Evacuation (Fig. 2.7 )
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Figure Procedural Steps Pearls
Fig. 2.7 Bur Holes (Right)
Once the initial eg ress of uid subsides, inspect each burhole site.
Provided the brain has not expande d to ll the subdural space,
a small red rubber cathete r may be introducedunder direct
vision.
Gravity irrigat ion may be performed with lukewarm saline. A x
a 10- to 20 -mLsyringewith the plunge r rem ovedto the ope n
end of the red rubber cathete r. Elevate the syringe, ll the ope n
end w ith irrigation, and allow it to funne l throug h the cathe ter,
into the subdural space. Monitor the bur hole sites during
this process to ensure that there is communication within thesubdural space between the two holes. Alternatively, the surgeon
may elect simply to ush irrigate betwe en the two bur holes.
Reo rient the cathe ter within the s ubdural space as necessary to
permit access to additional hematoma.
Cont inue irrigation until the returning uid is predo minant ly
clear in all directions.
Small Craniotom y (Left )
Coagulate the surface of the me mbrane and open it widely
within the craniotomy eldwith the bipolar and scissors.
There w ill be imm ediate e xpulsion of liquid hem atoma. Collecta spe cimen in the Lukens trap for patholog y. (Consider taking a
specimen of me mbrane as w ell.)
Use bulb irrigation with lukewarm saline to ush additional clotfrom the subdural space at the periphery of the craniotomy site.
Membranes and se ptations can be broken apart w ith bipolar
coagulation.
Irrigation w ith a red rubber catheter in a syste matic,
circumferential fashion unde r the cranioto my edg e is pe rformed
until the returning uid is clear in all directio ns.
Address bleeding po ints along the me mbrane and cortical surface
with bipolar electrocautery and/or adjuvant hemo static agent s as
necessary.
Additional holes m ay be placed along thedistal 2 to 3 cm of the red rubber cathet er,
taking care not to sever the t ubing.
If the uid introduced through one holedoes not exit t he second hole, there m ay
be an a dd itional mem bra ne th at is limiting
comm unication. Halt irrigation a nd reassess.
The red rubber catheter m ay be guidedin any direction where there is presumed
to be hematoma; however, if resistance
is encountered, do not force the catheter
into position. It is possible for the cathe terto pene trate brain parenchyma or t o tear a
bridg ing vein, resulting in hemorrhag e.
If acute hemorrhage is suspected (and theuid does n ot clear with cont inued irrigation),
consideration must b e given t o conversion
from bu r holes to a full craniotomy.
The me mbrane does not need t o be cutbeyond the e dges o f the cranioto my. The
vascularized membrane can bleed, and such
bleed ing m ay be di cult to con trol if remote
from the craniotomy.
Craniotomy also facilitat es ushing out of
more organized rests of hematom a notaccessible via bur holes.
The inner membrane, if present, is notstripped from t he surface of the brain due to
the risk of precipitating cort ical bleeding.
It is important to control active bleed ing.Placing gelatin sponge soaked in throm bin in
small pieces or strips along the und ersurface of
the bone can be helpful in stopping bleeding
from me mbrane