Surgical Approaches

Question 1

Standard OR planning

Answer 1

Op time out
Confirm laterality
Anesthesia: worried about
Antibiotics, AEDs, hypertonics/mannitol
Lines (Aline, IVs, central line)
Navigation
Neuromonitoring

Question 2

Hemicraniectomy

Answer 2

1. Consent, time out, laterality
2. Anesthesia: ancef, keppra, x2 large bore IV, aline
3. Position: supine with roll, turn side
4. Incision: reverse question mark, from tragus to 1-2 lateral to midline
5. Burr hole at root of zygoma, turn craniotomy flap
6. Measure at least 15cm diameter, down to temporal fossa
7. Open dural stellate fashion, avoiding sinus and bridging veins
8. Obtain hemostasis
9. JP flat drain and close

Complications: infection, bleeding (sinus bleeding), post op edema, hydrocephalus, blossoming contusions

Question 3

Craniotomy for Epidural/Subdural/ICH

Answer 3

1. Consent, timeout, laterality
2. Anesthesia: ancef, keppra; access (x2 large bore IV and aline, blood), SBP<140
3. Position: supine with shoulder bump
4. Linear or curvilinear incision/plan for hemicrani incision if needed
5. Burr holes, avoid sinus
6. Cruciate incision
7. Hemostasis
8. JP stain and closure

Question 4

Suboccipital Craniectomy

Answer 4

1. Consent, timeout
2. Anesthesia: ancef, 3%/mannitol, hyperventilate to PCO2 to 25
3. Consider right EVD
4. Position prone, mayfield
5. Incision: midline up to occipital turberance, below C2
6. Find bony landmarks, careful at C1 lateral
7. At least 4cm lateral to midline of occipital exposure
8. Turn bony flap, Y shape incision
9. Avoid taking brain unless herniating
10. Water tight closure with alloderm, duraseal
11. Close muscle and fascia layers

Post op: Keep EVD at 10cc/h to help wound
Complications: CSF leak, ventriculitis/meningitis, subdural hygromas, wound dehiscence

Question 5

Clipping ACom Aneurysm

Answer 5

1. Consent, timeout, laterality
2. Anesthesia: ancef, keppra, 3%/mannitol, adenosine
   Access: x2 large bore IV, aline, type and screen (x2 blood in room), 3rd suction
   Neuromonitoring (motor and step)
3. Supine with head turn 30 degree, malar eminence highest point
4. C shape incision, pterional craniotomy, drill sphenoid to flatten anterior skull base
5. Open dural in curvilinear fashion
6. Sylvian fissure (proximal to distal split for ruptured) - identify ICA for proximal control
7. Retract frontal lobe to expose chismatic cistern and acomm complex. Find bilateral A1 and A2
8. Burst suppression, temporary clip on A1
9. Permanent clip across aneurysm neck
10. ICG dye and intraop doppler to confirm
11. Closure

Post op complications: vasospasm, electrolyte