The use of bone wax: long pinch, remove excess wax end
The use of automatic brain plate: can effectively reduce postoperative cerebral edema brought about by surgical contusion, use a tampon with a sponge (moistened with water) under the brain plate, after the surgery is completed between the brain and the sponge gently flush with water, if there is adhesion indicates the presence of local cerebral contusion (because the moistened gelatin sponge does not adhere to the arachnoid membrane).
Site and direction of ventricular puncture.
Site: the junction of the parasternal opening 3 cm and 3 cm after the hairline (1.5 cm before the coronal suture), direction: the coronal position is located in the line of the two external auditory canals, and the sagittal position is 13 cm above the nasal root via Xu Guangbin, Department of Neurosurgery, Wuhu Second People’s Hospital
Treatment of paranasal injury: make an incision next to the fracture, expose all the depressed fracture fragments as much as possible, bite off the bone around the sinus that is caught in the vein, prepare the muscle piece and biologic adhesive and close two small stitches on both sides of the sinus, while removing the fracture fragments caught in the sinus, if there is bleeding, it should be quickly compressed with the muscle piece and biologic adhesive and tied with tight sutures. If the sinus is non-primary, it can be ligated (compress the ruptured sinus for 2-5 minutes if it is the primary sinus and the brain expands) → generally the right side is the primary sinus.
Incision for CPA approach: barb-shaped incision behind the ear; the lower border is flat at the level of the mandibular angle, the upper border is 1-1.5 cm above the transverse sinus, and the medial border is in the inner 2/3 of the line connecting the external occipital ridge and the star point, with the outer border against the hairline.
The body projection of the transverse sinus: in the line of two transverse finger points on the extra-occipital ridge and mastoid notch, the transverse sinus is higher in children than in adults
The incision of the corpus callosum approach: generally the right frontal approach is used, the left side is about 0.5-1.0cm past the midline to 1-2cm after the coronal suture, and the bend is about 5-6cm to the right side basically vertical, in an L-shaped incision
Location of the coronal suture on the body surface: in children the coronal suture is more obvious and can be reached on the body surface, in adults it is about 13cm from the nasal root
Distal lateral approach incision: The main purpose is to expose the posterior mastoid point, so the middle incision is located above the external occipital ridge, below it up to cervical 6-7, turning outward to behind the ear (at the level of the superior collar line) and then downward to the top of the mastoid tip. The flap is turned outward and downward.
Surgical incision for the anterior approach to the ethmoid sinus: an arcuate incision along the auricle, anteriorly located about 2 cm in front of the ear and above the zygomatic arch (depending on the location of the tumor), upward to about 6-7 cm above the auricle, and then horizontally backward to the posterior curvature of the ear downward to about the level of the angle of the mandible (depending on the location of the tumor on the slope).
Body projection of the pterygoid point: 3cm posterior to the external canthus
Incision of the pterygoid point approach: the patient is placed in a supine position with the shoulder of the surgical side padded so that the head is turned 20-30 degrees to the opposite side and the head frame is used to fix the head. The incision is generally made in the zygomatic-ear screen 1cm before the hairline after the coronal suture 3cm before the upward line to the midline, if the frontal floor requires more exposure, the incision can be over the midline some, if more temporal exposure is required, the incision can be biased towards the post-temporal arc to increase. The scalp, capitellar tendon membrane, temporalis muscle and fascia are incised layer by layer, and the capitellar tendon membrane and temporalis muscle should not be separated excessively to avoid losing the frontal branch of facial nerve. After incision, the skin, capitulum and temporalis muscle are turned forward in their entirety to expose the orbitofrontal, supraorbital rim and inferior temporal fossa. Four holes are usually drilled, the first at the orbitofrontal angle, the second at the midpoint of the coronal suture, the third in the middle temporal area, and the fourth in the infratemporal fossa. The orbitofrontal and infratemporal foramina are occluded to avoid dural hemorrhage and meningeal tears of the pterygoid crest. The pterygoid crest is occluded to level with the skull base so that the saddle area can be exposed intraoperatively without pulling too much brain tissue. The dura is first cut 1.5-2 cm posterior to the pterygoid crest, and then the frontotemporal dura is cut radially 2-3 cm
Causes of chronic hypertonic giant hematoma under the scalp.
1, malignant tumor bleeding
2.Hemorrhage from the infundibulum
3.Ruptured small arteries bleeding
Projection of each bony suture on the brain surface.
1) Coronal suture: central anterior gyrus
2）Temporal line
3）Pterygoid point: 3cm after the external canthus
4) Herringbone suture
Intraoperative identification of the diagonal gyrus and the supramarginal gyrus
Correspondence between the corpus callosum and the lateral fissure
The knee of the internal capsule is located on the lateral edge of the interventricular foramen so do not pull the lateral side during surgery.
The middle block can be cut during surgery, trying not to injure the anterior and vaulted unions.
Note that there is a superior pituitary artery between the internal carotid artery and the optic nerve, which should be electrocautery first.
POPPEN approach: inferior occipital superior curtain approach, suitable for tumors in the pineal region, posterior tricompartment, especially when the tumor is directly in or above the plane of the cerebellar curtain and the subject is on the side of surgery. The left or right occipital award is made according to the surgical need, and the sagittal sinus, transverse sinus and sinus sink are exposed. The dura is divided into two flaps and turned over, one with the base in the sagittal sinus and the other in the transverse sinus. The occipital pole is retracted medially and inferiorly in an outward and superior direction. The occipital lobe has few bridging veins into the sagittal sinus, transverse sinus, and sinus sink, and retraction is often done without sacrificing the bridging veins. The cerebellar curtain is dissected along the lateral aspect of the straight sinus, from the anterior aspect of the transverse sinus up to the incisive margin, and turned laterally. Open the globus pallidus of the cricoid and tegmental pools.
Incision of the trigeminal approach: mainly around the angular gyrus (3 cm posterior to 3 cm superior to the external auditory canal) or the supramarginal gyrus; the midline and transverse sinus and the lateral fissure and central sulcus are marked first.
Posterior cranial recess approach incision: posterior median incision, about 1-2cm up to the external occipital ramus, and the lower border to the cervical 4-5, below the external occipital ramus is the most likely site of postoperative cerebrospinal fluid leakage, so about 1cm of bone margin can be left during craniotomy drilling, and it should be tightly sutured.
The position of children after sacrococcygeal surgery should preferably not be supine, otherwise it is easy to cause local skin necrosis, and fasting should be done to prevent premature fecal contamination of the wound.
For postoperative hydrocephalus patients with ventriculo-peritoneal shunt, a high or medium pressure anti-siphon tube should be placed, but not a low pressure tube, to prevent excessive drainage causing subdural fluid accumulation.
Important body surface landmarks of the skull.
1）Superior border of the rocky crest: equivalent to the level of the superior border of the external auditory canal
2) Pterygoid point: about 3 cm after the level of the external canthus
3) Base of the middle cranial recess: at the level of the zygomatic arch
(4) Central sulcus: located 2 cm behind the midpoint of the line from the nasal root to the external occipital ridge and the line of the midpoint of the zygomatic arch
5）Temporal line: the upper edge of the temporal muscle attachment
6）Coronal suture: about 13cm after the root of the nose
7) External auditory canal
8) Median line
9）Lateral fissure: 1cm below the lateral ventricle, and its superior posterior border is about 3cm above the external auditory canal
Excision of angioreticular cell tumor: only the nodules of the tumor are required to be excised, and the cystic fluid is aspirated and flushed several times
Excision of cystic astrocytoma: not only the nodule but also the cyst wall should be removed, otherwise it is very easy to recur, and postoperative radiotherapy should be combined with it.
Resection of medulloblastoma: The tumor should be resected through cerebellar lead incision or cerebellar medullary fissure. Since the tumor is generally soft, it can be removed by suction, and when the fourth ventricle is open, tampons should be laid in time to protect the brainstem and medulla, and to prevent blood and tumor debris from flowing into the ventricular system to cause metastasis and postoperative fever. If the tumor invades the base of the fourth ventricle and is difficult to be removed, it should not be forced. After surgery, whole brain and whole spinal cord radiotherapy must be combined. If the ventricle is found to be enlarged after surgery, external ventricular puncture drainage should be actively performed to avoid brain herniation. There may be no signs before brain herniation in children. If postoperative fever is present, lumbar puncture should be performed promptly and as much cerebrospinal fluid as possible should be released.
Resection of tumor in occipital foramen: Generally, a straight incision through the posterior middle of occipital neck is used. If the tumor is located ventrally, a distal lateral approach should be adopted. The most important thing is not to injure the brainstem and protect the vertebral artery when removing the tumor from the occipital foramen. This is especially true if the vertebral artery needs to be exposed during the distal lateral approach. The surface of the medulla oblongata should be protected with wet cotton sheets and should not be pulled or pushed. In case of astrocytoma in the medulla oblongata and incomplete resection, the dura should be opened without suture and combined with radiation therapy after surgery. It should be removed after the second day of surgery when the patient is awake from general anesthesia and has normal cough reflex and strong tongue extension. After extubation, the patient should be closely monitored for respiratory condition and blood gas, and tracheotomy and ventilator assisted breathing should be performed if necessary. In some patients, carbon dioxide anesthesia occurs when the partial pressure of oxygen and oxygen saturation are normal, manifesting as indifference or unconsciousness, arterial blood gas analysis should be performed in time to clarify the partial pressure of carbon dioxide, and ventilator-assisted respiration should be performed (these patients generally show shallow and rapid breathing and respiratory muscle weakness).
Surgery of skull base: The blood vessels on the surface of the tumor often supply brain tissue and should not be cut off rashly. If these vessels do not supply blood to the tumor, they can always be separated from the tumor. The vessels can be freed and then drawn aside by cutting the fibrous tissue or arachnoid membrane around the vessels. However, some of the vessels are crossing the tumor, so care must be taken. The penetrating branches of the cerebral base artery ring are located in important structures and must not be damaged. The anterior and anterior communicating arteries of the brain supply blood to the optic nerve, optic cross, optic tract, and anterior wall of the third ventricle. The posterior cerebral, pericallosal, superior cerebellar, and posterior choroidal arteries supply blood to the corpus callosum and the posterior wall of the third ventricle. The anterior and posterior cerebral arteries have branches to the roof of the third ventricle and the medial aspect of the brain. The internal carotid and anterior and posterior communicating arteries supply the lateral wall of the third ventricle. Injury to the anterior part of the basilar artery ring often results in memory and personality changes, and injury to the posterior part of the basilar artery ring can cause impairment of consciousness and eye movements. Injury to the basilar and vertebral arteries and to the penetrating branches of their branches will result in coma and central life crisis. For surgically manipulated arteries, the artery may be covered with a cotton pad soaked in 3% poppy base, or the field may be soaked with two sticks of poppy base postoperatively.
Anterior approach to the sigmoid sinus: (also called posterior vagus approach)
1) The patient is placed in lateral position with the upper head frame so that the rock bone is located at the highest point of the operative field. Depending on the location of the tumor, the anterior end of the incision along the ear is taken to begin at the upper edge of the zygomatic arch, closely follow the ear, reach upward to 2 cm above the ear chakra in an arched bay backward, and reach 1 cm behind the mastoid process along the back of the ear. the temporalis muscle and tympanic membrane are peeled off and drawn forward and downward, respectively, to expose the external auditory canal.
(2) Drilling and bone window: Drill holes are drilled above and below the temporal and transverse sinuses, the number of holes can be slightly more to facilitate bite removal of the bone flap, as the dura and venous sinuses of the posterior cranial fossa often adhere to the skull so they should be carefully peeled off first with a stripper, and care should be taken in the presence of 2 relatively large guiding veins around the mastoid process. When biting off the bone flap, attention should be paid to the sigmoid sinus protruding into the bone flap and care should be taken not to tear it. Except for the holes above and below the transverse sinus, where the bone is bitten off with the biting forceps, the rest is milled away with a milling knife to form a free bone flap.
(3) Posterior resection of the rock bone: the mastoid process is done with a grinding drill to expose the sigmoid sinus straight to the jugular foramen. The supra-papillary airspace and posterior airspace of the facial nerve behind the posterior wall of the external auditory canal are milled away to expose the dural angle of the venous sinus and the Citelli angle, i.e., the supra-rocky sinus is revealed for ligation. The open air spaces are closed with bone wax.
4) Dural incision: The dura of the posterior and middle cranial fossa is cut along both sides of the sigmoid sinus, the supratentorial sinus is ligated, and the cerebellar curtain is cut posterior to the talocrural nerve, straight to the fissure of the cerebellar curtain. Bipolar electrocoagulation can also be used in case of incomplete bleeding from the supratentorial sinus ligation.
Transfrontal-temporal approach to the zygomatic arch: It is suitable for tumors in the medial aspect of the base of the middle cranial fossa, invading the sponge and internal carotid artery as well as the cranio-orbital communication. The lower end of the incision is 1 cm below the zygomatic arch and 2 cm in front of the ear screen. the frontal part is about 3 cm from the midline. The zygomatic arch should be as large as possible when breaking it. The frontal fascia should be turned down together to prevent damage to the frontal branch of the facial nerve.
Resection of meningioma of the cerebellar curtain: When the patient’s transverse sinus needs to be ligated, try to preserve a part of the cerebellar curtain margin so that the collateral circulation is formed or the already formed collateral circulation is not cut off.
Hematopoietic network (resection of brainstem tumors): multiple; with family history.
1) Small nodular macrocapsulas are mostly located in the cerebellar hemispheres, and a straight paramedian incision is feasible.
2) Solid tumor: mostly located in the base of the four ventricles or medulla oblongata, paramedian median incision is feasible.
(3) The blood supply mainly comes from the inferior and superior cerebellar arteries, and the adhesion with the medulla oblongata is obvious.
(4) When removing the tumor, the tumor should be separated strictly along the border of the tumor, never beyond the border, and there is often edema in the area and the vein should not be disconnected first.
5）Venous drainage methods: *drainage to cerebellum; *drainage to both sides; *drainage to the base of four ventricles
6）Wet sponge: to protect brain tissue; dry sponge: to stop bleeding.
7) Fasting for 3 days after surgery, nasal feeding for patients who cannot eat after 3 days. Remove the pneumonectomy cannula again when the cough reflex is good when feeding through the mouth without choking.
8）With neck dragging for 4-6 weeks
When brainstem tumor resection is performed, the brainstem should be separated strictly along the midline because the respiratory center is on both sides of the embolus. The same is true when performing spinal cord tumor resection.
Suturing of the scalp: The subcutaneous stitches should be wide apart, but the distance in and out of the stitches should also be wide. This is especially true for young women.
Cranio-orbital-zygomatic surgical approach: the surgical incision over the midline, sometimes with an asymmetric coronal incision. Inferior incision to 1-2 cm below the zygomatic arch. can be divided into 3 bone flaps or 2 bone flaps shaped. Careful attention should be paid to protecting the eye in the management of the superior orbital wall or lateral orbital wall. The bone of the supraorbital and lateral orbital walls is ground away.
Diagnosis and differential diagnosis of disease
The most significant features of MRI in craniopharyngioma: 1) with a tumor capsule and 2) with calcification
The main features of basal ganglion germ cell tumors: 1) prevalence in boys, 2) prevalence in the basal ganglion, 3) mixed MRI signal 4) less pronounced occupying effect compared to other tumors, 5) ipsilateral often associated with cortical atrophy. 6) ipsilateral or contralateral metastasis along the ventricular wall. –
Central neuroblastoma: 1) It is usually found in the pellucid septum and lateral ventricles. 2) It often has calcification. 3) It may have irregular enhancement, typically with foveal changes. 4) Surgery combined with radiotherapy should be used for treatment, and the prognosis is better.
Differentiation of ventricular meningioma and medulloblastoma: Ventricular meningioma usually occurs at the base of IV ventricle, the tumor growth is slower than medulloblastoma, so the medical history is longer, and the tumor mostly grows toward CPA, there are more cystic changes or calcification than the latter, so the MRI signal is not uniform than the latter, the cerebrospinal fluid gap around the tumor is mostly located at the dorsal side of the tumor, and metastasis is less common than the latter. Clinically, cerebellar damage is milder than the latter, even without ataxia.
Differentiation between astrocytoma and hemangioretinal tumor (cystic): the former has a thicker cystic wall with significant enhancement, whereas the latter has the opposite and has a tumor nodule.
Differentiation between olfactory sulcus meningioma and saddle node meningioma: the former has optic nerve papillary edema while the latter has primary optic papillary atrophy
Nerve sheath tumors: multicystic, styloid, occasionally calcified, most likely to invade the auditory nerve. It is more frequent in sensory nerves and less frequently in motor nerves.
Management of the disease
Teratoma: Patients with suspected teratoma should not undergo radiation therapy or they will evolve into malignant teratoma. Even malignant teratomas cannot be treated with radiation therapy, and there is no good treatment available.
Intraoperative and postoperative management of craniopharyngioma: 1) no sugar salts or salt during and after surgery, 2) review electrolytes immediately after surgery, 3) think of the possibility of hyponatremia or hypernatremia if postoperative seizures are encountered, 4) review electrolytes twice or once a day if urine popping is encountered, 5) give thyroxine and glucocorticoids orally 1 week after surgery (glucocorticoids are given after surgery), 6) keep track of 24-hour in and out volume.
7) Avoid the use of bipolar electrocoagulation as much as possible.
Postoperative nasal feeding in children: give plain water first, then rice soup, then white milk and other fluids, and the amount should be gradually increased.
Intrathecal injection of stable credible method: 500mg of stable credible diluted into 10ml, extract 0.5ml and then diluted into 10ml of sheath injection, the amount is 25mg, hold the tube for about 4 hours after injection and then open. It is suitable for subjugular infection and ventriculitis (for ventricular perfusion).
For obstructive hydrocephalus above the IV ventricle, general dehydrating drugs are ineffective and external drainage by ventricular puncture is required.
For ventricular meningioma, if there is no significant increase in size and no obvious symptoms in 3-5 years, surgery is not recommended because surgery may accelerate the growth of the tumor and may lead to malignant transformation.
Treatment of postoperative subcutaneous fluid (for those with subarachnoid communication)
1）Place a thick silicone tube directly under the skin to drain the fluid and put pressure on it, and continue to drain it for about one week.
(2) continuous drainage by lumbar subdural placement (this method is likely to lead to hydrocephalus for a long time)
The use of mannitol after surgery.
(1) For patients who do not involve the brain or whose brains are slightly strained, BID can be used and can be rehydrated with less than 2500 ml of fluid
(2) for postoperative patients prone to cerebral edema available TID, rehydration fluid should be about 3000ml
(3) For patients with obvious postoperative cerebral edema, Q4D should be used and the rehydration fluid should be around 3500ml, and the blood biochemistry should be reviewed at least daily to avoid renal failure.
The use of Nimoton
(1) Patients with possible cerebral vasospasm after surgery should be used, 20mg per day by micro-pump, and if combined with increased blood pressure should be increased to 30-40mg to maintain blood pressure in the normal range.
(2) Patients with high blood flow into the subarachnoid space during surgery or posterior cranial recess surgery should preferably use this drug postoperatively
(3) Patients after brainstem or spinal cord surgery or skull base surgery should apply this drug.
The use of rapid-acting coagulation.
1) Patients who are bedridden for a long time, especially elderly patients, should use it routinely and require the combined use of compression stockings
(2) Coagulation should be checked after 3 days of application to prevent bleeding tendency.
The use of dexamethasone
The dose should be tapered and should not be stopped suddenly. Attention should also be paid to the patient’s mental status during the discontinuation process. Some patients, especially those after saddle surgery, may wilt after the reduction of the drug. It is better to combine the use of antimicrobial and acid control drugs in the process of hormone use. To prevent the occurrence of infection or upper gastrointestinal bleeding.