Application of surgical instruments for craniocerebral injury
1.Action tube
As with other neurosurgical operations, the suction tube is a very important tool in the surgery of craniocerebral injury. Its functions include aspiration of blood from the surgical field, maintaining a clean surgical field, finding bleeding points, cutting open brain tissue, removing hematomas, removing inactivated fragmented brain tissue, assisting in probing the brain surface at the base of the skull, and aspirating cotton sheets pressed on gelatin sponges to assist in stopping bleeding. The regulation of attraction is a crucial aspect of the operation of the suction tube. Generally, a thicker suction tube is available when incising the scalp, and the attraction can be stronger to facilitate hemostasis of the scalp. In the case of cerebral operation, a finer suction tube should be replaced and the suction force should be adjusted according to the different objects. When removing epidural hematoma, the suction force can be larger, but it is not advisable to use strong suction force to remove small blood clots closely adhered to the dura mater; when absorbing water from cotton, the suction force can also be larger. When operating directly on the brain tissue, the force of attraction should be adjusted to the extent that the suction tube can only remove water and blood but not the brain tissue, blood vessels and nerves. It is advisable to have a cotton pad under the suction tube at all times to protect it during all operations. The force of attraction should not be too high when removing inactivated fragmented brain tissue to avoid damage to normal brain tissue and cerebral vessels. The adjustment of the force of attraction can be adjusted by the adjustment of the wall suction device or by the number of openings in the side wall of the suction tube.
2.Bipolar electrocoagulation
Because the surgery of cranial brain injury rarely uses microsurgery techniques, bipolar electrocoagulation rarely uses forceps with very fine tips. According to the principle of physical tip discharge, bipolar electrocoagulation forceps with too sharp a tip can only be used for electrocoagulation under weak current conditions, and a slight increase in power can cause scorching of the coagulated tissue, and also easily cause adhesion of the tissue to the forceps. Therefore, bipolar electrocoagulation forceps for cranial injury should preferably be used for forceps with a tip width greater than 1 mm. The size of the bipolar electrocoagulation power should be appropriate for the tissue to be electrocoagulated without being scorched, and 2-3 seconds after the electrocoagulation is opened, the tissue becomes yellow for a better power choice. The forceps for bipolar electrocoagulation should never be chipped or scraped with a blade or sharp instrument to avoid damaging the function of the forceps tip. Although bipolar electrocoagulation is less thermal damage to the tissue than monopolar electrocoagulation? Much, but the cortex and important functions using bipolar electrocoagulation should still be promptly flushed with saline to cool down.
3.Brain pressure plate
When removing intracerebral hematoma and probing the skull base, it is often necessary to use the brain pressure plate to help reveal the surgical field. The shape of the brain pressure plate should match the morphology of the brain tissue on the contact surface as much as possible, and it is important not to focus the force point on the tip of the brain pressure plate, otherwise it is easy to cause contusion of the compressed brain tissue or even to insert into the brain tissue. When supporting the brain pressure plate by hand, the force should be uniform, and it is easy to cause cerebral contusion and cerebral hemorrhage in the compressed area when it is loose or tight. In addition, it should always be remembered that at no time should the brain pressure plate be used to forcefully push the brain tissue
Some domestic and foreign specialized books mention more or less the use of surgical instruments, including the different gripping methods of the suction device. For example, Yasargil’s Microneurosurgery, book 4, mentions the differences in the use of instruments with different handles; Perneczky is keen on the rotation of microscopic instruments during surgery and the balance of the instruments in the hand, designing the handles in a circular shape.
Rhoton often writes about the use of surgical instruments, and some simple actions that most physicians consider correct should be pushed. For example, I have seen many neurosurgeons (myself included) fill gelatin sponges between the skull and dura mater after craniotomy and then suspend the dura mater. However, Rhoton states that the dura should not be separated and a narrow strip of gelatin sponge should be placed at the edge of the bone and then the dura should be suspended.
Refinement of electrocoagulation
1. the color of the vessel changes from white to yellow, and the vessel wall remains somewhat flexible.
2, the vessel wrinkles and the vessel diameter becomes significantly smaller, about half of the original vessel diameter.
3.No adhesion of the forceps tip to the vessel wall when electrocoagulation is completed.
4, general external force such as pulling, attraction or blood pressure, cranial pressure rise, etc., does not cause bleeding.
Important points
1, wider forceps tip (most commonly 0.9 mm) and lower electrocoagulation output (most commonly 2.5).
2, intermittent electrocoagulation method: each electrocoagulation for about 0.5 seconds, repeated several times until the standard of electrocoagulation perfection is reached.
3, the method of progressive electrocoagulation: from the proximal to the distal end of the vessel, gradually increase the number of intermittent electrocoagulation, until the surface of the electrocoagulated vessels blackened to
stop, the blackening of the blood vessels cut off.
4. blocked flow electrocoagulation method: for arteries larger than 1.5 mm in diameter or vessels with abnormally rapid blood flow (e.g. AVM), the blood flow is temporarily blocked with a vascular clip before electrocoagulation.
5, the length of the vascular cautery closure area is strived to be greater than 2~3 times its diameter.
6. The vessel wall must be moistened with saline before electrocoagulation.
Intracerebral hematoma must be beware of aneurysm
We can often encounter in the emergency room “traumatic? Hypertensive?” Intracerebral hematoma, when the site of hypertensive bleeding is atypical and traumatic bleeding does not coincide much with the way of injury, the possibility of cerebrovascular malformation and aneurysm should be considered, and blood should be adequately prepared before surgery, and aneurysm clips or temporary blood flow blocking clips should be prepared on to avoid getting caught off guard.
I have encountered a total of 3 aneurysms in a year (1 middle cerebral pseudoaneurysm, 1 middle cerebral aneurysm, and 1 distal anterior cerebral artery aneurysm), of which the middle cerebral pseudoaneurysm hemorrhaged the most rapidly, so I casually found an aneurysm clip iodine wipe and clip it on, but later I saw that it was a domestic aneurysm clip, and the vascular damage was heavy.
The first thing you need to do is to make sure that you have the right amount of money. I know it’s necessary, but it’s important to ask for a detailed medical history before surgery, whether it’s a headache after a fall or a headache after a fall, while aneurysm bleeding is mostly in the subsurface of the pearl retina, and intracerebral aneurysm bleeding is mostly in several locations.
1.Frontal pole medial side near the anterior longitudinal column
2.near the lateral column
3.near the line connecting the lateral column and the central sulcus
Aneurysm bleeding are more superficial hypertensive cerebral hemorrhage location is deeper
Regarding the use of flush, the use of electrocoagulation, the use of suction and other techniques, it is recommended to find more books to read carefully, from the works of Yasargil and Rand, to the various domestic surgical science, about various surgical techniques, it really varies.
However, it is not necessary to understand what you have read, but you must combine it with practice.
The keyhole drilling of the pterygoid approach was described by Seeger in 1986 or 1988. As neurosurgery has evolved, some techniques have been improved and some have been phased out; depending on the patient’s condition, some techniques should be changed and should not be copied. For example, doing the pterygoid point approach, which Yasargil himself was changing, and Koos and Samii were each doing it differently. Another example is that Seeger envisioned a trans-occipital approach as early as the 1980s, and by the 1990s the lateral inferior occipital pole approach was well developed, many people know Sehker, Sen, Heros and Al-mefty, but how many know Seeger?
It should be reminded that some of the surgical techniques in the domestic books are wrong, and I wonder if the authors were clear at first. The only way to understand is to make comparisons and keep practicing.
Also, some techniques should not be copied, such as opening the arachnoid of the lateral cleft, and there is a difference between aneurysm surgery and hypertensive brain hemorrhage surgery.
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The two circles above refer to the holes drilled in the supraorbital skull. Generally, we try to open as low as possible. After drilling the holes, we can use the striker to test how far the bone holes are from the skull base, and if they are already at the skull base, you can directly take a wire saw to open the skull. If there is still a distance, usually not more than half a centimeter, you can use bone shears to cut along the bone holes into the / ＼ two oblique openings shown above. The saw will open up and you’ll see, wow, it’s perfect! Also, because the dura is in loose contact with the skull here, even though the wire saw may not be on the wire saw guide, it doesn’t usually cut through the dura, which I’ve never done anyway.
These are the basic skills that a neurosurgeon must master. As for the specific method, it depends on the specific location, size and direction of expansion of the lesion you are dealing with, there is no set thing, including our own in the continuous summary.
1, the bone hole as far as possible against the skull base, sawing as far as possible towards the skull base direction to pull.
2.For some large tumors, or lesions growing in the direction of posterior cranial fossa and cavernous sinus, the lateral orbital rim can be removed together with the orbital rim sawing.
3.If the bone window is really a certain distance from the anterior skull base, the medial side of the skull base bone margin can be washed away to increase the exposure, and if necessary, the orbital rim can be redone with a bone office.
4. When Prof. Samii did pituitary tumor, the position was sometimes high (small tumor), but he used the method of constantly adjusting the microscope to achieve a very good reveal. It is not the same if the tumor is very large.
Keeping the field clean
Keeping the field clean is a good surgical habit, especially for deep surgery, and is very important for successful completion of the surgery. The so-called cleanliness is actually the absence of active bleeding in the surgical field. Nowadays, the technique of hemostasis makes it possible for everyone to do this, only the concept of surgery is different, not that they can’t do it, but they don’t do it. Starting from the incision of the scalp, each completed step should be carried out in the next step with complete hemostasis, and there should not be more than one bleeding point in the surgical field until the end of the operation. Do not underestimate scalp bleeding, as this bleeding continues throughout the surgery, even if it is small, and may sometimes affect the outcome. It is not required to be fast, the most important thing is the surgical result and the patient’s life is the first priority, not the fame of a certain doctor who does surgery fast. Of course, with more practice, it is natural to be fast. I always believe that maintaining a clear operative field is not a matter of technique, but a matter of perception.
The question about a clean operative field is indeed true during general surgery but during trauma surgery, time is extremely important and one cannot stick to scalp hemostasis and take one’s time, one must be bold and quick to enter the skull, cut the dura immediately after drilling, release the cerebrospinal fluid and bleeding, and give some decompression. This buys time and avoids prolonged pressure on the brain tissue with increased cranial pressure, which has a good impact on the patient’s postoperative recovery. Sometimes it is these precious minutes that determine the patient’s life and prognosis. However, it does not mean that trauma surgery should be done without a clean field, but after a certain amount of decompression. For those who do not have high cranial pressure, we should stop the bleeding at every step and keep the field clean.
For keeping the operation field clean, I would like to talk about my own learning experience.
1, the need to maintain a clean field need not be said, I personally feel that the ability to maintain a clean field reflects the basic quality of a neurosurgeon, is the basic skills, sometimes may also be the skill.
2, personal experience to keep the field clean in the craniotomy is the most important is to operate strictly according to the anatomical level, such as subcapsular tendon membrane, the white line of the posterior median approach, etc., after skilled operation of the median approach incision can be completed quickly with a sharp knife, without the use of electric knife separation; subdural operation requires skilled microsurgery techniques to complete the separation of the brain pool incision, in addition to the nature of different lesions and pathological features to complete the lesion Removal of the dura is crucial, but one has little experience in this area. In addition, some small actions should not be neglected, such as cutting the scalp with four fingers together to compress the exact length of each incision (including the number of scalp clips); separating along the muscle gap as much as possible; progressively during the operation; it is appropriate to remove the scalp clips in sections when suturing the scalp, etc. Good habits can ensure that the operation is both fast and beautiful, there will be no fee action.
3, for emergency treatment, I do not fully agree with Piao Yun’s approach. I personally think that if it is a great emergency, you can first make a small incision such as 2cm incision (generally designed in the incision line, not another cut), drilling decompression; after that should still operate quickly according to the principles. Otherwise, in case of unknown source of bleeding, fast bleeding or brain tissue expansion, the operation may be a mess, and the result will be half-hearted, and speed is not enough, and long operation time and bleeding are inevitable. The instructor often says that fast means slow and slow means fast, and this may be the meaning.
Surgical position
Improper positioning of the patient will directly affect the surgical exposure, intracranial pressure, hemodynamics, and even the surgical outcome. The appropriate position should be selected with due consideration to several aspects: 1, maximize the use of brain gravity to increase the exposure of the access and thus reduce the strain on the brain tissue. 2, take into account the impact of the position on intracranial pressure, cerebral blood flow and respiration. 3, avoid the transition of the neck to prevent the occurrence of venous reflux and ventilation disorders, as well as to avoid injury to the joints and nerves of the neck. 4, take into account the comfort of the operator and the comfort of the patient’s position. The patient’s position should be comfortable. The head should be elevated above the heart level to reduce bilateral jugular venous pressure and intracranial pressure. The upper part of the surgical bed should be elevated or positioned about 15-30 degrees, but not more than 45 degrees, otherwise there is a risk of air embolism. The value of the head above the heart can be determined by the central venous pressure, which facilitates surgical operations in or near the major venous sinuses. The central venous pressure can be controlled by adjusting the value of positive end-breath ventilation during anesthesia.
Five head positions are commonly used to increase exposure by gravity
1, supine position with the head tilted back 10-15 degrees, which facilitates the exposure of the anterior skull base and the saddle area. 2, lateral position with the head folded 15-20 degrees to the ground, which facilitates the exposure of the middle skull base. 3, sagittal direction parallel to the ground, which increases the exposure of the longitudinal fissure approach. 4, lateral or lateral prone position with the sagittal direction at an angle of 45 degrees to the ground, which facilitates the exposure of the occipital lobe and the cerebral lian and its straight sinus. 5, sitting and semi-sitting position facilitates the exposure of the superior cerebellar approach. The supracerebellar approach.
1, I know that when doing surgery for cerebral hemorrhage in the basal ganglia area of hypertension, the blood clot should be gently sucked into the center of the hematoma cavity, do not go to the forced aspiration of the hematoma wall clot, because the hematoma wall is the nucleus pulposus of the basal ganglia, which may aggravate the injury, as long as it achieves decompression, so that the cavity will hardly ooze blood after aspiration of the hematoma, and saline flushing will do.
2, hypertensive cerebral hemorrhage (basal ganglia) patients, cranial CT to clarify the site of bleeding, often surgery in found at the edge of the hematoma —- this is because the hematoma edge formed by bleeding low-density nerve fibers (internal capsule) extended displacement, so the cranial opening Be sure to pay attention to this point.
3, we in the craniotomy drilling, cut open the dura, often see due to drilling caused by cerebral soft membrane damage, under the soft membrane is bleeding, this should be used to compress the bleeding place with a cotton piece, bleeding will stop to reduce the incidence of postoperative epilepsy.
4, transfrontal pituitary tumor surgery, drilling should pay attention to the bone hole of “lateral cornea”, the advantages of drilling here (lateral cornea external corner): A. low position, at the base of the skull; B. can well expose the lateral fissure, release csf.
Tissue separation requires that the separation be performed without bleeding or damage to the surrounding vessels and normal brain structures. Blunt dissection should be performed in a relatively nonvascular area and along a discernible interface. The operator should carefully sense the feedback stress in the area of operation and avoid inappropriate forceful pulling. When more obvious tissue damage is found, or when the surrounding structures cannot tolerate more strain, it is necessary to change from blunt to sharp separation, using microscopic scissors or a microscopic knife, which is especially useful when the vessels and cranial nerves are significantly adhered or encapsulated by the tumor.
I have seen Wuhan Union Professor Zhang do surgery as soon as the stage is arranged bipolar electrocoagulation (Professor do this rarely yo ^_^), the right hand lightly hold the line left hand take electrocoagulation downward pull, to the elbow joint when the right hand pinch the line, the left hand hold electrocoagulation and one fold, and then pinch the line fixed in the edge of the table, think so the length of the line is exactly the same as the operator’s arm, the line will not be too short and not too long when the surgery seems messy. Later, I asked if this was indeed the case, and was taught by Professor Zhu. I felt comfortable with the clinical simulation.
Regarding the use of suction devices, it would be inspiring to look at the suction devices designed by Sugita and Fukushima in Japan. Of course, it is possible to design a device to adjust the amount of suction.
Frankchen mentioned that the orbital rim can be cut with a wire saw, and the direction of the saw can be adjusted according to the location of the drill hole, and part of the orbital roof and frontal zygomatic process can be cut, but care should be taken to protect the supraorbital nerve and orbital periosteum.
With regard to hypertensive internal hemorrhage, I agree with michel8 that “do not forcefully aspirate the clot from the hematoma wall because the wall is the nucleus pulposus of the basal ganglia, which may aggravate the injury, as long as decompression is achieved. If microscopic techniques are used, complete removal of the hematoma can sometimes be achieved, although it is not mandatory.
Drilling and drainage of chronic subdural hematoma
I know that when the chronic subdural hematoma is drilled and drained, the drilling point is one centimeter under each of the front of the parietal tuberosity, which is mostly feasible, and after drilling, a bone groove can be bitten, and the dura can be cut by electrocoagulation, and the bloody fluid is inserted when the drainage tube is seen, and the front end of the drainage tube should be bitten for a few more holes to make it soft, and the drilling point is at the highest after insertion, and the drainage tube is clamped closed after flushing to prevent air intake, and the drainage bottle is connected after suturing. A little experience.
A small experience of mine: the patient’s head position when drilling and draining a chronic subdural hematoma should place the drilling point in the highest position, which has the advantage of easy placement of the drainage tube. If the drilling point is too low (e.g., lying down in temporal drilling), the blood will flow out after the dura is cut, the brain tissue will collapse and may block the bone hole, and the brain tissue will be easily injured when the drainage tube is placed.
Chronic subdural hematoma is often associated with intracranial pneumatization after drilling and drainage, which has no significant effect on recovery but is best minimized. A few experiences.
1, after the hematoma is flushed, the hematoma cavity is filled with saline and exhausted
2, drainage tube placed in the high position of the hematoma cavity.
3, replace the drainage bag with a hemostatic forceps clamp the drainage tube near the end of the drainage bag and then remove the old drainage bag to replace the new drainage bag, so as to prevent gas from entering the process of replacing the drainage bag.
How do you guys feel about suspending the dura?
It seems that in most books the dural suspension is done before the dura is cut.
If the intracranial pressure is high, it is very difficult to suture.
If the suture is shallow – it will pull the dura mater when tying the knot and cause the work to be lost – re-sew.
If the suture is deep – it is easy to injure the blood vessels in the cerebral cortex, resulting in brain tissue damage.
We differ slightly in that we suspend the dura after cutting it open, and we do not violate any surgical principles.
After the dura is cut, a brain pressure plate is placed under the dura and the dura is pulled out with meningeal forceps (long forceps with teeth), and then it can be sutured as tightly as you want, and no blood vessels in the cerebral cortex can be sutured as tightly as you want. Also, pulling out the dura reduces the problem of postoperative suturing of the dura with too much tension, which makes it difficult to close.
Advantages.
1) The speed of surgery is increased and the dural suspension time is reduced.
2) The suture is firm and does.
3) No side injuries occur (e.g. cerebral cortical vascular injury).
4) Prepares the dura for postoperative suturing and reduces the chance of excessive dural tension.
5) In acute, high cranial pressure situations also allows for earlier reduction of intracranial pressure.
§ Rapid dural suspension is also possible in acute cerebral bulge, although the prognosis for most such patients is poor. *
Tips for dural suspension: After years of surgical experience, unless there is significant bleeding before cutting the dura, the dura should be suspended after suturing the dura, so that it is easier to suture the dura, and if there is no significant bleeding between the dura and the inner plate, it can be suspended directly without placing a gelatin sponge. This avoids separation of the dura from the endplate when placing the gelatin sponge and reduces foreign bodies. It is easier to use the tip of a needle to pick up the dura mater and then use meningeal forceps to hold the dura mater in place before suturing the suspension.
Classical wing point classical cephalic position.
4 positions.
1. head above the chest; 2. tilt back about 10°; 3. rotate about 30° to the contralateral side; 4. tilt about 15° to the contralateral shoulder. Each position has significance.
2.Principles of head position placement: make the frontal zygomatic process at the highest point and the center of the visual field so that the operator’s line of sight can reach the operating area of the parsaddle vertically along the pterygoid crest.
3.Some changes of head position are briefly described as follows, and we hope you will discuss them: the head position of this approach can be slightly changed according to the location and nature of intracranial lesions; the head should be tilted less for intra-saddle lesions, and slightly more for supra-saddle and supra-slope lesions; the olfactory groove meningioma can be slightly rotated to the opposite side and tilted more to the opposite shoulder; when the pterygoid point approach and longitudinal fissure approach are used to jointly investigate the tumor of the three ventricles, the head tilt and rotation should be reduced to a minimum. The tilt of the operating table and the height of the backboard can also be adjusted to adapt the head position to the needs of the approach.
About postoperative drainage tube
Epidural or subcutaneous drains may not be placed after complete hemostasis of the locked-hole surgery or other small incisions.
For traditional pterygoid approach, suboccipital approach, posterior median approach and distal lateral approach, epidural drains can be placed for 48-72 hours after surgery;
For intracerebroventricular tumor surgery (except for four ventricles), subdural drainage tube is placed for 48-72 hours after subdural hematoma removal or drainage;
Subdural drains may not be placed after complete hemostasis in microsurgery for cerebral hemorrhage, but they may be placed in case of emergency.
After complete hemostasis of non-intracerebral tumors, subdural drains are usually not placed.
One tip for scalp incision. Instead of cutting through the entire scalp at once and in a vertical plane, the scalp should be cut in layers, with the next level of tissue pushed 0.5 cm to the side of the flap, as shown in the figure below. The advantages of doing this are: 1 The bleeding point can be easily seen when the scalp is cut, and the assistant does not have to help hold the scalp to find the bleeding point. 2 The dural suspension can be easily sutured to the periosteum without the feeling of laxity. Thus, the dural suspension time can be reduced.3 It is easy to suture the periosteum to the periosteum and the muscle to the muscle when closing the skull. If the scalp incision is made on the same vertical plane, due to the retraction of the periosteum, the assistant is needed to help hold the muscle and the scalp to expose the periosteum, and the suture will feel awkward and unstable when it is closed. With the above-mentioned incision method, there is no such embarrassment, thus reducing the cranial closure time.
Some good habits for scalpotomy to reduce bleeding.
Scalp incision to peel the flap after bleeding is often more, some people take bipolar electrocoagulation to see where the bleeding is electrocoagulated, making a mess, stopping bleeding for a long time, the effect is not good, but also make the operating field buried. In addition to playing water before cutting the scalp, but also to develop good surgical habits. After turning the flap over first do not stop the blood of the flap, but cover the flap with wet gauze, then fold down, the blood of the flap naturally does not come out. At this time, electrocoagulation of the periosteal side is started, with the order of electrocoagulation from the high to the low side. The post-electrocoagulation site is covered with gauze. After stopping the bleeding, the skull is covered with brain cotton and then the gauze is removed from the flap and the bleeding is seen by gently lifting the flap to stop the bleeding in an orderly manner. When the flap is fixed after stopping the bleeding, the blood-stained brain cotton is removed and a clean operative field will be found.
Tips for scalp injection.
Scalp layered injection is done almost every day, and I know the following tips: use a longer 7-gauge trocar needle instead of a general needle, fan-shaped radial layered injection, which can reduce the number of scalp needle eyes, generally 3-4 flaps. Injecting a mound in the skin before removing the needle after each injection can avoid bleeding from the needle eye.
About electric knife
Do many people have this feeling, when using the electric knife always can not cut the tissue, the harder the more not. Electrocoagulation is also the same, the clamped blood vessels just do not clot. Why? Oh! In fact, it is too hard, the current conduction is not, no spark. To use the spark to cut, not the tip of the knife! Coagulation is the same, you can not stick to the blood vessels again, is the use of sparks !!!!! There is no common feeling it?
The first thing you need to do is to do a subdural hematoma on one side, with an epidural hematoma on the opposite side, and the midline is skewed toward the epidural hematoma side.
In this kind of patient, if the subdural hematoma is done first, intraoperative sudden enlargement of the contralateral epidural hematoma often occurs after decompression on the side of the subdural hematoma, thus causing intraoperative acute brain bulge and severe brain damage. Therefore, for such patients, we usually do the epidural hematoma side first after whole head disinfection, suspend the dura, take care not to cut the dura and retract the bone flap, and then operate on the subdural hematoma side. The epidural flap can wait for the contralateral side to be sutured after surgery to save time. This usually takes little time in skilled cases and can avoid serious consequences.
Depending on the situation, the causes of epidural hematoma formation should be analyzed. After decompression of the subdural hematoma side in the following cases, attention should be paid to the possibility of a dramatic increase in the hematoma 1, fracture line across the main trunk or major branches of the middle dural artery, 2, depressed fracture with significant fracture line misalignment, and 3, fracture line across the sinus cavity. In the above case support the epidural hematoma side first. In this case
Although the epidural hematoma is small, the removal substantially reduces the intracranial pressure according to the intracranial pressure curve, and the intracranial pressure is redistributed, avoiding the epidural hematoma side, as the hematoma collects and increases after decompression.
In the case of hemorrhage from a linear fracture plate barrier, the subdural hematoma side with more hematoma can be done first.
It is true as stated. But what about in cases where the midline structures have shifted to the EDH side? That is the point of the question. My opinion is that the general rule that an epidural hematoma has the potential to expand should be fully considered, based on a combination of factors such as the duration of the patient’s disease, the level of intracranial pressure and the lesion responsible for producing the cranial hypertension. Similar to this question, in the presence of both significant supratentorial, and infratentorial standing lesions, is the surgical procedure to deal with the infratentorial lesion first?
In the presence of both significant supratentorial and infratentorial standing lesions, is the surgical procedure to deal with the infratentorial lesion first?
Treating the subdural lesion first can cause further herniation of supratentorial brain tissue into the cerebellar curtain notch. This causes compression of vital structures and, furthermore, affects respiratory and circulatory function. It is obvious that supratentorial standing lesions should be treated first.
However, the management of lesions on both sides of the superior curtain involves different situations.
In cases where there is a midline shift, the most serious situation the patient faces is an overall increase in intracranial pressure, which is the first issue to be addressed. The epidural hematoma removal takes a short time, and after removal, the overall intracranial pressure is lowered to some extent, providing the time for resuscitation of the contralateral hematoma removal, and the brain is better supplied with blood and improved ischemia after the intracranial pressure is lowered, avoiding severe herniation of the brain; the disadvantage is that the brain is shifted to some extent toward that lateral approach, and this shift damages to some extent the medial structures, such as the lower extremity muscle strength is affected. This possible damage is much less severe than that caused by an epidural hematoma that expands sharply and causes brain bulge. Clinically, we often see that after the appearance of brain bulge, it is difficult to deal with, even though we consider the epidural hematoma due to rapid expansion, but then the brain is severely bulging has caused serious brain damage, the contralateral hematoma is often not urgent to remove. Yesterday, we had a case in our department where the right frontal lobe was decompressed and the brain expanded rapidly, so we had to end the case hastily because we couldn’t explore the distal part in a hurry.
As mentioned above, whether or not to do that side first should be considered in the context of the patient’s condition, weighing the possibility of a dramatic expansion of the epidural hematoma after decompression. In cases where there is a high likelihood as I described above, the epidural hematoma should be done first. In the less likely cases, the subdural hematoma should be done first and prepared for a contralateral craniotomy.
In addition, it is not necessary to remove the responsible lesion for cranial hypertension in order to reduce intracranial pressure; according to the pressure curve, in the case of cranial hypertension, removal of any lesion can significantly reduce intracranial pressure. The important thing to consider is to clarify the sequence of lesions.
In clinical RBR, the risk-benefit ratio is an important guiding factor.
Please consider, how damaging is acute brain bulge to the brain, is it manageable when it arises, and can it be managed in a timely manner? Is it tricky to deal with when it arises?
I have the impression that most domestic neurosurgeons approach the ventricular puncture with the needle direction mostly toward the bilateral external auditory canal line. However, during my study abroad, I found that they mostly inserted the needle in the direction of the first 1 cm of the external auditory canal. Through my clinical trial, I found that this puncture method can place the drainage tube near the interventricular foramen and facilitate the drainage of the third and fourth ventricles. In patients with cerebral hemorrhage breaking into the ventricles, especially those with casts in the third and fourth ventricles, the drainage effect is often very good.
Severe intraoperative acute cerebral bulge occurs in some patients even after complete removal of the hematoma. Its most common in patients with acute subdural hematoma combined with hypotension and hypoxia. We describe below the systematic approach to this problem. First, the correct position of the endotracheal tube should be further confirmed, and an arterial blood gas analysis should be performed. paO2 should be higher than 100 mmHg and paCO2 30-35 mmHg. elevate the head in the surgical bed to minimize head and neck rotation. Severe hypertension should be controlled, while mild hypotension should also be avoided, as lower blood pressure often causes a significant increase in intracranial pressure. After these measures, further anesthetic sedatives, inotropes, and mannitol should be given, and a ventriculotomy should be performed to release cerebrospinal fluid. The presence of invisible hemorrhage leading to the development of contralateral or ipsilateral intracranial hematoma must be confirmed. If conditions permit, intraoperative ultrasonography is feasible, and contralateral drilling for exploration is also feasible. For particularly persistent cases, barbiturate therapy is feasible: intravenous pentobarbital 10 mg/kg for 20-30 min. Alternating short-acting general anesthetics etomidate and propofol are given to effectively lower intracranial pressure. If the patient is at risk of hypotension, etomidate may be applied, while propofol and pentobarbital may significantly lower the patient’s blood pressure. The application of cerebroprotective agents is discussed in other parts of this chapter.
If the bulging brain persists despite these measures and no clear cause is found, further surgical decompression should be performed and the cranial CT should be reviewed; if intraoperative CT or intraoperative ultrasound findings are confident that there is no intracranial occupying lesion, anterior temporal lobectomy and medial temporal lobe repositioning of the herniated brain are feasible. In a group of 10 patients with severe unilateral cerebral hemisphere bulging who underwent total temporal lobectomy, 7 of them recovered well, with the option of intraoperative debridement or placement of a bone flap under the scalp to obtain more adequate decompression. Alternatively, a temporary bone flap may be placed under the abdominal skin for later application during skull repair. The use of a large bone flap for decompression is still controversial. Early studies did not support the use of large bone flaps, and more recently, Miller and Gaab and colleagues showed that large bone flap decompression is indicated in patients younger than 40 years of age with unilateral cerebral bulge. gaab reported 34 patients of this type with decompression and dural expansion using a decorticated frontotemporoparietal large bone flap, with 68% recovering well and 15% dying. Postoperatively, intracranial pressure was significantly reduced. Cranial CT should be performed immediately postoperatively even if no obvious cause of intraoperative brain bulge is found.
The approach to the paranasal sinus must be gentle. Although it is an epidural hemorrhage, arachnoid granular seepage can affect the mood of the operation if it is severe! For this type of hemorrhage you must not rush the operation and blindly stop the bleeding, but must carefully identify the bleeding point, press it with gelatin sponge and cotton pad, carefully suspend the dura, and use hemostatic gauze if necessary! Anxious words may lead to serious bleeding or even damage to the sinus.