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and Procedur of
Craniotomy
CEREBELLUM
CEREBRUM.
BRAINSTEM
SURFACE OF BRAIN
DEEP STRUCTURES
Hypothalamus
Pituitary gland
Thalamus
Pineal gland
MENINGES
The brain and spinal cord are covered and protected
by three layers of tissue called meninges.
From the outermost layer inward they are:The Dura
mater, Arachnoid mater, and Piamater.
Ventricles and Cerebrospinal fluid
The brain has hollow fluid-filled cavities called
ventricles. Inside the ventricles is a ribbon-like structure
called the choroid plexus that makes clear
colorless cerebrospinal fluid. CSF flows within and
around the brain and spinal cord to help cushion it from
injury. This circulating fluid is constantly being
absorbed and replenished.
Nervous system
The nervous system is divided into central and peripheral
systems.
That branch from the spinal cord and cranial nerves that
branch from the brain.
Cranial nerves
THE TWELVE CRANIAL NERVES
I olfactory Smell
II optic sight
Blunt(Closed) Penetrating
2 physician consent
Spinal precautions
◦ May need to log roll patient
Scalp Wounds
1. shave at least 3 cm around the wound
2. gently palpate the laceration with a gloved
finger. This may provide information regarding
an underlying fracture
3. if a fracture is found unexpectedly, do not
remove bone fragments: contact your
neurosurgeon at once.
4. Scalp wounds may bleed profusely and cause
hypertension. Secure haemostasis by pressure or
suturing early
5. if the wound edges are badly torn, excise non –
viable scalp and where possible suture the scalp
in two layers
Seldom used by neurosurgeons in CT era
Position supine
Shave entire head & drape to allow access to frontal, parietal,
& temporal areas
Burr holes typically on side of localizing neuro findings –
ipsilateral to dilated pupil or skull fracture, contralateral to
abN motor response
◦ If no hematoma found on suspected side, other side should be
explored
Initially burr hole placed in temporal region 2.5 cm above
zygomatic arch
Following dx of either ASDH or EDH, 2 additional burr holes
can be appropriately placed in parietal & frontal regions
Skin incision should be made in such a manner that if formal
craniotomy required, they can be joined to form skin flap
Scalp Incision
◦ Large question mark incision starting
1 cm in front of tragus at zygomatic
arch & curved backward & upward
above auricle to reach midline,
carried forward to frontal region
◦ Raney clips along skin edges
◦ Bovie incision in superficial temporal
fascia & temporalis muscle down to
the bone, close to margin of skin
opening
◦ Myocutaneous flap reflected
inferiorly
Dural Opening
◦ Opening in U-shaped fashion & flap
towards midline to avoid damaging
parasagittal bridging veins
◦ Alternatively, cruciate opening
Closure
◦ Meticulous hemostasis
◦ Dural tack-up sutures 2.5 cm apart
in circumferential fashion & central
tack-up suture in bone flap
◦ +/- drain
QUESTION
?
Dr. dr. Farhad Bal’afif, SpBS(K)
Bedah Saraf – FKUB / RSUD Dr Saiful Anwar
Malang
Hydrocephalus is the medical term for a
condition that is commonly called “water on
the brain.”
It is a combination of the Greek word “hydro,”
which means water and “cephalus” which
means head.
However, the liquid involved in hydrocephalus
is not really water at all, it is cerebrospinal
fluid or CSF.
CSF looks like water, but it contains
proteins, electrolytes, and nutrients that
help keep your brain healthy.
The most important purpose of CSF is to
cushion your brain and spinal cord against
injury.
Your brain produces about 1 pint of CSF per
day.
It circulates through a network of tiny
passageways in your brain, and ultimately
into your blood stream where it is absorbed
by your body.
Hydrocephalus occurs when the delicate
balance of CSF production and absorption is
disrupted and CSF builds up in the brain.
This build-up of CSF causes the brain to
swell, and for pressure to increase inside the
skull, resulting in nerve damage.
People who are born with hydrocephalus have a type
of hydrocephalus called congenital hydrocephalus.
It is usually caused by a birth defect or by the brain
developing in such a way that the cerebrospinal fluid
(CSF) in the brain cannot drain properly.
Most cases of hydrocephalus (more than 70%) occur
during pregnancy, at birth, or shortly after birth.
Causes of congenital hydrocephalus include:
Toxoplasmosis (an infection from eating undercooked meat,
or by coming in contact with infected soil or an infected
animal)
Cytomegalovirus (CMV, infection by a type of herpes virus)
Rubella (German measles)
A genetic disorder usually passed only from mother to son
Hydrocephalus can also develop later in life.
This type of hydrocephalus is called
acquired hydrocephalus, and it can occur
when something happens to prevent the
CSF in the brain from draining properly.
Causes of acquired hydrocephalus include:
Blocked CSF flow
Brain tumor or cyst
Bleeding inside the brain
Head trauma
Infection (such as meningitis)
A shunt is a piece of soft, flexible
plastic tubing that is about 1/8-
inch (3mm) in diameter.
Causes :
- congenital.
- degenerative.
- trauma.
aging process (most
common cause ).
herniated discs. (fig)
bone and joint
enlargement.
spondylolisthesis.
bone spurs.
Initial
Tx in most cases is
conservative.
◦ Rest.
◦ Weight loss.
◦ Epidural steroid injections.
◦ Analgesia.
◦ Anti-inflammatory agents.
◦ Muscle relaxant -if needed-
◦ Physiotherapy.
Spine surgery:
used when conservative treatment failed.
-laminectomy (removing bone behind the spinal
cord)
-foramenotomy (removing bone around the
spinal nerve).
-discectomy (removing the spinal disc to relieve
pressure).
Complications:
Dural tears.
Infections.
Instability of the spine.
Epidural abscess
◦ Usually bacterial
( staphylococcus is
common).
◦ Spread through:
hematogenous
Adjacent focus.
Direct inoculation.
• immunodeficiency
•AIDS.
•Alcoholism.
•Chronic renal failure.
•Diabetes mellitus.
•Intravenous drug abuse.
•Malignancy.
TRANSPORT :
ONCE STABILIZED REFER TO LEVEL 1 TRAUMA
CENTRE
TRENDELENBURG POSITION
LONG JOURNEY CONSIDER : NGT, IV LINE, URINARY
CATETHER
CME UI ‘05
CME UI ‘05
THE IN-HOSPITAL MANAGEMENT
EVALUATION OF A, B & C
PaO2 > 100 mmHg and PaCO2 < 45 mmHg
MAINTAIN BP > 90 mmHg
TREAT NEUROGENIC SHOCK !
Rupture of the disc or
prolapse as it is
usually called, can
press on the spinal
cord and its nerve
roots leading to pain,
numbness and
weakness and may
also affect the control
of bowel and urinary
bladder.
Dx: X-ray, CT scan or
MRI.
Initial Tx in most cases is
conservative.
◦ Rest.
◦ Analgesia.
◦ Anti-inflammatory agents.
◦ Muscle relaxant -if needed-.
◦ Physiotherapy.
laminectomy, involves excision of a portion
of the lamina and removal of the protruding
disk.
spinal fusion, may be necessary to overcome
segmental instability.
Laminectomy and spinal fusion are
sometimes performed concurrently to stabilize
the spine.
Microdiskectomy, can also be used to
remove fragments of nucleus pulposus.
Chemonucleolysis: Injection of the enzyme
chymopapain into the herniated disk produces
a loss of water and proteoglycans from the
disk, thereby reducing both the disk’s size
and the pressure in the nerve root.
Spondylolisthesis
is a condition in
which the there is a
defect in a portion
of the spine,
causing vertebra to
slip to one side of
the body.
Non-surgical treatment may include one or
a combination of:
- NSAID’s (e.g. ibuprofen, COX-2 inhibitors)
- Oral steroids
- Physical therapy
- Manual manipulation (e.g. chiropractic
manipulation).
CME UI ‘05
SUB AXIAL CERVICAL SPINE INJURIES
CME UI ‘05
SUB AXIAL CERVICAL SPINE INJURIES
CME UI ‘05
SUB AXIAL CERVICAL SPINE INJURIES
CME UI ‘05
QUESTION
?