Traditional craniotomy versus current minimally invasive surgery for spontaneous supratentorial intracerebral haemorrhage:A propensity-matched analysis

BACKGROUND Minimally invasive surgery(MIS)and craniotomy(CI)are the current treatments for spontaneous supratentorial cerebral haemorrhage(SSTICH).AIM To compare the efficacy and safety of MIS and CI for the treatment of SSTICH.METHODS Clinical and imaging data of 557 consecutive patients with SSTICH who underwent MIS or CI between January 2017 and December 2022 were retrospectively analysed.The patients were divided into two subgroups:The MIS group and CI group.Propensity score matching was performed to minimise case selection bias.The primary outcome was a dichotomous prognostic(favourable or unfavourable)outcome based on the modified Rankin Scale(mRS)score at 3 months;an mRS score of 0–2 was considered favourable.RESULTS In both conventional statistical and binary logistic regression analyses,the MIS group had a better outcome.The outcome of propensity score matching was unexpected(odds ratio:0.582;95%CI:0.281–1.204;P=0.144),which indicated that,after excluding the interference of each confounder,different surgical modalities were more effective,and there was no significant difference in their prognosis.CONCLUSION Deciding between MIS and CI should be made based on the individual patient,considering the hematoma size,degree of midline shift,cerebral swelling,and preoperative Glasgow Coma Scale score.

Endoscopic Assisted Eyebrow Craniotomy for Anterior Cranial Fossa Lesions: Clinical and Cosmetic Outcomes

Background: The eyebrow supraorbital keyhole approach could be considered a modified minimally invasive model for the classic pterional subfrontal approach in which an eyebrow incision and supraorbital mini craniotomy are performed for exposure of the anterior cranial fossa corridor. Methods: This study was retrospectively conducted on twenty four patients, age ranging from 20 to 65 years old, with anterior cranial fossa lesions who were meeting the eligibility criteria for eyebrow craniotomy in the period from August 2019 to January 2023. These patients were operated through eyebrow supraorbital approach in which microscopic endoscopic assisted technique were used. Extent of resection, clinical and cosmetic outcomes and complication incidence were assessed. Results: We included the twenty four patients who met inclusion criteria (17 females and 7 males) their ages ranged from 20 to 65 years. The most common pathology was meningioma in 19 patients. Two patients experienced supraorbital loss of sensation and only one patient experienced palsy of frontalis branch of facial nerve. Frontal sinus was breached in 3 patients with no patient experienced postoperative CSF leak. Total excision was accomplished for 23 patients. Four patients who had preoperative visual compromise, improvement of visual acuity and field defects was observed in 3 patients. No major intraoperative complications occurred. All patients filled cosmetic satisfaction questionnaire during their outpatient visits. For the eyebrow supraorbital approach, no incision related intolerable pain, no craniotomy defects or irregularities, no cosmetic complaints nor limitation of jaw opening were reported, and only minor symptoms in the form of limited eyebrow elevation, swelling and numbness in the forehead. Conclusions: The eyebrow craniotomy could be used safely as a more cosmetic and minimally invasive approach for a variety of anterior cranial fossa lesions. Endoscopic assistance has been found very useful for deeply seated lesions and hidden residuals with minimal brain retraction which couldn’t be accessed easily through microscopic field solely. Endoscopic assisted eyebrow supraorbital keyhole approach could be performed on a wider scale with great results but requires good selection of cases and more practice to expertise the needed skills.

Analysis of risk factors for postoperative deep vein thrombosis after craniotomy and nomogram model construction

BACKGROUND Deep vein thrombosis(DVT)of the lower extremity is one of the most common postoperative complications,especially after craniocerebral surgery.DVT may lead to pulmonary embolism,which has a devastating impact on patient prognosis.This study aimed to investigate the incidence and risk factors of DVT in the lower limbs following craniocerebral surgery.AIM To identify independent risk factors for the development of postoperative DVT and to develop an effective risk prediction model.METHODS The demographic and clinical data of 283 patients who underwent craniocerebral surgery between December 2021 and December 2022 were retrospectively analyzed.The independent risk factors for lower extremity DVT were identified by univariate and multivariate analyses.A nomogram was created to predict the likelihood of lower extremity DVT in patients who had undergone craniocerebral surgery.The efficacy of the prediction model was determined by receiver operating characteristic curve using the probability of lower extremity DVT for each sample.RESULTS Among all patients included in the analysis,47.7%developed lower extremity DVT following craniocerebral surgery.The risk of postoperative DVT was higher in those with a longer operative time,and patients with intraoperative intermittent pneumatic compression were less likely to develop postoperative DVT.CONCLUSION The incidence of lower extremity DVT following craniocerebral surgery is significant,highlighting the importance of identifying independent risk factors.Interventions such as the use of intermittent pneumatic compression during surgery may prevent the formation of postoperative DVT.

Acute and Persistent Post-Craniotomy Pain: A Prospective 6-Month Follow-Up Questionnaire Study

Introduction: The incidence of acute pain after craniotomy differs remarkably in previous studies, and the prevalence of persistent pain is not precisely known. We conducted 6-month follow-up surveys on the incidence and intensity of acute and persistent pain after elective craniotomy. Methods: We carried out a prospective cohort study via a series of structured questionnaires to record acute pain intensity preoperatively and postoperatively, and the incidence of persistent pain 3 and 6 months after a craniotomy in a tertiary care center. Patients scheduled for elective craniotomy were interviewed the day before surgery, postoperatively before discharge from the hospital, and 3 and 6 months after surgery. Pain was assessed on a numeric rating scale (0 - 10) at rest and movement, as well as expectations of pain before surgery, efficacy of pain therapy, and satisfaction with pain treatment. The incidence of adverse events, sleep time and interruptions caused by pain, different pain types, and drugs used for pain treatment were also recorded. Results: A total of 152 patients were enrolled in the study and completed the preoperative questionnaire;123 (81%) completed postoperative questionnaire and 108 (72%) completed the 3- and 6-month follow-ups. The average pain score at the time of the postoperative questionnaire was moderate, 4 at rest and 5 upon movement. The percentage of patients experiencing mild pain at rest and upon movement was 52% and 49%, and moderate pain was 15% and 16%, respectively. Severe postoperative pain was detected in 5% and 8% of patients at rest and upon movement, respectively. Three months after surgery, 6% of patients reported mild pain at rest, 3% moderate pain at rest, and 1% severe pain at rest. Persistent mild and moderate pain at rest after 6 months was reported by 3% and 1% of patients, respectively. The most common adverse events were postoperative nausea and vomiting (11%) and abdominal discomfort (8%). During postoperative pain treatment in the intensive care unit or post-anesthesia care unit, 92% of patients received acetaminophen, 88% fentanyl, and 24% oxycodone. During neurosurgical ward care, ibuprofen was used in 61% of patients. Satisfaction with analgesia was high throughout the study period with a median satisfaction score of 9 postoperatively and 10 at 3 and 6 months on the 0 - 10 scale. Conclusion: The findings indicate that most patients experience moderate or mild pain after craniotomy, but patient satisfaction with pain treatment is high. Persistent pain after 3 and 6 months is rare and mild in nature.

Effects of Continuous Non-Invasive Blood Pressure Monitoring on Intraoperative Hemodynamics and Postoperative Myocardial Injury in Craniotomy:Comparison Between Groups Based on Self-Control and Propensity Score Matching

Objective:To explore the effect of continuous non-invasive blood pressure monitoring on intraoperative hemodynamics and postoperative myocardial injury in craniotomy.Methods:120 cases of elective craniotomy were divided into the self-control group(continuous non-invasive blood pressure monitoring and intermittent cuff non-invasive blood pressure monitoring,CNAP group)and propensity score matching group(only intermittent cuff non-invasive blood pressure measurement in previous craniotomy,PSM group);Goal-directed hemodynamic management in CNAP group included heart rate(HR),blood pressure(BP),stroke volume(SV),stroke variability(SVV),and systemic vascular resistance index(SVRI).The main index is to compare the troponin level within 72 hours after operation between the CNAP group and the PSM group;The secondary indicators are the comparison of the hemodynamic conditions between the CNAP group and the PSM at 10 specific time points.Results:The incidence of postoperative myocardial injury in the CNAP group was significantly lower than that in the PSM group(12%vs.30%,P=0.01);in the CNAP group hypotensive episodes(6 vs.3,P=0.01),positive balance of fluid therapy(700 vs.500 mL,P<0.001),more use of vasoactive drugs(29 vs.18,P=0.04),more stable hemodynamics medical status(P=0.03)were recorded.Conclusion:The hemodynamic management strategy based on continuous non-invasive blood pressure monitoring can reduce the incidence of myocardial injury after elective craniotomy and maintain a more stable hemodynamic state.

Brain Abscess Surgery Outcome: A Comparison between Craniotomy with Membrane Excision versus Burr Hole Aspiration

Introduction: Brain abscess represents 8% of intracranial masses in developing countries. Despite the advances in neuro-imaging, still, the diagnosis of brain abscess is difficult and may need a biopsy in most cases to verify the diagnosis because may even lead to death. CT scan with contrast is a good tool for diagnosing and localizing brain abscesses in late stages, however, it is difficult to diagnose them in the early stages. The development of MRI helps to more accurately diagnose brain abscess. Surgical management of brain abscesses is either medical or surgical through craniotomy or burr holes. Indications of each are still a point of debate among most neurosurgeons. Methodology: This is a descriptive longitudinal prospective study to compare the outcomes of two surgical procedures used in The National Centre for Neurological Sciences-Khartoum-Sudan (NCNS) from 2012 to 2015, craniotomy and excision of the abscess membrane versus burr hole and aspiration of brain abscess in terms of duration of hospitalization, length of antibiotic use, recurrence rate, number of images needed for follow-up, and the final postoperative early and late outcomes. The data was collected through a designed questionnaire and was then analyzed using SPSS version 20. No significant ethical approval was required for this study. Results: Fifty-four patients were operated on through craniotomy (29/54) and burr hole (25/54). Their ages ranged from 1 year to 53 years with an average presentation at 13 years of age. Most patients presented with fever (23.1%), convulsions (16%), vomiting (16.7%) and headache (15.4%). The mean of illness for both groups was almost 2 months. The majority of patients in this study were having no risk factors (38.9%) while the major risk factors seen were cardiac diseases (14.8%), neurosurgical procedures (13%) and otitis media (11.1%). As most patients presented late, the diagnosis of most was made using CT brain with contrast (83.3%). In most of the patients (85.2%) there were no organisms separated in the culture. 8/54 patients had positive cultures, 7/8 were bacterial and only one (1/8) was fungal. Most patients received antibiotics for 45 days postoperatively in both craniotomy and burr hole groups. When both groups were compared, those operated with craniotomy were found to have a relatively higher length of hospital stay, however, no significant difference was found between both groups. Also, it was found that those operated on with craniotomy had a high cure rate and less recurrence in comparison with burr hole group. Deterioration and death were significantly higher among craniotomy group. Only CT brain was used as the imaging modality of choice for follow-up in both groups for 4 months’ duration and it was noted that complete evacuation was significantly higher among craniotomy group while remnants were higher among burr hole group. Conclusion: Brain abscess is still a challenging condition for neurosurgeons in Sudan. The limited number of Sudanese neurosurgeons, neurosurgical centers and diagnostic facilities contributed to delay in diagnosing brain abscess in most patients. It is important to design a strict protocol and precautions for any neurosurgical operation or bedside procedure to prevent infection and subsequent brain abscess development. CT brain with contrast is a good imaging tool for assessing the size, site and stage of brain abscesses. No significant difference between craniotomy or burr hole for clearance from brain abscess in terms of antibiotic used or duration of hospital stay. However, burr hole aspiration is associated with higher rates of recurrences. On the other hand, craniotomy and excision have relatively higher neurologic morbidity postoperative with expectantly higher post-operative hospitalization but no differences in the final outcome. Therefore, the selection of surgical technique should be individualized in each case based on the abscess site size source patient fitness for surgery and neurosurgeon’s preference.

Awake craniotomy for auditory brainstem implant in patients with neurofibromatosis type 2:Four case reports

BACKGROUND The auditory brainstem implant(ABI)is a significant treatment to restore hearing sensations for neurofibromatosis type 2(NF2)patients.However,there is no ideal method in assisting the placement of ABIs.In this case series,intraoperative cochlear nucleus mapping was performed in awake craniotomy to help guide the placement of the electrode array.CASE SUMMARY We applied the asleep-awake-asleep technique for awake craniotomy and hearing test via the retrosigmoid approach for acoustic neuroma resections and ABIs,using mechanical ventilation with a laryngeal mask during the asleep phases,utilizing a ropivacaine-based regional anesthesia,and sevoflurane combined with propofol/remifentanil as the sedative/analgesic agents in four NF2 patients.ABI electrode arrays were placed in the awake phase with successful intraoperative hearing tests in three patients.There was one uncooperative patient whose awake hearing test needed to be aborted.In all cases,tumor resection and ABI were performed safely.Satisfactory electrode effectiveness was achieved in awake ABI placement.CONCLUSION This case series suggests that awake craniotomy with an intraoperative hearing test for ABI placement is safe and well tolerated.Awake craniotomy is beneficial for improving the accuracy of ABI electrode placement and meanwhile reduces non-auditory side effects.

Traumatic Acute Subdural Hematoma: Treatment by Evacuation with Decompressive Craniotomy and Cranioplasty, Case Series and Surgical Outcome Analysis

Background: Acute subdural hematoma (ASDH) is considered the most common traumatic brain mass lesion. Its prognosis is still grave despite the improvements in treatment modalities. Its mortality rate was reported to be around 60% until the 1990s. In the last decade, ASDH mortality rate was reduced to the level of 20% - 40%. Standard treatment to decrease intracranial tension via hematoma evacuation is associated with decompressive craniotomy and followed by ICU management. Objective: To evaluate the outcome and prognostic factors in patients of acute subdural hematoma treated by surgical evacuation and decompressive craniotomy. Also, outcome of cranioplasty by repositioning of patients own bone or by synthetic mesh methods is evaluated. Patients and Methods: It is one year retrospective study. It was conducted on 53 patients, in trauma unit, Assiut university hospitals. We report time lag between trauma and performed surgery, initial Glasgow coma scale (GCS), age, sex and presence of other intracranial pathologies. Outcome assessment is based on Glasgow outcome scale (GOS) and fol-low-up extended for 6 months. We include those patients with only (isolated) head trauma, shift of midline more than 5 mm in CT brain. We excluded pa-tients with GCS 3 and fixed dilated pupils as well as patients with GCS higher than 12. We did decompressive craniotomy and duraplasty in all patients. Bone flap of decompressive craniotomy is situated in the abdomen. All func-tionally recovered patients were submitted for cranioplasty with either re-placing patient own bone or by Titanium mesh. Results: We had 39 males and 14 females. Age ranged between 7 and 65 years old. 23 deaths, 10 persis-tent vegetative state, 10 severe disability, 8 moderate disability and 2 good recovery. The outcome analysis was based on 6 month follow-up. Conclu-sion: Acute subdural hematoma is a very serious condition. Mortality and morbidity is intimately related to GCS on admission. Presence of associated cerebral pathology increases mortality and morbidity of patients with post-traumatic acute subdural hematoma. Early evacuation of posttraumatic acute subdural hematoma with decompressive craniotomy is an important method to control raised intracranial tension, reduce shift of midline and very benefi-cial in decreasing mortality and morbidity. Regarding infection and avoiding bone flap resorption, Titanium mesh is better than patient own bone during cranioplasty after patient recovery.

Monitored anesthesia care for craniotomy in a patient with Eisenmenger syndrome:A case report

BACKGROUND Eisenmenger syndrome(ES)is an uncorrected congenital cardiac defect with a left-to-right shunt,leading to pulmonary arterial hypertension.Patients with ES are susceptible to hemodynamic alterations during noncardiac surgery with general anesthesia,which increases perioperative morbidity and mortality.Monitored anesthesia care(MAC)is often used during minor procedures in patients with cardiac disease.However,few reports on MAC in patients with ES exist.CASE SUMMARY A 49-year-old man was admitted for a severe headache lasting 30 d.He had been diagnosed with a large perimembranous ventricular septal defect(VSD)with bidirectional shunt flow and pulmonary arterial hypertension 10 years ago.A round mass in the right frontal lobe was revealed by Magnetic resonance imaging.Stereotactic aspiration using a neuronavigation system was performed under MAC.The patient was stayed in the hospital for 5 d,and discharged without complications.CONCLUSION MAC may be effective for craniotomy in patients with ES.

Delayed Airway Obstruction in Posterior Fossa Craniotomy with Park-Bench Position—A Case Report and Review of the Literatures

Background: Park-bench position is a commonly used position in patients operated with cerebellopontine tumor, microvascular decompression, or lesions of cerebellar hemisphere and vertebral artery. Several complications associated with this positioning have been described. However, the delayed airway complication resulting from park-bench position has been rarely reported in the literatures. Herein, we report a rare case of delayed airway obstruction after a posterior-fossa craniotomy with park-bench position for acoustic neuroma. Case presentation: A 43-year-old woman, who has a right acoustic neuroma, was placed in the park-bench position for a posterior-fossa craniotomy. The anesthesia and operation were performed smoothly. However, progressive swelling in the left neck with extending to left face occurred two hours after endo-tracheal extubation. Computed tomographic scan of neck revealed diffuse swelling of the muscles and deep soft tissue in the left side. No obvious embolization of vascular system including jugular vein was found in the sonography. Because of obstruction in upper airway, orotracheal intubation and a head-up position were performed. The clinical symptoms improved gradually since the third post-operative day. She was discharged with obvious complications on the 23rd day after the operation. Conclusion: The possible mechanisms may originate from the kinking of the jugular vein due to hyper-flexed neck position during surgery. To prevent such complication, we must take great care of the anesthetized patients when placed in the forced neck position and always keep this rare but so critical complication in mind.

Awake Craniotomy and Coaching

Background: The importance of monitoring cognition during awake craniotomy has been well described in previous studies. The relevance of being coached during such a procedure has received less attention and questions still remain unanswered about what factors are the most important herein. Objective: The aim of this study was to qualitatively analyze what factors were, according to our patients, important in being coaching during awake craniotomy. Methods: Twenty-six patients who underwent awake craniotomy received a questionnaire about their experiences during the procedure. The questions concerned different aspects of the pre-operative part, the operation itself and coaching aspects. Answers were qualitatively analyzed by two investigators and per question, different answer categories were made. Results: Two thirds of the 20 patients who responded to the questionnaire reported anxiety in the days before or during the operation, varying from general anxiety for being awake during surgery to anxiety for very specific aspects such as opening the skull. The constant presence of the neuropsychologist and a transparent communication during the procedure were most frequently (65% of all the answers) reported as helpful in staying calm. Conclusion: Results of this descriptive study show that patients experience different anxieties before and during an awake craniotomy and give more insight into what factors are important for patients in being coached during such an operation. This study gives directions for clinicians in improving their role as a coach.

Decompressive Craniotomy and Fast-Track Duraplasty in Acute Subdural Hematomas

Background: Traumatic subdural hematoma is one of the severe injuries to brain with high mortality rates. Dural opening is often associated with brain herniation against the dural edges due to associated edema that would lead to venous infarction. Aim: The objective of this study is to describe a technical note that would allow fast and effective closure of the dura after hematoma evacuation via duraplasty with analysis of the safety and competency of the technique. Subjects and Methods: The fast-track technique was implemented in 15 successive cases with acute subdural hematoma where the fascia lata flap was prepared and sutured to the planned dural incision before opening the dura, which allowed fast and effective closure of the dura before brain herniation. Subdural bridges were planned by using Gelfoam to prevent venous compression. Analysis of the technique effectiveness was performed by the operative detection of brain herniation, as well as clinical and radiological follow-up of patients. Results: All patients had a Glasgow coma score (GCS) below six before the operation. Mean time from trauma to surgery was five hours. The dura could be effectively closed with no brain herniation in all cases. Nine patients survived (60%), where five of them ended up in a vegetative state. Of these two recovered and three continued in a persistent vegetative state. The mortality rate was 40%. Post-operative infarction was detected in post-operative imaging of four patients. Conclusion: The fast-track duraplasty technique is fast and effective in prevention of brain herniation during surgery with favorable clinical outcome in comparison with the poor and severely deteriorated preoperative clinical presentation. More studies to evaluate the impact of the technique on the survival rate are warranted.

Management of Post-Craniotomy Persistent CSF Subgaleal Collection in Skull Base Procedures: Local Experience

Background: Post-craniotomy CSF collection is a problem that may cause severe complications as meningitis, wound disruption, prolonged hospitalization, and additional surgeries. Objective: To evaluate our cases with resistant post-operative subgaleal CSF collection, trying to identify causes and optimal management. Methods: Retrospective review of elective skull base cases during the period of January 2104 to January 2019 identification of cases with post-operative CSF subgaleal collection, which either managed conservatively or needed a second surgery. Results: 219 patients, 30 of them suffered subgaleal CSF collection, 22 patients improved with non-operative measures, eight patients needed second surgery with pericranial graft augmentation, and obliteration of subgaleal space resulted in resolution of CSF leak with no morbidities. Conclusion: Meticulous tensionless dural closure, obliteration of subgaleal space, tethering of dural grafts to bone edges are useful techniques in preventing post-operative CSF leak.

Double J Fixation after Craniotomy: Technical Description of a Modification Method for Bone Flap Fixation (Hiederov Method)

Background: Fixation of bone flap following craniotomy is usually achieved by synthetic materials. In rural and poor funding areas, innovation for cheap, safe and applicable material is needed. Purpose: The aim is to assess our new innovative technique in bone flap fixation against traditional techniques. Patients and Methods: The study was a prospective randomized controlled study enrolled at Al-Amal Hospital and Al-Ahly Bank Hospital from 2014-2019. Forty-eight patients were randomized in the study. Group A (24 patients) underwent titanium miniplate fixation while group B (24 patients) underwent our new technique. The new technique is double J tunnels performed by craniotome on either side of the bone (flap and skull sides), then a Prolene suture is passed through the shared stem of J’ holes and secured in the wrapped side of J’s holes and tying it tightly. Both techniques were examined against fixation time, rigidity, offset and final judgment postoperatively. Result: There was no statistically significant difference in using both techniques as regard fixation time. Our new technique was not inferior to the traditional one in achieving rigidity (p > 0.05). The final postoperative assessment was as equal as that seen in miniplate fixation. Conclusion: This technique is a simple, easy, cheap and effective method of fixing craniotomy bone flap.

Surgical site infections after elective craniotomy for brain tumor:a study on potential risk factors and related treatments

Background Surgical site infection(SSI)is a common complication following craniotomy that increases morbidity,mortality,and medical expenses.The objectives of this study were to determine the relevant risk factors associated with SSI after elective craniotomy for brain tumor and analyse the treatments for SSI.Methods A retrospective nested case-control study was conducted using data from patients who underwent craniotomy for brain tumor resection at the Neurosurgical Oncology Department No.6 of Beijing Tiantan Hospital,Capital Medical University,between January 2019 and December 2021.Risk factors for SSI were determined using multivariate logistic regression analysis.We analyzed microbiological and related treatment data for different SSI types.Results Among 2061 patients who underwent craniotomy for brain tumor,31 had SSI(1.50%).In the multivariate logistic regression analysis,body mass index(BMI)and operative duration were identified as independent risk factors for SSI.The most common microorganism isolated from SSIs was Staphylococcus epidermidis(22.9%),and drug sensitivity results showed that gram-positive bacteria were sensitive to linezolid,vancomycin and tigecycline,whereas gram-negative bacteria were sensitive to meropenem,cefepime and ceftazidime.Six of the seven patients who underwent bone flap removal due to osteomyelitis were infected with gram-negative bacteria.Conclusions BMI and operative duration were identified as independent risk factors for SSI.Diabetes mellitus,previous ratio therapy,type of incision,recurrence tumor and other risk factors were not found to be associated with the occurrence of SSI in this study.

Endoscopic surgery versus craniotomy in the treatment of spontaneous intracerebral hematoma:a systematic review and meta-analysis

Background:Spontaneous intracerebral hemorrhage(SICH)has high morbidity and mortality,with no clear standard of treatment available.Compared with the craniotomy approach,neuroendoscopy is a relatively minimally invasive treatment method,and may be an efficient alternative.Therefore,this meta-analysis aimed to assess the clinical efficacy of neuroendoscopy and craniotomy in SICH patients.Methods:The electronic databases Web of Science,PubMed,EmBase,MEDLINE,and the Cochrane Library were systematically searched.According to the PRISMA template,we finally selected and analyzed 14 eligible studies that evaluated neuroendoscopy versus craniotomy.Primary outcomes included operation time,intraoperative blood loss volume,evacuation rate,residual hematoma,complications,hospital stay duration,clinical outcomes,and other parameters.Results:A total of 4 randomized controlled trials(RCTs)and 10 retrospective studies(non-RCTs)involving 1652 patients were included in the final analysis.In the neuroendoscopy(NE)group,operation time(p<0.00001),intraoperative blood loss volume(p<0.0001),hematoma evacuation rate(p=0.0002),complications(p<0.00001),hospitalization days(p=0.004),and mortality(p<0.0001)were significantly different from those of the craniotomy(C)group,with a higher rate of good recovery compared with the craniotomy group(P<0.00001).Conclusions:These findings suggest that patients with SICH and physicians may benefit more from neuroendoscopic surgery than craniotomy.

Standard large trauma craniotomy for severe traumatic brain injury

Objective: To study the effect of standard large trauma craniotomy(SLTC) on outcomes of patients with severe traumatic brain injury (TBI) (GCS≤8). Methods: 230 patients with severe TBI were randomly divided into two groups. 115 patients underwent SLTC (10 cm×12 cm) as an SLTC group, and other 115 patients underwent temporo parietal or fronto temporal craniotomy (6 cm×8 cm) according to the position of hematomas as a routine craniotomy (RC) group. Other treatments were identical in two groups. According to Glasgow outcome scale (GOS), the prognosis of the patients was evaluated and the complications were compared between two groups. Results: 27 patients got good outcome and moderate disability ( 23.5 %), 40 severe disability and vegetative survival ( 34.8 %), and 48 died ( 41.7 %) in SLTC group. 21 patients got good outcome and moderate disability ( 18.3 %), 28 severe disability and vegetative survival ( 24.3 %), and 66 died ( 57.4 %) in RC group. The incidence of incision hernia was lower in SLTC group than in RC group. However, the incidence of operative encephalocele, traumatic epilepsy and intracranial infection were not different in two groups. Conclusions: Standard large trauma craniotomy significantly reduces the mortality of patients with severe TBI without serious complications, but does not improve the life quality of the patients.

Comparison of standard large trauma craniotomy with routine craniotormy in treatment of acute subdural hematoma

Objective: To compare the therapeutic effect and indication between standard large trauma craniotomy and routine craniotomy. Methods: There were 97 patients in the standard large trauma craniotomy group and 110 patients in the routine craniotomy group. The mortality, postoperative ICP (intracranial pressure), ratio of pupil rebound, complication and results of six month follow up after operation were compared between the two groups. Results: Fifteen patients ( 15.6 %) died in the standard large trauma craniotomy group and 30 ( 27.7 %) in the routine craniotomy group. The postoperative mean ICP was 3.75 kPa±1.89 kPa in the standard large trauma craniotomy group and 5.11 kPa±1.57 kPa in the routine craniotomy group. The pupil rebound was found in 47 patients ( 61.0 %) in the standard large trauma craniotomy group and in 41 patients ( 46.1 %) in the routine craniotomy group (P< 0.01 ). The rate of complication was lower in the standard large trauma craniotomy group, but no obvious difference in long term therapeutic effect was found between the two groups. Conclusions: Standard large trauma craniotomy can attenuate brain hernia and the mortality of the patients with acute subdural hematoma . The incidence of complication can also be decreased. But the long term life quality of the patients can not be improved.

Burr-hole craniotomy treating chronic subdural hematoma： a report of 398 cases

Objective： To investigate the treatment of chronic subdural hematoma （CSDH） with burr-hole craniotomy in our hospital. Methods： From January 2004 to December 2009, 398 patients with CSDH, 338 males and 60 females （male/ female=5.63/1）, received burr-hole craniotomy in our hospital. The median age was 60 years with the mean age of （58.1± 18.1） years, （65.0±14.5） years for females and （57.0± 8.2） years for males. Trauma history was determined in 275 patients （69.1%）. Burr-hole craniotomy was performed under local anesthesia in 368 patients and general anesthesia in 30 patients. CSDH was classified into 3 groups according to the density on CT scan. Clinical data concerning etiologies, symptoms and signs, concomitant diseases, diagnosis, therapies and outcomes were investigated retrospectively. Patients＇ neu- rological status on admission and at discharge was also classified to judge the outcomes. Results： Generally, trauma history showed few dif- ferences between those over 60 years old and under 60 years old, but showed obvious differences when gender was taken into account. Totally 123 male patients （60.0% of 204 cases） suffering from head injuries were under 60 years, whereas 35 female patients （85.4% of 41 cases） with trauma histories were over 60 years. The duration from trauma to appearance of clinical symptoms was （84.0±61.7） days （range, 0-1493 days）. Traumatic accident was the leading etiology, other accompanying diseases such as cerebral vascular disease, hypertension, etc, were also predisposing factors. Commonly, the elderly presented with hemiplegia/ hemidysesthesia/hemiataxia and the young with headache. Most CSDH patients （95.6%） treated with burr-hole cran- iotomy successfully recovered. However, postoperative complications occurred in 17 cases, including recurrence of CSDH in 15 cases, subdural abscess in 1 case and pneumonia in 3 cases. Conclusion： Burr-hole craniotomy is an easy, efficient and reliable way to treat CSDH.

Large bone-flap decompressive craniotomy for treatment of serious craniocerebral injury associated with cere- bral infarction

Objective： To elucidate the therapeutic effect of subtemporal decompressive craniotomy with large flap resection on serious craniocerebral injury associated with cerebral infarction. Methods： Forty-eight cases of serious head injury accompanied by cerebral infarction were classified into two groups with each having 24 cases： treatment group, in which large bone-flap decompressive craniotomy was performed; control group, in which routine craniotomy and hematoma evacuation were adopted. The status of cerebral infarction pre- and post-operation, as well as the curative effect 3 months after operation were comparatively analysed be- tween the two groups. Results： There was no significant difference regard- ing the status of cerebral infarction on the first day after operation; while one week after operation, the size of cere- bral infarction was significantly smaller in treatment group than control one （P〈0.05）. Postoperative 3 months, the mor- tality rate was 20.8% in treatment group, being evidently superior to that of control group （33.3%, P〈0.05）. The mo- derate disability （good and fair） rate was 41.7% in treatment group, significantly higher than that in control group （25.0%,P〈0.05）. Conclusion： Large bone-flap decompressive cran- iotomy is confirmed effective and hence it offers us a prefer- able alternative of treatment by which to reduce disability and fatality rates for patients with serious head injury ac- companied by cerebral infarction.