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All Posts Tagged: Trepanation

Craniotomy in an awake patient

For several years now, with the great progress in anaesthesiology, neurophysiology and neurosurgery, it has been possible, and extremely beneficial for the patient in certain surgical procedures, to perform brain surgery without general anaesthesia.

This is technically possible, because of a truly spectacular event: The brain itself does not “feel” anything! So what this means in practice is that if we can somehow get there (by opening the anatomical structures that protect it, such as the skull bone for example), without causing pain, then we can remove a lesion (a tumour for example) from inside the brain without injuring the delicate neural circuits that control vital functions such as speech, understanding speech, body movement etc.

When this knowledge is combined with the use of neuronavigation technology (a system that directs us in the operating room, in real time, to a predetermined anatomical point within the brain), then, with minimal intervention, we can truly achieve miraculous surgical results without significant risks to the patient’s health and neurological condition.

You may have seen documentaries where a surgeon intervenes in a patient’s brain while they are talking, playing a musical instrument, singing, or moving their limbs. The point of such an intervention is not to show that it is technically possible or to impress with the progress of science. The point is that the area of damage is very close to an important functional area of the brain that controls a very important activity, such as fine finger movement. Thus, a musician, after the operation to remove the affected area, can continue his professional activity and maintain the great skills he has acquired with great effort during his life.

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Intracerebral hematoma (contusion)

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Post-traumatic intracerebral hematoma occurs following TBI. It may not be accompanied by a skull fracture. Its diagnosis is made by CT. Clinically, the patient presents with neurological symptoms such as disturbances of the level of consciousness, peritraumatic amnesia, disorientation, agitation, drowsiness, weakness of one side of the body, and other symptoms. If the contusion is limited and the neurological image is good, no surgery is required, only hospitalization for a few days and a repeat CT scan. However, if the symptoms are severe or worsen, surgical removal of the hematoma is required to decompress the brain. Permanent removal of part of the skull bone may be required to create enough space in the brain and to treat cerebral edema (swelling of the brain). Sometimes fractures are fatal despite surgery, or they may leave the patient with severe permanent disability.

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Skull fractures

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Skull fractures occur following a head injury and are diagnosed by a simple skull x-ray. Following that, a cerebral CT scan should always be performed, in order to rule out the coexistence of hematoma under the skull, which can put pressure on the brain and be life-threatening for the patient. If there is no hematoma, surgery is not required unless the fracture has displaced the bone inside the skull, exerting pressing on the brain (depressed cranial fructure). Therefore, the depressed cranial fracgture is restored with surgery, unless it is very small. If the head injury in the fracture area is open, then the fracture is called complicated and it requires surgical treatment to remove any foreign bodies to prevent infection. The patient is hospitalized for a few days in order for the patient’s neurological image to be monitored. In simple fractures, 1-2 days of hospitalization are enough for simple follow-up.

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Epidural hematoma

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This is a hematoma that forms under the bones of the skull, including the meninges of the brain. These hematomas usually occur following a fracture of the skull bones and are usually due to bleeding of the arteries running between the meninges and the bone, in the fracture area. The diagnosis is made by cerebral CT. It is more common in young people. If not diagnosed and operated on immediately, this can be fatal. The symptoms include severe headache, vomiting, drowsiness, loss of consciousness, neurological deficit (weakness of one side of the body), and after their onset, symptoms usually progress rapidly. If diagnosed early, symptoms are relieved via a simple craniotomy, which has a very good prognosis.

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Acute subdural hematoma

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Unlike the chronic subdural hematoma, acute subdural hematoma is a very severe condition with approx. 50% mortality. It is commonly seen in severe traumatic brain injuries and may coexist with other lesions, such as epidural hematoma and intracerebral hemorrhage. Clinically the patient’s neurological picture is poor, and if the hematoma is not removed, the patient rapidly progresses. In some cases, if the hematoma is small, does not cause displacement of the brain and the neurological image is good, the patient can be monitored in the hospital, having a clinical evaluation of his neurological clinical image and a repeat CT in a few days to see if the hematoma is absorbed. In such cases, it may develop into chronic hematoma.
Surgery, when required, removes the hematoma and usually one or more injured veins are identified in the area between the meninges and the brain. After surgery, the patient may be required to remain in the intensive care unit to treat and prevent possible cerebral edema and ischemia. Older people have a worse prognosis, and use of anticoagulants before the injury has a negative effect on the prognosis. Many of the surviving patients present with severe disabilities, and their recovery process is long and painstaking.

 

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Arteriovenous malformations

Arteriovenous malformations of the brain and spinal cord are classied as a category of diseases that involve the morphology of blood vessels. These are congenital anomalies and may involve arteries, veins, or even small (capillary) vessels. They can be imagined as a tangle of vessels, irregularly intertwined. The vessel wall is often fragile, or there may be communication between one vessel with vigorous blood flow and another whose wall is thinner, and therefore more vulnerable. The result is frequent hemorrhaging from these formations, causing hemorrhagic strokes. Typical arteriovenous malformation includes the vessels that carry blood to the area, the central formation (nidus, meaning nest) and the vessels that take blood away. Usually, the brain tissue is outside of these formations. Frequently, these malformations are manifested by seizures, due to the constant irritation of the brain by these vessels and their hemorrhaging.

Symptoms

Due to their morphology and the fact that they since birth, they bleed much more often than aneurysms, and they start at a younger age (about 10 years earlier). Their mortality is lower than aneurysms (~ 10%), but their morbidity is similar (30-50% chance of permanent neurological damage in every hemorrhage). They can manifest with chronic headaches, which may seem like migraines. It is a common cause of epilepsy, and may present with other neurological symptoms, either temporary or permanent, due to the fact that they can ‘steal’ quantities of blood that would otherwise perfuse the brain tissue (Subclavian Steal Syndrome).

Diagnosis

The diagnosis is possible via computed tomography and magnetic resonance imaging. Digital angiography or spinal cord angiography may also be required. If the CT scans are carried out after the bleeding, the malformation may not be obvious within the hematoma. Therefore, intracerebral spontaneous (not traumatic) hemorrhaging in a young person raises the suspicion of vascular malformation.

Treatment

Some of the symptoms are treated with medication. If this is not possible, or if the possible hemorrhaging is significant, then invasive treatment is required. This does not necessarily mean surgery

Surgical Treatment

Removal of malformations, in the case that they do not share vascularity with normal tissue (brain or spinal cord) is the most effective treatment. In the case that there are veins in the brain that drain blood from both the lesion and the brain or spinal cord, then removal is more complicated. There are cases of epilepsy where in order to treat the seizures, both the malformation and the part of the brain that is subject to the chronic injury must be removed, and therefore it has become the cause of the seizures. Of course, this should have been clearly demonstrated through preoperative neurophysiological examination. If surgery needs to be avoided, there are alternative treatments.

Embolization, Stereotactic Radiosurgery

The embolization is performed either in combination with the surgery (usually preoperatively) or independently, although in that case, the results are usually insufficient. In the case of radiosurgery (γ-knife), the results are better, and the goal can be achieved with a minimally invasive method. Its disadvantage, however, is that it is slow-acting (up to 2 years after surgery), so in the meantime, the risk of hemorrhaging remains.

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