For the past 50 years the pterional craniotomy has been the standard approach for anterior circulation aneurysms. However, this is a major procedure. As the trend is towards minimally invasive surgery generally, we have been developing a minimally invasive approach for anterior circulation aneurysms - the supraorbital microcraniotomy. We present first 50 patients who underwent this operation after an aneurysmal subarchnoid haemorrhage. The data were collected prospectively between 2001 and 2004. A total of 60 aneurysms were clipped (10 patients had two aneurysms). Forty-one of fifty patients (82%) were good grade (WFNS I and II) and 9/50 (18%) were poor grade (WFNS III - V) at the time of surgery. Anterior communicating aneurysms were the commonest (37%), but aneurysms at all of the usual anterior circulation sites were included, apart from ophthalmic aneurysms, as none presented during this period, and pericallosal aneurysms, which were not appropriate for it. Five patients (10%) also had an intracerebral haematoma on presentation. The overall management mortality for this series was 3/50 (6%) with 82% achieving a favourable outcome on the Glasgow Outcome Scale (GOS). For those in good grade at surgery, the mortality was 1/41 (2.4%) with 87.7% achieving a favourable outcome on the GOS.
Phenytoin is often used to prevent postcraniotomy seizures, but is not always effective. We investigate changes in plasma phenytoin level ([phenytoin]) following craniotomy. The [phenytoin] in 28 patients who were receiving phenytoin (oral/ intravenous) and undergoing a craniotomy were prospectively measured 24 h preoperatively, immediately pre- and postcraniotomy, 24 and 48 h postoperatively. Factors examined included patients' age, sex, pathology, preoperative [phenytoin], operative duration and blood loss. Fifteen patients had [phenytoin] concentrations outside the therapeutic range. Twenty-five patients experienced a decrease in [phenytoin] immediately postcraniotomy: pre-, post- and 24 h postcraniotomy mean [phenytoin] were 13.4, 10.0 and 12.9 mg/l, respectively. Preoperative [phenytoin], operative duration and blood loss had significant correlation with the decrease in [phenytoin] (p < 0.05). In conclusion, < 50% of the patients had therapeutic preoperative [phenytoin]. In most patients, [phenytoin] decreases by 26% after craniotomy and returns to preoperative level within 24 h. These may contribute to early postoperative seizure development.
Stereotactic radiosurgery for vesibular schwannoma requires long-term follow-up with complete MR imaging. We report two cases of a large secondary arachnoid cyst developing in the cerebellopontine angle following stereotactic radiosurgery. In one case this was associated with progressive ventriculomegaly and the onset of symptomatic hydrocephalus requiring emergency treatment. The second patient had ventriculomegaly at diagnosis, but developed an arachnoid cyst following treatment. Although both arachnoid cysts and hydrocephalus may also occur spontaneously in patients with vestibular schwanomma, the incidence is higher after stereotactic radiosurgery. As both complications may be associated with sudden clinical deterioration, follow-up with full cranial T1 and T2 weighted MR imaging is required to reveal these complications, in addition to assessing tumour response.
Commercial airline passengers are subject to numerous medical risks while in transit. Seventeen long-haul airline companies were questioned concerning fitness to travel and the case of a patient wishing to travel post craniotomy. Three airline companies gave satisfactory medical information, while the remaining airlines felt it was the decision of the operating surgeon rather than the airline company. A literature review shows that post operative pneumocephalus and the risk of tension pneumocephalus is the major medical concern when transporting patients post craniotomy. Evidence is contradictory with respect to the importance of this potentially life threatening problem. Postoperative 100% oxygen may improve the rate of pneumocephalus absorption. Airline companies have an unstandardised approach to unique medical problems, resulting in increased responsibility for the attending surgeon who may be ill equipped to deal with poorly researched aviation medicine.
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