Craniectomy

• Indications for rural neurosurgical intervention
  • Neurologically deteriorating pt and can’t do CT head
  • T/F to nearest N/S unit is > 2 hours away
  • Sizable intracranial haematoma
• Indications for Burr hole
  • GCS 8 or less with imaging showing epidural haematoma causing midline shift and unequal pupils
  • High clinical suspicion with palpable #, ipsilateral fixed dilated pupil and deteriorating neurology without imaging
• Burr Hole technique
  • Confirm side and position → Shave and prep
  • LA and 3cm incision to bone
  • Periosteal elevation and self-retainer
  • Hudson brace manual burr used perpendicular to skull with saline being applied for bone dust
  • Stop when resistance gives
  • Perforator for conical opening widened by cylinder burr
  • Epidural clot should evacuate now
  • If it doesn’t = Subdural → Open dura with knife
  • If no blood - confirm side/scan and if bleeding on-going DO NOT TAMPONADE
  • Transfer patient
• Locations:
  • Temporal - 1cm above Posterior Zygomatic Arch
  • Frontal - 10cm above pupil - over the Coronal Suture approx 10cm cephalad and in line with the Mid-Pupillary line
  • Parietal - 5cm above ear - over the Parietal Eminence
• Emergency Frontotemporal Craniectomy
  • Scalp incision from ant to ear curving up and anteriorly to follow temporal plane
  • Raise flap
  • Serial burr holes include edge of # and combine with Gigli saw
  • Elevate bone flap
  • Don’t dig out bone fragments from bone parenchyma - causes more injury
• Death occurs due to on-going bleeding → High ICP → Brain shift and herniation causing brain stem damage