Administer IV anti-epileptic drug (midazolam, phenytoin, levetiracetam)
R/O acute cause, such as intracerebral hemorrhage (ICH), pin perforation, etc.
Beware of patient pulling out of pins
If persistent, consider barbiturates
Intraoperative acute hydrocephalus (Table 11.1c)
Presentation
Acute external herniation of brain matter during surgery, typically in posterior fossa surgery and surgeries within ventricles, due to obstruction from blood clot
Diagnostic studies
Usually a clinical diagnosis
May consider use of intra-op U/S
Treatment
Emergent placement of ventriculostomy
Remember: to prep for emergent EVD placement before surgery or place drain before even starting craniotomy (safest)
Venous sinus laceration (Table 11.1d)
Presentation
Sudden massive dark venous bleeding
Diagnostic studies
Pre-op magnetic resonance venography (MRV): preoperatively assess sinus dominance, patency, and proximity to surgical site
Treatment
Notify anesthesia to be ready with IV fluids and blood
Irrigate field continuously to avoid air embolism
Hold gentle tamponade with gelfoam or muscle patch or “sinus patty” (patty + surgicel + floseal/surgiflo)
Consider collagen powder (avitene), fibrin glue, and other hemostyptic agents. Beware not to inadvertently pack them within Lumen of critical sinuses, since this may lead to sinus occlusion
If necessary, attempt repair with direct suturing or with use of patch (i.e., Pericranial flap)
Do not attempt to use bipolar coagulation; this maneuver only enlarges the hole
If all else fails and not a critical/dominant sinus, then sacrifice
Remember: always notify anesthesiologist before operating near venous sinus
Venous air embolism (Table 11.1e )
Presentation
Direct visualization of air being sucked into vein or venous sinus
Sudden and unexplained hypotension
Unexplained sudden drop in end-tidal Pco2
Diagnostic studies
Transesophageal echocardiography (has to be placed before surgery in cases with increased risk)
Precordial doppler U/S intraoperatively
Aspiration of blood foam through central venous catheter (has to be placed before surgery in cases with increased risk)
Treatment
Lower the head end of the bed immediately (Trendelenburg)
Flood operative field with copious irrigation
Repeated aspiration of blood foam via central venous catheter until foam clears
If source of embolism is apparent (i.e., venous sinus), attempt repair
Place patient in left lateral decubitus position, so that the air bubble moves to the right atrium
Start patient on 100% oxygen
Remember: always notify anesthesiologist before operating near venous sinus
CSF leak after craniotomy (Table 11.1f)
Presentation
Common after certain surgeries (up to 30% of skull base surgeries have CSF leaks)
May present as:
External leakage of clear or nearly clear fluid leaking from wound, ear, nose, or into mouth
If site is not apparent, consider thin-cut CT or cisternogram. Usually, there are air bubbles intracranially or opacified air sinus near leakage site
Treatment
Always R/O hydrocephalus
Basics:
Head of bed up 15 degrees
Avoid straining or blowing nose
Stool softeners
Consider short-term acetazolamide 250 mg orally every day (reduces CSF production)
For external skin leak: oversew the leak (use running–locking sutures over the leaking part + 1 cm proximal and 1 cm distal → convert external drainage into internal CSF collection)
CSF diversion for 3–7 d:
Lumbar drain (remember: this is a volume-driven CSF diversion and not pressure driven)
Start with 5 ml/h → increase daily as tolerated (headaches!!)
Caution: pneumocephalus—if air is sucked in from negative CSF drainage pressure
Apply external counter pressure for 3–14 d: tight head wrap with elastic bandage (ace bandage) ± tapping collection
Repeat surgery for direct repair: consider use of duraplasty, dura tissue glue (fibrin or other)
Lumboperitoneal (LP) shunt: if leak persists, some practitioners use LP shunt (communicating CSF spaces) or ventriculoperitoneal shunt. The primary author does not employ this because of high risk of pneumocephalus and infection
CSF leak after transsphenoidal surgery (Table 11.1g)
Presentation
Usually, obvious clear-fluid drainage from nose or into pharynx
Positional headaches
Diagnostic studies
Signs/studies indicating that rhinorrhea is due to CSF:
Reservoir sign
CSF target/ring sign
β2-transferrin or beta trace-protein test
Studies to identify source of leakage in difficult cases:
Intrathecal dye head CT study with thin-cut slices
Intrathecal fluorescein, followed by nasal endoscopy (direct visualization of CSF leak)
Treatment
If CSF become apparent during surgery
Repair anterior sellar wall with dura graft + vomer pieces
Pack sinus with sandwich layers with rectus abdominis fascia + fat + gelfoam
Consider placement of lumbar drain after surgery (even prophylactically)
b. If CSF in postop period
CSF diversion for 3–7 d:
Lumbar drain (remember: this is a volume-driven CSF diversion and not pressure driven)
Start with 5 ml/h, increase daily as tolerated (headaches!!)
Caution: pneumocephalus (if air is sucked in from negative CSF drainage pressure)
If CSF leak persists after clamping of lumbar drain following drainage for 7 d:
Return to OR and attempt primary repair as described above (may use fluorescein to identify leakage site)
Post-op continue lumbar drainage for 3–7 d
Carotid injury during transsphenoidal surgery (Table 11.1h)
Presentation
Massive arterial bleeding often obscuring view
Diagnostic studies
Post-op intraoperative angiography is a must
Treatment
Apply occlusive pressure to carotid arteries in the neck to slow bleeding down
Obtain hemostasis with hemostatic agents and direct pressure. Pack area
If necessary, place foley catheter in sphenoid sinus and inflate balloon to tamponade
Proceed directly to angiography suite for endovascular repair
Monitor postoperatively for formation of pseudoaneurysm
Bleeding during stereotactic needle biopsy (Table 11.1i)
Presentation
Blood dripping out of biopsy needle during surgery (hemorrhage is the most common complication of stereotactic biopsy occurring in > 5% of patients)
Diagnostic studies
Usually a clinical diagnosis
May consider intra-op U/S
Obtain STAT postop head CT to determine extent of hemorrhage and need for further treatment
Treatment
Leave biopsy needle in place and open: allow blood to drain until bleeding stops on its own
If bleeding does not stop after 5–10 min, consider injecting a small amount of hemostatic agent (surgiflo, floseal) and taking patient emergently to CT while informing OR to prepare for craniotomy
Inadvertent opening of air sinus (Table 11.1j)
Presentation
Following craniotomy, sinus mucosa or air cells become visible
Diagnostic studies
None
Treatment
Frontal paranasal sinus
If mucosa is intact, may just repair bony defect
If mucosa is violated cranialize sinus:
Strip mucosa (study frontal sinus anatomy, beware of duplicate orbital roof)
Drill thin layer of bone from entire sinus wall (in order to ensure that all mucous secreting cells have been removed)
Plug nasofrontal duct with gelfoam soaked with bacitracin ointment followed by muscle plug
Apply vascularized pericranium graft
b. Small air cells (mastoid cells)
Push wax into air cells rather than swipe wax across air cells
Pneumocephalus after craniotomy (Table 11.1k)
Presentation
Unspecific headaches
Neurological compromise is possible
Caution: deteriorating neurological status indicates tension pneumocephalus
Diagnostic studies
CT head
Treatment
For routine cases: 100% O2 via non-rebreather mask for 24 h
Tension pneumocephalus is an emergency!! → Emergently place needle into tension pneumocephalus for air aspiration (may be done under CT guidance). Occasionally, return to or for evacuation is required (see also Table 5.17)
Facial nerve palsy management (Table 11.1l)
Presentation
Postoperative CN VII palsy
Diagnostic studies
Serial ENoG (electroneuronography) studies
Treatment
Besides cosmetic issues, the main concern is corneal abrasions, which may even lead to blindness
Unless nerve is clearly transected during surgery, watchful waiting for up to 6–12 mo is indicated
General measures
Eye patch at night
Protective glasses
Lacri-Lube
Specific surgical treatments
Primary nerve graft repair during initial surgery, if nerve transected
CNs VII to XII nerve anastomosis
Temporalis muscle transposition
Eyelid gold weight implant
Tarsal strip
Long-term outcome
Depends on initial House–Brackmann grade
Synkinesis of facial branches is common
Crocodile tears
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