3 Surgery for Cerebral Contusions of the Frontal and Temporal Lobes, Including Lobar Resections



10.1055/b-0035-121749

3 Surgery for Cerebral Contusions of the Frontal and Temporal Lobes, Including Lobar Resections

Pal S. Randhawa and Craig Rabb

Introduction


Cerebral contusions are observed in up to 8.2% of all traumatic brain injuries 1 , 2 and are more common (13–35% of patients) in the setting of severe traumatic brain injury. 1 , 3 – 7 While contusions can occur in almost any lobe, most occur in the frontal and temporal lobes. 8 , 9 Most small lesions will not require surgical intervention 1 , 3 , 10 , 11 ; the majority will reabsorb in 4 to 6 weeks.



Indications




  • Guidelines may assist clinical decision making with respect to which contusions might require surgical intervention. 1



  • Operative intervention is indicated in the setting of:




    • A frontal or temporal contusion of greater than 20 cm 3 in volume and associated with any of the following:




      • Glasgow Coma Scale (GCS) score 6 to 8



      • Midline shift at least 5 mm



      • Cisternal compression



    • Any lesion calculated to be greater than 50 cm 3 in volume



    • A parenchymal mass lesion that is associated with:




      • Progressive neurologic decline attributable to the lesion



      • Refractory intracranial hypertension



      • Mass effect on computed tomography (CT) scan



    • A temporal lobe hematoma greater than 30 mL, with or without any midline shift or elevation of the middle cerebral artery. These patients are particularly at risk for transtentorial herniation given the limited space of the middle cranial fossa.



Preprocedure Considerations



Radiographic Imaging


Noncontrast head CT is vital in the evaluation of all severe traumatic brain injuries. CT allows for anatomic localization of surgical pathology and, in turn, facilitates planning of patient positioning and operative approach.


Fig. 3.1a, b Axial CT images demonstrating (a) frontal and (b) temporal lobe cerebral contusions.


Medication




  • The authors prefer the use of vancomycin for antibiotic prophylaxis, provided the patient does not have renal failure or any other contraindications. Given the increasing prevalence of methicillin-resistant Staphylococcus aureus, it is possible that the skin can or will be colonized by this microorganism.



  • Antiepileptic prophylaxis should be provided. Fosphenytoin may be administered in a loading dose of 17 to 20 mg phenytoin equivalents (PE)/kg in nonallergic patients who are not on standing antiepileptic medication; alternately, levetiracetam may be administered at a loading dose of 20 mg/kg.



Choice of Surgical Approach




  • Two different approaches—bicoronal and modified pterional—are outlined in the Operative Procedure section; the choice of approach will depend on the site of the pathology.



  • Bilateral or unilateral, medial contusions of the frontal lobes may be addressed optimally by a bicoronal approach.



  • A far lateral frontal contusion may be approached by a modified pterional approach.



  • Temporal contusions generally can be approached via a modified pterional approach.



Operative Field Preparation




  • Alcohol prep is performed before the application of povidone iodine or chlorhexidine.



  • The planned incisions are marked and infiltrated with 1% lidocaine with 1:100,000 epinephrine.



Operative Procedure



Bicoronal Approach



Positioning (Fig. 3.2)
Figure Fig. 3.2 Procedural Steps The patient is positioned supine, with the head in a neutral, upright position. The head is stabilized with Mayfield three-point fixation. The head of bed is elevated slightly. Pearls • Consider using a horseshoe headrest to facilitate more rapid decompression in the emergency setting, or if a skull fracture prevents use of a Mayfield three-point fixation.


Skin Incision (Fig. 3.3)
Figure Fig. 3.3 Procedural Steps Mark out a bicoronal incision, starting at the level of zygoma and extending superiorly toward the midline, just posterior to the hairline. Carry the incision across midline, in a mirror fashion, to the contralateral zygoma. Initiate the skin opening with a no. 10 blade. Carry the incision down to the pericranium above the superior temporal line and down to the temporalis fascia in the temporal region. Pearls • Scalp clips are applied to the skin edges to assist hemostasis.


Subcutaneous Dissection (Fig. 3.4)
Figure Fig. 3.4 Procedural Steps The pericranium is opened with monopolar electrocautery, in line with the scalp incision. The superficial temporal fascia and temporalis muscle are opened, likewise, using monopolar electrocautery. Pericranium and muscle are advanced with a combination of periosteal elevator and monopolar electrocautery. Leave the frontalis muscle intact if possible. The myocutaneous flap is reflected anteriorly until the anterior middle fossa and supraorbital areas are accessible. The flap is secured with mini-towel clips, hooks, or suture. Pearls • Special care must be taken to avoid compromising the frontalis branch of the facial nerve. Remain above the zygoma when approaching the inferior aspect of the incision. • A few rolled sponges are placed beneath the flap as it is reflected and secured.


Bur Hole Placement (Fig. 3.5)
Figure Fig. 3.5 Procedural Steps Bur holes are placed with a high-speed drill at the following sites: just above the root of zygoma; at the keyhole; and just above superior temporal line, anterior to coronal suture. An additional pair of holes are placed straddling the midline, anterior to coronal suture. The base of each hole is cleared with a curette. The dura is stripped from the undersurface of the bone, locally and between each pair of holes, with a separator (e.g., Penfield no. 3, Hoen, or similar). Pearls • Exercise particular care when stripping the dural attachments between the two paramedian holes overlying the sagittal sinus.


Craniotomy (Fig. 3.6)
Figure Fig. 3.6 Procedural Steps The craniotome is used to connect each pair of bur holes circumferentially, taking care to stay low in the frontal and temporal regions and making the final cut in the region of the superior sagittal sinus. The bone flap is carefully elevated away from the underlying dura and set aside in antibiotic solution. Bone wax is applied to the bony edges where necessary. Bleeding along the midline sagittal sinus may be controlled with a combination of fibrillar hemostatic material, thrombin-soaked gelatin sponge, and hemostatic matrix sealant. If all other measures fail, the superior sagittal sinus may be ligated anteriorly, at the level of the crista galli.

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Jun 13, 2020 | Posted by in NEUROSURGERY | Comments Off on 3 Surgery for Cerebral Contusions of the Frontal and Temporal Lobes, Including Lobar Resections

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