Operative Planning

• Resuscitate according to Advanced Trauma Life Support and traumatic brain injury guidelines
  
• Review imaging (usually computed tomography [CT] scan, may include magnetic resonance imaging, CT-angiogram, and angiogram)
  
  
  
  • Extent, size, and location of hematoma(s)
    
  • Amount of midline shift
    
  • Other cranial pathology; in particular, is there a fracture overlying a major venous sinus or the frontal sinus; skull or orbital fractures
    
  • Hydrocephalus
  
  
• Identify location and extent of scalp loss or lacerations
  
• Cervical spine: if feasible after trauma, clear cervical spine; if not, maintain collar
  
• Surgical evacuation or decompression should be performed as soon as possible when indicated
  
• Check coagulation status

Routine Equipment

• Major craniotomy tray with minor set-up
  
• Subdural head holder (e.g., donut)
  
• Mayfield head holder may be needed if a ruptured aneurysm is cause of pathology
  
• High-speed drill
  
• Headlamp and loupes
  
• Bipolar cautery
  
• Intracranial pressure and brain oxygen monitor
  
• Hemovac drain

• Ventricular drain for hydrocephalus (large bore if intraventricular hemorrhage)
  
• Dural substitutes (e.g., DuraGen, Dura-Guard [Synovis Surgical Innovations, St. Paul, MN])
  
• Aneurysm clips if ruptured aneurysm or AVM part of pathology
  
• Rapid infuser if venous sinus involved
  
• Leyla (Yasargil) bar can be used to help hold back scalp

Anesthetic Issues

• Major goals
  
  
  
  • Prevention of secondary cerebral insults (e.g., hypoxia, hypotension, hyperglycemia)
    
  • Prevent and reduce brain swelling
  
  
• Airway control; no tape or ties around the neck
  
• Ventilate to maintain PaO₂ > 100 mm Hg and PaCO₂ 25 to 30 mm Hg
  
• Two large bore intravenous (IV) needles
  
• Arterial catheter: maintain normotension (appropriate for patient)
  
• Transfusion products and replacement factors should be available particularly if there is a fracture over a major venous sinus
  
• Administer IV cefazolin 1 g (also 500 mg metronidazole if air sinus involved)
  
• IV mannitol 1 g/kg before skin incision
  
• Load with anticonvulsants: 1 g phenytoin (slow IV)