Sample Report Craniotomy and Hematoma Evacuation
Preoperative Diagnosis: Epidural hematoma with right temporal fracture, coma.
Postoperative Diagnosis: Epidural hematoma with right temporal fracture, coma.
Procedure Performed: Right temporal parietal craniotomy, evacuation of epidural hematoma, coagulation of middle meningeal bleeders, and right frontal bur holes through separate incision and placement of parenchymal Camino intracranial pressure monitor using Ventrix system and closure of dural laceration.
Anesthesia: General endotracheal.
Indications: The patient is a 13-year-old who had a bicycle accident where he flipped over his handlebars, hitting his head and causing a scalp laceration, hematoma. He was taken to the ER where a CAT scan was done, which showed a small epidural hematoma in the right temporal region and a small fracture. The patient was transferred to the hospital by ambulance and deteriorated en route. He was intubated en route and when he arrived he was decerebrate on the left, decorticate on the right, with dilated nonreactive pupils, right greater than left. The patient was hypertensive. He was taken immediately to the CAT scanner where the CT showed tremendous enlargement of the same epidural hematoma on the right side. He was taken immediately to the OR. I discussed the case very briefly with his mother, who accompanied us to the operating area, and discussed with her the emergent need to take care of her son.
Details of Procedure: With the patient in the OR, the hair on the right side of the head was shaved. The scalp was prepared in the usual septic fashion. A hockey-stick incision was made from about the zygoma just anterior to the right ear, and this was taken a little bit posteriorly and then in a coronal fashion toward the top of the head, then brought forward. Raney clips were applied, the temporalis muscle was incised with Bovie electrocautery, and cerebellar retractors were placed. A fracture down the temporal region was noticed. A bur hole was placed in the parietal region, and an oval bone flap was obtained. This was done immediately and a very large clot was evacuated. There was a small bleeder inferiorly in the temporal region and then there was more bleeding posterior. Two more loops of bone were taken with the craniotome, and the microscope was brought into place to enable me to see back. There was a small inferior bleeder that was over the posterior aspect of the petrous bone that was coagulated and at this point in time bleeding had stopped. The wound was irrigated copiously with antibiotic solution.
The dura was tented up all the way around through multiple holes in a very snug fashion. The bone flap was reconstructed using Synthes 1.5 system titanium plates and 4-mm screws; 5-hole and 2-hole plates were used and then this was replaced using same. This was nice and solid all the way around. It should be noted that three sets of tack-up sutures were placed in the bone flap and 4-0 Prolene was used to tack the dura up. A 7 flat Jackson-Pratt drain was placed and brought through a separate stab incision superiorly, temporalis muscle closed with running 3-0 Vicryl, as was the fascia. The scalp was closed in two layers with interrupted 3-0 Vicryl on the galea and staples on the skin.
Drape was taped down, the head was again prepped in the right frontal region, skin was infiltrated with 0.5% lidocaine with epinephrine, and a parasagittal incision was made in the mid pupillary line, centered approximately 10 cm back from the glabella, 3 cm to the right of midline, and small retractor was placed. A bur hole was placed; dura was incised with a #11 blade. With the Ventrix catheter, I made two passes at the ventricle and then left it in situ at about 5-cm depth and then had it tunneled out through a separate stab incision. The pressure in the OR was running about 11 mmHg.
The wound was irrigated with antibiotic solution and closed in two layers using interrupted 3-0 Vicryl on the galea and running 3-0 Prolene to close the skin. The ICP monitor was sutured at the exit site with 3-0 Prolene. The scalp laceration on the back was irrigated with antibiotic solution and closed with running 3-0 Prolene. Sterile dressing was applied, instrument and sponge counts correct. Estimated blood loss was 200 cc. Replacement was with that of crystalloid only. No complications.
The patient was taken intubated to the ICU. It should be noted that postop the dura was nice and pulsatile, brain was pulsatile, and the pupils were now both small and equal.
Postoperative Diagnosis: Epidural hematoma with right temporal fracture, coma.
Procedure Performed: Right temporal parietal craniotomy, evacuation of epidural hematoma, coagulation of middle meningeal bleeders, and right frontal bur holes through separate incision and placement of parenchymal Camino intracranial pressure monitor using Ventrix system and closure of dural laceration.
Anesthesia: General endotracheal.
Indications: The patient is a 13-year-old who had a bicycle accident where he flipped over his handlebars, hitting his head and causing a scalp laceration, hematoma. He was taken to the ER where a CAT scan was done, which showed a small epidural hematoma in the right temporal region and a small fracture. The patient was transferred to the hospital by ambulance and deteriorated en route. He was intubated en route and when he arrived he was decerebrate on the left, decorticate on the right, with dilated nonreactive pupils, right greater than left. The patient was hypertensive. He was taken immediately to the CAT scanner where the CT showed tremendous enlargement of the same epidural hematoma on the right side. He was taken immediately to the OR. I discussed the case very briefly with his mother, who accompanied us to the operating area, and discussed with her the emergent need to take care of her son.
Details of Procedure: With the patient in the OR, the hair on the right side of the head was shaved. The scalp was prepared in the usual septic fashion. A hockey-stick incision was made from about the zygoma just anterior to the right ear, and this was taken a little bit posteriorly and then in a coronal fashion toward the top of the head, then brought forward. Raney clips were applied, the temporalis muscle was incised with Bovie electrocautery, and cerebellar retractors were placed. A fracture down the temporal region was noticed. A bur hole was placed in the parietal region, and an oval bone flap was obtained. This was done immediately and a very large clot was evacuated. There was a small bleeder inferiorly in the temporal region and then there was more bleeding posterior. Two more loops of bone were taken with the craniotome, and the microscope was brought into place to enable me to see back. There was a small inferior bleeder that was over the posterior aspect of the petrous bone that was coagulated and at this point in time bleeding had stopped. The wound was irrigated copiously with antibiotic solution.
The dura was tented up all the way around through multiple holes in a very snug fashion. The bone flap was reconstructed using Synthes 1.5 system titanium plates and 4-mm screws; 5-hole and 2-hole plates were used and then this was replaced using same. This was nice and solid all the way around. It should be noted that three sets of tack-up sutures were placed in the bone flap and 4-0 Prolene was used to tack the dura up. A 7 flat Jackson-Pratt drain was placed and brought through a separate stab incision superiorly, temporalis muscle closed with running 3-0 Vicryl, as was the fascia. The scalp was closed in two layers with interrupted 3-0 Vicryl on the galea and staples on the skin.
Drape was taped down, the head was again prepped in the right frontal region, skin was infiltrated with 0.5% lidocaine with epinephrine, and a parasagittal incision was made in the mid pupillary line, centered approximately 10 cm back from the glabella, 3 cm to the right of midline, and small retractor was placed. A bur hole was placed; dura was incised with a #11 blade. With the Ventrix catheter, I made two passes at the ventricle and then left it in situ at about 5-cm depth and then had it tunneled out through a separate stab incision. The pressure in the OR was running about 11 mmHg.
The wound was irrigated with antibiotic solution and closed in two layers using interrupted 3-0 Vicryl on the galea and running 3-0 Prolene to close the skin. The ICP monitor was sutured at the exit site with 3-0 Prolene. The scalp laceration on the back was irrigated with antibiotic solution and closed with running 3-0 Prolene. Sterile dressing was applied, instrument and sponge counts correct. Estimated blood loss was 200 cc. Replacement was with that of crystalloid only. No complications.
The patient was taken intubated to the ICU. It should be noted that postop the dura was nice and pulsatile, brain was pulsatile, and the pupils were now both small and equal.
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