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Background Venous thromboembolism (VTE) represents a rare but preventable postoperative complication. Unfractionated heparin (UH) and low-molecular-weight heparin (LMWH) are used to prevent VTE, but comparative studies of their safety and efficacy in the neurosurgical context are limited. Objective To determine the relative safety and efficacy of UH and LMWH for prophylaxis after cranial surgery. Methods We performed a retrospective analysis of 3204 elective intracranial surgical admissions in 2901 patients over the period 2013 to 2018. From chart review, we extracted demographic and clinical features, including diagnosis and procedure, drugs administered, and the occurrence of VTE events. To compare postoperative outcomes, we performed propensity score matching of patients receiving different drugs, and reviewed postoperative cranial imaging. To contextualize our results, we selected 14 prior neurosurgical studies of VTE prophylaxis to compare our outcomes to the existing literature. Results In our sample of 3204 admissions, the overall rate of VTE was 0.8% (n = 27). Rates of VTE were not statistically different in matched cohorts receiving UH and LMWH (1.7% vs 1.0%, respectively); however, LMWH was associated with a higher rate of clinically significant intracranial hemorrhage (ICH) (3.4% vs 0.5%, P = .008). Literature review and meta-analysis supported these findings. Across studies, UH and LMWH were associated with similar rates of VTE. Studies in which patients received LMWH reported significantly higher rates of ICH (4.9% higher, P = .005). Conclusion We find that LMWH and UH show similar efficacy in preventing VTE; however, LMWH is associated with higher rates of ICH.

The use of direct oral anticoagulants is increasing rapidly, because of perceived benefits over older agents, such as predictable pharmacokinetics and a reduced risk of bleeding. Elderly patients, who are more likely to be prescribed these drugs, are also presenting for neurosurgical procedures more often. The combination of these factors will result in neurosurgeons and neuroanesthesiologists encountering patients prescribed direct oral anticoagulants on an increasingly frequent basis. This review provides a summary of the current evidence pertaining to the perioperative management of these drugs, in the context of elective and emergency intracranial surgery. It highlights emerging therapies, including specific antidotes, as well as areas where the evidence base is likely to improve in the future.

Background and importance Retraction injury can result in significant complications during intracranial operations. Alternative surgical techniques to minimize retraction pressure and duration of retraction can minimize the risk of retraction injury. We describe the use of a cottonoid "slider," which is a simple, cost-effective modification of a commonly used cottonoid, in multiple applications. Clinical presentation The cottonoid sliders are constructed preoperatively by overlaying an adhesive plastic incision drape on one side of a dry cottonoid patty and trimming the edges to fit the form of the cottonoid. Intraoperatively, the sliders can slide across the parenchymal surface atraumatically and are used for gentle retraction to expose desired areas. In addition, suction may be placed on the slider to clear fluid from the operative view. The plastic side of the slider prevents adherence to the parenchymal surface. Retractorless surgical techniques have been developed to minimize risk of retractor associated injury in intracranial surgery by reducing retraction pressure and duration. Given that the cottonoid sliders glide along the parenchyma, do not stick, and are used for dynamic retraction, the main objectives to minimize retraction injury can be met while not compromising operative efficiency. Conclusion Cottonoid sliders are a simple and cost-effective method of providing gentle exposure during intracranial surgery. This technique represents a valuable and cost-effective addition to the neurosurgical armamentarium.

Hypertension has been reported during emergence from anesthesia to be >90% in neurosurgical patients. We examined the effects of dexmedetomidine, remifentanil, and esmolol infusion on recovery profiles and cardiovascular responses of patients during the emergency period after a craniotomy. ASA I to III physical status patients, who were undergoing intracranial surgery for either vascular or space-occupying lesions, were eligible if aged between 17 and 65 years. Anesthesia was induced using propofol and dexmedetomidine and maintained using sevoflurane and dexmedetomidine infusion. Patients were randomly allocated in 3 groups. Dexmedetomidine infusion was continued until the initiation of skin closure in group D. Dexmedetomidine infusion was discontinued in other groups after placing the bone graft. Thereafter, remifentanil infusion (0.25 µg/kg/min) or esmolol infusion (0.25 mg/kg/min) were started in the other groups (group R or E) until the initiation of skin closure. Extubation time, recovery time, incidence of coughing during extubation, and hemodynamic variables during the emergence phase were recorded. During the emergence phase, the systolic and mean arterial blood pressures and heart rates were similar compared with baseline values in all study groups. The median extubation time was similar in the dexmedetomidine (4.9 min), remifentanil (3.9 min), and esmolol groups (2.7 min). The incidence of cough was similar in the dexmedetomidine group compared with the remifentanil or esmolol groups. Time to eye opening, time to orientation, and response to verbal command were longer in the dexmedetomidine group compared with the remifentanil group. We concluded that remifentanil, dexmedetomidine, and esmolol infusion can be used to control blood pressure during emergence from anesthesia after a craniotomy. © 2013 by Lippincott Williams and Wilkins.

A 1-day-old female newborn presenting with a severe left proptosis was found, on imaging, to have a cranial mass extending in both orbits and ethmoid sinuses. Tumor debulking and biopsy were performed through a lateral orbitotomy. Based on histologic findings, a diagnosis of infantile myofibroma was made. No involvement was found in other areas of the body. The patient died because of respiratory arrest after intracranial surgery that was performed 45 days after the orbital surgery. To the authors' knowledge, only one similar case of cranio-orbital myofibroma has been reported previously. This tumor should be considered in the differential diagnosis of congenital proptosis and cranio-orbital tumor. In such cases, tumor debulking can be performed through orbitotomy.

The number of elderly patients proposed for brain tumor removal is increasing. Only few data on long-term functional prognosis after intracranial surgery are available.Prospective, observational study of all patients greater than 70 year of age operated for intracranial tumors. Two scales for health status evaluation were used: Karnofsky Performance Scale (KPS) and Activities of Daily Living (ADL) score. Data were expressed as medians (first to third quartiles). The primary endpoint was the probability to remain nondependant (ADL3 and KPS≥70%) after 1 year.Between 2003 and 2007, 90 patients were included: 46 (51.1%) meningioma, 17 (18.9%) high-grade glioma, and 11 (12.2%) metastasis. At hospital admission, age was 73.50 years (71.25-76.00), American Society of Anesthesiology score 2 (2 to 3), KPS 80% (70-90), ADL 5.5 (4.5 to 6.0). Two patients died during the first 28 days, 3 others during the first year. Both KPS and ADL decreased after 1 year: KPS 80% (70 to 90; mean: 80%) at hospital admission versus 80% (60 to 90) at 1 year (mean: 70%), P=0.003; ADL 5.5 (4.5 to 6.0) at hospital admission versus 5.0 (3.25 to 5.50) at 1 year, P=0.001. In multivariate analysis, 2 preoperative parameters were associated with autonomy at 1 year: the ADL at hospital admission and meningioma as histologic type.In this series of elderly patients, intracranial tumor surgery was associated with low 1-year mortality. Meningioma was associated with a better postoperative functional outcome. Preoperative ADL score was a predictive of functional evolution 1 year after the surgery.

Desflurane in neurosurgery may be beneficial because it facilitates postoperative early neurologic evaluation. However, its use has been debated because of its capacity to promote cerebral vasodilatation. Sevoflurane has been extensively used in neurosurgical patients. In this prospective clinical trial, we compared early postoperative recovery and cognitive function in patients undergoing craniotomy for supratentorial expanding lesions and receiving sevoflurane or desflurane anesthesia.One hundred twenty patients, ASA physical status I-III (66 men), Glascow Coma Scale 15, undergoing craniotomy for supratentorial expanding lesions were enrolled in the study. Patients were randomly allocated to two anesthetic regimens. In Group S (60 patients, 52 +/- 16 yr), anesthesia was maintained using sevoflurane with end-tidal of 1.5%-2% and was age adjusted to obtain approximately 1.2 minimum alveolar anesthetic concentration. In Group D (60 patients, 60 +/- 14 yr), anesthesia was maintained using desflurane with end-tidal of 6%-7% and was age adjusted to obtain approximately 1.2 minimum alveolar concentration. Emergence time was measured as the time from drug discontinuation to the time at which patients opened their eyes; tracheal extubation time was measured as the time from anesthetic discontinuation and tracheal extubation. Recovery time was measured as the time elapsing from discontinuation of anesthetic and the time when patients were able to recall their name and date of birth. Cognitive behavior was evaluated with the Short Orientation Memory Concentration Test. In the postanesthesia care unit, a blinded observer monitored the patients for 3 h; the incidence of hemodynamic events, pain, nausea, and shivering requiring rescue medication was recorded.The mean emergence time (12.2 +/- 4.9 min in Group S vs 10.8 +/- 7.2 min in Group D; P = ns) was similar in the two groups, whereas the mean extubation time and recovery time were longer in Group S (15.2 +/- 3.0 min in Group S vs 11.3 +/- 3.9 min in Group D and 18.2 +/- 2.3 min in Group S vs 12.4 +/- 7.7 min in Group D, respectively; P0.001). The Short Orientation Memory Concentration Test score differed between the two groups only at the earliest assessment (15 min after extubation). No difference between the two groups was found in pain, shivering, nausea, vomiting, and incidence of postoperative hemodynamic events.Patients who received desflurane had a shorter extubation and recovery time but similar intraoperative and postoperative incidence of complications compared with those who received sevoflurane.

Dexmedetomidine has been shown to provide good perioperative hemodynamic stability with decreased intraoperative opioid requirements. This study was conducted to compare the effect of dexmedetomidine-remifentanil (DR) anesthesia and propofol-remifentanil (PR) anesthesia on perioperative hemodynamics and postanesthesia recovery profiles in patients undergoing intracranial surgery. After receiving Ethics Committee approval and informed patient consent, 78 American Society of Anesthesiologists physical status I or II patients between the ages of 19 and 70 years with a Glasgow Coma Scale score 14 or 15 who were scheduled for elective intracranial surgery with general anesthesia were recruited. Anesthesia induction was provided by intravenous remifentanil (0.5 µg/kg) and propofol (1.5-2 mg/kg) in both groups and maintained with infusion of DR (0.6-1.2 mg/kg/h and 0.25 µg/kg/min)-nitrous oxide/oxygen (n 2o/o2) in the DR group (n = 39) and infusion of PR (3-10 mg/kg/h and 0.25 µg/kg/min)-n2o/o2 in the PR group (n = 39). Hemodynamic variables were recorded before surgery, during the induction of anesthesia, after intubation, and during application of the headholder and skin incision; brain relaxation was also recorded. Times to extubation and awakening, eye opening, and response to commands as well as analgesic requirements were recorded after surgery. No significant difference was found in systolic blood pressure and mean arterial pressure throughout the study period except at the time of the dural incision (P < 0.05). These variables were significantly lower in the DR group (P < 0.05). Brain relaxation scores were similar between the 2 groups (P > 0.05). Time to extubation was significantly shorter in patients receiving PR anesthesia than in patients receiving DR anesthesia (3.6 minutes vs. 5.5 minutes). Analgesic requirements were significantly higher in the PR group than in the DR group (P = 0.013). No significant side effects were reported in the 2 groups (P > 0.05). In conclusion, dexmedetomidine (0.6-1.2 µg/kg-1/h-1) plus remifentanil (0.25 µg/kg-1 min-1) anesthesia offered lower analgesic requirements, a longer extubation time, and better hemodynamic stability compared with PR anesthesia for patients undergoing intracranial surgery. Copyright © 2005 by Lippincott Williams & Wilkins.

The isolated effects of hypothermia on hemostasis have not been investigated in healthy humans. We cooled 16 anesthetized patients scheduled for elective intracranial surgery to 32°C body core temperature and assessed prothrombin time (PT), activated partial thromboplastin time, thrombelastogram (TE

Major complications after intracranial surgery occur in 13-27% of patients. These complications may have multiple causes, but a body of arguments suggests that the haemodynamic and metabolic changes of anaesthesia recovery may be responsible for intracranial complications. The aim of this review is to explain the rationale of this hypothesis and analyse the recent studies relevant to neuroanaesthesia recovery.Rapid recovery and extubation after intracranial tumour surgery is desirable in order to make an early diagnosis of intracranial complications. Since light pharmacological sedation may worsen a neurological deficit, short-acting anaesthetics are preferable intraoperatively. Extubation in the operating room, however, may be associated with agitation, increased oxygen consumption, catecholamine secretion, hypercapnia and systemic hypertension. This may exacerbate cerebral hyperaemia observed even during an uneventful recovery, leading to cerebral oedema or haemorrhage.Pain, hypothermia, hypercapnia, hypoxia, hypoosmolality, hypertension, and anaemia should be avoided during emergence. Early emergence is associated with minimal haemodynamic and metabolic changes. If there is any doubt as to whether the patient should be extubated in the operating room, a gradual emergence in the intensive care unit makes it possible to decide whether or not extubation can be performed safely.

Plasma ropivacaine levels produced by routine scalp infiltration for field block were assayed in eight patients undergoing awake intracranial surgery. Levels peaked within approximately 13 minutes, indicating rapid systemic absorption of ropivacaine. Potentially toxic plasma drug levels were achieved in three of eight patients, although no untoward effects attributable to elevated levels of ropivacaine were observed. Clinical vigilance is indicated during scalp infiltration with ropivacaine.

This study brings to light the potential use of intracranial endoscopic techniques that can be combined with osteotomies and bone distraction to improve precision and reduce complications in craniofacial surgery. It also anticipates the widespread use of endoscopic techniques to reduce the morbidity and mortality of plastic surgical and neurosurgical intracranial surgery.

Two cases are described of patients, undergoing surgery for intracranial pathology, who developed polyuria intraoperatively. The urine output decreased to within normal range shortly after the administration of ketorolac, a nonsteroidal antiinflammatory drug. The possible mechanisms producing the increased urinary output and the influence of prostaglandins on renal function are discussed.

A comprehensive anesthetic plan for managing patients undergoing "awake: intracranial surgery (AICS) must include a means of rescuing the patient if the airway becomes obstructed. Since access to the patient's airway is limited, mask ventilation can be challenging and laryngoscopy and tracheal intubation, impossible. The need exists for an alternative airway device that is easy to insert, would allow controlled ventilation, and would facilitate a smooth emergence with minimal coughing. The cuffed oropharyngeal airway (COPA) was introduced as a supraglottic airway device in spontaneously breathing patients. The authors report their preliminary experience of its use in AICS. The COPA was inserted in 20 patients on 31 occasions. Insertion of the COPA was accomplished easily at the first attempt in all cases irrespective of patient position. Airway maneuvers were required when patients were supine but not lateral. The COPA is a useful device to instrument the airway in patients undergoing AICS using the asleep-awake-asleep technique in the lateral position.

A woman with rhinocerebral mucormycosis and brain abscess was successfully treated with medical management and limited sinus surgery. The patient's disease progressed while initially on amphotericin B deoxycholate and then on liposomal amphotericin B alone, but slowly improved and was cured with a combination of liposomal amphotericin B, caspofungin, and ciprofloxacin.

This is a prospective study of the treatment of penetrating missile injuries to the brain without intracranial surgery carried out at the American University of Beirut Medical Center between 1981 and 1988. Of 600 patients treated for missile injuries to the head. 32 satisfied the study criteria. There were 27 shrapnel and 5 bullet injuries. The mean patient age was 23 years (range, 3-51 years). Twenty patients had intracranial indriven bone fragments. Six patients had exposed brain tissue. The mean follow-up was 3.5 years (range, 1-7.5 years). The superficial entry wound was debrided and closed without drainage in the Emergency Room within a mean of 3 hours (range, 0.5-6 hours), and the patient received methicillin for 14 days. All patients survived and had no or improved neurological deficits. No leakage of the cerebrospinal fluid, infection, or seizures occurred in 31 patients. One patient with indriven bone fragments had leakage of the cerebrospinal fluid and developed seizures and a brain abscess 20 days after the injury. The management of penetrating missile injuries to the brain without intracranial surgery in a select patient population is a reasonable option. This treatment becomes important for a surgeon facing large numbers of casualties, or when operative personnel or resources are limited or unavailable.

The postoperative course of patients emerging from general anesthesia after intracranial surgery is frequently complicated by hypertension. This study examined the comparative efficacy of esmolol and labetalol in treating increases in blood pressure during emergence and recovery from anesthesia after intracranial surgery. Both esmolol and labetalol were equally effective in controlling systolic blood pressure on emergence and in the recovery room in patients undergoing intracranial surgery. However, decreases in heart rate were significantly more frequent in the immediate postoperative period in patients given labetalol. An increase in blood pressure after intracranial surgery appears to be a transitory phenomenon adequately treated with a short-acting antihypertensive agent such as esmolol.

The carbon dioxide laser has been used clinically in both otorhinolaryngology and neurological surgery for approximately 10 years. Only recently, however, have technical modifications allowed its use with the operating microscope, providing the increased precision and control necessary for intracranial surgery. This paper reports the authors' experience with the carbon dioxide laser in the removal of acoustic tumors, details the surgical technique involved, and describes the advantages that may accompany the use of the laser in the removal of these difficult lesions.

This history of the steps leading to the modern surgical treatment of intracranial aneurysms begins some 200 years ago when it was found that cervical carotid artery ligations (for trauma) could be tolerated. This discovery led, early in the 1800's to the use of carotid ligation for the treatment of carotid-cavernous fistulas and eventually for the treatment of intracranial saccular aneurysms. The era of modern intracranial surgery for aneurysms began after Moniz introduced cerebral angiography in 1927. The first trapping procedure (for a carotid-cavernous fistula) was performed in 1932, and the first successful planned intracranial operation for a saccular aneurysm was reported in 1933. Subsequent developments are chronologically cited, together with mention of methods now obsolete.

A group of 274 patients with a single intracranial aneurysm was randomly allocated to intracranial surgery. Forty patients had no surgical procedure. Only six had a vertebral-basilar aneurysm. The remaining 228 patients had an aneurysm on the anterior portion of the circle of Willis. Mortality during the six and one-half-year interval was 36.8%. When the operation was performed within 14 days following the last bleed, mortality was 44.5%; for those operated upon after the 14-day interval mortality was 23.2%. Postoperative complications occurred in 47.8%.

The purpose of this paper is to examine how well (or poorly) patients past the age of 60 tolerate intracranial surgery for aneurysms in all locations. The records of 93 consecutive good risk patients (Botterell Grades 1 and 2) have been reviewed. Co-existing chronic medical conditions, e.g., hypertension, were ignored in patient grading. The results indicate that, for treatment of aneurysms on the anterior circulation, older patients tolerate intracranial procedures as well as younger patients. This is not true for operations upon posterior circulation aneurysms. Some possible reasons for this discrepancy are suggested.

Massive intraoperative brain swelling is an infrequent but catastrophic occurrence. In this report, we describe the use of very large doses of thiopental as a means of treating such swelling. In our initial 11 cases (5 arteriovenous malformations, 4 hematomas, and 2 penetrating injuries), this approach produced the following outcomes: 6 patients made a good recovery, 2 are moderately disabled, 1 is severely disabled, and 2 are dead. These results indicate that this condition, which once was considered unmanageable, can indeed be managed and that treatment often results in an acceptable outcome. More recent experience in an additional 6 patients suggests that the use of planned deep thiopental anesthesia, with induced cerebral silence, during intracranial surgery may even prevent the occurrence of this phenomenon.

Fifteen institutions participated in a cooperative study for treatment of single ruptured intracranial aneurysms. Between June, 1963, and February, 1970, 1,005 protocols were submitted to the Central Registry. All patients had a single ruptured aneurysm on the internal carotid, middle cerebral, anterior cerebral-anterior communicating or vertebral-basilar arteries. The four treatments allocated randomly were regulated bed rest, drug-induced hypotension, carotid ligation, and intracranial surgery. This study was an attempt to provide the relative merits of these several modes of therapy.

One of the most catastrophic complications of intracranial surgery is infection. These infections present frequently as postoperative fever and a change in sensorium. Phenytoin is used frequently in conjunction with intracranial operation to prevent seizures. We report two patients in whom, although the full phenytoin sensitivity syndrome ultimately developed, the presenting sign was postoperative fever. The phenytoin sensitivity syndrome is reviewed with emphasis on the fact that all components of the syndrome are not always present initially. The clinical significance of the presentation of phenytoin hypersensitivity as postoperative fever is discussed.