Coronal and sagittal cuts were obtained during parietal or temporal craniotomies, and axial and sagittal slices in the case of frontal masses. After brain tumour. La incidencia de infecciones de craneotomía está en torno al 5%, con un rango entre . 2) had undergone an operation involving nasal sinuses (frontal sinus). Spanish term or phrase: craneotomia bifronto-orbitaria The “frontal bone” is “A cranial bone consisting of a vertical portion corresponding to.
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Preservation of bone flap after craniotomy infection. The standard treatment for infected craniotomies is bone flap discarding and delayed cranioplasty. Adequate cosmetic results, unprotected brain and disfiguring deformity until cranioplasty are controversial features following bone removal.
We present a limited series of five patients with craniotomy infection, that were successfully treated with wound debridement, in situ bone sterilization, reposition of the bone flap and antibiotic irrigation through a wash-in and wash-out draining system, all in the same surgical procedure. We retrospectively reviewed the records of 5 patients with craniotomy infection that presented with wound swelling, purulent discharge and fever.
The operative technique consisted on three manoeuvres: Also, crraneotomia received equal systemic endovenous antibiotherapy and oral antibiotics after discharge, until complete resolution of infection and wound healing. Patients in the series 2 women and 3 men ranged in age from 36 to Crnaeotomia patient had received prior radiation therapy and only one had undergone surgery involving nasal sinuses. The initial operations correspond to craniotomies performed for two intracranial tumours meningiomasone arteriovenous malformation and two decompressive craniotomies haemorrhagic contusions and acute subdural haematoma.
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The duration frontak surgeries ranged from 1h30′ to 5h30′, only two operations extending over 4 hours. The interval between the initial surgery and the reintervention ranged from 11 to days.
Staphyloccocus spp were cultured in all patients. For bone sterilization povidone scrubbing was used in all patients, autoclave in two and soaking the flap in a sterilizing solution in three. All patients cleared infection and achieved complete wound healing in weeks after the re-operation. Follow up ranged from 4 to 18 months.
One patient died as a consequence of crontal in the context of pneumonia some weeks after wound healing. Recent multivariate analyses have demonstrated that the presence of a CSF leak and the performance of repeated operations are the most important independent risk factors for craniotomy infection, with associated odds ratios for infection as high as and 7, respectively.
Regular antibiotic administration at anaesthesia induction seems to decrease the rate of craniotomy infection by half, both in the entire population and in low-risk subsets. Organisms involved in craniotomy infections are common pathogens usually contaminating neurosurgical procedures or normal skin flora germs.
Auguste and McDermott have xraneotomia presented a case series of 12 patients in which successful salvage procedures for infected craniotomy bone flaps were performed using a continuous wash-in, wash-out indwelling antibiotic irrigation system, that needed close observation of the neurological status since obstruction of craneoomia outflow system could precipitate brain herniation.
The method we present is as effective as theirs and avoids such complication since only small quantities of antibiotic solutions 20 cc are instilled during each dose administration.
Se cultivaron diversas especies de Staphyloccocus en todos los pacientes. El seguimiento estuvo entre 4 y 18 meses. Infection frontao a relatively uncommon complication of craniotomy.
Previously reported predisposing factors for craniotomy infection are prior radiation therapy, repeated surgery, CSF leak, duration of surgery over four hours, interventions involving nasal sinuses and emergency surgeries 2,3,5,13, The term “craniotomy infection” does not necessarily imply the presence of purulent collections in a cranial space in particular either subgaleal, epidural or below the dura mater.
It is usually referred to as a clinical setting consisting on wound swelling and erythema, purulent discharge through the skin, at least partial wound dehiscence, and general signs of infection like fever, anorexia or malaise Traditionally, infected bone flaps have been surgically removed and discarded 1,2,5, This standardized management implies the performance of a delayed cranioplasty once the infection is cleared.
Although this is a safe procedure and several simple-to-use cranioplasty materials have been developed, excellent cosmetic results are not always easy to achieve. Besides, there is a time interval in which the underlying brain is exposed to injury and the patient exhibits a somehow disfiguring deformity. Attempts to salvage infected craniotomies as an alternative to bone flap removal have been reported in the literature.
Simple debridement, suction-irrigation systems or wash-in, wash-out indwelling antibiotic irrigation methods have been used with favourable results 1,5.
We present a limited series of five patients with the diagnosis of craniotomy infection, that were successfully treated with wound debridement, intraoperative bone sterilization, reposition of the bone flap and antibiotic irrigation through wash-in and wash-out drains in the same surgical procedure.
Some technical aspects of this procedure are also discussed. We retrospectively reviewed the records of 5 patients in whom a craniotomy infection was diagnosed. All presented with wound swelling and dehiscence, purulent discharge and fever Figure 1. Four neurosurgeons participated in the surgeries. The technique consisted on three consecutive manoeuvres Figure 2. First, the wound was reopened, all devitalized tissues were carefully removed, purulent collections were thoroughly cleaned and samples for microbiological culture obtained.
Hemostasis was achieved with frontall forceps and the aid of absorbable hemostatic agents. New bone fixation material was used to secure the flap to the skull.
The wound was closed in a single layer with non-absorbable suture. The drains were craneotkmia away the incision line and secured with suture. The patient is allowed to ambulate the next day.
Wound dehiscence with purulent material dis-charge in the upper part of the incision case number 5. A second drain is inserted on the subgaleal space for antibiotic and debris evacuation. Drains are properly secured with non-absorbable suture. Antibiotic solution through the ventricular catheter was administered every 6 hours, kept inside the wound for one hour no more than 20 cc each time with the wash-out drainage tube closed during that interval and then opened to evacuate the solution and debris until craaneotomia next administration.
Doses for antibiotic irrigation were as follows: Drains were kept in place for several days depending on the process of wound healing. Systemic intravenous antibiotic therapy was administered to all patients as well during 14 days. After discharge, patients were placed on oral antibiotics for several weeks and followed in the outpatient office until resolution of the infection and complete wound healing see Table 1 for details.
Table 1 summarizes the clinical data of the patients. Infections occurred in the time period from May to October craneoromia The total number of craniotomies performed in that period was and the overall rate of infection was 2.
No patient had received prior crxneotomia therapy and only one cdaneotomia number 2 had undergone an operation involving nasal sinuses frontal sinus. The initial interventions correspond to craniotomies performed for two intracranial tumours meningiomasone arteriovenous malformation and two decompressive craniectomies for haemorrhagic contusions and acute subdural haematoma, respectively.
The duration of surgeries ranged from 1h30’to crraneotomiaonly two interventions extending over 4 hours. The time interval between the initial surgery and the intervention for the infected craniotomy ranged from 11 to days.
All patients presented with wound dehiscence, abundant purulent discharge and fever. Radiologic examination of the flap showed no evident signs of bone resorption; only mild marginal osteolysis in one patient case number 1, Figure 2. Organisms cultured in wound samples are listed in Table 1.
Referenceanatomical structures to perform a craniotomy in the pig
Wound debridement and drain placement was a standardized feature in all re-operations, as well as antibiotic irrigation and systemic dosage as described above. Outpatient medication varied according to drug tolerance and organism sensitivity as it is referred in Table 1. One patient case number 2 died as a consequence of sepsis in the context of pneumonia five weeks after wound healing.
Another patient suffered left hemiparesis after the initial intervention that resulted in hemiplegia when the infection occurred but ultimately improved to mild left upper limb paresis after ten months follow up.
Bone flap infection after craniotomy is a burdensome but fortunately uncommon complication following neurosurgical procedures. This range may be wider depending on the presence or not of certain risk factors. Malis reported a zero rate of infection over interventions in a commonly quoted paper from Neurosurgery inwhere he recommended intraoperative antibiotics Only, about half of all postneurosurgical infections correspond to true bone flap infections 3.
Postcraniotomy meningitis seems to be increased in patients undergoing interventions entering the sinus, those harbouring external ventricular drains or intracranial pressure probes and patients with higher ASA score, as it has been recently reported The distinction between superficial cranial wound infection and deep wound infection seems only theoretical since the subgaleal and epidural compartments are in contiguity when a craniotomy is performed. In our view, any craniotomy infection can be considered a bone flap osteitis as far as the treatment is concerned.
Also, some degree of bone resorption can be ascertained in the x-ray films or CT scans in many cases, depending on the latency until the infection is diagnosed. The standard management of bone flap osteitis includes wound debridement, bone removal and discarding and delayed cranioplasty with acrylic material or other substitute 1,2,5, Risk factors for craniotomy infection have been identified in several studies.
Multivariate analyses have demonstrated that the presence of a CSF leak and the performance of repeated operations are the main independent risk factors for craniotomy infection, with associated odds ratios for infection as high as and 7, respectively 13, Other predictive risk factors include: The absence of antibiotic prophylaxis also seems to predispose to infection 2, The patient’ s age, the individual surgeon or the number of operations per surgeon are still uncertain and debatable risk factors 3, No reliable data is available on the influence of other possible factors such as prior comorbidity, medications used in common neuro-anaesthetic procedures, the type of incision lineal versus curved flaps or whether the scalp was shaved or not.
Castilla et al have reported that minimum shaving of the incision line scalp does not seem to predispose to infection 6.
The rationale for the use of antibiotic prophylaxis relies on the fact that free craniotomy flaps are devascularized bones with a reduced resistance to infection and, once contaminated, this osteitis requires surgical removal.
Administration of a single prophylactic dose of vancomycin was recommended in a large randomized trial on the basis of a significantly reduced bone flap infection rate 4. Other trials have shown that second and third generation cephalosporin 7,21 or fusidic acid 18 seem to be as effective as vancomycin or combined treatments for preventing craniotomy infection. Various methods of bone flap sterilization are available. Commonly, they may be autoclaved or soaked in sterilizing solutions.
Parameters for autoclave procedure or which type of solution hydrogen peroxide, povidone-iodine, clorhexidine or others is optimum are not well-defined features.
No data is available in the literature concerning the best parameters in case of infected flaps. In any case, bone sterilization can be easily performed intraoperatively.
Abordajes Supratentoriales by alexander maza gonzalez on Prezi
Some authors consider indispensable autoclave sterilization of a frozen-preserved bone flap before reposition, a method that does not seem to increase the risk of infection or bone resorption Although not a sterilizing method, hyperbaric oxygen treatment has been evaluated as a therapeutic method for infections after craniotomy or laminectomy. In both uncomplicated and complicated radiation injury, malignancy, repeated surgery or implants cranial wound infections, bone flaps could be retained in the great majority of cases after hyperbaric treatment.
Also, all spinal cases undergoing hyperbaric therapy resolved without the removal of fixation systems These include gram-positive cocci such as Staphylococcus aureus or S. Propionibacterium acnes is commonly isolated but usually considered a contaminant. In the context of neurosurgical procedures it can cause postoperative CSF or craniotomy flap infections 9,