Annals of the Royal College of Surgeons of England (1974) vol 54

ASPECTS OF TREATMENT

Emergency craniotomy
H H Gossman FRCSEd Consultant Neurosurgeon, Plymouth General Hospital, Devon

Introduction This paper is concerned with the surgical treatment of closed head injuries only. The size of the problem of head injury shows no sign of abatement. Road accidents are the prime cause of dcath up to 45 years of age, and over two-thirds of these fatalities are due to head injuries'. For example, in a leading article in the British Medical Journal in 19732 it was stated that 'the increase in fatalities among car users in the U.K. [between I96I and 1970] was a staggering 86%, yet even that is lower than in any European country for which a valid comparison is possible'2. The treatment of head injuries must often be undertaken by surgeons working in district general hospitals, but in this region (Devon and Cornwall) such surgeons know that one or other of the specialist neurosurgeons in Plymouth is always available for telephoned advice and occasional personal help' 4. The same is no doubt true of other regions.

corded: (a) the vital signs; (b) the associated

injuries.

C) Central nervous system-signs of its involvement to be assessed and noted: level of consciousness; reaction of pupils; neck stiffness; posture, tone, and movement of limbs; and plantar responses. TRAIN yourself in the order in which further action is to be taken, once the airway has been secured: T) Check that tetanus toxoid has been given. R) Begin the resuscitation, using intravenous therapy, drawing blood at the same time (for grouping, cross-matching, haematocrit, and electrolytes). A) Are antibiotics and anticonvulsants indicated ? I) Check that the intubation is correct. N) Never forget to empty the stomach and the bladder. Vomiting should be prevented by emptying the stomach, even though the cuff of the endotracheal tube is blown up, in order to Assessment avoid raising the intracranial pressure. By the The ABC of immediate management in an same token, an empty bladder will diminish urgent case of coma due to trauma is as restlessness, establish as to whether or not follows: there is haematuria, and allow accurate reA) Airway adequacy and control. cording of the fluid output and the specific B) Baselines to be established and re- gravity of the urine.

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Indications for emergency craniotomy I{EAD INJURY INTERNAL IIAE2ORRHAGE Deterioration in the level of PULSE consciousness Levels of consciousness PLTSE should not be described in vague terms, sucl as 'disorientation', 'drowsiness', 'semi-coma' 'deep coma'. The level of consciouness should be recorded in the following terms: BLOOD PRESSURE BLOOD PRESSURE i) Patient responds to command sensibly. ) Patient will respond to command slowly. 3) Patient will respond to command only by grunting. 4) Patient will respond to pain (a) ap- FIG. I Baselines compared. propriately; or (b) by alteration in postural tone. the contralateral side and an absence or de5) Patient will not respond to pain but pression of the superficial, particularly the still responds to the elicitation of primitive abdominal, reflexes in children is quite reflexes, as by forceful stroking of the sole enough to alert the surgeon to the possibility of the foot; some response to disturbance of a surface clot compression of the brain of the endotracheal tube (the carinal reflex); on the side of the slowly reacting pupil. The the corneal reflex is still present (when this mechanism of the irritative paresis of the reflex is no longer obtainable the conjuctiva third nerve is thought to be pressure of the assumes a glassy stare and appears drier than surface clot moving the inferomedial temporal at a lighter level of consciousness). lobe across the tentorial edge immediately subjacent to which the third nerve is takAlteration in the vital signs Any al- ing its course to the superior orbital fissure. teration should be reported immediately to This partial lesion, which may be temporary the medical staff. I refer to the slowing of the and reversible, allows over-action of the pulse rate particularly. If the pulse rate is dilator pupillae to take place. Drugs which slow, full, and bounding, then the diagnosis interfere with the pupil reactions should not of increased intracranial pressure may well be be administered for this reason. If morphine correct. If it is different then the case, al- must be given, its time and dose should be though having a considerable concussional clearly recorded on a label attached to the component, is probably not one of increas- patient, or even on his forehead. ing intracranial pressure due to a surface clot compression of the brain. The point I wish to make is graphically illustrated in Figure i. Technique Exploratory burr holes* Preparation of the scalp, positioning on the operating table of focal neurological Development Here I would include the muscle and towelling up are procedures of great imsigns tone, plantar responses, and pupil reactions. portance, and the surgeon is responsible for It is not necessary to wait for one pupil to be- them. If there is lateralization to the left or come fixed, unreactive to light, and dilated, right cerebral hemisphere, then the first burr but the onset of sluggish reaction to light, with *A list of the necessary instruments is available from an increase in the deep tendon reflexes on the author.

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H H Gossman

available. Do not make a funnel opening in the bone. The first burr hole is at this site in order to show the anterior branch of the I __A 93 middle meningeal artery. This vessel is coagJulated, and if nothing is found in the extradural space it is now necessary to open the I 2 dura. The dura may be opened by sharp dissection, using a sharp hook and knife, or ~ Jt..by diathermy puncture. Whichever way it is \ ..done, the incision in the dura should be in a cruciate manner, and the four dural flaps should be coagulated. The findings may be: subdural blood; subdural clots; white 4 oedematous brain; or plum-coloured contused brain, the last two being usually under some FIG. Surface markings-crani ocerebral re- pressure. Whatever the findings on opening lations. (i) Pterion burr hole. (2 ) Scalp flap the subdural space, a further exploratory burr for craniectomy (extradural haesrnorrhage at hole should be made, as shown in Figure 2 (2). classic site). (3) Further burr hol (4) Fur- This burr hole is sited at the parietal eminther scalp flaps (cerebellar burr h Hori- ence, 5-6 cm posterior to the pterion burr zontal line in front of ear in dicates that hole along a line projected at an angle of portion of Reid's baseline represe by the 450 to the orbitomeatal line. It will be seen zygomatic arch. that this second burr hole can be incorporated in a scalp flap should this become neceshole should be sunk in the fror sary (Fig. 2 (2) ). region at the pterion on the appr opriate side. A subdural collection of blood may be fluid Fissure fractures elsewhere will be exposed or clotted. With the curved, blunt Adson deby the second or subsequent bur r holes. The pressor it should be possible to depress the pterion incision almost always co,nstitutes one brain, provided the pia-arachnoid is intact, limb of any scalp flap, as shown in Figure 2. and to wash the subdural space through. If Its surface marking is 2 1-3 cm ab ove the mid- this is not possible, then a trial to depress zygomatic point. A straight verttical incision the brain usually results in the instrument is made through the scalp, thce temporalis actually sinking into the brain substance and fascia, the temporalis muscle, ai the peri- doing more damage. Under such conditions cranium. An incision is made at right angles I rely in the first instance on chemical deto the first, through the muscl e and peri- hydration to bring the oedematous brain cranium, which are rongeured frcim the bone. under control. Before this was possible these The perforator is then used at right angles findings constituted an indication for subto the bone, and the burr follows ILhis after the temporal decompression. This operation is perforator has just opened the inlaer table for similar to that to be described for extradural I-2 mm. In using the burr it iis important haemorrhage except that in subtemporal deto sink the sides of the 'well' ab: solutely ver- compression the craniectomy is carried very tical, because for inspection yc are best low towards the middle cranial fossa floor served by having all the room ye can make in order to give the temporal lobe of the
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Emergency craniotomy brain maximal room for expansion. If an osteoplastic flap is fashioned the bone is invariably sacrificed. Further burr holes (Fig. 2 (3) ) may need to be made in the mid-frontal region-that is, about 3-4 cm lateral from the midline, approximately 8 cm above the root of the nose. This is usually the point where the hairline is situated. It is approximately 2-3 cm anterior to the coronal suture. The coronal suture is normally found at 12-I4 cm from the root of the nose. This third burr hole can be incorporated in a frontal flap. The fourth burr hole, if it is necessary, should be made immediately above the ear, the scalp being cut vertically or horizontally, very low indeed, to be sure to expose the floor of the middle cranial fossa. A fifth burr hole, a central one, can be made at a point midway between the frontal and parietal eminence burr holes, some 2-3 cm from the midline. When the pterion burr hole and the burr hole at the parietal eminence have yielded nothing more than oedematous or contused brain the procedure should be repeated on the opposite side, but when the pterion burr hole, or one at any other site (Fig. 2 (3) ), has
revealed extradural blood, then the surgeon should proceed to craniectomy. A scalp flap is fashioned, Craniectomy based on a suitable blood supply, as shown in Figs. 2 (2) and 2 (4) diagrammatically and in Figure 3 for illustration. The scalp flap is cut and the galea is secured with straight artery forceps gathered in three sets of six by sterile rubber bands. The galea on the opposite side of the incision is secured with curved forceps, similarly gathered and retracted over the superficial layers of the scalp to control bleeding. The scalp flap is then reflected. It is barely necessary to use the scalpel to separate the galea from the temporalis fascia. Forceps are used to secure the temporalis fascia and the temporalis muscle, which are rongeured off the underlying temporal bone. I still prefer to use the bone nibblers to remove whatever amount of bone is necessary to come to the edge of the blood clot. The craniectomy must be adequate. Osteoplastic flaps are a nicety but complicate an urgent procedure. You do not know how much bone requires to be removed; furthermore, rpplacement of

FIG. 4 Same patient. The right extradural haemorrhage, clotted and exposed, with the FIG. 3 J S, male, aged I3 months. Photo- bleeding point controlled by a proximal ligagraph to illustrate right parietotemporal ture on the posterior branch of the right craniectomy. Baby lying on left side-body middle meningeal artery (below and to left). Orientation as in Fig. 3. to the left, surgeons to the right.

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H H Gossman

a bone flap may compromise reexpansion of the compressed brain. 'Rebound' cerebral oedema is well taken care of by an adequate craniectomy. I cannot emphasize this too strongly. Once the limit of the clot has been found (Fig. 4), it is washed and sucked away. Again it is most important to remember that as much bone is removed as is required to afford decent access to the clot, whichever way it is extending. Sometimes bone must be removed anteriorly, and it may be indicated to make a relief incision in the scalp in order to extend the craniectomy. It is always possible to insert an appropriate acrylic or rib graft to the skull defect after an interval of time, usually 3 months. Often the bleeding point is not found and there is a general ooze from the surface of the dura, frequently venous. Under these circumstances repeated washings and gentle pressure on a swab soaked in 2o-volume hydrogen peroxide will, in time, bring the

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Same patient. A complete removal of the extradural clot with the overlying bone. The bone was cut with scissors from the pterion burr hole (indicated by tip of artery forceps) to connect up with a posteriorly situated fissure fracture so that the bone was in one piece. Craniectomy thereafter enlarged with nibblers (cf. Fig. 4).
FIG. 5

problem of haemorrhage under control. Figure 4 illustrates my last case, where ligation of the posterior branch of the right middle meningeal artery stopped the bleeding. With this achieved, and the dura having its normal sheen-in other words it does not look blue, betraying additional underlying subdural blood-I do not open the dura. When I suspect that there may be an additional subdural haematoma I make small openings in the dura, using the sharp hook and knife, and evacuate this blood by washing through the subdural space with a soft rubber catheter. I do not reflect a large flap of dura under these circumstances. In most instances the extradural haemorrhage is the major lesion and, when satisfactorily dealt with, requires no further exploration. If, however, there is a massive subdural associated with the extradural haematoma, which in my experience is rare, then the prognosis must be guarded. Assuming the extradural haemorrhage has been satisfactorily controlled, either by pressure or under-running and ligating the middle meningeal artery or its branches, then the dura is picked up and stitched with No. 3 0 silk to the pericranium over the bone edge. I lay some Sterispon (absorbable gelatin sponge) under the cut bone in order to prevent any sort of recurrence of bleeding in the extradural plane. It is essential to make use of this trick if there has been haemorrhage from one of the dural venous sinuses. This is a feared problem and should be suspected if a fracture approaches any venous sinuses. Loss of blood in cases of venous sinus tear can prove fatal on removing bone. The tear must be plugged with Sterispon, Oxycel (oxidised cellulose), or even gauze, and the dura used as described. The pericranium or temporalis fascia is then reconstituted without tension; the galea is approximated by interrupted 3 U silk sutures and the scalp closed in the usual way. The making of cerebellar burr holes should be

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carried out only in a neurosurgical unit. An extradural haemorrhage occurred in a one-year-old male child (J.S.) on gth March I973. He had fallen strapped to his highchair and hit the ground with the right side of his head. He went to sleep, according to the parents, and when six hours later he was still asleep they called their doctor, who suspected the diagnosis. To his great credit he personally brought the baby to the North Devon Infirmary where I happened to be visiting. The consultant surgeon asked me to deal with the case, which is illustrated in the accompanying photographs (Figs. 3, 4, and 5). The baby did well.

I am not able here to continue on the serious and important topic of the postoperative management of these cases because this is a subject in its own right. I would, however, leave with you the concept we have developed in the Plymouth unit, which is that of, so to speak, 'splinting' of the brain' to allow it to recover, if it will, and to take on its function of control over the vital processes of the body again. Every unit develops its own method of care of the unconscious patient. We have formulated this in booklet form for our own nursing and medical staff, but I am happy to refer you to the excellent monograph by Hitchcock and Masson cited under 'further reading.'
It is a pleasure to record my thanks to Dr A J Riley, of Bideford, and Mr John Partridge, FRCS, of the North Devon Infirmary, Barnstaple, who refcrred the case illustrated in this paper; to Mr Arthur Newton, FRCS, who took the photographs; to Miss Sylvia Easton for photographic help; and to Mrs Pauline Spicer, my former secretary, for typing the manuscript.

Conclusion Exploratory burr holes in cases of trauma are designed to exclude surface clot compression of the brain. They should be performed without resource to neuroradiological investigation, in my opinion, and on clinical grounds on the indications considered. Cases of extradural haemorrhage are important because the prognosis can be excellent; nevertheless they are uncommon. In the years I969-71 inclusive there were I95 cases of head injury which underwent emergency neurosurgery in the Plymouth unit, and only I5 of these (7.7%) were of the extradural type. The major pathological process in these cases is the bleeding, for which surgery has a remedy. This is in contradistinction to the remainder of cases of closed craniocerebral trauma, where subdural haemorrhage is an accompanying phenomenon of the much more serious underlying contusion or laceration of the brain. The prognosis must be guarded. Exploratory burr holes are nevertheless indicated in these latter cases, if only to establish the state of the underlying brain and so to obtain some guidelines as to the further management of the case and to evacuate any subdural blood.

References
1 Walker, A E (1971) In Head Injuries, Proceedings of an International Symposium held in Edinburgh and Madrid, p. 5. Edinburgh and London, Churchill Livingstone. 2 British Medical Journal (1973) 1, 370. 3 Gossman, H H (1971) In Head In juries, Proceedings of an International Symposium held in Edinburgh and Madrid, p. 158. Edinburgh and London, Churchill Livingstone. 4 Garfield, J (1972) British Journal of Hospital Medicine, 8, 262. 5 Nesling, A E. Personal communication.

Further useful reading: Rowbotham, G F, and Hammersley, D P (1953) Pictorial Introduction to Neurological Surgery. Edinburgh, Livingstone. Hitchcock, E R, and Masson, A H B (1970) Management of the Unconscious Patient. Oxford and Edinburgh, Blackwell Scientific Publications. Hunt, A C (1972) In Pathology of Injury, ed. A C Hunt, ch. 5. London, Harvey Miller and Medcalf.