NEUROLOGICAL/INTRACRANIAL SURGERY

 BURR HOLE
 CRANIOTOMY
CRANIECTOMY
 CRANIOPLASTY
 Intracranial surgery

Is an opening of the skull surgically to gain access to

intracranial structures
Types of Surgery:
1.Burr Hole
2.Craniotomy
3.Craniectomy
4.Cranioplasty
 BURR HOLE SURGERY

 Small circular incision opening into the cranium using

craniotomy
Purpose:
1. Obtain tissue biopsy
2. Aspirate CSF from a ventricle of the brain
3. Insertion of EVD-(external ventricular drain)
4. Relieves pressure cause by swelling and edema of
the brain
5. Evacuate intracranial hematoma or abscess
 BURR HOLE SURGERY

EVD
 CRANIOTOMY

 Scalp incision to explore the area

 The opening is curve and allow the bone flap to be
folded back and re-suture the bone

Purpose:
1. To remove blood clot, tumor & control hemorrhage
2. Reduce ICP
3. Reduce cerebral edema
4. Inspect the brain tissue
5. To remove tumor
Craniotomy
 2

3
 CRANIECTOMY
Craniectomy is neurosurgical procedure that involves
removing a portion of the skull in order to relieve
pressure on the underlying brain.
This procedure is typically done in cases where a patient
has experienced a very severe brain injury that involves
significant amounts of bleeding around the brain or
excessive swelling of the brain.
:Purpose
1. Remove shattered bone
2. Reduce ICP
3. Removing brain lobe &
removing blood clot
 CRANIECTOMY

• Craniectomy is typically performed as a life saving

measure.
• Patients who have experienced a severe brain injury
that is life threatening may have bleeding around
their brain or swelling of their brain so severe that it
can lead to brain compression and brain death.
 CRANIECTOMY
• Neurosurgeons remove portion of the skull, evacuate
any underlying clot that is compressing the brain, and
relieve pressure on the brain.
• The bone is removed. Typically the bone is stored in a
freezer.
• The bone also can be tunneled under patient skin for
later use .
• Removing the bone frees the brain to swell upward
rather than downward where it will compress the
brainstem and cause herniation , which is critical for
all of the basic vital functions, leading to brain death.
• Over time the brain swelling will subside and the
bone that was removed can be replaced.
POST CRANIECTOMY
 CRANIOPLASTY

 Replacement of a section of the cranium with a

material, such as; bone, cartilage, metal and silicone
 May perform electively post craniectomy

Purpose:
1. To establish the contour and integrity of the skull
2. To prevent secondary injury to the brain
3. Cosmetic purposes
 CRANIOPLASTY

MESH Bone replacement

Post Cranioplasty
 TYPES OF IMPLANTS USED FOR CRANIOPLSTY

1. Autologus (Bone and Cartilage)

• Involve bone – iliac crest, skull and ribs
• Disadvantages – expose the infection
- increase pain
- increase operation time
2. Non Autologus
• Bone transplant from other person
• Disadvantages: expose patient to the infectious agent
- expose to immunological
inflammatory reaction
3. Alloplastic implant
• Titanium and vitallium (metallic)
• Silicone (synthetic)
• Advantages – low risk of infection
- Geometrically stable
- Size and quantity pending on demand
Disadvantages:
- inflammatory tissue reaction
 Pre Operative Management
1. Diagnostic investigations
• CT Scan Brain, MRI Brain- to identify any abnormality or
lesion
• Blood tests: CBC/FBC, BUSE, Serum Osmolality, urine
Osmolality

2. Hyperosmotic agent e.g. IV Mannitol 20%

• Immediately or prior to surgery – to reduce brain swelling

3. Anticonvulsant agent e.g. IV Dilantin 250mg or Epillim

• As prophylactic agent and reduce risk of seizure post
surgery
4. Corticosteroid agent e.g. IV Hydrocortisone
• To reduce cerebral edema

5. Pre operative neurological assessment

• Assess any improvement or deterioration of motor
responses, conscious level and verbal response
• Check the pupil reaction to light, equality and size
• Sensory perception, motor ability and limb strength

6. Prepare patient – hair shampoo (if possible)

- hair will be shaved in OT
(specific area)
7. Routine pre Op checklist
 Post Operative Management
1. Vital signs including SpO2, GCS Chart and pupil
reaction
• Monitor for any improvement or deteriorationof the
conscious level
• Prop up bed/head at 30-45 degrees
• Monitor Vital signs, GCS every hour for 12 hours
then 2 hourly for 12 hours
• Apply artificial tears if patient is sedated and
paralized
2. Fluid resuscitation
• Administer IV fluid as ordered by the Doctor e.g.
Normal saline or Haemacell (Gelafundin)
 Post Operative Management

4. Wound inspection
• Observe for any bleeding
• Change dressing when necessary and as instructed
by the Doctor
• Remove blood clot at surrounding operation area to
reduce cause of infection
5. administer Antibiotic as ordered. IV Zinacef as
ordered
6. Check x-ray or CT Scan of the Brain –to observe for
improvement of the affected area
7. Blood investigations: Serum and Urine Osmolality, BUSE,
FBC

Health Education Post Intracranial Surgery

1. Activity and exercise
a. Activity and Exercise
• Explain the symptom of fatigue, tired, headache for few
weeks is normal
• Follow activity instruction given by the Doctor or Physician
• Do not drastically increase activity which may cause
increase ICP
 Post Operative Management
• Do not drive
• Do not lift any heavy object, avoid constipation
• Encourage to avoid coughing, it will increase ICP
• Do not lie on the craniotomy site – reduce blood
perfusion to the affected area which may raise the
complication of headache & other symptoms
• Use cap to cover the craniotomy site
• Don’t touch the incision site unnecessarily or without
washing hands
DIET
• No special diet unless contraindicated (allergy)
• High fiber, fruits and increase fluid intake to prevent
constipation
 Post Operative Management
Medication
1. Do not skip any medication especially anticonvulsant and
corticosteroid drugs as ordered and till reviewed.
Follow Up
• Follow as schedule for physician, physiotherapists
• Report immediately to the hospital or come to A& E if
experiencing;
- Double/Blurred vision
- Confusion, Fainting
- Stiff neck, headache
- Numbness or tingling
- Fever
- Photophobia
 NURSING DIAGNOSIS

1. Impaired cerebral tissue perfusion related to

increased ICP
2. Risk for respiratory distress related to intracranial
bleeding that compresses respiratory system
3. Pain related to surgical wound
4. Risk for infection related to intracranial surgery
 Impaired cerebral tissue perfusion related to
increased ICP

Widening of Pulse pressure • Watch for Cushing triad

SBP-DBP =More than 40

Irregular RR
Tachypnoea; increase
apnea;cheyne –
stroke;Kusamal;central neurogenic
hypoventilation
 Impaired cerebral tissue perfusion
related to increased ICP
• Increased ICP is a true emergency and must be treated
immediately through:
1- Invasive monitoring of ICP to :
► early identifying increased pressure
► quantify the degree of elevation
► initiate appropriate treatment
► provide access to CSF for sampling and drainage
► evaluate the effectiveness of treatment
 Ineffective tissue perfusion cerebral
related to increased ICP
2- Decreasing cerebral edema:
► Osmotic diuretics (mannitol)
► Corticosteroids (e.g. dexamethasone) in brain tumor

3- Maintaining cerebral perfusion:(>70 mm Hg)

► CPP = MAP - ICP
► by manipulating cardiac output
►Inotropic agents such as dobutamine
Ineffective tissue perfusion cerebral
related to increased ICP
3- Lowering the volume of CSF and cerebral blood:
► ventriculostomy/External ventricular drainage

4- Controlling fever:
► fever increases cerebral metabolism

5- Maintaining oxygenation:
► Arterial blood gases must be monitored
► optimizing the hemoglobin saturation
Ineffective tissue perfusion cerebral related to
increased ICP
6- Reducing metabolic demands:
► administration of high doses of barbiturates when
the patient is unresponsive to conventional
treatment
► administration of pharmacologic paralyzing agents:
the patient cannot respond or report pain
7- Hyperventilation:
► Monitor PaCO2 (normal range 35 to 45 mm Hg)
► reduce ICP (by cerebral vasoconstriction and a
decrease in cerebral blood volume)
8- surgical intervention
Ineffective tissue perfusion cerebral
related to increased ICP
9. Maintain head alignment and elevate head of bed 30 degrees. The
rationale is that hyperextension, rotation, or hyper flexion of the neck
causes decreased venous return from jugular vein and increases ICP.

10.Avoid extreme hip flexion as this increases intra-abdominal and

intrathoracic pressures, leading to rise in ICP.

11.Avoid straining at stool as it raises ICP. Administer stool softeners

as prescribed. If appropriate, provide high fiber diet.

12.Note abdominal distention. Avoid enemas

 Ineffective tissue perfusion cerebral
related to increased ICP
13.Minimal suctioning-less than 10 secs PRN

14.Minimal stimuli-TV; Radio

15.Avoid hyperglycemia
Potential respiratory distress related to intracranial bleeding
that compresses respiratory system.

1. Assess conscious level every 30 minutes to hourly during

acute phase by assessing eye opening response, motor
response and verbal response
• To identify immediate intervention
2. Check patient’s vital signs SpO2, pupil reaction to light
while checking GCS
• Pupil constriction indicate compression of the oculomotor
nerve
3. Insert airway if needed
To prevent blockage of the respiratory tract due to tongue fall
back
Potential respiratory distress related to intracranial
bleeding that compresses respiratory system.

4. administer Oxygen via facial mask at 15L/min

 To provide sufficient oxygenation that can cause cerebral
perfusion
5. Prop up bed at 30 degrees and maintain cervical
alignment
 Hard cervical collar reduces nerves compression
6. Administer IV Mannitol 20% as ordered by the Doctor
 To reduce possibility of cerebral edema
7. Inform the Doctor frequently regarding patient’s
condition
 To plan for immediate action if serious problems arises
 Altered in emotional status, anxiety related to intracranial
surgery
Nursing Interventions:
1. Assess level of knowledge pertaining to disease, outcome
and complication of the procedure
• To plan appropriate intervention
2. Explain the pre and post operative procedures to be done
to patient
• To reduce anxiety
2. Provide moral support by listening attentively and
answering necessary questions
• To reduce anxiety and shows nurse’s empathy towards
patient condition
 Altered in emotional status, anxiety related to
intracranial surgery

3. Encourage family members to be with the patient during

Doctor’s explanation and involve in nursing care
 To provide moral support and reduce patient’s anxiety
4. Encourage patient to ask questions if he has any doubt
especially on diagnostic results
 To allay patient’s anxiety
5. Answer all the patient’s questions accordingly
 Neurological patient usually ask the same questions
repeatedly because of amnesia
6. Be gentle when rendering Nursing Care
 To gain cooperation and make the patient feel at ease or
relax