RESUMO
Cranioplasty following extended, decompressive craniectomy is a formidable challenge and its complexity increases with the size of the bone defect. Several techniques and methods are described for preservation and sterilization of craniectomy bone flap, each has its own advantage and disadvantages. In this report the authors describe a simple and cheap method for preservation of large craniectomy bone flaps. To evaluate the technique of preservation of large craniectomy bone flap in the freezer at -18°C for long periods of time, by microbiological and histological examination. This prospective study was carried out at King Khalid University Hospital, College of Medicine, King Saud University, during the period January 2001 to December 2008. Twenty-four patients had decompressive craniectomy for intractable brain oedema due to different pathology. A protocol was designed to prepare the removed bone flap for preservation in domestic freezer at -18°C. Microbiology swabs and histology specimen were taken from 14 bone flaps and sent for microbiological and histological examination to check both sterility and viability of the bone flaps after long periods of preservation. During the study period 24 decompressive craniectomy bone flaps were preserved, 15 of them were bifrontal decompressive craniectomy. Sixteen bone flaps were reapplied to their patients while 8 flaps were kept in freezer for long periods of time after expiry of donor patients. The dimensions of bone flaps ranged from 5 x 7 cm to 13 x 25 cm with a mean surface area of 228 cm[2]. Duration of preservation ranged from 60 - 1920 days, mean 313. Fourteen bone flaps were examined histologically and microbiologically, all of them showed no bacterial contamination and were viable, except one flap was not viable. Mature lamellar bone was seen in 5 specimens preserved for [60, 60, 90, 120 and 150 days], mostly viable bone was seen in 4 specimens preserved for [360, 390, 480 and 900 days], focal loss of bone was seen in 4 specimens kept for [390, 630, 720 and 780 days], and one specimen was kept in freezer 1920 days and showed no viable bone. The follow-up period after cranioplasty ranged from 5 months to 6 years, mean 11 months. One patient developed superficial wound infection which was treated with antibiotics and repeated dressings. Another patient developed partial resorption of the bone flap which was treated conservatively as spontaneous bone regrowth appeared a few months later. Preservation of bone flap in the freezer at -18°C is very simple, cheap and safe and is available in all hospitals. Bone flaps preserved using our technique remains viable and sterile for periods of up to 12 months
RESUMO
Endoscopic third ventriculostomy [ETV] has become the standard surgical procedure for treatment of non-communicating hydrocephalus. The aim of this study is to report our results over the past ten years with reference to perioperative complications of ETV with a review of some specific anesthetic issues. The computerized database [in the Department of Neurosurgery] and the medical records of 128 patients who underwent ETV between February 1998 and February 2007 at our Hospital, were reviewed. Data collected were, age, sex, weight, height, preoperative biochemical analysis, duration of the procedure, anesthetic drugs used, amount of irrigation fluid used, blood loss, postoperative biochemical analysis and perioperative complications. Preoperative biochemical analysis for all patients was within normal ranges. Normal saline 0.9% was used as irrigation fluid for all patients. The volume during the procedure used ranged from 2 to 6 L [mean 3 L]. When correlating postoperative serum sodium mean values to the volume of irrigation fluid used, it showed non significant correlation [r = 0.07]. Serum potassium level has shown significant decrease postoperatively compared to preoperative levels [P <0.05]. The other biochemical analysis parameters showed non-significant changes postoperatively compared to preoperative data [P > 0.05]. Anesthesiologists should be aware of the intra and postoperative complications secondary to ETV. Intraoperative bradycardia is the commonest arrhythmia occuring during the procedure. Precautions, like alerting the surgeon and pulling out the scope, are enough to revert bradycardia if it occurs. Though postoperative electrolyte imbalance occurs we believe it has no clinical significance. We believe that either normal saline or lactated Ringer solutions could be safely used for intraoperative irrigation with minimal postoperative impact. Though the procedure is a minimally invasive procedure, close observation of vital signs, serum electrolytes as well as volume and temperature of the irrigation fluid and close communication between anesthesiologist and surgeon, are prerequisites for better outcome