Andi Ihwan

Divisi Bedah Saraf FK Unhas

Andi Ihwan, SpBS
• Bone, 30 Juni 1977
• FK Unhas, 1994-2001
• Bedah Saraf Unair, 2007-2012
• Puskesmas Malangke Barat, Luwu
Utara
• Puskesmas Tompobulu Gowa
• Divisi Bedah Saraf FK Unhas
• RS dr. Wahidin Sudirohusodo
Makassar
• RS Akademis Jaury Yusuf Makassar
• [email protected]
Tujuan
TIU : menjelaskan tata laksana operasi pada kasus neuropsikiatry
TIK :
* Menjelaskan indikasi operasi pada kasus neuropsikiatry
* Menjelaskan jenis tindakan operasi kasus neuropsikiatry
* Menjelaskan komplikasi operasi pada kasus neuropsikiatry
* Menjelaskan perawatan post operasi kasus neuropsikiatry
Pokok Bahasan : Tata Laksana Operasi neuropsikiatry
Sub Pokok Bahasan :
• Indikasi operasi Operasi neuropsikiatry
• Jenis tindakan operasi Operasi neuropsikiatry
• Komplikasi Operasi neuropsikiatry
• Perawatan post operasi Operasi neuropsikiatry
* Intracranial Pressure
•Primary Survey
A Assess and secure Airway whilst ensuring cervical spine
immobilization
B Assess Breathing and give high flow oxygen by mask
C Assess Circulation, obtain IV access, and commence fluid
resuscitation if indicated (signs of hypovolaemia)
D Determine conscious level using GLASGOW COMA SCALE or
AVPU scale (note any asymmetry in limb response), and
examine pupil size, symmetry and reaction to light.
E Check blood glucose level, treat if low
• Good oxygenation and circulatory resuscitation are essential to avoid further
brain injury (secondary brain injury).
• The presence of hypotension should be considered an emergency.
• If possible the neurological status should be reassessed following treatment of
hypoxaemia and hypotension.
• The best GCS after resuscitation is used for classification of the severity
of head injury.
• Intubation (after induction of anaesthesia) and mechanical ventilation may be
required as part of steps A or B during the primary survey.
• Establishing the mechanism of injury is important in assessing the risk of head
and/or spinal injury.
Signs of raised intracranial pressure include:
• Headache - Dizzines
• Nausea or vomiting - Seizure
• Loss of consciousness or fluctuating levels of consciousness
-
• Cushing's reflex (hypertension with bradycardia)
(NB - relative bradycardia alone can herald raised ICP before patient becomes
hypertensive)
• Unilateral or bilateral pupillary dilatation
• Deteriorating GCS > 2 points
• Developing focal signs
• Extensor posturing
This is an emergency and the child requires urgent CT
scan and neurosurgical review.
Management:
• Arrange ICU admission
• Aggressively treat hypotension with IV fluid boluses and vasopressors
• Provide adequate analgesia (morphine) and sedation (midazolam)
• Paralyse with muscle relaxants
• Mannitol 0.5-1 g/kg (2.5-5 ml/kg of 20% mannitol) by intravenous
infusion over 20 min
• Phenytoin 20 mg/kg should be given to prevent early post-traumatic
seizures.
• Hyperthermia should be avoided (> 37.5°C).
• The head of the bed should be elevated
Management:
• Neurosurgical consultation is required PRIOR to CT scan if
patient deteriorating:
- Deteriorating GCS > 2 points
- Dilating pupil
- Developing focal signs
- Extensor posturing
• Further management dependent on CT findings and
neurological status:
Operating Theatre
ICU/ward
* Epidural hematoma occurs in 1-2% of all head trauma cases and
in about 10% of patients who present with traumatic coma.
* Mortality rates range from 5-43%.
* EDH is uncommon in elderly patients
• Following injury, the patient may or may not lose consciousness.
• Lucid interval
• Severe headache
• Vomiting
• Seizure
• Posterior fossa epidural hematoma (EDH) may have a dramatic
delayed deterioration.
• The patient can be conscious and talking and a minute later
apneic, comatose, and minutes from death.
Surgery
* Indications
* Any symptomatic EDH
* Volume greater than 30 cc should be evacuated regardless of GCS
* Volume less than 30 cc/less than 15mm thickness/less than 5 mm
midline shift/GCS greater than 8 may be managed non-operatively
* Timing
* Any patient with acute EDH/GCS <9 / anisocoria should undergo
operation “as soon as possible”
Non Operative Operative
• Most common type of traumatic intracranial hematoma
• 24% of patients who present comatose.
• overall mortality rates 60%.
• Symptom:
• Headache
• Nausea or vomiting
• Decrease of consciousness
 Surgery
* Indications
*SDH with thickness > 10mm/midline shift > 5mm should be evacuated
regardless of GCS
*Patients with acute SDH and GCS < 9 should have ICP monitoring
*SDH with thickness < 10mm or < 5mm midline shift should be evacuated if
GCS drops 2 or more points from injury to admission, pupillary function is
abnormal, or ICP> 20 mm Hg

*Timing “As soon as possible”

*“Four hour rule” operated < 4 h -> mortality 30%, if delay > 4 hour ->
mortality 90%
*Methods
* Indications
* Parenchymal mass lesion with referable neurologic deterioration, medically
refractory intracranial hypertension or signs of mass effect on CT should be
evacuated
* Patients with GCS 6-8, with frontal or temporal lesion volume > 20cc with midline
shift >5mm or cisternal compression, or any lesion volume > 50cc should be
evacuated
* Parenchymal mass lesions without clinical neurologic compromise, with no signs of
mass effect and with controlled ICP can be treated non-operatively
* Methods
* Craniotomy
* Indications
* Open fractures with depression greater than the thickness of the skull should be treated surgically to
prevent infection
* Open depressed skull fractures may be treated non-operatively provided there is no evidence of dural
penetration, intraparenchymal hematoma, depression > 1 cm, frontal sinus involvement, gross cosmetic
deformity, wound infection, pneumocephalus, or gross wound contamination
* Closed depressed skull fractures may be treated non-operatively
* Timing
* “Early” operation is recommended
* Methods
* Elevation and debridement is recommended
* Primary bone fragment replacement is an option in the absence of wound infection at the time of surgery
* All management options for open depressed fractures should include antibiotics
* Neurosurgery 58:S2 1-62, 2006. www.braintrauma.org
Infants Toddlers and Older Children
* bulging fontanel, or soft spot on the * personality changes Young and Middle-Aged
surface of the skull * changes in facial structure Adults
* a rapid increase in head circumference * headaches
• chronic headaches
* eyes that are fixed downward * trouble eating
* irritability
• loss of coordination
* seizures * loss of coordination • difficulty walking
* vomiting * loss of bladder control • bladder problems
* excessive sleepiness * larger than normal head • vision problems
* low muscle tone and strength * vomiting or nausea • poor memory
* seizures
• difficulty concentrating
• have been used successfully and have become the primary
therapy for hydrocephalus treatment for nearly 60 years.
• An implanted shunt diverts CSF from the ventricles within the
brain or the subarachnoid spaces around the brain and spinal
cord to another body region where it will be absorbed.
• Timing
Hydrocephalus should undergo operation

“as soon as possible”

• Proximal end inserted into a CSF source (usually blocked)
• Ventricle
• Lumbar cistern of the spinal cord
• Distal end inserted near absorptive epithelial surface or directly
into the blood stream:
• Peritoneal cavity of the abdomen (most common)
• VP shunt = ventriculo-peritoneal shunt
• LP shunt = lumbar-peritoneal shunt
• Right Atrium of the heart (VA shunt)
• Pleural cavity of the lung (VPL shunt)
:

Most common shunt systems

Shunt Pathway Shunt Type CSF Inflow Location CSF Drainage Location

Ventriculo-peritoneal VP Ventricle Peritoneal cavity

Right atrium of the

Ventriculo-atrial VA Ventricle
heart

Ventriculo-pleural VPL Ventricle Pleural cavity

Lumbo-peritoneal LP Lumbar spine Peritoneal cavity

VP SHUNT VA SHUNT
LP SHUNT
*May also insert distal end into:
*gallbladder (mixes with bile)
*ureter (mixes with urine)

*Variety of forms:
*made of different materials (silicone)
*different types of pumps and uni-directional valves
*+/- programmable
Malfungsi shunt
• More common in childhood
• May require immediate shunt revision or shunt re-programming
• Shunt complications often mimic the symptoms that prompted initial
shunting
• headache
• double vision
• nausea / vomiting
• altered mentation (lethargy / irritability)
• bulging fontanelle
• Shunt failure rate 2 years after insertion - up to 50%
 Symptoms of Shunt Malfunction:
Infants Toddlers Children and Adults Adults Living with NPH
•Enlargement of the •Head enlargement •Vomiting •Return of symptoms
baby’s head •Vomiting •Headache that were present
•Fontanel is full and •Headache •Vision problems before shunt
tense when the infant •Irritability and/or •Irritability and/or
is upright and quiet sleepiness tiredness
•Prominent scalp veins •Swelling along the •Personality change
•Swelling along the shunt tract •Loss of coordination or
shunt tract •Loss of previous balance
•Vomiting abilities (sensory or •Swelling along the
•Irritability motor function) shunt tract
•Sleepiness •Difficulty in waking up
•Downward deviation of or staying awake
the eyes •Decline in academic
•Less interest in performance
feeding
• Incidence 1-20 %, average 10 %
• Usually intra-operative contamination of surgical wound by skin flora
• Common microbial agents
• Staph epi (coagulase negative staph) > 50%
• Staph aureus 20 %
• Gram negative bacilli 15 %
• Candida
• Symptoms – ICP, fever, WBC
• No correlation with shunt type
• Risk factors for shunt infection
• age < 6 months
1. Colonization of the shunt - most common
2. Wound infection
3. Peritonitis / distal infection
4. Meningitis
• It is often the preferred treatment when a tumor can be removed without
unnecessary risk of neurological damage.
• Surgery might be recommended to:
• Remove or destroy as much tumor as possible
• Provide a tumor tissue sample for an accurate diagnosis and for genomic testing
• Remove at least part of the tumor to relieve pressure inside the skull (intracranial
pressure), or to reduce the amount of tumor to be treated with radiation or
chemotherapy
• Enable direct access for chemotherapy, radiation implants or genetic treatment of
malignant tumors
• Relieve seizures (due to a brain tumor) that are difficult to control
• Location of the tumor.
• it is operable or inoperable.
• An operable tumor: can be surgically removed with minimal risk of brain damage.
• Inoperable: the tumor is so deep within the.
• Tumors located in the brain stem and thalamus are two examples.
• Other tumors may present a problem if located near a sensitive area in the brain that controls
language, movement vision or other important functions Diagnosis and size of tumor.
• Benign /malignant/a metastatic brain tumor
• Number of tumors, The borders, or edges, of the tumor.
• Neurological status.
• symptoms of increased intracranial pressure
• signs of nerve damage possibly caused by the tumor
• General health.
• Previous surgery.
• Other options.
• BIOPSY
• A biopsy may be performed for the sole purpose of
obtaining a tissue sample. It may also be done as part of
the surgery to remove the tumor.
• Needle biopsy.
• Stereotactic biopsy.
• performed with a computer-assisted guidance system that aids in the location
and diagnosis of the tumor.

• Open biopsy.
• The tissue sample is taken during an operation while the tumor is
exposed
• CRANIOTOMY
• The procedure typically involves remove a portion of the skull.
• This enables the neurosurgeon to find the tumor and remove as much as possible.
• After the tumor is removed, the portion of skull that was cut out is replaced, and
the scalp is stitched closed.
• DEBULKING
• reduce the size of a tumor by removing as much of it as possible.
• PARTIAL REMOVAL
• the remaining tumor usually requires additional treatment such as radiation
therapy or chemotherapy.
• Partially removed tumors also tend to regrow.
• COMPLETE REMOVAL
• A “complete removal” means that the neurosurgeon removed the entire tumor.
“gross total resection.”
• However, it is still possible that tumor cells might remain after a complete
removal.
• Antimicrobial therapy
• control increasing intracranial pressure
• surgical excision or drainage combined with prolonged antibiotics
(usually 4-8 wk) remains the treatment of choice.
• The first step is to verify the presence, size, and number of abscesses
using contrast CT scanning or MRI.
• Emergent surgery should be performed if a single abscess is present.
• Abscesses larger than 2.5 cm are excised or aspirated
• smaller than 2.5 cm or which are at the cerebritis stage are aspirated
for diagnostic purposes only.
• In cases of multiple abscesses -> repeated aspirations are preferred to
complete excision.
• High-dose antibiotics for an extended period
Candidates
• These medically intractable patients
• characteristic presentations or lesions that strongly suggest surgical
intervention might be curative.
* The primary objective of most epilepsy surgical procedures is to
accurately localize and then completely excise the epileptogenic
region without causing cognitive or neurologic deficit
* EEG activity
* functional MRI
• Lesionectomy
• Temporal resections
• Hemispherectomy
• Corpus Callosotomy
• implantation : a neurostimulator which sends
electrical impulses, through implanted
electrodes, to specific targets in the brain
• Parkinson's disease, essential tremor, dystonia,
chronic pain, major depression and obsessive–
compulsive disorder (OCD)
• assistance of image guidance/MRI
• A minimal invasive
• a three-dimensional cordinate system
• to perform: ablation, biopsi lesion, injection,
stimulation, implantation, radiosurgery (SRS)
Indication
Tumors: metastases, meningiomas, schwannomas, pituitary adenomas,
• arteriovenous malformations (AVM)
• trigeminal neuralgia,
Functional neurosurgery
• Parkinson's disease
• hyperkinesia,
• disorder of muscle tone, intractable pain,
• convulsive disorders and psychological phenomena
The Role of Surgery
• Clinical findings and MRI findings fit
• Failure of non-operative treatment
• Severe Pain
• Neurological deficit
• Weakness
• Bowel / bladder incontinence
• Leg or arm pain or weakness
HNP

spondilolistesis

Tumor medulla spinalis

• Laminectomy
• Microdiscectomy
• Fusion/Stabilisation