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I. PATIENTS DATA Name: Patient X II. ANATOMY/STRUSTURE/FUNCTION a.

Definition of operation performed A craniectomy is a surgical procedure that is used when an individual's brain is swelling to a degree that it could cause damage to the brain. In the neurosurgical procedure, a section of the skull is cut out and removed to give the swelling brain space to expand without being pressed up against the skull. The brain can swell for a variety of reasons ranging from injury to disease. Brain trauma can cause swelling in the brain, just as hitting one's knee can cause the knee to swell. An infection, such as meningitis, may also be responsible for swelling the the brain. A decompressive craniectomy procedure is typically only used when all other methods of reducing brain swelling have failed. It is a relatively controversial procedure as it is often ineffective and can cause great damage to the individual undergoing the procedure. The surgery can open a patient to diseases such as meningitis or brain abscess, both of which carry a risk of death. B. definition of anatomy involved BRAIN The cerebral hemispheres make up the largest portion of the human brain. The cerebral hemispheres appear as highly convoluted masses of gray matter that are organized into a folded structure. The crests of the cortical folds (gyri) are separated by furrows (sulci)or deeper fissures. The folding of the cortex into gyri and sulci permits the cranial vaultto contain a large area of cortex (nearly 2 1/2 square feet), more than 50% of which is hidden within the sulci and fissures. C. functions of organ/ body parts involved The temporal artery is a major artery of the head. It arises from the external carotid artery when it bifurcates into the superficial temporal artery and maxillary artery. The superficial temporal artery is the smaller of two terminal branches that bifurcate superiorly from the external carotid. Based on its direction, the superficial temporal artery appears to be a continuation of the external carotid. It begins in the substance of the parotid gland, behind the neck of the mandible, and passes superficially over the posterior root of the zygomatic process of the temporal bone; about 5 cm. above this process it divides into two branches, a frontal and a parietal.

D. Etiology of the disease The development of cerebral aneurysms remains a controversial topic. A multifactorial etiology is most likely, reflecting the interaction of environmental factors, such as atherosclerosis or hypertension, and a congenital predisposition associated with various vascular abnormalities. Abnormalities of the internal elastic lamina may be congenital or degenerative. E. signs and symptoms Ruptured aneurysm A sudden, severe headache is the key symptom of a ruptured aneurysm. This headache is often described as the "worst headache" ever experienced. Common signs and symptoms of a ruptured aneurysm include: Sudden, extremely severe headache Nausea and vomiting Stiff neck Blurred or double vision Sensitivity to light Seizure A drooping eyelid Loss of consciousness Confusion 'Leaking' aneurysm In some cases, an aneurysm may leak a slight amount of blood. This leaking (sentinel bleed) may cause only a: Sudden, extremely severe headache A more severe rupture almost always follows leaking. Unruptured aneurysm An unruptured brain aneurysm may produce no symptoms, particularly if it's small. However, a large unruptured aneurysm may press on brain tissues and nerves, possibly causing: Pain above and behind an eye A dilated pupil Change in vision or double vision Numbness, weakness or paralysis of one side of the face A drooping eyelid F. intraoperative and post operative risk factors Intraoperative risk factors Hypotension

Post operative risk factors - Dehiscence after a wound has healed is a known complication of craniotomy - Wound infections - bone flap osteitis - meningitis - brain abscesses - cerebrospinal fluid leakage - 1% chance of bleeding inside the skull - Seizure - Nerve damage, infection or permanent brain damage

III. Procedure a. Skin preparation - Gross soil, grease, skin oil, blood and other debris should be removed from the skin - A non-aseptic, non-irritating, non-flammable and non-toxic fat solvent or - degreaser should be used to cleanse the skin - surgical scrub - hair removal (also referred to as shave prep) - Head will be shaved and the skin over the surgical site will be cleansed with an antiseptic solution. b. Draping The present invention is a fenestrated craniotomy drape including a main sheet, translucent anesthesia side screens, a gusset forming the corners of the anterior edges of the drape, a run-off collection pouch whose back side is pressed flat and affixed to the drape, with a back side fenestration surrounding the fenestration of the main sheet, and a front side fenestration, and adjustable tube holders. The drape optionally includes a layer of a fenestrated absorbent material between the drape and the pouch, a solids screen and drain port in the pouch, and a ductile material about the edges of the front side fenestration of the pouch that holds the pouch open. The back-side fenestration of the pouch and those of the drape and the absorbent material are covered by an incise sheet, located between the back side of the pouch and the drape. The adhesive side of the incise sheet facing the patient is covered by a releasable backing. c. Anesthesia (technique used) - avoid hypoxia. Keep PAO2 > 100 torr - avoid hypo and hypercapnea, generally keep PaCO2 between 30-35 torr. Send ABG after induction, to correlate the ETCO2-PACO2 difference, and then follow ETCO2 for the remaining case - Maintain cerebral perfusion about 60 mmHg (MAP: 80-110 mmHg). Zero the CVP and MAP at the level of external auditory meatus. - achieve maximal muscle relaxation prior to intubation (use nerve stimulator, set in, await disappearance of twitches).

- achieve optimal depth of anesthesia prior to manipulation. - use of 1 mg/kg lidocaine 90 seconds prior to laryngoscopy to blunt increases ICP. d. Incision site format - incision may be made from behind the hairline in front of your ear - The scalp will be pulled up and clipped to control bleeding while providing access to the brain. - A medical drill may be used to make burr holes in the skull. A special saw may be used to carefully cut the bone. - The bone flap will be removed and saved.