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24Goldman(F)-24CHAPTER10/19/077:52 PMPage 64024Neurologic surgical opening of the most basic form of craniotomy is the burr hole, a limited opening through which blood or fluid may be evacuated or to divide neural tracts (as in prefrontal lobotomy). of the burr hole include biopsy of an intracranial mass/lesion of the contents of an abscess. A craniectomy refers to in which a section of the cranium is removed. to a procedure performed through burr holes that are those usually made to perform limited applicable, a twist drill is used in lieu of a burr. Computed tomography (CT).scan, magnetic resonance imaging (MRI), angiography or magnetoencephalography, electroencephalogram (EEG) mapping, tests, and ultrasound modalities are employed with three-dimensional (3D) coordinates to localize a lesion, localization. Image-guided stereotactic burr hole biopsy,.employing a CRW3 (or similar) head frame, provides accurate craniocortical entry transit and targeting minimizing craniocerebral traumaApproaches employing endoscopy and stereotactic morbidity and mortality; some cranial procedures specialized radiology departments or specially equipped are “same-day” noninvasive procedures, such as those Gamma knife. Intracerebral hematomas can be evacuated endoscopically through a burr hole; the cortical incision is approximately 6 mm . For removal of an intracranial hematoma, the cortical made from a location with the shortest trajectory to the clot. Endoscopic instruments, smaller but similar to standard instruments, used the procedure are inherently less traumatic to the brain. Endoscopic procedures may require more than one burr hole (port)During craniotomy (or burr hole procedure), intracranial pressure, when elevated, is reduced as a result of entry. In addition, tissues are manipulated, the location of the lesion shifts (thereby deviating somewhat from studies). In some institutions, highly sophisticated intraoperative MRI systems are in may be in the form of (F)-2410/19/077:52 PMPage 641Chapter 24Neurologic Surgery641MRI chamber, a section of which can be advanced for imaging to continue the surgery. Another system is one in which reference point electronic sensors are placed about the operative field with a computer to provide interactive localizationWhen a limited-access endoscopic procedure is not applicable, are made and a portion (a “flap”) of the cranium is lifted after is cut by craniotome (with periosteum and muscle attached), decompressive craniotomy is performed, bone ( soft tissues dissected away) is excised, ., craniectomy, for later reimplantation. Methods of bone preservation the skull section in the patient’s subcutaneous tissue, freezing section (in antibiotic solution), or sterilizing it with ethylene holding it in a bone/tissue bank for later fragment cannot be retained, a prosthetic substitute is made. prosthesis can be a plate made of polymethylmethacrylate.(PMMA) cement (fashioned over a mesh frame, ., template), titanium,.or Vitallium®, or various plastics may be used for making the substituteBurr holes can be repaired with silicone or other materialsNumerous neurosurgical conditions treated by craniotomy include the following:.Intracranial aneurysm is an arterial dilation secondary to muscular weakness prone to rupture or hemorrhage. blood pressure is essential during the

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