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13 results

  • Anesthetic Considerations for Surgical Treatment of Giant and Posterior Circulation Cerebral Aneurysms

  • Jason Chui, Stephen Lownie
  • Journal:
    Canadian Journal of Neurological Sciences , First View
    Published online by Cambridge University Press:
    26 March 2026, pp. 1-12

  • Microsurgical treatment of complex cerebral aneurysms – whether giant aneurysms or those in the technically challenging posterior circulation – carries substantial perioperative morbidity and mortality. Despite significant advances in endovascular therapy, surgical intervention remains the only definitive option for a subset of these lesions. To facilitate dissection and reduce tension within the aneurysm sac, various aneurysm flow arrest strategies have been developed. Early methods included local arrest (e.g., temporary clipping) and systemic arrest (e.g., adenosine-induced asystole, rapid ventricular pacing or total circulatory arrest). These have evolved into more targeted cerebral flow arrest techniques, such as retrograde suction decompression, providing greater precision and control. Because aneurysm flow arrest inherently risks distal cerebral ischemia, hypothermic neuroprotection was introduced to prolong the safe ischemic interval – transitioning from early high-morbidity systemic deep hypothermia to recent selective brain cooling with more favorable outcomes. The integration of multimodal intraoperative neuromonitoring, including evoked potential monitoring and respiratory rate monitoring, for real-time cerebral ischemia detection, has further improved safety. Together, controlled aneurysm flow arrest and selective brain protection with intraoperative neuromonitoring create brief, precisely timed windows that permit safe aneurysm manipulation and definitive treatment of high-risk lesions. As such complex cases are less commonly treated surgically, much of the specialized knowledge is passed informally. This article reviews the anesthetic considerations for the surgical management of giant and posterior circulation aneurysms, drawing on decades of our institutional experience.

  • Assessment of Driving Restrictions Following Craniotomy: A Survey of Canadian Neurosurgeons

  • Davaine Joel Ndongo Sonfack, David Bergeron, Taylor Duda, Shannon Hart, Michael Anthony Rizzuto, Malavan Ragulojan, Nicole Coote, Mark Alexander MacLean, Simon Walling, Sean Christie
  • Journal:
    Canadian Journal of Neurological Sciences , First View
    Published online by Cambridge University Press:
    17 February 2026, pp. 1-5
    • Article
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  • Background:

    Patients undergoing craniotomy experience a higher risk of seizures in the ensuing months. Consensus is lacking regarding the appropriate timeframe for safe return to driving following craniotomy in patients not otherwise limited by neurological deficits or a history of epilepsy.

    Methods:

    The Canadian Neurosurgery Research Collaborative (CNRC) distributed an anonymous, voluntary, electronic cross-sectional survey via SurveyMonkey to Canadian neurosurgeons. The survey comprised 16 questions designed to assess practice variations regarding recommendations for return to driving following craniotomy, stratified according to pathological diagnosis.

    Results:

    Forty-eight Canadian neurosurgeons responded to the survey. Driving recommendations varied greatly, with most surgeons recommending return to driving within one month of the craniotomy. The rationale behind these restrictions varied widely, consistent with the lack of evidence-based data to guide decision-making.

    Conclusion:

    This study emphasizes the lack of standardized practices regarding return to driving recommendations for patients undergoing craniotomy without prior seizures. Development of national return to driving guidelines would assist Canadian clinicians in making informed decisions regarding the optimal timeframe for the safe return to driving.

  • Return to Driving after a Craniotomy: A Systematic Review and Evidence-Based Approach

  • David Bergeron, Davaine Joel Ndongo Sonfack, Rana Moshref, Michael Anthony Rizzuto, Mark Alexander MacLean, Simon Walling, Sean Christie
  • Journal:
    Canadian Journal of Neurological Sciences , First View
    Published online by Cambridge University Press:
    24 October 2025, pp. 1-8
  • Background:

    Patients undergoing craniotomy experience a higher risk of seizures in the ensuing months. Consensus is lacking regarding the appropriate timeframe for safe return to driving following craniotomy in patients not otherwise limited by neurological deficits or a history of epilepsy.

    Methods:

    We performed a systematic literature review on driving recommendations post-craniotomy. We then performed a scoping review on the risk of seizure post-craniotomy and used risk calculations and accepted risk thresholds from the epilepsy literature to develop an evidence-based approach to driving recommendations post-craniotomy.

    Results:

    The systematic review of driving recommendations revealed national guidelines (the United Kingdom, New Zealand, Australia). We transposed risk calculations and accepted risk thresholds from the epilepsy literature (accident risk ratio [ARR] < 2; chance of occurrence of a seizure in the next year < 20%) to patients who undergo a craniotomy. Using data from a large meta-analysis of seizure risk post-craniotomy, we calculated ARRs for various underlying pathologies at different postoperative timepoints and compared them with accepted risk thresholds from the epilepsy literature. We determine that patients who undergo a craniotomy for a higher-risk condition (like high-grade glioma) may resume driving after at least 1 month without seizure, whereas those patients undergoing a craniotomy for lower-risk conditions (like infratentorial pathology) may resume driving without consideration for the risk of seizure.

    Conclusion:

    This systematic review of the literature and evidence-based approach to risk threshold calculations derived from the epilepsy literature provides a preliminary framework to guide clinicians regarding recommendations for return to driving following craniotomy.

  • Development of a spherical parallel manipulator for brain surgery applications: preliminary study on the dynamic analysis and verification

  • Didem Güzin, Erkin Gezgin
  • Journal:
    Robotica / Volume 40 / Issue 10 / October 2022
    Published online by Cambridge University Press:
    18 April 2022, pp. 3726-3750
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  • This study focuses on development, task planning, and dynamic analysis of a previously proposed spherical parallel robot manipulator that is conceptually enhanced to adapt various brain surgery scenarios. Conceptual design of the proposed manipulator was briefly introduced and explained. In order to simulate one of the possible surgery scenarios, a case study of craniotomy was designed along with its trajectory planning. Dynamic analysis of proposed manipulator was performed by Lagrange method, and required actuator torque values were calculated for the desired trajectory. At the end of the study, hardware verification was carried out on the manufactured prototype of the system by comparing both calculated/acquired torque values and desired/actual trajectories. Promising verification results in terms of system dynamics and trajectory execution were introduced.

  • Chapter 5 - The Closeness Problem

  • Joshua Stuchlik, University of St Thomas, Minnesota
  • Book:
    Intention and Wrongdoing
    Published online:
    02 December 2021
    Print publication:
    09 December 2021, pp 101-133

  • Summary

    The goal of Chapter 5 is to respond to a long-standing objection to the PDE known as the closeness problem. The problem is supposed to arise because intentions are sufficiently fine-grained that an agent need not intend harm in nearly any situation. The PDE therefore fails to rule out conduct that is intuitively objectionable in a host of cases unless it is supplemented with a criterion of excessive closeness, whose role is to identify things that are “too close” to harm to be considered incidental for purposes of double effect. However, it also proves extremely difficult to specify a criterion of closeness that is not arbitrary or subject to counterexamples. The closeness problem is often thought to be particularly acute for Anscombe-style accounts of intentional action, such as the one I presented in Chapter 4. I argue, however, that the magnitude of the closeness problem has been exaggerated and that the PDE does not need to be supplemented by a criterion of closeness.

  • 6.3 - Management of the Critical Care Patient Following Craniotomy

  • from Section 6 - Perioperative Care
  • Edited by Ned Gilbert-Kawai, The Royal Liverpool Hospital, Debashish Dutta, Princess Alexandra Hospital NHS Trust, Harlow, Carl Waldmann, Royal Berkshire Hospital, Reading
  • Book:
    Intensive Care Medicine
    Published online:
    27 July 2023
    Print publication:
    01 December 2021, pp 632-634

  • Summary

    Key Learning Points

    1. 1. Most patients undergoing elective supra-tentorial craniotomy can be discharged safely to the neurosurgical ward.

    2. 2. The use of vasoactive agents and insulin infusions and the need for cardiovascular monitoring and intracranial pressure management are among the most common interventions requiring critical care admission.

    3. 3. Intraoperative complications requiring critical care admission include, but are not exclusive to, failed endotracheal extubation, cardiovascular instability, extensive blood loss and cerebral swelling.

    4. 4. Post-operative complications usually involve respiratory, cardiovascular or central nervous systems. Metabolic derangements and infectious diseases may also warrant treatment and close monitoring in critical care.

    5. 5. Use of opioids, when carefully titrated, is considered safe in neurological patients. Opioids should be always considered, because craniotomies are typically painful procedures.

  • 3D-Printed Endoport vs. Open Surgery for Evacuation of Deep Intracerebral Hemorrhage

  • Everardo Garcia-Estrada, Jesús Alberto Morales-Gómez, Azalea Garza-Báez, Arturo Sotomayor-González, Isaac Jair Palacios-Ortiz, Mariana Mercado-Flores, Angel Raymundo Martínez-Ponce de León
  • Journal:
    Canadian Journal of Neurological Sciences / Volume 49 / Issue 5 / September 2022
    Published online by Cambridge University Press:
    29 July 2021, pp. 636-643
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  • Background:

    Large-sized clinical trials have failed to show an overall benefit of surgery over medical treatment in managing spontaneous intracerebral hemorrhages (ICH); less invasive techniques have shown to decrease brain injury caused by surgical manipulation in the standard open approach improving the clinical outcomes of patients. Thereby, we propose a low-cost 3D-printed endoport for a less invasive ICH evacuation. In this study, the authors compare the clinical outcomes of early surgical evacuation using a 3D-printed endoport vs. a standard open surgery (OS).

    Methods:

    A retrospective analysis was conducted comparing patients who underwent early evacuation of a deep hypertensive ICH through an endoport vs. OS at a single center from August 2017 to March 2019. Demographic, clinical, and radiologic data were reviewed. The primary outcomes were the 90-day post-stroke functional outcome and mortality.

    Results:

    A total of 36 patients were included. The two cohorts (18 endoport; 18 OS) showed no statistically significant differences in demographic, clinical, and radiologic characteristics, including median admission hemorrhage volume, Glasgow Coma Scale, and ICH scores. At 90-day post-stroke, 44% of patients in the endoport group and 17% in the OS group had a favorable functional outcome (mRS 0–3) (p = 0.039); moreover, the endoport group showed lower mortality (33% vs. 72%, p = 0.019).

    Conclusions:

    This study suggests that an endoport-assisted ICH evacuation may have better functional outcomes and lower mortality than OS. The proposed device could provide a safe, low-cost alternative for ICH’s surgical treatment. More rigorous research is hence needed to assess the potential benefits of this technique.

  • Opioid-Free Analgesia for Supratentorial Craniotomies: A Systematic Review

  • Denise Darmawikarta, Michel Sourour, Rachel Couban, Sriganesh Kamath, Kesava KV Reddy, Harsha Shanthanna
  • Journal:
    Canadian Journal of Neurological Sciences / Volume 46 / Issue 4 / July 2019
    Published online by Cambridge University Press:
    11 July 2019, pp. 415-422
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  • Background: Post-craniotomy pain can be severe and is often undermanaged. Opioids can interfere with neurological monitoring and are associated with adverse effects. This systematic review aimed to identify measures of opioid-free analgesia and compare their effectiveness with opioid analgesia for post-craniotomy pain in patients with supratentorial tumors. Methods: EMBASE, MEDLINE, and Cochrane databases were searched from their inception to February 14, 2017, for randomized controlled trials (RCTs) evaluating opioid versus non-opioid analgesia post-supratentorial craniotomy. Two reviewers independently carried out study selection and data extraction. Risk of bias assessment was performed using the Cochrane Collaboration’s tool. Outcomes were pain control (changes to pain scores or use of rescue analgesia) and adverse effects. Considering the number of studies and heterogeneity, a narrative synthesis was done without pooling and results were summarized using tables. Non-opioids were assessed for the potential to be equivalent to opioid-based analgesics for pain relief and adverse effects. Results: Of 467 RCTs, 4 met our inclusion criteria (n = 186 patients). Patients with scalp blocks (2 RCTs) had less post-operative nausea and vomiting (PONV), but scalp block was not superior to morphine for analgesia. Acetaminophen (1 RCT) was less likely to induce PONV but provided inadequate pain relief compared to morphine and sufentanil. Dexmedetomidine (1 RCT) was not superior to remifentanil for analgesia although it delayed time to rescue analgesia. Conclusions: Limited evidence suggests that scalp blocks and dexmedetomidine have the potential to eliminate the need for opioid analgesia. Multimodal analgesia should be considered as significant opioid-sparing effects have been shown.

  • 28 - Central nervous system infections and inflammation

  • from Section 4 - Neurointensive care
  • Edited by Basil F. Matta, David K. Menon, Martin Smith
  • Book:
    Core Topics in Neuroanaesthesia and Neurointensive Care
    Published online:
    05 December 2011
    Print publication:
    13 October 2011, pp 430-444

  • Summary

    This chapter explains anaesthetic procedures for selected neurosurgeries without craniotomy. It discusses neurosurgeries that include the transsphenoidal pituitary surgery, ventriculoperitoneal shunts and allied procedures, third ventriculostomy, stereotactic neurosurgery, functional neurosurgery, and deep brain stimulation (DBS). In contrast to most neuro anaesthetic procedures, the anaesthetist can be required to increase intracranial pressure (ICP) in order to facilitate exposure and surgical excision of the pituitary tumour. The chapter describes various anaesthetic techniques, including local anaesthesia with or without conscious sedation on an awake patient and methods that involve general anaesthesia, either throughout the entire procedure or temporarily as in an asleep-awake-asleep technique. The decision for general anaesthesia is best made before surgery after careful pre-operative assessment, as the presence of a stereotactic head frame can complicate airway management, and any unplanned conversion to general anaesthesia in the midst of the procedure carries significant risk.

  • Chapter 79 - Cavernous malformations

  • from Section 3 - Symptomatic epilepsy
  • Edited by Simon D. Shorvon, Frederick Andermann, Renzo Guerrini
  • Book:
    The Causes of Epilepsy
    Published online:
    05 March 2012
    Print publication:
    14 April 2011, pp 559-564

  • Summary

    The frequency of epilepsy in certain conditions is well known, for example, de novo epilepsy after operative treatment of intracranial abscess is around 70% but this would probably occur independent of the surgical technique used. It seems that craniotomy probably increases the liability of de novo epilepsy by 5-10%. The complexity of the procedure also increases the incidence. Studies of post-traumatic epilepsy with modern imaging techniques have shown the relationship between cortical damage, in particular cortical contusions and post-traumatic epilepsy. The literature on cerebral tumors suggests that late postoperative seizures are more likely to be partial seizures and may be more difficult to control. Antiepileptic drugs (AEDs) are known to be metabolized along established pathways that they may share with other AEDs and also with non-anticonvulsant drugs. Other treatments such as further surgery and adjuvant therapy for intracranial tumors may be useful in treating difficult de novo seizures.

  • Case 70 - Permissivehypertension in a patient with von Willebrand's disease and a preexisting ventriculoperitoneal shunt

  • from Section I - Neuroanesthesia
  • Edited by George A. Mashour, Ehab Farag
  • Book:
    Case Studies in Neuroanesthesia and Neurocritical Care
    Published online:
    03 May 2011
    Print publication:
    03 February 2011, pp 233-237

  • Summary

    Pediatric surgical patients present special anesthetic challenges including induction without intravenous (IV) access, a higher incidence of airway complications, and a greater incidence of hemodynamic instability due to surgical blood loss. Supratentorial tumors are the second most common location and include low-grade astrocytoma, malignant and mixed glioma, ependymoma, ganglioglioma, oligodendroglioma, choroid plexus tumor, and meningioma. This chapter presents a case study of a 8-year-old child presented with partial complex seizures characterized by staring spells accompanied by oral and manual automatisms. Preoperative evaluation (magnetic resonance imaging) demonstrated a non-enhancing heterogeneous lesion in the mesial aspect of the right temporal lobe consistent with lowgrade glial neoplasm. A neurologic assessment was performed after extubation and it showed no neurologic deficits. Subsequently the patient was transported to the pediatric intensive care unit where his recovery was satisfactory. Anticonvulsant medications should be continued and administered the day of surgery to prevent intraoperative and postoperative seizures.