Recibido el 26 de mayo de Aceptado el 8 de julio de On-line el 6 de septiembre de Awake craniotomy has become a common procedure and its application has been continually evolving. Anesthesia for awake craniotomy poses a unique challenge to anesthesiologists. The aims of this article are to review, under a critical perspective of the author, the current evidence and application of awake craniotomy and to briefly describe the principles of anesthetic management during this procedure. Por lo general se puede lograr una anestesia adecuada ya sea mediante un bloqueo de cuero cabelludo o un bloqueo regional del campo.

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Surgical treatment of isolated and syndromic craniosynostosis. Results and complications in consecutive cases. Resultados y complicaciones en casos consecutivos.

Hospital Infantil 12 de Octubre. To review the results and complications of the surgical treatment of craniosynostosis in consecutive patients treated between and Patients and methods. We used the classification of Whitaker et al. Complications of each technique and time of patients'hospitalization were also recorded.

The surgeries were classified in 12 different types according to the techniques used. Type I comprised endoscopic assisted osteotomies for sagittal synostosis 42 cases.

Type II included sagittal suturectomy and expanding osteotomies 46 cases. Type III encompassed procedures similar to type II but that included frontal dismantling or frontal osteotomies in scaphocephaly 59 cases. Type IV referred to complete cranial vault remodelling holocranial dismantling in scaphocephaly 13 cases.

Type V belonged to fronto-orbital remodelling without fronto-orbital bandeau in trigonocephaly 50 cases. Type VI included fronto-orbital remodelling without fronto-orbital bandeau in plagiocephaly 14 cases. In Type VII cases of plagiocephaly with frontoorbital remodelling and fronto-orbital bandeau were comprised 14 cases. Type VIII consisted of occipital advancement in posterior plagiocephaly 1 case.

Type IX included standard bilateral fronto-orbital advancement with expanding osteotomies 30 cases. Type X was used in multi-suture craniosynostosis 15 cases and consisted of holocranial dismantling complete cranial vault remodelling. Type XI included occipital and suboccipital craniectomies in multiple suture craniosynostosis 10 cases and Type XII instances of fronto-orbital distraction 26 cases.

The mortality rate of the series was 2 out of cases 0. These 2 patients died one year after surgery. All complications were resolved without permanent deficit. Mean age at surgery was 6. According to Whitaker et al's classification, patients were classified into Category I Regarding to craniofacial conformation, Of the patients with poor results, 6.

The most frequent complication was postoperative hyperthermia of undetermined origin The number of complications was higher in the group of re-operated patients In this subset of reoperations, infection accounted for In regard to the surgical procedures, endoscopic assisted osteotomies presented the lowest rate of complications, followed by standard fronto-orbital advancement in multiple synostosis, trigonocephaly and plagiocephaly. The highest number of complications occurred in complete cranial vault remodelling holocranial dismantling in scaphocephaly and multiple synostoses and after the use of internal osteogenic distractors.

Of note, are two cases of iatrogenic basal encephalocele that occurred after combined fronto-facial distraction. The best results were obtained in patients with isolated craniosynostosis and the worst in cases with syndromic and multi-suture craniosynostosis.

The rate and severity of complications were related to the type of surgical procedure and was higher among patients undergoing re-operations. The mean time of hospitalization was also modified by these factors. Finally, we report our considerations for the management of craniosynostosis taking into account each specific technique and the age at surgery, complication rates and the results of the whole series.

Key words: Craniosynostosis. Craniofacial surgery treatment. Craniofacial surgery results. Craniofacial surgery complications. Tipo VIII: avance occipital en plagiocefalias posteriores 1 caso. La mortalidad de la serie fue de 2 casos entre pacientes. Palabras clave: Craneosinostosis.

The diagnosis and treatment of craniosynostosis during the last decade have been improved by new and different techniques for diagnosis and surgical treatment. The use of 3-dimensional computerized tomography 3-D CT allows for a better vision of the skull, mostly of the cranial base. With the new magnetic resonance imaging MRI we can see the anatomic alterations of the posterior region of the skull and ascertain their role in the pathophysiology of intracranial hypertension, especially in syndromic craniosynostosis 38, Intracranial pressure ICP monitoring enables the establishment of an appropriate management of these patients.

On the other hand, there is no doubt that reabsorbable osteosynthesis has improved the stability of the cranial assemblies, osteogenic distraction has contributed to find further indications in these treatments, and endoscopic approaches have made some of these procedures less invasive 5,24,26, Nevertheless, some problems regarding treatment of craniosynostosis still remain unanswered 6,22,30, Although some reports have addressed the global results of craniosynostosis management 16,17,41 , most of them are from the last decade of the 20 th century 29,30,41 and, in our opinion, they are not sufficient to establish a universal accepted algorithm of treatment.

The scarcity of available publications dealing with complications is also surprising. In addition, most of them are included in clinical series regarding general aspects of the craniosynostoses 16,41, or dealing with postoperative infection 13,25, To review our experience on the treatment of patients with craniosynostosis seen during the last 9 years, aiming at establishing an algorithm of treatment based on patients' age at surgery, results and complications arising from the diverse surgical procedures.

The files of patients with craniosynostosis who underwent surgical procedures were retrospectively reviewed. Although our Craniofacial Unit started in , our study comprises a 9 year span from to The reasons to choose this period include the widespread use of 3D-CT and MRI for diagnosis, the homogeneity of the surgical techniques utilized and the stability of the staff performing these procedures.

Mean age of patients at the surgery was 6. All patients underwent transcranial procedures, such as diverse craniectomies and osteotomies. Reoperations accounted for 37 of surgical procedures Ten of these procedures were done at the time of the initial treatment posterior fossa craniectomy and occipital dismantling.

Cases of facial advancement were not included in this series. All children received at least two doses of anti-pneumococcal vaccine. Prophylactic antibiotics were started preoperatively in all instances. We employed the classification of Whitaker and associates 45 to evaluate the surgical results:.

Category I: no refinements or surgical revisions considered advisable or necessary. Category II: soft-tissue or lesser bone-contouring revisions advisable apt to be performed on an outpatient basis or requiring a maximum of 2-day hospitalization.

Category III: major alternative osteotomies or bonegrafting procedure advisable, i. Category IV: a major craniofacial procedure advisable, duplicating or exceeding the original operation. Complications were classified as cranial or extracranial, including those presenting for a long time-span that ranged from the immediate postoperative period to long-lasting craniolacunia appearing years after treatment.

Only osteosynthesis reabsorbable material was used. Infection was considered as cranial when either local signs of infection or subgaleal or intracranial swelling with concomitant fever were detected.

Therefore, cultures may have been negative as prophylactic antibiotics were used. On the other hand, to consider an infection as extracranial, cultures must have been positive.

To complete this study, the mean hospital stay was evaluated relating it to each surgical procedure. Surgical procedures were classified into 11 different types:. Type I: scaphocephaly. Endoscopic-assisted suturectomy and osteotomies. We started using this technique in , having treated by this method 42 children whose mean age at surgery was of 4. The surgical technique Fig. Figure 1. A: patient resting in modified prone position.

B: surgical patties showing subcutaneous dissection. C: sagittal suture excision complete. D: excised sagittal suture showing characteristic grooving of the superior sagittal sinus. Type II: scaphocephaly. Suturectomy and expanding osteotomies. Standard technique Fig. This technique includes 46 cases whose mean age was 6. Figure 2. A: Type II. Standard technique. Suturectomy and expanding osteotomies including frontal bone remodelling.

D: total cranial vault remodelling holocranial dismantling. Type III: scaphocephaly. Suturectomy and expanding osteotomies including frontal bone remodelling Fig.

In cases with severe frontal bulging, shell osteotomies in the frontal bone or complete dismantling and remodelling were added to the standard technique type III. We operated with this procedure 59 patients mean age 6.

Type IV: Scaphocephaly.


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Surgical treatment of isolated and syndromic craniosynostosis. Results and complications in consecutive cases. Resultados y complicaciones en casos consecutivos. Hospital Infantil 12 de Octubre. To review the results and complications of the surgical treatment of craniosynostosis in consecutive patients treated between and Patients and methods.


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La epilepsia mal controlada puede producir una serie de complicaciones y riesgos para la salud, entre los que se incluyen los siguientes:. Los riesgos pueden incluir los siguientes:. Estas pruebas pueden incluir las siguientes:. Se realiza una serie de pruebas para medir las habilidades de aprendizaje verbal y no verbal, y el funcionamiento de la memoria. Es probable que no puedas volver al trabajo o a la escuela por, aproximadamente, de uno a tres meses.


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