Ateneo de Davao University

School of Nursing
Jacinto, Davao City

In Partial Fulfillment in the Requirements in INP:

Anecdotal Report
Drug Study
Related Reading
Procedural Report

Submitted to:
Maam Theresa B. Kintanar.,RN.,MN
Clinical Instructor

Submitted by:
Kareen Kriezl Jane E. Rosales
BSN 4A
Group 3

January 8, 2014

Anecdotal Report
January 5, 2015 (MONDAY)
General Objectives:
Within my 8 hours duty in the Operating Room, I will be able to apply the skills and
knowledge that Ive learned from NCM.

Specific Objectives:
-

To be early for the duty and to bring the needed paraphernalia.

To portray/play the role of a scrub nurse and circulating nurse.
To complete my lacking cases
To learn something from the whole experience through the surgeons and nurses on
duty

Strengths:
I was able to bring the needed paraphernalia for the duty. I was also able to be a
circulating nurse and assisted the scrub nurses. I was able to answer calls from the surgeons
phone and relay the message to them, get the necessary instruments in the CSSD and more
needed medications for the operation and follow instructions from my clinical instructor. I was
so eager to finish every cases that Im going to handle and I reviewed my notes as a preparation
for this area.

Weaknesses:
It was the first day of the special area duty but I was not able to come on time or be early
because I woke up late. I was not able to complete my cases today. I was not able to portray or
play the role as a scrub nurse and I was not also able to display signs of physical weaknesses
because I have it in my mind to be stronger because the cases and operations that Ill be handling
are so tiring with a lot of things to do and standing.

Learnings:
I always learn a lot of things in this duty area. I love how I could learn that fast from the
surgeons and the nurses that are on duty. Some may have a bad day but the learnings that I got
from them are priceless. I was amazed with the improvements of the operating room from their
ISO operated instruments to the staffs that are well trained that made me dream to become one of
them someday. Some people wouldnt want my work with a lot of bloody interactions but with
this work, it made me more inspired to work hard and pursue the goals as a nurse in the future. In

Gods time, hopefully I could pass the board and have my license and work in this area. I just
had to believe in Him that I could do it all.
Recommendation:
I recommend myself to sleep early and wake up early so that I wont be late in my duty. I
also recommend myself to put extra effort in everything I do so that I could finish my case
immediately and to be more inspired so that to fuel up my desires to keep myself motivated in
my nursing career.

Anecdotal Report
January 7, 2014 (Wednesday)
General Objectives:
Within my 8 hours duty in the Operating Room, I will be able to apply the skills and
knowledge that Ive learned from NCM.

Specific Objectives:
-

To be early for the duty and to bring the needed paraphernalia.

To portray/play the role of a scrub nurse and circulating nurse.
To complete my lacking cases
To learn something from the whole experience through the surgeons and nurses on
duty

Strengths:
At the third day of our duty, I was already able to come to the duty area on time and bring
the needed paraphernalia. I ate breakfast to retain my stamina in the days tiring day. I was able
to complete my cases and assisted some cases just for experience. I was never a scrub nurse in
the 3 day duty but Im happy that even though I havent portrayed it, being a circulating nurse
made the whole rotation more memorable for I learned a lot.

Weaknesses:
I actually havent displayed any weaknesses in this day for being weak at this special day
and area is not in my vocabulary.

Learnings:
In my first case, it was a closed reduction supracondylar orthosurgery. This case will be
my last case to complete my cases. There was a consultant who has her interns and while shes
injecting anesthesia to the patient, she called my attention to come over and watch so that I could
learn something. And yes, she was right, I learned something from her demonstration. Even
though Im not her student, she knows that having my attention and come over would benefit me
a lot. She was kinda strict but it can be tolerated and I love how she teaches her students, it is
with great compassion to her work that made her a strong mentor so as to give a useful
information to the people she teaches.

Recommendations:
What else could I recommend myself but just to keep the faith in everything I do. In time,
all my effort and hardwork will be paid off.

DRUG STUDY
Generic Name

Brand name:

Acetaminophen
Tylenol, Aceta, Apacet, Atasol

Classification:

Antipyretic; Analgesic (Non-opioid)

Dosage:

Adults
-PO or PR
-By suppository, 325-650 mg q 4-6 hr or PO, 1,000 mg tid to qid.
Do not exceed 4 g/day.
Pediatric Patients
-PO or PR
-Doses may be repeated 4-5 times day; do not exceed five doses
in 24 hr; give PO or by suppository.
Age

Mode of Action:

Indication:

Dosage
(mg)
0-3 mo 40
4-11 mo 80
12-23
120
mo
2-3 yr
160
4-5 yr
240
6-8 yr
320
9-10 yr 400
11 yr
480
-Antipyretic: Reduces fever by acting directly on the
hypothalamic heat-regulating center to cause vasodilation and
sweating, which helps dissipate heat.
-Analgesic: Site and mechanism of action unclear.
-Analgesic- antipyretic in patients with aspirin allergy, hemostatic
disturbances, bleeding diatheses, upper GI disease, gouty arthritis
-Arthritis and rheumatic disorders involving musculoskeletal pain

(but lacks clinically significant antirheumatic and antiinflammatory effects)

-Common cold, flu, other viral and bacterial infections with pain
and fever
-Unlabeled
Contraindication:

Contraindicated with allergy to acetaminophen.

Use cautiously with impaired hepatic function, chronic

alcoholism, pregnancy, lactation.

Drug interactions:

Drug-drug

1. Increased toxicity with long-term, excessive ethanol ingestion

2. Increased hypoprothrombinemic effect of oral anticoagulants
3. Increased risk of hepatotoxicity and possible decreased
therapeutic effects with barbiturates, carbamazepine, hydantoins,
rifampin, sulfinpyrazone
4.Possible delayed or decreased effectiveness with
anticholinergics
5.Possible reduced absorption of acetaminophen with activated
charcoal
6.Possible decreased effectiveness of zidovudine
Drug-lab test
1.Interference with Chemstrip G, Dextrostix, Visidex II home
blood glucose measurement systems; effects vary
Side effects:

CNS: Headache

CV: Chest pain, dyspnea, myocardial damage when doses of

58 g/day are ingested daily for several weeks or when doses
of 4 g/day are ingested for 1 yr

GI: Hepatic toxicity and failure, jaundice

GU: Acute kidney failure, renal tubular necrosis

Hematologic: Methemoglobinemiacyanosis; hemolytic

anemiahematuria, anuria; neutropenia, leukopenia,
pancytopenia, thrombocytopenia, hypoglycemia

Hypersensitivity: Rash, fever

Nursing Responsibilities:

Assessment
History: Allergy to acetaminophen, impaired hepatic function,
chronic alcoholism, pregnancy, lactation
Physical: Skin color, lesions; T; liver evaluation; CBC, LFTs,
renal function tests
Interventions
1.Do not exceed the recommended dosage.
2.Consult physician if needed for children < 3 yr; if needed for
longer than 10 days; if continued fever, severe or recurrent pain
occurs (possible serious illness).
3.Avoid using multiple preparations containing acetaminophen.
Carefully check all OTC products.
4.Give drug with food if GI upset occurs.
5.Discontinue drug if hypersensitivity reactions occur.
6.Treatment of overdose: Monitor serum levels regularly, Nacetylcysteine should be available as a specific antidote; basic life
support measures may be necessary.
Educative
1.Do not exceed recommended dose; do not take for longer than
10 days.
2.Take the drug only for complaints indicated; it is not an antiinflammatory agent.
3.Avoid the use of other over-the-counter preparations. They may
contain acetaminophen, and serious overdosage can occur. If you
need an over-the-counter preparation, consult your health care
provider.4. Report rash, unusual bleeding or bruising, yellowing
of skin or eyes, changes in voiding patterns

Procedural Report
I.

Definition
1. Craniectomy is the surgical removal of a portion of the skull.
Source: Mosby's Medical Dictionary, 8th edition. 2009, Elsevier.
2. Craniectomy is neurosurgical procedure that involves removing a portion of the
skull in order to relieve pressure on the underlying brain. This procedure is
typically done in cases where a patient has experienced a very severe brain injury
that involves significant amounts of bleeding around the brain or excessive
swelling of the brain
Source:Smeltzer, Suzzane C. and Brenda G. Bare. Medical Surgical Nursing.
Volume 2. 10th Edition. Lippincott Williams & Wilkins: Philadelphia. Copyright
2010.
3. Craniectomy is a neurosurgical procedure in which part of the skull is removed to
allow a swelling brain room to expand without being squeezed. It is performed on
victims of traumatic brain injury and stroke. Use of the surgery is controversial.
Source: Kunze, E; Meixensberger J; Janka M; Sorensen N; Roosen K (1998).
"Decompressive craniectomy in patients with uncontrollable intracranial
hypertension". Acta Neurochirurica (Supplement) 71: 1618.

II.

Brief History

A. Pre-operation

Prior to undergoing craniotomy, nearly all patients will have undergone some type of
brain imaging.

CT scan of the head is the most widely used and accessible form of brain imaging, and,
along with CT angiography (CTA, useful for vascular pathology such as aneurysms and
AVMs), they continue to play a major role in operative planning.

MRI has largely replaced CT scanning in the delineation of brain tumors while
continuing to expand its role in stereotactic neurosurgery (image guidance), and its
application remains vast.

In certain circumstances, diagnostic cerebral angiography may be the primary mode of

imaging, although a patient nearly always undergoes angiography based on a finding
initially identified on CT scanning or MRI.

In addition to brain imaging, a patients preoperative assessment may include a recent set
of basic blood tests, electrocardiogram (ECG), and chest radiography, depending on the
patients medical history and recommendations of the treating physician.

No eating or drinking anything by mouth after midnight the night before the surgery. This
includes all foods and liquids (including water). Do not drink any liquids the morning of
the surgery. Exception: May take any oral medications if that feels necessary with a very
tiny sip of water. If diabetic, take only one half (1/2) of your normal morning dose.
Do not take any blood thinners, aspirin, or other anti-inflammatory medications for at
least 7 (seven) days prior to surgery. These include: Coumadin, Plavix, Warfarin,
Aggrenox, Lovenox, Aspirin, Motrin, Aleve, Advil, Ibuprofen, Excedrin, Relafen,
Bextra, Mobic, Celebrex, Daypro, Vioxx, etc. Tylenol is allowed.
If you develop a new illness such as a cold or infection, please notify the office as soon as
possible. It may be necessary to reschedule your surgery for when you are healthy.

Neurosurgical patients vary widely in their presentation, from an alert and

coherent patient presenting for an elective procedure to a patient with depressed
neurological status due a devastating neurological insult for an emergent
procedure. Hence, the diagnosis, preoperative physical and detailed neurological
status, and the urgency of the procedure are important preoperative considerations
to formulate an appropriate anesthetic plan. The time and place of the preoperative
interview will vary; for an elective procedure this may be in an anesthesia
preoperative consult clinic several weeks before surgery, for emergency
procedures in the neurosurgical critical care unit. In patients with a decreased level
of consciousness, obtaining of history and pertinent information may be
challenging and may only be obtainable from family members, caregivers, or
medical notes. Previous surgical procedures and anesthetic notes offer valuable
information and should be included.
In addition to the routine assessment and preparation of any preoperative patient,
emphasis should be placed on the review of the neurological system and
comorbidities of the disease and of the patient. A neurological history is
mandatory and should include the type and location of the lesion, symptoms, and
medications related to the neurological problem, as well as the plan for treatment
which may involve both surgery and/or endovascular therapy. Questions that will
help illicit further information include a history of seizures, neurological deficits,
signs and symptoms of raised intracranial pressure (ICP) such as headaches,
nausea, vomiting, confusion, and a history of transient ischemic attacks (TIA) or
stroke. Neurological examination should include the level of consciousness and

the neurological physical examination which involves the status of the sensory and
motor systems and evaluation of cranial nerves.
Preoperative cardiovascular disturbances are common in patients undergoing
neurosurgical interventions and include blood pressure fluctuations,
electrocardiographic abnormalities, arrhythmias, and myocardial ischemia or
failure. They can occur as consequences of central neurogenic effects on the
myocardium and the autonomic nervous system or concurrently associated
medical conditions. Preexisting cardiac disease should be identified, both
symptomatic and asymptomatic. The decision to perform further diagnostic
evaluations should follow established guidelines. Multiple studies have reported
improved outcome in patients receiving perioperative beta blockers, however
newer studies have reported that perioperative beta blockers may not be effective
if heart rate is not well controlled or in low risk patients. In a recent retrospective
review of patients for noncardiac surgery, acute surgical anemia with a reduction
in hemoglobin greater than 35% from baseline increased risks of cardiac
complications in beta-blocked patients hence suggesting that the transfusion
triggers should be higher for elective surgical patients on beta blockers. The
POISE trial showed a significant reduction in the primary outcome of
cardiovascular events and a 30% reduction in myocardial infarction rates, but a
significant increase in 30 day stroke and mortality. The current ACC/AHA
Guidelines on the perioperative beta blocker administration advocates that
perioperative beta blockade should be used in patients on beta blockers and those
with positive stress test undergoing major vascular surgery. It also stresses that
acute administration of beta blockers without titration may be harmful. Statins
have been shown to improve perioperative cardiac outcome, hence are continued
in patients currently taking them.
Review and optimizing of the respiratory system is important to ensure adequate
oxygenation and ventilation intra and postoperatively. Patients with acute and
chronic pulmonary disease need to have their disease stabilized preoperatively.
Patients with neurological disorders may have respiratory complications such as
aspiration of gastric contents and pneumonia, which can adversely affect
neurologic outcome and survival. Neurogenic pulmonary edema may occur in
patients with brain injury, subarachnoid hemorrhage (SAH), and stroke. History of
smoking and cessation of smoking should be part of the preoperative evaluation,
though most studies have not been able to identify preoperative smoking as an
independent risk factor for major cardiovascular events. Smoking diminishes the
measures of cardiovascular function such as maximal exercise capacity and
endothelium mediated vasodilatation, thus it is plausible that even brief period of
cessation may be of benefit. Cessation of cigarette smoking should ideally begin at
least 68 weeks prior to surgery as this period of abstinence is associated with
improved pulmonary function and overall perioperative morbidity. History of
obstructive sleep apnea (OSA) may influence the intra and postoperative care of

the patient. There are specific groups of patients, such as in acromegaly and
Cushings disease, where there may be a high incidence of OSA. Clinical
symptoms include daytime somnolence excessive snoring and fragmented night
sleep. The STOP questionnaire is a validated screening tool for OSA. Additional
information on the body mass index, age, neck circumference, and gender should
also be sought to increase the detection of the OSA patients. The incidence of
perioperative adverse events is increased in OSA patients.
Other medical disorders such as diabetes, renal impairment, and hepatic disease
will also affect the anesthetic management of the patient and need to be optimized.
There is an adverse association of hyperglycemia and neurosurgical outcome. In a
prospective analysis, the initiation of tight glycemic control reduced the mortality
in neurosurgical patients and other critically ill patients. In patients undergoing
image-guided stereotactic brain biopsy, blood glucose levels less than 200mg/dL
was associated with almost a 100% positive predictive value of morbidity. In
general, blood sugar should be monitored frequently with the goal of avoidance of
either hypo or hyperglycemia, and the maintenance of sugar levels between
100mg/dL and 150mg/dL.
In the preoperative period neurosurgical patients often present with rapid changes
in intravascular volume precipitated by hemorrhage, dehydration, diuretics and
mannitol administration, and fluid restriction. Fluid management in the
neurosurgical patient takes into consideration the restoration of intravascular
volume, the maintenance of cerebral perfusion pressure and the avoidance of
hyperglycemic and hypotonic fluids. Iso-osmolar solutions, such as plasmalyte
and 0.9% saline are used as they do not change the plasma osmolality, and
therefore do not increase brain water content. Glucose-containing solutions and
hypo-osmolar solutions, such as lactated Ringers are avoided as plasma
osmolality is reduced, consequently brain water content increases, worsening
cerebral edema. The administrations of medications, such as mannitol, will need to
be carefully titrated in the presence of renal impairment and congestive cardiac
failure.
Preoperative Medications
All current ongoing medications and allergies need to be reviewed. The preoperative
continuation of most ongoing medications is usually straightforward but continuing of
medications specific for neurological disorders will depend on recommendations from the
neurosurgeon or neurologist. Patients on antiepileptic medications are known to have
adverse effects from these medications as well as intraoperative pharmacokinetic
interactions. Patients who have been placed on preoperative dexamethasone may present
with elevated blood glucose levels which require careful monitoring. Patients with
cerebral insufficiency may be on antiplatelet agents or anticoagulants for treatment of
acute stroke, or secondary prevention of strokes from other disease as with patients with
cardiac disease including coronary artery stents, prostatic heart valve, and intracardiac

thrombus. The decision to stop this therapy before surgery is controversial and the
planning should ideally be clarified during the preoperative assessment. Consultation
with specialists such as hematologist, cardiologist and the surgeon is useful. The risks
and the benefits of discontinuing or continuing therapy should also be discussed with the
patient and family. Factors to consider are the urgency of the procedure and the presence
of thrombotic or hemorrhagic risks. Recommendations for elective surgery with high
hemorrhagic risk, such as intracranial and spinal procedures and moderate to high
thrombotic risks suggest that aspirin should be continued, but to withhold clopidogrel and
if the neurological and cardiovascular risks are low, the antiplatelet agents should be
withdrawn (7 days for aspirin, 10 days for clopidogrel and 14 days for ticlopidine).
Further consultation is needed when major thrombotic factors exist such as when the time
interval from bare metal stent insertion is less than six weeks or less than 12 months for
patients with drug eluting stents. Patients who are on anticoagulation with agents such as
warfarin need further consideration to determine the time interval to stop its
administration (4-5 days preoperatively) and if anticoagulation with low molecular
weight heparin and/or unfractionated heparin is needed in the interval. Additional
preoperative coagulation profile investigations may be needed. Latex allergy has to be
excluded from patients who have had repetitive surgical procedures performed, such as
for spinal bifida. Likewise an allergy to contrast medium or protamine sulfate will have
important considerations in the patient undergoing radiological and endovascular
procedures. There are subgroups of disorders, where patients may be on chronic pain
medication necessitating the planning for perioperative pain management.
The presence of preoperative anxiety is high among neurosurgical patients. A recent
study found that there was an increased need for information, especially about surgery, in
patients with high levels of preoperative anxiety. Preoperative treatment with anxiolysis
or opioids is a controversial subject. Patients who have increased ICP, or are obtunded
are at a high risk of developing respiratory depression and even further increases in ICP
with any sedation. Generally, for most neurosurgical patients with intracranial disease, if
any preoperative sedation is to be used, it should be administered to the patient in a
monitored environment where its reversal and airway management can be easy
performed.
B. Intra-op

What happens during surgery?

There are 6 main steps during a craniotomy/craniectomy. Depending on the underlying problem
being treated and complexity, the procedure can take 3 to 5 hours or longer.
Step 1: prepare the patient
No food or drink is permitted past midnight the night before surgery. Patients are admitted to the
hospital the morning of the craniotomy. With an intravenous (IV) line placed in your arm,

general anesthesia is administered while you lie on the operating table. Once asleep, your head is
placed in a 3-pin skull fixation device, which attaches to the table and holds your head in
position during the procedure (Fig. 2). Insertion of a lumbar drain in your lower back helps
remove cerebrospinal fluid (CSF), thus allowing the brain to relax during surgery. A brainrelaxing drug called mannitol may be given.

Figure 2. The patients head is placed in a three-pin Mayfield skull clamp. The clamp
attaches to the operative table and holds the head absolutely still during delicate brain
surgery. The skin incision is usually made behind the hairline (dashed line).

Step 2: make a skin incision

After the scalp is prepped with an antiseptic, a skin incision is made, usually behind the hairline.
The surgeon attempts to ensure a good cosmetic result after surgery. Sometimes a hair sparing
technique can be used that requires shaving only a 1/4-inch wide area along the proposed
incision. Sometimes the entire incision area may be shaved.
Step 3: perform a craniotomy, open the skull
The skin and muscles are lifted off the bone and folded back. Next, one or more small burr holes
are made in the skull with a drill. Inserting a special saw through the burr holes, the surgeon uses
this craniotome to cut the outline of a bone flap (Fig. 3). The cut bone flap is lifted and removed
to expose the protective covering of the brain called the dura. The bone flap is safely stored until
it is replaced at the end of the procedure.

Figure 3. A craniotomy is cut with a special saw called a craniotome. The bone flap is
removed to reveal the protective covering of the brain called the dura.
Step 4: expose the brain
After opening the dura with surgical scissors, the surgeon folds it back to expose the brain (Fig.
4). Retractors placed on the brain gently open a corridor to the area needing repair or removal.
Neurosurgeons use special magnification glasses, called loupes, or an operating microscope to
see the delicate nerves and vessels.

Figure 4. The dura is opened and folded back to expose the brain.
Step 5: correct the problem
Because the brain is tightly enclosed inside the bony skull, tissues cannot be easily moved aside
to access and repair problems. Neurosurgeons use a variety of very small tools and instruments
to work deep inside the brain. These include long-handled scissors, dissectors and drills, lasers,
ultrasonic aspirators (uses a fine jet of water to break up tumors and suction up the pieces), and
computer image-guidance systems. In some cases, evoked potential monitoring is used to

stimulate specific cranial nerves while the response is monitored in the brain. This is done to
preserve function of the nerve and make sure it is not further damaged during surgery.
Step 6: close the craniotomy
With the problem removed or repaired, the retractors holding the brain are removed and the dura
is closed with sutures. The bone flap is replaced back in its original position and secured to the
skull with titanium plates and screws (Fig. 5). The plates and screws remain permanently to
support the area; these can sometimes be felt under your skin. In some cases, a drain may be
placed under the skin for a couple of days to remove blood or fluid from the surgical area. The
muscles and skin are sutured back together. A turban-like or soft adhesive dressing is placed over
the incision.

Figure 5. The bone flap is replaced and secured to the skull with tiny plates and screws.
Position of patient:
Area of Skin Prep: Head of Patient
Type of Anesthesia: General Anesthesia
Sutures used: wire sutures
Types of dressing: A turban-like or soft adhesive dressing is placed over the incision

C. Post-op
What happens after surgery?
After surgery, you are taken to the recovery room where vital signs are monitored as you awake
from anesthesia. The breathing tube (ventilator) usually remains in place until you fully recover
from the anesthesia. Next, you are transferred to the neuroscience intensive care unit (NSICU)
for close observation and monitoring. You are frequently asked to move your arms, fingers, toes,
and legs.

A nurse will check your pupils with a flashlight and ask questions, such as "What is your name?"
You may experience nausea and headache after surgery; medication can control these symptoms.
Depending on the type of brain surgery, steroid medication (to control brain swelling) and
anticonvulsant medication (to prevent seizures) may be given. When your condition stabilizes,
youll be transferred to a regular room where youll continue to be monitored and begin to
increase your activity level.
The length of the hospital stay varies, from only 23 days or 2 weeks depending on the surgery
and development of any complications. When released from the hospital, youll be given
discharge instructions. Stitches or staples are removed 710 days after surgery in the doctors
office
Discharge Instructions
Discomfort

After surgery, headache pain is managed with narcotic medication. Because

narcotic pain pills are addictive, they are used for a limited period (2 to 4 weeks).
Their regular use may also cause constipation, so drink lots of water and eat high
fiber foods. Laxatives (e.g., Dulcolax, Senokot, Milk of Magnesia) may be bought
without a prescription. Thereafter, pain is managed with acetaminophen (e.g.,
Tylenol) and nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., aspirin;
ibuprofen, Advil, Motrin, Nuprin; naproxen sodium, Aleve).
A medicine (anticonvulsant) may be prescribed temporarily to prevent seizures.
Common anticonvulsants include Dilantin (phenytoin), Tegretol (carbamazepine),
and Neurontin (gabapentin). Some patients develop side effects (e.g., drowsiness,
balance problems, rashes) caused by these anticonvulsants; in these cases, blood
samples are taken to monitor the drug levels and manage the side effects.

Restrictions

Do not drive after surgery until discussed with your surgeon and avoid sitting for
long periods of time.
Do not lift anything heavier than 5 pounds (e.g., 2-liter bottle of soda), including
children.
Housework and yardwork are not permitted until the first follow-up office visit.
This includes gardening, mowing, vacuuming, ironing, and loading/unloading the
dishwasher, washer, or dryer.
Do not drink alcoholic beverages.

References:
-http://www.mayfieldclinic.com/PE-Craniotomy.htm
- Mosby's Medical Dictionary, 8th edition. 2009, Elsevier.
-Smeltzer, Suzzane C. and Brenda G. Bare. Medical Surgical Nursing. Volume 2. 10th Edition.
Lippincott Williams & Wilkins: Philadelphia. Copyright 2010.

- Kunze, E; Meixensberger J; Janka M; Sorensen N; Roosen K (1998). "Decompressive

craniectomy in patients with uncontrollable intracranial hypertension". Acta Neurochirurica
(Supplement) 71: 1618.