APPENDIX B: RESOURCES FOR CRANIAL PROCEDURES IN AUSTERE SETTING

Neurosurgical intervention is greatly facilitated by obtaining the recommended supplies and equipment. The risk of neurosurgical intervention is higher when proper equipment is not available. Every effort should be made to obtain the necessary supplies and equipment if neurosurgical procedures are within the scope of a surgical team’s mission. If only a Gigli saw and Hudson brace are available to an inexperienced provider, the risk of neurosurgical intervention may outweigh the benefit, and medical management may be preferred.

Recommended resources necessary to support non-neurosurgeons who may have to perform cranial procedures in an austere environment should include all of the following:

1. Teleconference capability (video-teleconference capability preferred).
2. Emergency cranial pack that includes an electric drill with cranial perforator bit and matchstick or cutting ball, a Leksell Rongeur, Penfield instruments, bipolar cautery, Raney clips or silk stitches to control scalp hemorrhage, dural substitutes, and hemostatic agents (i.e., gel foam, surgical, etc.). A Gigli saw and Hudson drill may be included as back up should the electric drill fail during the procedure.
3. Critical care capabilities.

NOTE: Non-invasive measures of intracranial injury are an emerging technologies that may be utilized to improve localization of injury or superficial hematoma.

Non-invasive Measurement Resources

1. Quantitative pupillometry: This is a small hand-held device that initiates a miotic pupillary response, records the speed of the response, and supplies a normative pupillary index (NPI).1,2

- As intracranial pressure increases, the NPI decreases.
- Asymmetric injury can result in asymmetric NPI and can aide with determining the hemisphere injured.

2. Near—infrared spectroscopy and ultrasound measurement of optic nerve sheath diameter are other technologies with ongoing investigations to determine efficacy for diagnosing intracranial hypertension or hemorrhage.3

References

1. Taylor WR, Chen JW, Meltzer H, Gennarelli TA, et al. Quantitative Pupillometry, a new technology: normative data and preliminary observations in patients with acute head injury. Technical note. J Neurosurg. 2003:98(1);205-13.
2. Martinez-Palacios K, Vasquez-Garcia S, Fariyike OA, et al. Quantitative Pupillometry for Intracranial Pressure (ICP) Monitoring in Traumatic Brain Injury: A Scoping Review. Neurocrtical Care. 13 Feb 2024.
3. Sen AN, Gopinath SP, Robertson CS. Clinical application of near-infrared spectroscopy in patients with traumatic brain injury: a review of the progress of the field. Neurophoton. 2016:3(3); 031409.
4. Yic CD, Pontet J, Mercado M, Muñoz M, Biestro A. Ultrasonographic measurement of the optic nerve sheath diameter to detect intracranial hypertension: an observational study. Ultrasound J. 2023 Feb 2;15(1):4.