Welcome to the classroom here at Toolworks General. This is where
the Chief Neurosurgeon will explain the essentials in the diagnosis
and treatment of various neurological dysfunctions and surgical
procedures. It is best to come here with your questions before
operating. The medical community frowns on experimenting with the
patients, especially unto death.
When you botch an operating you will find yourself the object of
a stern lecture from the Chief Neurosurgeon. He will also send you
back to this classroom for remedial course work and an occasional
Just point and click your mouse or mouse substitute on the screen
when you are finished reading its contents. The page will appear, or
you will return to the menu to select another classroom subject.
Whenever you are finished in the classroom, exit by clicking on the
door behind the chief neurosurgeon, or pressing ESC.
While making your rounds or just exploring Toolworks General,
merely point and click on your room of choice. You have your own
office next to the chief neurosurgeon's, where you can make staff
decisions and hide from family members. You may even visit the morgue
to reminisce over your past mistakes.
Once inside the various rooms you may find help text, click on
various objects or observe the activities related to that room. Just
click the EXIT sign to return to the main hospital screen. It isn't
quite as easy to leave the operating room when surgery is in progress.
To change the parameters of the game just click on the receptionist's
To exit Toolworks General (perhaps in embrassment on being yanked
from surgery), point and click outside the hospital walls on the main
hospital screen. Remember, brain surgery is always a matter of LIFE &
DEATH. Are your malpractice premiums paid up?
GENERAL DIAGNOSTIC PROCEDURES
When instructed to attend a patient in one of the four Toolworks
General private rooms, you will need to perform a physical examination
that involves a series of neurological tests. Those results and your
experience as a neurosurgeon will help you determine the proper course
Once inside the patient's room, click the chart (Patients Orders)
for his or her vital information and symptoms. Click off the chart and
click on the patient's face, arms or legs to continue the physical
examination in those areas.
For the face, a close-up of the patient's eyes apper, and a tray
of instruments just below. Grab the pointer object in the upper left
of the tray by pointing hand cursor and clicking. Position pointer
over face, click left button (or equivalent) and hold as you move it
around the screen to test eye movement for any abnormalities.
Replace the object by moving over tray and clicking. Use the
penlight to check pupils for light reactions and observe any abnormal
dilation. Test the patient's speech by grabbing the "SAY ALICE" card
and clicking it on the face area.
Next, take the pin to check sensory response on both sides of the
patient's face. Don't stick it where it doesn't belong unless you want
to go back to med school.
The clipboard at the lower right will track the results of all
your tests for future reference. Just click on it if you want to
review test results. Click off the image area to return to a room
Now moving to the arms, click for the close-up and examine the
patient's strength by pointing your hand on the patient's left hand.
Lift by clicking, holding and dragging the mouse upward. Release the
mouse button to observe how the patient's arm falls. It will fall
quickly if there are any weaknesses. Repeat for the right arm.
Test the patient's reflexes with the hammer by tapping (clicking)
at the elbow for both arms. An appropriate sound will indicate whether
you have tapped the right area. Observe any absent or aggravated
responses. Again take the pin to test sensory response in both arms.
Follow the same procedure for the legs as you did the arms. Don't
forget to lift each leg with your hand and observe weaknesses.
Once you have finished your examination, click on the clipboard
next to the tray to evaluate the results. The handy neurological
textbook will help you to determine which, if any, major tests may be
required, or confirm your diagnosis for a prescribed course of
treatment under the patient's clipboard.
When you have questions about medical imaging results, such as
CAT scans, MRI, x-ray and angiography, visit the imaging labs to see
some sample images. The labs are located in the back corridor of the
If you order any major tests, order only those indicated by your
physical examination results. Study them carefully, then check off the
prescribed treatment and initial (you do want credit if the treatment
is a success). If you are headed for surgery, you may want to stop in
the cafeteria for a quick cup of coffee and the latest gossip.
INTERPRETING SKULL X-RAYS
Skull X-Rays are a technique for providing images of the skull in
the diagnosis and treatment of neurological disorders. After a
complete physical examination, it may be necessary to order X-rays of
the skull to confirm the presence of a fracture, and its severity,
when a head injury is suspected as the cause of the patient's
The X-ray may provide valuable information to confirm the
likelihood of a subdural hematoma when ambiguous symptoms are present.
The image will reveal a fracture where the head injury occurred that
led to the collection of blood between the dura mater and the brain.
If an injury is suspected, or an fracture is found, a CAT scan
can also be performed to provide additional information. The X-ray, in
some cases, may be used to exclude hematoma when a fracture is not
found. However, exposing the patient to unnecessary risk and expense
is not considered good diagnostic form for a would-be brain surgeon.
Other significant and serious brain disorders such as ane rysms
and tumors will return a normal skull X-ray, therefore a normal skull
image does not rule out a brain disorder of those types.
INTERPRETING CAT SCANS
A CAT (computerized axial tomographic) scan is a diagnostic
technique which combines the use of a computer and X rays passed
through the body at different angles. The computer analyzes the
density of tissues and organs.
It produces cross-sectional images of the area being examined,
providing clearer and more detailed information than X-rays used
alone. CAT scanning tends to minimize the amount of radiation exposure
to the patient.
The scanned images reveal soft tissues (including tumors) more
clearly than normal X-ray pictures. The CAT scan images are valuable
in brain disorders due to their sharp definition of ventricles
Because CAT scans utilize iodine dye to contrast various tissues,
patients allergic to iodine should not be subjected this test. !!!
The MRI scan should be used instead. Additionally, the dye can
further damage an injured kidney. Patients subject to kidney damage
should not !!! be CAT scanned either.
CAT scans are valuable in confirming the preliminary diagnosis of
aneurysms (unless bleeding is very small), brain tumors, hematoma due
to head injury (scan will show abnormal clot and skull indentation)
and the damaged areas of the brain due to infarction (stroke) when
balanced against information from the patient's history and physical
INTERPRETING MRI SCANS
Magnetic Resonance Imaging (MRI) is a valuable diagnostic
technique that provides the neurosurgeon high quality cross-sectional
images of brain structures. The images produced by MRI scans fo not
employ the use of X-rays or other radiation. While similar to CAT
scans, the MRI scan usually gives greater contrast between normal and
During imaging, patients are exposed to short bursts of a
powerful magnetic field. The nuclei (protons) of the body's hydrogen
atoms then line up in parallel to each other as opposed to the normal
random arrangement. When they are knocked out of alignment by a strong
pulse of radio waves, they return a detectable radio signal as they
fall back in to place.
The computer interprets these signals by the varying strength
returned by different body tissues and convert the information into a
high quality image. Because of the strong magnetic field involved,
patients fitted with a pacemaker or other electrical devices should
not !!! undergo MRI scans. The CAT scan should be used instead. There
are no other known adverse effects.
MRI scans are particulary valuable in studying the brain an
spinal cord. This technique reveals tumors vividly, indicating their
precise extent. MRI scans also give detailed images of vessels and
thus reveal aneurysms (unless bleeding is small), hematomas (showing
clotting and skull indentations), and brain damage due to infarctions.
Angiography is the procedure where an angiogram is produced in
order to examine the integrity of blood vessels on film. It is used to
detect diseases that alter the appearance of the blood vessel channel
A contrast medium (dye) is injected into the patient's
bloodstream and X-rays are then taken to look for abnormalities.
Digital subtraction angiography uses computer techniques to remove, or
subtract, unwanted background information. This procedure is somewhat
safer because it uses smaller amounts of contrast medium.
For the neurosurgeon, angiograms provide valuable information for
diagnosis of aneurysms by indicating the location of the dilated blood
vessel. CAT and MRI scans may miss aneurysms if the bleeding is small.
In subdural hematoma, the angiogram will indicate displacement of
vessels by the blood clot. For patient's suffering infarction,
angiography often indicates the occlusion. This procedure will also
reveal an invisible mass compressing the blood vessel in the case of a
Ballooning of an artery due to the pressure of blood flowing
through a weakened vessel is called an aneurysm. Cerebral aneurysms
may persist for many years without causing symptoms, but their
proximity to many important neurological structures make them very
dangerous. These dilations may gradually enlarge until finally they
rupture and bleed into the brain.
SYMPTOMS. Sudden enlargement and bursting of an aneurysm produces
obvious symptoms and signs. Patient's may complain of severe headache
or experience unconsciouness (symptoms simlar to a stroke).
Look for weakness of the arms and legs, along with abnormal pupil
dilation, light reaction, and possible paralysis of eye movement on
the opposite side of the patient's body in relation to the aneurysm.
DIAGNOSIS. The angiogram produced through angiography provides
more detailed and definitive information in the confirming tests than
skull X-rays, which usually appear normal. The dilation may also
appear on the CAT scan or MRI scan and offer additional valuable
information (unless the bleeding is very small).
TREATMENT. Because a ruptured aneurysm can lead to fatal blood
loss and severe damage to the brain structure, proper diagnosis and
decisive action is imperative. Once confirmed through dianosis, the
patient should be prepared for surgery immediately. Bone up on your
knowledge of procedures though this one is tough sledding.
A tumor is an abnormal mass of tissue that forms when cells in a
specific area reproduce at an accelerated rate. Though tumors may be
malignant or benign, all brain tumors are serious. Malignant tumors
invade surrounding tissues, spread through the bloodstream or
lymphatic system to form a secondary growth.
Benign tumors tend to grow more slowly and remain within fibrous
capsule. This makes surgery and removal more straightforward. Because
tumors press on nearby structures, they are very dangerous in the
confined spaces of the skull.
SYMPTOMS. As the tumor grows it presses on normal brain tissues
causing headache or weakness in the arms or legs. Reflexes will be
aggravated accompanied with a loss of sensation on the opposite side
from the tumor. The patient's speech will be impaired if the tumor is
located on the left side of the brain.
DIAGNOSIS. To further confirm the physical examination, brain
tumors are located primarily by the use of a CAT scan or MRI scan to
view the abnormality. An angiogram may reveal an invisible mass
compressing the blood vessels. Skull X-rays are usually normal and
should be viewed as unnecessary if other symptoms preclude it.
TREATMENT. The patient's outlook is very poor if the tumor is not
removed by opening the skull. The majority of cases will end in death.
Once the diagnosis is confirmed, proceed immediately to OR and don't
forget to bring your patient with you. Refer to the classroom subject
"Excising Brain Tumors" to improve your changes for success.
An infarction (stroke) occurs when a blood vessel that supplies a
part of the brain becomes blocked or leakage occurs outside the vessel
walls. This loss of blood supply results in the death of that area of
tissue. Infarctions vary in their severity with one third of the cases
resulting in death.
SYMPTOMS. Infarctions will result in weakness and loss of
sensation on the opposite side of the body. Physical examination of
the head area will reveal abnormal pupil dilation, light reaction and
lack of eye movement on the opposite side. If the infarction occurs on
the left side of the brain, speech will be slurred. Reflexes may be
aggravated as well.
DIAGNOSIS. CAT and MRI scanning will show a damaged area in the
brain, showing that the symptoms were not caused by a tumor, subdural
hematoma or other brain disorder. The blockage will also appear on the
A stroke parallels some symptoms of aneurysms, tumors and
migraines, but with significant differences. Be careful to compare all
results of examination before deciding on a course of treatment.
TREATMENT. In tissue losses that are not immediately fatal, the
best course of action is to make every effort to restore impairments
through physical therapy, speech therapy and exercise. The degree of
recovery will vary patient to patient. Avoid extreme embarrasment by
not performing surgery on an otherwise normal brain.
Migraines are severe headaches lasting from two hours to two
days. Sufferers may experience one attack, but more commonly have
recurring attack at various intervals. They are caused by the dilation
or spasms of blood vessels in the brain.
SYMPTOMS. There are several types of migraine, and a number of
factors may singly or in combination brain on an attack. One type can
cause motor weakness of the arm and leg on one side, similar to a
stroke. Reflexes can be aggravated and speech wil often be impaired.
DIAGNOSIS. Special tests are rarely needed. Diagnosis should come
from the patient's history and physical examination.
TREATMENT. Severe migraines often require simple preventative
measures that avoid any known trigger factors. If that is
unsuccessful, it may be necessary to prescribe a more powerful drug
such as codeine.
A subdural hematoma is the enlarging collection of blood in the
space between the dura mater and the brain. The common cause is the
tearing of veins inside the dura mater following a blow to the head.
This may go unnoticed by the patient for weeks before the trauma
becomes sufficiently symptomatic.
SYMPTOMS. The bleeding occurs slowly, but increases pressure
within the skull, displacing and pressing on brain tissue. Headaches
and confusion may follow, along with one-sided weakness on the same
side as the injury. Physical examination will show abnormal pupil
dilation and light reaction. Speech may be slurred if the hematoma
occurs on the left side.
DIAGNOSIS. CAT and MRI scans will show abnormal blood clotting
and indentation of the skull. Angiography will show invisible
displacement of the blood vessels by the clotting. X-rays should
confirm location of injury by revealing a skull fracture.
TREATMENT. If the diagnosis is confirmed through major tests,
surgical treatment should follow immediately. Time is of the essence.
Though not the most complex of neurosurgeries, special care should be
taken to drain clot, repair vessels and provide continued drainage so
that the clot will not reform. Proper surgery usually allows complete
Hysteria is a term encompassing a broad range of physical or
mental symptoms. This was originally thought to be a disorder confined
to women. Many psychiatrists feel this term is not specific enough to
be useful in diagnosis. Hysterical paralysis is often seen in patients
suffering from such high anxiety, thus leading to some confusion about
whether or not the disorder is neurological in origin.
SYMPTOMS. A physical examination of the patient will reveal a
weakness in the arms and legs on one side of some patients. Facial and
other sensory defects may also be present.
DIAGNOSIS. In the absence of any other telling symptoms during
physical examination, major tests should not be ordered. CAT and MRI
scans, X-rays and angiograms will all be normal in patients suffering
TREATMENT. In the case of hysterical paralysis the best course of
treatment is a referral to a competent psychiatrist or counselor.
Ignoring the condition will not make it go away, and any further
deterioration in the patient could result in insanity, and non-payment
of your bill. A fate worse than death.
Neuropathy is simply a disease, inflammation or damage to the
peripheral nerves which connect the central nervous system to the
patient's extremities. In many cases there is no obvious cause. Nerves
may become acutely inflamed, often occurring after a viral infection.
SYMPTOMS. Depending on which nerves are affected, neuropathy can
be affected, neuropathy can be characterized by damage to nerve fibers
which may cause motor weakness or lack of sensation in one of the
DIAGNOSIS. A complete physical examination is necessary to
determine the extent of nerve damage. In the absence of any other
symptoms than the ones cited above, major tests such as CAT scan, MRI
scan, X-ray and angiogram should not be required for deciding the
course of treatment.
TREATMENT. Neuropathy is best treated by exercise of the affected
extremities. A full recovery is possible if the damaged nerve cells
have not been destroyed. Your recovery is far less predictable if you
should subject your neuropathy patient to the knife.
Drug addictions involve the compulsion to continue to take a
narcotic to produce the desired effects, or to prevent the ill effects
that occur when it is not taken. Cocaine was once used as a local
anesthetic, but because of its potential for abuse has been replaced
by other local anesthetics.
Morphine is the best known narcotic painkiller. Its euphoric
effects have led to its abuse. Long-term abuse will produce craving
and tolerance, which requires greater amounts for the same effect.
SYMPTOMS. Patients suffering from cocaine overdose will show
dilated pupils, but few, if any, additional abnormalities. Those
patients suffering from morphine addiction can be easily identified by
their narrowed, non-reacting pupils. The balance of the physical
examination for neurological disorders will appear normal.
DIAGNOSIS. The limitation of disorders in the physical
examination should provide ample clues pointing to the drug abuse
conclusion. In both the morphine and cocaine circumstance, CAT and MRI
scans, angiogram and X-rays are all normal.
TREATMENT. Effective treatment of drug addictions involve the
breaking of physical and psychological dependencies. Refer these
patients to qualified psychiatric and counselor care.
Headaches represent one of the most common types of pain
disorder, and are rarely associated with any underlying serious
condition. The expression of pain takes on varying characteristics,
localized or general. Causes can range from food types to poor
posture. A headache can be caused by brain tumors or aneurysms.
SYMPTOMS. The patient will complain of pain all over the head or
at some specific part. The pain may be deep or superficial, throbbing
or sharp, and may move around during its course. In the case of simple
headaches, symptoms associated with more severe migraines are
obviously not found.
DIAGNOSIS. Except for the complaint, all other aspects of the
physical neurological examination will be normal. Major tests such as
CAT scan, MRI scan, X-ray and angiogram should not be required and
will return normal results.
TREATMENT. Politely and patiently prescribe aspirin and have the
patient call you the following day. If you prescribe anything
stronger, you may be seeing them as drug addiction patients at a later
time. Make immediate arrangements for their discharge, and under no
circumstances practice your surgical technique on them.
GENERAL SURGICAL GUIDELINES
Direct physical intervention with instrument (surgery) into the
brain always amounts to major risk for the patient. Hopefully you're
reading this because you want to be prepared for surgical realities,
not because you've already botched a procedure in OR, and the chief
neurosurgeon har threatened your own life unless you go to class.
Here at Toolworks General, descriptions of procedure will refer
to the on-screen locator as your "hand". To grab something, you move
your hand over the object or instrument and "hold" it by pressing the
left mouse button (or equivalent). The locator is now the instrument
you have selected.
You will have to pick up and replace instruments to perform
surgery and to free your hands for other actions. You must move
objects back over the tray when changing procedure. Any click while an
instrument is over the patient will constitute its use. If the action
is uncalled for you, you may experience disasterous results.
Do not ignore the occasional remark by your assisting team. They
are there to help you succeed as a neurosurgeon. Always check the
dialog box in the lower right corner during an operation for
instructions and information on your patient's condition.
Watch the CO2 levels and blood pressure at regular intervals.
Always be ready to address negative changes with the appropriate
remedy (see Operational Hazards). Also keep an eye on the EKG for
abnormalities in hearth rhythm. Your knowledge of appropriate
treatment and quick response may be necessary to save a life.
Clicking on the "Exit" button will quit the game, as will ESC.
Many variables and life-threatening hazards can affect the
outcome of neurosurgery. That's why you can command such huge fees. If
your patients are going to survive, you must be prepared to deal with
surgical hazards quickly and effectively.
IV BOTTLE: Remember do not let the IV go dry. IV bottles are !!!
located in the lower drawer. Several types of IV are available
depending on the patient's current condition. If everything is stable,
use saline or glucose to keep the drip going.
RESPIRATION: You must check the arterial blood gas monitor at
regular intervals throughout the operation. The patient's respiration
will normally be kept at 30/minute. Occasionally, blood CO2 will
increase. If it is above the 30 level, turn the respirator to "high".
When the CO2 level goes down, turn the knob back to "low". If the
CO2 level rises above 45, then the patient's heart stops and death
follows. Be careful not to leave the respirator on "high" for too long
or the patient will hyperventilate.
EKG TRACE: Occasionally a patient may experience abnormal heart
rhythms. You must act quickly, and in appropriate manner, or the
patient will die. If the patient's EKG has an upside down trace (PVC),
inject !!! Lidocaine into the patient's body. If the EKG has two blips
in it (bradycardia), inject Atropine into the patient. !!!
Do not administer either of these substances during a normal EKG
trace or choose the wrong substance for an abnormal rhythm. If either
occurs, the patient will experience ventricular fibrillation and die.
BLOOD PRESSURE: Normally the patient's blood pressure should be
110/70. Something may occur during surgery to cause it to drop like
bleeding. If the blood pressure drops too low, the patient's heart
A drop in pressure can be combated in one of several ways:
- Saline drip may only be temporary effective, especially if
patient is bleeding.
- Blood transfusion is most the most effective action. !!!
Transitory if bleeding is not stopped.
- Administer dopamine is effective if the patient is not bleeding
(emergency use only.)
URINE OUTPUT: Periodically check the patient's urine bag. Low
urine output can be corrected by adding mannitol to the IV. If not !!!
corrected, the patient will go into shock due to renal failure.
BRAIN TIGHTNESS: Pressure in the cranial cavity will sometimes
lead to brain tightness. Click hand on the exposed brain to see if it
is relaxed. If it becomes tight, click on the spinal tap (next to IV
unit) !!! to open it and remove cerebrospinal fluid. Click to close
when the brain relaxes.
INCISING AND OPENING THE SCALP
Your patient has been wheeled in and their head shaved. Your
staff is hand picked and ready to assist you. The EKG has a reassuring
regular "blip" sound, and all your instruments are sterile and ready
for your skilled hands. This is not the time to stare blankly into
space wishing you had studied harder.
Always scrub first. Just grab the soap from the tray and you're
done. Next reach for your surgical gloves for a very impressive
beginning. Now select which side you will operate on and turn the
patient's head accordingly (very important).
Reach for the iodine to clean the patient's scalp with
antiseptic, swabbing the entire head area above the eyes. The risk of
post-operative infection is higher if the scalp is not completely
Now is a good time to inject the antibiotics. Grab the syringe
marked 'B' from the middle drawer and inject it into the patient. This
will also help prevent post-operative infection.
Next, select the drape from the upper left of the tray, move it
over patient's head and click to apply. You should now see only the
portion of scalp necessary for the surgery, along with the incision
You can't put off the scapel much longer. Depending on how steady
your hand is, you may want to give the patient a blood transfusion
before beginning to cut. This keeps the pressure up during the
incision process. Grab a bottle of blood from the tray, move it to the
IV bottle and click.
Now reach for the scapel, position it over the incision line to
the left, click and hold. You are now cutting. Drag scapel aldong line
carefully, noting the bleeders, until you have gone about one third
the distance. Release the mouse button to finish cut, replace scapel
to tray and grab the Rainey's clips one at a time.
Clip them over the bleeders on both sides of the incision to stop
the bleeding. Repeat procedure until incision in complete and there
are no bleeders. If you cut off the incision line accidentally, you
will get a warning. Carve anywhere else intentionally, and you'll get
yanked from surgery.
Now you get to see what's underneath. Place your hand above the
incision, click and drag upward. Don't let the tearing sound get to
you, it's only the beginning. Grab the fishhook from the tray and
click on the skin flap to keep it up and out of the way. It would be
very embarrassing to have it falling into your work.
Now that the scalp is open, you are ready to continue with the
procedure specific to your patient's disorder and you better hope he
or she isn't just suffering from a migraine.
TREATING SUBDURAL HEMATOMAS
Preliminary diagnosis indicated, and the X-ray confirmed a
subdural hematoma. You have successfully retracted the scalp (see
Incising and Opening the Scalp), and there should be a visible
fracture underneath which lies the hematoma.
If there is no fracture, guess what - you either misdiagnosed or
turned the patient's head the wrong way. Either way, the chief
neurosurgeon will have your head. If you see the fracture, you can
briefly breathe a sigh of relief. At least you've faked your way this
Check respiration, EKG and blood pressure immediately to make
sure everything is within safe limits. Select irrigation (the tube
with a bulb on the end) and position over the center of the fracture
and click. Make sure the irrigation tool begins to drip properly.
Now grab the drill, move over to the fracture and click-hold on
the center. Listen to the sound. IMMEDIATELY release the button when
sound goes up in pitch. You should have a cylindrical hole, not a
rounded depression, at the drill point. One hole is sufficient so
replace the drill.
Grasp the bone wax and click on the hole you just drilled to stop
bleeders. Replace the wax and the drill to the tray if you have not
already done so. Use the scapel to make an incision in the hole and
replace it on the tray. Select the suction instrument (tube with a
button) and click-hold in the hole.
You will notice that the tube is red. When the tube turns white
IMMEDIATELY release and click on the tray to replace the suction.
Now select the drain tube (with "u" hook on end) and click on the
hole. The Drain should appear. Make sure it is placed properly. Grasp
the suture (curved needle and thread) and click on the drain where it
lies on the scalp. Do not click on the bone or drape.
Without suturing the drain tube it will pull out after the
operation and be very messy. Replace suture on the tray. If you have
gotten this far, you might have what it takes to close up the
operation successfully (see General Closing Procedures).
OPENING THE SKULL
Neurosurgical procedures specific to aneurysms and brain tumors
require opening the skull for access and treatment of the affected
area. These two operations demand both caution and skill.
Now that the skin and muscle layer has been retracted (see
Incising and Opening the Scalp), you must drill four burr holes to
remove the bone flap. Select irrigation tool (the tube with a bulb on
the end) and position over the extreme right edge of the exposed skull
and click. Make sure the irrigation tool appears and begins to drip
Now grab the drill, move over to where the irrigation is dripping
and click-hold right where the drops land. Drill anywhere else and the
patient's brain will overheat, and death follows. Listen to the sound.
IMMEDIATELY release the button when sound goes up in pitch.
You should have a cylindrical hole, not a rounded depression, at
the drill point. Replace the drill on the tray, select the bone wax,
wipe around edge of burr hole to stop bleeders, and then replace wax.
Grasp irrigation to pick it up again, and repeat for three more
burr holes at the upper center, extreme left and lower center of the
exposed skull, and at reasonably equidistant points. When you have
completed those three burr holes, replace irrigation on the tray.
Now select the dissector (just under scapel) and click in each
burr hole to separate the dura from the bone flap. If you fail to do
this for each hole, the dura will stick to the bone flap and be torn
when it is removed. Replace the dissector when finished.
Next, click on the saw head ("L" shaped) to place it on the
drill. Select drill and drag between the adjacent holes to cut free
the diamond-shaped bone flap. Start the click inside a hole and drag
to the next adjacent hole, releasing when done. After connecting all
four burr holes, replace the drill.
Place your "hand" onto the bone flap and click. Then drag it to
the lower left of the operating table once to set it out of the way of
your surgery. You now have bleeders to attend, unless you improperly
prepared the dura. In that case you will be yanked into the chief
Quickly drag bone wax for all small bleeders along skull edge.
Electrocauterize the center of those remaining to staunch their
bleeding (the two-pronged instrument). You may need to swab heavy
bleeders with cotton to find their center again. Replace swab and
electocauterizer when all bleeding is stopped.
To clean jagged edges of the exposed skull bone, click on the
high-speed grinder drill-head (ball-shaped) to place it on the drill.
Select drill, click and drag it along the bone edge and over the dark
grey sphenoid ridge. Be sure to get all the sphenoid ridge and bone
edges. Use bone wax to stop bleeders.
Check all vital signs and take a deep breath. Congratulations,
the skull is now opened and you are ready for the next important step
(see Incising and Opening the Dura Mater).
INCISING/OPENING THE DURA MATER
Assuming you've gotten this far without a major mishap, the bone
flap is out, all bleeders have been stanched, the patient is
stabilized and you're ready to open the dura mater.
Click the fine drill head (needle-shaped) to place it on the
drill. Select the metal ribbon (oval shaped strip) and click on the
bone edge running from upper left to lower middle. The ribbon should
appear in a position underneath the skull edge to protect the dura
mater from drilling.
Now select the drill and click on the bone edge running from
upper left to lower middle, about midway between the bone edge and the
edge of the drape. This creates suture holes in the rim of the skull
IMPORTANT: make sure the drill is within the ribbon outline as it
would continue underneath the bone edge or you will drill into the
patient's brain. Click on tray to replace drill. Repeat those exact
steps for the other three edges. Click hand on metal ribbon to pick it
up and click on the tray to replace it.
Now create suture holes in the bone flap the same way. Select
drill and make sure it stil has the fine bit. Click and drill on the
bone flap once in the middle, and once near the center of each edge.
Replace the drill on the tray.
Now grasp the suture (upper tray, curved needle and thread), and
click on the fine drill holes along the bone edge to insert suture.
Also put one suture in the center of the exposed dura mater. Replace
the suture on the tray.
Place your hand over the bone flap and click once. Drag the bone
flap to the tray and let go. The bone flap will now appear on the tray
out of your way for the tricky stuff.
You must now induce hypotension by injecting nitroprusside. Grab
the syringe marked "N" and click it into the patient. This
artificially reduces the patient's blood pressure to prevent massive
bleeding when cutting or retracting the brain. Do not attempt to
inject dopamine to raise blood pressure while the brain is retracted,
or the patient may die from excessive bleeding.
At this point you must relax the patient's brain. To do this,
place your hand on the brain and click. If the brain is tight, you
will be told. At that point you must open the spinal tap and click on
the brain to relax it. Don't forget to close the spinal tap when you
Incise thye dura by selecting the scapel and clicking on the
exposed dura near the bone edge, just a little to the left of the top
corner. Click and drag counterclockwise hugging the bone edge until
you are just to the right of the top corner.
DO NOT COMPLETELY CONNECT THE INCISION. If you cut off the dura
completely, that tissue will die. Cauterize any bleeders.
Before lifting the dura mater, grab the gauze roll and click on
the scalp flap to apply moistened gauze. You will then see a layer of
gauze strips. Place your hand on the dura and click. The flap will
fold up. If you foret the gauze, the will dry out and that tissue will
REMEMBER: the brain must be irrigated every five minutes while it
is exposed, or it will dry out. You are ready for the next procedures
(see Excising Brain Tumors or Treating Brain Aneurysms depending on
your patient's condition).
EXCISING BRAIN TUMORS
Before this point in surgery, you have succesfully removed the
bone flap, incised the dural flap and lifted it out of the way. The
brain is exposed, and if irrigation is not used every minute or so the
brain will dry out. Now let's get that pesky tumor out.
To locate the tumor, click the ultrascan button (the one with the
box on a cable end, and waves coming down). The tray area is now
covered with the ultrasound window. Pick up the sensor at the bottom
right of the ultrascan screen. Click and hold the sensor over the
exposed brain while watching the display.
If you don't ding the tumor on the first layer, look in the
second by replacing the sensor and clicking the top right button of
the ultrascan unit. The button will change color to indicate you're on
a different layer. There are a maximum of three layers.
When you fing a large white blot, get it centered and note the
"X" and "Y" coordinates in the upper left corner of the ultrascan
window. The top one is X, and the bottom one is Y. Also note the layer
on which you found the tumor, because it corresponds to the microscope
layer used later. Click on the ultrascan window to turn it off.
During ultrascan, the tools on the tray cannot be accessed. If
the patient develops PVC's, turn off ultrascan before getting
Now click on microscope button and the microscope view will
appear. Note the X and Y scales. The top one is X and the right one is
Y. Click on the arrow buttons until the coordinates match the ones you
got from the ultrascan. The tumor should be near the center, about a
half inch in diameter, though you cannot see it at this point.
REMEMBER, keep irrigating.
Pay attention. This is a matter of life and death. There are five
layers of brain tissue, the tumor will be settled into one of the
first three layers, corresponding to the ultrascan layer. Each layer
of brain tissue is a different pattern and color; the tumor layer is
Select the suction instrument. You will use this to bore down to
the tumor and remove it. When you click and hold the suction, it makes
a small circular region. Every hole inside becomes one layer deeper,
and you will notice the holes change appearance as you drill deeper.
Suck up all the black tumor on its layer while getting as little
excess brain matter as possible. When the tumor is gone, replace the
suction onto the tray. Click on the microscope button and prepare to
close (see General Closing Procedures).
TREATING BRAIN ANEURYSMS
Before this point in surgery, you have successfully removed the
bone flap, incised the dural flap and lifted it out of the way. The
brain is exposed, and if irrigation is not used every minute or so,
the brain will dry out. Now for the hard part.
Click on the microscope button (the button next to respirator
switch), to insure you do not injure healthy brain tissue. A
microscope view will appear.
If you do not see a vague line running down the center, you did
not remove enough of the sphenoid ridge. Click the micro button, fold
down flap, and select the drill with high-speed grinder attachment.
Now run the grinder over the entire area of the sphenoid ridge.
Fold up the flap and hit the micro button again. Your view should
now be in position over the arachnoid membrane (you may need to repeat
this procedure until you're sure that the sphenoid ridge is completely
Elevate the arachnoid membrane by selecting the jeweler's forceps
(tweezers) and click to the left of the line (which is known as the
sylvan fissure.) This will prevent damage to the underlying
Now select the arachnoid knife (or the microscissors) to incise
the membrane. Move them to a position near the forceps and drag along
the sylvan fissure, then release. Replace both the arachnoid knife (or
microscissors) and the forceps before continuing.
Retract and separate the frontal and temporal lobes by grabbing
the retractors (the strip of metal with a curl on the end),
positioning them over each lobe. Click and drag on the brain lobe
which appears to the left of the fissure. Do not drag too far (about a
half inch) just enough to expose the connecting vessels.
You must cut the connecting vessels with the microscissors before
continuing the retraction process. Immediately electrocauterize any
resultant bleeders. Continue retraction carefully and by degrees until
second arachnoid membrane is visible. This will be the dark area to
one side of the large artery.
Incise with arachnoid knife as before, being doubly careful, as
the internal carotid artery and optic nerve are just beneath.
Use arrow buttons to move right or left, depending on where the
aneurysm is located. Drag the right or left retractor, again based on
the anerurysm location, until thickening is exposed.
Use the rhoton dissector (in the trio of black tools, with the
teardrop on the end) to click and drag over the thickening twice. This
retracts the two layers of tissue covering the aneurysm.
Now the forked artery with the ball (the aneurysm) is revealed.
Replace the dissector and select the rhoton hook (of the trio of
tools, it has the bend on the end). Move it to the middle of ball,
hooking it over the veins which cross the aneurysm.
Click and drag the veins down so that they are no longer
obscuring the ball. Replace the hook on the tray. Re-select the
dissector and click on the ball. Replace and re-select the rhoton hook
and click and drag across the tissue under ball. The aneurysm should
elevate (this may take a few attempts.)
Replace the hook. Apply the aneurysm clip to the neck of the
dilation by selecting, positioning correctly over the neck of the
aneurysm and clicking.
Now remove both retractors and replace on the tray so both
temporal and frontal lobes can relax back into position. Click on the
microscope button and close (see General Closing Procedures).
GENERAL CLOSING PROCEDURES
The worst is over the rest is a piece of cake. Close the dura
flap (Tumor and Aneurysm operations only) by placing your hand over it
and clicking. Stitch, don't staple the dura by selecting the suture
and clicking at least ten times around the incision.
Pick up the bone flap (Tumor and Aneurysm operations only.) Drag
it until it fills the hole, click again and it should drop in. Click
hand on each of the bone edge holes and center hole. This will tie off
all the sutures, attaching the bone flap to the skull.
Click on the fishhooks to remove them, and click on the tray to
replace. The scalp flap will fall back into place.
Remove the rainey clips one at a time and replace on the tray.
Finally, and don't get trigger happy, grab the staple gun tool and
click on the incision to apply staples. When enough are applied, you
are finished unless one of your contacts falpl out between the dura
and the bone flap, in which case you have to start all over again!