FloSeal hemostatic matrix use for intraventricular hemorrhage during a neuroendoscopic procedure

Methods of Hemostasis in Cranial Neurosurgery: An Anatomy-Based Stepwise Review

BACKGROUND

Hemostasis is crucial in preventing hemorrhage during cranial neurosurgical procedures and maintaining visualization of the surgical field. There is significant variation in the availability of hemostatic methods across different settings and hemostatic techniques are being continuously developed over the decades of practicing neurosurgery. The aim of this article is to provide an outline of the potential methods to achieve hemostasis based on the sequential operative anatomy of a cranial operation.

METHODS

A systematic review was conducted following the PRISMA guidelines. The PubMed database was searched from inception of the database to July 18, 2023. A total of 64 studies were identified fulfilling predefined inclusion criteria, and the risk of bias was assessed using the Joanna Briggs Institute checklists.

RESULTS

Seventy-one hemostatic agents, techniques, tools, and devices were identified, which were then categorized according to the operative phase for which they are indicated. Nine operative anatomic targets were addressed in the sequence in which they are involved during a cranial procedure. For each anatomic target, the following number of hemostatic techniques/agents were identified: 11 for scalp, 3 for periosteum, 10 for skull bone, 11 for dura mater, 9 for venous sinuses, 5 for arteries, 6 for veins, 12 for brain parenchyma, and 4 for cerebral ventricles.

CONCLUSIONS

Depending on the phase of the surgery and the anatomic structure involved, the selection of the appropriate hemostatic method is determined by the source of bleeding. Surgeon awareness of all the potential techniques that can be applied to achieve hemostasis is paramount, especially when faced with operative nuances and difficult-to-control bleeding during cranial neurosurgical procedures.

Multiple Meningioma Resection by Bilateral Extended Rostrotentorial Craniotomy with a 3D-Print Guide in a Cat

Simple Summary

Meningioma is the most common intracranial neoplasia in cats. Treatments for meningiomas—including complete surgical resection, debulking, irradiation, or palliative therapy—have been reported in veterinary medicine. However, multiple meningiomas (two or more meningiomas in the same patient, separated by anatomical location) have been reported to affect the complication rate and prognosis. Moreover, the characteristics of neurosurgery—such as accurate localization and awareness of the anatomical structures of the lesions—make the surgery especially difficult for inexperienced surgeons. Surgical navigation systems have been developed, but recently, patient-specific three-dimensional(3D)-printed models and guides have also been used in orthopedics and neurosurgeries for treating many disorders with good results. A 13-year-old castrated male domestic shorthair cat was referred with multiple meningiomas located within the right frontal and occipital lobes. The cat suffered from generalized tonic–clonic seizures and mild proprioceptive ataxia. After removing both of the tumors, the cat showed a favorable clinical outcome and no neurological abnormalities throughout long-term follow-up. With a patient-specific 3D guide technology, a craniotomy for multiple meningiomas can be performed safely and accurately.

Abstract

A 13-year-old castrated male domestic shorthair cat was referred for the surgical removal of multiple meningiomas. The cat experienced generalized tonic–clonic seizures, altered mentation, mild proprioceptive ataxia, and circling. Magnetic resonance imaging (MRI) revealed two round, solitary, well-delineated, space-occupying lesions suggestive of multiple meningiomas in the right frontal and occipital lobes. Before surgery, patient-specific three-dimensional (3D) printed models and guides were produced using a 3D program based on MRI and computed tomography (CT), and a rehearsal surgery was performed. With a 3D guide to find the location of the craniotomy lines, bilateral extended rostrotentorial craniotomy allowed en bloc resection of multiple meningiomas. The bone fragment was replaced and secured to the skull with a craniofacial plate and screws with an artificial dura. All of the surgical steps were performed without complications. The preoperative presenting signs were resolved by the time of follow-up examinations 2 weeks after surgery. Twelve months after the removal of the multiple meningiomas, the cat survived without further neurological progression. For the resection of multiple meningiomas, surgery can result in large bone defects and risk of massive hemorrhage. For this challenging surgery, patient-specific 3D models and guides can be effective for accurate and safe craniotomies.

Gelatin–thrombin Hemostatic Matrix-related Cyst Formation after Cerebral Hematoma Evacuation: A Report of Two Cases

The gelatin–thrombin matrix, Floseal, is an excellent novel hemostatic agent that is used in various surgical fields. Thrombin is a serine protease, and the conversion of prothrombin to thrombin is an essential step in the coagulation cascade. However, thrombin can induce blood–brain barrier (BBB) disruption and vasogenic brain edema. This report describes two cases of gelatin–thrombin matrix-related cyst formation after cerebral hematoma evacuation. An 82-year-old man with a gelatin–thrombin matrix-related cyst was treated by cyst drainage and fenestration to the lateral ventricle. Histological evaluation of the cyst wall showed a gelatin–thrombin matrix reserve, marked infiltration of inflammatory cells, and foam cell accumulation. In addition, an 85-year-old woman with a gelatin–thrombin matrix-related cyst was treated with steroids and responded well. In both cases, the post-treatment course was uneventful. Cyst shrinkage and no recurrence were observed. The gelatin–thrombin matrix can cause cyst formation with brain edema. This is the first report demonstrating the cyst wall pathology and the steroid responsivity on cyst shrinkage. The mechanism of cyst formation is thought to be thrombin-induced BBB disruption. Excess gelatin–thrombin matrix should be carefully removed from the surgical beds, particularly those having a blinded space from the neurosurgical microscope.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Use of a gelatin-thrombin hemostatic matrix in obstetrics and gynecological surgery

Gelatin-thrombin matrix (GTM) is a hemostatic sealant consisting of bovine-derived gelatin matrix and human-derived thrombin, combining both mechanical and active mechanisms to achieve hemostasis. It was approved by the Food and Drug Administration in 1999. GTM has been used by several surgical specialties; however, it is a possibly an under-used tool in obstetrics and gynecology. A limited number of studies have been performed on its use during laparoscopic endometrioma excision and myomectomy. It may prove useful in endometrioma excision in reproductive aged women because it is likely to harm ovarian reserve less than electrocautery; however, this conclusion needs to be validated. The only study on GTM use in myomectomy included 50 women randomized into GTM and control groups, and showed decreased blood loss and shorter hospital stays in the GTM group. In gynecologic oncology, it was successfully used to reduce lymphocele cases in a cohort study. GTM has been used successfully in obstetrics in a handful of cases of uncontrolled bleeding from caesarean scar, placental site, ectopic pregnancy, rectovaginal hematoma, and venous plexus over the vaginal vault after emergency postpartum hysterectomy. Risk of viral transmission is a major concern about GTM, yet there are no reports on disease transmission with GTM use to date. Rare but serious adverse effects and complications have been reported such as fatal or near-fatal thromboembolism and small bowel obstruction. Although GTM is mostly a safe product, it is still not free of complications and risks. In conclusion, although routine use of GTM cannot be recommended due to concerns about its safety, cost, and availability, it may prove useful when conventional hemostatic methods such as suturing and electrocauterization fail or are not appropriate.

Securing Hemostasis in Pediatric Low-Grade Posterior Cerebral Fossa Tumors: The Value of Thrombin-Gelatin Hemostatic Matrix

PURPOSE

We report our preliminary experience concerning the use of thrombin-gelatin hemostatic matrix to strengthen the final hemostasis after posterior fossa low-grade tumor surgery in children. To our knowledge, this is the first report regarding the use of hemostatic matrix in pediatric neurosurgery.

MATERIALS AND METHODS

Between 2012 and 2016, twenty-three patients underwent posterior fossa surgery for low-grade gliomas in our department. The mean age was 6.35 years; 12 patients were female and 11 male. Histology revealed pilocytic astrocytoma in 15 cases, ependymoma in 7 cases, and gangliocytoma in 1 case. At the end of the surgery, effective hemostasis was achieved using standard methods and, in order to strengthen the final hemostasis, we used a thrombin-gelatin hemostatic matrix. In all of the cases a postoperative MRI was performed within 24 after the surgery; during hospitalization the patients underwent a clinical evaluation. Moreover, blood samples were taken to evaluate inflammatory parameters, hemoglobin, and sodium, and kidney and liver tests were performed according to the standard protocol.

RESULTS

The postoperative MRI did not show any complications imputable to the matrix. Dur ing radiological and clinical follow-up none of the patients showed any delayed complications related to the matrix.

CONCLUSIONS

In our practice we found thrombin-gelatin hemostatic matrix sealant to be a valid and safe tool for strengthening hemostasis in pediatric low-grade posterior fossa surgery.

A Cost-Effective Delivery System for FloSeal During Endoscopic and Microscopic Brain Surgery

OBJECTIVE

To share our experience with a new delivery system for the flowable hemostatic matrix, FloSeal, in endoscopic and microscopic skull base surgery.

METHODS

We prospectively analyzed the use of FloSeal with a hemostatic delivery system in transnasal endoscopic and microscopic skull base procedures performed at the authors' institution from January 1, 2015, to June 30, 2015. In all cases the number of aliquots was noted for the entire operation, and the total number of FloSeal ampules of 5 mL was also recorded.

RESULTS

Our device allowed controlled application of small amounts (0.5-1 mL) of FloSeal to the site of bleeding. This controlled application resulted not only in increased visibility during its application, but it also reduced the amount of FloSeal required during the procedure. We were able to use 5-10 applications per 5-mL ampule of FloSeal within an individual procedure. No procedure required more than one 5-mL ampule of FloSeal. Therefore, the use of our device results in a reduction of costs. Prior to the use of our device, we were often only able to use 1 vial of 5 ml of material for 1 or 2 applications, especially in transnasal endoscopic procedures when working along a deep corridor.

CONCLUSIONS

Our results indicate that our delivery device of FlowSeal can effectively control hemostasis by applying small amounts of FlowSeal to the site of bleeding. This results in increased visibility during hemostasis and a reduction of cost.

[Hemostatic absorbable gel matrix for severe post-traumatic epistaxis]

INTRODUCTION

The management of traumatic epistaxis is an important issue for maxillofacial trauma patients, because of their frequency and severity. We assessed a single use sterile hemostatic gel matrix (surgiflo© [SF], Floseal © [FS]) available for this indication.

MATERIALS AND METHODS

Ten patients were managed between 2008 and 2012 by the same surgeon. The following data was documented for each patient: gender, age, mechanism of trauma or type of surgery, characteristics of epistaxis, the various hemostatic techniques used before using SF, and its effectiveness. The primary endpoint was SF effectiveness compared with usual techniques. The secondary endpoint was the evaluation of patient comfort compared to other hemostatic methods, using a visual analogue scale (VAS).

RESULTS

In nine out of ten cases, epistaxis was controlled after endonasal instillation of SF after failure of wicking, or double balloon catheter in first line treatment, or use of SF directly as first line treatment. The mean post procedure VAS was: 7/10 for wicking (eight patients), 9.3/10 for the double balloon catheter (three patients), 3.2/10 for SF (ten patients).

DISCUSSION

Our study highlights the effectiveness of hemostatic gel matrix in the management of post-traumatic epistaxis compared to usual methods. It also pointed out better patient comfort. A prospective comparative study on a larger cohort of patient would support the legitimacy of SF as first-line treatment for severe posttraumatic epistaxis.