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Kim YS, Joo SP, Ahn KH, Kim TS. Spontaneous intracranial hypotension presenting with bilateral subdural hematoma: Decision-making and treatment strategies. J Clin Neurosci 2024; 121:77-82. [PMID: 38367404 DOI: 10.1016/j.jocn.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/30/2023] [Accepted: 02/08/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND The timing and decision to drain subdural hematoma (SDH) in spontaneous intracranial hypotension (SIH) remains a dilemma. We reviewed our experience of bilateral SDH secondary to SIH, focusing on decision making and treatment strategies. METHODS We retrospectively reviewed bilateral SDH secondary to SIH between March 2010 and September 2021. Baseline characteristics of patients, diagnosis, radiologic findings, treatments, and clinical outcome were investigated. RESULTS Fifteen patients (7 men, 8 women) with bilateral SDH secondary to SIH were included in this study. Initially, patients were treated conservatively (4 patients, 26.7 %), with an epidural blood patch (EBP, 3 patients, 20.0 %), and SDH drainage followed by the Trendelenburg position (8 patients, 53.3 %). All 3 patients that were initially treated with EBP required SDH drainage. Of the 8 patients initially treated with SDH drainage via burr hole followed by Trendelenburg position, 7 patients showed sustained improvements without EBP; however, 1 patient needed EBP. Deterioration to coma occurred in 6 out of 15 patients (40.0 %). All 6 deteriorated patients immediately recovered after SDH drainage with Trendelenburg position; 5 achieved sustained improvement without EBP and 1 required EBP. During the follow-up period, 14 out of 15 patients (93.3 %) showed good recovery. CONCLUSIONS Evacuation of SDH is not always necessary in SIH; however, we did not hesitate to perform hematoma drainage, in deteriorated patients or those with thick hematoma that is associated with significant sagging and cistern effacement. This can prevent irreversible neurologic complications. Moreover, the Trendelenburg position may help to achieve sustained improvement without additional treatment.
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Affiliation(s)
- You-Sub Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea.
| | - Kang-Hee Ahn
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
| | - Tae-Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, Gwangju, Republic of Korea
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Baram A, Zaed I, Safa A, Robertis MD, Lasio G, Maira G, Cannizzaro D. Intracranial Hypotension Syndrome after Lumbar Drainage in Skull Base Surgery: Diagnosis and Correct Management. J Neurol Surg A Cent Eur Neurosurg 2023; 84:578-583. [PMID: 37263292 DOI: 10.1055/s-0042-1759825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Lumbar drainage is commonly used in skull base surgery; however, very few cases of intracranial hypotension syndrome are reported to be caused by this procedure. We present a clinical case of lumbar drainage-assisted orbital and optic canal decompression surgery for a recurrent voluminous spheno-orbital meningioma, together with a literature review. A 49-year-old woman became confused and drowsy on postoperative day 3, after initially experiencing neurologic stability. Computed tomography (CT) scan of the head showed extradural frontotemporal fluid collection with moderate right to left midline shift. Magnetic resonance imaging (MRI) of the brain showed signs of intracranial hypotension, such as brain sagging and diffuse dural contrast enhancement. Conservative treatment with bed rest, aggressive hydration, steroids, and aminophylline led to progressive neurologic improvement. A systematic literature review was also performed, and previous reported cases were analyzed. Overall, neurosurgeons must be aware of the lumbar drainage-induced hypotension syndrome in skull base surgeries, because immediate diagnosis is essential for therapeutic decision-making. In this setting, conservative management is the first-line treatment as surgery may lead to severe complications.
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Affiliation(s)
- Ali Baram
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Ismail Zaed
- Division of Neurosurgery, ASST Ovest Milanese, Legnano Hospital, Milan, Italy
| | - Adrian Safa
- Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
| | | | - Giovanni Lasio
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Giulio Maira
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Delia Cannizzaro
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
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Kim DY, Cho YH, Kim S, Jeong JH, Choi JH, Kang M, Park HS. Feasibility of Prompt Lumbar Drainage in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 175:e1032-e1040. [PMID: 37087037 DOI: 10.1016/j.wneu.2023.04.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Numerous studies have shown that continuous lumbar drainage (LD) reduces spontaneous subarachnoid hemorrhage (SAH)-related complications, decreasing the incidence of cerebral vasospasm, delayed cerebral ischemia , and hydrocephalus in patients treated with coiling or clipping, but performing LD before securing the aneurysm is still controversial. Our hospital has been implementing prompt LD for several years, and we present the results in this paper. METHODS Between January 2014 and December 2020, a total of 438 patients with SAH were included in this retrospective study. The indication for prompt LD was aneurysmal SAH of modified Fisher grade III or higher without dense intraventricular hemorrhage with obstructive hydrocephalus requiring extraventricular drainage or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 patients with SAH, and the control group included 209 patients. We compared in-hospital mortality and vasospasm or hydrocephalus occurrence and procedure-related complications between the two groups. RESULTS The in-hospital mortality rate was 7.4% for patients with prompt LD and 14.4% for patients without LD, and the difference was significant (P = 0.019). Vasospasm occurred in 10% of patients with prompt LD and 16.7% of controls (P = 0.039). Hydrocephalus requiring extraventricular drainage occurred in 10.9% of the LD group and 28.7% of the control group (P < 0.001). Rebleeding occurrence was 3.1% in the prompt LD group and 5.7% in the non-LD group (P = 0.168). Cerebrospinal fluid infection occurred in 0.4% of the prompt LD group and 1.4% of controls(P = 0.272). CONCLUSIONS Prompt LD is a feasible option for treating patients with selective aneurysmal SAH.
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Affiliation(s)
- Dae Young Kim
- Department of Neurosurgery, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Yong-Hwan Cho
- Department of Neurosurgery, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Sanghyeon Kim
- Department of Radiology, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Jin-Heon Jeong
- Department of Critical Care Medicine, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Jae Hyung Choi
- Department of Neurosurgery, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Myongjin Kang
- Department of Radiology, Busan Regional Cerebrovascular Center, Dong-A University Hospital, Busan, Republic of Korea
| | - Hyun-Seok Park
- Department of Neurosurgery, Cerebrovascular Center, Ulsan Medical Center, Nam-gu, Ulsan, Republic of Korea.
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Liang S, Wang Z, Wu P, Chen Z, Yang X, Li Y, Ren X, Zhang D, Ge Z. Risk Factors and Outcomes of Central Nervous System Infection After Spinal Surgery: A Retrospective Cohort Study. World Neurosurg 2023; 170:e170-e179. [PMID: 36328166 DOI: 10.1016/j.wneu.2022.10.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate the risk factor associated with central nervous system infection, a rare and dire complication after spinal surgery. METHODS Univariate and multivariate logistic regression analyses were performed to screen for the independent risk factors. According to the different administration methods of antibiotics, patients were divided into intravenous and intrathecal groups. The differences in time needed for body temperature, white blood cells (WBC), and C-reactive protein (CRP) to return to normal and the time of antibiotic application were compared between the 2 groups. In addition, the differences in WBC, neutrophil ratio, CRP, procalcitonin in blood, and WBC in cerebrospinal fluid were compared before intrathecal injection, after the first one, and the last one. The incidence of complications in the 2 groups was observed. RESULTS Dural tears, laminectomy, and operation time >3 hours were identified as independent risk factors. The time needed for body temperature, WBC, and CRP to return to normal and the antibiotic application time were significantly different between the 2 groups (all P < 0.05). Before and after the first intrathecal injection and after the last intrathecal injection, the differences in WBCs, neutrophil ratios, CRP, procalcitonin in blood, and cerebrospinal fluid-WBC were statistically significant in overall and pairwise comparisons (P < 0.05). Complications occurred in 2 and 14 cases, respectively. CONCLUSIONS The independent risk factors for central nervous system infection after spinal surgery were a dural tear, laminectomy, and operation time > 3 hours. Combined intravenous and intrathecal injections of antibiotics led to a better effect than intravenous injection alone; however, this approach was associated with more complications.
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Affiliation(s)
- Simin Liang
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Zhiqiang Wang
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Peng Wu
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Zhen Chen
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Xiaoyan Yang
- Medical Laboratory Center, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Ying Li
- Medical Record Room, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Xiaolu Ren
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Danmei Zhang
- Department of Nosocomial Infection, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Zhaohui Ge
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China.
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Zhang Y, Wu Y, Wu Y, Zhu G, Xue Y, Qu Y, Zhao T. The effect of postoperative early lumbar drainage on delayed fever after cerebellopontine angle tumour surgery: study protocol for a randomized controlled trial. Trials 2022; 23:1008. [PMID: 36510288 PMCID: PMC9746070 DOI: 10.1186/s13063-022-06950-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Postoperative fever is one of the common complications in neurosurgery, and intracranial aseptic inflammation and infection are important risk factors. Continuous drainage of cerebrospinal fluid (CSF) via lumbar drainage (LD) is often used in the treatment of postoperative intracranial infection or aseptic inflammation. Compared with the previously reported placement of LD after the onset of meningitis symptoms, we designed this randomized controlled trial (RCT) to evaluate the effectiveness and safety of early drainage (1st day postoperation) of CSF using the preset lumbar cistern to prevent delayed fever (fever occurred after the third day postoperation) or reduce its treatment time after cerebellopontine angle (CPA) tumour surgery. METHODS Patients suffering from CPA tumours and who underwent resection of the tumour with an intraoperative dura opening time > 4 h are recruited for this study. The study is a 2-arm RCT to compare the early LD group and the no early LD group. Postoperative duration and rate of delayed fever and postoperative length of stay (LOS), as the main outcomes, will be compared in the two groups. DISCUSSION Here, we present the study design of a prospective RCT to evaluate the safety and efficacy of using preoperative preset LD to treat or reduce postoperative delayed fever. TRIAL REGISTRATION China Clinical Trial Registry ChiCTR2100049057. Registered on July 20, 2021.
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Affiliation(s)
- Yunze Zhang
- grid.233520.50000 0004 1761 4404Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, No. 569 Xinsi Road, Xi’an, Shaanxi Province 710038 People’s Republic of China
| | - Yingxi Wu
- grid.233520.50000 0004 1761 4404Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, No. 569 Xinsi Road, Xi’an, Shaanxi Province 710038 People’s Republic of China
| | - Yang Wu
- grid.233520.50000 0004 1761 4404Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, No. 569 Xinsi Road, Xi’an, Shaanxi Province 710038 People’s Republic of China
| | - Gang Zhu
- grid.233520.50000 0004 1761 4404Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, No. 569 Xinsi Road, Xi’an, Shaanxi Province 710038 People’s Republic of China
| | - Yafei Xue
- grid.233520.50000 0004 1761 4404Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, No. 569 Xinsi Road, Xi’an, Shaanxi Province 710038 People’s Republic of China
| | - Yan Qu
- grid.233520.50000 0004 1761 4404Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, No. 569 Xinsi Road, Xi’an, Shaanxi Province 710038 People’s Republic of China
| | - Tianzhi Zhao
- grid.233520.50000 0004 1761 4404Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, No. 569 Xinsi Road, Xi’an, Shaanxi Province 710038 People’s Republic of China
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Carr MT, Gilligan J, Hickman ZL, Jones SA. Brainstem Hemorrhage Following Lumbar Drain for Post-traumatic Hydrocephalus. Cureus 2022; 14:e26349. [PMID: 35903572 PMCID: PMC9323864 DOI: 10.7759/cureus.26349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2022] [Indexed: 11/24/2022] Open
Abstract
Post-traumatic hydrocephalus is common after traumatic brain injury (TBI), particularly following decompressive craniectomy. Cerebrospinal fluid (CSF) removal by lumbar drain (LD) aids in the workup of post-traumatic hydrocephalus and serves as a bridge to definitive CSF diversion. Hemorrhagic complications following LD are rare but can include intracranial hemorrhage. We present a case of fatal brainstem hemorrhage following LD in a patient three months after craniectomy. A 32-year-old male presented with severe TBI and an acute subdural hematoma. He underwent emergent decompressive craniectomy and hematoma evacuation. The next day, he required ventriculostomy for elevated intracranial pressure (ICP), which was able to be successfully removed. Three months after the injury, the patient’s neurological exam declined, and computed tomography (CT) findings were consistent with communicating hydrocephalus. An LD was placed with 15 mL of CSF and drained every two hours. Five days after LD placement, the CSF became blood-tinged, and a repeat head CT demonstrated an acute brainstem hemorrhage. The patient ultimately expired. Given the prevalence of post-traumatic hydrocephalus and the frequent use of CSF diversion in the management of this condition, it is important for neurosurgeons to remain cognizant of the potential risk for catastrophic brainstem hemorrhage following LD in decompressive craniectomy patients.
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Lee SH, Ha CM, Hong SD, Choi JW, Seol HJ, Nam DH, Lee JI, Kong DS. Clinical Impact of Hydroxyapatite on the Outcome of Skull Base Reconstruction for Intraoperative High-Flow CSF Leak: A Propensity Score Matching Analysis. Front Oncol 2022; 12:906162. [PMID: 35600408 PMCID: PMC9116718 DOI: 10.3389/fonc.2022.906162] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 04/14/2022] [Indexed: 11/24/2022] Open
Abstract
Background Despite recent advances in skull base reconstructive techniques, including the multilayer technique during the last decade, complete reconstruction of grade 3 intraoperative high-flow cerebrospinal fluid (CSF) leak remains challenging. This study was designed to investigate the role of injectable hydroxyapatite (HXA) used in the multilayer technique on the clinical outcome of skull base reconstruction for intraoperative high-flow CSF leak. Materials and Methods This study enrolled 187 patients who experienced intraoperative high-flow CSF leak after endoscopic endonasal surgery for anterior skull base or suprasellar pathologies between January 2014 and July 2021. All skull base defects were reconstructed using the conventional multilayer technique including a vascularized naso-septal flap (NSF, n = 141) and the combined use of HXA with the conventional multilayer technique (HXA group, n = 46). We retrospectively evaluated the efficacy of the HXA group by 1:2 propensity score matching analysis. Results Overall, 17 of 187 patients (9.1%) showed postoperative CSF leaks, resulting in second reconstruction surgery. There were no statistical differences in patient age, sex, body mass index, tumor location, tumor type, and degree of resection, except for the follow-up period between the two groups. The HXA group showed a significantly lower incidence of postoperative CSF leak than the control group (0% vs. 12.1%, p < 0.05). Postoperative lumbar drain (LD) was performed in 8.7% of the HXA group compared to 46.1% of the control group (p < 0.01). CSF leak-related infection rates showed a decreasing tendency in the HXA group compared to the control group (0 vs. 7.1%, p = 0.06). A total of 46 patients in the HXA group were well matched with the control group (92 patients) at a 1:2 ratio. In the propensity score-matched control group, there were higher rates of postoperative CSF leaks than in the HXA group. Conclusion The use of HXA combined with the conventional multilayer technique completely reduced postoperative CSF leaks in this study. This technique resulted in reduced CSF leakage, even without postoperative LD, and decreased infection rates. Further randomized comparative studies are required to confirm our findings.
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Affiliation(s)
- Shin Heon Lee
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, South Korea
| | - Chang-Min Ha
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Wu Y, Zhao Y, Yu S, Li F, Cai S, Peng C, Wang Z, Yang Y, Wang B, Yang X. Reconstruction clipping of ruptured anterior circulation aneurysms via supraorbital lateral keyhole approach. Chin Neurosurg J 2022; 8:3. [PMID: 35164868 PMCID: PMC8842857 DOI: 10.1186/s41016-022-00272-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/29/2022] [Indexed: 11/17/2022] Open
Abstract
Background Intracranial aneurysm (IA) is a serious disease. Analyze and review the cases of anterior circulation ruptured IA by supraorbital lateral keyhole approach, and summarize the experiences of this approach. Methods Retrospective analysis of 16 cases of ruptured anterior circulation IA in our department from January 2019 to June 2020, CT angiography (CTA) was performed before operation. Analyzing the IA’s parameters by 3D-CT reconstruction. The IA was clipped by supraorbital lateral keyhole approach combined with the 3D-skull reconstruction. Extraventricular drainage was performed before craniotomy. Intraoperative neurophysiological monitoring was performed during the operation. After operation, fluorescein angiography and vascular ultrasound were performed to check the clipping effect. Intracranial pressure monitor was performed postoperatively. CTA was reexamined one week after operation. The modified Rankin Scale (MRS) was performed 6 months after operation. Results There were 7 males (43.8%) and 9 females (56.2%), and the average age is 52.31 ± 11.12 years old. Among them, 11 patients (68.8%) were anterior communicating artery aneurysms and 5 (31.2%) were middle cerebral artery aneurysms. All patients were out of hospital within 10 days without any death, without cerebral infarction, cerebrospinal fluid leakage and neurological impairments. About mRS score, after 6 months follow-up, 8 cases (50%) had 0 point, 4 cases (25%) had 1 point, and 4 cases (25%) had 2 points. Conclusions For ruptured anterior circulation IA, the supraorbital lateral keyhole approach combined with ventricular drainage, intraoperative electrophysiological monitoring, and intraoperative vascular ultrasound is a safe and minimally invasive treatment. The application of reconstruction clipping can reconstruct the diameter of parent vessel and reduce the recurrence rate of IA.
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Zhang A, Song J, Czerwein JK. Brain Herniation Secondary to Cerebrospinal Fluid Leak Following Elective Lumbar Spine Surgery. Cureus 2021; 13:e20266. [PMID: 35004068 PMCID: PMC8735843 DOI: 10.7759/cureus.20266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 12/03/2022] Open
Abstract
Lumbar spine surgery can be complicated by perioperative cerebrospinal fluid (CSF) leak. However, development of brain herniation secondary to CSF leak following lumbar spine surgery has not been previously reported in the current literature. This case report describes a 48-year-old woman who, after a revision lumbar decompression and fusion, experienced CSF leak followed by development of brain herniation, which resulted in patient demise. The postoperative period was complicated by patient nonadherence to conservative management of CSF leak.
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Ozeki T, Kubota A, Murai Y, Morita A. A case of suspected low-pressure hydrocephalus caused by spinal drainage following subarachnoid hemorrhage. J NIPPON MED SCH 2021; 89:238-243. [PMID: 34526456 DOI: 10.1272/jnms.jnms.2022_89-209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Hydrocephalus induced by low cerebrospinal fluid (CSF) pressure is extremely rare and sporadically reported. Subarachnoid hemorrhage, head trauma, and spinal drainage were reported to be the causative factors for surgical treatments. CASE DESCRIPTION A 33-year-old male with subarachnoid hemorrhage caused by right vertebral artery aneurysm rupture developed a headache. A trapping surgery was performed, and a spinal drain was inserted from the lumbar L4/5 for subarachnoid hemorrhage washout. On postoperative day 3, increase in subdural fluid accumulation at the posterior fossa craniotomy site and narrowing of the cerebellar sulci appeared in addition to mild enlargement of the ventricles. The patient complained of a headache during head elevation. Low-pressure hydrocephalus (LPH) was suspected. The spinal drain was removed, the headache was relieved, and cerebral ventriculomegaly disappeared. The subsequent clinical course was good. The patient was discharged 3 weeks after the surgery. DISCUSSION LPH is a rare disease caused by various factors and is treated by correcting liquorrhea or overdrainage, if any. Otherwise, drainage at a negative CSF pressure is necessary. Its symptoms and image findings are similar to those of intracranial hypertension and normal-pressure hydrocephalus. This paper reports a suspected LPH case caused by spinal drainage following subarachnoid hemorrhage with literature review.
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Affiliation(s)
- Tomohiro Ozeki
- Nippon Medical School, Department of Neurological Surgery
| | - Asami Kubota
- Nippon Medical School, Department of Neurological Surgery
| | - Yasuo Murai
- Nippon Medical School, Department of Neurological Surgery
| | - Akio Morita
- Nippon Medical School, Department of Neurological Surgery
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11
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Zhou J, Guo P, Guo Z, Sun X, Chen Y, Feng H. Fluid metabolic pathways after subarachnoid hemorrhage. J Neurochem 2021; 160:13-33. [PMID: 34160835 DOI: 10.1111/jnc.15458] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/12/2021] [Accepted: 06/20/2021] [Indexed: 01/05/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating cerebrovascular disease with high mortality and morbidity. In recent years, a large number of studies have focused on the mechanism of early brain injury (EBI) and delayed cerebral ischemia (DCI), including vasospasm, neurotoxicity of hematoma and neuroinflammatory storm, after aSAH. Despite considerable efforts, no novel drugs have significantly improved the prognosis of patients in phase III clinical trials, indicating the need to further re-examine the multifactorial pathophysiological process that occurs after aSAH. The complex pathogenesis is reflected by the destruction of the dynamic balance of the energy metabolism in the nervous system after aSAH, which prevents the maintenance of normal neural function. This review focuses on the fluid metabolic pathways of the central nervous system (CNS), starting with ruptured aneurysms, and discusses the dysfunction of blood circulation, cerebrospinal fluid (CSF) circulation and the glymphatic system during disease progression. It also proposes a hypothesis on the metabolic disorder mechanism and potential therapeutic targets for aSAH patients.
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Affiliation(s)
- Jiru Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Neurosurgery and State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Peiwen Guo
- Department of Neurosurgery and State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Zongduo Guo
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaochuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yujie Chen
- Department of Neurosurgery and State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Hua Feng
- Department of Neurosurgery and State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China.,Chongqing Key Laboratory of Precision Neuromedicine and Neuroregeneration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
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12
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Abdelbaky M, Papanikolaou D, Zafar MA, Ellauzi H, Shaikh M, Ziganshin BA, Elefteriades JA. Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repair. JTCVS Tech 2021; 6:1-8. [PMID: 34318127 PMCID: PMC8300913 DOI: 10.1016/j.xjtc.2020.12.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 12/02/2020] [Indexed: 11/17/2022] Open
Abstract
Objective We present our experience with routine application of the cerebrospinal fluid (CSF) drain (CSFD) during open aortic repair. Methods We retrospectively reviewed 100 patients with descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) or who underwent CSFD insertion before open repair between 2006 and 2017. All CSFDs were inserted by the cardiovascular anesthesia team. The goal was to keep intracranial pressure <10 mm Hg during the surgical procedure by draining CSF at a rate of 20 to 30 mL/h. Postoperatively, CSFD was set to maintain the lumbar pressure <10 mm Hg to reduce the risk of postoperative paraplegia. CSFD was part of our standard cord protection regimen. Results The mean patient age was 65.4 ± 11.7 years, and 60 (60%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay was 11.9 ± 11.8 days, and hospital mortality was 6%. Postoperative transient paresis was observed in 4 patients (4%), and permanent paraplegia was seen in 2 (2%). CSFD-related complications were reported in 14 patients (14%). Complications included persistent CSF leakage and blood-tinged CSF with and without intracranial hemorrhage and spinal cutaneous fistula in 7 (7%), 9 (9%), and 1 (1%), respectively. Long-term survival was excellent (68.4% at 10 years). Conclusions CSFD is a safe practice when applied routinely as an adjunct strategy to prevent paraplegia in surgical management of DTAA and TAAA. We feel that this contributed to good early and late clinical results.
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Affiliation(s)
- Mohamed Abdelbaky
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Dimitra Papanikolaou
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Mohammad A. Zafar
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Hesham Ellauzi
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Maryam Shaikh
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
| | - Bulat A. Ziganshin
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
- Department of Cardiovascular and Endovascular Surgery, Kazan State Medical University, Kazan, Russia
| | - John A. Elefteriades
- Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn
- Address for reprints: John A. Elefteriades, MD, PhD (hon), Aortic Institute at Yale-New Haven, Yale University School of Medicine, 789 Howard Ave, Clinic Building CB 317, New Haven, CT 06519.
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Tan J, Song R, Huan R, Huang N, Chen J. Intraoperative lumbar drainage can prevent cerebrospinal fluid leakage during transsphenoidal surgery for pituitary adenomas: a systematic review and meta-analysis. BMC Neurol 2020; 20:303. [PMID: 32799821 PMCID: PMC7429471 DOI: 10.1186/s12883-020-01877-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/04/2020] [Indexed: 12/11/2022] Open
Abstract
Background Perioperative cerebrospinal fluid (CSF) leakage is a major complication of pituitary adenomas transsphenoidal surgery. Lumbar drainage (LD) is a common method of treating CSF leakage. But whether intraoperative LD can prevent CSF leakage during the perioperative period of pituitary adenomas transsphenoidal surgery remains controversial. Clarity on the appropriate use of LD is needed. Methods A systematic literature review was conducted in the PubMed, EMBASE, and Web of science databases. Articles were included when they compared intraoperative LD with intraoperative no-LD CSF leakage rates during pituitary adenomas transsphenoidal surgery. Results Overall, 5 studies containing 678 cases met the inclusion criteria. When data were provided on intraoperative CSF leakage rates, the meta-analysis showed a significant difference in favor of intraoperative LD. When data were provided on postoperative CSF leakage rates, the meta-analysis also demonstrated a significant difference in favor of intraoperative LD. Conclusions Although the results of this meta-analysis suggest intraoperative LD can reduce the risk of CSF leakage during the perioperative period of pituitary adenomas transsphenoidal surgery, the available evidence is indefinite. To some extent the results suggest intraoperative LD’s potential positive role. Further studies that include well-designed prospective, randomized controlled clinical trials are necessary for further verification.
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Affiliation(s)
- Jiahe Tan
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Rui Song
- Department of Gastroenterology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Renzheng Huan
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Ning Huang
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Jin Chen
- Department of Neurosurgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
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14
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Zwagerman NT, Wang EW, Shin SS, Chang YF, Fernandez-Miranda JC, Snyderman CH, Gardner PA. Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg 2019; 131:1172-1178. [PMID: 30485224 DOI: 10.3171/2018.4.jns172447] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/17/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Based on a null hypothesis that the use of short-term lumbar drainage (LD) after endoscopic endonasal surgery (EES) for intradural pathology does not prevent postoperative CSF leaks, a trial was conducted to assess the effect of postoperative LD on postoperative CSF leak following standard reconstruction. METHODS A prospective, randomized controlled trial of lumbar drain placement after endoscopic endonasal skull base surgery was performed from February 2011 to March 2015. All patients had 3-month follow-up data. Surgeons were blinded to which patients would or would not receive the drain until after closure was completed. An a priori power analysis calculation assuming 80% of power, 5% postoperative CSF leak rate in the no-LD group, and 16% in the LD group determined a planned sample size of 186 patients. A routine data and safety check was performed with every 50 patients being recruited to ensure the efficacy of randomization and safety. These interim tests were run by a statistician who was not blinded to the arms they were evaluating. This study accrued 230 consecutive adult patients with skull base pathology who were eligible for endoscopic endonasal resection. Inclusion criteria (high-flow leak) were dural defect greater than 1 cm2 (mandatory), extensive arachnoid dissection, and/or dissection into a ventricle or cistern. Sixty patients were excluded because they did not meet the inclusion criteria. One hundred seventy patients were randomized to either receive or not receive a lumbar drain. RESULTS One hundred seventy patients were randomized, with a mean age of 51.6 years (range 19-86 years) and 38% were male. The mean BMI for the entire cohort was 28.1 kg/m2. The experimental cohort with postoperative LD had an 8.2% rate of CSF leak compared to a 21.2% rate in the control group (odds ratio 3.0, 95% confidence interval 1.2-7.6, p = 0.017). In 106 patients in whom defect size was measured intraoperatively, a larger defect was associated with postoperative CSF leak (6.2 vs 2.9 cm2, p = 0.03). No significant difference was identified in BMI between those with (mean 28.4 ± 4.3 kg/m2) and without (mean 28.1 ± 5.6 kg/m2) postoperative CSF leak (p = 0.79). Furthermore, when patients were grouped based on BMI < 25, 25-29.9, and > 30 kg/m2, no difference was noted in the rates of CSF fistula (p = 0.97). CONCLUSIONS Among patients undergoing intradural EES judged to be at high risk for CSF leak as defined by the study's inclusion criteria, perioperative LD used in the context of vascularized nasoseptal flap closure significantly reduced the rate of postoperative CSF leaks.Clinical trial registration no.: NCT03163134 (clinicaltrials.gov).
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Affiliation(s)
| | - Eric W Wang
- 2Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | - Carl H Snyderman
- 2Otolaryngology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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15
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Electroencephalogram Abnormalities During Positional Changes in Brain Sagging Syndrome. J Clin Neurophysiol 2018; 35:351-354. [DOI: 10.1097/wnp.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Liu JKC. Neurologic Deterioration Due to Brain Sag After Bilateral Craniotomy for Subdural Hematoma Evacuation. World Neurosurg 2018. [PMID: 29524703 DOI: 10.1016/j.wneu.2018.02.153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Intracranial hypotension from cerebrospinal fluid (CSF) hypovolemia resulting in cerebral herniation is a rare but known complication that can occur after neurosurgical procedures, usually encountered in correlation with perioperative placement of a lumbar subarachnoid drain. Decrease in CSF volume resulting in loss of buoyancy results in downward herniation of the brain without contributing mass effect, causing a phenomenon known as brain sag. Unreported previously is brain sag occurring without concomitant occult CSF leak or lumbar drainage. CASE DESCRIPTION This case report describes a patient who underwent bilateral craniotomies for subacute on chronic subdural hematoma with successful decompression but experienced acute neurologic deterioration secondary to brain sag. Despite an initial improvement in neurologic function, he subsequently experienced progressive neurologic deterioration with evidence of cerebral herniation on neuroimaging, without evidence of continued mass effect on the brain parenchyma. After a diagnosis of brain sag was determined based on imaging criteria, the patient was placed in a flat position, which resulted in rapid improvement in his neurologic function without any further intervention. CONCLUSIONS This case is unique in comparison with previous reports of intracranial hypotension after craniotomy in that the symptoms were completely reversed with positioning alone, without any evidence of active or occult CSF drainage. This report emphasizes that the diagnosis of brain sag should be taken into consideration when there is an unknown reason for neurologic decline after craniotomy, particularly bilateral craniotomies, if the imaging indicates herniation with imaging findings consistent with intracranial hypotension, without evidence of overlying mass effect.
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Affiliation(s)
- James K C Liu
- Department of Neuro-Oncology, Moffitt Cancer Center, Tampa, Florida, USA.
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Ling L, Guo L, Wang J, Zhang L, Zhu J, Huang Z. Nursing Management of Lumbar Drainage in Cryptococcal Meningitis: A Case Report. J Neurosci Nurs 2017; 49:198-202. [PMID: 28661942 DOI: 10.1097/jnn.0000000000000293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Raised intracranial pressure is a hallmark of cryptococcal meningitis and is associated with increased mortality. Continuous drainage of lumbar cerebrospinal fluid is suggested to control intracranial pressure. The complications induced by this treatment have been described. However, nursing care associated with identification and management of complications is less well known. We encountered a patient with human immunodeficiency virus-negative cryptococcal meningitis who developed increasing cerebrospinal fluid pressure, hearing impairment, and limb weakness. The patient's symptoms improved significantly by antifungal therapy and continuous lumbar drainage. Nurses play a vital role in monitoring patients with lumbar drainage for complications and to maintain integrity of the system. The nursing role in this approach is discussed with particular emphasis on recognition of complications and responses toward immediate emergent intervention.
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Affiliation(s)
- Ling Ling
- Ling Ling, RN BSN, is Nurse Practitioner, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China. Lu Guo, MD, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China. Jingjuan Wang, RN BSN, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China. Lili Zhang, PhD, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China. Jie Zhu, PhD, Institute of Surgery Research, Daping Hospital, Third Military Medical University, Chongqing, China
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