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Lee KS, Chari A, Motiwala M, Khan NR, Arthur AS, Lawton MT. Effectiveness of Cerebrospinal Fluid Lumbar Drainage Among Patients with Aneurysmal Subarachnoid Hemorrhage: An Updated Systematic Review and Meta-Analysis. World Neurosurg 2024; 183:246-253.e12. [PMID: 38246528 DOI: 10.1016/j.wneu.2024.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/11/2024] [Indexed: 01/23/2024]
Abstract
INTRODUCTION Cerebral vasospasm in patients after aneurysmal subarachnoid hemorrhage (aSAH) continues to be a major source of morbidity despite significant clinical and basic science research. The removal of blood and its degradation products from the subarachnoid space through prophylactic lumbar drainage (LD) is a favorable option. However, several studies have delivered conflicting conclusions on its efficacy after aSAH. METHODS Systematic searches of Medline, Embase, and Cochrane Central Register of Controlled Trials were performed. The primary outcome was a good functional outcome (modified Rankin scale score, 0-2). Secondary outcomes included symptomatic vasospasm, secondary cerebral infarction, and mortality. RESULTS A total of 14 studies reporting on 2473 patients with aSAH were included in the meta-analysis. Compared with the non-LD group, no significant differences were found in the rates of good functional outcomes in the LD group at discharge to 1 month (risk ratio [RR], 1.28; 95% confidence interval [CI], 0.64-2.58) or at 6 months (RR, 1.12; 95% CI, 0.97-1.41). These findings were consistent in the subgroup analyses of only randomized controlled trials or observational studies. LD was associated with lower rates of symptomatic vasospasm (RR, 0.61; 95% CI, 0.48-0.77), secondary cerebral infarction (RR, 0.59; 95% CI, 0.45-0.79), and mortality at discharge to 1 month (RR, 0.58; 95% CI, 0.41-0.82). The effect on mortality diminished at 6 months (RR, 0.70; 95% CI, 0.34-1.45). However, when analyzing only randomized controlled trials, the benefit of LD on lower rates of mortality continued even at 6 months (RR, 0.75; 95% CI, 0.58-0.99). CONCLUSIONS For aSAH patients, the use of LD is associated with benefits in the rates of vasospasm, secondary cerebral infarctions, and mortality, without an increased risk of adverse events.
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Affiliation(s)
- Keng Siang Lee
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA; Department of Neurosurgery, King's College Hospital, London, United Kingdom; Department of Basic and Clinical Neurosciences, Maurice Wohl Clinical Neuroscience Institute, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom.
| | - Aswin Chari
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom; Department of Neurosurgery, Great Ormond Street Hospital for Children, London, United Kingdom; Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Mustafa Motiwala
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nickalus R Khan
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Bandyopadhyay S, Schwendinger N, Jahromi BR, Lad SP, Blackburn S, Wolf S, Bulters D, Galea I, Hugelshofer M. Red Blood Cells in the Cerebrospinal Fluid Compartment After Subarachnoid Haemorrhage: Significance and Emerging Therapeutic Strategies. Transl Stroke Res 2024:10.1007/s12975-024-01238-9. [PMID: 38418755 DOI: 10.1007/s12975-024-01238-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
Subarachnoid haemorrhage (SAH) is a subtype of stroke that predominantly impacts younger individuals. It is associated with high mortality rates and can cause long-term disabilities. This review examines the contribution of the initial blood load and the dynamics of clot clearance to the pathophysiology of SAH and the risk of adverse outcomes. These outcomes include hydrocephalus and delayed cerebral ischaemia (DCI), with a particular focus on the impact of blood located in the cisternal spaces, as opposed to ventricular blood, in the development of DCI. The literature described underscores the prognostic value of haematoma characteristics, such as volume, density, and anatomical location. The limitations of traditional radiographic grading systems are discussed, compared with the more accurate volumetric quantification techniques for predicting patient prognosis. Further, the significance of red blood cells (RBCs) and their breakdown products in secondary brain injury after SAH is explored. The review presents novel interventions designed to accelerate clot clearance or mitigate the effects of toxic byproducts released from erythrolysis in the cerebrospinal fluid following SAH. In conclusion, this review offers deeper insights into the complex dynamics of SAH and discusses the potential pathways available for advancing its management.
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Affiliation(s)
- Soham Bandyopadhyay
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire, UK
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nina Schwendinger
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Spiros Blackburn
- Department of Neurosurgery, University of Texas Houston Health Science Center, Houston, TX, USA
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Diederik Bulters
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire, UK
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ian Galea
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire, UK
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Hugelshofer
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
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Goyal-Honavar A, Joseph J, Jonathan GE, Prabhu K. Recurrent post-operative extradural and subdural collections due to intracranial hypotension following a lumbar subarachnoid drain. J Neurosci Rural Pract 2024; 15:134-136. [PMID: 38476419 PMCID: PMC10927047 DOI: 10.25259/jnrp_320_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 07/30/2023] [Indexed: 03/14/2024] Open
Abstract
Intracranial hypotension (IH) represents a syndrome secondary to low cerebrospinal fluid pressure. This case of IH following a lumbar drain inserted before the excision of a left intraconal lesion, leading to recurrent post-operative unilateral subdural and extradural collections, was treated successfully with the evacuation of the collection and simultaneous epidural blood patch (EBP) injection. Our report provides an important perspective on the management of IH with recurrent intracranial collections and reiterates that IH should be considered when dealing with recurrent unilateral intracranial collections in the post-operative period. Evacuation with a simultaneous EBP is an effective strategy for managing IH.
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Affiliation(s)
| | - Jeena Joseph
- Department of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Krishna Prabhu
- Department of Neurosurgery, Christian Medical College, Vellore, Tamil Nadu, India
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Holladay JD, McKee C, Nafiu OO, Tobias JD, Beltran RJ. Continuous Erector Spinae Plane Block for Pain Management Following Thoracotomy for Aortic Coarctectomy. J Med Cases 2024; 15:26-30. [PMID: 38328811 PMCID: PMC10846499 DOI: 10.14740/jmc4177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/17/2024] [Indexed: 02/09/2024] Open
Abstract
Pain following thoracotomy is one of the most severe forms of postoperative pain. Post-thoracotomy pain may increase the risk of post-surgical pulmonary complications, postoperative mortality, prolong hospitalization, and increase utilization of healthcare resources. To mitigate these effects, anesthesia providers commonly employ continuous epidural infusions, paravertebral blocks, and systemic opioids for pain management and improvement of pulmonary mechanics. We report the use of a continuous erector spinae plane block (ESPB) via a peripheral nerve catheter for postoperative pain management of an 18-year-old patient who underwent complex aortic coarctation repair via lateral thoracotomy, aided by cardiopulmonary bypass. Continuous ESPB proved to be an acceptable alternative for postoperative pain control, producing a substantial multi-dermatomal sensory block, resulting in adequate pain control, reduced opioid consumption, and a potentially shorter hospital stay.
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Affiliation(s)
- Jay D. Holladay
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Christopher McKee
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Olubukola O. Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Joseph D. Tobias
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Ralph J. Beltran
- Department of Anesthesiology and Pain Medicine, Nationwide Children’s Hospital, Columbus, OH 43205, USA
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
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Chen YH, Chou SC, Tang SC, Lee JE, Tsai JC, Lai DM, Tu YK, Hsieh ST, Wang KC. Continuous lumbar drainage after aneurysmal subarachnoid hemorrhage decreased malondialdehyde in cerebrospinal fluid and improved outcome. J Formos Med Assoc 2023; 122:164-71. [PMID: 36117035 DOI: 10.1016/j.jfma.2022.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/31/2022] [Accepted: 09/01/2022] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The use of a continuous lumbar drain (LD) for the treatment of aneurysmal subarachnoid hemorrhage (aSAH), and malondialdehyde (MDA), a marker of oxidative stress, is correlated with clinical outcome. This study aimed to investigate the relationship between LD placement and MDA level after aSAH. METHODS Patients with modified Fisher's grade III and IV aSAH who underwent early aneurysm obliteration were enrolled. Cerebrospinal fluid (CSF) was obtained on day 7 after aSAH in non-LD group. In LD group, the LD was inserted on day 3 after aSAH for continuous CSF drainage. The levels of intrathecal hemoglobin, total bilirubin, ferritin, and MDA were measured. RESULTS There were 41 patients in non-LD group (age: 58.7 ± 13.7 years; female: 61.0%) and 48 patients in LD group (age: 58.3 ± 10.4 years; female: 79.2%). There were more favorable outcomes (Glasgow Outcome Scale ≥4) at 3 months after aSAH in LD group (p = 0.0042). The intrathecal hemoglobin, total bilirubin, ferritin, and MDA levels at day 7 after aSAH were all significantly lower in LD group. An older age (>60 years) (p = 0.0293), higher MDA level in the CSF (p = 0.0208), and delayed ischemic neurological deficit (p = 0.0451) were independent factors associated with unfavorable outcomes. LD placement was associated with a decreased intrathecal MDA level on day 7 after aSAH (p < 0.001). CONCLUSION The intrathecal MDA level at day 7 after aSAH can be an effective outcome indicator in modified Fisher's grade III/IV aSAH. Continuous CSF drainage via a LD can decrease the intrathecal MDA level and improve the functional outcome.
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Hulou MM, Essibayi MA, Benet A, Lawton MT. Lumbar Drainage After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 166:261-267.e9. [PMID: 35868504 DOI: 10.1016/j.wneu.2022.07.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study reviews the use of lumbar drains (LDs) after aneurysmal subarachnoid hemorrhage (aSAH) and compares the outcomes to those associated with external ventricular drains (EVDs) and controls. METHODS A comprehensive search of the literature was performed. English language studies with a sample size of more than 10 patients were included. One-arm and 2-arm meta-analyses were designed to compare external drainage groups. Random-effects models, heterogeneity measures, and risk of bias were calculated. RESULTS Seventeen studies were included in the meta-analysis. The 2-arm meta-analysis comparing the LD to no drainage after aSAH found a significant improvement in the postoperative modified Rankin Scale (mRS) score (0-2) within 1 month of hospital discharge in the LD group (P = 0.003), a lower mortality rate (P = 0.03), fewer cases of clinical vasospasm (P = 0.007), and a lower incidence of ischemic stroke or delayed ischemic neurological deficits (P = 0.003). When the LD was compared to EVDs, a significant improvement in the postoperative mRS score (0-2) within 1 month of discharge was found in the LD group (P < 0.001). In the LD group, rebleeding occurred in 15 (3.4%) cases and meningitis occurred in 50 (4.7%) cases. CONCLUSIONS Compared with patients without cerebrospinal fluid drainage, patients with the LD after aSAH had lower mortality rates, lower risk of clinical vasospasm, and lower risk of ischemic stroke, and they were more likely to have an mRS score of 0-2 within 1 month of discharge. Compared with patients with EVDs, patients with the LD were more likely to have an mRS score of 0-2 within 1 month of discharge.
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Pandit AS, Palasz J, Nachev P, Toma AK. Mechanical Complications of External Ventricular and Lumbar Drains. World Neurosurg 2022; 166:e140-e154. [PMID: 35787961 DOI: 10.1016/j.wneu.2022.06.127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND External ventricular drain (EVD) and lumbar drain insertion are 2 of the most commonly performed neurosurgical procedures worldwide for acute hydrocephalus. Mechanical complications, such as obstruction or cerebrospinal fluid (CSF) leakage, are often seen and may contribute toward significant patient morbidity. Different CSF drainage methods are advocated to reduce the incidence of complications, but evidence regarding comparative effectiveness is limited. METHODS In this single-center prospective cohort study, the incidence of mechanical complications and associated interventional factors, including choice of drain, collecting system, and location, were studied in patients requiring CSF diversion for acute hydrocephalus. Univariate analyses were performed to explore trends within the data, followed by a repeated-measures mixed-effects regression to determine the independent influence of drain device on mechanical failure. RESULTS Sixty-one patients required CSF diversion between January 2020 and March 2021, via 3 different drain types (lumbar drain, tunneled, and bolted EVD) and 2 collection systems (LiquoGuard 7 and AccuDrain), performed in either theater or intensive care. Twenty-one patients (39%) experienced a mechanical complication, with blockage being the most common. Multivariate analyses showed that bolted EVDs (odds ratio, 0.08; confidence interval, 0.01-0.58) and LiquoGuards (OR, 0.23; CI, 0.08-0.69) were significantly associated with fewer mechanical complications compared with tunneled EVDs and gravity-based collection systems, respectively (P ≤ 0.01). DISCUSSION Drain device has an influence on the occurrence of EVD-related complications. These preliminary findings suggest that choosing bolted EVDs and motor-assisted drainage can reduce drain-associated mechanical failure. A randomized controlled trial comparing drain devices is required to confirm these findings.
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Affiliation(s)
- Anand S Pandit
- High-Dimensional Neurology Group, UCL, London, United Kingdom; Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Joanna Palasz
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | | | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom.
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Fu W, Church J, Garton H, Geiger J, Newman E. Pre-operative lumbar drain placement: A technique for minimizing ischemic spinal cord injury during neuroblastoma resection. J Pediatr Surg 2022; 57:1443-1445. [PMID: 34903356 DOI: 10.1016/j.jpedsurg.2021.11.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Whitney Fu
- Department of Surgery, Michigan Medicine, 1500 East Medicine Center Drive, 2920 Taubman Center, SPC 5331, Ann Arbor, MI 48109, United States.
| | - Joseph Church
- Department of Surgery, Division of Pediatric Surgery, Michigan Medicine, Ann Arbor, MI, United States; Division of Pediatric General and Thoracic Surgery, University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Hugh Garton
- Department of Neurosurgery, Michigan Medicine, Ann Arbor, MI, United States
| | - James Geiger
- Department of Surgery, Division of Pediatric Surgery, Michigan Medicine, Ann Arbor, MI, United States
| | - Erika Newman
- Department of Surgery, Division of Pediatric Surgery, Michigan Medicine, Ann Arbor, MI, United States
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Huo CW, King J, Goldschlager T, Dixon B, Chen Zhao Y, Uren B, Wang YY. The effects of cerebrospinal fluid (CSF) diversion on post-operative CSF leak following extended endoscopic anterior skull base surgery. J Clin Neurosci 2022; 98:194-202. [PMID: 35189544 DOI: 10.1016/j.jocn.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/18/2022] [Accepted: 02/04/2022] [Indexed: 11/24/2022]
Abstract
There is a paucity of high quality evidence regarding the routine placement of lumbar drain (LD) in reducing post-operative (op) cerebrospinal fluid (CSF) leak after extended endoscopic trans-sphenoidal resection of anterior skull base lesions. In this study, we sought to compare the incidence of post-op CSF leak between patients with upfront LD insertion and those without it. This was a prospective randomized controlled trial conducted over a period of 5 years with patients undergoing extended endoscopic trans-sphenoidal surgery randomly assigned to either LD insertion at the time of surgery, or no LD placement. Thirty-eight patients with anterior skull base tumors were accrued from three tertiary hospitals of Melbourne. Post-op leak was confirmed by β2-transferrin-positive rhinorrhea, and/or worsening pneumocephalus on brain imaging. Skull base defect size and pedicled nasoseptal flap viability were assessed on post-op CT and MRI, respectively. There was no significant difference in post-op CSF leak incidence between the two subgroups (12.50% in LD arm vs. 9.10% in no LD arm). Patients with LD insertion however, demonstrated substantially raised complication rates, longer hospital lengths of stay and lower subjective quality of life measures at 12 months compared with those without LD. In conclusion, routine placement of LD at the time of surgery for extended anterior skull base trans-nasal approach did not reduce the risk of post-op CSF leak. Discretion is warranted when using LD as an adjunct due to its associated morbidities, prolonged hospital stay and adverse effect on patients' subjective outcome measures.
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Affiliation(s)
- Cecilia W Huo
- Department of Neurosurgery, St Vincent's Hospital Melbourne, VIC 3065, Australia.
| | - James King
- Department of Neurosurgery, The Royal Melbourne Hospital, VIC 3050, Australia
| | - Tony Goldschlager
- Department of Neurosurgery, Monash Medical Centre, VIC 3168, Australia
| | - Benjamin Dixon
- The Head and Neck/ENT Unit, St Vincent's Hospital Melbourne, VIC 3065, Australia
| | - Yi Chen Zhao
- The Head and Neck/ENT Unit, The Royal Melbourne Hospital, VIC 3050, Australia
| | - Brent Uren
- The Head and Neck/ENT Unit, Monash Medical Centre, VIC 3168, Australia
| | - Yi Yuen Wang
- Department of Neurosurgery, St Vincent's Hospital Melbourne, VIC 3065, Australia; Department of Surgery, The University of Melbourne, VIC Australia
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Lane BC, Scranton R, Cohen-Gadol AA. Risk of Brain Herniation After Craniotomy With Preoperative Lumbar Spinal Drainage: A Single-Surgeon Experience of 365 Patients Among 3000 Major Cranial Cases. Oper Neurosurg (Hagerstown) 2021; 20:E77-E82. [PMID: 32823289 DOI: 10.1093/ons/opaa262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/23/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Lumbar spinal drainage (LSD) can significantly facilitate brain relaxation and improve ease of surgical goals for a variety of neurosurgical indications. Although rapid drainage of large volumes of spinal fluid can theoretically produce shifts in brain compartments and herniation syndromes, the clinical significance of this phenomenon when LSD is used immediately before craniotomy is unclear. OBJECTIVE To report a large single-surgeon consecutive experience with symptomatic brain herniation after lumbar drainage before craniotomy. METHODS Included were 365 patients who underwent LSD with either lumbar drain or lumbar puncture for a variety of different neurosurgical pathologies between 2008 and 2018 immediately before craniotomy. We reviewed the surgical indications, craniotomy location, approach, type of LSD, presence of postoperative brain herniation on imaging, type of herniation, clinical symptoms, lesion pathology, and 30-d modified Rankin Scale score for each patient. RESULTS There was no patient who suffered from the development of new or worsening symptomatic or radiological brain herniation directly related to use of immediate preoperative LSD. This included 204 supratentorial and 161 infratentorial procedures. Surgical indications included 188 tumors, 5 aneurysms, 37 arteriovenous malformations, 2 revascularization procedures, 97 microvascular decompressions, 10 optic nerve decompressions requiring extradural clinoidectomy for tumor removal, and 26 "other" pathologies. CONCLUSION Brain herniation did not occur postoperatively with the use of immediate preoperative LSD in our series, regardless of craniotomy location, pathology, extent of mass effect, or approach. Our experience suggests that LSD is a potentially safe preoperative adjunct that can be used to facilitate surgical objectives.
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Affiliation(s)
- Brandon C Lane
- Department of Neurosurgery, Indiana University, Indianapolis, Indiana
| | - Robert Scranton
- Department of Neurosurgery, Indiana University, Indianapolis, Indiana
| | - Aaron A Cohen-Gadol
- Department of Neurosurgery, Indiana University, Indianapolis, Indiana.,The Neurosurgical Atlas, Indianapolis, Indiana
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Abstract
BACKGROUND Medical simulation for the teaching of procedural skills to health-care providers is an effective method of instruction to improve safety, quality, and procedural efficiency. There are several commercially available simulators for lumbar puncture training; however, there is currently no model available for lumbar drain intrathecal catheter placement. METHODS A modular lumbar drain simulator was assembled with the use of a spine model, ballstical gel, and Penrose drain tubing to recreate the procedural steps and tactile feedback of a live lumbar drain insertion. RESULTS The assembled simulator demonstrated the ability to provide users with manual feeback of a "pop" sensation when intrathecal puncture was achieved with a 14 gauge Touhy needle, as well as spontaneous CSF flow. A silastic catheter was able to be inserted into the simulated subarachnoid space in the same manner as a live procedure. CONCLUSIONS A high-fidelity lumbar drain simulator can be constructed in a cost-effective manner. We have detailed the materials and assembly of our successful design in order to provide a novel educational tool for procedural instruction and practice.
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Epstein NE. MEDICOLEGAL CORNER. Failure to replace obstructed lumbar drain after thoracic-abdominal aortic aneurysm repair leads to paraplegia. Surg Neurol Int 2021; 12:207. [PMID: 34084634 PMCID: PMC8168672 DOI: 10.25259/sni_191_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/04/2021] [Indexed: 11/04/2022] Open
Abstract
Background To avoid spinal cord ischemia following endovascular/open thoracic-abdominal aortic aneurysm (T-AAA) repair, lumbar drains (LDs) are placed to reduce intraspinal pressure, and increase spinal perfusion pressure. Here, we present a medicolegal case in which a critical care (CC) physician knew that the LD was obstructed following a T-AAA repair, but did not replace it until the patient became paraplegic. The patient was left with permanent sphincter loss, and a severe paraparesis. Methods A geriatric patient with multiple medical/cardiovascular comorbidities first underwent an endovascular T-AAA (Crawford Type II T-AAA) repair several years ago. Due to continued expansion of the aneurysm, the patient now required an open T-AAA repair. Results Prior to the open T-AAA surgery, a prophylactic LD was placed. Postoperatively, the patient required a second emergency operation to repair a leaking intercostal artery anastomosis. The next morning, the CC physician clearly documented the drain was obstructed, but chose to follow the patient; 3.5 hours later, the patient became paraplegic. The LD was replaced after the patient was first sent to MRI to rule out a spinal cord hematoma, resulting in a total delay of more than 6.5 h from when the CC physician first became aware of the non-functioning LD. The patient later regained only partial function, remaining significantly paraparetic with total loss of bowel/bladder function. Conclusion LD for endovascular/open T-AAA repairs reduce spinal fluid pressure, increase spinal cord perfusion pressures, and limits the frequency (i.e. 2.3-2.6%) of resultant spinal cord ischemia/paralysis. Here, despite the CC physician's failure to replace an obstructed LD after an open T-AAA, repair, the jury rendered a defense verdict.
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Affiliation(s)
- Nancy E Epstein
- Clinical Professor of Neurosurgery, School of Medicine, State U. of NY at Stony Brook
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Solamen LM, McGarry MD, Fried J, Weaver JB, Lollis SS, Paulsen KD. Poroelastic Mechanical Properties of the Brain Tissue of Normal Pressure Hydrocephalus Patients During Lumbar Drain Treatment Using Intrinsic Actuation MR Elastography. Acad Radiol 2021; 28:457-466. [PMID: 32331966 DOI: 10.1016/j.acra.2020.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 01/07/2023]
Abstract
RATIONALE AND OBJECTIVES Hydrocephalus (HC) is caused by accumulating cerebrospinal fluid resulting in enlarged ventricles and neurological symptoms. HC can be treated via a shunt in a subset of patients; identifying which individuals will respond through noninvasive imaging would avoid complications from unsuccessful treatments. This preliminary work is a longitudinal study applying MR Elastography (MRE) to HC patients with a focus on normal pressure hydrocephalus (NPH). MATERIALS AND METHODS Twenty-two ventriculomegaly patients were imaged and subsequently received a lumbar drain placement for cerebrospinal fluid (CSF) drainage. NPH lumbar drain responders and NPH syndrome nonresponders were categorized by clinical presentation. Displacement images were acquired using intrinsic activation (IA) MRE and poroelastic inversion recovered shear stiffness and hydraulic conductivity values. A stable IA-MRE inversion protocol was developed to produce unique solutions for both recovered properties, independent of initial estimates. RESULTS Property images showed significantly increased shear modulus (p = 0.003 in periventricular region, p = 0.005 in remaining cerebral tissue) and hydraulic conductivity (p = 0.04 in periventricular region) in ventriculomegaly patients compared to healthy volunteers. Baseline MRE imaging did not detect significant differences between NPH lumbar drain responders and NPH syndrome nonresponders; however, MRE time series analysis demonstrated consistent trends in average poroelastic shear modulus values over the course of the lumbar drain process in responders (initial increase, followed by a later decrease) which did not occur in nonresponders. CONCLUSION These findings are indicative of acute mechanical changes in the brain resulting from CSF drainage in NPH patients.
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Mitchell JL, Mollan SP, Tsermoulas G, Sinclair AJ. Telemetric monitoring in idiopathic intracranial hypertension demonstrates intracranial pressure in a case with sight-threatening disease. Acta Neurochir (Wien) 2021; 163:725-731. [PMID: 33411042 DOI: 10.1007/s00701-020-04640-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/03/2020] [Indexed: 10/22/2022]
Abstract
The understanding of raised intracranial pressure (ICP) is increasing with the directed use of intracranial telemetric ICP monitors. This case uniquely observed ICP changes by telemetric monitoring in a patient with idiopathic intracranial hypertension (IIH), who developed rapid sight-threatening disease. A lumbar drain was inserted, as a temporising measure, and was clamped prior to surgery. This resulted in a rapid rise in ICP, which normalised after insertion of a ventriculoperitoneal shunt. This case highlighted the utility of the ICP monitor and the lumbar drain as a temporising measure to control ICP prior to a definitive procedure as recommended by the IIH consensus guidelines.
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Affiliation(s)
- James L Mitchell
- Metabolic Neurology, Institute, of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, Queen Elizabeth Hospital, Birmingham, UK.
| | - Georgios Tsermoulas
- Department of Neurosurgery, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
| | - Alex J Sinclair
- Metabolic Neurology, Institute, of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Neurology, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, UK
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Soldozy S, Patel A, Yaeger K, Felbaum D, Spitz SM, Syed HR, Nair MN. Inadvertent intrathecal administration of daunomycin resulting in fatality: Case report and therapeutic considerations. eNeurologicalSci 2020; 22:100297. [PMID: 33364452 PMCID: PMC7750546 DOI: 10.1016/j.ensci.2020.100297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 12/03/2022] Open
Abstract
Background Daunomycin is a chemotherapeutic agent of the anthracycline family that is administered intravenously, most commonly in combination therapy. The authors report the first known adult case of inadvertently administered daunomycin directly into the human central nervous system and the neurologic manifestations and therapeutic interventions that followed. Clinical description A 53-year-old male presenting to the hospital for his second cycle of consolidation therapy for acute promyelocytic leukemia t(15;17) was accidentally administered 93 mg of intrathecal (IT) daunomycin. Within several hours of injection, the patient subsequently developed bilateral lower extremity pain, ascending paresthesias, headache, and left cranial nerve (CN) III palsy. Immediately following these neurologic sequalae, a subarachnoid lumbar drain was placed at the L4-5 interspace for the initial irrigation and drainage of cerebrospinal fluid (CSF). By hospital day 2, the patient's mental status significantly declined requiring an external ventricular drain (EVD) for hydrocephalus. Despite therapeutic interventions, the patient developed an ascending radiculomyeloencephalopathy with deterioration in clinical status. Eighteen days after the inadvertent injection of IT daunomycin, the patient became comatose and lost all cranial nerve function. Conclusions Accidental IT injection of daunomycin is a neurosurgical emergency and warrants prompt intervention. Symptoms can mimic other medical conditions, making it imperative an accurate diagnosis is made so that appropriate therapies are implemented. At this time, therapies include rapid removal of the chemotherapeutic agent from the IT compartment by aspiration and irrigation; however, it is unclear if neuroprotective agents may provide added benefit. The inadvertent intrathecal injection of daunomycin is fatal. Accurate diagnosis is difficult as symptoms often mimic other conditions. Cerebral spinal fluid lavage and continuous drainage should be initiated. Neuroprotective agents may be considered for salvage therapy.
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Affiliation(s)
- Sauson Soldozy
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Anant Patel
- Department of Radiology, New York Presbyterian-Weill Cornell Medical Center, New York, NY, USA
| | - Kurt Yaeger
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, USA
| | - Daniel Felbaum
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Steven M Spitz
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Hasan R Syed
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - M Nathan Nair
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, DC, USA
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16
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Livingston AJ, Laing B, Zwagerman NT, Harris MS. Lumbar drains: Practical understanding and application for the otolaryngologist. Am J Otolaryngol 2020; 41:102740. [PMID: 32979671 DOI: 10.1016/j.amjoto.2020.102740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/13/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Lumbar drains are frequently used in patients with otolaryngologic concerns. These can be used therapeutically or prophylactically with the primary purpose being to modulate CSF pressure. Within otolaryngology, lumbar drains are most frequently used for cerebrospinal fluid leaks - either due to cerebrospinal fluid fistulas or in skull base surgery as these allow for potential healing of the defect. While not typically placed by otolaryngologists, a basic understanding of lumbar drains is beneficial in the context of patient management. MANAGEMENT A lumbar drain is inserted into the intrathecal space in a patient's lumbar spine. Though considered to be a benign procedure, complications are relatively frequent, and adjustment or replacement of the drain may be required. Complications include infection, epidural bleeding, retained hardware, sequelae of relative immobility, or may relate to over-drainage, ranging from mild headache to cranial neuropathies, altered mental status, pneumocephalus, intracranial hemorrhage, and death. While in place, neurologic exams should be performed routinely and should include motor and sensory exams of the lower extremities. A patient should be monitored for fevers, nuchal rigidity, and other signs of infection or meningitis. The CSF fluid should be grossly examined to identify changes, but routine laboratory tests are not typically run on the fluid itself. Drainage rates will vary usually between 5 and 20 mL per hour and must be frequently reassessed and adjusted based upon signs of intracranial hypotension. Drains should be removed when appropriate and should not be left in more than 5 days due to the increased infectious risk. CONCLUSION Lumbar drains are important tools used in patients with otolaryngologic pathologies. Otolaryngologists and otolaryngology residents should be familiar with these catheters to determine if they are working correctly and to identify adverse effects as early as possible.
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Affiliation(s)
| | - Brandon Laing
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Nathan T Zwagerman
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States of America; Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Michael S Harris
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, United States of America; Department of Otolaryngology & Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, United States of America
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Plotkin A, Han SM, Weaver FA, Rowe VL, Ziegler KR, Fleischman F, Mack WJ, Hendrix JA, Magee GA. Complications associated with lumbar drain placement for endovascular aortic repair. J Vasc Surg 2020; 73:1513-1524.e2. [PMID: 33053415 DOI: 10.1016/j.jvs.2020.08.150] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/27/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE We reviewed the complications associated with perioperative lumbar drain (LD) placement for endovascular aortic repair. METHODS Patients who had undergone perioperative LD placement for endovascular repair of thoracic and thoracoabdominal aortic pathologies from 2010 to 2019 were reviewed. The primary endpoints were major and minor LD-associated complications. Complications that had resulted in neurological sequelae or had required an intervention or a delay in operation were defined as major. These included intracranial hemorrhage, symptomatic spinal hematoma, cerebrospinal fluid (CSF) leak requiring intervention, meningitis, retained catheter tip, arachnoiditis, and traumatic (or bloody) tap resulting in delayed operation. Minor complications were defined as a bloody tap without a delay in surgery, asymptomatic epidural hematoma, and CSF leak with no intervention required. Isolated headaches were recorded separately owing to the minimal clinical impact. RESULTS A total of 309 LDs had been placed in 268 consecutive patients for 222 thoracic endovascular aortic repairs, 85 complex endovascular aortic repairs (EVARs; fenestrated branched EVAR/parallel grafting), and 2 EVARs (age, 65 ± 13 years; 71% male) for aortic pathology, including aneurysm (47%), dissection (49%), penetrating aortic ulcer (3%), and traumatic injury (0.6%). A dedicated neurosurgical team performed all LD procedures; most were performed by the same individual, with a technical success rate of 98%. Radiologic guidance was required in 3%. The reasons for unsuccessful placement were body habitus (n = 2) and severe spinal disease (n = 3). Most were placed prophylactically (96%). The overall complication rate was 8.1% (4.2% major and 3.9% minor). Major complications included spinal hematoma with paraplegia in 1 patient, intracranial hemorrhage in 2, meningitis in 2, arachnoiditis in 3, CSF leak requiring a blood patch in 3, bloody tap delaying the operation in 1, and a retained catheter tip in 1 patient. Patients who had undergone previous LD placement had experienced significantly more major LD-related complications (12.2% vs 3%; P = .019). The rate of total LD-associated complications did not differ between prophylactic and emergent therapeutic placements (8.1% vs 7.7%; P = 1.00) nor between major or minor complications. On multivariate analysis, previous LD placement and an overweight body mass index were the only independent predictors of major LD-related complications. CONCLUSIONS The complications associated with LD placement can be severe even when performed by a dedicated team. Previous LD placement and overweight body mass index were associated with a significantly greater risk of complications; however, emergent therapeutic placement was not. Although these risks are justified for therapeutic LD placement, the benefit of prophylactic LD placement to prevent paraplegia should be weighed against these serious complications.
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Affiliation(s)
- Anastasia Plotkin
- Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Vincent L Rowe
- Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Kenneth R Ziegler
- Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Fernando Fleischman
- Division of Cardiothoracic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - William J Mack
- Department of Surgery and Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Joseph A Hendrix
- Department of Surgery and Department of Neurosurgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Keck School of Medicine of USC, University of Southern California, Los Angeles, Calif.
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Vilela MD, Rodrigues da Cunha MV, Ino JM, Abi-Saber Rodrigues Pedrosa H. Severe Intracranial Hypotension After a Middle Fossa Approach for Spontaneous Otogenic Pneumocephalus. World Neurosurg 2020; 141:184-187. [PMID: 32565372 DOI: 10.1016/j.wneu.2020.05.269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 05/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Spontaneous otogenic pneumocephalus is a rare condition caused by erosion of the tegmen tympani with subsequent entrance of air into the intracranial space. Its pathogenesis is thought to involve a previous state of intracranial hypotension, which pulls air into the intracranial cavity. The surgical management involves obliteration of the tegmen defect via a mastoidectomy or a middle fossa approach. Lumbar drainage has been used safely as an adjunct to middle fossa approaches so as to provide brain relaxation and decrease the incidence of postoperative cerebrospinal fluid leaks. CASE DESCRIPTION A 66-year-old male patient with otogenic pneumocephalus caused by nose blowing underwent repair of a tegmen tympani defect through a middle fossa approach, with the aid of intraoperative lumbar drainage. Progressive neurologic deterioration was seen postoperatively with obtundation and anisocoria. Computed tomography scans of the head demonstrated marked midline shift and transtentorial herniation. Recumbency and blood patch failed to improve the neurological condition. Intrathecal infusion of normal saline enabled clinical and radiological improvement. CONCLUSIONS Intraoperative lumbar drainage during a middle fossa approach for spontaneous otogenic pneumocephalus may dramatically aggravate a state of preexisting intracranial hypotension and lead to transtentorial herniation.
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Affiliation(s)
- Marcelo Duarte Vilela
- Neurosurgery, Hospital Mater Dei, Belo Horizonte, Brazil; Department of Neurological Surgery, University of Washington, Seattle, USA.
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19
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Abstract
Purpose of the Review Present an overview of perioperative considerations specific to endoscopic skull base surgery necessary to maximize successful outcomes. Recent Findings The majority of perioperative considerations for endoscopic skull base surgery lack strong supporting evidence and frequently have varied use or implementation amongst institutions. A notable exception comes from a recent randomized controlled trial demonstrating the benefit of lumbar drainage in high-risk cerebrospinal fluid leaks. Summary Skull base surgeons must consider a multitude of perioperative factors. While many components of perioperative management are extrapolated from related fields such as endoscopic sinus surgery or open cranial base surgery, additional high-quality studies are needed to delineate best practices specific to endoscopic skull base surgery.
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Affiliation(s)
- Adnan S Hussaini
- Department of Otolaryngology, Head and Neck Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Rd. NW, Gorman Building, 1st Floor, Washington, DC, 20007 USA
| | - Christine M Clark
- Department of Otolaryngology, Head and Neck Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Rd. NW, Gorman Building, 1st Floor, Washington, DC, 20007 USA
| | - Timothy R DeKlotz
- Department of Otolaryngology, Head and Neck Surgery, Medstar Georgetown University Hospital, 3800 Reservoir Rd. NW, Gorman Building, 1st Floor, Washington, DC, 20007 USA
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20
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Xue H, Yang Z, Liu J, Wang X, Bi Z, Liu P. Continuous dural suturing for closure of grade 3 leaks after tumor removal via an endoscopic endonasal approach. Neurosurg Rev 2019; 44:373-380. [PMID: 31832806 DOI: 10.1007/s10143-019-01199-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 10/11/2019] [Accepted: 10/24/2019] [Indexed: 11/25/2022]
Abstract
Cerebrospinal fluid (CSF) leakage is a major complication after extended endonasal transsphenoidal surgery (EETSS), which is commonly used in the treatment of anterior skull base tumors. Dural suturing and graded reconstruction are promising techniques to further decrease the incidence of postoperative CSF (poCSF) leakage. The effect of continuous dural suturing in endoscopic surgery was investigated in this retrospective study. A total of 79 EETSS patients were included; the procedures were performed for subdural tumor removal by a single endoscopic neurosurgical team. Comparisons were applied between patients who did and did not undergo endoscopic dural suturing after tumor removal. Multivariate logistic regression analysis was performed to identify variables that significantly influenced the incidence of poCSF leakage. In all, 79 adult patients developed Esposito's grade 3 intraoperative high-flow CSF leakage. Ten patients (12.7%) experienced poCSF leakage. One of the 36 patients who underwent intraoperative dural suturing developed poCSF leakage, compared with nine of 43 patients who did not undergo dural suturing (p = 0.016). Regression analysis showed that dural suturing could significantly decrease the incidence of poCSF leakage (p = 0.049, OR 0.108, 95% CI 0.013-0.899). Prophylactic lumbar drainage could also help decrease the CSF leakage rate. Dural suturing under endoscopy is a promising and effective method for application in skull base reconstruction after subdural skull base tumor removal. With future progress, lumbar drainage and even nasoseptal flap placement could be replaced in certain groups of patients undergoing EETSS.
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Affiliation(s)
- Hai Xue
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Disease, Beijing, China
| | - Zhijun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Disease, Beijing, China
- Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University,, Beijing, China
| | - Jian Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, The Second Hospital of Dalian Medical University, Dalian, China
| | - Xingchao Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Disease, Beijing, China
- Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University,, Beijing, China
| | - Zhiyong Bi
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Disease, Beijing, China
| | - Pinan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- China National Clinical Research Center for Neurological Disease, Beijing, China.
- Department of Neural Reconstruction, Beijing Neurosurgery Institute, Capital Medical University,, Beijing, China.
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21
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Yue JK, Hemmerle DD, Winkler EA, Thomas LH, Fernandez XD, Kyritsis N, Pan JZ, Pascual LU, Singh V, Weinstein PR, Talbott JF, Huie JR, Ferguson AR, Whetstone WD, Manley GT, Beattie MS, Bresnahan JC, Mummaneni PV, Dhall SS. Clinical Implementation of Novel Spinal Cord Perfusion Pressure Protocol in Acute Traumatic Spinal Cord Injury at U.S. Level I Trauma Center: TRACK-SCI Study. World Neurosurg 2019; 133:e391-e396. [PMID: 31526882 DOI: 10.1016/j.wneu.2019.09.044] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 09/05/2019] [Accepted: 09/06/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We sought to report the safety of implementation of a novel standard of care protocol using spinal cord perfusion pressure (SCPP) maintenance for managing traumatic spinal cord injury (SCI) in lieu of mean arterial pressure goals at a U.S. Level I trauma center. METHODS Starting in December 2017, blunt SCI patients presenting <24 hours after injury with admission American Spinal Injury Association Impairment Scale (AIS) A-C (or AIS D at neurosurgeon discretion) received lumbar subarachnoid drain (LSAD) placement for SCPP monitoring in the intensive care unit and were included in the TRACK-SCI (Transforming Research and Clinical Knowledge in Spinal Cord Injury) data registry. This SCPP protocol comprises standard care at our institution. SCPPs were monitored for 5 days (goal ≥65 mm Hg) achieved through intravenous fluids and vasopressor support. AISs were assessed at admission and day 7. RESULTS Fifteen patients enrolled to date were aged 60.5 ± 17 years. Injury levels were 93.3% (cervical) and 6.7% (thoracic). Admission AIS was 20.0%/20.0%/26.7%/33.3% for A/B/C/D. All patients maintained mean SCPP ≥65 mm Hg during monitoring. Fourteen of 15 cases required surgical decompression and stabilization with time to surgery 8.8 ± 7.1 hours (71.4% <12 hours). At day 7, 33.3% overall and 50% of initial AIS A-C had an improved AIS. Length of stay was 14.7 ± 8.3 days. None had LSAD-related complications. There were 7 respiratory complications. One patient expired after transfer to comfort care. CONCLUSIONS In our initial experience of 15 patients with acute SCI, standardized SCPP goal-directed care based on LSAD monitoring for 5 days was feasible. There were no SCPP-related complications. This is the first report of SCPP implementation as clinical standard of care in acute SCI.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Debra D Hemmerle
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Leigh H Thomas
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Xuan Duong Fernandez
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Nikolaos Kyritsis
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Jonathan Z Pan
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Lisa U Pascual
- Department of Rehabilitation Medicine, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Vineeta Singh
- Department of Neurology, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Philip R Weinstein
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Jason F Talbott
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - J Russell Huie
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Adam R Ferguson
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - William D Whetstone
- Department of Emergency Medicine, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Michael S Beattie
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Jacqueline C Bresnahan
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, California, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California, USA.
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22
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Oxford BG, Khattar NK, Adams SW, Schaber AS, Williams BJ. Posterior reversible encephalopathy syndrome with lumbar drainage and surgery: coincidence or correlation? A case report. BMC Neurol 2019; 19:214. [PMID: 31470816 PMCID: PMC6716908 DOI: 10.1186/s12883-019-1438-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder usually associated with specific medical conditions that cause a disturbance of the CNS homeostasis. It has seldom been reported to be a consequence of an iatrogenic intervention causing intracranial hypotension. CASE PRESENTATION We report the case of an individual 69-year-old male presenting with headache and blurred vision following cerebrospinal fluid (CSF) leak from resection of a sellar mass. The patient developed the condition following removal of the lumbar drain post-operatively. Magnetic Resonance Imaging showed bilateral occipital, parieto-occipital, and cerebellar T2 FLAIR hyper-intensities, suggesting a radiological diagnosis of posterior reversible encephalopathy syndrome (PRES). The patient's symptoms started to improve shortly afterwards and had completely resolved at 3 months follow-up. CONCLUSIONS The absence of severe hypertension and presence of an intraoperative CSF leak requiring placement of the lumbar drain suggests that decreased CSF volume and associated reactive hyperemia could have a role in the pathophysiology of the disease.
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Affiliation(s)
- Brent G Oxford
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Nicolas K Khattar
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Shawn W Adams
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Alexandra S Schaber
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA
| | - Brian J Williams
- Department of Neurological Surgery, University of Louisville School of Medicine, 220 Abraham Flexner Way, 15th Floor, Louisville, KY, 40202, USA.
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Caggiano C, Penn DL, Laws ER. The Role of the Lumbar Drain in Endoscopic Endonasal Skull Base Surgery: A Retrospective Analysis of 811 Cases. World Neurosurg 2018; 117:e575-e579. [PMID: 29935316 DOI: 10.1016/j.wneu.2018.06.090] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE With increasing use of the endoscopic endonasal transsphenoidal approach, wider attention is being paid to treatment and prevention of its complications. The aim of this study was to determine whether lumbar drainage (LD) has been effective in preventing and treating postoperative cerebrospinal fluid (poCSF) leakage or in assisting in achieving tumor gross total removal (GTR). METHODS Retrospective analysis of purely endoscopic endonasal transsphenoidal cases at a single center between 2008 and 2017 was done. We studied intraoperative cerebrospinal fluid (ioCSF) and poCSF leakage rates, duration of hospitalization, and GTR rate of the lesions, comparing patients with and without LD. RESULTS Among 811 endoscopic endonasal transsphenoidal procedures, LD was used in 38 cases. There was no statistically significant difference between patients with and without LD with regard to incidence of ioCSF leakage. A statistically significant difference was found in obese patients with LD, who had an apparently increased rate of poCSF leak. The length of stay of patients with LD was significantly longer than the control group without LD. The GTR rate was also higher in patients without LD. CONCLUSIONS Use of LD is correlated with longer immobilization and hospitalization without providing statistically significant advantages in terms of prevention or treatment of ioCSF and/or poCSF in low-risk and high-risk patients. Moreover, LD was not helpful in achieving GTR of tumors.
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Affiliation(s)
- Chiara Caggiano
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David L Penn
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward R Laws
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Liang B, Shetty SR, Omay SB, Almeida JP, Ni S, Chen YN, Ruiz-Treviño AS, Anand VK, Schwartz TH. Predictors and incidence of orthostatic headache associated with lumbar drain placement following endoscopic endonasal skull base surgery. Acta Neurochir (Wien) 2017. [PMID: 28643170 DOI: 10.1007/s00701-017-3247-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Orthostatic headache (OH) is a potential complication of lumbar drainage (LD) usage. The incidence and risk factors for OH with the use of lumbar drainage during endoscopic endonasal procedures have not been documented. OBJECTIVE To investigate the incidence of post-procedure OHs associated with placement of LD in patients undergoing endoscopic endonasal procedures. METHODS We prospectively noted the placement of LDs in a consecutive series of endoscopic endonasal skull base surgeries. Charts were retrospectively reviewed, and patients were divided into two groups: those with OH and those without. The patient demographics, drain durations, imaging findings of intracranial hypotension, pathologies and need for a blood patch were compared between the two groups. RESULTS Two hundred forty-nine patients were included in the study. Seven patients (2.8%) suffered post-dural puncture OH, which was mild to moderate and disappeared 2-8 days (median 3 days) after treatment. Blood patches were used in four patients. Significant predisposing factors were age (33.0 vs. 53.5, P = 0.014) and a strong trend for female gender (85.7% vs. 47.9%, P = 0.062). BMI and drain duration were not significant. Postoperative intracranial hypotension was diagnosed radiographically in 43% of OH patients and in 5.4% of those without OH (P = 0.003). Four (1.6%) patients required treatment with an epidural blood patch. CONCLUSION OH associated with intracranial hypotension in patients undergoing endoscopic endonasal procedures with LDs is an infrequent complication seen more commonly in young female patients. Radiographic signs of intracranial hypotension are a specific but not sensitive test for OH.
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Affiliation(s)
- Buqing Liang
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525, Box 99, New York, NY, 10065, USA
| | - Sathwik R Shetty
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525, Box 99, New York, NY, 10065, USA
| | - Sacit Bulent Omay
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525, Box 99, New York, NY, 10065, USA
| | - Joao Paulo Almeida
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525, Box 99, New York, NY, 10065, USA
| | - Shilei Ni
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525, Box 99, New York, NY, 10065, USA
| | - Yu-Ning Chen
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525, Box 99, New York, NY, 10065, USA
| | - Armando S Ruiz-Treviño
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525, Box 99, New York, NY, 10065, USA
| | - Vijay K Anand
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA
| | - Theodore H Schwartz
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, 525, Box 99, New York, NY, 10065, USA.
- Department of Otolaryngology, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA.
- Department of Neuroscience, Weill Cornell Medical College, New York Presbyterian Hospital, New York, NY, USA.
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Asad S, Peters-Willke J, Brennan W, Asad S. Clival Defect with Primary CSF Rhinorrhea: A Very Rare Presentation with Challenging Management. World Neurosurg 2017; 106:1052.e1-1052.e4. [PMID: 28711543 DOI: 10.1016/j.wneu.2017.07.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/02/2017] [Accepted: 07/05/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Primary spontaneous cerebrospinal fluid (CSF) rhinorrhea due to clival defect is an extremely rare presentation, and only 6 cases have been reported in the literature so far17. CASE DESCRIPTION We present a unique case of a 64-year-old woman who presented with a 2-year history of ongoing CSF rhinorrhea. She had similar episode at the age of 40 years and suffered from meningitis. She underwent magnetic resonance imaging, computed tomography cisternogram, as well as computed tomography of the brain, which showed clival defect with CSF leak into the sphenoid sinus. She underwent transsphenoidal repair of the clival defect with concurrent lumbar drain insertion for CSF drainage. She returned a few months later with recurrent CSF rhinorrhea and meningitis. She was administered broad-spectrum antibiotics and underwent septal reconstruction of clival defect. CONCLUSIONS Timely endoscopic transnasal, transsphenoidal repair of CSF leaks is the gold standard practice and could prevent devastating complications including repeated episodes of meningitis.
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Affiliation(s)
- Sheikh Asad
- Departments of Neurosurgery and ENT, Royal Hobart Hospital Tasmania, Hobart, Australia.
| | - Jens Peters-Willke
- Departments of Neurosurgery and ENT, Royal Hobart Hospital Tasmania, Hobart, Australia
| | - Warwick Brennan
- Departments of Neurosurgery and ENT, Royal Hobart Hospital Tasmania, Hobart, Australia
| | - Saima Asad
- Departments of Neurosurgery and ENT, Royal Hobart Hospital Tasmania, Hobart, Australia
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Alexander A, Mathew J, Varghese AM, Ganesan S. Endoscopic Repair of CSF Fistulae: A Ten Year Experience. J Clin Diagn Res 2016; 10:MC01-4. [PMID: 27656471 DOI: 10.7860/jcdr/2016/18903.8390] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/06/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Cerebrospinal Fluid (CFF) fistulae are repaired endoscopically with varying degrees of success around the world. Large series are still uncommon, and the results varied primarily because of the different techniques by different surgeons and also because of a variation in the patient profile in each series, for example, many series deal primarily with traumatic CSF leaks where the defects are larger and outcomes poorer. AIM To analyse the surgical outcomes of Endoscopic CSF rhinorrhea closure. MATERIALS AND METHODS This is a series of 34 cases operated upon primarily by one surgeon in two different centres over a period of 10 years. RESULTS Of the 34 cases, 76% of the patients were women. Among the patients only 20.6% patients had a history of trauma preceding the CSF leak. The most common site of leak was in the fovea ethmoidalis in 19 (55.8%) followed by 10 (29.4%) in the cribriform plate. An overlay technique of placing the multiple layers of fascia and mucosa was used in 26 (76.5%) patients and underlay technique in the remaining. Postoperative lumbar drain was used in all patients. CONCLUSION Based on the treatment outcome of the 34 patients, it can be concluded that the success rate of a single endoscopic procedure in our experience is 97% and 100% following the second. Endoscopic approach for closure of CSF leak is safe with minimal complications and little morbidity.
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Affiliation(s)
- Arun Alexander
- Associate Professor, Department of Otolaryngology and Head and Neck Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research , Puducherry, Tamil Nadu, India
| | - John Mathew
- Professor, Department of Otolaryngology and Head and Neck Surgery, Christian Medical College , Vellore, Tamil Nadu, India
| | - Ajoy Mathew Varghese
- Professor, Department of Otolaryngology and Head and Neck Surgery, Christian Medical College , Vellore, Tamil Nadu, India
| | - Sivaraman Ganesan
- Assistant Professor, Department of Otolaryngology and Head and Neck Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research , Puducherry, Tamil Nadu, India
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Bae IS, Yi HJ, Choi KS, Chun HJ. Comparison of Incidence and Risk Factors for Shunt-dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage Patients. J Cerebrovasc Endovasc Neurosurg 2014; 16:78-84. [PMID: 25045646 PMCID: PMC4102754 DOI: 10.7461/jcen.2014.16.2.78] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 04/30/2014] [Accepted: 05/15/2014] [Indexed: 11/26/2022] Open
Abstract
Objective The objective of this study was to compare the incidence of ventricular shunt placement for shunt-dependent hydrocephalus (SDHC) after clipping versus coiling of ruptured aneurysms. Materials and Methods A retrospective review was conducted in 215 patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent surgical clipping or endovascular coiling during the period from May 2008 to December 2011. Relevant clinical and radiographic data were analyzed with regard to the incidence of hydrocephalus and ventriculo-peritoneal shunt (VPS). Patients treated with clipping were assigned to Group A, while those treated with coiling were assigned to Group B. Results Of 215 patients (157 clipping, 58 coiling), no significant difference in the incidence of final VPS was observed between treatment modalities (15.3% vs. 10.3%) (p = 0.35). Independent risk factors for VPS for treatment of chronic hydrocephalus were as follows: (1) older than 65 years, (2) poorer Hunt-Hess grade IV and V, (3) Fisher grade III and IV, and (4) particularly initial presence of an intraventricular hemorrhage. Conclusion In this study comparing two modalities for treatment of aneurysm, there was no difference in the incidence of chronic hydrocephalus requiring VPS. A significantly higher rate of shunt dependency was observed for age older than 65 years, poor initial neurological status, and thick SAH with presence of initial intraventricular hemorrhage. By understanding these factors related to development of SDHC and results, it is expected that management of aneurysmal SAH will result in a better prognosis.
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Affiliation(s)
- In-Seok Bae
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyoung-Joon Chun
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
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Garcia-Navarro V, Anand VK, Schwartz TH. Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series. World Neurosurg 2011; 80:563-8. [PMID: 22120292 DOI: 10.1016/j.wneu.2011.08.034] [Citation(s) in RCA: 171] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 08/05/2011] [Accepted: 08/30/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess long-term efficacy of the gasket seal, a method for watertight closure of the cranial base using autologous fascia lata held in place by a rigid buttress, in a large case series. METHODS A prospectively acquired database of all endonasal endoscopic surgeries performed over a 5-year period at Weill Cornell Medical College starting in September 2005 was reviewed. RESULTS The gasket seal was used in 46 consecutive patients. Mean age was 53 years (range 7-83 years). All patients had extensive intracranial disease with a significant intraoperative cerebrospinal fluid (CSF) leak. Pathology included craniopharyngioma (39.1%), meningioma (23.9%), and pituitary adenoma (17.4%). After a mean follow-up of 28 months (range 3-63 months), two (4.3%) patients had a postoperative CSF leak. Excluding the patients with adenomas, the CSF leak rate was 5.2% (2 of 38 patients). One leak was controlled with reoperation, and the other was stopped with a lumbar drain (LD). The significance of pathology, type of approach, exposure of the ventricular system, use of fat graft, use of nasoseptal (NS) flap, and use of lumbar drain (LD) was examined, and none of these were significant predictors of postoperative CSF leak. CONCLUSIONS Gasket seal closure is a reliable long-term effective method for achieving watertight closure of the cranial base. It can be used in association with an intracranial fat graft, NS flap, LD, and tissue sealants. In this series, none of these other factors were significant predictors of postoperative CSF leak.
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Affiliation(s)
- Victor Garcia-Navarro
- Department of Neurosurgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York, USA
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Presutti L, Mattioli F, Villari D, Marchioni D, Alicandri-Ciufelli M. Transnasal endoscopic treatment of cerebrospinal fluid leak: 17 years' experience. Acta Otorhinolaryngol Ital 2009; 29:191-196. [PMID: 20161876 PMCID: PMC2816366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Accepted: 07/24/2009] [Indexed: 05/28/2023]
Abstract
Aim of this report is to describe the long-term results of endoscopic endonasal repair of cerebrospinal fluid leak using a septal mucoperichondrial graft. A case series of 52 patients operated for cerebrospinal fluid rhinorrhea between 1990 and 2006 is presented. All patients underwent surgical treatment for endoscopic endonasal closure of a cerebrospinal fluid leak using a septal mucoperichondrial graft. No lumbar drain and fluorescein tests were used. The intra-operative localization of the fistula was aided by Valsalva's manoeuvre by the anaesthetist. The success rate, after the first attempt, was 88.5% (46/52 patients); for the remaining 11.5% (6/52 patients), a second attempt was necessary which proved successful in 5 cases, raising the overall success rate to 98.1% (51/52 patients). Relapse occurred in only one case (1.9%), after the second attempt. In conclusion, a free mucoperichondrial graft offered good results for cerebrospinal fluid leak repair. In the Authors' experience, a high success rate can be achieved without the use of intrathecal fluorescein and lumbar drain.
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Affiliation(s)
- L Presutti
- Department of Otolaryngology, University Hospital of Modena, Modena, Italy
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Kwon OY, Kim YJ, Kim YJ, Cho CS, Lee SK, Cho MK. The Utility and Benefits of External Lumbar CSF Drainage after Endovascular Coiling on Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2008; 43:281-7. [PMID: 19096633 DOI: 10.3340/jkns.2008.43.6.281] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Accepted: 06/13/2008] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Cerebral vasospasm still remains a major cause of the morbidity and mortality, despite the developments in treatment of aneurysmal subarachnoid hemorrhage. The authors measured the utility and benefits of external lumbar cerebrospinal fluid (CSF) drainage to prevent the clinical vasospasm and its sequelae after endovascular coiling on aneurysmal subarachnoid hemorrhage in this randomized study. METHODS Between January 2004 and March 2006, 280 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Among them, 107 patients met our study criteria. The treatment group consisted of 47 patients who underwent lumbar CSF drainage during vasospasm risk period (about for 14 days after SAH), whereas the control group consisted of 60 patients who received the management according to conventional protocol without lumbar CSF drainage. We created our new modified Fisher grade on the basis of initial brain computed tomography (CT) scan at admission. The authors established five outcome criteria as follows : 1) clinical vasospasm; 2) GOS score at 1-month to 6-month follow-up; 3) shunt procedures for hydrocephalus; 4) the duration of stay in the ICU and total hospital stay; 5) mortality rate. RESULTS The incidence of clinical vasospasm in the lumbar drain group showed 23.4% compared with 63.3% of individuals in the control group. Moreover, the risk of death in the lumbar drain group showed 2.1% compared with 15% of individuals in the control group. Within individual modified Fisher grade, there were similar favorable results. Also, lumbar drain group had twice more patients than the control group in good GOS score of 5. However, there were no statistical significances in mean hospital stay and shunt procedures between the two groups. IVH was an important factor for delayed hydrocephalus regardless of lumbar drain. CONCLUSION Lumbar CSF drainage remains to play a prominent role to prevent clinical vasospasm and its sequelae after endovascular coiling on aneurysmal subarachnoid hemorrhage. Also, this technique shows favorable effects on numerous neurological outcomes and prognosis. The results of this study warrant clinical trials after endovascular treatment in patients with aneurysmal SAH.
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Affiliation(s)
- Ou Young Kwon
- Department of Neurosurgery, Dankook University, College of Medicine, Cheonan, Korea
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