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Wang H, Wang Y, Jiang Z, Zhang W. Case Report: Bacterial meningitis due to cerebrospinal fluid leakage following unilateral biportal endoscopic spinal surgery: a cautionary tale. Front Surg 2024; 11:1301905. [PMID: 38516395 PMCID: PMC10954800 DOI: 10.3389/fsurg.2024.1301905] [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: 09/26/2023] [Accepted: 02/23/2024] [Indexed: 03/23/2024] Open
Abstract
Unilateral biportal endoscopic spinal surgery (UBE) is a rapidly growing surgical method and has attracted much interest recently. The most common complication of this technique is cerebrospinal fluid (CSF) leakage due to intraoperative dural tears. There have been no reports of bacterial meningitis due to dural tears in UBE surgery and its treatment and prevention. We reported a 47 year-old man with CSF due to an intraoperative dural tear. A drainage tube was routinely placed and removed on the fourth day after surgery, resulting in fever and headache on the fifith postoperative day. Blood and CSF cultures showed Klebsiella pneumoniae infection, and with lumbar drainage and appropriate antibiotics based on sensitivity tests, the patient's fever and headache were effectively relieved. This case report suggests the importance of prolonged drainage tube placement, adequate drainage, careful intraoperative separation to avoid dural tears, and effective sensitive antibiotic therapy.
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Affiliation(s)
| | | | - Zhensong Jiang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Wen Zhang
- Department of Spine Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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2
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Lee HS, Cho KR, Park K, Jeon C. Management of Cerebrospinal Fluid Leakage after Microvascular Decompression Surgery: Clinical Strategy. Life (Basel) 2023; 13:1771. [PMID: 37629628 PMCID: PMC10455648 DOI: 10.3390/life13081771] [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: 07/11/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: Cerebrospinal fluid (CSF) leakage is one of the most common complications of microvascular decompression (MVD) surgery. Before fatal complications, such as intracranial infection, occur, early recognition and prompt treatment are essential. (2) Methods: The clinical data of 475 patients who underwent MVD surgery from September 2020 to March 2023 were retrospectively analyzed. In these patients, if there were any symptoms of CSF leakage, and if CSF leakage was evident, a lumbar drainage catheter was inserted immediately. (3) Results: CSF leakage was suspected in 18 (3.8%) patients. Five of these patients (1.1%) showed signs of CSF leakage during conservative management and subsequently underwent catheter insertion for lumbar drainage. The lumbar drain was removed after an average of 5.2 days, resulting in an average hospitalization of 14.8 days. In all 5 patients, CSF leakage was resolved without reoperation. (4) Conclusions: Our treatment strategy prevented the development of fatal complications. Close observation of the symptoms and postoperative temporal bone computed tomography and audiometry are considered to be good evaluation methods for all patients. If CSF leakage is certain, it is important to perform lumbar drainage immediately.
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Affiliation(s)
- Hyun-Seok Lee
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (H.-S.L.); (K.-R.C.); (K.P.)
| | - Kyung-Rae Cho
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (H.-S.L.); (K.-R.C.); (K.P.)
| | - Kwan Park
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (H.-S.L.); (K.-R.C.); (K.P.)
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06171, Republic of Korea
| | - Chiman Jeon
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan 15355, Republic of Korea
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Yamada SM, Iwamoto N, Tomita Y, Takeda R, Nakane M. Midline Shift Induced by the Drainage of Cerebrospinal Fluid in Three Patients With External Decompression. Cureus 2023; 15:e44355. [PMID: 37779764 PMCID: PMC10539714 DOI: 10.7759/cureus.44355] [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] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
It is not rare that progressive hydrocephalus worsens clinical conditions in a patient with external decompression and drainage or shunt surgery is required. However, spinal drainage or shunt surgeries potentially carry a risk of causing paradoxical herniation in a patient with decompressive craniectomy, particularly in a comatose case with wide craniectomy. Careful and strict observations are necessary for such patients. In our three comatose cases with craniectomy, paradoxical herniation occurred due to excessive drainage after 5-7 days of shunt surgery and lumbar drainage, although the drainage pressure was set at more than 10 cmH2O. Fortunately, in the three cases, the herniation improved within a few days after the drain was clamped and the bed was flattened. However, the Trendelenburg position and epidural blood patch might be necessary if paradoxical herniation occurs acutely after lumbar puncture or drainage because delayed resolution can be fatal in the herniation.
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Affiliation(s)
- Shoko M Yamada
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Naotaka Iwamoto
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Yusuke Tomita
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Ririko Takeda
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
| | - Makoto Nakane
- Neurosurgery, Teikyo University Mizonokuchi Hospital, Kawasaki, JPN
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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:S1878-8750(23)00551-X. [PMID: 37087037 DOI: 10.1016/j.wneu.2023.04.066] [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: 12/31/2022] [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 (DCI), 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 (IVH) with obstructive hydrocephalus requiring extraventricular drainage (EVD) or large intracranial hemorrhage requiring immediate decompression. Prompt LD was performed for 229 SAH patients, 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 EVD 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 selective aneurysmal SAH patients.
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Affiliation(s)
- Dae Young Kim
- Department of Neurosurgery, Busan Regional Cerebrovascular Center, Dong-A University Hospital, 26, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea
| | - Yong-Hwan Cho
- Department of Neurosurgery, Busan Regional Cerebrovascular Center, Dong-A University Hospital, 26, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea
| | - Sanghyeon Kim
- Department of Radiology, Busan Regional Cerebrovascular Center, Dong-A University Hospital, 26, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea
| | - Jin-Heon Jeong
- Department of Critical Care Medicine, Busan Regional Cerebrovascular Center, Dong-A University Hospital, 26, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea
| | - Jae Hyung Choi
- Department of Neurosurgery, Busan Regional Cerebrovascular Center, Dong-A University Hospital, 26, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea
| | - Myongjin Kang
- Department of Radiology, Busan Regional Cerebrovascular Center, Dong-A University Hospital, 26, Daesingongwon-ro, Seo-gu, Busan, 49201, Republic of Korea
| | - Hyun-Seok Park
- Department of Neurosurgery, Cerebrovascular Center, Ulsan Medical Center, 13, Wolpyeong-ro 171beon-gil, Nam-gu, Ulsan, 44686, Republic of Korea.
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Lasunin NV, Cherekaev VA, Usachev DY, Abdullaev AN, Okishev DN, Pronin IN, Konovalov AN. [Complicated course of the postoperative period with the development of epidural hygroma and intracranial hypotension after removal of cranio-orbital meningioma. Clinical case and literature review]. Zh Vopr Neirokhir Im N N Burdenko 2023; 87:94-103. [PMID: 37830474 DOI: 10.17116/neiro20238705194] [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] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Surgical removal of cranio-orbital meningiomas is an effective method of treating this pathology. Modern surgical techniques and technologies make it possible to perform operations with a low risk of complications. Lumbar drainage or repeated lumbar punctures are often used intraoperatively or in the early postoperative period to prevent nasal CSF leak; this rarely leads to the development of significant neurological symptoms. We present a case of the development of severe intracranial hypotension with the formation of a subdural hygroma in the early postoperative period after removal of a cranio-orbital meningioma in a 41-year-old patient. The operation was performed using an individual model and molds for simultaneous reconstruction of the bone defect with an implant made of polymethyl methacrylate. On the 1st and 2nd days after surgery, lumbar punctures were performed. From the 2nd day there was a progressive deterioration with the development of symptoms characteristic of intracranial hypotension. Computed tomography revealed an increasing displacement of the midline structures of the brain and an increasing volume of epidural fluid accumulation in the area of surgical intervention. Magnetic resonance imaging revealed characteristic signs of intracranial hypotension. Conservative treatment (bed rest, active hydration) had no effect. On the 6th day after surgery, an epidural blood patch procedure was performed and closed external drainage of the epidural hygroma was performed, and a rapid regression of neurological symptoms was noted. Our experience and literature data indicate that it is necessary to remember the possibility of developing clinically significant intracranial hypotension even after a single lumbar puncture. The formation of hygromas in the surgical area is characteristic of intracranial hypotension, but in most cases does not require additional surgical intervention and does not have a negative impact on the outcome of treatment. Conservative treatment of intracranial hypotension is the first choice and often sufficient. If there is no effect and the patient's condition worsens, it is necessary to perform an epidural blood patch procedure.
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Affiliation(s)
- N V Lasunin
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | - D N Okishev
- Burdenko Neurosurgical Center, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Center, Moscow, Russia
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Truckenmueller P, Früh A, Wolf S, Faust K, Hecht N, Onken J, Ahlborn R, Vajkoczy P, Zdunczyk A. Reduction in wound healing complications and infection rate by lumbar CSF drainage after decompressive hemicraniectomy. J Neurosurg 2022:1-9. [PMID: 36681955 DOI: 10.3171/2022.10.jns221589] [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: 07/06/2022] [Accepted: 10/07/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Wound healing disorders and surgical site infections are the most frequently encountered complications after decompressive hemicraniectomy (DHC). Subgaleal CSF accumulation causes additional tension of the scalp flap and increases the risk of wound dehiscence, CSF fistula, and infection. Lumbar CSF drainage might relieve subgaleal CSF accumulation and is often used when a CSF fistula through the surgical wound appears. The aim of this study was to investigate if early prophylactic lumbar drainage might reduce the rate of postoperative wound revisions and infections after DHC. METHODS The authors retrospectively analyzed 104 consecutive patients who underwent DHC from January 2019 to May 2021. Before January 2020, patients did not receive lumbar drainage, whereas after January 2020, patients received lumbar drainage within 3 days after DHC for a median total of 4 (IQR 2-5) days if the first postoperative CT scan confirmed open basal cisterns. The primary endpoint was the rate of severe wound healing complications requiring surgical revision. Secondary endpoints were the rate of subgaleal CSF accumulations and hygromas as well as the rate of purulent wound infections and subdural empyema. RESULTS A total of 31 patients died during the acute phase; 34 patients with and 39 patients without lumbar drainage were included for the analysis of endpoints. The predominant underlying pathology was malignant hemispheric stroke (58.8% vs 66.7%) followed by traumatic brain injury (20.6% vs 23.1%). The rate of surgical wound revisions was significantly lower in the lumbar drainage group (5 [14.7%] vs 14 [35.9%], p = 0.04). A stepwise linear regression analysis was used to identify potential covariates associated with wound healing disorder and reduced them to lumbar drainage and BMI. One patient was subject to paradoxical herniation. However, the patient's symptoms rapidly resolved after lumbar drainage was discontinued, and he survived with only moderate deficits related to the primary disease. There was no significant difference in the rate of radiological herniation signs. The median lengths of stay in the ICU were similar, with 12 (IQR 9-23) days in the drainage group compared with 13 (IQR 11-23) days in the control group (p = 0.21). CONCLUSIONS In patients after DHC and open basal cisterns on postoperative CT, lumbar drainage appears to be safe and reduces the rate of surgical wound revisions and intracranial infection after DHC while the risk for provoking paradoxical herniation is low early after surgery.
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Affiliation(s)
| | - Anton Früh
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Stefan Wolf
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Katharina Faust
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Nils Hecht
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Julia Onken
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Robert Ahlborn
- 2Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Germany
| | - Peter Vajkoczy
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
| | - Anna Zdunczyk
- 1Department of Neurosurgery, Charité-Universitätsmedizin Berlin
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Wu Y, Zhang Y, Wu Y, Zhu G, Xue Y, Qu Y, Zhao T. Postoperative Early Lumbar Drainage Can Reduce the Duration of Fever or Infection in Patients with Complicated Intracranial Tumors after a Long Operation Time. Neurol India 2022; 70:1435-1442. [PMID: 36076640 DOI: 10.4103/0028-3886.355097] [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] [Indexed: 11/04/2022]
Abstract
Background Intracranial fever or infection is one of the common complications after craniotomy, especially for complicated intracranial tumors such as deep skull base tumors. Objective We used early cerebrospinal fluid (CSF) drainage with a preplaced lumbar drainage (LD) tube after surgery and observed whether this procedure could reduce the rate and duration of fever or infection. Material and Methods The authors conducted a retrospective study of 142 patients who underwent complicated intracranial tumor surgery with no less than four hours of dural opening at the Center of Neurosurgery of Tangdu Hospital. The LD group underwent preoperative LD placement, intraoperative CSF release and postoperative continuous drainage, but the control group received routine craniotomy without preoperative LD. The primary outcomes included the rate, duration, and hospital length of stay (LOS) for patients with fever or infection after surgery, as compared between the two groups. The second outcome included complications related to LD and the rate of postoperative CSF leakage. Results There were 22 patients in the LD group and 23 patients in the control group who presented with delayed fever, which was supposed to be caused by intracranial infection or aseptic inflammation. The median duration of delayed fever in the LD group was obviously lower than that in the control group (7.762 ± 3.129 days vs 11.73 ± 5.239 days), and there was a statistically significant difference (P = 0.0046). In addition, there was a significant reduction in the median postoperative LOS (12 [8,10,15,21] days in the LD group vs 15 [9,13,20,28] days in the controls). Moreover, there was no significant difference in complications related to LD between the two groups. Three patients with brain herniation were observed in the LD group compared with one patient in the control group. All four patients had contemporary mild-to-moderate neurologic disorders after surgery or conservative treatment. Additionally, the rate of CSF leakage in the LD group was 5.41% (4/74), which was lower than that in the control group (8/68, [11.76%]), although there was no significant difference (P = 0.174). Conclusions For patients receiving complicated intracranial lesions following a long operation time, postoperative early LD was beneficial for the treatment of patients with fever or infection. It not only reduced the duration of infection or fever in postoperative patients but also decreased the postoperative LOS. We should minimize the complications related to LD by careful and standardized LD and management processes, and ensure the effectiveness and safety of this treatment.
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Affiliation(s)
- Yingxi Wu
- Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, Xi'an, China
| | - Yunze Zhang
- Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, Xi'an, China
| | - Yang Wu
- Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, Xi'an, China
| | - Gang Zhu
- Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, Xi'an, China
| | - Yafei Xue
- Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, Xi'an, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, Xi'an, China
| | - Tianzhi Zhao
- Department of Neurosurgery, Tangdu Hospital, The Air Force Medical University, Xi'an, China
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Guo X, Zhu Y, Hong Y. Efficacy and Safety of Intraoperative Lumbar Drain in Endoscopic Skull Base Tumor Resection: A Meta-Analysis. Front Oncol 2020; 10:606. [PMID: 32457833 PMCID: PMC7221155 DOI: 10.3389/fonc.2020.00606] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 10/27/2019] [Accepted: 04/02/2020] [Indexed: 12/17/2022] Open
Abstract
Objectives: This study aims to evaluate the efficacy and safety of lumbar drainage (LD) in preventing cerebrospinal fluid (CSF) leaks after endoscopic skull base tumor resection. Methods: A systematic online search was conducted using PubMed, Embase, Scopus, Web of Science, and Cochrane Library from January 2006 to July 2019. Data analyses were performed by the Cochrane Collaboration's Review Manager 5.3 software. Results: Eight studies, including two randomized controlled trials and six observational studies, met the inclusion criteria. No significant difference was found in the post-operative CSF leak rate between the LD group and the non-LD group [odds ratio (OR), 0.80; 95%CI, 0.37-1.74; I 2 = 37%; P = 0.57). Subgroup analysis of the intraoperative high-flow leaks, including 4 studies and 313 patients, showed that LD was associated with reduced likelihood of post-operative CSF leak (OR, 0.37; 95%CI, 0.17-0.83; I 2 = 0%; P = 0.02). The placement of LD was related to increased risk of headache compared with non-LD use, and no significant difference was found in the occurrence of deep vein thromboses and pulmonary emboli between two groups. Conclusion: LD is not recommended in all patients undergoing endoscopic skull base tumor resection. However, for patients with intraoperative high-flow leaks, LD is effective and safe in reducing risk of CSF leak.
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Affiliation(s)
- Xiaoming Guo
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yueli Zhu
- Department of Neurology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yuan Hong
- Department of Neurosurgery, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Ohshima T, Isaji T, Miyachi S, Matsuo N, Kawaguchi R, Maejima R, Takayasu M. Efficacy of three-dimensional rotational fluoroscopic unit guidance for lumbar cerebrospinal fluid drainage among patients with unsuccessful initial attempt at bedside. Interv Neuroradiol 2019; 25:357-360. [PMID: 31138040 DOI: 10.1177/1591019918823997] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Lumbar cerebrospinal fluid drainage has been widely performed in patients at the bedside; however, technical failure can occasionally occur as a result of blind maneuvering. Herein, we present the use of rotational fluoroscopic unit-guided lumbar drainage for patients with an unsuccessful initial attempt at bedside. In four of the 24 patients with aneurysmal subarachnoid hemorrhage, initial lumbar drainage could not be performed at bedside. Thus, a three-dimensional rotational technology guided by a high-quality fluoroscopic unit was used. After a cone-beam computed tomography scan was performed, an accurate puncture point and a target thecal sac were identified using the software. The fluoroscopic unit helped us to identify the puncture point and trajectory with a laser pointer on the patient. A needle was inserted along the tract until the cerebrospinal fluid was collected. The lumbar drainage tube was successfully inserted with a single puncture in all four patients. Rotational fluoroscopic technology helps to identify a suitable puncture point, trajectory and target site for lumbar spinal drainage. Our technique is considerably useful in an era wherein minimally invasive procedures are preferred.
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Affiliation(s)
- Tomotaka Ohshima
- 1 Neuroendovascular Therapy Center, Aichi Medical University, Nagakute, Japan
| | - Taiki Isaji
- 2 Department of Neurosurgery, Aichi Medical University, Nagakute, Japan
| | - Shigeru Miyachi
- 1 Neuroendovascular Therapy Center, Aichi Medical University, Nagakute, Japan
| | - Naoki Matsuo
- 2 Department of Neurosurgery, Aichi Medical University, Nagakute, Japan
| | - Reo Kawaguchi
- 2 Department of Neurosurgery, Aichi Medical University, Nagakute, Japan
| | - Ryuya Maejima
- 2 Department of Neurosurgery, Aichi Medical University, Nagakute, Japan
| | - Masakazu Takayasu
- 2 Department of Neurosurgery, Aichi Medical University, Nagakute, Japan
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Bauer M, Sohm F, Thomé C, Ortler M. Refractory intracranial hypertension in traumatic brain injury: Proposal for a novel score to assess the safety of lumbar cerebrospinal fluid drainage. Surg Neurol Int 2017; 8:265. [PMID: 29184716 PMCID: PMC5682699 DOI: 10.4103/sni.sni_98_17] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 08/23/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) drainage via ventricular puncture is an established therapy of elevated intracranial pressure (ICP). In contrast, lumbar CSF removal is believed to be contraindicated with intracranial hypertension. METHODS We investigated the safety and efficacy of lumbar CSF drainage to decrease refractory elevated ICP in a small cohort of patients with traumatic brain injury (TBI). A score (0-8 points) was used to assess computed tomography (CT) images for signs of herniation and for patency of the basal cisterns. All patients received lumbar CSF drainage either as a continuous drainage or as a single lumbar puncture (LP). Type and method of CSF drainage, mean ICP 24 h prior and after CSF removal, and adverse events were documented. Outcome was assessed after 3 months (with dichotomized Glasgow outcome scale). RESULTS Eight patients were evaluated retrospectively. n = 5 suffered a moderate, n = 2 a severe TBI (one Glasgow coma score not documented). The CT score was ≥5 in all patients prior to LP and decreased after puncture without clinical consequences in two patients. The amount of CSF removal did not correlate with score changes (P = 0.45). CSF drainage led to a significant reduction of mean ICP (from 22.3 to 13.9 mmHg, P = 0.002). Continuous drainage was more effective than a single LP. Three of eight patients reached a favorable outcome. CONCLUSIONS Lumbar CSF removal for the treatment of intracranial hypertension is effective and safe, provided the basal cisterns are discernible, equivalent to ≥5 points in the proposed new score. The score needs further validation.
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Affiliation(s)
- Marlies Bauer
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Sohm
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Martin Ortler
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
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11
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Abstract
BACKGROUND AND OBJECTIVES Vasospasm-related injury such as delayed ischemic neurological defect (DIND) or cerebral infarction is an important prognostic factor for aneurismal subarachnoid hemorrhage (SAH). Whether cerebrospinal fluid (CSF) drainage can achieve a better outcome in aneurismal SAH patients after coiling or clipping remains the subject of debate. Here, we report a meta-analysis of the related available literature to assess the effect of continuous CSF drainage on clinical outcomes in patients with aneurismal SAH. METHODS Case-control studies regarding the association between aneurismal SAH and CSF drainage were systematically identified through online databases (PubMed, Web of Science, Elsevier Science Direct, and Springer Link). Inclusion and exclusion criteria were defined for the eligible studies. The fixed-effects model was performed when homogeneity was indicated. Alternatively, the random-effects model was utilized. RESULTS This meta-analysis included 11 studies. Continuous CSF drainage obviously improved patients' long-term outcome (odds ratio [OR] of 2.86, 95% confidence interval [CI], 1.37-5.98, P < 0.01). CSF drainage also reduced angiographic vasospasm (OR of 0.35, 95% CI, 0.23-0.51, P < 0.01), symptomatic vasospasm (OR of 0.32, 95% CI, 0.32-0.43, P < 0.01), and DIND (OR of 0.48, 95% CI, 0.25-0.91, P = 0.03), but there was no significant difference between the CSF drainage group and the no CSF drainage group on shunt-dependent hydrocephalus (SDHC) prevention (OR of 1.04, 95% CI, 0.52-2.07, P = 0.91). Further analysis on lumbar drainage (LD) and external ventricular drainage (EVD) indicated that LD had a better outcome (OR of 3.11, 95% CI, 1.18-8.23, P = 0.02), whereas no significant difference in vasospasm-related injury was detected between the groups (OR of 1.13, 95% CI, 0.54-2.37, P = 0.75). CONCLUSION Continuous CSF drainage is an effective treatment for aneurismal SAH patients; lumbar drainage showed lower complications, but more well-designed studies are required to verify and consolidate this conclusion.
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Affiliation(s)
- Cong Qian
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Xiaobo Yu
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Jingyin Chen
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Chi Gu
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Lin Wang
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
| | - Gao Chen
- Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine
- Correspondence: Gao Chen, Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China (e-mail: ); Yuying Dai, Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, Zhejiang Province, China (e-mail: )
| | - Yuying Dai
- Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, Zhejiang Province, China
- Correspondence: Gao Chen, Department of Neurological Surgery, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China (e-mail: ); Yuying Dai, Department of Clinical Medicine, Hangzhou Medical College, Hangzhou, Zhejiang Province, China (e-mail: )
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Hirono S, Kawauchi D, Higuchi Y, Setoguchi T, Kihara K, Horiguchi K, Kado K, Sato M, Fukuda K, Nakamura T, Saeki N, Yamakami I. Life-Threatening Intracranial Hypotension after Skull Base Surgery with Lumbar Drainage. J Neurol Surg Rep 2015; 76:e83-6. [PMID: 26251819 PMCID: PMC4520994 DOI: 10.1055/s-0035-1547369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 08/12/2014] [Accepted: 12/16/2014] [Indexed: 01/29/2023] Open
Abstract
Although lumbar drainage (LD) is widely used in skull base surgery (SBS), no cases with intracranial hypotension (IH) following LD-assisted SBS have been reported, and skull base surgeons lack awareness of this potentially life-threatening condition. We report two cases of IH after LD-assisted SBS, a spheno-orbital meningioma and an osteosarcoma in the orbit. Despite a minimal amount of cerebrospinal fluid (CSF) drainage and early LD removal, severe postural headache and even a deteriorating consciousness level were observed in the early postoperative course. Neuroimages demonstrated epidural fluid collections, severe midline shift, and tonsillar sag compatible with IH. Epidural blood patch (EBP) immediately and completely reversed the clinical and radiologic findings in both patients. IH should be included in the differential diagnosis of postural headache after LD-assisted SBS that can be managed successfully with EBP. Persistent leakage of CSF at the LD-inserted site leads to IH. Broad dural dissection and wide removal of bony structure may be involved in the midline shift. EBP should be performed soon after conservative management fails. Further reports will determine the risk factors for IH development following LD-assisted SBS.
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Affiliation(s)
- Seiichiro Hirono
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Daisuke Kawauchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Yoshinori Higuchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Taiki Setoguchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Kazunori Kihara
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Kentaro Horiguchi
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Ken Kado
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Motoki Sato
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Kazumasa Fukuda
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Takao Nakamura
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
| | - Naokatsu Saeki
- Department of Neurological Surgery, Chiba University Graduate School of Medicine, Chuoku, Chiba, Japan
| | - Iwao Yamakami
- Department of Neurosurgery, Chiba Central Medical Center, Wakabaku, Chiba, Japan
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