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Colasanti R, Tailor ARA, Zhang J, Ammirati M. Functional Petrosectomy Via a Suboccipital Retrosigmoid Approach: Guidelines and Topography. World Neurosurg 2016; 87:143-54. [DOI: 10.1016/j.wneu.2015.11.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 11/28/2015] [Accepted: 11/30/2015] [Indexed: 11/28/2022]
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Konovalov AN, Pitskhelauri DI, Melikyan AG, Shishkina LV, Serova NK, Pronin IN, Eliseeva NM, Shkatova AM, Samborskiy DY, Bykanov AE, Golovteev AL, Grinenko OA, Kopachev DN. [Supracerebellar transtentorial approach to tumors of the posterior portions of the medial temporal region]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2016; 79:38-47. [PMID: 26529621 DOI: 10.17116/neiro201579438-47] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Despite the advances in microsurgery, the choice of the most adequate approach to the posterior part of the medial temporal region (MTR) remains a very controversial issue. The supracerebellar transtentorial approach (STA) is considered as the most preferable one, since it provides the optimal balance between retraction, incision, and resection of the brain tissue. Here, we present our consecutive series of 20 patients who underwent STA surgery. MATERIAL AND METHODS Twenty patients with glial tumors affecting the posterior MTR underwent STA surgery between 2006 and 2014. The mean age of the patients was 20 years. Benign tumors were predominant (18 out of 20 cases). RESULTS Resection of the posterior and middle MTRs was conducted in 16 cases. The anterior MTR was accessed through STA in 1 patient only; in 2 patients, STA was combined with the infraoccipital approach. Cerebellar edema occurred in 4 patients, with hemiparesis persisting in one of the cases for 1 year after surgery. Of 8 patients with drug resistant epilepsy, the Engel class 1 or 2 outcome was achieved in 6 cases within 1 year after surgery. CONCLUSION STA provides an excellent surgical route to the posterior and middle MTR portions; however, the anterior MTR portions cannot be reached safely. The operative risks of STA increase as the surgeon proceeds with resection of the anterior MTR portions. Anterior MTR structures can be removed using a combination of the supracerebellar and infraoccipital transtentorial approaches or two-stage resection.
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Affiliation(s)
| | | | - A G Melikyan
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - N K Serova
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - I N Pronin
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - N M Eliseeva
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A M Shkatova
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - A E Bykanov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - O A Grinenko
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - D N Kopachev
- Burdenko Neurosurgical Institute, Moscow, Russia
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Eckle VS, Neumann B, Greiner TO, Wendel HP, Grasshoff C. Intrajugular balloon catheter reduces air embolism in vitro and in vivo. Br J Anaesth 2015; 114:973-8. [PMID: 25835025 PMCID: PMC4436929 DOI: 10.1093/bja/aev040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2014] [Indexed: 01/05/2023] Open
Abstract
Background Neurosurgical procedures requiring a sitting position may put the patient at risk of a potentially life-threatening air embolism. Transient manual jugular venous compression limits further air entry in this situation. This study presents an alternative technique aimed at reducing the risk of air embolism. Methods In an in vitro model, an intrajugular balloon catheter was inserted to demonstrate that this device prevents air embolism. In an in vivo study, this device was bilaterally placed into jugular vessels in pigs. Using an ultrasound technique, blood flow was monitored and jugular venous pressure was recorded before and during cuff inflation. Air was applied proximally to the inflated cuffs to test the hypothesis that this novel device blocks air passage. Results In vitro, the intrajugular balloon catheter reliably prevented further air entry (n=10). Additionally, accumulated air could be aspirated from an orifice of the catheter (n=10). In vivo, inflation of the catheter balloon completely obstructed venous blood flow (n=8). Bilateral inflation of the cuff significantly increased the proximal jugular venous pressure from 9.8 (2.4) mm Hg to 14.5 (2.5) mm Hg (n=8, P<0.05). Under conditions mimicking an air embolism, air passage across the inflated cuffs was prevented and 78 (20%) (n=6) of the air dose could be aspirated by the proximal orifice of the catheter. Conclusions These findings may serve as a starting point for the development of intrajugular balloon catheters designed to reduce the risk of air embolism in patients undergoing neurosurgery in a sitting position.
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Affiliation(s)
- V S Eckle
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Germany
| | - B Neumann
- Department of Thoracic, Cardiac and Vascular Surgery, Clinical Research Laboratory, University Hospital Tübingen, Germany
| | - T O Greiner
- Department of Thoracic, Cardiac and Vascular Surgery, Clinical Research Laboratory, University Hospital Tübingen, Germany
| | - H P Wendel
- Department of Thoracic, Cardiac and Vascular Surgery, Clinical Research Laboratory, University Hospital Tübingen, Germany
| | - C Grasshoff
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Germany
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Clitherow HDS, Bain GI. Major neurovascular complications of clavicle fracture surgery. Shoulder Elbow 2015; 7:3-12. [PMID: 27582950 PMCID: PMC4935100 DOI: 10.1177/1758573214546058] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 06/25/2014] [Indexed: 01/05/2023]
Abstract
Clavicle fracture fixation is becoming an increasingly common operation, with good clinical outcomes and a low rate of significant complications. However, there are several reports of rare but potentially life or limb threatening, neurovascular complications. Arterial injuries are usually pseudoaneurysms associated with prominent screws. These may be clinically silent for several years before presenting as subcritical upper limb ischaemia. Venous injuries are a result of tearing of the vessel wall by fracture manipulation, drills or implants. This produces intra-operative haemorrhage and potentially air embolism, which can be fatal if not rapidly recognized and managed. Brachial plexopathy is the result of traction on adherent plexus or impingement by fracture fragments or callus. It presents as severe arm pain and paralysis immediately postoperatively. Neurovascular injuries can be avoided by a combination of pre-operative planning, communication with anaesthetic staff and strategic surgical technique. The plane of the surgical exposure, release of the soft tissues, drill direction and depth and screw length are all important factors.
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Affiliation(s)
- Harry DS Clitherow
- Department of Orthopaedics and Trauma, Modbury Public Hospital, Adelaide, Australia
- Department of Orthopaedics and Trauma, Royal Adelaide Hospital, Adelaide, Australia
| | - Gregory I Bain
- Department of Orthopaedics and Trauma, Flinders Hospital, Adelaide, Australia
- Department of Orthopaedics and Trauma, Flinders University, Adelaide, Australia
- Gregory I Bain, 196 Melbourne Street, North Adelaide, 5006, South Australia, Australia. Ph: +61 8 8361 8399. Fax: +61 8 8239 2237
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Hervías A, Valero R, Hurtado P, Gracia I, Perelló L, Tercero FJ, González JJ, Fàbregas N. Detección de embolismo aéreo venoso y de foramen oval permeable en pacientes neuroquirúrgicos intervenidos en posición de sedestación. Neurocirugia (Astur) 2014; 25:108-15. [DOI: 10.1016/j.neucir.2013.12.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Revised: 12/06/2013] [Accepted: 12/09/2013] [Indexed: 01/05/2023]
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Borghei-Razavi H, Daabak KM, Alhaj A, Schick U. The safety of the semisitting position in craniocervical 3-dimensional image-guided fusion surgery. World Neurosurg 2014; 81:e27-8. [PMID: 24487094 DOI: 10.1016/j.wneu.2014.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 01/25/2014] [Indexed: 11/30/2022]
Affiliation(s)
- Hamid Borghei-Razavi
- Department of Neurosurgery, Clemens Hospital, Academic Hospital of Münster University, Münster, Germany.
| | - Khairi Mohamed Daabak
- Department of Neurosurgery, Clemens Hospital, Academic Hospital of Münster University, Münster, Germany
| | - Aseem Alhaj
- Department of Neurosurgery, Clemens Hospital, Academic Hospital of Münster University, Münster, Germany
| | - Uta Schick
- Department of Neurosurgery, Clemens Hospital, Academic Hospital of Münster University, Münster, Germany
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Ooba H, Abe T, Momii Y, Fujiki M. Venous air embolism (VAE) associated with stereotactic biopsies. Acta Neurochir (Wien) 2014; 156:433-7. [PMID: 24105046 DOI: 10.1007/s00701-013-1903-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 09/27/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Venous air embolism (VAE) is a serious potential complication of neurosurgical procedures. Stereotactic biopsies can also cause VAE; therefore, we evaluated VAE patients to call attention to the risk of VAE associated with stereotactic biopsies. METHODS In this report, symptomatic VAE was defined as paroxysmal coughing with associated symptoms. Air in the dural sinus, cortical vein and/or pterygoid plexus on postoperative computed tomography (CT) scans was considered to be a radiographic VAE. RESULTS Three patients developed symptomatic VAE following 36 stereotactic biopsies, and the incidence of symptomatic VAE was 8.3 % (3/36). There were five patients with evidence of radiographic VAE on postoperative CT scans, with an incidence of 13.8 % (5/36). A high angle of the head seemed to be associated with VAE, allowing air to flow into the central venous system. CONCLUSIONS The present report emphasizes that VAE should be recognized as an important adverse effect of stereotactic biopsies because VAE occasionally requires additional treatment and/or termination of surgery. Surgeons must be aware of the possibility of VAE, especially when it is necessary to position the patient's head at a high angle.
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Affiliation(s)
- Hiroshi Ooba
- Department of Neurosurgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasamamachi, Oita, 879-5593, Japan,
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59
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Selection of Semisitting Position in Neurosurgery: Essential or Preference? World Neurosurg 2014; 81:62-3. [DOI: 10.1016/j.wneu.2013.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 02/02/2013] [Indexed: 11/22/2022]
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Laban JT, Rasul FT, Brecker SJD, Marsh HT, Martin AJ. Patent foramen ovale closure prior to surgery in the sitting position. Br J Neurosurg 2013; 28:421-2. [PMID: 24304266 DOI: 10.3109/02688697.2013.865709] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Previously, patent foramen ovale (PFO) was an absolute contraindication to surgery in the sitting position. We report two patients with PFO who underwent surgery in the sitting position after percutaneous PFO closure. To our knowledge this is the first report of this technique.
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Affiliation(s)
- James T Laban
- Department of Neurosurgery, Atkinson Morley Wing, St George's Healthcare NHS Trust , London , UK
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Oliveira J, Cerejo A, Silva PS, Polónia P, Pereira J, Vaz R. The infratentorial supracerebellar approach in surgery of lesions of the pineal region. Surg Neurol Int 2013; 4:154. [PMID: 24381797 PMCID: PMC3872645 DOI: 10.4103/2152-7806.122504] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Accepted: 11/16/2013] [Indexed: 11/30/2022] Open
Abstract
Background: Surgery of pineal region lesions is considered a challenging task, due to the particular relationship of lesions in this location with neural and vascular structures. Few series with a significant experience of dealing with these patients have been reported. Methods: We review our experience using infratentorial supracerebellar approach in the surgery of pineal region, regarding the extension of the removal, postoperative morbidity, and discussing details of the surgical technique. In all cases, a supracerebellar infratentorial approach was used in the semi sitting position. Results: A total of 32 patients were operated in the past 20 years (3 germinomas, 3 teratoma, 3 pineocitoma, 2 pineal tumor of intermediate differentiation, 6 pineoblastomas, 6 low grade astrocytoma, 2 glioblastoma, 2 metastasis, 1 ependymoma, 1 epidermoid tumor, 1 cavernoma, and 2 arachnoid cyst). Total removal was achieved in 15 cases and subtotal extensive removal in 7 patients. In the remaining cases, only partial removal was possible, due to the involved pathological types. There was no surgical mortality and no cases of cerebellar venous infarction. Morbidity consisted of transient ocular movement disturbance in 14 patients, transient ataxia in 3 patients, and 1 case of local cerebrospinal fluid (CSF) fistula with meningitis that required surgical treatment. Conclusion: Supracerebellar infratentorial is a safe approach to lesions in the pineal region, and total or extensive subtotal removal is possible in most cases, with acceptable morbidity.
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Affiliation(s)
- Joana Oliveira
- Department of Neurosurgery, Hospital S. João, Porto, Portugal
| | - António Cerejo
- Department of Neurosurgery, Hospital S. João, Porto, Portugal
| | | | | | - Josué Pereira
- Department of Neurosurgery, Hospital S. João, Porto, Portugal
| | - Rui Vaz
- Department of Neurosurgery, Hospital S. João, Porto, Portugal
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Austin LS, VanBeek C, Williams GR. Venous air embolism: an under-recognized and potentially catastrophic complication in orthopaedic surgery. J Shoulder Elbow Surg 2013; 22:1449-54. [PMID: 24054311 DOI: 10.1016/j.jse.2013.06.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Revised: 05/27/2013] [Accepted: 06/01/2013] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Venous air embolism (VAE) is the entry of air or other medical gases into the central venous system, producing an air embolism to the right heart or pulmonary artery. VAE is a largely iatrogenic complication with potentially devastating sequelae that can occur in a variety of surgical procedures. METHOD Within orthopaedics, VAE has been associated with both open and arthroscopic surgeries with the patient in a variety of positions (ie, prone, supine, sitting). These articles, as well as reports of VAE in other surgical settings outside of orthopaedics, are examined. CONCLUSION Diagnosis of VAE requires a high index of suspicion, as clinical presentation ranges from completely asymptomatic to fatal cardiopulmonary collapse. The vigilant surgeon should carefully watch for air entry at the operative site and the astute anesthesiologist must closely monitor end-tidal CO2 (ETCO2). Prevention of VAE is of paramount importance, as management is largely supportive and aimed at inhibiting further air ingress.
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Affiliation(s)
- Luke S Austin
- Shoulder and Elbow Service, Thomas Jefferson University, Rothman Institute, Philadelphia, PA, USA.
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63
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Buis DR, Lai YM. Use of grading scales in venous air emboli during neurosurgery. World Neurosurg 2013; 81:e31. [PMID: 23948649 DOI: 10.1016/j.wneu.2013.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 08/10/2013] [Indexed: 11/24/2022]
Affiliation(s)
- Dennis R Buis
- Neurosurgical Center Amsterdam, Amsterdam, the Netherlands.
| | - Yen-Mie Lai
- Neurosurgical Center Amsterdam, Amsterdam, the Netherlands
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LINDROOS ACB, NIIYA T, SILVASTI-LUNDELL M, RANDELL T, HERNESNIEMI J, NIEMI TT. Stroke volume-directed administration of hydroxyethyl starch or Ringer's acetate in sitting position during craniotomy. Acta Anaesthesiol Scand 2013; 57:729-36. [PMID: 23550716 DOI: 10.1111/aas.12105] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND To determine the volumes required for stable haemodynamics and possible effects on the coagulation, we studied stroke volume (SV)-directed administration of hydroxyethyl starch (HES 130 kDa/0.4) and Ringer's acetate (RAC) in neurosurgical patients operated on in a sitting position. METHODS Thirty craniotomy patients were randomised to receive either HES or RAC. Before positioning, SV, measured by arterial pressure waveform analysis, was maximised by boluses of fluid until SV did not increase more than 10%. SV was maintained by repeated administration of fluid. RAC 3 ml/kg/h was infused in both groups during surgery. RESULTS Comparable haemodynamics were achieved with the mean [standard deviation (SD)] cumulative doses of HES or RAC 271 (47) or 264 (50) ml (P = 0.699) before the sitting position. Mean (SD) doses of HES or RAC at 30 min after the positioning were 343 (94) or 450 (156) ml (P = 0.036), and at the end of surgery 464 (284) or 707 (425) ml, respectively (P = 0.087). The intraoperative fluid balance was more positive in the RAC than in the HES group [P = 0.044, 95% confidence interval (CI) -978 to -14]. Cardiac and stroke volume indexes [CI and stroke volume index (SVI)] increased in the HES group (P < 0.05) but not in the RAC group [non significant (N.S.)]. Neither coagulation profile nor blood loss differed between the groups. CONCLUSION Fluid filling with HES boluses resulted in a positive response in CI and SVI during the sitting position. The 34% smaller volume of HES than crystalloid and less positive fluid balance in the HES group might be important in craniotomy patients with decreased brain compliance.
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Affiliation(s)
- A.-C. B. LINDROOS
- Department of Anaesthesiology and Intensive Care Medicine; Helsinki University Central Hospital; Helsinki; Finland
| | - T. NIIYA
- Department of Anaesthesiology; Sapporo Medical University School of Medicine; Sapporo; Japan
| | - M. SILVASTI-LUNDELL
- Department of Anaesthesiology and Intensive Care Medicine; Helsinki University Central Hospital; Helsinki; Finland
| | - T. RANDELL
- Department of Anaesthesiology and Intensive Care Medicine; Helsinki University Central Hospital; Helsinki; Finland
| | - J. HERNESNIEMI
- Department of Neurosurgery; Helsinki University Central Hospital; Helsinki; Finland
| | - T. T. NIEMI
- Department of Anaesthesiology and Intensive Care Medicine; Helsinki University Central Hospital; Helsinki; Finland
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Catastrophic venous air embolism during craniotomy in the supine position: the bleeding pattern as a warning sign? J Craniofac Surg 2013; 24:e228-9. [PMID: 23714971 DOI: 10.1097/scs.0b013e3182869984] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Venous air embolism is a serious complication during a neurosurgical procedure. Here is a case of a massive venous air embolism causing cardiac arrest in the supine position surgery. Identifying the alternative inflation and collapse of the sinus and taking emergency measures to avoid catastrophic result are important.
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66
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Feigl GC, Decker K, Wurms M, Krischek B, Ritz R, Unertl K, Tatagiba M. Neurosurgical procedures in the semisitting position: evaluation of the risk of paradoxical venous air embolism in patients with a patent foramen ovale. World Neurosurg 2013; 81:159-64. [PMID: 23295634 DOI: 10.1016/j.wneu.2013.01.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 08/05/2012] [Accepted: 01/02/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To analyze the actual risk for patients with a patent foramen ovale (PFO) to experience a clinically relevant venous air embolism (VAE) during surgery performed in the semisitting position. METHODS All procedures were performed between January 2008 and December 2009, under general anesthesia and in the semisitting position. Transesophageal echocardiography (TEE) and capnometry were used intraoperatively to monitor for air bubbles in the venous system. RESULTS Of 200 consecutive patients who all were operated on in the semisitting position, 52 patients (26%) had a diagnosis of PFO. Rates of VAE in patients were graded as follows: grade 0 (no air bubbles visible, no air embolism), 23 patients (44.2%); grade I (air bubbles on TEE), 22 patients (42.3%); grade II (air bubbles on TEE with decrease of end-tidal carbon dioxide [ETCO2] ≤ 3 mm Hg), 2 patients (3.8%); grade III, air bubbles on TEE with decrease of ETCO2 >3 mm Hg, 4 patients (7.7%); grade IV, air bubbles on TEE with decrease of ETCO2 >3 mm Hg and decrease of mean arterial pressure ≥ 20% or increase of heart rate ≥ 40% (or both), 1 patient (1.9%); and grade V, VAE causing arrhythmia with hemodynamic instability requiring cardiopulmonary resuscitation, 0 patients (0%). There were no deaths in this series, and no new or unexplained, mild or severe neurologic deficits were caused by a VAE. CONCLUSIONS Under standardized anesthesia and neurosurgical protocols, patients with a PFO can be operated on safely in the semisitting position.
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Affiliation(s)
- Guenther C Feigl
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany.
| | - Karlheinz Decker
- Department of Anesthesiology, University of Tübingen Medical Center, Tübingen, Germany
| | - Max Wurms
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany
| | - Boris Krischek
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany
| | - Rainer Ritz
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany
| | - Klaus Unertl
- Department of Anesthesiology, University of Tübingen Medical Center, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany
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Ammirati M, Lamki TT, Shaw AB, Forde B, Nakano I, Mani M. A streamlined protocol for the use of the semi-sitting position in neurosurgery: a report on 48 consecutive procedures. J Clin Neurosci 2012. [PMID: 23178073 DOI: 10.1016/j.jocn.2012.05.037] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The semi-sitting position has lost favor among neurosurgeons partly due to unproven assumptions of increased complications. Many complications have been associated with this position; the most feared: venous air embolism and paradoxical air embolism. We report on this retrospective study of the outcome over 4 years of 48 neurosurgical patients operated on consecutively using a standardized protocol: 41 (85%) in the semi-sitting position, and seven (15%) in the prone position. Procedures included: tumor resection (34), posterior fossa decompression (12), cyst resection (1) and resection of arteriovenous malformation (1). Pre-operative workup was standardized. Vigilant intra-operative observation was done by an experienced neuroanesthetist. Pertinent data was extracted from surgical records. Of the 48 patients, 10 (20.8%) were found to have a patent foramen ovale (PFO) on trans-esophageal echocardiography. Of these, four (40%) patients underwent procedures in the semi-sitting position while six (60%) did not. A clinically significant venous air embolism (VAE) was detected during 2 of the 41 semi-sitting procedures (4.9%). Neither patient suffered any obvious sequelae. No other morbidity was encountered associated with surgical position. Our study suggests that a model similar to ours is effective in preventing major complications associated with the semi-sitting position. The semi-sitting position is a safe, practical position that should be considered in appropriate cases. The fear of dreadful complications seems unwarranted.
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Affiliation(s)
- Mario Ammirati
- Department of Neurosurgery, The Ohio State University, Columbus, OH 43210, USA.
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Muller JC, Kennard JW, Browne JS, Fecher AM, Hayward TZ. Hemodynamic monitoring in the intensive care unit. Nutr Clin Pract 2012; 27:340-51. [PMID: 22593102 DOI: 10.1177/0884533612443562] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients in the intensive care unit are often critically ill with inadequate tissue perfusion and oxygenation. This inadequate delivery of substrates at the cellular level is a common definition of shock. Hemodynamic monitoring is the observation of cardiovascular physiology. The purpose of hemodynamic monitoring is to identify abnormal physiology and intervene before complications, including organ failure and death, occur. The most common types of invasive hemodynamic monitors are central venous catheters, pulmonary artery catheters, and arterial pulse-wave analysis. Ultrasonography is a noninvasive alternative being used in intensive care units for hemodynamic measurements and assessments.
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Affiliation(s)
- Joseph C Muller
- Indiana University School of Medicine, Indianapolis, IN 46202, USA
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Türe U, Harput MV, Kaya AH, Baimedi P, Firat Z, Türe H, Bingöl CA. The paramedian supracerebellar-transtentorial approach to the entire length of the mediobasal temporal region: an anatomical and clinical study. J Neurosurg 2012; 116:773-91. [DOI: 10.3171/2011.12.jns11791] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
The exploration of lesions in the mediobasal temporal region (MTR) has challenged generations of neurosurgeons to achieve an appropriate approach. To address this challenge, the extensive use of the paramedian supracerebellar-transtentorial (PST) approach to expose the entire length of the MTR, as well as the fusiform gyrus, was investigated.
Methods
The authors studied the microsurgical aspects of the PST approach in 20 cadaver brains and 5 cadaver heads under the operating microscope. They evaluated the features, advantages, difficulties, and limitations of the PST approach and refined the surgical technique. They then used the PST approach in 15 patients with large intrinsic MTR tumors (6 patients), tumor in the posterior fusiform gyrus with mediobasal temporal epilepsy (MTE) (1 patient), cavernous malformations in the posterior MTR including the fusiform gyrus (2 patients), or intractable MTE with hippocampal sclerosis (6 patients) from December 2007 to May 2010. Patients ranged in age from 11 to 63 years (mean 35.2 years), and in 9 patients (60%) the lesion was located on the left side.
Results
In all patients with neuroepithelial tumors or cavernous malformations, the lesions were completely and safely resected. In all patients with intractable MTE with hippocampal sclerosis, the anterior two-thirds of the parahippocampal gyrus and hippocampus, as well as the amygdala, were removed selectively through the PST approach. There was no surgical morbidity or mortality in this series. Three patients (20%) with high-grade neuroepithelial tumors underwent postoperative radiotherapy and chemotherapy but needed a second surgery for recurrence during the follow-up period. In all patients with MTE, antiepileptic medication could be decreased to a single drug at lower doses, and no seizure activity has occurred until this point.
Conclusions
The PST approach provides the surgeon precise anatomical orientation when exposing the entire length of the MTR, as well as the fusiform gyrus, for removing any lesion. This is a novel technique especially for removing tumors involving the entire MTR in a single session without damaging neighboring neural or vascular structures. This approach can also be a viable alternative for selective removal of the parahippocampal gyrus, hippocampus, and amygdala in patients with MTE due to hippocampal sclerosis.
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Ingelmo Ingelmo I, Fábregas Juliá N, Rama-Maceiras P, Rubio Romero R, Badenes Quiles R, Valencia Sola L, Romero Krauchi O, Honorato C, Hernández Palazón J, Sánchez Ledesma MJ. [Questionnaire on the anaesthesiology treatment of patients subjected to posterior fossa neurosurgery]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2012; 59:118-126. [PMID: 22985752 DOI: 10.1016/j.redar.2012.02.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 02/10/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To find out, by means of a questionnaire, the procedures used by Spanish anaesthetists in peri-operative management of patients subjected to neurosurgery of the posterior cranial fossa. MATERIAL AND METHODS A closed-question type questionnaire was sent to Anaesthesiology Departments with a Neurosurgery Department on the participation of anaesthetists in the peri-operative treatment of patients subjected posterior fossa surgery. RESULTS The questionnaire was completed by 42 (57.5%) of the 73 national public hospitals with a Neurosurgery Department. The posterior fossa surgery was performed in the sitting position in 36 hospitals, although it was less frequently used than the lateral decubitus or prone decubitus position. There was little specific neurological monitoring, as well as little use of precordial and/or transcranial Doppler for detecting vascular air embolism. Nitrous oxide was used in less than 10% of the centres, and 15% avoided neuromuscular block when neurophysiological monitoring was used during the surgery. Cardiovascular problems were mentioned as being the most frequent in 29% of the centres, while in the post-operative period the most common complications were, cranial nerve déficit, airway oedema (23%), and post-operative vomiting (47%). CONCLUSIONS The results obtained from the questionnaire showed that the sitting position was less used than the prone position in posterior fossa surgery, and that neurophysiological monitoring is during surgery is hardly used.
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MESH Headings
- Adult
- Airway Obstruction/epidemiology
- Airway Obstruction/etiology
- Anesthesia/methods
- Anesthesia Department, Hospital/statistics & numerical data
- Anesthesia, Inhalation/statistics & numerical data
- Anesthesia, Intravenous/statistics & numerical data
- Anesthetics, Inhalation
- Cardiovascular Diseases/diagnosis
- Cardiovascular Diseases/epidemiology
- Child
- Cranial Fossa, Posterior/surgery
- Cranial Nerve Diseases/epidemiology
- Cranial Nerve Diseases/etiology
- Drug Utilization
- Embolism, Air/diagnostic imaging
- Embolism, Air/prevention & control
- Health Care Surveys
- Hospital Departments/statistics & numerical data
- Hospitals, Public/statistics & numerical data
- Humans
- Intraoperative Complications/diagnosis
- Intraoperative Complications/diagnostic imaging
- Intraoperative Complications/prevention & control
- Monitoring, Intraoperative/statistics & numerical data
- Neuromuscular Blocking Agents
- Neuromuscular Monitoring/statistics & numerical data
- Neurosurgery/organization & administration
- Neurosurgical Procedures
- Nitrous Oxide
- Patient Positioning
- Pneumocephalus/epidemiology
- Pneumocephalus/etiology
- Postoperative Complications/epidemiology
- Postoperative Nausea and Vomiting/epidemiology
- Surveys and Questionnaires
- Ultrasonography, Doppler, Transcranial/statistics & numerical data
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Schäfer ST, Sandalcioglu IE, Stegen B, Neumann A, Asgari S, Peters J. Venous air embolism during semi-sitting craniotomy evokes thrombocytopenia. Anaesthesia 2011; 66:25-30. [PMID: 21198503 DOI: 10.1111/j.1365-2044.2010.06584.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Venous air embolism activates platelets in vitro and can evoke platelet dysfunction in swine. We tested the hypothesis that venous air embolism during semi-sitting craniotomy induces thrombocytopenia in humans. We analysed the charts of 799 patients who had an elective craniotomy in the semi-sitting position between 1990 and June 2009. Venous air embolism occurred in 52 patients (6.5%) and was associated with a decrease in mean (SD) in platelet count from 270 (75) × 10⁹ l⁻¹ to 194 (62) × 10⁹ l⁻¹ (p < 0.001). In age-matched controls without venous air embolism mean (SD) platelet count did not change (254 (82) × 10⁹ l⁻¹ vs. 250 (97) × 10⁹ l⁻¹ (NS). While mean (SD) haematocrit fell slightly in both groups (venous air embolism: 0.40 (0.05) to 0.32 (0.04), p <0.001; no venous air embolism: 0.41 (0.04) to 0.35 (0.05), p < 0.001), normalising platelet count to haematocrit did not alter the results.
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Affiliation(s)
- S T Schäfer
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Germany.
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Abstract
STUDY DESIGN A unique case of a patient with intraoperative venous air embolism (VAE) during atlantoaxial arthrodesis has been discussed. OBJECTIVE To describe an uncommon complication of atlantoaxial arthrodesis, VAE. SUMMARY OF BACKGROUND DATA Although several techniques for atlantoaxial arthrodesis have proven effective, lateral mass or pedicle screw constructs have been shown to have superior strength with acceptable morbidity. Placement of lateral mass or pedicle screws into the C1 or C2 vertebrae requires consideration of relevant local anatomy, including vascular and nervous structures. We present a rare complication of surgery in this anatomic distribution, VAE. To the authors' knowledge, there has been no similar report described. METHODS A previously healthy 38-year-old man was found to have os odontoideum with atlantoaxial instability; arthrodesis was thus planned, with C1 lateral mass and C2 pedicle screws. Intraoperatively, during dissection of the C1-C2 joint capsule, the patient experienced a precipitous drop in blood pressure, end-tidal CO2, and oxygen saturation. Shortly thereafter, the patient was noted to be asystolic. RESULT With suspicion for air embolus, the surgical field was flooded with irrigant, the incision closed with haste, and the patient rolled to the supine position. Cardiopulmonary resuscitation was initiated with return of pulse within minutes. A transesophageal echocardiogram was performed approximately 15 minutes after the onset of suspected air embolus, revealing increased atrial pressures consistent with VAE. Following echocardiogram, the patient was returned to prone position for completion of arthrodesis. Remaining surgery and arousal were uneventful. CONCLUSION This is the first report of intraoperative VAE occurring with atlantoaxial arthrodesis. Enlarged venous anastomoses present at the atlantoaxial junction should be taken into consideration during surgical dissection, and the potential danger of VAE with atlantoaxial arthrodesis should be understood. With aggressive intraoperative treatment, this patient suffered no long-term complications.
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Sitting Position for Removal of Pineal Region Lesions: The Helsinki Experience. World Neurosurg 2010; 74:505-13. [DOI: 10.1016/j.wneu.2010.09.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 09/22/2010] [Accepted: 09/22/2010] [Indexed: 11/19/2022]
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Roy RC. Central venous pressure in clinical care algorithms: are anesthesiologists and intensivists ready? Anesth Analg 2010; 111:591-2. [PMID: 20733162 DOI: 10.1213/ane.0b013e3181e9f64f] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Gasser T, Senft C, Rathert J, Friedrich K, Hattingen E, Gerlach R, Seifert V. The combination of semi-sitting position and intraoperative MRI--first report on feasibility. Acta Neurochir (Wien) 2010; 152:947-51. [PMID: 20169370 DOI: 10.1007/s00701-010-0607-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 01/21/2010] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Intraoperative MRI (iMRI) has been established as a routine imaging modality with a remarkable impact on specific neurosurgical procedures. The technological advancement continuously extends the spectrum of iMRI, leading to an increasing number of installations. Yet, procedures in which a semi-sitting position would be advantageous were beyond the reach of iMRI. MATERIALS AND METHODS We performed an iMRI-guided surgical procedure in a patient with a cystic lesion of the inferior parieto-occipital lobe while the patient was placed in a semi-sitting position, employing a mobile 0.15-T intraoperative MRI system. For that purpose, we adapted a standard OR table according to the needs of iMRI. FINDINGS Patient positioning could be accomplished easily. For intraoperative scanning, the OR table was tilted backwards so as to position the patient's head in the magnet's aperture. Obtained images were used for neuronavigated cyst evacuation via burr hole trephination after repositioning the OR table. Subsequent intraoperative imaging documented collapse of the cyst at the end of the procedure. There were no adverse effects resulting from the combination of semi-sitting position and iMRI guidance. CONCLUSION This report demonstrates for the first time that the combination of iMRI and the semi-sitting position is feasible and that this procedure bears specific benefits. Issues such as brain shift due to table tilting warrant further investigations in order to expand this technique to posterior fossa craniotomies.
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Affiliation(s)
- Thomas Gasser
- Department of Neurosurgery, University of Duisburg-Essen, Hufelandstr. 55, 45122 Essen, Germany.
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Goldstein S. Pro: The General Anesthesiologist Should Be Trained and Certified in Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2010; 24:183-8. [DOI: 10.1053/j.jvca.2009.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2009] [Indexed: 11/11/2022]
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