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Teixidor-Rodríguez P, Brugada-Bellsolà F, Menéndez-Girón S, Tardáguila-Serrano M, González-Crespo A, Nuñez-Marín F, Montané E, Busquets-Bonet J, Muñoz-Narbona L, Domínguez-Alonso CJ. Effectiveness and safety of Tachosil® as a ventricular sealant: an observational cohort study. Acta Neurochir (Wien) 2024; 166:384. [PMID: 39331127 DOI: 10.1007/s00701-024-06276-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 09/18/2024] [Indexed: 09/28/2024]
Abstract
PURPOSE Surgery close to or in contact with the ventricular system is challenging due to the complications. We sought to evaluate the effectiveness and safety of TachoSil® as a ventricular sealant in preventing complications after cranial surgery with an open ventricular system (OVS). METHODS This is a single-center and prospective cohort study We included patients who underwent elective surgery for supratentorial craniotomy and periventricular pathology between December 2020 and November 2023. We registered surgical complications arising from CSF dynamics (such as percutaneous cerebrospinal fluid (CSF) leakage, hydrocephalus, pseudomeningocele), infections, and other complications (postsurgical hematoma) adverse drug reactions (ADRs), reintervention or hospital readmission up to 90 days after surgery. RESULTS Forty interventions were performed on 39 patients, whose median age was 56 years. Eleven patients (28.2%) had antecedents of previous surgery in the same location, 5 (12.8%) had previously received radiotherapy and chemotherapy, and 11 (28.2%) were smokers. Twenty-four patients (60%) underwent surgery for high-grade glioma, 8 (20%) for low-grade gliomas, 6 (15%) for metastasis and 2 (5%) for meningioma. Throughout the study and up to 90 days after surgery, none of the patients presented an ADR. Only 2 patients (5%) presented with a surgery complications derived from ventricular opening (one patient with a percutaneous CSF leakage and one patients with external hydrocephalus). Both patients resolved with a ventriculoperitoneal shunt. CONCLUSIONS TachoSil® is a dural sealant that can be used safely and effectively intraparenchymally in patients whose surgery involves a ventricular opening. Only 5% of treated patients presented complications arising from CSF hydrodynamics. No patients had pseudomeningocele, infections or complications related to the use of this sealant. To confirm these positive results, randomized and comparative clinical trials assessing the efficacy of TachoSil® in patients after cranial surgery with an OVS are essential. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION This study was registered in the Clinical Trials.gov (NCT05717335). Date May 1st, 2022.
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Affiliation(s)
- Pilar Teixidor-Rodríguez
- Department of Neurological Surgery, Hospital Universitari Germans Trias I Pujol, Ctra del Canyet Sn, CP 08916, Barcelona, Badalona, Spain.
| | - Ferran Brugada-Bellsolà
- Department of Neurological Surgery, Hospital Universitari Germans Trias I Pujol, Ctra del Canyet Sn, CP 08916, Barcelona, Badalona, Spain
| | - Sebastián Menéndez-Girón
- Department of Neurological Surgery, Hospital Universitari Germans Trias I Pujol, Ctra del Canyet Sn, CP 08916, Barcelona, Badalona, Spain
| | - Manuel Tardáguila-Serrano
- Department of Neurological Surgery, Hospital Universitari Germans Trias I Pujol, Ctra del Canyet Sn, CP 08916, Barcelona, Badalona, Spain
| | - Antonio González-Crespo
- Department of Neurological Surgery, Hospital Universitari Germans Trias I Pujol, Ctra del Canyet Sn, CP 08916, Barcelona, Badalona, Spain
| | - Fidel Nuñez-Marín
- Fidel Nuñez Marín, Image Radiology Institut, Hospital Vall d´Hebrón, Barcelona, Spain
| | - Eva Montané
- Clinical Pharmacology Service, Hospital Universitari Germans Trias I Pujol, 08916, Barcelona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Spain
| | - Jordi Busquets-Bonet
- Department of Anesthesiology, Hospital Universitari Germans Trias I Pujol, Barcelona, Badalona, Spain
| | - Lucia Muñoz-Narbona
- Neurosciences Department, Germans Trias I Pujol Research Institute, Barcelona, Badalona, Spain
| | - Carlos Javier Domínguez-Alonso
- Department of Neurological Surgery, Hospital Universitari Germans Trias I Pujol, Ctra del Canyet Sn, CP 08916, Barcelona, Badalona, Spain
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Parenrengi MA, Suryaningtyas W. Management of cerebrospinal-fluid-related intracranial abnormalities in frontoethmoidal encephalocele using "Shunt algorithm for frontoethmoidal encephalocele" (SAFE). Neurosurg Rev 2024; 47:110. [PMID: 38459217 DOI: 10.1007/s10143-024-02342-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/26/2024] [Accepted: 03/03/2024] [Indexed: 03/10/2024]
Abstract
A cerebrospinal-fluid-related (CSF-related) problem occurred in 25-30% of frontoethmoidal encephalocele (FEE) cases. Since there was no algorithm or guideline, the judgment to treat the CSF-related problem often relies upon the surgeon's experience. In our institution, the early shunt was preferable to treat the problem, but it added risks to the children. We developed an algorithm, "Shunt Algorithm for Frontoethmoidal Encephalocele" (SAFE), to guide the surgeon in making the most reasonable decision. To evaluate the SAFE's efficacy in reducing unnecessary early shunting for FEE with CSF-related intracranial abnormality. Medical records of FEE patients with CSF-related abnormalities treated from January 2007 to December 2019 were reviewed. The patients were divided into two groups: before the SAFE group as group 1 (2007 - 2011) and after the SAFE group as group 2 (2012 - 2019). We excluded FEE patients without CSF-related abnormalities. We compared the number of shunts and the complications between the two groups. One hundred and twenty-nine patient's medical records were reviewed. The males were predominating (79 versus 50 patients) with an average age of 58.2±7.1 months old (6 to 276 months old). Ventriculomegaly was found in 18 cases, arachnoid cysts in 46 cases, porencephalic cysts in 19 cases, and ventricular malformation in 46 cases. Group 1, with a score of 4 to 7 (19 cases), received an early shunt along with the FEE repair. Complications occurred in 7 patients of this group. Group 2, with a score of 4-7, received shunts only after the complication occurred in 3 cases (pseudomeningocele unresponsive with conservative treatment and re-operation in 2 cases; a sign of intracranial hypertension in 1 case). No complication occurred in this group. Groups 1 and 2, with scores of 8 or higher (6 and 8 cases, respectively), underwent direct shunt, with one complication (exposed shunt) in each group. The SAFE decision algorithm for FEE with CSF-related intracranial abnormalities has proven effective in reducing unnecessary shunting and the rate of shunt complications.
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Affiliation(s)
- Muhammad Arifin Parenrengi
- Department of Neurosurgery, Universitas Airlangga Faculty of Medicine- Dr. Soetomo General Academic Hospital, Gedung Pusat Diagnostik Terpadu (GDC), Lantai 5, Surabaya, Indonesia.
| | - Wihasto Suryaningtyas
- Department of Neurosurgery, Universitas Airlangga Faculty of Medicine- Dr. Soetomo General Academic Hospital, Gedung Pusat Diagnostik Terpadu (GDC), Lantai 5, Surabaya, Indonesia
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Kim MC, Lee JJ, Lee E, Lee MH. The Use of Histoacryl Injections to Treat Subgaleal Cerebrospinal Fluid Collection After Cranioplasty. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01051. [PMID: 38330410 DOI: 10.1227/ons.0000000000001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Accepted: 11/29/2023] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Cranioplasty is an important and basic operation in the neurosurgical field. An emergency craniectomy is performed to control malignant cerebral edema. If the patient survives, cranioplasty is performed to restore the skull defect; however, subgaleal cerebrospinal fluid collection (SCSFC) may occur. The authors aimed to identify risk factors for postoperative SCSFC and effective solutions with the subgaleal Histoacryl injection. METHODS From January 2020 to December 2022, 154 craniectomies were performed at our hospital to relieve significant cerebral edema after traumatic brain injury; of these, 67 patients survived and underwent cranioplasty. Ten cases of postcranioplasty SCSFC were identified, among which 6 received subgaleal Histoacryl injection. RESULTS Among the 10 SCSFC cases, 3 resolved with compression after cerebrospinal fluid aspiration, and 1 resolved after revision surgery and dural closure. Histoacryl injection was attempted for the other 6 patients. A single injection was sufficient for SCSFC resolution in 3 patients. One patient required 2 injections, and another required 3 injections. The remaining patient underwent epiduroperitoneal shunt surgery because of SCSFC persistence after 3 Histoacryl injections. Five of 6 patients (83.3%) showed an improvement of more than 80% after Histoacryl injection. CONCLUSION Subgaleal Histoacryl injection is not considered a fundamental treatment for postoperative SCSFC but can be a successful alternative treatment.
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Affiliation(s)
- Min Chan Kim
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, School of Medicine, The Catholic University of Korea, Seoul, Korea
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4
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Kinaci A, Slot EMH, Kollen M, Germans MR, Amin-Hanjani S, Carlson AP, Majeed K, Depauw PRAM, Robe PA, Regli L, Charbel FT, van Doormaal TPC. Risk Factors and Management of Incisional Cerebrospinal Fluid Leakage After Craniotomy: A Retrospective International Multicenter Study. Neurosurgery 2023; 92:1177-1182. [PMID: 36688661 PMCID: PMC10158880 DOI: 10.1227/neu.0000000000002345] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 11/05/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Incisional cerebrospinal fluid (iCSF) leakage is a serious complication after intradural cranial surgery. OBJECTIVE To determine the incidence and risk factors of iCSF leakage after craniotomy. Secondarily, the complications after iCSF leakage and the success rate of iCSF leakage treatment was studied. METHODS All patients who underwent an intradural cranial surgery from 2017 to 2018 at 5 neurosurgical centers were retrospectively included. Data were retrieved from medical records with 2 months of follow-up. First, univariate regression analyses were performed. Subsequently, identified risk factors were evaluated in a multivariate regression analysis. RESULTS In total 2310 consecutive patients were included. Total iCSF leakage rate was 7.1% (n = 165). Younger age, male, higher body mass index, smoking, infratentorial surgery, and use of a dural substitute were associated with increased iCSF leakage risk, and use of a sealant reduced that risk. The odds for developing a wound infection and/or meningitis were 15 times higher in patients with iCSF leakage compared with patients without leakage. Initial conservative iCSF leakage treatment failed in 48% of patients. In 80% of cases, external cerebrospinal fluid drainage ceased the iCSF leakage. A total of 32% of patients with iCSF leakage required wound revision surgery. CONCLUSION iCSF leakage risk increases by younger age, higher body mass index, smoking, infratentorial craniotomy, and dural substitute use, whereas sealant use reduced the risk for iCSF leakage. The leak increases the risk of postoperative infections. When iCSF leakage occurs, immediate external cerebrospinal fluid drainage or wound revision should be considered.
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Affiliation(s)
- Ahmet Kinaci
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Emma M. H. Slot
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Mare Kollen
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Menno R. Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sepideh Amin-Hanjani
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Kashif Majeed
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Paul R. A. M. Depauw
- Department of Neurosurgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands
| | - Pierre A. Robe
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Luca Regli
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Fady T. Charbel
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Tristan P. C. van Doormaal
- Department of Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, the Netherlands
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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5
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Cerebrospinal fluid leakage after intradural spinal surgery in children. Childs Nerv Syst 2023; 39:1013-1019. [PMID: 36790491 PMCID: PMC10160141 DOI: 10.1007/s00381-022-05797-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/08/2022] [Indexed: 02/16/2023]
Abstract
PURPOSE This study aimed to establish the incidence of CSF leakage in children and associated complications after intradural spinal surgery in three tertiary neurosurgical referral centers and to describe the treatment strategies applied. METHODS Patients of 18 years or younger who underwent intradural spinal surgery between 2015 and 2021 in three tertiary neurosurgical referral centers were included. Patients who died or were lost to follow-up within six weeks after surgery were excluded. The primary outcome measure was CSF leakage within six weeks after surgery, defined as leakage of CSF through the skin. Secondary outcome measures included the presence of pseudomeningocele (PMC), meningitis, and surgical site infection (SSI). RESULTS We included a total of 75 procedures, representing 66 individual patients. The median age in this cohort was 5 (IQR = 0-13 years. CSF leakage occurred in 2.7% (2/75) of procedures. It occurred on days 3 and 21 after the index procedure, respectively. One patient was treated with a pressure bandage and an external lumbar drain on day 4 after diagnosis of the leak, and the other was treated with wound revision surgery on day 1 after the leak occurred. In total, 1 patient developed a PMC without a CSF leak which was treated with wound revision surgery. SSI occurred in 10.7%, which included both cases of CSF leak. CONCLUSIONS CSF leakage after intradural spinal surgery in the pediatric population is relatively rare (2.7%). Nevertheless, the clinical consequences with respect to secondary complications such as infection and the necessity for invasive treatment are serious.
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Liang B, Zhang Y, Lyon K, Soto JM, Nguyen A, Huang JH, Feng D. Successful Management of Iatrogenic Cranial Pseudomeningocele With Subgaleal Shunt. Cureus 2023; 15:e34513. [PMID: 36874315 PMCID: PMC9984227 DOI: 10.7759/cureus.34513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Iatrogenic pseudomeningocele is a common complication of cranial surgeries. However, there are no evidence-based guidelines on how to manage this condition. We report two cases of iatrogenic postoperative cranial pseudomeningocele that failed conservative management including compressive head dressing. Subgaleal shunt placement was utilized with successful resolution in both cases. We postulate that subgaleal shunt placement may be an effective method in the management of iatrogenic subgaleal pseudomeningocele.
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Affiliation(s)
- Buqing Liang
- Neurosurgery, Baylor Scott & White Health, Temple, USA
| | - Yilu Zhang
- Neurosurgery, Baylor Scott & White Health, Temple, USA
| | | | - Jose M Soto
- Neurosurgery, Baylor Scott & White Health, Temple, USA
| | | | - Jason H Huang
- Neurosurgery, Baylor Scott & White Health, Temple, USA
| | - Dongxia Feng
- Neurosurgery, Baylor Scott & White Health, Temple, USA
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7
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Lewis D, Sethuraman C, Varthalitis D. Rapid ossification of a giant post-operative occipital pseudomeningocele following posterior fossa surgery. Childs Nerv Syst 2023; 39:1347-1351. [PMID: 36680566 PMCID: PMC10167119 DOI: 10.1007/s00381-023-05829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/05/2023] [Indexed: 01/22/2023]
Abstract
Pseudomeningocele formation following posterior fossa surgery is a well-recognised complication, occurring in up to 33% of operated cases in some series. Ossification of a cranial pseudomeningocele is, however, an exceptionally rare event with only three prior reported cases. We present the unique case of a paediatric patient who developed rapid ossification of a giant occipital pseudomeningocele following posterior fossa surgery. An 8-year-old female patient underwent a midline posterior fossa craniotomy for resection of an exophytic brainstem low-grade glioma. Post-surgery, the patient developed pan-ventricular hydrocephalus and a large occipital pseudomeningocele, which initially increased in size despite a successful endoscopic third ventriculostomy (ETV) being performed. At approximately 3 months post-surgery, reduction of the pseudomeningocele was observed with associated prominent ossification of the pseudomeningocele wall on computed tomography (CT) imaging. Surgical excision was subsequently undertaken, and intra-operatively, a large ossified pseudomeningocele was found. Follow-up MRI 1 month later demonstrated almost complete resolution of the pseudomeningocele with an associated reduction in the degree of pan-ventricular ventriculomegaly. This case highlights that ossification of even giant pseudomeningoceles can occur over a time period of just a few months and clinicians should consider ossification whenever a change in size or consistency of a post-operative pseudomeningocele is encountered.
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Affiliation(s)
- Daniel Lewis
- Department of Paediatric Neurosurgery, Royal Manchester Children's Hospital, Manchester, UK.
- Division of Neuroscience and Experimental Psychology, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Chitra Sethuraman
- Department of Paediatric Histopathology, Royal Manchester Children's Hospital, Manchester Academic Health Science Centre, Manchester, UK
| | - Dimitrios Varthalitis
- Department of Paediatric Neurosurgery, Royal Manchester Children's Hospital, Manchester, UK
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Management of pseudomeningocele following posterior fossa tumor surgery with absence of hydrocephalus: A case report. Int J Surg Case Rep 2022; 98:107552. [PMCID: PMC9468414 DOI: 10.1016/j.ijscr.2022.107552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/22/2022] [Accepted: 08/22/2022] [Indexed: 11/22/2022] Open
Abstract
Background The management of pseudomeningocele can be challenging and treatment options vary in the literature. There is currently no algorithm or standard protocol regarding the type and timing of treatment. Until now, there has been a little literature and no case report that used puncture techniques as a conservative treatment. We reported the effectiveness of fluid puncture and pressure dressing as an aggressive nonsurgical management of pseudomeningocele. Case presentation A 5-year-old boy with posterior fossa tumor underwent midline suboccipital craniotomy tumor removal and decompression. A week after the surgery, the patient developed buldging in the operation region. Head CT scan showed pseudomeningocele in suboccipital region, a residual calcified tumor was seen, and no enlargement of ventricle. Conservative management was taken and the patient was managed with fluid puncture and pressure dressing. The reduction in size of the pseudomeningocele appeared within 14 days. Conclusion Pseudomeningocele is a common complication of posterior fossa surgery. Nonsurgical treatment is the management of choice to reduce the symptoms. Fluid puncture and pressure dressing are effective in reducing symptoms. Surgical intervention is recommended when conservative treatment fails. There is currently no standard protocol regarding the type and timing of pseudomeningocele treatment following posterior fossa tumor surgery. Nonoperative intervention is preferred for pseudomeningocele without hydrocephalus. This case reported that fluid aspiration and pressure dressing are effective in reducing symptoms. Surgical intervention should be reserved for failure of conservative treatment
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Incidence, Characteristics, and Outcomes of Pseudomeningocele and CSF Fistula after Posterior Fossa Surgery. World Neurosurg 2022; 164:e1094-e1102. [DOI: 10.1016/j.wneu.2022.05.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 05/21/2022] [Accepted: 05/23/2022] [Indexed: 11/22/2022]
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Hoffman H, Bunch KM, Paul T, Krishnamurthy S. Comparison of Pericranial Autograft and AlloDerm for Duraplasty in Patients With Type I Chiari Malformation: Retrospective Cohort Analysis. Oper Neurosurg (Hagerstown) 2021; 21:386-392. [PMID: 34634804 DOI: 10.1093/ons/opab343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 07/04/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Pericranial autograft is a popular option for duraplasty during Chiari decompression with several theoretical advantages, but comparisons to other materials have yielded mixed results. OBJECTIVE To compare outcomes between pericranial autograft and AlloDerm (BioHorizons). METHODS Consecutive suboccipital craniectomies for patients with type I Chiari malformation (CM-I) over an 8-yr period at a single institution were identified. Exclusion criteria included revision surgeries and suboccipital decompressions without duraplasty. Outcomes included incisional cerebrospinal fluid (CSF) leakage, length of stay (LOS), wound complication, aseptic meningitis, syrinx improvement, and symptomatic improvement. RESULTS A total of 101 patients (70 females and 31 males) with a median (interquartile range) age of 17 yr (11-32) met the inclusion criteria. There were 51 (50%) patients who underwent duraplasty with pericranial autograft, and the remainder underwent duraplasty with AlloDerm. There were 9 (9%) patients who experienced a postoperative CSF leak. After adjusting for confounding factors, obesity (odds ratio [OR]: 4.69, 95% CI: 1.03-25.6) and use of AlloDerm (OR: 10.54, 95% CI: 1.7-206.12) were associated with CSF leak. Wound complication occurred in 8 (8%) patients but was not associated with graft type (P = .8). Graft type was not associated with LOS, syrinx improvement, or symptom improvement. Reoperations occurred in 10 patients with 4 in the autograft group and 6 in the AlloDerm group (P = .71). CONCLUSION In patients with CM-I, expansile duraplasty with AlloDerm was associated with greater odds of CSF leakage than pericranial autograft. Obesity was also associated with increased odds of CSF leakage.
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Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Katherine M Bunch
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Tyler Paul
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Satish Krishnamurthy
- Department of Neurosurgery, State University of New York Upstate Medical University, Syracuse, New York, USA
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Balasa A, Kunert P, Dziedzic T, Bielecki M, Kujawski S, Marchel A. Comparison of dural grafts and methods of graft fixation in Chiari malformation type I decompression surgery. Sci Rep 2021; 11:14801. [PMID: 34285298 PMCID: PMC8292506 DOI: 10.1038/s41598-021-94179-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 06/25/2021] [Indexed: 12/26/2022] Open
Abstract
Suboccipital decompression with duraplasty is a widely accepted method for treating patients with Chiari malformation type I. However, important details of the duraplasty technique are still controversial. This retrospective study analyzes clinical and radiological outcomes after surgery depending upon the type of graft and methods of graft fixation. Seventy consecutive decompressions with duraplasty were analyzed. Two types of grafts, nonautologous (Non-AutoG; 60.0%) and autologous (AutoG; 40.0%), and two methods of graft fixation, suturing (S; 67.1%) and gluing (G; 32.9%), were used in four different combinations: (Non-AutoG+S: 31.4%; Non-AutoG+G: 28.6%; AutoG+S: 35.7%; AutoG+G: 4.3%) according to surgeon preference. The mean follow-up was 63.4 months. According to gestalt and Chicago Chiari Outcome Scales, satisfactory results were obtained in 72.9% and 78.6% of cases, respectively, in the long term. The outcomes were not related to the kind of graft (p = 0.44), fixation method (p = 0.89) or duraplasty pattern (p = 0.32). Decreased syringomyelia was observed in 88.9% of cases, and no associations with the kind of graft (p = 0.84), fixation method (p = 1) or duraplasty pattern were found (p = 0.96). Pseudomeningocele occurred 5 times more often in the Non-AutoG group than in the AutoG group (52.4% vs. 10.7%; p < 0.05), whereas their formations were not related to the fixation method (p = 0.34). Three cases (12.0%) required reoperation with reduraplasty. Autologous and nonautologous dural grafts can be sutured or glued with similar clinical results; however, the use of nonautologous grafts is linked with a much higher risk of pseudomeningocele formation.
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Affiliation(s)
- Artur Balasa
- Department of Neurosurgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland.
| | - Tomasz Dziedzic
- Department of Neurosurgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
| | - Mateusz Bielecki
- Department of Neurosurgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
| | - Sławomir Kujawski
- Division of Ergonomics and Exercise Physiology, Department of Hygiene, Epidemiology, Ergonomics and Postgraduate Training, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, M. Sklodowskiej-Curie 9, 85-094, Bydgoszcz, Poland
| | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, ul. Banacha 1a, 02-097, Warsaw, Poland
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12
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Basil GW, Kumar V, Wang MY. Optimizing Visualization in Endoscopic Spine Surgery. Oper Neurosurg (Hagerstown) 2021; 21:S59-S66. [PMID: 34128069 DOI: 10.1093/ons/opaa382] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/21/2020] [Indexed: 12/30/2022] Open
Abstract
Given the inherent limitations of spinal endoscopic surgery, proper lighting and visualization are of tremendous importance. These limitations include a small field of view, significant potential for disorientation, and small working cannulas. While modern endoscopic surgery has evolved in spite of these shortcomings, further progress in improving and enhancing visualization must be made to improve the safety and efficacy of endoscopic surgery. However, in order to understand potential avenues for improvement, a strong basis in the physical principles behind modern endoscopic surgery is first required. Having established these principles, novel techniques for enhanced visualization can be considered. Most compelling are technologies that leverage the concepts of light transformation, tissue manipulation, and image processing. These broad categories of enhanced visualization are well established in other surgical subspecialties and include techniques such as optical chromoendoscopy, fluorescence imaging, and 3-dimensional endoscopy. These techniques have clear applications to spinal endoscopy and represent important avenues for future research.
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Affiliation(s)
- Gregory W Basil
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Vignessh Kumar
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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Tran DDT, Dinh TPH, Nguyen QB, Mai DT, Truong VT. Spontaneous Resolution of Postoperative Giant Frontal Pseudomeningocele. Asian J Neurosurg 2021; 16:372-375. [PMID: 34268167 PMCID: PMC8244681 DOI: 10.4103/ajns.ajns_18_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/01/2021] [Indexed: 11/18/2022] Open
Abstract
Cranial pseudomeningoceles are abnormal extradural collections of cerebrospinal fluid. Postoperative giant cranial pseudomeningoceles have been rarely reported in the literature and have no specific treatment guidelines. The optimal management strategy for this condition differs among authors, varying from conservative approach to surgical intervention. A spontaneous resolution of postoperative giant frontal pseudomeningocele is reported. A 41-year-old female presented a pseudomeningocele 3 weeks after a right frontal meningioma surgical resection. The pseudomeningocele progressed during the first 1.5-month postoperatively despite percutaneous aspiration and compressive bandage, it then shrank spontaneously and was completely resolved at the 15th month since the surgery. Nonoperative treatment with a close follow-up could be a good option for asymptomatic giant pseudomeningoceles, resulting in a spontaneous resolution.
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Affiliation(s)
- Duc Duy Tri Tran
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam.,Department of Neurosurgery, Xuyen A Hospital, Ho Chi Minh City, Vietnam
| | - Thi Phuong Hoai Dinh
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Quoc Bao Nguyen
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Dang Thi Mai
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam
| | - Van Tri Truong
- Department of Neurosurgery, Hue University Hospital, Hue University of Medicine and Pharmacy, Hue University, Hue, Vietnam.,Division of Orthopedics, Central Hospital of University of Montreal, University of Montreal, Montreal, Canada
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14
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Wang ZW, Fan XW, Wang Z, Du PY, Gao XD, Ding WY, Yang DL. Repair of Delayed Meningeal Cyst after Spinal Surgery with Paraspinal Muscle Flap under Microscope. J INVEST SURG 2021; 35:723-730. [PMID: 34039249 DOI: 10.1080/08941939.2021.1924899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Delayed meningeal cyst (DMC) is a rare complication after spinal surgery that is often ignored by clinicians, and its in-depth research is infrequent. In particular, no consensus has been reached about its surgical treatment. We found that patients with a DMC failed after conservative treatment, epidural blood patch, subarachnoid drainage, and initial attempts to eliminate the meningeal cyst. Therefore, we introduce the application of a paraspinal muscle flap repair under a microscope for the treatment of DMC. METHODS In this study, 13 patients who were repaired by a paraspinal muscle flap under a microscope for DMC from January 2007 to January 2017 were retrospectively reviewed. Their ages were 18-68 years old (mean age 48.7 years). The course of the disease ranged from 3 weeks to 28 months after the operation for the primary disease, with an average of 10.6 months. Length >5 cm was called a large DMC and length >8 was called a giant DMC. By analyzing the effect of surgical treatment, we summarized the treatment experience of DMC and evaluated the risk factors for the formation of DMC. RESULTS All patients were treated with paraspinal muscle flap repair under a microscope, and they healed well after the operation. There was no cerebrospinal fluid leakage or other operation-related complication. The mean follow-up was 16.5 months. Reexamination of the spine MRI showed no recurrence of the DMC. CONCLUSIONS The application of paraspinal muscle flap under a microscope combined with glue, bedrest, and CSF drain, was an effective option for the patients with DMC.
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Affiliation(s)
- Zhi-Wei Wang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Xi-Wen Fan
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Zheng Wang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Pei-Yu Du
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Xian-Da Gao
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China
| | - Wen-Yuan Ding
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China.,Hebei Provincial Key Laboratory of Orthopaedic Biomechanics, Shijiazhuang, PR China
| | - Da-Long Yang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, PR China
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15
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Mishinov S, Samokhin A, Panchenko A, Stupak V. A titanium implant for Chiari malformation Type 1 surgery. Surg Neurol Int 2021; 12:72. [PMID: 33767876 PMCID: PMC7982118 DOI: 10.25259/sni_960_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 01/21/2021] [Indexed: 11/04/2022] Open
Abstract
Background Concepts of Chiari malformation Type 1 (CM1) surgery in the present time significantly different. The most common complications are pseudomeningocele (12%) and postoperative CSF leak (5%). The development of pseudomeningocele may be associated with inappropriate restoration of bone and muscles relations. Methods The pilot study involved 11 patients aged 24-64 years with a diagnosis of CM1 who had indications for surgical treatment. Special titanium implant enabling fixation of the occipital and cervical muscles at the projections of their normal attachments was developed, it was placed to occipital bone on the final stages of surgical intervention. Surgical technique promoted tightened wound closure neutralizing formation of "dead space" at the place of occipital craniectomy and between muscle layers. The implant was produced by direct metal laser sintering method for each patient individually. Results There were no complications during the hospitalization and follow-up period. Postoperative MRI demonstrated adequate formation of the cisterna magna and the absence of pseudomeningocele. During follow-up period there were no signs of pseudomeningocele, CSF leak, surgical scar complications, implant-associated infections, and other complications. Conclusion In the study group, no pseudomeningocele cases as long as any other complications associated with surgery had been revealed. The efficacy of the proposed surgical technique using the developed implant should be evaluated in clinical trials with larger patient samples. To simplify preoperative planning and manufacturing of the implant for each patient individually, a set of implants with different specified sizes was developed.
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Affiliation(s)
- Sergey Mishinov
- Department of Neurosurgery, Novosibirsk Scientific Research Institute of Traumatology and Orthopedics, Ya.L. Tsivyan, Russian Federation
| | - Alexander Samokhin
- Department of Experimental, Novosibirsk Scientific Research Institute of Traumatology and Orthopedics, Ya.L. Tsivyan, Russian Federation
| | - Andrey Panchenko
- Department of 3D Printing, LLC Logeeks MS, Novosibirsk, Russian Federation
| | - Vyacheslav Stupak
- Department of Neurosurgery, Novosibirsk Scientific Research Institute of Traumatology and Orthopedics, Ya.L. Tsivyan, Russian Federation
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16
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Taydas O, Ogul H, Gozgec E, Kantarci M. Evaluation of craniocervical pseudomeningoceles with three-dimensional T2-SPACE sequence at 3T. Acta Radiol 2021; 62:80-86. [PMID: 32208742 DOI: 10.1177/0284185120912507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pseudomingocele is a postoperative fluid collection adjacent to the dural membrane. The distinction of pseudomeningocele from other postoperative collections is very important. PURPOSE To show the efficacy of three-dimensional (3D) T2-weighted sampling perfection with application-optimized contrasts using a different flip-angle evolution (SPACE) magnetic resonance imaging (MRI) sequence in the diagnosis of pseudomeningocele in which conventional MRI sequences may be insufficient. MATERIAL AND METHODS A total of 10 patients were included in the study. All of these patients also had 3D T2-SPACE high-resolution volumetric MR image in addition to conventional cervical and cerebral MR sequences. All MR examinations were reviewed by two neuroradiologists. RESULTS Pseudomeningocele neck was shown in six patients by both conventional sequences and SPACE sequence. In two patients, the neck was only shown in the SPACE sequence. Four pseudomeningocele necks were shown to have flow void with both conventional sequences and SPACE sequence. Flow void could only be demonstrated by SPACE sequence in two patients. CONCLUSION A T2-SPACE sequence can show the presence of pseudomeningocele neck and flow void even in cases where conventional MRI cannot show, thus contributing to the diagnosis of pseudomeningocele. Therefore, especially in postoperative imaging, the T2-SPACE sequence may be included in routine sequences to make the differential diagnosis correctly.
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Affiliation(s)
- Onur Taydas
- Department of Radiology, Medical Faculty, Sakarya University, Sakarya, Turkey
| | - Hayri Ogul
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
| | - Elif Gozgec
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
| | - Mecit Kantarci
- Department of Radiology, Medical Faculty, Ataturk University, Erzurum, Turkey
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17
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Slot EMH, van Baarsen KM, Hoving EW, Zuithoff NPA, van Doormaal TPC. Cerebrospinal fluid leakage after cranial surgery in the pediatric population-a systematic review and meta-analysis. Childs Nerv Syst 2021; 37:1439-1447. [PMID: 33538867 PMCID: PMC8084768 DOI: 10.1007/s00381-021-05036-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/01/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leakage is a common complication after neurosurgical intervention. It is associated with substantial morbidity and increased healthcare costs. The current systematic review and meta-analysis aim to quantify the incidence of cerebrospinal fluid leakage in the pediatric population and identify its risk factors. METHODS The authors followed the PRISMA guidelines. The Embase, PubMed, and Cochrane database were searched for studies reporting CSF leakage after intradural cranial surgery in patients up to 18 years old. Meta-analysis of incidences was performed using a generalized linear mixed model. RESULTS Twenty-six articles were included in this systematic review. Data were retrieved of 2929 patients who underwent a total of 3034 intradural cranial surgeries. Surprisingly, only four of the included articles reported their definition of CSF leakage. The overall CSF leakage rate was 4.4% (95% CI 2.6 to 7.3%). The odds of CSF leakage were significantly greater for craniectomy as opposed to craniotomy (OR 4.7, 95% CI 1.7 to 13.4) and infratentorial as opposed to supratentorial surgery (OR 5.9, 95% CI 1.7 to 20.6). The odds of CSF leakage were significantly lower for duraplasty use versus no duraplasty (OR 0.41 95% CI 0.2 to 0.9). CONCLUSION The overall CSF leakage rate after intradural cranial surgery in the pediatric population is 4.4%. Risk factors are craniectomy and infratentorial surgery. Duraplasty use is negatively associated with CSF leak. We suggest defining a CSF leak as "leakage of CSF through the skin," as an unambiguous definition is fundamental for future research.
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Affiliation(s)
- Emma M. H. Slot
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Kirsten M. van Baarsen
- Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Eelco W. Hoving
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands ,Department of Neuro-oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Nicolaas P. A. Zuithoff
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Tristan P. C van Doormaal
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands ,Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
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18
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Moussalem C, Ftouni L, Mrad ZA, Amine A, Hamideh D, Baassiri W, Bali B, Najjar M. Pediatric posterior fossa tumors outcomes: Experience in a tertiary care center in the Middle East. Clin Neurol Neurosurg 2020; 197:106170. [PMID: 32861036 DOI: 10.1016/j.clineuro.2020.106170] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/11/2020] [Accepted: 08/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Among all childhood cancers, brain tumors are second only to leukemia in incidence and are the most common solid pediatric tumors. More than 60 % of pediatric brain tumors are infra-tentorial. The first-line treatment for most infra-tentorial tumors in pediatric patients is surgical resection, with the goal of gross-total resection, relief of symptoms and hydrocephalus, and increased survival. The proximity to the fourth ventricle, and therefore, the cerebrospinal fluid (CSF) pathways, predisposes children with posterior fossa tumors to the development of obstructive hydrocephalus and multiple other co-morbidities pre and post-surgery. OBJECTIVES This study aims to present our series of pediatric posterior fossa tumor surgeries in the Neurosurgical Department at the American University of Beirut Medical Center(AUBMC) and perform internal quality control for our single-institution consecutive series as one of the largest referral and tertiary care centers in the region. The second purpose of this retrospective study is to weigh the risks of surgery against the presumed advantages and to have specific knowledge about the complication rates, especially those related to the CSF pathway, comparing our results to those in the literature. METHODS All pediatric patients (< 18 years of age), referred to our center from different regions in the middle east, and surgically treated for a posterior fossa tumor from June 2006 to June 2018 at the American University of Beirut Medical Center were included. A thorough review of all medical charts was performed to validate all the database records. RESULTS The patient sample consisted of 64 patients having a mean age of 6.19 ± 4.42 years and 59.37 % of whom were males. The most common tumor pathology was pilocytic astrocytoma (40.62 %) followed by medulloblastoma (35.93 %) and ependymoma. The most common type of tumor that was seen in patients that developed mutism postoperatively (n = 6, 9.37 %) was medulloblastoma (n = 4, 66.66 %). In this patient sample, 12.28 % (n = 7) of the patients developed hydrocephalus postoperatively.Midline tumors were more associated with the development of mutism(OR = 4.632, p = 0.306) and hydrocephalus (OR = 5.056, p = 0.135) postoperatively, albeit not statistically significantly.The presence of a preoperative shunt was shown to be protective against the development of CSF leak (OR = 0.636, p = 0.767), as none of the patients that came in with CSF diversion developed a CSF leak after their surgery. CONCLUSION This study from a single center experience accompanied by a thorough literature review sheds light on the complications frequently encountered after posterior fossa tumor surgery in children. These included transient cerebellar mutism, CSF leak, and hydrocephalus as seen in some of our patients. Our findings highlight the need for prospective studies with well-defined protocols directed at assessing novel ways and approaches to minimize the risk of these complications.
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Affiliation(s)
- Charbel Moussalem
- Neurosurgery Department, American university of Beirut Medical Center, Lebanon
| | - Louna Ftouni
- Faculty of Medecine, Beirut Arab University, Lebanon
| | - Zaki Abou Mrad
- Neurosurgery Department, American university of Beirut Medical Center, Lebanon
| | - Ali Amine
- Neurosurgery Department, American university of Beirut Medical Center, Lebanon
| | - Dima Hamideh
- Department of pediatrics and adolescent medicine, American University of Beirut Medical Center, Lebanon
| | - Wassim Baassiri
- Neurosurgery Department, American university of Beirut Medical Center, Lebanon
| | - Bassel Bali
- Neurosurgery Department, American university of Beirut Medical Center, Lebanon
| | - Marwan Najjar
- Neurosurgery Department, American university of Beirut Medical Center, Lebanon.
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19
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Shu W, Wang H, Zhu H, Li Y, Zhang J, Lu G, Ni B. Nerve root entrapment with pseudomeningocele after percutaneous endoscopic lumbar discectomy: A case report. J Spinal Cord Med 2020; 43:552-555. [PMID: 30211668 PMCID: PMC7480581 DOI: 10.1080/10790268.2018.1507802] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Context: Pseudomeningocele is a relatively uncommon postoperative complication of spine surgery. Although the condition tends to be asymptomatic and self-limiting, it may cause radicular pain and neurological defect due to herniation of the nerve root or the spinal cord. Its pathophysiology remains unclear. Only few cases with intraoperative photos have been reported. Finding: We present a case of pseudomeningocele with nerve root entrapment after percutaneous endoscopic lumbar discectomy (PELD). A 52-year-old man had undergone PELD for sciatic pain and showed good postoperative recovery. Unfortunately, he was readmitted for progressive right leg pain at six weeks after the surgery. After the failure of conservative therapy, he received PELD again to explore the surgical site. Intraoperatively, a pseudomeningocele-containing nerve root, herniating through a small defect in the dural sac, was identified. During the dissection process, the pseudomeningocele was broken, which led to entrapment of the nerve root. Thereafter, the microsurgical technique was adopted to relocate the nerve root into the thecae sac and to repair the dural tear by non-resorbable suture. Conclusion: To our knowledge, this case report is the first documented instance of identification of a pseudomeningocele under an endoscope, and provides insights into the transformation of a pseudomeningocele into a cerebrospinal fluid fistula with nerve root entrapment. For neurological deficit caused by pseudomeningocele following PELD, operative revision by the microsurgery technique is the appropriate strategy.
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Affiliation(s)
- Wei Shu
- Beijing Institute of Function Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Haipeng Wang
- Beijing Institute of Function Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Hongwei Zhu
- Beijing Institute of Function Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Yongjie Li
- Beijing Institute of Function Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Jiaxing Zhang
- Beijing Institute of Function Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Guang Lu
- Beijing Institute of Function Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
| | - Bing Ni
- Beijing Institute of Function Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, People’s Republic of China
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20
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Norrdahl SP, Jones TL, Dave P, Hersh DS, Vaughn B, Klimo P. A hospital-based analysis of pseudomeningoceles after elective craniotomy in children: what predicts need for intervention? J Neurosurg Pediatr 2020; 25:462-469. [PMID: 32005010 DOI: 10.3171/2019.11.peds19227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 11/06/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In pediatric patients, the development of a postoperative pseudomeningocele after an elective craniotomy is not unusual. Most will resolve with time, but some may require intervention. In this study, the authors analyzed patients who required intervention for a postoperative pseudomeningocele following an elective craniotomy or craniectomy and identified factors associated with the need for intervention. METHODS An institutional operative database of elective craniotomies and craniectomies was queried to identify all surgeries associated with development of a postoperative pseudomeningocele from January 1, 2010, to December 31, 2017. Demographic and surgical data were collected, as were details regarding postoperative events and interventions during either the initial admission or upon readmission. A bivariate analysis was performed to compare patients who underwent observation with those who required intervention. RESULTS Following 1648 elective craniotomies or craniectomies, 84 (5.1%) clinically significant pseudomeningoceles were identified in 82 unique patients. Of these, 58 (69%) of the pseudomeningoceles were diagnosed during the index admission (8 of which persisted and resulted in readmission), and 26 (31%) were diagnosed upon readmission. Forty-nine patients (59.8% of those with a pseudomeningocele) required one or more interventions, such as lumbar puncture(s), lumbar drain placement, wound exploration, or shunt placement or revision. Only race (p < 0.01) and duraplasty (p = 0.03, OR 3.0) were associated with the need for pseudomeningocele treatment. CONCLUSIONS Clinically relevant pseudomeningoceles developed in 5% of patients undergoing an elective craniotomy, with 60% of these pseudomeningoceles needing some form of intervention. The need for intervention was associated with race and whether a duraplasty was performed.
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Affiliation(s)
| | - Tamekia L Jones
- Departments of2Pediatrics and
- 3Preventive Medicine, University of Tennessee Health Science Center, Memphis
- 4Children's Foundation Research Institute, Memphis
| | | | - David S Hersh
- 6Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
- 7Le Bonheur Children's Hospital, Memphis; and
| | | | - Paul Klimo
- 6Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
- 7Le Bonheur Children's Hospital, Memphis; and
- 8Semmes Murphey, Memphis, Tennessee
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21
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Zhao Y, Chen L, Zhang J, You N, Liu Y, Yao A, Zhao K, Zhang J, Xu B. Duraplasty with Cervical Fascia Autograft to Reduce Postoperative Complications of Posterior Fossa Tumor Surgery with Suboccipital Midline Approach. World Neurosurg 2019; 134:e1115-e1120. [PMID: 31785439 DOI: 10.1016/j.wneu.2019.11.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The suboccipital midline approach is common dealing with posterior fossa tumors but has a high risk of postoperative complications, such as pseudomeningocele, cerebrospinal fluid (CSF) leak, and meningitis. Neurosurgeons used various kinds of method to lower its rate. METHODS A retrospective, single-center review of patients diagnosed with posterior fossa tumor underwent a suboccipital midline approach. Compare the rates of pseudomeningocele, CSF leak, and meningitis between 2 groups (artificial dura mater or cervical fascia autograft). We get the cervical fascia autograft from the superficial layer of deep cervical fascia just above the trapezius. RESULTS Our retrospective review involved 123 patients matching the inclusion criteria between January 2009 and April 2019. The complication rate of pseudomeningocele, CSF leak and meningitis were 8.9%, 4.9%, and 17.9%, respectively. The presence of pseudomeningocele or CSF leak for group "artificial" was 11 of 75 (14.67%) and for group "autograft" it was 3 of 48 (6.25%). The rate of meningitis for group "artificial" (24.0%, 18 of 75) was significantly higher (P = 0.027) than the one for group "autograft" (8.33%, 4 of 48). Multivariate regression analysis suggested that the age was negatively correlated with postoperative pseudomeningocele or CSF leak (P = 0.006), with meningitis (P < 0.001). Using cervical fascia autograft decreased the rate of meningitis (P = 0.021) while showing no statistically significant clinical impact on pseudomeningocele or CSF leak. CONCLUSIONS Applying the cervical fascia autograft to reconstruct the dura during posterior fossa surgery is a simple and effective method to reduce the rate of meningitis as compared with artificial dura mater.
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Affiliation(s)
- Yue Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Li Chen
- Department of Radiology, People's Hospital of Qinghai Province, Xining, Qinghai, China
| | - Jiashu Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Na You
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Yuyang Liu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Anhui Yao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Kai Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Jun Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Bainan Xu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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22
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Suter A, Spirig JM, Fornaciari P, Bachmann E, Götschi T, Klein K, Farshad M. Watertightness of wound closure in lumbar spine-a comparison of different techniques. JOURNAL OF SPINE SURGERY (HONG KONG) 2019; 5:358-364. [PMID: 31663047 PMCID: PMC6787369 DOI: 10.21037/jss.2019.08.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/19/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Since a primary watertight dural suture after incidental durotomies has a failure rate of 5-10%, a watertight closure technique of the overlying layers (fascia, subcutis and skin) is essential. The purpose of this cadaveric study was to find the most watertight closure technique for fascia, subcutis and skin. METHODS Different suturing techniques were tested for each layer in a sheep cadaveric model by measuring the leakage pressure. The specimens were mounted on a pressure chamber connected to a manometer and a water tube system. Subsequently, the leakage was over-sewed with a cross stitch and the experiment was repeated. RESULTS Cross stitch suturing [median =180 mbar (43; 660)] performed best compared to continuous [median =16 mbar (6; 52)] (P=0.003) but not to single knot [median =118 mbar (21; 387)] (P=1.0) or locking stitch suturing [median =109 mbar (3; 149)] (P=0.93) for fascia closure. Continuous suture [median =9 mbar (3; 14)] resulted in a higher leakage pressure than single knot [median =1 mbar (1; 6)] (P=0.017) for subcutaneous closure. No significant differences were found between intracutaneous, Donati-continuous, single knot and locking stitch for skin closures (P=0.075). However, the Donati-continuous stitch closure resulted in higher pressures in tendency. Over-sewing increased median leakage pressure from 8.0 to 11.0 mbar (P=0.068) and from 4.0 to 13.0 mbar (P=0.042) for single knot and for locking stitch skin closures, respectively. CONCLUSIONS Cross stitches for the fascia, continuous suturing technique for the subcutis and Donati-continuous stitch for the skin resulted in the most watertight closure within this experimental setting. If leakage occurs, over-sewing might relevantly improve the watertightness of the wound.
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Affiliation(s)
- Aline Suter
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - José Miguel Spirig
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Paolo Fornaciari
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Elias Bachmann
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Switzerland Laboratory for Orthopedic Biomechanics, Swiss Federal Institute of Technology in Zurich (ETHZ), Zurich, Switzerland
| | - Tobias Götschi
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Switzerland Laboratory for Orthopedic Biomechanics, Swiss Federal Institute of Technology in Zurich (ETHZ), Zurich, Switzerland
| | - Karina Klein
- Vetsuisse, Musculoskeletal Research Unit (MSRU), University of Zurich, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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23
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Hart A, Brzozowski M, Chenkin J. Young Man With Unilateral Neck Swelling. Ann Emerg Med 2019; 72:e13-e14. [PMID: 30031517 DOI: 10.1016/j.annemergmed.2018.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Alexander Hart
- Division of Emergency Ultrasound, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada
| | - Michael Brzozowski
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Chenkin
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Evaluative Clinical Sciences, Trauma, Emergency and Critical Care Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
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Galan D, Monuszko K, Sankey EW, Zakare-Fagbamila R, Yang Z, Niedzwiecki D, Gottfried O, Bagley CA, Krucoff MO. Fibrin glue as an adjuvant dural sealant reduces the rate of perioperative complications in posterior fossa decompression with duraplasty: A single center experience in 165 adult Chiari I patients. J Clin Neurosci 2019; 68:80-85. [PMID: 31327584 DOI: 10.1016/j.jocn.2019.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 07/07/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Diego Galan
- Duke University School of Medicine, United States
| | | | - Eric W Sankey
- Department of Neurosurgery, Duke University Medical Center, United States.
| | | | - Zidanyue Yang
- Department of Biostatistics and Bioinformatics, Duke University, United States
| | - Donna Niedzwiecki
- Department of Biostatistics and Bioinformatics, Duke University, United States
| | | | - Carlos A Bagley
- Department of Neurosurgery, University of Texas Southwestern Medical Center, United States
| | - Max O Krucoff
- Department of Neurosurgery, Duke University Medical Center, United States
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Li Z, Chen YA, Chow D, Talbott J, Glastonbury C, Shah V. Practical applications of CISS MRI in spine imaging. Eur J Radiol Open 2019; 6:231-242. [PMID: 31304197 PMCID: PMC6603258 DOI: 10.1016/j.ejro.2019.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/21/2019] [Accepted: 06/10/2019] [Indexed: 01/09/2023] Open
Abstract
Conventional spin echo imaging is limited by low spatial resolution and CSF pulsation artifact. CISS MRI enables submillimeter spatial resolution and myelographic contrast. Inherent flow compensation of the CISS technique reduces CSF pulsation artifact. CISS improves the delineation of a wide variety of spinal pathologies.
Routine magnetic resonance imaging evaluation of the spine is often limited by low spatial resolution and artifacts resulting from cerebrospinal fluid pulsation. Balanced steady-state free precession sequences can supplement routine spin echo sequences and provide exquisite anatomic detail and high cerebrospinal fluid-to-soft tissue contrast, adding significant diagnostic value to the evaluation of a wide variety of spine disorders.
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Affiliation(s)
- Zhixi Li
- Department of Radiology and Biomedical Imaging, University of California, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA
| | - Yingming Amy Chen
- Department of Radiology and Biomedical Imaging, University of California, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA
| | - Daniel Chow
- Department of Radiology and Biomedical Imaging, University of California, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA
| | - Jason Talbott
- Department of Radiology and Biomedical Imaging, University of California, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA
| | - Christine Glastonbury
- Department of Radiology and Biomedical Imaging, University of California, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA
| | - Vinil Shah
- Department of Radiology and Biomedical Imaging, University of California, 505 Parnassus Avenue, M-391, San Francisco, CA 94143-0628, USA
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Raudenbush BL, Molinari A, Molinari RW. Large Compressive Pseudomeningocele Causing Early Major Neurologic Deficit After Spinal Surgery. Global Spine J 2017; 7:206-212. [PMID: 28660101 PMCID: PMC5476350 DOI: 10.1177/2192568217694145] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
STUDY DESIGN Retrospective review. OBJECTIVES Large compressive pseudomeningocele causing a major neurologic deficit is a very rare complication that is not well described in the existing literature. METHODS Institutional review board consent was obtained to study 2552 consecutive extradural spinal surgical cases performed by a single senior spinal surgeon during a 10-year period. The surgeon's database for the decade was retrospectively reviewed and 3 cases involving postoperative major neurologic deficits caused by large compressive pseudomeningocele were identified. RESULTS The incidence of postoperative compressive pseudomeningocele causing major neurologic deficit was 0.12% (3/2552) per decade of spinal surgery with approximately 1.3% of cases incurring incidental durotomy. Average age of the patients was 57 years (range 45-78). One patient had posterior cervical spine surgery, and 2 patients had posterior lumbar surgery. All 3 patients had intraoperative incidental durotomy repaired during their index procedure. Large compressive pseudomeningocele causing major neurologic deficit occurred in the early 2-week postoperative period in all patients and was clearly identified on postoperative magnetic resonance imaging. All 3 patients were treated with emergent decompression and repair of the dural defect. All patients recovered neurologic function after revision surgery. CONCLUSIONS Incidental durotomy and repair causing a large compressive pseudomeningocele after spine surgery is a rare and potentially devastating event. Early postoperative magnetic resonance imaging assists in the diagnosis. Emergent decompression combined with revision dural repair surgery may result in improved outcomes. Surgeons should be cognizant of this rare cause of early postoperative major neurologic deficit in patients who had previous dural repair.
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Affiliation(s)
| | | | - Robert W. Molinari
- University of Rochester, Rochester, NY, USA,Robert W. Molinari, Department of Orthopaedics, University of Rochester, 601 Elmwood Ave, Box 665, Rochester, NY 14642, USA.
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Felbaum DR, Mueller K, Anaizi A, Mason RB, Jean WC, Voyadzis JM. Preservation of the Myofascial Cuff During Posterior Fossa Surgery to Reduce the Rate of Pseudomeningocele Formation and Cerebrospinal Fluid Leak: A Technical Note. Cureus 2016; 8:e946. [PMID: 28133584 PMCID: PMC5268379 DOI: 10.7759/cureus.946] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Suboccipital craniotomy is a workhorse neurosurgical operation for approaching the posterior fossa but carries a high risk of pseudomeningocele and cerebrospinal fluid (CSF) leak. We describe our experience with a simple T-shaped fascial opening that preserves the occipital myofascial cuff as compared to traditional methods to reduce this risk. Methods: A single institution, retrospective review of prospectively collected database was performed of patients that underwent a suboccipital craniectomy or craniotomy. Patient data was reviewed for craniotomy or craniectomy, dural graft, and/or sealant use as well as CSF complications. A pseudomeningocele was defined as a subcutaneous collection of cerebrospinal fluid palpable clinically and confirmed on imaging. A CSF leak was defined as a CSF-cutaneous fistula manifested by CSF leaking through the wound. All patients underwent regular postoperative visits of two weeks, one month, and three months. Results: Our retrospective review identified 33 patients matching the inclusion criteria. Overall, our cohort had a 21% (7/33) rate of clinical and radiographic pseudomeningocele formation with 9% (3/33) requiring surgical revision or a separate procedure. The rate of clinical and radiographic pseudomeningocele formation in the myofascial cuff preservation technique was less than standard techniques (12% and 31%, respectively). Revision or further surgical procedures were also reduced in the myofascial cuff preservation technique vs. the standard technique (6% vs 13%). Conclusions: Preservation of the myofascial cuff during posterior fossa surgery is a simple and adoptable technique that reduces the rate of pseudomeningocele formation and CSF leak as compared with standard techniques.
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Affiliation(s)
| | - Kyle Mueller
- Neurosurgery, Medstar Georgetown University Hospital
| | - Amjad Anaizi
- Neurosurgery, Medstar Georgetown University Hospital
| | | | - Walter C Jean
- Neurosurgery, Medstar Georgetown University Hospital
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Jens W, Bacharach R, Savaliya S, Kaur D. Pseudomenigiocele masquerading as monomelic amyotrophy. INTERDISCIPLINARY NEUROSURGERY 2016. [DOI: 10.1016/j.inat.2016.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Fluoroscopically Guided Epidural Blood Patch Effective for Treatment of a Postsurgical Pseudomeningocele in a Pediatric Patient. Reg Anesth Pain Med 2016; 41:542-3. [PMID: 27315177 DOI: 10.1097/aap.0000000000000405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Complicated Pseudomeningocele Repair After Chiari Decompression: Case Report and Review of the Literature. World Neurosurg 2015; 88:688.e1-688.e7. [PMID: 26704196 DOI: 10.1016/j.wneu.2015.11.056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/11/2015] [Accepted: 11/14/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Pseudomeningocele is a recognised complication after posterior fossa decompression for Chiari malformation. Its management can be challenging and treatment options vary in literature. CASE DESCRIPTION A difficult-to-treat case of a pseudomeningocele after posterior fossa decompression for a Chiari I malformation is presented. A 34-year-old woman underwent an initial decompression followed by multiple revision surgeries after the development of a symptomatic pseudomeningocele and a low-grade infection. Complications associated with standard treatment modalities, including lumbar drainage and dural repair, are discussed. A review of the existing literature is presented. CONCLUSIONS The reported case ultimately required complete removal of all dural repair materials to eliminate the patient's low-grade infection, a muscular flap, and placement of a ventricular-peritoneal shunt for definitive treatment after a trial of a lumbar drain led to herniation and development of a syrinx.
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