Incidence, Pathophysiology, and Prevention Strategies for Cerebral Venous Complications after Neurologic Surgery: A Systematic Review of the Literature

Hemorrhagic cerebral venous infarction after vein injury during intraoperative lesion resection: incidence, hemorrhagic stages, risk factors and prognosis

Objective

Cerebral venous infarction (CVI) after vein injury during intraoperative lesion resection is associated with intracranial hemorrhage. We conducted this study to identify the incidence, clinical and imaging features, and prognosis of hemorrhage CVI.

Methods

We performed a retrospective analysis of patients with confirmed CVI after vein injury who underwent craniotomy in our hospital. Postoperative clinical symptoms were observed, and imaging features were compared between patients with and without intracranial hemorrhages through CT examination. Variables were analyzed using univariate and multivariate regression analyses.

Results

Among 2,767 patients who underwent craniotomy, 93 cases of injured veins were identified intraoperatively. Hemorrhagic CVI was found in 38% (35/93). Multivariate analysis revealed that midline approach, meningioma, postoperative seizures, disorders of consciousness and interval in hours < 72 h were identified as predictors of hemorrhagic CVI. After 3 months of follow-up, the prognosis was poor in 15 cases (16%, 15/93), including death (two cases), vegetative survival (four cases), and severe disability (nine cases).

Conclusions

Hemorrhagic CVI, as a critical complication after venous injury, can have disastrous consequences. Do not injure known veins intraoperatively. In case of injury, requisite remedial measures should be adopted during and after surgery.

Handling Severe Intraoperative Hemorrhage and Avoiding Iatrogenic Stroke During Brain Tumor Surgery: Techniques for Prevention of Hemorrhagic and Ischemic Complications

BACKGROUND

Nationwide databases show that iatrogenic stroke and postoperative hematoma are among the commonest complications in brain tumor surgery, with a 10-year incidence of 16.3/1000 and 10.3/1000, respectively. However, techniques for handling severe intraoperative hemorrhage and dissecting, preserving, or selectively obliterating vessels traversing the tumor are sparse in the literature.

METHODS

Records of the senior author's intraoperative techniques during severe haemorrhage and vessel preservation were reviewed and analyzed. Intraoperative media demonstrations of key techniques were collected and edited. In parallel, a literature search investigating technique description in handling severe intraoperative hemorrhage and vessel preservation in tumor surgery was undertaken. Histologic, anesthetic, and pharmacologic prerequisites of significant hemorrhagic complications and hemostasis were analyzed.

RESULTS

The senior author's techniques for arterial and venous skeletonization, temporary clipping with cognitive or motor mapping, and ION monitoring were categorized. Vessels interfacing with tumor are labeled intraoperatively as supplying/draining the tumor, or traversing en passant, while supplying/draining functional neural tissue. Intraoperative techniques of differentiation were analyzed and illustrated. Literature search found 2 vascular-related complication domains in tumor surgery: perioperative management of excessively vascular intraparenchymal tumors and lack of intraoperative techniques and decision processes for dissecting and preserving vessels interfacing or traversing tumors.

CONCLUSIONS

Literature searches showed a dearth of complication-avoidance techniques in tumor-related iatrogenic stroke, despite its high prevalence. A detailed preoperative and intraoperative decision process was provided along with a series of case illustrations and intraoperative videos showing the techniques required to reduce intraoperative stroke and associated morbidity addressing a void in complication avoidance of tumor surgery.

Use of tubular retractors to access deep brain lesions: A case series

BACKGROUND

Deep-seated intracranial lesions can be accessed using blade retractors that may disrupt white matter tracts, exert pressure on adjacent tissue, and lead to post-operative venous injury. Tubular retractors may minimize disruption to white matter tracts by radially dispersing pressure onto surrounding tissue. This study characterizes perioperative outcomes in patients undergoing biopsy or resection of intracranial pathologies using tubular retractors.

METHODS

Adult patients (≥18 years) undergoing neurosurgical intervention using tubular retractors at a single health system (January 2016-February 2022) were identified through chart review. Demographics, disease characteristics, management data, and clinical outcomes were collected.

RESULTS

A total of 49 patients were included; 23 (47%) had primary brain tumors, 8 (16%) metastases, 6 (12%) intracranial hemorrhage (ICH), 5 (10%) cavernomas, and 7 (14%) other pathologies. Lesions were located subcortically (n = 19, 39%), intraventricularly (n = 15, 31%), and in deep gray matter (n = 11, 22%). Gross total resection (GTR) or near GTR was achieved in 21 of 26 (80.8%) patients with intracranial lesions where GTR was the goal of surgery; 10 of 11 (90.9%) biopsies in patients with masses were diagnostic. Five of six (83.3%) ICHs were totally or near totally evacuated. Seventeen patients (35%) had major complications post-operatively. The most common complications were DVT/PE (n = 7, 14%) and seizures (n = 6, 12%). For patients who experienced post-operative seizures, 3 had seizures preoperatively and 1 had seizures in the context of electrolyte derangements. No patients died of post-operative complications.

CONCLUSION

This operative approach may facilitate safe and efficacious biopsy or resection of deep-seated intracranial pathologies.

Venous Pathologies and Interventions of the Head

Intracranial venous pathologies are a historically underrecognized group of disorders that can have a devastating impact on patients. Despite advancements in peripheral venous disorders and arterial neurointerventions, intracranial venous pathologies have received comparatively little attention. Understanding the anatomy, physiology, clinical relevance, and treatment options of intracranial venous pathologies is fundamental to evolving therapies and research priorities. This article provides an overview of major intracranial venous pathologies, the respective pathophysiologies, and treatment options.

Risk factors influencing cerebral venous infarction after meningioma resection

BACKGROUND

Cerebral venous infarction (CVI) is a serious complication after meningioma resection. The risk factors of postoperative cerebral venous infarction after surgical resection of meningioma can be determined through large samples and this study can add evidence to the literature.

METHODS

The clinical and imaging data of 1127 patients with intracranial meningiomas who underwent resection in our hospital were retrospectively collected and analyzed. CVI was evaluated by postoperative imaging and clinical manifestations. Univariate and multivariate analyses were performed to identify risk factors associated with CVI.

RESULTS

Overall, 4.7% (53/1127) of patients experienced CVI after meningioma resection. Multivariate analysis revealed superficial meningioma, moderate to severe peritumoral edema, peritumoral critical vein and WHO grade II-III as independent predictors of a postoperative CVI. After timely intervention, the symptoms were clearly alleviated in one month, and the prognosis was good, but injury to key veins could cause irreversible neurological disorders.

CONCLUSIONS

Intraoperative protection of veins is the primary way to prevent CVI. The present study identified several significant and independent risk factors for postoperative venous infarction, thereby enabling the identification of high-risk patients who require special attention during clinical and surgical management.

Intraoperative risk factors for peritumoral infarctions following glioma surgery

Background

Surgical intraoperative risk factors for peritumoral infarctions are not much studied. In the present study, we explore the possible association between intraoperative factors and infarctions diagnosed from early postoperative MRIs.

Methods

We screened all adult patients operated for newly diagnosed or recurrent diffuse gliomas at out department from December 2015 to October 2020 with available postoperative MRI including DWI sequences. Patient data was prospectively collected in a local tumor registry. Immediately after surgery, the surgeon completed a questionnaire on tumor vascularization, tumor stiffness, delineation of tumor from normal brain tissue, which surgical tool(s) were used, and if they had sacrificed a functional artery or a significant vein.

Results

Data from 175 operations were included for analysis. Of these, 66 cases (38%) had postoperative peritumoral infarctions. 24 (36%) were rim-shaped and 42 (64%) infarctions were sector-shaped. The median infarction volume was 2.4 ​cm³. Surgeon reported sacrifice of a significant vein was associated with infarctions, but we found no clear “dose-response”, as “perhaps” was associated with fewer infarctions than “no”. None of the other studied factors reached statistical significance. However, there was a trend for more infarctions when an ultrasonic aspirator was used for tumor resection. Subgroup analyses were done for rim-shaped and sector-shaped infarctions, and ultrasonic aspirator was associated with sector-shaped infarctions (p ​= ​0.032). Infarction rates differed across surgeons (range 15%–67%), p ​= ​0.021).

Conclusion

In this single center study, no clear relationships between surgeon reported intraoperative factors and postoperative infarctions were observed. Still, risks seem to be surgeon dependent.

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Data on intraoperative factors from 175 operations for diffuse gliomas were assessed.

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No clear relationships between surgeon reported intraoperative factors and postoperative infarctions were observed.

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Risks of infarctions seems to be surgeon dependent.

A Case-Based Review of Cerebral Venous Infarcts With Perfusion Imaging and Comparison to Arterial Ischemic Stroke

Cerebral venous thrombosis (CVT) and cerebral venous infarcts (CVI) are diagnostic dilemmas secondary to their rarity, non-specific symptomatology at presentation, and variable imaging features. Despite its relatively infrequence, CVT is particularly prevalent in the younger adult population and is a potentially life-threatening disease with devastating neurological complications if not addressed in a timely manner. However, when treated promptly, CVT has the potential for a more reversible course and favorable prognosis than arterial ischemic strokes (AIS). The pathophysiology of CVI is distinct from that of AIS and is closely related to its potentially reversible nature. Familiarity with the conventional and variant venous anatomy, as well as the temporal evolution of imaging findings, is crucial in establishing diagnostic confidence. The use of MR perfusion imaging (MRP) and arterial spin-labeling (ASL) can potentially aid in the diagnosis of CVT/CVI via characterization of cerebral blood flow. The presence and extent of a cerebral perfusion deficit on either CT or MRI may play a role in clinical outcomes for patients with CVT, although future larger studies must be performed. This review presents a case-based overview focusing on the classic imaging characteristics of CVT and CVI in conjunction with bolus MRP and ASL findings in the adult population.

Classification of Peritumoral Veins in Convexity and Parasagittal Meningiomas and Its Significance in Preventing Cerebral Venous Infarction

OBJECTIVE

The medium (2-4 cm) convexity located closer to the sinus and parasagittal meningiomas (Sindou type I-Ⅲ) without obvious invasion of the superior sagittal sinus are considered simple to operate on. However, the tumors are often accompanied by the cortical bridging vein. Because of lack of collateral vein circulation in cortical areas, the damage of peritumoral veins will subsequently lead to venous infarction. To avoid the serious complications caused by intraoperative injury of peritumoral veins, it is necessary to define the classification of the progression of peritumoral veins and tumors to guide surgical safety.

METHODS

The clinical information of 57 patients with convexity and parasagittal meningiomas was collected and retrospectively analyzed. All patients underwent preoperative magnetic resonance imaging and magnetic resonance venography scanning to observe the imaging characteristics of peritumoral veins and preoperative evaluation. The actual relationship between the tumor and peritumoral vein was observed intraoperatively. Postoperative computed tomography and magnetic resonance imaging were used to determine tumor resection and the presence of venous infarction.

RESULTS

According to preoperative magnetic resonance venography and intraoperative findings, we divided the peritumoral veins into 3 types: type A (n = 33, 57.9%), the vein surrounds the tumor; type B (n = 15, 26.3%), the vein is located on the ventral side of the tumor; and type C (n = 9, 15.8%), the vein is located on the dorsal side of the tumor. Peritumoral vein injury occurred in 6 cases followed by serious complications. Treatments were as follows: 4 cases underwent decompression and 2 cases were treated conservatively. The prognosis Glasgow Outcome Scale (GOS) scores were as follows: 3 cases were score 5 for injury of posterior frontal vein or middle frontal vein, 2 cases were score 3 for injury of the central vein, 1 case was score 1 for death due to injury of the central vein. All cases were followed up for 6 months.

CONCLUSIONS

Attention should be paid to the peritumoral vein of special meningiomas. Injured vein in the medial third of superior sagittal sinus carries a high rate of postoperative morbidity. Understanding the type of peritumoral veins preoperatively can be used as a guide in determining the corresponding protective strategy during surgery, which can significantly decrease postoperative disability and improve quality of life.

The Anatomy of the Convergence of Major Deep Cerebral Veins in the Pineal Region: A Computed Tomography Angiography Study

BACKGROUND

The anatomy of the veins in the pineal region is one of the most complex areas in the brain because all major deep cerebral veins converge there: the internal cerebral veins (ICVs), the great cerebral vein of Galen (GV), the basal veins (BVs), and the internal occipital veins (IOVs). The aim of this study was to comprehensively describe the anatomy of the veins in the pineal region using computed tomography angiography.

METHODS

Head computed tomography angiography scans of 250 adult Polish patients were evaluated. We assessed the location of the junction of 2 ICVs and the presence of a narrowing of the GV and arachnoid granulation at the GV-straight sinus junction. We evaluated the presence, appearance, and termination of the BV, and the presence and termination of the IOV.

RESULTS

The study showed that 2 ICVs usually converged posterior to the splenium of the corpus callosum (62.4%). Narrowing of the BV was observed in 51.2% of patients, and the arachnoid granulation was found in 25.2%. The 3 segments of the BV were well visualized in 66% of the studied hemispheres. The BV flowed into the GV in 34.8% of the hemispheres. The IOV was present in 90.2% of the hemispheres and terminated medially in 84.5%.

CONCLUSIONS

Because an injury to major deep cerebral veins may result in severe postoperative neurologic deficits, it is essential for neurosurgeons to be familiar with both normal and variant patterns of veins in the pineal region.

Detecting small conflicting drainages with contrast-enhanced magnetic resonance venography for surgical planning: a technical description and quantified analysis

BACKGROUND

Recent studies have shown the challenges involved in detecting small conflicting vessels (1.0-1.5 mm) on contrast-enhanced (CE) T1 images during stereoelectroencephalography (SEEG) planning. Improving the resolution of non-invasive approaches to identify these vessels is possible and important. We present a superior sagittal sinus mapping-based CE-magnetic resonance venography (CE-MRV) protocol calibrated by craniotomies.

METHOD

Seven patients with epileptic symptoms who received craniotomy were enrolled. CE-MRV was acquired with a bolus mapping of the superior sagittal sinus. Together with the T1 image, 3D veins and the brain surface were visualized. The resolution of the CE-MRV was quantified by measuring the diameter of superficial drainages after exposure of the brain surface during craniotomy.

RESULTS

A total of 37 superficial drainages were exposed in the bone windows. CE-MRV visualized all these drainages. On average, one superficial drainage could be found in every 13.2 mm diameter of the bone window. The boundary resolution of the CE-MRV was 0.58-0.8 mm in vessel diameter, while drainages larger than 0.8 mm were visualized consistently.

CONCLUSIONS

The resolution of the CE-MRV in the present study met the requirement for detection of small conflicting vessels during SEEG planning. The visualized venous landmarks could be used for visual guidance to the surgical zone. As a non-invasive approach, CE-MRV is practical to use in the clinical setting.

Minimally invasive resection of intracranial lesions using tubular retractors: a large, multi-surgeon, multi-institutional series

PURPOSE

Lesions located in subcortical areas are difficult to safely access. Tubular retractors have been increasingly used successfully with low complication profile to access lesions by minimizing brain retraction trauma and distributing pressure radially. Both binocular operative microscope and monocular exoscope are utilized for lesion visualization through tubular retractors. We present the largest multi-surgeon, multi-institutional series to determine the efficacy and safety profile of a transcortical-transtubular approach for intracranial lesion resections with both microscopic and exoscopic visualization.

METHODS

We reviewed a multi-surgeon, multi-institutional case series including transcortical-transtubular resection of intracranial lesions using either BrainPath (NICO, Indianapolis, Indiana) or ViewSite Brain Access System (VBAS, Vycor Medical, Boca Raton, Florida) tubular retractors (n = 113).

RESULTS

One hundred thirteen transtubular resections for intracranial lesions were performed. Patients presented with a diverse number of pathologies including 25 cavernous hemangiomas (21.2%), 15 colloid cysts (13.3%), 26 GBM (23.0%), two meningiomas (1.8%), 27 metastases (23.9%), 9 gliomas (7.9%) and 9 other lesions (7.9%). Mean lesion depth below the cortical surface was 4.4 cm, and mean lesion size was 2.7 cm. A gross total resection was achieved in 81 (71.7%) cases. Permanent complication rate was 4.4%. One patient (0.8%) experienced one early postoperative seizure (< 1 week postop). No patients experienced late seizures (> 1 week follow-up). Mean post-operative hospitalization length was 4.1 days.

CONCLUSION

Tubular retractors provide a minimally invasive operative corridor for resection of intracranial lesions. They provide an effective tool in the neurosurgical armamentarium to resect subcortical lesions with a low complication profile.