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Baram A, Zaed I, Safa A, Robertis MD, Lasio G, Maira G, Cannizzaro D. Intracranial Hypotension Syndrome after Lumbar Drainage in Skull Base Surgery: Diagnosis and Correct Management. J Neurol Surg A Cent Eur Neurosurg 2023; 84:578-583. [PMID: 37263292 DOI: 10.1055/s-0042-1759825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Lumbar drainage is commonly used in skull base surgery; however, very few cases of intracranial hypotension syndrome are reported to be caused by this procedure. We present a clinical case of lumbar drainage-assisted orbital and optic canal decompression surgery for a recurrent voluminous spheno-orbital meningioma, together with a literature review. A 49-year-old woman became confused and drowsy on postoperative day 3, after initially experiencing neurologic stability. Computed tomography (CT) scan of the head showed extradural frontotemporal fluid collection with moderate right to left midline shift. Magnetic resonance imaging (MRI) of the brain showed signs of intracranial hypotension, such as brain sagging and diffuse dural contrast enhancement. Conservative treatment with bed rest, aggressive hydration, steroids, and aminophylline led to progressive neurologic improvement. A systematic literature review was also performed, and previous reported cases were analyzed. Overall, neurosurgeons must be aware of the lumbar drainage-induced hypotension syndrome in skull base surgeries, because immediate diagnosis is essential for therapeutic decision-making. In this setting, conservative management is the first-line treatment as surgery may lead to severe complications.
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Affiliation(s)
- Ali Baram
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Ismail Zaed
- Division of Neurosurgery, ASST Ovest Milanese, Legnano Hospital, Milan, Italy
| | - Adrian Safa
- Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
| | | | - Giovanni Lasio
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Giulio Maira
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Delia Cannizzaro
- Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Pieve Emanuele, Italy
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Liang S, Wang Z, Wu P, Chen Z, Yang X, Li Y, Ren X, Zhang D, Ge Z. Risk Factors and Outcomes of Central Nervous System Infection After Spinal Surgery: A Retrospective Cohort Study. World Neurosurg 2023; 170:e170-e179. [PMID: 36328166 DOI: 10.1016/j.wneu.2022.10.098] [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: 09/12/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate the risk factor associated with central nervous system infection, a rare and dire complication after spinal surgery. METHODS Univariate and multivariate logistic regression analyses were performed to screen for the independent risk factors. According to the different administration methods of antibiotics, patients were divided into intravenous and intrathecal groups. The differences in time needed for body temperature, white blood cells (WBC), and C-reactive protein (CRP) to return to normal and the time of antibiotic application were compared between the 2 groups. In addition, the differences in WBC, neutrophil ratio, CRP, procalcitonin in blood, and WBC in cerebrospinal fluid were compared before intrathecal injection, after the first one, and the last one. The incidence of complications in the 2 groups was observed. RESULTS Dural tears, laminectomy, and operation time >3 hours were identified as independent risk factors. The time needed for body temperature, WBC, and CRP to return to normal and the antibiotic application time were significantly different between the 2 groups (all P < 0.05). Before and after the first intrathecal injection and after the last intrathecal injection, the differences in WBCs, neutrophil ratios, CRP, procalcitonin in blood, and cerebrospinal fluid-WBC were statistically significant in overall and pairwise comparisons (P < 0.05). Complications occurred in 2 and 14 cases, respectively. CONCLUSIONS The independent risk factors for central nervous system infection after spinal surgery were a dural tear, laminectomy, and operation time > 3 hours. Combined intravenous and intrathecal injections of antibiotics led to a better effect than intravenous injection alone; however, this approach was associated with more complications.
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Affiliation(s)
- Simin Liang
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Zhiqiang Wang
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Peng Wu
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Zhen Chen
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Xiaoyan Yang
- Medical Laboratory Center, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Ying Li
- Medical Record Room, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Xiaolu Ren
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Danmei Zhang
- Department of Nosocomial Infection, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China
| | - Zhaohui Ge
- Department of Orthopaedics, General Hospital of Ningxia Medical University, Yinchuan City of Ningxia, China.
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Wong AK, Shinners M, Wong RH. Minimally Invasive Repair of Tegmen Defects Through Keyhole Middle Fossa Approach to Reduce Hospitalization. World Neurosurg 2020; 133:e683-e689. [DOI: 10.1016/j.wneu.2019.09.114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 12/31/2022]
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Leong JL, Citardi MJ, Batra PS. Reconstruction of Skull Base Defects after Minimally Invasive Endoscopic Resection of Anterior Skull Base Neoplasms. ACTA ACUST UNITED AC 2018; 20:476-82. [PMID: 17063741 DOI: 10.2500/ajr.2006.20.2931] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The endoscopic resection of the cribriform plate during minimally invasive endoscopic resection (MIER) of the anterior skull base neoplasms may result in large anterior skull base defects. The objective of this study is to describe techniques for the management of skull base defects after MIER. Methods Retrospective analysis was performed on patients undergoing MIER and skull base reconstruction between April 2000 and August 2005. Results Fourteen patients underwent endoscopic resection of anterior skull base tumors and reconstruction during the study period. The mean age was 57.4 years (range, 26–84 years). The sex distribution was eight men and six women. The specific indications for resection included 11 malignant and 3 benign neoplasms. Ten patients received adjuvant therapy, and in two instances this occurred before surgery. In all instances, the dura was exposed; however, only 10 cerebrospinal fluid (CSF) leaks were encountered intraoperatively. Reconstruction of the skull base was successfully performed, most commonly in a multilayer fashion, using an array of materials including cartilage, fat, acellular dermal graft, and mucosal free grafts. Lumbar drain placement was used in seven cases for an average of 5.6 days. No postoperative CSF leaks occurred. The mean follow-up was 18.0 months (range, 1–56 months). Conclusion This report describes methods for the reconstruction of the skull base after MIER. Reconstitution of the skull base barrier can be achieved through application of principles for surgical repair of CSF rhinorrhea.
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Affiliation(s)
- Jern-Lin Leong
- Department of Otolaryngology, Singapore General Hospital, Singapore
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Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol 2017; 29:191-210. [DOI: 10.1097/ana.0000000000000407] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Ahmed OH, Marcus S, Tauber JR, Wang B, Fang Y, Lebowitz RA. Efficacy of Perioperative Lumbar Drainage following Endonasal Endoscopic Cerebrospinal Fluid Leak Repair: A Meta-analysis. Otolaryngol Head Neck Surg 2016; 156:52-60. [DOI: 10.1177/0194599816670370] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective Perioperative lumbar drain (LD) use in the setting of endoscopic cerebrospinal fluid (CSF) leak repair is a well-established practice. However, recent data suggest that LDs may not provide significant benefit and may thus confer unnecessary risk. To examine this, we conducted a meta-analysis to investigate the effect of LDs on postoperative CSF leak recurrence following endoscopic repair of CSF rhinorrhea. Data Sources A comprehensive search was performed with the following databases: Ovid MEDLINE (1947 to November 2015), EMBASE (1974 to November 2015), Cochrane Review, and PubMed (1990 to November 2015). Review Method A meta-analysis was performed according to PRISMA guidelines. Results A total of 1314 nonduplicate studies were identified in our search. Twelve articles comprising 508 cases met inclusion criteria. Overall, use of LDs was not associated with significantly lower postoperative CSF leak recurrence rates following endoscopic repair of CSF rhinorrhea (odds ratio: 0.89, 95% confidence interval: 0.40-1.95) as compared with cases performed without LDs. Subgroup analysis of only CSF leaks associated with anterior skull base resections (6 studies, 153 cases) also demonstrated that lumbar drainage did not significantly affect rates of successful repair (odds ratio: 2.67, 95% confidence interval: 0.64-11.10). Conclusions There is insufficient evidence to support that adjunctive lumbar drainage significantly reduces postoperative CSF leak recurrence in patients undergoing endoscopic CSF leak repair. Subgroup analysis examining only those patients whose CSF leaks were associated with anterior skull base resections demonstrated similar results. More level 1 and 2 studies are needed to further investigate the efficacy of LDs, particularly in the setting of patients at high risk for CSF leak recurrence.
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Affiliation(s)
- Omar H. Ahmed
- Department of Otolaryngology–Head and Neck Surgery, New York University, New York, New York, USA
| | - Sonya Marcus
- Department of Otolaryngology–Head and Neck Surgery, New York University, New York, New York, USA
| | - Jenna R. Tauber
- School of Medicine, New York University, New York, New York, USA
| | - Binhuan Wang
- Department of Population Health, Division of Biostatistics, New York University, New York, New York, USA
| | - Yixin Fang
- Department of Mathematical Sciences, New Jersey Institute of Technology, Newark, New Jersey, USA
| | - Richard A. Lebowitz
- Department of Otolaryngology–Head and Neck Surgery, New York University, New York, New York, USA
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Ashayeri K, M Jackson E, Huang J, Brem H, Gordon CR. Syndrome of the Trephined: A Systematic Review. Neurosurgery 2016; 79:525-34. [PMID: 27489166 DOI: 10.1227/neu.0000000000001366] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Syndrome of the trephined (SoT) is a rare, important complication of a craniectomy characterized by neurological dysfunction that improves with cranioplasty. Its varied symptoms include motor, cognitive, and language deficits. Its exact characterization appears suboptimal, with differing approaches of evaluation. Accordingly, this topic is in great need of further investigation. OBJECTIVE To accurately describe SoT and explore methods of an objective diagnosis/evaluation. METHODS Electronic searches of PubMed, MEDLINE, Web of Knowledge, and PsycINFO databases used the key words "syndrome of the trephined" and "sinking skin flap." Non-English-language and duplicate articles were eliminated. Title and abstract reviews were selected for relevance. Full-text reviews were selected for articles providing individual characteristics of SoT patients. RESULTS This review identified that SoT most often occurs in male patients (60%) at 5.1 ± 10.8 months after craniectomy for neurotrauma (38%). The average reported craniectomy is 88.3 ± 34.4 cm and usually exists with a "sunken skin flap" (93%). Symptoms most commonly include motor, cognitive, and language deficits (57%, 41%, 28%, respectively), with improvement after cranioplasty within 3.8 ± 3.9 days. Functional independence with activities of daily living is achieved by 54.9% of patients after 2.9 ± 3.4 months of rehabilitation. However, evaluation of SoT is inconsistent, with only 53% of reports documenting objective studies. DISCUSSION SoT is a variable phenomenon associated with a prolonged time to cranioplasty. Due to current weaknesses in objectivity, we hypothesize that SoT is often underdiagnosed and recommend a multifaceted approach for consistent evaluation. CONCLUSION SoT is a serious complication that lacks exact characterization and deserves future investigation. Improved understanding and recognition have important implications for early intervention and patient outcomes. ABBREVIATIONS ADLs, activities of daily livingCBF, cerebral blood flowSoT, syndrome of the trephinedVP, ventriculoperitoneal.
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Affiliation(s)
- Kimberly Ashayeri
- *Albert Einstein College of Medicine, New York, New York; ‡Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; §Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Gerstein NS, Panikkath PV, Carlson AP, Pollock DM, Tayler E, Augoustides JG. CASE 4—2016. J Cardiothorac Vasc Anesth 2016; 30:548-54. [DOI: 10.1053/j.jvca.2015.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Indexed: 01/16/2023]
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Postoperative Low-Flow Cerebrospinal Fluid Leak of Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenoma--Wait and See, or Lumbar Drain? J Craniofac Surg 2016; 26:1261-4. [PMID: 26080170 PMCID: PMC4927314 DOI: 10.1097/scs.0000000000001691] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To assess the effectiveness of continuous lumbar drainage (LD) for management of postoperative cerebrospinal fluid leaks after endoscopic endonasal transsphenoidal approach for resection of pituitary adenoma. Three hundred eighty-four medical records of patients who were admitted to our institute during a 2.5-year period were retrospectively reviewed, 33 of them experienced low-flow cerebrospinal fluid leak postoperatively. If LD was used, all patients with low-flow cerebrospinal fluid leak were classified into 2 groups, lumbar drained group and conservatively treated group. The age, sex, management of cerebrospinal fluid leaks, and related complications were reviewed. Statistical comparisons between the 2 groups were made using SPSS 19.0 (IBM Corp, Armonk, NY). The differences were considered statistically significant if the P value was less than 0.05.Thirty-three of 384 (8.6%) experienced low-flow postoperative cerebrospinal fluid leaks. Cured rate of cerebrospinal fluid leak was 94.4% (17/18) in continuous lumbar drained group, and 93.3% (14/15) in control group. There were 2 (11.2%) patients who developed meningitis in the LD group and 1 (5.6%) patient in the control group. One patient required endoscopic repair of skull base because of persistent cerebrospinal fluid leak in both groups, with the rates of 5.6% and 6.7%, respectively. There was no significant difference noted in each rate in both groups.Placement of LD may not be necessary for the management of low-flow postoperative cerebrospinal fluid leak after using endoscopic endonasal transsphenoidal approach to pituitary adenoma.
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10
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Alaraj A, Munson T, Herrera SR, Aletich V, Charbel FT, Amin-Hanjani S. Angiographic features of "brain sag". J Neurosurg 2011; 115:586-91. [PMID: 21619407 DOI: 10.3171/2011.4.jns101168] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cerebrospinal fluid hypotension, or "brain sag," is a recently described phenomenon most commonly seen following craniotomy for the clipping of ruptured aneurysms along with preoperative lumbar drain placement. The clinical features and CT findings have been previously described. Clinical presentation can be similar to and often mistaken for cerebral vasospasm. In this study, the authors report on the angiographic findings in patients with brain sag. METHODS Five cases of brain sag were diagnosed (range 1-4 days) after the surgical treatment of ruptured aneurysms at the University of Illinois at Chicago. All patients met the clinical and CT criteria for brain sag. Admission cerebral angiograms and subsequent angiograms during symptoms of brain sag were obtained in all patients. In 3 patients, angiography was performed after the resolution of symptoms. RESULTS In all 5 patients, the level of the basilar artery apex was displaced inferiorly with respect to the posterior clinoid processes during brain sag. This displacement was significant enough to create a noticeable kink in the basilar artery ("cobra sign") in 3 patients. Other angiographic findings included foreshortening or kinking of the intracranial vertebral artery. In all patients, the posterior cerebral arteries were displaced medially and inferiorly. Three patients were treated for simultaneous severe radiological vasospasm. In 4 patients, the brain sag was recognized, and the patients' conditions improved when they were placed flat or in the Trendelenburg position, at times combined with an epidural blood patch. Patients with follow-up angiography studies after the symptoms had resolved displayed a reversal of the angiographic features. CONCLUSIONS Brain sag appears to be associated with characteristic angiographic features. Recognizing these features may help to diagnose brain sag as the cause of neurological deterioration in this patient population.
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Affiliation(s)
- Ali Alaraj
- Neuropsychiatric Institute, Department of Neurosurgery, University of Illinois at Chicago, Illinois 60612-5970, USA.
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11
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Ransom ER, Palmer JN, Kennedy DW, Chiu AG. Assessing risk/benefit of lumbar drain use for endoscopic skull-base surgery. Int Forum Allergy Rhinol 2011; 1:173-7. [PMID: 22287368 DOI: 10.1002/alr.20026] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2010] [Revised: 08/20/2010] [Accepted: 10/11/2010] [Indexed: 11/12/2022]
Abstract
BACKGROUND Lumbar drains (LD) are frequently employed with the goal of postoperative cerebrospinal fluid (CSF) leak prevention. LD placement is not without risk, however, and complications can significantly increase patient discomfort and resource utilization. The objective of this work was to characterize the risks, benefits, and resource utilization associated with LD use in endoscopic anterior skull-base surgery. METHODS A retrospective review of endoscopic anterior skull-base surgeries performed by the senior authors over the past 5 years was done. Cases with prospective LD were selected using anesthesia and billing records. Analysis was done of indications, LD duration, complications, revisions, and additional care required. RESULTS A total of 65 patients had LD placed prospectively at the time of surgery. LD were in place for an average of 63 ± 38 hours. Four cases (6.2%) required revision surgery for postoperative CSF leak. Leak rates did not differ between patients with neoplasm (7.7%) and without neoplasm (5.8%; p = 0.80). One readmission was attributable to a recurrent leak. Nine LD complications occurred in 8 patients (12.3%). Overall, 6 blood patches, 3 head computed tomography (CT) scans, 1 open removal of retained catheter fragments, 1 spine CT, and an infectious disease workup were required. Three readmissions and 10 additional hospital days were attributable to LD complications. No relationship was found between patient demographics or comorbidities and LD complications. Regression analysis showed no significant effect of body mass index (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.89-1.14; p = 0.87) or duration of LD (OR, 1.00; 95% CI, 0.98-1.02; p = 0.85) on complication risk. Diagnosis of neoplasm was associated with a significant increase in likelihood of complication (OR, 5.33; 95% CI, 1.11-25.64; p < 0.04). CONCLUSION Complications of LD may be more frequent than postoperative CSF leaks, adding significantly to health care resource utilization. It is difficult to predict which patients will suffer LD complications. Reduction of prospective LD use may avoid unnecessary morbidity and resource utilization.
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Affiliation(s)
- Evan R Ransom
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Herniación paradójica secundaria a drenaje continuo de líquido cefalorraquídeo en un paciente previamente craniectomizado. Neurologia 2010. [DOI: 10.1016/j.nrl.2010.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Paradoxical herniation due to a continuous cerebrospinal fluid drain in a previously craniectomised patient. NEUROLOGÍA (ENGLISH EDITION) 2010. [DOI: 10.1016/s2173-5808(10)70052-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Schievink WI, Palestrant D, Maya MM, Rappard G. Spontaneous spinal cerebrospinal fluid leak as a cause of coma after craniotomy for clipping of an unruptured intracranial aneurysm. J Neurosurg 2009; 110:521-4. [PMID: 19012477 DOI: 10.3171/2008.9.jns08670] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Spontaneous spinal CSF leaks are best known as a cause of orthostatic headache, but may also be the cause of coma. The authors encountered a unique case of a spontaneous spinal CSF leak causing coma 2 days after craniotomy for clipping of an unruptured aneurysm. This 44-year-old woman with autosomal dominant polycystic kidney disease underwent an uneventful craniotomy for an incidental anterior choroidal artery aneurysm. No intraoperative spinal CSF drainage was used. Two days after surgery the patient became comatose with a left oculomotor nerve palsy. Computed tomography scanning revealed a right extraceberal hematoma and loss of gray-white matter differentiation. The hematoma was evacuated and a diagnosis of hemodialysis disequilibrium syndrome was made. Continuous hemodialysis and hyperosmolar therapy were instituted without any improvement. The CT scans were then reinterpreted as showing sagging of the brain, and the patient was placed in the Trendelenburg position which resulted in prompt improvement in her level of consciousness. A CT myelogram demonstrated an upper thoracic CSF leak that eventually required surgical correction. The patient made a complete neurological recovery. Neurological deterioration after craniotomy may be caused by brain sagging caused by a spontaneous spinal CSF leak, similar to intracranial hypotension due to intraoperative lumbar CSF drainage.
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Affiliation(s)
- Wouter I Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, The Maxine Dunitz Neurosurgical Institute, Los Angeles, California 90048, USA.
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Abstract
The advent of rigid telescopes has revolutionized the management of rhinologic disease. These instruments have been used as a diagnostic and therapeutic tool for paranasal sinus inflammatory diseases since the 1970s. Endoscopic techniques have been used for treating increasingly complex intranasal pathology, including nasolacrimal duct obstruction, cerebrospinal fluid leaks/encephaloceles, dysthyroid orbitopathy, and optic neuropathy. Recently, endoscopic techniques have also been used successfully to manage selected tumors, including inverted papilloma, angiofibromas, and hypophyseal tumors. This article reviews patient evaluation strategies, surgical techniques, and outcomes data for the minimally invasive endoscopic resection.
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Affiliation(s)
- Pete S Batra
- Section of Nasal and Sinus Disorders, The Cleveland Clinic Head and Neck Institute, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Oyelese AA, Steinberg GK, Huhn SL, Wijman CAC. Paradoxical Cerebral Herniation Secondary to Lumbar Puncture after Decompressive Craniectomy for a Large Space-occupying Hemispheric Stroke: Case Report. Neurosurgery 2005; 57:E594; discussion E594. [PMID: 16145506 DOI: 10.1227/01.neu.0000170437.79760.df] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
ABSTRACT
OBJECTIVE AND IMPORTANCE:
The risk of transtentorial herniation after removal of cerebrospinal fluid from the lumbar cistern in the setting of a supratentorial lesion with significant mass effect, increased cerebrospinal fluid pressure, or midline shift is well known. We report a case of cerebral herniation from intracranial hypotension (so-called paradoxical herniation) secondary to a lumbar puncture 1 month after decompressive hemicraniectomy for a large right hemispheric stroke.
CLINICAL PRESENTATION:
A 50-year-old woman was transferred to our neurosurgical service for obtundation 4 days after a lumbar puncture to rule out meningitis and 1 month after decompressive craniectomy for a large right hemispheric stroke.
INTERVENTION:
Eighty grams of mannitol was administered before transfer. On arrival at our hospital, the patient was intubated and a computed tomographic scan was performed. The patient was diagnosed with low-pressure herniation after review of the computed tomographic scan. Rehydration was initiated, and the patient was placed in the Trendelenburg position. She became easier to arouse, but her pupils remained dilated. She experienced a sudden severe cardiac arrhythmia leading to a cardiac arrest. Attempted resuscitation was unsuccessful, and the patient was pronounced dead.
CONCLUSION:
Lumbar punctures may result in lethal intracranial hypotension in patients after hemicraniectomy and are thus contraindicated unless care is taken to remove the pressure gradient of atmospheric air across the lumbar cistern.
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Affiliation(s)
- Adetokunbo A Oyelese
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California 94305-5327, USA
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Lindstrom DR, Toohill RJ, Loehrl TA, Smith TL. Management of cerebrospinal fluid rhinorrhea: the Medical College of Wisconsin experience. Laryngoscope 2004; 114:969-74. [PMID: 15179197 DOI: 10.1097/00005537-200406000-00003] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The management of cerebrospinal fluid (CSF) rhinorrhea has evolved in recent years. The purpose of this comprehensive retrospective study is to assess issues related to the management of skull base defects associated with CSF rhinorrhea involving the nose and paranasal sinuses. METHODS A retrospective review of CSF leak management was conducted. This study included patients with CSF rhinorrhea managed by the Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, from 1992 to 2002. Data collected included site of leak, surgical approach, and any recurrence of leak. RESULTS Fifty-seven CSF leaks occurred in 53 patients with CSF rhinorrhea originating from the nose or paranasal sinuses. Twenty-eight of the 53 had iatrogenic injuries resulting in CSF rhinorrhea, 16 had leaks from trauma, and 13 developed spontaneous CSF leaks. Ten patients responded to nonoperative management with bed rest with or without lumbar drain placement. Forty-three patients with 47 leaks underwent surgical repair of CSF rhinorrhea, of which 38 resolved after initial repair. Five of these patients developed recurrent CSF leaks at the repair site but resolved with subsequent surgery. Of these, two initially presented with spontaneous CSF leaks, one patient had a gunshot wound with massive skull base injury, and two recurred after repair of an iatrogenic injury. Factors associated with failure included lateral sphenoid leaks and elevated body mass index (BMI). DISCUSSION Multiple approaches to the management of CSF rhinorrhea can be successful. An endoscopic repair results in resolution of CSF rhinorrhea in the majority of cases. Patients with spontaneous CSF rhinorrhea, elevated BMI, lateral sphenoid leaks, and extensive skull base defects are at increased risk for recurrence. Alternative management options may need to be considered in these cases.
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Affiliation(s)
- D Richard Lindstrom
- Division of Rhinology and Sinus Surgery, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, Milwaukee, WI, USA
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Gibbons KJ, Dare AO. The integration of neurosurgical techniques in current head and neck skull base surgery. Surg Oncol Clin N Am 2004; 13:231-9. [PMID: 15062371 DOI: 10.1016/s1055-3207(03)00116-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The recent advances in neurosurgery, applied to the growing field of skull base surgery, provide surgeons with new techniques to avoid the devastating complication of CSF leak, to improve patient selection by reducing the risk of stroke while expanding the operative options available to patients with head and neck malignancies, and to aid operative care through improved surgical planning and intraoperative localization.
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Affiliation(s)
- Kevin J Gibbons
- Department of Neurological Surgery, School of Medicine and Biomedical Sciences, State University of New York-Buffalo, 3 Gates Circle, Buffalo, NY 14209, USA.
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Samadani U, Huang JH, Baranov D, Zager EL, Grady MS. Intracranial hypotension after intraoperative lumbar cerebrospinal fluid drainage. Neurosurgery 2003; 52:148-51; discussion 151-2. [PMID: 12493112 DOI: 10.1097/00006123-200301000-00019] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2002] [Accepted: 09/11/2002] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE Intraoperative lumbar cerebrospinal fluid drainage is frequently performed in a variety of neurosurgical procedures. A retrospective review is presented of the complications of lumbar cerebrospinal fluid drainage. METHODS The records from 75 consecutive operations requiring intraoperative lumbar cerebrospinal drainage during a 1-year period at the Hospital of the University of Pennsylvania were reviewed to assess the types of complications attributable to spinal drainage and their rates of occurrence. The operations were categorized into 46 aneurysm clippings, 21 craniotomies for tumors, and 8 other cranial base procedures. RESULTS Two patients developed transient postoperative neurological complications as a result of intracranial hypotension that resolved after epidural blood patching, with a reexploration craniotomy to drain an epidural collection performed in one patient. A third patient in the study developed a persistent deficit when intracranial hypotension led to intraoperative transtentorial herniation, which resulted in an unusual constellation of multiple brainstem infarcts that caused cranial neuropathy. CONCLUSION Complications of intraoperative lumbar cerebrospinal fluid drainage resulting in transient (2 of 75 patients, 3%) or persistent (1 of 75 patients, 1%) neurological deficits caused by intracranial hypotension occur infrequently and may be related to preexisting conditions such as hydrocephalus.
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Affiliation(s)
- Uzma Samadani
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA.
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Samadani U, Huang JH, Baranov D, Zager EL, Grady MS. Intracranial Hypotension after Intraoperative Lumbar Cerebrospinal Fluid Drainage. Neurosurgery 2003. [DOI: 10.1227/00006123-200301000-00019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Patel MR, Caruso PA, Yousuf N, Rachlin J. CT-guided percutaneous fibrin glue therapy of cerebrospinal fluid leaks in the spine after surgery. AJR Am J Roentgenol 2000; 175:443-6. [PMID: 10915691 DOI: 10.2214/ajr.175.2.1750443] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study is to assess CT-guided percutaneous injection of fibrin glue for the management of cerebrospinal fluid leaks within the spine. CONCLUSION Percutaneous CT-guided placement of fibrin glue can provide a treatment option for postoperative cerebrospinal fluid leaks, potentially allowing a major surgical procedure to be avoided. However, the complication of aseptic meningitis may occasionally result from this procedure.
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Affiliation(s)
- M R Patel
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
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