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Shinya Y, Leonel LCPC, Hong S, Moussalem CK, Serioli S, De Bonis A, Nizzola M, Meyer JH, Bauman MMJ, Saez-Alegre M, Kin T, Peris-Celda M, Van Gompel JJ. SupraPetrous InfraTemporal Approach: A Supplemental Approach to Supracerebellar Infratentorial for Inferior Amygdala and Hippocampal Head Access-A Cadaveric Study With Case Illustrations. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01257. [PMID: 39012126 DOI: 10.1227/ons.0000000000001292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/04/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Access to the amygdala and hippocampus (A/H) is complex. To address the limitations and invasiveness of traditional approaches, including the Transsylvian, Subtemporal, and Supracerebellar infratentorial approaches, we developed the suprapetrous infratemporal (SPIT) approach. This study describes the nuances of this approach in both cadaveric studies and clinical cases. METHODS Three unilateral exposures were performed using microscopic and endoscopic methodologies in the SPIT approach. After cadaveric investigation, this approach was successfully implemented in representative clinical cases. RESULTS The SPIT approach enabled direct access to the inferior A/H, circumventing the requirement for temporal lobe retraction and detachment of the temporal lobe from the dura through a subtemporal route by drilling the upper part of the mastoid, consequently mitigating tension on the vein of Labbé. This enabled a bottom-up view because one would gain with a zygomatic osteotomy and forward projection like a mini-posterior petrosal view by using a transmastoid view, without cutting down the zygomatic arch and opening the dura subtemporally, limiting patient pain and preventing case comorbidity. The SPIT approach was performed in 2 cases of mesial temporal cavernoma presenting with seizures. The lesion was visualized intraoperatively and was successfully removed in these cases. The postoperative course was excellent with no complications, and gross total resection was radiographically confirmed with Engel Class 1a seizure freedom. CONCLUSION The SPIT approach is a complementary approach for inferior A/H disease, combining the combined middle fossa approach modified for intradural pathology. Limited drilling of the upper aspect of the mastoid with a medial dural opening at the level of the arcuate eminence provides a direct trajectory with minimal brain retraction. Additional research encompassing a larger patient cohort and extended follow-up periods is required to substantiate the advantages of SPIT in the management of inferior A/H lesions.
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Affiliation(s)
- Yuki Shinya
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Luciano César P C Leonel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Sukwoo Hong
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | | | - Simona Serioli
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Division of Neurosurgery, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alessandro De Bonis
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Mariagrazia Nizzola
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Jenna H Meyer
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurosurgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Megan M J Bauman
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
| | - Miguel Saez-Alegre
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Taichi Kin
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Maria Peris-Celda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Resection of posterior fossa tumors in the semi-sitting position in children younger than 4 years of age. Childs Nerv Syst 2023; 39:159-167. [PMID: 36348035 PMCID: PMC9968679 DOI: 10.1007/s00381-022-05725-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/25/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE The semi-sitting position for resection of posterior fossa tumors is a matter of ongoing debate. Here we report about our experience with this approach in children younger than 4 years of age. METHODS We retrospectively analyzed data of children younger than 4 years of age operated on in our institution in the semi-sitting position over a 15-year period. Patients were intraoperatively monitored for venous air embolism (VAE) by transthoracic Doppler (TTD) or transesophageal echocardiography (TEE). The severity of VAE was classified according to the Tübingen grading scale. Intraoperative incidents of VAE were recorded and the patients' course was followed postoperatively with a special focus on possible complications. RESULTS Twenty-four children (18 boys, 6 girls) were operated on in the semi-sitting position (26 operations). Mean age was 2.2 years (± 1.0), range between 0.4 and 3.9 years. External ventricular drains were inserted in 18 children with hydrocephalus preoperatively. VAE was detected in 6 instances during surgery (6/26 (23.1%)). In 3 patients with grade 1 VAE, no additional treatment was necessary. In one patient with grade 2 VAE, intracardiac air suction via the central venous catheter was performed, and in two patients with grade 4 VAE, additional cathecholamine-infusion was administered. No major intraoperative complications occurred. Postoperative CT images showed pneumocephalus in all children. In two children, small asymptomatic impression skull fractures at the site of the Mayfield pin occurred. Revision surgery was necessary in one child with a suboccipital CSF fistula. CONCLUSION The semi-sitting position for resection of tumors in the posterior fossa in children younger than 4 years of age can be safely performed in experienced centers taking special caution to detect and treat potential complications in an interdisciplinary setting.
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Al-Afif S, Elkayekh H, Omer M, Heissler HE, Scheinichen D, Palmaers T, Nakamura M, Hermann EJ, Samii M, Krauss JK. Analysis of risk factors for venous air embolism in the semisitting position and its impact on outcome in a consecutive series of 740 patients. J Neurosurg 2022; 137:258-265. [PMID: 34740183 DOI: 10.3171/2021.7.jns211107] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/01/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Routine use of the semisitting position, which offers several advantages, remains a matter of debate. Venous air embolism (VAE) is a potentially serious complication associated with the semisitting position. In this study, the authors aimed to investigate the safety of the semisitting position by analyzing data over a 20-year period. METHODS The incidence of VAE and its perioperative management were analyzed retrospectively in a consecutive series of 740 patients who underwent surgery between 1996 and 2016. The occurrence of VAE was defined by detection of bubbles on transthoracic Doppler echocardiography (TTDE) or transesophageal echocardiography (TEE) studies, a decrease of end-tidal CO2 (ETCO2) by 4 mm Hg or more, and/or an unexplained drop in systolic arterial blood pressure (≥ 10 mm Hg). From 1996 until 2013 TTDE was used, and from 2013 on TEE was used. The possible risk factors for VAE and its impact on surgical performance were analyzed. RESULTS There were 404 women and 336 men with a mean age at surgery of 49 years (range 1-87 years). Surgery was performed for infratentorial lesions in 709 patients (95.8%), supratentorial lesions in 17 (2.3%), and cervical lesions in 14 (1.9%). The most frequent pathology was vestibular schwannoma. TEE had a higher sensitivity than TTDE. While TEE detected VAE in 40.5% of patients, TTDE had a detection rate of 11.8%. Overall, VAE was detected in 119 patients (16.1%) intraoperatively. In all of these patients, VAE was apparent on TTDE or TEE. Of those, 23 patients also had a decrease of ETCO2, 18 had a drop in blood pressure, and 23 had combined decreases in ETCO2 and blood pressure. VAE was detected in 24% of patients during craniotomy before opening the dura mater, in 67% during tumor resection, and in 9% during wound closure. No risk factors were identified for the occurrence of VAE. Two patients had serious complications due to VAE. Surgical performance in vestibular schwannoma surgery was not affected by the presence of VAE. CONCLUSIONS This study shows that the semisitting position is overall safe and that VAE can be managed effectively. Persistent morbidity is very rare. The authors suggest that the semisitting position should continue to have a place in the standard armamentarium of neurological surgery.
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Affiliation(s)
- Shadi Al-Afif
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Hesham Elkayekh
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Mazin Omer
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Hans E Heissler
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Dirk Scheinichen
- 3Department of Anesthesiology and Intensive Care, Medical School Hannover, Germany; and
| | - Thomas Palmaers
- 3Department of Anesthesiology and Intensive Care, Medical School Hannover, Germany; and
| | - Makoto Nakamura
- 2Department of Neurosurgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany
| | - Elvis J Hermann
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Madjid Samii
- 4International Neuroscience Institute, Hannover, Germany
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Occurrence and severity of venous air embolism during neurosurgical procedures in semi-sitting versus supine position. World Neurosurg 2022; 163:e335-e340. [PMID: 35367647 DOI: 10.1016/j.wneu.2022.03.125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND At our institution, patients undergoing neurosurgical procedures in the posterior cranial fossa are placed either in the semi-sitting or in the supine position. The major risk of the semi-sitting positioning is a venous air embolism (VAE), which may, however, also occur in the supine position. METHODS In a prospective single-center study with 137 patients, we evaluated the occurrence of VAEs in patients in the supine and in the semi-sitting position over the period from January 2014 until April 2015. All patients were monitored for VAE by the use of a transesophageal echocardiography (TEE). RESULTS 50% of the patients experienced a VAE (with 56% of these patients underwent surgery in the semi-sitting and 11% in the supine position). 86% of the VAEs were just detected by the use of a TEE and did not lead to any changes in the end-expiratory (Et)CO2. We only observed VAEs with a decrease in EtCO2 in the semi-sitting position. However, none of the patients had any hemodynamic changes due to the VAE. CONCLUSIONS The semi-sitting position with TEE monitoring and a standardized protocol is a safe and advantageous technique, taking account of a significant rate of VAEs. VAEs also occur in the supine position, however, less frequently.
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Song G, Liu D, Wu X, Wang X, Zhou Y, Li M, Lin Q, Guo H, Tang J, Xiao X, Chen G, Bao Y, Liang J. Outcomes after semisitting and lateral positioning in large vestibular schwannoma surgery: A single-center comparison. Clin Neurol Neurosurg 2021; 207:106768. [PMID: 34175644 DOI: 10.1016/j.clineuro.2021.106768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 06/16/2021] [Accepted: 06/17/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The semisitting position (SSP) and lateral position (LP) in vestibular schwannoma (VS) surgery each have advantages and disadvantages, and which position is superior overall is debatable. Our objective was to determine the optimal position for surgical treatment of VSs with a diameter ≥3 cm. METHODS We retrospectively evaluated consecutive patients with a large VS treated between January 2010 and July 2020. Patients were grouped by surgical position and analyzed. RESULTS We enrolled 259 patients (LP group, n = 156; SSP group, n = 103). The resection extent was not significantly different between the SSP (gross-total resection [GTR], n = 89 [88.1%], near-total resection [NTR], n = 10 [9.9%], subtotal resection [STR], n = 2 [2.0%]) and LP (GTR, n = 125 [80.1%]; NTR, n = 24 [15.4%]; STR, n = 7 [4.5%]) groups. The rate of GTR with facial nerve (FN) functional preservation was higher in the SSP group than in the LP group (P = 0.014) at eight days after the operation. However, during follow-up (SSP group median, 31.5 months; LP group median, 19.5 months), there was no significant between-group difference in FN functional preservation. Two patients in the SSP group required conversion to the LP due to severe intraoperative venous air embolism (VAE). CONCLUSION Compared with the LP, the SSP did not produce significantly better FN outcomes in patients with a large VS. The duration of surgery was significantly longer in SSP cases than in LP cases. Given the risk of VAE associated with the SSP, the selection of the optimal surgical position should be made with caution on an individual basis.
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Affiliation(s)
- Gang Song
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Dong Liu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Xiaolong Wu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Xu Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Yiqiang Zhou
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Qingtang Lin
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Hongchuan Guo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Jie Tang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Xinru Xiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Ge Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Yuhai Bao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China
| | - Jiantao Liang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, 45 Changchun St, Xicheng District, Beijing, China.
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Serfozo K, Tarnal V. Anesthetic Management of Patients Undergoing Open Suboccipital Surgery. Anesthesiol Clin 2021; 39:93-111. [PMID: 33563388 DOI: 10.1016/j.anclin.2020.11.001] [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: 11/29/2022]
Abstract
The posterior cranial fossa with its complex anatomy houses key pathways regulating consciousness, autonomic functions, motor and sensory pathways, and cerebellar centers regulating balance and gait. The most common posterior fossa pathologies for which neurosurgical intervention may be necessary include cerebellopontine angle tumors, aneurysms, and metastatic lesions. The posterior cranial fossa can be accessed from variations of the supine, lateral, park-bench, prone, and sitting positions. Notable complications from positioning include venous air embolism, paradoxic air embolism, tension pneumocephalus, nerve injuries, quadriplegia, and macroglossia. An interdisciplinary approach with careful planning, discussion, and clinical management contributes to improved outcomes and reduced complications.
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Affiliation(s)
- Kelsey Serfozo
- Department of Anesthesiology, University Hospital, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA
| | - Vijay Tarnal
- Department of Anesthesiology, University Hospital, University of Michigan Medical School, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5048, USA.
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Giammattei L, Starnoni D, Benes V, Froelich S, Cossu G, Borsotti F, Májovsky M, Sufianov AA, Fava A, di Russo P, Elbabaa SK, González-López P, Messerer M, Daniel RT. Extreme Lateral Supracerebellar Infratentorial Approach: Surgical Anatomy and Review of the Literature. World Neurosurg 2021; 147:89-104. [PMID: 33333288 DOI: 10.1016/j.wneu.2020.12.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/05/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The extreme lateral supracerebellar infratentorial (ELSI) approach has the potential to access several distinct anatomical regions that are otherwise difficult to reach. We have illustrated the surgical anatomy through cadaveric dissections and provided an extensive review of the literature to highlight the versatility of this approach, its limits, and comparisons with alternative approaches. METHODS The surgical anatomy of the ELSI has been described using 1 adult-injected cadaveric head. Formalized noninjected brain specimens were also dissected to describe the brain parenchymal anatomy of the region. An extensive review of the literature was performed according to each targeted anatomical region. Illustrative cases are also presented. RESULTS The ELSI approach allows for wide exposure of the middle and posterolateral incisural spaces with direct access to centrally located intra-axial structures such as the splenium, pulvinar, brainstem, and mesial temporal lobe. In addition, for skull base extra-axial tumors such as petroclival meningiomas, the ELSI approach represents a rapid and adequate method of access without the use of extensive skull base approaches. CONCLUSIONS The ELSI approach represents one of the most versatile approaches with respect to its ability to address several anatomical regions centered at the posterior and middle incisural spaces. For intra-axial pathologies, the approach allows for access to the central core of the brain with several advantages compared with alternate approaches that frequently involve significant brain retraction and cortical incisions. In specific cases of skull base lesions, the ELSI approach is an elegant alternative to traditionally used skull base approaches, thereby avoiding approach-related morbidity.
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Affiliation(s)
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Vladimir Benes
- Department of Neurosurgery, Charles University and Military University Hospital, Prague, Czech Republic
| | | | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Francois Borsotti
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Martin Májovsky
- Department of Neurosurgery, Charles University and Military University Hospital, Prague, Czech Republic
| | - Albert A Sufianov
- Department of Neurosurgery, Federal Centre of Neurosurgery, Tyumen, Russia; Department of Neurosurgery, Sechenov University, Moscow, Russia
| | - Arianna Fava
- Department of Neurosurgery, Lariboisière Hospital, Paris, France
| | - Paolo di Russo
- Department of Neurosurgery, Lariboisière Hospital, Paris, France
| | - Samer K Elbabaa
- Department of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Pablo González-López
- Department of Neurosurgery, Hospital General Universitario de Alicante, Alicante, Spain
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne, Lausanne, Switzerland; Department of Neurosurgery, Sechenov University, Moscow, Russia; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
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Rahmani R, Susa ST, Sandwell SE, Kimmell KT, Maurer PK, Silberstein HJ, Nadler JW, Walter KA. Perioperative Risk of the Sitting Position for Elective Posterior Cervical Spine Surgery: A Retrospective Case Series. NEUROSURGERY OPEN 2020. [DOI: 10.1093/neuopn/okaa009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
BACKGROUND
The sitting cervical position for elective posterior cervical decompression and fusion affords advantages over prone positioning, but remains unpopular due to concerns about venous air embolism (VAE).
OBJECTIVE
To demonstrate the safety and efficacy of sitting cervical surgery in our series and in the literature.
METHODS
To evaluate the incidence of complications, we retrospectively identified all adult patients who underwent elective sitting posterior cervical surgeries at our institution from 2009 to 2014. Using International Classification of Diseases-9 coding, we searched for incidences of air embolism, myocardial infarction, pulmonary embolism, and deep vein thrombosis. Operative time, estimated blood loss, and case type distribution were also recorded. We then calculated the incidence of clinically significant VAE in sitting cervical surgeries.
RESULTS
Between 2009 and 2014, 558 surgeries were performed in the sitting cervical position. No VAE was identified. The average operative time was 1 h 25 min. A total of 30-d perioperative complications among sitting position patients included 3 myocardial infarctions, 1 pulmonary embolism attributed to venous thrombosis, and 2 patients with deep venous thrombosis for a total cardiovascular complication rate of 1.1%. The incidence of clinically significant VAE in the literature is 1.5%.
CONCLUSION
We present the second largest case series to date on the sitting position for cervical surgeries, highlighting its safety and efficacy. This position provides a surgical field with superior visualization, allowing decreased operative time and blood loss. The risk of clinically significant VAE is low. Intraoperative monitoring for these events with less invasive means is safe and effective.
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Affiliation(s)
- Redi Rahmani
- Department of Neurosurgery, University of Rochester, Rochester, New York
| | - Stephen T Susa
- Department of Neurosurgery, University of Rochester, Rochester, New York
| | | | | | - Paul K Maurer
- Department of Neurosurgery, Unity Hospital, Rochester, New York
| | | | - Jacob W Nadler
- Department of Anesthesiology, University of Rochester, Rochester, New York
| | - Kevin A Walter
- Department of Neurosurgery, University of Rochester, Rochester, New York
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Baro V, Lavezzo R, Marton E, Longatti P, Landi A, Denaro L, d'Avella D. Prone versus sitting position in pediatric low-grade posterior fossa tumors. Childs Nerv Syst 2019; 35:421-428. [PMID: 30610475 DOI: 10.1007/s00381-018-04031-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 12/17/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The choice between sitting and prone position to access the infratentorial space in a suboccipital craniotomy is still a matter of debate. The comparisons in terms of complications and outcome of both positions are scarce, and the pediatric population is indeed more infrequent in these in scientific reviews. In this paper, we assess intraoperative and postoperative complications and neurological outcome in pediatric patients undergoing posterior cranial fossa surgery for pilocytic astrocytoma in sitting and prone position respectively. METHODS We retrospectively analyzed 30 consecutive patients undergoing surgery for cerebellar pilocytic astrocytoma at the two neurosurgical units referring to the University of Padova Medical School from 1999 to 2017. Preoperative, intraoperative, and postoperative data were retrieved from our medical archives. RESULTS The statistical analysis did not show any differences between the two groups in terms of preoperative, intraoperative, and postoperative data. The neurological status at last follow-up was similar in both groups of patients. CONCLUSIONS Our results suggest that both sitting and prone position can be considered safe in suboccipital craniotomies. Further studies are needed to show if there are possible differences between these positions for other frequent pediatric tumors such as medulloblastomas and ependymomas.
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Affiliation(s)
- Valentina Baro
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy.
| | - Riccardo Lavezzo
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy
| | - Elisabetta Marton
- Department of Neurosurgery, Treviso Hospital, University of Padova Medical School, Via Piazzale 1, 31100, Treviso, Padova, Italy
| | - Pierluigi Longatti
- Department of Neurosurgery, Treviso Hospital, University of Padova Medical School, Via Piazzale 1, 31100, Treviso, Padova, Italy
| | - Andrea Landi
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy
| | - Luca Denaro
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy
| | - Domenico d'Avella
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy
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Saladino A, Lamperti M, Mangraviti A, Legnani FG, Prada FU, Casali C, Caputi L, Borrelli P, DiMeco F. The semisitting position: analysis of the risks and surgical outcomes in a contemporary series of 425 adult patients undergoing cranial surgery. J Neurosurg 2017; 127:867-876. [DOI: 10.3171/2016.8.jns16719] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVEThe objective of this study was to analyze the incidence of the primary complications related to positioning or surgery and their impact on neurological outcome in a consecutive series of patients undergoing elective surgery in the semisitting position.METHODSThe authors prospectively collected and retrospectively analyzed data from adult patients undergoing elective surgery in the semisitting position for a cranial disease. Patients were managed perioperatively according to a standard institutional protocol, a standardized stepwise positioning, and surgical maneuvers to decrease the risk of venous air embolism (VAE) and other complications. Intraoperative and postoperative complications were recorded. Neurointensive care unit (NICU) length of stay (LOS) and hospital LOS were the intermediate endpoints. Neurological outcome was the primary endpoint as determined by the modified Rankin scale (mRS) score at 6 months after surgery.RESULTSFour hundred twenty-five patients were included in the analysis. VAE occurred in 90 cases (21%) and it made no significant statistical difference in NICU LOS, hospital LOS, and neurological outcome. No complication was directly related to the semisitting position, although 46 patients (11%) experienced at least 1 surgery-related complication and NICU LOS and hospital LOS were significantly prolonged in this group. Neurological outcome was significantly worse for patients with complications (p < 0.0001).CONCLUSIONSEven in the presence of intraoperative VAE, the semisitting position was not related to an increased risk of postoperative deficits and can represent a safe additional option for the benefit of specific surgical and patient needs.
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Affiliation(s)
| | - Massimo Lamperti
- 2Neuro-Intensive Care Unit,
- 4Anesthesiology Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Antonella Mangraviti
- 1Department of Neurosurgery,
- 6Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, Maryland
| | | | | | | | - Luigi Caputi
- 3Department of Neurology, Cerebrovascular Diseases Unit, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Paola Borrelli
- 5Department of Public Health, Experimental and Forensic Medicine, Unit of Biostatistics and Clinical Epidemiology, University of Pavia, Italy; and
| | - Francesco DiMeco
- 1Department of Neurosurgery,
- 6Department of Neurological Surgery, Johns Hopkins Medical School, Baltimore, Maryland
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Günther F, Frank P, Nakamura M, Hermann EJ, Palmaers T. Venous air embolism in the sitting position in cranial neurosurgery: incidence and severity according to the used monitoring. Acta Neurochir (Wien) 2017; 159:339-346. [PMID: 27896454 DOI: 10.1007/s00701-016-3034-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 11/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is an ongoing debate about the sitting position (SP) in neurosurgical patients. The SP provides a number of advantages as well as severe complications such as commonly concerning venous air embolism (VAE). The best monitoring system for the detection of VAE is still controversial. METHODS In this retrospective analysis we compared 208 patients. Transesophageal echocardiography (TEE) or transthoracic Doppler (TTD) were used as monitoring devices to detect VAE; 101 cases were monitored with TEE and 107 with TTD. RESULTS The overall incidence of VAE was 23% (TTD: 10%; TEE: 37%), but the incidence of clinically relevant VAE (drop in end-tidal carbon dioxide above 3 mmHg) was higher in the TTD group (9 out of 17 VAE, 53%) compared to the TEE group (19 out of 62 VAE, 31%). None of the patients with recorded VAE had clinically significant sequelae. CONCLUSIONS In this small sample we found more VAE events in the TEE group, but the incidence of clinically relevant VAE was rare and comparable to other data. There is no consensus in the definition of clinically relevant VAE.
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Azan B, Teran F, Nelson BP, Andrus P. Point-Of-Care Ultrasound Diagnosis of Intravascular Air After Lower Extremity Intraosseous Access. J Emerg Med 2016; 51:680-683. [PMID: 27623218 DOI: 10.1016/j.jemermed.2016.05.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 04/08/2016] [Accepted: 05/17/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Vascular air embolism is a rare but potentially deadly phenomenon. Early diagnosis allows providers to initiate measures aimed at preventing further air entry, preventing the migration of air to the lungs, and mitigating the hemodynamic effects of pulmonary air embolism. CASE REPORT An emergency physician used point-of-care ultrasound to identify intravascular air before embolization to the pulmonary vasculature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Bedside ultrasound can be used as a tool for early diagnosis of intravascular air. Emergency physicians should be aware of the typical sonographic manifestations of intravascular air and the initial steps in treating vascular air embolism.
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Affiliation(s)
- Benjamin Azan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Felipe Teran
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bret P Nelson
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Phillip Andrus
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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Himes BT, Mallory GW, Abcejo AS, Pasternak J, Atkinson JLD, Meyer FB, Marsh WR, Link MJ, Clarke MJ, Perkins W, Van Gompel JJ. Contemporary analysis of the intraoperative and perioperative complications of neurosurgical procedures performed in the sitting position. J Neurosurg 2016; 127:182-188. [PMID: 27494821 DOI: 10.3171/2016.5.jns152328] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Historically, performing neurosurgery with the patient in the sitting position offered advantages such as improved visualization and gravity-assisted retraction. However, this position fell out of favor at many centers due to the perceived risk of venous air embolism (VAE) and other position-related complications. Some neurosurgical centers continue to perform sitting-position cases in select patients, often using modern monitoring techniques that may improve procedural safety. Therefore, this paper reports the risks associated with neurosurgical procedures performed in the sitting position in a modern series. METHODS The authors reviewed the anesthesia records for instances of clinically significant VAE and other complications for all neurosurgical procedures performed in the sitting position between January 1, 2000, and October 8, 2013. In addition, a prospectively maintained morbidity and mortality log of these procedures was reviewed for instances of subdural or intracerebral hemorrhage, tension pneumocephalus, and quadriplegia. Both overall and specific complication rates were calculated in relation to the specific type of procedure. RESULTS In a series of 1792 procedures, the overall complication rate related to the sitting position was 1.45%, which included clinically significant VAE, tension pneumocephalus, and subdural hemorrhage. The rate of any detected VAE was 4.7%, but the rate of VAE requiring clinical intervention was 1.06%. The risk of clinically significant VAE was highest in patients undergoing suboccipital craniotomy/craniectomy with a rate of 2.7% and an odds ratio (OR) of 2.8 relative to deep brain stimulator cases (95% confidence interval [CI] 1.2-70, p = 0.04). Sitting cervical spine cases had a comparatively lower complication rate of 0.7% and an OR of 0.28 as compared with all cranial procedures (95% CI 0.12-0.67, p < 0.01). Sitting cervical cases were further subdivided into extradural and intradural procedures. The rate of complications in intradural cases was significantly higher (OR 7.3, 95% CI 1.4-39, p = 0.02) than for extradural cases. The risk of VAE in intradural spine procedures did not differ significantly from sitting suboccipital craniotomy/craniectomy cases (OR 0.69, 95% CI 0.09-5.4, p = 0.7). Two cases (0.1%) had to be aborted intraoperatively due to complications. There were no instances of intraoperative deaths, although there was a single death within 30 days of surgery. CONCLUSIONS In this large, modern series of cases performed in the sitting position, the complication rate was low. Suboccipital craniotomy/craniectomy was associated with the highest risk of complications. When appropriately used with modern anesthesia techniques, the sitting position provides a safe means of surgical access.
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Li J, Gelb AW, Flexman AM, Ji F, Meng L. Definition, evaluation, and management of brain relaxation during craniotomy. Br J Anaesth 2016; 116:759-69. [PMID: 27121854 DOI: 10.1093/bja/aew096] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The term 'brain relaxation' is routinely used to describe the size and firmness of the brain tissue during craniotomy. The status of brain relaxation is an important aspect of neuroanaesthesia practice and is relevant to the operating conditions, retraction injury, and likely patient outcomes. Brain relaxation is determined by the relationship between the volume of the intracranial contents and the capacity of the intracranial space (i.e. a content-space relationship). It is a concept related to, but distinct from, intracranial pressure. The evaluation of brain relaxation should be standardized to facilitate clinical communication and research collaboration. Both advantageous and disadvantageous effects of the various interventions for brain relaxation should be taken into account in patient care. The outcomes that matter the most to patients should be emphasized in defining, evaluating, and managing brain relaxation. To date, brain relaxation has not been reviewed specifically, and the aim of this manuscript is to discuss the current approaches to the definition, evaluation, and management of brain relaxation, knowledge gaps, and targets for future research.
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Affiliation(s)
- J Li
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - A W Gelb
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA
| | - A M Flexman
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - F Ji
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, China
| | - L Meng
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA 94143, USA Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06520, USA
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The role and safety of the sitting position in instrumented cervical surgery. J Clin Neurosci 2016; 25:75-8. [DOI: 10.1016/j.jocn.2015.05.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 05/03/2015] [Indexed: 11/21/2022]
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Improved Postoperative Facial Nerve and Hearing Function in Retrosigmoid Vestibular Schwannoma Surgery Significantly Associated with Semisitting Position. World Neurosurg 2015; 87:290-7. [PMID: 26732954 DOI: 10.1016/j.wneu.2015.11.089] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 11/24/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The pros and cons of semisitting positioning (SSP) versus lateral, horizontal positioning (LP) during retrosigmoid vestibular schwannoma (VS) surgery, especially concerning postoperative cranial nerve and brain stem preservation, are under continuous discussion. METHODS In a single-center retrospective cohort study, 30 VSs operated on in SSP compared with 30 operated on in LP with comparable demography were analyzed. During SSP surgery, transesophageal echocardiographic monitoring for venous air embolism was used continuously. Electrophysiologic cranial nerve monitoring was used in both groups. RESULTS Length of surgery was significantly different between both groups: 183 minutes mean in SSP surgery versus 365 minutes mean in LP surgery (P = 0.0001). Postoperative rates of facial palsy and hearing loss were also significantly different. Six months postoperatively, 63% had normal facial nerve function after SSP surgery, whereas in LP surgery, 40% had no facial palsy (P = 0.02). Hearing preservation rate was also significantly different: 44% in SSP surgery compared with 14% in LP surgery who had preserved hearing (P = 0.006). Because of cerebrospinal fluid leaks, there were 3 operative revisions in the LP group (10%) and 1 (3.3%) in the SSP group. A clinically insignificant venous air embolism rate was found in 3.3% of patients (1/30) during SSP surgery. The neurologic outcome after 6 months was 1.2 on the Rankin Scale in the LP group and 1.0 in the SSP group, with zero mortality. CONCLUSIONS SSP compared with LP surgery was associated with significantly shorter operation time and better facial and cochlear nerve function in VS surgery postoperatively, without differences in complication rates.
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Carbon dioxide field flooding reduces the hemodynamic effects of venous air embolism occurring in the sitting position. Childs Nerv Syst 2015; 31:1321-6. [PMID: 25953098 DOI: 10.1007/s00381-015-2742-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Although the utility of the sitting position is undisputed for biomechanical and ergonomic reasons, it has been debated in recent years for its risks, particularly venous air embolism (VAE). In order to reduce the hemodynamic effect of VAE, we changed the composition of the surgical field air partially replacing nitrogen with carbon dioxide (CO2) that better dissolves in human tissues. METHODS First, we tested our method on a test dummy in the sitting position. Infrared CO2 sensors were placed close to the wound opening and on the facial mask of the surgeon. An oxygen sensor was connected to a computer for data recording (ALTAIR(®), MSA Safety). This model showed that 10 L/min CO2 flow provides efficient air displacement, maintaining safety for the surgeon. We reproduced the above-described surgical field environment in ten consecutive cases of posterior fossa surgery performed in the sitting position. A homogeneous group of ten patients operated in the sitting position with standard setting environment was used for control. We intraoperatively monitored VAE with trans-esophageal echocardiography (TEE), end-tidal CO2 (ETCO2), CO2 arterial pressure (PaCO2), and hemodynamic changes. RESULTS Although the percentage of VAE was 70% in both groups, hemodynamic effects occurred in 10% of cases in the study group and in 40% of cases in the control group. CONCLUSIONS Our preliminary study shows that a CO2-enriched sitting position surgical microenvironment significantly reduces the hemodynamic effects of VAE, more likely because arterial CO2 emboli are more soluble and consequently much better tolerated than air emboli.
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Giraldo M, Lopera LM, Arango M. Venous air embolism in neurosurgery. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1016/j.rcae.2014.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Venous air embolism in neurosurgery☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2015. [DOI: 10.1097/01819236-201543001-00007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Feigl GC, Decker K, Wurms M, Krischek B, Ritz R, Unertl K, Tatagiba M. Neurosurgical procedures in the semisitting position: evaluation of the risk of paradoxical venous air embolism in patients with a patent foramen ovale. World Neurosurg 2013; 81:159-64. [PMID: 23295634 DOI: 10.1016/j.wneu.2013.01.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 08/05/2012] [Accepted: 01/02/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To analyze the actual risk for patients with a patent foramen ovale (PFO) to experience a clinically relevant venous air embolism (VAE) during surgery performed in the semisitting position. METHODS All procedures were performed between January 2008 and December 2009, under general anesthesia and in the semisitting position. Transesophageal echocardiography (TEE) and capnometry were used intraoperatively to monitor for air bubbles in the venous system. RESULTS Of 200 consecutive patients who all were operated on in the semisitting position, 52 patients (26%) had a diagnosis of PFO. Rates of VAE in patients were graded as follows: grade 0 (no air bubbles visible, no air embolism), 23 patients (44.2%); grade I (air bubbles on TEE), 22 patients (42.3%); grade II (air bubbles on TEE with decrease of end-tidal carbon dioxide [ETCO2] ≤ 3 mm Hg), 2 patients (3.8%); grade III, air bubbles on TEE with decrease of ETCO2 >3 mm Hg, 4 patients (7.7%); grade IV, air bubbles on TEE with decrease of ETCO2 >3 mm Hg and decrease of mean arterial pressure ≥ 20% or increase of heart rate ≥ 40% (or both), 1 patient (1.9%); and grade V, VAE causing arrhythmia with hemodynamic instability requiring cardiopulmonary resuscitation, 0 patients (0%). There were no deaths in this series, and no new or unexplained, mild or severe neurologic deficits were caused by a VAE. CONCLUSIONS Under standardized anesthesia and neurosurgical protocols, patients with a PFO can be operated on safely in the semisitting position.
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Affiliation(s)
- Guenther C Feigl
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany.
| | - Karlheinz Decker
- Department of Anesthesiology, University of Tübingen Medical Center, Tübingen, Germany
| | - Max Wurms
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany
| | - Boris Krischek
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany
| | - Rainer Ritz
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany
| | - Klaus Unertl
- Department of Anesthesiology, University of Tübingen Medical Center, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tübingen Medical Center, Tübingen, Germany
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Sitting Position for Removal of Pineal Region Lesions: The Helsinki Experience. World Neurosurg 2010; 74:505-13. [DOI: 10.1016/j.wneu.2010.09.026] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Revised: 09/22/2010] [Accepted: 09/22/2010] [Indexed: 11/19/2022]
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Fathi AR, Eshtehardi P, Meier B. Patent foramen ovale and neurosurgery in sitting position: a systematic review. Br J Anaesth 2009; 102:588-96. [DOI: 10.1093/bja/aep063] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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Schäfer ST, Lindemann J, Brendt P, Kaiser G, Peters J. Intracardiac transvenous echocardiography is superior to both precordial Doppler and transesophageal echocardiography techniques for detecting venous air embolism and catheter-guided air aspiration. Anesth Analg 2008; 106:45-54, table of contents. [PMID: 18165549 DOI: 10.1213/01.ane.0000289646.81433.28] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Venous air embolism (VAE) is a potentially fatal complication during surgical procedures with patients in the sitting position. Since methods for detection of persistent low-volume VAE and targeted air aspiration are limited, we tested the hypotheses that transvenous intracardiac echocardiography (ICE) 1) improves detection of small air emboli in comparison to transesophageal echocardiography (TEE) and precordial Doppler monitoring (PCD) techniques, and that 2) image-guided multiorifice central venous catheter manipulation improves air recovery in moderate and large VAE, when compared with aspiration with the multiorifice central venous catheter in a static position. METHODS AND RESULTS Adult swine (73 +/- 4.6 kg, n = 7) were premedicated, anesthetized with propofol and fentanyl, endotracheally intubated, mechanically ventilated, and placed in a 45 degrees head-up position. First, nine different small volumes of air emboli (0.05-1 mL) were randomly injected via an ear vein, and VAE detection methods were applied in random order. For 378 small volume air injections, ICE had a much higher sensitivity (82.5%, P < 0.0001) on the analysis of VAE detection than TEE (52.8%) or PCD (46.8%), with no difference (P = 0.571) between TEE and PCD. An injected air volume as small as 0.15 mL was detected by ICE in 90% of injections performed, whereas PCD and TEE detected only half of the boluses of 0.25-0.30 mL of air, and required boluses of 0.4-1.0 mL to achieve 100% detection. Air recovery was assessed in a second series of moderate VAE (2, 5, 10 mL); image-guided aspiration-catheter manipulation recovered significantly more (34.1% vs 17.2%, P < 0.0001) intracardiac air than without catheter manipulation. In a third series of injections of large air volumes (25, 50, and 100 mL), air recovery was not significantly different with ultrasound-guided aspiration (41.3% vs 31.8%, P = 0.11). CONCLUSION Small air emboli are detected by ICE with much greater sensitivity compared with both PCD and TEE techniques. Furthermore, recovery of embolized air is enhanced by image-guided manipulation of a multiorifice central venous catheter. Clinical studies are required to assess this technique during surgery with patients in the sitting position.
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Affiliation(s)
- Simon T Schäfer
- Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen and Universitätsklinikum Essen, Essen, Deutschland, Germany.
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Gharabaghi A, Rosahl SK, Feigl GC, Safavi-Abbasi S, Mirzayan JM, Heckl S, Shahidi R, Tatagiba M, Samii M. Image-Guided Lateral Suboccipital Approach: Part 2—Impact on Complication Rates and Operation Times. Oper Neurosurg (Hagerstown) 2008; 62:24-9; discussion 29. [DOI: 10.1227/01.neu.0000317370.15265.8b] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
Objective:
Image-guidance systems are widely available for surgical planning and intraoperative navigation. Recently, three-dimensional volumetric image rendering technology that increasingly applies in navigation systems to assist neurosurgical planning, e.g., for cranial base approaches. However, there is no systematic clinical study available that focuses on the impact of this image-guidance technology on outcome parameters in suboccipital craniotomies.
Methods:
A total of 200 patients with pathologies located in the cerebellopontine angle were reviewed, 100 of whom underwent volumetric neuronavigation and 100 of whom underwent treatment without intraoperative image guidance. This retrospective study analyzed the impact of image guidance on complication rates (venous sinus injury, venous air embolism, postoperative morbidity caused by venous air embolism) and operation times for the lateral suboccipital craniotomies performed with the patient in the semi-sitting position.
Result:
This study demonstrated a 4% incidence of injury to the transverse-sigmoid sinus complex in the image-guided group compared with a 15% incidence in the non-image-guided group. Venous air embolisms were detected in 8% of the image-guided patients and in 19% of the non-image-guided patients. These differences in terms of complication rates were significant for both venous sinus injury and venous air embolism (P < 0.05). There was no difference in postoperative morbidity secondary to venous air embolism between both groups. The mean time for craniotomy was 21 minutes in the image-guided group and 39 minutes in non-image-guided group (P = 0.036).
Conclusion:
Volumetric image guidance provides fast and reliable three-dimensional visualization of sinus anatomy in the posterior fossa, thereby significantly increasing speed and safety in lateral suboccipital approaches.
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Affiliation(s)
- Alireza Gharabaghi
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
- Department of Neurosurgery, Eberhard Karls University Hospital, Tübingen, Germany
| | - Steffen K. Rosahl
- Department of Neurosurgery, Albert Ludwigs University Hospital, Freiburg, Germany
| | - Günther C. Feigl
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Sam Safavi-Abbasi
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Javad M. Mirzayan
- Department of Neurosurgery, Eberhard Karls University Hospital, Tübingen, Germany
| | - Stefan Heckl
- Image Guidance Laboratories, Stanford University, Palo Alto, California
| | - Ramin Shahidi
- Department of Neurosurgery, Eberhard Karls University Hospital, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
| | - Madjid Samii
- Department of Neurosurgery, International Neuroscience Institute, Hannover, Germany
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Hicks JW, Munis JR. The siphon controversy counterpoint: the brain need not be "baffling". Am J Physiol Regul Integr Comp Physiol 2005; 289:R629-32. [PMID: 16014454 DOI: 10.1152/ajpregu.00810.2004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- James W Hicks
- Department of Ecology and Evolutionary Biology, University of California-Irvine, Irvine, CA, USA
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