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Omara C, Mammi M, Kvilhaug M, Soni S, Arora H, Yoo H, Smith TR, Mekary RA. Dural Venous Sinus Thrombosis After Vestibular Schwannoma Surgery: Should We Anticoagulate? World Neurosurg 2024; 188:220-229.e3. [PMID: 38838938 DOI: 10.1016/j.wneu.2024.05.170] [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: 01/22/2024] [Revised: 05/27/2024] [Accepted: 05/28/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The incidence of dural venous sinus thrombosis (DVST) following vestibular schwannoma (VS) surgery remains understudied. The diverse clinical presentation complicates forming anticoagulation treatment guidelines. This meta-analysis aimed to investigate the incidence of DVST post-VS surgery and to evaluate the role of anticoagulation. METHODS A systematic review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist, was conducted. Studies reporting DVST incidence after VS surgery were included. DVST incidence stratified by detection method was the primary outcome. Adverse events per treatment strategy (anticoagulation or no anticoagulation) were the secondary outcome. Pooled incidence with respective 95% confidence intervals were calculated using the random-effects model via the DerSimonian and Laird method. RESULTS The overall DVST incidence post-VS resection was 15.5% (95% confidence interval: 10.3%, 22.5%; 10 studies). Stratification by detection method revealed 29.4% (19.2%, 42.3%) for magnetic resonance imaging, 8.2% (3.2%, 19.5%) for computed tomography, and 0.7% (0.2%, 2.8%) upon clinical suspicion. The pooled incidence of adverse events was 16.1% (6.4%, 35.0%) for the anticoagulation treatment and 4.4% (1.4%, 12.9%) for no anticoagulation treatment, with one mortality case being among the adverse events in this latter group. CONCLUSIONS DVST after VS surgery is more common than initially perceived, predominantly presenting asymptomatically. Variability in anticoagulation protocols hinders the establishment of definitive therapeutic stances; nevertheless, there is no supporting evidence to promote anticoagulation administration for DVST. This begs the need for further institutional comparative studies with a proper adjustment for confounding and well-defined anticoagulation regimens.
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Affiliation(s)
- Chady Omara
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Marco Mammi
- Neurosurgery Division, "M. Bufalini" Hospital, Cesena, Italy
| | - Magnar Kvilhaug
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Sahjesh Soni
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Harshit Arora
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Heejeung Yoo
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center (CNOC), Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA.
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Mirdamadi A, Javid M, Nemati S, Keivanlou MH, Javid M, Amini-Salehi E, Joukar F, Hassanipour S. Prevalence and patterns of cerebral venous sinus thrombosis following vestibular schwannoma surgery: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2024; 281:3879-3891. [PMID: 38443628 DOI: 10.1007/s00405-024-08534-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 02/05/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE Cerebral venous sinus thrombosis (CVST) is a potentially serious complication following surgical treatment of vestibular schwannoma, a benign tumor originating from Schwann cells of the vestibulocochlear nerve. This study aimed to determine the prevalence of CVST following surgical treatment of vestibular schwannoma and the factors contributing to its occurrence. METHOD Two independent researchers searched the global databases of PubMed, Web of Science, Scopus, and the Cochrane Library up to September 01, 2023. We employed a random-effects model for data analysis. Heterogeneity was evaluated using the I2 test. To assess the quality of the studies meeting our inclusion criteria, we employed the Joanna Briggs Institute Critical Appraisal Checklist. RESULTS We included 23 articles in this meta-analysis. The pooled prevalence of CVST after vestibular schwannoma surgery was 6.4% (95%CI 3.4-11.5%). The pooled prevalence of CVST following the retrosigmoid (RS), translabyrinthine (TL), and middle cranial fossa (MCF) approaches was 4.8% (95%CI 2.0-11.0%), 9.6% (95%CI 4.3-20.3%) and 9.9% (95%CI 1.6-42.2%), respectively, revealing a significant difference between the TL and the RS approaches (Odds ratio = 2.10, 95%CI 1.45-3.04, P < 0.001). The sigmoid sinus exhibited the highest post-operative thrombosis rate (7.9%), surpassing the transverse sinus (3.7%) and involvement of both sigmoid and transverse sinuses (1.6%), respectively. No significant associations were found with demographic or surgical factors. CONCLUSION In the current meta-analysis, we identified a 6.4% CVST prevalence following vestibular schwannoma surgery, with varying rates depending on the surgical approach. No significant associations with patient or surgical factors were found, emphasizing the need for heightened clinical vigilance and further research in this context. TRAIL REGISTRATION PROSPERO ID: CRD42023453513.
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Affiliation(s)
- Arian Mirdamadi
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Guilan University of Medical Sciences, Rasht, Iran
| | - Mona Javid
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Guilan University of Medical Sciences, Rasht, Iran
| | - Shadman Nemati
- Department of Otolaryngology, Head and Neck Surgery and Research Center, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohammad-Hossein Keivanlou
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Student Research Committee, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - Mohammadreza Javid
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Guilan University of Medical Sciences, Rasht, Iran
| | - Ehsan Amini-Salehi
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
- Guilan University of Medical Sciences, Rasht, Iran
| | - Farahnaz Joukar
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Soheil Hassanipour
- Gastrointestinal and Liver Diseases Research Center, Guilan University of Medical Sciences, Rasht, Iran.
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Trevisi G, Giovanni P, Ciaffi G, Auricchio AM, Sturiale CL. Venous Sinus Thrombosis-Associated with Posterior Cranial Fossa Surgery. A Systematic Review and Meta-Analysis of Natural History, Risk Factors, Treatment, and Outcome. World Neurosurg 2024; 186:122-132. [PMID: 38531470 DOI: 10.1016/j.wneu.2024.03.087] [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: 12/26/2023] [Revised: 03/15/2024] [Accepted: 03/16/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Venous sinus thromboses (VSTs) are rare complications of neurosurgical procedures in the proximity of the dural sinuses. Surgery of the posterior cranial fossa (PCF) and particularly of the cerebellopontine angle (CPA) shows increased risk of VST. VST management is challenging because anticoagulant therapy must be balanced with the risk of postoperative bleeding. We performed a systematic review and meta-analysis to summarize the most important neuroradiologic and clinical aspects of VST after PCF/CPA surgery. METHODS We performed a comprehensive literature search to identify articles reporting data on VST after PCF/CPA surgery. We selected only comparative studies providing adequate neuroimaging assessing VST and a control group. RESULTS We included 13 articles reporting 1855 patients. VST occurred in 251/1855 cases (estimated incidence, 17.3%; 95% confidence interval [CI], 12.4%-22.2%). Only presigmoid approach (odds ratio [OR], 2.505; 95% CI, 1.161-5.404; P = 0.019) and intraoperative sinus injury (OR, 8.95; 95% CI, 3.43-23.34; P < 0.001) showed a significant association with VST. VST-related symptoms were reported in 12/251 patients with VST (pooled incidence, 3.1%; 95% CI, 1%-5.2%). In particular, we found a significantly increased OR of cerebrospinal fluid leak (OR, 3.197; 95% CI, 1.899-5.382; P < 0.001) and cerebrospinal fluid dynamic alterations in general (OR, 3.625; 95% CI, 2.370-5.543; P < 0.001). Indications for VST treatment were heterogeneous: 58/251 patients underwent antithrombotics, with 6 treatment-related bleedings. Recanalization overall occurred in 56.4% (95% CI, 40.6%-72.2%), with no significant difference between treated and untreated patients. However, untreated patients had a favorable outcome. CONCLUSIONS VST is a relatively frequent complication after PCF/CPA surgery and a presigmoid approach and intraoperative sinus injury represent the most significant risk factors. However, the clinical course is generally benign, with no advantage of antithrombotic therapy.
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Affiliation(s)
- Gianluca Trevisi
- Department of Neurosciences, Imaging and Clinical Sciences, G. D'Annunzio University, Chieti-Pescara, Italy
| | - Pennisi Giovanni
- Fondazione Policlinico Universitario A, GemelliIRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Ciaffi
- Fondazione Policlinico Universitario A, GemelliIRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Maria Auricchio
- Fondazione Policlinico Universitario A, GemelliIRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carmelo Lucio Sturiale
- Fondazione Policlinico Universitario A, GemelliIRCCS, Università Cattolica del Sacro Cuore, Rome, Italy.
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Elms HL, Straka DM, Abouelella DK, Francis HW, Kaylie DM, Cunningham CD. Translabyrinthine Craniotomy Is Associated with Higher Risk of Asymptomatic Dural Venous Sinus Thrombosis in Vestibular Schwannoma Resection. Otol Neurotol 2023; 44:1066-1072. [PMID: 37696795 DOI: 10.1097/mao.0000000000004013] [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: 09/13/2023]
Abstract
OBJECTIVE Characterize the incidence, risk factors, and patient outcomes of dural venous sinus thrombosis identified on postoperative imaging after retrosigmoid or translabyrinthine craniotomy for vestibular schwannoma resection. STUDY DESIGN Retrospective cohort study. SETTING Single tertiary academic referral center. PATIENTS Eighty-one patients 19 to 82 years of age with vestibular schwannomas, 58% female. INTERVENTIONS Retrosigmoid or translabyrinthine craniotomy with postoperative magnetic resonance imaging/magnetic resonance venography. MAIN OUTCOME MEASURES Association between operative approach, age, sex, body mass index, tumor size, dominant sinus, operative time, laterality, and perioperative cerebrospinal fluid (CSF) leaks with rate of thrombosis. RESULTS Translabyrinthine craniotomy was associated with the highest relative risk of thrombosis (odds ratios [OR] = 19.82, 95% confidence interval [CI] = 1.75-224, p = 0.007), followed by male sex (OR = 5.53, 95% CI = 1.63-18.8, p = 0.035). Other patient and demographic risk factors were not associated with increased rates of dural venous thrombosis, nor was there an association with postoperative CSF leak. 81% (25/31) of thrombi had resolved within 3 years of surgery. CONCLUSIONS Translabyrinthine approach and male sex most strongly predicted postoperative dural venous thrombosis after postauricular craniotomy for vestibular schwannoma resection. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED Better understanding of risk factors and management of dural venous thrombosis after vestibular schwannoma surgery. LEARNING OBJECTIVE Characterize clinically significant risk factors for dural venous thrombosis in vestibular schwannoma surgery. DESIRED RESULT Identification of patient and operative risk factors for dural venous thrombosis. LEVEL OF EVIDENCE III. INDICATE IRB OR IACUC Exempt.
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Affiliation(s)
- Hunter L Elms
- Department of Head and Neck Surgery and Communication Sciences, Duke University, Durham, North Carolina
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5
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Layard Horsfall H, Khan DZ, Collins J, Cooke S, Freeman SR, Gurusinghe N, Hampton S, Hardwidge C, Irving R, Kitchen N, King A, Khalil S, Koh CH, Leonard C, Marcus HJ, Muirhead W, Obholzer R, Pathmanaban O, Robertson IJA, Shapey J, Stoyanov D, Teo M, Tysome JR, Saeed SR, Grover P. Generating Operative Workflows for Vestibular Schwannoma Resection: A Two-Stage Delphi's Consensus in Collaboration with the British Skull Base Society. Part 1: The Retrosigmoid Approach. J Neurol Surg B Skull Base 2023; 84:423-432. [PMID: 37671298 PMCID: PMC10477012 DOI: 10.1055/a-1886-5500] [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: 03/03/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022] Open
Abstract
Objective An operative workflow systematically compartmentalizes operations into hierarchal components of phases, steps, instrument, technique errors, and event errors. Operative workflow provides a foundation for education, training, and understanding of surgical variation. In this Part 1, we present a codified operative workflow for the retrosigmoid approach to vestibular schwannoma resection. Methods A mixed-method consensus process of literature review, small-group Delphi's consensus, followed by a national Delphi's consensus, was performed in collaboration with British Skull Base Society (BSBS). Each Delphi's round was repeated until data saturation and over 90% consensus was reached. Results Eighteen consultant skull base surgeons (10 neurosurgeons and 8 ENT [ear, nose, and throat]) with median 17.9 years of experience (interquartile range: 17.5 years) of independent practice participated. There was a 100% response rate across both Delphi's rounds. The operative workflow for the retrosigmoid approach contained three phases and 40 unique steps as follows: phase 1, approach and exposure; phase 2, tumor debulking and excision; phase 3, closure. For the retrosigmoid approach, technique, and event error for each operative step was also described. Conclusion We present Part 1 of a national, multicenter, consensus-derived, codified operative workflow for the retrosigmoid approach to vestibular schwannomas that encompasses phases, steps, instruments, technique errors, and event errors. The codified retrosigmoid approach presented in this manuscript can serve as foundational research for future work, such as operative workflow analysis or neurosurgical simulation and education.
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Affiliation(s)
- Hugo Layard Horsfall
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Danyal Z. Khan
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Justin Collins
- Department of Urooncology, University College London Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Stephen Cooke
- Department of Neurosurgery, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Simon R. Freeman
- Department of Otolaryngology, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, United Kingdom
| | - Nihal Gurusinghe
- Department of Neurosurgery, Lancashire Teaching Hospital, Preston, United Kingdom
| | - Susie Hampton
- Department of Ear, Nose and Throat, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Carl Hardwidge
- Department of Neurosurgery, University Hospital Sussex, Brighton, United Kingdom
| | - Richard Irving
- Department of Ear, Nose and Throat, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Neil Kitchen
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Andrew King
- Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Northern Care Alliance National Health Service Group, University of Manchester, Manchester, United Kingdom
| | - Sherif Khalil
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Royal National Throat, Nose and Ear Hospital, London, United Kingdom
| | - Chan H. Koh
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Colin Leonard
- Department of Ear, Nose and Throat, Belfast Health and Social Care Trust, Belfast, United Kingdom
| | - Hani J. Marcus
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - William Muirhead
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Rupert Obholzer
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Royal National Throat, Nose and Ear Hospital, London, United Kingdom
| | - Omar Pathmanaban
- Department of Neurosurgery, Manchester Centre for Clinical Neurosciences, Salford Royal Hospital, Salford, United Kingdom
| | - Iain J. A. Robertson
- Department of Neurosurgery, Nottingham University Hospitals, Nottingham, United Kingdom
| | - Jonathan Shapey
- Department of Neurosurgery, Kings College Hospital, London, United Kingdom
| | - Danail Stoyanov
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Mario Teo
- Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - James R. Tysome
- Department of Ear, Nose and Throat, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Shakeel R. Saeed
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- The Royal National Throat, Nose and Ear Hospital, London, United Kingdom
| | - Patrick Grover
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Przepiorka L, Wójtowicz K, Camlet K, Jankowski J, Kujawski S, Grabowska-Derlatka L, Marchel A, Kunert P. Postoperative Cerebral Venous Sinus Thrombosis Following a Retrosigmoid Craniotomy-A Clinical and Radiological Analysis. Brain Sci 2023; 13:1039. [PMID: 37508971 PMCID: PMC10377583 DOI: 10.3390/brainsci13071039] [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: 06/12/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Postoperative cerebral venous sinus thrombosis (CVST) is a rare complication of the retrosigmoid approach. To address the lack of literature, we performed a retrospective analysis. The thromboses were divided into those demonstrating radiological (rCVST) and clinical (cCVST) features, the latter diagnosed during hospitalization. We identified the former by a lack of contrast in the sigmoid (SS) or transverse sinuses (TS), and evaluated the closest distance from the craniotomy to quantify sinus exposure. We included 130 patients (males: 52, females: 78) with a median age of 46.0. They had rCVST in 46.9% of cases, most often in the TS (65.6%), and cCVST in 3.1% of cases. Distances to the sinuses were not different regarding the presence of cCVST (p = 0.32 and p = 0.72). The distance to the SS was not different regarding rCVST (p = 0.13). However, lower exposure of the TS correlated with a lower incidence of rCVST (p = 0.009). When surgery was performed on the side of the dominant sinuses, rCVSTs were more frequent (p = 0.042). None of the other examined factors were related to rCVST or cCVST. Surgery on the side of the dominant sinus, and the exposing of them, seems to be related with rCVST. Further prospective studies are needed to identify the risk factors and determine the best management.
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Affiliation(s)
- Lukasz Przepiorka
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Katarzyna Wójtowicz
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Katarzyna Camlet
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Jan Jankowski
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Sławomir Kujawski
- Department of Exercise Physiology and Functional Anatomy, Ludwik Rydygier Collegium Medicum in Bydgoszcz Nicolaus Copernicus University in Toruń, 85-077 Bydgoszcz, Poland
| | | | - Andrzej Marchel
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland
| | - Przemysław Kunert
- Department of Neurosurgery, Medical University of Warsaw, 02-097 Warsaw, Poland
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7
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Kutz JW, Tan D, Hunter JB, Barnett S, Isaacson B. Management of Complications in Vestibular Schwannoma Surgery. Otolaryngol Clin North Am 2023; 56:567-576. [PMID: 36964095 DOI: 10.1016/j.otc.2023.02.015] [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: 03/26/2023]
Abstract
Microsurgical removal of acoustic neuroma has advanced tremendously; however, complications still occur. Facial nerve injury is the most common detrimental complication and should take precedence over gross tumor removal in cases where there is an unfavorable tumor-facial nerve interface. Cerebrospinal fluid leakage can occur even with meticulous closure techniques and is generally treatable with either lumbar-subarachnoid drainage or revision wound closure. Meningitis is a serious complication that requires a high index of suspicion in the postoperative period. Other less common complications include intraoperative and postoperative vascular injuries. Early identification and treatment can prevent devastating outcomes.
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Affiliation(s)
- Joe Walter Kutz
- Departments of Otolaryngology and Neurological Surgery, The University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas TX 75390, USA.
| | - Donald Tan
- The University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas TX 75390, USA
| | - Jacob B Hunter
- The University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas TX 75390, USA
| | - Samuel Barnett
- Departments of Neurological Surgery and Otolaryngology, The University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas TX 75390, USA
| | - Brandon Isaacson
- Departments of Otolaryngology and Neurological Surgery, The University of Texas Southwestern Medical Center, 2001 Inwood Road, Dallas TX 75390, USA
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Freeman MH, Cass ND, Berndt DM, Kloosterman N, Poulos EA, Perkins EL, O'Malley MR, Tawfik KO, Bennett ML, Aulino JM, Haynes DS. Association of Postoperative Sigmoid Sinus Occlusion and Cerebrospinal Fluid Leak in Translabyrinthine Surgery. Otolaryngol Head Neck Surg 2023; 168:435-442. [PMID: 35671137 DOI: 10.1177/01945998221102817] [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: 01/25/2022] [Accepted: 04/28/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To characterize the incidence of sigmoid sinus occlusion (SSO) following translabyrinthine (TL) surgery for posterior fossa tumor resection and determine the association with cerebrospinal fluid (CSF) leak. STUDY DESIGN Retrospective case series. SETTING Tertiary referral center. METHODS Patients undergoing TL surgery for vestibular schwannoma from 2012 to 2020 were included. Demographic data, medical history, preoperative tumor length and volume, and postoperative complications including CSF leak were recorded. Neuroradiology review of postoperative magnetic resonance imaging was used to determine the presence or absence of flow through the sigmoid sinus. RESULTS Of 205 patients undergoing TL, 21 (10.2%) experienced CSF leak postoperatively. Overall 56 (27%) demonstrated SSO on immediate postoperative magnetic resonance imaging. CSF leaks were more likely in those with SSO (19.6%) than those without SSO (6.7%; odds ratio, 3.54 [95% CI, 1.25-10.17]). Tumor volume and body mass index were not significantly associated with CSF leak. In total, 105 (51%) patients had some degree of sigmoid sinus thrombosis, but nonocclusive thrombosis was not associated with CSF leak. CONCLUSION SSO after TL approaches is common and appears to be significantly associated with postoperative CSF leak development. Minimizing manipulation of the sigmoid sinus during TL surgery and compression after surgery may have a role in preventing CSF leak.
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Affiliation(s)
- Michael H Freeman
- The Otology Group, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nathan D Cass
- The Otology Group, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David M Berndt
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Eric A Poulos
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Elizabeth L Perkins
- The Otology Group, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew R O'Malley
- The Otology Group, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kareem O Tawfik
- The Otology Group, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marc L Bennett
- The Otology Group, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joseph M Aulino
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David S Haynes
- The Otology Group, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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9
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Gerges C, Malloy P, Rabah N, Defta D, Duan Y, Wright CH, van Keulen M, Wright J, Mowry S, Megerian CA, Bambakidis N. Functional Outcomes and Postoperative Cerebral Venous Sinus Thrombosis after Translabyrinthine Approach for Vestibular Schwannoma Resection: A Radiographic Demonstration of Anatomic Predictors. Skull Base Surg 2022; 83:e89-e95. [DOI: 10.1055/s-0040-1722716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 11/25/2020] [Indexed: 10/22/2022]
Abstract
Abstract
Introduction While regarded as an effective surgical approach to vestibular schwannoma (VS) resection, the translabyrinthine (TL) approach is not without complications. It has been postulated that postoperative cerebral venous sinus thrombosis (pCVST) may occur as a result of injury and manipulation during surgery. Our objective was to identify radiologic, surgical, and patient-specific risk factors that may be associated with pCVST.
Methods The Institutional Review Board (IRB) approval was obtained and the medical records of adult patients with VS who underwent TL craniectomy at University Hospitals Cleveland Medical Center between 2009 and 2019 were reviewed. Demographic data, radiographic measurements, and tumor characteristics were collected. Outcomes assessed included pCVST and the modified Rankin score (mRS).
Results Sixty-one patients ultimately met inclusion criteria for the study. Ten patients demonstrated radiographic evidence of thrombus. Patients who developed pCVST demonstrated shorter internal auditory canal (IAC) to sinus distance (mean: 22.5 vs. 25.0 mm, p = 0.044) and significantly smaller petrous angles (mean: 26.3 vs. 32.7 degrees, p = 0.0045). Patients with good mRS scores (<3) appeared also to have higher mean petrous angles (32.5 vs. 26.8, p = 0.016). Koos' grading and tumor size, in our study, were not associated with thrombosis.
Conclusion More acute petrous angle and shorter IAC to sinus distance are objective anatomic variables associated with pCVST in TL surgical approaches.
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Affiliation(s)
- Christina Gerges
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Patrick Malloy
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Nicholas Rabah
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Dana Defta
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Yifei Duan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Christina H. Wright
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Marte van Keulen
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - James Wright
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Sarah Mowry
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- Department of Otolaryngology, Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Cliff A. Megerian
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- Department of Otolaryngology, Head and Neck Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
| | - Nicholas Bambakidis
- Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States
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10
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Rayan T, Helal A, Graffeo CS, Perry A, Carlstrom LP, Driscoll CLW, Link MJ. Cerebrovascular Complications of Vestibular Schwannoma Surgery. Skull Base Surg 2022; 83:e443-e448. [DOI: 10.1055/s-0041-1730895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 04/23/2021] [Indexed: 10/21/2022]
Abstract
Abstract
Objective Cerebrovascular complications (CVC) are rare consequences of vestibular schwannoma (VS) surgery. Our objective was to assess incidences of findings suggestive of postoperative CVC in a large single surgeon cohort, as well as potential risk factors, and implications.
Study Design A cohort of 591 patients was retrospectively reviewed. Postoperative magnetic resonance images were screened for findings suggestive of stroke, T2 hyperintensity in the cerebellopontine angle structures or new encephalomalacia. Clinical records were queried for findings consistent with postoperative CVC.
Results In total, 61 patients had radiographic findings consistent with possible postoperative CVC (10%); of them, eight had documented intraoperative vascular injury (1.4%), and four had postoperative clinical exam changes indicative of CVC (0.7%). Clinically manifest intraoperative vascular injuries occurred in four patients and involved the petrosal venous complex (n = 3, 5%) or anterior inferior cerebellar artery (n = 1, 2%); clinical deficits included hemiparesis (n = 1, 2%), facial anesthesia (n = 2, 4%), dysphagia (n = 2, 2%), and unfavorable facial nerve function in two (50%). Three out of four patients in this group required out-of-home placement (75%). Clinical CVCs (n = 4) were not significantly associated with tumor size, tumor cyst, gross total resection, or length of stay. Patients with clinical CVC were significantly more likely to require posthospitalization rehabilitation (19 vs. 75%, p = 0.02; 14 vs. 100%, p = 0.0002).
Conclusion Although radiographic findings suggestive of CVC were unexpectedly common in this cohort, intraoperative vascular injury and postoperative clinical CVC were exceedingly rare. The association between unfavorable facial nerve outcome and clinical CVC is likely a marker for more difficult operations, predisposing to higher risk of complications.
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Affiliation(s)
- Tarek Rayan
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Ahmed Helal
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Lucas P. Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Colin L. W. Driscoll
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Departments of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J. Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
- Departments of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States
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11
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Lozouet M, Gilard V, Nassihi A, Marie J, Derrey S. Ruptured dural arteriovenous fistula and sinus venous thrombosis following surgical resection of a vestibular schwannoma: Case report and review of the literature. Neurochirurgie 2022; 68:688-692. [DOI: 10.1016/j.neuchi.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 03/16/2022] [Accepted: 03/24/2022] [Indexed: 10/18/2022]
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12
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Krystkiewicz K, Wrona D, Tosik M, Birski M, Szylberg Ł, Morawska A, Furtak J, Wałęsa C, Stopa K, Harat M. Dural sinus thrombosis after resection of vestibular schwannoma using suboccipital retrosigmoid approach-thrombosis classification and management proposal. Neurosurg Rev 2022; 45:2211-2219. [PMID: 35061140 DOI: 10.1007/s10143-022-01741-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 01/11/2022] [Accepted: 01/16/2022] [Indexed: 11/30/2022]
Abstract
Dural sinus thrombosis is one of the complications after posterior fossa surgery. However, that topic is not described well with regard to vestibular schwannoma surgery using the unique suboccipital retrosigmoid approach. We analyzed retrospectively medical records and radiological investigations of 116 patients. The including criteria were histopathologically confirmed vestibular schwannoma operated on using the retrosigmoid approach, preoperative and postoperative contrast-enhanced MRI, and at least 1-year follow-up. The patient group included 36% males and 64% females. The average age was 47.3 ± 13.9 years. Sixty percent of the tumors were classified as T4b according to the Hannover scale and their mean volume was 13.73 ± 10.28 cm3. There were no signs of thrombosis preoperatively. Postoperative changes in the dural sinuses were found in 26 (22%) cases. In 7 (27%) cases, there was an external compression by the hemostatic agent, and in 19 (73%) cases, a thrombus was visualized in the sinus lumen. The size of the sinus, age, and the tumor size were not risk factors for thrombosis, whereas an intraoperative sinus injury was a statistically significant risk factor (p = 0.0012). All of the patients diagnosed with thrombosis were in good clinical condition in long-term follow-up, except one fatal case. Complete recanalization was observed in 58% of cases after 1-year follow-up. Postoperative changes in the dural venous sinuses are a frequent finding after vestibular schwannoma surgery using the suboccipital retrosigmoid approach. Intraoperative dural injury is a risk factor for thrombosis. Thrombosis in that group of patients is usually asymptomatic and does not influence the prognosis.
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Affiliation(s)
- Kamil Krystkiewicz
- Department of Neurosurgery and Neurooncology, Copernicus Memorial Hospital, Pabianicka 62, 95-513, Łódź, Poland. .,Department of Neurosurgery, 10th Military Research Hospital, Bydgoszcz, Poland.
| | - Dawid Wrona
- Department of Neurosurgery and Neurooncology, Copernicus Memorial Hospital, Pabianicka 62, 95-513, Łódź, Poland
| | - Marcin Tosik
- Department of Neurosurgery and Neurooncology, Copernicus Memorial Hospital, Pabianicka 62, 95-513, Łódź, Poland
| | - Marcin Birski
- Department of Neurosurgery, 10th Military Research Hospital, Bydgoszcz, Poland
| | - Łukasz Szylberg
- Department of Clinical Pathomorphology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, Torun, Poland.,Department of Tumor Pathology and Pathomorphology, Oncology Center, Prof. Franciszek Łukaszczyk Memorial Hospital, Bydgoszcz, Poland.,Department of Pathomorphology, 10th Military Clinical Hospital, Bydgoszcz, Poland
| | - Anna Morawska
- Department of Neurosurgery, 10th Military Research Hospital, Bydgoszcz, Poland
| | - Jacek Furtak
- Department of Neurosurgery, 10th Military Research Hospital, Bydgoszcz, Poland
| | - Cezary Wałęsa
- Department of Radiology, 10th Military Clinical Hospital, Bydgoszcz, Poland
| | - Konrad Stopa
- Department of Radiology, 10th Military Clinical Hospital, Bydgoszcz, Poland
| | - Marek Harat
- Department of Neurosurgery, 10th Military Research Hospital, Bydgoszcz, Poland.,Department of Neurosurgery and Neurology, Collegium Medicum of the Nicolaus Copernicus University, Bydgoszcz, Poland
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13
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Yang JX, Aygun N, Nadgir RN. Imaging of the Postoperative Skull Base and Cerebellopontine Angle. Neuroimaging Clin N Am 2021; 32:159-174. [PMID: 34809836 DOI: 10.1016/j.nic.2021.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
For pathologic conditions affecting the skull base and cerebellopontine angle, imaging techniques have advanced to assess for residual disease, disease progression, and postoperative complications. Knowledge regarding various surgical approaches of skull base tumor resection, expected postoperative appearance, and common postsurgical complications guides radiologic interpretation. Complexity of skull base anatomy, small size of the relevant structures, lack of familiarity with surgical techniques, and postsurgical changes confound radiologic evaluation. This article discusses the imaging techniques, surgical approaches, expected postoperative changes, and complications after surgery of the skull base, with emphasis on the cerebellopontine angle, anterior cranial fossa, and central skull base regions.
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Affiliation(s)
- Jeffrey Xi Yang
- Division of Neuroradiology, Department of Radiology and Radiological Science, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Nafi Aygun
- Division of Neuroradiology, Department of Radiology and Radiological Science, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Rohini Narahari Nadgir
- Division of Neuroradiology, Department of Radiology and Radiological Science, Johns Hopkins Hospital, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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14
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Muelleman TJ, Alonso J, Barnard ZR, Maxwell AK, Mahboubi H, Stefan M, Lekovic GP, Slattery WH, Brackmann DE. Hypercoagulability in Vestibular Schwannoma Surgery. Otol Neurotol 2021; 42:e222-e226. [PMID: 33065597 DOI: 10.1097/mao.0000000000002934] [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: 11/26/2022]
Abstract
OBJECTIVE Patients with vestibular schwannoma who harbor a genetic predisposition for venous thromboembolism require special consideration when determining optimal therapeutic management. The primary objective of the current study was to provide recommendations on treatment of hypercoagulable patients with vestibular schwannoma through a case series and review of the literature. PATIENTS Two patients who underwent resection of vestibular schwannomas. INTERVENTIONS Surgical resection and diagnostic testing. MAIN OUTCOME MEASURES Postoperative venous thromboses. RESULTS One patient who underwent resection of vestibular schwannoma and suffered several postoperative thrombotic complications consistent with a clinical thrombophilia. One patient with known Factor V Leiden deficiency who underwent resection of vestibular schwannoma followed by postoperative chemoprophylaxis with a direct factor Xa inhibitor and experienced an uneventful postoperative course. CONCLUSIONS In patients with a known propensity for venous thromboembolism, the skull base surgeon should consider nonsurgical management. If the patient undergoes surgical resection, we recommend careful effort to minimize trauma to the sigmoid sinus. In addition, the surgeon may consider retrosigmoid or middle fossa approaches. Best practice recommendations include the use of pneumatic compression devices, early ambulation, and consideration of postoperative prophylactic anticoagulation in patients with a known genetic predisposition.
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Affiliation(s)
- Thomas J Muelleman
- Division of Neurotology, House Ear Institute
- Department of Head and Neck Surgery, UCLA Medical Center
| | - Jose Alonso
- Department of Head and Neck Surgery, UCLA Medical Center
| | | | - Anne K Maxwell
- Division of Neurotology, House Ear Institute
- Department of Head and Neck Surgery, UCLA Medical Center
| | - Hossein Mahboubi
- Division of Neurotology, House Ear Institute
- Department of Head and Neck Surgery, UCLA Medical Center
| | | | - Gregory P Lekovic
- Division of Neurosurgery, House Ear Institute, Los Angeles, California
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Wong AK, Wong RH. Successful treatment of superior sagittal sinus thrombosis after translabyrinthine resection of metastatic neuroendocrine tumor: A case report and review of literature. Surg Neurol Int 2020; 11:410. [PMID: 33365173 PMCID: PMC7749965 DOI: 10.25259/sni_656_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 11/07/2020] [Indexed: 11/09/2022] Open
Abstract
Background: Postoperative cerebral venous sinus thrombosis (pCVST) after resection of cerebellopontine angle and posterior fossa tumor resections occur almost exclusively in the lateral venous sinuses and are generally asymptomatic. Thrombus extension and involvement of the superior sagittal sinus (SSS) – a serious and potentially devastating complication – are rarely described and, as such, successful treatment for which is still poorly understood. We report a case of pCVST involving the SSS after translabyrinthine approach for resection of a metastatic neuroendocrine tumor (NET), and the first that was successfully treated with anticoagulation therapy. Case Description: A 40-year-old man presented with headaches, diminished right-sided hearing, and ataxia was found to have a large right-sided cerebellopontine angle (CPA) lesion with extra-axial and possible intraparenchymal invasion. A retrosigmoid craniotomy for debulking and diagnosis was undertaken. Postoperative imaging revealed patent venous sinuses. Pathology confirmed NET. Further imaging revealed a likely pancreatic primary lesion. The patient then underwent subsequent translabyrinthine approach for definitive surgical resection. Postoperative imaging again revealed patent venous sinuses. The patient subsequently developed headaches on postoperative day 10 and was found to have pCVST involving the ipsilateral internal jugular to the SSS. The patient was started on therapeutic heparin with significant improvement in pCVST and symptoms. Conclusion: Extensive pCVST involving the SSS after CPA and posterior fossa tumor resections is extremely rare. Initial management with anticoagulation can yield promising results and should be initiated early in the clinical course unless otherwise contraindicated.
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Affiliation(s)
- Andrew K Wong
- Department of Neurosurgery, Rush University Medical Center, Chicago, United States
| | - Ricky H Wong
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, Illinois, United States
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