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Çavuşoğlu N, Erol G, Sevgi UT, Bulgur F, Doğruel Y, Luzzi S, Gadol AAC, Güngor A. Graftless Primary Dural Closure Following Retrosigmoid Approach: Doing More With less. World Neurosurg 2024:S1878-8750(24)01204-X. [PMID: 39004178 DOI: 10.1016/j.wneu.2024.07.065] [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: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 07/16/2024]
Abstract
INTRODUCTION Achieving watertight dural closure without grafts via the retrosigmoid approach can be challenging, contributing to a significant rate of postoperative cerebrospinal fluid (CSF) leaks. This study describes a dural incision technique for achieving primary dural closure without grafts following the retrosigmoid approach and presents clinical data from the authors' experience. METHODS Clinical and surgical data of 227 patients who underwent the dural incision technique following the retrosigmoid approach for various pathologies were retrospectively reviewed. To achieve no-graft watertight dural closure, the dural incision involves 2 critical steps: a 1 cm transverse incision of the dura parallel to the foramen magnum to drain CSF from the cisterna magna, and a vertical linear opening of the retrosigmoid dura. Dural incisions were closed watertight with vicryl 4/0 running sutures, without the use of grafts, fibrin glue, hemostatic overlays, or dural substitutes. Pre- or postoperative lumbar drainage was not employed. RESULTS Primary watertight dural closure was successfully achieved in all patients without the use of grafts or duraplasty. The average duration of dura closure was 17.7 minutes. During an average follow-up period of 49.3 months, there were no instances of CSF leaks or meningitis. CONCLUSIONS In the authors' preliminary experience, the linear dural incision described herein was effective for achieving a no-graft, watertight primary dural closure in the retrosigmoid approach, with no CSF leaks or meningitis in our series. Validation of these preliminary data in a larger patient cohort is necessary.
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Affiliation(s)
- Neslihan Çavuşoğlu
- Department of Neurosurgery, Bakırköy Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Gökberk Erol
- Department of Neurosurgery, Ministry of Health Elmadag Dr Hulusi Alatas State Hospital, Ankara, Turkey
| | - Umut Tan Sevgi
- Department of Neurosurgery, Health Sciences University, İzmir City Hospital Hospital, Izmir, Turkey
| | - Feride Bulgur
- Department of Neurosurgery, Bakırköy Mazhar Osman Research and Training Hospital for Psychiatry, Neurology and Neurosurgery, Istanbul, Turkey
| | - Yücel Doğruel
- Department of Neurosurgery, Health Sciences University, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Sabino Luzzi
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy; Department of Surgical Sciences, Neurosurgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Aaron A Cohen Gadol
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Abuzer Güngor
- Department of Neurosurgery, Faculty of Medicine, Istinye University, Istanbul, Turkey.
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Brown EC, Fay S, Raslan AM, Sayama CM. Improving Quality Care and Patient Safety With Implementation of an Oversew Stitch in Lumbar Drains. J Healthc Qual 2024; 46:95-99. [PMID: 38421907 DOI: 10.1097/jhq.0000000000000414] [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: 03/02/2024]
Abstract
ABSTRACT The lumbar drain exit site purse string oversew stitch is a well-described bedside intervention to stop or prevent cerebrospinal fluid (CSF) leak. It is not routinely placed at the time of lumbar drain placement. Via four plan-do-study-act (PDSA) cycles, we test the effect of prophylactic utilization of the lumbar drain exit site oversew stitch on house officers' paging burden, need to redress the drain, need to oversew the drain to stop a CSF leak, and need to replace the drain. We found that the simple act of placing an oversew stitch at the time of lumbar drain placement significantly reduced paging burden and reduced the frequency at which an oversew stitch was required to stop a CSF leak. Subjectively, during PDSA cycles during which overstitches were placed prophylactically, in-house residents perceived that there were less lumbar drains on service, although objectively, the overall number was unchanged. We conclude that prophylactic lumbar drain exit site stitch placement reduces risk and bedside interventions for patients and also reduces overall call burden on house officers. This simple intervention may therefore provide a more widespread improvement in care quality beyond lumbar drain care because house officers experience less burnout during their call shifts.
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Liu D, He Q, Niu J, Li L, Geng R, Cao T, Wang X, Lv Z, He J, Zhao J, Chen G, Yang Y. Preoperative nomogram predicting ventriculoperitoneal shunt longevity after initial shunt failure. Front Neurol 2024; 14:1285604. [PMID: 38283682 PMCID: PMC10811779 DOI: 10.3389/fneur.2023.1285604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/28/2023] [Indexed: 01/30/2024] Open
Abstract
Background and objectives Initial shunt failure following ventriculoperitoneal (VP) shunt surgery has a significant impact on the working time of the shunt. However, there are few studies regarding factors affecting VP shunt longevity. Hence, in this study, we aimed to build a nomogram to predict the longevity of the replacement VP shunt in patients with initial shunt failure. Methods From 2011 to 2021, 142 patients with initial VP failure who underwent VP shunt revision were enrolled and relevant clinical and demographic factors were analyzed. Univariate and multivariate Cox proportional hazard regression models were used to choose predictors, and a nomogram was constructed using nine independent prognostic variables: sex, age, hydrocephalus type, intensive care unit admission, tracheostomy, decompressive craniectomy, craniotomy, lumbar cisterna drainage, and ventricular drainage. The prediction models' discrimination, accuracy, calibration, and clinical value were evaluated using Harrell's C-index, a calibration plot, and decision curve analysis. Results At 1 month, 3 months, and 5 years, the nomogram's C-index was 0.680, 0.708, and 0.694, respectively. The nomogram's calibration plot provided a good fit for the overall prediction over the course of 1 year. Decision curve analysis predicted that 1-3 months after surgery will yield good net benefits between 30 and 50% probability thresholds. Conclusion A preoperative nomogram may be an effective tool for assessing VP shunt longevity after initial VP shunt placement.
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Affiliation(s)
- Dongsheng Liu
- Department of Neurosurgery, Civil Aviation General Hospital, Beijing, China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qiheng He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianxing Niu
- Department of Neurosurgery, Civil Aviation General Hospital, Beijing, China
| | - Liangliang Li
- Department of Neurosurgery, Civil Aviation General Hospital, Beijing, China
| | - Ronghua Geng
- Department of Neurosurgery, Civil Aviation General Hospital, Beijing, China
| | - Tianqing Cao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaosong Wang
- Department of Neurosurgery, Civil Aviation General Hospital, Beijing, China
| | - Zeping Lv
- Department of Neurosurgery, National Research Center for Rehabilitation Technical Aids, Beijing, China
- Department of Neurosurgery, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China
- Key Laboratory of Neuro-functional Information and Rehabilitation Engineering of the Ministry of Civil Affairs, Beijing, China
| | - Jianghong He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guoqiang Chen
- Department of Neurosurgery, Civil Aviation General Hospital, Beijing, China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, National Research Center for Rehabilitation Technical Aids, Beijing, China
- Department of Neurosurgery, Rehabilitation Hospital, National Research Center for Rehabilitation Technical Aids, Beijing, China
- Key Laboratory of Neuro-functional Information and Rehabilitation Engineering of the Ministry of Civil Affairs, Beijing, China
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Sunada Y, Yagi K, Tao Y, Nishimura H, Hishikawa T. Preoperative examination and intraoperative cerebrospinal fluid leakage test for minimally invasive surgery of spinal extradural arachnoid cysts: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 6:CASE23319. [PMID: 37992305 PMCID: PMC10664627 DOI: 10.3171/case23319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/06/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND Spinal extradural arachnoid cysts (SEACs) are rare and can cause spinal dysfunction. Total cyst removal and duraplasty via multiple laminectomies are commonly performed. However, to avoid postoperative spinal deformity and axial pain, a minimally invasive surgery via selective laminectomy may be optimal. Therefore, preoperative detection of the dural fistula site is required. OBSERVATIONS A 25-year-old male presented with a 2-month history of progressive gait disturbance and back pain. Conventional magnetic resonance imaging (MRI) revealed SEACs at the T9 to L2 level but did not reveal the dural fistula. Further examinations were performed using sagittal time-spatial labeling inversion pulse MRI and cone-beam computed tomography myelography with a spinal intrathecal catheter, which indicated a dural fistula on the left side at the T12 level. On the basis of these results, dural repair was performed via selective laminectomy. Furthermore, an intraoperative cerebrospinal fluid leakage test by intrathecally injecting saline via a spinal catheter confirmed complete closure of the dural fistula, with no other fistulas. LESSONS These comprehensive pre and intraoperative examinations may be useful for minimally invasive and selective surgeries in patients with SEACs.
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Lee HS, Cho KR, Park K, Jeon C. Management of Cerebrospinal Fluid Leakage after Microvascular Decompression Surgery: Clinical Strategy. Life (Basel) 2023; 13:1771. [PMID: 37629628 PMCID: PMC10455648 DOI: 10.3390/life13081771] [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: 07/11/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: Cerebrospinal fluid (CSF) leakage is one of the most common complications of microvascular decompression (MVD) surgery. Before fatal complications, such as intracranial infection, occur, early recognition and prompt treatment are essential. (2) Methods: The clinical data of 475 patients who underwent MVD surgery from September 2020 to March 2023 were retrospectively analyzed. In these patients, if there were any symptoms of CSF leakage, and if CSF leakage was evident, a lumbar drainage catheter was inserted immediately. (3) Results: CSF leakage was suspected in 18 (3.8%) patients. Five of these patients (1.1%) showed signs of CSF leakage during conservative management and subsequently underwent catheter insertion for lumbar drainage. The lumbar drain was removed after an average of 5.2 days, resulting in an average hospitalization of 14.8 days. In all 5 patients, CSF leakage was resolved without reoperation. (4) Conclusions: Our treatment strategy prevented the development of fatal complications. Close observation of the symptoms and postoperative temporal bone computed tomography and audiometry are considered to be good evaluation methods for all patients. If CSF leakage is certain, it is important to perform lumbar drainage immediately.
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Affiliation(s)
- Hyun-Seok Lee
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (H.-S.L.); (K.-R.C.); (K.P.)
| | - Kyung-Rae Cho
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (H.-S.L.); (K.-R.C.); (K.P.)
| | - Kwan Park
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (H.-S.L.); (K.-R.C.); (K.P.)
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06171, Republic of Korea
| | - Chiman Jeon
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan 15355, Republic of Korea
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Lele AV, Theard MA, Vavilala MS. Cerebrospinal fluid diversion devices and shunting procedures: a narrative review for the anesthesiologist. Int Anesthesiol Clin 2023; 61:29-36. [PMID: 37249174 DOI: 10.1097/aia.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Affiliation(s)
- Abhijit Vijay Lele
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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External Ventricular Drainage: A Practical Guide for Neuro-Anesthesiologists. Clin Pract 2023; 13:219-229. [PMID: 36826162 PMCID: PMC9955739 DOI: 10.3390/clinpract13010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 02/05/2023] Open
Abstract
External ventricular drainage is often considered a life-saving treatment in acute hydrocephalus. Given the large number of discussion points, the ideal management of EVD has not been completely clarified. The objective of this study was to review the most relevant scientific evidence about the management of EVD in its main clinical scenarios. We reviewed the most recent and relevant articles about indications, timing, management, and complications of EVD in neurocritical care, with particular interest in patients with subarachnoid hemorrhage (SAH), severe traumatic brain injury (TBI), and intraventricular hemorrhage (IVH) using the following keywords alone or matching with one another: intracranial pressure, subarachnoid hemorrhage, traumatic brain injury, intraventricular hemorrhage, external ventricular drainage, cerebrospinal shunt, intracranial pressure monitoring, and ventriculoperitoneal shunt. In the management of EVD in SAH, the intermittent drainage strategy is burdened with an elevated risk of complications (e.g., clogged catheter, hemorrhage, and need for replacement). There seems to be more ventriculoperitoneal shunt dependency in rapid weaning approach-managed patients than in those treated with the gradual weaning approach. Although there is no evidence in favor of either strategy, it is conventionally accepted to adopt a continuous drainage approach in TBI patients. Less scientific evidence is available in the literature regarding the management of EVD in patients with severe TBI and intraparenchymal/intraventricular hemorrhage. EVD placement is a necessary treatment in several clinical scenarios. However, further randomized clinical trials are needed to clarify precisely how EVD should be managed in different clinical scenarios.
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Lee CY, Jang KM, Wui SH, Park SW. The Benefits and Feasibility of External Lumbar Cerebrospinal Fluid Drainage for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage: Meta-Analysis and Trial Sequential Analysis. World Neurosurg 2022; 167:e549-e560. [PMID: 35977676 DOI: 10.1016/j.wneu.2022.08.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 08/08/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Cerebral vasospasm after aneurysmal subarachnoid hemorrhage is a main cause contributing to poor outcomes. Removal of blood from the subarachnoid may decrease development of cerebral vasospasm. The purpose of this study is to determine the effect of lumbar cerebrospinal fluid (CSF) drainage on cerebral vasospasm and related complications through meta-analysis and trial sequential analysis (TSA). METHODS A systematic search of the literature was performed. Case-control studies of the effects of external lumbar drainage in patients with subarachnoid hemorrhage were included. The association between lumbar drain and vasospasm, cerebral infarction, subsequent treatment, and mortality were evaluated. RESULTS Eleven of 122 articles were included in the meta-analysis. Lumbar CSF drainage reduces occurrence of vasospasm and related complications. In meta-analysis, the pooled odds ratio for symptomatic vasospasm, cerebral infarct, endovascular treatment for vasospasm, and mortality was 0.40 (95% confidence interval [CI], 0.31-0.51; P = 0.00001), 0.47 (95% CI, 0.35-0.62; P < 0.0001), 0.29 (95% CI, 0.18-0.46; P < 0.0001), and 0.41, (95% CI, 0.23-0.74; P = 0.003), respectively, compared with the non-lumbar drainage group. In TSA, the cumulative Z line crossed α-spending boundaries and reached the required sample size in analysis of symptomatic vasospasm and endovascular treatment for vasospasm. CONCLUSIONS Lumbar CSF drainage can decrease symptomatic vasospasm, cerebral infarction, subsequent endovascular treatment, and mortality. Through TSA, the accuracy and reliability of the effect of lumbar CSF drainage-related cerebral vasospasm and endovascular treatment are increased. Further studies of the association between lumbar drain and cerebral infarction and mortality are required to confirm the generalization of the results.
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Affiliation(s)
- Cheol Young Lee
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea.
| | - Kyoung Min Jang
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
| | - Seong Hyun Wui
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
| | - Seung Won Park
- Department of Neurosurgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong City, South Korea
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Lumbar Drainage After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2022; 166:261-267.e9. [PMID: 35868504 DOI: 10.1016/j.wneu.2022.07.061] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE This study reviews the use of lumbar drains (LDs) after aneurysmal subarachnoid hemorrhage (aSAH) and compares the outcomes to those associated with external ventricular drains (EVDs) and controls. METHODS A comprehensive search of the literature was performed. English language studies with a sample size of more than 10 patients were included. One-arm and 2-arm meta-analyses were designed to compare external drainage groups. Random-effects models, heterogeneity measures, and risk of bias were calculated. RESULTS Seventeen studies were included in the meta-analysis. The 2-arm meta-analysis comparing the LD to no drainage after aSAH found a significant improvement in the postoperative modified Rankin Scale (mRS) score (0-2) within 1 month of hospital discharge in the LD group (P = 0.003), a lower mortality rate (P = 0.03), fewer cases of clinical vasospasm (P = 0.007), and a lower incidence of ischemic stroke or delayed ischemic neurological deficits (P = 0.003). When the LD was compared to EVDs, a significant improvement in the postoperative mRS score (0-2) within 1 month of discharge was found in the LD group (P < 0.001). In the LD group, rebleeding occurred in 15 (3.4%) cases and meningitis occurred in 50 (4.7%) cases. CONCLUSIONS Compared with patients without cerebrospinal fluid drainage, patients with the LD after aSAH had lower mortality rates, lower risk of clinical vasospasm, and lower risk of ischemic stroke, and they were more likely to have an mRS score of 0-2 within 1 month of discharge. Compared with patients with EVDs, patients with the LD were more likely to have an mRS score of 0-2 within 1 month of discharge.
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Stevens AR, Soon WC, Chowdhury YA, Toman E, Yim S, Veenith T, Chelvarajah R, Belli A, Davies D. External Lumbar Drainage for Refractory Intracranial Hypertension in Traumatic Brain Injury: A Systematic Review. Cureus 2022; 14:e30033. [PMID: 36348893 PMCID: PMC9637378 DOI: 10.7759/cureus.30033] [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] [Accepted: 10/07/2022] [Indexed: 11/07/2022] Open
Abstract
Considerable variation exists in the clinical practice of cerebrospinal fluid diversion for medically refractory intracranial hypertension in patients with acute traumatic brain injury (TBI), which is achievable via lumbar or ventricular drainage. This systematic review sought to compile the available evidence for the efficacy and safety of the use of lumbar drains for intracranial pressure (ICP) control. A systematic review of the literature was performed with the search and data extraction performed by two reviewers independently in duplicate. Nine independent studies were identified, enrolling 230 patients, 159 with TBI. Efficacy for ICP control was observed across all studies, with immediate and sustained effect, reducing medical therapy requirements. Lumbar drainage with medical therapy appears effective when used alone and as an adjunct to ventricular drainage. Safety reporting varied in quality. Clinical or radiological incidents of cerebral herniation (with an unclear relationship to lumbar drainage) were observed in 14/230 patients resulting in one incident of morbidity without adverse patient outcome. The available data is generally poor in quality and volume, but supportive of the efficacy of lumbar drainage for ICP control. Few reports of adverse outcomes are suggestive of, but are insufficient to confirm, the safety of use in the appropriate patient and clinical setting. Further large prospective observational studies are required to generate sufficient support of an acceptable safety profile.
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Affiliation(s)
- Andrew R Stevens
- Neurosurgery, University Hospitals Birmingham, Birmingham, GBR
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham, Birmingham, GBR
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, GBR
| | - Wai C Soon
- Neurosurgery, University Hospitals Birmingham, Birmingham, GBR
| | | | - Emma Toman
- Neurosurgery, University Hospitals Birmingham, Birmingham, GBR
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham, Birmingham, GBR
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, GBR
| | - Sebastian Yim
- Medical and Dental Sciences, University of Birmingham, Birmingham, GBR
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, GBR
- Anaesthesia and Critical Care, University Hospitals Birmingham, Birmingham, GBR
| | - Ramesh Chelvarajah
- Neurosurgery, University Hospitals Birmingham, Birmingham, GBR
- Life and Environmental Sciences, University of Birmingham, Birmingham, GBR
| | - Antonio Belli
- Neurosurgery, University Hospitals Birmingham, Birmingham, GBR
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham, Birmingham, GBR
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, GBR
| | - David Davies
- Neurosurgery, University Hospitals Birmingham, Birmingham, GBR
- National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham, Birmingham, GBR
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, GBR
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Bertino F, Shin DS, Weaver JJ, Jeyakumar A, Chick JFB, Woods MA, Monroe EJ. Combined ultrasound and fluoroscopy guided tunneled external lumbar drain placement in children. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:581-584. [PMID: 34939680 DOI: 10.1002/jcu.23113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 11/22/2021] [Accepted: 12/12/2021] [Indexed: 06/14/2023]
Abstract
External lumbar drain placement has been shown to be an efficacious and safe approach to managing various forms of intracranial hypertension in adult patients and children. The use of ultrasound guidance for lumbar punctures in young patients has been described however, but the modality is not routinely used for the placement of tunneled lumbar drains. In this report, two cases are presented that detail experience using ultrasound guidance for tunneled lumbar drains in children.
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Affiliation(s)
- Frederic Bertino
- Division of Vascular & Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington, USA
| | - David S Shin
- Division of Vascular & Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington, USA
| | - John J Weaver
- Division of Vascular & Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Arthie Jeyakumar
- Division of Vascular & Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington, USA
| | - Jeffrey Forris Beecham Chick
- Division of Vascular & Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington, USA
- Division of Vascular & Interventional Radiology, Department of Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Michael A Woods
- Division of Vascular & Interventional Radiology, Department of Radiology, University of Wisconsin, Madison, Wisconsin, USA
- Division of Vascular & Interventional Radiology, Department of Radiology, American Family Children's Hospital, Madison, Wisconsin, USA
| | - Eric J Monroe
- Division of Vascular & Interventional Radiology, Department of Radiology, University of Wisconsin, Madison, Wisconsin, USA
- Division of Vascular & Interventional Radiology, Department of Radiology, American Family Children's Hospital, Madison, Wisconsin, USA
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Conservative Management of Post-Operative Cerebrospinal Fluid Leak following Skull Base Surgery: A Pilot Study. Brain Sci 2022; 12:brainsci12020152. [PMID: 35203915 PMCID: PMC8870023 DOI: 10.3390/brainsci12020152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/20/2022] [Accepted: 01/21/2022] [Indexed: 02/04/2023] Open
Abstract
Background/aims: Iatrogenic CSF leaks after endoscopic endonasal transsphenoidal surgery remain a challenging entity to manage, typically treated with CSF diversion via lumbar drainage. Objective: To assess the safety and efficacy of high-volume lumbar puncture (LP) and acetazolamide therapy to manage iatrogenic CSF leaks. Methods: We performed a prospective pilot study of four patients who developed iatrogenic postoperative CSF leaks after transsphenoidal surgery and analyzed their response to treatment with concomitant high-volume lumbar puncture followed by acetazolamide therapy for 10 days. Data collected included demographics, intra-operative findings, including methodology of skull base repair and type of CSF leak, time to presentation with CSF leak, complications associated with high-volume LP and acetazolamide treatment, and length of follow-up. Results: Mean patient age was 44.28 years, with an average BMI of 27.4. Mean time from surgery to onset of CSF leak was 7.71 days. All four patients had resolution of their CSF leak at two- and four-week follow-up. Mean overall follow-up time was 179 days, with a 100% CSF leak cure rate at the last clinic visit. No patient suffered perioperative complications or complications secondary to treatment. Conclusion: Although our pilot case series is small, we demonstrate that a high-volume LP, followed by acetazolamide therapy for 10 days, can be considered in the management of post-operative CSF leaks.
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CHAN CH, DESAI SR, HWANG NC. Cerebrospinal Fluid Drains: Risks in Contemporary Practice. J Cardiothorac Vasc Anesth 2022; 36:2685-2699. [DOI: 10.1053/j.jvca.2022.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/03/2022] [Accepted: 01/12/2022] [Indexed: 11/11/2022]
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Banerjee C, Cross B, Rumley J, Devine J, Ritter E, Vender J. Multiple-Layer Lumbosacral Pseudomeningocele Repair with Bilateral Paraspinous Muscle Flaps and Literature Review. World Neurosurg 2020; 144:e693-e700. [PMID: 32942058 DOI: 10.1016/j.wneu.2020.09.038] [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] [Received: 06/13/2020] [Revised: 09/09/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pseudomeningocele is an uncommon but widely recognized complication of spinal surgery that can be challenging to correct. When conservative measures fail, patients frequently require reoperation to attempt primary closure of the durotomy, yet attempts at true watertight closures of the dura or fascia sometimes fall short. We describe a technique of lumbosacral pseudomeningocele repair involving a 2-layer pants-over-vest closure of the pseudomeningocele coupled with mobilization of bilateral paraspinal musculature to create a Z-plasty, or a Z-shaped flap. We have demonstrated a high success rate with our small series. METHODS The technique used meticulous manipulation of the pseudomeningocele to make a 2-layer pants-over-vest closure. This closure coupled with wide mobilization and importation of paraspinous muscle into the wound effectively obliterated dead space with simultaneous tamponade of the dural tear. The lateral row perforators were left intact, providing excellent vascularity with adequate mobility to the patient. RESULTS This technique was incorporated into the care of 10 patients between 2004 and July 2019. All wounds were closed in a single stage after careful flap section based on the wound's needs. We demonstrated successful pseudomeningocele resolution in all 10 patients with no observed clinical recurrence of symptomatic pseudomeningocele after at least 6 months of follow-up. CONCLUSIONS This technique provides a straightforward option for the spine surgeon to manage these challenging spinal wounds with minimal, if any, need for further laminectomy as well as a high fistula control rate with minimal morbidity.
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Affiliation(s)
- Christopher Banerjee
- Department of Neurological Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA.
| | - Brandy Cross
- Department of General Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Jacob Rumley
- Department of Orthopedic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - John Devine
- Department of Orthopedic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - Edmond Ritter
- Department of Plastic Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
| | - John Vender
- Department of Neurological Surgery, Medical College of Georgia at Augusta University, Augusta, Georgia, USA
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Wengier A, Ram Z, Warshavsky A, Margalit N, Fliss DM, Abergel A. Endoscopic skull base reconstruction with the nasoseptal flap: complications and risk factors. Eur Arch Otorhinolaryngol 2019; 276:2491-2498. [DOI: 10.1007/s00405-019-05531-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 06/22/2019] [Indexed: 11/24/2022]
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16
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Zhang Q, Li H, Zhang K, Arastehfar A, Daneshnia F, Fang W, He P, Kuang W, Jiang G, Chen M, Boekhout T, Li S, Jiang W, Liao W, Pan W. Lumbar drainage for the treatment of refractory intracranial hypertension in HIV-negative cryptococcal meningitis. Future Microbiol 2019; 14:859-866. [PMID: 31165635 DOI: 10.2217/fmb-2019-0084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Aim: This study aims to evaluate lumbar drainage (LD) for controlling refractory intracranial hypertension among non-HIV cryptococcal meningitis patients. Patients & methods: A case–control study was designed to compare LD (case) with repeated lumbar puncture (control). Results: Both LD and repeated lumbar puncture can efficiently control refractory intracranial hypertension. LD group showed better clinical symptom remission, such as lower rate of headache, vision disorders, signs of meningeal irritation and conscious disturbance, than control group. LD group was reported with higher intracranial pressure reduction (173.75 ± 17.72 mmH2O) than those among control group (113.50 ± 14.94 mmH2O; p < 0.05). Conclusion: LD is an effective and safe alternative to control refractory intracranial hypertension in HIV-negative cryptococcal meningitis patients.
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Affiliation(s)
- Qilong Zhang
- Department of Internal Neurology, Jiangxi Chest Hospital, Jiangxi 330000, PR China
| | - Hang Li
- Department of Internal Neurology, Jiangxi Chest Hospital, Jiangxi 330000, PR China
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Institute of Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
| | - Keming Zhang
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Institute of Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
| | - Amir Arastehfar
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands
| | - Farnaz Daneshnia
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands
| | - Wenjie Fang
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Institute of Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
| | - Peijuan He
- Department of Internal Neurology, Jiangxi Chest Hospital, Jiangxi 330000, PR China
| | - Weifeng Kuang
- Department of Internal Neurology, Jiangxi Chest Hospital, Jiangxi 330000, PR China
| | - Guoqiang Jiang
- Department of Internal Neurology, Jiangxi Chest Hospital, Jiangxi 330000, PR China
| | - Min Chen
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Institute of Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
| | - Teun Boekhout
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Institute of Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
- Westerdijk Fungal Biodiversity Institute, Utrecht, The Netherlands
- Institute of Biodiversity & Ecosystem Dynamics, University of Amsterdam, Amsterdam 1012 WX, The Netherlands
| | - Shuai Li
- Department of Clinical Laboratory, Yan'an People’s Hospital, Shanxi 716000, PR China
| | - Weiwei Jiang
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Institute of Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
| | - Wanqing Liao
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Institute of Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
| | - Weihua Pan
- Shanghai Key Laboratory of Molecular Medical Mycology, Shanghai Institute of Mycology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
- Department of Dermatology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai 200003, PR China
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Barber SM, Fridley JS, Konakondla S, Nakhla J, Oyelese AA, Telfeian AE, Gokaslan ZL. Cerebrospinal fluid leaks after spine tumor resection: avoidance, recognition and management. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:217. [PMID: 31297382 DOI: 10.21037/atm.2019.01.04] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Post-operative CSF leaks are a known complication of spine surgery in general, and patients undergoing surgical intervention for spinal tumors may be particularly predisposed due to the presence of intradural tumor and a number of other factors. Post-operative CSF leaks increase morbidity, lengthen hospital stays, prolong immobilization and subject patients to a number of associated complications. Intraoperative identification of unintended durotomies and effective primary repair of dural defects is an important first step in the prevention of post-operative CSF leaks, but in patients who develop post-operative pseudomeningoceles, durocutaneous fistulae or other CSF-leak-related sequelae, early recognition and secondary intervention are paramount to preventing further CSF-leak-related complications and achieving the best patient outcomes possible. In this article, the incidence, risk factors and complications of CSF leaks after spine tumor surgery are reviewed, with an emphasis on avoidance of post-operative CSF leaks, early post-operative identification and effective secondary intervention.
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Affiliation(s)
- Sean M Barber
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jared S Fridley
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Sanjay Konakondla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Jonathan Nakhla
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, RI, USA
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Lewis A, Rothstein A, Pacione D. Results of a quality improvement initiative reassessing an institutional lumbar drain infection prevention protocol. J Neurosurg Spine 2018; 29:54-58. [PMID: 29701568 DOI: 10.3171/2017.11.spine171023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to determine the effects of a quality improvement initiative in which daily antibiotics and daily sampling of cerebrospinal fluid (CSF) were discontinued for patients with lumbar drains. METHODS The frequency of surgical site infections (SSIs), antibiotic-related complications (development of Clostridium difficile infection [CDI] and growth of resistant bacteria), and cost for patients with lumbar drains were compared during 3 periods: 1) prolonged prophylactic systemic antibiotics (PPSA) until the time of drain removal and daily CSF sampling (September 2013-2014), 2) PPSA and CSF sampling once after placement then as needed (January 2015-2016), and 3) antibiotics only during placement of the lumbar drain and CSF sampling once after placement then as needed (April 2016-2017). RESULTS Thirty-nine patients were identified in period 1, 53 patients in period 2, and 39 patients in period 3. There was no change in the frequency of SSI after discontinuation of routine CSF testing or PPSA (0% in period 1, 2% in period 2, and 0% in period 3). In periods 1 and 2, 3 patients developed infections due to resistant organisms and 2 patients had CDI. In period 3, 1 patient had an infection due to a resistant organism. The median cost of CSF tests per patient was $100.68 (interquartile range [IQR] $100.68-$134.24) for patients in period 1 and $33.56 (IQR $33.56-$33.56) in periods 2 and 3 (p < 0.001). The median cost of antibiotics per patient was $26.32 (IQR $26.32-$30.65) in periods 1 and 2 and $3.29 ($3.29-$3.29) in period 3 (p < 0.001). The cost associated with growth of resistant bacteria and CDI was $91,291 in periods 1 and 2 and $25,573 in period 3. CONCLUSIONS After discontinuing daily antibiotics and daily CSF sampling for patients with lumbar drains, the frequency of SSI was unchanged and the frequency of antibiotic-related complications decreased.
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Affiliation(s)
- Ariane Lewis
- Departments of1Neurology and.,2Neurosurgery, NYU Langone Medical Center, New York, New York
| | | | - Donato Pacione
- 2Neurosurgery, NYU Langone Medical Center, New York, New York
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Zhai J, Panchal RR, Tian Y, Wang S, Zhao L. The Management of Cerebrospinal Fluid Leak After Anterior Cervical Decompression Surgery. Orthopedics 2018; 41:e283-e288. [PMID: 29451938 DOI: 10.3928/01477447-20180213-06] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 12/15/2017] [Indexed: 02/03/2023]
Abstract
Cerebrospinal fluid (CSF) leak is a rare but potentially troublesome and occasionally catastrophic complication after anterior cervical decompression surgery. There is limited literature describing this complication, and the management of CSF leak varies. The aim of this study was to retrospectively review the treatment of cases with CSF leak and develop a management algorithm. A series of 14 patients with CSF leak from January 2011 to May 2016 were included in this study. Their characteristics, management of CSF leak, and outcomes were documented. There were 5 male and 9 female patients. Mean age at surgery was 57.1±9.9 years (range, 37-76 years). All instances of CSF leak, except 1 noted postoperatively, were indirectly repaired intraoperatively. A closed straight wound drain was placed for all patients. A lumbar subarachnoid drain was placed immediately after surgery in 4 patients and postoperatively in 7 patients. In 1 patient, lumbar drain placement was unsuccessful. In 2 additional patients, the surgeon decided not to place a lumbar drain. One patient developed meningitis and recovered after antibiotic therapy with meropenem and vancomycin. Another patient had a deep wound infection and required a revision surgery. Wound drains and lumbar drains should be immediately considered when CSF leak is identified. Antibiotics also should be considered to prevent intradural infection. [Orthopedics. 2018; 41(2):e283-e288.].
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Chen S, Cui A, Yu K, Huang C, Zhu M, Chen M. Risk Factors Associated with Meningitis after Neurosurgery: A Retrospective Cohort Study in a Chinese Hospital. World Neurosurg 2017; 111:e546-e563. [PMID: 29288858 DOI: 10.1016/j.wneu.2017.12.110] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Meningitis is a serious complication occurring after neurosurgical operations, which can result in severe morbidity and high mortality. This retrospective cohort study aimed to determine the risk factors of postoperative meningitis in a large clinical center of neurosurgery in China. METHODS Patients who underwent a neurosurgical procedure between January 2014 and December 2015 were selected, and 1016 cases were included our final analysis. On the basis of propensity scores, 84 patients with postoperative meningitis were successfully matched to 84 patients without postoperative meningitis. RESULTS After propensity score matching, age, hospitalization duration, intraoperative use of corticoids, intraoperative use of antibiotics, external ventricular drainage, lumbar drainage, enteral nutrition, duration of surgery, major craniotomy, and transsphenoidal surgery were associated with postoperative meningitis. Furthermore, preoperative use of corticoids, intraoperative use of corticoids, intraoperative use of antibiotics, external ventricular drainage, lumbar drainage, and major craniotomy were independent predictors of postoperative meningitis in propensity score-matched cohort. A prediction model including these 6 independent predictors was established. Finally, receiver operating characteristic curve and discriminant analysis confirmed that this model has strong predictive power for evaluating postoperative meningitis. CONCLUSIONS The prediction model built in our study can be an excellent tool for predicting meningitis after neurosurgical procedures.
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Affiliation(s)
- Shengsen Chen
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - An Cui
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Kangkang Yu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Chong Huang
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Mengqi Zhu
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China
| | - Mingquan Chen
- Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China.
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Abstract
STUDY DESIGN Basic science. OBJECTIVE This study aimed to compare the techniques of surgical repair of dural tear using bioabsorbable material and fibrin glue. SUMMARY OF BACKGROUND DATA Cerebrospinal fluid (CSF) leakage caused by dural tear can often be difficult to manage even after repair when the same materials are used in a similar manner. METHODS Burst pressure was measured for repaired porcine dura with holes of different diameters using spray of combined fibrinogen and thrombin solution (fibrin spray) alone as a control and the 5-mm hole following different methods using fibrinogen and thrombin solutions plus polyglactin 910 sheet (PGS). For group 1, fibrinogen was applied on the dura followed by PGS and thrombin. For group 2, thrombin was followed by PGS and fibrinogen. For group 3, fibrinogen was followed by PGS and fibrin spray. For group 4, thrombin was followed by PGS and fibrin spray. Microscopic observation was conducted for each specimen. RESULTS Repair using fibrin spray alone was successful for the 0.3-mm diameter pinhole (breakdown pressure: 27.8 ± 8.6 mmHg), but was not able to cover the 2.7- and 5-mm holes. For a 5-mm diameter hole, the breakdown pressure was 54.4 ± 38.8 mmHg in group 1, 26.3 ± 19.4 mmHg in group 2, 147.7 ± 65.0 mmHg in group 3, and 35.5 ± 23.4 mmHg in group 4 (P < 0.001). There was little fibrin glue in the burst layer between the dural surface and PGS with thrombin on the dural surface (group 2 and group 4). CONCLUSION Suppression of excessive CSF leakage could be successful by performing several cycles of the group 1 method (fibrinogen was applied on the dura followed by PGS and thrombin), followed by the group 3 method (fibrinogen was applied on the dura followed by PGS and fibrin spray), with thrombin solution wash each time. LEVEL OF EVIDENCE 4.
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Soavi L, Rosina M, Stefini R, Fratianni A, Cadeo B, Magri S, Latronico N, Fontanella M, Signorini L. Post-neurosurgical meningitis: Management of cerebrospinal fluid drainage catheters influences the evolution of infection. Surg Neurol Int 2016; 7:S927-S934. [PMID: 28031985 PMCID: PMC5180437 DOI: 10.4103/2152-7806.195228] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 10/01/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND In order to better define the pathogenic role of cerebrospinal fluid (CSF) drainage catheters in postoperative patients, we comparatively analyze the clinical course of device and non-device-related meningitis. METHODS This is an observational, partially prospective, study on consecutive adult patients who developed meningitis after undergoing neurosurgical procedures at the Neurosurgery and Neurointensive care Departments, Spedali Civili, Brescia, Italy, between January 1999 and August 2007. RESULTS All 77 consecutive post-neurosurgical meningitis events in 65 patients were included in the analysis. Most were classified as external ventricular drainage (EVD)-related meningitis (23 cases, group A), external spinal drainage (ESD)-related meningitis (12 cases, group B), and non-device-related post-neurosurgical meningitis (30 cases, group C). Proven meningitis was identified in 78.3%, 91.7% and 56.7% of the events, respectively. ESD-related meningitis had a shorter onset time vs EVD and non-device-associated meningitis (3 days versus 6 and 7 days, respectively). Median antibiotic treatment duration was 20, 17, and 22.5 days in groups A, B, and C, respectively. Overall, 8 patients (34.8%) in group A, 3 (25.0%) in group B, and 3 (10.0%) in group C died. Median time to become afebrile was shorter in group C than in group A (10 days versus 12 days, P = 0.04). Removal of the device later than 48 hours after meningitis onset, as well as implantation of a second device were associated with a slower time of meningitis resolution. CONCLUSIONS Early device removal and avoiding implantation of a second device were associated with short illness duration. Larger studies are warranted to confirm the conclusions of this study.
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Affiliation(s)
- Laura Soavi
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
| | - Manuela Rosina
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
| | - Roberto Stefini
- Department of Neurosurgery, ASST - Ovest Milanese, Legnano, Italy
| | | | - Barbara Cadeo
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
| | - Silvia Magri
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
| | - Nicola Latronico
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili Hospital, Brescia, Italy
| | - Marco Fontanella
- Department of Neurosurgery, Spedali Civili Hospital, Brescia, Italy
| | - Liana Signorini
- Clinic of Infectious and Tropical Diseases, Spedali Civili Hospital, Brescia, Italy
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Some cool considerations of external lumbar drainage during its widespread application in neurosurgical practice: a long way to go. Chin Neurosurg J 2016. [DOI: 10.1186/s41016-016-0033-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Kunert P, Dziedzic T, Czernicki T, Nowak A, Marchel A. Surgery for sporadic vestibular schwannoma. Part II. Complications (not related to facial and auditory nerves). Neurol Neurochir Pol 2016; 50:90-7. [DOI: 10.1016/j.pjnns.2016.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 11/23/2015] [Accepted: 01/06/2016] [Indexed: 10/22/2022]
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Risk Factors for Infections Related to Lumbar Drainage in Spontaneous Subarachnoid Hemorrhage. Neurocrit Care 2016; 25:243-9. [DOI: 10.1007/s12028-015-0239-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hulou MM, Abd-El-Barr MM, Gormley WB, Zamani AA, Dunn IF, Al-Mefty O. The frequency and severity of intracranial hypotension post-intraoperative lumbar drainage using a Tuohy needle and the traditional needle. Br J Neurosurg 2016; 30:438-43. [DOI: 10.3109/02688697.2015.1122172] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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27
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Infektionsschutz und spezielle Hygienemaßnahmen in klinischen Disziplinen. KRANKENHAUS- UND PRAXISHYGIENE 2016. [PMCID: PMC7152143 DOI: 10.1016/b978-3-437-22312-9.00005-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Sladky JH, Piwinski SE. Lumbar Puncture Technique and Lumbar Drains. Atlas Oral Maxillofac Surg Clin North Am 2015; 23:169-176. [PMID: 26333905 DOI: 10.1016/j.cxom.2015.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- John H Sladky
- Department of Neurology, San Antonio Military Medical Center, Uniformed Services University of the Health Sciences, University Texas Health Science Center, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA
| | - Stephen E Piwinski
- Department of Medicine, San Antonio Military Medical Center, Uniformed Services University of the Health Sciences, 3551 Roger Brooke Drive, Fort Sam Houston, TX 78234, USA.
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Chee CG, Lee GY, Lee JW, Lee E, Kang HS. Fluoroscopy-Guided Lumbar Drainage of Cerebrospinal Fluid for Patients in Whom a Blind Beside Approach Is Difficult. Korean J Radiol 2015; 16:860-5. [PMID: 26175586 PMCID: PMC4499551 DOI: 10.3348/kjr.2015.16.4.860] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 04/12/2015] [Indexed: 11/15/2022] Open
Abstract
Objective To evaluate the rates of technical success, clinical success, and complications of fluoroscopy-guided lumbar cerebrospinal fluid drainage. Materials and Methods This retrospective study was approved by the Institutional Review Board of our hospital, and informed consent was waived. Ninety-six procedures on 60 consecutive patients performed July 2008 to December 2013 were evaluated. The patients were referred for the fluoroscopy-guided procedure due to failed attempts at a bedside approach, a history of lumbar surgery, difficulty cooperating, or obesity. Fluoroscopy-guided lumbar drainage procedures were performed in the lateral decubitus position with a midline puncture of L3/4 in the interspinous space. The catheter tip was positioned at the T12/L1 level, and the catheter was visualized on contrast agent-aided fluoroscopy. A standard angiography system with a rotatable C-arm was used. The definitions of technical success, clinical success, and complications were defined prior to the study. Results The technical and clinical success rates were 99.0% (95/96) and 89.6% (86/96), respectively. The mean hospital stay for an external lumbar drain was 4.84 days. Nine cases of minor complications and eight major complications were observed, including seven cases of meningitis, and one retained catheter requiring surgical removal. Conclusion Fluoroscopy-guided external lumbar drainage is a technically reliable procedure in difficult patients with failed attempts at a bedside procedure, history of lumbar surgery, difficulties in cooperation, or obesity.
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Affiliation(s)
- Choong Guen Chee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Guen Young Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Joon Woo Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Eugene Lee
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
| | - Heung Sik Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam 463-707, Korea
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Park S, Yang N, Seo E. The effectiveness of lumbar cerebrospinal fluid drainage to reduce the cerebral vasospasm after surgical clipping for aneurysmal subarachnoid hemorrhage. J Korean Neurosurg Soc 2015; 57:167-73. [PMID: 25810855 PMCID: PMC4373044 DOI: 10.3340/jkns.2015.57.3.167] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Revised: 07/21/2014] [Accepted: 12/15/2014] [Indexed: 11/28/2022] Open
Abstract
Objective Removal of blood from subarachnoid space with a lumbar drainage (LD) may decrease development of cerebral vasospasm. We evaluated the effectiveness of a LD for a clinical vasospasm and outcomes after clipping of aneurysmal subarachnoid hemorrhage (SAH). Methods Between July 2008 and July 2013, 234 patients were included in this study. The LD group consisted of 126 patients, 108 patients in the non LD group. We investigated outcomes as follow : 1) clinical vasospasm, 2) angioplasty, 3) cerebral infarction, 4) Glasgow outcome scale (GOS) score at discharge, 5) GOS score at 6-month follow-up, and 6) mortality. Results Clinical vasospasm occurred in 19% of the LD group and 42% of the non LD group (p<0.001). Angioplasty was performed in 17% of the LD group and 38% of the non LD group (p=0.001). Cerebral infarctions were detected in 29% and 54% of each group respectively (p<0.001). The proportion of GOS score 5 at 6 month follow-up in the LD group was 69%, and it was 58% in the non LD group (p=0.001). Mortality rate showed 5% and 10% in each group respectively. But, there was no difference in shunt between the two groups. Conclusion LD after aneurysmal SAH shows marked reduction of clinical vasospasm and need for angioplasty. With this technique we have shown favorable GOS score at 6 month follow-up.
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Affiliation(s)
- Soojeong Park
- Department of Neurosurgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Narae Yang
- Department of Neurosurgery, School of Medicine, Ewha Womans University, Seoul, Korea
| | - Euikyo Seo
- Department of Neurosurgery, School of Medicine, Ewha Womans University, Seoul, Korea
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The incidence and risk factors of meningitis after major craniotomy in China: a retrospective cohort study. PLoS One 2014; 9:e101961. [PMID: 25003204 PMCID: PMC4087000 DOI: 10.1371/journal.pone.0101961] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 06/12/2014] [Indexed: 11/19/2022] Open
Abstract
Background Meningitis after neurosurgery can result in severe morbidity and high mortality. Incidence varies among regions and limited data are focused on meningitis after major craniotomy. Aim This retrospective cohort study aimed to determine the incidence, risk factors and microbiological spectrum of postcraniotomy meningitis in a large clinical center of Neurosurgery in China. Methods Patients who underwent neurosurgeries at the Department of Neurosurgery in Huashan Hospital, the largest neurosurgery center in Asia and the Pacific, between 1stJanuary and 31st December, 2008 were selected. Individuals with only shunts, burr holes, stereotactic surgery, transsphenoidal or spinal surgery were excluded. The complete medical records of each case were reviewed, and data on risk factors were extracted and evaluated for meningitis. Results A total of 65 meningitides were identified among 755 cases in the study, with an incidence of 8.60%. The risk of meningitis was increased by the presence of diabetes mellitus (odds ratio [OR], 6.27; P = 0.009), the use of external ventricular drainage (OR, 4.30; P = 0.003) and the use of lumbar drainage (OR, 17.23; P<0.001). The isolated microorganisms included Acinetobacter baumannii, Enterococcus sp, Streptococcus intermedius and Klebsiella pneumonia. Conclusions Meningitis remains an important source of morbidity and mortality after major craniotomy. Diabetic patients or those with cerebral spinal fluid shunts carry significant high risk of infection. Thus, identification of the risk factors as soon as possible will help physicians to improve patient care.
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Hu F, Gu Y, Zhang X, Xie T, Yu Y, Sun C, Li W. Combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap multilayered reconstruction technique for high-flow cerebrospinal fluid leaks after endonasal endoscopic skull base surgery. World Neurosurg 2014; 83:181-7. [PMID: 24915070 DOI: 10.1016/j.wneu.2014.06.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Revised: 10/31/2013] [Accepted: 06/03/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the efficacy of the combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap (VP-NSF) multilayered reconstruction technique for high-flow cerebrospinal fluid (CSF) leaks resulting from endonasal endoscopic skull base surgery. METHODS From October 2009-June 2011, a VP-NSF multilayered reconstruction technique was used (single technique group) for patients with intraoperative high-flow CSF leaks; from July 2011-February 2013, a combination of a gasket seal closure and a VP-NSF multilayered reconstruction technique was used (combined technique group). A lumbar drain was placed after the operation. The rates of postoperative CSF leaks and repair-related complications in the 2 groups were analyzed. RESULTS The single technique group comprised 18 patients with a mean follow-up of 31.7 months; there were 5 postoperative CSF leaks (27.7%). The combined technique group comprised 15 patients with a mean follow-up of 13.6 months; no CSF leaks occurred (P < 0.05). The rate of intracranial infection in the single technique group was significantly higher than in the combined technique group. CONCLUSIONS The combined use of a gasket seal closure and a VP-NSF multilayered reconstruction technique for high-flow CSF leaks after endonasal endoscopic skull base surgery may significantly reduce the rates of postoperative CSF leaks and intracranial infections. Lumbar drainage after the operation is a necessary auxiliary method.
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Affiliation(s)
- Fan Hu
- Department of Neurosurgery at Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Image Computing and Computer Assisted Intervention, Shanghai, China
| | - Ye Gu
- Department of Neurosurgery at Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaobiao Zhang
- Department of Neurosurgery at Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Image Computing and Computer Assisted Intervention, Shanghai, China.
| | - Tao Xie
- Department of Anatomy/Digital Medical Research Center, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yong Yu
- Department of Neurosurgery at Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chongjing Sun
- Department of Neurosurgery at Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wensheng Li
- Department of Anatomy/Digital Medical Research Center, Shanghai Medical College, Fudan University, Shanghai, China
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Dural tear and resultant cerebrospinal fluid leaks after cervical spinal trauma. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 23:1772-6. [DOI: 10.1007/s00586-014-3332-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 04/23/2014] [Accepted: 04/24/2014] [Indexed: 10/25/2022]
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Selden NR, Anderson VC, McCartney S, Origitano TC, Burchiel KJ, Barbaro NM. Society of Neurological Surgeons boot camp courses: knowledge retention and relevance of hands-on learning after 6 months of postgraduate year 1 training. J Neurosurg 2013; 119:796-802. [PMID: 23590128 DOI: 10.3171/2013.3.jns122114] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In July 2010, the Society of Neurological Surgeons (SNS) introduced regional courses to promote patient safety and teach fundamental skills and knowledge to all postgraduate Year 1 (PGY1) trainees entering Accreditation Council for Graduate Medical Education (ACGME)-accredited US neurosurgery residency programs. Data from these courses demonstrated significant didactic learning and high faculty and resident satisfaction with hands-on training. Here, the authors evaluated the durability of learning from and the relevance of participation in SNS PGY1 courses as measured midway through PGY1 training. METHODS Resident participants were resurveyed 6 months after boot camp course attendance to assess knowledge retention and course effectiveness. Exposure to relevant hands-on experiences during PGY1 training and the subjective value of pre-residency simulated training in the courses were assessed. RESULTS Ninety-four percent of all residents entering US PGY1 neurosurgical training participated in the 2010 SNS boot camp courses. One hundred sixty-four (88%) of these resident participants responded to the survey. Six months after course completion, 99% of respondents believed the boot camp courses benefited beginning neurosurgery residents and imparted skills and knowledge that would improve patient care. The PGY1 residents' knowledge of information taught in the courses was retained 6 months after initial testing (p < 0.0001). CONCLUSIONS The learning and other benefits of participation in a national curriculum for residents entering PGY1 neurosurgical training were maintained 6 months after the courses, halfway through the initial training year.
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Affiliation(s)
- Nathan R Selden
- Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon, USA
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Ormond DR, Dressler A, Kim S, Ronecker J, Murali R. Lumbar drains may reduce the need for permanent CSF diversion in spontaneous subarachnoid haemorrhage. Br J Neurosurg 2012. [DOI: 10.3109/02688697.2012.743971] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kourbeti I, Vakis A, Papadakis J, Karabetsos D, Bertsias G, Filippou M, Ioannou A, Neophytou C, Anastasaki M, Samonis G. Infections in traumatic brain injury patients. Clin Microbiol Infect 2012; 18:359-64. [DOI: 10.1111/j.1469-0691.2011.03625.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Al-Tamimi YZ, Bhargava D, Feltbower RG, Hall G, Goddard AJP, Quinn AC, Ross SA. Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage: a prospective, randomized, controlled trial (LUMAS). Stroke 2012; 43:677-82. [PMID: 22282887 DOI: 10.1161/strokeaha.111.625731] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE A single-center prospective randomized controlled trial has been conducted to determine if lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage reduces the prevalence of delayed ischemic neurological deficit and improves clinical outcome. METHODS Patients with World Federation of Neurological Surgeons Grade 1 to 3 aneurysmal subarachnoid hemorrhage and modified Fisher Grades 2, 3, 4, and 3+4 were randomized to either the study group of standard therapy plus insertion of a lumbar drain or the control group of standard therapy alone. The primary outcome measure was the prevalence of delayed ischemic neurological deficit. RESULTS Two hundred ten patients with aneurysmal subarachnoid hemorrhage (166 female, 44 male; median age, 54 years; interquartile range, 45-62 years) were recruited into the control (n=105) and study (n=105) groups of the trial. World Federation of Neurological Surgeons grade was: 1 (n=139), 2 (n=60), and 3 (n=11); Fisher grade was: 2 (n=87), 3 (n=85), and 4 (n=38). The prevalence of delayed ischemic neurological deficit was 35.2% and 21.0% in the control and study groups, respectively (P=0.021). The prevalence of a modified Rankin Scale score of 4, 5, or 6 at Day 10 and 6 months, respectively, was 62.5% and 18.6% in the control group and 44.8% and 19.8% in the study group (P=0.009 and 0.83, respectively). CONCLUSIONS Lumbar drainage of cerebrospinal fluid after aneurysmal subarachnoid hemorrhage has been shown to reduce the prevalence of delayed ischemic neurological deficit and improve early clinical outcome but failed to improve outcome at 6 months after aneurysmal subarachnoid hemorrhage. CLINICAL TRIAL REGISTRATION URL: www.clinicaltrials.gov. Unique identifier: NCT00842049.
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Affiliation(s)
- Yahia Z Al-Tamimi
- Department of Neurosurgery, Level G Jubilee Wing, Leeds General Infirmary, Great George Street, Leeds, West Yorkshire, UK LS1 3EX.
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Goyal R. Lumbar drainage of cerebrospinal fluid in a child with tetralogy of Fallot and cerebral infarct. Med J Armed Forces India 2012; 68:63-4. [PMID: 24623919 DOI: 10.1016/s0377-1237(11)60117-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 09/01/2011] [Indexed: 10/14/2022] Open
Affiliation(s)
- Rakhee Goyal
- Classified Specialist (Anaesthesia & Critical Care), Command Hospital (SC), Pune - 40
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Farhat HI, Elhammady MS, Levi AD, Aziz-Sultan MA. Cervical subarachnoid catheter placement for continuous cerebrospinal fluid drainage: a safe and efficacious alternative to the classic lumbar cistern drain. Neurosurgery 2011; 68:52-6; discussion 56. [PMID: 21206317 DOI: 10.1227/neu.0b013e318207b20a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) drainage serves an important role in the management of patients with established or potential CSF fistulae. Classically, a lumbar CSF drain has been used for this purpose and has been shown to be safe and effective. In certain cases, such as extensive previous lumbar surgery, a lumbar drain cannot be used. In such instances, a cervical CSF drain can be inserted via a lateral C1-2 puncture and provides an excellent and safe alternative. OBJECTIVE To describe the technique, safety, and effectiveness of placing a cervical drain for CSF drainage. Pitfalls and possible complications and their avoidance are also discussed. METHODS Twenty-seven cervical drains were placed in 24 patients with a mean age of 56.1 years (range, 19-82 years). There were 13 women and 11 men. All cervical drains were placed via a lateral C1-2 puncture under direct fluoroscopic vision. A standard Hermetic closed-tip lumbar catheter was used in all cases. The drains were in place for an average of 5.96 days (range, 3-11 days). CSF surveillance was performed on the day of placement as well as every 48 hours that the drain was in place. RESULTS Cervical drain placement was achieved in all cases, allowing for continuous CSF drainage. No permanent procedural complications occurred. There were no instances of meningitis. CONCLUSIONS Placement of a cervical intrathecal catheter for CSF drainage is a safe and effective alternative when lumbar access is contraindicated or not achievable.
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Affiliation(s)
- Hamad I Farhat
- Department of Neurological Surgery, University of Miami, Miller School of Medicine, Miami, Florida 33136, USA.
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Mazur M, Jost GF, Schmidt MH, Bisson EF. Management of cerebrospinal fluid leaks after anterior decompression for ossification of the posterior longitudinal ligament: a review of the literature. Neurosurg Focus 2011; 30:E13. [DOI: 10.3171/2010.12.focus10255] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Anterior decompression is an effective way to treat cervical myelopathy associated with ossification of the posterior longitudinal ligament (OPLL); however, this approach is associated with an increased risk of a dural tear and resultant CSF leak because fusion of the dura with the ossified PLL is common in these cases. The authors review the literature and present an algorithm for treatment of CSF leaks in these patients.
Methods
A MEDLINE review was performed to identify papers related to CSF leak after anterior decompression for OPLL, and data were summarized to identify treatment options for various situations. A treatment algorithm was identified based on these findings and the experience of the authors.
Results
Eleven studies were identified that presented data on intra- and postoperative management of a CSF leak during ventral surgery for OPLL. The incidence of cervical dural tears and CSF leaks after anterior decompression procedures for OPLL ranged from 4.3% to 32%. Techniques including preventative measures, intraoperative dural repair with various materials, and postoperative drainage or shunt placement have all been used.
Conclusions
Although direct dural repair is the preferred treatment for CSF leak, this technique is not always technically possible. In these cases, intraoperative adjuncts in combination with postoperative measures can be used to decrease the pressure gradient across the dural tear.
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Maguire RC, Gull J, Weaver M, Sataloff RT. Otolaryngologic uses for spinal drains. EAR, NOSE & THROAT JOURNAL 2011; 89:E17-22. [PMID: 20981648 DOI: 10.1177/014556131008901004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Cerebrospinal fluid (CSF) fistulae have been encountered by otolaryngologists often since the advent of modern endoscopic sinus surgery, otologic surgery, and skull base surgery. Treatment of CSF leaks may include bed rest, head-of-bed elevation, stool softeners, external spinal fluid drainage, and surgery. External CSF drainage is accomplished via a lumbar spinal drain. Placement of spinal drains is often performed by neurosurgeons and anesthetists. A few otolaryngologists have been trained in the placement and management of lumbar drains, but at most otolaryngology training institutions, education in lumbar drains is not provided. However, in some circumstances, it may fall to an otolaryngologist to accomplish the task. We believe that every otolaryngologist, from the generalist in private practice to the academic neuro-otologic surgeon, should understand the proper technique for the insertion and management of a lumbar drain. Otolaryngologists should be familiar with the physiologic properties of CSF, the methods used to diagnose fistulae, and the techniques used to repair leaks. External spinal drainage is an important element in the management of CSF fistulae, and it has been used in treating perilymphatic fistulae and "gushers." Much controversy surrounds its routine use. Otolaryngologists need to understand the risks, benefits, and outcomes of spinal drain use in order to decide which patients may benefit from this procedure.
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Affiliation(s)
- Raymond C Maguire
- Department of Otolaryngology-Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA 19103, USA
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Perfect JR, Dismukes WE, Dromer F, Goldman DL, Graybill JR, Hamill RJ, Harrison TS, Larsen RA, Lortholary O, Nguyen MH, Pappas PG, Powderly WG, Singh N, Sobel JD, Sorrell TC. Clinical practice guidelines for the management of cryptococcal disease: 2010 update by the infectious diseases society of america. Clin Infect Dis 2010; 50:291-322. [PMID: 20047480 PMCID: PMC5826644 DOI: 10.1086/649858] [Citation(s) in RCA: 1725] [Impact Index Per Article: 123.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Cryptococcosis is a global invasive mycosis associated with significant morbidity and mortality. These guidelines for its management have been built on the previous Infectious Diseases Society of America guidelines from 2000 and include new sections. There is a discussion of the management of cryptococcal meningoencephalitis in 3 risk groups: (1) human immunodeficiency virus (HIV)-infected individuals, (2) organ transplant recipients, and (3) non-HIV-infected and nontransplant hosts. There are specific recommendations for other unique risk populations, such as children, pregnant women, persons in resource-limited environments, and those with Cryptococcus gattii infection. Recommendations for management also include other sites of infection, including strategies for pulmonary cryptococcosis. Emphasis has been placed on potential complications in management of cryptococcal infection, including increased intracranial pressure, immune reconstitution inflammatory syndrome (IRIS), drug resistance, and cryptococcomas. Three key management principles have been articulated: (1) induction therapy for meningoencephalitis using fungicidal regimens, such as a polyene and flucytosine, followed by suppressive regimens using fluconazole; (2) importance of early recognition and treatment of increased intracranial pressure and/or IRIS; and (3) the use of lipid formulations of amphotericin B regimens in patients with renal impairment. Cryptococcosis remains a challenging management issue, with little new drug development or recent definitive studies. However, if the diagnosis is made early, if clinicians adhere to the basic principles of these guidelines, and if the underlying disease is controlled, then cryptococcosis can be managed successfully in the vast majority of patients.
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Affiliation(s)
- John R Perfect
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Leverstein-van Hall MA, Hopmans TEM, van der Sprenkel JWB, Blok HEM, van der Mark WAMA, Hanlo PW, Bonten MJM. A bundle approach to reduce the incidence of external ventricular and lumbar drain-related infections. J Neurosurg 2010; 112:345-53. [DOI: 10.3171/2009.6.jns09223] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
An important complication of external CSF drainage is bacterial meningitis or ventriculitis, resulting in increased morbidity, mortality, and health care costs. In 2003, a high rate (37%) of probable drain-related infections was identified at the authors' hospital. A multidisciplinary working group was installed to reduce this incidence to < 10% within 1.5 years.
Methods
An intervention strategy based on 5 pillars (increased awareness, focused standard operating procedures, a diagnostic and therapeutic algorithm, timely administration of prophylaxis, and improvement of the drainage system) was designed and implemented from 2004 to 2006. During this period all patients with external CSF drainage were prospectively monitored.
Results
Between 2004 and 2006, there were 467 patients in whom 579 drains (external ventricular and external lumbar) had been placed. The overall incidence of drain-related infections was 16.2% in 2004, 8.9% in 2005, and 11.3% in 2006. For external lumbar drains the number of infections per 100 drain days was 2.4 in 2004, 0.6 in 2005, and 0.8 in 2006. For external ventricular drains these rates were 1.7, 1.0, and 1.2, respectively. Meanwhile, the causative noncutaneous microorganisms, indicative for systemic-contamination during manipulation, decreased. By retrospective analysis, the proportion of patients with a probable drain-related infection decreased from 37% in 2003 to 9% in 2005 and 2006.
Conclusions
The authors' multidisciplinary approach in which different preventive measures were combined was associated with a significant reduction in the incidence of drain-related secondary meningitis, and thus provides an important improvement of patient safety.
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Affiliation(s)
- Maurine A. Leverstein-van Hall
- 1Departments of Microbiology, Infectious Diseases and Inflammation, and Hospital Hygiene and Infection Prevention
- 3Center of Disease Control (CIb), National Institute for Public Health and the Environment (RIVM), Utrecht, The Netherlands
| | - Titia E. M. Hopmans
- 1Departments of Microbiology, Infectious Diseases and Inflammation, and Hospital Hygiene and Infection Prevention
| | | | - Hetty E. M. Blok
- 1Departments of Microbiology, Infectious Diseases and Inflammation, and Hospital Hygiene and Infection Prevention
| | | | - Patrick W. Hanlo
- 2Department of Neurosurgery, University Medical Center Utrecht; and
| | - Marc J. M. Bonten
- 1Departments of Microbiology, Infectious Diseases and Inflammation, and Hospital Hygiene and Infection Prevention
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Zunt JR. Infections of the central nervous system in the neurosurgical patient. HANDBOOK OF CLINICAL NEUROLOGY 2010; 96:125-141. [PMID: 20109679 DOI: 10.1016/s0072-9752(09)96009-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Joseph R Zunt
- Department of Neurology, Harborview Medical Center, Seattle, WA 98104, USA.
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McKenzie A, Sherwood M. Continuous spinal analgesia after extensive lumbar spine surgery. Anaesth Intensive Care 2009; 37:473-6. [PMID: 19499871 DOI: 10.1177/0310057x0903700309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 77-year-old male underwent L-1 to S-1 spine decompression and fusion from L-3 to S-1. A 25 G spinal catheter was placed intraoperatively and bupivacaine 1.25 mg/ml, fentanyl 2 microg/ml and morphine 3 microg/ml infused. The patient was pain-free for the duration of the infusion. Continuous spinal analgesia was effective after extensive spinal surgery. The risks of post-dural puncture headache, infection of wound and/or meninges and the optimum drug doses and combinations are yet to be quantified in this setting.
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Affiliation(s)
- A McKenzie
- Wakefield Hospital, Wellington, New Zealand
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Manosuthi W, Sungkanuparph S, Chottanapund S, Tansuphaswadikul S, Chimsuntorn S, Limpanadusadee P, Pappas PG. Temporary external lumbar drainage for reducing elevated intracranial pressure in HIV-infected patients with cryptococcal meningitis. Int J STD AIDS 2008; 19:268-71. [DOI: 10.1258/ijsa.2007.007286] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to investigate safety and impact of temporary external lumbar drainage for continuous release of cerebrospinal fluid among patients with HIV-associated cryptococcal meningitis and elevated intracranial pressure (ICP). We conducted a retrospective cohort study among patients with cryptococcal meningitis in whom temporary external lumbar drains were placed to reduce intractable elevated ICP between January 2002 and December 2005. Patients were followed for three months after the procedure. Among 601 HIV-infected patients with cryptococcal meningitis, 54 (8.9%) underwent lumbar drain placement. Of these patients, mean age was 33 years and 80% were males. The median duration of an indwelling lumbar drain was seven days. There were 61 placement procedures among 54 patients, totalling to 473 device-days of observation. Overall incidence of secondary bacterial infections was 6.3 per 1000 device-days, and three (4.9%) of 61 catheters became secondarily infected with nosocomially acquired bacteria. All three drains were removed and appropriate antibiotics were given. There was no difference in median duration of placement between infected and uninfected drains (six days vs. seven days, P = 0.572). The overall mortality rate was 5.6% in this cohort of 54 patients. In conclusion, the incidence of nosocomial infection of external lumbar drains is low. In resource-limited settings, the use of temporary external lumbar drainage is a safe and effective management strategy for intractable elevated ICP in HIV-infected patients with cryptococcal meningitis.
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Affiliation(s)
- Weerawat Manosuthi
- Department of Medicine, Bamrasnaradura Infectious Diseases Institute, Tiwanon Road, Nonthaburi 11000
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Somnuek Sungkanuparph
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand
| | - Suthat Chottanapund
- Department of Medicine, Bamrasnaradura Infectious Diseases Institute, Tiwanon Road, Nonthaburi 11000
| | - Somsit Tansuphaswadikul
- Department of Medicine, Bamrasnaradura Infectious Diseases Institute, Tiwanon Road, Nonthaburi 11000
| | - Sukanya Chimsuntorn
- Department of Medicine, Bamrasnaradura Infectious Diseases Institute, Tiwanon Road, Nonthaburi 11000
| | - Putthiporn Limpanadusadee
- Department of Medicine, Bamrasnaradura Infectious Diseases Institute, Tiwanon Road, Nonthaburi 11000
| | - Peter G Pappas
- Department of Medicine, Division of Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
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Greenberg BM, Williams MA. INFECTIOUS COMPLICATIONS OF TEMPORARY SPINAL CATHETER INSERTION FOR DIAGNOSIS OF ADULT HYDROCEPHALUS AND IDIOPATHIC INTRACRANIAL HYPERTENSION. Neurosurgery 2008; 62:431-5; discussion 435-6. [DOI: 10.1227/01.neu.0000316010.19012.35] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Spinal catheters are often inserted for treatment of cerebrospinal fluid leaks; however, they have recently been recommended for elective cerebrospinal fluid drainage to identify patients with possible normal pressure hydrocephalus who are most likely to respond to shunt surgery. The rate of spinal catheter-associated meningitis with elective spinal catheter insertion is unknown. The objective was to determine the rate of infection and risk factors associated with elective spinal catheter insertion for evaluation of hydrocephalus and idiopathic intracranial hypertension (IIH).
METHODS
We retrospectively analyzed clinical and microbiological data and cerebrospinal fluid results of patients admitted during 60 consecutive months who had elective spinal catheter insertion for evaluation of normal pressure hydrocephalus or IIH.
RESULTS
A total of 461 spinal catheters were inserted in 454 patients, including 419 (90.9%) for treatment of hydrocephalus and 42 (9.1%) for IIH. The infection rate was 3.3% (15 out of 461 patients) for the entire cohort, 3.6% (15 out of 419 patients) for the hydrocephalus cohort, and 0% for the IIH cohort. There was one death (0.2%) in the hydrocephalus cohort. The infection rate was reduced and sustained at 1.8% for 225 catheters after the topical antiseptic was changed to chlorhexidine (two-sided Fisher's exact test; P = 0.114).
CONCLUSION
Although infection is the most serious complication of spinal catheter insertion for evaluation of hydrocephalus or IIH, the infection rate can be maintained below 2% with use of chlorhexidine topical antiseptic application, single-dose preprocedural antibiotic administration, and clinical surveillance of the patient. The benefit of cerebrospinal fluid drainage via spinal catheter for normal pressure hydrocephalus outweighs the risks associated with the procedure.
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Affiliation(s)
| | - Michael A. Williams
- LifeBridge Health Brain Spine Institute, Adult Hydrocephalus Center, Baltimore, Maryland
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49
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Subarachnoid lumbar drains: A case series of fractured catheters and a near miss. Can J Anaesth 2007; 54:829-34. [DOI: 10.1007/bf03021711] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Brunnekreef GB, Heijmen RH, Gerritsen WB, Schepens MA, ter Beek HT, van Dongen EP. Measurements of Cerebrospinal Fluid Concentrations of S100β Protein During and After Thoracic Endovascular Stent Grafting. Eur J Vasc Endovasc Surg 2007; 34:169-72. [PMID: 17408991 DOI: 10.1016/j.ejvs.2007.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2006] [Accepted: 01/20/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Thoracic endovascular aortic repair is associated with postoperative spinal cord ischemia in approximately 1 to 12.5% of all cases. S100beta is a protein that is released during acute damage of the central nervous system. This study was performed to determine the concentration of S100beta in cerebrospinal fluid during and after stenting of the thoracic aorta in patients at high risk for spinal cord ischemia. DESIGN Prospective clinical study. MATERIALS AND METHODS Eight patients who underwent elective thoracic aortic stent grafting underwent lumbar spinal fluid drainage. These patients were at high risk to develop spinal cord ischemia. METHODS CSF samples for analysis of S100beta protein were drawn after induction of anesthesia, during stenting, once every hour the following six hours and 20 hours after repair. RESULTS No significant increase in S100beta protein could be detected in CSF and no neurological deficits were detected postoperatively. CONCLUSIONS The results of this study show us that there is no significant release of S100beta protein in CSF during stenting of the thoracic aorta in this subgroup of patients at high risk for spinal cord ischemia, consistent with clinical exam that there was no significant damage to the central nervous system.
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Affiliation(s)
- G B Brunnekreef
- Department of Anesthesiology and Intensive Care, St. Antonius Hospital, The Netherlands.
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