Paramedian thalamic infarction caused by cisternal drain placement in open clipping for aneurysmal subarachnoid hemorrhage: Two case reports

The Role of Cisternostomy and Cisternal Drainage in the Treatment of Aneurysmal Subarachnoid Hemorrhage: A Comprehensive Review

Aneurysmal subarachnoid hemorrhage (aSAH) provokes a cascade reaction that is responsible for early and delayed brain injuries mediated by intracranial hypertension, hydrocephalus, cerebral vasospasm (CV), and delayed cerebral ischemia (DCI), which result in increased morbidity and mortality. During open microsurgical repair, cisternal access is achieved essentially to gain proximal vascular control and aneurysm exposition. Cisternostomy also allows brain relaxation, removal of cisternal clots, and restoration of the CSF dynamics through the communication between the anterior and posterior circulation cisterns and the ventricular system, with the opening of the Membrane of Liliequist and lamina terminalis, respectively. Continuous postoperative CSF drainage through a cisternal drain (CD) is a valuable option for treating acute hydrocephalus and intracranial hypertension. Moreover, it efficiently removes the blood and toxic degradation products, with a potential benefit on CV, DCI, and shunt-dependent hydrocephalus. Finally, the CD is an effective pathway to administer vasoactive, fibrinolytic, and anti-oxidant agents and shows promising results in decreasing CV and DCI rates while minimizing systemic effects. We performed a comprehensive review to establish the adjuvant role of cisternostomy and CD performed in cases of direct surgical repair for ruptured intracranial aneurysms and their role in the prevention and treatment of aSAH complications.

Oculomotor nerve palsy presumably caused by cisternal drain during microsurgical clipping

Background:

Oculomotor nerve palsy can be caused by diverse etiologies, but no report has yet documented its association with a cisternal drain.

Case Description:

A 35-year-old woman presented with severe headache. The patient did not exhibit oculomotor nerve palsy at presentation. Cranial computed tomography (CT) revealed diffuse subarachnoid hemorrhage. The patient underwent open microsurgical clipping of a ruptured middle cerebral artery aneurysm. During surgery, a cisternal drain was placed in the basal cistern at the medial aspect of the clinoidal portion of the internal carotid artery. The patient presented with the left oculomotor nerve palsy immediately after surgery. CT revealed displacement of the cisternal drain to the lateral aspect of the anterior clinoid process. The patient’s mydriasis and sluggish light reaction recovered after 7 days, while extraocular movements persisted for 50 days. The constructive interference steady-state sequence detected the left oculomotor nerve coursing adjacent to the clinoidal internal carotid artery.

Conclusion:

Oculomotor nerve palsy can be caused by collision with a thin silastic tube placed during surgery for aneurysmal subarachnoid hemorrhage. Withdrawal of the drain as early as possible is recommended when drain-associated oculomotor nerve palsy is suspected.