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Piazza A, Alexander AY, Peris-Celda M, Lanzino G. How I do it: surgical ligation of posteromedial tentorial dural arteriovenous fistulas. Acta Neurochir (Wien) 2024; 166:382. [PMID: 39325275 DOI: 10.1007/s00701-024-06272-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 09/13/2024] [Indexed: 09/27/2024]
Abstract
BACKGROUND Tentorial dural arteriovenous fistulas (dAVFs) are categorized based on venous drainage and location. Although their angioarchitecture may initially appear intimidating, once "decodified," treatment is straightforward. Posteromedial tentorial dAVFs have an arterialized draining vein that emanates from the inferior tentorium along the posterior third of the straight sinus, just slightly off the midline. METHOD With the aid of anatomical dissections, intraoperative photos, and operative videos, we outline the key steps for surgical treatment of posteromedial tentorial dAVFs. CONCLUSION Posteromedial tentorial dAVFs constitute a precise and well-defined subtype of tentorial dAVF for which surgical ligation has an important role.
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Affiliation(s)
- Amedeo Piazza
- Department of Neurological Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55905, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Neurosurgery, "Sapienza" University, 00185, Rome, Italy
| | - A Yohan Alexander
- Department of Neurological Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55905, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Maria Peris-Celda
- Department of Neurological Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55905, USA
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA
- Department of Clinical Anatomy, Mayo Clinic, Rochester, MN, USA
| | - Giuseppe Lanzino
- Department of Neurological Surgery, Mayo Clinic, 200 1St St SW, Rochester, MN, 55905, USA.
- Rhoton Neurosurgery and Otolaryngology Surgical Anatomy Program, Mayo Clinic, Rochester, MN, USA.
- Department of Radiology, Mayo Clinic, Rochester, MN, USA.
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Al-Afif S, Lang JM, Abdulbaki A, Palmaers T, Scheinichen D, Abu-Fares O, Hermann EJ, Krauss JK. The safety and utility of the semi-sitting position for clipping of posterior circulation aneurysms. Acta Neurochir (Wien) 2024; 166:341. [PMID: 39160268 PMCID: PMC11333526 DOI: 10.1007/s00701-024-06229-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2024] [Accepted: 08/08/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND The semi-sitting position offers advantages for surgeries in the posterior cranial fossa. However, data on its safety and effectiveness for clipping aneurysms in the posterior cerebral circulation are limited. This retrospective cohort study evaluates the safety and effectiveness of using the semi-sitting position for these surgeries. METHODS We conducted a retrospective study of 17 patients with posterior cerebral circulation aneurysms who underwent surgical clipping in the semi-sitting position in the Department of Neurosurgery at Hannover Medical School over a 10-year period. RESULTS The mean age at surgery was 62 years (range, 31 to 75). Fourteen patients were admitted with subarachnoid hemorrhage and 3 patients had incidental aneurysmas. Fifteen patients had PICA aneurysms, and two had aneurysms of the vertebral artery and the superior cerebellar artery, respectively. The median diameter of the aneurysms was 5 mm (range 3-17 mm). Intraoperative venous air embolism (VAE) occurred in 4 patients, without affecting the surgical or clinical course. VAE was associated with a mild decrease of EtCO2 levels in 3 patients and in 2 patients a decrease of blood pressure occurred which was managed effectively. Surgical procedures proceeded as planned in all instances. There were no complications secondary to VAE. Two patients died secondary to respiratory problems (not related to VAE), and one patient was lost to follow-up. Eleven of fourteen patients were partially or completely independent (Barthel index between 60 and 100) at a median follow-up duration of 13.5 months (range, 3-103 months). CONCLUSION The semi-sitting position is a safe and effective technique for the surgical clipping of aneurysms in the posterior cerebral circulation. The incidence of VAE is comparable to that seen in tumor surgery. However, it is crucial for the surgical and anesthesiological team to be familiar with potential complications and to react immediately in case of an occurrence of VAE.
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Affiliation(s)
- Shadi Al-Afif
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
| | - Josef M Lang
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Arif Abdulbaki
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Thomas Palmaers
- Department of Anaesthesiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Dirk Scheinichen
- Department of Anaesthesiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Omar Abu-Fares
- Institute of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Elvis J Hermann
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
| | - Joachim K Krauss
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany
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Serag I, Abdelhady M, Awad AA, Wageeh A, Shaboub A, Elhalag RH, Aljabali A, Abouzid M. Postoperative elevated bed header position versus supine in the management of chronic subdural hematoma: a systematic review and meta-analysis. Acta Neurol Belg 2024; 124:1177-1187. [PMID: 38802719 PMCID: PMC11266250 DOI: 10.1007/s13760-024-02571-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 05/06/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a prevalent type of intracranial hemorrhage. Surgical interventions, such as Twist Drill Craniostomy and Burr Hole Craniostomy, are employed for its treatment. However, limited information exists regarding the impact of postoperative head position (supine vs. elevated) on clinical outcomes. We aim to assess whether patients' head position after surgery influences their prognosis. METHOD We conducted a PRISMA-compliant systematic review and meta-analysis. Our search encompassed PubMed, Cochrane CENTRAL, Scopus, Web of Science, and Embase databases to identify relevant published studies. Data were meticulously extracted, pooled using a fixed model, and reported as risk ratios (RR) with 95% confidence intervals (CI). Statistical analysis was performed using R and Stata MP v.17. RESULTS Five studies involving 284 patients were included in our meta-analysis. We focused on three primary clinical outcomes, comparing the supine and elevated header positions. Notably, there was no statistically significant difference between the supine and elevated positions in terms of recurrence rate (RR 0.77, 95% CI [0.44, 1.37]), second intervention for recurrence (RR 1.07, 95% CI [0.42, 2.78]) and postoperative complications (RR 1.16, 95% CI [0.70, 1.92]). CONCLUSION Current studies have proved no difference between supine and elevated bed header positions regarding recurrence rate, second intervention for recurrence, and postoperative complications. Future RCTs with long-term follow-ups are recommended.
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Affiliation(s)
- Ibrahim Serag
- Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | | | | | - Ahmed Wageeh
- Faculty of Medicine, Menoufia University, Menoufia, Egypt
| | - Ahmed Shaboub
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Rowan H Elhalag
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ahmed Aljabali
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohamed Abouzid
- Department of Physical Pharmacy and Pharmacokinetics, Faculty of Pharmacy, Poznan University of Medical Sciences, Rokietnicka 3 St, 60-806, Poznan, Poland.
- Doctoral School, Poznan University of Medical Sciences, 60-812, Poznan, Poland.
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Hevia Rodríguez P, Elúa Pinín A, Larrea Aseguinolaza A, Samprón N, Armendariz Guezala M, Úrculo Bareño E. Semisitting position for cerebello-pontine angle surgery: Analysis of complications and how to avoid it. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:18-29. [PMID: 37442433 DOI: 10.1016/j.neucie.2023.07.001] [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: 04/11/2022] [Accepted: 05/16/2023] [Indexed: 07/15/2023]
Abstract
OBJECTIVE To analyze the primary complications related to semisitting position in patients undergoing cerebelo-pontine angle surgery. METHODS Retrospective data analysis from patients undergoing elective tumoral cerebelo-pontine angle surgery in a semisitting position. The incidence, severity, occurrence moment, treatment, duration, and outcomes of venous air embolism (VAE), pneumocephalus, postural hypotension, and other complications were recorded. Neurointensive care unit (NICU), length of stay (LOS), hospital LOS, and modified Rankin scale scores were calculated six months after surgery. RESULTS Fifty patients were operated on. Eleven (22%) presented VAE (mean duration 8±4.5min): five (10%) during tumor resection, and four (8%) during dural opening. Ten (20%) were resolved by covering the surgical bed, air bubbles aspiration, jugular compression, and one (2%) tilted to a steep Trendelenburg position. One (2%) had intraoperative hemodynamic instability. The only variable associated with VAE was meningioma at histopathology OR=4.58, p=0.001. NICU was higher in patients with VAE (5.5±1.06 vs. 1.9±0.20 days, p=0.01). There were no differences in the Rankin scale. All patients presented postoperative pneumocephalus with a good level of consciousness, except one (2%) who required evacuation. Seven patients (14%) showed postural hypotension, three (6%) after positioning, and one (2%) after developing a VAE; all were reversed with usual vasoactive drugs. No other position-related complications or mortality were registered in this series. CONCLUSIONS The semisitting position is a safe option with the knowledge, prevention, detection, and early solution of all the possible complications. The development of VAE rarely implies hemodynamic instability or greater disability after surgery. Postoperative pneumocephalus is very common and rarely requires evacuation. Excellent cooperation between anesthesia, nursing, neurophysiology, and neurosurgery teams is essential to manage complications.
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Affiliation(s)
- Pelayo Hevia Rodríguez
- Servicio de Neurocirugía, Hospital Universitario Donostia, Donostia, San Sebastián, Gipuzkoa, Spain.
| | - Alejandro Elúa Pinín
- Servicio de Neurocirugía, Hospital Universitario Donostia, Donostia, San Sebastián, Gipuzkoa, Spain
| | - Amaia Larrea Aseguinolaza
- Servicio de Anestesia y Reanimación, Hospital Universitario Donostia, Donostia, San Sebastián, Gipuzkoa, Spain
| | - Nicolás Samprón
- Servicio de Neurocirugía, Hospital Universitario Donostia, Donostia, San Sebastián, Gipuzkoa, Spain
| | - Mikel Armendariz Guezala
- Servicio de Neurocirugía, Hospital Universitario Donostia, Donostia, San Sebastián, Gipuzkoa, Spain
| | - Enrique Úrculo Bareño
- Servicio de Neurocirugía, Hospital Universitario Donostia, Donostia, San Sebastián, Gipuzkoa, Spain
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Krauss P, Kahl KH, Bonk MN, Wolfert C, Sommer B, Stueben G, Shiban E. Intraoperative radiotherapy after resection of brain metastases located in the posterior fossa. Analysis of postoperative morbidity and mortality in a single center cohort. J Clin Neurosci 2023; 118:1-6. [PMID: 37832264 DOI: 10.1016/j.jocn.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/16/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION In order to improve surgical outcome and accelerate the adjuvant oncologic therapy, intraoperative Radiotherapy (IORT) has become a treatment option in oncologic surgery for various diseases including glioma and brain metastasis (BM). BMs are often located in the cranial posterior fossa (PF) requiring specific surgical considerations due to its complex anatomy. Up until now, data on IORT for BMs is limited and detailed description in the use of IORT for lesions in the PF is lacking. Our aim is to provide more insight into this emerging treatment strategy. METHODS We performed a retrospective analysis of patients receiving surgery for BMs and undergoing IORT at our institution. Each patient was discussed at the interdisciplinary tumor board decision before the intervention. Patient characteristics, functional status (Karnofsky Performance Score, KPS) before and after surgery, disease (recursive partitioning analysis, lesion size) and operative parameters were analyzed. Adverse events (AE) were recorded up until 30 days after the intervention and rated according to the Clavien Dindo Rating scale. RESULTS Nine patients (5 female) were included. None underwent prior radiotherapy (RT). Mean age was 66 ± 11 years. Preoperative median KPS was 80%. Mean BM diameter was 3.2 ± 0.9 cm. There was no statistically significant deterioration of the functional status after the intervention. Two patients experienced AEs with both of them needing revision surgery. CONCLUSION Surgery for BMs with IORT in the PF seems safe and feasible. Further studies are needed to evaluate the influence of IORT on long-term outcome after BM surgery.
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Affiliation(s)
- Philipp Krauss
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany.
| | - Klaus Henning Kahl
- Department of Radiooncology, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Maximilian Niklas Bonk
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Christina Wolfert
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Bjoern Sommer
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Georg Stueben
- Department of Radiooncology, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
| | - Ehab Shiban
- Department of Neurosurgery, University Hospital Augsburg, Stenglinstrasse 2, 86156 Augsburg, Germany
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Garg B, Bansal T, Mehta N, Sharan AD. Patient Positioning in Spine Surgery: What Spine Surgeons Should Know? Asian Spine J 2023; 17:770-781. [PMID: 37226380 PMCID: PMC10460667 DOI: 10.31616/asj.2022.0320] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/15/2022] [Indexed: 05/26/2023] Open
Abstract
Spine surgery has advanced tremendously over the last decade. The number of spine surgeries performed each year has also been increasing constantly. Unfortunately, the reporting of position-related complications in spine surgery has also been steadily increasing. These complications not only result in significant morbidity for the patient but also raises the risk of litigation for the surgical and anesthetic teams. Fortunately, most position-related complications are avoidable with basic positioning knowledge. Hence, it is critical to be cautious and take all necessary precautions to avoid position-related complications. We discuss the various position-related complications associated with the prone position, which is the most commonly used position in spine surgery, in this narrative review. We also discuss the various methods for avoiding complications. Furthermore, we briefly discuss less commonly used positions in spine surgery, like the lateral and sitting positions.
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Affiliation(s)
- Bhavuk Garg
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi,
India
| | - Tungish Bansal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi,
India
| | - Nishank Mehta
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi,
India
| | - Alok D. Sharan
- Spine and Orthopedics, NJ Spine and Wellness, Matawan, NJ,
USA
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The semi-sitting position in patients with indwelling CSF shunts: perioperative management and avoidance of complications. Acta Neurochir (Wien) 2023; 165:421-427. [PMID: 36502472 PMCID: PMC9922215 DOI: 10.1007/s00701-022-05430-4] [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: 10/31/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Posterior fossa or midline tumors are often associated with hydrocephalus and primary tumor removal with or without perioperative placement of an external ventricular drain (EVD) is commonly accepted as first-line treatment. Shunting prior to posterior fossa surgery (PFS) is mostly reserved for symptomatic cases or special circumstances. There are limited data regarding the anticipated risk for symptomatic pneumocephalus and the perioperative management using the semi-sitting position (SSP) in such a scenario. Here, we therefore assessed the safety of performing PFS in a consecutive series of patients over a period of 15 years to allow the elaboration of recommendations for perioperative management. METHODS According to specific inclusion and exclusion criteria a total of 13 patients who underwent 17 operations was identified. Supratentorial pneumocephalus was evaluated with semiautomatic-volumetric segmentation. The volume of pneumocephalus was evaluated according to age and ventricular size. RESULTS Ten of the 13 patients had a programmable valve (preoperative valve setting range 6-14 cmH20; mean 7.5 cmH20) while 3 patients had non programmable valves. A variable amount of supratentorial air collection was evident in all patients postoperatively (range 3.2-331 ml; mean 122.32 ml). Positive predictors for the volume of postoperative pneumocephalus were higher age and a preoperative Evans ratio > 0.3. In our series, we encountered no cases of tension pneumocephalus necessitating an air replacement procedure as well as no obstruction, disconnection, infection or hardware malfunction of the shunt system. CONCLUSIONS Our findings indicate that a CSF shunt in situ is not a contraindication for performing PFS in the semi-sitting position and it does not increase the pre-existing risk for postoperative tension pneumocephalus. In cases of primary shunting for hydrocephalus associated with posterior fossa tumors a programmable valve set at a medium opening pressure with a gravitational device is a valid option when PFS in the semi-sitting position is opted. In patients with an indwelling shunt diversion system special caution is indicated in order to prevent and detect overdrainage especially in not adjustable valves or shunts without antisiphon devices.
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Resection of posterior fossa tumors in the semi-sitting position in children younger than 4 years of age. Childs Nerv Syst 2023; 39:159-167. [PMID: 36348035 PMCID: PMC9968679 DOI: 10.1007/s00381-022-05725-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/25/2022] [Indexed: 11/10/2022]
Abstract
PURPOSE The semi-sitting position for resection of posterior fossa tumors is a matter of ongoing debate. Here we report about our experience with this approach in children younger than 4 years of age. METHODS We retrospectively analyzed data of children younger than 4 years of age operated on in our institution in the semi-sitting position over a 15-year period. Patients were intraoperatively monitored for venous air embolism (VAE) by transthoracic Doppler (TTD) or transesophageal echocardiography (TEE). The severity of VAE was classified according to the Tübingen grading scale. Intraoperative incidents of VAE were recorded and the patients' course was followed postoperatively with a special focus on possible complications. RESULTS Twenty-four children (18 boys, 6 girls) were operated on in the semi-sitting position (26 operations). Mean age was 2.2 years (± 1.0), range between 0.4 and 3.9 years. External ventricular drains were inserted in 18 children with hydrocephalus preoperatively. VAE was detected in 6 instances during surgery (6/26 (23.1%)). In 3 patients with grade 1 VAE, no additional treatment was necessary. In one patient with grade 2 VAE, intracardiac air suction via the central venous catheter was performed, and in two patients with grade 4 VAE, additional cathecholamine-infusion was administered. No major intraoperative complications occurred. Postoperative CT images showed pneumocephalus in all children. In two children, small asymptomatic impression skull fractures at the site of the Mayfield pin occurred. Revision surgery was necessary in one child with a suboccipital CSF fistula. CONCLUSION The semi-sitting position for resection of tumors in the posterior fossa in children younger than 4 years of age can be safely performed in experienced centers taking special caution to detect and treat potential complications in an interdisciplinary setting.
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Al-Afif S, Elkayekh H, Omer M, Heissler HE, Scheinichen D, Palmaers T, Nakamura M, Hermann EJ, Samii M, Krauss JK. Analysis of risk factors for venous air embolism in the semisitting position and its impact on outcome in a consecutive series of 740 patients. J Neurosurg 2022; 137:258-265. [PMID: 34740183 DOI: 10.3171/2021.7.jns211107] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/01/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Routine use of the semisitting position, which offers several advantages, remains a matter of debate. Venous air embolism (VAE) is a potentially serious complication associated with the semisitting position. In this study, the authors aimed to investigate the safety of the semisitting position by analyzing data over a 20-year period. METHODS The incidence of VAE and its perioperative management were analyzed retrospectively in a consecutive series of 740 patients who underwent surgery between 1996 and 2016. The occurrence of VAE was defined by detection of bubbles on transthoracic Doppler echocardiography (TTDE) or transesophageal echocardiography (TEE) studies, a decrease of end-tidal CO2 (ETCO2) by 4 mm Hg or more, and/or an unexplained drop in systolic arterial blood pressure (≥ 10 mm Hg). From 1996 until 2013 TTDE was used, and from 2013 on TEE was used. The possible risk factors for VAE and its impact on surgical performance were analyzed. RESULTS There were 404 women and 336 men with a mean age at surgery of 49 years (range 1-87 years). Surgery was performed for infratentorial lesions in 709 patients (95.8%), supratentorial lesions in 17 (2.3%), and cervical lesions in 14 (1.9%). The most frequent pathology was vestibular schwannoma. TEE had a higher sensitivity than TTDE. While TEE detected VAE in 40.5% of patients, TTDE had a detection rate of 11.8%. Overall, VAE was detected in 119 patients (16.1%) intraoperatively. In all of these patients, VAE was apparent on TTDE or TEE. Of those, 23 patients also had a decrease of ETCO2, 18 had a drop in blood pressure, and 23 had combined decreases in ETCO2 and blood pressure. VAE was detected in 24% of patients during craniotomy before opening the dura mater, in 67% during tumor resection, and in 9% during wound closure. No risk factors were identified for the occurrence of VAE. Two patients had serious complications due to VAE. Surgical performance in vestibular schwannoma surgery was not affected by the presence of VAE. CONCLUSIONS This study shows that the semisitting position is overall safe and that VAE can be managed effectively. Persistent morbidity is very rare. The authors suggest that the semisitting position should continue to have a place in the standard armamentarium of neurological surgery.
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Affiliation(s)
- Shadi Al-Afif
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Hesham Elkayekh
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Mazin Omer
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Hans E Heissler
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Dirk Scheinichen
- 3Department of Anesthesiology and Intensive Care, Medical School Hannover, Germany; and
| | - Thomas Palmaers
- 3Department of Anesthesiology and Intensive Care, Medical School Hannover, Germany; and
| | - Makoto Nakamura
- 2Department of Neurosurgery, University of Witten/Herdecke, Cologne Merheim Medical Center, Cologne, Germany
| | - Elvis J Hermann
- 1Department of Neurosurgery, Medical School Hannover, Germany
| | - Madjid Samii
- 4International Neuroscience Institute, Hannover, Germany
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Wu X, Wang X, Song G, Li M, Hou C, Chen G, Guo H, Xiao X, Tang J, Lin Q, Bao Y, Liang J. The effects of different surgical positions (semi-sitting and lateral position) on the surgical outcomes of large vestibular schwannoma: study protocol for a randomized controlled trial. Trials 2022; 23:492. [PMID: 35701794 PMCID: PMC9194341 DOI: 10.1186/s13063-022-06437-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 05/29/2022] [Indexed: 11/18/2022] Open
Abstract
Background There is an ongoing discussion about the advantages and disadvantages of different surgical positions (semi-sitting and lateral position) for vestibular schwannoma surgery. Each position has its advantages, disadvantages, challenges, and risk profiles. The objectives of this study are to compare the effects of different surgical positions (semi-sitting and lateral position) on the outcomes of large vestibular schwannoma, primarily including effectiveness and safety. Methods In this single-centre, open, randomized controlled trial, we will recruit a total of 116 participants according to the inclusion and exclusion criteria who will be randomized to an experimental group or control group. Patients will undergo operations in semi-sitting and lateral positions. The primary endpoint will be the percentage of gross total resection. The secondary endpoints will include the facial nerve function, hearing preservation, surgical position placement time, time of operation (skin-to-skin surgical time), hospital stay, total hospitalization fee, and complications. The follow-up period will be at least 12 months, during which time patients will be evaluated both clinically and radiologically. Discussion This issue is still debated after 30 years since the first large comparative study was published in 1989, so the study will be useful. Therefore, more high-quality studies are required to compare clinical outcomes, complications, and other factors associated with these two positions. Trial registration Chinese Clinical Trial Registry ChiCTR1900027550. Registered on 17 November 2019
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Affiliation(s)
- Xiaolong Wu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Xu Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Gang Song
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Mingchu Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Chengbei Hou
- Centre for Evidence-Based Medicine, Xuanwu Hospital, Beijing, China
| | - Ge Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Hongchuan Guo
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Xinru Xiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Jie Tang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Qingtang Lin
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Yuhai Bao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,International Neuroscience Institute (China-INI), Beijing, China
| | - Jiantao Liang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China. .,International Neuroscience Institute (China-INI), Beijing, China.
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Lubnin AY. [Sitting position in neurosurgery: realizing the risks]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2022; 86:99-108. [PMID: 35758085 DOI: 10.17116/neiro20228603199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The author discusses potential intraoperative complications following neurosurgical interventions in sitting position: venous air embolism and paradoxical air embolism, postural hypotension, pneumocephalus, cervical flexion neuropathy, positional damage to peripheral nerves and others. Naturally, prevention of these complications is also considered, and the most effective approach is surgery in lying position.
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Affiliation(s)
- A Yu Lubnin
- Burdenko Neurosurgical Center, Moscow, Russia
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De Cassai A, Geraldini F, Zarantonello F, Sella N, Negro S, Andreatta G, Salvagno M, Boscolo A, Navalesi P, Munari M. A practical guide to patient position and complication management in neurosurgery: a systematic qualitative review. Br J Neurosurg 2021; 36:583-593. [PMID: 34726549 DOI: 10.1080/02688697.2021.1995593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE Adequate patient positioning is of paramount importance in neurosurgery. Complications related to the position are common and make up for more than 16% of the claims towards anaesthesiologists and neurosurgeons. This paper aims to provide the anaesthesiologist with a practical guide to avoid common pitfalls related to the patient positioning process. METHOD We performed a systematic review of the medical literature for the identification, screening, and inclusion of articles. The bibliographic search was conducted on June 1st, 2021 by two of the authors. In this review, we included articles indexed by MEDLINE, Cochrane Library, or Google Scholar. RESULTS We retrieved a total of 5706 unique papers from our initial search. However, after the initial screening, 5363 papers were removed is not related to our research leaving a total of 343 papers. We examined the full text of all the 343 articles including 68 of them in the final qualitative analysis. DISCUSSION In this review we examine the most common neurosurgical positions: supine, sitting, lateral, park-bench, prone, jack-knife, and knee-chest. For each of them, the proper positioning and related complications are described. Particular attention is given to the prevention and management of these complications, providing a practical guide for clinicians.
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Affiliation(s)
- Alessandro De Cassai
- Anesthesia and Intensive Care Unit, University-Hospital of Padova, Padova, Italy
| | - Federico Geraldini
- Anesthesia and Intensive Care Unit, University-Hospital of Padova, Padova, Italy
| | | | - Nicolò Sella
- UOC Anaesthesia and Intensive Care Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Sebastiano Negro
- UOC Anaesthesia and Intensive Care Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Giulio Andreatta
- UOC Anaesthesia and Intensive Care Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Michele Salvagno
- UOC Anaesthesia and Intensive Care Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Annalisa Boscolo
- Anesthesia and Intensive Care Unit, University-Hospital of Padova, Padova, Italy
| | - Paolo Navalesi
- UOC Anaesthesia and Intensive Care Unit, Department of Medicine-DIMED, University of Padua, Padua, Italy
| | - Marina Munari
- Anesthesia and Intensive Care Unit, University-Hospital of Padova, Padova, Italy
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Roser F, Maiti T, Elhammady MS. Endoscopic-assisted resection of vestibular schwannomas in high-riding jugular bulb. NEUROSURGICAL FOCUS: VIDEO 2021; 5:V4. [PMID: 36285241 PMCID: PMC9550009 DOI: 10.3171/2021.7.focvid2198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 07/22/2021] [Indexed: 06/16/2023]
Abstract
The present surgical video demonstrates safe opening of the internal auditory canal (IAC) during vestibular schwannoma surgery via a retrosigmoid approach in the sitting position. Resection of the intrameatal portion of a tumor is important for progression-free survival. Preoperative thin-sliced CT revealed a high-riding jugular bulb obscuring the trajectory. After dural opening, the IAC was approached anteriorly and superiorly. The posterior margin of IAC drilling was above the Tubingen line. Drilling was performed under continuous jugular compression. The vein was pushed down to augment visibility. An angled endoscope was helpful. IAC can be drilled safely in a high-riding jugular bulb with the technique mentioned in the video. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID2198.
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Affiliation(s)
- Florian Roser
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Tanmoy Maiti
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
| | - Mohamed Samy Elhammady
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic Abu Dhabi, United Arab Emirates
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14
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Tufegdzic B, Lamperti M, Siyam A, Roser F. Air-embolism in the semi-sitting position for craniotomy: A narrative review with emphasis on a single centers experience. Clin Neurol Neurosurg 2021; 209:106904. [PMID: 34482115 DOI: 10.1016/j.clineuro.2021.106904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/20/2021] [Accepted: 08/21/2021] [Indexed: 01/05/2023]
Abstract
Albeit the semi-sitting position in neurosurgery has been in use for several decades, its application remains controversial in the neurosurgical and neuro-anaesthesia communities. The imminent and most feared risk of the sitting position is air entry into the vascular system due to the negative intravascular pressure leading to potentially life-threatening air embolism with its consequences. Recent advents in neurosurgical (improvement of the operating microscope, employment of intra-operative neurophysiological monitoring) and neuro-anaesthesia care (new anaesthetics, advanced monitoring modalities) have significantly impacted the approach to these surgeries. Vigilant intra-operative observation by an experienced team and peri-operative patient management guided by institutional protocols improves the safety profile of these surgeries. This review outlines the workflow and protocols used in our institution for all cases of semi-sitting position for skull base neurosurgery.
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Affiliation(s)
- Boris Tufegdzic
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE.
| | - Massimo Lamperti
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Amira Siyam
- Anaesthesiology Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Florian Roser
- Neurological Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
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15
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Pristipino C, Germonpré P, Toni D, Sievert H, Meier B, D'Ascenzo F, Berti S, Onorato E, Bedogni F, Mas JL, Scacciatella P, Hildick-Smith D, Gaita F, Kyrle P, Thomson J, Derumeaux G, Sibbing D, Chessa M, Hornung M, Zamorano J, Dudek D. European position paper on the management of patients with patent foramen ovale. Part II - Decompression sickness, migraine, arterial deoxygenation syndromes and select high-risk clinical conditions. EUROINTERVENTION 2021; 17:e367-e375. [PMID: 33506796 PMCID: PMC9724983 DOI: 10.4244/eij-d-20-00785] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Patent foramen ovale (PFO) is implicated in the pathogenesis of a number of medical conditions but to date only one official position paper related to left circulation thromboembolism has been published. This interdisciplinary paper, prepared with the involvement of eight European scientific societies, reviews the available evidence and proposes a rationale for decision making for other PFO-related clinical conditions. In order to guarantee a strict evidence-based process, we used a modified grading of recommendations, assessment, development, and evaluation (GRADE) methodology. A critical qualitative and quantitative evaluation of diagnostic and therapeutic procedures was performed, including assessment of the risk/benefit ratio. The level of evidence and the strength of the position statements were weighed and graded according to predefined scales. Despite being based on limited and observational or low-certainty randomised data, a number of position statements were made to frame PFO management in different clinical settings, along with suggestions for new research avenues. This interdisciplinary position paper, recognising the low or very low certainty of existing evidence, provides the first approach to several PFO-related clinical scenarios beyond left circulation thromboembolism and strongly stresses the need for fresh high-quality evidence on these topics.
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Affiliation(s)
- Christian Pristipino
- San Filippo Neri - ASL Roma 1 Hospital, Via Alessandro Poerio 140, 00152 Rome, Italy
| | | | - Danilo Toni
- Hospital Policlinico Umberto I, Sapienza University, Rome, Italy
| | - Horst Sievert
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany,Anglia Ruskin University, Chelmsford, United Kingdom,University California San Francisco (UCSF), San Francisco, CA, USA
| | | | - Fabrizio D'Ascenzo
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Jean-Louis Mas
- Hôpital Sainte-Anne, Université Paris Descartes, Paris, France
| | | | - David Hildick-Smith
- Sussex Cardiac Centre, Brighton and Sussex University Hospitals, Brighton, United Kingdom
| | - Fiorenzo Gaita
- Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | | | | | | | - Dirk Sibbing
- Privatklinik Lauterbacher Mühle am Ostersee, Iffeldorf and Ludwig-Maximilians-Universität (LMU) München, Munich, Germany
| | - Massimo Chessa
- IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Marius Hornung
- CardioVascular Center Frankfurt (CVC Frankfurt), Frankfurt, Germany
| | | | - Dariusz Dudek
- Jagiellonian University Medical College, Krakow, Poland,Maria Cecilia Hospital, GVM Care & Research, Cotignola (RA), Italy
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16
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Basma J, Anagnostopoulos C, Tudose A, Harty M, Michael LM, Teo M, Porter DG. History, Variations, and Extensions of the Retrosigmoid Approach: Anatomical and Literature Review. J Neurol Surg B Skull Base 2021; 83:e324-e335. [DOI: 10.1055/s-0041-1729177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/27/2021] [Indexed: 10/20/2022] Open
Abstract
AbstractThe retrosigmoid approach is the workhorse for posterior fossa surgery. It gives a versatile corridor to tackle different types of lesions in and around the cerebellopontine angle. The term “extended” has been used interchangeably in the literature, sometimes creating confusion. Our aim was to present a thorough analysis of the approach, its history, and its potential extensions. Releasing cerebrospinal fluid from the subarachnoid spaces and meticulous microsurgical techniques allowed for the emergence of the retrosigmoid approach as a unilateral variation of the traditional suboccipital approach. Anatomical landmarks are helpful in localizing the venous sinuses and planning the craniotomy, and Rhoton's rule of three is the key to unlock difficult neurovascular relationships. Extensions of the approach include, among others, the transmastoid, supracerebellar, far-lateral, jugular foramen, and perimeatal approaches. The retrosigmoid approach applies to a broad range of pathologies and, with its extensions, can provide adequate exposure, obviating the need for extensive and complicated approaches.
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Affiliation(s)
- Jaafar Basma
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, United States
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - Christos Anagnostopoulos
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - Andrei Tudose
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - Mikhail Harty
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - L. Madison Michael
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee, United States
- Semmes-Murphey Clinic, Memphis, Tennessee, United States
| | - Mario Teo
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
| | - David G. Porter
- Department of Neurosurgery, Bristol Institute of Clinical Neuroscience, Southmead Hospital, Bristol, United Kingdom
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17
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Awake surgery in sitting position for chronic subdural hematoma. Acta Neurochir (Wien) 2021; 163:1857-1865. [PMID: 33464424 DOI: 10.1007/s00701-021-04704-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Chronic subdural hematoma (CSDH) is a common pathology in neurosurgery, especially in the elderly patients, and its incidence is likely to double in the next decade. Considering various features of CSDH and the procedure itself, a sitting position may retain the best characteristics of classic positioning, while offering additional comfort for both the patient and the surgeon. The aim of this study was to describe the technical aspects of this procedure in the sitting position, to evaluate safety and discuss the benefits and shortcomings of this modification. METHOD This study included a series of 55 patients surgically treated for CSDH in a sitting position at our department between December 2017 and September 2019, representing all the patients operated on during the study period by a single surgeon. Bilateral hematomas were present in 19 patients. Outcomes, during the 6-month follow-up period, were defined as good (CSDH and symptoms resolved) or poor (lethal outcome or reoccurrence). All complications were noted, with emphasis on pneumocephalus, and complications related to the sitting position: tension pneumocephalus, venous air embolism, and compression nerve injury. RESULTS Complications previously associated with the sitting position were not noted. The Glasgow Coma Scale and Markwalder Grading Scale scores improved significantly after the surgery (p < 0.001 and p = 0.018). Complications were noted in 17 patients (30.9%), and included 5 cerebrospinal fluid drainages, 3 hematoma reoccurrences, 2 wound infections, and 9 more single-occurring complications. The in-hospital mortality was 5.4% (3 out of 55 patients), while the overall mortality was 16.4% within the 6-month follow-up period. CONCLUSIONS In our series, even the severely ill patients tolerated the position well. No complications associated with the sitting position were noted. Future studies should confirm the safety of this position and evaluate the potential advantages for both the patient and the surgeon.
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18
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Baumgarten C, Aggad M, Kerdiles G, Amelot A. Massive cerebral venous air embolism promoting fatal subdural hematoma? Neurochirurgie 2021; 68:252-254. [PMID: 33915147 DOI: 10.1016/j.neuchi.2021.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/13/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022]
Affiliation(s)
- C Baumgarten
- Department of Neurosurgery, University Hospital of Grenoble, France.
| | - M Aggad
- Department of Neurosurgery, University Hospital of Tours, France
| | - G Kerdiles
- Department of Neurosurgery, University Hospital of Tours, France
| | - A Amelot
- Department of Neurosurgery, University Hospital of Tours, France
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19
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Eibl T, Hammer A, Yakubov E, Blechschmidt C, Kalisch A, Steiner HH. Medulloblastoma in adults - reviewing the literature from a surgeon's point of view. Aging (Albany NY) 2021; 13:3146-3160. [PMID: 33497354 PMCID: PMC7880386 DOI: 10.18632/aging.202568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 01/04/2021] [Indexed: 06/12/2023]
Abstract
Medulloblastoma is a common primary brain tumor in children but it is a rare cancer in adult patients. We reviewed the literature, searching PubMed for articles on this rare tumor entity, with a focus on tumor biology, advanced neurosurgical opportunities for safe tumor resection, and multimodal treatment options. Adult medulloblastoma occurs at a rate of 0.6 per one million people per year. There is a slight disparity between male and female patients, and patients with a fair skin tone are more likely to have a medulloblastoma. Patients present with cerebellar signs and signs of elevated intracranial pressure. Diagnostic efforts should consist of cerebral MRI and MRI of the spinal axis. Cerebrospinal fluid should be investigated to look for tumor dissemination. Medulloblastoma tumors can be classified as classic, desmoplastic, anaplastic, and large cell, according to the WHO tumor classification. Molecular subgroups include WNT, SHH, group 3, and group 4 tumors. Further molecular analyses suggest that there are several subgroups within the four existing subgroups, with significant differences in patient age, frequency of metastatic spread, and patient survival. As molecular markers have started to play an increasing role in determining treatment strategies and prognosis, their importance has increased rapidly. Treatment options include microsurgical tumor resection and radiotherapy and, in addition, chemotherapy that respects the tumor biology of individual patients offers targeted therapeutic approaches. For neurosurgeons, intraoperative imaging and tumor fluorescence may improve resection rates. Disseminated disease, residual tumor after surgery, lower radiation dose, and low Karnofsky performance status are all suggestive of a poor outcome. Extraneural spread occurs only in very few cases. The reported 5-year-survival rates range between 60% and 80% for all adult medulloblastoma patients.
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Affiliation(s)
- Thomas Eibl
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Alexander Hammer
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Eduard Yakubov
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Cristiane Blechschmidt
- Department of Neuropathology, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Alexander Kalisch
- Department of Oncology, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
| | - Hans-Herbert Steiner
- Department of Neurosurgery, Paracelsus Medical University, Nuremberg 90471, Bavaria, Germany
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20
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Machetanz K, Leuze F, Mounts K, Trakolis L, Gugel I, Grimm F, Tatagiba M, Naros G. Occurrence and management of postoperative pneumocephalus using the semi-sitting position in vestibular schwannoma surgery. Acta Neurochir (Wien) 2020; 162:2629-2636. [PMID: 32712719 PMCID: PMC7550361 DOI: 10.1007/s00701-020-04504-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/17/2020] [Indexed: 11/25/2022]
Abstract
Background The semi-sitting position in neurosurgical procedures is still under debate due to possible complications such as venous air embolism (VAE) or postoperative pneumocephalus (PP). Studies reporting a high frequency of the latter raise the question about the clinical relevance (i.e., the incidence of tension pneumocephalus) and the efficacy of a treatment by an air replacement procedure. Methods This retrospective study enrolled 540 patients harboring vestibular schwannomas who underwent posterior fossa surgery in a supine (n = 111) or semi-sitting (n = 429) position. The extent of the PP was evaluated by voxel-based volumetry (VBV) and related to clinical predictive factors (i.e., age, gender, position, duration of surgery, and tumor size). Results PP with a mean volume of 32 ± 33 ml (range: 0–179.1 ml) was detected in 517/540 (96%) patients. The semi-sitting position was associated with a significantly higher PP volume than the supine position (40.3 ± 33.0 ml [0–179.1] and 0.8 ± 1.4 [0–10.2], p < 0.001). Tension pneumocephalus was observed in only 14/429 (3.3%) of the semi-sitting cases, while no tension pneumocephalus occurred in the supine position. Positive predictors for PP were higher age, male gender, and longer surgery duration, while large (T4) tumor size was established as a negative predictor. Air exchange via a twist-drill was only necessary in 14 cases with an intracranial air volume > 60 ml. Air replacement procedures did not add any complications or prolong the ICU stay. Conclusion Although pneumocephalus is frequently observed following posterior fossa surgery in semi-sitting position, relevant clinical symptoms (i.e., a tension pneumocephalus) occur in only very few cases. These cases are well-treated by an air evacuation procedure. This study indicates that the risk of postoperative pneumocephalus is not a contraindication for semi-sitting positioning.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Felix Leuze
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Kristin Mounts
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Leonidas Trakolis
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Isabel Gugel
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Florian Grimm
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
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21
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Wang X, Li M, Liang J, Liu Q, Ma T, Chen G, Guo H, Song G, Ling F, Bao Y. Monitoring of intracranial venous sinus pressure and prevention for venous air embolism during operation with semi-sitting position. J Clin Neurosci 2020; 81:220-226. [DOI: 10.1016/j.jocn.2020.09.063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/22/2020] [Accepted: 09/28/2020] [Indexed: 10/23/2022]
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22
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Himes BT, Abcejo AS, Kerezoudis P, Bhargav AG, Trelstad-Andrist K, Maloney PR, Atkinson JLD, Meyer FB, Marsh WR, Bydon M. Outcomes in single-level posterior cervical spine surgeries performed in the sitting and prone positions. J Neurosurg Spine 2020; 33:667-673. [PMID: 32619981 DOI: 10.3171/2020.4.spine191323] [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: 11/04/2019] [Accepted: 04/20/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The sitting or semisitting position in neurosurgery allows for several technical advantages, including improved visualization of the surgical field. However, it has also been associated with an increased risk of venous air embolisms and positioning-related complications that limit its commonplace adoption. The authors report a large, single-center series of cervical spine procedures performed with patients in the sitting or prone position in order to assess the perceived risk of intraoperative and postoperative complications associated with the sitting position. METHODS Noninstrumented, single-level posterior cervical spine procedures performed with patients in the sitting/semisitting or prone position from 2000 to 2016 at a single institution were reviewed. Institutional abstraction tools (DataMart and Chart Plus) were used to collect data from the medical records. The two positions were compared with regard to preoperative factors, intraoperative variables, and postoperative outcomes. Multivariable logistic regression models were fitted for 30-day readmission, 30-day return to the operating room, and complication rates. RESULTS A total of 750 patients (sitting, n = 480; prone, n = 270) were analyzed. The median age was 53 years for those who underwent surgery in the prone position and 50 years for those who underwent surgery in the sitting position (IQRs 45-62 years and 43-60 years, respectively), and 35% of the patients were female. Sitting cases were associated with significantly longer anesthetic times (221 minutes [range 199-252 minutes] vs 205 minutes [range 179-254 minutes]) and operative times (126 minutes [range 101-163 minutes] vs 149 minutes [120-181 minutes]). Cardiorespiratory events in the postanesthesia care unit (PACU) were comparable between the two groups, with the exception of episodes of apnea (2.6% vs 0.6%, p = 0.041) and hypoventilation (4.4% vs 0.8%, p < 0.003), which were more frequent in the prone-position cohort. On multivariable analysis, the effect of the sitting versus the prone position was not significant for 30-day readmission (OR 0.77, 95% CI 0.34-1.71, p = 0.52) or reoperation (OR 0.71, 95% CI 0.31-1.60, p = 0.40). The sitting position was associated with lower odds of developing any complication (OR 0.31, 95% CI 0.16-0.62, p < 0.001). CONCLUSIONS Based on the intraoperative and postoperative complications chosen in this study, the sitting position confers a similar safety profile to the prone position. This can be explained by a more anatomic positioning accounting for reduced temporary neurological deficits and reduced PACU-associated hypoventilation noted in this series. Nevertheless, the findings may also reflect institutional familiarity, experience, and mastery of this position type, and outcomes may not reflect practices in general.
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Affiliation(s)
| | | | | | - Adip G Bhargav
- 3Mayo Clinic Alix School of Medicine, Rochester, Minnesota; and
| | | | - Patrick R Maloney
- Departments of1Neurologic Surgery and
- 460th Surgical Operations Squadron, David Grant USAF Medical Center, Fairfield, California
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Kurihara M, Nishimura S. Estimation of the head elevation angle that causes clinically important venous air embolism in a semi-sitting position for neurosurgery: a retrospective observational study. Fukushima J Med Sci 2020; 66:67-72. [PMID: 32507799 PMCID: PMC7470760 DOI: 10.5387/fms.2019-33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Introduction: The benefits of a sitting position for neurosurgery involving the posterior fossa remain controversial. The main concern is the risk of venous air embolism (VAE). A recent study showed that the rate of VAE was higher when the head was elevated to 45° than when it was elevated to 30°. However, the degree of head elevation that causes clinically important VAE is unclear. The purpose of this study was to estimate the head elevation angle at which the probability of VAE is 50% by using EtCO2 monitoring to detect of VAE. Methods: The anesthesia records of 23 patients who underwent neurosurgery in a sitting position were reviewed retrospectively. Intraoperative ventilation was set to maintain EtCO2 at approximately 38-42 mmHg. The head elevation angle in each case was determined from a photograph taken by the anesthesiologist or brain surgeon. Nineteen of the 23 cases had photographs available that contained a horizontal reference in the background. Seven cases were treated as VAE during the operation. Six of these cases met the criteria for VAE in this study. Data analysis was performed on a total of 18 patients. The angle between the line connecting the hip joint and the shoulder joint and the horizontal reference was obtained by ImageJ software. Logistic regression was performed using the Python programming language to determine the head elevation angle at which the probability of air embolism was 50%. Results: The decision boundary in the logistic regression was 35.7°. This head elevation angle was the boundary where the probability of VAE was 50%. Conclusion: The angle of head elevation that caused clinically important VAE was estimated to be 35.7°.
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Rahmani R, Susa ST, Sandwell SE, Kimmell KT, Maurer PK, Silberstein HJ, Nadler JW, Walter KA. Perioperative Risk of the Sitting Position for Elective Posterior Cervical Spine Surgery: A Retrospective Case Series. NEUROSURGERY OPEN 2020. [DOI: 10.1093/neuopn/okaa009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT
BACKGROUND
The sitting cervical position for elective posterior cervical decompression and fusion affords advantages over prone positioning, but remains unpopular due to concerns about venous air embolism (VAE).
OBJECTIVE
To demonstrate the safety and efficacy of sitting cervical surgery in our series and in the literature.
METHODS
To evaluate the incidence of complications, we retrospectively identified all adult patients who underwent elective sitting posterior cervical surgeries at our institution from 2009 to 2014. Using International Classification of Diseases-9 coding, we searched for incidences of air embolism, myocardial infarction, pulmonary embolism, and deep vein thrombosis. Operative time, estimated blood loss, and case type distribution were also recorded. We then calculated the incidence of clinically significant VAE in sitting cervical surgeries.
RESULTS
Between 2009 and 2014, 558 surgeries were performed in the sitting cervical position. No VAE was identified. The average operative time was 1 h 25 min. A total of 30-d perioperative complications among sitting position patients included 3 myocardial infarctions, 1 pulmonary embolism attributed to venous thrombosis, and 2 patients with deep venous thrombosis for a total cardiovascular complication rate of 1.1%. The incidence of clinically significant VAE in the literature is 1.5%.
CONCLUSION
We present the second largest case series to date on the sitting position for cervical surgeries, highlighting its safety and efficacy. This position provides a surgical field with superior visualization, allowing decreased operative time and blood loss. The risk of clinically significant VAE is low. Intraoperative monitoring for these events with less invasive means is safe and effective.
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Affiliation(s)
- Redi Rahmani
- Department of Neurosurgery, University of Rochester, Rochester, New York
| | - Stephen T Susa
- Department of Neurosurgery, University of Rochester, Rochester, New York
| | | | | | - Paul K Maurer
- Department of Neurosurgery, Unity Hospital, Rochester, New York
| | | | - Jacob W Nadler
- Department of Anesthesiology, University of Rochester, Rochester, New York
| | - Kevin A Walter
- Department of Neurosurgery, University of Rochester, Rochester, New York
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Intraoperative Management of Large Resuscitation-Associated Venous Air Embolism (VAE) for Emergent Neurological Surgery. Case Rep Anesthesiol 2020; 2020:8868037. [PMID: 32566316 PMCID: PMC7294353 DOI: 10.1155/2020/8868037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/19/2020] [Accepted: 05/22/2020] [Indexed: 11/17/2022] Open
Abstract
Venous air embolism (VAE) is a well-described phenomenon that may have life-threatening cardiopulmonary and neurological consequences. Accidental administration of air during resuscitation while using a rapid infuser is rare. Furthermore, there is a paucity of published data describing the intraoperative management of VAE during emergent nonseated neurological surgery. We report a 22-year-old previously healthy female who experienced a motor vehicle accident with severe facial and head trauma, and mixed subdural and epidural hematomas with an 8 mm midline shift. Computed tomography revealed significant air entrainment in the right heart and main pulmonary artery, with venous air tracking from the right axillary vein. Given her age, lack of preexisting cardiac comorbidities, hemodynamic stability, and critical cerebral herniation risk, further cardiac evaluation was deferred, and the patient was transferred to the operating room for emergent decompressive craniotomy. Intraoperatively, she experienced acute decrease in mean arterial pressure and end-expiratory carbon-dioxide with loss of pulse oximetry waveform concerning for obstructive VAE physiology. She was responsive to fluid resuscitation and epinephrine administration and did not experience any recurrence of obstructive VAE. This challenging case report describes positive neurologic and hemodynamic outcomes after resuscitation-associated VAE and cardiopulmonary collapse during emergency neurosurgery. Comprehensive evaluation of risk, urgency of procedure, and need for diagnostic monitoring and treatment should be personalized.
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Surgical approach to the posterior fossa in children, including anesthetic considerations and complications: The prone and the sitting position. Technical note. Neurochirurgie 2020; 67:46-51. [PMID: 32540342 DOI: 10.1016/j.neuchi.2020.04.128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 03/30/2020] [Accepted: 04/13/2020] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Medulloblastoma (MB) in children is, in most cases, a midline lesion located in the posterior fossa, with a high tendency to invade the fourth ventricle (and sometimes its floor). METHODS In this technical note, we present both the sitting and the prone position for children with medulloblastoma. These positions will be described together by deliberately deciding not to oppose one against the other. The park bench position, seldom used in pediatric neurosurgery is not described here. The latter procedure can be useful, however, for MB located more laterally or within the cerebellopontine angle. RESULTS The aim of this technical note is to provide the reader with a step by step procedure (from installation to closure), at least from the author's point of view. A special focus regarding anesthetic considerations is also provided. This anesthesia requires perfect coordination and communication between both the anesthetic and surgical teams. Complications of posterior fossa surgery are mentioned as well. Some of the advantages and disadvantages of each positions are mentioned. CONCLUSION Only careful installation, respect of certain surgical principles (careful attention of the vermis and dentate nuclei for example), knowledge of anatomy, closure and perioperative monitoring, screening and immediate correction of potentially devastating complications will enable surgeons to obtain the best results from their surgery.
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Ghali MGZ. Microsurgical techniques for achieving gross total resection of ependymomas of the fourth ventricle. Acta Chir Belg 2020; 120:149-166. [PMID: 32284025 DOI: 10.1080/00015458.2020.1711593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Ependymomas arising from the ventricular surface present a major challenge to achieving a complete operative extirpation when located in the fourth ventricle given the presence of significant adherence to the floor of the same. Overzealous dissection and removal of a tumor from this zone may precipitate potentially catastrophic neurological deficits attributable to cranial nucleopathies and cranial neuropathies. Consequently, the classic neurosurgical teaching has advised attempted gross total resection, leaving adherent residual in the floor of the fourth ventricle, in order to prevent the development of major cranial nucleopathies and cranial neuropathies. Following surgical tumoral extirpation, residual tumor is adjuvantly stereotactically irradiated. Authors have consequently developed novel neurophysiologically guided microsurgical techniques designed to remove adherent tumor from the fourth ventricular floor. These strategies have successfully and consistently facilitated gross total resection and improved clinical outcomes in patients harboring ependymomas of the fourth ventricle. We discuss and evaluate the innovation in microsurgical strategies developed to achieve complete operative extirpation of tumoral adherence to the floor of the fourth ventricle.
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Affiliation(s)
- Michael G. Z. Ghali
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, USA
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Averyanov DA, Lakotko RS, Shchyogolev AV, Svistov DV, Gayvoronsky AI. The impact of transesophageal echocardiography based protocol for management of adults in the sitting position on the incidence of clinically significant venous air embolism. RUSSIAN OPEN MEDICAL JOURNAL 2020. [DOI: 10.15275/rusomj.2020.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The purpose of the study was to evaluate the impact of transesophageal echocardiography (TEE) – based protocol for management of adults in the sitting position during elective neurosurgical interventions on the incidence of clinically significant venous air embolism (VAE). Material and Methods ― The study involved 155 adult neurosurgery patients (70 in prospective group and 85 in retrospective group). Surgery in both groups was done in the sitting position. In the prospective group TEE-based protocol was used. Retrospective group served as control. The primary endpoint was considered to be a decrease in the frequency of clinically significant VAE in the prospective group in comparison with the retrospective one. In the prospective group, VAE with Tuebingen grade 3-5 was considered clinically significant. The PFO incidence and severity and the effect of the number of episodes of VAE per case on its maximum severity during surgery were also analyzed. Any complication in the postoperative period believed to be associated with the position of the patient on the table during the surgery was recorded. Results ― The incidence of the clinically significant VAE in the retrospective group was 23.5% (95% CI 15-34) and was 16.4% higher than the frequency in the prospective group (chi-square=7.6197, df=1, p=0.005). 50% (95% CI 38-62) of patients in prospective group developed VAE during surgery. In 16 cases, the number of episodes was more than one. The number of episodes of VAE in the observation was reliably associated with the maximum severity of VAE during the observation (Z=4.11; p<0.001). A moderate strength relationship was determined between them (SomersDelta=0.43; 95% CI 0.17-0.7). Not a single case of paradoxical air embolism was detected in a series of observations. None of the patients has got a neurological deficit or cardiopulmonary complications associated with the position on the surgical table in the postoperative period. Pneumocephalus was found in 100% of cases on head computed tomography, which, however, did not need surgical treatment. PFO in the prospective group was detected in 62% (95% CI 52-73) of patients. In 25% (95% CI 16-35), shunting was significant. A large PFO without Valsalva maneuver was detected in 12.5% (95% CI 6-21) of cases. Conclusion ― The use of the TEE-based protocol for the management of adult patients in a sitting position during elective neurosurgical interventions can reduce the incidence of clinically significant VAE.
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Mavarez-Martinez A, Israelyan LA, Soghomonyan S, Fiorda-Diaz J, Sandhu G, Shimansky VN, Ammirati M, Palettas M, Lubnin AY, Bergese SD. The Effects of Patient Positioning on the Outcome During Posterior Cranial Fossa and Pineal Region Surgery. Front Surg 2020; 7:9. [PMID: 32232048 PMCID: PMC7082226 DOI: 10.3389/fsurg.2020.00009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Accepted: 02/24/2020] [Indexed: 01/05/2023] Open
Abstract
Background: Surgery on posterior cranial fossa (PCF) and pineal region (PR) carries the risks of intraoperative trauma to the brainstem structures, blood loss, venous air embolism (VAE), cardiovascular instability, and other complications. Success in surgery, among other factors, depends on selecting the optimal patient position. Our objective was to find associations between patient positioning, incidence of intraoperative complications, neurological recovery, and the extent of surgery. Methods: This observational study was conducted in two medical centers: The Ohio State University Wexner Medical Center (USA) and The Burdenko Neurosurgical Institute (Russian Federation). Patients were distributed in two groups based on the surgical position: sitting position (SP) or horizontal position (HP). The inclusion criteria were adult patients with space-occupying or vascular lesions requiring an open PCF or PR surgery. Perioperative variables were recorded and summarized using descriptive statistics. The post-treatment survival, functional outcome, and patient satisfaction were assessed at 3 months. Results: A total of 109 patients were included in the study: 53 in SP and 56 in HP. A higher proportion of patients in the HP patients had >300 mL intraoperative blood loss compared to the SP group (32 vs. 13%; p = 0.0250). Intraoperative VAE was diagnosed in 40% of SP patients vs. 0% in the HP group (p < 0.0001). However, trans-esophageal echocardiographic (TEE) monitoring was more common in the SP group. Intraoperative hypotension was documented in 28% of SP patients compared to 9% in HP group (p = 0.0126). A higher proportion of SP patients experienced a new neurological symptom compared to the HP group (49 vs. 29%; p = 0.0281). The extent of tumor resection, postoperative 3-months survival, functional outcome, and patient satisfaction were not different in the groups. Conclusions: The SP was associated with, less intraoperative bleeding, increased intraoperative hypotension, VAE, and postoperative neurological deficit. More HP patients experienced macroglossia and increased blood loss. At 3 months, there was no difference of parameters between the two groups. Clinical Trial Registration:ClinicalTrials.gov: registration number NCT03364283.
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Affiliation(s)
- Ana Mavarez-Martinez
- Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY, United States
| | - Lusine A Israelyan
- Department of Anesthesiology, Burdenko Neurosurgical Institute, Moscow, Russia
| | - Suren Soghomonyan
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Juan Fiorda-Diaz
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Gurneet Sandhu
- Department of Anesthesiology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Vadim N Shimansky
- Department of Posterior Cranial Fossa and Scull Base Surgery, Burdenko Neurosurgical Institute, Moscow, Russia
| | - Mario Ammirati
- Department of Neurological Surgery, Mercy Health St. Rita Medical Center, Lima, OH, United States.,Department of Biology, College of Science and Technology, Sbarro Health Organization, Temple University, Philadelphia, PA, United States
| | - Marilly Palettas
- Center for Biostatistics, The Ohio State University, Columbus, OH, United States
| | - Andrei Yu Lubnin
- Department of Anesthesiology, Burdenko Neurosurgical Institute, Moscow, Russia
| | - Sergio D Bergese
- Department of Anesthesiology, Stony Brook Medicine, Stony Brook, NY, United States
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Urgent Repositioning After Venous Air Embolism During Intracranial Surgery in the Seated Position: A Case Series. J Neurosurg Anesthesiol 2020; 31:413-421. [PMID: 30148744 DOI: 10.1097/ana.0000000000000534] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Venous air embolism (VAE) is a well-described complication of neurosurgical procedures performed in the seated position. Although most often clinically insignificant, VAE may result in hemodynamic or neurological compromise resulting in urgent change to a level position. The incidence, intraoperative course, and outcome in such patients are provided in this large retrospective study. METHODS Patients undergoing a neurosurgical procedure in the seated position at a single institution between January 2000 and October 2013 were identified. Corresponding medical records, neurosurgical operative reports, and computerized anesthetic records were searched for intraoperative VAE diagnosis. Extreme VAE was defined as a case in which urgent seated to level position change was performed for patient safety. Detailed examples of extreme VAE cases are described, including their intraoperative course, VAE management, and postoperative outcomes. RESULTS There were 8 extreme VAE (0.47% incidence), 6 during suboccipital craniotomy (1.5%) and 2 during deep brain stimulator implantation (0.6%). VAE-associated end-expired CO2 and mean arterial pressure reductions rapidly normalized following position change. No new neurological deficits or cardiac events associated with extreme VAE were observed. In 5 of 8, surgery was completed. Central venous catheter placement and aspiration during VAE played no demonstrable role in patient outcome. CONCLUSIONS Extreme VAE during seated intracranial neurosurgical procedures is infrequent. Extreme VAE-associated CO2 exchange and hemodynamic consequences from VAE were transient, recovering quickly back to baseline without significant neurological or cardiopulmonary morbidity.
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Fernandez-Garcia C, Alonso-Frech F, Monje MHG, Matias-Guiu J. Role of deep brain stimulation therapy in the magnetic resonance-guided high-frequency focused ultrasound era: current situation and future prospects. Expert Rev Neurother 2019; 20:7-21. [PMID: 31623494 DOI: 10.1080/14737175.2020.1677465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Deep brain stimulation (DBS) is a well-established treatment of movement disorders; but recently there has been an increasing trend toward the ablative procedure magnetic resonance-guided focused ultrasound (MRgFU). DBS is an efficient neuromodulatory technique but associated with surgical complications. MRIgFUS is an incision-free method that allows thermal lesioning, with fewer surgical complications but irreversible effects.Areas covered: We look at current and prospective aspects of both techniques. In DBS, appropriate patient selection, improvement in surgical expertise, target accuracy (preoperative and intraoperative imaging), neurophysiological recordings, and novel segmented leads need to be considered. However, increased number of older patients with higher comorbidities and risk of DBS complications (mainly intracranial hemorrhage, but also infections, hardware complications) make them not eligible for surgery. With MRgFUS, hemorrhage risks are virtually nonexistent, infection or hardware malfunction are eliminated, while irreversible side effects can appear.Expert commentary: Comparison of the efficacy and risks associated with these techniques, in combination with a growing aged population in developed countries with higher comorbidities and a preference for less invasive treatments, necessitates a review of the indications for movement disorders and the most appropriate treatment modalities.
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Affiliation(s)
- C Fernandez-Garcia
- Department of Neurosurgery, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Madrid, Spain.,Medicine Department, Universidad Complutense, Madrid, Spain
| | - F Alonso-Frech
- Department of Neurology, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Universidad Complutense, Madrid, Spain.,HM CINAC, Hospital Universitario HM Puerta del Sur, Universidad CEU-San Pablo, Móstoles, Madrid, Spain
| | - M H G Monje
- HM CINAC, Hospital Universitario HM Puerta del Sur, Universidad CEU-San Pablo, Móstoles, Madrid, Spain
| | - J Matias-Guiu
- Medicine Department, Universidad Complutense, Madrid, Spain.,Department of Neurology, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Universidad Complutense, Madrid, Spain
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Karacaer F. Posterior fossa cerrahisinde anestezi yönetimi. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.510832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Baro V, Lavezzo R, Marton E, Longatti P, Landi A, Denaro L, d'Avella D. Prone versus sitting position in pediatric low-grade posterior fossa tumors. Childs Nerv Syst 2019; 35:421-428. [PMID: 30610475 DOI: 10.1007/s00381-018-04031-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 12/17/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The choice between sitting and prone position to access the infratentorial space in a suboccipital craniotomy is still a matter of debate. The comparisons in terms of complications and outcome of both positions are scarce, and the pediatric population is indeed more infrequent in these in scientific reviews. In this paper, we assess intraoperative and postoperative complications and neurological outcome in pediatric patients undergoing posterior cranial fossa surgery for pilocytic astrocytoma in sitting and prone position respectively. METHODS We retrospectively analyzed 30 consecutive patients undergoing surgery for cerebellar pilocytic astrocytoma at the two neurosurgical units referring to the University of Padova Medical School from 1999 to 2017. Preoperative, intraoperative, and postoperative data were retrieved from our medical archives. RESULTS The statistical analysis did not show any differences between the two groups in terms of preoperative, intraoperative, and postoperative data. The neurological status at last follow-up was similar in both groups of patients. CONCLUSIONS Our results suggest that both sitting and prone position can be considered safe in suboccipital craniotomies. Further studies are needed to show if there are possible differences between these positions for other frequent pediatric tumors such as medulloblastomas and ependymomas.
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Affiliation(s)
- Valentina Baro
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy.
| | - Riccardo Lavezzo
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy
| | - Elisabetta Marton
- Department of Neurosurgery, Treviso Hospital, University of Padova Medical School, Via Piazzale 1, 31100, Treviso, Padova, Italy
| | - Pierluigi Longatti
- Department of Neurosurgery, Treviso Hospital, University of Padova Medical School, Via Piazzale 1, 31100, Treviso, Padova, Italy
| | - Andrea Landi
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy
| | - Luca Denaro
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy
| | - Domenico d'Avella
- Academic Neurosurgery, Department of Neurosciences, University of Padova Medical School, via Giustiniani 5, 35100, Padova, Italy
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Golub D, Mehan ND, Kwan K, Salas SJ, Schulder M. Supracerebellar Transtentorial Approach for Occipital Meningioma to Maximize Visual Preservation: Technical Note. Oper Neurosurg (Hagerstown) 2018; 17:E177-E183. [DOI: 10.1093/ons/opy380] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 11/18/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND AND IMPORTANCE
Surgery for resection of tentorial meningiomas compressing primary visual cortex carries a significant risk of worsening vision. This concern is especially acute in patients with a preexisting visual deficit. Approaches that involve mechanical retraction of the occipital lobe further threaten visual function. The supracerebellar transtentorial (SCTT) approach, which does not carry a risk of occipital retraction injury, should be considered for patients with occipital tentorial meningiomas to maximize functional visual outcomes.
CLINICAL PRESENTATION
A 54-yr-old woman underwent 2 resections and radiation therapy for a right occipital oligodendroglioma as a teenager. She was left with a complete left homonymous hemianopsia. The patient now presented with progressive vision loss in her remaining right visual field. Imaging revealed a left occipital superiorly projecting tentorial meningioma. To preserve her remaining visual function the SCTT approach was chosen for resection. A Simpson grade 1 removal was achieved without disrupting the occipital lobe pia or requiring mechanical cerebellar retraction. A diagnosis of a WHO grade II meningioma (presumably radiation induced) was made. The patient's vision returned to premorbid baseline 1 wk after surgery.
CONCLUSION
The SCTT approach should be considered for the surgical management of patients with occipital tentorial meningiomas when visual preservation is at risk. This approach avoids transgression of visual cortex and minimizes the risk of venous infarction or contusions from retraction injury.
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Affiliation(s)
- Danielle Golub
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
- Department of Neurosurgery, Department of Neurology, New York University School of Medicine, New York, New York
| | - Neal D Mehan
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Kevin Kwan
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
| | - Sussan J Salas
- Department of Neurosurgery, Henry Ford Hospital System, Detroit, Michigan
| | - Michael Schulder
- Department of Neurosurgery, North Shore University Hospital, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York
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Sachkova A, Schemmerling T, Goldberg M, Solomiichuk V, Rohde V, von Eckardstein KL, Schatlo B. Predictors of ventricular tension pneumocephalus after posterior fossa surgery in the sitting position. Acta Neurochir (Wien) 2018; 160:525-538. [PMID: 29307024 DOI: 10.1007/s00701-017-3444-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 12/21/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Ventricular pneumocephalus is a rare but potentially life-threatening complication of cranial surgery in the sitting position. OBJECTIVE The objective of the study is to assess the incidence and risk factors of postoperative ventricular pneumocephalus. METHODS We performed a retrospective chart review of 307 consecutive patients (147 men, 160 women) treated at our institution by intracranial surgery in the sitting position from January 2010 to October 2014. Ventricular air entrapment with lack of arousal or neurologic deterioration requiring external ventriculostomy (EVD) was defined as ventricular tension pneumocephalus (VTP). Demographic variables were recorded along with radiological and clinical data. The occurrence of pneumocephalus was correlated with patient-related and surgical variables. RESULTS VTP was observed in 12 cases (3.9%). These patients had higher intraventricular air volumes (48.5 cm3 (CI 95% [29.06-67.86])) compared to asymptomatic patients (7.4 cm3 (CI 95% [5.43-9.48])). Opening of the fourth ventricle was the most potent predictor of VTP (OR = 34.7, CI 95% [4.4-273.5], p = 0.001). In patients undergoing no additional treatment for pneumocephalus, ventricular air volume declined to an average of 41.7% of the initial postoperative volume on postoperative day 3. CONCLUSIONS Entrapment of intracranial and particularly ventricular air requiring emergent EVD occurred in 3.9% cases of intracranial surgery in the sitting position. Especially the opening of the fourth ventricle was associated with the development of VTP, which should warrant particularly diligent postoperative observation of these patients. In cases without neurological symptoms, the rate of spontaneous air resorption is sufficiently high to warrant expectant management.
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Patent Foramen Ovale and Elective Posterior Fossa Craniotomy in the Park-bench Position: How Should We Proceed? J Neurosurg Anesthesiol 2017; 31:263-264. [PMID: 29252688 DOI: 10.1097/ana.0000000000000482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rosahl S, Bohr C, Lell M, Hamm K, Iro H. Diagnostics and therapy of vestibular schwannomas - an interdisciplinary challenge. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2017; 16:Doc03. [PMID: 29279723 PMCID: PMC5738934 DOI: 10.3205/cto000142] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Vestibular schwannomas (VS) expand slowly in the internal auditory canal, in the cerebellopontine angle, inside the cochlear and the labyrinth. Larger tumors can displace and compress the brainstem. With an annual incidence of 1:100,000 vestibular schwannoma represent 6-7% of all intracranial tumors. In the cerebellopontine angle they are by far the most neoplasm with 90% of all lesions located in this region. Magnetic resonance imaging (MRI), audiometry, and vestibular diagnostics are the mainstays of the clinical workup for patients harboring tumors. The first part of this paper delivers an overview of tumor stages, the most common grading scales for facial nerve function and hearing as well as a short introduction to the examination of vestibular function. Upholding or improving quality of life is the central concern in counseling and treating a patient with vestibular schwannoma. Preservation of neuronal function is essential and the management options - watchful waiting, microsurgery and stereotactic radiation - should be custom-tailored to the individual situation of the patient. Continuing interdisciplinary exchange is important to monitor treatment quality and to improve treatment results. Recently, several articles and reviews have been published on the topic of vestibular schwannoma. On the occasion of the 88th annual meeting of the German Society of Oto-Rhino-Laryngology, Head and Neck surgery a special volume of the journal "HNO" will be printed. Hence this presentation has been designed to deviate from the traditional standard which commonly consists of a pure literature review. The current paper was conceptually woven around a series of interdisciplinary cases that outline examples for every stage of the disease that show characteristic results for management options to date. Systematic clinical decision pathways have been deduced from our experience and from results reported in the literature. These pathways are graphically outlined after the case presentations. Important criteria for decision making are size and growth rate of the tumor, hearing of the patient and the probability of total tumor resection with preservation of hearing and facial nerve function, age and comorbidity of the patient, best possible control of vertigo and tinnitus and last but not least the patient's preference and choice. In addition to this, the experience and the results of a given center with each treatment modality will figure in the decision making process. We will discuss findings that are reported in the literature regarding facial nerve function, hearing, vertigo, tinnitus, and headache and reflect on recent studies on their influence on the patient's quality of life. Vertigo plays an essential role in this framework since it is an independent predictor of quality of life and a patient's dependence on social welfare. Pathognomonic bilateral vestibular schwannomas that occur in patients suffering from neurofibromatosis typ-2 (NF2) differ from spontaneous unilateral tumors in their biologic behavior. Treatment of neurofibromatosis type-2 patients requires a multidisciplinary team, especially because of the multitude of separate intracranial and spinal lesions. Off-label chemotherapy with Bevacizumab can stabilize tumor size of vestibular schwannomas and even improve hearing over longer periods of time. Hearing rehabilitation in NF2 patients can be achieved with cochlear and auditory brainstem implants.
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Affiliation(s)
- Steffen Rosahl
- Department of Neurosurgery, Helios Hospital of Erfurt, Germany
| | - Christopher Bohr
- Department of Otolaryngology, University Hospital of Erlangen, Germany
| | - Michael Lell
- Institute for Radiology and Nuclear Medicine, Hospital of Nuremberg, Germany
| | - Klaus Hamm
- Cyberknife Center of Central Germany, Erfurt, Germany
| | - Heinrich Iro
- Department of Neurosurgery, Helios Hospital of Erfurt, Germany
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Han Y, Ma XL, Hu YC, Miao J, Zhang JD, Bai JQ, Xia Q. Circumferential Reconstruction of Subaxial Cervical and Cervicothoracic Spine by Simultaneously Combined Anterior-posterior Approaches in the Sitting Position. Orthop Surg 2017; 9:263-270. [PMID: 28960819 DOI: 10.1111/os.12341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Accepted: 02/19/2017] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To introduce and analyze the feasibility of a new surgical strategy for circumferential reconstruction of subaxial cervical and cervicothoracic spine by simultaneously combined anterior-posterior approach in the sitting position. METHODS A retrospective review was performed for seven patients who underwent the above surgical procedure between July 2011 and January 2015. Among the seven patients, there were six men and one woman, with an average age of 52 years (range, 36-79 years). Six patients were confirmed to have a lower subaxial cervical fracture and dislocation with a locked facet joint, and the other patient had an invasive tumor involving both anterior and posterior parts of vertebrae and lamina, detected by radiological examination. The levels involved for all patients were from C4 to T2 . According to American Spinal Injury Association (ASIA) classification, one case was class A, four were class B, and two were class D. The patients were restricted in the sitting position with traction and a halo in extension to immobilize the head during the operation. The simultaneously combined anterior-posterior operation for reduction, decompression or tumor resection and circumferential reconstruction was carried out. RESULTS Both anterior and posterior procedures were successfully completed simultaneously in the sitting position in all cases. There were no perioperative complications. The average operative time was 175 ± 32 min (range, 120-240 min), and the mean blood loss was 430 ± 85 mL (range, 200-1100 mL). The patients were followed up for 35.8 months (range, 18-60 months). The symptom of neck pain improved distinctly and no evidence of implant failure was noted in any patients. Neurological status improvement was confirmed in six patients, who had suffered incomplete paralysis. The ASIA grade improved in five patients, and two cases had no change in grade. CONCLUSIONS The "sitting position" simultaneously combined anterior-posterior approach is safe and is superior to the traditional prone position and supine position, and the surgical results are satisfactory.
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Affiliation(s)
- Yue Han
- Department of Spine Surgery, Tianjin Hospital, Tianjin, China
| | - Xin-Long Ma
- Department of Spine Surgery, Tianjin Hospital, Tianjin, China
| | - Yong-Cheng Hu
- Department of Spine Surgery, Tianjin Hospital, Tianjin, China
| | - Jun Miao
- Department of Spine Surgery, Tianjin Hospital, Tianjin, China
| | - Ji-Dong Zhang
- Department of Spine Surgery, Tianjin Hospital, Tianjin, China
| | - Jian-Qiang Bai
- Department of Spine Surgery, Tianjin Hospital, Tianjin, China
| | - Qun Xia
- Affiliated Hospital of Logistics University of People's Armed Police, Tianjin, China
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Malik N, Claus PL, Illman JE, Kligerman SJ, Moynagh MR, Levin DL, Woodrum DA, Arani A, Arunachalam SP, Araoz PA. Air embolism: diagnosis and management. Future Cardiol 2017. [DOI: 10.2217/fca-2017-0015] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Air embolism is an uncommon, but potentially life-threatening event for which prompt diagnosis and management can result in significantly improved patient outcomes. Most air emboli are iatrogenic. Arterial air emboli may occur as a complication from lung biopsy, arterial catheterization or cardiopulmonary bypass. Immediate management includes placing the patient on high-flow oxygen and in the right lateral decubitus position. Venous air emboli may occur during pressurized venous infusions, or catheter manipulation. Immediate management includes placement of the patient on high-flow oxygen and in the left lateral decubitus and/or Trendelenburg position. Hyperbaric oxygen therapy is the definitive treatment which may decrease the size of air emboli by facilitating gas reabsorption, while also improving tissue oxygenation and reducing ischemic reperfusion injury.
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Affiliation(s)
- Neera Malik
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55902, USA
| | - Paul L Claus
- Department of Hyperbaric & Altitude Medicine, Mayo Clinic, 200 1st St SW, Rochester, MN 55905, USA
| | - Jeffery E Illman
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55902, USA
| | - Seth J Kligerman
- Department of Radiology & Nuclear Medicine, University of Maryland School of Medicine, 655 W Baltimore Street, Baltimore, MD 21201, USA
| | - Michael R Moynagh
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55902, USA
| | - David L Levin
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55902, USA
| | - David A Woodrum
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55902, USA
| | - Arvin Arani
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55902, USA
| | | | - Philip A Araoz
- Department of Radiology, Mayo Clinic, 200 1st St SW, Rochester, MN 55902, USA
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