Prevention of subdural fluid collections following transcortical intraventricular and/or paraventricular procedures by using fibrin adhesive

Transcallosal approach and post-operative subdural collections: 12-year paediatric neurosurgery tertiary centre experience

INTRODUCTION

Following transcallosal surgery for tumour resection, the formation of convexity or interhemispheric subdural cerebrospinal fluid collections may lead to clinical deterioration and may influence decision-making with regards to additional interventions. The aim of this study was to determine the incidence, risk factors, and management of subdural collections following the transcallosal approach in a paediatric cohort.

METHODS

A retrospective case note and radiological review of all children who underwent transcallosal surgery for intraventricular and thalamic tumours was carried out covering a 12-year period (2012-2023) in a single-centre tertiary paediatric neurosurgery unit. Parameters including demographics and clinical information including lesion location, pathology, extent of resection, need for and type of shunt required, as well as depth, laterality, and location of the collection were analysed prior to shunting, and at approximately 3 weeks, 3 months, and latest follow-up available post-operatively in order to further elucidate the natural history of these subdural collections and their clinical significance.

RESULTS

Sixty-four cases satisfied the inclusion criteria of transcallosal surgery for tumour resection; 13 did not have adequate post-operative imaging and were excluded. Of the remaining 51 cases, there were 32 children (63%) with post-operative CSF subdural collections, of which 59% were ipsilateral, with the remainder showing bilateral distribution. The overall shunt insertion rate was 25.5% (12 ventriculoperitoneal and 1 subdural-peritoneal shunt) at 3 months, with a mean time to shunting of 19 days post-operatively. Children who developed post-operative subdural collections had a higher rate of shunting, at 37.5%, compared to 5.2% in those who did not. Pre- and post-operative hydrocephalus and subtotal resection were identified as risk factors for development of subdural collections post-operatively. Subdural collections showed a natural course of reduction and regression over follow-up, with the exception of 3 children where they persisted or increased over time; although none of these required shunting. Those children who underwent shunt insertion showed greater regression in the size of the subdural collection over time compared to the non-shunted group.

CONCLUSION

In this paediatric cohort, 25.5 % of children required insertion of a shunt by 3 months following transcallosal surgery. Pre- and post-operative hydrocephalus and subtotal tumour resection were risk factors for development of subdural collections post-operatively.

Subdural collection after transcortical approach for pediatric brain tumors; avoidance, consequence and solutions

Introduction

Subdural collections, following brain surgeries in pediatrics, are common and unfortunately not always easily treated; especially in huge parenchymal tumors, intraventricular tumors and paraventricular tumors. Different approaches for prevention and treatment of theses subdural collections have been discussed by several studies, but till now no solid consensus has been reached. One of these approaches is to approximate incised cortical edges by suturing the pia, use of fibrin adhesive glue and subsequent Ringer inflation. The aim of our study is to avoid cortical mantle collapse and to prevent the development of progressive pressurizing subdural fluid collections.

Patients and methods

This study included 12 pediatric cases operated for large sized brain tumors between 2014 and 2019, in the department of Pediatric Neurosurgery at Alexandria University. All cases were operated via transcortical approach. Patients were followed prospectively for postoperative complications including postoperative subdural collections. In all patients, gel foam and fibrin glue on the cortical and ependymal edges, with suture approximation of the cortical edges and subsequent Ringer lactate inflation in the residual cavity were routinely done.

Results

With the consecutive follow-up images, six cases (50%) showed persistent subdural collection following tumor resection. Three cases had 5–6 mm asymptomatic subdural collection thickness that resolved within 3 to 6 months, and the rest three cases showed more than 7 mm thickness subdural collection. In these 3/12 (25%) cases patients had symptomatic and progressive increase in the subdural fluid collections. A subdural-peritoneal shunt was necessary only for 1 patient (8%). After finishing his adjuvant therapy, it was possible to remove the subdural-peritoneal shunt. While in the other 2 patients, the subdural collection was managed surgically with just a burr hole evacuation. The clinical manifestations resolved postoperatively but complete resolution of these 2 subdural collections occurred within 7 and 9 months.

Conclusion

The use of sutures and fibrin adhesive to seal surgical defects with inflation of the residual cavity with Ringer lactate solution might decrease the development of subdural fluid collections, through avoiding the cortical mantle collapse.

Cerebrospinal fluid disturbances after transcallosal surgery: incidence and predictive factors

OBJECTIVE

CSF dynamics after transcallosal resection of intraventricular lesions can be altered, and the need for shunt implantation complicates the management of these patients. Because the pathophysiological mechanism and contributing factors are poorly understood and the incidence has largely not been described, the authors conducted a study to elucidate these factors.

METHODS

The authors retrospectively reviewed data from patients who had been operated on at their institution via a transcallosal approach between March 2002 and December 2016. They evaluated the need for a shunt implantation up to 3 months after surgery by assessing clinical variables. These variables were age at surgery, the need for perioperative external CSF drainage, histology of the lesion, and the following radiological parameters: pre- and postoperative Evans index, maximal postoperative extension of subdural effusions (SDEs) measured on axial images, and maximal interhemispheric fissure (IHF) width measured on coronal images assessed at 4 different points in time (preoperatively, day 1, days 2-4, and days 4-8 after surgery). To identify potential risk factors, univariate and multivariate regression models were constructed. Receiver operating characteristic (ROC) curves for significant predictors, as well as the area under the curve (AUC), were calculated.

RESULTS

Seventy-four patients (40 female and 34 male) were identified; their median age at surgery was 17.6 years (range 4 months to 76 years). Shunt implantation was necessary in 13 patients (ventriculoperitoneal [VP] shunt, n = 7; subdural peritoneal [SDP] shunt, n = 6) after a median interval of 24 days (range 10 days to 3 months). Univariate logistic regression models revealed a significant effect of IHF width on days 4-8 (OR 1.31, 95% CI 1.03-1.66; p = 0.027), extension of SDE on days 2-4 (OR 1.33, 95% CI 1.11-1 0.60; p = 0.003), and age (OR 0.932, 95% CI 0.88-0.99; p = 0.02). In the multiple regression model, the effect of the independent variable extension of the SDE remained significant. ROC curves for the predictors IHF width on days 4-8 and extension of SDE on days 2-4 revealed an AUC equal to 0.732 and 0.752, respectively. Before shunt implantation, the ventricles were smaller compared to the preoperative size in 9 of the 13 patients (SDP shunt, n = 5; VP shunt, n = 4).

CONCLUSIONS

The rate of shunt-dependent hydrocephalus 3 months after surgery in this heterogeneous group of patients was 17.6% (95% CI 9.7%-28.2%). The authors identified as predictive factors the variables extension of the convexity space, IHF 1 week after surgery, and younger age.

Clinical characteristics of and treatment protocol for trapped temporal horn following resection of lateral ventricular trigone meningioma: a single-center experience

OBJECTIVE

Trapped temporal horn (TTH) is a rare subtype of loculated hydrocephalus that is often managed surgically. The natural history of TTH is not well understood, and there are few data on the outcomes of conservative management of this condition. The aim of this study was to analyze the clinical features and outcomes of conservatively and surgically managed cases of TTH.

METHODS

The authors retrospectively reviewed the clinical data for 19 consecutive cases of TTH that developed after microsurgical resection of lateral ventricular trigone meningioma between 2011 and 2015.

RESULTS

The 19 cases involved 6 male and 13 female patients (mean age [± SD] 39.9 ± 13.8 years). The mean time interval from tumor resection to onset of TTH was 3.2 ± 3.0 months (range 3 days-10 months). Symptoms of intracranial hypertension were the most common complaints at presentation. The mean Karnofsky Performance Scale (KPS) score at onset was 52.1 ± 33.3 (range 10-90). Midline shift was observed in 15 cases (78.9%), and the mean amount of midline shift was 6.0 ± 4.8 mm (range 0-15 mm). Eleven cases (57.9%) were managed with surgical intervention, while 8 cases (42.1%) were managed conservatively. All patients (100%) showed improved clinical status over the course of 4.8 ± 1.0 years (range 2.8-6.3 years) of follow-up. The mean KPS score at last follow-up was 87.9 ± 11.3 (range 60-100). Eighteen patients (94.7%) showed signs of radiographic improvement, and 1 patient (5.3%) exhibited stable size of the temporal horn. Significant differences were observed between the surgical and nonsurgical cohorts for the following variables: KPS score at onset, presence of intracranial hypertension, and midline shift. The mean KPS score at onset was greater (better) in the nonsurgical group than in the surgical group (82.5 ± 8.9 vs 30 ± 25.7, p = 0.001). A greater proportion of patients in the surgical group presented with symptoms of intracranial hypertension (81.8% vs 0%, p = 0.001). The extent of midline shift was greater in the surgical group than in the nonsurgical group (9.0 ± 3.8 mm vs 2.0 ± 2.4 mm, p = 0.001).

CONCLUSIONS

The majority of patients with TTH presented in a delayed fashion. TTH is not always a surgical entity. Spontaneous resolution of TTH may be under-reported. Conservative management with clinical and radiological follow-up is effective in selected patients.

Efficacy of Arachnoid-Plasty on Chronic Subdural Hematoma Following Surgical Clipping of Unruptured Intracranial Aneurysms

BACKGROUND

We aimed to elucidate the effects of arachnoid plasty (ARP) on chronic subdural hematoma (CSDH) occurrence following clipping surgery.

METHODS

In total 217 patients (ARP, n = 97; non-ARP, n = 120) who had undergone unruptured intracranial aneurysm (UIA) surgical clipping via the pterional approach were retrospectively assessed. Predisposing factors for CSDH development following the surgery were investigated. Thickness and volume of the subdural fluid collection (SDFC) were measured to determine whether ARP affects postoperative SDFC.

RESULTS

The occurrence of postoperative CSDH was higher in patients without ARP compared to those with ARP (12.5 vs. 3.1%; P = 0.01). In multivariate analyses, having an SDFC volume ≥15 mL on postoperative day (POD) 8, (odds ratio [OR] = 15.113; range = 3.159-72.290), and male sex (OR = 4.274; range = 1.291-14.148) were identified as independent predictive factors. Having had ARP (OR = 0.228; range = 0.056-0.927) was, as an independent variable, negatively correlated with the occurrence of CSDH (P < 0.05). Moreover, SDFC volume ≥15 ml on POD 8 was significantly less common in the ARP group compared with the non-ARP group (P = 0.03).

CONCLUSION

Patients who underwent ARPs developed fewer CSDHs following UIA clipping surgery. The factors that predicted the development of CSDH included male sex, SDFC volume on POD 8, and ARP. In addition, the ARP patients had lower SDFC volumes (<15 mL). These findings suggested that ARP reduced the incidence of CSDHs after surgical clippings in patients with unruptured aneurysms.

Postoperative subdural hygroma and chronic subdural hematoma after unruptured aneurysm surgery: age, sex, and aneurysm location as independent risk factors

OBJECTIVE

This study investigated the incidence and risk factors for the postoperative occurrence of subdural complications, such as a subdural hygroma and resultant chronic subdural hematoma (CSDH), following surgical clipping of an unruptured aneurysm. The critical age affecting such occurrences and follow-up results were also examined.

METHODS

The case series included 364 consecutive patients who underwent aneurysm clipping via a pterional or superciliary keyhole approach for an unruptured saccular aneurysm in the anterior cerebral circulation between 2007 and 2013. The subdural hygromas were identified based on CT scans 6-9 weeks after surgery, and the volumes were measured using volumetry studies. Until their complete resolution, all the subdural hygromas were followed using CT scans every 1-2 months. Meanwhile, the CSDHs were classified as nonoperative or operative lesions that were treated by bur-hole drainage. The age and sex of the patients, aneurysm location, history of a subarachnoid hemorrhage (SAH), and surgical approach (pterional vs superciliary) were all analyzed regarding the postoperative occurrence of a subdural hygroma or CSDH. The follow-up results of the subdural complications were also investigated.

RESULTS

Seventy patients (19.2%) developed a subdural hygroma or CSDH. The results of a multivariate analysis showed that advanced age (p = 0.003), male sex (p < 0.001), middle cerebral artery (MCA) aneurysm (p = 0.045), and multiple concomitant aneurysms at the MCA and anterior communicating artery (ACoA) (p < 0.001) were all significant risk factors of a subdural hygroma and CSDH. In addition, a receiver operating characteristic (ROC) curve analysis revealed a cut-off age of > 60 years, which achieved a 70% sensitivity and 69% specificity with regard to predicting such subdural complications. The female patients ≤ 60 years of age showed a negligible incidence of subdural complications for all aneurysm groups, whereas the male patients > 60 years of age showed the highest incidence of subdural complications at 50%-100%, according to the aneurysm location. The subdural hygromas detected 6-9 weeks postoperatively showed different follow-up results, according to the severity. The subdural hygromas that converted to a CSDH were larger in volume than the subdural hygromas that resolved spontaneously (28.4 ± 16.8 ml vs 59.6 ± 38.4 ml, p = 0.003). Conversion to a CSDH was observed in 31.3% (5 of 16), 64.3% (9 of 14), and 83.3% (5 of 6) of the patients with mild, moderate, and severe subdural hygromas, respectively.

CONCLUSIONS

Advanced age, male sex, and an aneurysm location requiring extensive arachnoid dissection (MCA aneurysms and multiple concomitant aneurysms at the MCA and ACoA) are all correlated with the occurrence of a subdural hygroma and CSDH after unruptured aneurysm surgery. The critical age affecting such an occurrence is 60 years.

Cortical gluing and Ringer lactate solution inflation to avoid cortical mantle collapse and subdural fluid collections in pediatric neurosurgery: safety and feasibility

INTRODUCTION

Subdural fluid collections following intraventricular and/or paraventricular procedures in pediatric neurosurgery are common and can be hard to treat. We describe our technique to close cortical defects by the aid of a fibrin adhesive and subsequent Ringer inflation with the aim to avoid cortical mantle collapse and to prevent the development of subdural fluid collections.

MATERIALS AND METHODS

We report the preliminary results of a prospective study on a consecutive series of 29 children who underwent 37 transcortical or transcallosal surgical procedures since 2008 in our department.

RESULTS

In 17 procedures, we performed a transcortical approach on lesions, and in other 19 operations, we operated by a transcallosal. In 5/17 transcortical approaches (29%) and in 3/20 transcallosal approaches (15%), we observed a 5-mm-thick subdural fluid collection of the 5 patients with subdural fluid collections in the transcortical group, 3 patients (17%) underwent surgery for symptomatic or progressive subdural fluid collections. Of the 3 patients in the transcallosal group, a subduro-peritoneal shunt was necessary only for 1 patient (5%). At the very end of the treatment (including chemotherapy and radiotherapy), it was possible to remove the subduro-peritoneal shunt in all these patients because of disappearance of the subdural fluid collections.

CONCLUSION

In pediatric patients after transcortical or transcallosal procedures, the use of a fibrin adhesive to seal surgical opening and subsequent inflation of the residual cavity with Ringer lactate solution to avoid cortical mantle collapse seems safe and appears to prevent the development of subdural fluid collections.

Efficacy of arachnoid plasty with collagen sheets and fibrin glue: An in vitro experiment and a case review

Background:

Postoperative subdural fluid collection sometimes occurs after clipping of cerebral aneurysms. Arachnoid plasty is used to prevent such postoperative complications; however, the optimal materials for arachnoid plasty remain unclear. In this study, we aimed to clarify the optimal materials for arachnoid plasty and report our experience of arachnoid plasty after clipping of unruptured aneurysms.

Methods:

In an in vitro experiment, adhesive strengths of three materials permitted for use in the intradural space, such as collagen sheets, gelatin sponge, and oxidized cellulose sheets, were measured by assessing their water pressure resistance. Then, 80 consecutive cases surgically treated unruptured cerebral aneurysms were retrospectively reviewed to examine the occurrence rate of postoperative subdural fluid collection.

Results:

The collagen sheet exhibited the greatest adhesive strength, so we used collagen sheets for the arachnoid plasty procedures. In all of these cases, arachnoid plasty was performed with fibrin glue-soaked collagen sheets. No postoperative subdural fluid collection, inflammation, or allergic reactions occurred in any case.

Conclusions:

The present study suggests that collagen sheet might be one of the optimal materials for arachnoid plasty. This technique is simple and may be effective to prevent subdural fluid collection after clipping.

Analysis of 30-day readmissions among neurosurgical patients: surgical complication avoidance as key to quality improvement

OBJECT.: In terms of measuring quality of care and hospital performance, an outcome of increasing interest is the 30-day readmission rate. Recent health care policy making has highlighted the necessity of understanding the factors that influence readmission. To elucidate the rate, reason, and predictors of readmissions at a tertiary/quaternary neurosurgical service, the authors studied 30-day readmissions for the Department of Neurosurgery at two University of California, Los Angeles (UCLA), hospitals.

METHODS

Over a 3-year period, the authors retrospectively identified adult and pediatric patients who had been discharged from the UCLA Medical Center after having undergone a major neurosurgical procedure and being readmitted within 30 days. Data were obtained on demographics, follow-up findings, diagnosis and reason for readmission, major operations performed, and length of stay during index admission and readmission. Reasons for readmission were broadly categorized into surgical, medical diagnosis/complication, problem associated with the original diagnosis, neurological decompensation, pain management, and miscellaneous. For further characterization, subgroup analysis and in-depth chart review were performed.

RESULTS

Over the study period, 365 (6.9%) of 5569 patients were readmitted within 30 days. The most common diagnosis at index admission was brain tumor (102 patients), followed by CSF shunt malfunction (63 patients). The most common reason for readmission was surgical complication (50.1%). Among those with surgical complications, the largest subgroup consisted of patients with CSF shunt-related problems (77 patients). The second and third largest subgroups were surgical site infection and CSF leakage (41 and 31 patients, respectively). Medical diagnosis/complication was the second most frequent (27.9%) reason for readmission.

CONCLUSIONS

Surgical complications seem to be a major reason for readmission at the neurosurgical practice studied. Results indicate that the outcomes that are amenable to and would have the greatest effect on quality improvement are CSF shunt-related complications, surgical site infections, and CSF leaks.

Postoperative extra-axial cerebrospinal fluid collection--its pathophysiology and clinical management

OBJECTIVE

External hydrocephalus, introduced by Dandy and Blackfan in 1914 [Am J Dis Child 1914;8:406-482], is used to describe the clinical condition of cerebrospinal fluid (CSF) accumulation in the subarachnoid space with its space expansion and increased intracranial pressure in pediatric patients. Benign subdural effusion, subdural hygroma and pseudohydrocephalus are some terms used to describe some conditions, not clearly defined at the moment as separate pathological entities. We report 3 pediatric cases which had CSF collections after craniotomy. Neuroimaging investigations revealed CSF collection after surgery. All 3 cases had a poor clinical course with resolution after shunting. This report analyzes the mechanisms and pathophysiology of postoperative extra-axial CSF collections (PECC), indicating that CSF accumulations in the extra-axial spaces (inside or outside the arachnoid) after surgery have a common pathophysiology. Therefore, the treatment protocol can be specific.

PATIENTS

Three pediatric cases, aged from 11 months to 6 years, had large tumors located from their suprasellar region to the hypothalamus and third ventricle. The tumors were excised surgically through either an anterior interhemispheric translamina-terminalis or a transsylvian translamina-terminalis approach or both. The surgery conducted created a wide opening of the anterior interhemispheric or the sylvian fissures, dissecting the lamina terminalis and Liliequist's membrane resulting in a new artificial CSF tract from the basal cisterns to the subdural space. Clinical symptoms such as deterioration of consciousness level developed within a few weeks after surgery, and a follow-up computed tomography image confirmed subdural CSF collection. Symptoms improved after ventriculoperitoneal (V-P) shunting.

DISCUSSION

External hydrocephalus, subdural effusion and the other entities mentioned above are frequently observed in children, and little is known about their pathophysiology. To differentiate from the whole entity of CSF accumulation within the subdural and subarachnoid space, we use the term PECC to specify the main pathophysiological condition resulting from a wide dissection and opening of the arachnoid membrane and communication with the basal cisterns.

CONCLUSION

We present the occurrence of CSF collections in the extra-axial space after surgery as the specific condition of PECC. Broadly dissecting the arachnoid membrane, with a communication remaining with the ventricles, is the main factor contributing to PECC, and patients have shown that V-P shunting is an effective procedure preventing progression and effectively treating PECC.

Use of tissue glue to prevent collapse of the cortical mantle during and after cranial surgery in children: a technical note

INTRODUCTION

Young children with significant ventricular dilatation or large intracranial fluid spaces often have a very thin cortical mantle as a result of persistently raised intracranial pressure. This rim of cortex has a tendency to fall away from the dura into the cavity during and after intracranial surgery, due to the lack of support, once the pressure in the fluid cavity has been reduced. This can lead to tearing of cortical bridging veins and the formation of post-operative subdural haematomas.

METHODS

We describe a simple technique that attempts to prevent this phenomenon occurring using tissue glue. Once the craniotomy has been performed and the dura has been formally opened, tissue glue is applied to the underside of the dura around the edge of the wound, prior to corticotomy.

RESULTS AND CONCLUSION

This results in the cortical mantle adhering to the undersurface of the dura and prevents the mantle from falling into the cavity either during the procedure or post-operatively.

The complications of cerebral hydatid cyst surgery in children

PURPOSE

Complications related to cerebral hydatid cyst surgery are not uncommon but require prompt diagnosis and treatment. The aim of this study is to demonstrate the radiological findings that would indicate complications after cerebral hydatid cyst surgery in children and to report our results.

METHOD

The data of 25 pediatric patients who underwent surgery for cerebral hydatid cysts over a 16-year period were analyzed retrospectively. The complications related to surgical technique and cyst location were recorded. Postoperative radiological findings of the patients were documented.

RESULTS

Intraoperative cyst rupture occured in three patients. Subdural effusion developed in five patients, porencephalic cyst in four, subdural effusion associated with porencephalic cyst in two, hemorrhage in two, epidural hematoma in one, and pneumocephalus in three patients. Subdural-peritoneal shunt was placed in two patients. Recurrence of cerebral hydatid cyst was observed in only one patient who experienced intraoperative cyst rupture. There was no surgery-related death.

CONCLUSIONS

The complications following cerebral hydatid cyst surgery in children are various and usually not fatal. When appropriate surgical procedures are planned and carefully applied, the results will be excellent with no mortality.

Cylindrical channel retractor for intraventricular tumour surgery--a simple and inexpensive device

Ventricular tumors are excised using both microscope and endoscope as the viewing device. Excision of these tumors requires corticectomy. After these corticectomies, brain has tendency to fall because of CSF drainage. Currently available retractor systems are fixed and thus can be traumatic. On the other hand few systems that require small corticectomy need stereotactic or navigation system aid. These all methods and equipment are costly. Our simple method of using a cylindrical channel retractor custom made out of 20 cc plastic syringe in OT helps in making minimum possible corticectomy. It gives surgeon minimally traumatic, inexpensive, hands free retractor.

Use of an inflatable balloon on a catheter to prevent subdural fluid collections after intraventricular tumor surgery: technical note

Ventricular tumor surgeries pose significant challenges to the neurosurgeon. Apart from the operative challenges and typical complications of surgery, subdural fluid collection is common after these surgeries. Various methods have been used to prevent this complication. The authors' technique of implanting an inflatable balloon attached to a catheter after resection of a huge intraventricular tumor was highly effective in preventing the development of a subdural fluid collection.

The use of fibrin glue to stop venous bleeding in the epidural space, vertebral venous plexus, and anterior cavernous sinus: technical note

OBJECTIVE

Various techniques have been used to stop venous bleeding from the epidural space, vertebral venous plexus, and cavernous sinus. Here, we describe our experience with the use of fibrin glue to stop venous bleeding in these areas.

METHODS

During the last 8 years, the senior author (LNS) has used injection of Tisseel fibrin glue (Baxter Healthcare Corp., Deerfield, IL) into the epidural space (n = 200 patients), anterior cavernous sinus (n = 46 patients), vertebral venous plexus (n = 20 patients), and superior petrosal sinus (n = 20 patients) to assist in hemostasis. The technical nuances are illustrated in three videos.

RESULTS

Injection of fibrin glue in the epidural space, anterior cavernous sinus, and vertebral venous plexus yielded good results in assisting with hemostasis. Two patients experienced complications caused by occlusion of veins draining the brainstem after fibrin glue was injected into the superior petrosal sinus.

CONCLUSION

Fibrin glue injection is an excellent option for hemostasis in the epidural space, anterior cavernous sinus, and vertebral venous plexus. However, based on our experience, fibrin glue injection into the superior petrosal sinus is not recommended.

Prevention of postoperative subdural fluid collections following transcortical transventricular approach

BACKGROUND

Subdural fluid collections appear in about 39% of patients after the removal of intra- and paraventricular tumors. This extracerebral fluid collection requires surgical intervention when progressive fluid accumulation takes place. The authors retrospectively and prospectively studied the efficacy of gelfoam and fibrin adhesive in closing cortical and ependymal defects after intraventricular and/or paraventricular lesion resection to prevent the development of SFCs.

METHODS

From 1999 to 2004, we used gelfoam and fibrin adhesive on the cortical and ependymal defects of 28 patients who underwent the resection of intraventricular and/or paraventricular lesions via the transcortical approach associated with the communicated ventricle. We investigated the percentage of symptomatic and asymptomatic SFC.

RESULTS

The patients median age was 59.5 years (range, 30-76 years), and the male/female ratio was 16:12. A frontal approach was performed in 18 patients, an occipital approach in 2, a parietal approach in 4, and a temporal approach in 4. The incidence of SFCs was 7% (2 patients). Of the 2 patients with SFCs, 1 required temporary drainage. The other patient was asymptomatic, and the SFCs were spontaneously absorbed 2 months later.

CONCLUSIONS

The use of gelfoam and fibrin adhesive to seal cortical and ependymal defects after a transcortical procedure might be a viable method of preventing the development of SFC.

Risk reduction of subdural collections following endoscopic third ventriculostomy

OBJECT

To evaluate the efficacy and safety using fibrin glue and absorbable hemostats for packing the endoscopic tract in a pediatric population in the prevention of subdural fluid collections after endoscopic third ventriculostomy.

MATERIALS AND METHODS

Twenty-one endoscopic third ventriculostomies were performed in 20 hydrocephalic children with a mean age of 22 months over a 4-year period using uniformly this technique. Six children, with age ranged 6 days to 22 months (mean 9 months), had severe ventriculomegaly with thin brain mantle less than 10 mm. There was no mortality and no permanent morbidity related to the endoscopic procedure. One child developed an asymptomatic collection, which could be managed conservatively and was most likely attributed to the young age of the child and the assumed poor cerebrospinal fluid absorption ability. Lost compliance of the brain parenchyma may play an additional role, which was not related to the thickness of the brain mantle. No adverse effects regarding the material used for sealing were observed over a mean follow-up of 23 months.

CONCLUSIONS

Subdural fluid collections could be prevented in 20 out of 21 procedures by using this technique regardless of the thickness of the brain mantle, the application of mixture of fibrin glue and hemostatic agents seems to be safe, and we consider this technique effective in reducing the risk of this potential complication.

Ventricular reservoir migration into the lateral ventricle through the endoscopic tract after unsuccessful third ventriculostomy

We report a case of reservoir migration into the lateral ventricle through an enlarged endoscopic tract. A full-term female infant with a myelomeningocele, which was repaired surgically after birth, came to us with hydrocephalus, and a reservoir was placed after an unsuccessful endoscopic third ventriculostomy. The tract gradually enlarged and the reservoir eventually slipped into the lateral ventricle 16 days after implantation. This complication may be unique to children, in whom the bone is malleable. As endoscopic surgery is being used more often in infants, the risk of this complication may also be increasing with concurrent reservoir implantation. We believe this complication can be avoided with careful attention to several key points during surgery.

Prevention of cerebrospinal fistulae and reduction of epidural scar with new surgical hemostat device in a porcine laminectomy model

STUDY DESIGN

In a porcine laminectomy model, a standard dural/arachnoid incision was made and tested for cerebrospinal fluid leak after material application. Sites were graded for scar formation and healing response at 3 weeks.

OBJECTIVE

This study compares effectiveness of CoStasis, Tissucol, and suture for prevention of cerebrospinal fluid leaks and epidural scar formation after spinal dural incisions.

SUMMARY OF BACKGROUND DATA

Cerebrospinal fluid leaks following cranial and spinal surgery are potentially serious complications. Epidural scar formation is exacerbated by improper control of hemostasis. A hemostatic agent with dural sealant properties may be advantageous.

METHODS

Total laminectomy was performed at three levels in seven pigs. At each level, a uniform 1.5 cm incision was made in the dura and arachnoid. A single suture was placed to approximate the edges and sites were treated with one of three methods: CoStasis, Tissucol, or no treatment. At sacrifice, 3 weeks later, epidural scar was graded, pressure testing of some sites was done, and tissue for histologic sections was harvested.

RESULTS

CoStasis and Tissucol produced immediate dural sealing when the valsalva maneuver was applied. One suture-only site leaked. At sacrifice, all sites were sealed. CoStasis and Tissucol had less scar formation than control sites. Pressure testing results were similar at CoStasis and Tissucol sites.

CONCLUSION

CoStasis and Tissucol have comparable effectiveness in sealing CSF leaks immediately and at 3 weeks after complete laminectomy. CoStasis demonstrated comparable performance to Tissucol with less epidural scar formation than primary suture alone.

Transcortical or transcallosal approach to ventricle-associated lesions: a clinical study on the prognostic role of surgical approach

Most entities in and around the anterior two-thirds of the supratentorial ventricles can be reached via transcortical or transcallosal approach. This study examined the effect of surgical approach on the postoperative neurological outcome. Thirty-eight patients with intra- and periventricular supratentorial lesions were operated on by either frontal transcortical or anterior transcallosal approach. Postoperative diencephalic damage occurred in 22% of patients in the transcortical group and in 36% in the transcallosal group; transient mutism was virtually equivalent in the two groups. Postoperative epilepsy (26%) and subdural fluid collections (30%) occurred only in the transcortical group. The incidence of postoperative hemiparesis was higher in the transcallosal group. There was a high correlation between postoperative Glasgow Outcome Score of 5 and preoperative severity of neurological disease but no correlation between postoperative Glasgow Outcome Score of 5 and location of the lesion or between postoperative clinical course and surgical approach. Surgical outcome of ventricle-associated lesions depends mainly on the severity of preoperative symptoms and not on surgical approach. Additionally, the incidence of postoperative seizures and subdural fluid collections after transcortical surgery is high.

Tissue sealing

The tissue adhesive property of fibrinogen was first described 60 years ago. However, it was not until the availability of concentrated plasma fibrinogen and bovine thrombin that the use of fibrin sealants in surgical practice became widespread. Today, fibrin sealants are used for tissue sealing across a range of surgical procedures, including cardiothoracic, gastrointestinal, neurosurgery, and vascular surgery. Tissue sealing with fibrin sealant reduces perioperative hemorrhage and controls blood loss from cut surfaces of tissues that are difficult to suture. The use of fibrin sealants can also reduce perioperative and postoperative complications by reducing fluid leakage, air leakage, and by preventing fistulae formation. Fibrin sealants have a unique physiologic action, and the resulting fibrin clot is fully degraded by the body's natural wound healing process. The range of surgeries and types of procedure that incorporate the use of fibrin sealants in tissue sealing is expanding. As commercially prepared fibrin sealants become more widely available, the number of patients and surgeons benefiting from improved surgical outcomes is also set to increase. This article reviews the areas of surgery within which fibrin sealants are currently used to assist tissue sealing and highlights the improved surgical outcomes, such as reduced blood loss, operative time, and postoperative complications.

Pediatric supratentorial intraventricular tumors

A variety of mass lesions can arise within or in proximity to the ventricular system in children. These lesions are relatively uncommon, and they present a unique diagnostic and surgical challenge. The differential diagnosis is determined by tumor location in the ventricular system, clinical presentation, age of the patient, and the imaging characteristics of the lesion. In this report the authors provide an introduction to and an overview of the most common pediatric supratentorial intraventricular tumors. The typical radiographic features of each tumor and location preference within the ventricular system are reviewed. Management and treatment considerations are discussed. Examination of tissue samples to obtain diagnosis is usually required for accurate treatment planning, and resection without adjuvant therapies is often curative. The critical management decision frequently involves determining which lesions are appropriate for surgical therapy. Care ful preoperative neuroimaging is extremely useful in planning surgery. Knowledge of the typical imaging characteristics of these tumors can help to determine the diagnosis with relative certainty when a tissue sample has not been obtained, because a small subset of these lesions can be managed expectantly.

Transcortical surgery for lateral ventricular tumors

Object

Tumors of the lateral ventricle can be removed via two major approaches: the transcallosal or the transcortical route. The purpose of this study is to discuss the techniques and outcomes in transcortical surgery of tumors located in the lateral ventricle.

Methods

An experience with 29 consecutive lateral ventricular tumors resected via the transcortical route, over a 5-year period, is presented. The risks, complications, and outcomes of this surgical series, as well as those reported in the literature, are discussed. Surgical approaches to all five regions of the lateral ventricle are described. Neuropsychological, functional, and neurological outcomes are evaluated.

Conclusions

The transcortical technique makes it possible to resect lesions in each of the five regions of the lateral ventricle. It provides superior microsurgical working space and flexibility for maneuvering within the lateral ventricle. The key to a successful transcortical approach is an understanding of the functional anatomy of eloquent cortex to be broached, the location of the lesion, and its vascular supply. A clear understanding of the advantages and limitations of the transcortical approach makes performing this procedure for resection of large lesions in the ventricle both safe and effective. The majority of the patients in this series (86%) had a good outcome, returning to baseline functional status and suffering minimal morbidity. In the microsurgical era, transcortical surgery–related postoperative morbidity and outcome are dependent more on tumor histological type and site of origin than on approach.