Reconstruction after retrosigmoid approaches using autologous fat graft-assisted Medpor Titan cranioplasty: assessment of postoperative cerebrospinal fluid leaks and headaches in 60 cases

Background

Postoperative cerebrospinal fluid (CSF) leaks and headaches remain potential complications after retrosigmoid approaches for lesions in the posterior fossa and cerebellopontine angle. The authors describe a simple repair technique with an autologous fat graft-assisted Medpor Titan cranioplasty and investigate the incidence of postoperative CSF leaks and headaches using this technique.

Methods

A retrospective chart review was conducted on all cases (n?=?60) of retrosigmoid craniectomy from September 2009 to May 2014 in patients who underwent fat graft-assisted cranioplasty. After obtaining a watertight dural closure and sealing off any visible mastoid air cells with bone wax, an autologous fat graft was placed over the dural suture line and up against the waxed-off air cells. The fat graft filled the retrosigmoid cranial defect and was then bolstered with a Medpor Titan (titanium mesh embedded in porous polyethylene) cranioplasty. A postoperative mastoid pressure dressing was applied for 48 h, and prophylactic lumbar drainage was not used. Factors examined in this study included postoperative CSF leak (incisional, rhinorrhea, otorrhea), pseudomeningocele formation, incidence and severity of postoperative headache, length of hospital stay, and length of follow-up.

Results

No patients developed postoperative CSF leaks (0 %), pseudomeningoceles (0 %), or new-onset postoperative headaches (0 %) with the described repair technique. There were no cases of graft site morbidity such as hematoma or wound infection. Mean duration of postoperative hospital stay was 3.8 days (range 2–10 days). Mean postoperative follow-up was 12.4 months (range 2.0–41.1 months).

Conclusions

Our multilayer repair technique with a fat graft-assisted Medpor Titan cranioplasty appears effective in preventing postoperative CSF leaks and new-onset postoperative headaches after retrosigmoid approaches. Postoperative lumbar drainage may not be necessary.     

Postpartum workup of postdural puncture headache leads to diagnosis and surgical treatment of thoracic pseudomeningocele: a case report

Purpose

Postdural puncture headache is a well-known complication of neuraxial anesthesia in childbirth. There are, however, many other causes of postpartum headache, some of which may present like postdural puncture headache and confuse the diagnosis. We report a case of postpartum headache due to pseudomeningocele.

Clinical features

A 31-yr-old primigravida presented at 35 weeks gestation for induction of labour. A pre-pregnancy history of migraines was suspicious for low cerebrospinal fluid headache, but this had been ruled out by normal brain magnetic resonance imaging (MRI), and the headaches had resolved with pregnancy. A labour epidural was easily placed at L3/4. On postpartum day one the patient complained of mild headache, and the severe pre-pregnancy headache returned within weeks. The pounding occipital/hemispheric headache was associated with nausea and vomiting; it worsened over the day, and improved when the patient was supine. A repeat brain MRI showed evidence of intracranial hypotension, and an epidural blood patch was performed at L3/L4 with no improvement. A second blood patch was performed ten days later, still with no improvement. A subsequent brain MRI showed unchanged intracranial hypotension, and a spine MRI revealed a pseudomeningocele at T7. A computed tomography myelogram confirmed a T7/8 pseudomeningocele. The patient underwent direct microsurgical exploration and repair four months later, which was followed by re-operation ten months later. The patient’s condition has since remained significantly improved.

Discussion

This case highlights the importance of maintaining a wide differential in the workup of postpartum headache after regional anesthesia, particularly in cases refractory to blood patch. This case also reveals a T7 pseudomeningocele causing spontaneous intracranial hypotension that otherwise may not have been detected and corrected.     

Flow-regulated external lumbar drain: applications and complications

Background

A novel flow-regulated external drain (FRED) was devised to overcome the problems of the pressure-regulated systems and serial lumbar taps.

Methods

Eleven patients who underwent lumbar external drainage received a flow-regulated system using simple and inexpensive materials available in most hospital settings.

Results

The system proved to be reliable at removing a set amount of cerebrospinal fluid (CSF). We did not encounter any serious complications in its application.

Conclusions

The FRED system offered better patient compliance and comfort, providing them with greater mobility, while maintaining a safer steady removal of a set amount of CSF. In opposition to the pressure-regulated systems, we describe the possible indications, advantages and disadvantages of a flow regulated device. Extensive clinical trials are needed to study the use of FRED in patients with different CSF circulation physiology, pressure and composition.     

Reversal of high spinal anesthesia with cerebrospinal lavage after inadvertent intrathecal injection of local anesthetic in an obstetric patient

Purpose

High or total spinal anesthesia commonly results from accidental placement of an epidural catheter in the intrathecal space with subsequent injection of excessive volumes of local anesthetic. Cerebrospinal lavage has been shown to be effective at reversing the effects of high/total spinal anesthesia but is rarely considered in obstetric cases. Here, we describe the use of cerebrospinal lavage to prevent potential complications from high/total spinal anesthesia after unintentional placement of an intrathecal catheter in a labouring obstetric patient.

Clinical features

A 34-yr-old female presented to the labour and delivery unit in active labour. Epidural anesthesia was initiated, and after the first bolus dose, the patient experienced lower extremity motor block and shortness of breath. A high spinal was confirmed, and cerebrospinal lavage was performed. In total, 40 mL of cerebrospinal fluid (CSF) were exchanged for an equal volume of normal saline. The patient’s breathing difficulties and motor block resolved quickly, and a new epidural catheter was placed after removal of the spinal catheter. Pain control was effective, and the patient delivered a healthy baby.

Conclusion

We show that exchange of CSF for normal saline can be used successfully to manage a high spinal in an obstetric patient. Our results suggest that CSF lavage could potentially be an important and helpful adjunct to the conventional supportive management of obstetric patients in the event of inadvertent high or total spinal anesthesia.     

Accuracy of colonoscopic localization

Background

The objective of this study was to evaluate the accuracy of preoperative colonoscopic localization of colonic lesions. Localization of the colonic lesion plays a key role in determining the type of operation a patient may require. Inaccurate localization may result in removal of the wrong segment of colon and/or a change in the operation performed.

Methods

A retrospective review of patients who had a colon resection by a single surgeon after preoperative colonoscopic localization between 1991 and 2008 was performed. A comparison of the preoperative colonoscopic localization and the final intraoperative localization was made. Clinical and demographic information was gathered to determine accuracy rates and identify predictive factors.

Results

Three hundred and seventy-four patients were included and 184 (49%) were male. The mean age was 61.6 years. Three hundred and sixty-two (97%) patients underwent colon resection for cancer. Fifteen (4%) patients had nonconcordant colonoscopic and intraoperative findings. Fourteen of the 15 (93%) were resected for cancer and 1 for inflammatory bowel disease (IBD). Seven (47%) lesions were inaccurately localized in the sigmoid colon, four (27%) in the descending colon, two (13%) in the ascending colon, one (7%) in the rectum, and one (7%) lesion was not visualized preoperatively. Eleven of the 15 (73%) patients with nonconcordant localization had a modification of their planned procedure. Ten patients underwent a different segmental colectomy and one patient had an extended resection.

Conclusion

Preoperative colonoscopic localization of colorectal lesions was reasonably accurate (96%) in this large series. The majority of inaccurately identified lesions occurred in the sigmoid and descending colon. Erroneous localization, even though not common, can result in significant changes in the intraoperative plan and the ultimate outcome. Therefore, every effort should be made to localize the lesion before surgery, especially when thought to be in the left or sigmoid colon, to reduce the need for intraoperative localization efforts, the need for an intraoperative change in procedure, and the risk of a surprise for the patient after surgery.     

Intracranial hypotension with a sixth cranial nerve palsy subsequent to massive thoracic CSF hygroma: a rare complication of thoracic disc excision

Background

Thoracic cerebrospinal fluid (CSF) hygroma is a rare and potentially devastating complication of the anterior thoracic approach to the spine. We present two cases in which this complication resulted in acute cranial nerve palsy and discuss the pathoanatomy and management options in this scenario.

Case reports

Two male patients presented to our department with neurological deterioration due to a giant herniated thoracic disc. The extruded disc fragment was noted pre-operatively to be calcified in both patients. A durotomy was performed at primary disc prolapse resection in the first patient, whereas an incidental durotomy during the procedure caused complication in the second patient. These were repaired primarily or sealed with Tachosil^®. Both patients re-presented with acute diplopia. Imaging of both patients confirmed a massive thoracic cerebrospinal fluid hygroma and evidence of intracranial changes in keeping with intracranial hypotension, but no obvious brain stem shift. The hemithorax was re-explored and the dural repair was revised. The first patient made a full recovery within 3 months. The second patient was managed conservatively and took 5 months for improvement in his ophthalmic symptoms.

Conclusions

The risk of CSF leakage post-dural repair into the thoracic cavity is raised due to local factors related to the chest cavity. Dural repairs can fail in the presence of an acute increase in CSF pressure, for example whilst sneezing. Intracranial hypotension can result in subsequent hygroma and possibly haematoma formation. The resultant cranial nerve palsy may be managed expectantly except in the setting of symptomatic subdural haematoma or compressive pneumocephaly.     

Pushing the Limits of Local Excision for Rectal Cancer: Transanal Minimally Invasive Surgery for an Upper Rectal/Rectosigmoid Lesion

Background

Transanal minimally invasive surgery (TAMIS) is an evolving technique for the local excision of early rectal cancers,1 particularly for mid-rectal lesions. The approach to upper rectal lesions is significantly more challenging and prone to complications. We demonstrate TAMIS for an upper rectal/rectosigmoid lesion, with transanal repair of an intraoperative rectal/rectosigmoid perforation.

Methods

The patient is an elderly male in whom colonoscopy demonstrated a large polypoid lesion of the upper rectum/rectosigmoid colon. On rigid proctoscopy, the lesion was 4 cm in size and occupied 40 % of the rectal circumference, with distal extent at 14 cm from the anal verge. Endoscopic ultrasound was consistent with T_isN₀ disease. Multiple attempts at endoscopic mucosal resection were unsuccessful and the patient refused radical resection. The patient underwent TAMIS with a disposable transanal access port, using our previously published stepwise technique.2

Results

The patient successfully underwent TAMIS. Intraoperatively, a small full-thickness perforation was created proximal to the excision site and was primarily repaired. A stepwise approach to excision and repair is described. Postoperatively, the patient had low-grade fevers for which he was treated empirically with antibiotics. The fevers resolved without further intervention. Pathologic examination revealed a 3.5 cm villous adenoma with focal high-grade dysplasia, negative margins, and two negative lymph nodes. On outpatient follow-up, the patient was symptom-free and had no fevers, pain, bleeding, fecal incontinence, or genitourinary functional deficits. He is disease-free 10 months from his procedure.

Conclusions

TAMIS of upper rectal lesions is technically challenging, but can be accomplished safely in well-selected patients.     

The Frankfurt horizontal plane as a reference for the implantation of gravitational units: a series of 376 adult patients

Background

The in-line combination of adjustable differential pressure valves with fixed gravitational units is increasingly recommended in the literature. The spatial positioning of the gravitational unit is thereby decisive for the valve opening pressure. We aimed at providing data on factors contributing to primary overdrainage and underdrainage of cerebrospinal fluid (CSF), with special attention paid to the implantation angle of the gravitational unit.

Methods

Weretrospectively analyzed the postoperative course of 376 consecutive patients who received a ventriculoperitoneal shunt with a proGAV valve. The incidence of both primary CSF overdrainage and underdrainage was correlated with the implantation angle of the gravitational unit in regard to the Frankfurt horizontal plane and the patients’ general parameters.

Results

Primary overdrainage was found in 41 (10.9 %) patients. Primary underdrainage was found in 113 (30.1 %) patients. A mean deviation of 10° (±7.8) for the gravitational unit in regard to the vertical line to the Frankfurt horizontal plane was found. In 95 % of the cases the deviation was less than 25°. No significant correlation between the implantation angle and the incidence of overdrainage or underdrainage of CSF was found. The patients’ age and having single hydrocephalus entities were identified as factors significantly predisposing patients to overdrainage or underdrainage.

Conclusion

The implantation of the gravitational unit of the proGAV valve within a range of at least 10° in regard to the vertical line to the Frankfurt horizontal plane does not seem to predispose patients to primary overdrainage or underdrainage in ventriculoperitoneal shunting. The plane may serve as a useful reference for the surgeon’s orientation.     

A practical grading system of ultrasonographic visibility for intracerebral lesions

Background

Intraoperative ultrasound for intracranial neurosurgery was largely abandoned in the 1980s due to poor image resolution. Despite many technological advances in ultrasound since then, the use of this imaging modality in contemporary practice remains limited. Our aim was to evaluate the utility of modern intraoperative ultrasound in the resection of a wide variety of intracranial pathologies.

Methods

A total of 105 patients who underwent intracranial lesion resection in a contiguous fashion were prospectively included in the study. Ultrasound images acquired intraoperatively were used to stratify lesions into one of four grades (grades 0–3) on the basis of their ultrasonic echogenicity and border visibility.

Results

Forty-two out of 105 lesions (40 %) were clearly identifiable and had a clear border with normal tissue (grade 3). Fifty-five of 105 lesions (52 %) were clearly identifiable but had no clear border with normal tissue (grade 2). Eight of 105 lesions (8 %) were difficult to identify and had no clear border with normal tissue (grade 1). None (0 %) of the lesions could not be identified (grade 0). High-grade gliomas, cerebral metastases, meningiomas, ependymomas, and haemangioblastomas all demonstrated a median ultrasonic visibility grade of 2 or greater. Low-grade astrocytomas and oligodendrogliomas demonstrated a median ultrasonic visibility grade of 2 or less.

Conclusion

Intraoperative ultrasound can be of tremendous benefit in allowing the surgeon to appraise the location, extent, and local environment of their target lesion, as well as to reduce the risk of preventable complications. We believe that our grading system will provide a useful adjunct to the neurosurgeon when deciding for which lesions intraoperative ultrasound would be useful.     

Early awareness of cerebrospinal fluid hypovolemia after craniotomy for microsurgical aneurysmal clipping

Background

Mild cerebrospinal fluid (CSF) hypovolemia is a well-known clinical entity, but critical CSF hypovolemia that can cause transtentorial herniation is an unusual and rare clinical entity that occurs after craniotomy. We investigated CSF hypovolemia after microsurgical aneurysmal clipping for subarachnoid hemorrhage (SAH).

Method

This study included 144 consecutive patients with SAH. Lumbar drainage (LD) was inserted after general anesthesia or postoperatively as a standard perioperative protocol. CSF hypovolemia diagnosis was based on three criteria.

Results

Eleven patients (7.6 %) were diagnosed with CSF hypovolemia according to diagnostic criteria in a postoperative range of 0–8 days. In all patients, signs or symptoms of CSF hypovolemia improved within 24 hours by clamping LD and using the Trendelenburg position.

Conclusions

As a cause of acute clinical deterioration after aneurysmal clipping, CSF hypovolemia is likely under-recognized, and may actually be misdiagnosed as vasospasm or brain swelling. We should always take the etiology of CSF hypovolemia into consideration, and especially pay attention in patients with pneumocephalus and subdural fluid collection alongside brain sag on computed tomography. These patients are at higher risk developing of pressure gradients between their cranial and spinal compartments, and therefore, brain sagging after LD, than after ventricular drainage. We should be vigilant to strictly manage LD so as not to produce high pressure gradients.     

Focused approach to ectopic mediastinal parathyroid surgery assisted by radio-guided navigation

Purpose

Surgical removal of a mediastinal ectopic parathyroid is always challenging. We attempted to apply intraoperative radio-guided navigation for the minimally invasive focused removal of ectopic hyperparathyroid lesions in the mediastinum, and evaluated its significance.

Methods

Five cases with ectopic mediastinal hyperfunctioning parathyroid were treated by intraoperative radio-guided navigation surgery. MIBI (methoxyisobutylisonitrile)-SPECT (single-photon emission computed tomography) was used to plan the surgical approach. ^99mTc-MIBI (11.1 MBq/kg) was administered 2 h before surgery, and a handheld gamma probe was used intraoperatively to detect radioactivity in the lesion.

Results

Two lesions found on the aortic arch were excised by left thoracoscopic resection. Two other lesions on the tracheal bifurcation were approached by right thoracotomy. We could remove two hidden adenomas by en bloc resection with the adjacent lymph nodes under radio-guidance. Another lesion, located at the ligamentum arteriosum, was excised with sternal division. Accumulations of radioactivity were identified in all lesions removed, with decreased radioactivity in the surgical field.

Conclusions

Intraoperative radio-guided navigation is a useful tool for the focused removal of an ectopic mediastinal parathyroid by providing instant feedback to help guide the surgeon, while also providing precise localization of lesions.     

Dural tear and resultant cerebrospinal fluid leaks after cervical spinal trauma

Purpose

Traumatic cervical spinal cord injuries (SCIs) frequently develop dural tears and resultant cerebrospinal fluid (CSF) leaks. They are not usually identified with advanced imaging, and there are no reports on managing CSF leaks after cervical trauma. Hence, the authors evaluated the incidence of CSF leaks after cervical SCIs and described how to predict and manage CSF leaks.

Methods

An observational retrospective study was done confirming intraoperative CSF leaks among 53 patients with anterior cervical surgery after cervical spine trauma between 2004 and 2011.

Results

Seven patients (13.2 %) had dural tears and resultant CSF leaks intraoperatively (M:F ratio of 6:1; mean age, 44.7 years). An initial poor American Spinal Injury Association (ASIA) scale was significantly associated with CSF leaks (p = 0.009). From magnetic resonance imaging (MRI), disruption of the ligamentum flavum was correlated with CSF leaks (p = 0.02). Intraoperative application of fibrin glue on the operated site, postoperative management through the early removal of the wound drain within the first 24 h and early rehabilitation were performed in patients with CSF leaks without perioperative insertion of a lumbar drain. During the follow-up period, none of the patients developed CSF-leak-related complications.

Conclusion

The incidence of CSF leaks after traumatic cervical SCI is relatively higher than that of degenerative cervical spinal surgery. An initial poor neurological status and disruption of the ligamentum flavum on the MRI in patients were predictable factors of dural tears and CSF leaks.     

Intraoperative low-field MR-guided frameless stereotactic biopsy for intracerebral lesions

Background

To present our intraoperative low-field magnetic resonance imaging (ioMRI) technique for stereotactic brain biopsy in various intracerebral lesions.

Method

Seventy-eight consecutive patients underwent stereotactic biopsies with the PoleStar N-20/N-30 ioMRI system and data were evaluated retrospectively. Biopsy technique included ioMRI before surgery, followed by insertion of the biopsy cannula in the lesion, and ioMRI before and after biopsy. Statistical analysis was performed to compare subgroups using Excel and SPSS statistic software.

Results

In all patients, stereotactic biopsy was possible, with a mean intraoperative surgery time of 86.2?±?28.6 min and a mean hospital stay of 11.6?±?4.6 days. In 97.4 % (n?=?76), histology was conclusive, representing 58 brain tumors and 18 other pathologies. Five patients were biopsied previously without conclusive diagnosis, and all biopsies were conclusive this time. Mean cross-sectional lesion size in MRI T1 with contrast (n?=?64) was 6.9?±?5.7 cm², and in lesions without T1 contrast enhancement (n?=?14), T2 mean cross-sectional lesion size was 5.5?±?3.9 cm². Mean distance from the cortex surface to the lesion was 3.4?±?1.2 cm. One patient suffered from a postoperative wound dehiscence; neither clinically or radiologically significant hemorrhage after surgery, nor intraoperative complications occurred.

Conclusions

Low-field ioMR-guided frameless stereotactic biopsy accurately diagnosed different intracerebral lesions without major complications for the patients, and within an acceptable surgery time and hospital stay. In repeated non-conclusive biopsies in particular, low-field ioMRI offers a technique for arriving at a diagnosis.     

Mitigating effects of external ventricular drain usage in the management of severe head injury

Background

Cerebrospinal fluid (CSF) drainage has been variably employed to lower intracranial pressure (ICP) in patients with severe head injury. The efficacy of this manoeuvre remains under-explored (Brain Trauma Foundation Recommendation—optional treatment). This work seeks to report the results of CSF drainage via external ventricular drain (EVD) in severe head injury in comparison to other treatment options.

Methods

Retrospective observational comparative study of all consecutive patients admitted to a major trauma centre with severe traumatic brain injury over a period of 12 months.

Results

Out of a total 139 patients, 33 had delayed elevation of ICP despite conventional medical therapy, 16 patients were treated with EVD insertion (4 placed under AxiEM image guidance [Medtronic]) and 17 received either decompressive craniectomy or barbiturate coma. Subsequently, two patients with decompression had further ICP elevation and needed EVD. Two patients with EVD had raised ICP—one underwent decompression and the other was treated with barbiturate coma. One patient with EVD developed infection, which was successfully treated. Patients treated with EVD had a lower risk of needing definitive treatment for ICP control, i.e. decompressive craniectomy or barbiturate coma.

Conclusions

EVD was a safe and less invasive procedure, and achieved sustained control of ICP in this patient group.     

A comparison of simple tests to distinguish cerebrospinal fluid from saline

Purpose

This prospective study was undertaken to determine if anesthesiologists of different levels of training, using simple tests, can distinguish cerebrospinal fluid (CSF) from saline.

Methods

Thirty-two anaesthetists, divided into four groups, dependent upon levels of training, participated in the study. Each was asked to distinguish saline from an artificial CSF solution using four different tests: tactile temperature, glucose strip, pH strip, and turbidity when mixed with thiopental.

Results

Participants identified cerebrospinal fluid correctly with 84% accuracy using the temperature test, 97% using the glucose test, 91 % using the pH test, and 50% using the thiopentone test. More than half of the participants guessed while using the thiopentone test, and those who did not guess were only 47% accurate.

Conclusion

Level of training made no difference in distinguishing CSF from saline. No one test was 100% reliable. Clinical utility of the thiopentone test appears to be limited. The temperature, glucose, and pH tests, when used together, appear to be a useful way of distinguishing CSF from saline.     

Reconstruction of intracranial vertebral artery with radial artery and occipital artery grafts for fusiform intracranial vertebral aneurysm not amenable to endovascular treatment: technical note

Background

Symptomatic fusiform intracranial vertebral artery aneurysms pose a formidable treatment challenge when not amenable to endovascular treatment. In this paper, we illustrate the microsurgical management of such an aneurysm.

Methods

To prevent neurological deterioration, anatomical reconstruction preserving all vessels including posterior inferior cerebellar artery and perforators is essential. In this case illustration, the occipital artery was used as a donor to a perforator originating from the aneurysmal segment. This bypass was performed in an end-to-side fashion. Subsequently, the aneurysmal component of the vertebral artery was resected and an end-to-side (V4 to V3) bypass was performed using a radial artery graft.

Results

The patient achieved complete resection of the aneurysm preserving normal anatomy of the posterior circulation without any ischemic complications.

Conclusions

Complex cerebral artery bypass techniques are essential in the armamentarium of cerebrovascular for the treatment of complex lesions not amenable to endovascular therapy.