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Journal of Neurosurgical Sciences Apr 2024Although endoscopic techniques have become more widespread in repair of frontal sinus (FS) defects, certain pathologies still require open approach (extensive trauma or...
BACKGROUND
Although endoscopic techniques have become more widespread in repair of frontal sinus (FS) defects, certain pathologies still require open approach (extensive trauma or tumors). Under certain circumstances even multiple complex open reconstructive procedures might fail to resolve persistent pneumocephalus or CSF leak and subsequently surgeons tend to escalate the invasiveness and employ even more complex and aggressive approaches. We present our experience treating persistent pneumocephalus or CSF leak after previously failed transcranial reconstruction utilizing an endoscopic endonasal approach (EEA).
METHODS
We retrospectively reviewed a prospectively maintained database of all patients undergoing an EEA for repair of persistent pneumocephalus or CSF leak following FS cranialization between 2016 and 2020.
RESULTS
Six patients who underwent cranialization of the FS with subsequent persistent pneumocephalus or CSF leak were identified; two patients suffered a traumatic fracture of the FS, remaining four patients had undergone previous cranial surgery. Clear violation of the FS was not recognized in one patient. All patients underwent cranialization of the FS either directly following initial craniotomy or during open repair of a FS fracture. Two patients underwent multiple transcranial surgeries including using vascularized free tissue transfer. Complete cessation of pneumocephalus/CSF leak was achieved in 83.3% (5/6) after the first and 100% (6/6) after two endoscopic procedures. No morbidity or mortality resulted from the endoscopic procedure.
CONCLUSIONS
Skull base defects following a failed cranialization of FS are usually located in or in close proximity to the frontal recess. These defects can be safely and effectively repaired via an EEA.
PubMed: 38619187
DOI: 10.23736/S0390-5616.24.06202-7 -
Tremor and Other Hyperkinetic Movements... 2024We present the case of a patient who developed intra-operative pneumocephalus during left globus pallidus internus deep brain stimulation (DBS) placement for Parkinson's...
CLINICAL VIGNETTE
We present the case of a patient who developed intra-operative pneumocephalus during left globus pallidus internus deep brain stimulation (DBS) placement for Parkinson's disease (PD). Microelectrode recording (MER) revealed that we were anterior and lateral to the intended target.
CLINICAL DILEMMA
Clinically, we suspected brain shift from pneumocephalus. Removal of the guide-tube for readjustment of the brain target would have resulted in the introduction of movement resulting from brain shift and from displacement from the planned trajectory.
CLINICAL SOLUTION
We elected to leave the guide-tube cannula in place and to pass the final DBS lead into a channel that was located posterior-medially from the center microelectrode pass.
GAP IN KNOWLEDGE
Surgical techniques which can be employed to minimize brain shift in the operating room setting are critical for reduction in variation of the final DBS lead placement. Pneumocephalus after dural opening is one potential cause of brain shift. The recognition that the removal of a guide-tube cannula could worsen brain shift creates an opportunity for an intraoperative team to maintain the advantage of the 'fork' in the brain provided by the initial procedure's requirement of guide-tube placement.
Topics: Humans; Deep Brain Stimulation; Pneumocephalus; Brain; Globus Pallidus; Movement
PubMed: 38617832
DOI: 10.5334/tohm.873 -
Neurosurgical Review Mar 2024Burr hole craniotomy is a common technique employed in the treatment of chronic subdural hematoma. However, its effectiveness and the occurrence of additional... (Meta-Analysis)
Meta-Analysis Review
Burr hole craniotomy is a common technique employed in the treatment of chronic subdural hematoma. However, its effectiveness and the occurrence of additional complications with various irrigation techniques utilized during the surgery remain unclear. The paper aims to compare the effectiveness and safety of burr hole craniotomy with and without irrigation in the treatment of chronic subdural hematoma. We conducted a systematic review by searching PubMed, Cochrane Library, Scopus, Ovid, and Web of Science for comparative studies that fit the eligibility criteria. All studies up to January 2023 were included, and the two groups were compared based on five primary outcomes using Review Manager Software. Data reported as odds ratio (OR) or risk ratio (RR) and 95% confidence interval (CI). A p-value of less than 0.05 was considered statistically significant. Our analysis included 12 studies with a total of 1581 patients. There was no significant difference between the two techniques in terms of recurrence rate (OR = 0.94; 95% CI [0.55, 1.06], p-value = 0.81) and mortality rate (RR = 1.05, 95% CI [0.46, 2.40], p-value = 0.91). Similarly, there was no significant difference in postoperative infection (RR = 1.15, 95% CI [0.16, 8.05], p-value = 0.89) or postoperative pneumocephalus (RR = 2.56, 95% CI [0.95, 6.89], p-value = 0.06). The burr hole drainage with irrigation technique was insignificantly associated with a higher risk of postoperative hemorrhagic complication (RR = 2.23, 95% CI [0.94, 5.29], p-value = 0.07); however, sensitivity analysis showed significant association based on the results of two studies (RR = 4.6, 95% CI [1.23, 17.25], p-value = 0.024). The two techniques showed comparable recurrence, mortality rate, postoperative infection, and postoperative pneumocephalus results. However, irrigation in burr hole craniotomy could possibly have a higher risk of postoperative hemorrhage compared with no irrigation, as observed during sensitivity analysis, which requires to be confirmed by other studies. Further research and randomized controlled trials are required to understand these observations better and their applicability in clinical practice.
Topics: Humans; Treatment Outcome; Hematoma, Subdural, Chronic; Pneumocephalus; Craniotomy; Trephining; Drainage; Postoperative Complications; Recurrence; Retrospective Studies
PubMed: 38538863
DOI: 10.1007/s10143-024-02368-2 -
Indian Journal of Surgical Oncology Mar 2024Watertight repair of the skull base defect is necessary during endonasal skull base surgery to avoid postoperative CSF leak (poCSFl) and consequent intracranial...
Watertight repair of the skull base defect is necessary during endonasal skull base surgery to avoid postoperative CSF leak (poCSFl) and consequent intracranial complications. Various techniques have been described for reconstructing sphenoid-sellar defects with varying success rates. We have described the immediate and long-term outcomes following the reconstruction of sphenoid-sellar defects with our technique. A retrospective analysis of the patients following transsphenoidal sellar surgery underwent barrier restoring reconstruction by multi-layered (inlay-overlay) with autologous thigh fat, fascia lata, fibrin glue, knitted collagen, and absorbable gelatin sponge (modified gasket seal technique). A total of 44 patients were included in the study ( = 44). Reconstruction with modified gasket seal technique was done for all patients. 26 (59.1%) had intraoperative CSF leak (ioCSFl), and 9 (20.4%) patients had grade 3 Esposito-Kelly ioCSFl requiring adjunct short-term pressure reducing procedure (Lumbar drain) intraoperatively. 11/44 (25%) had poCSFl, 7/11 patients with poCSFl were managed conservatively, and 4/11 patients required rescue second surgery and ventriculoperitoneal shunting. 1 (2.3%) had severe meningitis and succumbed to it. Pneumocephalus was seen in 6 (13.6%). Multivariate analysis showed that revision surgery, GH-secreting tumors, and defects extending to the suprasellar region had higher chances of poCSFl ( < 0.001). All 43 alive patients had no CSF leak on long-term follow-up. The modified gasket seal technique is a viable technique for endoscopic sellar reconstruction for ioCSFl with an immediate success rate of 79.6% and 97.72% in the long term in preventing the postoperative CSF leak with a 13.6% rate of meningitis.
PubMed: 38511043
DOI: 10.1007/s13193-023-01826-5 -
Brain & Spine 2024The reconstruction of frontobasal defects following oncologic resections of paranasal and anterior skull base (ASB) malignancies remains challenging. Ineffective...
Dural reconstruction with or without a bone graft of paranasal and anterior skullbase malignancies: Retrospective single-center analysis of 11 cases and review of literature.
INTRODUCTION
The reconstruction of frontobasal defects following oncologic resections of paranasal and anterior skull base (ASB) malignancies remains challenging. Ineffective reconstruction could lead to cerebrospinal fluid leak, meningitis, and tension pneumocephalus.
RESEARCH QUESTION
Aim of this investigation was to analyse postoperative complication rates with or without bone graft for anterior skull base reconstruction.
MATERIAL AND METHODS
In this retrospective study, we included patients following resection of paranasal and/or anterior skull base malignancies between October 2013 and December 2022. Complications were analysed with regards to the type of skull base reconstruction.
RESULTS
Eleven patients were identified (2 female, 9 male, age (median, SD) 64 ± 14.1 years (range 38-81). There were nine cases of paranasal sinus and nasal cavity carcinomas and two cases of olfactory neuroblastomas. Overall survival was 22.5 ± 28 months (range: 5-78), progression free survival was 17.0 ± 20.3 months (range: 11-78). Bone skull base reconstruction using a split graft was performed in three cases. Postoperative complications requiring surgical intervention were seen in 33% (one tension pneumocephalus) of cases in the bone reconstruction group and 50% (three patients with cerebrospinal fluid leak, one infection) in the non-bone reconstruction group.
DISCUSSION AND CONCLUSION
The structural reinforcement of structural bone chip grafting might provide additional support of the ASB and prevent CSF leakage or encephalocele. Especially in large (>10 cm) bone defects of advanced sinonasal malignancies extending into the middle cranial fossa, the full armamentarium of reconstruction possibilities should be considered.
PubMed: 38510629
DOI: 10.1016/j.bas.2023.102740 -
World Neurosurgery May 2024Chronic subdural hematoma (CDH) is a prevalent condition in neurosurgery. Standard care includes surgical evacuation with drainage of residual subdural cavity. We... (Comparative Study)
Comparative Study
OBJECTIVES
Chronic subdural hematoma (CDH) is a prevalent condition in neurosurgery. Standard care includes surgical evacuation with drainage of residual subdural cavity. We hypothesized that effective and timely drainage of subdural space may improve clinical and radiological outcomes. This study was conducted to compare the effectiveness of standard closed drainage and underwater drainage.
METHODS
Medical data of 300 surgically treated chronic subdural hematoma CDH patients were retrospectively collected and analyzed. The patients were divided into two 2 groups: Group I with underwater drainage, and Group II with closed drainage. Groups were compared in terms of gender, age, complication rates, recurrence rates, seizure rates, and length of hospital stay.
RESULTS
Underwater drainage was found superior to closed system by all clinical and radiographic parameters. The recurrence rate was significantly lower in Group I (2%) compared to with Group II (10%). Subdural empyema was observed in 10 patients in Group II and none in Group I. The seizure rate was higher in Group II (18%) compared to with Group I (5%). Postoperative pneumocephalus rates was were 20% in Group I and 54% in Group II. The length of hospital stay was 6±2.6 days in Group I and 8.9±6.1 days in Group II. The length of intensive care unit (ICU) stay was 0.6±1.12 days in Group I and 2.7±5 days in Group II. A minority (5%) of the patients in Group II required reoperation due to recurrence.
CONCLUSIONS
The use of underwater system significantly the reduces the rates of pneumocephalus, seizures, infection, and recurrence. Additional benefits are shorter intensive care unit ICU and total hospital stays.
Topics: Humans; Hematoma, Subdural, Chronic; Male; Female; Drainage; Middle Aged; Retrospective Studies; Aged; Treatment Outcome; Adult; Length of Stay; Postoperative Complications; Neurosurgical Procedures; Aged, 80 and over
PubMed: 38479641
DOI: 10.1016/j.wneu.2024.03.004 -
Journal of Neurosurgery Mar 2024Chronic subdural hematoma (CSDH) is known to occur after endoscopic endonasal surgery (EES); however, the detailed clinical picture remains unclear. In this study, the...
OBJECTIVE
Chronic subdural hematoma (CSDH) is known to occur after endoscopic endonasal surgery (EES); however, the detailed clinical picture remains unclear. In this study, the authors aimed to examine the incidence of and risk factors for post-EES CSDH, with a focus on the quantitative evaluation of postoperative pneumocephalus.
METHODS
The authors retrospectively collected data on consecutive patients who, between November 2016 and December 2022, had undergone EES during which intraoperative cerebrospinal fluid (CSF) leakage occurred. Using CT images obtained immediately after surgery (CT0), the authors measured the extent of pneumocephalus in detail. The locations of pneumocephalus were divided into two groups: remote and local. Remote pneumocephalus was further subdivided into convexity and ventricular. The incidence of post-EES CSDH was calculated, and its risk factors were analyzed.
RESULTS
Among the 159 EES patients included in the study, Esposito grade 1, 2, and 3 intraoperative CSF leakage was confirmed in 22 (14%), 27 (17%), and 110 (69%) patients, respectively. CSDH occurred in 6 patients (3.8%). One patient (0.6%) required unilateral burr hole surgery, whereas the hematomas spontaneously disappeared in the others. All CSDHs occurred in patients with Esposito grade 3 CSF leakage and convexity pneumocephalus on CT0. In the multivariate analysis of 149 sides with convexity pneumocephalus on CT0, the product of the diameter and the thickness of convexity pneumocephalus on CT0 was significantly associated with subsequent CSDH (OR 1.21, 95% CI 1.06-1.38, p = 0.004). Using a cutoff value of 10 cm2, CSDH development could be predicted with a sensitivity of 0.82 and specificity of 0.74.
CONCLUSIONS
The incidence of post-EES CSDH is acceptably low, and surgery is rarely required. Patients with extensive convexity pneumocephalus on immediate postoperative CT are prone to develop CSDH and thus should be carefully monitored.
PubMed: 38457806
DOI: 10.3171/2024.1.JNS231953 -
Before lumbar surgery is blamed for pneumocephalus, alternative causes must be thoroughly ruled out.Revista Espanola de Anestesiologia Y... 2024
Topics: Female; Lumbar Vertebrae; Pneumocephalus; Postoperative Complications
PubMed: 38431046
DOI: 10.1016/j.redare.2024.02.026 -
The Journal of Rheumatology Mar 2024Granulomatosis with polyangiitis (GPA) is a systemic autoimmune disease that causes necrotizing vasculitis of small- to medium-sized blood vessels and necrotizing...
Granulomatosis with polyangiitis (GPA) is a systemic autoimmune disease that causes necrotizing vasculitis of small- to medium-sized blood vessels and necrotizing granulomatous inflammation, primarily of the upper and lower respiratory system. A 33-year-old woman presented with a 16-month history of headaches, nasal obstruction, and anosmia.
PubMed: 38428961
DOI: 10.3899/jrheum.2023-1231 -
Clinical Neurology and Neurosurgery Mar 2024Deep brain stimulation (DBS) surgery is an effective treatment for movement disorders. Introduction of intracranial air following dura opening in DBS surgery can result...
BACKGROUND
Deep brain stimulation (DBS) surgery is an effective treatment for movement disorders. Introduction of intracranial air following dura opening in DBS surgery can result in targeting inaccuracy and suboptimal outcomes. We develop and evaluate a simple method to minimize pneumocephalus during DBS surgery.
METHODS
A retrospective analysis of prospectively collected data was performed on patients undergoing DBS surgery at our institution from 2014 to 2022. A total of 172 leads placed in 89 patients undergoing awake or asleep DBS surgery were analyzed. Pneumocephalus volume was compared between leads placed with PMT and leads placed with standard dural opening. (112 PMT vs. 60 OPEN). Immediate post-operative high-resolution CT scans were obtained for all leads placed, from which pneumocephalus volume was determined through a semi-automated protocol with ITK-SNAP software. Awake surgery was conducted with the head positioned at 15-30°, asleep surgery was conducted at 0°.
RESULTS
PMT reduced pneumocephalus from 11.2 cm±9.2 to 0.8 cm±1.8 (P<0.0001) in the first hemisphere and from 7.6 cm ± 8.4 to 0.43 cm ± 0.9 (P<0.0001) in the second hemisphere. No differences in adverse events were noted between PMT and control cases. Lower rates of post-operative headache were observed in PMT group.
CONCLUSION
We present and validate a simple yet efficacious technique to reduce pneumocephalus during DBS surgery.
Topics: Humans; Deep Brain Stimulation; Retrospective Studies; Pneumocephalus; Brain Neoplasms; Wakefulness; Parkinson Disease
PubMed: 38422743
DOI: 10.1016/j.clineuro.2024.108174