Subject(s)
Autonomic Nervous System Diseases/diagnosis , Autonomic Nervous System Diseases/physiopathology , Cerebellar Diseases/diagnosis , Intracranial Hemorrhages/diagnosis , Thalamus/pathology , Autonomic Nervous System Diseases/etiology , Cerebellar Diseases/complications , Cerebellar Diseases/diagnostic imaging , Fever/etiology , Humans , Hyperhidrosis/etiology , Hypertension/etiology , Intracranial Hemorrhages/complications , Intracranial Hemorrhages/diagnostic imaging , Male , Middle Aged , Mydriasis/etiology , Tachycardia/etiology , Thalamus/diagnostic imagingABSTRACT
BACKGROUND: The use of extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support is indicated for refractory respiratory failure but carries a high morbidity and mortality in the neurosurgical setting due to associated risks of intracranial hemorrhage. CASE DESCRIPTION: We describe the case of a 62-year-old man who underwent craniotomy for resection of an esthesioneuroblastoma involving the anterior skull base and extending intracranially, through the cribriform plate into the right epidural space. He developed refractory hypoxemic and hypercapnic respiratory failure and circulatory shock in the immediate postoperative period. Our patient was successfully treated with ECMO after other aggressive resuscitative measures proved unsuccessful for several hours. The patient was managed with ECMO for 6 days, after which he was successfully weaned without developing any neurologic complications. CONCLUSION: Our case report is significant because it describes the safe use of ECMO in a controversial setting because our patient had recently undergone craniotomy. We conclude that in dire circumstances the use of ECMO is appropriate and may be safe even in the setting of recent craniotomy.
Subject(s)
Esthesioneuroblastoma, Olfactory/surgery , Nasal Cavity , Nose Neoplasms/surgery , Postoperative Complications/therapy , Respiratory Insufficiency/therapy , Craniotomy , Extracorporeal Membrane Oxygenation , Humans , Hypercapnia/therapy , Hypoxia/therapy , Male , Middle Aged , Neurosurgical Procedures , Shock/therapyABSTRACT
OBJECTIVE: An inflammatory response occurs after aneurysmal subarachnoid hemorrhage (aSAH) and predicts poor outcomes. Glucocorticoids suppress inflammation and promote fluid retention. Dexamethasone is often administered after aSAH for postoperative cerebral edema and refractory headache. Our objective was to examine the impact of dexamethasone use on functional outcomes and delayed cerebral ischemia (DCI) after aSAH. METHODS: Patients with aSAH admitted between 2010 and 2015 were included; the data source was a single-center subarachnoid hemorrhage registry. The intervention of interest was a dexamethasone taper used <7 days from ictus. The primary outcome was poor discharge functional outcome, with a modified Rankin Scale score >3. Other outcomes included DCI and infection. A propensity score for use of dexamethasone was calculated using a logistic regression model that included potential predictors of dexamethasone use and outcome. The impact of dexamethasone on outcomes of interest was calculated and the propensity score was controlled for. RESULTS: A total of 440 patients with subarachnoid hemorrhage were admitted during the study period and 309 met eligibility criteria. Dexamethasone was administered in 101 patients (33%). A total of 127 patients (41%) had a discharge modified Rankin Scale score >3, 105 (34%) developed DCI, and 94 (30%) developed an infection. After propensity score analysis, dexamethasone use was associated with a significant reduction in poor functional outcomes (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.19-0.66) but showed no significant association with DCI (OR, 0.93; 95% CI, 0.53-1.64) or infection (OR, 0.60; 95% CI, 0.34-1.06). CONCLUSIONS: Dexamethasone use after aSAH was associated with a reduction in poor functional outcomes at discharge but not DCI, controlling for predictors of dexamethasone use.
