Perioperative risk factors for major complications after bone replacement in decompressive craniectomy.

INTRODUCTION: Bone flap replacement after a decompressive craniectomy is a low complexity procedure, but with complications that can negatively impact the patient's outcome. A better knowledge of the risk factors for these complications could reduce their incidence. PATIENTS AND METHODS: A retrospective review of a series of 50 patients who underwent bone replacement after decompressive craniectomy at a tertiary center over a 10-year period was performed. Those clinical variables related to complications after replacement were recorded and their risk factors were analyzed. RESULTS: A total of 18 patients (36%) presented complications after bone flap replacement, of which 10 (55.5%) required a new surgery for their treatment. Most of the replacements (95%) were performed in the first 90 days after the craniectomy, with a tendency to present more complications compared to the subsequent period (37.8% vs 20%, p > 0.05). The most frequent complication was subdural hygroma, which appeared later than infection, the second most frequent complication. The need for ventricular drainage or tracheostomy and the mean time on mechanical ventilation, ICU admission, or waiting until bone replacement were greater in patients who presented post-replacement complications. Previous infections outside the nervous system or the surgical wound was the only risk factor for post-bone flap replacement complications (p = 0.031). CONCLUSIONS: Postoperative complications were recorded in more than a third of the patients who underwent cranial bone flap replacement, and at least half of them required a new surgery. A specific protocol aimed at controlling previous infections could reduce the risk of complications and help establish the optimal time for cranial bone flap replacement.

Investigating acetazolamide effectiveness on CSF leak in adul patients after spinal surgery / Investigación de la eficacia de la acetazolamida en la fuga de LCR en pacientes adultos después de una cirugía de column

Introduction and objectives Despite the use of acetazolamide in the management of CSF leak in most patients after CNS surgeries, there is scant evidence in the literature about the efficacy of this established protocol among adult patients in post-spinal surgery observations. We investigated the potential positive effect of acetazolamide in reducing CSF leak after spine surgery. Materials and methods We conducted a single-center, double-blind, randomized-controlled trial comparing Oral Acetazolamide plus Corrected body (prone) position (CP+A) versus Corrected body (prone) position alone(CP−A) from January 2014 to September 2015 in the Neurosurgery ward of Shariati Teaching Hospital, Tehran University of Medical Sciences, Tehran, Iran. Seventy-two Patients divided into two groups [CP−A group (n=36, 50%) and CP+A group (n=36, 50%)] were randomly assigned to this Clinical Trial study. CP+A group (maintained the 3/4 lateral position+dose of acetazolamide 20mg/kg/day in 3–4 divided doses for 7 days), and CP−A group (Control group) (maintained the 3/4 lateral position for 7 days with no acetazolamide). Results Baseline characteristics between the two groups showed no significant differences: Sex (P<0.637), Age (P<0.988) and previous CNS operation at other location besides the spine (P<0.496). Although we reported post-surgical CSF leak in 2/36 (5.55%) of CP+A group and 4/36(11.11%) of CP−A (control) group, there was no significant difference observed between the two groups (95%CI, 0.081–2.748; OR=0.471; P<0.402; Adjusted P<0.247). Additionally, no significant differences were observed when we examined surgical characteristics, such as the size of the dural opening (P<0.489) and type of operation (P<0.465). Conclusion Acetazolamide has no positive effect in controlling CSF leak after dural ... (AU)

Introducción y objetivos A pesar del uso de acetazolamida en el manejo de la fuga de LCR en la mayoría de los pacientes después de cirugías del SNC, existe escasa evidencia en la literatura sobre la eficacia de este protocolo establecido entre pacientes adultos en observaciones poscirugía de columna. Investigamos el posible efecto positivo de la acetazolamida en la reducción de la fuga de LCR después de la cirugía de columna. Materiales y métodos Realizamos un ensayo controlado aleatorio, doble ciego, de un solo centro comparando acetazolamida oral más posición corporal (prona) corregida (CP + A) versus posición corporal (prona) corregida sola (CP-A) desde enero de 2014 hasta septiembre de 2015 en la sala de neurocirugía del Hospital Docente Shariati, Universidad de Ciencias Médicas de Teherán, Teherán, Irán. Setenta y dos pacientes divididos en dos grupos [grupo CP-A (n = 36, 50%) y grupo CP + A (n = 36, 50%)] fueron asignados aleatoriamente a este ensayo clínico. Grupo CP + A (mantuvo la posición lateral 3/4 + dosis de acetazolamida 20mg/kg/día en 3-4 dosis divididas durante 7 días) y grupo CP-A (grupo Control) (mantuvo la posición lateral 3/4 durante 7 días). 7 días sin acetazolamida). Resultados Las características basales entre los dos grupos no mostraron diferencias significativas: sexo (P <0,637), edad (P <0,988) y operación previa del SNC en otra ubicación además de la columna (P <0,496). Aunque informamos fuga de LCR posquirúrgica en 2/36 (5,55%) del grupo CP + A y 4/36 (11,11%) del grupo CP-A (control), no se observaron diferencias significativas entre los dos grupos (95% IC, 0,081-2,748; OR = 0,471; P <0,402; P ajustado <0,247). Además, no se observaron diferencias significativas cuando examinamos las características quirúrgicas, como el tamaño de la abertura dural (P <0,489) y el tipo de operación (P <0,465). Conclusión La acetazolamida no tiene un efecto positivo... (AU)

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.

Coexistent Supratentorial and Infratentorial Subdural Hygromas with Hydrocephalus After Chiari Decompression Surgery: Review of Literature.

BACKGROUND: Foramen magnum decompression (FMD) is the standard procedure for Chiari I malformation. Although seemingly a straightforward procedure, recent articles have reported an increase in various complications. We describe a rare complication of coexistent supratentorial and infratentorial subdural hygromas (SDHs) with hydrocephalus noted after FMD and provide a detailed review of the literature on this topic. METHODS: A 34-year-old woman presented with strain-related suboccipital headache and myelopathy for 6 months. Imaging revealed tonsillar herniation up to C2 level and cervical syringomyelia. A standard FMD, C1 posterior arch removal, and tonsillar reduction was performed. After an initial uneventful postoperative course, she had 2 readmissions with headache, vomiting, and ataxia. Imaging showed a tense pseudomeningocele and concomitant supratentorial and infratentorial (initially right-sided, followed by left-sided) SDHs with ventriculomegaly. She was conservatively managed with antiedema measures and had excellent relief of symptoms. For the literature review, only cases with concomitant supratentorial and infratentorial SDHs with hydrocephalus were searched online and analyzed. RESULTS: Including ours, 10 cases have been reported. Mean age was 25.3 years. The male-to-female ratio was 1:2.3. Symptoms appeared an average of 12.6 days postoperatively. Treatment was with conservative management in 3 cases, and 3 cases required permanent cerebrospinal fluid diversions. Mean follow-up duration was 9.4 months (range, 1-27 months). CONCLUSIONS: Coexistent supratentorial and infratentorial SDHs with hydrocephalus after Chiari decompression is a very rare occurrence. Treatment needs to be individualized based on the predominant symptomatic lesion, and surgical options need to be judiciously considered. Good prognosis is the rule in most cases.

Delayed methotrexate excretion in infants and young children with primary central nervous system tumors and postoperative fluid collections.

PURPOSE: High-dose methotrexate (HD-MTX) has been used to treat children with central nervous system tumors. Accumulation of MTX within pleural, peritoneal, or cardiac effusions has led to delayed excretion and increased risk of systemic toxicity. This retrospective study analyzed the association of intracranial post-resection fluid collections with MTX plasma disposition in infants and young children with brain tumors. METHODS: Brain MRI findings were analyzed for postoperative intracranial fluid collections in 75 pediatric patients treated with HD-MTX and for whom serial MTX plasma concentrations (MTX) were collected. Delayed plasma excretion was defined as (MTX) ≥1 µM at 42 hours (h). Leucovorin was administered at 42 h and then every 6 h until (MTX) <0.1 µM. Population and individual MTX pharmacokinetic parameters were estimated by nonlinear mixed-effects modeling. RESULTS: Fifty-eight patients had intracranial fluid collections present. Population average (inter-individual variation) MTX clearance was 96.0 ml/min/m² (41.1 CV %) and increased with age. Of the patients with intracranial fluid collections, 24 had delayed excretion; only 2 of the 17 without fluid collections (P < 0.04) had delayed excretion. Eleven patients had grade 3 or 4 toxicities attributed to HD-MTX. No significant difference was observed in intracranial fluid collection, total leucovorin dosing, or hydration fluids between those with and without toxicity. CONCLUSIONS: Although an intracranial fluid collection is associated with delayed MTX excretion, HD-MTX can be safely administered with monitoring of infants and young children with intracranial fluid collections. Infants younger than 1 year may need additional monitoring to avoid toxicity.

Early pressure dressing for the prevention of subdural effusion secondary to decompressive craniectomy in patients with severe traumatic brain injury.

This study was performed to investigate the effect of early pressure dressing on the prevention of postoperative subdural effusion secondary to decompressive craniectomy (DC) in patients with severe traumatic brain injury (STBI). Patients with STBI who had undergone DC for refractory increased intracranial pressure between January 2008 and December 2011 (n = 169) were randomly divided into early pressure dressing (n = 82) and control (n = 87) groups. Early pressure dressing with an elastic bandage or general wrapping (control treatment) was applied 7 to 10 days after DC. Patients' age, sex, preoperative Glasgow Coma Scale score, incidence rate of subdural effusion, hospitalization time, and postoperative Glasgow Outcome Scale score were compared between groups. Intracranial pressure was measured immediately before and on the day after pressure dressing. No significant difference in age, sex, preoperative Glasgow Coma Scale score, or postoperative Glasgow Outcome Scale score was observed between groups (P > 0.05). Subdural effusion incidence rates were significantly lower in the early pressure dressing group than those in the control group (χ² = 5.449, P = 0.021), and a larger proportion of patients in the early pressure dressing group was hospitalized for 30 days or less (χ² = 5.245, P = 0.027). Early pressure dressing 7 to 10 days after DC, which is a noninvasive, simple procedure, reduced the incidence rate of subdural effusion and shortened hospitalization time after DC for STBI.

MR imaging evaluation of endoscopic cranial base reconstruction with pedicled nasoseptal flap following endoscopic endonasal skull base surgery.

INTRODUCTION: Postoperative CSF leak is the most common complication of endoscopic endonasal approach (EEA) to skull base lesions. Endoscopic multilayer closure of skull base defect using pedicled nasoseptal flaps (NSF) based off the sphenopalatine artery reduces CSF leaks. EEA robustly expands in surgical arena, yet postoperative imaging evaluation remains poorly studied. This work illustrates normal MR imaging appearance of skull base reconstruction utilizing NSFs during immediate postoperative period. METHODS: We retrospectively identified patients who had skull base reconstructions utilizing NSFs following EEAs and immediate postoperative-enhanced brain MRI. NSFs and free grafts were evaluated for signal intensity, thickness, configuration, enhancement, vascular pedicle of NSF, relationship in multilayer reconstruction, and defect coverage. Imaging findings were correlated with surgical technique and CSF leaks. RESULTS: Twenty-eight patients had 26 multilayer reconstructions and 34 NSFs. Twenty-nine NSFs showed enhancing C-shaped arc at the skull base. Of those, 26 flaps (90%) were confidently identified by visualization of their vascular pedicles, 3 were not distinguishable from adjacent mucosa and pedicles were not identified. Five NSFs showed no enhancement (1 CSF leak). Twenty-seven enhancing NSFs approximated defects with close abutment to free grafts. One flap was displaced; one incompletely covered the defect (2 CSF leaks). Fisher exact test demonstrated an association between incomplete defect coverage and displacement of NSFs with CSF leak (P=0.05). CONCLUSION: Endoscopic skull base reconstruction utilizing NSF has characteristic MR imaging appearance. Non-enhancing mucosal gap or displacement of NSF may indicate incomplete defect coverage, identifying patients at risk for CSF leak.

Intracranial application of free fasciocutaneous flaps in a novel sandwich technique for skull base reconstruction.

Free tissue transfer has been the gold standard of extensive skull base reconstruction, but the onlay of free flaps onto skull base defects carries the risk of cerebrospinal fluid (CSF) leakage. The purpose of this study was the evaluation of a novel technique of a combined sub- and onlay concept with a partially intracranially positioned folded free fasciocutaneous flap in terms of flap applicability, versatility and complication rate. Within 5 years, 7 patients with anterior (n=4), middle (n=2) or posterior (n=1) skull base defects were reconstructed with free extended lateral arm (n=3) or anterolateral thigh (n=4) flaps. The flaps were partially intracranially positioned and fixed with osteo-dermal sutures. Both flaps proved to be applicable in terms of sealing efficiency, minimizing intracranial flap volume and folding. No flap loss was observed. Specific complications consisted of one pneumocranium via an accessory frontal sinus and one cerebellar herniation due to lumbar CSF loss. No flap failure or haematoma of the intracranial flap part occurred. This new concept of intracranial positioning of fasciocutaneous flaps in a sandwich technique using osteo-dermal sutures should be considered as a primary treatment for skull base reconstruction rather than merely as a salvage manoeuvre.

Corticotomy closure avoids subdural collections after hemispherotomy.

BACKGROUND: Subdural collection is a possible adverse event that can occur after hemispherotomy. OBJECTIVE: : We describe our surgical technique to avoid subdural collection after peri-insular hemispherotomy in children. METHODS: Since 2008, we have closed the corticotomy with interrupted pial sutures and fibrinogen glue in 16 patients. RESULTS: This operative technique stopped the occurrence of postoperative subdural collection and was not associated with an increased incidence of postoperative hydrocephalus. CONCLUSION: We recommend closing ventricular access after functional hemispherotomy, notably in patients who have had a stroke.

Withstand pressure of a simple fibrin glue sealant: experimental study of mimicked sellar reconstruction in extended transsphenoidal surgery.

BACKGROUND: To examine the strength and tolerance of the fibrin glue sealant in a situation of extended transsphenoidal surgery. The withstand pressure of fibrin glue sealant was measured using a simple sellar reconstruction model. METHODS: A 15-mm diameter hole at the bottom of a 51-cm high cylinder was covered with a Gore-Tex (Gore-Tex, Tokyo, Japan) sheet. A small plate was placed on the center for a brief fixation, and 3 mL of fibrin glue was applied over the entire bottom. Then water was gradually filled in five cylinders, and the water level at leakage was measured as withstand pressures at 10 minutes and 24 hours after sealant application. The stability of the sealant under pressures of 20 and 30 cm H(2)O for 12 hours was also examined. RESULTS: The median initial withstand pressure at 10 minutes was 32 cm H(2)O (n = 5), and was significantly increased to 47.5 cm H(2)O after 24 hours (n = 4). In four of five cylinders, fibrin glue sealants were stable against a pressure of 20 cm H(2)O for 12 hours and 30 cm H(2)O for the next 12 hours. CONCLUSIONS: The withstand pressure of simple fibrin glue sealant without other biological reactions could be estimated to be more than 20 cm H(2)O after application, and increased to more than 40 cm H(2)O after 24 hours. These data are practical for neurosurgeons to comprehend the strength and limit of fibrin glue sealant and suggests the importance to control the intracranial pressure to less than 20 cm H(2)O, especially for the first 12 to 24 hours.

The use of a reconstituted collagen foil dura mater substitute in paediatric neurosurgical procedures--experience in 47 patients.

BACKGROUND: CSF leakage is a common complication of neurosurgical procedures, with defective dural suture thought to be the most frequent cause. We report our experience with a new collagen foil (TissuDura, Baxter Healthcare SA, Switzerland) utilized as dural substitute in paediatric neurosurgical procedures. METHODS: TissuDura was used in children consecutively operated on at the department of paediatric neurosurgery, Catholic University, Rome, from March 2004 to August 2007. Children underwent surgical procedures in supratentorial, infratentorial and spinal compartments. In supratentorial and spinal procedures, the dural graft was used according to the overlay technique. In the posterior fossa procedures, the underlay technique was used. RESULTS: Forty-seven patients received TissuDura during surgery. Thirty-one patients underwent surgery for the removal of posterior fossa tumours, nine for supratentorial tumours and seven for spinal dysraphisms. No CSF leakage was observed following the use of TissuDura in supratentorial procedures. Two post-operative CSF leaks occurred in patients who had undergone spinal surgery. No post-operative hydrocephalus was noted in these two surgery groups. Three cases of CSF leakage occurred in patients who had undergone posterior cranial fossa surgery. All 3 cases had an associated supratentorial ventricular dilation present prior to the removal of the tumour (one case) or occurring after the tumour excision (two cases). No clinically evident adverse reactions directly related to TissuDura were observed. CONCLUSIONS: The main advantages of TissuDura were its apparent ability to prevent CSF leakage when utilized in a specific subset of patients, and the absence of reactions or postoperative infections.

Dural augmentation: part I-evaluation of collagen matrix allografts for dural defect after craniotomy.

OBJECTIVE: Primary closure of the dura remains difficult in many neurosurgical cases. One option for dural grafting is the collagen sponge, which is available in multiple forms, namely, monolayer collagen and bilayer collagen. Our primary goal was to assess differences in the incidence of postoperative cerebrospinal fluid (CSF) leak, including fistula and pseudomeningocele, and postoperative infection between monolayer collagen and bilayer collagen grafts. METHODS: A single-center retrospective analysis of 475 consecutive neurosurgical procedures was performed. Primary endpoints were CSF leak and infection, adjusting for the impact of additional nonautologous materials. Multivariate regression analysis was used to identify predictors of postoperative CSF leak and infection. RESULTS: The overall frequency of postoperative CSF leak was 6.7%. There was no significant difference in the incidence of CSF leak based on the type of collagen sponge (monolayer versus bilayer) used (5.5% versus 7.5%, respectively; P = 0.38). The overall frequency of postoperative infection was 4.2%. There was no significant difference in the incidence of infection between groups (4.9% versus 3.8%; P = 0.54). Bilayer sponges were associated with a significantly lower incidence of CSF leak than monolayer sponges (odds ratio, 0.09; 95% confidence interval, 0.01-0.73). CONCLUSION: Bilayer collagen sponges are associated with a reduction in postoperative CSF leak, notably in posterior fossa surgery. The need for additional non-native materials is predictive of postoperative CSF leak, along with location and type of procedure. Intrinsic patient characteristics (e.g., age, diabetes, smoking) do not seem to affect the efficacy of collagen sponge dural grafts.

Should epidural drain be recommended after supratentorial craniotomy for epileptic patients?

BACKGROUND: ED was once and is still commonly applied to prevent mainly EH and subgaleal CSF collection. We designed this study to observe if ED could decrease the incidence and volume of EH and subgaleal CSF collection after supratentorial craniotomy in epileptic patients. METHODS: Three hundred forty-two epileptic patients were divided into 2 groups according to their first craniotomy date (group 1 in odd date and group 2 in even date). Patients in group 1 had ED and those in group 2 had no ED. The patient numbers and volumes of EH and subgaleal CSF collections in both groups were recorded and statistically analyzed. RESULTS: There were 22 EHs in group 1 and 20 EHs in group 2. There were 11 and 10 subgaleal CSF collections in groups 1 and 2, respectively. The average volume of EH was 13.5 +/- 8.12 and 14.65 +/- 7.72 mL in groups 1 and 2, respectively. The average volume of subgaleal CSF collection was 42.76 +/- 12.09 and 43.75 +/- 11.44 mL in groups 1 and 2, respectively. There were no statistical differences in the incidence and average volume of EH and subgaleal CSF collection between the 2 groups. CONCLUSIONS: ED cannot decrease the incidence and volume of EH and subgaleal CSF collection. ED should not be recommended after supratentorial epileptic craniotomy.