Excessive Cerebrospinal Fluid Drainage Research Articles

Supratentorial Acute Subdural Hematoma During Fully Endoscopic Microvascular Decompression Surgery for Hemifacial Spasm

The endoscope has been widely used in microvascular decompression (MVD), which is the best curative treatment for hemifacial spasm. Supratentorial subdural hematoma (SDH) is rarely happened in MVD. The authors report 2 cases of SDH during full endoscopic MVD. The origin of bleeding is not confirmed during the operation. Rapid and excessive drainage of cerebrospinal fluid and the operation position may result the rupture of bridging veins, which result in the occurrence of SDH. However, there is no clear evidence to explain the clinical symptoms.

Clinical Study of Cranioplasty Combined With Ipsilateral Ventriculoperitoneal Shunt in the Treatment of Skull Defects With Hydrocephalus.

To explore the clinical effect and safety of cranioplasty combined with ipsilateral ventriculoperitoneal shunts in the treatment of skull defects with hydrocephalus. The clinical data of 78 patients with skull defects with hydrocephalus were analyzed retrospectively. All patients were treated with cranioplasty and ventriculoperitoneal shunts in 1 stage, including 35 cases of cranioplasty combined with ipsilateral ventriculoperitoneal shunts (ipsilateral operation group) and 43 cases of contralateral operations (contralateral operation group). The incision length (28.97 ± 4.55 cm), operation time (139.00 ± 42.27 minutes), and intraoperative hemorrhage (174.57 ± 79.35 mL) in the ipsilateral operation group were significantly better than those in the contralateral operation group (respectively they were 37.15 ± 5.83 cm, 214.07 ± 34.35 minutes, and 257.21 ± 72.02 mL), and the difference was statistically significant (t = 6.786, 8.656, and 4.815, all P < 0.05). The degree of postoperative hydrocephalus was significantly improved in both groups, but there was no statistically significant difference in the degree of hydrocephalus between the 2 groups (P > 0.05). Among the postoperative complications, there was no statistically significant difference in infection, epilepsy, subdural effusion, titanium plate effusion, or excessive cerebrospinal fluid drainage between the 2 groups (P > 0.05), but the incidence of intracranial hemorrhage in the ipsilateral operation group (2.86%) was significantly lower than that in the contralateral operation group (20.93%, χ2 = 4.138, P = 0.042). The postoperative Glasgow Coma Scale scores of the 2 groups were improved compared with those before the operation (P < 0.05), and there was no statistically significant difference in the postoperative Glasgow Coma Scale scores (P > 0.05). At 6 months after surgery, there was no statistically significant difference in Glasgow Outcome Scale effectiveness between the 2 groups (χ2 = 0.005, P = 0.944). Cranioplasty combined with ipsilateral ventriculoperitoneal shunt has the same therapeutic effect as a contralateral operation, but it has the advantage of a short operation time, less intraoperative trauma, less bleeding, and less risk of intracranial hemorrhage, which is suitable for clinical applications.

Case Report: Direct Visualization of the Nervus Intermedius During the Microvascular Decompression Procedure: Should We Take It Seriously?

Background: Nervus intermedius neuralgia (NIN), known as geniculate neuralgia (GN), is an uncommon cranial nerve disease caused by an offending vessel compressing the nervus intermedius (NI). Microvascular decompression (MVD) has now become a valued treatment approach for NIN because it can resolve neurovascular conflict (NVC) at the root entry zone of the NI. In the era of continuously optimizing and improving the surgical technique of MVD, further minimization of all possible postoperative complications is not only welcome but also necessary.Objective: The aim of this work is to assess the postoperative outcome of direct visualization of the NI during the MVD procedure.Methods: This study retrospectively reviewed the clinical records of a group of seven consecutive patients with NIN who underwent MVD in the period of 2013–2020 in our clinic and 16 studies reported NIN patients who underwent MVD in the period of 2007–2020.Results: In total, 91.3% of all patients experienced immediate and complete relief of cranial neuralgia after MVD. Six of 23 patients have experienced direct visualization of the NI intraoperatively, and 66.7% of those patients had complications such as facial paralysis, dysacousia, or a combination of these conditions postoperatively. Slight surgical approach-related complications such as complaints associated with excessive drainage of cerebrospinal fluid (CSF), nausea and vertigo, and delayed wound union were observed in 80% of the remaining 15 patients, and these symptoms are totally relieved in the telephone and outpatient follow-up after 6 months.Conclusion: Our case series shows that MVD produced immediate pain relief in the majority of NIN patients. MVD carries surgical risk, especially in patients who experience direct visualization of the NI after mechanical stretch and blunt dissection in surgical procedures. Attempts to avoid mechanical stretch and blunt dissection of the compressed nerve were important for intraoperative neuroprotection, especially facial nerve protection

Microvascular Decompression of the VII/VIII Cranial Nerve Complex for the Treatment of Intermediate Nerve Neuralgia: A Retrospective Case Series.

Intermediate nerve neuralgia (INN) is a rare and often overlooked form of primary otalgia. The pathophysiological mechanism is unknown, although one of the possible contributing factors is a neurovascular conflict at the root entry zone of the intermediate nerve. The pain can be severely debilitating, and the palette of treatment options is small. To assess the outcome of microvascular decompression (MVD) of the VII/VIII cranial nerve complex for treating INN. We retrospectively reviewed the records of a group of 8 consecutive patients with INN who underwent MVD of the VII/VIII cranial nerve complex in the period 1994 to 2015. In total, 7 of the 8 patients experienced almost immediate and complete relief of pain, which remained at long-term follow-up (mean 35 mo ± 24 mo, range 8-84 mo). Postoperatively, 1 patient had a cerebrospinal fluid (CSF) leak, 3 patients experienced permanent ipsilateral hearing loss, and 3 patients had temporary complaints associated with excessive drainage of CSF. This study suggests MVD as a valid treatment for medically refractory INN. MVD carries surgical risk, but given the severity of complaints of these patients, we believe the treatment benefits outweigh the associated complications.

Cerebral Hernia Caused By Epidural Hygroma Due to Excessive Drainage of Cerebrospinal Fluid: A Rare Case and Literature Review

The cerebral hernia is usually caused by intracranial hematoma, tumor, abscess. Here, we report a rare case of cerebral hernia caused by severe epidural hygroma. The patient was a 51-year-old male, with a large, right-sided skull defect and severe scalp depression, who had received a decompressive craniectomy for traumatic brain injury and a lumboperitoneal shunt for secondary hydrocephalus 6 months earlier. A cranioplasty with titanium mesh was performed after admitted. Unfortunately, he suffered from a complication of epidural fluid collection. Through repeated local treatment of the hygroma, the patient was not better but rather became more and more serious, and developed to cerebral hernia eventually. However, after finding out the root cause, the patient got dramatically improvement just by elevating the valve pressure of the lumboperitoneal shunt. The case and literature review are instructive to the treatment of patients with skull bone defect associated with hydrocephalus.

Remote cerebellar hemorrhage after unruptured cerebral aneurysm surgery: two cases report.

Remote cerebellar hemorrhage (RCH) occurring distant to the site of original surgery, such as supratentorial or spinal surgery, is rare but potentially fatal. Because the pathophysiology of RCH is thought to be excessive cerebrospinal fluid drainage during the perioperative periods, its diagnosis usually depends on the occurrence of unexpected neurologic disturbances and/or postoperative brain computerized tomography imaging. Because of its rarity, RCH-associated neurologic disturbances such as delayed awakening or nausea and vomiting may often be misdiagnosed as the effects of residual anesthetics or the effect of postoperative analgesic agents unless radiologic images are taken. Treatment for RCH ranges from conservative treatment to decompressive craniectomy, with prognoses ranging from complete resolution to fatality. Here, we report two cases of RCH after surgical clipping of an unruptured cerebral aneurysm of the anterior communicating artery and review anesthetic considerations.

Acute Subdural Hematoma Following Thoracoabdominal Aortic Repair in a Patient with Marfan Syndrome: A Rare Complication of Cerebrospinal Fluid Drainage

Cerebrospinal fluid (CSF) drainage is a routinely used adjunct in operation of thoracoabdominal aortic aneurysm (TAAA), which may reduce the incidence of perioperative paraplegia by improving spinal cord perfusion. Neurological complications of CSF drainage have been reported, possibly due to excessive CSF drainage, and acute subdural hematoma (SDH) in particular may lead to catastrophic complications. We present a rare case of acute SDH due to CSF drainage that was not excessive, after TAAA repair in a patient with Marfan syndrome, who recovered without invasive treatment.

General solutions to poroviscoelastic model of hydrocephalic human brain tissue

Hydrocephalus is a well-known disorder of brain fluidic system. It is commonly associated with complexities in cerebrospinal fluid (CSF) circulation in brain. In this paper, hydrocephalus and shunting surgery which is used in its treatment are modeled. Brain tissues are considered to follow a poroviscoelastic constitutive model in order to address the effects of time dependence of mechanical properties of soft tissues and fluid flow hydraulics. Our solution draws from Biot's theory of poroelasticity, generalized to account for viscoelastic effects through the correspondence principle. Geometrically, the brain is conceived to be spherically symmetric, where the ventricles are assumed to be a hollow concentric space filled with cerebrospinal fluid. A generalized Kelvin model is considered for the rheological properties of brain tissues. The solution presented is useful in the analysis of the disorder of hydrocephalus as well as the treatment associated with it, namely, ventriclostomy surgery. The sensitivity of the solution to various factors such as aqueduct blockage level and trabeculae stiffness is thoroughly analyzed using numerical examples. Results indicate that partial aqueduct stenosis may be a cause of hydrocephalus. However, only severe occlusion of the aqueduct can cause a significant increase in the ventricle and brain's extracellular fluid pressure. Ventriculostomy shunts are commonly used as a remedy to hydrocephalus. They serve to reduce the ventricular pressure to the normal level. However, sensitivity analysis on the shunt's fluid deliverability parameter has shown that inappropriate design or selection of design shunt may cause under-drainage or over-drainage of the ventricles. Excessive drainage of CSF may increase the normal tensile stress on trabeculae. It can cause rupture of superior cerebral veins or damage to trabeculae or even brain tissues which in turn may lead to subdural hematoma, a common side-effect of the surgery. These Post-Surgery Reaction (PSR) patterns might occur on much larger time scales than those of the surgery itself, depending on the flow conductivity parameters of the brain. The viscoelastic effects can be significant contingent on the long term tissue moduli and their contrast with the initial ones.

Does ventricular opening promote remote cerebellar haemorrhage ?

Cerebellar haemorrhage after supratentorial craniotomy is a rare complication Because of its significant morbidity and mortality rates, being aware of this complication is important for early diagnosis. In a 30-year-old male with multiple intracranial cavernomas, remote cerebellar haemorrhage (RCH) was observed after removal of symptomatic left temporal lesion. The lateral wall of the temporal horn that was tightly attached to the cavernoma was also opened and excessive drainage of the CSF occurred. The haemorrhage is attributed to opening of the ventricle wall and excessive drainage of cerebrospinal fluid (CSF) during the procedure.

Surgery in sitting position in patient with ventriculoperitoneal shunt in situ may be hazardous!

Dear Editor: Complications in sitting position are encountered more often than other surgical positions [1]. Literature search did not reveal any case demonstrating development of an extradural hematoma as a result of surgery in sitting position. We report a case of a 4-year-old female child, weighing 10 kg, admitted in our neurosurgical ward with complaints of headache, vomiting, and difficulty in walking for the last 6 months. A magnetic resonance image scan revealed a contrast enhanced lesion in the pineal region suggestive of pineal tumor. She had earlier undergone endoscopic biopsy removal and a right ventriculoperitoneal shunt surgery. Her medical history was unremarkable, and all preoperative routine investigations were within normal limits. She was scheduled for an elective midline suboccipital craniectomy in sitting position. Following a standard fasting protocol, the child was premedicated with oral atropine 0.4 mg, an hour before surgery. Inside the operation theater routine monitors were attached. General anesthesia was induced with fentanyl 20 mcg and thiopentone 50 mg. To facilitate tracheal intubation with cuffed tube size 5.0, rocuronium 10 mg was administered. Anesthesia was maintained with isoflurane in oxygen and nitrous oxide mixture and intermittent boli of fentanyl 1 mcg/kg and rocuronium 0.1 mg/kg. A double lumen central venous catheter was placed in the right subclavian vein. An arterial line placed in the right dorsalis pedis artery allowed continuous monitoring of blood pressure. The child was placed in sitting position with head supported in a three-pin head rest. A near total excision of the tumor was performed by supracerebellar infratentorial approach. The surgical and anesthetic course lasting approximately 4 h was uneventful. There was no episode of venous air embolism. It was planned to mechanically ventilate the lungs until spontaneous reversal of neuromuscular blockade. The patient was shifted for routine CT scan postoperatively, which revealed a large pneumocephalus (Fig. 1a) along with a high right parietal hematoma measuring 4.8× 1.3 cm (Fig. 1b). However, there was no midline shift and mass effect visible on the scan. A burr hole evacuation of hematoma was performed, and patient was weaned off mechanical ventilation on the second postoperative day. A repeat CT scan revealed resolving pneumocephalus, and no other abnormality. We believe that the ventriculoperitoneal shunt tube in situ may have resulted in such a complication. Excessive drainage of cerebrospinal fluid via the drain could have resulted in intracranial hypotension causing rupture of bridging veins, leading to hematoma formation. H. Prabhakar :G. P. Singh :A. Bindra Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India 110029

Cerebral epidural hematoma following cerebrospinal fluid drainage during thoracoabdominal aortic repair

Cerebrospinal fluid (CSF) drainage is a common adjunct to thoracoabdominal aortic aneurysm (TAAA) repair. CSF drainage may improve perioperative spinal cord perfusion and thereby decrease the incidence of paraplegia or paraparesis. Complications of CSF drainage may arise. We present a case of cerebral epidural hematoma (EDH), possibly arising from excessive CSF drainage, during thoracoabdominal aortic repair.

CSF overdrainage in shunted intracranial arachnoid cysts: a series and review

Cerebrospinal fluid (CSF) overdrainage in hydrocephalus is well recognized. Overshunting following cysto-peritoneal (CP) drainage in patients with arachnoid cysts (AC) is rarely documented. We report five patients with acquired Chiari malformation I and three with posterior fossa overcrowding due to excessive CSF drainage in shunted intracranial ACs. We review our observations and discuss the current knowledge on the pathogenesis and management of this complication. The medical records of the eight patients were analyzed in regard to clinical manifestation, cyst and shunt characteristics, management, and outcomes. Mean age of the patients was 5.5 years. After an average interval of 5 years, five patients developed symptoms related to hindbrain herniation and three to severe shunt overdrainage following CP shunting. Several management modalities were utilized that achieved a good result in seven instances. Some shunted ACs may evolve with overdrainage syndromes. Posterior fossa overcrowding and tonsillar herniation constitute their most severe forms. CSF hypotension, bone changes, venous engorgement, and probably cerebral chronic edema at the posterior fossa constitute the main factors involved in the pathogenesis of this entity. We also review previous instances of acquired Chiari malformation originating after AC shunting. Posterior fossa overcrowding and acquired Chiari I malformation can develop after excessive CSF drainage of intracranial ACs. Overshunting manifestations require prompt recognition and management. Preventive measures consist of making a stringent selection of cases being considered for surgery, avoiding CP drainage, and placing of a programmable valve as initial treatment of intracranial ACs if shunting is considered.

Unilateral hearing loss following shunt placement for normal pressure hydrocephalus with a unilateral patent cochlear aqueduct

Hearing loss in patients who have undergone shunt placement for a hydrocephalus is perhaps an underestimated complication rather than a rare event. There appears to be a correlation between the occurrence of hearing loss and patient characteristics consistent with excessive drainage of cerebrospinal fluid (CSF) and patent cochlear aqueduct (CA). We present the case of a 77-year-old man with unilateral dominant sensorineural hearing loss after a shunt placement for normal pressure hydrocephalus (NPH) combined with a patent cochlear aqueduct. Based on our experience and a review of the literature, we suggest an early restoration of the reduced CSF pressure using a programmable valve as a treatment strategy, which might prevent the persistent hearing loss.

Case 3—2005 Risk and Benefits of Cerebrospinal Fluid Drainage During Thoracoabdominal Aortic Aneurysm Surgery

Repair of descending thoracic and thoracoabdominal aortic aneurysms (TAAAs) is associated with a substantial risk of perioperative spinal cord ischemia that may or may not lead to permanent postoperative paralysis. Several techniques that aim to increase the ischemia tolerance time of the spinal cord during the period of aortic cross-clamping have been described in the literature. 1 Afifi S. Cerebrospinal fluid drainage protects the spinal cord during thoracoabdominal aortic reconstruction surgery. J Cardiothorac Vasc Anesth. 2002; 16: 643-649 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar Hypothermia, left heart bypass, various shunts, myriad drugs, and cerebrospinal fluid (CSF) drainage have all been used alone or in combination to potentially improve neurologic outcome after surgery. CSF drainage and distal aortic perfusion have been shown to lower the incidence of neurologic complications after repair of type I and type II TAAAs. 2 Coselli J. Cerebrospinal fluid drainage reduces paraplegia after thoracoabdominal aortic aneurysm repair Results of a randomized clinical trial. J Vasc Surg. 2002; 35: 631-639 Abstract Full Text Full Text PDF PubMed Scopus (527) Google Scholar Distal aortic perfusion increases distal aortic pressure, and CSF drainage decreases CSF pressure. These techniques potentially lead to an augmentation of spinal cord perfusion pressure during the period of aortic cross-clamping. However, CSF drainage can be associated with potentially serious complications, including fracture of the catheter during removal, catheter-associated meningitis, and/or temporary abducens nerve palsy, among others. 3 Cheung A.T. Pochettino A. Guvakov D.V. et al. Safety of lumbar drains in thoracic aortic operations performed with extracorporeal circulation. Ann Thorac Surg. 2003; 76: 1190-1197 Abstract Full Text Full Text PDF PubMed Scopus (76) Google Scholar Also, epidural hematoma at the catheter insertion site can complicate the clinical assessment of postoperative spinal ischemic injury. 4 Weaver K. Weisman D.B. Farber M. et al. Complications of lumbar drainage after thoracoabdominal aortic aneurysm repair. J Vasc Surg. 2001; 34: 623-627 Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Intracranial subdural hematomas, with excessive CSF drainage, have also been reported and are associated with significant morbidity and mortality. 5 Dardik A. Perler B.A. Roseborough G.S. et al. Subdural hematoma after thoracoabdominal aortic aneurysm repair An underreported complication of spinal fluid drainage?. J Vasc Surg. 2002; 36: 47-50 Abstract Full Text PDF PubMed Scopus (122) Google Scholar Subsequently, some authors have challenged the efficacy of CSF drainage and question the acceptable risk:benefit ratio of the technique. 6 Wallace L. Cerebrospinal fluid drainage does not protect the spinal cord during thoracoabdominal aortic reconstruction surgery. J Cardiothorac Vasc Anesth. 2002; 16: 650-652 Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar , 7 Ling E. Arellano R. Systematic overview of the evidence supporting the use of cerebrospinal fluid drainage in thoracoabdominal aneurysm surgery for prevention of paraplegia. Anesthesiology. 2000; 93: 1115-1122 Crossref PubMed Scopus (48) Google Scholar

Experience with a programmable valve shunt system

The goal of this study was to clarify the efficacy of the Codman Hakim programmable valve. Clinical data obtained in 179 patients with hydrocephalus or other intracranial fluid-accumulating diseases were analyzed. Shunt placement operations were effective in 168 patients, approximately one half (50.6%) of whose devices required reprogramming of opening pressure postoperatively. This was a significantly larger number of shunts than the authors had thought would need reprogramming. Extremely narrowed ventricles observed on computerized tomography scans, as well as clinical symptoms related to inadequate or excessive cerebrospinal fluid drainage, improved in patients after shunt reprogramming. Shunt reprogramming frequently was necessary in patients with posthemorrhagic acute hydrocephalus; the programmable valve proved particularly beneficial for such patients. Subdural effusion and arachnoid cyst also proved to be good indications for use of the valve. Twelve patients (7%) suffered complications postoperatively. The most common complication was valve obstruction, which occurred in five patients, most of whom had brain tumors. The programmable valve was beneficial for the treatment of hydrocephalus and other intracranial fluid-accumulating diseases. It is important to be careful in selecting patients for treatment with the programmable valve, because complications involving the valve seem more likely in brain tumor cases. The valve proved to be poorly resistant to magnetic fields; therefore, it is essential to confirm opening pressure after every magnetic resonance imaging examination. The authors recommend that an identification system for patients be developed so that medical personnel will be aware of the presence of the valve and the previous setting of opening pressure.

Arachnoid cyst as a complication of ventricular shunting

Overdrainage of cerebrospinal fluid (CSF) is a well-known complication of shunting procedures. Several clinical manifestations of excessive drainage of CSF have been documented, such as subdural hematoma, subdural effusions, slit ventricles, isolated IV ventricle, etc. To the authors' knowledge, this is the first report of an arachnoid cyst due to the excessive function of a VP shunt.