Lumbar Subarachnoid Drain Research Articles

Risk factors impacting intra- and postoperative cerebrospinal fluid rhinorrhea on the endoscopic treatment of pituitary adenomas: A retrospective study of 250 patients.

We aimed to identify the risk factors associated with intra- and postoperative cerebrospinal fluid (CSF) leakage in pituitary adenomas treated with endoscopic transsphenoidal surgery.This study is a retrospective analysis of 250 pituitary adenoma cases from January 2017 to December 2019 at our hospital. All patients underwent endoscopic endonasal transsphenoidal surgeries. Univariate and multivariate analyses were performed to investigate the risk factors associated with intra- and postoperative CSF rhinorrhea.Eighty (32.0%) and nine (3.6%) patients had intra- and postoperative CSF leakage, respectively. Tumor size was an independent risk factor for intraoperative CSF leakage (odds ratio [OR], 1.229; 95% confidence interval [CI], 1.133–1.334; P < .001); intraoperative CSF leakage was an independent risk factor for postoperative CSF leakage (OR, 7.707; 95% CI, 1.336–44.455; P = .022). Chronic respiratory disease (OR, 57.500; 95% CI, 8.031–411.682; P < .001) was also an independent risk factor for postoperative CSF leakage. Vascularized septal mucosal flap was a protective factor (OR, 0.107; 95% CI, 0.013–0.894; P = .039).Intraoperative CSF leakage is more likely to occur in large pituitary adenomas. In the presence of intraoperative CSF leakage, postoperative CSF rhinorrhea is very likely to occur. Patients with chronic respiratory disease are also more likely to develop postoperative CSF leakage. The sellar base reconstructed using vascularized nasal septal flaps can significantly decrease the risk. The Knosp grade, degree of tumor resection, and postoperative use of a lumbar subarachnoid drain did not have any effects on postoperative CSF rhinorrhea.

Pedicled Multifidus Muscle Flap To Treat Inaccessible Dural Tear In Spine Surgery: Technical Note And Preliminary Experience

To assess the usefulness, feasibility, and limitations of pedicled multifidus muscle flaps (PMMFs) for the treatment of inaccessible dural tears during spine surgery. The technique of PMMF harvesting was investigated together with relevant anatomy. We prospectively evaluated 8 patients treated with the PMMF technique between January 2017 and December 2019. Results were compared with a retrospective series of 9 patients treated with a standard technique between January 2014 and December 2016. Inclusion criteria were inaccessible dural tear or dural tear judged not amenable to direct repair because of tissue loosening. Exclusion criteria were surgical treatment of intradural disease. Clinical and demographic data of all patients were collected. Clinical evaluations were performed according to American Spinal Injury Association criteria and Oswestry Disability Index. Preoperative and postoperative computed tomography was performed in all patients. The primary end point was wound healing (cerebrospinal fluid leakage, infection, and fluid collection); secondary end points were neurologic outcome and complications. Control group: 1 death as a result of wound infection secondary to cerebrospinal fluid fistula and 2 patients needed lumbar subarachnoid drain; neurologic outcome: 3 patients improved and 6 were unchanged. Flap group: no wound-related complications were observed; neurologic outcome: 3 patients improved and 5 were unchanged. No flap-related complications were described. Flap harvesting was feasible in all cases, with an average 20 minutes adjunctive surgical time. The PMMF technique was feasible and safe; in this preliminary experience, its use is associated with lower complications as a result of dural tears but larger series are needed to confirm its effectiveness.

Prevention of Intra-Operative Cerebrospinal Fluid Leaks by Lumbar Cerebrospinal Fluid Drainage during Endoscopic Endonasal Trans- Sphenoidal Surgery for Pituitary Macroadenomas

Aim and Objective: Postoperative cerebrospinal fluid leak is a recognized complication of endoscopic endonasal trans- sphenoidal surgery for pituitary macroadenomas. In this study we assess the utility of prophylactic use of lumbar drain in preventing intra-operative cerebrospinal fluid leakage during endscopic endonasal transsphenoidal surgery for pituitary macroadenoma which will ultimately reduce the rate of persistent post-operative cerebrospinal fluid leakage.&#x0D; Materials and Methods: 34 patients who underwent endscopic endonasal transsphenoidal surgery for pituitary macroadenoma were dividedd into two groups by non-probability convenient sampling technique. In one group of which lumbar subarachnoid drain were given just before induction of anesthesia named LD Group and another group went through conventional method without giving lumbar drain named No LD Group. In all patients of LD Group 20-30 ml of CSF was drawn through lumbar drain before giving dural incision. Valsalva maneuver was used in each group to identify intraoperative CSF leaks at the end of definitive surgery before repairing the sellar floor.Zero degree rigid endoscope was used in all cases. Intraoperative CSF leak was categorized as ‘Yes’ or ‘No’ which was decided by surgeon.Lumbar drains were removed within 24 hours of operation in 16 patients of LD Group and in case 1,who developed intraoperative CSF leak, lumbar drain was removed later.&#x0D; Results: Thirty four patients were eligible for inclusion, of which 17 were assigned to the LD Group and 17 to the no LD Group. There were no statistically significant differences in patient demographics, tumor pathology, or radiology between the two groups. In LD Group intraoperative CSF leak occurred in 1(5.9%) patient and leak did not occur in 16(94.1%) patients, in No LD Group intraoperative CSF leak occurred in 14(82.4%) patients and leak did not occur in 3(17.6%) patients. Intraoperative CSF drainage significantly reduced the incidence of intraoperative CSF leaks from 82.4% in the No LD group to 5.9% in the LD group (P &lt; 0.001). There were no catheter related complications.&#x0D; Conclusion: Intraoperative CSF drainage significantly reduces the incidence of intraoperative CSF leakage in patients undergoing endoscopic endonasal transsphenoidal surgery for pituitary macroadenomas.&#x0D; Bang. J Neurosurgery 2020; 10(1): 52-56

Clinical Implementation of Novel Spinal Cord Perfusion Pressure Protocol in Acute Traumatic Spinal Cord Injury at U.S. Level I Trauma Center: TRACK-SCI Study

We sought to report the safety of implementation of a novel standard of care protocol using spinal cord perfusion pressure (SCPP) maintenance for managing traumatic spinal cord injury (SCI) in lieu of mean arterial pressure goals at a U.S. Level I trauma center. Starting in December 2017, blunt SCI patients presenting <24 hours after injury with admission American Spinal Injury Association Impairment Scale (AIS) A-C (or AIS D at neurosurgeon discretion) received lumbar subarachnoid drain (LSAD) placement for SCPP monitoring in the intensive care unit and were included in the TRACK-SCI (Transforming Research and Clinical Knowledge in Spinal Cord Injury) data registry. This SCPP protocol comprises standard care at our institution. SCPPs were monitored for 5 days (goal ≥65 mm Hg) achieved through intravenous fluids and vasopressor support. AISs were assessed at admission and day7. Fifteen patients enrolled to date were aged 60.5 ± 17 years. Injury levels were 93.3% (cervical) and 6.7% (thoracic). Admission AIS was 20.0%/20.0%/26.7%/33.3% for A/B/C/D. All patients maintained mean SCPP ≥65 mm Hg during monitoring. Fourteen of 15 cases required surgical decompression and stabilization with time to surgery 8.8 ± 7.1 hours (71.4% <12 hours). At day 7, 33.3% overall and 50% of initial AIS A-C had an improved AIS. Length of stay was 14.7 ± 8.3 days. None had LSAD-related complications. There were 7 respiratory complications. One patient expired after transfer to comfort care. In our initial experience of 15 patients with acute SCI, standardized SCPP goal-directed care based on LSAD monitoring for 5 days was feasible. There were no SCPP-related complications. This is the first report of SCPP implementation as clinical standard of care in acute SCI.

Initial Experience of Spinal Cord Perfusion Pressure Goals in Lieu of Mean Arterial Pressure Goals in Acute Traumatic Spinal Cord Injury at a United States Level I Trauma Center: A Transforming Research and Clinical Knowledge-Spinal Cord Injury Study

Abstract INTRODUCTION Management of traumatic spinal cord injury (SCI) includes urgent decompression and decreasing secondary injury through blood pressure augmentation. Mean arterial pressure (MAP) targets have been the standard of care for decades, however recent clinical trial data have demonstrated the relationship between spinal cord perfusion pressure (SCPP) and neurologic recovery. These data led to implementation of a novel standard of care protocol at our institution focused on SCPP, in lieu of MAP goals. We provide the initial experience of implementation of protocolized SCPP goals for acute SCI at a US level I trauma center. METHODS Starting December 2017, all moderate/severe blunt SCI patients at our institution presenting &lt; 24 h of injury received lumbar subarachnoid drain placement (LSAD) for intraspinal pressure (ISP) and SCPP monitoring in the neurological intensive care unit (NICU), and were included in the Transforming Research and Clinical Knowledge in Spinal Cord Injury (TRACK-SCI) data registry. This is known as the SCPP Protocol, and comprises standard care at our institution. SCPPs were monitored for 5 d with goal = 65 mmHg achieved through intravenous fluids and vasopressor support. American Spinal Injury Association Impairment Scale (AIS) grades were assessed at admission and day 7. RESULTS In 15 patients enrolled to date, age was 60.5 ± 17.0 yr and 46.7% were = 65. Injury level was 93.3% cervical and 6.7% thoracic. Admission AIS were 20.0%/20.0%/26.7%/33.3% for A/B/C/D, respectively. A total of 14 patients underwent surgical decompression with time to surgery 8.8 ± 7.1 h and 71.4% &lt; 12 h. Hospital length of stay (LOS) was 14.7 ± 8.3 d. NICU LOS was 11.5 ± 8.9 d. No patient had lumbar drain-related complications. Seven patients had respiratory complications and 1 expired after family transitioned to comfort care. AIS grade improvement of 1 occurred in one-third of patients (2 AIS = B, 3 AIS = C). CONCLUSION In our initial experience of 15 patients with acute traumatic SCI, standardized SCPP goal-directed care through lumbar ISP monitoring for the first 5 d postinjury was feasible and without SCPP-related complications.

The Management of Cerebrospinal Fluid Leak After Anterior Cervical Decompression Surgery.

Cerebrospinal fluid (CSF) leak is a rare but potentially troublesome and occasionally catastrophic complication after anterior cervical decompression surgery. There is limited literature describing this complication, and the management of CSF leak varies. The aim of this study was to retrospectively review the treatment of cases with CSF leak and develop a management algorithm. A series of 14 patients with CSF leak from January 2011 to May 2016 were included in this study. Their characteristics, management of CSF leak, and outcomes were documented. There were 5 male and 9 female patients. Mean age at surgery was 57.1±9.9 years (range, 37-76 years). All instances of CSF leak, except 1 noted postoperatively, were indirectly repaired intraoperatively. A closed straight wound drain was placed for all patients. A lumbar subarachnoid drain was placed immediately after surgery in 4 patients and postoperatively in 7 patients. In 1 patient, lumbar drain placement was unsuccessful. In 2 additional patients, the surgeon decided not to place a lumbar drain. One patient developed meningitis and recovered after antibiotic therapy with meropenem and vancomycin. Another patient had a deep wound infection and required a revision surgery. Wound drains and lumbar drains should be immediately considered when CSF leak is identified. Antibiotics also should be considered to prevent intradural infection. [Orthopedics. 2018; 41(2):e283-e288.].

Posttraumatic Hydrocephalus: Risk Factors, Treatment Modalities, and Prognosis

Background Posttraumatic hydrocephalus (PTH) is a rare clinicopathological entity seen as a sequel of head injury (HI). The described incidence in literature is 7 to 29%. Aims and Objectives To study the incidence, risk factors, treatment options, and prognosis. Materials and Methods We retrospectively reviewed our HI database from our institution and identified patients with PTH. The data were obtained from the case files, radiologic records, telephonic interviews, and letters. Results PTH was diagnosed in 32 patients with mean age being 33.7 ± 16.0 years. Severe HI was present in 22(68.75%) patients, and all of them underwent decompressive craniectomy (DC). Remaining patients had either cranial base repair for cerebrospinal fluid (CSF) leak or conservative management. Average duration for development of PTH after the HI was 11.05 ± 0.58 months in DC group and 17.0 ± 1.25 months in the non-DC group. Patients were treated by CSF diversion (ventriculoperitoneal [VP] or thecoperitoneal shunt) and lumbar subarachnoid drainage in the perioperative period of cranioplasty. Average interval between DC and cranioplasty was 6.21 ± 14.0 months. Mean follow-up was 72.23 ± 0.67 months and observed mortality was 32%. Statistical analysis showed correlation between severity of HI, DC, and development of PTH. DC also had correlation with early development of PTH. Conclusion The incidence of PTH is low and the etiology is multifactorial. Severe HI, DC, and delayed cranioplasty (&gt;6 months) are associated with higher chances of PTH development. Though VP shunt placement is the established treatment modality, temporary lumbar subarachnoid drain placement in perioperative period of cranioplasty in selected cases is an option.

Delayed Spontaneous Cerebrospinal Leak through Clival Recess: Emphasis on Technique of Repair

ABSTRACT Objective To report a rare case of delayed spontaneous cerebrospinal fluid (CSF) leak through clival region in the sphenoid sinus. Case report A 35-year-old female presented to our outdoor clinic with watery right nasal discharge for past 2 months, which increased on bending forward. Her medical history, general physical and neurological examinations were unremarkable. High-resolution computed tomographic scan and magnetic resonance cisternography were performed and suggestive of defect in right cribriform plate and right sphenoid sinus. Endoscopic repair was done but same symptoms occurred after 1 month. Repeat magnetic resonance imaging showed fistula in the lateral wall of right sphenoid sinus. Revision endoscopic transnasal CSF rhinorrhea repair was done. Lumbar subarachnoid drain was left in place for 5 days. No recurrence was noted at 12-week follow-up. Conclusion Endoscopic transnasal approach is the best modality of treatment for midline skull base defects. Delayed leaks can present from previously weak areas and all the doubtful areas must be examined during surgery. How to cite this article Mohindra S, Mohindra S, Joshi K, Sodhi HS. Delayed Spontaneous Cerebrospinal Leak through Clival Recess: Emphasis on Technique of Repair. Clin Rhinol An Int J 2017;10(1):42-44.

Early Identification of Traumatic Durotomy Associated with Atlantooccipital Dislocation May Prevent Retropharyngeal Pseudomeningocele Development

Atlantooccipital dislocation can be complicated by a traumatic durotomy that may lead to the rare development of a retropharyngeal pseudomeningocele. To our knowledge this has been reported only five times previously. We present the case of a 60-year-old man involved in a motor vehicle accident who suffered an atlantooccipital dislocation and C5-C6 three-column injury. A unique MRI image of a defect in the ventral dura posterior to C2 was appreciated. He underwent occiput to T2 internal fixation and arthrodesis. During surgery, CSF egress was seen caudal to the right C2 nerve root. A DuraMatrix onlay patch reinforced with DuraSeal was placed to stop the CSF leak. A lumbar subarachnoid drain was also placed. The patient made a satisfactory recovery with residual mild weakness of his right upper extremity. In this report, we demonstrate that careful MRI review can reveal a ventral durotomy in a traumatic atlantooccipital dislocation and, if discovered, effective treatment including a lumbar subarachnoid drain for CSF diversion may prevent progression to a retropharyngeal pseudomeningocele. The literature on this rare presentation and associated durotomy is provided.

Management and outcome of cerebrospinal fluid leakage during anterior cervical fusion for an ossified posterior longitudinal ligament

The rate of dural tears during anterior cervical diskectomy or corpectomy with fusion is higher in those patients with ossified posterior longitudinal ligaments (OPLL) than with those with other causes of cervical spinal stenosis. Various techniques have been described to deal with dural tears with cerebrospinal fluid (CSF) leakage in OPLL. Dural repair accompanied by a shunting technique with a lumbar subarachnoid drain is most commonly used. However, overdrainage of CSF fluid can cause further complications. Monitoring to keep the lumbar drain from overdrainage has not been described well in previous reports. In our series, 50 patients diagnosed with OPLL underwent anterior cervical surgery between July 2005 and June 2012. Dural tears with CSF leakage occurred in three patients. The dural defects were all about 1 mm in length. The dural defect was covered with a blood clot and gelfoam sponge. A closed suction drain (Hemovac) was placed as usual. After completion of the cervical surgery, a lumbar subarachnoid drain was inserted. The purpose of the lumbar drain was to shunt CSF pressure and avoid CSF leakage at the tear site. The lumbar drain rate was set at <20 mL/hour to prevent further complications. The effects of the lumbar drain were monitored and the drain rate was decreased gradually by observing the amount of cervical closed drainage, which should be minimal. The lumbar drains were used for 7 days in these three cases. There were no infections, severe headaches, or any other CSF leakage-related complications. None of the patients required reoperation for CSF leakage. Using a blood clot and gelfoam sponge to cover a dural tear site and placing a distant lumbar drain to shunt CSF pressure is an effective and successful method to treat CSF leakage in cervical operations.

Symptomatic Postlaminectomy Cerebrospinal Fluid Leak Treated With 4-Dimensional Ultrasound-guided Epidural Blood Patch

A persistent cerebrospinal fluid leak after spinal surgery can be associated with both meningitis and/or pneumocephalus. Therefore, early active intervention is recommended with surgical exploration, lumbar subarachnoid drain, and less commonly epidural blood patch. In the absence of a ligamentum flavum, the use of high-resolution ultrasound (US) spine imaging enables real-time advancement of a Tuohy needle towards the dura and the precise injection of blood to cover the dural defect. Six patients, after lumbar spine surgery with instrumentation and primary closure was complicated by incidental dural tears, developed severe symptomatic headaches that failed conservative therapy. All patients underwent US-guided epidural blood patch. Precise needle advancement to the dura was observed with US guidance, and 4-dimensional US scanning was used to confirm the expansion of blood over the dura in real time. All patients had symptomatic relief of their headaches and successful treatment of dural leaks using US-guided blood patch. Real-time US guidance allowed accurate positioning of the Tuohy needle and deposition of the epidural blood patch in the setting of a surgically removed ligamentum flavum. Further investigations are needed to confirm that an US-guided epidural blood patch may offer reliable symptomatic relief to postsurgical persistent cerebrospinal fluid leak and may serve as an intermediate step along a spectrum between conservative initial management and surgical reexploration.

Abducens Nerve Palsy Following Lumbar Subarachnoid Drain Placement: A Case Report and Review of the Literature

Introduction: Abducens nerve palsy is a rare complication following lumbar dural puncture for spinal anesthesia, diagnostic cerebrospinal fluid (CSF) analysis, and lumboperitoneal shunting. We describe the first known case of abducens nerve palsy from lumbar subarachnoid drain placement during pituitary macroadenoma resection.

Lumbar Subarachnoid Drainage in Cerebrospinal Fluid Leaks After Lateral Skull Base Surgery

To determine the efficacy of lumbar drainage in managing cerebrospinal fluid (CSF) leak after lateral skull base surgery. Retrospective case review. Academic tertiary referral center. Patients who had a lumbar subarachnoid drain placed after a lateral skull base procedure between July 1999 and February 2010 were included. Patients were identified by searching medical records for lateral skull base approach Current Procedural Terminology codes. The following variables were recorded for each subject: diagnosis, type of lateral skull base operation, duration of lumbar drainage, need for revision surgery, and presence of meningitis. Successful cessation of postoperative CSF leakage. Five hundred eight charts were reviewed, and 63 patients were identified who received a lumbar drain after a lateral skull base operation. The most common diagnosis was acoustic neuroma in 61.9%. The most common skull base approaches were the translabyrinthine, middle fossa, and transpetrosal approaches. Approximately 60.3% of patients had CSF rhinorrhea, 23.8% had an incisional leak, and 14.3% had otorrhea. The mean duration of lumbar drainage was 4.6 days. Forty eight (76.2%) study subjects had resolution of their CSF leak with lumbar drainage. Fifteen patients (23.8%) required revision surgery to stop the CSF leak. Lumbar drainage was successful in 90% of leaks after the translabyrinthine approach but in only 50% of those undergoing a suboccipital approach, which was a statistically significant difference. Postoperative CSF leaks after lateral skull base surgery can be managed with a lumbar subarachnoid drain in a majority of cases but is more successful after the translabyrinthine than the suboccipital approach. Recurrent CSF leaks after lumbar drainage is likely to require a revision operation.

Meningitis Following Lateral Skull Base Surgery

Objective: 1) Determine the clinical course of meningitis in the following lateral skull base surgery. 2) Examine risk factors leading to meningitis following lateral skull base surgery. Method: Retrospective review of patients undergoing lateral skull base surgery between February 1999 and March 2010. All subjects had culture-proven meningitis in the postoperative period. Medical records were compared with the lateral skull base patients who did not develop meningitis. Results: Fourteen of 508 patients (2.8%) developed meningitis following lateral skull base surgery. The most common diagnosis was acoustic neuroma in 78.5%. A total of 64.3% of patients had a CSF leak prior to meningitis onset, and 42.9% received a lumbar drain. The mean time to onset of meningitis was 16.1 days. The most common pathogens were staphylococcus, streptococcus, and enterococcus species; each in 14.3% of cases. A total of 10.3% of patients with postoperative CSF leakage and 9.2% with lumbar drains developed meningitis. The odds ratio of developing meningitis in the setting of a postoperative CSF leak is 7.3. There were no meningitis associated mortalities. Conclusion: Postoperative meningitis was seen in 2.8% of lateral skull base surgeries. As expected a CSF leak and placement of a lumbar subarachnoid drain are significant risk factors for developing meningitis. No mortality was associated with meningitis.

Adjuvant enoxaparin therapy may decrease the incidence of postoperative thrombotic events though does not increase the incidence of postoperative intracranial hemorrhage in patients with meningiomas

Patients with brain tumors including intracranial meningiomas are at increased risk for developing deep vein thrombosis (DVTs) and suffering thromboembolic events (VTEs). Many surgeons are concerned that early use of low dose enoxaparin may increase the risk of intracranial hemorrhage which outweighs the benefit of DVT/VTE reduction. We aimed to address concerns around the use of enoxaparin after meningioma resection in the development of postoperative intracranial hemorrhages and DVT/VTEs. This is a retrospective review of 86 patients with intracranial meningiomas who underwent craniectomy and surgical resection of the mass, treated by one attending surgeon at UCSF Medical Center between 2000 and 2005. Within 48 h after surgery patients treated 2003-2005 routinely received enoxaparin therapy unless there was documented intracranial hemorrhage, lumbar subarachnoid drain, enoxaparin hypersensitivity, or thrombocytopenia (n = 24). These were compared to a cohort treated 2000-2002 who did not receive the drug (n = 62). Exclusion criteria were prior VTEs or coagulopathies. The groups were similar in tumor and surgical characteristics. Enoxaparin therapy did not increase the incidence of intracranial hemorrhage following surgical meningioma resection and the incidence of DVTs/VTEs was 0% (n = 0) versus 4.8% (n = 3) in the non-enoxaparin group. Results did not reach statistical significance. In this retrospective study, postoperative administration of enoxaparin following meningioma resection does not increase the risk of intracranial hematoma though enoxaparin administration may slightly decrease the incidence of post-surgical thromboembolic events. Due to study design and power, we were not able to demonstrate DVT/VTE reduction with statistical significance.

Cerebrospinal Fluid Leak During Cervical Corpectomy for Ossified Posterior Longitudinal Ligament

Retrospective. To study the incidence of intraoperative cerebrospinal fluid (CSF) leak in patients with ossified posterior longitudinal ligament (OPLL) undergoing central cervical corpectomy (CC) and to describe a reliable technique for treating the leak after CC. The rate of dural tear after CC is higher in patients with OPLL compared to other causes of cervical spinal stenosis. Various techniques have been described to deal with dural tears with CSF leak in OPLL. We assessed the efficacy of the repair technique used to deal with this complication in our patients with OPLL who had undergone CC. A retrospective study was performed of all patients diagnosed with OPLL (n = 144) who had undergone CC between July 1992 and June 2007 (15 years). The dural defect was repaired with an onlay graft of crushed muscle/fascia and a layer of gelatin sponge. Bed rest and a lumbar subarachnoid drain were used for 5 days after surgery. Intraoperative CSF leak was noted in 9 patients (6.3%). The dural defects ranged in size from a few mm to about 15 mm (10-75 mm). All patients had a successful repair with no patient requiring reoperation for the CSF leak. Intraoperative CSF leak was encountered in 6.3% of patients undergoing CC for OPLL. A successful repair was achieved using fascial graft, gelatin sponge, lumbar CSF drainage, and bed rest.

Myocardial stunning secondary to aneurysmal subarachnoid hemorrhage

Background Although subarachnoid hemorrhage (SAH) is often associated with electrocardiographic abnormalities, profound effects on cardiac performance are rare. CASE DESCRIPTION A 57-year-old woman who developed loss of consciousness, respiratory distress, severe hypotension, and left ventricular hypokinesis with minimal coronary artery disease is described. Despite normal appearance of the coronary arteries on angiography, left ventricle function was so severely depressed that she required intra-aortic balloon pump support for 24 hours. Mental status changes prompted a head computed tomographic (CT) scan, which showed severe SAH and an intraventricular hemorrhage (IVH). Cerebral angiography demonstrated a basilar apex aneurysm. An echocardiogram done on hospital day 6 was normal. A left frontal ventriculostomy catheter was placed. This was later changed to a lumbar subarachnoid (SA) drain. The patient underwent an orbito-zygomatic craniotomy and aneurysm clipping. Although several serious medical problems occurred during her hospitalization, at follow-up, her sole neurological impairment was a minimal and resolving oculomotor paresis. CONCLUSION This patient’s respiratory failure and severe hypotension were initially thought to be due to a chemical pneumonitis or a cardiomyopathy. However, her symptoms ultimately proved to be secondary to a ruptured basilar apex aneurysm. The complex relationship of SAH to myocardial stunning, as illustrated by this patient, is discussed.

Symptomatic Pneumocephalus after Transsphenoidal Surgery

Background Symptomatic pneumocephalus after transsphenoidal surgery, though reported, is a rare phenomenon. We report three cases of pneumocephalus in a series of 300 transsphenoidal operations for sellar/suprasellar mass lesions done over the past 12 years. Methods and Results Three cases of symptomatic pneumocephalus occurring after transsphenoidal surgery are presented to illustrate the causative factors, methods of prevention, and management. In case 1, an intraoperative cerebrospinal fluid (CSF) leak occurred and drainage of CSF through a lumbar subarachnoid drain resulted in pneumocephalus, in spite of repair of the sellar floor. In case 2, partial excision of tumor and subsequent reduction of intracranial pressure due to a ventriculoperitoneal (VP) shunt led to pneumocephalus. In case 3, radiotherapy-induced shrinkage of a partially excised tumor resulted in pneumocephalus. The sellar floor had not been repaired in cases 2 and 3 as there was no intraoperative CSF leak and only a partial excision had been done. Conservative management failed in the two patients in whom it was tried. Repair of the sella and sphenoid sinus had to be done in all three cases. Conclusions Repair of the sellar floor should be done after a transsphenoidal approach in all cases, even when no intraoperative leak has been identified and only a partial excision of tumor has been done. Once pneumocephalus has occurred, the sellar floor and sphenoid sinus should be repaired early before reducing the intracranial pressure (ICP) by tapping ventricular air and draining or diverting CSF.

Prolonged lumbar spinal drainage after the resection of tumors of the skull base

A combined transcranial and facial approach was used for an en bloc resection of a malignant angiosarcoma of the ethmoid sinuses. The patient awoke neurologically intact and was monitored in the Intensive Care Unit. A lumbar subarachnoid drain was placed for the continuous removal of the cerebrospinal fluid (CSF). Approximately 36 hours after surgery, she deteriorated neurologically and demonstrated bilateral extensor posturing to painful stimuli. A computed tomographic scan demonstrated obliteration of the basal cisterns indicative of transtentorial herniation and a small amount of extradural air. Eight hours after the lumbar drain was turned off, the patient had recovered completely. We propose that the patient manifested transtentorial herniation caused by a pressure gradient between the supratentorial and lumbar cistern compartments brought on by the continuous removal of CSF from the lumbar subarachnoid space. We suggest that ventricular drainage should be considered for these cases rather than lumbar drainage. This offers the same advantage of removing the CSF and maintaining low-to-normal intracranial pressure without the risk of transtentorial herniation.

Prolonged Lumbar Spinal Drainage after the Resection of Tumors of the Skull Base: A Cautionary Note

Abstract A combined transcranial and facial approach was used for an en bloc resection of a malignant angiosarcoma of the ethmoid sinuses. The patient awoke neurologically intact and was monitored in the Intensive Care Unit. A lumbar subarachnoid drain was placed for the continuous removal of the cerebrospinal fluid (CSF). Approximately 36 hours after surgery, she deteriorated neurologically and demonstrated bilateral extensor posturing to painful stimuli. A computed tomographic scan demonstrated obliteration of the basal cisterns indicative of transtentorial herniation and a small amount of extradural air. Eight hours after the lumbar drain was turned off, the patient had recovered completely. We propose that the patient manifested transtentorial herniation caused by a pressure gradient between the supratentorial and lumbar cistern compartments brought on by the continuous removal of the CSF from the lumbar subarachnoid space. We suggest that ventricular drainage should be considered for these cases rather than lumbar drainage. This offers the same advantage of removing the CSF and maintaining low-to-normal intracranial pressure without the risk of transtentorial herniation.