Perioperative Cerebrospinal Fluid Research Articles

Immunocompetent isolated cerebral mucormycosis presenting with obstructive hydrocephalus: illustrative case.

Isolated cerebral mucormycosis is rare in immunocompetent adults and is only sparsely reported to be associated with obstructive hydrocephalus. Here, the authors report a case of obstructive hydrocephalus secondary to central nervous system mucormycosis without other systems or rhino-orbital involvement and its technical surgical management. A 23-year-old, incarcerated, immunocompetent patient with history of intravenous (IV) drug use presented with syncope. Although clinical and radiographic findings failed to elucidate an infectious pathology, endoscopy revealed an obstructive mass lesion at the level of the third ventricle, which, on microbiological testing, was confirmed to be Rhizopus fungal ventriculitis. Perioperative cerebrospinal fluid diversion, endoscopic third ventriculostomy, endoscopic biopsy technique, patient outcomes, and the literature are reviewed here. The patient received intrathecal and IV amphotericin B followed by a course of oral antifungal treatment and currently remains in remission. The patient's unique presentation and diagnosis of isolated cerebral mucormycosis reveal this pathogen as a cause of ventriculitis and obstructive hydrocephalus in immunocompetent adult patients, even in the absence of infectious sequelae on neuroimaging.

Perioperative Cerebrospinal Fluid Drain Placement Does Not Increase Venous Thromboembolism Risk After Thoracic and Fenestrated Endovascular Aortic Repair

Venous thromboembolism (VTE) incidence after thoracic and fenestrated endovascular aortic repair (TEVAR/FEVAR) is high (up to 6-7%) relative to other vascular procedures; however, the etiology for this discrepancy remains unknown. Notably, patients undergoing TEVAR/FEVAR commonly receive cerebrospinal fluid drains (CSFDs) for neuroprotection, requiring interruption of perioperative anticoagulation and prolonged immobility. We hypothesized that CSFDs are a risk factor for VTE after TEVAR/FEVAR. Consecutive TEVAR/FEVAR patients at a single center were reviewed (2011-2020). CSFDs were placed based on surgeon preference preoperatively or for spinal cord ischemia (SCI) rescue therapy postoperatively. The primary end-point was VTE occurrence, defined as any new deep venous thrombosis (DVT) or pulmonary embolism (PE) confirmed on imaging within 30-days postoperatively. Routine postoperative VTE screening was not performed. Patients with and without VTE, and subjects with and without CSFDs were compared. Logistic regression was used to explore associations between VTE incidence and CSFD exposure. 897 patients underwent TEVAR/FEVAR and 43% (n=387) received a CSFD at some point during their care (preoperative: 94%[n=365/387]; post-operative SCI rescue therapy: 6%[n=22/387]). CSFD patients were more likely to have previous aortic surgery (44% vs. 37%; p=.028) and received more postoperative blood products (780 vs. 405mL; p=.005). The overall VTE incidence was 2.2% (n=20). 70% (14) patients with VTE had DVT, 50% (10) had PE, and 20% (4) had DVT and PE. Among TEVAR/FEVAR patients with VTE, 65% (n=13) were symptomatic. Most VTEs (90%, n=18) were identified in-hospital and the median time to diagnosis was 12.5 (IQR 7.5-18) days postoperatively. Patients with VTE were more likely to have non-elective surgery (95% vs. 41%; p<.001), had higher ASA classification (4.1 vs. 3.7; p<.001), required longer ICU admission (24 vs. 12-days; p<.001), and received more blood products (1386 vs. 559mL; p<.001). VTE incidence was 1.8% in CSFD patients compared to 3.5% in non-CSFD patients (OR 0.70 [95% CI 0.28-1.78, p = .300). However, patients receiving CSFDs postoperatively for SCI rescue therapy had significantly greater VTE incidence (9.1% vs. 1.1%; p=.044). CSFD placement was not associated with an increased risk of VTE in patients undergoing TEVAR/FEVAR. VTE risk was greater in patients undergoing nonelective surgery and those with complicated perioperative courses. VTE risk was greater in patients receiving therapeutic CSFDs compared to prophylactic CSFDs, highlighting the importance of careful patient selection for prophylactic CSFD placement.

Predictive factors for persistent postoperative hydrocephalus in children undergoing surgical resection of periventricular tumors.

The aim of this study is to identify the factors predicting persistent hydrocephalus after periventricular tumor resection in children and assess the need and efficacy of perioperative cerebrospinal fluid (CSF) intervention. We performed a retrospective analysis of pediatric patients who underwent resection surgery of a periventricular tumor between March 2012 and July 2021 at the Department of Neurosurgery in Zhujiang Hospital of South Medical University. Demographic, radiographic, perioperative, and dispositional data were analyzed using univariate and multivariate models. A total of 117 patients were enrolled in our study. Incidence of postoperative persistent hydrocephalus varied with tumor pathology (p = 0.041), tumor location (p = 0.046), surgical approach (p = 0.013), extension of resection (p = 0.043), tumor volume (p = 0.041), preoperative Evan's index (p = 0.002), and preoperative CSF diversion (p = 0.024). On logistic regression, posterior median approach (OR = 5.315), partial resection (OR = 20.984), volume > 90cm3 (OR = 5.768), and no preoperative CSF diversion (OR = 3.661) were independent predictors of postoperative persistent hydrocephalus. Preoperative Evan's index is significantly correlated with tumor volume (p = 0.019). Meanwhile, the need for preoperative CSF drainage in patients in this cohort was significantly correlated with tumor location (p = 0.019). Tumor pathology, location, surgical approach, the extension of resection, tumor volume, preoperative Evan's index, and preoperative CSF diversion were considered to be predictive factors for postoperative persistent hydrocephalus. Notably, posterior median approach, partial resection, and tumor volume > 90cm3, without preoperative CSF diversion, were identified as independent risk factors for persistent postoperative hydrocephalus. Preoperative identification of children at risk of developing persistent postoperative hydrocephalus would avoid delays in planning the cerebrospinal fluid diversion. Active and effective preoperative hydrocephalus intervention in children with periventricular tumors is beneficial to reduce the incidence of persistent hydrocephalus and ventriculoperitoneal shunt surgery after resection.

Abstract No. 241 Safety and efficacy of fluoroscopically guided cerebrospinal fluid drainage for thoracoabdominal aortic aneurysm repair

To review the safety and efficacy of perioperative cerebrospinal fluid (CSF) drainage catheter placement using fluoroscopic guidance in patients undergoing thoracoabdominal aortic aneurysm (TAAA) repair

Superior Semicircular Canal Dehiscence Revision Surgery Outcomes: A Single Institution's Experience

Superior semicircular canal dehiscence (SSCD) is an abnormality of the otic capsule, which normally overlies the superior semicircular canal. Surgical management is indicated in patients with persistent and debilitating symptoms. Given the complexity of the disease, there are patients who experience less favorable surgical outcomes and require revision surgery. The purpose of this study was to report to the rate of postoperative symptomatic improvement in patients who required revision surgery. A retrospective analysis of patients undergoing SSCD surgical repair at a single institution was performed. Information on patient demographics, primary and secondary surgical approaches, surgical outcomes, and follow-up length was collected. Seventeen patients underwent 20 revision surgeries. There were eleven (65%) females and six (35%) males. Mean age of the cohorts was 50 years (range 30-68 years), and mean follow-up length was 6.8 months (range 0.1-31.1 months). Cerebrospinal fluid leak was noted in 67% of cases. The greatest postoperative symptomatic resolution was reported in oscillopsia (100%), headache (100%), and internal sound amplification (71%), while the least postoperative symptomatic resolution was reported in tinnitus (42%), aural fullness (40%), and dizziness (29%). Revision surgery can provide symptomatic improvement in select SSCD patients; however, patients should be cautioned about the possibility of less favorable outcomes than in index surgery. Revision surgeries are associated with a considerably higher rate of perioperative cerebrospinal fluid leak.

A Prospective Study and Analysis of Ventriculoperitoneal Shunt Surgery: Their Indication and Complication in a Single Tertiary Care Center

Abstract Background Ventriculoperitoneal (VP) shunt insertion is routinely performed for the treatment of hydrocephalus due to different indications like congenital, infective, tumor, posttraumatic, and normal pressure hydrocephalus (NPH). A lot of common and rare complications following this procedure have been reported. Objectives To analyze the clinical profile, indications, anesthetic, and postoperative complications for VP shunt surgery in our center. Materials and Methods This prospective clinical review study was conducted in the Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, between October 2018 to January 2020 and included 454 cases of hydrocephalus who underwent VP shunt surgery. The data was compiled and analyzed. Results A total of 454 patients with male predominance were studied. Pediatric and adolescent patients were 48.9% (222/454). Obstructive hydrocephalus due to tumors was the etiology of 48.7% (221/454) cases. The incidence of overall shunt complications was 9.7% (44/454), of which obstruction and infection was 5.9% (27/454) and 3.1% (14/454), respectively. Factors associated with increased shunt complications include redo and infective etiology and cases having higher protein in perioperative cerebrospinal fluid (CSF) analysis. Neuronavigation, antibiotic-impregnated shunt and biventricular shunt are associated with lower complications. Conclusion Obstructive hydrocephalus due to tumors happened to be the most common cause of VP shunt, and shunt obstruction is most common complication, especially in infective and redo cases.

Cerebrospinal Fluid Proteome Changes in Older Non-Cardiac Surgical Patients with Postoperative Cognitive Dysfunction.

Background:Postoperative cognitive dysfunction (POCD), a syndrome of cognitive deficits occurring 1–12 months after surgery primarily in older patients, is associated with poor postoperative outcomes. POCD is hypothesized to result from neuroinflammation; however, the pathways involved remain unclear. Unbiased proteomic analyses have been used to identify neuroinflammatory pathways in multiple neurologic diseases and syndromes but have not yet been applied to POCD.Objective:To utilize unbiased mass spectrometry-based proteomics to identify potential neuroinflammatory pathways underlying POCD.Methods:Unbiased LC-MS/MS proteomics was performed on immunodepleted cerebrospinal fluid (CSF) samples obtained before, 24 hours after, and 6 weeks after major non-cardiac surgery in older adults who did (n = 8) or did not develop POCD (n = 6). Linear mixed models were used to select peptides and proteins with intensity differences for pathway analysis.Results:Mass spectrometry quantified 8,258 peptides from 1,222 proteins in > 50%of patient samples at all three time points. Twelve peptides from 11 proteins showed differences in expression over time between patients with versus withoutPOCD (q < 0.05), including proteins previously implicated in neurodegenerative disease pathophysiology. Additionally, 283 peptides from 182 proteins were identified with trend-level differences (q < 0.25) in expression over time between these groups. Among these, pathway analysis revealed that 50 were from 17 proteins mapping to complement and coagulation pathways (q = 2.44*10–13).Conclusion:These data demonstrate the feasibility of performing unbiased mass spectrometry on perioperative CSF samples to identify pathways associated with POCD. Additionally, they provide hypothesis-generating evidence for CSF complement and coagulation pathway changes in patients with POCD.

Safety of perioperative cerebrospinal fluid drain as a protective strategy during descending and thoracoabdominal open aortic repair.

ObjectiveWe present our experience with routine application of the cerebrospinal fluid (CSF) drain (CSFD) during open aortic repair.MethodsWe retrospectively reviewed 100 patients with descending thoracic aortic aneurysm (DTAA) or thoracoabdominal aortic aneurysm (TAAA) or who underwent CSFD insertion before open repair between 2006 and 2017. All CSFDs were inserted by the cardiovascular anesthesia team. The goal was to keep intracranial pressure <10 mm Hg during the surgical procedure by draining CSF at a rate of 20 to 30 mL/h. Postoperatively, CSFD was set to maintain the lumbar pressure <10 mm Hg to reduce the risk of postoperative paraplegia. CSFD was part of our standard cord protection regimen.ResultsThe mean patient age was 65.4 ± 11.7 years, and 60 (60%) were male. A CSFD was successfully inserted in all patients. The mean hospital length of stay was 11.9 ± 11.8 days, and hospital mortality was 6%. Postoperative transient paresis was observed in 4 patients (4%), and permanent paraplegia was seen in 2 (2%). CSFD-related complications were reported in 14 patients (14%). Complications included persistent CSF leakage and blood-tinged CSF with and without intracranial hemorrhage and spinal cutaneous fistula in 7 (7%), 9 (9%), and 1 (1%), respectively. Long-term survival was excellent (68.4% at 10 years).ConclusionsCSFD is a safe practice when applied routinely as an adjunct strategy to prevent paraplegia in surgical management of DTAA and TAAA. We feel that this contributed to good early and late clinical results.

Commentary: The aggregation of marginal gains for spinal cord protection

Commentary: The aggregation of marginal gains for spinal cord protection

Risk factors of postoperative remote intracerebral hemorrhage after craniotomy for ruptured cerebral aneurysms.

ObjectiveWe aimed to identify the relation between perioperative cerebrospinal fluid (CSF) drain through lumbar drainage (LD) and development of postoperative (POP) remote intracerebral hemorrhage (rICH) in craniotomy to treat ruptured intracranial aneurysms.MethodsWe retrospectively reviewed consecutive patients who underwent craniotomy for ruptured cerebral aneurysms at the authors’ institution between 1998 and 2004. We subsequently compared the incidence and characteristics of POP rICH between the patients who had a perioperative LD and those who did not. All statistical analyses were conducted using the software package SPSS 19.0 (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant.ResultsWe enrolled 688 patients, of which 80 patients (11.6%) received perioperative LD, and 608 did not. LD and non-LD groups were comparable because although clinical characteristics of the two groups were significantly different considering history of hypertension, timing of surgery, and closed system negative pressure suction drain (SD) placement, none of these three variables was an independent risk factor associated with POP rICH in multivariate analysis. POP rICH incidence was significantly higher in the LD goup (12.5%) than non-LD group (0.8%) (p=0.000) in univariate analysis. LD placement was the only independent risk factor associated with the development of rICH in multivariate logistic regression analysis.ConclusionsPOP rICH incidence was significantly higher in patients who were managed with perioperative LD than in those who did not. LD insertion in craniotomy for ruptured intracranial aneurysm, should be closely monitored to address the occurrence of POP rICH.

Reconstruction Following Endoscopic Endonasal Skull Base Surgery: Options and Technical Considerations

To provide a brief overview of the options available for reconstruction of the skull base and to discuss their technical considerations. To review the contemporary literature surrounding adjunctive measures such as acetazolamide and perioperative cerebrospinal fluid (CSF) diversion. A recent randomized, control trial examining perioperative lumbar drainage following endoscopic skull base surgery has demonstrated that perioperative lumbar drainage is significantly associated with decreased incidence of postoperative CSF leak in specific anatomical subsites. Many factors must be weighed when considering proper skull base reconstruction. For large defects, multilayered repair with vascularized tissue is the gold standard. Perioperative lumbar drainage is recommended for large anterior or posterior fossa defects. The effect of acetazolamide on postoperative CSF leak remains unclear. Indocyanine green angiography (ICG) is a promising innovation that can aid in assessment of vascularized flaps.

Effect of Intraoperative Lumbar Drainage on Gross Total Resection and Cerebrospinal Fluid Leak Rates in Endoscopic Transsphenoidal Surgery of Pituitary Macroadenomas

To assess whether controlled, intraoperative lumbar drainage (LD) of cerebrospinal fluid (CSF) could facilitate resection of pituitary macroadenomas and reduce the rate of CSF leak. A retrospective cohort study from a prospective database was conducted on 189 patients with pituitary macroadenoma who received endoscopic transsphenoidal surgery between 2013-2017. Patients were classified into two groups: 119 patients received an intraoperative LD (LD group) and 70 patients underwent routine endoscopic surgery without LD (control group). In the LD group, lumbar catheters were placed preoperatively and CSF was drained intermittently during tumor resection. The rates of GTR and CSF leaks were assessed both intraoperatively and postoperatively. Intraoperative LD was associated with a higher rate of GTR (92.4% in the LD group vs. 78.6% in the control group, P=0.006), especially in macroadenomas with suprasellar extension (90.3% vs. 75.0%, P=0.012). Both intraoperative and postoperative CSF leak rates were significantly decreased in the LD group (intraoperative: 10.1% vs. 31.4%, P< 0.001; postoperative: 3.4% vs. 11.4%, P=0.035). In functioning adenomas, a better remission rate of excess-hormone secretion was observed in the LD group compared with the controls (89.1% vs. 60.6%, P=0.001). Patients in the LD group also had an enhanced recovery with a shorter postoperative length of stay (LOS) (7 d vs. 5 d, P=0.020). Intraoperative LD may assist surgeons during endoscopic transsphenoidal resection of pituitary macroadenomas by achieving a higher rate of GTR and a lower rate of perioperative CSF leaks. Validation in prospective randomized controlled studies is needed.

Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata "Button" Graft and Nasoseptal Flap: Surgical Technique and Case Series.

Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m 2 (median = 31 kg/m 2 ), with 18 patients meeting criteria for obesity (BMI > 30 kg/m 2 ) and 12 patients overweight (25 kg/m 2 < BMI < 29.9 kg/m 2 ). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

Continuous Lumbar Drainage for the Prevention and Management of Perioperative Cerebrospinal Fluid Leakage.

Background:Cerebrospinal fluid (CSF) leak is an unfortunate, yet well-recognized complication of skull base fractures, skull base surgeries, and variety of spinal procedures. Continuous lumbar drainage (CLD) of leaking CSF has shown a high success rate with minimal morbidities in handling CSF leak in these patients. Therefore, we conducted this study to illustrate the efficacy of CLD as a prophylactic and therapeutic method for CSF leakage with the assessment of clinical outcome and early postoperative sequel.Materials and Methods:In the period from January to December 2017, patients with traumatic or postoperative CSF leak and those susceptible for postoperative CSF leak as skull base and spinal intradural surgeries at the Neurosurgery Department, Fayoum University, were included in our study.Results:A total of 20 eligible patients were included in the study. All patients showed successful cessation of CSF leakage at different durations of CLD. Fifteen patients showed excellent results; four showed good results; and one showed fair results. Besides a minimal pneumocephalus, headache was the most common presenting complication in our population, which occurred to all patients. Six patients had vomiting beside headache, whereas two patients experienced vomiting and nausea in addition to headache. There were neither mortalities nor life-threatening complications noted; however, a superficial wound infection occurred in a single case.Conclusion:CLD is a simple, safe, and efficient method in the management of CSF leakage at operative sites, CSF rhinorrhea, and CSF otorrhea of various etiologies.

Three-Dimensional Computed Tomography Angiography Assisted Resection of Ventral Foramen Magnum and Jugular Foramen Tumours via Modified Far Lateral Suboccipital Approach

Objective: The anatomical relationship of ventral foramen magnum and jugular foramen tumour is complex and the operation is very difficult. The aim of this study was to summarize the microsurgical experience of the removal of the ventral foramen magnum and jugular foramen tumours via the modified far lateral suboccipital approach assisted by three-dimensional computed tomography angiography (3D-CTA). Methods: The clinical data and follow-up results of 13 cases of 3D-CTA assisted suboccipital far lateral approach from July 2011 to September 2017 were analyzed retrospectively. There were 5 males and 8 females. Preoperative CT and MRI were used for routine imaging diagnosis, and the 3D-CTA simulated surgical approach was performed. The preoperative operation scheme was established, and the risk of operation was evaluated according simulated operation. After individualized exposure, the modified far lateral suboccipital approach was completed under the neuroelectrophysiological monitoring technique. Results: The preoperative images were completely consistent with the findings in the surgery. There were 9 cases of jugular foramen tumour and 4 cases of ventral foramen magnum tumour. Of the 13 cases, only 1 case of jugular glomus tumour had extra-cranial residual, while the whole intracranial tumour was removed. In other 12 cases, the tumours were completely removed under the microscope. After operation, the headache disappeared, and hearing loss was improved. There was no perioperative deaths, infection and cerebrospinal fluid leakage. The facial paralysis was occurred in 1 patient. After 3–39 months of follow-up, there was no recurrence of tumour, or new nerve function defect. Hoarseness, choking of drinking water and numbness of limbs were all improved at the end of the follow-up period. The symptoms of postoperative facial paralysis were also improved during the follow-up period. Conclusion: After the preoperative simulation and evaluation by 3D-CTA, the ventral foramen magnum and jugular foramen tumours can be rescted safely and effectively via far modified lateral suboccipital approach.

Erratum to: Perioperative cerebrospinal fluid drainage for the prevention of spinal ischemia after endovascular aortic repair

Erratum to: Perioperative cerebrospinal fluid drainage for the prevention of spinal ischemia after endovascular aortic repair

Automated pressure-controlled cerebrospinal fluid drainage during open thoracoabdominal aortic aneurysm repair

ObjectivePerioperative cerebrospinal fluid (CSF) drainage is a well-established technique for spinal cord protection during thoracoabdominal aortic aneurysm (TAAA) open repair and is usually performed using dripping chamber-based systems. A new automated device for controlled and continuous CSF drainage, designed to maintain CSF pressure around the desired set values, thus avoiding unnecessary drainage, is currently available. The aim of our study was to determine whether the use of the new LiquoGuard automated device (Möller Medical GmbH, Fulda, Germany) during TAAA open repair was safe and effective in maintaining the desired CSF pressure values and whether the incidence of complications was reduced compared with a standard catheter connected to a dripping chamber. MethodsData of patients who underwent surgical TAAA open repair using perioperative CSF drainage at our institution between October 2012 and October 2014 were recorded. The difference in CSF pressure values between patients who underwent CSF drainage with a conventional dripping chamber-based system (manual group) and patients who underwent CSF drainage with the LiquoGuard (automated group) was measured at the beginning of the intervention (T1), 15 minutes after aortic cross-clamping (T2), just before unclamping (T3), at the end of surgery (T4), and 4 hours after the end of surgery (T5). The choice of the draining systems was randomly alternated with one-to-one rate until the last six patients consecutively treated with LiquoGuard were enrolled. Primary outcomes were occurrence of spinal cord ischemia, intracranial hemorrhage, postdural puncture headache, and in-hospital mortality. ResultsThe study included 152 patients who underwent open surgical TAAA repair during the study period: 73 patients underwent CSF drainage with the traditional system and 79 with LiquoGuard. The CSF pressure values at T1 and T5 were not considerably different in the two groups. By repeated-measures analysis of variance, a significant upward trend of perioperative CSF pressure was observed in the automated group at T2, T3, and T4 (group × time interaction = F3,66; P < .001). No difference was reported in the occurrence of spinal cord ischemia, intracranial hemorrhage, or mortality. The LiquoGuard group reported significantly reduced postdural puncture headache (3.3% vs 16.9%; P = .01). ConclusionsPerioperative use of LiquoGuard during TAAA open repair was safe and effective. Despite slightly higher intraoperative CSF pressures, the rate of spinal cord ischemia did not increase in the LiquoGuard group, and postdural puncture headache significantly decreased.

Perioperative cerebrospinal fluid and plasma inflammatory markers after orthopedic surgery.

BackgroundPostoperative delirium is prevalent in older patients and associated with worse outcomes. Recent data in animal studies demonstrate increases in inflammatory markers in plasma and cerebrospinal fluid (CSF) even after aseptic surgery, suggesting that inflammation of the central nervous system may be part of the pathogenesis of postoperative cognitive changes. We investigated the hypothesis that neuroinflammation was an important cause for postoperative delirium and cognitive dysfunction after major non-cardiac surgery.MethodsAfter Institutional Review Board approval and informed consent, we recruited patients undergoing major knee surgery who received spinal anesthesia and femoral nerve block with intravenous sedation. All patients had an indwelling spinal catheter placed at the time of spinal anesthesia that was left in place for up to 24 h. Plasma and CSF samples were collected preoperatively and at 3, 6, and 18 h postoperatively. Cytokine levels were measured using ELISA and Luminex. Postoperative delirium was determined using the confusion assessment method, and cognitive dysfunction was measured using validated cognitive tests (word list, verbal fluency test, digit symbol test).ResultsTen patients with complete datasets were included. One patient developed postoperative delirium, and six patients developed postoperative cognitive dysfunction. Postoperatively, at different time points, statistically significant changes compared to baseline were present in IL-5, IL-6, I-8, IL-10, monocyte chemotactic protein (MCP)-1, macrophage inflammatory protein (MIP)-1α, IL-6/IL-10, and receptor for advanced glycation end products in plasma and in IFN-γ, IL-6, IL-8, IL-10, MCP-1, MIP-1α, MIP-1β, IL-8/IL-10, and TNF-α in CSF.ConclusionsSubstantial pro- and anti-inflammatory activity in the central neural system after surgery was found. If confirmed by larger studies, persistent changes in cytokine levels may serve as biomarkers for novel clinical trials.Electronic supplementary materialThe online version of this article (doi:10.1186/s12974-016-0681-9) contains supplementary material, which is available to authorized users.

Remote cerebellar hemorrhage after supratentorial procedures (part 1): a systematic review.

A remote cerebellar hemorrhage (RCH) is a spontaneous bleeding in the posterior fossa, which may rarely occurs as a complication of supratentorial procedures, and it shows a typical bleeding pattern defined "the zebra sign." However, its pathophysiology still remains unknown. We performed a comprehensive review collecting all cases of RCH after supratentorial craniotomies reported in literature in order to identify the most frequently associated procedures and the possible risk factors. We assessed percentages of incidence and 95% confidence intervals of all demographic, neuroradiological, and clinical features of the patients. Univariate and multivariate analyses were used to evaluate their association with outcome. We included 49 articles reporting 209 patients with a mean age of 49.09 ± 17.07years and a male/female ratio 130/77. A RCH was more frequently reported as a complication of supratentorial craniotomies for intracranial aneurysms, tumors debulking, and lobectomies. In the majority of cases, RCH occurrence was associated with impairment of consciousness, although some patients remained asymptomatic or showed only slight cerebellar signs. Coagulation disorders, perioperative cerebrospinal fluid drainage, hypertension, and seizures were the most frequently reported risk factors. Zebra sign was the most common bleeding pattern, being observed in about 65% out of the cases, followed by parenchymal hematoma and mixed hemorrhage in similar percentages. A multivariate analysis showed that symptomatic onset and intake of antiplatelets/anticoagulants within a week from surgery were independent predictors of poor outcome. However, about 75% out of patients showed a good outcome and a RCH often appeared as a benign and self-limiting condition, which usually did not require surgical treatment, but only prolonged clinical surveillance, unless in the event of the occurrence of complications.

Bilateral Encephaloceles and CSF Rhinorrhea after Facial Advancement in Craniofacial Dysostoses: Considerations for Repair

Objectives: (1) Describe the first reported case in otolaryngology literature of a patient with Crouzon syndrome with late cerebrospinal fluid (CSF) rhinorrhea and encephalocele formation after prior Le Fort III facial advancement surgery. (2) Review the literature pertaining to the incidence and management of this complication in craniofacial dysostoses (CD). (3) Analyze issues surrounding repair of these complications, including occult elevations in intracranial pressure (ICP), the use of perioperative CSF shunts, and the importance of considering alternative repair schemes. Methods: Literature review of studies describing CSF rhinorrhea and encephalocele formation following facial advancement in CD, focusing on management strategies. Results: CSF rhinorrhea and encephalocele formation are rare complications of craniofacial advancement procedures. Occult elevations in ICP complicate the prospect of permanent surgical repair, necessitating the use of transcranial repair and CSF shunts in addition to the now more common endoscopic approach. Though no consensus exists regarding the use of perioperative CSF drains, strong associations exist between elevated ICP and failed surgical repair. Additionally, the anatomic changes in the frontal and ethmoid sinuses after facial advancement present a challenge to endoscopic management. Conclusions: Otolaryngologists should be aware of the possibility of occult elevations in ICP as well as sinonasal anatomic abnormalities when repairing CSF rhinorrhea in patients with CD. Clinicians should consider CSF shunt placement and carefully weigh the advantages of the open, transcranial approach versus endonasal, endoscopic techniques.