Spinal Drainage Research Articles

Reintervention and Spinal Cord Ischemia After Thoracic Endovascular Aortic Repair for Acute Type B Aortic Dissection With a Zone 3 Entry Tear

Treatment of acute type B aortic dissections (TBADs) using thoracic endovascular aortic repair (TEVAR) is influenced by the location and extent of the pathology, the presence of high-risk features, and complication status. The technical aspects of TEVAR for TBAD (specifically the location of the proximal seal zone [PSZ], the need to cover the left subclavian artery [LSA], distal seal zone [DSZ; length of aortic coverage]), the benefits of LSA revascularization, and prophylactic lumbar spinal drainage are still debated.

Editor's Choice – Multicentre Outcomes of Redo Fenestrated/Branched Endovascular Aneurysm Repair to Rescue Failed Fenestrated Endografts

To report the outcomes of redo fenestrated and/or branched endovascular aortic repair (F/BEVAR in FEVAR) to rescue previous failed FEVAR. Retrospective review of all consecutive patients undergoing F/BEVAR in FEVAR at eight aortic centres including pre-, intra-, and post-operative data according to a pre-established protocol. Follow up consisted of at least yearly computed tomography angiography. Values are presented as median and interquartile range, and survival as estimate ± standard error in percentage. 18 male patients (76 years old; range 69 - 78 years) receiving FEVAR involving two (two or three) target vessels between 2006 and 2016 underwent F/BEVAR in FEVAR between 2012 and 2019 (aneurysm diameter of 63 mm; range 56 - 69 mm). Median interval between the procedures was 53 (29 - 103) months. The indication for F/BEVAR in FEVAR was type Ia endoleak in 16 cases (eight isolated and eight combined with graft migration), one graft migration without endoleak and one migration with significant proximal aortic expansion. F/BEVAR in FEVAR involved all patent renovisceral arteries and had an operating time of 260 (204 - 344) minutes. Technical success was achieved in 15 (83%) cases. There was a failure to bridge one renal artery, one renal capsular bleed with the subsequent need for renal artery embolisation within 24 hours and one persistent type Ib endoleak despite iliac extension. There was no peri- or in hospital death. Two patients developed spinal cord ischaemia, one transient paraparesis and one permanent paraplegia. The latter occurred in a non-staged procedure where spinal drainage was used. During a follow up of 27 (7 - 39) months, three (17%) patients underwent late re-interventions. Overall survival at 24 months was 70 ± 11% with no aneurysm related death and a secondary clinical success at 24 months of 84 ± 11%. F/BEVAR in FEVAR is a technically challenging but feasible solution to rescue failed FEVAR. The outcomes are promising in many aortic centres but need to be confirmed by further studies with longer follow up.

Cerebrospinal Fluid Drainage in Thoracic and Thoracoabdominal Endovascular Aortic Repair: A Survey of Current Clinical Practice in European Medical Centers

The aim of this survey was to evaluate the daily clinical practice in European hospitals regarding the modalities to prevent spinal cord ischemia, with an emphasis on cerebrospinal fluid drainage (CSFD), in patients undergoing thoracic and thoracoabdominal endovascular repair. A 21-item online survey on current practice of spinal cord protection with an emphasis on CSFD. Online service using Castor EDC software. Members of the European Association of Cardiothoracic Anaesthesiology and Intensive Care and European Society of Vascular Surgeons. None. One hundred eighty invitations were sent and 104 were used for analysis. A majority of respondents used a written protocol for spinal cord protection during endovascular thoracic and thoracoabdominal repair (81/104=78%). The most common protective measures used were CSFD (79/81=98%), controlled hypertension (59/81=73%), drugs (11/81=14%), and hypothermia (6/81=7%). The two most common indications for placement of a spinal catheter were the length of the stent (83/104=80%) and location of aneurysm (71/104=68%). Preventive placement of the spinal drain (96/104) is the most common approach. In the subgroup of high-volume centers, 86% (12/14) of the respondents used a written protocol and all protocols include CSFD. Ninety-two percent (11/12) had included controlled arterial hypertension in the protocol compared with 70% (48/69) of the non-high-volume centers respondents. The majority of European centers use a written protocol that includes CSFD. This survey showed the similarities and differences in the management of CSFD in patients undergoing endovascular thoracic and thoracoabdominal repair.

Tier-three therapies for refractory intracranial hypertension in adult head trauma.

Refractory intracranial hypertension after traumatic brain injury (TBI) is defined as recurrent increase of intracranial pressure above 20-22 mmHg for sustained period of time (10-15 min), despite conventional therapies, such as osmotic therapy, cerebral spinal fluid drainage and mild hyperventilation. As such, more aggressive treatments should be taken into consideration. In particular, therapeutic hypothermia, barbiturates administration and decompressive craniectomy are considered as tier-three or "salvage" interventions, as they have shown to be able to control refractory hypertension; however, they are also associated with an increased risk of significant side effects. Therefore, the aim of this review was to describe the evidence supporting the use of these tier-three therapies in the management of refractory intracranial hypertension in TBI patients.

“Awake” Spinal Cord Monitoring Under Local Anesthesia and Conscious Sedation in Fenestrated and Branched Endovascular Aortic Repair

Introduction Endovascular repair of thoracoabdominal aortic aneurysms carries a risk of spinal cord ischemia, the causes of which remain uncertain. We hypothesized that local anesthesia (LA) with conscious sedation could abrogate the potential suppressive cardiovascular effects of general anesthesia (GA) and facilitate intraoperative monitoring of neurological function. Here, we examine the feasibility of this technique during fenestrated (FEVAR) or branched endovascular aortic repair (BEVAR). Materials and Methods Consecutive patients undergoing FEVAR or BEVAR under LA and conscious sedation by a team at a single center were analyzed. Patients received conscious sedation using intravenous remifentanil and propofol infusions in conjunction with a local anesthetic agent. No patient had a prophylactic spinal drain inserted. Outcome measures included conversion to GA, need for vasopressors and/or spinal drainage, length of stay, complications, and patient survival. Results A total of 44 patients underwent FEVAR or BEVAR under LA and conscious sedation. The cohort included thoracoabdominal aortic aneurysms (n=41) and pararenal aneurysms treated with endografts covering the supraceliac segment (n=3). Four patients (9%) required conversion to GA at a median operative duration of 198 minutes (range 97–495 minutes). Vasopressors were required intraoperatively in 3 of the cases that were converted to GA. No patient developed spinal cord ischemia and none had insertion of a spinal drain. The median hospital length of stay was 4 days (range 2–41 days). Postoperative delirium and hospital-acquired pneumonia was seen in 7% of patients. All patients survived to 30 days, with 95% alive at a median follow-up of 15 months (range 3–26 months). Conclusion LA and conscious sedation is a feasible anesthetic technique for the endovascular repair of thoracoabdominal aortic aneurysms.

Selective Versus Routine Spinal Drain Use for Fenestrated/Branched Endovascular Aortic Repair (F-BEVAR)

BackgroundSpinal drains are used to ameliorate spinal cord ischemia (SCI), but their use may result in inherent morbidity and mortality. Although prophylactic spinal drain has proven of benefit in open repairs, that is not the case for endovascular repairs. The aim of this study was to assess the outcomes of spinal cord protection with and without the routine use of spinal drains during fenestrated-branched endovascular repair (F-BEVAR). MethodsA retrospective single center study was performed using a prospectively maintained dataset of all patients undergoing F-BEVAR over a 4-year period. The primary endpoint of the study was the frequency of SCI. Prophylactic spinal drain was placed pre-operatively in 33 patients (23%) with a median time for removal of 3 days (IQR, 2-3 days). Routine intraoperative neuromonitoring was used. Spinal cord protection relied primarily on maintaining a perioperative systolic blood pressure between 140 and 160 mm Hg or a mean arterial pressure >90 mm Hg, avoiding hypotension, preservation of as many collateral beds as possible, staged repairs and early lower extremity reperfusion based on neuromonitoring. ResultsA total of 145 patients, 104 men (71%) and 41 women (28%) with a median age of 70 years (interquartile range [IQR], 53–62) underwent F-BEVAR. Branched custom-made devices (CMDs) (11%), fenestrated CMDs (70%) and off-the-shelf T-Branch device (17%) were used with a median number of branches/fenestrations of 4 (IQR, 3–4). SVS classification of implantation zones were determined as follows: 9 (6%) zone 2, 21 (20%) zone 3, 26 (18%) zone 4 and 89 (61%) zone 5. SCI was present in 8 patients (5.5%) and classified according to the SVS SCI grading system as follows: 1 grade 1, 5 grade 2 and 2 grade 3a. When evaluating implantation zone independently of coverage length and patency of collateral beds, a high implantation zone (1–4) was not associated with SCI (P = 0.9). Similarly, prophylactic spinal drain did not demonstrate association with the occurrence of SCI (3[9%] vs. 5[4%], with and without spinal drain, respectively) (P = 0.3). For patients with high implantation zones, staged repair was performed in 38 patients (26%) at a median time of 2 months (IQR, 2–6 months). Among these patients, the frequency of SCI was 13%. Staged repair was associated with an 80% reduction in the frequency of SCI (OR, 0.19 [95% CI, 0.04–0.084]) (P = 0.02). ConclusionF-BEVAR can be performed with a minimal risk of SCI without the need for routine prophylactic spinal drains. High implantation zones did not predict SCI after F-BEVAR; however, staged repair significantly decreased the risk of SCI after F-BEVAR.

Immobilization Hypercalcemia (IH) in an Adult After Spinal Cord Injury

Background: Immobilization hypercalcemia (IH) is an uncommon diagnosis and little has been published about management of this condition. We present a case of IH and discuss clinical aspects of this unique bone metabolism state. Case: 32-year-old female with history significant for IV drug use, presented to the hospital with features of septic shock, Work up showed MRSA bacteremia associated with tricuspid endocarditis and septic pulmonary emboli. MRI of the spine done for progressive weakness of extremities revealed a cervical epidural abscess leading to spinal cord compression and myelomalacia. She underwent spinal abscess drainage and corpectomy, remained quadriplegic. 8 weeks later we were consulted to see her at inpatient rehabilitation facility for hypercalcemia. Labs showed Creat(0.6 mg/dl), hypercalcemia with corrected Calcium of 12.9 mg/dl f. Further workup showed suppressed PTH (< 6), V D-25 at (< 10 mg/dl). Phosphate (normal). ACE levels, PTHrp, Vit. D 1,25, SPEP, UPEP,and TSH were all normal. 24 hours urine calcium showed hypercalciuria, 400 mg/ml. Fasting Bone markers were elevated with serum N-telopeptide > 40 nM BCE, ref range (6.2–19.0) and C-Telopeptide is 2060 pg/ml ref range (60–650), which indicates increase bone turnover. IH was diagnosed and hydration attempted for few weeks. Serum calcium remained at 13 mg/dl, so she received a single slow infusion of pamidronate 30 mg. 4 days after infusion, calcium levels decreased to normal value of 10.2 mg/dl without any side effects. She remained normocalcemic 5 weeks post infusion. Discussion: IH is an uncommon condition but early recognition and intervention will minimize secondary long-term complications such as kidney stones, Osteoporosis or low bone mass, renal failure and acute pancreatitis. Albert, Fuller described IH in 1941(1). Most cases of IH had been reported in children and adolescents with high bone turn over following recent spinal cord injury(2–3). Very few reports have been published in young adults such as our patient,IH is attributed to prolonged immobilization from paralysis due to spinal cord injury,and other etiology (2–4), Proposed mechanism includes decreased mechanical stress on the bone which leads to increase bone resorption and remodeling and demineralization. To establish the diagnoses of IH, an exhaustive evaluation is warranted to rule out other causes of PTH dependent and independent hypercalcemia(5). Multiple treatment approaches have been used over the past few decades including early mobilization, hydration., saline diuresis, subcutaneous Calcitonin, glucocorticoids (6), IV sodium sulphate and phosphate (7). Bisphosphonates are the preferred pharmacological treatment of IH. Nonnitrogen containing bisphosphonates including clodronate and etidronate (8–9),. are not preferred due to concern for bone demineralization and osteomalacia. (10). Pamidronate has been used to treat IH due to its efficacy, safely and cost (11). Caution to be exercised in those patients with kidney disease.

In Reply: Risk of Brain Herniation After Craniotomy With Preoperative Lumbar Spinal Drainage: A Single-Surgeon Experience of 365 Patients Among 3000 Major Cranial Cases.

To the Editor: We sincerely appreciate the kind words of the colleagues1 who deserve our respect for their work and contributions. We rarely use diuretics for brain relaxation, as cerebrospinal fluid drainage obviates the need for this class of agents. In addition, we do not believe that the mechanism of edema among the patients described in our paper2 was related to a lack of use of diuretics because those edema episodes were localized. We look forward to the upcoming results of our colleagues’ studies. Funding This study did not receive any funding or financial support. Disclosures The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

Spinal drainage complications after aortic surgery

Objective/BackgroundSpinal drain (SD) placement is an adjunct used in open and endovascular aortic surgery to mitigate the risk of spinal cord injury. SD placement can lead to subdural hematoma and intracranial hemorrhage (SDH/ICH). Previous studies have highlighted a correlation between incidence of SDH/ICH and amount of cerebrospinal fluid (CSF) drained. We have two philosophies of SD management in our institution. One protocol allows fluid removal for pressure >10 cm H2O with no volume restriction. A second, similar protocol restricts CSF drainage to <25 mL/h. We examined SD complications and the influence of volume restriction. MethodsPatients were identified according to the Current Procedure Terminology codes for SD placement, thoracic endovascular aortic repair, fenestrated/branched endovascular aortic repair, endovascular abdominal aortic repair, and open thoracic or thoracoabdominal aortic repair between January 1, 2012, and December 31, 2015. Patients' demographics included age, gender, race, body mass index, and comorbidities such as hypertension, chronic obstructive pulmonary disease, stroke, transient ischemic attack, diabetes mellitus, bleeding disorder, and connective tissue disorders. Management protocol was classified as volume independent (VI) or volume dependent (VD) by physician order. Postoperative complications related to the SD were noted. ResultsWe identified 948 patients who had an SD placed during the study period; 473 were done before aortic surgeries. A total of 364 patients (77%) underwent endovascular aortic surgery. The mean age at the time of procedure was 67.2 years, and 66% of patients were male. Thirty-nine patients (8.3%) were noted to have connective tissue disorders. Bloody SD placement occurred in 14 patients (3.1%) requiring rescheduling of the operation. SDH/ICH occurred in 11 patients (2.3%), postoperative blood tinged SD output in 94 patients (19.9 %), and 22 patients (4.7 %) had a CSF leak after SD removal. The incidence of SDH/ICH was not affected by the management protocol (2.6% VI vs 2.0% VD, P = .66), whereas the incidence of postoperative blood tinged SD output was significantly higher in the VI group (25.1% VI vs 15.0% VD, P = .006). Perioperative low-dose aspirin (81 mg) and prophylactic subcutaneous heparin did not increase the incidence of SDH/ICH. Postoperative thrombocytopenia was found to be associated with higher incidence of SDH/ICH (median 86,000 vs 113,000, P = .002). ConclusionsSevere complications of SD placement (SDH/ICH) occur in 2.3% of SD patients undergoing aortic surgery, and the risk is higher in the setting of postoperative thrombocytopenia. SD volume limitation, blood tinged drainage, antiplatelet medication, and low-dose heparin do not affect the risk of SDH/ICH. The risks of spinal drains for aortic surgery should be balanced against potential benefits.

Abstract No. 592 TEVAR for complicated type B aortic dissection: utilizing 2020 guidelines for outcomes assessment

The 2020 Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards were developed for type B dissection. This study seeks to analyze outcomes in patients undergoing TEVAR utilizing the guidelines. Data for patients undergoing TEVAR from 2001 to 2019 in a single-center, retrospective review was analyzed. Patient demographics, comorbidities, and postoperative outcomes were obtained. Computed tomography angiography was utilized to assess preoperative imaging and to identify the proximal entry and distal re-entry. Primary outcomes were postoperative complications and 30-day mortality. Data was analyzed using univariate analysis. There were 64 patients that underwent TEVAR for complicated type B aortic dissection. The mean age was 60 years old. 79.68% of patients had a history of hypertension. 90.6% of patients had general anesthesia and 9.38% had spinal anesthesia. 7.8% of patients had a spinal drain. Intraoperative complications occurred for 3.1% of patients, minor and major perioperative complications occurred for 31.2% of patients, and late onset complications occurred for 14.1% of patients. 4.7% of patients had a neurologic complication. The majority of patients had proximal entry at Zone III (50%), followed by Zone IV (14.1%). Distal re-entry was zone 11 in the majority of patients (37.5%) followed by Zone 9 (12.5%) and Zone 10 (12.5%). Mortality was 12.5% for patients with proximal entry at Zone 3, 11.1% for patients with proximal entry at Zone 4, 25% for patients with distal reentry at Zone 11. Utilizing these reporting standards as a basis for outcomes studies may allow for risk stratification of patients with Complicated type B aortic dissections and future models to predict postoperative outcomes.

Optimization of factors for the prevention of spinal cord ischemia in thoracic endovascular aortic repair.

Spinal cord ischemia following thoracic endovascular aortic repair (TEVAR) is a devastating complication. This study seeks to demonstrate how a standardized protocol to prevent spinal cord ischemia affects incidence in patients undergoing TEVAR. Using CPT codes 33880 and 33881, all TEVAR procedures performed at a single tertiary care center from January 2017 to December 2018 were examined. Patients who had concomitant ascending aortic repairs or a TEVAR for traumatic indications were excluded from analysis, leaving 130 TEVAR procedures. Comorbid conditions, procedural characteristics, extent of coverage, peri-procedural management strategies, and post-operative outcomes were collected and analyzed retrospectively. One hundred thirty patients undergoing TEVAR were examined for four perioperative variables: postoperative hemoglobin greater than 10 g/dL, subclavian revascularization, preoperative spinal drain placement, and somatosensory evoked potential monitoring (SSEP). All conditions were met in 46.2% (60/130) of procedures; 37.8% (28/74) in emergent/urgent cases and 61.5% (32/52) in elective cases. Of patients who required subclavian coverage, 87.1% (54/62) underwent subclavian revascularization; 70.8% (92/130) of patients received spinal drains preoperatively; 68.5% (89/130) of patients had SSEP monitoring; 73.8% (93/130) of patients obtained a postoperative hemoglobin of >10 g/dL. Out of all patients, two (1.5%) developed spinal cord ischemia. Incidence of spinal cord ischemia in our cohort was low at 1.5% (2/130). Individual and bundled interventions for the prevention of spinal cord ischemia were unable to demonstrate a statistically significant effect given the low rate. Nonetheless, we advocate for a proactive approach for the prevention of spinal cord ischemia given our experience in this complex population.

Preliminary results from a multicenter Italian registry on the use of a new branched device for the treatment of thoracoabdominal aortic aneurysms

ObjectiveThe study purpose was to present early outcomes of patients treated for thoracoabdominal aortic aneurysms or complex abdominal aortic diseases using endovascular repair with a new branched endograft. MethodsThis multicenter, retrospective, observational cohort study included all patients treated with a new branched endograft. All elective patients were treated with a staged operative strategy and spinal drainage Primary outcomes of interest were technical success, early (≤30 days) mortality, and late (≥30 days) survival, and freedom from adverse aortic events. ResultsA total of 16 consecutive patients were treated for Crawford's extent type I (n = 1), type II (n = 7), type III (n = 1), and type IV (n = 5) endoleaks, with an additional two complex pararenal abdominal aortic lesions (enlarging type Ia endoleak, n = 1; anastomotic pseudoaneurysm, n = 1). There were 13 male (81%) and 3 female (19%) patients with a median age of 72.5 years (interquartile range [IQR], 69-78 years). The median diameter of the aortic aneurysm was 65 mm (IQR, 58-81 mm) and the median EuroSCORE prediction for mortality was 18% (IQR, 12%-36%). Thoracoabdominal aortic aneurysm was secondary to a previous dissection in four patients. A total of 62 of the 64 visceral vessels (96.9%) were stented. Technical success was achieved in 14 (87.5 %) and the cumulative aorta-related mortality rate was 19%. Spinal cord ischemia did not occur. The mean follow-up was 8 ± 4 months (range, 2-15 months). No type I or type III endoleaks were detected. Primary bridging stent patency was 98% (one asymptomatic thrombotic occlusion of a celiac trunk branch). No aortic reintervention was required. ConclusionsEndovascular repair of complex aortic aneurysms with this new branched endograft can be performed with high technical success and acceptable morbidity. A 19% mortality is quite high; however, it is tolerable in such a high-risk cohort. The survival rate was acceptable, and graft-related outcomes at early follow-up included an absence of threatening endoleaks and a high target visceral vessel patency.

Selective vs. Routine Spinal Drain Use for Fenestrated/Branched Endovascular Aortic Repair (F-BEVAR)

Spinal drains are used to ameliorate spinal cord ischemia(SCI), but their use may result in inherent morbidity and mortality. The role of spinal drains for F-BEVAR has not been demonstrated. The aim of this study was to assess the outcomes of spinal cord protection with and without the routine use of spinal drains during F-BEVAR.

External Brain Tamponade Paradoxically Induced by Cerebrospinal Fluid Hypovolemia After Decompressive Craniectomy: A Retrospective Cohort Study

ABSTRACT BACKGROUND Symptomatic hygroma after decompressive craniectomy (DC) presenting with a mass effect has been reported as external brain tamponade (EBT). However, the pathology of EBT is unclear. OBJECTIVE To survey the clinical characteristics and explore the potential causes of EBT. METHODS The incidence, timing of onset, and symptoms of EBT were examined among 155 patients undergoing supratentorial DC at Nara Medical University. The factors associated with EBT were investigated and compared with those with hygroma to estimate the potentially causative mechanisms. RESULTS We identified 81 hygromas within 30 d after DC. Among them, 10 patients had EBT, including 7 with aneurysmal subarachnoid hemorrhage (aSAH), 2 with traumatic head injury accompanying skull base fracture, and 1 with a brain tumor. The median interval between DC and EBT was 3.5 d (range 1-21 d). Altered mental status was observed in 9, and oculomotor palsy was present in 3 patients. Univariate analysis demonstrated that risk factors for EBT were aSAH (P = .02) and lumbar spinal drainage (LSD; P &lt; .001). On the other hand, independent risk factors for hygroma included aSAH (odds ratio [OR]: 3.67, 95% confidence interval [CI]: 1.45-9.3, P &lt; .01) and ventricular drainage (OR: .14, 95% CI: .03-.802, P = .03). CONCLUSION Cerebrospinal fluid (CSF) hypovolemia after DC should be considered a potential cause of EBT, which includes brain herniation into the hiatus centralis and paradoxical formation of a hygroma. Correction of CSF dynamics and cranioplasty may be effective treatments for EBT.

Acute Aortic Dissection as a Rare Complication of Descending Thoracic Aortic Aneurysm

A 55 year old man was scheduled for thoracic endovascular repair of a > 60 mm descending thoracic aortic aneurysm (dTAA) (A). Acute chest pain (blood pressure 137/91 mmHg) led to computed tomography angiography revealing type B retrograde aortic dissection originating from the dTAA, extending proximally to the left subclavian artery (LSA), and distally to the diaphragm (B). TEVAR was performed using a 37 × 100 mm C-TAG stent graft (WL Gore & Associates, Flagstaff, USA), deployed distal to the LSA origin without spinal drainage. Acute aortic dissection is an uncommon complication which should be considered in the setting of acute chest pain in patients with known dTAA.Image 1

Risk of Brain Herniation After Craniotomy With Preoperative Lumbar Spinal Drainage: A Single-Surgeon Experience of 365 Patients Among 3000 Major Cranial Cases.

Lumbar spinal drainage (LSD) can significantly facilitate brain relaxation and improve ease of surgical goals for a variety of neurosurgical indications. Although rapid drainage of large volumes of spinal fluid can theoretically produce shifts in brain compartments and herniation syndromes, the clinical significance of this phenomenon when LSD is used immediately before craniotomy is unclear. To report a large single-surgeon consecutive experience with symptomatic brain herniation after lumbar drainage before craniotomy. Included were 365 patients who underwent LSD with either lumbar drain or lumbar puncture for a variety of different neurosurgical pathologies between 2008 and 2018 immediately before craniotomy. We reviewed the surgical indications, craniotomy location, approach, type of LSD, presence of postoperative brain herniation on imaging, type of herniation, clinical symptoms, lesion pathology, and 30-d modified Rankin Scale score for each patient. There was no patient who suffered from the development of new or worsening symptomatic or radiological brain herniation directly related to use of immediate preoperative LSD. This included 204 supratentorial and 161 infratentorial procedures. Surgical indications included 188 tumors, 5 aneurysms, 37 arteriovenous malformations, 2 revascularization procedures, 97 microvascular decompressions, 10 optic nerve decompressions requiring extradural clinoidectomy for tumor removal, and 26 "other" pathologies. Brain herniation did not occur postoperatively with the use of immediate preoperative LSD in our series, regardless of craniotomy location, pathology, extent of mass effect, or approach. Our experience suggests that LSD is a potentially safe preoperative adjunct that can be used to facilitate surgical objectives.

Commentary: Risk of Brain Herniation After Craniotomy With Preoperative Lumbar Spinal Drainage: A Single-Surgeon Experience of 365 Patients Among 3000 Major Cranial Cases.

Commentary: Risk of Brain Herniation After Craniotomy With Preoperative Lumbar Spinal Drainage: A Single-Surgeon Experience of 365 Patients Among 3000 Major Cranial Cases Morgan Broggi, MD, PhD, Morgan Broggi, MD, PhD Correspondence: Morgan Broggi, MD, PhD, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Via Celoria 11, 20133 Milano, Italy. Email: morgan.broggi@istituto-besta.it https://orcid.org/0000-0001-8818-1317 Search for other works by this author on: Oxford Academic Google Scholar Costanza M Zattra, MD, Costanza M Zattra, MD https://orcid.org/0000-0003-0061-6553 Search for other works by this author on: Oxford Academic Google Scholar Paolo Ferroli, MD Paolo Ferroli, MD Search for other works by this author on: Oxford Academic Google Scholar Operative Neurosurgery, Volume 20, Issue 2, February 2021, Pages E83–E84, https://doi.org/10.1093/ons/opaa348 Published: 11 December 2020 Article history Received: 12 August 2020 Accepted: 19 August 2020 Published: 11 December 2020

Surgical ischemia and reperfusion of the spinal cord – effect on specific perfusion and neurological outcome. Experimental study

Clamping of the thoracoabdominal aorta reduces perfusion of the spinal cord significantly, which clinically may present as paraparesis or paraplegia – devastating and unpredictable complications of open thoracoabdominal aortic surgery. Introduction of monitoring of evoked potentials and/or biochemical markers, methods increasing distal arterial pressure, indirect procedures enhancing residual flow (like liquor drainage), drugs, and use of hypothermia contributed to achieve better outcome. Preconditioning of spinal cord circulation is also a promising method. New endovascular techniques for thoracoabdominal aortic aneurysms and dissections reduced surgical trauma significantly. Despite all these progressions spinal cord ischemic damage is still a significant risk. To address this problem we carried out an experimental work using a canine model focusing on the protective effect of distal arterial perfusion, spinal fluid drainage, and their combination in a one hour setting of thoracoabdominal aortic clamping. In this paper we publish our data of circulatory and specific perfusion parameters of the spinal cord during and after declamping in correlation of final neurologic outcome.

Outcomes of Thoracic Endovascular Aneurysm Repair (TEVAR) in Patients With Connective Tissue Disorders

A review of the Vascular Quality Initiative national registry from January 2010 to December 2018 was performed. Of 12,207 patients treated with thoracic endovascular aortic repair (TEVAR), 102 were identified as having Marfan syndrome (86%), Ehlers-Danlos syndrome (EDS; 9%), or Loeys-Dietz syndrome (5%). The indications were type B dissection in 75% and aneurysmal disease in 25% of the patients. Spinal drains were placed in one half of the patients. No significant differences were found in the incidence of perioperative complications between those with dissections and those with aneurysms. The overall mortality was 5%. The mean follow-up was slightly longer than 1 year. Endoleak occurred during follow-up in 27% (eight acute type B dissections) of 30 patients for whom endoleak data were available. TEVAR for patients with connective tissue disorders can be performed with low perioperative mortality, spinal cord ischemia, and stroke. Acute type B aortic dissections represent a higher risk subgroup with increased rates of endoleak and retrograde dissection.

Mycotic Aneurysm Rupture Due to Clostridium septicum Thoracic Aortitis

An 85 year old female was referred with a diagnosis of mycotic aortitis with foci of gas within the descending aortic wall (A). Blood cultures were positive for Clostridium septicum, initiating targeted antibiotic therapy with metronidazole. A computed tomography (CT) scan at 10 days showed a ruptured descending thoracic aortic aneurysm (TAA; B). The mycotic TAA rupture was treated successfully by an endovascular approach. A Valiant Navion 34-31-200 mm (Medtronic, Dublin, Ireland) stent graft was deployed in the descending aorta without spinal drainage. Metronidazole was continued lifelong. Check CT scan at one month confirmed exclusion of the rupture with no new mycotic features.Image 1