Strategies For Complication Avoidance Research Articles

Brain aneurysm rupture during mechanical thrombectomy for large vessel occlusion: Technical case series and complication avoidance strategies.

Endovascular therapy became the mainstream treatment for patients with acute stroke due to emergent large vessel occlusion (LVO). With increasing number of interventions, it is not uncommon for incidental vascular pathologies to be found during mechanical thrombectomy. Overall, intracranial aneurysms can occur in up to 4% of the population, but previous studies suggest a slightly higher prevalence of intracranial aneurysms in stroke patients as they may share common risk factors. We report on three patients with acute stroke secondary to LVO undergoing mechanical thrombectomy with brain aneurysms incidentally discovered and discuss the potential implications and technical considerations of performing revascularization in these scenarios. In the first case, a patient treated with stent-retriever and aspiration developed a carotid-cavernous fistula without clinical repercussion. The second case illustrates an internal carotid artery posterior communicating segment aneurysm rupture with a massive subarachnoid hemorrhage. The third case exemplifies an unruptured middle cerebral artery bifurcation aneurysm related to an M2 occlusion managed with a different strategy, avoiding aneurysm rupture. Intraprocedural aneurysm rupture is a potential complication during mechanical thrombectomy, especially when anatomical challenges are present. Interventionalists should be aware of the potential risk and constraints in this setting in order to mitigate adverse events.

Complication Avoidance in Surgical Management of Vertebral Column Tumors

The surgical management of spinal tumors has grown increasingly complex as treatment algorithms for both primary bone tumors of the spine and metastatic spinal disease have evolved in response to novel surgical techniques, rising complication rates, and additional data concerning adjunct therapies. In this review, we discuss actionable interventions for improved patient safety in the operative care for spinal tumors. Strategies for complication avoidance in the preoperative, intraoperative, and postoperative settings are discussed for approach-related morbidities, intraoperative hemorrhage, wound healing complications, cerebrospinal fluid (CSF) leak, thromboembolism, and failure of instrumentation and fusion. These strategies center on themes such as pre-operative imaging review and medical optimization, surgical dissection informed by meticulous attention to anatomic boundaries, and fastidious wound closure followed by thorough post-operative care.

Expanded Transsphenoidal Trans-Lamina Terminalis Approach to Tumors Extending Into the Third Ventricle: Technique Notes and a Single Institute Experience

ObjectThe trans lamina terminalis approach (TLTA) has been described as a way to remove third ventricular tumors. The aim of this paper was to analyze the feasible outcomes of TLTA applied to tumors extending into the third ventricle in our institute.MethodsSuprasellar tumors (n = 149) were treated by the extended endonasal approach from September 2019 to December 2020 in Beijing Tiantan Hospital. Eleven of the tumors were treated by TLTA or TLTA via the trans-chiasm-pituitary corridor (TCPC). The surgical technique notes of TLTA were described and indications and outcomes of the approach were analyzed.ResultsThere were 11 patients enrolled in the study, six with papillary craniopharyngiomas, two with adamantinomatous craniopharyngiomas, one with a germinal cell tumor (GCT), one with cavernous malformation and one with chordoid glioma. Four of the patients received a radical resection by TLTA alone, while seven of them received TLTA via the TCPC. Gross total resection was achieved in eight patients (72.7%), and partial resection in three patients (27.3%). Visual function was improved in four of the 11 patients (36.4%), was unchanged in five patients (45.5%), and deteriorated in two patients (18.2%). New-onset hypopituitarism occurred in seven patients (63.3%) and new-onset diabetes insipidus occurred in two patients (18.2%). Electrocyte imbalance were observed in six patients (54.5%) at post-operative week 2. There were no surgery-related deaths or cerebrospinal fluid leaks. Postoperative intracranial infection was observed in one patient (9.1%), and during the follow-up period, tumor recurrence occurred in one patient (9.1%).ConclusionThe expanded TLTA provides a feasible suprachiasm corridor to remove tumors extending into the third ventricle, especially for craniopharyngiomas. Sound understanding of the major strengths and limitations of this approach, as well as strategies for complication avoidance, is necessary for its safe and effective application.

Endovascular Management of Intracranial Dural Arteriovenous Fistulas: Transarterial Approach.

In this second of 3 review articles on the endovascular management of intracranial dural AVFs, we discuss transarterial treatment approaches. The treatment goal is to occlude the fistulous point, including the most distal portion of the arterial supply together with the most proximal portion of the draining vein (ie, the "foot" of the vein), which can be accomplished with liquid embolic agents via transarterial access. Anatomic factors to consider when assessing the safety and efficacy of a transarterial approach using liquid embolic agents include location, angioarchitecture, and proximity of arterial feeders to both the vasa nervosum of adjacent cranial nerves and the external carotid-internal carotid/vertebral artery anastomoses. Anatomic locations typically favorable for transarterial approaches include but are not limited to the transverse/sigmoid sinus, cerebral convexity, and superior sagittal sinus. In this review article, we discuss the technical approaches, outcomes, potential complications, and complication avoidance strategies for transarterial embolization.

Posterior atlantoaxial fixation: A cadaveric and fluoroscopic step-by-step technical guide.

Background:Atlantoaxial surgical fixation is widely employed treatment strategy for a myriad of pathologies affecting the stability of the atlantoaxial joint. The most common technique used in adults, and in certain cases in children, involves a posterior construct with C1 lateral mass screws, and C2 pars or pedicle screws. This technical note aims to provide a step-by-step guide to this procedure using cadaveric and fluoroscopic images.Methods:An embalmed, human, cadaveric, specimen was used for this study. The subject did not have obvious occipital-cervical pathology. Dissections and techniques were performed to mimic actual surgical technique. Photographs were taken during each step, and the critical aspects of each step were highlighted. Fluoroscopic images from a real patient undergoing C1/C2 fixation were also utilized to further highlight the anatomic-radiographic relationships. This study was performed without external or industry funding.Results:Photographic and radiographic pictures and drawings are presented to illustrate the pertinent anatomy and technical aspects of this technique. The nuances of each step, including complication avoidance strategies are also highlighted.Conclusions:Given the widespread utilization of this technique, described step-by-step guide is timely for surgeons and trainees alike.

Trans-Lamina Terminalis Approach to Third Ventricle using Supraorbital Craniotomy: Technique Description and Literature Review for Outcome Comparison with Anterior, Lateral and Trans-Sphenoidal Corridors

The trans-lamina terminalis approach has been described to remove third ventricular tumors. Various surgical corridors for this approach include anterior (via bifrontal craniotomy), anterolateral (via supra-orbital craniotomy), lateral (via pterional craniotomy) and trans-sphenoidal corridors. Supra-orbital craniotomy offers a minimally invasive access for resection of third ventricular tumors. The trans-lamina terminalis technique through a supra-orbital craniotomy is described. Also, a literature review of clinical outcome data was performed for the comparison of different surgical corridors (anterior, antero-lateral, lateral, and trans-sphenoidal). The operative steps and anatomic landmarks for supra-orbital craniotomy are discussed, along with 3 representative cases and respective outcomes. Gross total resection was achieved in 2 patients, and one patient required reoperation for recurrence. Based on the current literature, the clinical outcomes after supra-orbital craniotomy for trans-lamina terminalis approach are comparable to other surgical corridors. The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for third ventricular tumors. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long working distance is a major limitation. The clinical outcomes are comparable to other surgical corridors. Sound understanding of major strengths, limitations, and strategies for complication avoidance is necessary for its safe and effective application.

Complications and outcomes after spinal deformity surgery in the elderly: review of the existing literature and future directions

The elderly population (age > 60 years) is the fastest-growing age group in the US. Spinal deformity is a major problem affecting the elderly and, therefore, the demand for surgery for spinal deformity is becoming increasingly prevalent in elderly patients. Much of the literature on surgery for adult deformity focuses on patients who are younger than 60 years, and therefore there is limited information about the complications and outcomes of surgery in the elderly population. In this study, the authors undertook a review of the literature on spinal deformity surgery in patients older than 60 years. The authors discuss their analysis with a focus on outcomes, complications, discrepancies between individual studies, and strategies for complication avoidance. A systematic review of the MEDLINE and PubMed databases was performed to identify articles published from 1950 to the present using the following key words: "adult scoliosis surgery" and "adult spine deformity surgery." Exclusion criteria included patient age younger than 60 years. Data on major Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores, patient-reported outcomes, and complications were recorded. Twenty-two articles were obtained and are included in this review. The mean age was 74.2 years, and the mean follow-up period was 3 years. The mean preoperative ODI was 48.6, and the mean postoperative reduction in ODI was 24.1. The mean preoperative VAS score was 7.7 with a mean postoperative decrease of 5.2. There were 311 reported complications for 815 patients (38%) and 5 deaths for 659 patients (< 1%). Elderly patient outcomes were inconsistent in the published studies. Overall, most elderly patients obtained favorable outcomes with low operative mortality following surgery for adult spinal deformity.

Nerve injury during the transpsoas approach for lumbar fusion

A lateral transpsoas approach to achieve interbody fusion in the lumbar spine using either the extreme lateral interbody fusion or direct lateral interbody fusion technique is an increasingly popular method to treat spinal disease. Dissection and dilation through the iliopsoas muscle places the lumbosacral plexus at risk for injury, but there is very limited information in the published literature about adverse clinical events resulting in postoperative motor deficits or reports of failure of electrophysiological monitoring to detect nerve injury. The authors present 2 cases of postoperative motor deficits following the transpsoas approach not detected by intraoperative monitoring, review the medical literature, and discuss strategies for complication avoidance.

Expanded Endonasal Approaches to the Anterior Skull Base

ABSTRACTRecent technological advances and growing cooperation between otorhinolaryngologists and neurosurgeons, coupled with an increasing knowledge of the anatomy of the ventral skull base, have led to the development of a series of surgical approaches to this region. Utilizing the nasal corridor, these expanded endonasal approaches (EEAs) benefit from the increased luminosity and definition provided by the endoscope to navigate through this corridor and reach a multitude o pathologies, both neoplastic and degenerative in nature. One of their common uses is to address tumors that arise from or invade the anterior cranial fossa; these lesions may include olfactory groove meningiomas, esthesioneuroblastomas and sinonasal malignancies. In order to safely resect these tumors through EEAs the surgical team must adhere to a series of steps, while planning the procedure as well as carrying it out. In this review article, the authors present these steps and describe the main patient selection criteria and complication avoidance strategies related to expanded endonasal approaches to the anterior skull base.

Vertebroplasty and Kyphoplasty: Case Presentation, Complications, and Their Prevention

Objective. To describe vertebroplasty and kyphoplasty, which are relatively new techniques used to treat painful vertebral compression fractures. Design Setting Patients. This article briefly reviews the procedural indications, technical aspects of the procedure, and strategies for complication avoidance. Results. Percutaneous vertebroplasty is the injection of a vertebral body with bone cement, generally polymethylmethacrylate. Kyphoplasty is the placement of balloons (called “tamps”) into the vertebral body with an inflation/deflation sequence to create a cavity prior to the cement injection. These procedures are most often performed in a percutaneous fashion on an outpatient (or short stay) basis. The mechanism of action is unknown, but it is postulated that stabilization of the fracture leads to analgesia. The procedure is indicated for painful vertebral compression fractures due to osteoporosis or malignancy, and painful hemangiomas. The procedure has efficacy in painful vertebral metastasis and traumatic compression fractures. Much evidence favors the use of this procedure for pain associated with these disorders. The overall risks of the procedure are low but serious complications can occur. The serious complications include spinal cord compression, nerve root compression, venous embolism, pulmonary embolism including cardiovascular collapse, and others. With good patient selection and careful technique, these complications are avoidable, making the risk-to-benefit ratio highly favorable. Conclusions. Vertebroplasty and kyphoplasty are effective and safe techniques used to treat painful spinal fractures.

Tongue base abscess requiring emergent tracheotomy: A complication of volumetric RFA

Objectives: A case of a near-obstructing tongue base abscess secondary to radiofrequency volumetric tongue-base reduction is presented. Methods: Case report and review of the literature. Results: A 39-year-old woman presented with severe odynophagia, “hot-potato” voice, and increasing respiratory difficulty 8 days following a radiofrequency volumetric tongue-base reduction procedure. Examination revealed marked fullness of her tongue base with vallecular effacement, significant narrowing of the oropharyngeal airway, and exquisite tenderness to palpation over the tongue base and neck. CT scan revealed a large, rim-enhancing tongue base fluid collection measuring 3.3 × 5.2 × 3.8 cm. The diagnosis was felt to be consistent with an abscess, and due to the large size of the lesion and impending airway obstruction, the patient was taken to the operating room for emergent tracheotomy and drainage of the abscess. Conclusion: The complication of tongue base abscess secondary to radiofrequency ablation procedures has been well described in the literature, however, this is the first reported case of a tongue-base abscess requiring emergent tracheotomy. Clinical complication avoidance strategies for tongue-base RFA, which have been previously recommended, should be followed closely in an attempt to minimize the risk of this potentially life-threatening complication.

Complications of radiofrequency ablation in the treatment of sleep-disordered breathing

Objective: To evaluate complications of radiofrequency ablation (RFA) in the treatment of sleep-disordered breathing and to outline complication avoidance strategies. Study Design and Setting: Retrospective review of 51 consecutive RFA treatment sessions for SDB to the soft palate and tongue base by a single surgeon at a tertiary medical center. Results: Over 2 years, 51 treatments comprising 26 palatal and 25 tongue base RFA treatments were performed for sleep-disordered breathing on 30 patients. Complications included palatal mucosal breakdown (11 cases), temporary tongue base neuralgias (4 cases), uvular sloughing (2 cases), tongue base abscesses (2 cases), and floor of mouth edema with airway compromise (2 cases). Conclusions/Significance: This is the first paper focusing on complications of RFA. While complications from soft palate RFA present rapidly and are self-limiting, complications from tongue base RFA may be delayed and life threatening. A detailed strategy is provided to avoid and treat these complications. (Otolaryngol Head Neck Surg 2001;125:462-7.)

Prevention and treatment of thromboembolic and ischemic complications associated with endovascular procedures: Part II--Clinical aspects and recommendations.

We reviewed the incidence, risk factors, and clinical features of thromboembolic and ischemic events associated with diagnostic cerebral angiography, endovascular treatment of aneurysms using coils or balloons, angioplasty and stent placement to treat extracranial carotid artery stenosis, and embolization of arteriovenous malformations using glue or other embolic agents. We performed a cumulative analysis to determine the frequency and characteristics of these events and a subset analysis (whenever possible) to determine the benefits of various strategies for complication avoidance. Of the 1,547 patients who underwent Guglielmi detachable coil treatment, thromboembolic events were observed for 127 (8.2%), consisting of asymptomatic events for 12 patients, transient ischemic attacks for 29, and strokes for 86. The outcomes for the 86 patients with strokes were categorized as full recovery for 15, good recovery for 27, partial recovery for 19, no recovery for 11, death for 12, and undetermined outcome for 2. Of the 834 patients who underwent carotid angioplasty and stent placement, thromboembolic events were observed for 73 (8.8%), consisting of transient ischemic attacks for 26 patients and strokes for 47. The outcomes for the patients with strokes were categorized as full recovery for 20, good recovery for 15, partial recovery for 6, no recovery for 2, and death for 4. High rates of thromboembolic events were also observed with balloon occlusion of aneurysms (11%) or parent arteries (19%) and carotid angioplasty alone (5.9%). Arteriovenous malformation embolization was associated with an ischemic event/procedure rate of 9.4%. High rates of thromboembolic and ischemic complications, with subsequent morbidity and death, are associated with most endovascular procedures. Further research and the formulation of standard preventive guidelines may help to reduce these risks and improve the overall success of these procedures.