A graded approach to cerebrospinal fluid (CSF) leak repair after transsphenoidal surgery is presented.
Patients undergoing endonasal tumor removal during an 8-year period were reviewed. ...Intraoperative CSF leaks were classified as Grade 0, no leak observed; Grade 1, small leak without obvious diaphragmatic defect; Grade 2, moderate leak; or Grade 3, large diaphragmatic/dural defect. Cranial base repair was tailored to the leak grade as Grade 0, collagen sponge; Grade 1, two-layered collagen sponge repair with intrasellar titanium mesh buttress; Grade 2, intrasellar and sphenoid sinus fat grafts with collagen sponge overlay and titanium buttress; and Grade 3, same as Grade 2 with CSF diversion in most cases. A provocative tilt test was performed before patient discharge to assess the integrity of the CSF leak repair. Protocol modifications adopted in 2003 included an intrasellar fat graft in Grade 1 leaks with a large intrasellar dead space, frequent use of BioGlue (CryoLife, Inc., Atlanta, GA) in Grade 1, 2, and 3 leaks, and CSF diversion for all Grade 3 leaks.
Among 668 cases in 620 patients (475 pituitary adenomas and 145 other lesions), an intraoperative CSF leak was observed in 57% of the cases: 32.5% Grade 1, 15% Grade 2, and 8.7% Grade 3. Postoperative repair failures occurred in 17 cases (2.5%), including 0.7, 3, 1, and 12% of Grade 0, 1, 2, and 3 CSF leaks, respectively. Bacterial meningitis occurred in three patients (0.45%). After protocol modifications in 2003, repair failures decreased from 4 to 1.2% (P = 0.02).
A graded repair approach to CSF leaks in transsphenoidal surgery avoids tissue grafts and CSF diversion in more than 60% of patients. Protocol modifications adopted in the last 340 cases have reduced the failure rate to 1% overall and 7% for Grade 3 leaks. Provocative tilt testing before patient discharge is helpful in the timely diagnosis of postoperative CSF leaks.
Abstract
BACKGROUND:
Remote ischemic conditioning (RIC) is a powerful endogenous mechanism whereby a sublethal ischemic stimulus confers a protective benefit against a subsequent severe ischemic ...insult. RIC has significant potential clinical implications for the prevention of delayed ischemic neurological deficit after aneurysmal subarachnoid hemorrhage (aSAH). Although RIC has been extensively investigated in animal models, it has not been fully evaluated in humans.
OBJECTIVE:
To assess the feasibility and safety of RIC for aSAH in a phase I clinical trial.
METHODS:
Consecutive patients hospitalized for treatment of an aSAH who met the inclusion/exclusion criteria were approached for consent. Enrolled patients received up to 4 RIC sessions on nonconsecutive days. Primary end points were the development of a symptomatic deep venous thrombosis, bruising, or injury to the limb and request to stop by the patient or surrogate. The secondary end points were the development of new neurological deficits or cerebral infarct, demonstrated by brain imaging after enrollment, and neurological deficit and condition at follow-up.
RESULTS:
Twenty patients were enrolled and underwent 76 RIC sessions, 75 of which were completed successfully. One session was discontinued when the patient became confused. No patient developed a deep venous thrombosis or injury to the preconditioned limb. No patient developed delayed ischemic neurological deficit during enrollment. At follow-up, median modified Rankin Scale score was 1 and Glasgow Outcome Scale score was 5.
CONCLUSION:
The RIC procedure was well tolerated and did not cause any injury. RIC for aSAH warrants investigation in a subsequent pivotal clinical trial.
Abstract
BACKGROUND:
Several forms of indirect cerebral revascularization have been proposed to promote neovascularity to the ischemic brain.
OBJECTIVE:
To present clinical and angiographic outcomes ...of indirect revascularization by encephaloduroarteriosynangiosis and burr holes for the treatment of Moyamoya disease in adults and children.
METHODS:
Data from 63 hemispheres treated in 42 patients (average age, 30 years; 33 adults; 30 female patients; median follow-up, 14 months) were reviewed. In hemispheres with preoperative and postoperative (6- to 12-month) angiograms available, superficial temporal artery (STA) and middle meningeal artery (MMA) diameters were measured. Preoperative and postoperative corrected arterial sizes were compared.
RESULTS:
Seven patients (17%) had transient ischemic attacks that resolved within 1 month of surgery. No patients suffered moyamoya-related hemorrhage after treatment. Two patients developed additional symptoms many years after surgery. In 18 hemispheres with preoperative and postoperative angiograms, there was an average postoperative increase in STA and MMA diameters of 51% (P = .003) and 49% (P = .002), respectively. Both children and adults displayed revascularization. Two patients did not demonstrate increased vessel size. STA blush and new branches and MMA blush and new branches were identified in 12, 14, 14, and 16 hemispheres, respectively. Angiographic blush was identified in 59% of frontal and 19% of parietal burr holes (P = .03). Surgical complications included 2 subdural hemorrhages requiring evacuation and 2 new ischemic deficits (1 transient).
CONCLUSION:
Indirect revascularization by encephaloduroarteriosynangiosis and burr holes for moyamoya results in long-term resolution of ischemic and hemorrhagic manifestations in 95% of adults and children. The MMA appears to contribute significantly to the revascularization on follow-up angiograms with increased size and neovascularity comparable to that of the STA. Angiographically, parietal burr holes do not contribute as significantly as frontal burr holes.
The extended transsphenoidal approach, which requires a bone and dural opening through the tuberculum sellae and posterior planum sphenoidale, is increasingly used for the treatment of nonadenomatous ...suprasellar tumors. The authors present their experiences in using the direct endonasal approach in patients with nonadenomatous suprasellar tumors.
Surgery was performed with the aid of an operating microscope and angled endoscopes were used to assess the completeness of resection. Bone and dural defects were repaired using abdominal fat, collagen sponge, titanium mesh, and, in most cases, lumbar drainage of cerebrospinal fluid (CSF). Twenty-six procedures for tumor removal were performed in 24 patients (ages 9-79 years), including two repeated operations for residual tumor. Gross-total removal could be accomplished in only 46% of patients, with near-gross-total removal or better in 74% of 23 patients (five of eight with craniopharyngiomas, six of seven with meningiomas, five of six with Rathke cleft cysts, and one of two with a dermoid or epidermoid cyst); a patient with a lymphoma only underwent biopsy. Of 13 patients with tumor-related visual loss, 85% improved postoperatively. The complications that occurred included five patients (21%) with postoperative CSF leaks, one patient (4%) with bacterial meningitis; five patients (21%) with new endocrinopathy; and two patients (8%) who needed to undergo repeated operations to downsize suprasellar fat grafts. The only permanent neurological deficit was anosmia in one patient; there were no intracranial vascular injuries.
The direct endonasal skull-base approach provides an effective minimally invasive means for resecting or debulking nonadenomatous suprasellar tumors that have traditionally been approached through a sublabial or transcranial route. Procedures in the supraglandular space can be performed effectively with excellent visualization of the optic apparatus while preserving pituitary function in most cases. The major challenge remains developing consistently effective techniques to prevent postoperative CSF leaks.
ABSTRACT
OBJECTIVE
Transsphenoidal adenomectomy carries the possibility of new pituitary failure and recovery. Herein, we present rates and determinants of postoperative hormonal status.
METHODS
All ...consecutive patients who underwent endonasal transsphenoidal adenoma removal over an 8-year period were analyzed. Those with previous sellar radiotherapy were excluded. Pre- and postoperative hormonal status (at least 3 mo after surgery) were determined and correlated with clinical parameters using a multivariate statistical model.
RESULTS
Of 444 patients (median age 45 years, 75% macroadenoma, 19% with multiple operations), 9 had preoperative panhypopituitarism. Of the remaining 435 patients, new hypopituitarism occurred in 5.5% of patients (anterior loss in 5%; permanent diabetes insipidus in 2.1%; including 2 patients who had total hypophysectomy). Of 346 patients with preoperative hormonal dysfunction, 170 (49%) had improved function. “Stalk compression” hyperprolactinemia resolved in 73% of 133 patients; recovery of at least 1 other anterior axis (excluding isolated hypogonadism associated with “stalk compression” hyperprolactinemia) occurred in 24% of 209 patients. Multivariate analysis showed that new hypopituitarism was most strongly associated with larger tumor diameter (P = 0.04). Of 223 patients with an endocrine-inactive adenoma, new hypopituitarism was seen in 0, 7.2, and 13.6% of patients with tumor diameters of <20, 20 to 29, and ≥30 mm, respectively (P = 0.005). Multivariate analysis revealed that resolution of hypopituitarism was related to younger age (39 versus 52 years, P < 0.0001), absence of an intraoperative cerebrospinal fluid leak and, in patients with an endocrine-inactive adenoma, absence of systemic hypertension (24% versus 6%, P = 0.009).
CONCLUSION
After transsphenoidal adenomectomy, new unplanned hypopituitarism occurs in approximately 5% of patients, whereas improved hormonal function occurs in 50% of patients. The likelihood of new hormonal loss or recovery appears to depend on several factors. New hypopituitarism occurs most commonly in patients with tumors larger than 20 mm in size, whereas hormonal recovery is most likely to occur in younger, nonhypertensive patients and those without an intraoperative cerebrospinal fluid leak.
Internal carotid artery (ICA) injury during sellar dural opening is a potentially catastrophic complication of transsphenoidal surgery. We describe two ICA injuries that occurred early in our ...endonasal transsphenoidal experience. We then describe our subsequent protocol to prevent this complication in which we use the Doppler probe for carotid localization and micro-hook blades for lateral dural opening.
All patients undergoing endonasal tumor removal were analyzed since beginning this approach in 1998. Of 631 procedures (585 patients), three patients sustained an ICA injury.
In the first 114 procedures (105 patients) in which the Doppler probe was not used and hook blades were used infrequently, two (1.8%) ICA injuries occurred. In both cases, a right nostril approach was used and the left ICA was punctured on dural opening with a straight scalpel; both patients recovered without neurological sequelae. In the subsequent 517 procedures in which the Doppler probe and hook blades were used in all cases, one (0.19%) probable ICA injury occurred during an attempted removal of a cavernous sinus schwannoma, although there was no angiographic evidence of vascular injury. There were no ICA or other intracranial vascular injuries in the last 510 procedures for tumors not solely confined to the cavernous sinus.
Cavernous carotid localization with the Doppler probe before dural opening and angled hook blades for lateral dural opening can help minimize the risk of ICA injury and are recommended for all transsphenoidal operations. Because of the wider contralateral exposure provided by the endonasal approach, the ICA contralateral to the nostril of approach is at higher risk of injury on dural opening.
Encephaloduroarteriosynangiosis (EDAS) is a form of revascularization that has shown promising early results in the treatment of adult patients with moyamoya disease (MMD) and more recently in ...patients with intracranial atherosclerotic steno-occlusive disease (ICASD). Herein the authors present the long-term results of a single-center experience with EDAS for adult MMD and ICASD.
Patients with ischemic symptoms despite intensive medical therapy were considered for EDAS. All patients undergoing EDAS were included. Clinical data, including recurrence of transient ischemic attack (TIA) and/or stroke, functional status, and death, were collected from a retrospective data set and a prospective cohort. Perren revascularization and American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) collateral grades were recorded from angiograms.
A total of 107 EDAS procedures were performed in 82 adults (36 with ICASD and 46 with MMD). During a median follow-up of 22 months, 2 (2.4%) patients had strokes; both patients were in the ICASD group. TIA-free survival and stroke-free survival analyses were performed using the product limit estimator (Kaplan-Meier) method. The probability of stroke-free survival at 2 years in the ICASD group was 94.3% (95% CI 80%-98.6%). No patient in the MMD group suffered a stroke. The probability of TIA-free survival at 2 years was 89.4% (95% CI 74.7%-96%) in ICASD and 99.7% (95% CI 87.5%-99.9%) in MMD. There were no hemorrhages or stroke-related deaths. Angiograms in 85.7% of ICASD and 92% of MMD patients demonstrated Perren Grade 3 and improvement in ASITN/SIR grade in all cases.
EDAS is well tolerated in adults with MMD and ICASD and improves collateral circulation to territories at risk. The rates of stroke after EDAS are lower than those reported with other treatments, including intensive medical therapy in patients with ICASD.
The complex pathophysiology of traumatic brain injury (TBI) involves not only the primary mechanical event but also secondary insults such as hypotension, hypoxia, raised intracranial pressure and ...changes in cerebral blood flow and metabolism. It is increasingly evident that these initial insults as well as transient events and treatments during the early injury phase can impact hypothalamic-pituitary function both acutely and chronically after injury. In turn, untreated pituitary hormonal dysfunction itself can further hinder recovery from brain injury. Secondary adrenal insufficiency, although typically reversible, occurs in up to 50% of intubated TBI victims and is associated with lower systemic blood pressure. Chronic anterior hypopituitarism, although reversible in some patients, persists in 25-40% of moderate and severe TBI survivors and likely contributes to long-term neurobehavioral and quality of life impairment. While the rates and risk factors of acute and chronic pituitary dysfunction have been documented for moderate and severe TBI victims in numerous recent studies, the pathophysiology remains ill-defined. Herein we discuss the hypotheses and available data concerning hypothalamic-pituitary vulnerability in the setting of head injury. Four possible pathophysiological mechanisms are considered: (1) the primary brain injury event, (2) secondary brain insults, (3) the stress of critical illness and (4) medication effects. Although each of these factors appears to be important in determining which hormonal axes are affected, the severity of dysfunction, their time course and possible reversibility, this process remains incompletely understood.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Abstract Objectives Remote ischemic preconditioning (RIPC) is a powerful endogenous mechanism whereby a brief period of ischemia is capable of protecting remote tissues from subsequent ischemic ...insult. While this phenomenon has been extensively studied in the heart and brain in animal models, little work has been done to explore the effects of RIPC in human patients with acute cerebral ischemia. This study investigates whether chronic peripheral hypoperfusion, in the form of pre-existing arterial peripheral vascular disease (PVD) that has not been surgically treated, is capable of inducing neuroprotective effects for acute ischemic stroke. Methods Individuals with PVD who had not undergone prior surgical treatment were identified from a registry of stroke patients. A control group within the same database was identified by matching patient's demographics and risk factors. The two groups were compared in terms of outcome by NIH Stroke Scale (NIHSS), modified Rankin scale (mRS), mortality, and volume of infarcted tissue at presentation and at discharge. Results The matching algorithm identified 26 pairs of PVD-control patients (9 pairs were female and 17 pairs were male). Age range was 20–93 years (mean 73). The PVD group was found to have significantly lower NIHSS scores at admission (NIHSS ≤ 4: PVD 47.1%, control 4.35%, p < 0.003), significantly more favorable outcomes at discharge (mRS ≤ 2: PVD 30.8%, control 3.84%, p < 0.012), and a significantly lower mortality rate (PVD 26.9%, control 57.7%, p = 0.024). Mean acute stroke volume at admission and at discharge were significantly lower for the PVD group (admission: PVD 39.6 mL, control 148.3 mL, p < 0.005 and discharge: PVD 111.7 mL, control 275 mL, p < 0.001). Conclusion Chronic limb hypoperfusion induced by PVD can potentially produce a neuroprotective effect in acute ischemic stroke. This effect resembles the neuroprotection induced by RIPC in preclinical models.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
OBJECTIVE:To determine the prevalence, time course, clinical characteristics, and effect of adrenal insufficiency (AI) after traumatic brain injury (TBI).
DESIGN:Prospective intensive care unit–based ...cohort study.
SETTING:Three level 1 trauma centers.
PATIENTS:A total of 80 patients with moderate or severe TBI (Glasgow Coma Scale score, 3–13) and 41 trauma patients without TBI (Injury Severity Score, >15) enrolled between June 2002 and November 2003.
MEASUREMENTS:Serum cortisol and adrenocorticotropic hormone levels were drawn twice daily for up to 9 days postinjury; AI was defined as two consecutive cortisols of ≤15 μg/dL (25th percentile for extracranial trauma patients) or one cortisol of <5 μg/dL. Principal outcome measures includedinjury characteristics, hemodynamic data, usage of vasopressors, metabolic suppressive agents (high-dose pentobarbital and propofol), etomidate, and AI status.
MAIN RESULTS:AI occurred in 42 TBI patients (53%). Adrenocorticotropic hormone levels were lower at the time of AI (median, 18.9 vs. 36.1 pg/mL; p = .0001). Compared with patients without AI, those with AI were younger (p = .01), had higher injury severity (p = .02), had a higher frequency of early ischemic insults (hypotension, hypoxia, severe anemia) (p = .02), and were more likely to have received etomidate (p = .049). Over the acute postinjury period, patients with AI had lower trough mean arterial pressure (p = .001) and greater vasopressor use (p = .047). Mean arterial pressure was lower in the 8 hrs preceding a low (≤15 μg/dL) cortisol level (p = .003). There was an inverse relationship between cortisol levels and vasopressor use (p = .0005) and between cortisol levels within 24 hrs of injury and etomidate use (p = .002). Use of high-dose propofol and pentobarbital was strongly associated with lower cortisol levels (p < .0001).
CONCLUSIONS:Approximately 50% of patients with moderate or severe TBI have at least transient AI. Younger age, greater injury severity, early ischemic insults, and the use of etomidate and metabolic suppressive agents are associated with AI. Because lower cortisol levels were associated with lower blood pressure and higher vasopressor use, consideration should be given to monitoring cortisol levels in intubated TBI patients, particularly those receiving high-dose pentobarbital or propofol. A randomized trial of stress-dose hydrocortisone in TBI patients with AI is underway.
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