POSTOPERATIVE POSTOPERATIVE CEREBRAL VENOUS CEREBRAL VENOUS
INFARCTION:INFARCTION:A neurosurgical blind A neurosurgical blind
spot?spot?VIKAS NAIK, DEEPAK AGRAWALVIKAS NAIK, DEEPAK AGRAWALDEPARTMENT OF NEUROSURGERY,DEPARTMENT OF NEUROSURGERY,
NEUROSCIENCES & GAMMA-KNIFE CENTRE,NEUROSCIENCES & GAMMA-KNIFE CENTRE,
AIIMS, NEW DELHIAIIMS, NEW DELHI
Introduction (POCVI)Introduction (POCVI) Advent of microneurosurgeryAdvent of microneurosurgery
- incr risk of postop - incr risk of postop complicationscomplications
Symptomatology and prognosis is Symptomatology and prognosis is variablevariable
Limited literarure regarding the Limited literarure regarding the pathophysiology and management of pathophysiology and management of POCVIPOCVI
Introduction Introduction
Incidence is difficult to determine Incidence is difficult to determine due to:due to:
- unclear definition- unclear definition
- variability of symptoms - variability of symptoms
- inclusion of other factors like - inclusion of other factors like brain brain retraction during the retraction during the operation operation
Pathophysiology Pathophysiology
The severity of cerebral venous The severity of cerebral venous compromise depends upon venous compromise depends upon venous collaterals.collaterals.
Venous congestion produces Venous congestion produces interstitial edema (Fig 1A), which interstitial edema (Fig 1A), which can lead to hypoperfusion and can lead to hypoperfusion and infarction.infarction.
Aims and objectivesAims and objectives
To study the incidence and clinico-To study the incidence and clinico-radiological course of POCVI in a radiological course of POCVI in a tertiary level neurosurgical unit.tertiary level neurosurgical unit.
Material and methodsMaterial and methods
Prospective study Prospective study January – August 2006January – August 2006
Materials and MethodsMaterials and Methods
Inclusion criteria:Inclusion criteria: All pts undergoing elective cranial All pts undergoing elective cranial
surgerysurgery
Exclusion criteriaExclusion criteria:: Emergency proceduresEmergency procedures ReexplorationReexploration Traumatic brain injuryTraumatic brain injury Shunts Shunts Biopsies & burr-hole procedures,Biopsies & burr-hole procedures, spinal proceduresspinal procedures
History & examination History & examination Preop radiology (CT head/MRI brain) Preop radiology (CT head/MRI brain)
reviewed to document any preexisting reviewed to document any preexisting infarcts. infarcts.
Postoperatively all patients underwent CT Postoperatively all patients underwent CT scan of the head within 24hrs. scan of the head within 24hrs.
Patients were monitored for neurological Patients were monitored for neurological deterioration anddeterioration and
CT scan was repeated as required by the CT scan was repeated as required by the attending neurosurgeonattending neurosurgeon
Materials and MethodsMaterials and Methods
Operation findings & any Operation findings & any intraoperative events were also intraoperative events were also recordedrecorded
Materials and MethodsMaterials and Methods
RADIOLOGYRADIOLOGY
POCVI was divided POCVI was divided
hemorrhagic hemorrhagic
non-hemorrhagic types non-hemorrhagic types
RADIOLOGYRADIOLOGY
The diagnosis of hemorrhagic POCVI The diagnosis of hemorrhagic POCVI was based on presence of was based on presence of Subcortical, multifocal Subcortical, multifocal hyperdensities with irregular hyperdensities with irregular margins and or low density areas in margins and or low density areas in the perioperatively fieldsthe perioperatively fields
RADIOLOGYRADIOLOGY
Non-hemorrhagic POCVI was Non-hemorrhagic POCVI was diagnosed if CT showed a localized diagnosed if CT showed a localized hypodensity poorly demarcated the hypodensity poorly demarcated the subcortical white matter with/without subcortical white matter with/without mass effect, mass effect, alongalong with presence of with presence of fresh neurological deficits.fresh neurological deficits.
Treatment Treatment
Standard NS managent Standard NS managent
-Decongestants-Decongestants
-Decompressive craniectomy -Decompressive craniectomy
observationsobservations
376 patients 376 patients M:f 1.2:1 M:f 1.2:1 age = 6-68yrs (50-50) age = 6-68yrs (50-50) 26 pts (7%) developed POCVI26 pts (7%) developed POCVI
In pts who developed POCVIIn pts who developed POCVI Sixteen (61%) patients developed Sixteen (61%) patients developed
hemorrhagic POCVI and hemorrhagic POCVI and 10 (39%) patients developed non 10 (39%) patients developed non
hemorrhagic POCVI. hemorrhagic POCVI. The mean time to POCVI detection The mean time to POCVI detection
was 72 hours (range 24-144hours). was 72 hours (range 24-144hours).
ResultsResults
In pts who developed POCVIIn pts who developed POCVI 3(11%) had focal deficit as 3(11%) had focal deficit as
presenting manifestationpresenting manifestation 13(50%) had altered sensorium13(50%) had altered sensorium 5 (19%) had both,5 (19%) had both, 5(19%) were asymptomatic 5(19%) were asymptomatic
ResultsResults
In pts who developed POCVIIn pts who developed POCVI Most of the patients operated were Most of the patients operated were
for intracranial for intracranial tumours(20)76% ,followed by tumours(20)76% ,followed by vascular (4 )15% pathology.vascular (4 )15% pathology.
There was one case each of intra There was one case each of intra cranial abscess and csf rhinorrhiacranial abscess and csf rhinorrhia
ResultsResults
In pts who developed POCVIIn pts who developed POCVI Meningioma (9 )45% Meningioma (9 )45% Glioma ( 5)25% Glioma ( 5)25% Acoustic neuroma (4)20%,Acoustic neuroma (4)20%, one each of craniopharyngioma and one each of craniopharyngioma and
colloid cyst .colloid cyst .
ResultsResults
Intraoperative findingsIntraoperative findings
In pts who developed POCVIIn pts who developed POCVI There was one patient with frontal There was one patient with frontal
venous sinus injury, however no venous sinus injury, however no major cortical vein injury major cortical vein injury documented in any of these patients.documented in any of these patients.
17(65% ) patients had dura tense on 17(65% ) patients had dura tense on openingopening
In pts who developed POCVIIn pts who developed POCVI Seventeen (66%) patients were Seventeen (66%) patients were
managed conservativelymanaged conservatively nine (34%) patients in underwent nine (34%) patients in underwent
decompressive craniectomy as an decompressive craniectomy as an additional procedure for management additional procedure for management of POCVIof POCVI
In five patients, the infarction was an In five patients, the infarction was an incidental findingincidental finding
ResultsResults
Hospital stay ranged from 4 days in Hospital stay ranged from 4 days in asymptomatic to 77 days(mean20 asymptomatic to 77 days(mean20 days). days).
ResultsResults
5 () pts remained asymptomatic5 () pts remained asymptomatic 13 (50%) patients improved 13 (50%) patients improved
neurologically and were discharged neurologically and were discharged with residual deficits. with residual deficits.
Two (7%) showed no neurological Two (7%) showed no neurological improvement till discharge, andimprovement till discharge, and
6(23%) died during the hospital stay 6(23%) died during the hospital stay following POCVIfollowing POCVI
ResultsResults
DiscussionDiscussion Kageyama et al venous infarction in 13% of Kageyama et al venous infarction in 13% of
the 120 cases operated by them and the 120 cases operated by them and Al-Mefty and Krisht showed that brain Al-Mefty and Krisht showed that brain
edema occurred in 10% of the cases in which edema occurred in 10% of the cases in which the superficial sylvian vein was sacrificed 2.the superficial sylvian vein was sacrificed 2.
Kuboto reported that 40% of the patients Kuboto reported that 40% of the patients with vein sacrifice during an with vein sacrifice during an interhemispheric approach suffered from interhemispheric approach suffered from brain damage.brain damage.
Robertson quoted complication rate of Robertson quoted complication rate of venous insufficiency at 1.5 per 1000 cases of venous insufficiency at 1.5 per 1000 cases of skull base surgeryskull base surgery
POCVI carries a high mortality POCVI carries a high mortality (23%) and morbidity (57%) {in our (23%) and morbidity (57%) {in our series}series}
A significant percentage (19%) of A significant percentage (19%) of the pts remain asymptomatic inspite the pts remain asymptomatic inspite of hemorrhagic POCVIof hemorrhagic POCVI
Conclusion Conclusion
Conclusion Conclusion
Incidence of POCVI at AIIMS is Incidence of POCVI at AIIMS is comparable to that seen in literaturecomparable to that seen in literature
Further research needs to be done Further research needs to be done to elucidate the pathophysiology & to elucidate the pathophysiology & management of this important management of this important problemproblem
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