Supratentorial Epidural Hematoma after Posterior Fossa Surgery

Supratentorial Epidural Hematoma after Posterior Fossa Surgery

Non-traumatic, non-arterial origin delayed Epidural Hematoma after posterior fossa surgery is extremely rare. Moreover, the pathogenesis of its supratentorial extension is obscure.

The possible causes include sudden decompression of ventricular pressure in the supratentorial compartment, rupture of cortical veins in the sitting positioncoagulopathy, hemodynamic fluctuations during surgery, and position-related ischemia 1).

The lowering of the ventricular pressure by the ventricular tapduring the operation may play significant role in the formation of the extradural hematoma.

The younger age of the cases and the long history of increased intracranial pressure were stressed in the literature2).

Wolfsberger et al., stressed the importance of early postoperative CT scan and optimal management of ventricular pressure and coagulation status to detect and prevent this possibly life-threatening complication 3).

Avci et al., from Mersin, reported a case during removal of a huge Posterior fossa dermoid cyst 4).

Pandey et al., from Bangalore reported in 2008 a large bifrontal extradural hematoma following posterior fossa surgery for a vermian medulloblastoma5).

Tsugane et al., reported five cases of the supratentorial extradural hematomas secondary to the posterior fossa craniectomy.

The site of the hematoma was far from the operative field and two cases showed acute course and three were rather mild. The symptoms of this complication were the unsuspected sensorium disturbance, anisocoria and the non-functioning ventricular drainage. Two cases died of this complication and two were severely disabled 6).

Multiple Supratentorial Epidural Hematomas

Tyagi et al., from Bangalore published Multiple Remote Sequential Supratentorial Epidural Hematoma7).

Wolfsberger et al., from Vienna published a 31-year-old female who presented with a history of chronic hydrocephalus due to fourth-ventricular plexus papilloma. Following resection of the posterior fossa tumor with intraoperative placement of a ventricular drainage, she consecutively developed four supratentorial epidural haematomas at different locations, all necessitating evacuation. The clinical manifestations ranged from subtle neurological deficits to signs of tentorial herniation; the ultimate outcome was complete recovery. Rapid tapering of CSF pressure after long-standing hydrocephalus and clotting disorders could be implicated as causative factors. They stressed the importance of early postoperative CT scan and optimal management of ventricular pressure and coagulation status to detect and prevent this possibly life-threatening complication 8).

References

1) , 5)

Pandey P, Madhugiri VS, Sattur MG, Devi B I. Remote supratentorial extradural hematoma following posterior fossa surgery. Childs Nerv Syst. 2008 Jul;24(7):851-4. doi: 10.1007/s00381-007-0573-5. Epub 2008 Jan 31. PubMed PMID: 18236051.
2) , 6)

Tsugane R, Sugita K, Sato O. [Supratentorial extradural hematomas following posterior fossa craniectomy (author’s transl)]. No Shinkei Geka. 1976 Apr;4(4):401-3. Japanese. PubMed PMID: 944882.
3) , 8)

Wolfsberger S, Gruber A, Czech T. Multiple supratentorial epidural haematomas after posterior fossa surgery. Neurosurg Rev. 2004 Apr;27(2):128-32. Epub 2003 Dec 2. PubMed PMID: 14652780.
4)

Avci E, Dagtekin A, Baysal Z, Karabag H. Intraoperative supratentorial epidural haematoma during removal of a huge posterior fossa dermoid cyst. Neurol Neurochir Pol. 2010 Nov-Dec;44(6):609-13. PubMed PMID: 21225525.
7)

Tyagi G, Bhat DI, Indira Devi B, Shukla D. “Multiple Remote Sequential Supratentorial Epidural Hematomas – An Unusual and Rare Complication Following Posterior Fossa Surgery”. World Neurosurg. 2019 May 6. pii: S1878-8750(19)31225-2. doi: 10.1016/j.wneu.2019.04.228. [Epub ahead of print] PubMed PMID: 31071445.

Convexity meningioma surgery

Convexity meningioma surgery

Surgical safety checklist

Preoperative antibiotic prophylaxis

Skin Preparation

Positioning

For convexity meningioma, the head is positioned so that the center of the tumor is uppermost, the same position as described for parasagittal tumors or for tumors close to the midline.

Skin incision – Burr Holes – Dura mater opening

The incision and bone flap must be large enough to allow for excision of a good margin of dura around the tumor attachments.

The meningeal arteries are occluded as they are exposed.

Technical issues

These tumors can be removed intact by placing gentle traction on the dural attachment and working circumferentially around the tumor to divide the attachments to the cortex. However, if the surface of the tumor cannot be easily visualized without placing significant retraction on the cortex, internal decompression of the tumor is done and the capsule is reflected into the area of decompression.

In a situation where the tumor arises over the frontal temporal junction and grows into the sylvian fissure, the medial capsule and the dural attachment may extend down onto the lateral floor of the anterior fossa and anterior wall of the middle fossa, and the medial capsule of the tumor can be attached to branches of the middle cerebral artery.

A study showed that meningioma recurrence was unlikely when autologous cranioplasty was done with refashioned hyperostotic bone. This could be done in the same setting with meningioma excision. There was no recurrence at a mean of 5-year follow-up in convexity meningiomas 1).

Videos

1)

Lau BL, Che Othman MI, Fakhri M, San Liew DN, San Lim S, Bujang MA, Hieng Wong AS. Does putting back hyperostotic bone flap in meningioma surgery causes tumor recurrence? An observational prospective study. World Neurosurg. 2019 Mar 26. pii: S1878-8750(19)30863-0. doi: 10.1016/j.wneu.2019.03.183. [Epub ahead of print] PubMed PMID: 30926555.

Cervical spondylotic myelopathy surgery outcome

Cervical spondylotic myelopathy surgery outcome

see Machine learning for degenerative cervical myelopathy.

Whilst decompressive surgery can halt disease progression, existing spinal cord damage is often permanent, leaving patients with lifelong disability.

Early surgery improves the likelihood of recovery, yet the average time from onset of symptoms to correct diagnosis is over 2 years. The majority of delays occur initially, before and within primary care, mainly due to a lack of recognition. Symptom checkers are widely used by patients before medical consultation and can be useful for preliminary triage and diagnosis. Lack of recognition of Degenerative Cervical Myelopathy (DCM) by symptom checkers may contribute to the delay in diagnosis.

The impact of the changes in myelopathic signs following cervical decompression surgery and their relationship to functional outcome measures remains unclear.

Surgery is associated with a significant quality of life improvement. The intervention is cost effective and, from the perspective of the hospital payer, should be supported 1).

Surgical decompression for CSM is safe and results in improved functional status and quality of life in patients around the world, irrespective of differences in medical systems and socio-cultural determinants of health 2).

The successful management of CSM depends upon an early and accurate diagnosis, an objective assessment of impairment and disability, and an ability to predict outcome. In this field, quantitative measures are increasingly used by clinicians to grade functional and neurological status and to provide decision-making support 3).


In addition, objective assessment tools allow clinicians to quantify myelopathy severity, predict outcome, and evaluate surgical benefits by tracking improvements throughout follow-up 4) 5) 6).

Several outcome measures assess functional impairment and quality of life in patients with cervical myelopathy 7) 8) 9) 10) 11).

A validated “gold standard,” however, has not been established, preventing the development of quantitative guidelines for CSM management 12).

In this field, one of the most widely accepted tool for assessing functional status is the modified Japanese Orthopaedic Association scale (mJOA).

Some studies have found that resolution of T2 hyperintensity in subjects with CSM who undergo ventral decompressive surgery correlates with improved functional outcomes. Other studies have found little correlation with postoperative outcome 13) 14).

References

1)

Witiw CD, Tetreault LA, Smieliauskas F, Kopjar B, Massicotte EM, Fehlings MG. Surgery for degenerative cervical myelopathy: a patient centered quality of life and health economic evaluation. Spine J. 2016 Oct 25. pii: S1529-9430(16)31022-1. doi: 10.1016/j.spinee.2016.10.015. [Epub ahead of print] PubMed PMID: 27793760.
2)

Fehlings MG, Ibrahim A, Tetreault L, Albanese V, Alvarado M, Arnold P, Barbagallo G, Bartels R, Bolger C, Defino H, Kale S, Massicotte E, Moraes O, Scerrati M, Tan G, Tanaka M, Toyone T, Yukawa Y, Zhou Q, Zileli M, Kopjar B. A Global Perspective on the Outcomes of Surgical Decompression in Patients with Cervical Spondylotic Myelopathy: Results from the Prospective Multicenter AOSpine International Study on 479 patients. Spine (Phila Pa 1976). 2015 May 27. [Epub ahead of print] PubMed PMID: 26020847.
3) , 12)

Singh A, Tetreault L, Casey A, et al. A summary of assessment tools for patients suffering from cervical spondylotic myelopathy: a systematic review on validity, reliability, and responsiveness [published online ahead of print September 5, 2013]. Eur Spine J. doi:10.1007/s00586-013-2935-x.
4)

Laing RJ. Measuring outcome in neurosurgery. Br J Neurosurg 2000;14:181–4.
5)

Holly LT, Matz PG, Anderson PA, et al. Clinical prognostic indicators of surgical outcome in cervical spondylotic myelopathy. J Neurosurg Spine 2009;11:112–8.
6)

Kalsi-Ryan S, Singh A, Massicotte EM, et al. Ancillary outcome measures for assessment of individuals with cervical spondylotic myelopathy. Spine (Phila Pa 1976) 2013;38:S111–22.
7)

Singh A, Crockard HA. Quantitative assessment of cervical spondylotic myelopathy by a simple walking test. Lancet 1999;354:370–3.
8)

Nurick S. The natural history and the results of surgical treatment of the spinal cord disorder associated with cervical spondylosis. Brain 1972;95:101–8.
9)

Olindo S, Signate A, Richech A, et al. Quantitative assessment of hand disability by the nine-hole-peg test (9-HPT) in cervical spondylotic myelopathy. J Neurol Neurosurg Psychiatry 2008;79:965–7.
10)

Hosono N, Sakaura H, Mukai Y, et al. A simple performance test for quantifying the severity of cervical myelopathy [erratum in: J Bone Joint Surg Br 2008;90:1534]. J Bone Joint Surg Br 2008;90:1210–3.
11)

Casey AT, Bland JM, Crockard HA. Development of a functional scoring system for rheumatoid arthritis patients with cervical myelopathy. Ann Rheum Dis 1996;55:901–6.
13)

Sarkar S, Turel MK, Jacob KS, Chacko AG. The evolution of T2-weighted intramedullary signal changes following ventral decompressive surgery for cervical spondylotic myelopathy. J Neurosurg Spine. 2014;21(4):538-546.
14)

Vedantam A, Rajshekhar V. Change in morphology of intramedullary T2- weighted increased signal intensity after anterior decompressive surgery for cervical spondylotic myelopathy. Spine (Phila Pa 1976). 2014;39(18):1458-1462.
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