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