Using an electronic clinical decision support system to reduce the risk of epidural hematoma.

Epidural hematoma is a major complication that can occur when neuraxial anesthesia is used concurrently with newer anticoagulation and antiplatelet medications. In complex hospital environments, the opportunity of performing a neuraxial procedure in an anticoagulated patient or starting potent anticoagulants on a patient with existing epidural catheter still exists. We describe a technique to use an electronic clinical decision support ordering system that helps reduce this risk of epidural hematoma. Through a series of automated warnings that bring to light existing anticoagulant or antiplatelet medications at the time of doing the procedure or a secondary warning system to those practitioners initiating anticoagulant medications on a patient with an existing epidural, we hope to reduce the number of medication errors. Before initiating the alert system, we had 26 events noted in the medical chart over a 3-month period. We noted only 11 events after the initiation of the new alert systems and clinical decision support in a similar 3-month period. Using electronic clinical decision support systems can help reduce medication errors related to neuraxial anesthesia and anticoagulation medications in a large hospital system.

Benefits, risks and complications of perioperative use of epidural anesthesia.

Use of thoracic epidurals is widespread for intraoperative and postoperative analgesia. Thoracic epidural anaesthesia (TEA) reduces sympathetic activity and thereby influences perioperative function of vital organ systems. A results of recent studies suggest that TEA decreases postoperative morbidity and mortality. There is better pain control with TEA in a wide range of surgical procedures. Use of TEA is associated with the risk of harm, but also the other methods used to control perioperative pain and stress response carry specific risks. Timely diagnosis and treatment of spinal compression or infection are crucial to ensure patient safety with TEA. The benefits of TEA outweigh the risks with respect to the perioperative outcome and organ protection, if basic guidelines are followed.

[Transient monoparesis of the right arm after carotid artery stenting]. / Transiente Monoparese des rechten Arms nach Karotisstenting.

We report on an 80-year-old hypertensive patient with a left-sided high-grade carotid stenosis who developed transient monoparesis of the right arm after stenting of the carotid artery. Computed tomography (CT) of the brain (cranial CT) performed immediately after the symptomatic had begun showed a linear hyperdensity in the ipsilateral, precentral sulcus with a moderate, local brain swelling and edema. Transcranial doppler sonography revealed an accelerated post-interventional systolic blood flow velocity and in the ipsilateral medial cerebral artery compared to the preoperative value and an increased cerebral blood flow, so that the diagnosis of hyperperfusion syndrome with a subpial hematoma was confirmed. After strict blood pressure control and -reduction the neurological deficit regressed gradually and the hyperdensity had completely disappeared in control CCT after 15 h.

[Effect of epidural drainage and dural tenting suture on epidural hematoma in 145 cases of craniotomy].

OBJECTIVE: To evaluate the efficacy of dural tenting suture and epidural drainage in craniotomy. METHODS: In 145 cases of intracranial lesions, dural tenting suture and epidural drainage were performed to prevent epidural hematoma. RESULTS: Postoperative computed tomography (CT) showed no epidural hematoma required surgery in both groups. CONCLUSION: Both dural tenting suture and epidural drainage are effective in preventing epidural hematoma. Hemostasis is the key step. Dural tenting suture without epidural drainage relieves psychological stress. It decreases the risk of intracranial infection and avoids some unusual complications.

Necessity of dural tenting sutures in modern neurosurgery: protocol for a systematic review.

INTRODUCTION: The ongoing need for dural tenting sutures in a contemporary neurosurgical practice has been questioned in the literature for over two decades. In the past, these sutures were supposed to prevent blood collecting in the potential space between the skull and the dura by elevating the latter. Theoretically, with modern haemostasis and proper postoperative care, this technique should not be necessary and the surgery time can be shortened. Unfortunately, there is no evidence-based proof to either support or reject this hypothesis. METHODS AND ANALYSIS: The systematic review will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement and The Cochrane Handbook for Systematic Reviews of Interventions. Eight electronic databases of peer-reviewed journals will be searched, as well as other sources. Eligible articles will be assessed against inclusion criteria. The intervention is not tenting the dura and this will be compared with the usual dural tenting sutures. Where possible, 'summary of findings' tables will be generated. ETHICS AND DISSEMINATION: Ethical committee approval is not required for a systematic review protocol. Findings will be presented at international neurosurgical conferences and published in a peer-reviewed medical journal. PROSPERO REGISTRATION NUMBER: CRD42018097089.

A surgical strategy to prevent delayed epidural hematoma after posterior fossa surgery using lateral suboccipital retrosigmoid approach.

Although non-traumatic postoperative delayed epidural hematoma (EDH) after posterior fossa surgery is rare, measures to prevent it need to be pursued due to its catastrophic results. In this report, we describe a surgical strategy to prevent delayed EDH after posterior fossa surgery. Key dural tacking sutures were performed at the medial and cephalic margin of the dura. We have performed key dural tacking sutures on 454 patients with neurovascular compression syndrome during microvascular decompression surgeries since April 2016, and no hemorrhagic complication, including delayed EDH, occurred. We discovered that key dural tacking sutures can be helpful in preventing postoperative posterior fossa delayed EDH.

Is there a way to avoid surgical complications of twist drill craniostomy for evacuation of a chronic subdural hematoma?

BACKGROUND: Although twist drill craniostomy for evacuation of a chronic subdural hematoma is a rapid and minimally invasive procedure, it carries the risk of complications because it is a 'blind' technique. Our aim was to analyse the complications in a series of patients treated by this technique in order to identify methods of avoidance by modifications in the surgical technique. METHOD: Thirty-nine patients with a chronic subdural hematoma underwent twist drill craniostomy between November 2002 and December 2005 in our clinic. When a surgical complication happened we modified our surgical technique to see if this avoided it in future patients. FINDINGS: Surgical complications happened in 7 patients (17.9%) including inadequate drainage, brain penetration, acute epidural hematoma and catheter folding. After preventive modifications these complications did not recur. CONCLUSIONS: Modifications in the technique of twist drill craniostomy are described in this paper which may minimise the occurrence of surgical complications.

Impact of Helmet Use on Severity of Epidural Hematomas in Cambodia.

BACKGROUND: Traumatic brain injury is a major cause of morbidity and mortality worldwide, often necessitating neurosurgical intervention to evacuate intracranial bleeding. Since the early 2000s, Cambodia has been undergoing a rapid increase in motorcycle transit and in road traffic accidents, but the prevalence of helmet usage remains low. Epidural hematomas are severe traumatic brain injuries that can necessitate neurosurgical intervention. METHODS: This is a retrospective cohort study of patients with epidural hematoma secondary to motorcycle accidents who presented to a major national tertiary care center in Phnom Penh, Cambodia, between November 2013 and March 2016. All patients were diagnosed with computed tomography of the head. RESULTS: In this cohort, 21.6% of patients in motorcycle accidents presented with epidural hematoma and 89.1% of patients were men, 47.6% were intoxicated, and were 87.8% were not wearing helmets at the moment of impact. Not wearing a helmet was associated with a 6.90-fold increase in odds of presenting with a moderate-to-severe Glasgow coma scale score and a 3.76-fold increase in odds of requiring craniotomy or craniectomy for evacuation of hematoma. Male sex was also associated with increased odds of higher clinical severity at presentation and indication for craniotomy or craniectomy, and alcohol intoxication at the time of accident was not associated with either. CONCLUSIONS: Helmet usage is protective in reducing the severity of presentation and need for neurosurgical intervention for patients with epidural hematoma secondary to motorcycle accidents.

A technical modification of Cloward's posterior lumbar interbody fusion.

The concept of interbody (intercorporal) fusion as a useful treatment for intervertebral disc disease in the cervical area has been well received. Thirty-two years have passed since Cloward first introduced his technique of posterior lumbar intervertebral fusion. The author believes that the delayed acceptance of this procedure is due to fear of technical difficulties. A technical modification of Cloward's posterior lumbar interbody fusion is introduced. It entails better technique in controlling epidural bleeding by careful positioning of the patient and the use of oxidized cellulose as a tampon in the epidural space. The integrity of the facet is preserved through a more limited interlaminal approach. Osteosynthesis of the grafts is assured by multiple perforations of the cortical plate in accordance with Robinson's principle utilized in cervical interbody fusion. The author believes that the modification simplifies the Cloward posterior lumbar interbody fusion. It also assures better stability after surgery by retention of the facet and lessening the dangers of settlement of the graft by preservation of the cortical plate. In a series of 75 cases, tomograms made 4 months after operation have shown a viable graft with active osteosynthesis between the graft and the adjoining vertebral bodies in 94%.

Continuous epidural anesthesia in abdominal vascular surgery. A review of 100 consecutive cases.

The use of continuous epidural anesthesia in 100 consecutive abdominal aortic operations since 1975 was reviewed. There were no anesthetic complications. Low-dose systemic heparinization was used. General anesthetic and narcotic requirements were reduced, and postoperative pain was greatly alleviated.

Use of single-dose epidural morphine in a patient undergoing an abdominal aortic aneurysm resection.

To avoid possible trauma to the epidural venous plexus in a 56-year-old male who presented for abdominal aortic aneurysm resection, the authors preoperatively injected a single dose of epidural morphine rather than inserting an indwelling epidural catheter. The patient's intraoperative anesthetic requirements appeared to have been decreased, he was extubated shortly after the end of the procedure, and he experienced good postoperative analgesia. No untoward neurologic sequelae occurred. The authors feel that a single dose of epidural morphine, compared to epidural catheter placement when systemic heparinization is planned, decreases intraoperative anesthetic requirements, provides good postoperative analgesia, and may have the benefit of decreasing the possibility of epidural hematoma formation.

Neuroaxial blocks and LMWH thromboprophylaxis.

In the last 12 months, the Food and Drug Administration issued two documents warning the medical profession about the concurrent use of low molecular weight heparins (LMWHs) and neuroaxial blocks. This article summarizes the American and European experiences with LMWH thromboprophylaxis that could help with risk assessment.

Epidural and spinal anaesthesia and the use of anticoagulants.

Neurological injuries after epidural/spinal analgesia are a serious but uncommon problem. Spinal haematoma cause a proportion of these complications, and can be minimized by avoiding central nervous blockade in high-risk patients, especially those receiving anticoagulant therapy. Early recognition of spinal haematoma by basic neurological monitoring allows early intervention and improves outcome.

[Repeated intracranial hemorrhages, their prevention and treatment]. / Povtornye vnutricherepnye krovoizliianiia, ikh profilaktika i lechenie.

The formation of recurrent hematomas was encountered in patients operated on for intracranial hematomas of traumatic and nontraumatic origin and for contusion of the brain. To prevent recurrent hemorrhages, the authors employed active aspiration of the wound canal contents by means of a three-jar aspirator or a microaspirator in the postoperatice period in 56 cases. It is noted that active aspiration of the wound discharge, continued for 2--4 days, makes it possible to avoid the formation of recurrent intracranial hematoma and to reduce resorption of the decomposition products, this improves the course of the postoperative period.

Should epidural drain be recommended after supratentorial craniotomy for epileptic patients?

BACKGROUND: ED was once and is still commonly applied to prevent mainly EH and subgaleal CSF collection. We designed this study to observe if ED could decrease the incidence and volume of EH and subgaleal CSF collection after supratentorial craniotomy in epileptic patients. METHODS: Three hundred forty-two epileptic patients were divided into 2 groups according to their first craniotomy date (group 1 in odd date and group 2 in even date). Patients in group 1 had ED and those in group 2 had no ED. The patient numbers and volumes of EH and subgaleal CSF collections in both groups were recorded and statistically analyzed. RESULTS: There were 22 EHs in group 1 and 20 EHs in group 2. There were 11 and 10 subgaleal CSF collections in groups 1 and 2, respectively. The average volume of EH was 13.5 +/- 8.12 and 14.65 +/- 7.72 mL in groups 1 and 2, respectively. The average volume of subgaleal CSF collection was 42.76 +/- 12.09 and 43.75 +/- 11.44 mL in groups 1 and 2, respectively. There were no statistical differences in the incidence and average volume of EH and subgaleal CSF collection between the 2 groups. CONCLUSIONS: ED cannot decrease the incidence and volume of EH and subgaleal CSF collection. ED should not be recommended after supratentorial epileptic craniotomy.