Tension Pneumocranium Following Transsphenoidal Surgeries-A Case Report and Systematic Review of Literature with Analysis of Predisposing Factors and Treatment Regimens: Is Early Skull Base Repair Better than Conservative Treatment?

BACKGROUND: Conclusive evidence describing the outcomes following different treatment strategies for tension pneumocranium (TP) is lacking. Impact of predisposing conditions like multiple transnasal transsphenoidal (TNTS) procedures, intraoperative cerebrospinal fluid leak, obstructive sleep apnea, continuous positive airway pressure, violent coughing, nose blowing, positive pressure ventilation on TP outcomes is also unknown. METHODS: PubMed, Embase, Cochrane, and Google Scholar were searched for articles using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Multivariate logistic regression analysis was done using STATA/ BE ver 17.0. RESULTS: Thirty-five studies with 49 cases of endoscopic TNTS surgeries were included. Tension pneumocephalus was seen in 77.5% (n = 38), tension pneumosella in 7 (14.28%), and tension pneumoventricle in 4 (8.16%). Nonfunctional pituitary adenomas (40.81%) were most common lesions associated with TP. The need of mechanical ventilation was significantly higher in patients who received conservative management (odds ratio, 1.34; confidence interval, 0.65-2.74) (P < 0.01). However, incidence of meningitis or mortality were not influenced by factors like age, gender, pathological diagnosis, initial conservative management or early skull base repair, use of adjuvant radiation, intraoperative cerebrospinal fluid leak, multiple TNTS explorations, or presence of precipitating factors. CONCLUSIONS: Nonfunctional pituitary adenomas were the most common lesions associated with TP. Multiple TNTS procedures did not increase incidence of meningitis or mortality. Conservative management increased the need for mechanical ventilation but did not worsen the mortality outcomes.

Endoscopic evacuation of septated chronic subdural hemorrhage - Technical considerations, results, and outcome.

BACKGROUND: Chronic subdural hematoma (cSDH) is a common entity in the elderly. Homogeneous or well-liquefied CSDH has a standard line of treatment through burr hole and irrigation. However, the management of septated chronic subdural hematoma (sCSDH) with multiple membranes does not have a well-defined surgical approach. The neomembranes forming septations prevent evacuation of clots through burr holes, and the small remaining loculi with clots will enlarge overtime to cause recurrence. METHODS: Patients with sCSDH were operated through a minicraniotomy (2.5 cm × 2.5 cm) using rigid endoscopes for visualization of the subdural space. Using endoscope, the entire subdural space can be visualized. The neomembranes are removed with standard neurosurgical microinstruments. The entire cavity is irrigated under vision to remove all clots and ensures hemostasis. RESULTS: Eighty-three endoscope-assisted evacuations were done in 68 patients from January 2016 to April 2020. Fifty (73.5%) patients had unilateral and 18 (26.5%) had bilateral subdural. Only 1 patient (1.47%) had a clinically significant recollection of subdural bleeding 1 month after the procedure. Over a mean follow-up period of 25.3 months (range 1-53 months), rest of patients did not show any recollection. CONCLUSION: Endoscopic evacuation of sCSDH is a safe and effective method and can be used to improve clot evacuation, and remove neomembranes under direct vision to reduce the rates of recollection. This method also obviates the need for larger craniotomies to remove membranes.

External ventricular drain related complications-whether continuous csf drainage via ommaya reservoir is the answer?

BACKGROUND AND AIMS: External ventricular drainage (EVD) is one of the commonest procedures in neurosurgical practice to manage acute hydrocephalus. We evaluated the infectious and non-infectious complications associated with a modified technique for EVD using an Ommaya reservoir. METHODS: Ommaya reservoir was placed in all patients who required EVD placement for CSF drainage. CSF drainage was achieved using a needle placed in a non-coring fashion percutaneously into the Ommaya reservoir to achieve CSF drainage externally. CSF was monitored for signs of infection regularly using CSF biochemistry and cultures. CSF infection was defined by a positive culture or a secondary infection in patients with already infected CSF. RESULTS: 59 patients required continuous CSF drainage during the study period from January 2014 to June 2017. 46 (77.96%) patients had non-infected CSF at time of starting drainage and 13 (22.03%) patients required external CSF drainage for primarily infected CSF. The study period had a total of 793 CSF drainage days (Range 3-64 days) with an average of 13.4 days per patient. The cumulative rate of new infection was 5.08%. No ventricular catheter blockage or dislodgement was seen in any of the patients. CONCLUSIONS: External ventricular drainage through an Ommaya chamber is a safe and effective method and can be used to reduce the catheter related complications like infection, catheter blockage and dislodgement.

Syringe Port: A Convenient, Safe, and Cost-Effective Tubular Retractor for Transportal Removal of Deep-Seated Lesions of the Brain.

OBJECTIVE: Minimally invasive transportal resection of deep intracranial lesions has become a widely accepted surgical technique. Many disposable, mountable port systems are available in the market for this purpose, like the ViewSite Brain Access System. The objective of this study was to find a cost-effective substitute for these systems. METHODS: Deep-seated brain lesions were treated with a port system made from disposable syringes. The syringe port could be inserted through minicraniotomies placed and planned with navigation. All deep-seated lesions like ventricular tumours, colloid cysts, deep-seated gliomas, and basal ganglia hemorrhages were treated with this syringe port system and evaluated for safety, operative site hematomas, and blood loss. RESULTS: 62 patients were operated on during the study period from January 2015 to July 2017, using this innovative syringe port system for deep-seated lesions of the brain. No operative site hematoma or contusions were seen along the port entry site and tract. CONCLUSIONS: Syringe port is a cost-effective and safe alternative to the costly disposable brain port systems, especially for neurosurgical setups in developing countries for minimally invasive transportal resection of deep brain lesions.

Application of a Far-Lateral Approach to the Subaxial Spine: Application, Technical Difficulties, and Results.

OBJECTIVE: The far-lateral approach has traditionally been used as an approach to ventral foramen magnum pathologies. Ventral pathologies in the cervical spine and cervicodorsal regions also provide unique surgical challenges. Traditional posterior surgical approaches to the ventral cervical pathologies require significant cord retraction, and anterior approaches require significant bone removal with implant stabilization. We approached these lesions using a modification of the far-lateral approach for lesions in the subaxial spine. METHODS: Four patients underwent operations using this approach for ventral intradural pathologies in the subaxial spine. Two of the patients had recurrence of the lesions and underwent previous operations using a traditional midline approach. RESULTS: All 4 patients underwent operations using this approach. This provided a unique view of the ventral pathologies and a scarless field in recurrent cases. All 4 patients improved neurologically after the surgery and had no deterioration or complications related to the surgery. CONCLUSION: We propose extension of far-lateral approach to ventral intradural extramedullary lesions in the subaxial spine up to the cervicothoracic junction. The far-lateral approach can be extended safely to the ventral and ventrolateral lesions of the subaxial cervical spine, especially for recurrent or residual lesions previously approached from the midline posteriorly.