Brain Shift and Pneumocephalus Assessment During Frame-Based Deep Brain Stimulation Implantation With Intraoperative Magnetic Resonance Imaging.

BACKGROUND: Brain shift and pneumocephalus are major concerns regarding deep brain stimulation (DBS). OBJECTIVE: To report the extent of brain shift in deep structures and pneumocephalus in intraoperative magnetic resonance imaging (MRI). METHODS: Twenty patients underwent bilateral DBS implantation in an MRI suite. Volume of pneumocephalus, duration of procedure, and 6 anatomic landmarks (anterior commissure, posterior commissure, right fornix [RF], left fornix [LF], right putaminal point, and left putaminal point) were measured. RESULTS: Pneumocephalus varied from 0 to 32 mL (median = 0.6 mL). Duration of the procedure was on average 195.5 min (118-268 min) and was not correlated with the amount of pneumocephalus. There was a significant posterior displacement of the anterior commissure (mean = -1.1 mm, P < .001), RF (mean = -0.6 mm, P < .001), LF (mean = -0.7 mm, P < .001), right putaminal point (mean = -0.9 mm, P = .001), and left putaminal point (mean = -1.0 mm, P = .001), but not of the posterior commissure (mean = 0.0 mm, P = .85). Both RF (mean = -.7 mm, P < .001) and LF (mean = -0.5 mm, P < .001) were posteriorly displaced after a right-sided burr hole. There was a correlation between anatomic landmarks displacement and pneumocephalus after 2 burr holes (rho = 0.61, P = .007), but not after 1 burr hole (rho = 0.16, P = .60). CONCLUSION: Better understanding of how pneumocephalus displaces subcortical structures can significantly enhance our intraoperative decision making and overall targeting strategy.

Use of Tisseel fibrin sealant in neurosurgical procedures: incidence of cerebrospinal fluid leaks and cost-benefit analysis in a retrospective study.

OBJECTIVE: To determine the clinical efficacy and cost effectiveness of using the fibrin sealant (FS) Tisseel (Baxter Healthcare Corp., Deerfield, IL) for patients undergoing anterior cranial base, infratemporal, and retromastoid surgical procedures. METHODS: A retrospective review was performed, comparing two matched populations of patients who underwent surgical procedures using anterior cranial, infratemporal, or retromastoid approaches to intracranial pathological lesions. The incidences of cerebrospinal fluid (CSF) leaks in matched groups treated with the FS Tisseel or treated without FS were compared. The costs of Tisseel use were examined in comparison with the costs of postoperative management of CSF leaks and/or tension pneumocranium with spinal drainage and occasionally surgical reexploration, when lumbar drainage failed. RESULTS: Patients who received the FS Tisseel exhibited no detectable postoperative CSF leaks or tension pneumocranium. Patients who did not receive Tisseel demonstrated 4 to 16% incidences of postoperative leaks, depending on the surgical approach used. The costs of treating those leaks far exceeded the costs of using Tisseel, even if it were used indiscriminately for all patients. CONCLUSION: This retrospective review indicates that the FS Tisseel reduces the incidence of postoperative CSF leaks and tension pneumocranium while reducing overall management costs. Further prospective study is needed to determine which patients can benefit most from FS use.

Incidence and perioperative management of tension pneumocephalus following craniofacial resection.

This study is a retrospective review to evaluate factors associated with the risk of pneumocephalus following craniofacial resection and the management of tension pneumocephalus. Twenty-two craniofacial operative procedures were reviewed in 18 patients entered into the Neurosciences Critical Care Unit, Johns Hopkins Hospital, during a 54 month period, from 1986-1991. Pneumocephalus developed after 7 of 22 operations; of these seven, two developed tension pneumocephalus. The use of lumbar cerebral spinal fluid (CSF) drainage during the operation correlated most strongly with the development of pneumocephalus. The diagnosis of esthesioblastoma also correlated significantly. Both episodes of tension pneumocephalus occurred after craniofacial resection in which lumbar drainage of CSF was performed. Tension pneumocephalus was successfully treated in these two patients with a combination of air evacuation and medical management of raised intracranial pressure. Transient diabetes insipidus developed in both patients. The risk of pneumocephalus following craniofacial procedures is significant, and may be increased by the use of lumbar drainage of CSF intraoperatively. Rapid neurologic deterioration following craniofacial resection may be caused by the development of tension pneumocephalus. Early diagnosis of tension pneumocephalus and aggressive management of raised intracranial pressure may be important in preventing serious neurological complications.