Temporal lobe injury with middle fossa approach to intracanalicular vestibular schwannomas: a systematic review.

There are several surgical approaches for vestibular schwannoma (VS) resection. However, management has gradually shifted from microsurgical resection, toward surveillance and radiosurgery. One of the arguments against microsurgery via the middle fossa approach (MFA) is the risk of temporal lobe retraction injury or sequelae. Here, we sought to evaluate the incidence of temporal lobe retraction injury or sequela from a MFA via a systematic review of the existing literature. This systematic review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Relevant studies reporting temporal lobe injury or sequela during MFA for VS were identified. Data was aggregated and subsequently analyzed to evaluate the incidence of temporal lobe injury. 22 studies were included for statistical analysis, encompassing 1522 patients that underwent VS resection via MFA. The overall rate of temporal lobe sequelae from this approach was 0.7%. The rate of CSF leak was 5.9%. The rate of wound infection was 0.6%. Meningitis occurred in 1.6% of patients. With the MFA, 92% of patients had good facial outcomes, and 54.9% had hearing preservation. Our series and literature review support that temporal lobe retraction injury or sequelae is an infrequent complication from an MFA for intracanalicular VS resection.

Insertion of intracranial pressure monitors in fulminant hepatic failure patients: early experience using recombinant factor VII.

BACKGROUND: Cerebral edema contributes to the high morbidity and mortality of fulminant hepatic failure (FHF). OBJECTIVE: We report the results of our early experience with insertion of intraparenchymal intracranial pressure (ICP) monitors in these highly coagulopathic patients. METHODS: Eleven consecutive patients with FHF met the criteria for invasive ICP monitoring. Recombinant activated factor VII (rFVIIa) was administered at an average dose of 3 mg intravenous bolus (average, 36.7 microg/kg). We inserted the intraparenchymal ICP monitor within 15 minutes to 2 hours after rFVIIa administration, without waiting for the repeat coagulation results. Postprocedure computed tomographic scans of the brain were obtained in all patients. RESULTS: No hemorrhagic complications were detected on the immediate postprocedure computed tomographic scans. There were no thrombotic complications in this group of patients. CONCLUSION: In this group of patients with FHF, placement of an ICP monitor without hemorrhagic or thrombotic complications was feasible after administration of rFVIIa. This is a report of our early experience, and caution is advised. Further collaborative randomized studies are needed to prove the efficacy, optimal dosing, and cost effectiveness of rFVIIa for the placement of ICP monitors in this group of patients.