ABSTRACT
Facial and cochlear nerve preservation in large vestibular schwannomas is a major challenge. Bimanual pincers or plate-knife dissection techniques have been described as crucial for nerve preservation. The authors demonstrate a recently applied diamond knife dissection technique to peel the nerves from the tumor capsule. This technique minimizes the nerve trauma significantly, and complete resection of a large vestibular schwannoma without any facial nerve palsy and hearing preservation is possible. The authors illustrate this technique during surgery of a 2.6-cm vestibular schwannoma in a 27-year-old male patient resulting in normal facial function and preserved hearing postoperatively. The video can be found here: https://stream.cadmore.media/r10.3171/2021.7.FOCVID21104.
ABSTRACT
Importance: Perioperative stroke is a major complication for patients undergoing surgery. Patent foramen ovale (PFO) represents a possible anatomical link between venous thrombosis and stroke. Objective: To determine whether a preoperatively diagnosed PFO is associated with increased risk of perioperative ischemic stroke. Design, Setting, and Participants: Retrospective cohort study from Massachusetts General Hospital and 2 affiliated community hospitals between January 1, 2007, and December 31, 2015. Participants were 182â¯393 consecutive adults undergoing noncardiac surgery with general anesthesia. Exposures: Preoperatively diagnosed PFO. Main Outcomes and Measures: Perioperative ischemic stroke occurring within 30 days of surgery; stroke subtype by Oxfordshire Community Stroke Project classification and stroke severity by National Institute of Health Stroke Scale (NIHSS). Results: Among the 150â¯198 patient cases analyzed (median [SD] age, 55 [16] years), 1540 (1.0%) had a diagnosis of PFO before surgery. A total of 850 (0.6%) ischemic strokes occurred within 30 days of surgery (49 [3.2%] among patients with PFO and 801 [0.5%] among patients without PFO). In adjusted analyses, patients with PFO had an increased risk of ischemic stroke compared with patients without PFO (odds ratio, 2.66 [95% CI, 1.96-3.63]; P < .001). The estimated risks of stroke were 5.9 for every 1000 patients with PFO and 2.2 for every 1000 patients without PFO (adjusted absolute risk difference, 0.4% [95% CI, 0.2%-0.6%). Patients with PFO also had an increased risk of large vessel territory stroke (relative risk ratio, 3.14 [95% CI, 2.21-4.48]; P < .001) and a more severe stroke-related neurologic deficit measured by NIHSS (median, 4 [interquartile range {IQR}, 2-10] vs median, 3 [IQR, 1-6] for those without PFO; P = .02). Conclusions and Relevance: Among adult patients undergoing noncardiac surgery at 3 hospitals, having a preoperatively diagnosed PFO was significantly associated with increased risk of perioperative ischemic stroke within 30 days after surgery. Further research is needed to confirm these findings and to determine whether interventions would decrease this risk.