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POSTOPERATIVE CEREBRAL VENOUS INFARCTION: A neurosurgical blind spot? VIKAS NAIK, DEEPAK AGRAWAL DEPARTMENT OF NEUROSURGER...
 
 
 
 
Introduction (POCVI) <ul><li>Advent of microneurosurgery </li></ul><ul><li>- incr risk of postop complications </li></ul><...
Introduction  <ul><li>Incidence is difficult to determine due to: </li></ul><ul><li>-  unclear definition </li></ul><ul><l...
Pathophysiology  <ul><li>The severity of cerebral venous compromise  depends upon venous collaterals. </li></ul><ul><li>Ve...
Aims and objectives <ul><li>To study the incidence and clinico-radiological course of POCVI in a tertiary level neurosurgi...
Material and methods <ul><li>Prospective study  </li></ul><ul><li>January – August 2006 </li></ul>
Materials and Methods <ul><li>Inclusion criteria: </li></ul><ul><li>All pts undergoing elective cranial surgery </li></ul>...
<ul><li>History & examination  </li></ul><ul><li>Preop radiology (CT head/MRI brain) reviewed to document any preexisting ...
<ul><li>Operation findings & any intraoperative events were also recorded </li></ul>Materials and Methods
RADIOLOGY <ul><li>POCVI was divided  </li></ul><ul><li>hemorrhagic  </li></ul><ul><li>non-hemorrhagic types  </li></ul>
RADIOLOGY <ul><li>The diagnosis of hemorrhagic POCVI was based on presence of Subcortical, multifocal hyperdensities with ...
RADIOLOGY <ul><li>Non-hemorrhagic POCVI was diagnosed if CT showed a localized hypodensity poorly demarcated the subcortic...
Treatment  <ul><li>Standard NS managent  </li></ul><ul><li>-Decongestants </li></ul><ul><li>-Decompressive craniectomy  </...
observations <ul><li>376 patients  </li></ul><ul><li>M:f  1.2:1  </li></ul><ul><li>age = 6-68yrs (50-50)  </li></ul><ul><l...
<ul><li>In pts who developed POCVI </li></ul><ul><li>Sixteen (61%) patients developed hemorrhagic POCVI and  </li></ul><ul...
<ul><li>In pts who developed POCVI </li></ul><ul><li>3(11%) had  focal deficit as presenting manifestation </li></ul><ul><...
<ul><li>In pts who developed POCVI </li></ul><ul><li>Most of the patients  operated were for intracranial tumours(20)76% ,...
<ul><li>In pts who developed POCVI </li></ul><ul><li>Meningioma  (9 )45%  </li></ul><ul><li>Glioma  ( 5)25%  </li></ul><ul...
Intraoperative findings <ul><li>In pts who developed POCVI </li></ul><ul><li>There was one patient with frontal venous sin...
<ul><li>In pts who developed POCVI </li></ul><ul><li>Seventeen (66%) patients were managed conservatively </li></ul><ul><l...
<ul><li>Hospital stay ranged from 4 days in asymptomatic to 77 days(mean20 days).  </li></ul>Results
<ul><li>5 () pts remained asymptomatic </li></ul><ul><li>13 (50%) patients improved neurologically and were discharged wit...
Discussion <ul><li>Kageyama et al venous infarction in 13% of the 120 cases operated by them and  </li></ul><ul><li>Al-Mef...
<ul><li>POCVI carries a high mortality (23%) and morbidity (57%) {in our series} </li></ul><ul><li>A significant percentag...
Conclusion  <ul><li>Incidence of POCVI at AIIMS is comparable to that seen in literature </li></ul><ul><li>Further researc...
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Postoperative cerebral venous infarction

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Postoperative cerebral venous infarction

  1. 1. POSTOPERATIVE CEREBRAL VENOUS INFARCTION: A neurosurgical blind spot? VIKAS NAIK, DEEPAK AGRAWAL DEPARTMENT OF NEUROSURGERY, NEUROSCIENCES & GAMMA-KNIFE CENTRE, AIIMS, NEW DELHI
  2. 6. Introduction (POCVI) <ul><li>Advent of microneurosurgery </li></ul><ul><li>- incr risk of postop complications </li></ul><ul><li>Symptomatology and prognosis is variable </li></ul><ul><li>Limited literarure regarding the pathophysiology and management of POCVI </li></ul>
  3. 7. Introduction <ul><li>Incidence is difficult to determine due to: </li></ul><ul><li>- unclear definition </li></ul><ul><li>- variability of symptoms </li></ul><ul><li>- inclusion of other factors like brain retraction during the operation </li></ul>
  4. 8. Pathophysiology <ul><li>The severity of cerebral venous compromise depends upon venous collaterals. </li></ul><ul><li>Venous congestion produces interstitial edema (Fig 1A), which can lead to hypoperfusion and infarction. </li></ul>
  5. 9. Aims and objectives <ul><li>To study the incidence and clinico-radiological course of POCVI in a tertiary level neurosurgical unit. </li></ul>
  6. 10. Material and methods <ul><li>Prospective study </li></ul><ul><li>January – August 2006 </li></ul>
  7. 11. Materials and Methods <ul><li>Inclusion criteria: </li></ul><ul><li>All pts undergoing elective cranial surgery </li></ul><ul><li>Exclusion criteria : </li></ul><ul><li>Emergency procedures </li></ul><ul><li>Reexploration </li></ul><ul><li>Traumatic brain injury </li></ul><ul><li>Shunts </li></ul><ul><li>Biopsies & burr-hole procedures, </li></ul><ul><li>spinal procedures </li></ul>
  8. 12. <ul><li>History & examination </li></ul><ul><li>Preop radiology (CT head/MRI brain) reviewed to document any preexisting infarcts. </li></ul><ul><li>Postoperatively all patients underwent CT scan of the head within 24hrs. </li></ul><ul><li>Patients were monitored for neurological deterioration and </li></ul><ul><li>CT scan was repeated as required by the attending neurosurgeon </li></ul>Materials and Methods
  9. 13. <ul><li>Operation findings & any intraoperative events were also recorded </li></ul>Materials and Methods
  10. 14. RADIOLOGY <ul><li>POCVI was divided </li></ul><ul><li>hemorrhagic </li></ul><ul><li>non-hemorrhagic types </li></ul>
  11. 15. RADIOLOGY <ul><li>The diagnosis of hemorrhagic POCVI was based on presence of Subcortical, multifocal hyperdensities with irregular margins and or low density areas in the perioperatively fields </li></ul>
  12. 16. RADIOLOGY <ul><li>Non-hemorrhagic POCVI was diagnosed if CT showed a localized hypodensity poorly demarcated the subcortical white matter with/without mass effect, along with presence of fresh neurological deficits. </li></ul>
  13. 17. Treatment <ul><li>Standard NS managent </li></ul><ul><li>-Decongestants </li></ul><ul><li>-Decompressive craniectomy </li></ul>
  14. 18. observations <ul><li>376 patients </li></ul><ul><li>M:f 1.2:1 </li></ul><ul><li>age = 6-68yrs (50-50) </li></ul><ul><li>26 pts (7%) developed POCVI </li></ul>
  15. 19. <ul><li>In pts who developed POCVI </li></ul><ul><li>Sixteen (61%) patients developed hemorrhagic POCVI and </li></ul><ul><li>10 (39%) patients developed non hemorrhagic POCVI. </li></ul><ul><li>The mean time to POCVI detection was 72 hours (range 24-144hours). </li></ul>Results
  16. 20. <ul><li>In pts who developed POCVI </li></ul><ul><li>3(11%) had focal deficit as presenting manifestation </li></ul><ul><li>13(50%) had altered sensorium </li></ul><ul><li>5 (19%) had both, </li></ul><ul><li>5(19%) were asymptomatic </li></ul>Results
  17. 21. <ul><li>In pts who developed POCVI </li></ul><ul><li>Most of the patients operated were for intracranial tumours(20)76% ,followed by vascular (4 )15% pathology. </li></ul><ul><li>There was one case each of intra cranial abscess and csf rhinorrhia </li></ul>Results
  18. 22. <ul><li>In pts who developed POCVI </li></ul><ul><li>Meningioma (9 )45% </li></ul><ul><li>Glioma ( 5)25% </li></ul><ul><li>Acoustic neuroma (4)20%, </li></ul><ul><li>one each of craniopharyngioma and colloid cyst . </li></ul>Results
  19. 23. Intraoperative findings <ul><li>In pts who developed POCVI </li></ul><ul><li>There was one patient with frontal venous sinus injury, however no major cortical vein injury documented in any of these patients. </li></ul><ul><li>17(65% ) patients had dura tense on opening </li></ul>
  20. 24. <ul><li>In pts who developed POCVI </li></ul><ul><li>Seventeen (66%) patients were managed conservatively </li></ul><ul><li>nine (34%) patients in underwent decompressive craniectomy as an additional procedure for management of POCVI </li></ul><ul><li>In five patients, the infarction was an incidental finding </li></ul>Results
  21. 25. <ul><li>Hospital stay ranged from 4 days in asymptomatic to 77 days(mean20 days). </li></ul>Results
  22. 26. <ul><li>5 () pts remained asymptomatic </li></ul><ul><li>13 (50%) patients improved neurologically and were discharged with residual deficits. </li></ul><ul><li>Two (7%) showed no neurological improvement till discharge, and </li></ul><ul><li>6(23%) died during the hospital stay following POCVI </li></ul>Results
  23. 27. Discussion <ul><li>Kageyama et al venous infarction in 13% of the 120 cases operated by them and </li></ul><ul><li>Al-Mefty and Krisht showed that brain edema occurred in 10% of the cases in which the superficial sylvian vein was sacrificed 2. </li></ul><ul><li>Kuboto reported that 40% of the patients with vein sacrifice during an interhemispheric approach suffered from brain damage. </li></ul><ul><li>Robertson quoted complication rate of venous insufficiency at 1.5 per 1000 cases of skull base surgery </li></ul>
  24. 28. <ul><li>POCVI carries a high mortality (23%) and morbidity (57%) {in our series} </li></ul><ul><li>A significant percentage (19%) of the pts remain asymptomatic inspite of hemorrhagic POCVI </li></ul>Conclusion
  25. 29. Conclusion <ul><li>Incidence of POCVI at AIIMS is comparable to that seen in literature </li></ul><ul><li>Further research needs to be done to elucidate the pathophysiology & management of this important problem </li></ul>

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