Graft dural closure is associated with a reduction in CSF leak and hydrocephalus in pediatric patients undergoing posterior fossa brain tumor resection

2020 ◽  
Vol 25 (3) ◽  
pp. 228-234
Author(s):  
Andrew T. Hale ◽  
Stephen R. Gannon ◽  
Shilin Zhao ◽  
Michael C. Dewan ◽  
Ritwik Bhatia ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Wound Infection ◽  
Posterior Fossa ◽  
Pediatric Patients ◽  
Tumor Resection ◽  
Csf Leak ◽  
Multivariate Logistic Regression ◽  
Dural Closure ◽  
Csf Diversion ◽  
Persistent Hydrocephalus

OBJECTIVEThe authors aimed to evaluate clinical, radiological, and surgical factors associated with posterior fossa tumor resection (PFTR)–related outcomes, including postoperative complications related to dural augmentation (CSF leak and wound infection), persistent hydrocephalus ultimately requiring permanent CSF diversion after PFTR, and 90-day readmission rate.METHODSPediatric patients (0–17 years old) undergoing PFTR between 2000 and 2016 at Monroe Carell Jr. Children’s Hospital of Vanderbilt University were retrospectively reviewed. Descriptive statistics included the Wilcoxon signed-rank test to compare means that were nonnormally distributed and the chi-square test for categorical variables. Variables that were nominally associated (p < 0.05) with each outcome by univariate analysis were included as covariates in multivariate linear regression models. Statistical significance was set a priori at p < 0.05.RESULTSThe cohort consisted of 186 patients with a median age at surgery of 6.62 years (range 3.37–11.78 years), 55% male, 83% Caucasian, and average length of follow-up of 3.87 ± 0.25 years. By multivariate logistic regression, the variables primary dural closure (PDC; odds ratio [OR] 8.33, 95% confidence interval [CI] 1.07–100, p = 0.04), pseudomeningocele (OR 7.43, 95% CI 2.23–23.76, p = 0.0007), and hydrocephalus ultimately requiring permanent CSF diversion within 90 days of PFTR (OR 9.25, 95% CI 2.74–31.2, p = 0.0003) were independently associated with CSF leak. PDC versus graft dural closure (GDC; 35% vs 7%, OR 5.88, 95% CI 2.94–50.0, p = 0.03) and hydrocephalus ultimately requiring permanent CSF diversion (OR 3.30, 95% CI 1.07–10.19, p = 0.0007) were associated with wound infection requiring surgical debridement. By multivariate logistic regression, GDC versus PDC (23% vs 37%, OR 0.13, 95% CI 0.02–0.87, p = 0.04) was associated with persistent hydrocephalus ultimately requiring permanent CSF diversion, whereas pre- or post-PFTR ventricular size, placement of peri- or intraoperative extraventricular drain (EVD), and radiation therapy were not. Furthermore, the addition of perioperative EVD placement and dural closure method to a previously validated predictive model of post-PFTR hydrocephalus improved its performance from area under the receiver operating characteristic curve of 0.69 to 0.74. Lastly, the authors found that autologous (vs synthetic) grafts may be protective against persistent hydrocephalus (p = 0.02), but not CSF leak, pseudomeningocele, or wound infection.CONCLUSIONSThese results suggest that GDC, independent of potential confounding factors, may be protective against CSF leak, wound infection, and hydrocephalus in patients undergoing PFTR. Additional studies are warranted to further evaluate clinical and surgical factors impacting PFTR-associated complications.

Postoperative facial palsy after pediatric posterior fossa tumor resection

2021 ◽  
pp. 1-6
Author(s):  
Jason K. Chu ◽  
Peter A. Chiarelli ◽  
Nolan D. Rea ◽  
Norianne Pimentel ◽  
Benjamin E. Flyer ◽  
...  
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Posterior Fossa ◽  
Facial Palsy ◽  
Tumor Resection ◽  
Significant Risk ◽  
Posterior Fossa Tumor ◽  
Facial Weakness ◽  
Multivariate Logistic Regression ◽  
Study Results

OBJECTIVE Facial palsy can be caused by masses within the posterior fossa and is a known risk of surgery for tumor resection. Although well documented in the adult literature, postoperative facial weakness after posterior fossa tumor resection in pediatric patients has not been well studied. The objective of this work was to determine the incidence of postoperative facial palsy after tumor surgery, and to investigate clinical and radiographic risk factors. METHODS A retrospective analysis was conducted at a single large pediatric hospital. Clinical, radiographic, and histological data were examined in children who were surgically treated for posterior fossa tumors between May 1, 1994, and June 1, 2011. The incidence of postoperative facial weakness was documented. A multivariate logistic regression model was used to analyze the predictive ability of clinicoradiological variables for facial weakness. RESULTS A total of 163 patients were included in this study. The average age at surgery was 7.4 ± 4.7 years, and tumor pathologies included astrocytoma (44%), medulloblastoma (36%), and ependymoma (20%). The lesions of 27 patients (17%) were considered high grade in nature. Thirteen patients (8%) exhibited preoperative symptoms of facial palsy. The overall incidence of postoperative facial palsy was 26% (43 patients), and the incidence of new postoperative facial palsy in patients without preoperative facial weakness was 20% (30 patients). The presence of a preoperative facial palsy had a large and significant effect in univariate analysis (OR 11.82, 95% CI 3.07–45.44, p < 0.01). Multivariate logistic regression identified recurrent operation (OR 4.45, 95% CI 1.49–13.30, p = 0.01) and other preoperative cranial nerve palsy (CNP; OR 3.01, 95% CI 1.24–7.29, p = 0.02) as significant risk factors for postoperative facial weakness. CONCLUSIONS Facial palsy is a risk during surgical resection of posterior fossa brain tumors in the pediatric population. The study results suggest that the incidence of new postoperative facial palsy can be as high as 20%. The presence of preoperative facial palsy, an operation for recurrent tumor, and the presence of other preoperative CNPs were found to be significant risk factors for postoperative facial weakness.

scholarly journals Primary Dural Closure for Retrosigmoid Approaches

2017 ◽  
Vol 79 (04) ◽  
pp. 330-334 ◽  
Author(s):  
Garrett Venable ◽  
Mallory Roberts ◽  
Ryan Lee ◽  
L. Michael
Keyword(s):  
Posterior Fossa ◽  
Primary Closure ◽  
Chart Review ◽  
Tumor Resection ◽  
Retrospective Chart Review ◽  
Csf Leak ◽  
Dural Defect ◽  
Dural Closure ◽  
Lesion Type ◽  
Csf Leaks

Object Primary closure of posterior fossa dura can be challenging, and postoperative cerebrospinal fluid (CSF) leaks continue to represent a common complication of the retrosigmoid approach. We describe a simple technique to allow for primary closure of the dura following retrosigmoid approaches. The incidence of CSF leaks using this method is reported. Methods A retrospective chart review was conducted on all cases of retrosigmoid craniotomies performed by the senior surgeon from February 2009 to February 2015. The primary outcome was development of postoperative CSF leak or pseudomeningocele. Length of stay, lesion type, and other surgical complications were also reported. Results Eighty-six patients underwent a retrosigmoid craniotomy during the study period. The most common indications for retrosigmoid craniotomy were microvascular decompression (58%) and tumor resection (36%). No allo- or autografts to repair the dural defect were needed, and no lumbar drains were used. No patients developed CSF otorrhea, rhinorrhea, or incisional leak postoperatively. Conclusion Primary dural closure is possible in retrosigmoid approaches without the use of allo- or autografts and may prevent postoperative CSF leaks when combined with other posterior fossa closure techniques. Careful attention to the handling of the dural flap is necessary to achieve this.

scholarly journals Intradural pathology and pathophysiology associated with Chiari I malformation in children and adults with and without syringomyelia

2017 ◽  
Vol 20 (6) ◽  
pp. 526-541 ◽  
Author(s):  
Brian J. Dlouhy ◽  
Jeffrey D. Dawson ◽  
Arnold H. Menezes
Keyword(s):  
Logistic Regression ◽  
Posterior Fossa ◽  
Fourth Ventricle ◽  
Posterior Inferior Cerebellar Artery ◽  
Type I ◽  
Csf Flow ◽  
Multivariate Logistic Regression ◽  
Tonsillar Herniation ◽  
Chiari Malformation Type I ◽  
Flow Channels

OBJECTIVEThe pathophysiology underlying tonsillar herniation and CSF obstruction in Chiari malformation Type I (CM-I) is unclear, and the cause of CM-I–associated syringomyelia is not well understood. A better understanding of this pathophysiology is important for an improved treatment strategy. Therefore, the authors sought to identify, characterize, and examine the intradural pathology and CSF flow pathophysiology in the posterior fossa and at the level of the foramen magnum that occurs in the setting of CM-I. They determined the incidence of these intradural findings and assessed differences across age, with the degree of tonsillar herniation, and in the presence and absence of syringomyelia.METHODSA prospective database initiated in March 2003 recorded all intraoperative findings during surgical treatment of children and adults with CM-I with or without syringomyelia. A total of 389 surgeries for CM-I were performed in 379 patients between March 2003 and June 2016. A total of 109 surgeries were performed in 109 patients with CM-I (without osseoligamentous abnormalities) in whom both a posterior fossa extradural and intradural decompression with duraplasty was performed (first-time intradural procedures). Using a surgical microscope, intradural pathology and obstruction of CSF channels were identified and assessed. Student t-tests and Fisher’s exact tests compared groups in a series of univariate analyses, followed by multivariate logistic regression.RESULTSThe following intradural pathological entities were observed (prevalence noted in parentheses). These include those that did not obstruct CSF flow channels: opacified arachnoid (33.0%), thickened arachnoid (3.7%), ischemic and gliotic tonsils (40.4%), tonsillar cysts (0.9%), and inferior descent of the fourth ventricle and cervicomedullary junction (CMJ) (78.0%). The following intradural pathological entities were observed to obstruct CSF flow channels: medialized tonsils (100%), tonsil overlying and obstructing the foramen of Magendie (21.1%), intertonsillar and tonsil to CMJ arachnoid adhesions (85.3%), vermian posterior inferior cerebellar artery branches obstructing the foramen of Magendie (43.1%), and arachnoid veils or webs obstructing or occluding the foramen of Magendie (52.3%). Arachnoid veils varied in type and were observed in 59.5% of patients with CM-I who had syringomyelia, which was significantly greater than the 33.3% of patients with CM-I without syringomyelia who had an arachnoid veil (p = 0.018). The presence of CM-I with an arachnoid veil had 3.22 times the odds (p = 0.013, 95% CI 1.29–8.07, by multivariate logistic regression) of being associated with syringomyelia, adjusting for tonsillar herniation. The inferior descent of the fourth ventricle and CMJ occurred with a greater degree of tonsillar herniation (p < 0.001) and correlated with a cervicomedullary kink or buckle on preoperative MRI.CONCLUSIONSIntradural pathology associated with CM-I with or without syringomyelia exists in many forms, is more prevalent than previously recognized in patients of all ages, and may play a role in the pathophysiology of CM-I tonsillar herniation. Arachnoid veils appear to partially obstruct CSF flow, are significantly more prevalent in cases of CM-I with syringomyelia, and therefore may play a role in the pathophysiology of CM-I–associated syringomyelia.

The pathophysiology of oral pharyngeal apraxia and mutism following posterior fossa tumor resection in children

1995 ◽  
Vol 83 (3) ◽  
pp. 467-475 ◽  
Author(s):  
Andrew T. Dailey ◽  
Guy M. McKhann ◽  
Mitchel S. Berger
Keyword(s):  
Posterior Fossa ◽  
Pediatric Patients ◽  
Tumor Resection ◽  
Posterior Fossa Tumor ◽  
Posterior Fossa Tumors ◽  
Lower Cranial Nerve ◽  
Content Type ◽  
Cranial Nerve Function ◽  
Pharyngeal Musculature ◽  
Fine Print

✓ Mutism following posterior fossa tumor resection in pediatric patients has been previously recognized, although its pathophysiology remains unclear. A review of the available literature reveals 33 individuals with this condition, with only a few adults documented in the population. All of these patients had large midline posterior fossa tumors. To better understand the incidence and anatomical substrate of this syndrome, the authors reviewed a 7-year series of 110 children who underwent a posterior fossa tumor resection. During that time, nine (8.2%) of the 110 children exhibited mutism postoperatively. They ranged from 2.5 to 20 years of age (mean 8.1 years) and became mute within 12 to 48 hours of surgery. The period of mutism lasted from 1.5 to 12 weeks after onset: all children had difficulty coordinating their oral pharyngeal musculature as manifested by postoperative drooling and inability to swallow. Further analysis of these cases revealed that all children had splitting of the entire inferior vermis at surgery, as confirmed on postoperative magnetic resonance studies. Lower cranial nerve function was intact in all nine patients. Current concepts of cerebellar physiology emphasize the importance of the cerebellum in learning and language. The syndrome described resembles a loss of learned activities, or an apraxia, of the oral and pharyngeal musculature. To avoid the apraxia, therefore, the inferior vermis must be preserved. For large midline tumors that extend to the aqueduct, a combined approach through the fourth ventricle and a midvermis split may be used to avoid injuring the inferior vermis.

Natural Course of Cerebral Cavernous Malformations in Children: A Five-Year Follow-Up Study

Stroke ◽  
2021 ◽  
Author(s):  
Alejandro N. Santos ◽  
Laurèl Rauschenbach ◽  
Dino Saban ◽  
Bixia Chen ◽  
Annika Herten ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Brain Stem ◽  
Odds Ratio ◽  
Pediatric Patients ◽  
Cox Regression ◽  
Cerebral Cavernous Malformations ◽  
Multivariate Logistic Regression ◽  
Cavernous Malformations ◽  
History Of

Background and Purpose: The purpose of this study was to investigate the natural course of cerebral cavernous malformations (CCM) in the pediatric population, with special emphasis on the risk of first and recurrent bleeding over a 5-year period. Methods: Our institutional database was screened for patients with CCM treated between 2003 and 2020. Patients ≤18 years of age with complete magnetic resonance imaging data set, clinical baseline characteristics, and ≥1 follow-up examination were included. Surgically treated individuals were censored after CCM removal. We assessed the impact of various parameters on first or recurrent intracerebral hemorrhage (ICH) at diagnosis using univariate and multivariate logistic regression adjusted for age and sex. Kaplan-Meier and Cox regression analyses were performed to determine the cumulative 5-year risk for (re)hemorrhage. Results: One hundred twenty-nine pediatric patients with CCM were analyzed. Univariate logistic regression identified brain stem CCM (odds ratio, 3.15 [95% CI, 1.15−8.63], P =0.026) and familial history of CCM (odds ratio, 2.47 [95% CI, 1.04−5.86], P= 0.041) as statistically significant predictors of ICH at diagnosis. Multivariate logistic regression confirmed this correlation (odds ratio, 3.62 [95% CI, 1.18−8.99], P= 0.022 and odds ratio, 2.53 [95% CI, 1.07−5.98], P =0.035, respectively). Cox regression analysis identified ICH as mode of presentation (hazard ratio, 14.01 [95% CI, 1.80−110.39], P= 0.012) as an independent predictor for rehemorrhage during the 5-year follow-up. The cumulative 5-year risk of (re)bleeding was 15.9% (95% CI, 10.2%−23.6%) for the entire cohort, 30.2% (20.2%−42.3%) for pediatric patients with ICH at diagnosis, and 29.5% (95% CI, 13.9%−51.1%) for children with brain stem CCM. Conclusions: Pediatric patients with brain stem CCM and familial history of CCM have a higher risk of ICH as mode of presentation. During untreated 5-year follow-up, they revealed a similar risk of (re)hemorrhage compared to adult patients. The probability of (re)bleeding increases over time, especially in cases with ICH at presentation or brain stem localization.

scholarly journals Management of hydrocephalus and subdural hygromas in pediatric patients after decompression of Chiari malformation type I: case series and review of the literature

2018 ◽  
Vol 22 (4) ◽  
pp. 426-438 ◽  
Author(s):  
Andrew C. Vivas ◽  
Nir Shimony ◽  
Eric M. Jackson ◽  
Risheng Xu ◽  
George I. Jallo ◽  
...  
Keyword(s):  
Literature Review ◽  
Posterior Fossa ◽  
Chiari Malformation ◽  
Pediatric Patients ◽  
High Dose ◽  
Posterior Fossa Decompression ◽  
Type I ◽  
Chiari Malformation Type I ◽  
Dural Graft ◽  
Csf Diversion

OBJECTIVEHydrocephalus associated with subdural hygromas is a rare complication after decompression of Chiari malformation type I (CM-I). There is no consensus for management of this complication. The authors present a series of 5 pediatric patients who underwent CM-I decompression with placement of a dural graft complicated by posterior fossa hygromas and hydrocephalus that were successfully managed nonoperatively.METHODSA retrospective review over the last 5 years of patients who presented with hydrocephalus and subdural hygromas following foramen magnum decompression with placement of a dural graft for CM-I was conducted at 2 pediatric institutions. Their preoperative presentation, perioperative hospital course, and postoperative re-presentation are discussed with attention to their treatment regimen and ultimate outcome. In addition to reporting these cases, the authors discuss all similar cases found in their literature review.RESULTSOver the last 5 years, the authors have encountered 194 pediatric cases of CM-I decompression with duraplasty equally distributed at the 2 institutions. Of those cases, 5 pediatric patients with a delayed postoperative complication involving hydrocephalus and subdural hygromas were identified. The 5 patients were managed nonoperatively with acetazolamide and high-dose dexamethasone; dosages of both drugs were adjusted to the age and weight of each patient. All patients were symptom free at follow-up and exhibited resolution of their pathology on imaging. Thirteen similar pediatric cases and 17 adult cases were identified in the literature review. Most reported cases were treated with CSF diversion or reoperation. There were a total of 4 cases previously reported with successful nonoperative management. Of these cases, only 1 case was reported in the pediatric population.CONCLUSIONSDe novo hydrocephalus, in association with subdural hygromas following CM-I decompression, is rare. This presentation suggests that these complications after posterior fossa decompression with duraplasty can be treated with nonoperative medical management, therefore obviating the need for CSF diversion or reoperation.

Polyethylene Glycol Hydrogel Dural Sealant May Reduce Incisional Cerebrospinal Fluid Leak after Posterior Fossa Surgery

2008 ◽  
Vol 63 (suppl_1) ◽  
pp. ONS182-ONS187 ◽  
Author(s):  
Khoi D. Than ◽  
Clinton J. Baird ◽  
Alessandro Olivi
Keyword(s):  
Cerebrospinal Fluid ◽  
Polyethylene Glycol ◽  
Fibrin Glue ◽  
Posterior Fossa ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
P Value ◽  
Posterior Fossa Surgery ◽  
Dural Closure ◽  
Fluid Leak

Abstract Objective: Incisional cerebrospinal fluid (CSF) leak remains a significant cause of morbidity, particularly after posterior fossa surgery, with ranges between 4 and 17% in most series. We aimed to determine whether the use of a new polyethylene glycol (PEG) dural sealant product (DuraSeal; Confluent Surgical, Waltham, MA) is effective at preventing incisional CSF leak after posterior fossa surgery. Methods: One hundred cases of posterior fossa surgery with the PEG dural sealant applied at the time of dural closure were prospectively observed from May 2005 to April 2006. All patients underwent posterior fossa craniotomy or craniectomy. Clinical histories were followed to document cases of incisional CSF leak, pseudomeningocele, meningitis, wound infection, and interventions required to treat a CSF leak or pseudomeningocele. A retrospective cohort of 100 patients treated in a similar fashion but with fibrin glue augmented dural closure served as controls. Results: In the PEG group, two of 100 (2%) patients developed an incisional CSF leak postoperatively. By comparison, 10 of 100 (10%) patients in whom fibrin glue was used developed an incisional CSF leak. This difference was statistically significant, with a P value of 0.03. There were no significant differences in the rates of pseudomeningocele, meningitis, or other postoperative interventions. Conclusion: The application of PEG dural sealant to the closed dural edges may be effective at reducing incisional CSF leak after posterior fossa surgery.

scholarly journals Incidental durotomy in the pediatric spine population

2018 ◽  
Vol 22 (5) ◽  
pp. 591-594
Author(s):  
James L. West ◽  
Madison Arnel ◽  
Atilio E. Palma ◽  
John Frino ◽  
Alexander K. Powers ◽  
...  
Keyword(s):  
Pediatric Patients ◽  
Primary Repair ◽  
Pediatric Population ◽  
Treatment Options ◽  
Spinal Cord Tumor ◽  
Tumor Resection ◽  
Pedicle Screws ◽  
Tethered Cord ◽  
Csf Leak ◽  
Incidental Durotomy

OBJECTIVESpine surgery is less common in children than adults. These surgeries, like all others, are subject to complications such as bleeding, infection, and CSF leak. The rate of incidental durotomy in the pediatric population, and its associated complications, has scarcely been reported in the literature.METHODSThis is a retrospective chart review of all pediatric patients operated on at Wake Forest Baptist Health from 2012 to 2017 who underwent spine surgeries. The authors excluded any procedures with intended durotomy, such as tethered cord release or spinal cord tumor resection.RESULTSFrom 2012 to 2017, 318 pediatric patients underwent surgery for a variety of indications, including adolescent idiopathic scoliosis (51.9%), neuromuscular scoliosis (27.4%), thoracolumbar fracture (2.83%), and other non–fusion-related indications (3.77%). Of these patients, the average age was 14.1 years, and 71.0% were female. There were 6 total incidental durotomies, resulting in an overall incidence of 1.9%. The incidence was 18.5% in revision operations, compared to 0.34% for index surgeries. Comparison of the revision cohort to the durotomy cohort revealed a trend toward increased length of stay, operative time, and blood loss; however, the trends were not statistically significant. The pedicle probe was implicated in 3 cases and the exact cause was not ascertained in the remaining 3 cases. The 3 durotomies caused by pedicle probe were treated with bone wax; 1 was treated with dry Gelfoam application and 2 were treated with primary repair. Only 1 patient had a persistent leak postoperatively that eventually required wound revision.CONCLUSIONSIncidental durotomy is an uncommon occurrence in the pediatric spinal surgery population. The majority occurred during placement of pedicle screws, and they were easily treated with bone wax at the time of surgery. Awareness of the incidence, predisposing factors, and treatment options is important in preventing complications and disability.

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