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Intracranial Hemorrhage following Spinal Surgery: A Systematic Review of a Rare Complication
Al-Saadi T, Al-Kindi Y, Allawati M, Al-Saadi H
Surgery journal (New York, N.Y.). 2022;8(1):e98-e107
Abstract
Introduction Intracranial hemorrhage (ICH) is a potentially severe complication of spinal surgeries. The occurrence of such complications causes deterioration of the patient's clinical status and delayed discharge from the hospital. Although no specific etiological factors were identified for this complication, but multiple risk factors might play role in its development, they include the use of anticoagulants, presence of uncontrolled hypertension, and perioperative patient positioning. Aim A systematic review of the literature to investigate the prevalence of different types of intracranial hemorrhages in patients who underwent spinal surgeries. Methods A literature review was conducted using multiple research databases. Data were extracted using multiple variables that were formulated incongruent with the study aim and then further analyzed. Results A total of 79 studies were included in our analysis after applying the exclusion criteria and removing of repeated studies, 109 patients were identified where they were diagnosed with intracranial hemorrhage after spine surgery with a mean age of 54 years. The most common type of hemorrhage was cerebellar hemorrhage (56.0%) followed by SDH and intraparenchymal hemorrhage; 23.9 and 17.4%, respectively. The most common spine surgery was laminectomy (70.6%), followed by fixation and fusion (50.5%), excision of spinal lesions was done in 20.2% of the patient, and discectomy (14.7%). Conclusion The data in this study showed that out of 112 patients with ICH, cerebellar hemorrhage was the most common type. ICH post-spine surgery is a rare complication and the real etiologies behind this complication are still unknown, cerebrospinal fluid drain and durotomy were suggested.
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Collagen-bound fibrin sealant (TachoSil®) for dural closure in cranial surgery: single-centre comparative cohort study and systematic review of the literature
Carretta A, Epskamp M, Ledermann L, Staartjes VE, Neidert MC, Regli L, Stienen MN
Neurosurgical review. 2022
Abstract
Cerebrospinal fluid (CSF) leakage is a well-known complication of craniotomies and there are several dural closure techniques. One commonly used commercial product as adjunct for dural closure is the collagen-bound fibrin sealant TachoSil®. We analysed whether the addition of TachoSil has beneficial effects on postoperative complications and outcomes. Our prospective, institutional database was retrospectively queried, and 662 patients undergoing craniotomy were included. Three hundred fifty-two were treated with dural suture alone, and in 310, TachoSil was added after primary suture. Our primary endpoint was the rate of postoperative complications associated with CSF leakage. Secondary endpoints included functional, disability and neurological outcome. Systematic review according to PRISMA guidelines was performed to identify studies comparing primary dural closure with and without additional sealants. Postoperative complications associated with CSF leakage occurred in 24 (7.74%) and 28 (7.95%) procedures with or without TachoSil, respectively (p = 0.960). Multivariate analysis confirmed no significant differences in complication rate between the two groups (aOR 0.97, 95% CI 0.53-1.80, p = 0.930). There were no significant disparities in postoperative functional, disability or neurological scores. The systematic review identified 661 and included 8 studies in the qualitative synthesis. None showed a significant superiority of additional sealants over standard technique regarding complications, rates of revision surgery or outcome. According to our findings, we summarize that routinary use of TachoSil and similar products as adjuncts to primary dural sutures after intracranial surgical procedures is safe but without clear advantage in complication avoidance or outcome. Future studies should investigate whether their use is beneficial in high-risk settings.
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External ventricular drain management in subarachnoid haemorrhage: a systematic review and meta-analysis
Palasz J, D'Antona L, Farrell S, Elborady MA, Watkins LD, Toma AK
Neurosurgical review. 2021
Abstract
External ventricular drainage (EVD) is one of the most commonly performed neurosurgical procedures. Despite this, the optimal drainage and weaning strategies are still unknown. This PRISMA-compliant systematic review and meta-analysis analysed the outcomes of patients undergoing EVD procedures, comparing continuous versus intermittent drainage and rapid versus gradual weaning. Four databases were searched from inception to 01/10/2020. Articles reporting at least 10 patients treated for hydrocephalus secondary to subarachnoid haemorrhage were included. Other inclusion criteria were the description of the EVD drainage and weaning strategies used and a comparison of continuous versus intermittent drainage or rapid versus gradual weaning within the study. Random effect meta-analyses were used to compare functional outcomes, incidence of complications and hospital length of stay. Intermittent external CSF drainage was associated with lower incidence of EVD-related infections (RR = 0.20, 95% CI 0.05-0.72, I-squared = 0%) and EVD blockages compared to continuous CSF drainage (RR = 0.45, 95% CI 0.27-0.74, I-squared = 0%). There was no clear advantage in using gradual EVD weaning strategies compared to rapid EVD weaning; however, patients who underwent rapid EVD weaning had a shorter hospital length of stay (SMD = 0.34, 95% CI 0.22-0.47, I-squared = 0%). Intermittent external CSF drainage after SAH is associated with lower incidence of EVD-related infections and EVD blockages compared to continuous CSF drainage. Patients who underwent rapid EVD weaning had a shorter hospital length of stay and there was no clear clinical advantage in using gradual weaning.
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The outcome in patients with spinal cavernomas presenting with symptoms due to mass effect and/or hemorrhage: conservative vs surgical management. A meta-analysis: Direct Comparison of Approach-Related Complications
Fotakopoulos G, Kivelev J, Andrade-Barazarte H, Tjahjadi M, Goehre F, Hernesniemi J
World neurosurgery. 2021
Abstract
AIMS: To examine the conservative treatment of symptomatic spinal cavernomas as well as to evaluate the efficacy and safety of surgical management of SCCMs. METHODS This meta-analysis included articles comparing outcomes of conservative treatment and surgical management of spinal cavernomas, published in the full-text form (from 2000 to June 31, 2020). Collected variables included: first author name, country, covered study period, publication year, the total number of patients and at follow-up, bleeding, motor weakness, pain, bladder and/ or bowel dysfunction neurological improvement or deterioration after discharge and the need for re-intervention after subtotal surgical resection or hemorrhage. RESULTS After the initial searching, and applying all exclusion and inclusion criteria, there were 9 articles left in the final article pool. The total number of patients was 396 with 264 (66.6 %) undergoing surgical resection and 132 (33.4%) electing conservative management. Regarding motor weakness, Bladder/Bowel dysfunction, Deterioration, and Re-intervention the final results demonstrated no potential significant difference between the two groups. As regards the subgroup of patients with Bleeding, Improvement, and Pain the results of the analysis showed a statistically significant difference between the two groups. CONCLUSIONS Patients who have experienced a hemorrhagic episode should consider surgical intervention which decreases the risk of recurrent hemorrhage and further neurological deterioration. In addition, surgical decompression obtained by resection of the hemorrhage and cavernoma seems to lead to slight neurological improvement in some patients. In non-hemorrhagic cavernomas, conservative treatment might be optimal due to surgery-related morbidity risks.
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EXPRESS: Therapeutic Hypothermia for Intracerebral Hemorrhage: Systematic Review and Meta-Analysis of the Experimental and Clinical Literature
Baker T, Durbin J, Troiani Z, Ascanio-Cortez L, Baron R, Costa A, Rincon F, Colbourne F, Lyden P, Mayer S, et al
International journal of stroke : official journal of the International Stroke Society. 2021;:17474930211044870
Abstract
BackgroundIntracerebral hemorrhage (ICH) remains the deadliest form of stroke worldwide, inducing neuronal death through a wide variety of pathways. Therapeutic hypothermia (TH) is a robust and well studied neuroprotectant widely used across a variety of specialties. AimsThis review summarizes results from preclinical and clinical studies to highlight the overall effectiveness of TH to improve long-term ICH outcomes while also elucidating optimal protocol regimens to maximize therapeutic effect.Summary of Review A systematic review was conducted across three databases to identify trials investigating the use of TH to treat ICH. A random-effects meta-analysis was conducted on preclinical studies, looking at neurobehavioral outcomes, blood brain barrier breakdown (BBB), cerebral edema, hematoma volume, and tissue loss. Several mixed-methods meta-regression models were also performed to adjust for variance and variations in hypothermia induction procedures. 21 preclinical studies and 5 human studies were identified. The meta-analysis of preclinical studies demonstrated a significant benefit in behavioral scores (ES=-0.43, p=0.02), cerebral edema (ES=1.32, p=0.0001), and BBB (ES=2.73, p=<0.00001). TH was not found to significantly affect hematoma expansion (ES=-0.24, p=0.12) or tissue loss (ES=0.06, p=0.68). Clinical study outcome reporting was heterogeneous, however there was recurring evidence of TH-induced edema reduction. ConclusionsThe combined preclinical evidence demonstrates that TH reduced multiple cell death mechanisms initiated by ICH, yet there is no definitive evidence in clinical studies. The cooling strategies employed in both preclinical and clinical studies were highly diverse, and focused refinement of cooling protocols should be developed in future preclinical studies. The current data for TH in ICH remains questionable despite the highly promising indications in preclinical studies. Definitive randomized controlled studies are still required to answer this therapeutic question.
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Timing of temporizing neurosurgical treatment in relation to shunting and neurodevelopmental outcomes in post-hemorrhagic ventricular dilatation of prematurity: a meta-analysis
Lai GY, Chu-Kwan W, Westcott AB, Kulkarni AV, Drake JM, Lam S
The Journal of pediatrics. 2021
Abstract
OBJECTIVE To determine the relationship between timing of initiation of temporizing neurosurgical treatment and rates of ventriculoperitoneal shunting (VPS) and neurodevelopmental impairment in premature infants with post-hemorrhagic ventricular dilatation (PHVD). STUDY DESIGN We searched MEDLINE, EMBASE, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, and Cochrane Center Register of Controlled Trials for studies that reported on premature infants with PHVD who received TNP. Timing of TNP, gestational age, birth weight, and outcomes of conversion to VPS, moderate-to-severe NDI, infection, TNP revision, and death at discharge were extracted. RESULTS Sixty-two full-length articles and six conference abstracts (n=2533 patients) published through November 2020 were included. Pooled rate for conversion to VPS was 60.5% (95% CI=54.9-65.8), moderate-severe NDI 34.8% (95% CI=27.4-42.9), infection 8.2% (95% CI=6.7-10.1), revision 14.6% (95% CI=10.4-20.1), and death 12.9% (95% CI=10.2-16.4). Average age at TNP was 24.2+/-11.3 days. On meta-regression, older age at TNP was a predictor of conversion to VPS (p<0.001) and NDI (p<0.01). Later year of publication predicted increased survival (p<0.01) and external ventricular drains were associated with more revisions (p=0.001). Tests for heterogeneity reached significance for all outcomes and qualitative review showed heterogeneity in study inclusion and diagnosis criteria for PHVD and initiation of TNP. CONCLUSIONS Later timing of TNP predicted higher rates of conversion to VPS and moderate-severe NDI. Outcomes were often reported relative to number of patients who received TNP and criteria for study inclusion and initiation of TNP varied across institutions. There is need for more comprehensive outcome reporting that includes all infants with PHVD regardless of treatment.
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Neurosurgical Intervention for Supratentorial Intracerebral Hemorrhage
Sondag L, Schreuder FH, Boogaarts JD, Rovers MM, Vandertop WP, Dammers R, Klijn CJ
Ann Neurol. 2020
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Abstract
OBJECTIVE The effect of surgical treatment for supratentorial spontaneous intracerebral hemorrhage and whether it is modified by key baseline characteristics and timing remains uncertain. METHODS We performed a systematic review and meta-analysis of randomized controlled trials of surgical treatment of supratentorial spontaneous intracerebral hemorrhage aimed at clot removal. We searched MEDLINE, Embase and Cochrane databases up to February 21(st) , 2019. Primary outcome was good functional outcome at follow-up; secondary outcomes were death and serious adverse events. We analyzed all types of surgery combined and minimally invasive approaches separately. We pooled risk ratios with 95% confidence intervals and assessed the modifying effect of age, Glasgow Coma Scale, hematoma volume and timing of surgery with meta-regression analysis. RESULTS We included 21 studies with 4145 patients; four (19%) were of the highest quality. Risk ratio of good functional outcome after any type of surgery was 1.40 (95% confidence interval 1.22-1.60; I(2) 46%; 20 studies) and after minimally invasive surgery 1.47 (1.26-1.72; I(2) 47%; 12 studies). For death the risk ratio for any type of surgery was 0.77 (0.68-0.85; I(2) 23%; 21 studies), and for minimally invasive surgery 0.68 (0.56-0.83; I(2) 14%; 13 studies). Serious adverse events were reported infrequently. Surgery seemed more effective when performed sooner after symptom onset (p = 0.04; 12 studies). Age, Glasgow Coma Scale and hematoma volume did not modify the effect of surgery. INTERPRETATION Surgical treatment of supratentorial spontaneous intracerebral hemorrhage may be beneficial, in particular with minimally invasive procedures and when performed sooner after symptom onset. Further well-designed randomized trials are needed to demonstrate whether (minimally-invasive) surgery improves functional outcome after ICH and to determine the optimal time-window of the treatment after symptom onset. This article is protected by copyright. All rights reserved.
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Efficacy and safety of four interventions for spontaneous supratentorial intracerebral hemorrhage: a network meta-analysis
Guo G, Pan C, Guo W, Bai S, Nie H, Feng Y, Li G, Deng H, Ma Y, Zhu S, et al
Journal of neurointerventional surgery. 2020
Abstract
OBJECT To investigate the efficacy and safety of four interventions of spontaneous intracerebral hemorrhage simultaneously. METHODS PubMed, EmBase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) investigating endoscopic surgery (ES), minimally invasive puncture surgery (MIPS), conventional craniotomy (CC), and/or conservative medical treatment (CMT). Good functional outcome, death, and hemorrhage recurrence rates were evaluated by a network meta-analysis. RESULTS 20 RCTs with 3603 patients were included. Compared with CMT, a higher rate of good functional outcome was found after ES (RR=2.21, 95% CI 1.37 to 3.55) and MIPS (RR=1.47, 95% CI 1.24 to 1.73). Both ES (RR=0.62, 95% CI 0.44 to 0.86) and MIPS (RR=0.72, 95% CI 0.58 to 0.90) markedly reduced the rate of death. However, there was no significant difference in efficacy and safety between ES and MIPS. The top ranked P score for the efficacy outcome was for ES (P score=0.9810). ES (P-score=0.0709) ranked lowest for the primary safety outcome. There was a higher risk of hemorrhage recurrence after CC (RR=3.80, 95% CI 1.90 to 7.63) and MIPS (RR=2.86, 95% CI 1.70 to 4.82) compared with CMT whereas no significant difference was found for ES (RR=1.46, 95% CI 0.53 to 4.02). CONCLUSIONS The results suggest that both ES and MIPS significantly improve neurological function and reduce the risk of death compared with CMT, and there is no significant difference between ES and MIPS. Ranking of P scores revealed that ES may be the most optimal intervention to improve functional outcome and prevent death. This needs to be evaluated further.
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Minimally invasive puncture versus conventional craniotomy for spontaneous supratentorial hemorrhage: a meta-analysis
Ding WL, Xiang Y, Liao J, Wang X
Neuro-Chirurgie. 2020
Abstract
Background Minimally invasive puncture and conventional craniotomy are both utilized in the treatment of spontaneous supratentorial hemorrhage. The purpose of this study is to review evidence that compares the safety and effectiveness of these two techniques. Methods We searched EMBASE, Cochrane Library, Web of Science, and PubMed for studies published between 2000 and 2019 that compared the minimally invasive puncture procedure with the conventional craniotomy for the treatment of spontaneous supratentorial hemorrhage. Results Seven trials (2 randomized control trials and 5 observational studies) with a total of 970 patients were included. The odds ratio indicated a statistically significant difference between the minimally invasive puncture and conventional craniotomy in terms of good functional outcome (OR 2.36, 90% CI 1.24-4.49). The minimally invasive puncture procedure was associated with lower mortality rates (OR 0.61, 90% CI 0.44-0.85) and rebleeding rates (OR 0.48, 95%CI 0.24-0.99; p=0.003). Conclusions The use of the minimally invasive puncture for the management of spontaneous supratentorial hemorrhage was associated with better functional outcome results, a lower mortality rate, and decreased rebleeding rates. However, because insufficient data has been published thus far, we need more robust evidence to provide a better guide for future management.
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Only Tumors Angiographically Identified as Hypervascular Exhibit Lower Intraoperative Blood Loss Upon Selective Preoperative Embolization of Spinal Metastases: Systematic Review and Meta-Analysis
Gong Y, Wang C, Liu H, Liu X, Jiang L
Frontiers in oncology. 2020;10:597476
Abstract
BACKGROUND The role of preoperative embolization (PE) in reducing intraoperative blood loss (IBL) during surgical treatment of spinal metastases remains controversial. METHODS A systematic search was conducted for retrospective studies and randomized controlled trials (RCTs) comparing the IBL between an embolization group (EG) and non-embolization group (NEG) for spinal metastases. IBL data of both groups were synthesized and analyzed for all tumor types, hypervascular tumor types, and non-hypervascular tumor types. RESULTS In total, 839 patients in 11 studies (one RCT and 10 retrospective studies) were included in the analysis. For all tumor types, the average IBL did not differ significantly between the EG and NEG in the RCT (P = 0.270), and there was no significant difference between the two groups in the retrospective studies (P = 0.05, standardized mean difference [SMD] = -0.51, 95% confidence interval [CI]: -1.03 to 0.00). For hypervascular tumors determined as such by consensus (n = 542), there was no significant difference between the two groups (P = 0.52, SMD = -0.25, 95% CI: -1.01 to 0.52). For those determined as such using angiographic evidence, the IBL was significantly lower in the EG than in the NEG group, in the RCT (P = 0.041) and in the retrospective studies (P = 0.004, SMD = -0.93, 95% CI: -1.55 to -.30). For IBL of non-hypervascular tumor types, both the retrospective study (P = 0.215) and RCT (P = 0.947) demonstrated no statistically significant differences in IBL between the groups. CONCLUSIONS Only tumors angiographically identified as hypervascular exhibited lower IBL upon PE in this study. Further exploration of non-invasive methods to identify the vascularity of tumors is warranted.
