Original Article Clinical characteristics and causes of ... · craniopharyngioma, osteochondroma,...

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Int J Clin Exp Med 2016;9(7):14353-14360 www.ijcem.com /ISSN:1940-5901/IJCEM0026728 Original Article Clinical characteristics and causes of emergency reoperation after skull base surgery: a report of 14 cases Runfa Tian 1,2,3* , Shuyu Hao 1,2,3* , Xinru Xiao 1,2,3 , Jie Tang 1,2,3 , Zhen Wu 1,2,3 , Baiyun Liu 1,2,3 , Liwei Zhang 1,2,3 , Junting Zhang 1,2,3 1 Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China; 2 China National Clinical Research Center for Neurological Diseases, Beijing, China; 3 Beijing Key Laboratory of Central Nervous System Injury, Beijing, China. * Equal contributors. Received February 26, 2016; Accepted June 4, 2016; Epub July 15, 2016; Published July 30, 2016 Abstract: Objective: To investigate the clinical characteristics and causes of the patients who received an emergen- cy reoperation involving a craniotomy after neurosurgery for skull base tumors. Materials and methods: A retrospec- tive analysis was performed with 14 patients who underwent an emergency reoperation involving a craniotomy after received skull base surgery in the Skull Base and Brainstem Division of the Neurosurgery Department at Beijing Tiantan Hospital, Capital Medical University, between October 2008 and October 2013. The clinical characteristics and causes for reoperation were analyzed and determined by the surgeons and a group of experts and confirmed via consultation of the entire department. Results: There were 6 cases of skull base meningiomas, 3 cases of schwannoma, and 1 case each of pituitary adenoma, craniopharyngioma, osteochondroma, angioleiomyoma, and glomus jugular tumor. The mean length of the first surgery was 9.2 hours, and the mean blood loss was 2750 mL. Among the patients who underwent reoperation, 9 patients exhibited declined consciousness and vitality, 2 patients were identified as having an abnormal postoperative recovery from anesthesia, 2 patients were identified by a rou- tine postoperative computed tomography (CT) examination and 1 patient had sudden bleeding from the wound. The average time to detect abnormalities via CT exam was 16.9 hours after surgery. There were 4 cases of intratumoral hemorrhage, 4 cases of intracerebral hematoma accompanied by cerebral laceration, 2 cases of massive cerebral infarction, 1 case of intracerebral hematoma complicated by subdural hematoma, 2 cases of epidural hematoma, and 1 case of bleeding from the vertebral artery. Conclusions: Perioperative management should be strengthened for patients who receive skull base surgery to reduce the incidence of reoperation. Keywords: Causes, clinical characteristics, emergency reoperation, neurosurgery, skull base tumor Instroduction Skull base tumors have a deep location, and surgical treatment is difficult, risky, and time consuming [1, 2]. Early postoperative cranioto- my is considered as a severe complication and seriously affects the prognosis of patients [3, 4]. The skull base surgeon should strive to avoid such situations. However, there are still few researches focus this point on skull base surgery. This report analyzes the clinical char- acteristics of 14 patients who underwent an early emergency reoperation involving cranioto- my after they received skull base surgery in the Skull Base and Brainstem Division of the Neurosurgery Department at Beijing Tiantan Hospital, an affiliated hospital of Capital Me- dical University, between October 2008 and October 2013. The aim of our study was to investigate the clinical characteristics and causes of the patients who received an emer- gency reoperation involving a craniotomy after neurosurgery for skull base tumors. Patients and methods Clinical data There were a total of 14 cases, 8 males and 6 females, accounting for 0.6% of skull base elec- tive surgery during the same period (14/2500). The patients, aged 19-69 years, with a mean

Transcript of Original Article Clinical characteristics and causes of ... · craniopharyngioma, osteochondroma,...

Page 1: Original Article Clinical characteristics and causes of ... · craniopharyngioma, osteochondroma, angi-oleiomyoma, and glomus jugular tumor. First surgery The surgical approach was

Int J Clin Exp Med 2016;9(7):14353-14360www.ijcem.com /ISSN:1940-5901/IJCEM0026728

Original ArticleClinical characteristics and causes of emergency reoperation after skull base surgery: a report of 14 cases

Runfa Tian1,2,3*, Shuyu Hao1,2,3*, Xinru Xiao1,2,3, Jie Tang1,2,3, Zhen Wu1,2,3, Baiyun Liu1,2,3, Liwei Zhang1,2,3, Junting Zhang1,2,3

1Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China; 2China National Clinical Research Center for Neurological Diseases, Beijing, China; 3Beijing Key Laboratory of Central Nervous System Injury, Beijing, China. *Equal contributors.

Received February 26, 2016; Accepted June 4, 2016; Epub July 15, 2016; Published July 30, 2016

Abstract: Objective: To investigate the clinical characteristics and causes of the patients who received an emergen-cy reoperation involving a craniotomy after neurosurgery for skull base tumors. Materials and methods: A retrospec-tive analysis was performed with 14 patients who underwent an emergency reoperation involving a craniotomy after received skull base surgery in the Skull Base and Brainstem Division of the Neurosurgery Department at Beijing Tiantan Hospital, Capital Medical University, between October 2008 and October 2013. The clinical characteristics and causes for reoperation were analyzed and determined by the surgeons and a group of experts and confirmed via consultation of the entire department. Results: There were 6 cases of skull base meningiomas, 3 cases of schwannoma, and 1 case each of pituitary adenoma, craniopharyngioma, osteochondroma, angioleiomyoma, and glomus jugular tumor. The mean length of the first surgery was 9.2 hours, and the mean blood loss was 2750 mL. Among the patients who underwent reoperation, 9 patients exhibited declined consciousness and vitality, 2 patients were identified as having an abnormal postoperative recovery from anesthesia, 2 patients were identified by a rou-tine postoperative computed tomography (CT) examination and 1 patient had sudden bleeding from the wound. The average time to detect abnormalities via CT exam was 16.9 hours after surgery. There were 4 cases of intratumoral hemorrhage, 4 cases of intracerebral hematoma accompanied by cerebral laceration, 2 cases of massive cerebral infarction, 1 case of intracerebral hematoma complicated by subdural hematoma, 2 cases of epidural hematoma, and 1 case of bleeding from the vertebral artery. Conclusions: Perioperative management should be strengthened for patients who receive skull base surgery to reduce the incidence of reoperation.

Keywords: Causes, clinical characteristics, emergency reoperation, neurosurgery, skull base tumor

Instroduction

Skull base tumors have a deep location, and surgical treatment is difficult, risky, and time consuming [1, 2]. Early postoperative cranioto-my is considered as a severe complication and seriously affects the prognosis of patients [3, 4]. The skull base surgeon should strive to avoid such situations. However, there are still few researches focus this point on skull base surgery. This report analyzes the clinical char-acteristics of 14 patients who underwent an early emergency reoperation involving cranioto-my after they received skull base surgery in the Skull Base and Brainstem Division of the Neurosurgery Department at Beijing Tiantan

Hospital, an affiliated hospital of Capital Me- dical University, between October 2008 and October 2013. The aim of our study was to investigate the clinical characteristics and causes of the patients who received an emer-gency reoperation involving a craniotomy after neurosurgery for skull base tumors.

Patients and methods

Clinical data

There were a total of 14 cases, 8 males and 6 females, accounting for 0.6% of skull base elec-tive surgery during the same period (14/2500). The patients, aged 19-69 years, with a mean

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Table 1. The clinical characters and causes of 14 cases with skull base tumor surgery reoperation

No. Gender Age Primary disease Surgery approach Tumor size(cm)

Blooding volume

(ml)

Surgery length

(h)

CT abnor-mality after surgery (h)

Cause for first surgery

Post op-erative GOS

scoreCause for second surgery

1 F 58 recurrent glomus jugular tumor

far-lateral retro-condylar approach

4×5×5 5500 14 0 ruptured vertebral artery

1 vertebral artery rupture and hemor-rhage

2 M 64 sphenoid ridge meningiomas

subtemporalpreauricular approach

4×5×5 800 5 18 subdural and intra-cerebral hematoma

1 liver dysfunction induced coagulopathy

3 M 50 pituitary adenoma subfrontal approach 4×5×6 800 8 12 brain infarction 1 residual tumor hemorrhage induced large area of brain infarction

4 M 40 anterior skull base meningiomas

subfrontal approach 6×6×5 9000 15 8 intracerebral hema-toma

2 postoperative cerebral perfusion pressure breakthrough induced intra-cerebral hemorrhage

5 F 27 parasellarmenin-giomas

subtemporalpreauricular approach

4×4×5 8000 16 12 brain infarction 3 blood supply of tumor is too rich to hemostasis completely

6 F 23 parasellarangi-oleiomyoma

subtemporalpreauricular approach

7.7× 5.5×5.5 5000 10 12 tumor cavity hemor-rhage

3 blood supply of tumor is too rich to hemostasis completely

7 M 54 petroclivalosteo-chondroma

subtemporal approach via the petrous bone

2×3×3 200 7.5 19 intracerebral hema-toma

4 temporal vein contusion

8 M 69 petroclivalschwan-noma

subtemporal approach via the petrous bone

3×3×4 100 6 3 intracerebral hema-toma and contusion

4 temporal vein disconnection

9 M 41 petroclivalmenin-giomas

fronto-orbitozygomatic approach

4.5×5×6 4000 12.5 2.5 epidural hematoma 5 meningeal artery incompletely hemostasis

10 F 42 petroclivalmenin-giomas

presigmoid approach 4×5×5 2000 14 8 epidural hematoma 5 dural stripping

11 F 23 suprasellarcranio-pharyngioma

transcorpuscallosal approach

3×4×4 200 4.5 10 tumor cavity hema-toma

5 incompletely hemostasis

12 M 19 cerebellopontin-eschwannoma

retrosigmoid approach 5.5×5.5×6 600 6 20 tumor cavity hema-toma

5 incompletely hemostasis

13 M 45 anterior clinoidme-ningiomas

fronto-orbitozygomatic approach

4.5×4.5×5 2200 6.5 94 tumor cavity hema-toma

5 incompletely hemostasis

14 F 58 petroclivalmenin-giomas

subtemporal approach via the petrous bone

2×3×3 100 4 2 intracerebral hema-toma

5 excessive traction on brain tissues

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age of 43.8 years, included 1 patient with a his-tory of hypertension, 2 patients with a history of hepatitis, 1 patient with a recurrent glomus jugular tumor, and 1 patient with pre-operative embolization for a large endothelial meningio- ma.

Primary disease site and pathology

The most common primary disease site includ-ed petroclival, parasellar and sellar or suprasel-lar (Table 1). Postoperative pathology including 7 cases of meningiomas, 2 cases of schwan-noma, and 1 case each of pituitary adenoma, craniopharyngioma, osteochondroma, angi-oleiomyoma, and glomus jugular tumor.

First surgery

The surgical approach was selected based the location of the tumors, including subtemporal approach via the petrous bone, subtemporal-preauricular approach to the middle cranial fossa, fronto-orbitozygomatic approach and so on (Table 1). The length of the surgery ranged from 4 to 16 hours, with an average of 9.2 hours. The mean intraoperative blood loss ranged from 100 to 9000 mL, with an average of 2750 mL. There were 12 cases of total resection and 2 cases of subtotal resection. The patients were monitored in the intensive care unit (ICU) after the surgery.

Analysis of the cause for reoperation

The cause was determined through analysis by the surgeon and the expert group and con-firmed via consultation of the entire depart- ment.

Results

First symptoms of the reoperated patients

Nine patients exhibited a decline in conscious-ness and vitality after awaking from the first surgery, 2 patients were identified due to abnor-mal postoperative recovery from anesthesia, 2 patients were identified during a postoperative routine computed tomography (CT) examina-tion, and 1 patient had sudden bleeding from the wound.

CT findings

Among this group of patients, 13 exhibited abnormalities in the CT examination before the emergency reoperation at 2 to 94 hours after

the first surgery, with an average of 16.96 hours. There were 4 cases of intratumoral hem-orrhage, 4 cases of intracerebral hematoma accompanied by cerebral laceration, 2 cases of massive cerebral infarction, 1 case of intrace-rebral hematoma with complication of subdural hematoma, and 2 cases of epidural hematoma. A patient who had bleeding wounds directly underwent surgical exploration, without CT examination.

Surgery and prognosis

Eight patients had a surgical approach via the original incision, while 6 patients had a surgical approach through an expanded incision. Six patients had well-subsided brain tissues with a restored bone flap, whereas the remaining patients underwent decompressive craniecto-my. According to the Glasgow Outcome Scale (GOS), there were 6 cases of grade V, 2 cases of grade IV, 2 cases of grade III, 1 case of grade II, and 3 cases of grade I.

Causes of reoperation

There were 4 cases of incomplete hemostasis, 2 cases of injured subtemporal vein (Figure 1), 2 cases of massive cerebral infarction due to vasospasm (Figure 2), 2 cases of epidural hematoma caused by dural stripping, 1 case of coagulation disorder, 1 case of cerebral hemor-rhage from traction and contusion, 1 case of hemorrhage from rupture of the vertebral artery, and 1 case of intracerebral hematoma from perfusion pressure in remote regions.

Discussion

The present study found that the most common symptom was declined consciousness and vitality after awaking from the first surgery, the average time of exhibited abnormalities in CT examination after the first surgery was 16.96 hours, and the most common causes of re- operation including incomplete hemostasis, injured subtemporal vein, massive cerebral infarction due to vasospasm and epidural hematoma caused by dural stripping. To the best of our knowledge, this report is the first study to demonstrate the clinical characteris-tics and causes analysis of emergency reopera-tion after skull base surgery.

With a better understanding of the skull base anatomy and improved instruments, neuro- logical protection has been greatly improved.

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Nevertheless, surgery on skull base tumors is associated with objective risks [5]. When emer-gency reoperation is required after skull base surgery, patients frequently had a poor out-come and even died [3]. Tahara et al. reported surgical treatment of 15 cases of petroclival meningioma, with 2 deaths due to hematoma and massive cerebral infarction in the surgical region [6]. It is difficult for physicians and

patients to accept a mortality rate of 13.3%. Therefore, retrospective analysis is necessary for reoperation after skull base surgery.

The causes for emergency reoperation follow-ing skull base surgery include postoperative hematoma, severe cerebral infarction, cerebral edema, and other unexpected causes such as vertebral artery rupture in the patients of this

Figure 1. Patient, male, 69 years of age. Magnetic resonance imaging (MRI) revealed a space-occupying mass in the left petrous apex (A, B). The patient was operated on via the left subtemporalanteropetrosal approach and did not awaken until 3 hours after the surgery. Cranial CT indicated a left temporal intracerebral hematoma (C). The hematoma was surgically removed, with satisfactory results (D). Cause analysis: The intracerebral hematoma was caused by injury to the subtemporal vein.

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study [7]. Little et al. reported 137 cases of petroclival meningioma surgery, with 2 cases of reoperation due to postoperative hematoma [8]. Zhen Wu et al. reported 259 cases of petro-clival meningiomas treated with surgery, and 7 patients had intracranial hematomas and received reoperation [9].

The major causes for postoperative hemato- ma include incomplete hemostasis and skull base venous injuries [10-14]. With improve-ments in the techniques and materials used for hemostasis, venous injuries have become the primary cause of postoperative hematoma after skull base surgery [15]. Intraoperative arterial rupture is easier to detect, whereas venous injuries are more elusive and will lead to venous hemorrhage without sufficient atten-tion. Venous hemorrhage mostly manifests as diffuse high-density lesions upon CT examina-tion. Non-arterial bleeding yields mass-like hemorrhagic foci. For example, when the vein of Labbé in the subtemporal approach is injured, the resultant impaired drainage is likely to cause postoperative temporal lobe hemato-ma [16, 17]. Therefore, the drainage vein must be fully considered when making a surgery plan for skull base lesions. First, a preoperative imaging exam, such as enhanced magnetic resonance venography (MRV), can predict the course of drainage veins. Furthermore, the sur-gical approach may need to be selected accord-ing to the entry sinus type of the drainage veins at the skull base. Second, the drainage veins must be protected throughout the entire surgi-cal process, from drilling the skull, milling the bone flap, and cutting the dura to draining the skull base fluid and tumor resection. Some- times, to protect the drainage veins that are attached to the dura, the dura must be cut into several pieces. In this study, the subtemporal vein was accidentally injured while cutting the dura during a craniotomy in a patient, who remained unconscious after the surgery. CT examination indicated an intracerebral hema-toma, and the patient underwent reoperation. Furthermore, when postoperative cerebral tis-

sue subsidence was unsatisfactory after tumor resection, a B-type ultrasound or CT scan can be used for intraoperative exploration to dis-cover intracerebral hematoma and avoid reop-eration after the patient regains conscious-ness. In addition, in this study, there were 4 cases of postoperative hematoma caused by incomplete hemostasis, with 3 cases exhibit- ing massive intraoperative bleeding (2 cases of angiomatous meningioma and 1 case of angioleiomyoma). Preoperative superselective embolization may reduce intraoperative bleed-ing for tumors with a rich blood supply. Special care is required for this type of tumor to control bleeding during the surgery and to avoid post-operative hematoma.

Intracerebral hematoma and brain contusion and laceration are common in skull base sur-gery due to excessive traction on brain tissues [18]. Skull base surgery has stringent techni- cal requirements. Exposing the skull base can reduce traction on brain tissues. In elderly patients, excessive intraoperative traction can lead to brain contusion due to increased fragil-ity of brain tissues. In this study, a 69-year-old patient with hypertension for 25 years had a smooth surgery but still experienced postoper-ative intracerebral hematoma, which was likely caused by excessive intraoperative traction on the brain tissues.

In reoperation for skull base tumors, the intra-cranial pressure must be reduced first. Regard- less of whether it is intracerebral hematoma or massive cerebral infarction, hematoma remov-al, in combination with decompressive craniec-tomy, can well reduce the intracranial pressure to save the patients’ lives [19, 20]. The goal of reoperation is to mitigate the impact from a hematoma on the cerebral nerves and deep blood vessels. For example, in the case of sel-lar tumors, mild bleeding can cause visual impairment, and surgical removal of the hema-toma can save the patient’s vision. In addition, all of major blood vessels travel through the skull base and bleeding into the surgical cavity

Figure 2. Patient, male, 50 years of age. MRI revealed a very large suprasellar space-occupying lesion in the sellar region (A, B). Subtotal tumor resection was performed through a craniotomy with a right frontal coronal incision. In-tratumoral bleeding was found 12 hours after the surgery (C) and was treated with conservative therapy. The patient exhibited decreased consciousness on the third day. Cranial CT indicated large right frontal temporoparietal and left frontal ischemic lesions (D, E). The patient was given emergency decompressive craniectomy, showing a plump cortex and changes in ischemia during the surgery (F). The patient died after leaving the hospital voluntarily. Cause analysis: The suprasellar tumor was not completely removed, and bleeding in the residual tumor led to vasospasm and massive cerebral infarction.

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during skull base surgery can lead to vaso-spasm in the Circle of Willis, basilar artery, or brainstem perforator vessels. If the hematoma is not removed in time, vasospasm of the perfo-rator vessels will not be improved after the sur-gery, even with effective conservative treat-ment. In this study, one patient with an invasive pituitary adenoma suffered a postoperative hematocele in the surgical area, with generally stable conditions and conservative treatment. However, the patient experienced a massive cerebral infarction 3 days after the surgery and died. Furthermore, bloody cerebrospinal fluid causes clogging of the arachnoid granules and increases the incidence of hydrocephalus. Therefore, if necessary, the reoperation after skull base surgery should be performed as soon as possible to benefit the patients.

Serious postoperative complications can only be avoided through continuing education in skull base surgical techniques and incorporat-ing clinical training and experience. In situa-tions when emergency surgery is necessary, it is important to have a positive attitude during active surgical treatment.

Acknowledgements

This study was supported by the National Key Basic Research Program of China (No. 2014CB542006), National Natural Science Foundation of China (No. 81471238), the grant from Beijing Nova program (No. XX2012033), National Key Technology Re- search and Development Program of the Ministry of Science and Technology of China (2013BAI09B03) and Beijing Institute for Brain Disorders (BIBD-PXM2013_014226_07_ 000084).

Disclosure of conflict of interest

None.

Address correspondence to: Dr. Junting Zhang, Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, 6 Tiantan Xili, Dongcheng District, Beijing 100050, China. Tel: 86-10-67098431; Fax: 86-10-67051377; E-mail: [email protected]

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