Postoperative pneumocephalus after posterior fossa surgeries in the semi-sitting position – Comparison of intracranial air collections and clinical outcome according to the surgical approach by means of voxel-based volumetry
Helene Hurth (Tübingen), Kathrin Machetanz (Tübingen), Florian Heinrich Ebner (Essen; Tübingen), Eliette Clement (Tübingen), Berthold Drexler (Tübingen), Marcos Tatagiba (Tübingen), Georgios Naros (Tübingen)
To assess the extent and distribution of postoperative pneumocephalus in patients undergoing posterior fossa surgery in the semi-sitting position after midline vs. lateral surgical approaches.
In a retrospective analysis 465 patients who underwent posterior fossa surgery in the semi-sitting position were included. Patients" individual postoperative CCT scans were registered and normalized to the common MNI space. Intraventricular, subdural, and total intracranial air were measured by voxel-based volumetry and compared between patient groups according to the surgical approach. Clinical details such as age, duration of surgery and outcome were evaluated.
Indication for surgery was resection of a posterior fossa tumor in 95.9% (n=446) of which 69.0% were vestibular schwannomas and 18.1% meningiomas. A lateral suboccipital (LA) and a midline suboccipital approach (MA) were performed in 92.0% (n=428) and in 8.0% (n=37), respectively. The total intracranial air volume (38ml vs. 29ml, p=0.049) and the intraventricular air volume (9.2ml vs. 0.0ml, p<0.001) were significantly higher in MAs. Clinically relevant tension pneumocephalus (TP) was present in a total of 3.0% of patients (n=14), which was treated by frontal air exchange with saline in 64.3% (n=9) and external ventricular drainage (EVD) in 35.7% (n=5). TP occurred significantly more often in MAs (10.8%) than in LAs (2.3%; p=0.019). Air replacement was performed via EVD in all cases of TP after a MA and via a frontal twist-drill in 90% of TP cases after a LA. In two patients, revision surgery was necessary after air exchange. No permanent disabilities occurred due to air replacement therapy. A weak correlation was found between total intracranial air and age (ρ=0.28, p<0.001) as well as time to extubation (ρ=0.1, p=0.026). A weak negative correlation was found between intraventricular air and BMI (ρ=-0.15, p=0.001). No association was detected between air volumes and duration of surgery, ICU or inpatient stay or postoperative Karnofsky index.
MAs harbor a significantly higher risk of clinically relevant TP than LAs. These patients usually showed intraventricular air requiring external ventricular drainage as opposed to more frequent subdural air collections in LAs. Overall outcome was good even in patients requiring air replacement indicating that, if treated subsequently, the semi-sitting position can be safely performed in patients with midline pathologies.
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