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20 Primary Brain Lesion Resection Complications : An Overview and Malignant Brain Swelling After Resection of Superior Sagittal Sinus Meningioma VINAYAK NARAYAN , VIJAY AGARWAL , MICHAEL J. LINK , ANIL NANDA

H I G H L I G H T S • The overall incidence of complications associated with primary

brain tumor resection worldwide ranges from 20% to 35%. • These complications can be broadly divided into neurologic,

regional, and systemic complications. • The surgery of superior sagittal sinus meningioma carries high

risk of complications. • Due to the advancements in neuroimaging, neuroanesthesia,

and surgical adjunct precision in modern times, gross total resection of a primary brain tumor can be performed without signifi cant complications.

• The careful selection of patients, a proper surgical plan, meticulous operative technique, anticipation of a complication, and the precautions to avoid the same are the main keys to a good surgical outcome.

Introduction Th e surgical management of brain tumors has taken a paradigm shift over the last century from the Cushing era of cytoreduction surgery to the present golden period of advanced tumor surgery. Neurosurgical adjuncts such as cortical mapping, frameless stereo-taxy, and intraoperative magnetic resonance imaging (MRI) play a huge role in the safe resection of primary brain tumors with absent or minimal complications. Th e objectives of brain tumor resection are the establishment of exact histopathologic diagnosis, neurologic recovery, and prolongation of patient survival. Th e overall incidence of complications associated with primary brain tumor resection worldwide ranges from 20% to 35%. 1–4 Th is chapter throws light on a variety of complications associated with resection

of primary brain lesions, its classifi cation, diagnostic methods, and management strategies.

Th e defi nition of complication in primary brain tumor surgery is mostly subjective. Most surgical series defi ne the adverse events as complications without giving due regard to whether they are expected. 1–3,5 Apart from the surgeon ’ s knowledge and skill, there are various factors directly or indirectly involved in the incidence of a complication. Th e patient ’ s age, physical/neurologic status, previous treatment, tumor size and location, extent of resection, availability of monitoring/operative navigational devices, and histopathologic characteristics are a few of them. 3 Th e neurosurgeon should have good acumen on all tumor-related complications because it helps in better counseling of the patient and family, both before and after surgery.

Classifi cation of Neurosurgical Complications A neurosurgical complication is not a single entity. It encompasses a spectrum of surgical complications as well as medical complications that may happen in the perioperative period 3 ( Table 20.1 ). Sawaya et al. provide a rational framework for categorizing complications associated with brain tumor surgery. 3 In this classifi cation pattern, the neurosurgery-related complications are broadly organized into neurologic, regional, and systemic complications. 3 Neurologic complications are adverse events that directly impair motor, sensory, language, or visual functions (e.g., hematoma, vascular injury, edema), whereas regional complications are related either to the wound (e.g., infection, pseudomeningocele) or to the brain (e.g., seizures, hydrocephalus), but they are not associated with any

SECTION 2 Cranial Complications Primary Brain Lesion Resection Complications

100 SECTION 2 Cranial Complications

by proper positioning of the patient, hyperventilation, high-dose corticosteroids, diuretics, and intermittent retractor placement. Frameless stereotaxy also helps in determining the optimal surgi-cal trajectory and reduces the need for prolonged retraction and consequent cerebral edema. 7 Th e gross total resection of a malignant glioma is associated with reduced postoperative edema/hematoma (wounded glioma syndrome) and the resulting morbidity compared with its partial-resection counterparts. 1,3,9 Th e risk of vascular injury while performing surgery can be reduced by the strong anatomic suspicion of the location of vascular structures, early identifi cation of arteries and veins, judicious sacrifi ce of draining veins, careful and intermittent retraction, surgery along the subpial plane, and careful use of an ultrasonic aspirator. Most of the operative site hematomas can be avoided by careful preoperative preparation, meticulous operative technique, and vigilant postoperative care.

Regional Complications Regional complications are events associated with the surgical site (e.g., infection, pseudomeningocele) or the brain (e.g., seizures, hydrocephalus, pneumocephalus) without any neurologic defi cits. 3 A complication occurs in 1% to 5% of patients undergoing cra-niotomy for removal of intrinsic brain tumors. 1,2–4 Redo surgery and radiotherapy are two plausible factors that can lead to wound infection. 4,5 Th e tumor proximity to the motor cortex and a history of preoperative epilepsy are the strongest predictors for seizures. 10 Local factors such as degree of cortical injury, prolonged retraction while performing the operation, and postoperative edema/hematoma as well as systemic factors such as hyponatremia and acidosis infl uence the incidence of postoperative seizures. 2,10 Even though there is a controversy regarding the administration of prophylactic antiepileptics, most surgical series demonstrated a lower frequency of seizures in patients who received phenytoin either before or during surgery. 11–13 Postoperative seizures must be managed aggres-sively with intravenous (IV) lorazepam, phenytoin, and IV fl uids, and computed tomography (CT) imaging must be done to rule out a structural cause.

Th e risk of postoperative infections ranges from 1% to 2%, and it can extend from superfi cial to deep, involving bone, meninges, and brain parenchyma. 3,14 Th e most common microbes involved are Staphylococcus aureus and S. epidermidis, although nosocomial infections can happen also with Gram-negative organisms. 14 Th e predisposing factors for wound infection are proximity to paranasal sinus, presence of foreign body, prolonged surgery, corticosteroid administration, cerebrospinal fl uid fi stula, previous surgery, and cytotoxic therapy. 3,5,14 Th e administration of prophylactic antibiotics and meticulous wound closure help in reducing the incidence of postoperative wound infection. 14

Systemic Complications Th e incidence of medical complications ranges from 5% to 10% of patients undergoing craniotomy and removal of primary brain tumor. 3 Th e spectrum of medical complications includes deep venous thrombosis, pulmonary embolism, myocardial infarction, infection, gastrointestinal hemorrhage, and electrolyte disturbances, of which the most frequent is deep venous thrombosis. 3,15 Th e predisposing factors are elderly population, poor KPS score, preexist-ing medical conditions, prolonged surgery, and bed rest.

Several perioperative mechanical and pharmacologic prophylactic measures can reduce the risk of thromboembolic events. Th e use of elastic stockings and compression boots and the administration of minidose heparin (5000 units subcutaneously twice a day) or

neurologic defi cits. Systemic complications include more generalized medical conditions (e.g., thromboembolism, pneumonia). Neuro-logic complications are the most common cause of postoperative mortality. Th ese three complications can be further subclassifi ed into major and minor complications based on the severity, duration of defi cit, and need of reexploration surgery.

Complications and Strategy for Their Avoidance

Neurologic Complications Th e incidence of a new neurologic defi cit (minor or major) after craniotomy for intrinsic tumor ranges from 10% to 25% in many surgical series. 1,3–4 Several predictors of adverse neurologic outcome have been described in previous surgical series: age older than 60 years, Karnofsky Performance Scale (KPS) score less than 60, deep tumor location, and tumor in proximity to eloquent brain areas. 1–3,5 Th e surgical strategy must be ideally planned based on these factors.

Th e main causes for neurologic complications are direct brain parenchymal injury, brain edema, vascular injury, and hematoma. Th e wrong localization of the tumor in relation to the adjacent eloquent brain areas is the main reason for inadvertent brain injury. Brain edema is also a notorious cause of neurosurgical morbidity. Th e predisposing factors for postoperative brain edema include excessive brain retraction and subtotal resection of the tumors, commonly high-grade gliomas. Th e incidence rate of vascular injury associated with primary brain tumor surgery is around 1% to 2%. 1 A major venous occlusion can result in a hemorrhagic stroke where the neurologic manifestations may be delayed, whereas an arterial occlusion or injury can have an immediate catastrophic eff ect. Th e probable diff erence between these two problems is that in the former case, there can be a gradual recovery over a period of time, whereas in the latter it may permanently aff ect the patient ’ s quality of life. Postoperative hematomas, including subdural and extradural hematomas, cause neurologic defi cits in 1% to 5% of patients; they are usually detected in the early postoperative period when the patient develops altered sensorium, seizures, or focal neurologic defi cit. 1–3

Th e conventional knowledge of the tumor in relation to the normal brain and precise eloquent areas as well as the tumor ’ s identifi cation/confi rmation using various adjuncts such as cortical mapping, frameless stereotactic navigation, intraoperative MRI, or awake stimulation helps to a great extent in avoiding direct brain injury. 4,6–8 Similarly, excessive brain retraction can be minimized

Summary of the Complications Associated With Primary Brain Tumor Surgery

TABLE 20.1

Neurologic Regional Systemic

Motor defi cit Sensory defi cit Aphasia/dysphasia Visual fi eld defi cit

Hydrocephalus Seizure Pneumocephalus Wound infection Meningitis Brain abscess

Pulmonary embolism Deep vein thrombosis Pneumonia Urinary infection Sepsis Myocardial infarction Gastrointestinal bleed Electrolyte disturbances

Courtesy Winn HR. Youmans Neurological Surgery, 6th edition, Surgical Complications of

Brain Tumors and Their Avoidance. Elsevier Saunders, 2011, Philadelphia.

CHAPTER 20 Primary Brain Lesion Resection Complications 101

guidelines for the management of these lesions or their complications, and treatment paradigms vary signifi cantly between institutions.

Anatomic Insights

Venous Anatomy Th e intracranial venous system can be divided into a superfi cial and a deep system ( Fig. 20.1 ). Th e superfi cial system is comprised of the sagittal sinuses and cortical veins. Th e deep system drains the deep gray structures via the internal cerebral veins, basal veins of Rosenthal, vein of Galen, and the straight sinus. Th e SSS, the lateral sinuses (including the transverse and sigmoid sinus), and the cavernous sinus are the most frequently thrombosed dural sinuses, followed by the straight sinus and vein of Galen. 24 Studies have shown a permanent morbidity range of 6% to 20% from cerebral venous thrombosis, although prognosis is thought to be better than for arterial stroke. 25,26 Detailed evaluation of the venous sinuses and information on patency are best obtained via a venous MR angiogram, CT venography, or a digital subtraction angiography with late venous phases.

Dural Sinuses Superfi cial veins of both hemispheres drain via the SSS, which starts at the foramen cecum and runs posteriorly toward the internal occipital protuberance, at which point it joins the straight and lateral sinuses to form the torcular Herophili. Th e SSS increases in size from anterior to posterior and ranges in width from 4.3 to

low-molecular-weight heparin after craniotomies are some of them. 16–20 Th e neurosurgeon should keep a vigilant eye in the postoperative period to avoid or minimize the aforementioned complications to a great extent.

Next is an example of primary brain tumor; superior sagittal sinus (SSS) meningioma and the complications associated with its resection are discussed.

Neurosurgical Complications After Resection of Superior Sagittal Sinus Meningioma Th e treatment of meningiomas that invade the intracranial venous system remains a signifi cant and controversial challenge for neu-rosurgeons. 21 Specifi cally, damage to the major dural venous sinuses, the deep cerebral veins, and the vein of Labbé, among others, can lead to major complications such as seizures, hemorrhage, sinus occlusion, corticovenous thrombosis, and regional or diff use brain swelling. 22,23 Th ese complications can lead to signifi cant morbidity and mortality. Meningiomas in the parasagittal region comprise 21% to 31% of all intracranial meningiomas. 21,22 Invasion of the SSS is common with these lesions and increases the risk of subtotal resection and thus recurrence. Meningiomas along the SSS range from 14.8% to 33.9% in the anterior third, from 44.8% to 70.4% in the middle third, and from 9.2% to 29.6% in the posterior third of the sinus. 21 Th ose lesions involving the posterior two-thirds of the SSS pose a substantially increased risk, whereas the previous literature has supported the sacrifi ce of the anterior one-third, with minimal consequence.

Th ere is a current lack of large published series of parasagittal meningiomas that invade the SSS. Due to this, there are no accepted

• Fig. 20.1 Venous anatomy. (Copyright © Mayo 2002.)

102 SECTION 2 Cranial Complications

also receives the paired basilar veins of Rosenthal (which begins at the anterior perforated substance by the union of the anterior cerebral vein, the middle cerebral vein, and the striate vein); the veins from the corpus callosum, the cerebellum, and the occipi-tal cortex; and the vermian precentral vein. Th e deep veins are often encountered when operating in the lateral ventricle, third ventricle, and pineal region. Th e great cerebral vein of Galen is approximately 1 to 2 cm long and passes posterosuperiorly behind the splenium of the corpus callosum in the quadrigeminal cistern. Injury or occlusion of the vein of Galen can have cata-strophic consequences. Th ere have been case reports of ligation of the vein of Galen without signifi cant clinical sequelae, but this is likely due to the development of collateral circulation and to the signifi cant anatomic variation of the vein of Galen and its tributaries. 28,29

Surgical Resection of SSS Meningiomas Meningiomas invading the SSS remain a challenging lesion for neurosurgeons. Th ey can be diffi cult to resect completely and carry signifi cant risk of morbidity, including intraoperative and postopera-tive hemorrhage, sinus occlusion, and corticovenous thrombosis. 22 Although subtotal resection is associated with a high rate of recurrence, absolute care must be taken to preserve the collateral channels at all steps of the surgery. 30–32

Venous invasion by the meningioma can range from invasion of the outer surface of the venous wall to complete invasion and occlusion of the sinus. Th e fi rst detailed classifi cation scheme was proposed by Merrem and Krause et al. and then later modifi ed by Bonnal and Brotchi et al. 33 A simplifi ed version was proposed by Sindou and Hallacq in 1998. 23 Th is classifi cation included the categorization described later.

With the advent of microsurgical techniques, intracranial dural venous sinus reconstruction became possible. In 1971, Kapp et al. used an autogenous great saphenous vein and shunt device to reconstruct the SSS. 32 Th is was followed by Marks et al. in 1986 and Sakaki et al. in 1987. 30,34 Reconstructive materials have included autologous great saphenous vein, neck superfi cial veins, Dacron, and silicone tubing. 35–37 Sindou and Hallacq reported a series of 47 meningiomas: 41 of the sagittal sinus, 4 of the transverse sinus, and 2 torcular. 23 A gross total resection was achieved in all cases. Th irty-nine patients were reported as having good outcomes and resumed their previous activities, whereas fi ve patients had permanent neurologic defi cit due to central venous infarction (all in the middle one-third of the sagittal sinus). Th ree patients died from brain swelling; all three involved meningio-mas totally occluding the sinus, and in all three patients resec-tion was achieved without sinus reconstruction. Nine patches, six Gore-Tex bypasses, and nine autologous vein bypasses were employed. Th e authors recommended the following: excision of the outer layer of sinus wall and coagulation of dural attach-ment in Type 1, removal of intraluminal fragment and repair of dural defect with a patch in Type 2, resection of sinus wall and repair by patch graft in Type 3, repair by patch or bypass with saphenous or external jugular vein graft in Type 4, and removal of involved portion of sinus and restoration by venous bypass in Types 5 and 6.

Mathiesen et al. supported the practice of sagittal sinus repair or reconstruction after resection by invasive meningiomas when attempting a macroscopic radical removal. 38 Th ey proposed a direct primary repair when resecting just an invaded edge; closure with a patch graft of dural, falcine, or pericranial tissue when resecting

9.9 mm. 27 As mentioned, the sacrifi ce of the anterior one-third of the SSS is usually well tolerated, but complications can include akinetic mutism, short-term memory defi cits, or personality changes from compromise of prefrontal aff erent drainage. At times, this anterior portion is narrow or absent, replaced by two superior cerebral veins. 21 Th e middle one-third of the SSS drains the central group of cortical veins, and, as such, its sacrifi ce has the potential to cause bilateral hemiplegia or akinesia. A good landmark for division of the anterior and middle one-third of the SSS is the coronal suture. Occlusion of the posterior one-third of the SSS, or the torcular Herophili, carries a signifi cant risk of potentially fatal diff use brain edema. Fibrous septa at the inferior angle of the sinus, in addition to turbulent fl ow from draining superfi cial cortical veins, are felt to account for a greater risk of SSS thrombosis. Th e SSS, along with the other dural venous sinuses, receives blood from diploic, meningeal, and emissary veins. Th is accounts for the frequent occurrence of cerebral venous thrombosis as a complication of infectious pathologies, such as in cavernous sinus thrombosis in facial infections, lateral sinus thrombosis in chronic otitis media, and sagittal sinus infection in scalp infections. Because the dural sinuses contain the pacchionian or arachnoid granulations, thrombosis can lead to intracranial hypertension and papilledema.

The Superfi cial Veins of the Brain Th e superfi cial veins can be classifi ed into three categories: (1) midline aff erents to the SSS, (2) inferior cerebral aff erents to the transverse sinus, or (3) superfi cial sylvian aff erents to the cavernous sinus. Midline aff erents are primarily encountered when using interhemispheric approaches. Sacrifi ce of the midline central group of veins within 2 cm posterior to the coronal suture carries a signifi cant risk. Other small-caliber midline veins can be taken with minimal risk. Th e vein of Trolard, or the superior anastomotic vein, is the primary connecting midline aff erent and usually enters into the SSS in the postcentral region. Inferior cerebral veins are cortical bridging veins that primarily channel into the basal sinuses or the deep venous system. Small-caliber veins in this system can usually be sacrifi ced with minimal consequence if they do not contribute signifi cantly to the Labbé system. Th e vein of Labbé, or inferior anastomotic vein, connects the superfi cial sylvian vein and the transverse sinus. Injury to the vein of Labbé, particularly in the dominant hemisphere, can cause an infarct in the posterior hemisphere with severe, permanent neurologic defi cit. Th e superfi cial sylvian vein is formed from the connection of the temporosylvian veins and enters into the cavernous sinus.

Important superfi cial veins include: • Superior cerebral veins: drain the superior surface; empty into

the SSS • Superfi cial middle cerebral vein: drains the lateral surface of

each hemisphere; empties into the cavernous or sphenopalatine sinuses

• Inferior cerebral veins: drain the inferior aspect of each cerebral hemisphere; empty into the cavernous and transverse sinuses.

• Superior anastomotic vein (vein of Trolard): connects the superfi cial middle cerebral vein and the SSS

• Inferior anastomotic vein (vein of Labbé): connects the superfi cial middle cerebral vein and the transverse sinus

The Deep Veins of the Brain Th e deep veins of the brain drain into the confl uence of the Galen complex, which, in turn, drains into the straight sinus. In addition to the paired internal cerebral veins, the Galen system

CHAPTER 20 Primary Brain Lesion Resection Complications 103

or with lesions that exhibit growth. Close examination of preoperative imaging for extent of SSS invasion is essential to guide the surgeon ’ s goals of care. After exposure or injury of the sagittal sinus during meningioma surgery, the patient is at risk for intraoperative excessive blood loss or air embolism. In most cases, injury is controllable with packing by Surgicel, Gelfoam, and microsurgical patties. Care should be taken with injectable thrombotic agents to avoid inadvertent occlusion. If there is planned resection of a portion of the SSS during surgery, a preoperative formal angiogram may be very helpful in evaluating the collat-eral venous anatomy to avoid inadvertently interrupting critical pathways.

Complications of Venous Injury Th e risk of postoperative seizures after craniotomy is a well-recognized phenomenon. 40 Th ey are generally classifi ed into three categories based on time interval: immediately postoperatively, occurring within 24 hours; early seizures, within 1 week; and late seizures, 1 week or more after the craniotomy. 41 Immediately postoperative seizures occur in approximately 4.3% of craniotomy patients. 42 Patients with supratentorial meningiomas or supratento-rial low-grade gliomas are at a much higher risk than patients with lesions in various other intracranial locations. 40,43–52 Generalized tonic-clonic seizures are the most common postoperative seizure noted in the neurologic intensive care unit, but a high index of suspicion must be maintained because some patients will present with neurologic deterioration and decreased level of consciousness rather than with convulsions.

Literature regarding the benefi t of prophylactic treatment with antiepileptics in brain tumor patients is inconsistent. 43,53,54 Further-more, the exact choice of antiepileptic agent remains controversial. Phenytoin, phenobarbital, carbamazepine, valproic acid, zonisamide, and levetiracetam have all been used for the prevention of early postoperative seizures with varying results. 40 However, inadequate dosing is common, and caregivers must be vigilant about maintaining appropriate levels. 42,55 Seizures manifesting from a reversible primary source such as cerebral edema, intracranial hemorrhage, meningitis, or infection should be addressed by aggressively reversing the source.

one to two invaded walls; and using an interposition venous graft when resecting three sinus walls. In this prospective study of 100 patients, the authors had good to excellent outcomes in 94 patients but found that microscopic radical resection was diffi cult to achieve. Gamma Knife radiosurgery was used as an adjunct in patients with tumors of low proliferative index, and the authors felt that tumor control was better when Gamma Knife radiosurgery was used as a primary treatment strategy than when it was employed only after tumor progression.

Over time, however, extensive reconstruction of the SSS after meningioma resection has played a diminishing role. In 2014, Mantovani et al. reported on the management of meningiomas invading the major dural venous sinuses. 39 Th e authors reported on 38 patients who underwent operations for meningioma resection: 26 patients with lesions in the SSS, 5 with lesions in the torcular Herophili, 5 with lesions in the transverse sinus, and 2 with lesions in the sigmoid sinus. Twenty-seven patients had World Health Organization (WHO) Grade I meningiomas, and 11 had WHO Grade II meningiomas. In 50% of cases (13 patients), the sinus was completely occluded. A gross total resection was achieved in 86.9% of patients. Sinus reconstruction was performed in 21 cases: 13 by direct suture and 8 using a patch. Postoperatively, the sinus was found to be patent in 52.4% of patients and narrowed in 33.3% of patients. Correspondingly, an occlusion rate of 14.3% was found. No deaths were reported, and one major postopera-tive complication occurred. Further diminishing the role of sinus reconstruction, DiMeco et al. reported on their surgical experience in 108 cases of meningiomas invading the SSS. 22 Th irty patients with meningiomas completely occluding the SSS had complete resection of the involved portion of sinus, and Simpson Grade I or II resection was achieved in 100 patients. Two perioperative deaths were noted. Serious complications included brain swelling in 9 patients (8.3%) and postoperative hematoma in 2 patients (1.85%). At a mean follow-up of 79.5 months, tumor recurrence was noted in 15 patients (13.9%). Th e authors concluded that if extreme care is taken to preserve cortical veins, good results are achieved without reconstruction of the sinus.

Surgical management of meningiomas of the SSS remains controversial. Resection should be off ered to those with symptoms

SURGICAL REWIND

My Worst Case

This is the case of 52-year-old woman who was referred for treatment of petroclival and SSS meningiomas invading into and occluding the SSS at the level of the coronal suture ( Fig. 20.2 ). She was asymptomatic until approximately 1 year prior, when she noted the onset of right face tingling and the onset of headache centered over the right orbit. She did not note face pain, weakness, or numbness. She also noted a distant history of right-sided hearing loss. Approximately 4 months before presentation she developed diplopia with a right lateral gaze palsy. She subsequently underwent Gamma Knife radiosurgery to treat her right cavernous sinus Meckel ’ s cave meningioma (marginal dose of 14 Gy and a maximum dose of 28 Gy to a volume of 9.1 cm 3 ) ( Fig. 20.3 ). After Gamma Knife treatment her diplopia resolved, and she had no new symptoms. A cerebral angiogram confi rmed that the SSS was completely occluded at the site of the tumor, with collateral venous circulation around the tumor.

Approximately 3 months after Gamma Knife therapy, she underwent a bifrontal craniotomy for complete resection of her meningioma involving the anterior one-third of the SSS and overlying bone. At the time of craniotomy,

extensive venous bleeding was noted arising from collateral veins and the SSS at the posterior margin of the tumor. This was controlled with Gelfoam soaked in thrombin, bipolar coagulation, and 5-0 monofi lament suture. There were no other adverse events during tumor resection, and she did not require blood transfusion. Immediately upon awakening from anesthesia, she was noted to have diffi culty speaking. A CT scan showed a small intraparenchymal hematoma in the medial left frontal lobe beneath the tumor resection. The patient was taken to the neurosurgery intensive care unit for postoperative monitoring. She continued to follow commands but had a complete motor aphasia. She had some diffi culty with following commands with the tongue and mouth.

On postoperative day 2, she suffered a generalized seizure. She was taken to the CT scanner for a repeat scan, which revealed some new circumferential hemorrhage around the previous hematoma as well as increased edema around the hematoma with minimal left-to-right shift ( Fig. 20.4 ). The patient recovered and was able to move three of her four extremities purposefully and without motor defi cit. Her left lower extremity

Continued

104 SECTION 2 Cranial Complications

was weak. It was intended to reload the patient with phenytoin; however, it was written as a per oral order, and she did not receive it because she was not deemed safe for oral intake.

Four hours after her seizure, she suffered a respiratory arrest felt possibly secondary to another seizure. She was apneic with desaturation, and she was intubated. She also required resuscitation for hypotension during this episode. Once hemodynamically stable, she was taken to the CT scanner, which showed increased size of her hematoma and diffuse cerebral edema. An intracranial pressure monitor was placed in the left frontal area with readings in the range of 110 to 120 mm Hg. She was taken to the operating room for a left frontal lobectomy and decompressive hemicraniectomy. Gross herniation was noted. She was taken back to the intensive care unit and subsequently progressed to clinical brain death.

In the case presented here, even though the anterior one-third of the SSS was completely occluded by the tumor, both frontal lobes were draining via cortical collaterals and then entering the SSS at the posterior margin of the tumor. These veins were injured during the craniotomy and subsequently sacrifi ced to control the bleeding. In retrospect, performing a small craniectomy with a diamond burr over this area would have been much safer than elevating a large bone fl ap that put these veins at risk. The immediate frontal lobe dysfunction also should have been an indication that there was a vascular problem and that the patient would be at risk of increased intracranial pressure. Finally, after her initial generalized seizure, anticonvulsant therapy should have been aggressively pursued. Likely, after the initial seizure she hypoventilated, which increased her PCO 2 and cerebral blood fl ow with aggravation of already elevated ICP from insuffi cient venous drainage of the frontal lobes.

• Fig. 20.3 Axial magnetic resonance image of the brain with contrast showing the right cavernous sinus

Meckel ’ s cave meningioma that was treated with Gamma Knife therapy.

• Fig. 20.2 Sagittal magnetic resonance image of the brain with con-

trast showing a meningioma invading and occluding the superior sagittal

sinus at the level of the coronal suture.

CHAPTER 20 Primary Brain Lesion Resection Complications 105

NEUROSURGERY SELFIE MOMENT

Due to advancements in neuroimaging, neuroanesthesia, and surgical adjunct precision in modern times, gross total resection of a primary brain tumor can be performed without signifi cant complications. The careful selection of patients, a proper surgical plan, meticulous operative technique, anticipation of a complication and the precautions to avoid the same are the main keys to a better outcome.

Venous injury during resection of SSS meningiomas can have severe consequences. It is imperative to closely examine preoperative imaging for patency of the sagittal sinus and orientation of collateral fl ow. Due to the high recurrence rate, aggressive surgical resection is warranted, but the collateral fl ow must be vigilantly maintained. If resection of the SSS is undertaken, the anterior one-third is felt to pose the least risk of new neurologic morbidity. After injury or resection of a portion of the SSS, close observation must be maintained for the onset of seizures or brain edema. Early intervention is critical in the event of complications arising from dural venous compromise.

A

C D

B

• Fig. 20.4 (A) Computed tomography (CT) scan of the brain without contrast directly from the operating

room showing hemorrhage in surgical resection bed. (B) Repeat CT scan of the brain without contrast

showing blossomed blood products and edema. (C) CT scan of the brain without contrast taken post-

seizure showing continued increased hemorrhage and edema. (D) CT scan of the brain taken after apneic

arrest showing diffuse cerebral edema and graying of the gray–white matter border.

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