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Acute Intraoperative Brain Herniation During Elective Neurosurgery

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Acute Intraoperative Brain Herniation During Elective Neurosurgery 58458ournal ofNeurology, Neurosurgery, and Psychiatry 1996;61:584-590 Acute intraoperative brain herniation during J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.61.6.584 on 1 December 1996. Downloaded from elective neurosurgery: pathophysiology and management considerations Ian R Whittle, Rajaraman Viswanathan Abstract dure and closure of the cranium may also Objectives-To describe operative proce- have contributed to the often very satis- dures, pathophysiological events, man- factory clinical outcome. agement strategies, and clinical outcomes after acute intraoperative brain hernia- (j Neurol Neurosurg Psychiatry 1996;61:584-590) tion during elective neurosurgery. Methods-Review of clinical diagnoses, operative events, postoperative CT find- Keywords: brain hemiation; intraoperative aneurysm rupture; subarachnoid haemorrhage; intraventricular ings, intracranial pressure, and arterial haemorrhage blood pressure changes and outcomes in a series of patients in whom elective neuro- surgery had to be abandoned because of Profound intraoperative brain swelling and severe brain herniation. herniation through an elective craniotomy was Results-Acute intraoperative brain her- in most instances, before modern neuroanaes- niation occurred in seven patients. In thesia, related to either hypercarbia or to high each patient subarachnoid or intraven- venous pressures. Nowadays such an event is tricular haemorrhage preceded the brain uncommon and is only occasionally found herniation. The haemorrhage occurred after evacuation of a post-traumatic acute sub- after intraoperative aneurysm rupture dural haematoma.' In this situation the hernia- either before arachnoidal dissection tion is thought to be related to cerebral (three) or during clip placement (one); vasodilatation and hydrostatic brain oedema after resection of 70% of a recurrent secondary to brain decompression2 4 and to hemispheric astroblastoma; after resec- alterations in the biomechanics of the brain tion of a pineal tumour; and after a after craniotomy. Less commonly it may be stereotactic biopsy of an AIDS lesion. In related to the development of distant intracra- all patients the procedure was abandoned nial haematomata." because of loss of access to the intracra- Because profound brain swelling and hernia- nial operating site, medical measures to tion during elective neurosurgery is infre- control intracranial pressure undertaken quently reported we present seven patients, all (intravenous thiopentone), an intraven- under the care of the senior author (IRW), in http://jnnp.bmj.com/ tricular catheter or Camino intracranial whom such complications occurred. The aims pressure monitor inserted, and CT per- are to clarify the pathophysiological mecha- formed immediately after scalp closure. nisms underlying such brain swelling and to The patients were transferred to an inten- make certain management recommendations. sive care unit for elective ventilation and Pathophysiological mechanisms are implied multimodality physiological monitoring. from observed intraoperative events, immedi- this strategy all patients recovered ate postoperative neuroimaging studies, and Using on September 30, 2021 by guest. Protected copyright. from the acute ictus and no patient had recording of multiple systemic and neurophys- intracranial pressure > 35 mm Hg. iological variables. Management strategies Although one patient with an aneurysm were based on the principles of providing an rebled and died three days later the other optimal systemic and intracranial milieu to six patients did well considering the dra- minimise secondary brain insults. matic and apparently catastrophic nature of the open brain herniation. Department of Clinical Conclusions-There are fundamental dif- Methods Neurosciences, ferences in the pathophysiological mecha- The case records of seven patients who all Western General and developed profound brain herniation during Hospital, Edinburgh nisms, neuroradiological findings, EH4 2XU, UK outcomes between open brain herniation elective neurosurgical procedures were thor- I R Whittle occurring in post-traumatic and elective oughly reviewed. This cohort comprised about R Viswanathan neurosurgical patients. The surprisingly 0 7% of all cranial procedures performed by Correspondence to: the senior author over the time of the study. Mr I R Whittle, Department good outcomes in this series may have of Clinical Neurosciences, occurred because the intraoperative brain The clinical and surgical details, preoperative Western General Hospital, observation charts, intraoperative anaesthetic Crewe Road, Edinburgh, herniation was secondary to extra-axial EH4 2X, UK. subarachnoid or intraventricular haem- records, and postoperative intensive care unit Received 2 June 1995 orrhage rather than intraparenchymal records were analysed and all measured physi- and in final revised form ological variables were plotted on appropri- 29 January 1996 haemorrhage or acute brain oedema. Accepted 9 February 1996 Expeditious abandonment of the proce- ately scaled graphs so the time course of Acute intraoperative brain herniation during elective neurosurgery: pathophysiology and management considerations 585 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.61.6.584 on 1 December 1996. Downloaded from changes in these variables could be analysed in Operative details relation to the apparently catastrophic intraop- Patients were positioned supine with the head erative event. Immediate postsurgical CT radi- rotated to one side with the contralateral ographs were compared with preoperative shoulder raised for aneurysm surgery. The studies. patient undergoing stereotactic biopsy was in the supine position. The patient undergoing pineal surgery was prone, with head slightly Clinical details extended and rotated to the right. The patient Three patients had subarachnoid haemorrhage having reoperation for brain tumour was in the from anterior communicating artery aneurysm lateral position. The Mayfield pin headrest rupture and were WFNS grade I or II preoper- was used for all patients except the stereotactic atively (surgery being performed two, seven, biopsy. Head up tilt of 150 was routine. Severe and 11 days after aneurysmal rupture). One brain herniation ocurred within minutes in patient had subarachnoid haemorrhage from a every patient. In three patients (1, 2, and 4) it posterior communicating internal carotid ocurred after pterional craniotomy (with a free artery aneurysm and was WFNS grade I pre- bone flap) and dural opening but before either operatively (surgery performed on day 1). One basal or sylvian fissure arachnoidal dissection. patient had AIDS, toxoplasma retinitis, and In these patients it was assumed to be due to intracerebral lesions unresponsive to two introperative aneurysmal rupture because of weeks of antitoxoplasma treatment. Neuro- the profuse basal arterial bleeding that accom- logically he had profound psychomotor slow- panied the herniation. In each patient the pro- ing but neither features of raised intracranial cedure was abandoned and the scalp was pressure nor focal neurological deficit. Two closed in a single layer over the herniating others had intracerebral tumours (patient 6 a brain. In one patient (4) the free bone flap was pineoblastoma and patient 7 a recurrent left left "floating" subcutaneously whereas in the temporal astroblastoma) with fixed focal neu- other two patients this was physically impossi- rological deficits despite preoperative steroid ble. In another patient (3) rupture of the therapy. Neither had impairment of concious aneurysm ocurred at the time of clip place- state or papilloedema despite hydrocephalus ment and was followed by brain swelling and (patient 6) and a large mass lesion (patient 7). herniation. However, in this patient definitive Table 1 summarised the clinical features of aneurysmal clip placement was possible by these patients. using temporary anterior cerebral artery clip- ping before obliteration of the surgical field by the swelling brain. The wound was closed Anaesthetic details rapidly in a single layer over the herniating In all patients endotracheal general anaesthe- brain. sia was administered by an experienced con- One patient (5), with AIDS and multiple sultant neuroanaesthetist. Premedication was intracerebral lesions, had an uneventful biopsy with 5 mg droperidol and 0O6 mg atropine. of a parietal lesion. After a second target in the Thiopentone and alcuronium were used for frontal region was biopsied arterial blood was induction and anaesthesia was maintained noted to flow from the biopsy track. It was with phenoperidine and nitrous oxide/oxygen assumed that a small cortical arteriole at the mixture (Fio, 0 3). Neither a nor adrenergic base of a sulcus was avulsed and rapidly there- http://jnnp.bmj.com/ blocking agents were given before or during after cerebral tissue herniated (like toothpaste intubation, induction, or maintanance of coming out of a tube) through the dural open- anaesthesia. Multiple physiological variables ing and burr hole site. In patient 6 brisk including arterial blood pressure (radial artery venous bleeding occurred after a 2X5 cm line), heart rate, central venous pressure, oxy- pineoblastoma had been excised and tumour gen saturation (Sao,), and end tidal CO, were bed haemostasis obtained. The onset of bleed- continuously monitored throughout the opera- ing followed withdrawal of two microretrac- on September 30, 2021 by guest. Protected copyright. tion. All variables were
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