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2. Intraoperative complications in aneurysm surgery : a prospective national study

Author

Fridriksson, Steen, Säveland, Hans, Jakobsson, Karl-Erik, Edner, Göran, Zygmunt, Stefan, Brandt, Lennart, Hillman, Jan, Fridriksson, Steen, Säveland, Hans, Jakobsson, Karl-Erik, Edner, Göran, Zygmunt, Stefan, Brandt, Lennart, and Hillman, Jan

Abstract

Object. With increasing use of endovascular procedures, the number of aneurysms treated surgically will decline. In this study the authors review complications related to the surgical treatment of aneurysms and address the issue of maintaining quality standards on a national level. Methods. A prospective, nonselected amalgamation of every aneurysm case treated in five of six neurosurgical centers in Sweden during 1 calendar year was undertaken (422 patients; 7.4 persons/100,000 population/year). The treatment protocols at these institutions were very similar. Outcome was assessed using clinical end points. In this series, 84.1% of the patients underwent surgery, and intraoperative complications occurred in 30% of these procedures. Poor outcome from technical complications was seen in 7.9% of the surgically treated patients. Intraoperative aneurysm rupture accounted for 60% and branch sacrifice for 12% of all technical difficulties. Although these complications were significantly related to aneurysm base geometry and the competence of the surgeon, problems still occurred apparently at random and also in the best of hands (17%). The temporary mean occlusion time in the patients who suffered intraoperative aneurysm rupture was twice as long as the temporary arrest of blood flow performed to aid dissection. Conclusions. The results obtained in this series closely reflect the overall management results of this disease and support the conclusion that surgical complications causing a poor outcome can be estimated on a large population-based scale. Intraoperative aneurysm rupture was the most common and most devastating technical complication that occurred. Support was found for a more liberal use of temporary clips early during dissection, regardless of the experience of the surgeon. Temporary regional interruption of arterial blood flow should be a routine method for aneurysm surgery on an everyday basis. A random occurrence of difficult intraoperative problems was clearl

Published
2002
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21. Positron Emission Tomography with 68GaEDTA in the Diagnosis and Localization of CSF Fistulas

Author

Bergstrand, Gustaf, Bergström, Mats, Eriksson, Lars, Edner, Göran, and Widén, Lennart

Abstract

Five patients with cerebrospinal fluid (CSF) rhinorrhea were investigated with computed tomography (CT) and positron emission tomography (PET) to localize the site of a CSF fistula. After intrathecal injection of 10 MBq of 68Ga-EDTA, radioactivity was demonstrated in the basal cisterns. In three cases, the site of the fistula was visualized with PET. It is not always possible to demonstrate a CSF leakage with CT cisternography (CTC) using metrizamide, particularly in cases with minute fistulas or intermittent CSF rhinorrhea. With further experience and improved PET techniques, it may be possible to detect even very small fistulas.

Published
1982

22. Soluble Fibrin and DDimer as Detectors of Hypercoagulability in Patients with Isolated Brain Trauma

Author

Bredbacka, Sixten and Edner, Göran

Abstract

To test the hypothesis that hypercoagulability after brain trauma was related to the severity of injury and also to outcome, new coagulation markers were used in 20 patients with isolated brain trauma. In addition to routine coagulation tests, soluble fibrin SF, Ddimer, and antithrombin AT levels were assessed. Thirteen of 20 patients had a Glasgow coma score GCS of ≤7 on admission and severe disability SD or worse on the Glasgow outcome scale GOS. Eight patients had a very bad outcome GOS dead D or vegetative V. All patients had increased SF levels ref. <15 nmolL at admission. Six patients with SF <50 nmolL had a good outcome with moderate disability MD or better. Patients with increasingly higher SF levels had a worse outcome Three of five patients with SF 50 to 150 nmolL were severely disabled SD or worse four of six patients with SF >150 nmolL remained vegetative V or died D. Four of the six patients with the highest Ddimer levels at admission remained vegetative V or died D. Six of 13 patients with a significant drop in AT levels had a bad outcome D or V whereas only two of seven patients without AT consumption did poorly. Routine coagulation studies were often pathologic, i.e., reduced platelet count, but there was no relation to outcome. Increased SF and Ddimer levels at admission followed by a secondary decrease in AT concentration and platelets seem to be good markers of the posttraumatic hypercoagulation often seen after brain injury. There was a significant relation between SF levels, severity of brain injury GCS, and subsequent outcomes GOS in severely headinjured patients.

Published
1994

26. Neuronavigation for arteriovenous malformation surgery by intraoperative three-dimensional ultrasound angiography.

Author

Mathiesen T, Peredo I, Edner G, Kihlström L, Svensson M, Ulfarsson E, and Andersson T

Subjects
Adult, Aged, Cerebral Angiography, Female, Humans, Intracranial Arteriovenous Malformations diagnosis, Magnetic Resonance Angiography, Male, Middle Aged, Monitoring, Intraoperative methods, Neuronavigation methods, Neurosurgical Procedures adverse effects, Prospective Studies, Ultrasonography, Interventional instrumentation, Imaging, Three-Dimensional instrumentation, Intracranial Arteriovenous Malformations diagnostic imaging, Intracranial Arteriovenous Malformations surgery, Monitoring, Intraoperative instrumentation, Neuronavigation instrumentation, Neurosurgical Procedures instrumentation
Abstract

Objective: Neuronavigational devices have traditionally used preoperative imaging with limited possibilities for adjustment to brain shift and intraoperative manipulation of the surgical lesions. We have used an intraoperative imaging and navigation system that uses navigation on intraoperatively acquired three-dimensional ultrasound data, as well as preoperatively acquired magnetic resonance imaging scans and magnetic resonance angiograms. The usefulness of this system for arteriovenous malformation (AVM) surgery was evaluated prospectively., Methods: Nine consecutive patients with Spetzler Grade 1 (n = 3), 2 (n = 3), 3(n = 2) or 4 (n = 1) AVMs underwent operation using this intraoperative imaging and navigation system. The system provides real-time rendering of three-dimensional angiographic data and can visualize such projections in a stereoscopic (virtual reality) manner using special glasses. The experiences with this technology were analyzed and the outcomes assessed. Angiographic reconstructions of three-dimensional images were obtained before and after resection., Results: Conventional navigation on the basis of preoperative magnetic resonance angiography was helpful to secure positioning of the bone flap; stereoscopic visualization of the same data represented a powerful means to construct a mental three-dimensional picture of the extent of the AVM and the feeder anatomy even before skin incision. Intraoperative ultrasound corresponded well to the intraoperative findings and allowed confirmation of feeding vessels in surrounding gyri and rapid identification of the perinidal dissection planes, regardless of brain shift. The latter feature was particularly helpful because the intraoperative navigational identification of surgical planes leads to minimal exploration into the nidus or dissection at a greater distance from the malformation. Application of the system was thought to increase surgical confidence. In two patients, postresection ultrasound prompted additional nidus removal. Ultrasound angiography seemed to allow some degree of resection control, although its sensitivity was not thought to be sufficient. All AVMs were radically removed without new permanent morbidity., Conclusion: The complexities of handling the pathological vessels of AVMs were ameliorated by intraoperative three-dimensional ultrasound and navigation because the three-dimensional outline of the vasculature (feeders, nidus, and draining veins) provided a means to adapt resection strategies, define dissection planes, and interpret intraoperative findings. It is difficult to provide a scientifically valid definition of "added value." However, in our experience, the added confidence and the improved mental image of the lesion that resulted from this technology improved the quality and flow of surgery.

Published
2007
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