11/38. Benefits and limitations of image guidance in the surgical treatment of intracranial dural arteriovenous fistulas.BACKGROUND: Despite major advances in endovascular embolization techniques, microsurgical resection remains a reliable and effective treatment modality for dural arteriovenous fistulas (DAVF). However, intraoperative detection of these lesions and identification of feeding arteries and draining veins can be challenging. In a series of 6 patients who were not candidates for definitive treatment by endovascular embolization we evaluated the benefits and limitations of computer-assisted image guidance for surgical ablation of DAVF. methods: Of the 6 patients, 5 presented with haemorrhage and one with seizures. diagnosis of DAVF was made by conventional angiography and dynamic contrast enhanced MR angiography (CE-MRA). All patients were surgically treated with the assistance of a 3D high resolution T1-weighted MR data set and time-of-flight MR angiography (MRA) obtained for neuronavigation. Registration was based on cranial fiducials and image-guided surgery was performed with the navigation system. FINDINGS: Four of the 6 patients suffered from DAVF draining into the superior sagittal sinus, one fistula drained into paracavernous veins adjacent to the superior petrosal sinus and one patient had a pial fistula draining in the straight sinus. DAVF diagnosed with conventional angiography could be located on CE-MRA and MRA prior to surgery. MRI and MRA images were combined on the neuronavigation workstation and DAVF were located intraoperatively by using a tracking device. In 4 out of 6 cases neuronavigation was used for direct intraoperative identification of DAVF. brain shift prevented direct tracking of pathological vessels in the other 2 cases, where navigation could only be used to assist craniotomy. Microsurgical dissection and coagulation of the fistulas led to complete cure in all patients as confirmed by angiography. CONCLUSIONS: neuronavigation may be used as an additional tool for microsurgical treatment of DAVF. However, in this small series of 6 cases, surgical procedures have not been substantially altered by the use of the neuronavigation system. Image guidance has been beneficial for the location of small, superficially located DAVF, whereas a navigated approach to deep-seated lesions was less accurate due to the familiar problem of brain shift and brain retraction during surgery.- - - - - - - - - - ranking = 1keywords = haemorrhage (Clic here for more details about this article) |
12/38. Development of torsade de pointes caused by exacerbation of QT prolongation during clipping of cerebral artery aneurysm in a patient with subarachnoid haemorrhage.We report the case of a 79-yr-old woman with subarachnoid haemorrhage (SAH) in whom torsade de pointes (TdP) caused by worsening the QT prolongation occurred during clipping of cerebral artery aneurysm. This patient shows a potential risk of occurrence of life-threatening tachyarrhythmia, TdP by prolonging the QT interval during surgery in patients with SAH even with no additional factors that predispose to TdP. Therefore, a proper monitoring of the QT interval is necessary as a predictor of TdP. When ventricular tachyarrhythmia occurs, recognition of TdP is important because antiarrhythmic drug therapy for TdP is different from that for ventricular tachyarrhythmias that is not TdP.- - - - - - - - - - ranking = 5keywords = haemorrhage (Clic here for more details about this article) |
13/38. Haemodynamic changes after intracisternal papaverine instillation during intracranial aneurysmal surgery.Cerebral vasospasm remains a significant cause of mortality and morbidity after aneurysmal subarachnoid haemorrhage. Use of either intra-arterial or intracisternal papaverine as an alternative treatment of refractory cerebral vasospasm has been associated with various complications including haemodynamic instabilities. However, our search in literature did not reveal association of bradycardia and hypotension with the use of papaverine by either of these routes. Here, we describe a case of anterior communicating artery aneurysm with hydrocephalus. The patient underwent craniotomy and clipping of the aneurysm followed by third ventriculostomy. Instillation of papaverine at the surgical site caused significant haemodynamic changes possibly because of stimulation of hypothalamus in the third ventricle or vagal nuclei in the fourth ventricle, or even both. We recommend cautious use of intracisternal papaverine in such scenario especially when third ventriculostomy has been performed as an adjunct surgical procedure.- - - - - - - - - - ranking = 1keywords = haemorrhage (Clic here for more details about this article) |
14/38. Injury to the superior mesenteric artery during pancreatectomy for chronic pancreatitis.Four cases are described of injury to the superior mesenteric artery (SMA) during pancreatectomy for chronic pancreatitis. review of the literature indicates that this is a rare event. In three patients (arterial ligation, 2; haemorrhage, 1), the injury was immediately recognised and successfully repaired. In the fourth (with probable occlusion of the vessel), the problem was not appreciated at operation and the patient eventually died. Vessels adherent to a pseudocyst are at particular risk of injury, as in two of our patients. Two patients had ectopic origin of the right hepatic artery. Since awareness of such vascular anomalies is important, we now perform selective mesenteric angiography in all patients requiring pancreatic resections, whether proximal or distal.- - - - - - - - - - ranking = 1keywords = haemorrhage (Clic here for more details about this article) |
15/38. Controlled hypotension for cerebral aneurysm surgery in the presence of severe aortic coarctation.A patient is described with a bicuspid aortic valve and an undiagnosed aortic coarctation, presenting with a subarachnoid haemorrhage. A cerebral aneurysm was clipped under controlled hypotension. In view of the risk of inducing severe hypotension in the distal aorta in this patient, femoral arterial pressure was monitored. A marked reduction in the radial-femoral arterial pressure gradient during controlled hypotension was noted.- - - - - - - - - - ranking = 1keywords = haemorrhage (Clic here for more details about this article) |
16/38. Internal jugular catheterisation. Case report of a potentially fatal hazard.A case is presented of acute life-threatening haemorrhage caused by laceration of the subclavian artery as a result of attempted cannulation of the internal jugular vein. This sequence of events has not been reported previously, and probably resulted from use of a cannula-over-needle system.- - - - - - - - - - ranking = 1keywords = haemorrhage (Clic here for more details about this article) |
17/38. Inferior vena cava ligation for intractable pelvic haemorrhage.Inferior vena cava ligation was performed as the last resort in a case of iatrogenic injury to the common iliac veins during pelvic surgery. The post-operative recovery was satisfactory.- - - - - - - - - - ranking = 4keywords = haemorrhage (Clic here for more details about this article) |
18/38. Aberrant intratympanic internal carotid artery: a potentially hazardous anomaly.A case is presented of a 3-year-old girl with no previous history of ear disease or developmental defects who bled profusely upon (right) myringotomy. The haemorrhage could only be stopped with the aid of an ear insert and a nasopharyngeal balloon catheter. The balloon catheter was removed the following day but the girl had to use an ear insert for a total of 76 days following myringotomy because of repeated haemorrhage from the ear. The subsequent investigation using CT and angiography revealed an aberrant internal carotid artery in the middle ear. It is concluded that the one most important factor in the handling of these cases is to be aware of the existence of aberrant internal carotid arteries and to have a high degree of suspicion when encountering any abnormal clinical or radiological findings which might point in the direction of vascular abnormalities. The failure to detect this condition before any surgical intervention on the affected ear can have disastrous consequences. The method of choice in handling these cases is one of avoidance of middle ear manipulation in order not to cause haemorrhage from the aberrant artery.- - - - - - - - - - ranking = 3keywords = haemorrhage (Clic here for more details about this article) |
19/38. Haemorrhage during minitracheotomy: reduction of risk by altered incision.A 46-year-old male was admitted to an intensive care unit: for 11 days he waa ventilated via a naso-tracheal tube. Because of excess tracheal secretions, a mini tracheotomy was attempted on the unit which resulted in profuse arterial haemorrhage, necessitating immediate reintubation and subsequent formal tracheostomy. The authors feel that this complication was due to a mid-line vertical incision and that this could have been avoided by a horizontal incision across the lower part of the cricothyroid membrane, as close to the cricoid cartilage as possible. They describe their recommended technique.- - - - - - - - - - ranking = 1keywords = haemorrhage (Clic here for more details about this article) |
20/38. The control of carotid arterial haemorrhage in head and neck surgery by balloon catheter tamponade and detachable balloon embolisation.Radical surgery in the neck is hazardous after irradiation. rupture of the carotid artery may lead to uncontrollable haemorrhage. Reported mortality rates following this serious complication are between 18% and 50% (Heller and Strong, 1979). We describe a simple method for controlling acute carotid haemorrhage using a standard Fogarty biliary catheter, with selective detachable balloon embolisation for permanent occlusion of the carotid artery.- - - - - - - - - - ranking = 6keywords = haemorrhage (Clic here for more details about this article) |
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