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Matthew Quigley

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Pankaj A. Gore, Harvinder Maan, Steve Chang, Alan M. Pitt, Robert F. Spetzler, and Peter Nakaji

Object

Postsurgical pneumocephalus is an unavoidable sequela of craniotomy. Sufficiently large volumes of intracranial air can cause headaches, lethargy, and neurological deficits. Supplemental O2 to increase the rate of absorption of intracranial air is a common but unsubstantiated neurosurgical practice. To the authors' knowledge, this is the first prospective study to examine the efficacy of this therapy and its effect on the rate of pneumocephalus absorption.

Methods

Thirteen patients with postoperative pneumocephalus that was estimated to be ≥ 30 ml were alternately assigned to breathe 100% O2 using a nonrebreather mask (treatment group) or to breathe room air (control group) for 24 hours. Head computed tomography (CT) scans without contrast enhancement were obtained at the beginning and end of treatment or control therapy. A neuroradiologist blinded to the type of treatment used software to calculate the 3D volume of the pneumocephalus from the CT scans. The percentage of pneumocephalus absorption was calculated for each study participant.

Results

There was no statistically significant difference between the treatment and control groups regarding the mean initial pneumocephalus volume or time interval between CT scans. There was a significant difference (p = 0.009) between the mean rate of pneumocephalus volume reduction in the treatment (65%) and control groups (31%) per 24 hours. No patient suffered adverse effects related to treatment.

Conclusions

Administration of postsurgical supplemental O2 through a nonrebreather mask significantly increases the absorption rate of postcraniotomy pneumocephalus as compared with breathing room air.

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Pankaj A. Gore, Peter Nakaji, Vivek Deshmukh, and Harold L. Rekate

✓ Simultaneous endoscopic and microsurgical (synchronous) approaches represent a new paradigm in the treatment of complex ventricular lesions. This technique is well suited for lesions that involve multiple ventricular or cisternal compartments, have a nonlinear axis, or adhere to critical anatomical or neurovascular structures. Two distinct operative corridors, one endoscopic and the other microsurgical, are used during synchronous approaches to address such lesions, increasing the likelihood of a safe and complete resection.

The authors present the cases of two children and an adult treated via synchronous approaches. All patients had multi-compartmental lesions involving the ventricles and/or cisterns. One patient presented with a suprasellar Rathke cyst with a significant third ventricular component, one with a hypothalamic hamartoma having a substantial cisternal component, and the remaining patient with a choroid plexus papilloma in the left lateral ventricle that extended from midbody to the temporal horn.

In the cases of the Rathke cyst and the hamartoma, debulking in the third ventricle and controlled detachment of the lesion from the hypothalamus were undertaken using endoscopy, and simultaneous resection of the suprasellar component was performed through a subfrontal craniotomy. In the case of the choroid plexus papilloma, selective cautery of the choroidal feeding vessels and detachment from the temporal tela choroidea were performed using endoscopy, and the tumor from the ventricular body to the atrium was resected via a craniotomy. In each case the resection concluded with the intersection of endoscopic and microsurgical fields. All three patients had good outcomes.

Endoscopic and microsurgical approaches can be used concurrently to treat multicompartment ventricular and/or cisternal lesions with good results. The probable advantages of this method are more complete resection and improved safety.