Management of severe intraoperative hemorrhage during intraventricular neuroendoscopic procedures: the dry field technique

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OBJECTIVE

The unexpected intraoperative intraventricular hemorrhage is a rare but feared and life-threatening complication in neuroendoscopic procedures because of loss of endoscopic vision. The authors present their experience with the so-called “dry field technique” (DFT) for the management of intraventricular hemorrhages during purely endoscopic procedures. This technique requires the aspiration of the entire intraventricular CSF to achieve clear visualization of the bleeding source.

METHODS

More than 500 neuroendoscopic intraventricular procedures were retrospectively analyzed over the last 24 years for documented severe hemorrhages, which were treated by the application of the DFT.

RESULTS

The technique was required in 6 cases, including tumor resection/biopsy, cyst resection, and intraventricular lavage. Additionally, the technique was applied as part of the planned strategy in 3 cases of endoscopic tumor removal. The hemorrhage was stopped in all cases and no associated postoperative deficits occurred.

CONCLUSIONS

Although severe hemorrhages are rare, the neurosurgeon needs to be aware of them and has to establish strategies for their management. Most hemorrhages can be stopped by constant irrigation and coagulation. In the other rare cases, the DFT is a safe, reliable technique and can be easily incorporated into endoscopic surgery.

ABBREVIATIONS DFT = dry field technique; ICP = intracranial pressure.

Article Information

Correspondence Joachim Oertel: Universität des Saarlandes, Homburg, Germany. joachim.oertel@uks.eu.

INCLUDE WHEN CITING Published online September 21, 2018; DOI: 10.3171/2018.4.JNS172537.

Disclosures Joachim Oertel and Henry Schroeder are consultants for Karl Storz Company.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 6. Example of intraoperative hemorrhage management. The patient, pretreated with a shunt, was scheduled for an endoscopic resection of a colloid cyst (A and B). After cyst fenestration, the mucoid part was aspirated (C and D). After removal of the cyst walls, an intraoperative hemorrhage occurred during the last steps of cyst wall resection (E and F). As the hemorrhage was persistent under constant irrigation after more than 30 minutes, the CSF was completely aspirated and hemostasis was achieved using the DFT (G–I). Final inspection and postoperative CT scans obtained 24 and 72 hours after surgery (J–L) showing complete hemostasis. Figure is available in color online only.

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    Use of the DFT during the endoscopic resection of a grade III astrocytoma. A: Preoperative MR image shows the tumor at the frontal horn. B–D: Intraoperative views using the GAAB II neuroendoscopy set. Note the superficial vein on the tumor surface, requiring coagulation. Figure is available in color online only.

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    Use of the DFT during endoscopic resection of a subependymoma. A: Preoperative MR image shows the tumor at the third ventricle. B and C: Intraoperative views using the GAAB II neuroendoscopy set. Resection of the tumor was performed with application of an ultrasound aspirator during DFT. Note the excellent vision despite the small blood clot at the floor. D: Overview with complete hemostasis after complete resection and additional endoscopic third ventriculostomy. Figure is available in color online only.

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