Lack of functional patency of the lamina terminalis after fenestration following clipping of anterior circulation aneurysms

Clinical article

View More View Less
  • 1 Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico; and
  • | 2 Department of Radiology, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

Object

Fenestration of the lamina terminalis (FLT) during aneurysm surgery for subarachnoid hemorrhage can, in theory, improve CSF circulation from the lateral and third ventricles to the cortical subarachnoid space, which may, in turn, decrease the incidence of hydrocephalus and vasospasm. However, the actual effects of FLT on CSF circulation have been difficult to determine, due to confounding factors. In addition, it is unclear whether the lamina terminalis remains functionally patent when the brain resumes its normal position. The goal of this study was to assess the functional patency of the fenestrated lamina terminalis in patients who underwent surgery for ruptured aneurysms.

Methods

This prospective study included 15 patients who underwent surgical clipping of ruptured anterior circulation aneurysms, with FLT performed during surgery. On postoperative Day 1, the external ventricular drain of each patient was closed, and 1 ml of Omnipaque 300, an iodine based contrast agent, was injected intraventricularly, accompanied by cranial maneuvering designed to position the contrast agent adjacent to the lamina terminalis. Three to 5 minutes after cranial maneuvering, the flow of contrast agent into the basal cisterns was assessed with CT imaging. Flow was verified by an increase in Hounsfield units in a prespecified “region of interest” within the basal cisterns on the CT scan. This procedure was performed using a standardized protocol designed in consultation with the Department of Radiology and approved by the institutional review board. One patient who underwent endoscopic third ventriculostomy was recruited as a positive control to validate the technique, and 1 patient who underwent aneurysm clipping but not FLT was recruited as a negative control.

Results

Seventeen patients consented to study participation. In the 15 patients who underwent aneurysm clipping and FLT, and the negative control patient who underwent aneurysm clipping but not FLT, the contrast agent followed the normal ventricular pathway from the lateral ventricles into the fourth ventricle, and did not appear in the basal cisterns. In the positive control patient, the contrast agent robustly and immediately filled the basal cisterns.

Conclusions

Fenestration of the lamina terminalis did not result in functional patency of the lamina terminalis when performed as part of surgical clipping for ruptured aneurysms.

Abbreviations used in this paper:

aSAH = aneurysmal subarachnoid hemorrhage; ETV = endoscopic third ventriculostomy; FLT = fenestration of the lamina terminalis; SDHCP = shunt dependent hydrocephalus.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Akyuz M, & Tuncer R: The effects of fenestration of the interpeduncular cistern membrane arousted to the opening of lamina terminalis in patients with ruptured ACoA aneurysms: a prospective, comparative study. Acta Neurochir (Wien) 148:725732, 2006

    • Search Google Scholar
    • Export Citation
  • 2

    Andaluz N, & Zuccarello M: Fenestration of the lamina terminalis as a valuable adjunct in aneurysm surgery. Neurosurgery 55:10501059, 2004

    • Search Google Scholar
    • Export Citation
  • 3

    Auer LM, & Mokry M: Disturbed cerebrospinal fluid circulation after subarachnoid hemorrhage and acute aneurysm surgery. Neurosurgery 26:804809, 1990

    • Search Google Scholar
    • Export Citation
  • 4

    Carlson AP, & Yonas H: Portable head computed tomography scanner-technology and applications: experience with 3421 scans. J Neuroimaging 22:408415, 2012

    • Search Google Scholar
    • Export Citation
  • 5

    Dandy W: An operative procedure for hydrocephalus. Johns Hopkins Hosp Bull 33:189190, 1922

  • 6

    de Divitiis O, , Angileri FF, , d'Avella D, , Tschabitscher M, & Tomasello F: Microsurgical anatomic features of the lamina terminalis. Neurosurgery 50:563570, 2002

    • Search Google Scholar
    • Export Citation
  • 7

    Dehdashti AR, , Rilliet B, , Rufenacht DA, & de Tribolet N: Shuntdependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality. J Neurosurg 101:402407, 2004

    • Search Google Scholar
    • Export Citation
  • 8

    Dorsch NW: Therapeutic approaches to vasospasm in subarachnoid hemorrhage. Curr Opin Crit Care 8:128133, 2002

  • 9

    Foroutan M, , Mafee MF, & Dujovny M: Third ventriculostomy, phase-contrast cine MRI and endoscopic techniques. Neurol Res 20:443448, 1998

    • Search Google Scholar
    • Export Citation
  • 10

    Fukuhara T, , Vorster SJ, , Ruggieri P, & Luciano MG: Third ventriculostomy patency: comparison of findings at cine phasecontrast MR imaging and at direct exploration. AJNR Am J Neuroradiol 20:15601566, 1999

    • Search Google Scholar
    • Export Citation
  • 11

    Gruber A, , Reinprecht A, , Bavinzski G, , Czech T, & Richling B: Chronic shunt-dependent hydrocephalus after early surgical and early endovascular treatment of ruptured intracranial aneurysms. Neurosurgery 44:503512, 1999

    • Search Google Scholar
    • Export Citation
  • 12

    Higashi K, , Hatano M, , Okamura T, & Yamashita T: [Liliequist membranotomy for patients with ruptured intracranial aneurysms (author's transl).]. No Shinkei Geka 7:11091114, 1979. (Jpn)

    • Search Google Scholar
    • Export Citation
  • 13

    Hosoda K, , Fujita S, , Kawaguchi T, , Shose Y, , Hamano S, & Iwakura M: Effect of clot removal and surgical manipulation on regional cerebral blood flow and delayed vasospasm in early aneurysm surgery for subarachnoid hemorrhage. Surg Neurol 51:8188, 1999

    • Search Google Scholar
    • Export Citation
  • 14

    Jack CR Jr, & Kelly PJ: Stereotactic third ventriculostomy: assessment of patency with MR imaging. AJNR Am J Neuroradiol 10:515522, 1989

    • Search Google Scholar
    • Export Citation
  • 15

    Joseph VB, , Raghuram L, , Korah IP, & Chacko AG: MR ventriculography for the study of CSF flow. AJNR Am J Neuroradiol 24:373381, 2003

  • 16

    Kassell NF, , Torner JC, , Jane JA, , Haley EC Jr, & Adams HP: The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: Surgical results. J Neurosurg 73:3747, 1990

    • Search Google Scholar
    • Export Citation
  • 17

    Komotar RJ, , Hahn DK, , Kim GH, , Khandji J, , Mocco J, & Mayer SA, et al.: The impact of microsurgical fenestration of the lamina terminalis on shunt-dependent hydrocephalus and vasospasm after aneurysmal subarachnoid hemorrhage. Neurosurgery 62:123134, 2008

    • Search Google Scholar
    • Export Citation
  • 18

    Komotar RJ, , Hahn DK, , Kim GH, , Starke RM, , Garrett MC, & Merkow MB, et al.: Efficacy of lamina terminalis fenestration in reducing shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a systematic review. Clinical article. J Neurosurg 111:147154, 2009

    • Search Google Scholar
    • Export Citation
  • 19

    Komotar RJ, , Olivi A, , Rigamonti D, & Tamargo RJ: Microsurgical fenestration of the lamina terminalis reduces the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 51:14031413, 2002

    • Search Google Scholar
    • Export Citation
  • 20

    Mura J, , Rojas-Zalazar D, , Ruíz A, , Vintimilla LC, & Marengo JJ: Improved outcome in high-grade aneurysmal subarachnoid hemorrhage by enhancement of endogenous clearance of cisternal blood clots: a prospective study that demonstrates the role of lamina terminalis fenestration combined with modern microsurgical cisternal blood evacuation. Minim Invasive Neurosurg 50:355362, 2007

    • Search Google Scholar
    • Export Citation
  • 21

    Ohta H, & Ito Z: [Cerebral infraction due to vasospasm, revealed by computed tomography (author's transl).]. Neurol Med Chir (Tokyo) 21:365372, 1981. (Jpn)

    • Search Google Scholar
    • Export Citation
  • 22

    Rapanà A, , Bellotti A, , Iaccarino C, , Pascale M, & Schönauer M: Intracranial pressure patterns after endoscopic third ventriculostomy. Preliminary experience. Acta Neurochir (Wien) 146:13091315, 2004

    • Search Google Scholar
    • Export Citation
  • 23

    Roos YB, , de Haan RJ, , Beenen LF, , Groen RJ, , Albrecht KW, & Vermeulen M: Complications and outcome in patients with aneurysmal subarachnoid haemorrhage: a prospective hospital based cohort study in the Netherlands. J Neurol Neurosurg Psychiatry 68:337341, 2000

    • Search Google Scholar
    • Export Citation
  • 24

    Sindou M: Favourable influence of opening the lamina terminalis and Lilliequist's membrane on the outcome of ruptured intracranial aneurysms. A study of 197 consecutive cases. Acta Neurochir (Wien) 127:1516, 1994

    • Search Google Scholar
    • Export Citation
  • 25

    Vora YY, , Suarez-Almazor M, , Steinke DE, , Martin ML, & Findlay JM: Role of transcranial Doppler monitoring in the diagnosis of cerebral vasospasm after subarachnoid hemorrhage. Neurosurgery 44:12371248, 1999

    • Search Google Scholar
    • Export Citation
  • 26

    Yaşargil M, Preface. Tomasello F, , D'Avella D, & de Divitiis O: Chronic Hydrocephalus Following Aneurysmal Subarachnoid Hemorrhage Bologna, Monduzzi Editore, 1999. 56

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 815 148 25
Full Text Views 448 27 3
PDF Downloads 179 20 4
EPUB Downloads 0 0 0