AUTHOR=Roethlisberger Michel , Eberhard Noëmi Elisabeth , Rychen Jonathan , Al-Zahid Saif , Jayapalan Ronie Romelean , Zweifel Christian , Karuppiah Ravindran , Waran Vicknes 

TITLE=Supratentorial cerebrospinal fluid diversion using image-guided trigonal ventriculostomy during retrosigmoid craniotomy for cerebellopontine angle tumors

JOURNAL=Frontiers in Surgery

VOLUME=10

YEAR=2023

URL=https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2023.1198837

DOI=10.3389/fsurg.2023.1198837

ISSN=2296-875X

ABSTRACT=<sec><title>Background</title><p>Cerebellar contusion, swelling and herniation is frequently encoutered upon durotomy in patients undergoing retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors, despite using standard methods to obtain adequate cerebellar relaxation.</p></sec><sec><title>Objective</title><p>The aim of this study is to report an alternative cerebrospinal fluid (CSF)-diversion method using image-guided ipsilateral trigonal ventriculostomy.</p></sec><sec><title>Methods</title><p>Single-center retro- and prospective cohort study of <italic>n</italic> = 62 patients undergoing above-mentioned technique. Prior durotomy, CSF-diversion was performed to the point where the posterior fossa dura was visibly pulsatile. Outcome assessment consisted of the surgeon's intra- and postoperative clinical observations, and postoperative radiological imaging.</p></sec><sec><title>Results</title><p>Fifty-two out of <italic>n</italic> = 62 (84%) cases were eligible for analysis. The surgeons consistently reported successful ventricular puncture and a pulsatile dura prior durotomy without cerebellar contusion, swelling or herniation through the dural incision in <italic>n</italic> = 51/52 (98%) cases. Forty-nine out of <italic>n</italic> = 52 (94%) catheters were placed correctly within the first attempt, with the majority of catheter tips (<italic>n</italic> = 50, 96%) located intraventricularly (grade 1 or 2). In <italic>n</italic> = 4/52 (8%) patients, postoperative imaging revealed evidence of a ventriculostomy-related hemorrhage (VRH) associated with an intracerebral hemorrhage [<italic>n</italic> = 2/52 (4%)] or an isolated intraventricular hemorrhage [<italic>n</italic> = 2/52 (4%)]. However, these hemorrhagic complications were not associated with neurological symptoms, surgical interventions or postoperative hydrocephalus. None of the evaluated patients demonstrated radiological signs of upward transtentorial herniation.</p></sec><sec><title>Conclusion</title><p>The method described above efficiently allows CSF-diversion prior durotomy to reduce cerebellar pressure during retrosigmoid approach for CPA tumors. However, there is an inherent risk of subclinical supratentorial hemorrhagic complications.</p></sec>