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Gelfoam Scaffold for Vein Prolapse During Brain Tumor Surgery
Peer-Review Short Reports
Gelfoam Scaffold for Vein Prolapse During Brain Tumor Surgery Shawn L. Hervey-Jumper, Jonathan Breshears, Mitchel S. Berger
Key words Gelfoam - Glioma - Glioma surgery - Vein prolapse -
Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA To whom correspondence should be addressed: Shawn L. Hervey-Jumper, M.D. [E-mail: [email protected]]
When resecting gliomas, extra-axial tumors, or their overlying cortex, cortical veins may become suspended over the resection cavity and ultimately prolapse and kink into the cavity, promoting venous thrombosis. To prevent this, we describe a technique to secure a Gelfoam scaffold beneath the cortical vein at the edge of the resection cavity to prevent kinking and possible thrombosis from taking place after tumor removal. Depending on the diameter of the resection cavity, this can be done at 1 or both edges of the resection cavity to prevent prolapse of the vein into the cavity. In our experience with this technique, during the past 10 years, there have been no cases of venous thrombosis after tumor removal on postoperative imaging or clinical examination.
Citation: World Neurosurg. (2014) 82, 5:912.e11-912.e13. http://dx.doi.org/10.1016/j.wneu.2014.08.011 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
INTRODUCTION During the course of resecting gliomas or extra-axial tumors, it often becomes necessary to remove tumor surrounding a cortical vein or remove cortex overlying a tumor that contains a cortical vein (2). This can result in prolapse of the vein into the resection cavity. During the course of prolapse the vein can kink at the margin of the resection cavity, thereby promoting venous thrombosis. The overall rate of venous infarction after craniotomy is 2.2%, and this is particularly an issue in meningioma surgery (1, 5). However, when removing intra-axial tumors, such as gliomas, cortical veins can become skeletonized after removing tumor or adjacent cortex, which could result in venous prolapse into a large resection cavity (4). To prevent this, we developed a technique to create a Gelfoam scaffold at the resection margins to prevent venous prolapse from occurring. In our experience, during the past 10 years of using this technique, we have not had 1 case of venous infarction in the region of the resection cavity from a floating vein that becomes kinked after removing a glioma. METHODS AND OPERATIVE TECHNIQUE During the course of tumor resection, the cortical vein tends to prolapse into the
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resection cavity. This vein is especially vulnerable to kinking at the edges of the resection cavity, and the risk for kinking increases as overall diameter of the resection cavity increases. After tumor resection is complete, if there is venous prolapse with any degree of kinking, a piece of Gelfoam, sized slightly larger than the maximal diameter of the vein, is placed underneath the vein at the margin of the resection cavity (Figures 1 and 2). The Gelfoam is secured in place with Tisseel (Baxter International Inc., Deerfield, Illinois, USA), which is placed on top and aids in adhesion of Gelfoam to the vein and to the side of the resection cavity. This Gelfoam scaffold alleviates any existing kinking and prevents kinking from occurring while the cavity continues to fill with cerebrospinal fluid after surgery and during the next several days. This technique can be used at 1 or both sides of the resection cavity. It is particularly important to use a dry piece of Gelfoam, which has more tensile strength than wet Gelfoam, before securing in place with Tisseel. After this technique, closure of the dura proceeds as usual.
DISCUSSION Postoperative stroke from venous thrombosis is a recognized complication of brain tumor surgery, which can affect the outcome in these patients (2). The loss of even small cortical veins can have adverse
consequences. Therefore, it is critical to consider not only preserving en-passage arteries, which typically do not kink because of their tensile strength when overlying a resection cavity, but also to pay attention to the veins, which due to their thinner walls, are prone to kinking at the edge of a resection cavity (3, 5). This kinking risk tends to increase as the diameter of the resection cavity increases (5). Therefore, at the end of tumor resection, if the vein is kinked to any degree, it could be prone to venous thrombosis and therefore the Gelfoam scaffold technique could prevent this from happening. During the past 10 years of using this technique, we have had no cases of venous infarction around the resection cavity related to venous prolapse and kinking. After analysis of the past 151 craniotomies for glioma, venous prolapse was identified in 4 patients (2.6%). Of these 4 patients, the Gelfoam scaffold technique was used for each case. Follow-up imaging confirmed postoperative venous patency and absence of stroke or venous infarct (Figure 3).
CONCLUSION We describe a successful technique to reverse cortical vein prolapse and kinking into a resection cavity after tumor removal by using a Gelfoam scaffold. This can be a very reliable and safe technique to prevent venous infarction after creating a large resection cavity and removal of an underlying tumor.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.08.011
PEER-REVIEW SHORT REPORTS SHAWN L. HERVEY-JUMPER ET AL.
Figure 1. Diagrams illustrating (A) coronal view of kinked cortical vein after tumor resection within resection cavity. (B) Coronal and (C) surgeon’s view
GELFOAM SCAFFOLD FOR VEIN PROLAPSE
after placement of Gelfoam scaffolds shows preservation of cortical vein in unkinked position.
Figure 2. Photographs of resection cavity from 2 patients after tumor removal shows preserved superficial cortical draining vein (white arrows) suspended above the resection cavity using 2 stacked pieces of Gelfoam supported with fibrin glue (gray arrows).
Figure 3. Preoperative FLAIR sequence (A) and magnetic resonance imaging (MRI) with gadolinium enhancement (tumor, arrow) (B) reveals a prominent vein (arrow) lying across the posterior aspect of the intra-axial
tumor. After resection, the vein (arrow) can be seen suspended above the resection cavity (C). Follow-up MRI confirms postoperative venous patency (arrow) and absence of stroke or venous infarct (D).
WORLD NEUROSURGERY 82 [5]: 912.e11-912.e13, NOVEMBER 2014
www.WORLDNEUROSURGERY.org
912.E12
PEER-REVIEW SHORT REPORTS SHAWN L. HERVEY-JUMPER ET AL.
REFERENCES 1. Jang W-Y, Jung S, Jung T-Y, Moon K-S, Kim I-Y: Predictive factors related to symptomatic venous infarction after meningioma surgery. Br J Neurosurg 26:705-709, 2012. 2. Kiya K, Satoh H, Mizoue T, Kinoshita Y: Postoperative cortical venous infarction in tumours firmly adherent to the cortex. J Clin Neurosci 8 (Suppl 1):109-113, 2001. 3. Kurokawa Y, Uede T, Honda O, Kato T, Wanibuchi M, Honmou O, Hashi K: Technical
912.E13
www.SCIENCEDIRECT.com
GELFOAM SCAFFOLD FOR VEIN PROLAPSE
tactics to preserve cortical venous drainage in interhemispheric approach for anterior communicating artery aneurysms [in Japanese]. No Shinkei Geka 22:29-34, 1994.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
4. Sanai N, Polley M-Y, Berger MS: Insular glioma resection: assessment of patient morbidity, survival, and tumor progression: clinical article. J Neurosurg 112:1-9, 2010.
Received 12 February 2014; accepted 6 August 2014; published online 10 August 2014
5. Sughrue ME, Rutkowski MJ, Shangari G, Fang S, Parsa AT, Berger MS, McDermott MW: Incidence, risk factors, and outcome of venous infarction after meningioma surgery in 705 patients. J Clin Neurosci 18:628-632, 2011.
Journal homepage: www.WORLDNEUROSURGERY.org
Citation: World Neurosurg. (2014) 82, 5:912.e11-912.e13. http://dx.doi.org/10.1016/j.wneu.2014.08.011
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.08.011
Gelfoam Scaffold for Vein Prolapse During Brain Tumor Surgery Shawn L. Hervey-Jumper, Jonathan Breshears, Mitchel S. Berger
Key words Gelfoam - Glioma - Glioma surgery - Vein prolapse -
Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA To whom correspondence should be addressed: Shawn L. Hervey-Jumper, M.D. [E-mail: [email protected]]
When resecting gliomas, extra-axial tumors, or their overlying cortex, cortical veins may become suspended over the resection cavity and ultimately prolapse and kink into the cavity, promoting venous thrombosis. To prevent this, we describe a technique to secure a Gelfoam scaffold beneath the cortical vein at the edge of the resection cavity to prevent kinking and possible thrombosis from taking place after tumor removal. Depending on the diameter of the resection cavity, this can be done at 1 or both edges of the resection cavity to prevent prolapse of the vein into the cavity. In our experience with this technique, during the past 10 years, there have been no cases of venous thrombosis after tumor removal on postoperative imaging or clinical examination.
Citation: World Neurosurg. (2014) 82, 5:912.e11-912.e13. http://dx.doi.org/10.1016/j.wneu.2014.08.011 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
INTRODUCTION During the course of resecting gliomas or extra-axial tumors, it often becomes necessary to remove tumor surrounding a cortical vein or remove cortex overlying a tumor that contains a cortical vein (2). This can result in prolapse of the vein into the resection cavity. During the course of prolapse the vein can kink at the margin of the resection cavity, thereby promoting venous thrombosis. The overall rate of venous infarction after craniotomy is 2.2%, and this is particularly an issue in meningioma surgery (1, 5). However, when removing intra-axial tumors, such as gliomas, cortical veins can become skeletonized after removing tumor or adjacent cortex, which could result in venous prolapse into a large resection cavity (4). To prevent this, we developed a technique to create a Gelfoam scaffold at the resection margins to prevent venous prolapse from occurring. In our experience, during the past 10 years of using this technique, we have not had 1 case of venous infarction in the region of the resection cavity from a floating vein that becomes kinked after removing a glioma. METHODS AND OPERATIVE TECHNIQUE During the course of tumor resection, the cortical vein tends to prolapse into the
912.E11
www.SCIENCEDIRECT.com
resection cavity. This vein is especially vulnerable to kinking at the edges of the resection cavity, and the risk for kinking increases as overall diameter of the resection cavity increases. After tumor resection is complete, if there is venous prolapse with any degree of kinking, a piece of Gelfoam, sized slightly larger than the maximal diameter of the vein, is placed underneath the vein at the margin of the resection cavity (Figures 1 and 2). The Gelfoam is secured in place with Tisseel (Baxter International Inc., Deerfield, Illinois, USA), which is placed on top and aids in adhesion of Gelfoam to the vein and to the side of the resection cavity. This Gelfoam scaffold alleviates any existing kinking and prevents kinking from occurring while the cavity continues to fill with cerebrospinal fluid after surgery and during the next several days. This technique can be used at 1 or both sides of the resection cavity. It is particularly important to use a dry piece of Gelfoam, which has more tensile strength than wet Gelfoam, before securing in place with Tisseel. After this technique, closure of the dura proceeds as usual.
DISCUSSION Postoperative stroke from venous thrombosis is a recognized complication of brain tumor surgery, which can affect the outcome in these patients (2). The loss of even small cortical veins can have adverse
consequences. Therefore, it is critical to consider not only preserving en-passage arteries, which typically do not kink because of their tensile strength when overlying a resection cavity, but also to pay attention to the veins, which due to their thinner walls, are prone to kinking at the edge of a resection cavity (3, 5). This kinking risk tends to increase as the diameter of the resection cavity increases (5). Therefore, at the end of tumor resection, if the vein is kinked to any degree, it could be prone to venous thrombosis and therefore the Gelfoam scaffold technique could prevent this from happening. During the past 10 years of using this technique, we have had no cases of venous infarction around the resection cavity related to venous prolapse and kinking. After analysis of the past 151 craniotomies for glioma, venous prolapse was identified in 4 patients (2.6%). Of these 4 patients, the Gelfoam scaffold technique was used for each case. Follow-up imaging confirmed postoperative venous patency and absence of stroke or venous infarct (Figure 3).
CONCLUSION We describe a successful technique to reverse cortical vein prolapse and kinking into a resection cavity after tumor removal by using a Gelfoam scaffold. This can be a very reliable and safe technique to prevent venous infarction after creating a large resection cavity and removal of an underlying tumor.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.08.011
PEER-REVIEW SHORT REPORTS SHAWN L. HERVEY-JUMPER ET AL.
Figure 1. Diagrams illustrating (A) coronal view of kinked cortical vein after tumor resection within resection cavity. (B) Coronal and (C) surgeon’s view
GELFOAM SCAFFOLD FOR VEIN PROLAPSE
after placement of Gelfoam scaffolds shows preservation of cortical vein in unkinked position.
Figure 2. Photographs of resection cavity from 2 patients after tumor removal shows preserved superficial cortical draining vein (white arrows) suspended above the resection cavity using 2 stacked pieces of Gelfoam supported with fibrin glue (gray arrows).
Figure 3. Preoperative FLAIR sequence (A) and magnetic resonance imaging (MRI) with gadolinium enhancement (tumor, arrow) (B) reveals a prominent vein (arrow) lying across the posterior aspect of the intra-axial
tumor. After resection, the vein (arrow) can be seen suspended above the resection cavity (C). Follow-up MRI confirms postoperative venous patency (arrow) and absence of stroke or venous infarct (D).
WORLD NEUROSURGERY 82 [5]: 912.e11-912.e13, NOVEMBER 2014
www.WORLDNEUROSURGERY.org
912.E12
PEER-REVIEW SHORT REPORTS SHAWN L. HERVEY-JUMPER ET AL.
REFERENCES 1. Jang W-Y, Jung S, Jung T-Y, Moon K-S, Kim I-Y: Predictive factors related to symptomatic venous infarction after meningioma surgery. Br J Neurosurg 26:705-709, 2012. 2. Kiya K, Satoh H, Mizoue T, Kinoshita Y: Postoperative cortical venous infarction in tumours firmly adherent to the cortex. J Clin Neurosci 8 (Suppl 1):109-113, 2001. 3. Kurokawa Y, Uede T, Honda O, Kato T, Wanibuchi M, Honmou O, Hashi K: Technical
912.E13
www.SCIENCEDIRECT.com
GELFOAM SCAFFOLD FOR VEIN PROLAPSE
tactics to preserve cortical venous drainage in interhemispheric approach for anterior communicating artery aneurysms [in Japanese]. No Shinkei Geka 22:29-34, 1994.
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
4. Sanai N, Polley M-Y, Berger MS: Insular glioma resection: assessment of patient morbidity, survival, and tumor progression: clinical article. J Neurosurg 112:1-9, 2010.
Received 12 February 2014; accepted 6 August 2014; published online 10 August 2014
5. Sughrue ME, Rutkowski MJ, Shangari G, Fang S, Parsa AT, Berger MS, McDermott MW: Incidence, risk factors, and outcome of venous infarction after meningioma surgery in 705 patients. J Clin Neurosci 18:628-632, 2011.
Journal homepage: www.WORLDNEUROSURGERY.org
Citation: World Neurosurg. (2014) 82, 5:912.e11-912.e13. http://dx.doi.org/10.1016/j.wneu.2014.08.011
Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2014 Elsevier Inc. All rights reserved.
WORLD NEUROSURGERY, http://dx.doi.org/10.1016/j.wneu.2014.08.011