Patterns in neurosurgical adverse events: endovascular neurosurgery

Abstract

<jats:p>As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in endovascular neurosurgery concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice.</jats:p> <jats:p>Based on a review of the literature, thromboembolic events appeared to be the most common adverse events in endovascular neurosurgery, with a reported incidence ranging from 2% to 61% depending on aneurysm rupture status and mode of detection of the event. Intraprocedural and periprocedural prevention and rescue regimens are advocated to minimize this risk; however, evidence on the optimal use of anticoagulant and antithrombotic agents is limited. Furthermore, it is unknown what proportion of eligible patients receive any prophylactic treatment.</jats:p> <jats:p>Groin-site hematoma is the most common access-related complication. Data from the cardiac literature indicate an overall incidence of 9% to 32%, but data specific to neuroendovascular therapy are scant. Manual compression, compression adjuncts, and closure devices are used with varying rates of success, but no standardized protocols have been tested on a broad scale. Contrast-induced nephropathy is one of the more common causes of hospital-acquired renal insufficiency, with an incidence of 30% in high-risk patients after contrast administration. Evidence from medical fields supports the use of various preventive strategies.</jats:p> <jats:p>Intraprocedural vessel rupture is infrequent, with the reported incidence ranging from 1% to 9%, but it is potentially devastating. Improvements in device technology combined with proper endovascular technique play an important role in reducing this risk.</jats:p> <jats:p>Occasionally, anatomical or technical difficulties preclude treatment of the lesion of interest. Reports of such occurrences are scant, but existing series suggest an incidence of 4% to 6%. Management strategies for radiation-induced effects are also discussed. The incidence rates are unknown, but protective techniques have been demonstrated.</jats:p> <jats:p>Many of these complications have strategies that appear effective in reducing their risk of occurrence, but development and evaluation of systematic guidelines and protocols have been widely lacking. Furthermore, there has been little monitoring of levels of adherence to potentially effective practices. Protocols and monitoring programs to support integrated implementation may be broadly effective.</jats:p>

Sellar and parasellar tumor removal without discontinuing antithrombotic therapy

“…20,26,27,31,42 Temporary discontinuation of antithrombotic therapy or introduction of bridging therapy is rarely mentioned in cases of internal carotid artery dissection, 40 as is placement of cutaneousventricular drainage for patients after intravascular treatment. 41 However, these cases do not provide a high level of medical evidence.…”

“…[1][2][3][6][7][8][9][10][11][12][13][14][15][16][17][18][19][21][22][23][24][25]29,30,[32][33][34][35][36][37][38] However, procedures without discontinuation of antithrombotic treatment have received little attention, 39 and the perioperative period in neurosurgical procedures has also been less well studied. 20,26,27,31,[40][41][42] The present clinical study retrospectively analyzed a series of transsphenoidal surgeries performed without discontinuation of antithrombotic therapy for comparison with the same number of transsphenoidal surgeries performed in the absence of antithrombotic therapy.…”

Strategies to Minimize Complications During Intraoperative Aneurysmal Hemorrhage: A Personal Experience

“…The rates of intraprocedural rupture are significantly lower for endovascular therapy, with studies estimating an incidence of 1%e9% (13). However, management of IOR may be more difficult through endovascular routes.…”

A checklist for endonasal transsphenoidal anterior skull base surgery

“…17 In neurosurgical procedures, these complications can vary widely. [34][35][36][37][38] In endonasal transsphenoidal neurosurgical procedures, complications include CSF leak, vision loss, hemorrhage, epistaxis, postoperative infection, and, rarely, death. 21 Although these transsphenoidal operations are considered relatively safe in comparison with open cranial procedures, overall complication rates nevertheless are reported as around 20% for primary endoscopic transnasal operations, with repeat operations having slightly higher rates.…”

“…Recent evidence indicates the role for additional, procedure-specific checklists, which could standardize treatment and reduce neurosurgical risk. [34][35][36][37][38]40 The purpose of this study was to develop a checklist that is highly specific to endonasal transsphenoidal anterior skull base procedures and can be modified in accordance with a variety of surgical practice settings.…”