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Diagnostic usefulness of intraoperative ultrasonography for unexpected severe brain swelling in ultra-early surgery for ruptured intracranial aneurysms

  • Clinical Article
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Abstract

Background

In ultra-early aneurysm surgery, the few hours from admission to aneurysm clipping present the greatest risk for an in-hospital recurrent hemorrhage, the development of acute hydrocephalus, and severe brain edema. Thus, severe brain swelling encountered after dural opening in a craniotomy can sometimes not be explained by a preoperative computed tomography (CT) scan. Therefore, neurosurgeons need a diagnostic tool to determine the exact cause of the brain swelling to apply appropriate intraoperative management. Accordingly, the authors propose a designated optimal ultrasound window for evaluating brain swelling during a pterional craniotomy, and assess its diagnostic usefulness and clinical impact.

Methods

Intraoperative ultrasonography was performed during pterional craniotomies to identify the causes of severe brain swelling in 23 out of 185 patients treated using a policy of ultra-early treatment after a subarachnoid hemorrhage. Paine’s point was used as the sonographic window to provide axial images showing the anterior interhemispheric fissure, lentiform nucleus, insular cortex, sylvian fissure, and ventricular system.

Results

The intraoperative ultrasonography revealed significant changes from the preoperative CT findings in 9 (39.1 %) of the 23 patients. These changes included the occurrence of an intracerebral hemorrhage (ICH, n = 2) related to aneurysm rebleeding with aggravated hydrocephalus and the development (n = 5) or aggravation (n = 2) of acute hydrocephalus without rebleeding. Meanwhile, for 14 (60.9 %) of the 23 patients, the ultrasonography showed no intracranial changes. For the total 23 patients with severe brain swelling, the intraoperative management included aspiration of an ICH (n = 3), a ventriculostomy (n = 16), and medical management (n = 8) with additional mannitol and/or mild hyperventilation.

Conclusions

When severe brain swelling is encountered during a pterional craniotomy for clipping a ruptured aneurysm, an intraoperative ultrasonography technique using Paine’s point as a sonographic window provides useful and reliable diagnostic information on the causes of the brain swelling, enabling the neurosurgeon to select appropriate intraoperative management.

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Disclosure

This study was supported by a grant from the Korea Healthcare Technology R & D Project, Ministry of Health & Welfare (A100870), Republic of Korea. The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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Authors and Affiliations

  1. Department of Neurosurgery, Cardiocerebrovascular Center, Kyungpook National University, Daegu, Republic of Korea

    Jaechan Park & Hyunjin Woo

  2. Department of Radiology, Cardiocerebrovascular Center, Kyungpook National University, Daegu, Republic of Korea

    Gab Chul Kim

  3. Department of Neurosurgery, Kyungpook National University Hospital, 50, Samduk 2-Ga, Jung-Gu, Daegu, 700-721, Republic of Korea

    Jaechan Park

Authors
  1. Jaechan Park
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  2. Hyunjin Woo
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  3. Gab Chul Kim
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Corresponding author

Correspondence to Jaechan Park.

Additional information

Comment

This is a clever paper and a useful intervention proposed by good surgeons who have obviously perfected the technique of intraoperative brain sonography far better than most of us have done. For our part, we pretty much abandoned operative ultrasound years ago with the feeling that it did not give us consistent data, was subject to many technical errors, and involved too much guesswork on the part of the surgeon to make decisions where truly critical data was needed. Our subsequent attempts to involve radiologists in the interpretation process added enormous process delay without yielding much novel useful information The more useful tests, as pointed out by these authors, are intraoperatve CT or MRI, if they are available.

This being said, this group has perfected ultrasound to the degree that it does give them useful and reproducible data regarding acute hydrocephalus and/or fresh hematoma from rebleeding in patients undergoing ultra-early aneurysm clipping. The data they represent is compelling, and the supplied images for publication are relatively clear, and impress me that perhaps this technique is worth another look.

I commend them for the clarity of their analysis and the quality of their publication as well.

Christopher Miranda Loftus, Philadelphia, USA

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Park, J., Woo, H. & Kim, G.C. Diagnostic usefulness of intraoperative ultrasonography for unexpected severe brain swelling in ultra-early surgery for ruptured intracranial aneurysms. Acta Neurochir 154, 1869–1875 (2012). https://doi.org/10.1007/s00701-012-1467-1

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  • DOI: https://doi.org/10.1007/s00701-012-1467-1

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