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

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

doi:10.3389/fsurg.2023.1198837

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

Front Surg. 2023 May 23:10:1198837. doi: 10.3389/fsurg.2023.1198837. eCollection 2023.

Authors

Michel Roethlisberger^#^{1

2

3

4}, Noëmi Elisabeth Eberhard^#¹, Jonathan Rychen¹, Saif Al-Zahid^{4

5}, Ronie Romelean Jayapalan³, Christian Zweifel^{1

2

6}, Ravindran Karuppiah³, Vicknes Waran³

Affiliations

¹ Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland.
² Faculty of Medicine, University of Basel, Basel, Switzerland.
³ Department of Surgery, Division of Neurosurgery, University Malaya, Jalan Universiti, Kuala Lumpur, Malaysia.
⁴ Department of Otorhinolaryngology (ORL), University Malaya Specialist Centre, University of Malaya, Jalan Universiti, Kuala Lumpur, Malaysia.
⁵ Department of Otorhinolaryngology, Hereford County Hospital, Hereford, United Kingdom.
⁶ Department of Neurosurgery, Cantonal Hospital Graubuenden, Chur, Graubuenden, Switzerland.

^# Contributed equally.

Abstract

Background: 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.

Objective: The aim of this study is to report an alternative cerebrospinal fluid (CSF)-diversion method using image-guided ipsilateral trigonal ventriculostomy.

Methods: Single-center retro- and prospective cohort study of n = 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.

Results: Fifty-two out of n = 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 n = 51/52 (98%) cases. Forty-nine out of n = 52 (94%) catheters were placed correctly within the first attempt, with the majority of catheter tips (n = 50, 96%) located intraventricularly (grade 1 or 2). In n = 4/52 (8%) patients, postoperative imaging revealed evidence of a ventriculostomy-related hemorrhage (VRH) associated with an intracerebral hemorrhage [n = 2/52 (4%)] or an isolated intraventricular hemorrhage [n = 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.

Conclusion: 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.

Keywords: cerebellopontine angle; cerebrospinal fluid diversion; hemorrhage; image guided surgery; retrosigmoid craniotomy; trigonal; upward transtentorial herniation; ventriculostomy.

Grants and funding

This work was supported by the Martin Allgöwer Foundation, the Departments of Surgery and Neurosurgery of the University Hospital Basel (Basel, Switzerland), and the Gottfried and Julia Bangerter-Rhyner Foundation (Bern, Switzerland). The University of Basel (Basel, Switzerland) and the University of Malaya Medical (UMMC) and Specialist (UMSC) Center (Kuala Lumpur, Malaysia) supported this study.