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Intracranial Pressure Concerns in Lateral
Intracranial Pressure Concerns in Lateral
Intracranial Pressure Concerns in Lateral
40 (2007) 455–462
This work was supported by the Listen for Life Foundation at the Virginia Mason
Medical Center.
* Corresponding author.
E-mail address: otoddb@vmmc.org (D.D. Backous).
0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.03.012 oto.theclinics.com
456 CLEMEN & BACKOUS
the foramina of Luschka (laterally) and Magendie (midline) into the spinal
canal. CSF is absorbed into the cerebral venous system through arachnoid
villi, which are located mainly in the sagittal sinus (Fig. 1) [2].
CSF has four main functions. It provides physical support and buoyancy
for the brain. This ‘‘water jacket’’ is protective because CSF volume fluctuates
reciprocally with changes in intracranial blood volume to contribute to a safe
ICP. Because the brain is devoid of a lymphatic system, byproducts of metab-
olism are principally removed by the capillary circulation or directly by trans-
fer through the CSF. The direct CSF route is particularly important when
increased amounts of lactic acid are produced in the brain. Finally, CSF main-
tains a safe chemical environment for brain tissues [3].
Because of the phenomenon of autoregulation, the brain is able to regu-
late arterial blood flow in accord with metabolic demand. Intracranial
Fig. 1. Schematic diagram of CSF production and absorption pathways. The circulation of the
CSF to the subarachnoid space and its absorption into the venous systems via the arachnoid
villi are shown.
LATERAL SKULL BASE SURGERY 457
where If is CSF formation rate, Rout is resistance to outflow of CSF, and Pss
is sagittal sinus pressure.
A large increase in the rate of CSF formation, as in the rare instance of
a choroid plexus papilloma, would be required to create an impact CSF
pressure. Outflow resistance can be altered by increased protein concentra-
tion in the CSF, inflammatory changes in the dura caused by meningitis, or
blood in the subarachnoid space causing resistance to outflow by impairing
CSF absorption at the arachnoid villi [4]. Superior vena cava syndrome, jug-
ular venous occlusion, surgical removal of a dominant jugular vein, and
acute thrombosis of the sagittal sinus elevate sinus pressure and impair
flow from the subarachnoid space.
Central venous anatomic variations may predispose patients to transient
ICP changes intraoperatively. Approximately 41.3% of people are right
dominant, 37.6% have equal drainage, and 18.5% are left dominant in re-
gard to drainage through the sigmoid sinus and jugular bulb. Two percent
have only right-sided venous outflow, and 0.53% have left-only drainage
through the skull base into the neck (Fig. 2) [5].
Positioning the neck in a flexed position on a shoulder roll, a common
technique in head and neck surgery, can compromise venous drainage in
a dominant jugular vein and result in elevated ICP. Compounding this prob-
lem is the placement of central venous catheters in the jugular system during
surgery, sacrifice of an internal jugular vein during neck dissection, or cases
that require sacrifice of a jugular bulb to remove a neoplasm. When evalu-
ating CT or MRI scans during preoperative planning, surgeons should
determine the side of dominance for jugular venous outflow to prevent po-
tential complications.
The Monro-Kellie hypothesis states that the skull is a rigid sphere occu-
pied by noncompressible, liquid/gel tissues [6,7]. Blood (75 mL), CSF (150
mL), and brain matter (1400 mL) are the principal tissues in the cranial
vault. Acute changes in ICP result in shifting or compression of the fixed
brain liquid/gel mass within the intracranial cavity. Compression of brain
against the falx cerebri or tentorium cerebelli, herniation through the fora-
men magnum, or leakage of CSF from sites in the skull or spinal canal can
458 CLEMEN & BACKOUS
Fig. 2. Axial T1-weighted MRI with gadolinium of the posterior fossa shows right-sided
venous outflow dominance (A). Non-dominent sigmoid sinus (B).
occur in situations in which ICP remains high or when there has been spon-
taneous, traumatic, or iatrogenic violation of the dura.
Fig. 3. (A) Intraoperative view of right tegmen dehiscence (B) High-resolution coronal CT scan
of the right temporal bone. The white arrow indicates a tegmen defect.
Fig. 4. Sagittal T1 MRI shows diffuse dural enhancement (arrow) in a case of low CSF pressure
and CSF leak.
460 CLEMEN & BACKOUS
Lumbar puncture
External lumbar drainage is a common modality used postoperatively for
prevention or treatment of CSF fistulae. It serves as a helpful control of ICP
through the removal of designated amounts of CSF based on daily produc-
tion of CSF. Overdrainage may create a negative ICP and result in
pneumocephalus.
Lumbar drain
External lumbar drainage is commonly used as an intraoperative or post-
operative adjunct for preventing or treating CSF fistulae. Extreme caution
must be exercised regarding the amount of CSF drained; overdrainage
LATERAL SKULL BASE SURGERY 461
can result in headaches or violation of dural bridging veins and result in sub-
dural bleeding. External lumbar drainage is an effective modality; however,
the duration should be restricted because the risk of complications increases
with the duration of drain maintenance [16].
Chronic management
Lumboperitoneal shunts
Lumboperitoneal shunts are valuable therapy for CSF decompression in
the setting of communicating hydrocephalus but are ill advised in cases of
noncommunicating hydrocephalus because of risk of tonsillar herniation
[17]. The lumboperitoneal shunt has a single-chamber reservoir and two dis-
tal slit valves. Similar to external lumbar drainage, the perforated end of the
catheter is introduced into the subarachnoid space. The end of the catheter
with the slit valves is tunneled subcutaneously to the abdominal region and
inserted into the peritoneum. Prevention of catheter misplacement is greatly
increased through meticulous dissection and identification of various tissue
layers.
Complications associated with lumboperitoneal shunts include bowel in-
jury, wound infection, obstruction, spinal epidural hematoma, and over-
drainage headaches. No reservoir or flush chamber is available for CSF
withdrawal or fluid injection with the umboperitoneal shunt. If overdrain-
age headaches result, the lumboperitoneal shunt is either ligated or removed.
Such patients may require the placement of a ventriculoperitoneal shunt
with a programmable valve that allows for drainage volume adjustments [3].
Ventriculoperitoneal shunts
Ventriculoperitoneal shunting is used to relieve chronically elevated ICP
caused by hydrocephalus through the redirection of CSF from the ventricles
of brain into the abdominal cavity. Ventriculoperitoneal shunt systems in-
volve three components: a ventricular catheter, a valve reservoir, and a peri-
toneal catheter. The ventricular catheter is inserted into the lateral ventricle
via an occipital trajectory. Complications with ventriculoperitoneal shunts
include incorrect insertion, obstruction, wound infection, and poorly regu-
lated CSF drainage. Insertion of the ventricular catheter also carries a small
significant risk of intracerebral bleeding. Symptoms of shunt malfunctions
include headache, fever, drowsiness, and convulsions.
Summary
To prevent unanticipated acute shifts in ICP in patients who are under-
going lateral skull base surgery, a basic understanding of CSF metabolism
and ICP homeostasis is essential for skull base surgeons. Although
462 CLEMEN & BACKOUS
autoregulation protects the intracranial arterial blood flow with little impact
on ICP, acute fluctuations in central venous outflow translate directly to el-
evations of ICP. Central line placement in the neck should be avoided, and
critical planning for patient positioning to avoid compromise to the jugular
venous system can avoid ICP shifts. The internal jugular vein should be sac-
rificed only when absolutely necessary. Early identification of patients with
elevated ICP can reduce the risk of damage to critical brain structures. In-
clusion of a neurosurgeon and possibly a critical care specialist is essential to
maximize patient performance as pharmacotherapy and external drainage
procedures are implemented.
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