Paramedian thalamic infarction caused by cisternal drain placement in open clipping for aneurysmal subarachnoid hemorrhage: Two case reports
- Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa, Tokyo,
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Sugita, Fujinomiya, Shizuoka, Japan.
Department of Neurosurgery, NTT Medical Center Tokyo, Shinagawa, Tokyo,
DOI:10.25259/SNI_47_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Sho Tsunoda, Tomohiro Inoue, Hideaki Ono, Kazuaki Naemura, Atsuya Akabane. Paramedian thalamic infarction caused by cisternal drain placement in open clipping for aneurysmal subarachnoid hemorrhage: Two case reports. 27-Jun-2020;11:164
How to cite this URL: Sho Tsunoda, Tomohiro Inoue, Hideaki Ono, Kazuaki Naemura, Atsuya Akabane. Paramedian thalamic infarction caused by cisternal drain placement in open clipping for aneurysmal subarachnoid hemorrhage: Two case reports. 27-Jun-2020;11:164. Available from: https://surgicalneurologyint.com/surgicalint-articles/10111/
Background: Some complications associated with cisternal drainage have been reported; however, there are few reports on direct vascular injury caused by cisternal drain. We experienced two rare cases of thalamic infarction caused by cisternal drain placement during open clipping for a ruptured anterior communicating artery (AcomA) aneurysm through an anterior interhemispheric approach.
Case Description: Two cases of ruptured AcomA aneurysm were treated by surgical clipping through an anterior interhemispheric approach, and then a cisternal drain was inserted from opticocarotid space toward prepontine cistern. Postoperatively, the magnetic resonance imaging showed unilateral anterior-medial thalamic infarction in both two cases. By reviewing the postoperative computed tomography and digital subtraction angiography, it was suspected that the cisternal drain, which was inserted slightly deep, obstructed the P1 perforator because of an anatomical variation involving a lowered basilar bifurcation and caused postoperative unilateral paramedian thalamic infarction.
Conclusion: To avoid these complications, neurosurgeons should consider the potential for P1 perforator injury related to cisternal drain placement.
Keywords: Cisternal drainage, Complication, Subarachnoid hemorrhage, Thalamic infarction
Cerebral vasospasm often occurs in subarachnoid hemorrhage (SAH) patients secondary to a ruptured intracranial aneurysm and is a known prognostic factor for poor outcome. The spasmogenic substances released from the subarachnoid blood clots, and vascular hyperreactivity, are considered the leading causes of cerebral vasospasm.[
A 44-year-old man presenting with severe headache and disturbance in consciousness was admitted to our hospital with a Glasgow Coma Scale of 14 (E3V5M6), and no focal symptoms. Three-dimensional computed tomography (CT) scan revealed diffuse thickened SAH [
Postoperatively, CT scan demonstrated that tip of the cisternal drain was placed at the interpeduncular fossa [
A 41-year-old women presented with WFNS Grade 2 SAH as same as Case 1. The image findings revealed diffuse SAH [
Cisternal drainage has great value in the management of SAH, despite the risks of meningitis and delayed hydrocephalus. Indeed, in our two cases, cisternal drainage allowed rapid removal of the subarachnoid clots. Nevertheless, our cases show the potential for direct vascular injury following cisternal drain placement. Horiuchi et al. reported medial branch injury of the basilar artery caused by cisternal drain placement.[
In our two cases, the sites of infarction involved the paramedian thalamic region, and we suspected perforator injury arising from the P1 segment of the posterior cerebral artery. Pedroza et al. classified P1 perforator injury into that involving the paramedian thalamic artery, superior paramedian mesencephalic artery, and inferior paramedian mesencephalic artery locations.[
Cisternal drains are generally placed from the opticocarotid or carotidtentorial (retrocarotid) space along the clinoid line connecting the anterior and posterior processes, as in our two cases [
The premammillary artery, which is a perforating branch of posterior communicating artery (PcomA), also supplies the anterior medial thalamus. This artery normally branches from the anterior half of PcomA, which is close to the internal carotid artery, and runs outward. Therefore, there is little risk of injury unless the drain is inserted quite laterally toward the dorsal side of the internal carotid artery.
The infarctions in our two cases did not cause severe prognostic symptoms because they involved the unilateral medial thalamus. Nevertheless, the paramedian thalamic artery has a varied branching pattern, and originates from the unilateral P1 segment and terminates in the bilateral medial thalamus in 50% of cases.[
To avoid the potential for thalamic injury, neurosurgeons should consider the potential for P1 perforator injury related to cisternal drain placement. Thus, it is important to confirm the position of the basilar bifurcation preoperatively, and to not insert the drain too deeply.
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