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Patent foramen ovale and neurosurgery in sitting position: a systematic review

2009; Elsevier BV; Volume: 102; Issue: 5 Linguagem: Inglês

10.1093/bja/aep063

1471-6771

Ali-Reza Fathi, Parham Eshtehardi, Bernhard Meier,

Intracranial Aneurysms: Treatment and Complications

We have conducted a systematic review of air embolism complications of neurosurgery in the sitting position and patent foramen ovale (PFO) closure. It assesses the risk and benefit of PFO closure before neurosurgery in the sitting position. The databases Medline, Embase, and Cochrane Controlled Trial Register were systematically searched from inception to November 2007 for keywords in both topics separately. In total, 4806 patients were considered for neurosurgery in sitting position and 5416 patients underwent percutaneous PFO closure. The overall rate of venous air embolism during neurosurgery in sitting position was 39% for posterior fossa surgery and 12% for cervical surgery. The rate of clinical and transoesophageal echocardiography detected paradoxical air embolism was reported between 0% and 14%. The overall success rate for PFO closure using new and the most common closure devices was reported 99%, whereas the average risk of major complications is <1%. On the basis of our systematic review, we recommend screening for PFO and considering closure in cases in which the sitting position is the preferred neurosurgical approach. Our proposed management including the time of PFO closure according to available data is presented. However, the conclusions from our systematic review may be limited due to the lack of level A evidence and from using data from observational cohort studies. Thus, definite evidence-based recommendations require prospective evaluation of the issue in well-designed studies. We have conducted a systematic review of air embolism complications of neurosurgery in the sitting position and patent foramen ovale (PFO) closure. It assesses the risk and benefit of PFO closure before neurosurgery in the sitting position. The databases Medline, Embase, and Cochrane Controlled Trial Register were systematically searched from inception to November 2007 for keywords in both topics separately. In total, 4806 patients were considered for neurosurgery in sitting position and 5416 patients underwent percutaneous PFO closure. The overall rate of venous air embolism during neurosurgery in sitting position was 39% for posterior fossa surgery and 12% for cervical surgery. The rate of clinical and transoesophageal echocardiography detected paradoxical air embolism was reported between 0% and 14%. The overall success rate for PFO closure using new and the most common closure devices was reported 99%, whereas the average risk of major complications is 40% in adults with cryptogenic stroke.72Lechat P Mas JL Lascault G et al.Prevalence of patent foramen ovale in patients with stroke.N Engl J Med. 1988; 318: 1148-1152Crossref PubMed Google Scholar The presence of a PFO represents a significant contraindication to neurosurgery in the sitting position, and many surgeons avoid the sitting position in order to minimize the risk of PAE.19Black S Ockert DB Oliver Jr, WC Cucchiara RF Outcome following posterior fossa craniectomy in patients in the sitting or horizontal positions.Anesthesiology. 1988; 69: 49-56Crossref PubMed Google Scholar, 37Domaingue CM Anaesthesia for neurosurgery in the sitting position: a practical approach.Anaesth Intensive Care. 2005; 33: 323-331PubMed Google Scholar 45Elton RJ Howell RS The sitting position in neurosurgical anaesthesia: a survey of British practice in 1991.Br J Anaesth. 1994; 73: 247-248Abstract Full Text PDF PubMed Google Scholar, 49Gale T Leslie K Anaesthesia for neurosurgery in the sitting position.J Clin Neurosci. 2004; 11: 693-696Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar 52Girard F Ruel M McKenty S et al.Incidences of venous air embolism and patent foramen ovale among patients undergoing selective peripheral denervation in the sitting position.Neurosurgery. 2003; 53 (discussion 9–20): 316-319Crossref PubMed Google Scholar, 74Leonard IE Cunningham AJ The sitting position in neurosurgery—not yet obsolete!.Br J Anaesth. 2002; 88: 1-3Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar 76Liutkus D Gouraud JP Blanloeil Y The sitting position in neurosurgical anaesthesia: a survey of French practice.Ann Fr Anesth Reanim. 2003; 22: 296-300Crossref PubMed Scopus (0) Google Scholar, 90Porter JM Pidgeon C Cunningham AJ The sitting position in neurosurgery: a critical appraisal.Br J Anaesth. 1999; 82: 117-128Abstract Full Text PDF PubMed Google Scholar 96Schaffranietz L Gunther L The sitting position in neurosurgical operations. Results of a survey.Anaesthesist. 1997; 46: 91-95Crossref PubMed Scopus (0) Google Scholar Therefore, transoesophageal echocardiography (TOE) or transcranial Doppler ultrasound has become a routine preoperative evaluation in many centres to rule out a PFO in such patients.52Girard F Ruel M McKenty S et al.Incidences of venous air embolism and patent foramen ovale among patients undergoing selective peripheral denervation in the sitting position.Neurosurgery. 2003; 53 (discussion 9–20): 316-319Crossref PubMed Google Scholar, 70Kwapisz MM Deinsberger W Muller M et al.Transesophageal echocardiography as a guide for patient positioning before neurosurgical procedures in semi-sitting position.J Neurosurg Anesthesiol. 2004; 16: 277-281Crossref PubMed Scopus (0) Google Scholar 74Leonard IE Cunningham AJ The sitting position in neurosurgery—not yet obsolete!.Br J Anaesth. 2002; 88: 1-3Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 85Mirski MA Lele AV Fitzsimmons L Toung TJ Diagnosis and treatment of vascular air embolism.Anesthesiology. 2007; 106: 164-177Crossref PubMed Scopus (247) Google Scholar 90Porter JM Pidgeon C Cunningham AJ The sitting position in neurosurgery: a critical appraisal.Br J Anaesth. 1999; 82: 117-128Abstract Full Text PDF PubMed Google Scholar, 95Schaffranietz L Grothe A Olthoff D Use of the sitting position in neurosurgery. Results of a 1998 survey in Germany.Anaesthesist. 2000; 49: 269-274Crossref PubMed Scopus (0) Google Scholar However, neurosurgery in the sitting position cannot always be avoided in this population, as some neurosurgeons feel uncomfortable with the horizontal position for certain operations and are prepared to accept the increased risk for PAE.19Black S Ockert DB Oliver Jr, WC Cucchiara RF Outcome following posterior fossa craniectomy in patients in the sitting or horizontal positions.Anesthesiology. 1988; 69: 49-56Crossref PubMed Google Scholar, 94Samii M Matthies C Management of 1000 vestibular schwannomas (acoustic neuromas): the facial nerve—preservation and restitution of function.Neurosurgery. 1997; 40: 684-694Crossref PubMed Scopus (266) Google Scholar Meanwhile, percutaneous PFO closure using dedicated devices has become a routine procedure with a low risk and high success rate.116Wahl A Kunz M Moschovitis A et al.Long-term results after fluoroscopy-guided closure of patent foramen ovale for secondary prevention of paradoxical embolism.Heart. 2008; 94: 336-341Crossref PubMed Scopus (0) Google Scholar The indications of preoperative PFO closure in order to minimize the risk for neurosurgery in the sitting position remain to be defined. The aim of this systematic review is to assess the risk and benefit of PFO closure before neurosurgery in the sitting position. Two groups were defined for the literature review: Group 1, studies of air embolism during neurosurgical procedures in sitting position, and Group 2, percutaneous PFO closure studies. The databases Medline, Embase, and Cochrane Controlled Trial Register were systematically searched from inception to November 2007 by various combinations of the keyword groups: (i) neurosurgery, sitting position, air embolism, complications, patent foramen ovale and (ii) patent foramen ovale, persistent foramen ovale, PFO, and closure. All abstracts were screened according to the research question. Bibliographies of identified articles and reviews in this field were also searched. Additionally, hand searching of pertinent journals for issues in the last 6 months was undertaken. Articles in multiple languages were searched. Inclusion criteria for Group 1 were cohort studies with 10 or more patients undergoing neurosurgical procedures in the sitting position with reporting of episodes of VAE or PAE. Inclusion criteria for Group 2 were cohort studies including 10 or more patients undergoing percutaneous PFO closure for any reason with follow-up of at least 3 months. The reports including both PFO and atrial septal defect (ASD) closures were included when the data were stratified for PFO and ASD closures. Exclusion criteria for both groups were studies of exclusively paediatric patients, experimental studies, animal studies, case reports, expert opinions, repeated reports from individual centres (the last all-inclusive report was used), and studies with unclear methods. Database search and data extraction were performed independently by two authors and resulted in 127 abstracts meeting the inclusion and exclusion criteria for Group 1 and 89 for Group 2. After full-text analysis, 28 remained in Group 1 and 33 in Group 2. All were in English, except for two papers in French. Quality was independently assessed by two reviewers (A.-R.F. and P.E.) and differences were reconciled by mutual agreement of the senior author (B.M.). The following data were tabulated from included studies and inserted into a standardized excel sheet (Microsoft Office 2000, Microsoft, Redmond, WA, USA). Groups 1 and 2: author, publication year, journal, language, study design, number of cases, mean age of patients. Group 1: type of neurosurgical procedure, rates of VAE and PAE, method of air embolism detection, screening for PFO, PFO prevalence, author recommendations regarding PFO, and neurosurgery in the sitting position. Group 2: PFO closure reasons, PFO closure devices, procedural success rates, major and minor peri-procedural complication rates, and residual shunt rates. Comparison of clinical outcome of air embolism was not feasible due to clinical heterogeneity between studies with regard to populations, interventions, form of outcome assessment, or study method. The data were pooled using Comprehensive Meta-analysis Version 2, Biostat, Englewood, NJ, USA (2005), when it was feasible, and there was no heterogeneity in definitions or methodologies. The definitions of PAE and VAE were given above. The most frequently used methods were TOE, precordial Doppler study, and end-tidal CO2 (e′co2). PFO closure success rates were defined as successful device implantation. Minor procedural complications were haematoma or bleeding not requiring transfusion, transient atrial arrhythmia or atrioventricular node block, device embolization, air embolization, transient ST-segment elevation, or femoral arteriovenous fistula. Major complications were death, stroke, cardiac tamponade, emergency surgery, haematoma, or bleeding requiring blood transfusion or surgery, transient ischaemic attack, significant (persistent) arrhythmia, cardiac perforation, device malposition, septicaemia, myocardial infarction, and massive pulmonary embolism. No randomized controlled trial or studies with level A evidence were found. Therefore, we included both retrospective and prospective clinical cohort studies (evidence level B of American Academy of Family Physicians).104Siwek J Gourlay ML Slawson DC Shaughnessy AF How to write an evidence-based clinical review article.Am Fam Physician. 2002; 65: 251-258PubMed Google Scholar Twenty-eight studies published between 1972 and 2007 were included for data analysis.2Albin MS Babinski M Maroon JC Jannetta PJ Anesthetic management of posterior fossa surgery in the sitting position.Acta Anaesthesiol Scand. 1976; 20: 117-128Crossref PubMed Google Scholar, 3Albin MS Carroll RG Maroon JC Clinical considerations concerning detection of venous air embolism.Neurosurgery. 1978; 3: 380-384Crossref PubMed Google Scholar 15Bithal PK Pandia MP Dash HH Chouhan RS Mohanty B Padhy N Comparative incidence of venous air embolism and associated hypotension in adults and children operated for neurosurgery in the sitting position.Eur J Anaesthesiol. 2004; 21: 517-522Crossref PubMed Scopus (38) Google Scholar, 18Black S Muzzi DA Nishimura RA Cucchiara RF Preoperative and intraoperative echocardiography to detect right-to-left shunt in patients undergoing neurosurgical procedures in the sitting position.Anesthesiology. 1990; 72: 436-438Crossref PubMed Google Scholar 19Black S Ockert DB Oliver Jr, WC Cucchiara RF Outcome following posterior fossa craniectomy in patients in the sitting or horizontal positions.Anesthesiology. 1988; 69: 49-56Crossref PubMed Google Scholar, 25Buckland RW Manners JM Venous air embolism during neurosurgery. A comparison of various methods of detection in man.Anaesthesia. 1976; 31: 633-643Crossref PubMed Google Scholar 33Cucchiara RF Nugent M Seward JB Messick JM Air embolism in upright neurosurgical patients: detection and localization by two-dimensional transesophageal echocardiography.Anesthesiology. 1984; 60: 353-355Crossref PubMed Google Scholar, 38Domaingue CM Neurosurgery in the sitting position: a case series.Anaesth Intensive Care. 2005; 33: 332-335PubMed Google Scholar 42Duke DA Lynch JJ Harner SG Faust RJ Ebersold MJ Venous air embolism in sitting and supine patients undergoing vestibular schwannoma resection.Neurosurgery. 1998; 42 (discussion 6–7): 1282-1286Crossref PubMed Scopus (0) Google Scholar, 47Engelhardt M Folkers W Brenke C et al.Neurosurgical operations with the patient in sitting position: analysis of risk factors using transcranial Doppler sonography.Br J Anaesth. 2006; 96: 467-472Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar 52Girard F Ruel M McKenty S et al.Incidences of venous air embolism and patent foramen ovale among patients undergoing selective peripheral denervation in the sitting position.Neurosurgery. 2003; 53 (discussion 9–20): 316-319Crossref PubMed Google Scholar, 53Glenski JA Cucchiara RF Transcutaneous O2 and CO2 monitoring of neurosurgical patients: detection of air embolism.Anesthesiology. 1986; 64: 546-550Crossref PubMed Google Scholar 70Kwapisz MM Deinsberger W Muller M et al.Transesophageal echocardiography as a guide for patient positioning before neurosurgical procedures in semi-sitting position.J Neurosurg Anesthesiol. 2004; 16: 277-281Crossref PubMed Scopus (0) Google Scholar, 71Lechat P Guggiari M Lascault G et al.Detection by contrast ultrasonography of patent foramen ovale before neurosurgery.Presse Med. 1986; 15: 1409-1410PubMed Google Scholar 75Leslie K Hui R Kaye AH Venous air embolism and the sitting position: a case series.J Clin Neurosci. 2006; 13: 419-422Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 77Losasso TJ Muzzi DA Dietz NM Cucchiara RF Fifty percent nitrous oxide does not increase the risk of venous air embolism in neurosurgical patients operated upon in the sitting position.Anesthesiology. 1992; 77: 21-30Crossref PubMed Google Scholar 79Mammoto T Hayashi Y Ohnishi Y Kuro M Incidence of venous and paradoxical air embolism in neurosurgical patients in the sitting position: detection by transesophageal echocardiography.Acta Anaesthesiol Scand. 1998; 42: 643-647Crossref PubMed Google Scholar, 81Matjasko J Petrozza P Cohen M Steinberg P Anesthesia and surgery in the seated position: analysis of 554 cases.Neurosurgery. 1985; 17: 695-702Crossref PubMed Scopus (133) Google Scholar 84Michenfelder JD Miller RH Gronert GA Evaluation of an ultrasonic device (Doppler) for the diagnosis of venous air embolism.Anesthesiology. 1972; 36: 164-167Crossref PubMed Google Scholar, 87Papadopoulos G Kuhly P Brock M Rudolph KH Link J Eyrich K Venous and paradoxical air embolism in the sitting position. A prospective study with transoesophageal echocardiography.Acta Neurochir (Wien). 1994; 126: 140-143Crossref PubMed Google Scholar 92Rath GP Bithal PK Chaturvedi A Dash HH Complications related to positioning in posterior fossa craniectomy.J Clin Neurosci. 2007; 14: 520-525Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 97Schmitt HJ Hemmerling TM Venous air emboli occur during release of positive end-expiratory pressure and repositioning after sitting position surgery.Anesth Analg. 2002; 94 (table of contents): 400-403PubMed Google Scholar 99Schwarz G Fuchs G Weihs W Tritthart H Schalk HV Kaltenbock F Sitting position for neurosurgery: experience with preoperative contrast echocardiography in 301 patients.J Neurosurg Anesthesiol. 1994; 6: 83-88Crossref PubMed Google Scholar, 103Simo Moyo J Adnet P Wambo M Detection of gas embolism in neurosurgery by capnography. Apropos of 32 patients surgically treated in seated position.Cah Anesthesiol. 1995; 43: 77-79PubMed Google Scholar 107Standefer M Bay JW Trusso R The sitting position in neurosurgery: a retrospective analysis of 488 cases.Neurosurgery. 1984; 14: 649-658Crossref PubMed Google Scholar, 109Stendel R Gramm HJ Schroder K Lober C Brock M Transcranial Doppler ultrasonography as a screening technique for detection of a patent foramen ovale before surgery in the sitting position.Anesthesiology. 2000; 93: 971-975Crossref PubMed Google Scholar 115Voorhies RM Fraser RA Van Poznak A Prevention of air embolism with positive end expiratory pressure.Neurosurgery. 1983; 12: 503-506Crossref PubMed Google Scholar, 120Young ML Smith DS Murtagh F Vasquez A Levitt J Comparison of surgical and anesthetic complications in neurosurgical patients experiencing venous air embolism in the sitting position.Neurosurgery. 1986; 18: 157-161Crossref PubMed Google Scholar In total, 4806 patients were included (Supplementary Table S1 in online version). Fifty-four per cent of the studies were prospective, six reported on VAE rates during posterior fossa surgery alone, two during cervical procedures alone, and 21 reported on both procedures. No study evaluated the occurrence of PAE for either procedure separately. The overall occurrence of VAE ranged from 0% to 76% irrespective of the method of detection and position. The incidence of VAE derived from pooled data was 1–76% in the sitting position and 0–12% in the horizontal position. The incidence of VAE from the studies comparing two positions was 28.4% (15–45%) (95% CI, 20.3–38.0) sitting and 5.5% (0–12%) (95% CI, 2.6–11.3) horizontal (Table 1). The rate of VAE was 38.6% (7–76%) (95% CI, 30.5–47.4) in posterior fossa surgery and 11.8% (2–35%) (95% CI, 6.7–19.9) in cervical procedures (Table 2). In the studies included, patients were screened before operation for the presence of PFO in 10 (36%) studies, and seven of them published their prevalence. A PFO was detected in 5–33% of the neurosurgical patients. Overall, 10 studies considered the presence of PFO as an absolute contraindication for the sitting position and patients were operated in the horizontal position. Two of the 28 studies did not consider the presence of PFO, if known, as a contraindication for neurosurgery in the sitting position. Of note, none of the studies mentioned the possibility of preoperative PFO closure. The rate of clinical and TOE detected PAE was reported in 20 of 28 studies (0−14%, 0% in 14 studies). Of the 28 studies included, TOE was used as a detection method in nine. In three studies, the presence of a PFO was not regarded as a contraindication to neurosurgery in the sitting position (or at least not mentioned as a contraindication). In these three studies, VAE was found in 38%, 43%, and 60% and PAE in 14%, 0%, and 6.6% of the study population, respectively (the one with 0% PAE had partly excluded patients with PFO).Table 1Comparison of the rate of VAE between sitting position and horizontal positionAuthorsYear of publicationVAE in SPVAE in HPMethod of detectionAlbin and colleagues197625%11%PDBlack and colleagues198845%12%PDDuke and colleagues199828%5%e′co2 and PDRath and colleagues200715%1%e′co2Schwarz and colleagues199427%0%e′co2 and PDOverall28.4% (95% CI, 20.3–38.0)5.5% (95% CI, 2.6–11.3) Open table in a new tab Table 2Comparison of the rate of VAE between posterior fossa surgery and cervical surgery in sitting positionAuthorsYear of publicationVAE in posterior fossa surgeryVAE in cervical surgeryMichenfelder and colleagues197242%24%Albin and colleagues197625%Buckland and Manners197633%Cucchiara and colleagues198460%TOEStandefer and colleagues19847%Matjasko and colleagues198541%9%Young and colleagues198643%13%Black and colleagues198845%Losasso and colleagues199243%7%Papadopoulos and colleagues199476%25%TOESimo Moyo and colleagues199531%Duke and colleagues199828%Stendel and colleagues200075%35%TOESchmitt and Hemmerling200272%TOEGirard and colleagues20032%Bithal and colleagues200428%Leslie and colleagues200615%6%Overall38.6% (95% CI, 30.5–47.4)11.8% (95% CI, 6.7–19.9)Overall of studies with TOE73.7% (95% CI, 66.9–79.5)30.6% (95% CI, 21.7–41.2) Open table in a new tab Thirty-three non-randomized studies published between 1992 and 2007, 19 prospective and 14 retrospective, were included for data analysis (Supplementary Table S2 in online version).1Alameddine F Block PC Transcatheter patent foramen ovale closure for secondary prevention of paradoxical embolic events: acute results from the FORECAST registry.Catheter Cardiovasc Interv. 2004; 62: 512-516Crossref PubMed Scopus (0) Google Scholar 6Aslam F Iliadis AE Blankenship JC Percutaneous closure of patent foramen ovale: success and outcomes of a low-volume procedure at a rural medical center.J Invasive Cardiol. 2007; 19: 20-24PubMed Google Scholar, 7Azarbal B Tobis J Suh W Chan V Dao C Gaster R Association of interatrial shunts and migraine headaches: impact of transcatheter closure.J Am Coll Cardiol. 2005; 45: 489-492Crossref PubMed Scopus (188) Google Scholar, 8Bailey CE Allaqaband S Bajwa TK Current management of patients with patent foramen ovale and cryptogenic stroke: our experience and review of the literature.WMJ. 2004; 103: 32-36PubMed Google Scholar 11Beitzke A Schuchlenz H Gamillscheg A Stein JI Wendelin G Catheter closure of the persistent foramen ovale: mid-term results in 162 patients.J Interv Cardiol. 2001; 14: 223-229Crossref PubMed Google Scholar, 12Berger F Ewert P Bjornstad PG et al.Transcatheter closure as standard treatment for most interatrial defects: experience in 200 patients treated with the Amplatzer Septal Occluder.Cardiol Young. 1999; 9: 468-473PubMed Google Scholar, 13Bijl JM Ruygrok PN Hornung TS Wilson NJ West T Percutaneous closure of patent foramen ovale.Intern Med J. 2005; 35: 706-710Crossref PubMed Google Scholar 21Braun M Gliech V Boscheri A et al.Transcatheter closure of patent foramen ovale (PFO) in patients with paradoxical embolism. 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