Introduction: Postoperative intracranial hypotension-associated venous congestion (PIHV), previously termed pseudohypoxic brain swelling, is a rapid, severe, and potentially fatal postoperative complication which has been reported as a result of rapid cerebrospinal fluid (CSF) loss through wound suction drainage. A number of reports describing PIHV have been published in recent years, but few detail treatment attempts and outcomes. We describe two new cases of PIHV we consulted on, the treatment methods utilized, and their respective outcomes.
Methods: We review the clinical hallmarks, radiological findings, and course associated with PIHV. We analyze two new cases of PIHV following spinal surgery with successful and unsuccessful outcomes respectively, and examine potential treatment and avoidance strategies.
Results: PIHV was successfully reversed in one case with the administration of osmotherapy (mannitol) in combination with a loop diuretic (furosemide) and 30° head elevation. The patient made a full recovery with no permanent neurological deficits. A second case at a different institution was treated with hypertonic saline solution and corticosteroids for subsequent vasogenic edema. These treatments failed to significantly reduce the level of edema and the patient died 48 hours after surgery. Hyperventilation or induced hypothermia was not attempted.
Conclusions: PIHV is a serious operative complication that should be considered when applying wound vacuum drainage. As this phenomenon is only beginning to emerge in literature, further study is necessary to study specified treatment successes. The use of thrombolytic and/or anticoagulant therapy in combination with osmotherapy should be evaluated for patients with demonstrated venous infarction where decompressive craniotomy is not anticipated.
Patient Care: By describing indications of PIHV as well as successful and unsuccessful treatment attempts, clinicians will be able to more quickly diagnose this rare complication and hopefully reduce its high rate of mortality.
Learning Objectives: By the conclusion of this session, participants should be able to identify the clinical indications of postoperative intracranial hypotension-associated venous congestion and discuss potential treatment strategies for reversing its effects.