Pseudohypoxic brain swelling: a newly defined complication after uneventful brain surgery, probably related to suction drainage.
OBJECTIVE
This is the first description of a severe and sometimes fatal complication after uneventful intracranial surgery. The clinical presentation and imaging features mimic those of global cerebral hypoxia. Extensive investigations were performed to discover the pathogenesis.


METHODS
Seventeen cases of pseudohypoxic brain swelling (PHBS) were collected from our institution and from various other neurosurgical departments and were studied for common features. PHBS can occur in a mild, moderate, or severe degree. It is characterized by a very early postoperative onset of clinical deterioration (clouded or lost consciousness and pupillary abnormalities), in association with typical bilateral computed tomographic or magnetic resonance imaging changes (hypodensities or altered intensities in the basal ganglia and/or thalamus). The following variables were considered: age, primary pathological lesion and intracranial location, previous cranial surgery, anesthetic risk, type of anesthesia, approach and duration of surgery, intraoperative observations, technical monitoring results, and blood gas analyses. The results of postoperative computed tomography and various other imaging studies, intracranial pressure measurements, transcranial Doppler sonography, toxicological analyses, brain and muscle biopsies, and autopsies were also considered in the investigation. Several countermeasures were instituted and evaluated.


RESULTS
Anoxemic and ischemic hypoxia was excluded as a cause of PHBS. No evidence was found for inhibition of the respiratory chain, mitochondriopathy, poisoning, or adverse effects of drugs.


CONCLUSIONS
Indications of intracranial hypotension, induced by suction drainage, being the main pathomechanism of PHBS are discussed. A serious warning is issued regarding the use of suction drainage after intracranial surgery.
Van Roost
Dirk
D
Department of Neurosurgery, University of Bonn, Bonn, Germany. Dirk.VanRoost@uzgent.be
Thees
Christof
C
Brenke
Christopher
C
Oppel
Falk
F
Winkler
Peter A
PA
Schramm
Johannes
J
D000328:Adult; D000368:Aged; D001927:Brain Diseases / Q000601:surgery; D001929:Brain Edema / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology*; D005260:Female; D006801:Humans; D002534:Hypoxia, Brain / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology*; D007427:Intracranial Pressure / Q000502:physiology; D008297:Male; D008875:Middle Aged; D019635:Neurosurgical Procedures / Q000009:adverse effects*; D012189:Retrospective Studies; D012307:Risk Factors; D013396:Suction / Q000009:adverse effects*