Fatal complications following microvascular decompression: could it be avoided and salvaged?

Although the microvascular decompression (MVD) surgery has become an effective remedy for cranial nerve rhizopathies, it is still challengeable and may result in a fatal sequel sometimes. Therefore, the operative skill needs to be further highlighted with emphasis on the safety and a preplan for management of postoperative fatal complications should be established. We retrospectively analyzed 6974 cases of MVD. Postoperatively, 46 patients (0.66 %) presented decline in consciousness with a positive finger-nose test (or failure to be tested) after wake up from the anesthesia, whom were focused on in this study. Their surgical findings and intraoperative manipulation as well as computer tomography (CT) delineation were reviewed in detail. These cases consisted of trigeminal neuralgia in 37 and hemifacial spasm in 9. All these patients underwent an immediate CT scan, which demonstrated cerebellar hemorrhages in 38 and epidural hematomas in 6. A later magnetic resource image delineated cerebral infarctions in basal ganglia in 2. Eventually, 15 (0.2 %) died and 31 survived. Data analysis showed that the mortality is significantly higher in trigeminal cases with cerebellar hematoma and an immediate hematoma evacuation plus ventricular drainage could give the patient more chance of survival (p < 0.05). It appeared that the cerebellar hemorrhage was the predominant cause contributable to the postoperative consciousness decline, which occurred more often in trigeminal cases. To have a safe MVD, an appropriate surgical technique is the priority. It is very important to create a satisfactory working space before decompression of the cranial nerve root, which is obtained by a patient microdissection of the arachnoids rather than blind retraction of the cerebellum and hotheaded sacrifice of the petrous vein. Once a cerebellar hematoma is confirmed, an emergency surgery should not be hesitated. A prompt evacuation of the hematomas followed by a dual ventricular drainage via both the frontal horns may save the patient.