A Systematic Review of the Semi-Sitting Position in Neurosurgical Patients with Patent Foramen Ovale - How Frequent is Paradoxical Embolism?

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A Systematic Review of the Semi-Sitting Position in Neurosurgical Patients with Patent Foramen Ovale - How Frequent is Paradoxical Embolism?

World Neurosurg. 2018 Apr 25;:

Authors: Klein J, Juratli TA, Weise M, Schackert G

Abstract
The semi-sitting position is preferred in some surgeries of the posterior fossa and the cervical spine. At the same time, it is associated with the risk of air embolism. In the presence of a patent foramen ovale (PFO) with intracardial right-to-left shunt, an air embolism can result in a paradoxical embolism to the heart or brain. It is unclear whether the risk-benefit ratio favors the semi-sitting position in this scenario. Therefore, we conducted a systematic review of the relevant studies published after 2007 by searching the databases PubMed, Science Direct and the Cochrane Database of Systematic Reviews for relevant articles. Studies were included in the analysis if the presence of PFO was stated and if the occurrence of paradoxical embolism was evaluated in patients who underwent neurosurgical procedures in the semi-sitting position. We identified four observational studies with a total of 977 patients who underwent surgery of the posterior fossa or cervical spine in the semi-sitting position; among them, 82 had a PFO. In 33 of these patients (40.2%) air embolism occurred. No paradoxical embolism was detected. In experienced medical centers, neurosurgery in the semi-sitting position is feasible with acceptable risk even in patients with PFO. If the PFO is large or a permanent right-to-left shunt is present in a patient with a history of paradoxical embolism, it may be reasonable to repair the PFO before surgery if the semi-sitting position is strongly preferred. The risk analysis must be made on a case-by-case basis.

PMID: 29704690 [PubMed - as supplied by publisher]

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