Original ArticlePostoperative Neurosurgical Infection Rates After Shared-Resource Intraoperative Magnetic Resonance Imaging: A Single-Center Experience with 195 Cases
Introduction
During the past decade, intraoperative magnetic resonance imaging (ioMRI) increasingly has been implemented for numerous neurosurgical procedures.1, 2, 3, 4, 5, 6, 7 Although the use of high-field ioMRI has greatly influenced the management of neuro-oncological patients by increasing the extent of tumor resection and therefore survival time,8 the acquisition and maintenance costs of high-field scanners are considerably high, imposing a challenge for many neurosurgical clinics.9 As a cost-effective alternative to the 1-room ioMRI, the 2-room ioMRI suite comprises a high-field scanner that is spatially separated from the operating theater by a double-layered sliding door (Figure 1). This setting allows for continuous nonsurgical outpatient magnetic resonance imaging (MRI) examinations outside the ioMRI time window, thereby sharing resources and greatly improving the scanner's cost-effectiveness.10
Although procedures in 1-room ioMRI suites have infection rates as low as conventional operations,11, 12 there are concerns whether such a shared-resource design imposes a greater risk for infections or anesthesia-related complications.13 For example, patient transportation into the MRI room imposes a challenge to anesthesia, and it is still unclear whether exposure to a nonsterile environment such as the ioMRI, the repetitive draping and undraping of the operation site, as well as the longer procedure time of approximately 1 hour increase the risk of surgical-site infections (SSIs).13 Although several studies find low infection rates in shared-resource designs,9, 14, 15, 16 their validity is restricted because they only investigated a small number of patients and rarely included transsphenoidal procedures.
This study is part of an ongoing quality assessment of neurosurgical complication rates at our clinic.17 Specifically, in this study we prospectively documented SSIs after 195 consecutive procedures involving a 2-room ioMRI. The rates of infections and infection-related reoperations of 2 operative groups (craniotomies and transsphenoidal approaches) were then compared with rates from previous studies without ioMRIs and single-room scanners to assess whether the use of this 2-room setting imposes a greater infection risk for patients. Furthermore, logistic regression analysis was used to determine whether the likelihood of infection changes with the accumulative number of operations performed in this new setting.
Section snippets
Patients
We prospectively documented all 195 consecutive neurosurgical interventions with our 2-room ioMRI that occurred between April 2013 and June 2016. Ethical board approval was given (KEK-ZH 2012-0244). Operations were performed by 11 surgeons at the University Hospital Zurich, led by one of the two senior authors. The use of the ioMRI was decided on medical indication and the surgeon's preference. The surgeries were grouped by approach (109 craniotomies on 102 patients and 86 transsphenoidal skull
Patient Cohorts and Operative Statistics
Patient characteristics are listed in Table 1. The average age of the craniotomy group was considerably lower than in the transsphenoidal group (40 [21, 57] vs. 46 [33, 63.75] years median age and quartiles) because of the high proportion of pediatric patients in this cohort (22%). The majority of the procedures were first-time operations (83% of the transsphenoidal procedures, 58% of the craniotomies). Craniotomies were performed for revascularization (10%) and resection of tumors (glioma in
Incidence of SSIs in Neurosurgical Operations with Shared-Resource ioMRI Is within Normal Range
In this study, we have evaluated the incidence of postoperative infections in neurosurgical procedures that involved a shared-resource ioMRI. During the study period, we performed 109 craniotomies and 86 transsphenoidal skull-base surgeries with involvement of a shared-resource ioMRI and observed 6 cases of SSI (5.5%) among patients who underwent craniotomy and 6 cases of postoperative infection among patients who underwent transsphenoidal surgery (7.0%), although only 4 of the infections in
Conclusions
Despite transportation into a nonsterile environment and prolonged operation time, the use of a 2-room ioMRI in neurosurgical procedures did not demonstrate increased infection rates compared with other studies. However, the incidence of postoperative infections in both study groups was initially greater than targeted. The likelihood of infection significantly decreased with the number of operations, underlining the importance of surgical staff training after the introduction of the novel
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2019, World NeurosurgeryCitation Excerpt :Patient-specific data were collected as shown in our previous study.13 The analyzed variables included race; age; sex; height; weight; initial National Institutes of Health Stroke Scale (NIHSS) score after admission into operating room; interval from the onset of stroke to operation; atrial fibrillation; history of hypertension; type II diabetes mellitus; tobacco use; duration of surgery; and urine volume; 6% HES 130/0.4 transfusion; crystalloid transfusion (sodium acetate ringer); positive balance fluids administered before, during, and after (within the first day) surgery; systolic blood pressure on admission; hematocrit, PO2, glucose on admission, and during surgical treatment; postoperative complications (delayed intracranial hematomas, acute respiratory distress syndrome, pneumonia, sepsis, and AKI); and length of hospital stay, which were systematically confirmed by clinical criteria according to previous studies.13-15 One year after surgical treatment, the status of patients with space-occupying cerebral infarction was determined based on the modified Rankin Scale (mRS) according to the record of a personal interview by clinic visit or telephone.
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Conflict of interest statement: The Department of Neurosurgery and the Department of Neuroradiology at the University Hospital Zurich are reference centers for ioMRI scanners of Siemens AG.