Safety Profile of Superior Petrosal Vein (the Vein of Dandy) Sacrifice in Neurosurgical Procedures

A Systematic Review

Vinayak Narayan, MD, MCh; Amey R. Savardekar, MD, MCh; Devi Prasad Patra, MD, MCh; Nasser Mohammed, MD, MCh; Jai D. Thakur, MD; Muhammad Riaz, MD, FCPS; Anil Nanda, MD, MPH

Disclosures

Neurosurg Focus. 2018;45(1):e3 

In This Article

Abstract and Introduction

Abstract

Objective: Walter E. Dandy described for the first time the anatomical course of the superior petrosal vein (SPV) and its significance during surgery for trigeminal neuralgia. The patient's safety after sacrifice of this vein is a challenging question, with conflicting views in current literature. The aim of this systematic review was to analyze the current surgical considerations regarding Dandy's vein, as well as provide a concise review of the complications after its obliteration.

Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A thorough literature search was conducted on PubMed, Web of Science, and the Cochrane database; articles were selected systematically based on the PRISMA protocol and reviewed completely, and then relevant data were summarized and discussed.

Results: A total of 35 publications pertaining to the SPV were included and reviewed. Although certain studies report almost negligible complications of SPV sectioning, there are reports demonstrating the deleterious effects of SPV obliteration when achieving adequate exposure in surgical pathologies like trigeminal neuralgia, vestibular schwannoma, and petroclival meningioma. The incidence of complications after SPV sacrifice (32/50 cases in the authors' series) is 2/32 (6.2%), and that reported in various case series varies from 0.01% to 31%. It includes hemorrhagic and nonhemorrhagic venous infarction of the cerebellum, sigmoid thrombosis, cerebellar hemorrhage, midbrain and pontine infarct, intracerebral hematoma, cerebellar and brainstem edema, acute hydrocephalus, peduncular hallucinosis, hearing loss, facial nerve palsy, coma, and even death. In many studies, the difference in incidence of complications between the SPV-sacrificed group and the SPV-preserved group was significant.

Conclusions: The preservation of Dandy's vein is a neurosurgical dilemma. Literature review and experiences from large series suggest that obliterating the vein of Dandy while approaching the superior cerebellopontine angle corridor may be associated with negligible complications. However, the counterview cannot be neglected in light of some series showing an up to 30% complication rate from SPV sacrifice. This review provides the insight that although the incidence of complications due to SPV obliteration is low, they can happen, and the sequelae might be worse than the natural history of the existing pathology. Therefore, SPV preservation should be attempted to optimize patient outcome.

Introduction

Walter E. Dandy described the anatomical course of the superior petrosal vein (SPV), its relation to the trigeminal nerve and cerebellum, and its significance during surgery for trigeminal neuralgia (TN), in 1929.[5] SPV, also termed "the vein of Dandy," is an important venous drainage system in the posterior cranial fossa because it drains the anterior aspect of the cerebellum and brainstem, and ultimately empties into the superior petrosal sinus (SPS).[19] Neurosurgeons commonly sacrifice this vein to widen the operative exposure at the apex of the cerebellopontine angle (CPA) while performing operations for TN, vestibular schwannomas, and petrous or petroclival meningiomas (PCMs). The safety of SPV sacrifice is a challenging question, which has not been addressed adequately in the literature. The aim of our systematic review was to analyze the current surgical considerations of Dandy's vein, as well as provide a concise review of the complications after its obliteration.

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