Abstract
After a difficult brain tumor surgery, refractory intracranial hypertension (RICH) may occur due to residual tumor or post-operative complications such as hemorrhage, infarction, and aggravated brain edema. We investigated which predictors are associated with prognosis when using barbiturate coma therapy (BCT) as a second-tier therapy to control RICH after brain tumor surgery. The study included adult patients who underwent BCT after brain tumor surgery between January 2010 and December 2016. The primary outcome was neurological status upon hospital discharge, which was assessed using the Glasgow Outcome Scale (GOS). In the study period, 4,296 patients underwent brain tumor surgery in total. Of these patients, BCT was performed in 73 patients (1.7%). Among these 73 patients, 56 (76.7%) survived to discharge and 25 (34.2%) showed favorable neurological outcomes (GOS scores of 4 and 5). Invasive monitoring of intracranial pressure (ICP) was performed in 60 (82.2%) patients, and revealed that the maximal ICP within 6 h after BCT was significantly lower in patients with favorable neurological outcome as well as in survivors (p = 0.008 and p = 0.028, respectively). Uncontrolled RICH (ICP ≥ 22 mm Hg within 6 h of BCT) was an important predictor of mortality after BCT (adjusted hazard ratio 12.91, 95% confidence interval [CI] 2.788–59.749), and in particular, ICP ≥ 15 mm Hg within 6 h of BCT was associated with poor neurological outcome (adjusted odds ratio 9.36, 95% CI 1.664–52.614). Therefore, early-controlled ICP after BCT was associated with clinical prognosis. There were no significant differences in the complications associated with BCT between the two neurological outcome groups. No BCT-induced death was observed. The active and timely control of RICH may be beneficial for clinical outcomes in patients with RICH after brain tumor surgery.
Highlights
Increased intracranial pressure (ICP) generally occurs in patients with brain tumor because of tumor-associated brain edema, tumor per se, or tumor bleeding [1]
We excluded patients who were aged less than 18 years, those who received less than 48 h of Barbiturate coma therapy (BCT), those with insufficient or incomplete medical records, and those who had a history of head trauma or chronic neurological abnormality (Glasgow Outcome Scale [GOS] 3) following admission to the intensive care unit (ICU)
Invasive ICP monitoring was performed during BCT in 60 (82.2%) patients
Summary
Increased intracranial pressure (ICP) generally occurs in patients with brain tumor because of tumor-associated brain edema, tumor per se, or tumor bleeding [1]. RICH may be caused by residual tumor or post-operative complications such as hemorrhage, infarction, and aggravated brain edema. The management of RICH and brain edema are crucial issues in patients undergoing brain tumor surgery. Barbiturate coma therapy (BCT) is currently used as a second-tier therapy to control RICH, and it has been shown to be associated with potential benefits in traumatic brain injury (TBI) or malignant infarction [2,4,5]. BCT may be helpful for controlling RICH after brain tumor surgery. There have been limited reports on BCT after brain tumor surgery. The objective of this study was to investigate which predictors are associated with clinical outcomes when BCT is used as a second-tier therapy to control RICH after brain tumor surgery
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