Abstract
BackgroundPostoperative ischemia is a frequent phenomenon in patients with brain tumors and is associated with postoperative neurological deficits and impaired overall survival. Particularly in the field of cardiac and vascular surgery, the application of a brief ischemic stimulus not only in the target organ but also in remote tissues can prevent subsequent ischemic damage. We hypothesized that remote ischemic preconditioning (rIPC) in patients with brain tumors undergoing elective surgical resection reduces the incidence of postoperative ischemic tissue damage and its consequences.MethodsSixty patients were randomly assigned to two groups, with 1:1 allocation, stratified by tumor type (glioma or metastasis) and previous treatment with radiotherapy. rIPC was induced by inflating a blood pressure cuff placed on the upper arm three times for 5 min at 200 mmHg in the treatment group after induction of anesthesia. Between the cycles, the blood pressure cuff was released to allow reperfusion. In the control group no preconditioning was performed. Early postoperative magnetic resonance images (within 72 h after surgery) were evaluated by a neuroradiologist blinded to randomization for the presence of ischemia and its volume.ResultsFifty-eight of the 60 patients were assessed for occurrence of postoperative ischemia. Of these 58 patients, 44 had new postoperative ischemic lesions. The incidence of new postoperative ischemic lesions was significantly higher in the control group (27/31) than in the rIPC group (17/27) (p = 0.03). The median infarct volume was 0.36 cm3 (interquartile range (IR): 0.0–2.35) in the rIPC group compared with 1.30 cm3 (IR: 0.29–3.66) in the control group (p = 0.09).ConclusionsApplication of rIPC was associated with reduced incidence of postoperative ischemic tissue damage in patients undergoing elective brain tumor surgery. This is the first study indicating a benefit of rIPC in brain tumor surgery.Trial registrationGerman Clinical Trials Register, DRKS00010409. Retrospectively registered on 13 October 2016.
Highlights
Postoperative ischemia is a frequent phenomenon in patients with brain tumors and is associated with postoperative neurological deficits and impaired overall survival
Between September 2015 and June 2016, 107 patients with suspected primary or metastatic brain tumors were assessed for eligibility, of whom 60 patients were included and randomly assigned to the remote ischemic preconditioning (rIPC) group (29 patients) or the control group (31 patients)
The incidence of new postoperative ischemic lesions was significantly higher in the control group (27/31) than in the rIPC group (17/27) (Pearson chisquare test, p = 0.03; relative risk (RR) = 0.722, 95% confidence interval (CI) 0.525–0.994)
Summary
Postoperative ischemia is a frequent phenomenon in patients with brain tumors and is associated with postoperative neurological deficits and impaired overall survival. We hypothesized that remote ischemic preconditioning (rIPC) in patients with brain tumors undergoing elective surgical resection reduces the incidence of postoperative ischemic tissue damage and its consequences. Some studies have proven the clinical benefits of rIPC in patients undergoing coronary artery bypass surgery [2, 10]. A randomized controlled trial with 57 patients observed a significantly reduced overall serum troponin release after surgery in the rIPC group [2]. A prospective, randomized, double-blind controlled trial with 180 patients undergoing cardiac surgery with cardiopulmonary bypass failed to demonstrate the efficacy of rIPC in reducing the incidence of postoperative neurocognitive dysfunction [8]
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