Letter: Frailty-Based Prehabilitation for Patients Undergoing Intracranial Meningioma Resection.

Abstract

To the Editor: Intracranial meningioma resection (IMR) carries significant morbidity and mortality despite being a benign tumor and less aggressive than malignant brain tumors.1,2 In recent years, moving beyond chronological age, baseline frailty status has been identified as a more robust predictor of postoperative outcomes of IMR.3-8 Frail patients undergoing IMR have been reported to have increased incidence of postoperative complications, increased length of hospital stay, and nonhome discharge destination.3-8 Cole et al3 reported that frail patients undergoing resection of intracranial meningiomas were approximately 11 times more likely to develop postoperative adverse events. Frailty affects how the body responds to the alteration of homeostasis during surgery,9 and frailty-based prehabilitation of patients at risk can lead to improved outcomes. Although this association has been extensively demonstrated using various frailty indices and preoperative risk stratification tools in spine surgery patients,10,11 frailty-based prehabilitation remains yet to be implemented for brain tumor resection patients in general and for IMR in particular. This remains relevant for IMR as most of these patients (apart from high-grade meningiomas with obstructive symptoms) do not require emergent/urgent surgery and can undergo frailty-based prehabilitation for improved outcomes (Figure).FIGURE.: A graphical representation of frailty-directed prehabilitation measures to improve postoperative outcomes.Several studies have reported on worse postoperative outcomes predicted by poor preoperative frailty status assessed by using different indices (Table), including the Risk Analysis Index (RAI) and the Modified Frailty Index (MFI).12,13 RAI is a robust frailty score based on 11 variables that captures the true phenotypic manifestation of frailty—sex, age, cancer diagnosis (excluding melanoma), unintentional weight loss, renal failure, congestive heart failure, poor appetite, shortness of breath at rest, residence defined as not independent living, cognitive deterioration, and activities of daily living (ADL) defined as functional status. Each component of RAI has significance in frailty assessment and serves as a guide to prehabilitation. For instance, interventions such as smoking cessation and inspiratory muscle training target shortness of breath and have been shown to reduce the overall LOS after elective surgical procedures.14 Exercise and physical therapy helps reduce functional dependence before surgery.15 Other frailty-specific interventions that have proven efficacy in enhancing postoperative outcomes include nutritional rehabilitation to target poor appetite and cognitive behavioral therapy in patients with excessive fear or cognitive deterioration.11 The 5-factor MFI assigns 1 point each based on the presence of diabetes mellitus, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and dependent functional status.13 It is largely made up on comorbid conditions that may not capture true frailty, thus compromising its effectiveness in determining prehabilitative measures. RAI has proven to be a better predictor of outcomes after surgery and could be a more useful tool during prehabilitation measures.16 TABLE. - Predictive Ability of Preoperative Frailty Score on Postoperative Outcomes of IMR Author Year FI Outcomes OR (95% CI) Thommen et al 6 2022 RAI Major complications 2.94 (1.39-6.20) Clavien IV complications 3.99 (1.68-9.46) LOS 15.73 (7.45-33.24) Nonhome discharge destination 13.61 (6.40-28.94) Cole et al 3 2022 mFI-5 Mortality 11.17 (3.45-36.19) Major complications 4.15 (2.46-6.99) Unplanned readmission 4.37 (2.68-7.12) Unplanned reoperation 2.31 (1.17-4.55) Extended LOS 4.28 (2.74-6.68) Nonhome discharge 9.34 (6.03-14.47) Dicpinigaitis et al 4 2021 mFI-11 LOS (1.20, 1.10-1.32) Life-threatening complications/mortality (1.40, 1.17- 1.68) Theriault et al 5 2020 mFI-11 Nonhome discharge 0.131 (0.022-0.773) Readmission 0.131 (0.022-0.773) Taricotti et al 7 2022 FI Early (14.752, 1.463-148.777) and late (35.457, 25.210-41.318) postoperative functional deterioration Ikawa et al 8 2022 mFI-5 Worsening Barthel Index score 1.4 (1.1-1.7) In-hospital mortality 5.0 (2.2-11.1) Complications 1.7 (1.4-2.0) FI, Frailty Index; IMR, intracranial meningioma resection; LOS, length of stay; OR, odds ratio; RAI, Risk Analysis Index. A recent study by our group has shown RAI's robust predictive ability for brain tumor resection outcomes including IMR,6 thus raising the possibility of using RAI-based prehabilitaion for IMR patients. Emphasizing on preoperative rehabilitation measures for IMR could improve a patient's physiological reserve and reduce postoperative adverse events.7 Unlike malignant tumors, intracranial meningiomas are associated with lower rates of mortality and recurrence.17 We believe that the less urgent need to proceed with surgical resection in patients harboring these tumors could allow for preoperative optimization of a patient's physiological reserve. This would guide clinical decision-making by allowing for a tailored approach to improving a patient's ability to cope with surgery.