Craniotomy Patients Research Articles

Early effects of surgery and radiotherapy on activity levels in patients with brain tumours: preliminary data from the BrainWear trial

Abstract Background BrainWear is a phase II observational clinical trial which collects data on patient activity levels, fatigue, Quality of Life (QoL) and imaging in patients with brain tumours Methods Newly diagnosed patients were offered wrist worn accelerometers (Axivity AX3) to be worn continuously throughout their treatment (surgery, chemoradiotherapy or radiotherapy) to monitor physical activity. We collected standardised measures of QoL, fatigue, MRI imaging data and disease progression. Here, we report early results on activity data 5 days before and after treatment. Results Of 23 patients recruited, we report complete pre and post treatment data in 4 patients (2 HGG, 2 metastatic) who underwent craniotomy (2), fractionated radiotherapy (1) and SRS (1). Both craniotomy patients experienced an immediate 60 – 70% reduction in activity, and were successfully discharged at day 2 post-op even though their activity was still significantly reduced. Both patients recovered another 10% in their activity levels following discharge. Radiotherapy patients experienced no early change within 5 days of starting treatment. Conclusion As expected craniotomy results in much larger changes in activity levels than SRS and radical radiotherapy. Activity levels recover post craniotomy, but this takes > 5 days. Using wearable activity monitors in brain tumour patients is feasible, although there are multiple practical problems. Interpreting such data will require consideration of inpatient vs. outpatient settings.

Logistic Regression Analysis of Risk Factors for Intracranial Infection After Multiple Traumatic Craniotomy and Preventive Measures.

The aim of this study was to study the risk factors of intracranial infection after traumatic craniotomy in multiple trauma to provide references for clinical prevention and control of intracranial infection. A total of 34 multiple trauma patients treated with craniotomy and complicated with intracranial infection from February 2012 to December 2016 in the department of neurosurgery of our hospital were selected as infection group, and 60 multiple trauma patients who had not been infected after craniotomy during the same period were selected as control group. Related risk factors were screened by univariate analysis at first and analyzed by Logistic regression. Of the 34 patients in the infection group, 13 cases were cured, 21 cases improved, whereas in the control group, 15 cases were cured and 45 cases improved. There was no significant difference in prognosis between the 2 groups (P > 0.05). Univariate analysis showed that surgical approach, surgical duration, postoperative cerebrospinal fluid leakage, and external drainage were important factors for intracranial infection after craniotomy (P < 0.05). Further Logistic regression analysis showed that postoperative external drainage, cerebrospinal fluid leakage, surgical time, and posterior fossa approaches were independent risk factors for intracranial infection after craniotomy. High attention should be paid to the risk factors of intracranial infection after craniotomy such as postoperative cerebrospinal fluid leakage, external drainage, surgical duration and approach, and taking effective preventive measures to reduce the incidence of intracranial infection after craniotomy in patients with multiple traumatic injuries.

Multimodal analgesia for craniotomy.

To explore the data for and against the use of the various components of multimodal analgesia in cranial neurosurgery. Postcraniotomy pain is a challenging clinical problem in that analgesia must be accomplished without affecting neurologic function (i.e. 'losing the neurologic exam'). The traditional approach with low-dose opioids is often insufficient and can cause well recognized side effects. Newer multimodal analgesic approaches have proven beneficial in a variety of other surgical patient populations. The combined use of multiple nonopioid analgesics offers the promise of improved pain control and reduced opioid administration, while preserving the clinical neurologic exam. Specifically, acetaminophen and gabapentinoids should be considered for craniotomy patients, both preoperatively and postoperatively. The gabapentinoids have the added benefit of reduced nausea. Scalp blocks have moderate quality evidence supporting their use over incisional infiltration alone, with analgesia that extends into the postoperative period. Intraoperative dexmedetomidine reduces postoperative opioid requirements with the added benefit of reduced postcraniotomy hypertension. Methocarbamol, NSAIDs [both nonspecific cyclooxygenase (COX) 1 and 2 inhibitors and specific COX-2 inhibitors], ketamine, and intravenous lidocaine require further data regarding safety and efficacy in craniotomy patients. Opioids are the mainstay for treating acute postcraniotomy pain but should be minimized. The evidence to support a multimodal approach is growing; neuroanesthesiologists and neurosurgeons should seek to incorporate multimodal analgesia into the perioperative care of craniotomy patients. Preoperative and postoperative gabapentin and acetaminophen, intraoperative dexmedetomidine, and scalp blocks over incisional infiltration have the most data for benefit, with good safety profiles. Further research is needed to define the safety, efficacy, and dosing parameters for NSAIDs including COX-2 inhibitors, methocarbamol, ketamine, and intravenous lidocaine in cranial neurosurgery.

Routine screening for hepatitis C viral infection in patients undergoing elective cranial neurosurgery.

Undiagnosed hepatitis C virus (HCV) and HIV in patients present risks of transmission of bloodborne infections to surgeons intraoperatively. Presurgical screening has been suggested as a protocol to protect surgical staff from these pathogens. The authors sought to determine the incidence of HCV and HIV infection in elective craniotomy patients and analyze the cost-effectiveness of universal and risk factor-specific screening for protection of the surgical staff. All patients undergoing elective craniotomy between July 2009 and July 2016 at the National Brain Aneurysm Center who did not refuse screening were included in this study. The authors utilized rapid HCV and HIV tests to screen patients prior to elective surgery, and for each patient who tested positive using the rapid HCV or HIV test, qualitative nucleic acid testing was used to confirm active viral load, and risk factor information was collected. Patients scheduled for nonurgent surgery who were found to be HCV positive were referred to a hepatologist for preoperative treatment. The authors compared risk factors between patients who tested positive on rapid tests, patients with active viral loads, and a random sample of patients who tested negative. The authors also tracked the clinical and material costs of HCV and HIV rapid test screening per patient for cost-effectiveness analysis and calculated the cost per positive result of screening all patients and of screening based on all patient risk factors that differed significantly between patients with and those without positive HCV test results. The study population of patients scheduled for elective craniotomy included 1461 patients, of whom 22 (1.5%) refused the screening. Of the 1439 patients screened, 15 (1.0%) tested positive for HCV using rapid HCV screening; 9 (60%) of these patients had active viral loads. No patient (0%) tested positive for HIV. Seven (77.8%) of the 9 patients with active viral loads underwent treatment with a hepatologist and were referred back for surgery 3-6 months after sustained virologic response to treatment, but the remaining 2 patients (22.2%) required urgent surgery. Of the 9 patients with active viral loads, 1 patient (11%) had a history of both intravenous drug abuse and tattoos. Two of the 9 patients (22%) had tattoos, and 3 (33%) were born within the age-screening bracket (born 1945-1965) recommended by the Centers for Disease Control and Prevention. Rates of smoking differed significantly (p < 0.001) between patients who had active viral loads of HCV and patients who were HCV negative, and rates of smoking (p < 0.001) and IV drug abuse (p < 0.01) differed significantly between patients who were HCV rapid-test positive and those who were HCV negative. Total screening costs (95% CI) per positive result were $3,877.33 ($2,348.05-$11,119.28) for all patients undergoing HCV rapid screening, $226.29 ($93.54-$312.68) for patients with a history of smoking, and $72.00 ($29.15-$619.39) for patients with a history of IV drug abuse. The rate of undiagnosed HCV infection in this patient population was commensurate with national levels. While the cost of universal screening was considerable, screening patients based on a history of smoking or IV drug abuse would likely reduce costs per positive result greatly and potentially provide cost-effective identification and treatment of HCV patients and surgical staff protection. HIV screening found no infected patients and was not cost-effective.

Postoperative Craniotomy Pain in Emergent versus Non-emergent Cases.

Background: Postoperative pain control in craniotomies poses multiple challenges. Pain must be addressed, but the use of medications must be weighed against risks. Craniotomies risk neurologic injury and so postoperative examinations are critical. Medications used to address pain can alter the neurological examination or cause bleeding leading to misdiagnosis of complications.Objective: Determine if there is a significant difference in postoperative pain from emergent craniotomies vs. non-emergent craniotomiesMethods: A retrospective review included 102 cases performed from 2010-2016; pain scores were compared on post-operative days one, two, and three between emergent and non-emergent craniotomies.Results: Pain scores for emergent cases on post-operative days one through three were 5.1 (standard deviation (SD)=2.9), 5.9 (SD=2.1), 4.7 (SD=3.0) respectively. Pain scores for non-emergent cases on post-operative days one through three were 5.7 (SD=2.6), 4.8 (SD=2.8), and 4.6 (SD=3.0) respectively. A one-way analysis of variance (ANOVA) was conducted to compare pain scores between groups for each post-operative day. On post-operative day, one there was no significant difference between the groups [F(1,100)=0.49, p=0.485]. On post-operative day two, there was no significant difference between the groups [F(1,100)=2.17, p=0.143]. On post-operative day three, there was no significant difference between the groups [F(1,98)=0.002, p=0.957].Conclusion: There is no significant difference in the level of pain on postoperative days one through three between emergent and non-emergent craniotomy patients.

Pre- and Postoperative Neratinib for HER2-Positive Breast Cancer Brain Metastases: Translational Breast Cancer Research Consortium 022

PurposeThis pilot study was performed to test our ability to administer neratinib monotherapy before clinically recommended craniotomy in patients with HER2-positive metastatic breast cancer to the central nervous system, to examine neratinib’s central nervous system penetration at craniotomy, and to examine postoperative neratinib maintenance. Patients and MethodsPatients with HER2-positive brain metastases undergoing clinically indicated cranial resection of a parenchymal tumor received neratinib 240 mg orally once a day for 7 to 21 days preoperatively, and resumed therapy postoperatively in 28-day cycles. Exploratory evaluations of time to disease progression, survival, and correlative tissue, cerebrospinal fluid (CSF), and blood-based analyses examining neratinib concentrations were planned. The study was registered at ClinicalTrials.gov under number NCT01494662. ResultsWe enrolled 5 patients between May 22, 2013, and October 18, 2016. As of March 1, 2019, patients had remained on the study protocol for 1 to 75+ postoperative cycles pf therapy. Two patients had grade 3 diarrhea. Evaluation of the CSF showed low concentrations of neratinib; nonetheless, 2 patients continued to receive therapy without disease progression for at least 13 cycles, with one on-study treatment lasting for nearly 6 years. Neratinib distribution in surgical tissue was variable for 1 patient, while specimens from 2 others did not produce conclusive results as a result of limited available samples. ConclusionNeratinib resulted in expected rates of diarrhea in this small cohort, with 2 of 5 patients receiving the study treatment for durable periods. Although logistically challenging, we were able to test a limited number of CSF- and parenchymal-based neratinib concentrations. Our findings from resected tumor tissue in one patient revealed heterogeneity in drug distribution and tumor histopathology.

Postoperative Admission of Adult Craniotomy Patients to Neuroscience Floor Unit Reduces Cost and Length of Stay

Abstract INTRODUCTION The neurointensive care unit (NICU) is costly but has traditionally been the default recovery unit after adult elective craniotomies for brain tumor resection. Given the rising healthcare costs and associated change in practice patterns, we assessed whether admitting these patients to a neuroscience floor unit instead of NICU for recovery resulted in an equivalent outcome while reducing the cost and length of stay. METHODS We retrospectively analyzed the clinical and cost data of all adult brain tumor elective supratentorial craniotomy patients at a university hospital within the last 5 yr who had a length of stay of less than 7 d. We compared those who stayed in the ICU for 1 d during admission versus those who did not stay in the ICU. Patients undergoing shunts, endoscopic, burr hole craniotomies, posterior fossa craniotomies, and vascular procedures were excluded. RESULTS A total of 688 patients were included, with 428 patients staying in the NICU for 1 d (NICU1) and 259 not staying in the NICU (NICU0). There was no difference in University Hospital Consortium (UHC) expected length of stay (P = .338). However, the actual length of stay for the NICU1 group was 12 h longer than the NICU0 group (3.6 vs 3.1 d) (P &lt; .0001), and the difference was still significant in multivariate analysis controlling for age, MS DRG, OR hours, insurance type, discharge disposition, and admit day. While the NICU1 group had longer surgeries (mean OR hours charged 6.8 vs 6.5 h), there was no statistically significant difference in the cost of surgery. The NICU0 group reduced the direct hospital cost by $3070 per admission on average (P &lt; .001). Clinically, there were no statistically significant differences in the rate of return to OR, ED readmission, or hospital readmission within 30 d. CONCLUSION Admitting to a neuroscience floor unit reduced the length of stay and direct hospital cost associated with admission, without significant differences in clinical outcome.

The Impact of Preoperative Opioids on Outcomes in Craniotomy Patients

Abstract INTRODUCTION There is an unprecedented opioid epidemic in the United States with the rate of drug overdose deaths tripling between 2000 and 2014. The literature suggests that preoperative opioid exposure prior to any surgery independently predicts poorer surgical outcomes. There is a paucity of research on preoperative opioid use and craniotomies. This study proposes to characterize the effects of opioid use on craniotomy outcomes, and triangulate epidemiological sources that predispose patients to adverse outcomes. METHODS From January 1, 2013 to October 1, 2018, 861 craniotomy patients were identified by CPT codes. Relevant medical and surgical information was extracted from the electronic medical record. Adverse outcomes and readmissions were recorded within 90 d of discharge. Opioid use was recorded by converting dosage into a milligram morphine equivalent (MME) using the Oregon Health Authority online calculator. Regression analysis determined significant factors impacting postoperative outcomes. RESULTS Patients receiving opioids preoperatively were more likely to be prescribed higher MMEs postoperatively (beta = 0.445, 95% CI 0.320-0.569; P &lt; .001) and at discharge (beta = 0.151, 95% CI 0.069-0.232; P &lt; .001). Preoperative MME significantly impacted postoperative respiratory failure (OR 1.004, 95% CI 1.002-1.006; P &lt; .001) and pneumonia (OR 1.005, 95% CI 1.002-1.007; P &lt; .001). Preoperative MME positively correlated with an increased length of stay (LOS) (beta = 0.024, 95% CI 0.014-0.034, P &lt; .001). Preoperative MME did not correlate with other adverse outcomes. Employment and insurance status lacked correlation with preoperative MME. CONCLUSION Craniotomy patients with higher preoperative MMEs are more likely to suffer from respiratory failure, pneumonia, and have a longer LOS compared to the no-opioids group. Our findings show that these patients should be more closely monitored for these negative events postoperatively. The lack of significance with other outcomes suggests that other factors impact negative outcomes in the opioid-exposed craniotomy population. Future work should further elucidate the mechanisms behind adverse events in this patient population.

A Novel Protocol for Reducing Intensive Care Utilization After Craniotomyh

Abstract INTRODUCTION There is increasing evidence that ICU admission may be unnecessary for all craniotomy patients. However, there are no guidelines for level of care requirements in this population. We sought to devise and implement a standardized protocol for craniotomy patients who would be eligible to transition directly to the ward the NonIntensive CarE (NICE) protocol. METHODS We preoperatively identified patients undergoing elective craniotomy for simple neurosurgical procedures with the age &lt;65 criterion and ASA Class of 1, 2, or 3. Postoperative eligibility was confirmed by the surgical and anesthesia teams and each patient was observed in the post-anesthesia care unit for stable hemodynamics and satisfactory pain control. Exclusion criteria included surgical/anesthetic concerns as well as need for significant pain, blood pressure or blood sugar management. Upon arrival to the ward, patients were staffed with a neuroscience nurse for hourly neurological examinations. A retrospective review of the prospectively enrolled cohort was conducted. Demographics, clinical characteristics and surgical outcomes were collected. RESULTS From February 2018 to 2019, 63 patients were included in the NICE protocol with a mean age of 45 yr and 65% female predominance. ASA Class breakdown was as follows: ASA1 9/5%, ASA2 57.1% and ASA3 33.3%. Of the operations performed, 38% were microvascular decompressions, 31.7% were craniotomy for tumor and 15.9% were cavernous malformation resections. About 7 operations were redos. Overall, no patients required transfer to the intensive care unit. Mean length of stay was 1.8 d (range 1-5 d) and 96.8% of patients went home. There was an 11.1% overall readmission rate within the mean follow-up period of 74.2 d. About 3 patients required reoperation (postoperative subdural hematoma, pseudomeningocele, and wound infection). CONCLUSION Appropriately selected craniotomy patients may be safely transferred to a neurosurgical ward with low risk of transfer to intensive care.

Rare case of iatrogenic tension pneumocephalus

Background: Pneumocephalus is a common complication of craniotomies. Since it has little or no clinical significance, it usually requires no treatment. However, tension pneumocephalus could also be associated with raised intracranial pressure and neurological deterioration. This emergency requires immediate radical approach to achieve surgical decompression.Objectives: To create awareness that the onset of post craniotomy tension pneumocephalus may be delayed and also to show that the radiological appearance may deviate from the classical Mount Fuji model.Case Description: A pituitary mass was successfully removed overseas from a 49-year-old man by transcranial approach. He improved, returned home and presented himself for clinical review on arrival without any significant complaint. The patient was brought back in coma two weeks later with blood pressure of 150/100 mmHg and aseptic CSF rhinorrhoea. The cranial CT scan showed marked dilatation of the lateral ventricles with obvious gas lucencies (Hounsfield unit = -1000HU).Concluson: High index of suspicion of tension pneumocephalus should be borne in mind in post operative reviews of craniotomy patients, as timely appropriate intervention is imperative.

Perioperative hypertension associated neurohumoral stress response in craniotomy patients: Effects of β-blocker and angiotensin converting enzyme inhibitor

BackgroundDevelopment of perioperative hypertension in craniotomy procedures is commonly associated with activation of sympathetic events through renin-angiotensin-aldosterone system (RAAS). Preemptive therapy with β-blockers or angiotensin converting enzyme (ACE) inhibitors may attenuate this hypertensive response. We conducted a randomized, double blind; placebo controlled study to compare the effect of β-blocker (atenolol) and an ACE inhibitor (Lisinopril) on perioperative hypertension in patients undergoing for the craniotomy and also studied biochemical markers of these two systems. MethodsEighty five patients undergoing craniotomy for supratentorial tumor removal were screened and randomized into three groups to receive either (atenolol; lisinopril or placebo). Blood analysis of renin, aldosterone, norepinephrine and sodium levels was drawn 12 h prior to surgery, at the time of dural opening, and at the time of extubation. Differences in mean arterial pressure (MAP), hear rate (HR) and biochemical markers between three groups were analyzed using one-way ANOVA. ResultsPerioperative hemodynamic changes were highly associated with biochemical markers in all the three groups. Specifically, HR was significantly attenuated by atenolol in the immediate extubation period (p < 0.01) persisted till 12 h postoperatively and this was associated with low plasma renin levels at the extubation. MAP was lowered by lisinopril and both aldosterone and norepinephrine levels were significantly lower (p < 0.01) at dural incision and extubation periods. ConclusionsPretreatment with atenolol or lisinopril significantly attenuated perioperative hypertension in patients undergoing craniotomy procedures. Lisinopril was better in lowering perioperative MAP while atenolol attenuated HR changes. RAAS inhibition may be the possible mechanism responsible for this hypertension effect in craniotomy procedures.

P.120 Rapid intraoperative reconstruction of cranial implants for craniotomy procedures: a feasibility study

Background: The aim of this study was to investigate intraoperative methods to generate patient-specific PMMA bone implants during a craniotomy. The proposed methods combine a cost-efficient, and non-invasive structured light scanner (SLS) as an imaging modality and a prototype printer for rapid generation of implant molds. Methods: This simulation study was performed using retrospective data from three craniotomy patients. The extracted bone flap and the cranial defect were scanned using a SLS, which generates a 3D surface model of an object by projecting a series of light-patterns on it. Prototype printed implant models were generated using two different techniques. The molds were then used to shape PMMA bone implants. These implants were evaluated regarding their accuracy to reconstruct the natural skull anatomy and compared to freehand formed implants. Results: The patient-specific bone implants reconstructed the preoperative anatomy with an average RMS error of 1.37mm (StDev 0.27), compared to an error of 1.5mm (StDev 0.43) for the freehand shaped implants. On average the intraoperative scanning time was 4.7min. The average time to generate and print the implant molds was 204 min. Conclusions: Results of this study have shown great promise for the proposed method to be used for patient-specific bone flap reconstruction during craniotomies.

The LACE+ index fails to predict 30–90 day readmission for supratentorial craniotomy patients: A retrospective series of 238 surgical procedures

Objective: The LACE + index (Length of stay, Acuity of admission, Charlson Comorbidity Index (CCI) score, and Emergency department visits in the past 6 months) is a tool utilized to predict 30–90 day readmission and other secondary outcomes. We sought to examine the effectiveness of this predictive tool in patients undergoing brain tumor surgery.Patients and methods: Admissions and readmissions for patients undergoing craniotomy for supratentorial neoplasm at a single, multi-hospital, academic medical center, were analyzed. Key data was prospectively collected with the Neurosurgery Quality Improvement Initiative (NQII)-EpiLog tool. This included all supratentorial craniotomy cases for which the patient was alive at 90 days after surgery (n = 238). Simple logistic regression analyses were used to assess the ability of the LACE + index and subsequent single variables to accurately predict the outcome measures of 30–90 day readmission, 30–90 day emergency department (ED) visit, and 30–90 day reoperation. Analysis of the model’s or variable’s discrimination was determined by the receiver operating characteristic curve as represented by the C-statistic.Results: The sample included admissions for craniotomy for supratentorial neoplasm (n = 238) from 227 patients, of which 50.00% were female (n = 119). The average LACE + index score was 53.48 ± 16.69 (Range 9–83). The LACE + index did not accurately predict 30–90 day readmissions (P = 0.127), 30–90 day ED visits (P = 0.308), nor reoperations (P = 0.644). ROC confirmed that the LACE + index was little better than random chance at predicting these events in this population (C-statistic = 0.51−0.58). However, a single unit increase in LACE + leads to a 0.97 times reduction in the odds of being discharged home with fair predictive accuracy (P < 0.001, CI = 0.96−0.98, C-statistic = 0.69).Conclusion: The results of this study show that the LACE + index is ill-equipped to predict 30–90 day readmissions in the brain tumor population and further analysis of significant covariates or other prediction tools should be undertaken.

Postoperative analgesia for pediatric craniotomy patients: a randomized controlled trial

BackgroundPain is often observed in pediatric patients after craniotomy procedures, which could lead to some serious postoperative complications. However, the optimal formula for postoperative analgesia for pediatric neurosurgery has not been well established. This study aimed to explore the optimal options and formulas for postoperative analgesia in pediatric neurosurgery.MethodsThree hundred and twenty patients aged 1 to 12-years old who underwent craniotomy were randomly assigned to receive 4 different regimens of patient-controlled analgesia. The formulas used were as follows: Control group included normal saline 100 ml, with a background infusion of 2 ml/h, bolus 0.5 ml; Fentanyl group was used with a background infusion of 0.1–0.2 μg/k·h, bolus 0.1–0.2 μg/kg; Morphine group was used with a background infusion of 10–20 μg/kg·h, bolus 10–20 μg/kg; while Tramadol group was used with a background infusion of 100–400 μg/kg·h, bolus 100–200 μg/kg. Postoperative pain scores and analgesia-related complication were recorded respectively. Comparative analysis was performed between the four groups.ResultsIn comparison of all groups with each other, lower pain scores were shown at 1 h and 8 h after surgery in Morphine group versus Tramadol, Fentanyl and Control groups (P < 0.05). Both Tramadol and Fentanyl groups showed lower pain scores in comparison to Control group (P < 0.05). Nausea and vomiting were observed more in Tramadol group in comparison to all other groups during the 48 h of PCIA usage after operation (P = 0.020). Much more rescue medicines including ibuprofen and morphine were used in Control group (CI = 0.000–0.019). Changes in consciousness and respiratory depression were not observed in study groups. Moderate-to-severe pain was observed in a total of 56 (17.5%) of the study population. Multiple regression analysis for identifying risk factors for moderate-to-severe pain revealed that, younger children (OR = 1.161, 1.027–1.312, P = 0.017), occipital craniotomy (OR = 0.374, 0.155–0.905, P = 0.029), and morphine treatment (OR = 0.077, 0.021–0.281, P < 0.001) are the relevant factors.ConclusionsCompared with other analgesic projects, PCIA or NCIA analgesia with morphine appears to be the safest and most effective postoperative analgesia program for pediatric patients who underwent neurosurgical operations.Trial registrationChinese Clinical Trial Registry. No: ChiCTR-IOC-15007676. Prospective registration. http://www.chictr.org.cn/index.aspx.

A Meta-analysis for Evaluating Efficacy of Neuroendoscopic Surgery versus Craniotomy for Supratentorial Hypertensive Intracerebral Hemorrhage.

ObjectiveHypertensive intracerebral hemorrhage is a potentially life-threatening neurological deficit with the highest morbidity and mortality. In recent years, neuroendoscopy has been used to treat intracerebral hemorrhages (ICHs). However, the choice of neuroendoscopic surgery or craniotomy for patients with ICHs is controversial. The objective of this meta-analysis was to assess the efficacy of neuroendoscopic surgery compared to craniotomy in patients with supratentorial hypertensive ICH.Materials and MethodsA systematic electronic search was performed using online electronic databases such as Pubmed, Embase, and Cochrane library updated on December 2017. The meta-analysis was performed by only including studies designed as randomized controlled trials.ResultsThree randomized controlled trials met our inclusion criteria. Pooled analysis of death showed that neuroendoscopic surgery decreased the rate of death compared to craniotomy (RR=0.58, 95% CI: 0.26–1.29; P=0.18). Pooled results of complications showed that neuroendoscopic surgery tended to have fewer complications than craniotomy had (RR=0.37, 95% CI: 0.28–0.49; P < 0.0001).ConclusionAlthough the presenting analyses suggest that neuroendoscopic surgery should have fewer complications than craniotomy dose, it had no superior advantage in morbidity rate definitely. Therefore, it may be necessary for the neurosurgeons to select best optimal patients for individual treatment.

Analgesia nociception index and hemodynamic changes during skull pin application for supratentorial craniotomies in patients receiving scalp block versus pin-site infiltration: A randomized controlled trial.

Background:Noxious stimulation such as skull pin insertion for craniotomy elicits a significant hemodynamic response. Both regional analgesic techniques (pin-site infiltration [PSI] and scalp block [SB]), and systemic strategies (opioids, alpha-2 agonists, anesthetics, and beta-blockers) have shown to attenuate this response. Analgesia Nociception Index (ANI) provides objective information about the magnitude of nociception and adequacy of analgesia. This study compared ANI and hemodynamic changes in patients receiving local anesthetic SB versus PSI during skull pin application for craniotomy.Materials and Methods:Sixty adult patients scheduled for elective supratentorial tumor surgery were randomly allocated to receive local anesthetic SB or PSI for skull pin insertion after the induction of anesthesia. Data regarding heart rate (HR), blood pressure (BP), and ANI were collected every minute for 5 min after the skull pin insertion beginning from the baseline.Results:A significant difference was observed in ANI values between the SB (higher ANI) and the PSI groups during skull pin insertion, P < 0.001 and P = 0.003 for ANIi and ANIm, respectively. Similarly, a significant difference was seen in HR and BP both within and between the two groups during skull pin insertion (P < 0.001 for both). The magnitude and duration of change were smaller in the SB group compared with the PSI group for the parameters studied. A strong negative linear correlation was noted between ANI and hemodynamic parameters.Conclusions:The changes in HR, BP, and ANI were significantly less with local anesthetic SB compared with PSI during skull pin insertion in patients undergoing supratentorial craniotomy.

Effects of Sevoflurane and Propofol on Neurological Recovery of Traumatic Brain Injury Patients in the Early Postoperative Stage: A Retrospective Cohort Study

ObjectiveTo investigate the effects of propofol and sevoflurane on neurological recovery of traumatic brain injury (TBI) patients in the early postoperative stage. MethodsWe retrospectively analyzed the clinical data of TBI patients who underwent craniotomy or decompressive craniectomy. Generalized additive mixed model (GAMM) was used to analyze effects of propofol and sevoflurane on Glasgow Coma Scale (GCS) on postoperative days 1,3, and 7. Multivariate regression analysis was used to analyze effects of the two anesthetics on Glasgow Outcome Scale (GOS) at discharge. ResultsA total of 340 TBI patients were enrolled in this study. There were 110 TBI patients who underwent craniotomy including 75 in the propofol group and 35 in the sevoflurane group, and 134 patients who underwent decompressive craniectomy including 63 in the propofol group and 71 in the sevoflurane group. It showed no significant difference in GCS at admission between the propofol and the sevoflurane groups among craniotomy patients (β = 0.75, 95%CI: –0.55 to 2.05, p = 0.260). However, elevation in GCS from baseline was 1.73 points (95%CI: –2.81 to –0.66, p = 0.002) less in the sevoflurane group than that in the propofol group on postoperative day 1, 2.03 points (95%CI: –3.14 to –0.91, p < 0.001) less on day 3, and 1.31 points (95%CI: –2.43 to –0.19, p = 0.022) less on day 7. The risk of unfavorable GOS (GOS 1,2, and 3) at discharge was higher in the sevoflurane group (OR = 4.93, 95%CI: 1.05 to 23.03, p = 0.043). No significant difference was observed among two-group decompressive craniectomy patients in GCS and GOS. ConclusionsCompared to propofol, sevoflurane was associated with worse neurological recovery during the hospital stay in TBI patients undergoing craniotomy. This difference was not detected in TBI patients undergoing decompressive craniectomy.

Effect of prophylactic palonosetron and sugammadex on postoperative nausea and vomiting in patients undergoing microvascular decompression under propofol-maintained anesthesia

Microvascular decompression (MVD) is associated with a particularly high risk of postoperative nausea and vomiting (PONV) among craniotomy patients. However, there is no information regarding the effect of prophylactic palonosetron and sugammadex on PONV in patients undergoing MVD under propofol-maintained anesthesia.Medical records of 274 adults who had undergone MVD under propofol-maintained anesthesia were reviewed. Patients were classified into 4 groups, based on the reversal agent used (sugammadex/pyridostigmine) and whether or not prophylactic palonosetron was used. The PONV incidence and risk factors were analyzed according to the use of these agents.The overall incidence of PONV was 30.7% during the first 24 hours postoperatively. The incidence of PONV was lower in the group using combination of prophylactic palonosetron and sugammadex (19.3%) compared with the group not using both agents (37.2%). The combined use of the prophylactic palonosetron and sugammadex was identified as a factor affecting the occurrence of PONV in both univariable (OR = 0.40, 95% CI: 0.21–0.77, P = .006) and multivariable (OR = 0.38, 95% CI: 0.20–0.75, P = .005) logistic regression analyses. In multivariable logistic regression analysis, female sex was also significant independent risk factor in PONV (OR = 2.62, 95% CI: 1.35–5.08, P = .004).In this retrospective observational study, the combined use of prophylactic palonosetron before anesthetic induction and sugammadex as a reversal of neuromuscular blockade are associated with a reduction in the incidence of PONV in patients undergoing MVD under propofol-maintained anesthesia.

Topical Vancomycin Reduces Surgical-Site Infections After Craniotomy: A Prospective, Controlled Study.

Surgical-site infections (SSIs) are an important cause of morbidity and mortality in neurosurgical patients. Topical antibiotics are one potential method to reduce the incidence of these infections. To examine the efficacy of topical vancomycin applied within the wound during craniotomy in a large prospective cohort study at a major academic center. Three hundred fifty-five patients were studied prospectively in this cohort study; 205 patients received 1 g of topical vancomycin powder in the subgaleal space while 150 matched control patients did not. Patients otherwise received identical care. The primary outcome variable was SSI rate factored by cohort. Secondary analysis examined cost savings from vancomycin usage estimated from hospital costs associated with SSI in craniotomy patients. The addition of topical vancomycin was associated with a significantly lower rate of SSI than standard of care alone (0.49% [1/205] vs 6% [9/150], P=.002). Based on the costs of revision surgery for infections, topical vancomycin usage was estimated to save $1367 446 per 1000 craniotomy patients. No adverse reactions occurred. Topical vancomycin is a safe, effective, and cost-saving measure to prevent SSIs following craniotomy. These results have broad implications for standard of care in craniotomy.

Biomaterial suture Vicryl Plus reduces wound-related complications.

ObjectiveTo compare the wound-related complications following craniotomy in patients with brain gliomas undergoing wound closure using either absorbable antibacterial Vicryl Plus suture or traditional braided silk suture.Materials and methodsTwo hundred and forty-five patients undergoing craniotomy for supratentorial gliomas from January 1, 2011 to December 31, 2013 were retrospectively analyzed. We divided the patients into two groups: the Vicryl Plus group (using absorbable antibacterial Vicryl Plus suture) and the control group (using traditional braided silk suture). The clinical data and wound-related complications after surgery between two groups have been summarized.ResultsPatients in the Vicryl Plus suture group had lower incidence of wound-related complications compared with traditional braided silk suture group (P<0.05). No statistically significant difference was found between the two groups in terms of total medical expense.ConclusionIncision closure using absorbable antibacterial Vicryl Plus suture had less wound-related complications than using traditional braided silk suture, without increasing medical expense. Vicryl Plus suture could be a better choice for scalp closure in patients undergoing craniotomy surgery.