Post Craniotomy Research Articles

DEXAMETHASONE WEAN POST CRANIOTOMY FOR MENINGIOMA- A CASE STUDY

Abstract AIMS Case review/analysis of dexamethasone wean post craniotomy for meningioma. To identify any quality of life issues experienced during the wean, how and why steroid wean was adjusted and any impact steroid use had on serum cortisol level causing adrenal insufficiency. METHOD Review of documentation to identify steroid related side effects, how and when this impacted on the patient’s quality of life. Collection of data; steroid doses, length of time on steroids (pre-surgery and post-surgery), serum cortisol result. Clinical choices regarding dose/timings of dexamethasone reviewed and compared to literature. RESULTS Delays/changes with theatre dates, capacity, neurological symptoms on presentation led this individual to a four month pre-surgical dose of dexamethasone which led to weight gain, pre-diabetes and insomnia. Quality of life pre and post-surgically affected by steroid use namely mental health, employment and social belonging. This case study confirms adrenal insufficiency was precipitated by the prolonged pre-surgical use of dexamethasone. Clinical nurse specialists are integral in adjusting steroid dose to manage neurological recovery and safely wean steroids to zero as well as identifying adrenal insufficiency. CONCLUSION Data collection from a large sample size is required to confirm how many patients coming through the neurooncology surgical pathway have confirmed adrenal insufficiency post neurosurgery secondary to Dexamethasone. Once data is collected guidance on how to manage a safe post surgical steroid wean and minimise impact of quality of life can be formalised.

Onabotulinumtoxina (craniotomy scar combined with cranial suture line injections) for persistent post craniotomy headache: Case series with long-term follow-up.

There is no defined preventive treatment protocol for persistent post-craniotomy headache. In several small case series and individual case reports onabotulinumtoxinA injected into the craniotomy scar has shown possible efficacy. What is lacking is long term follow-up and if focusing on the cranial suture lines along with the craniotomy scar can enhance improvement and provide more sustained benefit. Retrospective chart review with case series. Four patients (three women, one man) with ICHD-3 defined persistent post craniotomy headache were treated using a novel onabotulinumtoxinA injection protocol. All the patients presented with continuous head pain of moderate to severe intensity. All had severe allodynia on the side of their craniotomy. All had significant reduction in quality of life. Our application of onabotulinumtoxinA involved injection into both the surgical scar and the transected/irritated cranial suture lines noted on neuroimaging and physical examination. With treatment all patients demonstrated significant benefit including a reduction in daily pain intensity (75%-100%), developing periods of pain freedom (2-7 days per week) and having a dramatic improvement in quality of life (close to 100% in all). The benefit was sustained for at least five years of follow-up. From our case series it appears that injection not only along the painful craniotomy scar but into the involved cranial suture lines provides positive efficacy and sustained improvement in patients with persistent post craniotomy headache.

Clinical characteristics and therapeutic effectiveness of post craniotomy cervicogenic headache

From January 2019 to December 2021, the clinical data of 151 patients with post craniotomy cervicogenic headache from Beijing Tiantan Hospital affiliated to Capital Medical University were retrospectively collected. The characteristics of cervicogenic headache were summarized, the numerical rating score (NRS) of patients before and after treatment of compound opioids and/or cervical nerve block was compared, and the occurrence of related adverse reactions and complications was counted. The onset of cervicogenic headache in 151 patients was on the (5.5±2.0) d after craniotomy, of which 131 (86.8%) had unilateral pain, pain in 127 (84.1%) could be induced by cervical activity, and 118 (78.1%) had limited neck movement. Of the 124 patients treated with compound capsule of oxycodone and acetaminophen, 85 (68.5%) patients had an NRS of (8.01±0.82) before treatment and 2.0 (1.0, 3.0) after treatment (P<0.001). Thirty-nine patients who did not respond to medical therapy received cervical nerve block, and the NRS scores before and after receiving the nerve block were (7.49±1.12) and 2.0 (1.0, 2.5), respectively, with a statistically significant difference (P<0.001). Twenty-seven patients who received cervical nerve block without medical treatment, and the NRS before and after treatment was (9.0±0.9) and 1.0 (1.0, 3.0), respectively, with a statistically significant difference (P<0.001). Among the 124 patients receiving medication, 14 (11.3%) developed mild dizziness and nausea, which were resolved after stopping the drug, and no other drug-related adverse reactions were found. None of the patients who received nerve blocks saw complications associated with nerve block procedures. Compound capsule of oxycodone and acetaminophen are effective for most of patients with post craniotomy cervicogenic headache. Cervical nerve block is effective and safe for patients with or without drug resistance.

H - 27 TBI and PTSD in an Indigenous Patient: It's Complicated.

Neuropsychological assessment of American Indian/Alaska Native (AI/AN) patients presents challenges due to limited normative data, stigma, possible differential validity of measures, and limited access to healthcare. Additionally, differentiating traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) is increasingly important for proper diagnosis and treatment of indigenous patients. This case study describes the use of comprehensive neuropsychological testing across two timepoints to assist with treatment planning. The patient was a 38-year-old Native American male referred by primary care to assist in educational, career, and treatment planning. His history was remarkable for TBI status post craniotomy and craniectomy. The patient completed initial and follow-up comprehensive neuropsychological evaluations. Follow-up was completed at 9-months following cranioplasty. On initial evaluation, the patient demonstrated deficits in immediate learning, delayed recall, executive functioning, processing speed, and fine motor abilities consistent with major neurocognitive impairment due to TBI. On follow-up evaluation, the patient demonstrated variable processing speed and executive functioning. Follow-up testing showed improvements in encoding of verbal information and immediate learning of visual information. Modest improvements were noted in processing speed, executive functioning, and fine motor skills. Follow-up testing evidenced declines in immediate learning, spontaneous recall, verbal fluency, and worsening PTSD symptoms. While TBI and PTSD can co-occur, understanding how to differentiate cognitive profiles of each, while considering linguistic, sociocultural, and educational differences, is vital for proper diagnosis and treatment. Adherence to treatments following TBI can promote physical and cognitive improvements, though certain symptoms may worsen due to psychological symptoms, which may present differently across cultures.

Effectiveness of 30o Head Elevation Intervention on Head Pain Levels in Patients with Space Occupying Lesion (SOL) Intracranial Tumor Post-Op Craniotomy : Case Study

ABSTRACT Intracranial tumors are abnormal mass growths in the brain that originate from tissue that grows and divides uncontrollably. Space Occupying Lesion (SOL) is a space pressure caused by an increase in volume within the brain due to the accumulation of blood, cerebro-spinal fluid or brain tissue. A common treatment for intracranial tumors is craniotomy. According to research, about 60% of patients who undergo craniotomy experience moderate to high levels of headache pain. Non-pharmacological pain management that can be done includes deep breathing interventions with guided imagery techniques, monitoring patient hemodynamics and 30o head elevation. The purpose of this study was to present the effect of 30o head elevation nursing intervention on pain levels in patients with SOL intracranial tumors post craniotomy. The method in this study used a case study design conducted in November 2022 at Sumedang Regional General Hospital. The results showed that head elevation of 30o can reduce head pain levels because it can maximize the entry of oxygen into the intracranial and increase the return flow of blood from the brain to the heart, help activate the parasympathetic nervous system which functions to control various activities of the human body at rest and maximize relaxed conditions in patients, resulting in a stable pulse frequency, respiratory frequency, blood pressure. The intervention of elevating the head position or head elevation of 30o is one of the many nonpharmacological therapies that are useful for improving intracranial pressure so that the headache felt by the patient improves and cerebral perfusion can be resolved. Keywords: SOL, Post-op Craniotomy, Head Elevation

Assessing use of vancomycin powder in craniotomy: randomized controlled trial (AVIC)

Background: Surgical-site infections (SSIs) can lead to greater postoperative morbidity, mortality, and health care costs. Despite current prophylactic measures, rates of SSIs have been reported in up to 5% of patients post craniotomy. Intrawound vancomycin powder has been studied extensively in spinal fusion surgeries and been found to reduce rates of surgical site infections (SSIs) significantly. Despite its success in spinal surgeries, topical vancomycin has not been extensively studied with respect to cranial neurosurgery. Methods: Our study is Prospective Randomized clinical trial. Patients will be divided in this Trial into two groups, first group (intervention arm) they will receive the drug (vancomycin) in the wound before the closure of the skin at the end of the surgical procedure. The second group (control arm) they will not receive the drug, otherwise both groups they will receive identical measure to decrease the postoperative SSI. The primary outcome variable will be SSI rate factored by cohort. Secondary outcome will be to monitor the safety and any complication related to the use of vancomycin . SSI found to be around 0.49% when vancomycin was used, while SSI in standard care found to be 5%, to get power of study 80% and level of significance 5%. Sample size will be 250 in each group using sample size calculator. Discussion: This study is designed to evaluate the efficacy of vancomycin compared to standard method in neuro-surgical cases undergoing craniotomy . Additionally, safety of vancomycin will be assessed in these patients.

Persistent incisional pain at 1 year after craniotomy: a retrospective observational study

BackgroundThere have been few reports on persistent incisional pain at 1 year after craniotomy. Hence, this study aimed to explore the distribution of pain at 1 year after elective craniotomy and its related factors.MethodsThis retrospective study included data prospectively collected to assess postoperative functional disability. We included patients aged > 55 years at the time of recruitment for our initial study and who had complete data regarding the pain numeric rating scale (NRS) score at 1 year post craniotomy. The primary outcome was the pain NRS score, which was assessed at the postanesthetic clinic as well as at 3 months and 1 year after craniotomy. Multivariable negative binomial regression analysis was performed to analyze the relationship between the pain NRS score at 1 postoperative year and 12 clinically meaningful covariates. These included the Short Form-8 scores for bodily pain and mental health, with higher scores indicating better health.ResultsWe analyzed data from 102 patients. The mean (95% confidence interval) pain NRS scores at the three measurement points were 2.8 (2.3–3.3), 1.2 (0.8–1.6), and 0.6 (0.3–0.8), respectively. Multivariable analysis revealed that preoperative bodily pain (risk ratio, 0.93; 95% confidence interval, 0.88–0.98) and the pain NRS score at the postanesthetic clinic (risk ratio, 1.32; 95% confidence interval, 1.14–1.52) were associated with the risk of persistent pain at 1 postoperative year.ConclusionsThe pain score at 1 year after elective craniotomy was minor; however, preoperative bodily pain and postoperative pain scores were significantly related factors.

Ineffective Effort in Patients With Acute Brain Injury Undergoing Invasive Mechanical Ventilation.

Ineffective effort (IE) is a frequent patient-ventilator asynchrony in invasive mechanical ventilation. This study aimed to investigate the incidence of IE and to explore its relationship with respiratory drive in subjects with acute brain injury undergoing invasive mechanical ventilation. We retrospectively analyzed a clinical database that assessed patient-ventilator asynchrony in subjects with acute brain injury. IE was identified based on airway pressure, flow, and esophageal pressure waveforms collected at 15-min intervals 4 times daily. At the end of each data set recording, airway-occlusion pressure (P0.1) was determined by the airway occlusion test. IE index was calculated to indicate the severity of IE. The incidence of IE in different types of brain injuries as well as its relationship with P0.1 was determined. We analyzed 852 data sets of 71 subjects with P0.1 measured and undergoing mechanical ventilation for at least 3 d after enrollment. IE was detected in 688 (80.8%) data sets, with a median index of 2.2% (interquartile range 0.4-13.1). Severe IE (IE index ≥ 10%) was detected in 246 (28.9%) data sets. The post craniotomy for brain tumor and the stroke groups had higher median IE index and lower P0.1 compared with the traumatic brain injury group (2.6% [0.7-9.7] vs 2.7% [0.3-21] vs 1.2% [0.1-8.5], P = .002; 1.4 [1-2] cm H2O vs 1.5 [1-2.2] cm H2O vs 1.8 [1.1-2.8] cm H2O, P = .001). Low respiratory drive (P0.1 < 1.14 cm H2O) was independently associated with severe IE in the expiratory phase (IEE) even after adjusting for confounding factors by logistic regression analysis (odds ratio 5.18 [95% CI 2.69-10], P < .001). IE was very common in subjects with acute brain injury. Low respiratory drive was independently associated with severe IEE.

Cytoprotective effect and clinical outcome of perioperative progesterone in brain tumors, a randomized microscopically evidence study

ABSTRACT Background and Aims Although progesterone role on TBI patients and its antitumor activity have been proved, its perioperative use in surgical brain tumors remains unclear. Primary outcome is to investigate any neuroprotective effects of perioperative intramuscular progesterone on the brain’s cellular inflammatory and neuro-excitotoxic response to tumor resection evidenced by neuronal cells immunohistochemistry and CT scanning. Secondary outcome is to explore the postoperative clinical course, any related complications, and post craniotomy short-term (3 months) outcome. Methods Two hundred fifty-two (252) adult patients, ASA class І-ІІ undergoing elective craniotomy were randomly allocated into two groups: progesterone (PR) and control (C) groups to receive either 1.0 mg/kg progesterone (diluted to a total volume of 2 ml) or 2 ml of isotonic saline daily intramuscular for five days before and after craniotomy. Results Histopathological biopsies revealed significant increase the expression of active nuclear PR receptors on oligodendrocytes and astrocytes (P-value = 0.0001), cytoplasmic and nuclear neuro-quiescence endorsed by keeping blood vessel integrity and preventing neutrophilic infiltration and cytoplasmic oedema (P-value = 0.005) in PR group. Follow up CT2 (on the morning of surgery) and CT3 (on the 3rd postoperative day) recorded a significant reduction of brain oedema (P = 0.0001&0.001). Also, significant earlier weaning with shorter ICU stay (P = 0.0001) and better postoperative 3 months outcome (P = 0.001) were demonstrated in progesterone group without any detectable complications. Conclusion Perioperative progesterone offered anti-neuroinflammatory and neuroprotective effect and reduced cytoplasmic brain oedema evidenced by histopathological biopsies and CT scanning. Also, it improved postoperative course and 3 months neurological outcome in surgical brain tumors.

GAMBARAN LENGTH OF STAY BERDASARKAN TINGKAT PRIORITAS DI INTENSIVE CARE UNIT RSUD ULIN BANJARMASIN

Patient admitted to the intensive care unit were categorized into four admission indications, namely patients with priority one, two, three and four. Patients classified as priorities three and four have longer ICU care compared to priorities one and two. This study aims to determine the description of the Length of Stay (LOS) based on the priority level in ICU of Ulin Hospital Banjarmasin. The sampling technique in this study used a non-probability sampling with consecutive sampling. The sample in this study amounted to 31 patients. The results showed that the average age value was 41 years. The majority respondents were female, namely 19 people. Most of the patients admitted to the intensive care room at the Ulin Banjarmasin Hospital were priority 1 patients, from 31 people there were 17 patients who entered priority 1 criteria. The longest LOS was the post craniotomy tumor patient with LOS of 22 days. The number of ICU rooms is very limited and is not proportional to patients who neeed treatment in the intensive care unit, so priority criteria are used to determine patients who deserve treatment in the ICU.

NIMG-11. THE EXTENT OF NECROSIS IN BRAIN METASTASES MAY PREDICT SUBTYPES OF PRIMARY CANCER AND OVERALL SURVIVAL IN PATIENTS RECEIVING CRANIOTOMY

Abstract Although necrosis is common in brain metastasis (BM), its biological and clinical significances remain unknown. We evaluated necrosis extent differences by primary cancer subtype and correlated BM necrosis to overall survival post craniotomy. We analyzed 145 BM patients receiving craniotomy. Necrosis to tumor ratio (NTR) was measured. Patients were divided into two groups by NTR: BMs with sparse necrosis and with abundant necrosis. Clinical features were compared. To investigate factor relevance for BM necrosis, multivariate logistic regression, random forests, and gradient boosting machine analyses were performed. Kaplan–Meier analysis and log-rank tests were performed to evaluate the effect of BM necrosis on overall survival. Lung cancer was a more common origin for BMs with abundant necrosis (42/72, 58.33%) versus sparse necrosis (23/73, 31.51%, p&amp;lt; 0.01). Primary cancer subtype and tumor volume were the most relevant factors for BM necrosis (p&amp;lt; 0.01). BMs harboring moderately abundant necrosis showed longer survival, versus sparse or highly abundant necrosis (p=0.03). Lung cancer BM may carry larger necrosis than BMs from other cancers. Further, moderately abundant necrosis in BM may predict a good prognosis post craniotomy.

NIMG-108. PHYSICAL STRESSES IN BRAIN TUMORS

Abstract Solid stress, distinct from fluid pressure, is a physical force contained in and transmitted by solid components of the brain tumor, including cells and the matrix they produce. Solid stress has been shown to promote tumor progression, and decrease anticancer therapy efficacy. This is especially relevant in brain tumors, as the rigid skull results in these trapped forces, increasing intracranial pressure, and potentially leading to other complications, including neuronal cell death. Here we present a novel method of quantifying these physical stresses in situ in both mice (glioblastoma [U87], brain metastasis [BT474], and ependymoma models) and patients. Briefly, following a craniotomy, mechanical forces that include solid stress are released, which causes the tissue to deform in peaks (areas under compression) and valleys (areas originally under tension). This tissue deformation is imaged via high-resolution ultrasound and analysed via custom MATLAB code to produce an accurate 3D model of the entire mouse brain, including the tumour region. For human samples, a pre-operative MRI is used to generate a detailed 3D model of the human brain. During surgery, the trapped physical stresses results in a bulge of the dura post craniotomy. We use BrainLab to measure the craniotomy induced brain deformation, which is then registered to the pre-operation MRI before being analysed in an identical fashion to the murine models using SolidWorks and Abaqus. We further show that in the brain metastases model, chemotherapy reduces compression stresses by 51%. Further, our technique results in fast processing time (~ 15 minutes), and has the potential to prevent the need for intraoperative MRI based on position simulations. As such, solid stress measurements provide a new class of mechanical biomarkers that can be correlated to clinical outcomes for predictive and prognostic value.

Refractory Hyponatremia on Therapy in Syndrome of Inappropriate Antidiuretic Hormone: A Case Report

Hyponatremia is particularly common in neurosurgical patients, occurring in up to 50% of cases depending on the underlying diagnosis. One of the causes is the syndrome of inappropriate antidiuretic hormone (SIADH). Treatment for this condition mainly increases sodium intake and fluid restriction. Both of these therapies are potentially dangerous in some cases. Thus the therapy should be considered thoroughly. In this case we present, A 33-years-old male with refractory hyponatremia day-8 post craniotomy. Serum sodium was measured after every treatment. The patient was given hypertonic saline, fluid restriction advice, and a combination of those treatments. Yet every treatment gave various outcomes. Although the theory was put into practice, therapy in SIADH is harder than expected due to variations in the patient’s condition

Our experience of scalp reconstruction in a tertiary care centre of Nepal

Introduction: Scalp defects are difficult to manage due to their inelastic nature, thus possess significant surgical and aesthetic concerns. The objective of the study was to analyse various scalp defects in terms of their clinical presentation, management and outcome in the context of Nepal. Methods: This was a retrospective review conducted by analysing clinical records of all the scalp reconstructions performed at Tribhuvan University Teaching Hospital (TUTH) from May 2018 to March 2021. Results: Among the 69 patients operated there were 37 females and 32 males. Most patients were in the age group of 0-10 years and 31-40 years with mean age of 30 years. Most common cause for defect was trauma (27 cases), followed by post oncologic resection (15), burn (11), raw area post craniotomy (7) and benign scalp lesions in 9 cases. Skin grafting was the most common procedure performed (16 cases), followed by transposition flap (15), primary closure (13), rotation flap (9) and free flap in 4 cases. Four patients had tissue expander placed over the scalp. Four patients had developed graft loss, two had infection post operatively requiring intervention, five had wound dehiscence and there was one free flap failure. There were two mortalities both due to pneumonia post operatively. Conclusion: Defect size, location, presence or absence of pericranium and quality of surrounding scalp tissue all influence the selection of reconstructive technique.

Should intravenous acetaminophen be considered for post craniotomy pain management? A meta-analysis of randomized controlled trials.

Post-craniotomy pain management with opioids is challenging due to their side effects, which might mask neurological deterioration symptoms. Recently, intravenous (IV) acetaminophen has been tested in this population. This meta-analysis aimed to synthesize evidence from published randomized controlled trials (RCTs) about the efficacy of IV acetaminophen in reducing pain scores in postoperative craniotomy patients. A computer literature search of PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL) was conducted. We selected RCTs comparing IV acetaminophen versus placebo for postoperative pain management in craniotomy patients. Data on the Visual Analog Scale (VAS), opioid requirements, hospital stay, and patients' satisfaction were extracted and pooled as standardized mean difference (SMD) with the corresponding 95% confidence intervals (CI) in the meta-analysis model. Five RCTs, with a total of 493 patients, were pooled in the final analysis. Patients in the IV acetaminophen group had significantly lower VAS pain scores compared to the placebo group (SMD=-0.28, 95% CI: -0.46 to -0.10). However, in terms of opioid requirement, hospital stay, and patients' satisfaction, there were no statistically significant differences between both groups (P>0.05). This meta-analysis provides class one evidence that IV Acetaminophen can significantly reduce postoperative pain in craniotomy patients with an excellent safety profile; however, there are not benefits in terms of hospital stay, opioid requirement, or patients' satisfaction.

Functional rehabilitation in intensive care units for post craniotomy patients: study protocol

INTRODUCTION: Craniotomy makes insight and approach towards the brain easier but accompanies ailments. Intensive care units are equipped with trained professional physical therapists working over these deleterious after-effects of this surgical program, but a progressive, defined, and evidence-supported protocol for such patients is lacking. OBJECTIVE: To assess the feasibility of a Neuro-rehabilitation protocol devised for post-craniotomy patients within their stay in the Intensive Care Unit (ICU) to improve their functional outcomes and reduce their length of stay (LOS). MATERIALS AND METHODS: It will be a single group pre-test post-test quasi feasibility trial. Fifteen patients undergoing craniotomy will be recruited for the trial and will be rendered with Neuro-rehabilitation protocol for 60 minutes from the first day of surgery up to 15 days of surgery. The primary outcome will be the Early Functional Abilities (EFA) Scale to measure functional outcomes like conscious level, sensorimotor abilities, cognitive-perceptual abilities, and oro-motor abilities of patients, which will be assessed first-day post craniotomy. Secondary outcomes will include Glasgow Coma Scale (GCS), Coma Recovery Scale-Revised (CRS-R), Sensory Modality Assessment Rehabilitation Technique (SMART), Modified Ashworth Scale (mMAS), Montreal Cognitive Assessment Score (MoCA), and Medical Research Council Scale (MRC). Assessments will be taken on the first and fifteenth days post-surgery. PERSPECTIVES: It is expected that this protocol might improve functional outcomes and may reduce the occurrence of comorbidities in patients after Craniotomy in ICUs.

Cranial suture headache: An extracranial head pain syndrome originating in the cranial sutures of the skull

Objective: To define a new type of head pain syndrome termed “cranial suture headache” which is a localized headache originating along the cranial suture lines of the skull. Background: Well localized headaches maybe extracranial in origin. As trigeminal nociceptors are localized within the cranial sutures of the skull, these fibrous joints maybe the source of head pain for some patients. Methods: Case series. To diagnose cranial suture headache, the patient’s pain had to be localized to the skull and elicited/mimicked by mild to moderate palpation over one or more distinct cranial suture lines. Results: Ten cases are presented. Most of the patients were women (9/10). The headache started daily from onset in all cases. Range of age of headache onset was 32–64 years. Headache was one sided, unless confined to the midline and typically lacked any migrainous and/or cranial autonomic symptoms. Most cranial suture headaches localized to either the sagittal, coronal or squamosal suture lines. Headache duration prior to diagnosis was on average 8.5 years. Triggering events: three began immediately after head trauma, two had very remote head trauma, one was post infectious, one was post craniotomy, while three patients had no known triggering event. All patients were treatment refractory failing at least three preventive medications. All improved with localized anesthetic injection to the suture line(s) and/or onabotulinum toxin A injection only to the cranial sutures. Discussion: Without the recognition of cranial suture-based pain, patients may have unremitting headaches that can last years to decades. The observation that “cranial suture” headache improves with localized treatment only to the cranial sutures would seem to suggest the extracranial origin of the pain.

“The historical timeline of cranioplasty”

Cranioplasty, defined as the reconstruction of cranial defects, not only offers protective effects with an aesthetically pleasing outcome, but also reverses the altered physiology post craniotomy and craniectomy. The journey of cranioplasty from its roots to the neoteric armamentarium depicts how enormously the innovation of surgical techniques have changed the face of plastic surgery.

TAMI-64. PHYSICAL STRESSES IN BRAIN TUMORS

Abstract Solid stress, distinct from fluid pressure, is a physical force contained in and transmitted by solid components of the brain tumor, including cells and the matrix they produce. Solid stress has been shown to promote tumor progression, and decrease anticancer therapy efficacy. This is especially relevant in brain tumors, as the rigid skull results in these trapped forces, increasing intracranial pressure, and potentially leading to other complications, including neuronal cell death. Here we present a novel method of quantifying these physical stresses in situ in both mice (glioblastoma [U87], brain metastasis [BT474], and ependymoma models) and patients. Briefly, following a craniotomy, mechanical forces that include solid stress are released, which causes the tissue to deform in peaks (areas under compression) and valleys (areas originally under tension). This tissue deformation is imaged via high-resolution ultrasound, and analysed via custom code to produce an accurate 3D model of the entire mouse brain, including the tumour region. For human samples, a pre-operative MRI is used to generate a detailed 3D model of the human brain. During surgery, the trapped physical stresses results in a bulge of the dura post craniotomy, which is mapped via Brainlab. These deformations are analysed in an identical fashion to the murine model. We further show that in the brain metastases model, chemotherapy reduces compression stresses by 51%. Further, our technique results in fast processing time (~ 15 minutes), and has the potential to prevent the need for intraoperative MRI based on position simulations. As such, solid stress measurements provide a new class of mechanical biomarkers that can be correlated to clinical outcomes for predictive and prognostic value.

Diabetes insipidus after suprasellar tumor surgery: case report

Introduction: Diabetes insipidus (DI) is a rare water and electrolyte imbalance with hypovolemic hypernatremia characteristic (1:25.000) however can be potentially fatal if not well-anticipated and managed adequately. Brain tumors, either operated or not, may lead to DI (25%). Based on anatomical location, the suprasellar tumor may cause hypophyseal hormone dysfunction. Sellar region tumors can be classified into hypophyseal (90%) and non-hypophyseal (10%). Non-hypophyseal tumors with neurological deficits are more often causing hypophyseal hormone hyposecretion including DI. Sellar tubercle meningioma is one of the sellar region non-hypophyseal tumors which is often encountered and surgically managed. Worsening symptoms may become the surgical indication e.g. headache and visual disturbance. Case: We are reporting two meningioma cases in Salatiga local hospital with almost similar tumor characteristics either size and frontal lobe location. Both cases were managed by similar transcranial tumor excision craniotomy. Their differences were in the presence of neurological manifestations and the degree of hypothalamic compression. One patient developed postoperative DI without thirst thus the clinical manifestation was polyuria which was closely monitored in the intensive ward. We were convinced that the DI incidence was affected by the tumor manifestation and location which can be assessed by computed tomography (CT) scans. Conclusion: The clinicians should anticipate the possibility of post craniotomy DI thus may provide adequate monitoring and management in patients developing postoperative DI.