Preoperative Karnofsky Performance Score Research Articles

Repeat Resection for Recurrent Glioblastoma in the WHO 2021 Era: A Prospective Matched Case-Control Study

INTRODUCTION: The role of resection for recurrent glioblastoma remains unclear. METHODS: Patients who underwent repeat resection for recurrent IDH-wild-type glioblastoma were prospectively matched with 1:1 control cohort (n = 30:30). The two groups signed the consent and were matched for age, gender, comorbidities, eloquent vs. non-eloquent location, preoperative tumor volume and extent of resection in first surgery, neuropathological features as in WHO 2021 classification, time to progression, tumor volume at the time of recurrence, Park Score, ventricular wall involvement, use of steroids or multiple antiseizure medications and adjuvant therapy. Primary aim was to evaluate the overall survival in two cohorts. The secondary aim was to determine predictive factors for long term survival after repeat resection. RESULTS: After matching, patients had a long term follow up until death. Median overall survival times for patients who underwent repeat and one resection was 23.8 months vs 9.1 months, respectively (Log-Rank p < 0.001). Two predictive factors for long term survival after repeat resection were preoperative Karnofsky Performance Score >70 and Glasgow Coma Scale >13 (Fisher p = 0.07 and p < 0.001, respectively) while age, time to surgery, preoperative volume, extend of resection in repeat resection, location of tumor, its extension to ventricular wall, ependymal enhancement, comorbidities, tumor histological and molecular features did not correlate with postoperative survival. CONCLUSIONS: This is the first prospective matched case-control study revealing survival benefit of repeat resection for recurrent gliomas with long term follow up in a select group.

Insights from a Multicenter Study on Adult H3 K27M-Mutated Glioma: Surgical Resection's Limited Influence on Overall Survival, ATRX as Molecular Prognosticator.

H3 K27M-mutated gliomas were first described as a new grade 4 entity in the 2016 WHO classification. Current studies have focused on its typical appearance in children and young adults, increasing the need to better understand the prognostic factors and impact of surgery on adults. Here, we report a multicentric study of this entity in adults. We included molecularly confirmed H3 K27M-mutated glioma cases in patients >18 years diagnosed between 2016 and 2022. Clinical, radiological, and surgical features were analyzed. Univariate and multivariate analyses were performed to identify prognostic factors. Among 70 patients with a mean age of 36.1 years, the median overall survival (OS) was 13.6 + 14 months. Gross-total resection was achieved in 14.3% of patients, whereas 30% had a subtotal resection and 54.3% a biopsy.Tumors located in telencephalon/diencephalon/myelencephalon were associated with a poorer OS, while a location in the mesencephalon/metencephalon showed a significantly longer OS (8.7 vs. 25.0 months, p=0.007). Preoperative Karnofsky Performance Score (KPS) < 80 showed a reduced OS (4.2 vs. 18 months, p=0.02). Furthermore, ATRX loss, found in 25.7%, was independently associated with an increased OS (31 vs. 8.3 months, p=0.0029). Notably, patients undergoing resection showed no survival benefit over biopsy (12 vs. 11 months, p=0.4006). The present study describes surgical features of H3 K27M-mutated glioma in adulthood in a large multicentric study. Our data reveal that ATRX status, location and KPS significantly impact OS in H3 K27M-mutated glioma. Importantly, our dataset indicates that resection does not offer a survival advantage over biopsy.

Enhancing outcomes: neurosurgical resection in brain metastasis patients with poor Karnofsky performance score - a comprehensive survival analysis.

A reduced Karnofsky performance score (KPS) often leads to the discontinuation of surgical and adjuvant therapy, owing to a lack of evidence of survival and quality of life benefits. This study aimed to examine the clinical and treatment outcomes of patients with KPS < 70 after neurosurgical resection and identify prognostic factors associated with better survival. Patients with a preoperative KPS < 70 who underwent surgical resection for newly diagnosed brain metastases (BM) between 2007 and 2020 were retrospectively analyzed. The KPS, age, sex, tumor localization, cumulative tumor volume, number of lesions, extent of resection, prognostic assessment scores, adjuvant radiotherapy and systemic therapy, and presence of disease progression were analyzed. Univariate and multivariate logistic regression analyses were performed to determine the factors associated with better survival. Survival > 3 months was considered favorable and ≤ 3 months as poor. A total of 140 patients were identified. Median overall survival was 5.6 months (range 0-58). There was no difference in the preoperative KPS between the groups of > 3 and ≤ 3 months (50; range, 20-60 vs. 50; range, 10-60, p = 0.077). There was a significant improvement in KPS after surgery in patients with a preoperative KPS of 20% (20 vs 40 ± 20, p = 0.048). In the other groups, no significant changes in KPS were observed. Adjuvant radiotherapy was associated with better survival (44 [84.6%] vs. 32 [36.4%]; hazard ratio [HR], 0.0363; confidence interval [CI], 0.197-0.670, p = 0.00199). Adjuvant chemotherapy and immunotherapy resulted in prolonged survival (24 [46.2%] vs. 12 [13.6%]; HR 0.474, CI 0.263-0.854, p = 0.013]. Systemic disease progression was associated with poor survival (36 [50%] vs. 71 [80.7%]; HR 5.975, CI 2.610-13.677, p < 0.001]. Neurosurgical resection is an appropriate treatment modality for patients with low KPS. Surgery may improve functional status and facilitate further tumor-specific treatment. Combined treatment with adjuvant radiotherapy and systemic therapy was associated with improved survival in this cohort of patients. Systemic tumor progression has been identified as an independent factor for a poor prognosis. There is almost no information regarding surgical and adjuvant treatment in patients with low KPS. Our paper provides novel data on clinical outcome and survival analysis of patients with BM who underwent surgical treatment.

SURG-18. ONCO-FUNCTIONAL OUTCOME AFTER RESECTION FOR ELOQUENT GLIOBLASTOMA (GLIOFO STUDY): A PROPENSITY-SCORED ANALYSIS OF AN INTERNATIONAL, MULTICENTER COHORT STUDY

Abstract BACKGROUND Minimizing residual tumor volume and preventing functional loss are the primary goal in glioblastoma resections in eloquent areas. However, their combined impact on patient outcomes remains poorly understood. We therefore developed a novel onco-functional outcome (OFO) classification and evaluated its benefit in subgroups based on age, preoperative neurological morbidity (NIHSS), and preoperative Karnofsky Performance Score (KPS). METHODS Propensity-score matching was used to match OFO 1 (no residual volume, no postoperative functional loss) vs. non-OFO 1 patients for the overall cohort and subgroups based on age, NIHSS, and KPS. Cox proportional-hazard regressions were performed to analyze the association between OFO class and postoperative neurological deficits, KPS deterioration, receipt of adjuvant therapy, overall survival, and progression-free survival. Logistic regressions were performed to analyze the predictive value of perioperative factors on OFO class. Findings Between 2010 and 2020, 858 patients with tumor resection for primary eloquent glioblastoma were included as the overall unmatched cohort. After matching, the overall matched cohort comprised of 512 patients: 256 received OFO 1 and 256 received non-OFO 1. In the overall matched cohort and matched subgroups, OFO 1 resulted in fewer postoperative neurological deficits, lower rates of postoperative KPS deterioration, higher rates of receipt of adjuvant therapy, longer overall survival (median 21.0 months vs. 13.0 months, p &amp;lt; 0.001), and longer progression-free survival (median 10.0 months vs. 7.5 months, p &amp;lt; 0.001). Patients who underwent awake craniotomy more often received OFO 1 (43.0% vs. 26.9%, p &amp;lt; 0.001), and awake craniotomy was an independent predictor for OFO 1 (OR 1.93, p = 0.0070). Interpretation OFO 1 is beneficial in patients with glioblastoma in eloquent areas to improve surgical outcomes, irrespective of age, preoperative NIHSS, or KPS. Furthermore, awake craniotomy was significantly associated with achieving this status. These results might aid neurosurgeons with their surgical decision making in individual patients.

CTNI-40. A MULTICENTER, RETROSPECTIVE ANALYSIS OF PROGNOSTIC FACTORS IN INTRACRANIAL H3 K27M-MUTANT DIFFUSE MIDLINE GLIOMA IN ADULTS

Abstract H3 K27M-mutant glioma were first described as a new grade IV entity in the 2016 WHO classification. Current studies have focused on its common pediatric appearance, increasing the need to better understand this entity in adults. Here we report a multicentric, retrospective analysis of 70 diffuse midline glioma in adults. We included molecularly confirmed H3K27M-mutant glioma in patients &amp;gt;18 years of age between 2015-2022. Clinical-, radiological- and surgical features were analyzed. Univariate and multivariate analyses were then performed to identify prognostic factors. The study was approved by the ethics committee (PV4904). Overall, 70 patients were identified, with a mean age of 36.13 years at the initial diagnosis. Median overall survival was 13.62 + 14 months. H3K27M-mutated glioma showed a midline involvement in 61.4%. Clinically, obstructive hydrocephalus was observed in almost half of the patients (46.3%). Gross total resection (GTR) was achieved in 14.5% of all patients. 30.4% had a subtotal resection (STR), and 55.1% received a biopsy. Intraoperative cryo-section resulted in low-grade glioma in 25%, high-grade glioma in 63.9% and no tumor in 11.1%. Tumors located in telencephalon/diencephalon/myelencephalon were associated with a poorer OS, while a location site in the mesencephalon/metencephalon showed a significantly longer survival (8.3 vs. 16.2 months, p = 0.009). Preoperative Karnofsky Performance Score (KPS) below 80 showed a reduced OS (6 vs. 11.24 months, p = 0.03). Patients, who received resection (GTR/STR) showed no significant survival benefit compared with biopsied patients (9.6 vs. 8 months, p = 0.4817). The present study describes surgical features of DMG with H3K27M mutation in one of the most extensive multicentric studies to date in adult patients. Our data show that location and preoperative KPS impact OS significantly in DMG. Furthermore, in our dataset resection of K27M-mutated glioma provided no significant survival benefit compared with biopsy.

SURG-11. RISKS AND BENEFITS OF REPEATED RESECTION FOR GLIOBLASTOMA: A SINGLE INSTITUTION REVIEW OF CHARACTERISTICS AND OUTCOMES OF RESECTION OF RECURRENT GLIOBLASTOMA

Abstract Maximal safe resection is standard for newly diagnosed glioblastoma, but for recurrent glioblastoma the value of resection is less clear. We performed a retrospective, single-institution analysis of sequential patients undergoing re-resection for recurrent glioblastoma and analyzed pre-operative risk factors, progression free and overall survival from time of re-resection to death or last follow-up (PFS/OS), and complication rates. Between 2017 and 2022, 38 patients underwent re-resection of glioblastoma (defined by 2016 WHO criteria, 86.8% IDH wild type) and were followed for an average of 157 weeks (range 17-553). The cohort had a mean age of 59.4 years (range 39-87), was 55% male, and included 68.4% MGMT unmethylated tumors. Preoperatively, median Karnofsky Performance Score (KPS) was 80 (range 50-100), and median modified frailty index (mFI-5) was 0 (range 0-4). Re-resection occurred an average of 55.3 weeks after initial resection (SD 59.6, range 5-314), 25.0 weeks after chemotherapy (SD 51.8), and 39.9 weeks after radiation (SD 45.1). Mean OS after re-resection was 67.4 weeks (SD 91.5, range 1-505 weeks), median 59.5 weeks. Average PFS was 24.5 weeks (SD 25.3, range 1-139). The complication rate was 34.2% (n = 15), including 6 patients (15.8%) with a wound infection and 5 (13.1%) with symptomatic hemorrhage. 12 (31.6%) patients had a new neurologic deficit. Postoperative KPS was lower than preoperative KPS (p = .002). Patients with &amp;lt;20 weeks between surgeries, mFI &amp;gt;1, or KPS &amp;lt;80 had higher rates of complications (respectively p = .04, p = .03, p = .03). Patients with mFI &amp;gt;1 or KPS &amp;lt;70 were more likely to die within 30-days of surgery (respectively p = .014; p = .018). Re-resection demonstrated a survival benefit, especially for patients younger than 65 with a mFI of &amp;lt; 2. Though complications were common, post-operative complications were not associated with a shorter overall survival. Consideration for age, frailty, KPS, and timing of surgery may guide selection of patients for re-resection.

NCOG-12. SURVIVAL OF THE ELDERLY: OUTCOMES OF VERY OLD GLIOBLASTOMA PATIENTS – RESULTS FROM AN AUSTRIAN MULTICENTER STUDY

Abstract INTRODUCTION Glioblastoma (GBM) outcomes in very old patients remain understudied. Limited data exist on outcomes and treatment options for this specific population, necessitating further research. Materials and METHODS We retrospectively analyzed all elderly GBM patients ( &amp;gt;65 years), who underwent treatment at two Austrian academic centers from 2007 to 2021. We conducted a comparative analysis between patients aged 65-79 years (old cohort) and a cohort of patients aged over 80 years (very old cohort). RESULTS 387 patients were included, 43 of them over 80 years of age at the time of surgery. Median preoperative Karnofsky Performance Score (KPS) amounted to 80, median preoperative tumor volume was 26.44cm3. Among elderly patients 283 (75%) underwent resection and 61 (25%) only biopsy. 66.5% of the elderly cohort underwent adjuvant treatment following the EORTC protocol. 88 patients (25.6%) experienced preoperative seizures. Among the very old cohort 29 patients (67%) underwent resection and 14 (33%) biopsy only. 42.5% received adjuvant treatment, 5 patients (11.6%) presented with preoperative epilepsy. Mean PFS was 8.9 months in old patients and 8.4 months in very old patients. Kaplan Meier Analysis revealed a mean OS of 12.8 vs 10.7 months respectively. Elderly patients showed significantly better preoperative KPS (p=0.033) as well as higher preoperative tumor volumes (p=0.039). Old patients showed significantly higher incidences of both preoperative (p=0.043) and postoperative (p=0.032) epilepsy. Furthermore, old patients underwent significantly more often resection (p=0.020) and adjuvant therapy (p=0.009) compared to very old patients. However, survival analysis showed no statistic differences regarding PFS and OS between the two groups (p &amp;gt;0.05). CONCLUSION Despite preexisting unfavorable prognostic features, we could not find any significant differences between old and very old GBM patients. Hence, the treatment of glioblastoma in very old patients should adopt a more inclusive approach considering the patient's overall health status and comorbidities.

P11.83.B ONCO-FUNCTIONAL OUTCOME (OFO) AFTER RESECTION FOR ELOQUENT GLIOBLASTOMA (GLIOFO STUDY): A PROPENSITY-SCORED ANALYSIS OF AN INTERNATIONAL, MULTICENTER COHORT STUDY

Abstract BACKGROUND Minimizing residual tumor volume and preventing functional loss are the primary goal in glioblastoma resections in eloquent areas. However, their combined impact on patient outcomes remains poorly understood. We therefore developed a novel onco-functional outcome (OFO) classification and evaluated its benefit in subgroups based on age, preoperative neurological morbidity (NIHSS), and preoperative Karnofsky Performance Score (KPS). MATERIAL AND METHODS Propensity-score matching with a 1:1 ratio was used to match OFO 1 (no residual volume, no postoperative functional loss) vs. non-OFO 1 patients for the overall cohort and subgroups based on age, NIHSS, and KPS. Cox proportional-hazard regressions were performed to analyze the association between OFO class and postoperative neurological deficits, KPS deterioration, receipt of adjuvant therapy, overall survival, and progression-free survival. Logistic regressions were performed to analyze the predictive value of perioperative factors on OFO class. RESULTS Between Jan 1, 2010, and Oct 31, 2020, 3919 patients were recruited, of whom 858 with tumor resection for primary eloquent glioblastoma were included in analyses as the overall unmatched cohort. After propensity-score matching, the overall matched cohort comprised of 512 patients, of whom 256 received OFO 1 and 256 received non-OFO 1. In the overall matched cohort and matched subgroups, OFO 1 resulted in fewer postoperative neurological deficits at 6 weeks postoperatively (overall cohort: 10.2% vs. 25.8%, p &amp;lt;0.001), 3 months postoperatively (overall cohort: 12.7% vs. 9.9%, p &amp;lt;0.001), and 6 months postoperatively (overall cohort: 21.0% vs. 35.1%, p = 0.0010), lower rates of KPS deterioration at 3 months (overall cohort: 14.2% vs. 52.4%, p &amp;lt;0.001), and 6 months postoperatively (overall cohort: 26.5% vs. 52.9%, p&amp;lt;0.001), higher rate of receipt of adjuvant therapy (overall cohort: HR 3.91 [2.19-7.62], p &amp;lt;0.001), longer overall survival (overall cohort: median 21.0 months [19.0-25.0] vs. 13.0 months 12.0-15.5], p&amp;lt;0.001), and longer progression-free survival (overall cohort: median 10.0 months [9.0-11.0] vs. 7.5 months [6.0-8.0], p&amp;lt;0.001). Patients who underwent awake craniotomy more often received OFO 1 (43.0% vs. 26.9%, p &amp;lt;0.001), and awake craniotomy was an independent predictor for OFO 1 (OR 1.93, p = 0.0070). CONCLUSION OFO 1 is beneficial in patients with glioblastoma in eloquent areas to improve surgical outcomes, irrespective of age, preoperative NIHSS, or KPS, in terms of survival outcomes, functional outcomes, and receipt of adjuvant therapy. Furthermore, awake craniotomy was significantly associated with achieving this status. These results might aid neurosurgeons with their surgical decision making in individual patients, and they will be validated in the SAFE trial (NCT03861299) and the PROGRAM study (NCT04708171).

Evaluating Predictors of Successful Postoperative Day 1 Discharge Following Posterior Fossa Tumor Resection

Current trends in surgical neuro-oncology show that early discharges are safe and feasible with shorter lengths of stay (LOS) and fewer thromboembolic complications, fewer hospital-acquired infections, reduced costs, and greater patient satisfaction. Traditionally, infratentorial tumor resections have been associated with longer LOS and limited data exists evaluating predictors of early discharge in these patients. The objective was to assess patients undergoing posterior fossa craniotomies for tumor resection and identify variables associated with postoperative day 1 (POD1) discharge. A retrospective review of posterior fossa craniotomies for tumor resection at our institution was performed from 2011 to 2020. Laser ablations, non-tumoral pathologies, and biopsies were excluded. Demographic, clinical, surgical, and postoperative data were collected. 173 patients were identified and 25 (14.5%) were discharged on POD1. Median length of stay was 6 days. The POD1 discharges had significantly better preoperative Karnofsky performance scores (p<0.001) and modified Rankin scores (p=0.002) and more frequently presented electively (p=0.006) and without preoperative neurologic deficits (p=0.021). No statistically significant difference in 30-day readmissions and rates of PE, UTI, and DVT was found. Univariate logistic regression identified better preoperative functional status, elective admission, and lack of preoperative hydrocephalus as predictors of POD1 discharge, however only the latter remained significant in the multivariable model (p=0.001). Discharging patients on POD1 is feasible following posterior fossa tumor resection in a select group of patients. Although we found that the only independent predictor for a longer LOS was preoperative hydrocephalus, larger, prospective studies are needed to confirm these findings.

Clinical characteristics of 13 cases with entrapped temporal horn syndrome and efficacy of refined temporal-to-frontal horn shunt

Thirteen consecutive patients with entrapped temporal horn syndrome in the Department of Neurosurgery of Beijing Tiantan Hospital from February 2018 to September 2022 were retrospectively analyzed, and there were 5 males and 8 females, with a mean age of (43±21) years. Increased intracranial pressure caused by hydrocephalus was the main clinical symptom. All the patients underwent refined temporal-to-frontal horn shunt, and all the symptoms were improved after surgery. Postoperative Karnofsky performance score (KPS) [90 (90, 100)] was higher than preoperative KPS [57 (40, 70)] (P=0.001). However, postoperative entrapped temporal horn volume [13.85 (8.90, 15.25) cm3] decreased, compared with preoperative volume [66.52 (38.65, 88.65) cm3] (P=0.001). Likewise, postoperative midline shift [0.77 (0, 1.50) mm] was longer than preoperative midline shift [6.69 (2.50, 10.00) mm] (P=0.002). No surgery-related complications were observed after the operation. Therefore, the refined temporal-to-frontal horn shunt is safe and effective treatment for entrapped temporal horn syndrome, with favorable outcomes.

Craniofacial malignant tumors, their extensions, and surgical strategy for their treatment

Purpose: To identify extension routes of craniofacial malignancies and formulate a surgical treatment plan based thereupon. Material and Methods: We retrospectively reviewed the medical records of 253 patients with craniofacial malignancies who underwent surgical treatment at the Romodanov Neurosurgery Institute from 2002 through 2022. Of the 253 patients, 112 had a primary tumor, and 141, a secondary tumor. Preoperative Karnofsky performance scores ranged from 50 to 70 points. Patients underwent neurological and ophthalmological status assessment, as per routine protocols. Results: Epithelial malignancies were the most common (53.7%), whereas anaplastic meningioma and embryonal malignancies were rather uncommon (1.2% and 0.4%, respectively) craniofacial malignancies. The presence of certain clinical symptoms was associated primarily with tumor origin and extension. A high rate of general brain and rhinological symptoms in our study sample was caused by a high percentage of intracranial and paranasal sinus tumors. Craniofacial malignancies most commonly originate from the midline (particularly, anterior midline skull base). Ethmoidal labyrinth was the most common site of origin (45.0%), followed by a sphenoid sinus (12.2%), pterygopalatine and infratemporal fossae (9.9%), whereas the cavernous sinus and olfactory fossa were the least common sites of origin (0.4% and 1.2%, respectively). Craniofacial tumors extended most commonly intracranially (transdurally, epidurally, via adhesion to the dura mater, and/or cavernous sinus growth) or intraorbitally. Anterior craniofacial resection (bifrontal craniotomy with combined with either lateral rhinotomy or supraorbital advancement; or a subcranial approach) was the most common surgical treatment. Postoperative cerebrospinal fluid rhinorrhea and infectious complications (meningitis and meningoencephalitis) were the most frequent complications. The overall postoperative mortality rate was 2.0%. Conclusion: First, compared to the transcranial and facial approaches, the craniofacial resection is advantageous in terms of the radicality of tumor excision. Second, the subcranial approach is preferable to the bifrontal approach in the presence of marked extracranial tumor component, whereas the transbasal Derome approach is effective in the presence of marked extracranial and/or intracranial tumor components. Finally, both the orbitozygomatic and infratemporal approaches allow for the radicality of excision of lateral skull base malignancies, but the latter approach is associated with a lower rate of complications.

Risk factors analysis of clinical features with surgical resection rate and prognosis of petroclival meningioma with main body in posterior fossa

ObjectiveOur retrospective study aimed to investigate the relation of clinical features with surgical resection degree and prognosis of petroclival meningioma (PCM) whose main body in the posterior fossa and summarized the experience of surgery. We worked on improving the cure rate of PCM patients from both clinical data analysis and surgical experience. MethodsWe retrospectively analyzed 62 patients of the main body of PCM locating in the posterior fossa. Clinical data included basic information of patients, video of surgery, and post-operation follow-up. Clinical results were evaluated by Karnofsky Performance Score (KPS). The degree of surgical resection was evaluated by Simpson grade. Tumor resection degree and postoperative complications were performed by univariate and multivariate analyses. ResultsThe analyses showed gross total resection achieved in 50 cases (81.97%), and subtotal resection in 11 cases (18.03%). There were 38 cases (62%) without complications after operation. The preoperative KPS score of 19 cases were ≥ 80, and the postoperative KPS score of 51 cases were ≥80. The results showed that resection degree and quality of life were connected to Edema and adhesion of the brainstem, and postoperative complications were associated with age, tumor size and wrap of vessel. ConclusionsEdema and adhesion of the brainstem caused by tumor compression is an independent risk factor of surgical resection degree and quality of life in patients with PCM; Age, tumor size and wrap of vessel are independent risk factors of postoperative complications in patients with PCM.

Survival in patients with surgically treated brain metastases: does infratentorial location matter?

Surgical resection is a common treatment modality for brain metastasis (BM). Location of the BM might significantly impact patient survival and therefore might be considered in clinical decision making and patient counseling. In the present study, the authors analyzed infra- and supratentorial BM location for a potential prognostic difference. Between 2013 and 2019, 245 patients with solitary BM received BM resection at the authors’ neuro-oncological center. In order to produce a covariate balance for commonly-known prognostic variables (tumor entity, age, preoperative Karnofsky Performance Score, and preoperative Charlson Comorbidity Index), a propensity score matching at a ratio of 1:1 between the cohort of patients with infra- and supratentorial BM location was performed using R. Overall survival (OS) rates were assessed for both matched cohorts of patients with BM. Sixty-one of 245 patients (25%) with solitary BM exhibited an infratentorial tumor location; 184 patients (75%) suffered from supratentorial solitary BM. Patients with infratentorial BM revealed a median OS of 11 months (95% confidence interval (CI) 7.4–14.6 months). Compared with this, median OS for the group of 61 individually matched patients with solitary supratentorial solitary BM was 13 months (95% CI 10.9-15.1 months) (p = 0.32). The present study suggests that the prognostic value of infra- and supratentorial BMs does not significantly differ in patients that undergo surgery for solitary BM. These results might encourage physicians to induce surgical therapy of supra- and infratentorial BM in a similar manner.

Development of an enhanced recovery protocol after laser ablation surgery protocol: a preliminary analysis.

Enhanced recovery after surgery (ERAS) programs are a model of care that aim to improve patient outcomes, reduce complications, and facilitate recovery while reducing healthcare-associated costs and admission length. While such programs have been developed in other surgical subspecialties, there have yet to be guidelines published specifically for laser interstitial thermal therapy (LITT). Here we describe the first multidisciplinary ERAS preliminary protocol for LITT for the treatment of brain tumors. Between the years 2013 and 2021, 184 adult patients consecutively treated with LITT at our single institution were retrospectively analyzed. During this time, a series of pre, intra, and postoperative adjustments were made to the admission course and surgical/anesthesia workflow with the goal of improving recovery and admission length. The mean age at surgery was 60.7 years with a median preoperative Karnofsky performance score of 90 ± 13. Lesions were most commonly metastases (50%) and high-grade gliomas (37%). The mean length of stay was 2.4 days, with the average patient being discharged 1.2 days after surgery. There was an overall readmission rate of 8.7% with a LITT-specific readmission rate of 2.2%. Three of 184 patients required repeat intervention in the perioperative period, and there was one perioperative mortality. This preliminary study shows the proposed LITT ERAS protocol to be a safe means of discharging patients on postoperative day 1 while preserving outcomes. Although future prospective work is needed to validate this protocol, results show the ERAS approach to be promising for LITT.

Outcomes of surgical excison of mass in the eloquent areas of brain : A prospective study at National Academy of Medical Sciences, Bir Hospital

Introduction: The treatment of choice for high and low-grade gliomas is primarily surgical resection, many gliomas of highly eloquent cortical regions still are not operated because of the impending risk of surgery-related deficits. Tumors of eloquent areas like sensorial, motor and language cortex need to be operated carefully so that the symptoms don’t worsen after surgery. However, Intra operative computerized tomography (IOCT), neuronavigation including optical as well as EM (electromagnetic), Neuromonitoring, stereotaxy and awake surgery increase safety, which allows resection of most of these tumors with a considerably low rate of new deficits postoperatively. Materials and Methods: Between 2021 and 2022, a consecutive series of 30 patients who had undergone surgery for tumors on eloquent area of brain, at National Neurosurgical Referral Center (NNRC), National Academy of Medical Sciences (NAMS), Bir hospital were included in this study. Ethical approval was taken from Institutional review board (IRB) of NAMS for the study. Preoperative functional MRI, DTI scan that revealed mass in eloquent brain areas were evaluated. The preformed proforma was used to collect the data including preoperative karnofsky performance score, age, gender, clinical. Manifestations, size and location of tumor, degree of resection, pathological grade. Patient are followed postoperatively for 3 months and postoperative KPS, morbidity and mortality was recorded. SPSS version 22 was used for statistical analysis. Results: Out of these 30 lesion were 13 (43.3%) were WHO grade IV, 5 (16.6% ) were WHO grade III astrocytoma, 3 (10% ) were WHO grade III oligodendroglioma , 2 (6.6% ) were WHO grade II astrocytoma, 4 ( 13.3%) were WHO grade I astrocytoma, 2 were tuberculoma and 1 was cavernoma. Majority of the patients (70%) (n=21 out of 30) presented with seizures. The mean age of the patient was 41.7 years (ranging from 21-71 years). Male predilection was observed accounting 60 % of the cases. Conclusion: The surgery of eloquent areas of brain though carries the risk of increased post operative neurological deficit, with assistance of advanced technology and experienced surgeons it still feasible option especially for young patients with good karnosky score and low grade tumors which has improved overall survival.

OS02.7.A The role of epilepsy in elderly patients with Glioblastoma: An Austrian multicenter analysis

Abstract Background Higher age is a significant predictor of poor outcome in glioblastoma multiforme (GBM) patients. Thus, acquisition of a better understanding of additional prognostic factors in these often-frail patients is of utmost importance. Epileptic seizures correlate with improved overall survival (OS) in low-grade gliomas; however, the impact of epilepsy in GBM patients on outcome parameters is poorly defined. Furthermore, persisting epilepsy significantly influences the patients’ quality of life (QoL). This study aims at specifically evaluating the impact of epilepsy in elderly GBM patients. Material and Methods Two Austrian academic neurosurgical centers retrospectively analyzed all elderly (≥65 years) GBM patients with de-novo tumors, who underwent tumor resections between 09/2006 and 07/2021. Epidemiological, histopathological and survival data were gained from patients’ electronic charts and screened for presence of epilepsy preoperatively or during follow-up. Results 391 patients (55% males, 45% females) with a median age at surgery of 73 years (Interquartile Range (IqR) 68.5-77.5) were analyzed. The mean predicted OS was recorded to be 12.4 months (CI95% 10.9-14.0). Median preoperative Modified Rankin Scale (mRS) was 2 (IqR 1-3), and median preoperative Karnofsky performance score was 80 (IqR 60-90). Mean follow-up was 10.4 months (CI95% 9.1-11.6) in our cohort. 95/391 patients (24%) suffered from preoperative epilepsy. 17 (18%) patients still suffered from epilepsy after tumor resection with eight patients who developed new postoperative seizures, and four patients (1.0%) showed a worsening of already preoperatively diagnosed seizures. Major surgery-associated neurological complications included new motor deficits in 29 (7%) and new aphasia in 16 (4%) patients. Logistic regression showed, patients with seizures had significantly lower mRS (OR=0.735 [CI95% 0.563 0.961], p=0.032) and less frequently occipital tumor location (OR=0.347 [CI95% 0.152-0.791], p=0.018). Postoperative epilepsy resulted in significantly prolonged hospitalization after the surgery (OR=2.622[CI95% 1.496-3.979], p=0.009). Survival did not correlate with preoperative epilepsy (p&amp;gt;0.05). However, Cox regression revealed that multifocal tumor location (HR=1.777 [CI95% 1.197-2.639], p=0.025) as well as thalamic involvement (HR=11.121 [CI95% 3.431-36,046], p=0.030) negatively influenced OS. Furthermore, surgery-associated complications shortened OS significantly (HR=1.945 [CI95% 1,296-2,916], p=0.025). Conclusion Even though epilepsy was not found to directly impact survival in elderly GBM patients, we found that surgery led to epilepsy freedom in a significant proportion of our patient cohort, thereby potentially leading to improved QoL. Greatest focus should be set on avoiding any surgery-associated deficits, since these severely influence the OS.

P66. Does functional outcome improve after surgery for metastatic spine tumors in patients with SINS 7-12 and SINS >12?

P66. Does functional outcome improve after surgery for metastatic spine tumors in patients with SINS 7-12 and SINS >12?

Effect of awake craniotomy in glioblastoma in eloquent areas (GLIOMAP): a propensity score-matched analysis of an international, multicentre, cohort study.

Awake mapping has been associated with decreased neurological deficits and increased extent of resection in eloquent glioma resections. However, its effect within clinically relevant glioblastoma subgroups remains poorly understood. We aimed to assess the benefit of this technique in subgroups of patients with glioblastomas based on age, preoperative neurological morbidity, and Karnofsky Performance Score (KPS). In this propensity score-matched analysis of an international, multicentre, cohort study (GLIOMAP), patients were recruited at four tertiary centres in Europe (Erasmus MC, Rotterdam and Haaglanden MC, The Hague, Netherlands, and UZ Leuven, Leuven, Belgium) and the USA (Brigham and Women's Hospital, Boston, MA). Patients were eligible if they were aged 18-90 years, undergoing resection, had a histopathological diagnosis of primary glioblastoma, their tumour was in an eloquent or near-eloquent location, and they had a unifocal enhancing lesion. Patients either underwent awake mapping during craniotomy, or asleep resection, as per treating physician or multidisciplinary tumour board decision. We used propensity-score matching (1:3) to match patients in the awake group with those in the asleep group to create a matched cohort, and to match patients from subgroups stratified by age (<70 years vs ≥70 years), preoperative National Institute of Health Stroke Scale (NIHSS) score (score of 0-1 vs ≥2), and preoperative KPS (90-100 vs ≤80). We used Cox proportional hazard regressions to analyse the effect of awake mapping on the primary outcomes including postoperative neurological deficits (measured by deterioration in NIHSS score at 6 week, 3 months, and 6 months postoperatively), overall survival, and progression-free survival. We used logistic regression to analyse the predictive value of awake mapping and other perioperative factors on postoperative outcomes. Between Jan 1, 2010, and Oct 31, 2020, 3919 patients were recruited, of whom 1047 with tumour resection for primary eloquent glioblastoma were included in analyses as the overall unmatched cohort. After propensity-score matching, the overall matched cohort comprised 536 patients, of whom 134 had awake craniotomies and 402 had asleep resection. In the overall matched cohort, awake craniotomy versus asleep resection resulted in fewer neurological deficits at 3 months (26 [22%] of 120 vs 107 [33%] of 323; p=0·019) and 6 months (30 [26%] of 115 vs 125 [41%] of 305; p=0·0048) postoperatively, longer overall survival (median 17·0 months [95% CI 15·0-24·0] vs 14·0 months [13·0-16·0]; p=0·00054), and longer progression-free survival (median 9·0 months [8·0-11·0] vs 7·3 months [6·0-8·8]; p=0·0060). In subgroup analyses, fewer postoperative neurological deficits occurred at 3 months and at 6 months with awake craniotomy versus asleep resection in patients younger than 70 years (3 months: 22 [21%] of 103 vs 93 [34%] of 272; p=0·016; 6 months: 24 [24%] of 101 vs 108 [42%] of 258; p=0·0014), those with an NIHSS score of 0-1 (3 months: 22 [23%] of 96 vs 97 [38%] of 254; p=0·0071; 6 months: 27 [28%] of 95 vs 115 [48%] of 239; p=0·0010), and those with a KPS of 90-100 (3 months: 17 [19%] of 88 vs 74 [35%] of 237; p=0·034; 6 months: 24 [28%] of 87 vs 101 [45%] of 223, p=0·0043). Additionally, fewer postoperative neurological deficits were seen in the awake group versus the asleep group at 3 months in patients aged 70 years and older (two [13%] of 16 vs 15 [43%] of 35; p=0·033; no difference seen at 6 months), with a NIHSS score of 2 or higher (3 months: three [13%] of 23 vs 21 [36%] of 58; p=0·040) and at 6 months in those with a KPS of 80 or lower (five [18%] of 28 vs 34 [39%] of 88; p=0·043; no difference seen at 3 months). Median overall survival was longer for the awake group than the asleep group in the subgroups younger than 70 years (19·5 months [95% CI 16·0-31·0] vs 15·0 months [13·0-17·0]; p<0·0001), an NIHSS score of 0-1 (18·0 months [16·0-31·0] vs 14·0 months [13·0-16·5]; p=0·00047), and KPS of 90-100 (19·0 months [16·0-31·0] vs 14·5 months [13·0-16·5]; p=0·00058). Median progression-free survival was also longer in the awake group than in the asleep group in patients younger than 70 years (9·3 months [95% CI 8·0-12·0] vs 7·5 months [6·5-9·0]; p=0·0061), in those with an NIHSS score of 0-1 (9·5 months [9·0-12·0] vs 8·0 months [6·5-9·0]; p=0·0035), and in those with a KPS of 90-100 (10·0 months [9·0-13·0] vs 8·0 months [7·0-9·0]; p=0·0010). No difference was seen in overall survival or progression-free survival between the awake group and the asleep group for those aged 70 years and older, with NIHSS scores of 2 or higher, or with a KPS of 80 or lower. These data might aid neurosurgeons with the assessment of their surgical strategy in individual glioblastoma patients. These findings will be validated and further explored in the SAFE trial (NCT03861299) and the PROGRAM study (NCT04708171). None.

Recurrent brain metastases: the role of resection of in a comprehensive multidisciplinary treatment setting

BackgroundTreatment decision for recurrent symptomatic brain metastases (BM) is challenging with scarce data regarding surgical resection. We therefore evaluated the efficacy of surgery for pretreated, recurrent BM in a comprehensive multidisciplinary treatment setting.MethodsIn a retrospective single center study, patients were analyzed, who underwent surgical resection of recurrent BM between 2007 and 2019. Intracranial event-free survival (EFS) and overall survival (OS) were evaluated by Kaplan-Maier and Cox regression analysis.ResultsWe included 107 patients with different primary tumor entities and individual previous treatment for BM. Primary tumors comprised non-small cell lung cancer (NSCLC) (37.4%), breast cancer (19.6%), melanoma (13.1%), gastro-intestinal cancer (10.3%) and other, rare entities (19.6%). The number of previous treatments of BM ranged from one to four; the adjuvant treatment modalities comprised: none, focal or whole brain radiotherapy, brachytherapy and radiosurgery. The median pre-operative Karnofsky Performance Score (KPS) was 70% (range 40–100) and improved to 80% (range 0-100) after surgery. The complication rate was 26.2% and two patients died during the perioperative period. Sixty-seven (62.6%) patients received postoperative local radio-oncologic and/or systemic therapy. Median postoperative EFS and OS were 7.1 (95%CI 5.8–8.2) and 11.1 (95%CI 8.4–13.6) months, respectively. The clinical status (postoperative KPS ≥ 70 (HR 0.27 95%CI 0.16–0.46; p < 0.001) remained the only independent factor for survival in multivariate analysis.ConclusionsSurgical resection of recurrent BM may improve the clinical status and thus OS but is associated with a high complication rate; therefore a very careful patient selection is crucial.

Surgical Outcome Analysis of Large and Giant Petroclival Meningiomas with Special Reference to Quality of Life Issues.

Management strategies for petroclival menigiomas remain controversial. We share our experience in management of large and giant true petroclival meniongiomas with special emphasis on patient reported quality of life parameters. This is a single center study of 47 patients between 2008 and 2018. All patients were checked for tumor specific parameters, clinical parameters, extent of surgical excision, and outcome, as assessed by Karnofsky performance score (KPS), Glasgow outcome score, clinical status, and by SF-36 questionnaire. 32/47 patients' data were assessed. Symptoms included headache (62.5%), involvement of 5th nerve (47%), facial nerve (40.6%), lower cranial nerves (37.5%), cerebellar signs (84%), and long tract signs in (50%) of patients. The mean preoperative KPS was 83.75+/-6.59. Surgical approaches included retromastoid suboccipital craniotomy (50%), Kawase's approach (31.25%), and others in 18.25% patients. 40.625% (n = 13) had a gross total excision, near total resection (NTR) was achieved in 53.125% (n = 17), and 6.25% (n = 2) had a subtotal excision (STE). In 13 patients who had gross total resection (GTR), there were 12 (70.5%) new neurological deficits, while among the 19 patients with NTR, only 5 (29.5%) new neurological deficits were seen. No new onset neurological deficit was seen in patients with STE of tumor. Patient assessed QoL parameters were worse in patients with GTR and best in patients with NTR/STE + GKRS. In patients of large/giant petroclival meningiomas, NTE/STE with adjuvant GKRS provided better preservation of quality of life.