Brain Tumor Resection Research Articles

Clinical significance of intraoperative bidirectional corticocortical evoked potential monitoring to evaluate language function.

Awake craniotomy is commonly used to resect lesions located near the language area during brain surgery. However, it is often difficult to perform language tasks due to several limitations such as difficulty in awakening during surgery and intraoperative seizures. This study investigated the clinical significance of bidirectional corticocortical evoked potential (CCEP) monitoring as a new approach to evaluate intraoperative language function. This study enrolled 12 patients who underwent awake brain tumor resection with intraoperative CCEP monitoring to assess language function. Electrodes were placed on the frontal and temporoparietal lobes based on the location of the arcuate fasciculus identified with preoperative diffusion tensor imaging to measure CCEPs intraoperatively in two directions: from the frontal lobe to the temporoparietal lobe of the language-dominant side, and vice versa. Correlations between CCEP amplitudes or latencies before and after tumor removal in each direction and postoperative language function assessed with the Western Aphasia Battery were analyzed. Nine of the 12 patients showed language-related CCEP responses in both directions before, during, and after tumor removal. One patient who showed decreased CCEP amplitudes in both directions after tumor removal exhibited aphasia for as long as 1 month postoperatively. In contrast, of the 6 patients whose CCEP amplitude in only a single direction was reduced or disappeared, 4 had no deterioration of language function and the other 2 had temporary deterioration of language function during the 1st postoperative week, which improved by 1 month postoperatively. This study indicated that bidirectional CCEP measurement may increase the precision of intraoperative language function monitoring.

Frailty Predicts Failure to Rescue following Malignant Brain Tumor Resection: A NSQIP Analysis of 14,721 Patients (2012- 2020).

Failure to rescue (FTR) is defined as mortality within 30 days following a major complication. While FTR has been studied in various brain tumor resections, its predictors in malignant brain tumor resection (mBTR) remain unexplored. This study aims to identify FTR predictors in mBTR resection patients using a frailty-driven model. Patients undergoing craniotomy for mBTR were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2012- 2020), with frailty measured by the Risk Analysis Index (RAI). Of 14,721 mBTR patients, 1,275 (8.66%) developed major postoperative complications, and 166 (13.01%) experienced FTR. The cohort's median age was 59, interquartile range (47-68). Multivariate analysis revealed non-elective surgery (OR: 1.48, 95% CI: 1.02-2.16, p<.05) as an independent risk factor for FTR. Frailty was a significant independent predictor of FTR with mBTR, with both frail (N=110) and very frail (N=22) patients having a 5.34-fold and 8.10-fold higher odds of FTR, respectively (p<.001). Expectedly, major postoperative complications were predictive of FTR, including unplanned intubation (OR: 2.56, CI: 1.66-3.95, p<.001), prolonged ventilation (OR: 2.00, CI: 1.37-3.14, p<.01), cardiac arrest (OR: 16.64, CI: 8.20-33.74, p<.001), and septic shock (OR: 2.08, CI: 1.10-3.91, p<.05). The RAI-driven frailty model demonstrated excellent discriminatory accuracy for predicting FTR patients undergoing mBTR (c-statistic: 0.82, 95% CI: 0.79-0.85). Preoperative RAI-measured frailty, alongside non-elective surgery and major postoperative complications were significant predictors of FTR in mBTR patients. Identifying mBTR patients at risk for FTR using frailty strata may aid in preoperative neurosurgical risk stratification to optimize patients prior to surgery.

Image Quality Assessment and Reliability Analysis of Artificial Intelligence-Based Tumor Classification of Stimulated Raman Histology of Tumor Biobank Samples.

Stimulated Raman histology (SRH) is a label-free optical imaging method for rapid intraoperative analysis of fresh tissue samples. Analysis of SRH images using Convolutional Neural Networks (CNN) has shown promising results for predicting the main histopathological classes of neurooncological tumors. Due to the relatively low number of rare tumor representations in CNN training datasets, a valid prediction of rarer entities remains limited. To develop new reliable analysis tools, larger datasets and greater tumor variety are crucial. One way to accomplish this is through research biobanks storing frozen tumor tissue samples. However, there is currently no data available regarding the pertinency of previously frozen tissue samples for SRH analysis. The aim of this study was to assess image quality and perform a comparative reliability analysis of artificial intelligence-based tumor classification using SRH in fresh and frozen tissue samples. In a monocentric prospective study, tissue samples from 25 patients undergoing brain tumor resection were obtained. SRH was acquired in fresh and defrosted samples of the same specimen after varying storage durations at -80 °C. Image quality was rated by an experienced neuropathologist, and prediction of histopathological diagnosis was performed using two established CNNs. The image quality of SRH in fresh and defrosted tissue samples was high, with a mean image quality score of 1.96 (range 1-5) for both groups. CNN analysis showed high internal consistency for histo-(Cα 0.95) and molecular (Cα 0.83) pathological tumor classification. The results were confirmed using a dataset with samples from the local tumor biobank (Cα 0.91 and 0.53). Our results showed that SRH appears comparably reliable in fresh and frozen tissue samples, enabling the integration of tumor biobank specimens to potentially improve the diagnostic range and reliability of CNN prediction tools.

Patient-derived glioma organoids real time identification of IDH mutation, 1p/19q-codeletion and CDKN2A/B homozygous deletion with differential ion mobility spectrometry.

Extent of brain tumor resection continues to be one of the central decisions taken during standard of care in glioma patients. Here, we aimed to evaluate the most essential molecular factors, such as IDH (isocitrate dehydrogenase) mutation in gliomas classification with patient-derived glioma organoids (PGOs) using differential mobility spectrometry (DMS). we prospectively recruited 12 glioma patients, 6 IDH-mutated and 6 IDH wild-type tumors, from which PGOs were generated ex-vivo. Altogether, 320 PGOs DMS spectra were analyzed with a classifier algorithm based on linear discriminant analysis (LDA). LDA model classification accuracy (CA) obtained between IDH-mutant and IDH wild-type PGOs was 90% (91% sensitivity and 89% specificity). Furthermore, 1p/19q codeletion classification within IDH mutant PGOs reached 98% CA (93% sensitivity and 99% specificity), while CDKN2A/B homozygous loss status had 86% CA (63% sensitivity 93% specificity). DMS suitability to differentiate IDH-mutated PGOs was thus validated in ex vivo cultured samples, PGOs. Preliminary results regarding 1p/19q codeleted PGOs and CDKN2A/B loss PGOs identification endorse testing in a prospective intraoperative glioma patient cohort. Our results reveal a sample classification set-up that is compatible with real-time intraoperative surgery guidance.

Concordance of Extent of Resection Between Intraoperative Ultrasound and Postoperative MRI in Brain and Spine Tumor Resection.

Objective Evaluate the utility of intraoperative ultrasound (IOUS) in brain and spinal tumor resections and the concordance of the extent of resection between IOUS and postoperative magnetic resonance imaging (MRI). Methods A retrospective analysis of prospectively collected data was performed. Thirty-nine lesions (36 patients) in the brain and spine were operated on for resection using IOUS between May 2020 and December 2022. All patients who underwent brain or spinal tumor resection were included, and who underwent IOUS during tumor resection and postoperative MRI was done within 48 hours of surgery. The Cohen's kappa coefficient was performed to the concordance of resection by IOUS and postoperative MRI. Results Forty-one patients underwent surgery, of which 36 met the inclusion criteria and five were excluded due to incomplete clinical records. Of the 36 patients included, two presented lesions in different locations, one with frontal and parietal metastases and the other with extradural and intradural spinal lesions, and one patient had a recurrence of glioblastoma, for which 39 procedures were included. Of the 36 patients, 36% were women, and the average age was 51.4 years with an age range of one year and two months to 94 years. The concordance of the degree of resection by ultrasound and the degree of resection by postoperative magnetic resonance is high. Conclusions The higher degree of concordance between IOUS and postoperative MRI would suggest that IOUS is a reliable tool for assessing the extent of tumor resection during surgery and provides real-time information to make decisions to adjust surgery plans based on the benefit/risk ratio.

Detection of face motor activation in the precentral gyrus with functional thermography following inconclusive direct electrical stimulation mapping: illustrative case.

The leading method of identifying critical functional regions during brain tumor resection is direct electrical stimulation (DES). In awake craniotomy patients, DES employs electric current to induce functional responses or task inhibition. In contrast, thermography uses infrared imaging to detect regions of increased blood flow from patient tasks, inferring the location of functional activity similarly to blood oxygen level-dependent (BOLD) functional magnetic resonance imaging (fMRI). DES seldom produces no detectable response, but the case herein is an example featuring the subsequent use of thermography. The authors present the case of a 40-year-old male in whom awake craniotomy DES for high-grade glioma re-resection produced no detectable response at the upper levels of tolerated current amplitude. Following inconclusive DES, infrared thermography was performed with a lip-pursing task, and face motor activation was thermally detected in regions corroborated by both preoperative BOLD fMRI and literature on BOLD fMRI face motor mapping. The lack of a detectable DES response was attributed to significant peritumoral edema, as evidenced by preoperative fluid-attenuated inversion recovery MRI. Findings indicate that infrared thermography overcomes the limitations of DES in an extensive edema setting and that thermography offers a useful complement to standard cortical mapping protocols for resection planning. https://thejns.org/doi/10.3171/CASE24549.

EXTH-28. DEVELOPING A NOVEL INJECTABLE IMMUNOTHERAPEUTIC GEL FOR ENCAPSULATION OF NATURAL KILLER CELLS FOR POST-SURGICAL GLIOBLASTOMA TREATMENT

Abstract Malignant brain tumors are one of the leading causes of death among all cancers. Approximately 40,000 people are diagnosed with malignant brain tumors every year. Among these patients, 15,000 cases are glioblastoma (GBM) with a very poor prognosis; even after aggressive surgical resection and adjuvant chemo/radiotherapy, the median survival is only 14.6 months. The major reason for poor prognosis is the blood-brain barrier, which prevents therapeutic agents from reaching the target area. Therefore, there are only a few choices of drugs available for brain tumor treatment. To date, temozolomide (TMZ) and the Gliadel wafer have been clinically used as standard chemotherapy agents after brain tumor resection. However, drug resistance to TMZ and the poor drug diffusion rate of the Gliadel wafer still result in ineffective suppression of residual cancer cells. To overcome the above-mentioned difficulties in clinical brain tumor treatment, in situ self-crosslinking multifunctional hydrogels was developed to carry natural killer cells (NK cells) and radiosensitizers as a novel brain tumor treatment system. Unlike traditional hydrogels catalyzed by pH value or temperature, this new system is stable and consistent as an immune cell carrier. We used fibrinogen, thrombin, and alginic acid as the backbone of the in situ self-crosslinking hydrogel, tested the properties of the synthesized hydrogel, and analyzed the gel-formation time and swelling rate. The release rate of NK cells was also examined. In a brain tumor animal model, the use of hydrogel-NK cells significantly inhibited tumor proliferation and prolonged animal survival time. In conclusion, this therapeutic hydrogel carrying NK cells can serve as a novel post-operation adjuvant therapeutic tool for malignant brain tumors.

Coping with an awake brain tumour resection in patients and their primary contacts: a qualitative study

Abstract Background The diagnosis and awake removal of a brain tumour is a major life event. A better understanding of the needs of this group of patients and their primary contacts in the perioperative trajectory can further improve care. Methods Adult patients who underwent an awake craniotomy in the Erasmus MC, the Netherlands, and their primary contacts were interviewed 1-2 weeks prior to surgery and 2-4 weeks after surgery. Semi-structured interviews on the impact of the diagnosis on their lives and coping mechanisms with the AC-procedure were conducted. Interview transcripts were analyzed in accordance with the principles of grounded theory. Results 21 patients and 19 primary contacts were interviewed at least once during this period. Analyses and coding of the transcripts resulted in a conceptual model, distinguishing coping with the disease and coping with specific procedure of awake craniotomy. In general, participants tended to rely on their pre-existing ways of coping. Situation specific coping mostly referred to perceiving control, and related to that, trust in the medical team. Conclusion Patients with a brain tumour and their primary contacts perceive coping with the AC-procedure as a part of coping with the disease. Although the procedure may be perceived as stressful, at the same time it offers hope and prospect. In coping with the specifics of the AC-procedure, we found that feeling in control and as an extension of that, trust in the AC-team were key aspects.

Predicting Postoperative Motor Function After Brain Tumor Resection With Motor Evoked Potential Monitoring Using Decision Tree Analysis.

Background Motor evoked potential (MEP) monitoring is a commonly employed method in neurosurgery to prevent postoperative motor dysfunction. However, it has low prediction accuracy for postoperative paralysis. This study aimed to develop a decision tree (DT) model for predicting postoperative motor function using MEP monitoring data. Methodology In this retrospective cohort study, we used datasets, comprising 14 variables including MEP amplitudes, obtained from 125 patients who underwent brain tumor resection with intraoperative MEP monitoring at our hospital. Prediction models were developed using DT and receiver operating characteristic (ROC) curve analyses. Model performance was assessed for accuracy, sensitivity, specificity, kappa (κ) coefficient, and area under the ROC curve (AUC) for internal and external validation. For the external validation of the classification model, we retrospectively collected data from an additional 28 patients who underwent brain tumor surgery with MEP monitoring. Results The amplitude of the last measured MEP and amplitude ratio were independent predictors of outcomes. The DT model achieved an accuracy of 0.921, sensitivity of 0.917, specificity of 0.923, and AUC of 0.931 using the internal test. In comparison, the ROC curve based on the amplitude of the last measured MEP achieved a sensitivity of 0.875, specificity of 0.906, and AUC of 0.941. External validation was performed and the DT model was superior to prediction by cutoff values from ROC curves in terms of accuracy, sensitivity, specificity, and κ coefficient. Conclusions Our study suggested the usefulness of DT modeling for predicting postoperative paralysis. However, this study has several limitations, such as the retrospective design and small sample size of the validation dataset. Nonetheless, the DT modeling presented in this study might be applicable to surgeries using MEP monitoring and is expected to contribute to devising treatment strategies by predicting postoperative motor function in various patients.

Safety and Efficacy of Ketorolac After Craniotomy for Tumor Resection

ObjectivePostoperative pain is the most common undesirable outcome after neurosurgery. Ketorolac is a non-steroidal anti-inflammatory drug (NSAID) which is administered parenterally and carries a theoretical increased risk of bleeding. Our study aims to determine whether ketorolac after craniotomy for tumor resection significantly changes the rate of postoperative adverse events, adequately controls pain, and decreases concurrent narcotic usage. MethodsWe performed a retrospective chart review of all adult patients who underwent craniotomy for brain tumor resection from 2013 to 2022. Analysis of patients who received ketorolac and those who did not in the post-operative period were compared for adverse events associated with ketorolac use. Secondary outcomes included patient-reported pain scores and postoperative opioid usage. Results1,114 patients were included, of which 70 received ketorolac in the postoperative period. Patients who received ketorolac often received it after narcotics failed to provide adequate pain control. Patients receiving ketorolac were younger (p=0.001) and had a lower comorbidity index (p=0.041) compared to the non-ketorolac group. Patients receiving ketorolac did not experience a significantly increased rate of bleeding events (p=0.850). Patients recieving ketorolac had significantly higher baseline levels of pain (p=0.018) and opioid usage (p=0.047). When matched for chronic comorbidities including pain disorders, the ketorolac group only displayed higher levels of pain early in the postoperative course (POD 0-1) but not in latter part of the initial postoperative period. ConclusionsKetorolac is a safe and effective option for pain control after craniotomy for tumor resection. Prospective data is needed to better validate these retrospective observations.

Comparison of Awake Craniotomy with Craniotomy Under General Anesthesia for Resection of Tumors in Eloquent Areas of Brain

Objective: To compare awake craniotomy with craniotomy under general anesthesia for early post-operative parameters in patients undergoing resection of tumors in eloquent areas of brain. Study Design: Quasi experimental study. Place and Duration of Study: Department of Anesthesia, Combined Military Hospital, Rawalpindi Pakistan Apr 2021 to May 2022. Methodology: All the patients who underwent resection surgeries for brain tumors in eloquent areas of brain were included in the study. They were divided into two Groups via lottery method. Group A underwent awake craniotomy while Group B underwent craniotomy under general anesthesia. Relevant intraoperative and early post-operative parameters were compared in both the Groups. Results: A total of 60 patients who underwent resection of eloquent area brain tumors in our hospital during the study period were included in the final analysis. Out of these 40(66.7%) underwent craniotomy under general anesthesia while 20(33.3%) underwent awake craniotomies. Mean age of the study participants was 45.61±7.889 years. Frontal lobe tumors were the most encountered brain tumors in our study participants. Patients who underwent awake craniotomy had statistically significantly lower KORNAFSKY score, lesser days of post-operative admission days and lesser neurological deficits (p-value &lt;0.005) as compared to those who underwent craniotomy under general anesthesia. Conclusion: Awake craniotomy emerged as superior option as compared to craniotomy under general anesthesia in terms of early post-operative parameters. Lower KORNAFSKY score, lesser days of post-operative admission days and lesser neurological deficits were seen in patients undergoing awake craniotomy.

Advancements in Imaging and Neurosurgical Techniques for Brain Tumor Resection: A Comprehensive Review.

Brain tumor surgery has witnessed significant advancements over the past few decades, resulting in improved patient outcomes. Despite these advancements, brain tumors remain a formidable public health challenge due to their high morbidity and mortality rates. This review explores the evolution of neurosurgical techniques for brain tumor resection, emphasizing the balance between minimizing invasiveness and maximizing precision. Traditional approaches like craniotomy and keyhole surgery remain crucial, but the rise of minimally invasive techniques such as endoscopic endonasal surgery and laser interstitial thermal therapy (LITT) has revolutionized the field. Awake craniotomy has been a substantial stepping stone towards the preservation of neurological function among brain tumor patients. Additionally, the integration of brain mapping technologies including intraoperative MRI, ultrasound and fluorescence-guided surgery has enhanced the precision of tumor resections, particularly in eloquent brain areas. These innovations, while promising, also come with challenges, including steep learning curves and limited access to advanced technology in certain regions. As the field progresses, ongoing research is essential to refine these techniques and improve accessibility, ultimately aiming to increase survival rates and preserve neurological function in patients with brain tumors. The integration of advanced imaging techniques refined surgical tools, and artificial intelligence (AI) in surgical planning is expected to further improve the safety and effectiveness of neurosurgical procedures in the future. This review provides a comprehensive analysis of current surgical strategies and explores potential future directions in brain tumor surgery.

Utility and Safety of 5-ALA Guided Surgery in Pediatric Brain Tumors: A Systematic Review.

Background: 5-Aminolevulinic acid-guided surgery for adult gliomas has been approved by the European Medicines Agency and the US Food and Drug Administration, becoming a reliable tool for improving gross total resection rates and patient outcomes. This has led several medical centers to explore the off-label use of 5-ALA in the resection of pediatric brain tumors, assessing its efficacy and safety across various tumor types. However, given the differences between children and adults, the appropriateness of 5-ALA use in pediatric populations has not yet been fully established. Methods: We collected eligible publications from Embase, Scopus, PubMed, and Proquest, ultimately selecting 27 studies. Data extraction and retrospective analysis of 249 surgical cases were conducted to determine the current efficacy and safety of 5-ALA in pediatric brain tumors. The fluorescence rate and utility stratified by several clinical features, including WHO grade, tumor classification, and tumor location, were analyzed. Results: Most studies suggest that 5-ALA can enhance tumor identification in high-grade tumors, including glioblastomas and anaplastic astrocytomas. Changes in survival or recurrence rates associated with 5-ALA-guided resection have not been reported. None of the cases reported significant postoperative complications related to the use of 5-ALA. Conclusions: 5-ALA can aid in the resection of high-grade gliomas in pediatric patients. The efficacy of 5-ALA in low-grade gliomas and other tumors may require enhancement with additional tools or modified administration protocols. The safety of 5-ALA has reached a preliminary consensus, although further randomized controlled trials and data on survival and molecular characteristics are needed.

Case Report: Postoperative Complication Epidural Haematoma after Brain Tumor Resection

Postoperative intracranial haemorrhage is one of the most dangerous complications in cranial surgery, especially epidural haematoma although it is very rare with an incidence of 1.0%. The exact mechanism of occurrence is still unknown and with appropriate treatment can result in a good outcome. A 34-year-old female, 63 kg, who lost consciousness after extubation following resection of a meningioma in the parietooccipital region. In the recovery room, the patient regained consciousness and was transferred to the ICU for observation. The patient suddenly lost consciousness after 30 minutes in the ICU, reintubation was performed and a CT scan of the head showed an epidural hematoma after tumour resection. An emergency decompressive craniotomy was performed, with total intravenous anaesthesia (TIVA) combination of remifentanil 0.1 mcg/kg/min and thiopental 2 mg/kg/h, The operation lasted for one hour. The patient was admitted to the intensive care unit (ICU) for seven days under mechanical ventilation. The patient was extubated on the eighth day and transferred to the ward on the following day. There are several causes of epidural hematoma after brain tumour resection, namely sudden decrease in ICP, massive CSF drainage, uneven ICP distribution, coagulopathy factors, and excessive pin fixation. Excessive loss of CSF during surgery causes displacement of the brain and creates negative pressure in the remote area. In this case, it is suspected that the sudden decrease in ICP caused traction on the meningeal blood vessels, so that the negative pressure made the dura pulled and caused extradural haematoma. Conclusion: Postoperative epidural haematoma is a serious and relatively rare complication but if treated promptly, will result in a favourable outcome.

SURGICAL OUTCOMES OF TUBULAR RETRACTOR SYSTEMS IN THE MANAGEMENT OF BRAIN TUMOURS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract AIMS Retraction is a critical step in surgical removal of brain tumours, enabling visualisation and resection. Conventional retraction applies focal pressure to overlying tissue, potentially resulting in retraction-induced injury. Tubular retractors (minimally invasive parafascicular surgery) circumferentially distribute pressure to theoretically minimise injury. Whilst previous reviews have provided insight into their potential, the literature has since significantly expanded, necessitating an update. The objective was to synthesise all current evidence regarding surgical outcomes of tubular retractors in resection of brain tumours. METHOD Studies reporting on use of tubular retractors to resect brain tumours in adult patients were eligible. PRISMA guidelines were followed. MEDLINE, Embase and the Cochrane Library were searched to 18th October 2023. Duplicate title/abstract screening, data extraction and risk of bias assessments were conducted. RESULTS Of the 2453 studies screened, 49 were included in the final synthesis, involving 690 patients. Tubular retractor systems assessed were: BrainPath (n=199), VBAS (n=198), METRx (n=63) and other (n=230). Pooled estimate of gross total resection rate was 75% (95% CI 0.65-0.84; I2=83%), whilst pooled estimate of complication rate was 17% (95% CI 0.11-0.24; I2=75%). Sub-group analysis of gross total resection rate was conducted for: glioma (150 patients, pooled prevalence 47%, 95% CI 0.36-0.57; I2=29%), colloid cyst (121 patients, pooled prevalence 100%, CI 0.99-1.00; I2=0%), and metastasis (114 patients, pooled prevalence 82%, 95% CI 0.67-0.94; I2=64%). There was no significant difference between tubular retractor systems with regards to gross total resection or complication rate (p&amp;gt;0.05). CONCLUSION There is mounting evidence for the utility of tubular retractors in resection of brain tumours. However, this evidence remains largely in the form of low-quality case-series, providing proof-of-concept, but limited in its ability to draw more robust comparisons to conventional retraction. Future studies with greater sample sizes and inclusion of control groups are now needed to consolidate the position of tubular retractors in neuro-oncology.

Letter to the Editor Regarding “Incidence and Risk Factors of Delirium Following Brain Tumor Resection: A Retrospective National Inpatient Sample Database Study”

Letter to the Editor Regarding “Incidence and Risk Factors of Delirium Following Brain Tumor Resection: A Retrospective National Inpatient Sample Database Study”

Routine ICU Surveillance after Brain Tumor Surgery: Patient Selection Using Machine Learning.

Background/Objectives: Routine postoperative ICU admission following brain tumor surgery may not benefit selected patients. The objective of this study was to develop a risk prediction instrument for early (within 24 h) postoperative adverse events using machine learning techniques. Methods: Retrospective cohort of 1000 consecutive adult patients undergoing elective brain tumor resection. Nine events/interventions (CPR, reintubation, return to OR, mechanical ventilation, vasopressors, impaired consciousness, intracranial hypertension, swallowing disorders, and death) were chosen as target variables. Potential prognostic features (n = 27) from five categories were chosen and a gradient boosting algorithm (XGBoost) was trained and cross-validated in a 5 × 5 fashion. Prognostic performance, potential clinical impact, and relative feature importance were analyzed. Results: Adverse events requiring ICU intervention occurred in 9.2% of cases. Other events not requiring ICU treatment were more frequent (35% of cases). The boosted decision trees yielded a cross-validated ROC-AUC of 0.81 ± 0.02 (mean ± CI95) when using pre- and post-op data. Using only pre-op data (scheduling decisions), ROC-AUC was 0.76 ± 0.02. PR-AUC was 0.38 ± 0.04 and 0.27 ± 0.03 for pre- and post-op data, respectively, compared to a baseline value (random classifier) of 0.092. Targeting a NPV of at least 95% would require ICU admission in just 15% (pre- and post-op data) or 30% (only pre-op data) of cases when using the prediction algorithm. Conclusions: Adoption of a risk prediction instrument based on boosted trees can support decision-makers to optimize ICU resource utilization while maintaining adequate patient safety. This may lead to a relevant reduction in ICU admissions for surveillance purposes.

The Pediatric Physiatric Posterior Fossa Symptoms scale (3PFSs): Impairments and outcome in pediatric inpatient rehabilitation for posterior fossa brain tumors.

Clinical recognition of the post-operative neurologic sequelae of posterior fossa tumors is inconsistent. This study aimed to characterize functional impairments and recovery trajectories in pediatric patients admitted to inpatient rehabilitation following surgical resection of posterior fossa brain tumors. This study also introduces the Pediatric Physiatric Posterior Fossa Symptom scale (3PFSs) for serial assessment of post-operative symptoms in pediatric posterior fossa brain tumors. This retrospective cohort study included 49 patients aged 1.1 to 19.9 years admitted to a pediatric unit of a free-standing rehabilitation hospital following resection of a posterior fossa brain tumor. Functional Independence Measure for Children (WeeFIM) and 3PFSs scores at admission and discharge were the primary outcome measures. Across the group, WeeFIM score improved from 51.5±23.5 points at admission to 74.2±28.2 points at discharge (t=4.34, p<0.001). The 3PFSs score also showed improvement from 10[IQR=9-12] points at admission to 8[7-10] points at discharge (t=9.3, p<0.0001). While change in both the WeeFIM and 3PFSs captured statistically significant improvement in function, there was low inter-rating correlation (p>0.7). In addition, mortality was correlated with higher discharge 3PFSs score (p=0.007) but not discharge WeeFIM score. In pediatric patients with post-operative neurologic sequelae due to posterior fossa brain tumors, inpatient rehabilitation resulted in global and domain specific functional improvements. This initial application of the 3PFSs demonstrates potential applicability for stratifying patients to appropriate levels of rehabilitation, capturing functionally relevant response to rehabilitation treatment, and prognosticating long-term outcomes. These initial results are promising but require additional validation in a larger cohort.

Toward standardized brain tumor tissue processing protocols in neuro-oncology: a perspective for gliomas and beyond.

Implementation of standardized protocols in neurooncology during the surgical resection of brain tumors is needed to advance the clinical treatment paradigms that use tissue for diagnosis, prognosis, bio-banking, and treatment. Currently recommendations on intraoperative tissue procurement only exist for diffuse gliomas but management of other brain tumor subtypes can also benefit from these protocols. Fresh tissue from surgical resection can now be used for intraoperative diagnostics and functional precision medicine assays. A multidisciplinary neuro-oncology perspective is critical to develop the best avenues for practical standardization. This perspective from the multidisciplinary Oncology Tissue Advisory Board (OTAB) discusses current advances, future directions, and the imperative of adopting standardized protocols for diverse brain tumor entities. There is a growing need for consistent operating room practices to enhance patient care, streamline research efforts, and optimize outcomes.

Procedural volume is linearly associated with mortality, major complications, and readmissions in patients undergoing malignant brain tumor resection.

Improved outcomes have been noted in patients undergoing malignant brain tumor resection at high-volume centers. Studies have arbitrarily chosen high-volume dichotomous cutoffs and have not evaluated volume-outcome associations at specific institutional procedural volumes. We sought to establish the continuous association of volume with patient outcomes and identify cutoffs significantly associated with mortality, major complications, and readmissions. We hypothesized that a linear volume-outcome relationship can estimate likelihood of adverse outcomes when comparing any two volumes. The patient cohort was identified with ICD-10 coding in the Nationwide Readmissions Database(NRD). The association of volume and mortality, major complications, and 30-/90-day readmissions were evaluated in multivariate analyses. Volume was used as a continuous variable with two/three-piece splines, with various knot positions to reflect the best model performance, based on the Quasi Information Criterion(QIC). From 2016 to 2018, 34,486 patients with malignant brain tumors underwent resection. When volume was analyzed as a continuous variable, mortality risk decreased at a steady rate of OR 0.988 per each additional procedure increase for hospitals with 1-65 cases/year(95% CI 0.982-0.993, p < 0.0001). Risk of major complications decreased from 1 to 41 cases/year(OR 0.983, 95% CI 0.979-0.988, p < 0.0001), 30-day readmissions from 1 to 24 cases/year(OR 0.987, 95% CI 0.979-0.995, p = 0.001) and 90-day readmissions from 1 to 23 cases/year(OR 0.989, 95% CI 0.983-0.995, p = 0.0003) and 24-349 cases/year(OR 0.9994, 95% CI 0.999-1, p = 0.01). In multivariate analyses, institutional procedural volume remains linearly associated with mortality, major complications, and 30-/90-day readmission up to specific cutoffs. The resulting linear association can be used to calculate relative likelihood of adverse outcomes between any two volumes.