Resection Of Primary Brain Tumors Research Articles

"Non-Eloquent" brain regions predict neuropsychological outcome in tumor patients undergoing awake craniotomy.

Supratotal resection of primary brain tumors is being advocated especially when involving "non-eloquent" tissue. However, there is extensive neuropsychological data implicating functions critical to higher cognition in areas considered "non-eloquent" by most surgeons. The goal of the study was to determine pre-surgical brain regions that would be predictive of cognitive outcome at 4-6 months post-surgery. Cortical reconstruction and volumetric segmentation were performed with the FreeSurfer-v6.0 image analysis suite. Linear regression models were used to regress cortical volumes from both hemispheres, against the total cognitive z-score to determine the relationship between brain structure and broad cognitive functioning while controlling for age, sex, and total segmented brain volume. We identified 62 consecutive patients who underwent planned awake resections of primary (n = 55, 88%) and metastatic at the University of New Mexico Hospital between 2015 and 2019. Of those, 42 (23 males, 25 left hemispheric lesions) had complete pre and post-op neuropsychological data available and were included in this study. Overall, total neuropsychological functioning was somewhat worse (p = 0.09) at post-operative neuropsychological outcome (Mean = -.20) than at baseline (Mean = .00). Patients with radiation following resection (n = 32) performed marginally worse (p = .036). We found that several discrete brain volumes obtained pre-surgery predicted neuropsychological outcome post-resection. For the total sample, these volumes included: left fusiform, right lateral orbital frontal, right post central, and right paracentral regions. Regardless of lesion lateralization, volumes within the right frontal lobe, and specifically right orbitofrontal cortex, predicted neuropsychological difference scores. The current study highlights the gaps in our current understanding of brain eloquence. We hypothesize that the volume of tissue within the right lateral orbital frontal lobe represents important cognitive reserve capacity in patients undergoing tumor surgery. Our data also cautions the neurosurgeon when considering supratotal resections of tumors that do not extend into areas considered "non-eloquent" by current standards.

CNSC-22. CANCER NEUROSCIENCE IN THE OR: ELECTROPHYSIOLOGIC INSIGHTS AT THE TIME OF BRAIN TUMOR RESECTION

Abstract Pioneering works by Venkatesh and Venkataramani demonstrated that formation of functional neural-glial synapses fosters development and growth of glial neoplasms. Resultant peritumoral neural hyperexcitability associates with tumor progression, though limited in vivo human data have been evaluated to date. We sought to enrich our understanding of these mechanisms by obtaining thin film intraoperative micro-electrocorticography (µECoG) recordings from patients undergoing primary brain tumor resection. METHODS: Intraoperative µECoG data for 8 patients with low- (LGG) and high-grade glioma (HGG, WHO grades 3 and 4) of various tumor histology were included. Analyses excluded any operative behavioral or cognitive tasks and evaluated data prior to stimulation for language or motor mapping. Following low pass (< 200 Hz) and notch filtering at 60, 120, and 180 Hz for ambient electrical noise, bandpower was calculated using multitaper spectral analysis for low frequency (LF, < 1 Hz), delta (1-4 Hz), beta (12-30 Hz), gamma (30-80 Hz), and high gamma (80-200 Hz) bands. RESULTS: Compared to isocitrate dehydrogenase (IDH) wild-type tumors, those with IDH-mutation (n = 3; two WHO grade 3, one grade 4) demonstrated the highest proportion of power within the LF band (92.2% vs 71.4%) with relatively lower proportional beta (3.6% vs 18.3%) and gamma (2.2% vs 8.7%) bandpower. The same pattern was seen in HGG (n = 5) vs LGG (n = 3) tumors with higher LF (84.5% vs 70.3%) and lower beta (10.3% vs 16.8%) and gamma (3.5% vs 10.8%) bandpower, perhaps driven by three HGGs with IDH mutation. Absolute bandpower was highest at all bands in a patient with left frontal glioblastoma. CONCLUSIONS: Interesting patterns are emerging that corroborate differential high and low frequency neural activity among patients with primary brain tumors. Disparities in LF and beta/gamma bands may represent therapeutic targets or a non-invasive biomarker of disease activity but require further, ongoing data collection and analyses.

Seizure outcomes after resection of primary brain tumors in pediatric patients: a systematic review and meta-analysis.

Primary brain neoplasms are the most common solid tumors in pediatric patients and seizures are a common presenting symptom. Surgical intervention improves oncologic outcomes and seizure burden. A better understanding of factors that influence seizure outcomes in the surgical management of primary brain tumors of childhood can guide treatment approach thereby improving patient quality of life. We performed a systematic analysis using articles queried from PubMed, EMBASE, and Cochrane published from January 1990 to August 2022 to determine predictors of seizure outcomes in pediatric patients undergoing resection of primary brain tumors. We identified 24 retrospective cohort studies, one prospective cohort study, and one mixed retrospective and prospective study for the systematic analysis. A total of 831 pediatric patients were available for analysis. 668 (80.4%) patients achieved seizure freedom after surgery. Complete tumor resection increased the likelihood of a seizure-free (Engel I) outcome compared to subtotal resection (OR 7.1, 95% CI 2.3-21.9). Rates of Engel I seizure outcomes did not significantly differ based on factors such as age at seizure onset, duration of epilepsy, gender, tumor laterality, or age at surgery, but trended towards significance for improved outcomes in temporal lobe tumors. Primary brain tumors in the pediatric population are commonly associated with seizures. Resection of these lesions reduces seizure burden and is associated with high rates of seizure freedom. Complete resection, compared to subtotal resection, significantly increases the likelihood of seizure-free outcomes.

Engineered cell-based therapies in ex vivo ready-made CellDex capsules have therapeutic efficacy in solid tumors

Encapsulated cell-based therapies for solid tumors have shown promising results in pre-clinical settings. However, the inability to culture encapsulated therapeutic cells prior to their transplantation has limited their translation into clinical settings. In this study, we created a wide variety of engineered therapeutic cells (ThC) loaded in micropore-forming gelatin methacryloyl (GelMA) hydrogel (CellDex) capsules that can be cultured in vitro prior to their transplantation in surgically debulked solid tumors. We show that both allogeneic and autologous engineered cells, such as stem cells (SCs), macrophages, NK cells, and T cells, proliferate within CellDex capsules and migrate out of the gel in vitro and in vivo. Furthermore, tumor cell specific therapeutic proteins and oncolytic viruses released from CellDex capsules retain and prolong their anti-tumor effects. In vivo, ThCs in pre-manufactured Celldex capsules persist long-term and track tumor cells. Moreover, chimeric antigen receptor (CAR) T cell bearing CellDex (T-CellDex) and human SC releasing therapeutic proteins (hSC-CellDex) capsules show therapeutic efficacy in metastatic and primary brain tumor resection models that mimic standard of care of tumor resection in patients. Overall, this unique approach of pre-manufactured micropore-forming CellDex capsules offers an effective off-the-shelf clinically viable strategy to treat solid tumors locally.

404 Identification of Persistent Racial Inequities in Recommendations for Resection of Primary Brain Tumors Using a Harmonized Dual Registry Analysis

INTRODUCTION: Disparities in outcomes disproportionately affect minority populations in many surgical fields. In contrast, racial disparities in surgical decision-making remains an enigma due to the difficulty in capturing surgeon recommendations during initial patient workup. METHODS: The odds of recommendation against surgical resection at initial diagnosis of primary brain neoplasms was determined using multivariable logistic regression with clinical, demographic, and socioeconomic factors. A dual registry analysis was designed using two national databases (NCDB and SEER), with independent analyses that were harmonized to ensure robustness of conclusions. Adults with the six most common intracranial neoplasms were included in the analysis. RESULTS: Two registries were queried to identify adults with meningioma (n = 63674, n = 222673), glioblastoma (n = 35258, n = 104047), pituitary adenoma (n = 27506, n = 87772), vestibular schwannoma (n = 11525, n = 30745), astrocytoma (n = 5402, n = 10631), and oligodendroglioma (n = 3977, n = 9187) in SEER and NCDB databases, respectively. Multivariable analysis in SEER demonstrated that, independent of clinical, demographic, and socioeconomic factors, Black patients had significantly higher odds of recommendation against surgical resection of meningioma (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.06-1.21, p < 0.001), glioblastoma (OR 1.14, 95% CI 1.01-1.28, p = 0.038), pituitary adenoma (OR 1.13, 95% CI 1.05-1.22, p < 0.001), and vestibular schwannoma (OR 1.48, 95% CI 1.19-1.84, p < 0.001) when compared to White patients in the SEER dataset. Performing a parallel analysis in NCDB confirmed these results in meningioma (OR 1.26, 95% CI 1.22-1.30, p < 0.001), glioblastoma (OR 1.20, 95% CI 1.13-1.29, p < 0.001), pituitary adenoma (OR 1.26, 95% CI 1.22-1.31), p < 0.001), and vestibular schwannoma (OR 1.30, 95% CI 1.15-1.48, p < 0.001). These findings persisted independent of both patient comorbidities and potential overlap between the databases. CONCLUSIONS: Racial disparities in surgery recommendations for patients with primary brain tumors independent of multiple potential confounders including clinical, demographic, and socioeconomic factors.

Assessment of the Milan Complexity Scale for prediction of postoperative morbidity in pediatric neuro-oncological surgery.

To assess the performance of the risk-predicting Milan Complexity Scale (MCS) on postoperative morbidity in pediatric neuro-oncological surgery. Aretrospective dual-center review of children undergoing primary brain tumor resection in Denmark over a 10-year period. MCS scoring was performed based on preoperative imaging, blinded to individual outcomes. Surgical morbidity was registered according to existing complication scales and dichotomized as significant or nonsignificant morbidity. The MCS was evaluated using logistic regression modeling. 208 children (50% female, mean age 7.9 y, and SD 5.2) were included. Of the original "Big Five" predictors included in the MCS, only posterior fossa (OR: 2.31, 95% CI: 1.25-4.34, p-value = 0.008) and eloquent area (OR: 3.32, 95% CI: 1.50-7.68, p-value= 0.004) locations were significantly associated with increased risk of significant morbidity in our pediatric cohort. The absolute MCS score correctly classified 63.0% of cases. Its accuracy increased to 69.2% when mutually adjusting for each of the "Big Five" predictors with corresponding positive and negative predictive values of 66.2% and 71.0%, using a predicted probability cutoff of 0.5. The MCS is predictive of postoperative morbidity also in pediatric neuro-oncological surgery, although only two of its original five variables were significantly associated with poor outcome in children. The clinical value of the MCS is likely limited for the experienced pediatric neurosurgeon. Future clinically impactful risk-prediction tools should include a larger number of relevant variables and be tailored to the pediatric population.

Risk for hydrocephalus, hygroma, and tumor dissemination after ventricular opening during resection of supratentorial neoplasms in children.

The possibility that ventricular opening generates postoperative complications after surgical tumor treatment often restricts the degree of tumor resection. This study aims to determine whether the ventricular opening is associated with more complications in surgeries for resectioning supratentorial intra-axial brain tumors in the pediatric population. A retrospective review analysis was performed of patients treated at IOP/GRAACC between 2002 and 2020 under 19years of age and underwent surgery for supratentorial intra-axial primary brain tumor resection. Data were collected from 43 patients. Glial tumor was more common than non-glial (65% vs. 35%, p = 0.09). The ventricular opening was not related to neoplastic spreads to the neuroaxis (6% vs. 0, p > 0.9) or leptomeningeal (3% vs. 0, p > 0.9). Of the patients whose ventricle was opened, 10% developed hydrocephalus requiring treatment, while none of the patients in the group without ventricular opening developed hydrocephalus (p = 0.5). There was also no statistical difference regarding ventriculitis. Postoperative subdural hygroma formation correlated with the ventricular opening (43% vs. 0, p = 0.003). The survival at 1, 5, and 10years of cases with the ventricular opening was 93.2%, 89.7%, and 75.7%, respectively, while in cases without ventricular opening, it was 100%, 83%, and 83%, respectively, respectively, with no statistical difference between the mortality curves. Our study demonstrated that ventricular violation was not associated with the occurrence of significant complications. It was related to the formation of subdural hygroma, which did not require additional treatment.

DISP-12. RACIAL DISPARITY IN LENGTH OF STAY FOLLOWING CRANIOTOMY FOR PRIMARY BRAIN GLIOMA

Abstract Introduction The racial disparities of opportunity to receive the appropriate surgical intervention and insurance coverage for adjuvant care may result in surgical outcome and survival disparities among different races. Length of stay (LOS) is an important quality metric measure for determining the distribution of medical resources and their consumption. This study aims to provide a perspective on racial disparities in the overall length of stay and complications for patients undergoing craniotomy for primary brain glioma. METHODS The authors performed a retrospective chart review of all patients who underwent craniotomies for resection of primary brain tumors at the Moffitt Cancer Center from 2004-2018. Patients age, race, tumor type, comorbidities, length of stay and complications were reviewed. RESULTS A total of 701 patients underwent craniotomies for primary brain glioma, but 66 were excluded due to insufficient follow-up or incomplete records. The racial categories include Caucasians, African American, Asian, Hispanic, and other. Due to the prevalence of Caucasians, the minorities groups were pooled as non-Caucasians. Both cohorts were similar in baseline comorbidities, KPS, tumor characteristics, and surgical factors. Mean LOS remained lower for Caucasians versus non-Caucasians (3.6 vs. 5.5 d). The differences in LOS remain among different tumor types, including GBM (4 vs. 6.7 d), anaplastic astrocytoma (2 vs. 4.4 d), and oligodendroglioma (2.3 vs. 3.7 d). Interestingly, among astrocytoma, Caucasians had a longer LOS (3 vs 1.2 d). CONCLUSION Our results highlight disparate treatment patterns that reflect in LOS among patients undergoing craniotomies for primary brain gliomas. These findings warrant further investigation regarding current health-care practices and policies.

INNV-31. PROTECT: PROCARBAZINE, LOMUSTINE, AND VINCRISTINE VERSUS TEMOZOLAMIDE IN HIGH-RISK, LOW-GRADE GLIOMAS: A RETROSPECTIVE COHORT STUDY

Abstract INTRODUCTION Low-grade gliomas (LGG), specifically WHO grade 2 diffuse astrocytoma and oligodendroglioma, are increasingly considered for adjuvant chemotherapy with high-risk features (age ≥ 40y or subtotal resection). This is based on prospective studies showing improvement in survival with adjuvant procarbazine, CCNU, vincristine (PCV) or temozolomide (TMZ) in this cohort. Use of PCV or TMZ is variable without published head-to-head comparison. PROTECT is a Canadian multicentre retrospective study aiming to compare overall survival (OS) in high-risk LGGs receiving PCV or TMZ. We are presenting results from The Ottawa Hospital Cancer Centre (TOHCC). METHODS Patients age ≥ 18y with LGG that received PCV or TMZ within 6 months of primary brain tumor resection at TOHCC from 2005 to 2019 were included. The primary outcome is OS. Secondary outcomes include 1)time to progression (TTP), 2)rate of completion of 6 cycles of PCV or TMZ, and 3)rate of hospitalization or death due to chemotherapy-related complications. RESULTS Of 250 cases, 20 patients (11 diffuse astrocytoma, 9 oligodendroglioma) were eligible. IDH status was mutated in 11, wild-type in 1, and unknown in 5 cases. 1p/19q co-deletion was present in 6, non-co-deleted in 1, and unknown in 13 cases. Six patients received PCV, and 14 received TMZ. Hematologic toxicity (CTCAE Grade 1-2) occurred in 3 PCV patients and 0 of 11 of assessable TMZ patients; no severe toxicity was observed. Median follow-up was 64.5 (IQR 42.5–88) months. The median OS and TTP for PCV and TMZ groups were not reached. The 5-year OS and TTP were 75% vs. 100 % (p=0.08) and 83.3% vs 81.3% (p=0.7) respectively. CONCLUSIONS There are insufficient cases and follow-up time to determine OS and TTP amongst patients treated with PCV or TMZ. Hematologic toxicity appears to be more common with PCV. Patient screening and data collection is ongoing at 8 other cancer centres.

Topical vancomycin reduces surgical site infections in patients subjected to craniotomy for primary brain tumor resection: A comprehensive cancer center experience

BackgroundCraniotomies for resection of neoplastic lesions are at increased risk for surgical site infections (SSIs) as compared to non-neoplastic pathologies. SSIs can be detrimental due to delay in pivotal adjuvant therapies. ObjectiveThe purpose of this study was to determine the rate of SSI in primary brain tumors, to analyze risk factors, and to evaluate effectiveness of topical vancomycin in reducing SSIs. MethodsA retrospective cohort study was conducted at a National Cancer Institutedesignated Comprehensive Cancer Center. Patients with primary brain tumors (n = 799) who were subjected to craniotomy from 2004 to 2014 were included. Patient demographics, tumor characteristics, use of topical vancomycin and clinical outcomes were analyzed. ResultsTopical vancomycin was associated with a significantly lower rate of SSI (0.8%) compared to standard care (5%), ( p = 0.00071; OR = 0.15; 95% CI = 0.02 – 0.5). Narcotic use ( p = 0.043; OR = 2.24; 95% CI = 0.96 – 4.81), previous brain radiation ( p = 0.043; OR = 2.08; 95% CI = 1.02 – 4.29), length of hospitalization ( p = 0.01; OR= 1.04; 95% CI = 1.01 – 1.08), and 30 day re-operation ( p = 1.58 ×10 −10; OR = 15.23; 95% CI = 7.06 – 32.71) were associated with increased risk for SSI. ConclusionTopical vancomycin effectively reduced the rate of SSI in patients subjected to craniotomy for primary brain tumor resection. Furthermore, preoperative narcotic use, previous head/brain radiation, length of hospitalization, and 30-day reoperation were associated with increased risk of SSI.

Treatment Results of 14 Patients with Dysphagia after Resection of Primary Brain Tumor at a Medical Facility Specializing in Rehabilitation

Treatment Results of 14 Patients with Dysphagia after Resection of Primary Brain Tumor at a Medical Facility Specializing in Rehabilitation

Risk factors for osteonecrosis of the femoral head in brain tumor patients receiving corticosteroid after surgery.

PurposeNon-traumatic osteonecrosis of the femoral head (ONFH) is a plausible complication in brain tumor patients. Frequent use of corticosteroid therapy, chemotherapy, and oxidative stress for managing brain tumors may be associated with the development of ONFH. However, there is little knowledge on the prevalence and risk factors of ONFH from brain tumor. This study aimed to investigate the prevalence and risk factors of ONFH in patients with primary brain tumors.MethodsThis retrospective cohort study included data from consecutive patients between December 2005 and August 2016 from a tertiary university hospital in South Korea. A total of 73 cases of ONFH were identified among 10,674 primary brain tumor patients. After excluding subjects (25 out of 73) with missing data, history of alcohol consumption or smoking, history of femoral bone trauma or surgery, comorbidities such as systemic lupus erythematosus (SLE), sickle cell disease, cancer patients other than brain tumor, and previous diagnosis of contralateral ONFH, we performed a 1:2 propensity score-matched, case–control study (ONFH group, 48; control group, 96). Risk factors of ONFH in primary brain tumor were evaluated by univariate and multivariate logistic regression analyses.ResultsThe prevalence of ONFH in patients with surgical resection of primary brain tumor was 683.9 per 100,000 persons (73 of 10,674). In this cohort, 55 of 74 patients (74.3%) underwent THA for ONFH treatment. We found that diabetes was an independent factor associated with an increased risk of ONFH in primary brain tumor patients (OR = 7.201, 95% CI, 1.349–38.453, p = 0.021). There was a significant difference in univariate analysis, including panhypopituitarism (OR = 4.394, 95% CI, 1.794–11.008, p = 0.002), supratentorial location of brain tumor (OR = 2.616, 95% CI, 1.245–5.499, p = 0.011), and chemotherapy (OR = 2.867, 95% CI, 1.018–8.069, p = 0.046).ConclusionsThis study demonstrated that the prevalence of ONFH after surgical resection of primary brain tumor was 0.68%. Diabetes was an independent risk factor for developing ONFH, whereas corticosteroid dose was not. Routine screening for brain tumor-associated ONFH is not recommended; however, a high index of clinical suspicion in these patients at risk may allow for early intervention and preservation of the joints.

HOUT-25. PROGNOSTIC FACTORS FOR PROLONGED LENGTH OF STAY AND READMISSION FOLLOWING CRANIOTOMY FOR PRIMARY BRAIN TUMORS

Abstract BACKGROUND Escalating costs of healthcare has brought on a paradigm shift that links reimbursement to quality care. Important quality metric measures include hospital length of stay, 30-day readmission and re-operation rates. Identifying modifiable factors can provide information essential for reducing medical costs and improving the quality of medical care patients receive. METHODS The authors performed a retrospective chart review of all patients who underwent craniotomies for resection of primary brain tumors at the Moffitt Cancer Center from 2004–2014. Patient demographics (age, gender), clinical characteristics (comorbidities, steroid dose, seizure status, neurologic deficit, KPS), tumor characteristics (tumor type, location), surgical factors (primary or redo, length of surgery, blood loss), 30-day complications (infection, DVT/PE, seizure), 30-day readmission, and length of stay were assessed. Multivariate analysis was performed to determine risk factors associated with prolonged length of stay and 30-day readmission. RESULTS 806 consecutive patients underwent craniotomies for primary brain tumors. High BMI (p< 0.001), CAD (p< 0.001), hyperglycemia (p< 0.04), peri-operative seizures (p< 0.03), low Karnofsky Performance Status score (p< 0.001), prolonged operative times (p< 0.001), and surgical blood loss (p< 0.001) contributed to prolonged length of hospital stay; whereas, preoperative hyperglycemia and perioperative seizures were associated with 30-day readmission. CONCLUSIONS This study identifies modifiable risk factors that contribute to poorer outcome following craniotomies for primary brain tumors and lays the groundwork for risk stratifying patients undergoing surgery.

Perioperative Hyperchloremia and its Association With Postoperative Acute Kidney Injury After Craniotomy for Primary Brain Tumor Resection: A Retrospective, Observational Study.

Hyperchloremia is known to influence postoperative outcomes and may result in postoperative acute kidney injury (AKI). This study sought to investigate whether hyperchloremia was associated with postoperative AKI in patients who underwent surgery for primary brain tumor resection. This is a retrospective, observational study of patients who underwent craniotomy for primary brain tumor resection at a single tertiary care hospital between January 2005 and October 2017. Maximum levels of serum chloride (mmol/L) measured on postoperative days (PODs) 0 to 3 and increase in serum chloride (mmol/L), (maximum serum chloride-baseline serum chloride before surgery) were measured. We examined whether perioperative hyperchloremia was associated with postoperative AKI during PODs 0 to 3. Univariate and multivariate logistic regression analyses were used in this study. A total of 726 patients were included in the analysis; of these, 39 (5.4%) were diagnosed with postoperative AKI during PODs 0 to 3. The risk of postoperative AKI was associated with maximum chloride levels (odds ratio, 1.10; 95% confidence interval, 1.02-1.19; P=0.015) and with an increase in serum chloride levels during PODs 0 to 3 (odds ratio, 1.11; 95% confidence interval, 1.04-1.19; P=0.004). Our study shows that perioperative hyperchloremia during PODs 0 to 3 was associated with an increased risk of postoperative AKI during this period after craniotomy for primary brain tumor resection.

Pretreatment serum lactate level as a prognostic biomarker in patients undergoing supratentorial primary brain tumor resection.

IntroductionMalignant primary brain tumors are one of the most aggressive cancers. Pretreatment serum nonneuronal biomarkers closely associated with postoperative outcomes are of high clinical relevance. The present study aimed to identify potential pretreatment serum biomarkers that may influence oncological outcomes in patients with primary brain tumors.MethodsA total of 74 patients undergoing supratentorial primary brain tumor resection were enrolled. Before tumor resection, serum neuronal biomarkers, namely neuron-specific enolase (NSE), S100β, and glial fibrillary acidic protein (GFAP), and serum nonneuronal biomarkers, namely neutrophil gelatinase-associated lipocalin (NGAL), lactate dehydrogenase (LDH), and lactate, were measured and associated postoperative oncological outcomes, including brain tumor grading, progression-free survival (PFS), and overall survival (OS), were compared.ResultsPatients with high-grade brain tumors had significantly higher pretreatment serum lactate levels (p = 0.011). By contrast, other biomarkers were comparable between patients with high-grade and low-grade brain tumors. Receiver operating characteristic curve analysis of serum lactate levels yielded an area under the curve of 0.71 for differentiating between high-grade and low-grade brain tumors. Kaplan–Meier survival analysis revealed patients with high serum lactate levels (≧2.0 mmol/L) had shorter PFS and OS (p = 0.021 and p = 0.093, respectively). In a multiple regression model, only elevated serum lactate levels were associated with poor PFS and OS (p = 0.021 and p = 0.048, respectively).ConclusionsAn elevated pretreatment serum lactate level is a prognostic biomarker of high-grade primary brain tumors and is significantly associated with poor PFS in patients with supratentorial brain tumors undergoing tumor resection. By contrast, other serum biomarkers are not significantly associated with oncological outcomes.

Incidence, risk factors and outcomes of seizures occurring after craniotomy for primary brain tumor resection.

Objective:To determine the incidence, risk factors and outcomes of early post-craniotomy seizures.Method:This was a retrospective cohort study of all patients who underwent craniotomy for primary brain tumor resection (2002-2011) and admitted postoperatively to the intensive care unit. The patients were divided into 2 groups depending on the occurrence of seizures within 7 days.Results:One-hundred-ninety-three patients were studied: 35.8% had preoperative seizure history and 16.6% were on prophylactic antiepileptic drugs (AEDs). Twenty-seven (14%) patients had post-craniotomy seizures. The tumors were mostly meningiomas (63% for the post-craniotomy seizures group versus 58.1% for the other group; p=0.63) and supratentorial (92.6% for the post-craniotomy seizures versus 78.4% for the other group, p=0.09) with tumor diameter=3.7±1.5 versus 4.2±1.6 cm, (p=0.07). One (3.1%) of the 32 patients on prophylactic AEDs had post-craniotomy seizures compared with 12% of the 92 patients not receiving AEDs preoperatively (p=0.18). On multivariate analysis, predictors of post-craniotomy seizures were preoperative seizures (odds ratio, 2.62; 95% confidence interval, 1.12-6.15) and smaller tumor size <4 cm (odds ratio, 2.50; 95% confidence interval, 1.02-6.25). Post-craniotomy seizures were not associated with increased morbidity or mortality.Conclusion:Early seizures were common after craniotomy for primary brain tumor resection, but were not associated with worse outcomes. Preoperative seizures and smaller tumor size were independent risk factors.

Emergency department evaluation and 30-day readmission after craniotomy for primary brain tumor resection in New York State.

OBJECTIVE Fragmentation of care has been recognized as a major contributor to 30-day readmissions after surgical procedures. The authors investigated the association of evaluation in the hospital where the original procedure was performed with the rate of 30-day readmissions for patients presenting to the emergency department (ED) after craniotomy for primary brain tumor resection. METHODS A cohort study was conducted, involving patients who were evaluated in the ED within 30 days after discharge following a craniotomy for primary brain tumor resection between 2009 and 2013, and who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database of New York State. A propensity score-adjusted model was used to control for confounding, whereas a mixed-effects model accounted for clustering at the hospital level. RESULTS Of the 610 patients presenting to the ED, 422 (69.2%) were evaluated in a hospital different from the one where the original procedure was performed (28.9% were readmitted), and 188 (30.8%) were evaluated at the original hospital (20.3% were readmitted). In a multivariable analysis, the authors demonstrated that being evaluated in the ED of the original hospital was associated with a decreased rate of 30-day readmission (OR 0.64, 95% CI 0.41-0.98). Similar associations were found in a mixed-effects logistic regression model (OR 0.63, 95% CI 0.40-0.96) and a propensity score-adjusted model (OR 0.64, 95% CI 0.41-0.98). This corresponds to one less readmission per 12 patients evaluated in the hospital where the original procedure was performed. CONCLUSIONS Using a comprehensive all-payer cohort of patients in New York State who were evaluated in the ED after craniotomy for primary brain tumor resection, the authors identified an association of assessment in the hospital where the original procedure was performed with a lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.

Intraoperative Probe-Based Confocal Laser Endomicroscopy in Surgery and Stereotactic Biopsy of Low-Grade and High-Grade Gliomas: A Feasibility Study in Humans.

The management of gliomas is based on precise histologic diagnosis. The tumor tissue can be obtained during open surgery or via stereotactic biopsy. Intraoperative tissue imaging could substantially improve biopsy precision and, ultimately, the extent of resection. To show the feasibility of intraoperative in vivo probe-based confocal laser endomicroscopy (pCLE) in surgery and biopsy of gliomas. In our prospective observational study, 9 adult patients were enrolled between September 2014 and January 2015. Two contrast agents were used: 5-aminolevulinic acid (3 cases) or intravenous fluorescein (6 cases). Intraoperative imaging was performed with the Cellvizio system (Mauna Kea Technologies, Paris). A 0.85-mm probe was used for stereotactic procedures, with the biopsy needle modified to have a distal opening. During open brain surgery, a 2.36-mm probe was used. Each series corresponds to a separate histologic fragment. The diagnoses of the lesions were glioblastoma (4 cases), low-grade glioma (2), grade III oligoastrocytoma (2), and lymphoma (1). Autofluorescence of neurons in cortex was observed. Cellvizio images enabled differentiation of healthy "normal" tissue from pathological tissue in open surgery and stereotactic biopsy using fluorescein. 5-Aminolevulinic acid confocal patterns were difficult to establish. No intraoperative complications related to pCLE or to use of either contrast agent were observed. We report the initial feasibility and safety of intraoperative pCLE during primary brain tumor resection and stereotactic biopsy procedures. Pending further investigation, pCLE of brain tissue could be utilized for intraoperative surgical guidance, improvement in brain biopsy yield, and optimization of glioma resection via analysis of tumor margins. 5-ALA, 5-aminolevulinic acidpCLE, probe-based confocal laser endomicroscopyPpIX, protoporphyrin IX.

Stereotactic probability and variability of speech arrest and anomia sites during stimulation mapping of the language dominant hemisphere.

OBJECTIVE Functional mapping using direct cortical stimulation is the gold standard for the prevention of postoperative morbidity during resective surgery in dominant-hemisphere perisylvian regions. Its role is necessitated by the significant interindividual variability that has been observed for essential language sites. The aim in this study was to determine the statistical probability distribution of eliciting aphasic errors for any given stereotactically based cortical position in a patient cohort and to quantify the variability at each cortical site. METHODS Patients undergoing awake craniotomy for dominant-hemisphere primary brain tumor resection between 1999 and 2014 at the authors' institution were included in this study, which included counting and picture-naming tasks during dense speech mapping via cortical stimulation. Positive and negative stimulation sites were collected using an intraoperative frameless stereotactic neuronavigation system and were converted to Montreal Neurological Institute coordinates. Data were iteratively resampled to create mean and standard deviation probability maps for speech arrest and anomia. Patients were divided into groups with a "classic" or an "atypical" location of speech function, based on the resultant probability maps. Patient and clinical factors were then assessed for their association with an atypical location of speech sites by univariate and multivariate analysis. RESULTS Across 102 patients undergoing speech mapping, the overall probabilities of speech arrest and anomia were 0.51 and 0.33, respectively. Speech arrest was most likely to occur with stimulation of the posterior inferior frontal gyrus (maximum probability from individual bin = 0.025), and variance was highest in the dorsal premotor cortex and the posterior superior temporal gyrus. In contrast, stimulation within the posterior perisylvian cortex resulted in the maximum mean probability of anomia (maximum probability = 0.012), with large variance in the regions surrounding the posterior superior temporal gyrus, including the posterior middle temporal, angular, and supramarginal gyri. Patients with atypical speech localization were far more likely to have tumors in canonical Broca's or Wernicke's areas (OR 7.21, 95% CI 1.67-31.09, p < 0.01) or to have multilobar tumors (OR 12.58, 95% CI 2.22-71.42, p < 0.01), than were patients with classic speech localization. CONCLUSIONS This study provides statistical probability distribution maps for aphasic errors during cortical stimulation mapping in a patient cohort. Thus, the authors provide an expected probability of inducing speech arrest and anomia from specific 10-mm2 cortical bins in an individual patient. In addition, they highlight key regions of interindividual mapping variability that should be considered preoperatively. They believe these results will aid surgeons in their preoperative planning of eloquent cortex resection.

The role of 5-aminolevulinic acid in brain tumor surgery: a systematic review.

Recently, 5-aminolevulinic acid (5-ALA) has been utilized as an adjuvant to the surgical resection of primary brain tumors and metastases. We conducted a systematic review of the literature to further understand the role of 5-ALA in neurosurgery. Our goal was to identify the utility of 5-ALA during resection by evaluating its sensitivity and specificity for different tumor types, as well as the extent of tumor resection achieved while using 5-ALA. A search of the literature was conducted using the PubMed database for the period January 1990 through May 2014. Surgical series in which 5-ALA was used for brain neoplasm resections were evaluated for tumor histology, sensitivity, specificity, extent of resection, complications, and outcomes. Twenty-two series, involving 1163 patients, were included in our review. 5-ALA sensitivity was highest in high-grade gliomas (85%) and meningiomas (81%). 5-ALA specificity was high in meningiomas (100%), as well as metastases (84%) and high-grade gliomas (82%). Gross total resection (GTR) was achieved using 5-ALA in 66.2% of all gliomas and 69.6% of meningiomas, regardless of histological subtype. 5-ALA may be a useful tool in increasing the extent of resection and achieving GTR in intracranial tumors. The resection of tumors for which 5-ALA has high sensitivity and specificity, such as high-grade gliomas, may lead to an increase in extent of resection when compared to operations using only standard white light. Further evidence for the use of 5-ALA in meningiomas and certain subtypes of metastases may be needed to qualify its efficacy.