Supratentorial Brain Tumors Research Articles

Quantitative Subcortical Motor Mapping and Continuous Motor-Evoked Potential Monitoring during Surgery of Supratentorial Brain Tumors

Aim: Mapping and monitoring are increasingly used during the resection of tumors located close to the corticospinal tract (CST). The objective was to compare lowest subcortical stimulation thresholds (MT) and motor-evoked potential (MEP) monitoring signal abnormalities in correlation to motor function outcome.

A49 An Audit of Post-operative Analgesia Requirements after a Supratentorial Craniotomy with and without an Intra-operative Scalp Block

Background and Goal of Study: Post-operative pain after a craniotomy can be a common problem and is described as moderate to severe and is often more than expected (1,2,3,4). It is for this reason, and concern of drug side-effects that it is often poorly managed (1,2). Some studies describe the significant effect of a scalp block (2,4,5,). A recent systematic review concluded that overall the evidence does suggest an analgesic effect but it was unable to give any firm recommendations (1). The aim of the study was to assess whether the peri-operative insertion of a scalp block, in patients having a supra-tentorial craniotomy, altered post-operative analgesia requirements. Methods: From June to November 2011, 40 patients that had a supra-tentorial craniotomy were retrospectively identified from the Neurosurgical Theatre Logbook. The case notes were requested and an audit proforma completed. Exclusion criteria included a post-operative Glasgow Coma Score less than 15 and patients on chronic pain medications. Results: All scalp blocks involved the use of 0.5% Levobupivicaine, with over 75% receiving 20mls. 50% of scalp blocks had the addition of 1/200,000 Adrenaline. Intra-operatively, 40% of the scalp block group received an opioid for analgesia, whereas 75% of the non-scalp block group received an opioid for analgesia. In recovery, 30% of both audit groups received an opioid. Post-operatively, by 4 hours, 50% of the non-scalp block group received an opioid for analgesia. 85% of the non-scalp block group had an opioid by 12 hours. Post-operatively, it was not until 10 hours that 50% of the scalp block group received an opioid. At 14 hours, it was still only 50% of the scalp block group that had received an opioid. Conclusions and Discussion: There does appear to be a role for the use of an intra-operative scalp block in all patients having a supra-tentorial craniotomy. There is a difference in intra-operative and post-operative use of opioids between the two groups, although there was no difference in the recovery room. The scalp block has many advantages as a technique. It is considered a low risk procedure, easy to insert and has less side effects. It provides effective analgesia without compromising neurological function. As the study represents our local patient population, we will use it to inform practice in our department. References Hansen, M.S, Brennum, J, Moltke, F.B, Dahl, J.B. (2011) Pain treatment after craniotomy: where is the (procedure specific) evidence? A qualitative systematic review. European Journal of Anaesthesiology. Vol 28, Issue 12, pp 821-829. Saringcarinkul, A, Boonsri, S. (2008) Effect of Scalp Infiltration on Postoperative Pain Relief in Elective Supratentorial Craniotomy with 0.5% Bupivicaine with Adrenaline 1:400,000. Journal of The Medical Association of Thailand. Vol 91, No 10, pp 1518-1523. Gazoni, F.M, Pouratian, N, Nemergut, E.C. (2008) Effect of ropivacaine skull block on perioperative outcomes with supratentorial brain tumors and comparison with remifentanil: a pilot study. Journal of Neurosurgery. Vol 109, No 1, pp 44-49. Nguyen A, Girard, F, Boudreault, D, Fugere, F, Ruel M, Moumdjian, R, Bouthilier, A, Caron, J.L, Bojanowski, M.W, Girard, D.C. (2001) Scalp Nerve Blocks Decrease the Severity of Pain After Craniotomy. Anesthesia & Analgesia. Vol 93, No 5, pp 1272-1276. Bala, I, Gupta, B, Bhadwaj, N, Ghai, B, Khosla, V. (2006) Effect of scalp block for post-operative pain relief in craniotomy patients. Anaesthesia and Intensive Care. Vol 34, Issue 2, pp 224-227.

Estudio comparativo del perfil cognitivo de niños en edad escolar con tumores cerebrales infratemporales y supratentoriales que finalizaron el tratamiento médico. Impacto en el funcionamiento escolar y social de la calidad de vida relacionada con salud

Introduction: Due to scientific advances, there is a growing number of pediatric patients surviving cancer. In general, for children who suffer from central nervous system tumors, this survival is associated with secondary adverse effects, such as cognitive deficits. Objetive: To assess cognitive functions and quality of life in children with infratentorial and supratentorial brain tumors. Methods: An analytical observational and prospective study was conducted. The total sample consisted of 51 subjects. The following measurement instruments were used: Wechsler Intelligence Scale for Children, Fourth Edition (WISC IV), Cognitive Assessment System (CAS), Test of Memory and Learning (TOMAL), Graffar Scale; and Peds Quality of Life 4.0 Results: The comparison of the results did not show significant differences between infratentorial and supratentorial tumor location. All patients that were evaluated in the post-cancer-treatment period reveled a similar significant impairment in all the areas studied compared with the level expected in the general population. The most severely affected cognitive functions were processing speed and attention span, mainly on the planning tasks. The findings also show that quality of life at school is severely affected in these children. Conclusions: This is a preliminary study whose results may define a general trend of neurocognitive status, analyzing its impact on quality of life of the study population an posing useful questions for future research.

Outcomes after discontinuation of antiepileptic drugs after surgery in patients with low grade brain tumors and meningiomas

Low grade tumors are associated with a high risk of seizures. Prolonged use of antiepileptic drugs (AEDs) is associated with morbidity. Determining which patients can safely discontinue AEDs perioperatively is difficult. We examined patients with low grade supratentorial brain tumors to determine characteristics of patients who underwent AED withdrawal. A retrospective chart review was performed in patients who underwent resection between 1/1/2004 and 12/31/2005 at a single center. Data were collected regarding the use of postoperative AEDs, occurrence of postoperative seizures, and patient/tumor characteristics. We examined 169 patients with a median follow-up of 3.1 years. AEDs were withdrawn or never started in 111 patients; post-withdrawal seizures occurred in 11 (9.9%). The rate was similar between meningiomas and primary brain tumors. No independent risk factors for post-withdrawal seizures were found. Of 58 patients whose AEDs were not withdrawn, postoperative seizures occurred in 28 (48%). Predictors of AED continuation included existence of preoperative seizures, temporal tumor location, tumor recurrence, incomplete resection, and male sex. The decision to continue AEDs was predictive for postoperative seizures even after controlling for known risk factors. Although clinicians are able to identify patients at high risk for postoperative seizures, treatment with AEDs is ineffective in many patients.

A tribute to Euryclides de Jesus Zerbini, MD

Zerbini was born in a modest home in the rural countryside of Sao Paulo State, Brazil, on May 17, 1912. Born prematurely, the infant Zerbini could fit into a shoebox. As he grew, he decided to take up medicine because of pressure from his father—an elementary school teacher of Italian origin but a naturalized Brazilian who wanted his five children to pursue high positions in life. Zerbini came to Sao Paulo in December 1929. He was 17 years old at the time and had graduated first in his class. Entrance into medical school required an examination; only the first 50 candidates were accepted. Zerbini ranked among the top 10. Alone in Sao Paulo, he knew no one well enough to share his joy of having been admitted into medical school at the University of Sao Paulo. At that time, the University enjoyed an excellent reputation, supported in part by the Rockefeller Foundation. Studying medicine in Sao Paulo was not inexpensive, even considering that tuition was free. Zerbini relieved his father’s financial burden by teaching chemistry, physics, and natural history during his first year of medical school. In 1933, Zerbini went to the “Sao Paulo Santa Casa de Misericordia,” one of the most fashionable teaching hospitals in Brazil, where he met the famous surgeon Alipio Correa Netto. Alipio had fought in the Brazilian Expeditionary Force in the Allied campaign in Italy and was the only non-American surgeon authorized to operate on American soldiers. In Alipio, Zerbini found a mentor and source of inspiration that would guide his entire career. Circumstances led Zerbini to operate on the human thorax. At that time, the heart was still an “anatomical fiction” that could be directly viewed or touched only in the morgue. Thoracic surgeons in the 1930s ventured only near the lungs and, even then, with reservation. Pulmonary surgery, which did not involve direct intervention on the lungs, was primarily for tuberculosis. The sanatoria were full and the only hope for survival for many tuberculosis sufferers was to undergo thoracoplasty. Operating on tuberculosis patients was almost a social mission, posing grave risks for the surgeon because of the possibility of patient-to-physician contamination. Zerbini, however, never contracted the disease. Four years after graduating from medical school, Zerbini was the youngest head of a division at the Medical School of the University of Sao Paulo. To fill the highly coveted post of first assistant in the discipline, a position immediately below that of full professor, Dr Alipio Correia Netto could have chosen one of his longtime assistants. Surprisingly, he opted to appoint Zerbini to the position. At the age of 29, Zerbini took up the senior teaching position at the Medical School of the University of Sao Paulo. To this end, he studied hard for 1 year to compete for a position that normally required 5 years of preparation. He was required to take oral and written examinations on live and cadaveric operations, and to defend a thesis. The subject chosen for his lecture was supratentorial brain tumors. His score for the examination was 9.41 on a 10-point scale [1]. Address reprint requests to Dr Salerno, Division of Cardiothoracic Surgery, Jackson Memorial Hospital, PO Box 016960 (R114), Miami, FL 33101; e-mail: tsalerno@med.miami.edu.

Correlation between contrast enhancement on intraoperative magnetic resonance imaging and histopathology in glioblastoma

Object:Glioblastoma is a highly malignant brain tumor, for which standard treatment consists of surgery, radiotherapy, and chemotherapy. Increasing extent of tumor resection (EOTR) is associated with prolonged survival. Intraoperative magnetic resonance imaging (iMRI) is used to increase EOTR, based on contrast enhanced MR images. The correlation between intraoperative contrast enhancement and tumor has not been studied systematically.Methods:For this prospective cohort study, we recruited 10 patients with a supratentorial brain tumor suspect for a glioblastoma. After initial resection, a 0.15 Tesla iMRI scan was made and neuronavigation-guided biopsies were taken from the border of the resection cavity. Scores for gadolinium-based contrast enhancement on iMRI and for tissue characteristics in histological slides of the biopsies were used to calculate correlations (expressed in Kendall's tau).Results:A total of 39 biopsy samples was available for further analysis. Contrast enhancement was significantly correlated with World Health Organization (WHO) grade (tau 0.50), vascular changes (tau 0.53), necrosis (tau 0.49), and increased cellularity (tau 0.26). Specificity of enhancement patterns scored as “thick linear” and “tumor-like” for detection of (high grade) tumor was 1, but decreased to circa 0.75 if “thin linear” enhancement was included. Sensitivity for both enhancement patterns varied around 0.39-0.48 and 0.61-0.70, respectively.Conclusions:Presence of intraoperative contrast enhancement is a good predictor for presence of tumor, but absence of contrast enhancement is a bad predictor for absence of tumor. The use of gadolinium-based contrast enhancement on iMRI to maximize glioblastoma resection should be evaluated against other methods to increase resection, like new contrast agents, other imaging modalities, and “functional neurooncology” – an approach to achieve surgical resection guided by functional rather than oncological-anatomical boundaries.

Plasma Phenytoin Levels and Incidence of Seizure in Patients Undergoing Craniotomy for Supratentorial Brain Tumors

Phenytoin is often used to prevent seizures especially postoperative seizures after craniotomy for supratentorial brain tumors but the effectiveness is controversy. To investigate perioperative changes in plasma phenytoin levels and incidence of immediate postoperative seizure in patients undergoing craniotomy for supratentorial brain tumors. The study is prospective observational descriptive study. Twenty patients who received phenytoin and undergoing craniotomy for supratentorial brain tumors were enrolled in this study. The measurement of plasma phenytoin levels were done at preoperative, intraoperatively and postoperative period after the second dose of phenytoin. Demographic data of the patients were recorded include age, sex, weight, preoperative seizure, pathology, size and location of brain tumors, operative duration, amount of fluid replacement and blood loss. If postoperative seizure occurred, plasma phenytoin level was measured again.

Accuracy of non-invasive intracranial pressure measurement

AbstractNon-invasive measurement of intracranial pressure (ICP) reduces the complications and cost for both patient and health care systems. Improvement of non-invasive methods has led to development of systems for reproducing continuous, real-time non-invasive ICP signals. So far, non-invasive methods have been tailored for the patients with head trauma. We have used Schmidt’s auto-adaptive method to assess the accuracy of this method for patients after surgery for supratentorial brain tumors. Data from forty patients with the diagnosis of brain tumor operated from 2008 to 2010 were used to estimate the accuracy of Schmidt’s method in our patients. We obtained the model parameters from 30 recordings. We determined the ICP wave form for the remaining patients by both invasive and non-invasive techniques. In the test group, by invasive method, the mean ICP±2SD was 17.1 ± 6.6 mmHg and using non-invasive method, the mean ICP ± 2SD was 16.5 ± 5.4 mmHg. The calculated error was 4.6 mmHg using root mean square errors. The average Pearson correlation between the estimated and real waveforms was 0.92. We believe that application of this method is acceptable for post-operative assessment of ICP in brain tumor patients.

P11.3 Role of intraoperative neurophysiological monitoring in predicting clinical outcome of supratentorial brain tumors resection

P11.3 Role of intraoperative neurophysiological monitoring in predicting clinical outcome of supratentorial brain tumors resection

P03-60 - Levetiracetam showed lower depression, insomnia and mood instability incidence than phenytoin after supratentorial tumour neurosurgery

BackgroundPhenytoin used to prevent seizures linked to brain cancer neurosurgery has shown many undesirable side effects and drug interactions with chemotherapy.AimTo evaluate the incidence of depression, insomnia, mood instability and early post surgery seizures, after Phenytoin (PHE) vs. Levetiracetam (LEV) monotherapy in patients with brain tumour subjected to a supratentorial brain tumour resection.MethodsA prospective study in patients with supratentorial cancer diagnosis subjected to neurosurgery of resection was done. Patients were consecutive randomized to be treated with PHE (n = 26) 15 ml/kg IV-bolus, 125 mg/8 h IV x48 h, 100 mg/8 h O x7 days or with LEV (n = 34) 500 mg/12 h IV x48 h, 500 mg/12 h O x 7 days. Clinical, histological, TAC, EEG, seizures and undesirable side effects were analyzed.Results and discussion60 patients (53% male, aged 52.5 ± 20 years) with glioblastoma multiform 45%, meningioma 43%, Ewing's sarcoma 6.7%, others 5.3% (size between 3–6 cm, in the right brain site-65.2%, in the frontal lobe-56.2%) were subjected to followed for a week after tumour resection. Undesirable side effects (USE) were (%LEV/%PHE): total (7.3%/31.5%), somnolence (0%/32.8%), headache (6.1%/22.3%), dizziness (0%/25.6%), difficulty with coordination (0%/23.5%), depression (6.2%/18.7%), lack of energy/strength (12.5%/33.8%), insomnia (11.3%/37.9%), mood instability (12.5%/22,6%), leukopenia (0%/16.9%) after surgery (p < 0.05). None of the patients taking Levetiracetam vs. 4 of the patients taking Phenytoin (0% vs. 15.3%) had seizures after surgery (p < 0.05).ConclusionLevetiracetam showed lower depression, insomnia, mood instability and seizures incidence than Phenytoin after supratentorial tumour neurosurgery.

A Comparison of 3% Saline and Mannitol for Brain Relaxation During Elective Supratentorial Brain Tumor Surgery

A Comparison of 3% Saline and Mannitol for Brain Relaxation During Elective Supratentorial Brain Tumor Surgery

Neuropsychological differences between survivors of supratentorial and infratentorial brain tumours

The purpose of this study is to evaluate the relationship between brain tumour location and core areas of cognitive and behavioural functioning for paediatric brain tumour survivors. The extant literature both supports and refutes an association between paediatric brain tumour location and neurocognitive outcomes. We examined neuropsychological test data to identify any differences in neurocognitive and behavioural profile associated with supratentorial versus infratentorial tumour location. Following Institutional Review Board approval, the medical records and neuropsychological test data collected between 1997 and 2002 for 70 children treated for brain tumour at Children's Hospital Los Angeles were reviewed. Fifty-one per cent of the participants had tumours located in the supratentorial regions of the brain, whereas 49% had infratentorial tumours. Primary medical treatments involved tumour resection (90%), cranial radiation therapy (76%), chemotherapy (71%), and 59% all three medical procedures. The two tumour location groups did not differ significantly in the cumulative treatment dose of irradiation to the tumour bed or in the dose delivered to the whole brain. Neuropsychological test data included measures of verbal and non-verbal intellectual functioning, attention/working memory, processing speed, verbal and visual memory, fine motor skills, visual-motor integration, academic achievement, and social-emotional functioning. Differences between the two groups were evaluated using anova, t-tests and chi-squared statistical tests. The supratentorial and infratentorial tumour location groups did not differ on measures of intellectual functioning. However, survivors of infratentorial tumours performed more poorly on selected measures of more specific cognitive functions and on parent-report of social-emotional functioning relative to survivors of supratentorial tumours, even when age at diagnosis was held as a covariate. Higher frequency of auditory deficits was noted in the infratentorial tumour group and was associated with lowered academic achievement scores. The differences by location found in more specific neurocognitive and social-emotional variables, after controlling for age at diagnosis, may possibly reflect tumour location-specific effects. However, this interpretation remains tentative given the limitations in our study and inability to control for the range of medical and treatment-related factors that may have contributed towards the outcomes observed in our sample. At the same time, most of our findings appear consistent with reports from recent studies in this area.

A Comparison for 3% Hypertonic Saline and Mannitol for Brain Relaxation During Elective Supratentorial Brain Tumor Surgery

A Comparison for 3% Hypertonic Saline and Mannitol for Brain Relaxation During Elective Supratentorial Brain Tumor Surgery

Desmoplastic non-infantile ganglioglioma in late adulthood

Desmoplastic infantile ganglioglioma (DIG) is an uncommon supratentorial neuroepithelial brain tumor that typically occurs in infants younger than 24 months. Desmoplastic non-infantile ganglioglioma (DNIG) is a rare variant of this intracranial neoplasm. There are only 16 DNIG cases reported in the literature, with all patients under the age of 25 at the time of presentation. These DIG and DNIG cases were radiologically and histologically similar, with good outcome after treatment. Despite the size and high mitotic index for patients with DNIG, the prognosis is generally favorable and gross total resection is sufficient. We present a case of a 59-year-old woman with a DNIG. To the best of our knowledge, this is the first case reported of DNIG in late adulthood. Clinical presentation, histological and radiological findings are discussed.

Erratum to: Perioperative levetiracetam for prevention of seizures in supratentorial brain tumor surgery

Erratum to: Perioperative levetiracetam for prevention of seizures in supratentorial brain tumor surgery

Perioperative levetiracetam for prevention of seizures in supratentorial brain tumor surgery

Efficacy and tolerability of levetiracetam (LEV) as perioperative seizure prophylaxis in supratentorial brain tumor patients were retrospectively studied. Between February 2007 and April 2009 in a single institution, 78 patients with primary or secondary supratentorial brain tumors [40 female, 38 male; mean age 57 years, from 27 to 89 years; gliomas in 42 patients (53.8%), brain metastases in 17 (21.8%), meningiomas in 16 (20.5%), 1 primary central nervous system (CNS) lymphoma patient, and 2 patients with radiation necrosis] received between 1,000 mg and 3,000 mg LEV perioperatively. Preoperatively, 30 patients had experienced seizures (38.5%), most commonly glioma patients (47.6%), but also meningioma patients (31.3%) or patients with brain metastases (23.5%). No more seizures occurred in patients receiving 1-3 g LEV preoperatively. Within the first week postoperatively, a single seizure occurred in two patients (2.6%). At the end of the follow-up period (mean 10.5 months, range 0-31 months), 71 of the 78 patients (91%) were seizure free and 21 (26%) patients were not taking antiepileptic drugs. We observed side-effects in five patients (6.4%), including non-tumor-associated progressive somnolence in three patients (1.5 g, 1.5 g, and 2 g LEV daily) and reactive psychosis in two patients (1 and 1.5 g LEV daily), regressing after dose reduction. Perioperative LEV in supratentorial brain tumor patients was well tolerated. Compared with the literature, it resulted in low (2.6%) [corrected] seizure frequency in the early postoperative period. Additionally, its advantage of lacking cytochrome P450 enzyme induction allowed early initiation of effective postoperative chemotherapy in malignant glioma patients.

A Comparison of 3% Hypertonic Saline and Mannitol for Brain Relaxation During Elective Supratentorial Brain Tumor Surgery

In this study, we compared the effects of 3% hypertonic saline (HTS) and 20% mannitol on brain relaxation during supratentorial brain tumor surgery, intensive care unit (ICU) stays, and hospital days. This prospective, randomized, and double-blind study included patients who were selected for elective craniotomy for supratentorial brain tumors. Patients received either 160 mL of 3% HTS (HTS group, n = 122) or 150 mL of 20% mannitol infusion (M group, n = 116) for 5 minutes at the start of scalp incision. The PCO(2) in arterial blood was maintained within 35 to 40 mm Hg, arterial blood pressure was controlled within baseline values +/-20%, and positive fluid balance was maintained intraoperatively at a rate of 2 mL/kg/h. Outcome measures included fluid input, urine output, arterial blood gases, serum sodium concentration, ICU stays, and hospital days. Surgeons assessed the condition of the brain as "tight," "adequate," or "soft" immediately after opening the dura. Brain relaxation conditions in the HTS group (soft/adequate/tight, n = 58/43/21) were better than those observed in the M group (soft/adequate/tight, n = 39/42/35; P = 0.02). The levels of serum sodium were higher in the HTS group compared with the M group over time (P < 0.001). The average urine output in the M group (707 mL) was higher than it was in the HTS group (596 mL) (P < 0.001). There were no significant differences in fluid input, ICU stays, and hospital days between the 2 groups. Our results suggest that HTS provided better brain relaxation than did mannitol during elective supratentorial brain tumor surgery, whereas it did not affect ICU stays or hospital days.

Desmoplastic infantile ganglioglioma: Report of a case and review of the literature

Desmoplastic infantile ganglioglioma (DIG) is a rare supratentorial brain tumor occurring mostly before the age of 2 years. It has a good prognosis and total excision of the tumor is curative, necessitating no further treatment. An accurate pathologic diagnosis is crucial. Until now, <60 cases of this tumor type have been reported. Herein, we report a 3-month-old boy with intractable seizure who was found to have DIG after surgery.

A Comparison of 3% Hypertonic Saline and Mannitol for Brain Relaxation During Elective Supratentorial Brain Tumor Surgery

A Comparison of 3% Hypertonic Saline and Mannitol for Brain Relaxation During Elective Supratentorial Brain Tumor Surgery

Cerebral Blood Flow, Blood Volume, and Mean Transit Time Responses to Propofol and Indomethacin in Peritumor and Contralateral Brain Regions

The regional cerebral blood flow (CBF) response to propofol and indomethacin may be abnormal in patients with brain tumors. First, the authors tested the hypothesis that during propofol anesthesia alone and combined with indomethacin, changes in CBF, cerebral blood volume (CBV), and plasma mean transit time (MTT) differ in the peritumoral tissue compared with the contralateral normal brain region. Second, the authors tested the hypothesis that CBF and CBV are reduced and MTT is prolonged, in both regions during propofol anesthesia and indomethacin administration compared with propofol alone. The authors studied eight patients subjected to craniotomy under propofol-fentanyl anesthesia for supratentorial brain tumors. Magnetic resonance imaging, including perfusion- and diffusion-weighted and structural sequences, was performed (1) on the day before surgery, (2) before and (3) after administration of indomethacin in the propofol-fentanyl anesthetized patient, and (4) 2 days after surgery. Maps of CBF, CBV, and MTT were calculated. The regions of interest were peritumoral gray matter and opposite contralateral gray matter. Analysis of variance was used to analyze flow data. Propofol anesthesia was associated with a median 32% (range, 3-61%) and 47% (range, 17-67%) reduction in CBF in the peritumoral and contralateral regions, respectively.The interaction between intervention with propofol and indomethacin and region of interest was not significant for any flow modalities. Neither intervention nor region was significant for MTT, CBF, and CBV (P > 0.05). The CBF, CBV, and MTT responses to propofol and indomethacin are not different in the peritumoral region compared with contralateral brain tissue. Indomethacin did not further influence regional CBF, CBV, and MTT during propofol anesthesia.