Supratentorial Brain Tumors Research Articles

Prophylactic antiepileptic drug administration following brain tumor resection: results of a recent AANS/CNS Section on Tumors survey.

OBJECTIVE Antiepileptic drugs (AEDs) are often administered prophylactically following brain tumor resection. With conflicting evidence and unestablished guidelines, however, the nature of this practice among tumor surgeons is unknown. METHODS On November 24, 2015, a REDCap (Research Electronic Database Capture) survey was sent to members of the AANS/CNS Section on Tumors to query practice patterns. RESULTS Responses were received from 144 individuals, including 18.8% of board-certified neurosurgeons surveyed (across 86 institutions, 16 countries, and 5 continents). The majority reported practicing in an academic setting (85%) as a tumor specialist (71%). Sixty-three percent reported always or almost always prescribing AED prophylaxis postoperatively in patients with a supratentorial brain tumor without a prior seizure history. Meanwhile, 9% prescribed occasionally and 28% rarely prescribed AED prophylaxis. The most common agent was levetiracetam (85%). The duration of seizure prophylaxis varied widely: 25% of surgeons administered prophylaxis for 7 days, 16% for 2 weeks, 21% for 2 to 6 weeks, and 13% for longer than 6 weeks. Most surgeons (61%) believed that tumor pathology influences epileptogenicity, with high-grade glioma (39%), low-grade glioma (31%), and metastases (24%) carrying the greatest seizure risk. While the majority used prophylaxis, 62% did not believe or were unsure if prophylactic AEDs reduced seizures postoperatively. The vast majority (82%) stated that a well-designed randomized trial would help guide their future clinical decision making. CONCLUSIONS Wide knowledge and practice gaps exist regarding the frequency, duration, and setting of AED prophylaxis for seizure-naive patients undergoing brain tumor resection. Acceptance of universal practice guidelines on this topic is unlikely until higher-level evidence supporting or refuting the value of modern seizure prophylaxis is demonstrated.

Evidence for cerebellar motor functional reorganization in brain tumor patients: An fMRI study

Functional reorganization of the motor system following brain damage has been studied extensively in stroke patients, in which not only the cerebrum but also the cerebellum (Cbll) undergoes substantial reorganization. However, the role of Cbll in motor functional reorganization in brain tumor patients remains poorly investigated. Because brain damages in brain tumor patients occur much more slowly than in stroke patients, the neural mechanisms for motor functional reorganization might differ between these two disease conditions. This functional magnetic resonance imaging (fMRI) study investigated whether Cbll constitutes the neural substrates for motor functional reorganization in eighteen supratentorial brain tumor patients who exhibited no clinical signs of paresis. The patients and normal volunteers underwent a unilateral hand movement task. In the patients, the locus of primary sensory motor (SM1) activation during contralesional hand movement was significantly displaced by the tumor, suggesting functional compromise and/or reorganization in the central sulcus region. In addition, their contralesional Cbll activation during contralesional hand movement was substantially increased as compared to normal controls. The finding represents the first conclusive evidence that Cbll is involved in the motor-related functional reorganization in patients with brain tumor.

Preoperative Grading of Astrocytic Supratentorial Brain Tumors with Diffusion-Weighted Magnetic Resonance Imaging and Apparent Diffusion Coefficient.

BackgroundDiffusion-weighted imaging (DWI) is a form of magnetic resonance imaging (MRI) based on measuring the random Brownian motion of water molecules within the biological tissues and is particularly useful in tumor characterization.ObjectivesThe purpose of this study was to evaluate the diagnostic value of DW MRI and the apparent diffusion coefficient (ADC) for preoperative grading of astrocytic supratentorial brain tumors.Patients and MethodsTwenty-three patients (14 females, 9 males, mean age 43 years) with astrocytic supratentorial brain tumors underwent preoperative conventional MR imaging and DW MRI. The minimum, maximum and mean ADC values and the minimum, maximum and mean DWI signal intensities of each tumor were taken by placing several regions of interest in the tumor on DWI images and ADC maps. To assess the relationship between these values and the tumor grade, we used the Mann-Whitney U test and the Spearman correlation. Receiver operating characteristic (ROC) analysis was used to determine the cutoff value of the minimum, maximum and mean ADC values and the minimum, maximum and mean DWI signal intensities that had the best composition of sensitivity and specificity for differentiating low-grade and high-grade astrocytic brain tumors.ResultsAccording to the pathology reports, 10 patients had low-grade astrocytomas (grades I, II) and 13 patients had high-grade astrocytomas (grades III, IV). The minimum ADC value showed a significantly inverse correlation with astrocytic tumor grade (P = 0.006). The correlation between the maximum ADC value and the maximum DWI signal intensity with tumor grade was direct (P = 0.013, P = 0.035). According to the ROC analysis, the cutoff values of 0.843 × 10-3 mm2/s, 2.117 × 10-3 mm2/s and 165.2 for the minimum ADC, maximum ADC and maximum DWI respectively, obtained the best combination of sensitivity and specificity for distinguishing low-grade and high-grade astrocytomas.ConclusionMeasuring minimum ADC, maximum ADC and maximum DWI signal intensity can provide valuable information for grading of astrocytic supratentorial brain tumors before surgery.

Calcification on CT is a simple and valuable preoperative indicator of 1p/19q loss of heterozygosity in supratentorial brain tumors that are suspected grade II and III gliomas.

Gliomas with 1p/19q loss of heterozygosity (LOH) are known to be associated with longer patient survival and higher sensitivity to treatment than tumors without 1p/19q LOH. This study was designed to clarify whether the preoperative finding of calcification on CT was correlated with 1p/19q LOH in patients with suspected WHO grade II and III gliomas. This study included 250 adult patients who underwent resection for primary supratentorial tumors at Tokyo Women's Medical University Hospital. The tumors were suspected, based on MRI findings, to be WHO grade II or III gliomas. The presence of calcification on the patients' CT images was qualitatively evaluated before treatment. After surgery, the resected tumors were examined to determine their 1p/19q status and mutations of IDH1 and p53. The presence of calcification was significantly correlated with 1p/19q LOH (P<0.0001), with a positive predictive value of 91%. The tumors of all the 78 patients with calcification were diagnosed as oligodendroglial tumors. Seventy of these patients showed classic oligodendroglial features, while 8 patients showed non-classic features. Calcification on CT is a simple and valuable preoperative indicator of 1p/19q LOH in supratentorial brain tumors that are suspected to be WHO grade II and III gliomas.

Treatment of epilepsy in children with brain tumors

Symptomatic focal epilepsy is frequently caused by supratentorial brain tumors that may be surgically removed. The authors studied outcomes of surgical treatment depending on the use of electrocorticography c (ECoG). Seventy-five children, aged 5-7 years, with supratentorial brain tumors were examined. Symptomatic epilepsy was found in 52 (69.3%) patients. Dysembryoplastic neuroepithelial tumors (DNET) and fibrillary astrocytomas were the most epileptogenic tumors. The outcomes on the Engel scale were as follows: in 27 patients with surgical intervention without ECoG: class I - 9 patients, class II - 7 patients, class III - 5 patients, class IV - 6 patients and in 25 patients operated with ECoG: class I - 19 patients, class II - 4 patients and class III - 2 patients. The significant difference (p<0.01) between I+II Engel classes in comparison with III+IV Engel classes in operated patients demonstrated the necessity of ECoG during surgery in the resection of supratentorial brain tumors in patients with symptomatic epilepsy.

PRE-SURGERY MR-VISUALIZATION OF THE EPILEPTOGENIC SUPRATENTORIAL BRAIN TUMORS IN CHILDREN

Symptomatic focal epilepsies are commonly caused by the supratentorial brain tumors in chtldren. Among the 79 pediatric patients with supratentorial brain tumors 56 patients had symptomatic epilepsy (69,3%). The most epileptogenic tumors were dysembryoplastic neuroepithelial tumors (DNET), diffuse astrocytomas (DA) and gangliogliomas (GG). In all the cases of DNET and in 4 patients with GG epileptic seizures were the first manifestation, and in 4 of 5 cases of DNEO they were the only clinical sign of tumor. On the neuroimaging the MR-features of DNET, DA and GG were represented by iso- or hypointensive signal on T1 weighted image (WI) and varying in intensity from moderate to hyperintensive signal in T2 and FLAIR WI, while in cases with DNET and GG practically no mass effect and perifocal edema were seen, and on FLAIR WI the so-called "spume-like" (multicystic) structure was most clearly observed. During the follow up period no significant changes in the dimensions of identified DNET and GG were observed. In one case the combination of DNET with focal cortical dysplasia was noted. In DA it is difficult to distinguish the perifocal edema from tumorous tissue and normal brain tissue, and the growth potential of tumor is slow. The contrast enhancement of these tumors is ambiguous. Along with DNET (which is epileptogenic in 100% of cases), the most epileptogenic brain tumors are DA (in 91.7% of cases) and GG (in 80% of cases) which should be excluded in drug-resistant cases of focal epilepsy.

THE ROLE OF MAGNETIC RESONANCE IMAGING IN COMPLEX CLINICAL-EEG-IMAGING EXAMINATION OF EPILEPTOGENIC BRAIN TUMORS IN CHILDREN

Symptomatic epilepsy is common for patients with supratentorial brain tumors. Among 75 children with supratentorial brain tumors 52 patients had symptomatic epilepsy (69,3%). The most epileptogenic tumors were dysembryoplastic neuroepithelial tumors (DNET), diffuse astrocytomas (DA) and gangliogliomas (GG). In all the cases of DNET and in 4 patients with GG epileptic seizures were the first symptom, and in 4 of 5 cases of DNET seizures were the only clinical sign of tumor presence. DNET, DA and GG looked as iso- or hypointensive lumps on T1-weighted images and as moderate or hyperintensive lesions on T2-weighted and FLAIR images, without mass effect or perifocal edema in cases of DNET and GG. On FLAIR images DNET and GG have so-called “spume-like” (multicystic) structure. Follow up MRI did not reveal significant change in DNET and GG. In one case DNET was noted to be associated with focal cortical dysplasia. In DA it is difficult to distinguish the perifocal edema from tumorous tissue and normal brain tissue, and the growth potential of tumor was slow. The tumors differently cumulate contrast and interpretation of scans with contrast enhancement is ambiguous. Along with DNET (which is epileptogenic in 100% of cases), DA and GG are also epileptogenic brain tumors (seizures occur in 91.7% of cases of DA and in 80% of cases of GG) which should be excluded during diagnosis of drug-resistant focal epilepsy.

Are preoperative sex-related differences of affective symptoms in primary brain tumor patients associated with postoperative histopathological grading?

Our objective was to explore the impact of the histopathological tumor type on affective symptoms before surgery among male and female patients with supratentorial primary brain tumors. A total of 44 adult patients were included in the study. Depression and anxiety were measured using the Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory. Additionally, clinical interviews, including the Hamilton Depression Rating Scale (HDRS), were conducted. The general function of patients was measured with the Karnofsky Performance Status scale (KPS). All measures were obtained before surgery and therefore before the final histopathological diagnosis. All self-rating questionnaires but not the HDRS, showed significantly higher scores in female patients. The functional status assessed with the KPS was lower in female patients and correlated to the somatic part of the BDI. We further found a tendency for higher HDRS scores in male patients with a WHO grade 4 tumor stage compared to female patients. This finding was supported by positive correlations between HDRS scores and WHO grade in male and negative correlations between HDRS scores and WHO grade in female patients. In conclusion the preoperative evaluation of affective symptoms with self-rating questionnaires in patients with brain tumors may be invalidated by the patient’s functional status. Depression should be explored with clinical interviews in these patients. Sex differences of affective symptoms in this patient group may also be related to the malignancy of the tumor, but further studies are needed to disentangle this relationship.

Serum B-Type Natriuretic Peptide is Affected by Neoplastic Edema in Patients with a Brain Tumor

A positive correlation between serum B-type natriuretic peptide levels and the amount of dislodgement of intracranial structures (mass effect) produced by brain tumors has been demonstrated previously. The aim of our prospective observational study was to evaluate a possible relationship between serum B-type natriuretic peptide levels and the amount of neoplastic edema in patients affected by brain tumor. We prospectively studied 110 patients with a supratentorial brain tumor. Serum N-terminal-pro B-type natriuretic peptide was measured and brain magnetic resonance images were analyzed to discriminate between neoplastic tissue and perilesional edema. A multivariate linear regression model predictive for serum N-terminal-pro B-type natriuretic peptide levels was generated. The radiologic diagnoses were meningioma in 45 patients (40.9%), glioma in 33 (30%), and metastasis in 32 (29.1%). A mass effect was present in 29 (26.4%) patients. Serum N-terminal-pro B-type natriuretic peptide was 125.61 ± 174.14 pg/mL (median 60 pg/mL, interquartile range 28-139 pg/mL). Four variables were entered into a multivariate linear regression model predictive for serum N-terminal-pro B-type natriuretic peptide values: age, neoplastic edema volume, metastatic lesion, and the presence of a mass effect (whole model P < 0.0001; R(2) = 0.5555; adjusted R(2) = 0.5294). Our data demonstrate that serum B-type natriuretic peptide levels are positively correlated to neoplastic brain edema in patients with a brain tumor and suggest a possible cerebral source for this phenomenon.

Affective Symptoms and White Matter Changes in Brain Tumor Patients

Affective symptoms are frequent in patients with brain tumors. The origin of such symptoms is unknown; either focal brain injury or reactive emotional distress may be responsible. This cross-sectional pilot study linked depressive symptoms and anxiety to white matter integrity. The objective was to test the hypothesis of a relationship between tissue damage and brain function in patients with brain tumors and to provide a basis for further studies in this field. Diffusion tensor imaging was performed in 39 patients with newly diagnosed supratentorial primary brain tumor. Patients completed the Beck Depression Inventory, and examiners rated them on the Hamilton Depression Rating Scale (HDRS). State and trait anxiety were measured using the State-Trait Anxiety Inventory. Correlations between fractional anisotropy (FA) and psychological measures were assessed on the basis of regions of interest; the defined regions of interest corresponded to clearly specified white matter tracts. Statistical analysis revealed correlations between FA in the left internal capsule and scores on the HDRS, Beck Depression Inventory, and State-Trait Anxiety Inventory (P < 0.05). HDRS scores were also correlated with FA in the right medial uncinate fasciculus, and state anxiety scores were significantly correlated with FA in the left lateral and medial uncinate fasciculus (P < 0.05). Our results suggest that neurobiologic mechanisms related to the integrity of tissue in specific white matter tracts may influence affective symptoms in patients with brain tumors, and these mechanisms can be investigated with diffusion tensor imaging. However, prospective observational studies are needed to investigate further the links between brain structures and the severity of affective symptoms in this patient population.

HG-15 * TARGETED NEXT GENERATION SEQUENCING IN MALIGNANT SUPRATENTORIAL PEDIATRIC BRAIN TUMORS REVEALS ACTIONABLE MUTATIONS

BACKGROUND: Pediatric supratentorial brain tumors have been difficult to appropriately categorize using standard clinical and pathological criteria. Next generation sequencing (NGS) is a promising tool to evaluate many genes simultaneously; genomic alterations identified using NGS could improve diagnosis and identify actionable alterations. Currently, there is no data on the clinical utility of NGS in pediatric brain tumors. METHODS: Twelve formalin-fixed paraffin embedded tumor samples were retrieved from 9 patients with high-grade supratentorial pediatric brain tumors resected between 2008 and 2012. Original and relapse samples were obtained from 3 patients. DNA was extracted and analyzed on a 194 gene NGS platform that has been validated clinically for use in adult malignancies with emphasis on detection of drug targets. Genetic findings were correlated with histology and immunohistochemistry. RESULTS: We found one or more pathologic genetic variant (mutation, amplification, or deletion) in 8 of 9 (89%) of patients studied, including alterations in multiple subjects of EGFR (n = 3), PDGFRA (n = 2), CDK4 (n = 2) and CDKN2A (n = 2). An identical EGFR exon 20 insertion was identified in 2 subjects, which has not been previously described in pediatric malignancy. In addition, NGS identified mutations in genes associated with familial cancer predisposition syndromes in 5 patients, including TP53 (n = 2), PTEN, CHEK2, and MSH2. Comparison of primary to relapse samples showed additional mutations and amplifications in PDGFRA and EGFR detected solely in latter relapse samples. The single patient without actionable mutations was in one of only two long-term survivors. CONCLUSIONS: Targeted deep sequencing may be useful in rare pediatric brain tumors to identify driver mutations, suggest constitutional and familial testing for cancer predisposition syndromes, and select molecular targets worthy of further study.

Does scalp block with general anesthesia in craniotomy affect the intraoperative course and outcome in geriatric patients?

Background The noxious stimuli during supratentorial brain tumor resection in geriatric patients result in a vigorous hemodynamic response and stress response, which represents a challenge during anesthesia. Patients and methods A total of 80 patients were enrolled in the study. There were 43 male and 37 female patients undergoing elective supratentorial craniotomy. Patients were randomly assigned into two equal groups: group B patients had scalp block using bupivacaine (0.5%) and epinephrine (1 : 400 000) and group F patients received fentanyl 2 μg/kg (during maintenance of general anesthesia (GA)). Heart rate (HR), mean arterial pressure (MAP), plasma cortisol level, and intracranial pressure (ICP) were recorded at baseline (before induction of anesthesia), 1 min after intubation, 1 min after skin incision, 1 min after dural incision, 1 min after dural closure, 1 min after skin closure, and 1 min after extubation. ICP measurement ceased at dural incision. Time to recovery from anesthesia was also recorded. Results MAP, HR, and plasma cortisol level showed significant differences between groups, wherein group F had higher MAP, HR, and plasma cortisol level than group B. Group B had rapid recovery period. Conclusion Scalp block with 0.5% bupivacaine with adrenaline 1 : 400 000 can be used as an alternative to general anesthesia with fentanyl in preventing the increase in arterial blood pressure (ABP), HR, ICP, cerebral perfusion pressure (CPP), and cortisol level, and also it allows early extubation and assessment of conscious level.

Awakening Properties of Isoflurane, Sevoflurane, and Desflurane in Pediatric Patients After Craniotomy for Supratentorial Tumours

The aim of this prospective, comparative, randomized study was to compare the inhalational anesthetics isoflurane, sevoflurane, and desflurane in pediatric patients undergoing craniotomy for excision of supratentorial tumors. We assessed early postoperative recovery outcome, intraoperative hemodynamics, and degree of brain swelling, as well as postoperative vomiting and shivering. Sixty patients scheduled for supratentorial brain tumor excision, were randomly allocated into 1 of 3 groups (20 patients each); isoflurane, sevoflurane, and desflurane group. After IV induction of anesthesia, maintenance was achieved using the inhalational anesthetic according to the allocated group. Tracheal extubation time was the primary endpoint. The secondary endpoints included: emergence time and the interval time needed to reach Aldrete score ≥9, intraoperative degree of brain swelling, intraoperative heart rate and mean arterial blood pressure, as well as postoperative vomiting and shivering. The mean emergence time, extubation time, and the interval required to reach Aldrete score 9 were significantly shorter in the desflurane and sevoflurane groups than the isoflurane group. No statistically significant changes in the 3 groups regarding intraoperative brain swelling, hemodynamics, and postoperative shivering or vomiting were noted. Desflurane and sevoflurane can be used to facilitate early emergence from anesthesia in neurosurgical pediatric patients. Emergence times are shorter with desflurane or sevoflurane than with isoflurane. The patients who received desflurane or sevoflurane have similar intraoperative and postoperative incidence of adverse effects compared with those who received isoflurane. Thus, desflurane and sevoflurane can be considered as suitable for emergence in pediatric neurosurgical anesthesia.

Benefits of dynamic susceptibility-weighted contrast-enhanced perfusion MRI for glioma diagnosis and therapy.

Glioma are the most common supra-tentorial brain tumor in the USA with an estimated annual incidence of 17,000 new cases per year. Dynamic susceptibility-weighted contrast-enhanced (DSC) perfusion MRI noninvasively characterizes tumor biology allowing for the diagnosis and therapeutic monitoring of glioma. This MRI technique utilizes the rapid changes in signal intensity caused by a rapid intravascular bolus of paramagnetic contrast agent to calculate physiologic perfusion metrics. DSC perfusion MRI has increasingly become an integrated part of glioma imaging. The specific aim of this article is to review the benefits of DSC perfusion MRI in the therapy of glioma.

Surgery for primary supratentorial brain tumors in the United States, 2000-2009: effect of provider and hospital caseload on complication rates.

The object of this study was to examine how procedural volume and patient demographics impact complication rates and value of care in those who underwent biopsy or craniotomy for supratentorial primary brain tumors. The authors conducted a retrospective cohort study using data from the Nationwide Inpatient Sample (NIS) on 62,514 admissions for biopsy or resection of supratentorial primary brain tumors for the period from 2000 to 2009. The main outcome measures were in-hospital mortality, routine discharge proportion, length of hospital stay, and perioperative complications. Associations between these outcomes and hospital or surgeon case volumes were examined in logistic regression models stratified across patient characteristics to control for presentation of disease and comorbid risk factors. The authors further computed value of care, defined as the ratio of functional outcome to hospital charges. High-case-volume surgeons and hospitals had superior outcomes. After adjusting for patient characteristics, high-volume surgeon correlated with reduced complication rates (OR 0.91, p=0.04) and lower in-hospital mortality (OR 0.43, p<0.0001). High-volume hospitals were associated with reduced in-hospital mortality (OR 0.76, p=0.003), higher routine discharge proportion (OR 1.29, p<0.0001), and lower complication rates (OR 0.93, p=0.04). Patients treated by high-volume surgeons were less likely to experience postoperative hematoma, hydrocephalus, or wound complications. Patients treated at high-volume hospitals were less likely to experience mechanical ventilation, pulmonary complications, or infectious complications. Worse outcomes tended to occur in African American and Hispanic patients and in those without private insurance, and these demographic groups tended to underutilize high-volume providers. A high-volume status for hospitals and surgeons correlates with superior value of care, as well as reduced in-hospital mortality and complications. These findings suggest that regionalization of care may enhance patient outcomes and improve value of care for patients with primary supratentorial brain tumors.

The impact of surgical resection of giant supratentorial brain tumor in pediatric patients: safety and neurological outcome evaluated in 23 consecutive cases.

This study aims to evaluate the impact of gross total resection of giant supratentorial brain tumors (GSBT) on survival and neurological outcome in a consecutive single-center pediatric series. Clinical data of 23 patients under 18 years of age operated with GSBT (≥5 cm in diameter) were reviewed to determine epidemiological aspects, clinical presentation, associated factors, histopathological features, and outcome. Volumetric measurements were performed on magnetic resonance imaging or computed tomography scans obtained at the time of the initial surgical procedure. The group included 23 patients (mean age 4.5 years). Signs and symptoms of raised intracranial pressure were present in 19 patients (82.6%). The most frequent tumor location was the parietal lobe in 19 patients (82.6%), and the mean tumor volume was 208 cm(3). Gross total or radical resection was achieved in all patients. Histopathological analysis revealed malignant brain tumors in 18 cases (78.2%). The most common neoplasm was choroid plexus carcinoma in seven (30.4 %). Mean intraoperative blood transfusion volume was 51.2 ml/kg. Chemotherapy and/or radiotherapy were performed as adjuvant treatment in 16 patients (69.5%). Mean length of follow-up was 36.7 months. Tumor malignancy grade significantly correlated with recurrence of the disease (P = 0.03) and death (P = 0.01), as opposed to tumor location, size, and extension to the ventricles. Our clinical experience suggests that tumor mass reduction by en bloc surgery seems to be an effective approach in pediatric patients with GSBT, relieving symptoms related to raised intracranial pressure and providing a better response to adjuvant treatment.

NT-14 * EARLY EXPERIENCE WITH TRANS-SULCAL PARAFASCICULAR EXOSCOPIC RESECTION OF SUPRATENTORIAL BRAIN TUMORS

BACKGROUND: Resection of subcortical lesions is limited by concern for procedure-related injury to critical structures. Such a concern may impede the ability to resect completely and such an injury may affect post-operative recovery significantly. The parafascicular approach involves planned navigation of working channel parallel to critical fascicles when accessing subcortical lesions. This reduces shear injury to major white matter tracts and is achieved by inserting a tapered dilating access device (Neuroport) through a sulcus. Use of an exoscope increases illumination and clarity in optics that go hand in hand with the tenants of this approach. Here we present our early experience with this technique. METHODS: We reviewed our first 10 supratentorial brain tumors that were resected using the 6-pillar approach of parafascicular minimally invasive exoscopic resection. The eligible patients underwent further data analysis focusing on pathology and outcome from this approach. RESULTS: Ten patients with a mean age of 63 years underwent resection of both primary and metastatic lesions. There were no adverse events related to port placement or approach. Eight had primary neoplasm of which 6 were WHO grade IV. Two other lesions were metastatic in nature. Two patients died but both succumbed to their neoplasm and not surgery or its complications. One developed supplementary motor area syndrome following resection of rapidly growing left frontal Glioblastoma. Tumor resection was gross total in all cases. Hospital stay averaged 2.5 days. CONCLUSIONS: Trans-sulcal parafascicular navigated exoscopic resection is rapidly becoming an established way of managing subcortical brain tumors and other lesions, especially intra-cerebral hematomas. Our early results are better than conventional open surgical resection, with inaccessible lesions becoming accessible and shorter hospital stays. With this minimally invasive (minimally disruptive) approach, we see decrease in injury to both vital cortex and significant large white matter tracts thus preserving maximum neurological function.

The Brain Relaxation and Cerebral Metabolism in Stroke Volume Variation–directed Fluid Therapy During Supratentorial Tumors Resection

Compared with goal-directed crystalloid therapy, goal-directed colloid therapy during high-risk surgery may improve postoperative outcome. Whether intraoperative fluid therapy based on goal-directed protocol with different types of fluid has distinctive effects on brain relaxation and cerebral metabolism during craniotomy remains unclear. Forty patients with supratentorial brain tumors undergoing craniotomy were randomly assigned to either a Ringer's Lactate-based goal-directed group (LR group, n=20) or a 6% hydroxyethyl starch-based goal-directed group (HES group, n=20). The goal was achieved by maintaining a target stroke volume variation (SVV<13%) by volume loading with LR or HES throughout the procedure. The primary outcome is brain relaxation scales, an indirect evaluation of ICP; secondary endpoints include cerebral metabolism variables (jugular venous oxygen saturation [SjvO(2)], arterial-jugular venous differences in oxygen [CajvO(2)], glucose [A-JvGD], lactate [A-JvLD], and cerebral extraction ratio for oxygen [CERO(2)]) and fluid volumes. There is no significant difference between the LR and HES groups on brain relaxation scales (P=0.845), or measures of cerebral oxygenation and metabolism. Intragroup comparisons showed that CERO(2) increased by 14.3% (P=0.009, LR group) and 13.2% (P=0.032, HES group), respectively, and SjvO(2) was decreased by 8.8% (P=0.016, LR group) and 8.1% (P=0.026, HES group), respectively, after tumor removal, compared with baseline. During surgery, the LR group (3070±1138 mL) received more fluid than the HES group (2041±758 mL, P=0.002). In patients undergoing supratentorial tumor resection, goal-directed HES therapy was not superior to goal-directed LR therapy for brain relaxation or cerebral metabolism, although less fluid was needed to maintain the target SVV in the HES-based group than in the LR-based group.

Quantitative longitudinal evaluation of diaschisis-related cerebellar perfusion and diffusion parameters in patients with supratentorial hemispheric high-grade gliomas after surgery.

Decreased cerebral blood volume (CBV) in contralateral cerebellar gray matter (cGM) in conjunction with cerebellar white matter (cWM) damage, consistent with crossed cerebro-cerebellar diaschisis (cCCD) develop following supratentorial hemispheric stroke. In this study, we investigated the longitudinal evolution of diaschisis-related cerebellar perfusion and diffusion tensor-imaging (DTI) changes in patients after surgery for supratentorial brain tumors. Eight patients (M:F 5:3, age 8-22years) who received surgery for supratentorial high-grade gliomas were evaluated. Initial MRI studies were performed 19-54days postoperatively, with follow-ups at 2- to 3-month intervals. For each study, parametric maps of the cerebellum were generated and coregistered to T1-weighted images that had been previously segmented for cGM and cWM. Aggregate mean values of CBV, cerebral blood flow (CBF), and fractional anisotropy (FA) were obtained separately for cGM and cWM, and asymmetry indices (AIs) were calculated. Hemodynamic changes were more robust in cGM than in cWM. Seven patients showed decreased perfusion within cGM contralateral to the supratentorial lesion on the first postoperative study, and asymmetry was significant for both CBV (p = 0.008) and CBF (p < 0.01). For CBV, follow-up studies showed a significant trend towards recovery (p < 0.02). DTI changes were more pronounced in cWM. FA values suggested a "paradoxical" increase at initial follow-up, but steadily declined thereafter (p = 0.0003), without evidence of subsequent recovery. Diaschisis-related hemodynamic alterations within cGM appear on early postoperative studies, but CBV recovers over time. Conversely, cWM DTI changes are delayed and progressive. Although the clinical correlates of cCCD are yet to be elucidated, better understanding of longitudinal structural and hemodynamic changes within brain remote from the area of primary insult could have implications in research and clinical rehabilitative strategies.

Postoperative complications in children and adults with sub - and supratentorial brain tumors

Postoperative complications in children and adults with sub - and supratentorial brain tumors