Supratentorial Brain Tumors Research Articles

Lag Time of Pediatric Supra Tentorial Brain Tumors in Lower Middle Income Countries (LMIC)

Background: The most common and frequent tumors in the children’s are central nervous system tumors (CNS). Objective: For evaluation of the lag time and clinical spectrum of pediatric supratentorial brain tumors from the time of appearance of symptoms in a patient to the time the patient presents to the hospital. Study design: It is an observational and cohort study conducted in the radiology and oncology department of our institute teaching hospital. Material and Methods: This prospective research was conducted at the oncology department of the children hospital ICH Lahore for one year. The study was approved by the IRB. The duration of the study was from March 2021 to March 2022. The sample size was calculated. The patients of age range between 0 months to 17 years were included in the study. SPSS version 24.0 was used for statistical analysis. Data will be stratified to see the effect modulators. Results: This study included 60 patients 30 girls and 30 boys. The average age of the patients at the time they were diagnosed with pediatric supratentorial brain tumor was 7 years. The majority of the patients reported to have type I neurofibromatosis. Some of the most common symptoms that the patients reported were vomiting, oculo-visual issues, motor problems, headache and endocrine dysfunction. Conclusion: The lag time and clinical spectrum of pediatric supratentorial brain tumors from the time of appearance of symptoms in a patient to the time the patient presents to the hospital was reported to be 2-6 months in majority almost 61% of the children. The 71% children visited the two regional area doctors before visiting the tertiary care hospital. The complex interplay of underdiagnoses, unavailability of the neuro-oncology treatments facilities and higher rates of abandonment in the LIMC are the basic reason behind survival gaps of the delayed presented patients. Keywords: Pediatric supratentorial brain tumors, lag time, low/middle income countries (LMIC), Central nervous system (CNS) tumors and intraxial tumors.

Postoperative intensive care management and residual endocrinopathy of pediatric supratentorial brain tumors: a retrospective cohort study

Endocrinopathy can occur as a postoperative sequel in children treated for supratentorial tumors (STTs). We assessed prediction of a residual hypothalamic/pituitary insufficiency (HPI) in these patients andfactors associated with prolonged length of hospital stay (LOS). This is a retrospective cohort study of children who had surgery for STTs in two tertiary centers in Saudi Arabia (2009-2019). We assessed PICU postoperative management and risk of HPI. Data were analyzed using SPSS V24.0 and a logistic regression model for a prediction of a prolonged LOS. Data included 55 children (1-18 years, mean 9.5±4.9 years) who required STT surgeries, 32 (54%) females. Craniopharyngioma (27.3%) was the commonest STTs and 20% of patients had initial symptoms of HPI. PICU management included the use of different types of intravenous fluids (IVFs) and medications such as steroids and desmopressin (DDAVP). An early postoperative DI was reported in 21.8% (n=12/55). Residual HPI included 24 (43.6%) presumed cortisol deficient and 18 (32.7%) central DI patients. Risk factors for postoperative HPI were female gender, age<6 years, headache and preoperative pituitary symptoms. LOS (Median=25.5±12.2days) was significantly prolonged in patients who required two or more doses of DDAVP [B=13; 95% CI= (1.7-24.3) days] and reduced in patients who had suspected preoperative HPI [B=-19.6; 95% CI= (-31.1,-8.2) days]. Prediction of postoperative HPI in pediatric STTs enhances an early initiation of treatment in PICU and reduces LOS. A meticulous use of IVF and medications supervised by a multidisciplinary team is essential for a favorable outcome.

Soft Coagulation Monopolar Suction for Rapid Resection of Supratentorial Brain Tumors: Feasibility of a New Technique and Outcomes

The aims of this study were to evaluate the feasibility of a new rapid tumor resection technique using soft coagulation monopolar suction (SCMS) and to strengthen neurosurgeons' understanding, use, and attention to this new electrosurgical technique. The rapid surgical resection technique used herein comprised monopolar suction in soft coagulation mode applied by the ERBE VIO 300s workstation and conventional microsurgical suction. We applied this technique to supratentorial tumors in 12 patients (5 with glioblastomas, 4 with astrocytomas, 2 with metastases, and one with lymphoma) as the SCMS group. The conventional bipolar electrocautery and suction method was used for another 12 patients (non-SCMS group). The surgical results and perioperative complications were retrospectively evaluated. Radiographic and histologic analyses were performed to describe the degree of thermal damage. The mean estimated operative time and total blood loss were 3.63±0.61hours (P= 0.0048) and 308.33±172.99mL(P= 0.0482) in the SCMS group, respectively, and these values were significantly lower than those in the non-SCMS group (4.33±0.49hours and 466.67±196.95mL, respectively). No significant differences in perioperative complications, Karnofsky Performance Status scores, perioperative area edema volumes, perioperative ischemic areas, or mean residual tumors were observed between the groups. Histological examination revealed that SCMS produced uniform coagulation and completely obstructed most small vessel structures on the tumor surface. This new technique involving SCMS allows for a smooth surgical procedure and appears to be safe and feasible for the rapid resection of supratentorial brain tumors. Thus, neurosurgeons should consider using this technique in the future.

Resting state fMRI brain mapping in pediatric supratentorial brain tumors

BackgroundFunctional mapping of eloquent brain areas is crucial for preoperative planning in patients with brain tumors. Resting state functional MRI (rs-fMRI) allows the localization of functional brain areas without the need for task performance, making it well-suited for the pediatric population. In this study the independent component analysis (ICA) rs-fMRI functional mapping results are reported in a group of 22 pediatric patients with supratentorial brain tumors. Additionally, the functional connectivity (FC) maps of the sensori-motor network (SMN) obtained using ICA and seed-based analysis (SBA) are compared.ResultsDifferent resting state networks (RSNs) were extracted using ICA with varying levels of sensitivity, notably, the SMN was identified in 100% of patients, followed by the Default mode network (DMN) (91%) and Language networks (80%). Additionally, FC maps of the SMN extracted by SBA were more extensive (mean volume = 25,288.36 mm3, standard deviation = 13,364.36 mm3) than those found on ICA (mean volume = 13,403.27 mm3, standard deviation = 9755.661 mm3). This was confirmed by statistical analysis using a Wilcoxon signed rank t test at p < 0.01.ConclusionsResults clearly demonstrate the successful applicability of rs-fMRI for localizing different functional brain networks in the preoperative assessment of brain areas, and thus represent a further step in the integration of computational radiology research in a clinical setting.

Awake craniotomy with dexmedetomidine during resection of brain tumours located in eloquent regions.

An awake craniotomy (AC) is the gold standard for the resection of supra-tentorial brain tumours in eloquent areas. Intraoperative monitoring "on-demand" of essential eloquent brain functions and the increasing need to preserve higher intellectual functions during surgery requires aunique anaesthetic approach during AC. Dexmedetomidine is considered the first-choice pharmacological agent for sedation during AC. Twenty-six patients with asingle brain tumour located in areas of eloquent brain function were enrolled in this prospective study. The patients underwent AC under conscious sedation. Motor-evoked potentials and brainstem-evoked auditory potentials were measured using neurophysiological tests during surgery to assess brain potentials. Intraoperative brain relaxation was reached using amodified Bristow scale. Neuromonitoring and psychological tests were maintained until meningeal closure. All operations were carried out successfully, and no reoperations were needed. No significant impact on circulatory and respiratory parameters was observed during conscious sedation based on dexmedetomidine. Neither instrumental airway support nor conversion to general anaesthesia was necessary. Brain relaxation was good in 84% of cases. Intraoperative epileptic episodes were observed in 15% of the patients. Neuro-logical and psychological monitoring was satisfactory. Unaltered muscle force was observed postoperatively in 88% of the patients. AC performed under conscious sedation, and dexmedetomidine infusion without instrumental airway support, was safe and well-tolerated by patients with comfortable physiological sleep for most of the procedure. This approach to AC was associated with minimal risk of perioperative adverse events and may be particularly beneficial in patients with severe comorbidities.

Comparison between Sevoflurane and Isoflurane for Controlled Hypotensive Anaesthesia in Patients undergoing Craniotomy for Supratentorial Intracranial Surgery: A Randomised Single-blinded Study

Introduction: The controlled hypotensive anaesthesia technique is widely used for decades to create a bloodless surgical field and decrease intraoperative blood loss during neurosurgical procedures. Inhalation agents like isoflurane and sevoflurane provide the benefit of being hypnotic and hypotensive agents at clinical concentrations and predictable dose-dependent effects made them popular in neurosurgery. Aim: To compare the effects of sevoflurane and isoflurane for producing controlled hypotensive anaesthesia in surgeries for supratentorial brain tumours. Materials and Methods: Sixty-six patients of either sex in the age group of 20-60 years, with American Society of Anaesthesiologists (ASA) Grade I and II posted for elective craniotomy for supratentorial brain tumour under general anaesthesia were enrolled for this study. Patients were randomly allocated to two aesthetic regimens: Group I received isoflurane 1 Minimum Alveolar Concentration (MAC), and Group S received sevoflurane 1 MAC. The Systolic Blood Pressure (SBP) was lowered to less than 100 mmHg before the skin incision and was maintained throughout the surgery.If the blood pressure was not maintained within the above-mentioned range, then injection propofol bolus dose of 20 mg was given intravenously. The quality of the surgical field, brain relaxation, blood loss, duration of surgery, and postoperative complications were compared. Time taken for onset and recovery of controlled hypotension and the requirement of propofol for maintaining controlled hypotension in both groups were also compared. Results: The group S had better brain relaxation (N=26 vs N=20), less blood loss (241.5±61.62 vs 380.65±203.9 mL), and a shorter duration of surgery (135.45±25.6 vs 171.4±60.5 minutes) than group I. Group S had a few patients who required propofol (5 vs 17) to maintain controlled hypotension. The mean time to achieve the target Mean Arterial Pressure (MAP) and time to recovery was faster in group S (10.55±2.54 minutes) vs 15.35±0.99 minutes in group I and 12.95±3.24 minutes in Group S vs 17.85±2.21 minutes in Group I, respectively; p&lt;0.001). Conclusion: Sevoflurane is a safer and more potent drug than isoflurane to achieve controlled hypotension during surgery for a supratentorial brain tumour.

Effect of sphenopalatine ganglion block on intracranial pressure and cerebral venous outflow oxygenation during craniotomy for supratentorial brain tumours

BackgroundIntraoperative intracranial pressure (ICP) control continues to be a challenge for anaesthetists during craniotomies. Although many standard brain-dehydrating protocols are available, they may be ineffective in certain surgical situations and may result in harm either to the systemic or cerebral circulation. Sphenopalatine ganglion block (SPGB) can reverse the vasodilatory effects of anaesthesia during craniotomy. MethodsThis prospective randomised study was carried from June 2020 to February 2021. Fifty-two patients were randomly allocated into two groups, the block group (B) and the non-block control group (Non). Twenty-six patients were enrolled in the (B) group and received a bilateral transnasal SPG block with 2% lidocaine using a hallow culture swab prior to anaesthesia induction. Intraoperative monitoring was performed using standard American Society of Anesthesiologists (ASA) monitors in addition to invasive monitoring using intra-arterial cannulas and jugular venous bulb catheters. Subdural ICP monitors were also employed. The arterio-jugular oxygen difference in mmol/l (AjvDO2) was then calculated. Mean flow velocity cm/s (MFV) and pulsatility index (PI) were monitored in both groups using Transcranial Doppler. Haemodynamic data were recorded every 30 min from induction of anaesthesia until the closure of the dura. ResultsThere was a significant difference in ICP prior to the dural opening between the block group (B), mean ± sd 7.58 ± 1.47, and the non-block group (Non), mean ± sd (11.69 ± 1.72), p-value < 0.001. There was no significant difference in MFV between (B) group, mean ± sd 72.65 ± 2.28 and (Non) group, mean ± sd 71.19 ± 3.09 before intubation (baseline values). While there was a significant difference after intubation between block group, mean ± sd 72.12 ± 1.77 and non-block group, mean ± sd 74.62 ± 5.07, p-value = 0.02. There was an insignificant difference between (B) and (Non) groups before intubation regarding PI values, while PI was significantly higher in (B) group than the (Non) group after intubation where mean ± sd was 1.17 ± 0.05 versus 0.96 ± 0.09, respectively, p-value = 0.001. There was no significant difference regarding cerebral oxygenation between the groups. ConclusionsSPGB can control factors that increase CBF during anaesthesia by the block of parasympathetic vasodilatory fibres to the arterial system in the anterior cerebral circulation, while neither hindering cerebral venous drainage nor impairing cerebral oxygenation, as it gives no supply to cerebral veins and does not affect basal CBF. Additionally, it does not affect systemic circulation.

Embryonal tumor with multilayered rosettes; rare pediatric CNS tumor. A case report and review of literature

Embryonal tumor with multilayered rosettes (ETMR), C19MC-altered is a newly designated entity of the embryonal tumors of the central nervous system (CNS) according to the 2016 WHO classification system of CNS. Characteristically, these tumors are newly defined based on their specific molecular genetic amplification in chromosome 19q13.42 found at locus C19MC. To the best of our knowledge, we present the first reported case of ETMR in Saudi Arabian pediatric population. A 2-year-old boy presented to the hospital with generalized tonic-colonic seizure, vomiting, irritability, and inability to walk. Computed tomography (CT) scan showed a large left thalamic supratentorial brain tumor. The tumor measured 6.1 × 5.6 × 5.6 cm and was characterized by cystic changes, prominent vasculature, and calcifications. Histopathology, immunohistochemistry examination, and fluorescence in situ hybridization (FISH) analysis confirmed the diagnosis of ETMR. In addition to reporting this rare case, we provide a brief literature review, treatment options, patient outcome, and disease prognosis.

Expression of Vascular Endothelial Growth Factor A and Its Type 1 Receptor in Supratentorial Neoplasm.

Vascular endothelial growth factor (VEGF) is one of the primary angiogenesis regulators in solid cancers. Brain solid tumors are life-threatening diseases in which angiogenesis is an important phase of tumor development and progression. In the present study, VEGF-A and VEGF receptor (VEGF-R1) gene expression was evaluated in CNS brain tumors. VEGF-A and VEGF-R1 expression was quantified using real-time PCR on fresh biopsies of 38 supratentorial brain tumors compared to 30 non-tumoral tissues. Then, the correlations were investigated with clinic-pathological and demographic factors of the patients. PCR product sequencing confirmed the validity of qRT-PCR. Although VEGF-A and VEGF-R1 expression showed increasing trends with the progression of cell proliferation in different stages of astrocytoma, VEGF-R1 did not meet the 95% confidence interval in other brain tumors. An increasing trend in VEGF-A expression and a declining trend in VEGF-R1 expression from Stage I to II were observed in meningioma. VEGF-A and VEGF-R1 expression had no significant correlation with age and gender. Although peritumoral brain edema (PTBE) in astrocytoma was significantly associated with tumor stages, VEGF-A and VEGF-R1 were not correlated with PTBE in meningioma and metastasis. VEGF-A is a valuable factor for the prognosis of PTBE and malignancy in astrocytoma and is helpful in monitoring treatment approaches.

Ketamine Alleviates Depressive Symptoms in Patients Undergoing Intracranial Tumor Resection: A Randomized Controlled Trial.

Depressive symptoms occur in over 40% of neurosurgical patients during the perioperative period. However, no measure has been suggested to have a rapid effect on depressive surgical patients during increasingly shorter stays in the hospital. This study aimed to determine whether ketamine could improve depressive symptoms rapidly and safely during the hospital stay. This was a randomized, placebo-controlled, and double-blinded trial. Patients with moderate-to-severe depressive symptoms undergoing elective supratentorial brain tumor resection were randomized to intravenously receive either (1) 0.5 mg·kg-1 ketamine for 40 minutes or (2) an identical volume of normal saline. The primary outcome was treatment response on postoperative day 3, defined as a ≥50% reduction from the baseline depressive score. The secondary outcomes included the rate of remission and safety outcomes. The Montgomery-Åsberg Depression Rating Scale was applied by trained psychiatrists to evaluate depressive symptoms. A total of 84 neurosurgical patients were enrolled in the trial. The response rate was increased by the administration of ketamine (41.5% [17/41] vs 16.3% [7/43]; relative risk [RR]: 2.51, 95% confidence interval [CI], 1.18-5.50) relative to the administration of placebo at 3 days. Furthermore, the remission rate at discharge (29.3% [12/41] vs 7.0% [3/43]; RR: 4.20, 95% CI, 1.28-13.80) was also improved by ketamine. No psychotic symptoms or adverse events were reported to be substantially higher in the ketamine group. The trial indicates that the intraoperative administration of ketamine could alleviate moderate-to-severe depressive symptoms in neurosurgical patients without worsening safety.

The role of patient primary language in access to brain tumor resection: Evaluating emergent admission and hospital volume

BackgroundThis study investigated the effect of limited English proficiency on access to neuro-oncologic surgery. We compared rates of emergent/urgent admission and admission to high-volume hospitals for English and non-English primary language patients with brain neoplasms. MethodsUsing the AHRQ-HCUP New Jersey State Inpatient Database, we included patients 18–90 years old who underwent resection of a supratentorial primary brain tumor (PBT), meningioma (MA) or brain metastasis (BM) from 2009–2017. Outcomes were emergent/urgent admission and annual hospital procedure volume. Univariable and multivariable analyses compared Spanish (SPL), Non-English Non-Spanish (NENS), and English (EPL) primary language groups. Results7,402 patients were included: 2,996 PBT, 2,115 MA, and 2,291 BM. SPL patients (n = 300) were younger and had a greater proportion of non-commercially insured, low-income patients with lower comorbidity scores. NENS patients (n = 260) had similar age and comorbidity scores as EPL patients, but a greater proportion had non-commercial insurance and low income (p < 0.001). Multivariable analysis revealed NENS, but not SPL, patients had increased odds of emergent/urgent admission (2.10(1.50−2.93), p < 0.001), but demonstrated no association between admission to higher volume centers and primary language. ConclusionPatient primary language may influence access to timely neurosurgical care, but access to high-volume centers appears to be mediated by other factors. Policy summary statementIn addition to efforts to improve health care access for patients with limited English proficiency, multilingual health literacy and patient education interventions may help to promote timely presentation for brain tumor resection among this vulnerable patient population.

The Outcome of Surgical Excision of Giant Supratentorial Brain Tumors in Pediatrics: A Study of Consecutive 70 Cases at our Institute

Abstract Background: Surgery of giant supratentorial pediatric brain tumors (GSPBT) is challenging. Diagnosis may be misled by the inconspicuous symptoms and signs. Surgery is difficult due to the propensity for severe hemorrhage which is risky in this age group. Aim of Study: We discuss the surgical management of GSPBT with emphasis on how to reach maximal safe resection and different surgical strategies to improve the outcome. Patients and Methods: All Patients with GSPBT under-going elective surgery were included of age 3 months to 12 years. Giant tumors were defined by being larger than 5cm. General anesthesia was performed by neuroanesthesiologists. Various tools and instruments were used such as Cavitating ultrasonic aspirator, microscope and endoscope. Blood trans-fusion was performed as early as possible to replace losses. Extent of removal was assessed from CT or MRI scans. Results: This study included 70 children operated for GSPBT. There were 47 males (67.1%) and 23 females (32.9%). The age ranged from 3 to 144 months with a mean age of 56.3 months. The commonest presenting symptoms were those of raised intracranial pressure (ICP) in 61 cases (87.1%). Gross total resection was achieved in 57 patients (81.4%), debulking up to 80% in 3 patients (4.3%), debulking up to 50% in 1 patient (1.3%) and partial resection less than 50% in 9 patients (12.9%). The amount of blood transfusion ranged from 5 to 300ml/kg with a mean amount of 39.4ml/kg. PNET was the most common pathological diagnosis. Two cases required interruption of the procedure due to massive bleeding causing hypotension (2.9%). There were no complications due to massive blood transfusion. There were no cases of mortality. Conclusion: GSPBT can be totally resected with a good outcome. This needs a team approach including a good an-esthesia team and proper postoperative care. Surgical tech-niques including sub-pial technique, endo scope- assisted microsurgery, and the CUSA may help accomplish this target.

Remote extradural hematoma after supratentorial brain tumor surgery: A rare complication of a routine surgery

Background: Hemorrhages in the surgical cavity post resection of tumor aren’t uncommon and neurosurgeons are well versed with this entity, however occurrence of an Extra Dural Hematoma(EDH), that too at a site remote to the surgical cavity, is rare. The study presents 3 cases of post operative remote site EDH after tumor resection with review of literature and an attempt to define and discuss the variables which play a role in determining the occurrence, extent and prognosis of the same.&#x0D; Methods: The study investigated 601 patients who underwent tumor resection in the Department of Neurosurgery, Dr D Y Patil Hospital, from January 2017 to December 2019. All patients had a normal coagulation profile preoperatively. Postoperative remote EDH occurred in 3 patients whose data was examined closely in terms of age, sex, location, final diagnosis and treatment.&#x0D; Results: Of the 601 patients who underwent tumor resection from Jan 2017 to Dec 2019, a total of 3 patients in our study were found to have a post-operative remote site EDH. Two of these patients were male and 1 female. The age range was 35 to 46 years with a mean of 41 years. Neither did any of these patients have a pre-existing hydrocephalus nor were they subjected to a CSF diversion procedure preoperatively. All 3 patients developed EDH on the ipsilateral side wherein 2 of our patients had a hematoma in the ipsilateral frontal region anterior to the surgical cavity while 1 patient developed hematoma in ipsilateral parietal region posterior to surgical cavity. Hematomas were unilateral with no extension to opposite side. Two patients had to be re-operated in an emergency setting while one patient was conservatively managed. &#x0D; Conclusion: In patients with an expected volume loss via large tumor size, excess blood and CSF loss and a large craniotomy, remote EDH may develop and the neurosurgeon must have a high index of suspicion for this entity

Operative duration and early outcomes in patients having a supratentorial craniotomy for brain tumor: A propensity matched analysis

It is unclear how variations in operative duration affect outcomes after craniotomy for supratentorial brain tumor. We characterized three populations of patients with typical, shorter, and longer durations of craniotomy for supratentorial brain tumor using prospectively collected clinical data from 16,335 patients in the 2012–2018 ACS National Surgical Quality Improvement Program (NSQIP) database. We compared baseline characteristics including demographics, comorbidities, tumor type, and operative features. We used propensity score matching to attain covariate balance and logistic regression to assess odds of unfavorable outcomes. Patients with the shortest operation durations tended to be older, with fewer males, higher ASA class, more metastatic brain tumors, more medical comorbidities, and less use of intraoperative microscope or ultrasound. Patients with the longest operative durations tended to be younger, with more males, fewer non-white minorities, more obesity, lower ASA classes, more intrinsic brain tumors, fewer medical comorbidities, fewer emergency operations, and increased use of intraoperative microscope. For patients with the shortest operations, after matching, we observed significantly decreased odds of prolonged length-of-stay (LOS), major complication, any complication, reoperation, and discharge to a facility; however, there was a significantly increased risk of 30-day mortality. For patients with the longest operations, after matching, we observed significantly increased odds of prolonged LOS; minor, major, and any complication; discharge to facility; and 30-day reoperation. After matching to balance baseline characteristics, operative duration has implications for outcomes following craniotomy for supratentorial brain tumor.

Non-English Primary Language Is Associated with Short-Term Outcomes After Supratentorial Tumor Resection

Despite research indicating that patients with non-English primary language (NEPL) have increased hospital length of stay (LOS) for craniotomies, there is a paucity of neurosurgical research examining the impact of language on short-term outcomes. This study sought to evaluate short-term outcomes for patients with English primary language (EPL) and NEPL admitted for resection of a supratentorial tumor. Using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project New Jersey State Inpatient Database, this study included patients 18-90 years old who underwent resection of a supratentorial primary brain tumor, meningioma, or brain metastasis from 2009 to 2017. The primary outcomes were total, preoperative, and postoperative LOS. Secondary outcomes were complications, mortality, and discharge disposition. Univariable and multivariable analyses compared Spanish primary language (SPL), non-English non-Spanish (NENS) primary language, and EPL groups. A total of 7324 patients were included: 2962 with primary brain tumor, 2091 with meningioma, and 2271 with brain metastasis. Patients with SPL (n= 297) were younger and more likely to have noncommercial insurance, lower income, and fewer comorbidities. Patients with NENS (n= 257) had similar age and comorbidities to the EPL group but had a greater proportion of noncommercially insured and low-income patients (P < 0.001). Multivariable analysis showed that patients with NENS had increased postoperative LOS (adjusted incidence rate ratio, 1.10; P= 0.008) and higher odds of a complication (adjusted odds ratio, 1.36; P= 0.015), and patients with SPL had higher odds of being discharged home (adjusted odds ratio, 1.55; P= 0.017). Patients with NEPL have different short-term outcomes after supratentorial tumor resection that varies based on primary language. More research is needed to understand the mechanisms driving these findings and to clarify unique experiences for different populations with NEPL.

Effects of Dexmedetomidine On the Postoperative Shivering, Nausea, and Vomiting Among Opium User Patients Undergoing Elective Supratentorial Brain Tumor Surgery: A Randomized, Placebo, Controlled Clinical trials.

Postoperative nausea and vomiting (PONV) and shivering are common general anesthesia complications. Hence, this study evaluates the effect of dexmedetomidine, given as a premedication, on PONV and shivering in patients with opium use who underwent elective supratentorial brain tumor surgeries. In a randomized clinical trial, 100 opium user patients who were candidates for elective supra-tentorial brain tumor surgery under general anesthesia were studied in two groups of 50 patients. The intervention group received dexmedetomidine (within 10 minutes infusion) 30 minutes before the anesthesia induction. Group placebo that received normal saline as a group. PONV and shivering rates were compared between the two groups. Both groups did not differ in hemodynamic parameters during operation, including pulse rate, systolic and diastolic blood pressure, and anesthesia duration. In the dexmedetomidine group, patients suffered less from PONV and shivering rather than controls, and these differences were both significant (P=0.001 and P=0.027, respectively). Dexmedetomidine administration before major surgeries might reduce post-operative nausea and vomiting and the occurrence of shivering, particularly in opium-addicted patients.

Effects of Dexmedetomidine On the Postoperative Shivering, Nausea, and Vomiting Among Opium User Patients Undergoing Elective Supratentorial Brain Tumor Surgery: A Randomized, Placebo, Controlled Clinical trials

Background: Postoperative nausea and vomiting (PONV), and shivering are common general anesthesia complications. Hence, this study evaluates the effect of dexmedetomidine, given as a premedication, on PONV and shivering in patients with opium use who underwent elective supratentorial brain tumor surgeries. Materials and Methods: In a randomized clinical trial, 100 opium user patients who were candidates for elective supra-tentorial brain tumor surgery under general anesthesia were studied in two groups of 50 patients. The intervention group received dexmedetomidine (within 10 and 30 minutes infusion) before the anesthesia induction. Group placebo that received normal saline as a group. PONV and shivering rates were compared between the two groups. Results: Both groups did not differ in hemodynamic parameters during operation, including pulse rate, systolic and diastolic blood pressure, and anesthesia duration. In the dexmedetomidine group, patients suffered less from PONV and shivering rather than controls, and these differences were both significant (P=0.001 and P=0.027, respectively). Discussion: Dexmedetomidine administration before major surgeries might reduce post-operative nausea and vomiting and the occurrence of shivering, particularly in opium-addicted patients.[GMJ.2021;10:e2146]

The Role of PET in Supratentorial and Infratentorial Pediatric Brain Tumors.

Objective: This review aims to provide a summary of the clinical indications and limitations of PET imaging with different radiotracers, including 18F-fluorodeoxyglucose (18F-FDG) and other radiopharmaceuticals, in pediatric neuro-oncology, discussing both supratentorial and infratentorial tumors, based on recent literature (from 2010 to present). Methods: A literature search of the PubMed/MEDLINE database was carried out searching for articles on the use of PET in pediatric brain tumors. The search was updated until December 2020 and limited to original studies published in English after 1 January 2010. Results: 18F-FDG PET continues to be successfully employed in different settings in pediatric neuro-oncology, including diagnosis, grading and delineation of the target for stereotactic biopsy, estimation of prognosis, evaluation of recurrence, treatment planning and assessment of treatment response. Nevertheless, non-18F-FDG tracers, especially amino acid analogues seem to show a better performance in each clinical setting. Conclusions: PET imaging adds important information in the diagnostic work-up of pediatric brain tumors. International or national multicentric studies are encouraged in order to collect larger amount of data.

Surgical techniques in the management of supratentorial pediatric brain tumors: 10 years' experience at a tertiary care center in the Middle East.

Background: The goal of this retrospective study is to present the first epidemiological data on pediatric supratentorial central nervous system (CNS) tumors in Lebanon and to review the various surgical management strategies used.Methods: We conducted a retrospective case series of all pediatric patients who presented with a supratentorial CNS tumor and underwent surgery at our institution between 2006 and 2016. We collected and analyzed demographic characteristics, tumor location, clinical manifestations, histopathology, and surgical management strategies and outcome, and discussed them after dividing the tumors as per location and in view of published literature.Results: Ninety-nine children were studied with a male-to-female ratio of 2.3:1 and a mean age of 8.5 years. The most common location was convexity (44%) and included low-grade and high-grade glial tumors, along with other miscellaneous lesions. The next location was sellar/diencephalic (34%), including craniopharyngiomas, hypothalamic/optic pathway/thalamic gliomas, hamartomas, and pituitary/Rathke’s cyst, where there was notable use of endoscopic techniques (21%). Tumors in the pineal region (13%) were tectal gliomas, germ cell tumors, and pineoblastomas and were mostly treated endoscopically. The last group was lateral intraventricular tumors (8%) and was mostly choroid plexus lesions and ependymomas. Overall, the surgical objective was achieved in 95% with mild/moderate complications in 17%.Conclusion: A variety of pathologies may affect the pediatric population in the supratentorial region. Different surgical strategies, including microsurgical and endoscopic techniques, may be employed to remove, debulk, or biopsy these tumors depending on their location, suspected diagnosis, prognosis, and the need for treatment of possible associated hydrocephalus.

HGG-19. 5-AMINOLEVULINIC ACID (5-ALA)-GUIDED RESECTION OF PEDIATRIC BRAIN TUMORS

Between tumor and normal brain, allowing a higher degree of resection, and improved patient outcomes. In recent years, several reports have emerged regarding the use of 5-ALA in other brain tumor entities, including pediatric brains tumors. Since gross total resection (GTR) of many brain tumors in children is crucial, the role of 5-ALA-guided resection requires elucidation.MethodsA systematic literature review of EMBASE and MEDLINE/PubMed databases revealed 20 eligible publications encompassing 186 5-ALA-guided operations on pediatric brain tumors. To reduce bias, publications were revised independently by two authors.Results5-ALA-guided resection enabled the surgeons to identify the tumor more easily and was considered helpful mainly in cases of glioblastoma (GBM, 21/27, 78%), anaplastic ependymoma WHO grade III (10/14, 71%), and anaplastic astrocytoma (4/6, 67%). In contrast, cases of pilocytic astrocytomas (PAs) and medulloblastomas 5-ALA-guided surgery did not show consistent fluorescent signals and 5-ALA was considered helpful only in 12% and 22% of cases, respectively. Accumulation of fluorescent porphyrins seems to depend on WHO tumor grading. In case fluorescence signal was considered helpful, it was associated with a greater degree of resection. One study showed an association between visible fluoresce signal and concentration of protopophyrin IX (PPIX) concentration. A threshold of 4μg/ml was required in order to visualize the fluorescence signal. The rate of adverse events related to 5-ALA was negligible, especially new postoperative sequelae.Conclusion5-ALA could play a role in resection of malignant, contrast enhancing, supratentorial pediatric brain tumors. At present, we are conducting a prospective phase I-II multicenter clinical trial to evaluate side effects and feasibility of 5-ALA guided surgery.