Supratentorial Brain Tumors Research Articles

Diffusion Kurtosis Imaging in the Assessment of Peritumoral Brain Edema in Glioblastomas and Brain Metastases

Aim: to explore the opportunities of application of diffusionkurtosis imaging (DKI) for assessment and estimation of diffusion scalar metrics in different locations of peritumoral edema for extra- and intracerebral tumors and in contralateral normal tissue.Materials and methods. 38 patients with supratentorial brain tumors were investigated: 24 (63%) patients with primarily revealed glioblastomas (GB) and 14 (37%) patients with solitary cancer brain metastasis (MTS). MRI was performed on 3.0 T MR-scanner (Signa HDxt, General Electric, USA) with the standard protocols for brain tumor and additional protocol for DKI. The standard protocol for brain tumor included: T1-, T2-weighted images, T2-FLAIR, DWI, T1 with contrast enhancement. Diffusion kurtosis MRI based on SE EPI with TR = 10000 ms, TE = 102 ms, FOV = 240 mm, isotropic voxel size 3 × 3 × 3 mm3, 60 noncoplanar diffusion directions. We used three b-values: 0, 1000 and 2500 s/mm2. Аcquisition time was 22 min. Total acquisition time was near 40 min. This study was approved by Ethical committee of Burdenko National Scientific and Practical Center for Neurosurgery. Parametric maps were constructed for the following diffusion coefficients: mean (MK), transverse / radial (RK), longitudinal / axial (AK) kurtozis; medium (MD), transverse / radial (RD) and longitudinal / axial (AD) diffusion; fractional anisotropy (FA) and a bi-exponential diffusion model coefficients: axonal water fractions (AWF), axial (AxEAD) and radial (RadEAD) extra-axonal water diffusion and the water molecules trajectory tortuosity index (TORT). Normative quantitative indicators were obtained for the six regions of the peritumoral zone as they moved away from the tumor (region 2) to the edema periphery (regions 4–5), as well as in the normal brain on the contralateral hemisphere (C/L) (zone 7). A comparative analysis of these indicators was conducted for cases with GB and MTS. DKI scalar metrics were estimated using Explore DTI (http://www.exploredti.com/).Results. Anatomic MRI (T1 without/with contrast enhancement) for all cases with GB and MTS visualized a contrast enhancement tumor. The peritumoral edema, spreading mainly over the brain white matter, was well visualized on T2-FLAIR. Diffusion kurtosis coefficients decreased in the near peritumoral edema (regions 2–3) and a gradually increased to the edema periphery (regions 5–6). In Region 2, MK in both GB and MTS groups were MKGB(2) = 0.637 ± 0.140 and MKMTS(2) = 0.550 ± 0.046; RK in this region were RKGB(2) = 0.690 ± 0.154 and RKMTS (2) = 0.584 ± 0.051. Differences both MK and RK coefficients in patients with GB and MTS of region 2 were significant (p < 0.001). There were no differences in AK values for GB and MTS in region 2 (p > 0.05), but in regions 3 and 4 differences were observed (p < 0.01). The minimum value of AK in the central edema (regions 3–4) was AKMTS(3–4) = 0.433 ± 0.063 in patients with MTS. The values of MK and RK on the contralateral side in patients with MTS were significantly higher than in the GB group (p < 0.02); MKC/LMTC = 0.954 ± 0.140, RKC/LMTC = 1.257 ± 0.308 and MKC/LGB = 0.829 ± 0.146, RKc/LGB = 0.989 ± 0.282. There was no significant difference for contralateral AK between the groups.Conclusions. We found that DKI scalar metrics are the sensitive tumor biomarkers. It allows us to perform a robust differentiation between the infiltrating GB tumor and purely vasogenic edema of МТS. The obtained results will allow further differential diagnosis of extra- and intracerebral tumors and can be used to plan surgical / radiosurgical treatment for brain tumors.

The Utility of Routine Intensive Care Admission for Patients Undergoing Intracranial Neurosurgical Procedures: A Systematic Review.

Patients who have undergone intracranial neurosurgical procedures have traditionally been admitted to an intensive care unit (ICU) for close postoperative neurological observation. The purpose of this study was to systematically review the evidence for routine ICU admission in patients undergoing intracranial neurosurgical procedures and to evaluate the safety of alternative postoperative pathways. We were interested in identifying studies that examined selected patients who presented for elective, non-emergent intracranial surgery whose postoperative outcomes were compared as a function of ICU versus non-ICU admission. A systematic review was performed in July 2016 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist of the Medline database. The search strategy was created based on the following key words: "craniotomy," "neurosurgical procedure," and "intensive care unit." The nine articles that satisfied the inclusion criteria yielded a total of 2227 patients. Of these patients, 879 were observed in a non-ICU setting. The most frequent diagnoses were supratentorial brain tumors, followed by patients with cerebrovascular diseases and infratentorial brain tumors. Three percent (30/879) of the patients originally assigned to floor or intermediate care status were transferred to the ICU. The most frequently observed neurological complications leading to ICU transfer were delayed postoperative neurological recovery, seizures, worsening of neurological deficits, hemiparesis, and cranial nerves deficits. Our systematic review demonstrates that routine postoperative ICU admission may not benefit carefully selected patients who have undergone elective intracranial neurosurgical procedures. In addition, limiting routine ICU admission may result in significant cost savings.

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

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

English

BACKGROUND: Twenty percent mannitol is widely used to reduce brain bulk and facilitate the surgical approach in intracranial surgery. However, a dose-response relationship has not yet been established. In this study, we compared the effects of 0.5, 1.0 and 1.5 gkg_1 mannitol on brain relaxation during elective supratentorial brain tumor craniotomy MATERIALS AND METHODS: In this prospective, randomized, single-blind study, we enrolled 48 patients undergoing supratentorial craniotomy for tumor resection. Patients were assigned to receive 0.5 gkg_1 (Group A), 1.0 gkg_1 (Group B) or 1.5 gkg_1 (Group C) of 20% mannitol at surgical incision. Brain relaxation was assessed immediately after opening of the dura on a scale (rozet quentin scale) ranging from 1 to 4 (Scale 1: perfectly relaxed (shrunken dura with prominent veins) (Scale 2: satisfactorily relaxed (only prominent veins) Scale 3: firm brain, Scale 4: bulging brain). Secondary outcome measures like mean arterial blood pressure, arterial blood electrolytes, blood PH, urine output and temperature also measured. RESULTS: There was no significant difference between the three groups regarding age, sex, body mass index, and brain tumor localization or size. We then used a proportional odds model to adjust for this unbalanced distribution and to assess the group effect (low-dose verses high-dose mannitol) on brain relaxation scores. Serum electrolytes, blood gases, urine output and hemodynamic stability are better maintained in group C. CONCLUSION: In this study, from the data and statistical analysis, shows that 1.5 gkg_1 OF 20% mannitol results in better brain relaxation scores than 0.5 and 1.0 gkg_1 in patients undergoing craniotomy for supratentorial brain tumor. In this study, it is concluded that 1.5 gkg_1 OF 20% mannitol gives better brain relaxation scores with blood electrolytes, blood PH, urine output and hemodynamic stability are better maintained.

Prevention and management of postoperative seizures in neuro-oncology

IntroductionEpilepsy related to brain tumors is often difficult to treat and may impact the quality of life. We performed a review of current recommendations for the prevention of postoperative seizures and optimizing the anti-epileptic treatment. Material and methodsBased on studies performed since 2000 we conducted the review by (1) analyzing the incidence of tumoral epilepsy and mechanisms of epileptogenicity; (2) describing the current medical and surgical strategy according to oncologic treatments; (3) discussing the management of postoperative seizures; (4) considering the drug withdrawal after oncologic therapy. ResultsEpilepsy related to supra-tentorial brain tumors is frequent (40–60%) especially in low-grade gliomas, glioneuronal tumors, fronto-temporal and eloquent cortex locations. Seizures can occur as a presenting symptom or during the course of the tumor, including after surgery and oncological treatments. Maximal safe surgical resection is the more effective therapy, alone or combined with adjuvant therapy (chemotherapy, radiotherapy). Anti-epileptic drugs are not indicated for epilepsy prophylaxis in patients without seizures but only after the first seizure due to high risk of recurrence. As they may generate adverse effects and interfere with oncological treatments, the choice is based on efficacy, tolerability and potential interactions. New anti-epileptic non-enzyme-inducing drugs are recommended in first-line monotherapy in association with adjuvant oncological therapies. Enzyme-inhibiting drugs could have a favorable effect on survival. Late seizures are often related to tumor progression or recurrence. Discontinuation of anti-epileptic drugs could be considered after successful oncological treatment and a stable medical condition. ConclusionThese guidelines are helpful for a rational therapy in tumoral epilepsy.

Quality of life before and after treatment for supratentorial brain tumors in children

Quality of life before and after treatment for supratentorial brain tumors in children

Development of cystic malacia after high-dose cranial irradiation of pediatric CNS tumors in long-term follow-up.

The purpose of this study is to investigate the incidence of cystic malacia in long-term survivors of pediatric brain tumors treated with high-dose cranial irradiation. Between 1997 and 2015, we treated 41 pediatric patients (26 males, 15 females; age ranging from 3.3 to 15.7years, median 9-year-old) of pediatric brain tumors [17 medulloblastomas, 7 primitive neuroectodermal tumors (PNET), 3 pineoblastomas, 6 non-germinomatous germ cell tumors (NGGCT), 8 gliomas (including 4 ependymomas, 1 anaplastic astrocytoma, 1 oligodendroglioma, 1 pilocytic astrocytoma, 1 astroblastoma)] with high-dose craniospinal irradiation. Follow-up ranged from 14.0 to 189.2months (median 86.0months, mean 81.5months), the irradiation dose to the whole neural axis ranged from 18 to 41.4Gy, and the total local dose from 43.2 to 60.4Gy. All patients underwent follow-up magnetic resonance imaging (MRI) studies at least once a year. Diagnosis of cystic malacia was based solely on MRI findings. Of the 41 patients, 31 were censored during their follow-up due to recurrence of the primary disease (n=5), detection of secondary leukemia after development of cystic malacia (n=1), or the absence of cystic malacia on the last follow-up MRI study (n=25). We also evaluated the development of post-irradiation cavernous angioma and white matter changes. Following irradiation treatment, 11 patients developed 19 cystic malacia during a median course of 30.8months (range 14.9 to 59.3months). The site of predilection for cystic malacia was white matter around trigone of lateral ventricles with an incidence of 47.4% (9 of 19 lesions, 7 in 11 patients). Patients with supratentorial tumors developed cystic malacia statistically earlier than the patients with infratentorial tumors (P=0.0178, log-rank test). Among the same patient group, incidence of post-irradiation cavernous angioma increased progressively, while the incidence of post-irradiation cystic malacia did not increase after 5years. White matter degeneration developed earlier than cystic malacia or cavernous angioma, and these three clinical entities developed mutually exclusive of each other. We attribute the higher incidence of post-irradiation cystic malacia, in our long-term follow-up study, to the cranial irradiation for pediatric brain tumors, particularly supratentorial brain tumors, and recommend a regular, long-term follow-up of brain tumor patients treated with cranial irradiation.

Effects of an alveolar recruitment maneuver on subdural pressure, brain swelling, and mean arterial pressure in patients undergoing supratentorial tumour resection: a randomized crossover study

Although recruitment maneuvers have been advocated as part of a lung protective ventilation strategy, their effects on cerebral physiology during elective neurosurgery are unknown. Our objectives were to determine the effects of an alveolar recruitment maneuver on subdural pressure (SDP), brain relaxation score (BRS), and cerebral perfusion pressure among patients undergoing supratentorial tumour resection. In this prospective crossover study, patients scheduled for resection of a supratentorial brain tumour were randomized to undergo either a recruitment maneuver (30 cm of water for 30 sec) or a "sham" maneuver (5 cm of water for 30 sec), followed by the alternative intervention after a 90-sec equilibration period. Subdural pressure was measured through a dural perforation following opening of the cranium. Subdural pressure and mean arterial pressure (MAP) were recorded continuously. The blinded neurosurgeon provided a BRS at baseline and at the end of each intervention. During each treatment, the changes in SDP, BRS, and MAP were compared. Twenty-one patients underwent the study procedure. The increase in SDP was higher during the recruitment maneuver than during the sham maneuver (difference, 3.9 mmHg; 95% confidence interval [CI], 2.2 to 5.6; P < 0.001). Mean arterial pressure decreased further in the recruitment maneuver than in the sham maneuver (difference, -9.0 mmHg; 95% CI, -12.5 to -5.6; P < 0.001). Cerebral perfusion pressure decreased 14 mmHg (95% CI, 4 to 24) during the recruitment maneuver. The BRS did not change with either maneuver. Our results suggest that recruitment maneuvers increase subdural pressure and reduce cerebral perfusion pressure, although the clinical importance of these findings is thus far unknown. This trial was registered with ClinicalTrials.gov, NCT02093117.

Neurocognitive status in patients with newly-diagnosed brain tumors in good neurological condition: The impact of tumor type, volume, and location

ObjectiveNeurocognitive function is of great importance in patients with brain tumors. Even patients in good neurological condition may suffer from neurocognitive dysfunction that affects their daily living. The purpose of the present study was to identify risk factors for neurocognitive dysfunction in patients suffering from common supratentorial brain tumors with minor neurological deficits. MethodsA prospective study evaluating neurocognitive dysfunction in patients with a newly-diagnosed brain tumor in good neurological condition was performed at a major German academic institution. Patients underwent extensive neurocognitive testing assessing perceptual speed, executive function, visual-spatial and verbal working memory, short- and long-term memory, verbal fluency, fluid intelligence, anxiety, and depression. For each patient, a healthy control was pair-matched based on age, sex, handedness, and profession. ResultsA total of 46 patients and 46 healthy controls underwent neurocognitive testing. Patients suffered from glioblastoma multiforme (10), cerebral metastasis (10), pituitary adenoma (13), or meningioma (13). There was neither any difference in age, educational level, fluid intelligence, neurological deficits, and anxiety nor in any depression scores between tumor subgroups. Overall, neurocognitive performance was significantly worse in patients compared to healthy controls. Larger tumor volume, frontal location, and left/dominant hemisphere were associated with worse executive functioning and verbal fluency. Additionally, larger tumors and left/dominant location correlated with impairments on perceptual speed tasks. Frontal tumor location was related to worse performance in visual-spatial and short- and long-term memory. Tumor type, clinical presentation, and patient self-awareness were not associated with specific neurocognitive impairments. ConclusionsPatients suffering from newly-diagnosed brain tumors presenting in good neurological condition display neurocognitive impairments in various domains. Larger tumor volumes, frontal location, and left/dominant hemisphere are important predictors for potential neurocognitive deficits. Tumor type, clinical presentation, or self-awareness are less significant at the time of diagnosis.

Clinical Profile of Brain Tumour in Children

Background: This study was designed to evaluate the clinical profile and location of brain tumours in children so that brain tumour cases could be diagnosed and managed earlier.Materials and Methods: This cross sectional study was carried out from April 2011 to April 2012. A total 50 clinically suspected cases of brain tumour and supported by MRI were enrolled in this study.Results: Brain tumour of children was predominant in male where male to female ratio was almost 1.9:1. Supratentorial and Infratentorial brain tumour were found in 36% and 64% cases respectively in children. According to MRI findings in the supratentorial location, craniopharyngioma were commonest (50%) followed by cerebral astrocytoma (22.2%). In the infratentorial region, medulloblastoma was observed in (40.6%), followed by cerebellar astrocytoma (31.3%). Vertigo, weakness of limbs were found in 46.9% and 87.5% cases respectively in infratentorial group which were significantly (p&lt;0.05) higher than supratentorial group. Growth failure and behavioral change were found in 16.7% and 22.2% cases respectively in supratentorial which were significantly (p&lt;0.05) higher than infratentorial group. Papilloedema, reduced muscle power, increased muscle tone, exaggerated deep reflexes, clonus, gait disturbance and cerebellar signs were significantly (p&lt;0.05) higher in infratentorial group.Conclusion: Craniopharyngioma and medulloblastoma were more common findings in MRI evaluation in the supratentorial and infratentorial location respectively. Growth failure and behavioral change were found higher in supratentorial than infratentorial group. Vertigo, weakness of limbs, papilloedema, reduced muscle power, increased muscle tone, exaggerated deep reflexes, clonus, gait disturbance and cerebellar signs were higher in infratentorial group.J Shaheed Suhrawardy Med Coll, June 2016, Vol.8(1); 8-12

Rationale and Design of a Phase I Clinical Trial to Evaluate HSV G207 Alone or with a Single Radiation Dose in Children with Progressive or Recurrent Malignant Supratentorial Brain Tumors

Rationale and Design of a Phase I Clinical Trial to Evaluate HSV G207 Alone or with a Single Radiation Dose in Children with Progressive or Recurrent Malignant Supratentorial Brain Tumors

Erratum to: Same-day discharge after craniotomy for supratentorial tumour surgery: a retrospective observational single-centre study.

Enhanced Recovery After Surgery is a multimodal perioperative care pathway designed to achieve early discharge in patients undergoing major surgery. Recent advances in neurosurgery allow for shorter duration of anesthesia and surgery, faster recovery, and earlier discharge from hospital. The purpose of this retrospective observational study was to assess the incidence of early discharge from hospital in patients undergoing craniotomy for supratentorial brain tumours as well as to explore the associated perioperative factors, anesthesia techniques, and complications. The medical records of all patients who underwent craniotomy (less than four-hour duration) for supratentorial tumour over a five-year period were retrospectively reviewed. The data analyzed included the postoperative discharge destination, type of anesthesia—i.e., general anesthesia (GA) vs awake craniotomy (AC), and the incidence of adverse events. Data from 329 patients [mean (SD) age 48 (12) yr; 164 male, 165 female] were analyzed, including 198 (AC, n = 157; GA, n = 41) patients who were preoperatively scheduled for same-day discharge. Successful same-day discharge occurred in 175/198 (88.4%) of these patients (AC, n = 139; GA, n = 36). Five (2.9%) of the 175 patients (4 AC, 1 GA) with same-day discharge required readmission to hospital within the first 12 hr after discharge. Six (1.8%) of the 329 total patients had a documented postoperative intracranial bleed, but none occurred after initial discharge from hospital. Same-day discharge from hospital is possible in carefully selected patients after both GA and AC for supratentorial tumour surgery.

Assessment of the role of gabapentin in patients with supratentorial tumours undergoing craniotomy under general anaesthesia: A double-blind randomised study

Background: Gabapentin attenuates the haemodynamics, decreases the catecholamine release and has a neuroprotective effect. The aim of the present study was to assess the effect of gabapentin in patients with supratentorial brain tumours undergoing craniotomy under general anaesthesia. Methods: A radial arterial line, central venous line and ventriculostomy catheters were inserted before surgery. Anaesthesia was induced with thiopental, fentanyl and atracurium and maintained with sevoflurane, fentanyl and atracurium infusion. The study included 160 patients classified randomly into two groups: Group G: The patients received gabapentin capsules 1200 mg orally 2 h before surgery. Group C: The patients received placebo capsules. Results: The heart rate, mean arterial blood pressure and intracranial pressure decreased significantly with gabapentin as compared to the control group ( P P P P P Conclusions: Pre-operative administration of gabapentin in patients undergoing craniotomy under general anaesthesia minimised the fluctuations in haemodynamics, reduced the requirements for sevoflurane and fentanyl, decreased intracranial pressure and improved the outcomes. There were some side effects associated with gabapentin such as hypotension and bradycardia.

The risk of hypotension and seizures in patients receiving prophylactic anti-epileptic drugs for supratentorial craniotomy.

Perioperative seizure prophylaxis with antiepileptic drugs (AED) has been advocated in patients undergoing supratentorial craniotomy. The practice remains controversial. The reasoning presupposes that the possibility of an adverse drug reaction from the AED is lower than the probability of harm from a seizure. Even short periods of hypotension during the operation can lead to acute kidney and myocardial injury. We retrospectively evaluated cardiovascular effects and tolerability of levetiracetam (LEV) alone, LEV and lacosamid (LCM) as compared to phenytoin (PHT). After IRB approval, the charts of individuals who underwent craniotomy from April 2007 to September 2011 were reviewed. Those receiving PHT were compared to those receiving LEV alone and LEV/LCM. The patient data included demographic, indication and procedure related data. The cumulative dose of norepinephrine (NET), atropine (ATR) and the change in systolic blood pressure during and after the administration of the AED were analyzed. Five hundred thirty-eight patients were screened of which 122 were included for analysis. 40 patients with primary or secondary supratentorial brain tumors received LEV (19 female, 21 male; mean age 56 years), 41 patients received LEV/ LCM (16 female, 25 male; mean age 56 years) and 41 patients received PHT (15 female, 26 male; mean age 50 years). The commonest indications for craniotomy were glioblastoma (N.=14 vs. N.=12 vs. N.=15), meningiomas (N.=9 vs. N.=7 vs. N.=10), low-grade gliomas (N.=6 vs. N.=13 vs. N.=6) and brain metastases (N.=5 vs. N.=4 vs. N.=5). 1 LEV/LCM patient (2%) and 4 PHT patients (4.5%) had a seizure despite prophylaxis. Possible side effects were observed in 2 patients associated with PHT. During anesthesia there was a significant drop in systolic blood pressure in the PHT group after administration of the AED perioperatively when compared to LEV (P=0.001) and LEV/LCM (P≤0.0001) respectively. The mean cumulative doses of NET and ATR over the course of the operation did not differ significantly. LEV alone and in combination with LCM for patients without and with symptomatic epilepsy as seizure prophylaxis provides a safe and feasible alternative to PHT. PHT was associated with an unfavorable drop in blood pressure during anesthesia and more adverse reactions.

Preoperative neurocognitive evaluation as a predictor of brain tumor grading in pediatric patients with supratentorial hemispheric tumors.

The objective of the present study was to retrospectively evaluate the relationship between tumor grading and a selective evaluation of neurocognitive and behavioral functions in children with supratentorial hemispheric brain tumors. Children admitted with a diagnosis of supratentorial hemispheric tumors involving the cerebral hemispheres or the thalamus at the Pediatric Neurosurgery Unit of the Catholic University of Rome between January 2008 and January 2014 were considered for the present study. Exclusion criteria were represented by age less than 2years, severe neurological deficits, seizures, and a metastatic disease. A selective neurocognitive and behavioral workout was used for children aged less and more than 5years. Global cognitive functions as well as selective neurocognitive and behavioral profiles were found to be significantly worse in children with low-grade tumors, compared with those affected by higher-grades histotypes. Frontal locations for cortical tumors and thalamic lesions were significantly related with worse results, with a clear contribution of dominant vs. nondominant hemisphere involvement and an age higher than 5years. Preoperative global and selective neurocognitive evaluation might contribute to the prediction of the tumor aggressiveness. Due to a longer clinical history, more benign tumors more frequently arrive to the diagnosis with a neurocognitive compromise in spite of an apparently mild presence of neurological symptoms and signs.

Erratum. A prospective randomized trial of the optimal dose of mannitol for intraoperative brain relaxation in patients undergoing craniotomy for supratentorial brain tumor resection.

OBJECTIVE Mannitol is used intraoperatively to induce brain relaxation in patients undergoing supratentorial brain tumor resection. The authors sought to determine the dose of mannitol that provides adequate brain relaxation with the fewest adverse effects. METHODS A total of 124 patients were randomized to receive mannitol at 0.25 g/kg (Group A), 0.5 g/kg (Group B), 1.0 g/kg (Group C), and 1.5 g/kg (Group D). The degree of brain relaxation was classified according to a 4-point scale (1, bulging; 2, firm; 3, adequate; and 4, perfectly relaxed) by neurosurgeons; Classes 3 and 4 were considered to indicate satisfactory brain relaxation. The osmolality gap (OG) and serum electrolytes were measured before and after mannitol administration. RESULTS The brain relaxation score showed an increasing trend in patients receiving higher doses of mannitol (p = 0.005). The incidence of satisfactory brain relaxation was higher in Groups C and D than in Group A (67.7% and 64.5% vs 32.2%, p = 0.011 and 0.022, respectively). The incidence of OG greater than 10 mOsm/kg was also higher in Groups C and D than in Group A (100.0% in both groups vs 77.4%, p = 0.011 for both). The incidence of moderate hyponatremia (125 mmol/L ≤ Na+ 5.0 mmol/L) was observed in 12.9% of patients in Group D only. CONCLUSIONS The higher doses of mannitol provided better brain relaxation but were associated with more adverse effects. Considering the balance between the benefits and risks of mannitol, the authors suggest the use of 1.0 g/kg of intraoperative mannitol for satisfactory brain relaxation with the fewest adverse effects. Clinical trial registration no.: NCT02168075 ( clinicaltrials.gov ).

Same-day discharge after craniotomy for supratentorial tumour surgery: a retrospective observational single-centre study.

Enhanced Recovery After Surgery is a multimodal perioperative care pathway designed to achieve early discharge in patients undergoing major surgery. Recent advances in neurosurgery allow for shorter duration of anesthesia and surgery, faster recovery, and earlier discharge from hospital. The purpose of this retrospective observational study was to assess the incidence of early discharge from hospital in patients undergoing craniotomy for supratentorial brain tumours as well as to explore the associated perioperative factors, anesthesia techniques, and complications. The medical records of all patients who underwent craniotomy (less than four-hour duration) for supratentorial tumour over a five-year period were retrospectively reviewed. The data analyzed included the postoperative discharge destination, type of anesthesia-i.e., general anesthesia (GA) vs awake craniotomy (AC), and the incidence of adverse events. Data from 329 patients [mean (SD) age 48 (12) yr; 164 male, 165 female] were analyzed, including 198 (AC, n = 157; GA, n = 41) patients who were preoperatively scheduled for same-day discharge. Successful same-day discharge occurred in 175/198 (88.4%) of these patients (AC, n = 139; GA, n = 36). Five (2.9%) of the 175 patients (4 AC, 1 GA) with same-day discharge required readmission to hospital within the first 12 hr after discharge. Six (1.8%) of the 329 total patients had a documented postoperative intracranial bleed, but none occurred after initial discharge from hospital. Same-day discharge from hospital is possible in carefully selected patients after both GA and AC for supratentorial tumour surgery.

A prospective randomized trial of the optimal dose of mannitol for intraoperative brain relaxation in patients undergoing craniotomy for supratentorial brain tumor resection.

OBJECTIVE Mannitol is used intraoperatively to induce brain relaxation in patients undergoing supratentorial brain tumor resection. The authors sought to determine the dose of mannitol that provides adequate brain relaxation with the fewest adverse effects. METHODS A total of 124 patients were randomized to receive mannitol at 0.25 g/kg (Group A), 0.5 g/kg (Group B), 1.0 g/kg (Group C), and 1.5 g/kg (Group D). The degree of brain relaxation was classified according to a 4-point scale (1, bulging; 2, firm; 3, adequate; and 4, perfectly relaxed) by neurosurgeons; Classes 3 and 4 were considered to indicate satisfactory brain relaxation. The osmolality gap (OG) and serum electrolytes were measured before and after mannitol administration. RESULTS The brain relaxation score showed an increasing trend in patients receiving higher doses of mannitol (p = 0.005). The incidence of satisfactory brain relaxation was higher in Groups C and D than in Group A (67.7% and 64.5% vs 32.2%, p = 0.011 and 0.022, respectively). The incidence of OG greater than 10 mOsm/kg was also higher in Groups C and D than in Group A (100.0% in both groups vs 77.4%, p = 0.011 for both). The incidence of moderate hyponatremia (125 mmol/L ≤ Na+ < 130 mmol/L) was significantly higher in Group D than in other groups (38.7% vs 0.0%, 9.7%, and 12.9% in Groups A, B, and C; p < 0.001, p = 0.008, and p = 0.020, respectively). Hyperkalemia (K+ > 5.0 mmol/L) was observed in 12.9% of patients in Group D only. CONCLUSIONS The higher doses of mannitol provided better brain relaxation but were associated with more adverse effects. Considering the balance between the benefits and risks of mannitol, the authors suggest the use of 1.0 g/kg of intraoperative mannitol for satisfactory brain relaxation with the fewest adverse effects. Clinical trial registration no.: NCT02168075 ( clinicaltrials.gov ).

Role of mass effect, tumor volume and peritumoral edema volume in the differential diagnosis of primary brain tumor and metastasis

IntroductionThe differentiation of metastatic and primary brain tumors with certainty is important since clinical management and treatment of these two types of tumors are radically different.The purpose of the present study was to evaluate the effect of peritumoral edema volume, tumor volume and mass effect of tumor on differential diagnosis of metastatic and primary brain tumors. Also we have planned to investigate if the relationship between edema volume and mass affect can contribute to the differential diagnosis. Material and methodsWe retrospectively reviewed MR images of patients with primary (n=40) and metastatic (n=40) intra-axial supratentorial brain tumor. Supratentorial primary solitary brain tumor group was also subdivided as GBM subgroup (n=24) and other than GBM subgroup (n=16) for statistical analysis. Metastasis at suitable localization which can lead to midline shift (due to mass effect) were selected. Tumor volume, peritumoral edema volume and mass-edema index (peritumoral edema volume/tumor volume) were calculated. Displacement of the midline structures (subfalcian herniation) was measured.Metastasis, GBM and other than GBM groups were evaluated for subfalcian shift, shift grade, tumor volume, peritumoral edema volume and mass-edema index by using Kruskal-Wallis test after Bonferroni correction. Mann-Whitney U test was used to analise subfalcian shift, tumor volume, peritumoral edema volume and mass-edema index of primary tumor and methastasis groups since the data was not normally distributed. Shift grade of the two groups was analised with chi-square test. ResultsMidline shift, tumor volume and mass-edema index were significantly different between metastasis and primary tumor groups (p=0.001, p<0.001, p=0.001 respectively). Midline shift and tumor volume of the primary tumor group were greater than metastasis group while mass-edema index was less. Shift grade of metastasis and primary tumor groups was also significant (p=0.041). A midline shift more than 5mm (grade 2) was more common in primary tumors. There was no significant difference between GBM and other than GBM groups. ConclusionMeasurement of midline shift, tumor volume and mass-edema index may contribute to the differential diagnosis of brain metastasis from primary brain tumors. Also mass-edema index can be a useful tool for differential diagnosis in the future. But further studies with larger series are needed.

Role of magnetic resonance spectroscopy & diffusion weighted imaging in differentiation of supratentorial brain tumors

PurposeTo evaluate the role of magnetic resonance spectroscopy & diffusion weighted imaging (DWI) in differentiating between primary and secondary brain tumors. Patients & methodsThis prospective study was performed for 40 patients. Diffusion weighted image (DWI) and apparent diffusion co-efficient (ADC) maps were acquired by using b-values of 0 and 1000mm2/s. Standard mean ADC values were calculated automatically and expressed in 10−3mm2/s in both intra-lesional and peri-lesional regions. Multi voxel MR spectroscopy was performed using a spin-echo mode sequence.The metabolites were identified including the following: N-acetylaspartate (NAA) at 2.0ppm, creatine (Cr) at 3.0ppm, choline (Cho) at 3.2ppm, lipid at the range of 0.7–1.3ppm, lactate at 1.33ppm and myoinositol at 3.56ppm. The ratios that were calculated include the following: Cho/NAA and Cho/Cr in both intralesional and perilesional regions. ResultsIntralesional ADC values showed no difference between the metastases (0.6: 1×10−3mm2/s with mean 0.86) and high grade primary tumors (0.6: 1.1×10−3mm2/s with mean 0.73). Perilesional ADC value Findings in the study revealed that primary tumors have low ADC values (0.9: 1.1×10−3mm2/s with mean 0.95) in their peri-lesional voxels denoting peri-lesional infiltration, while higher ADC values in metastasis (1.3–1.6×10−3mm2/s mean 1.41) due to the absence of peri-lesional infiltration increase in CHO/Cr ratios (>1) in primary high grade tumors (indicating perilesional infiltration) while there was no increase in CHO/Cr ratio in cases of metastases. Low grade primary tumors showed low lactate and lipid, with increasing malignancy, and tumors showed increasing levels of lactate and lipid peaks (indicating necrosis) with remarkable difference in lipid peaks between low and high grade tumors. There was no significant difference between primary & metastatic brain tumors as regards lactate peak. ConclusionIntra-lesional ADC values are not useful in the differentiation between primary and metastatic tumors. Perilesional ADC values can differentiate between primary & metastatic brain tumors. Intralesional MRS values (CHO/Cr ratio) were able to grade the tumor and differentiate between high and low grade tumors, while Perilesional MRS values (CHO/Cr ratio) could be able to differentiate primary tumors from metastasis.