PROCON Study: Preventive Antiepileptic Treatment in Supratentorial Neurosurgery - A Retrospective Before-After Analysis of a Change in Clinical Guidelines.

There is significant heterogeneity related to the use of prophylactic antiseizure medications (ASM) following supratentorial craniotomy. We conducted a systematic review and meta-analysis assessing ASM primary prophylaxis in adults hospitalized following supratentorial neurosurgery with no prior seizure history. The following population, intervention, comparator, and outcome (PICO) questions were assessed: (1) Should ASM versus no ASM be used as seizure prophylaxis in adult patients undergoing supratentorial neurosurgery? (2) If an ASM is used, should levetiracetam (LEV) or phenytoin/fosphenytoin (PHT) be preferentially used? and (3) Should a long (> 7days) versus short (≤ 7days) duration of prophylaxis be used? The main outcomes were early seizure (≤ 14days), late seizures (> 14days), adverse events, mortality, and functional and cognitive outcomes. We utilized Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to generate recommendations. The initial literature search yielded 1988 articles, and 16 formed the basis of the recommendations. PICO 1: while meta-analysis of randomized controlled trials (RCTs) demonstrated a significant benefit for early seizure prevention, meta-analyses including all study designs was nonsignificant. Further, there were no differences in late seizure or mortality rates, and there was a trend toward higher adverse event rates with ASM. PICO 2: LEV was associated with significantly lower early seizure rates than PHT, and there were trends toward fewer late seizures and adverse events with LEV. PICO 3: only three studies examined the duration of ASM treatment, and there was no significant difference in seizure events between subjects treated for a short versus long duration. We suggest that either prophylactic ASM or no ASM be used for seizure prophylaxis in patients undergoing supratentorial neurosurgery (conditional recommendation, low quality of evidence). If an ASM is used, we suggest LEV over PHT (conditional recommendation, very low quality of evidence) for a short duration (conditional recommendation, very low quality of evidence).

The use of prophylactic subgaleal vancomycin powder for preventing surgical site infections (SSI) has gained traction among cranial surgeons. However, its broad application remains controversial as the studies supporting its use are skewed toward high infection risk pathologies and have significant limitations. This study aimed to evaluate the efficacy of vancomycin powder in reducing SSIs in a cohort of patients with nonmalignant cranial pathologies. A retrospective chart review was conducted for 987 patients who underwent cranial surgeries for nonmalignant pathologies between July 2021 and June 2024 at a major academic center. Patients were divided into 2 groups: those who received prophylactic vancomycin powder (682 patients) and those who did not (305 patients). Data on demographics, comorbidities, procedure types, and SSI occurrences were collected. Established infection risk characteristics were nonsignificantly different between groups. There was no significant SSI difference when comparing patients not receiving vancomycin vs those who received the antibiotic (0.3% vs 0.7%, P = .578). There were 6 infections in total, 3/6 (50%) occurred with atypical meningiomas, 2/6 (33%) occurred with schwannomas, and 1/6 (17%) occurred with an amoebic abscess. Supratentorial craniotomies (odds ratio 0.95, P = .810) and posterior fossa craniotomies (odds ratio 1.18, 0.545) were the most common procedures and were nonsignificantly different between the cohorts. Meningiomas represented the largest portion of pathologies and were equally represented in both groups. This study suggests that the routine use of prophylactic vancomycin powder in nonmalignant cranial surgeries may be unnecessary, given an overall low incidence and lack of significant difference in SSIs between groups. These findings advocate for a more tailored approach to antibiotic prophylaxis, weighing the potential benefits against the known risks.

Outpatient supratentorial craniotomy for brain lesions: a pilot feasibility and safety study.

Background and Aims:Patients undergoing neurosurgical procedures are at a high risk of post-operative nausea and vomiting (PONV). Amisulpride, a dopamine (D2, D3) receptor antagonist, has been recently approved for intravenous use in antiemesis and has demonstrated safety and efficacy in managing PONV in non-neurosurgical settings. We hypothesised that amisulpride would be non-inferior to ondansetron in preventing PONV.Methods:Adult patients scheduled for elective supratentorial craniotomy for tumour surgery under general anaesthesia were randomised to receive either intravenous amisulpride (5 mg) or intravenous ondansetron (4 mg) intra-operatively, administered 30 minutes before skin closure. Patients were then assessed for PONV in the post-operative intensive care unit. The primary objective was to evaluate the incidence of nausea and vomiting in the first 24 hours post-operatively. Secondary outcomes included nausea severity, the need for rescue antiemetic medications, and treatment-related adverse events. Incidence of PONV was compared using the Chi-square test. Secondary outcomes like severity of nausea, rescue medications, and adverse events were tested using Chi-square/Fisher’s exact test. Non-inferiority of amisulpride to ondansetron was assessed using the pre-specified absolute non-inferiority margin of 20%.Results:A total of 100 patients were included in the final analysis. The incidence of nausea and vomiting was significantly lower in the amisulpride group (22% and 8%) compared to the ondansetron group (36% and 8%) (P = 0.032 and P = 0.045, respectively). Nausea severity was also significantly lower in the amisulpride group during the first four post-operative hours (P < 0.05). Additionally, patients receiving amisulpride required fewer rescue antiemetics. No treatment-related adverse events were observed in the amisulpride group.Conclusion:A single intra-operative intravenous dose of amisulpride (5 mg) at the end of the surgery was found to be non-inferior to 4 mg intravenous ondansetron in reducing the incidence and severity of PONV in patients undergoing supratentorial craniotomy.

Anesthetic management in neurosurgical procedures requires rapid recovery and stable hemodynamics to enable early neurological evaluation. Sevoflurane and desflurane, with low blood-gas solubility, are commonly used inhalational agents. Dexmedetomidine, an α2-adrenergic agonist, provides sedation and hemodynamic stability. Limited studies have compared sevoflurane and desflurane in combination with dexmedetomidine for neurosurgical recovery. To compare the recovery profile, cognitive function, and intraoperative brain relaxation in patients undergoing supratentorial tumor surgery under sevoflurane-dexmedetomidine versus desflurane-dexmedetomidine anesthesia. This prospective observational study was conducted at Kasturba Medical College, Mangalore, between March 2023 and August 2024. Ninety-six patients aged 40-65 years undergoing elective supratentorial craniotomy were enrolled and divided into two groups: Group A (sevoflurane with dexmedetomidine) and Group B (desflurane with dexmedetomidine). Recovery times (emergence, extubation, orientation), cognitive function (Short Orientation Memory Concentration Test, SOMCT), brain relaxation score, hemodynamics, and adverse events were assessed. Data were analyzed using independent t-tests and Chi-square tests, with P < 0.05 considered significant. Desflurane group showed significantly shorter emergence (8.1 ± 1.4 vs. 12.9 ± 1.2 min), extubation (13.9 ± 2.8 vs. 18.8 ± 1.3 min), and orientation times (36.2 ± 4.8 vs. 41.6 ± 4.3 min) compared to sevoflurane (P < 0.001). Cognitive recovery was faster with desflurane (SOMCT 7.8 ± 1.6 vs. 13.2 ± 3.0; P < 0.001). Brain relaxation was superior in the desflurane group (P < 0.001). Adverse events were fewer with desflurane (4.2% vs. 20.8%; P = 0.01). Hemodynamics remained stable in both groups. Desflurane with dexmedetomidine provides faster emergence, better cognitive recovery, superior brain relaxation, and fewer adverse events compared to sevoflurane in supratentorial neurosurgery. It may be preferred when rapid postoperative neurological assessment is required.

Dexmedetomidine versus low-dose ketamine as an anaesthetic adjuvant for intraoperative hemodynamic stability in elective supratentorial craniotomy: A prospective, randomized, double-blind study

Work-related musculoskeletal pain has become a growing concern in the practice of neurosurgery.A cross-sectional online survey study was conducted among neurosurgery consultants and residents in the Philippines. The survey was adapted from previously published literature on work-related musculoskeletal pain in surgical specialties, and consisted of questions for demographic data, case load, operating room ergonomics, and the Borg pain scale for five index neurosurgical operations: supratentorial craniotomy (SC), infratentorial craniotomy (IC), transsphenoidal surgery (TS), ventriculoperitoneal shunt (VPS) insertion, and spine surgery (SS).There were a total of 100 respondents (56 consultants and 44 residents), with a response rate of 46% (100/217). The mean pain scores were greater in residents than consultants across all anatomic regions and index operations. For consultants, the greatest prevalence of pain was found at the neck (SC 76.8%, IC 89.3%, TS 69.6%, VPS 33.9%, and SS 71.4%). For residents, it was at the lower back (SC 84.1%, IC 86.4%, TS 75.0%, VPS 47.7%, and SS 79.5%). The most common intraoperative response was to stretch or change the height of the neurosurgical field or microscope angulation, while the most common behavioral response was increased irritability and decreased patience.Consultants, who are older and have more medical and musculoskeletal comorbidities, but have more experience in the practice of neurosurgery and more time devoted to exercise, had lower pain scores than residents. Future studies can be geared towards instituting ergonomic training and educational programs for consultant and resident health.

Bone flap osteomyelitis (BFO) in the paediatric population following craniotomy is rare but is a cause of significant morbidity. We studied the incidence, microbiological profile and surgical outcomes of children who developed BFO. A retrospective review of medical records of patients < 18years of age who underwent supratentorial craniotomy in a single neurosurgical unit between January 2004 and December 2023, for non-traumatic and non-infectious indications, was performed. Of the 519 children studied, nine (1.7%) developed BFO. These nine patients had a median age of 8years (range, 2-17years) with the following primary diagnoses - craniopharyngioma (n = 3), moyamoya disease (n = 3), craniosynostosis (n = 2) and ganglioglioma (n = 1). All underwent repeat surgery to either remove the bone flap (n = 7) or debride the osteomyelitic bone (n = 2) and were also administered 6weeks of antibiotic therapy based on culture reports. The median interval between initial craniotomy and onset of symptom of BFO was 4months (IQR, 4-6months) while the median interval between symptom onset and removal of infected bone was 4months (IQR, 2-9months). The most common organism isolated was Staphylococcus aureus (n = 4). Histopathological examination of the bone flap in three (33.3%) among the nine patients revealed necrotizing granulomatous inflammation suggestive of tuberculous osteomyelitis, and these patients additionally received anti-tuberculous therapy. At median follow-up of 14months (IQR, 8-49months), none of the patients had recurrence of symptoms. BFO can occur in up to 2% of children following supratentorial craniotomy. Aggressive debridement of the bone flap and removal of osteomyelitic bone combined with appropriate antibiotic therapy yields good long-term outcomes. It is important to consider Mycobacterium tuberculosis as a possible aetiology of BFO, particularly in regions endemic for tuberculosis.

The intensive care unit (ICU) management of neurosurgical patients is critical for early detection of complications, optimizing recovery, and improving outcomes. The study aimed to determine the outcomes of neurosurgical patients admitted to ICU. After taking exemption from ethical review committee, study was conducted from November 2020 to May 2023 at ICU of a The Aga Khan University Hospital, Pakistan. All adult neurosurgical patients requiring ICU admission were included. Data including demographic variables, comorbid conditions, reasons for ICU referral, complications and expected outcomes were gathered and was analyzed using R. Studio. Total 93 neurosurgical patients (mean age of 40 years, 69% males) were analyzed. Most of them were admitted to ICU after supratentorial craniotomy (40%). ICU course for them was associated with neurological (78%), metabolic (78%), respiratory (56%), cardiovascular (38%), and infectious (34%) complications. 50% of patients required tracheostomy. The mean length of stay (LOS) in ICU was 6.99 days with ICU mortality of 14.6%. Significant number of these patients (77%) were transferred from the ICU to ward care. The average LOS in ward was 8.43 days, with ward mortality of seven percent. The average LOS in hospital stay was 15.3 days. Comparison of adverse outcomes revealed, patients admitted from ward tend to have the longest ICU stay, higher frequency of having neurological deficit, seizures and sepsis. While higher chances of unsuccessful extubation and need of tracheostomy in patients presented with head injury. Despite medical advances, morbidity and mortality remain high in neurosurgical patients. The high incidence of neurological, metabolic and respiratory complications and related outcome particularly patients coming from ward and after trauma needs special consideration.

Elective supratentorial craniotomies may affect short-term prognoses. This study investigates the utility of the preoperative Hemoglobin, Albumin, Lymphocyte, and Platelet (HALP) score for predicting patient outcomes following such procedures. We retrospectively analyzed patients who underwent elective supratentorial craniotomy at a single center between January 2018 and August 2022. Outcomes were categorized as favorable or unfavorable according to survival and the occurrence of major complications. The HALP score was calculated from preoperative blood samples collected within 24 hours before surgery. Postoperative evaluation encompassed monitoring of complications, cognitive function using the Montreal Cognitive Assessment (MoCA), and neurological status assessed with the Glasgow Coma Scale (GCS). After propensity score matching, 150 patients were analyzed (75 per group). Preoperative HALP scores in the good prognosis group were significantly higher than those of the poor prognosis group (73.24 ± 8.45 vs. 61.67 ± 7.82, P < 0.001). Multivariate analysis confirmed that lower values of HALP components independently increased the risk of poor prognosis. The receiver operator characteristic (ROC) analysis showed that the HALP score (AUC = 0.841) was better as a predictor of poor prognosis than its component alone, with an optimal intersection value of 69.42 (sensitivity = 0.84, specificity = 0.747). Patients with a low HALP score also experienced less than ideal perioperative outcomes, including longer surgery times, more blood loss, longer hospital stays, and higher rates of neurological dysfunction, consciousness disorders, and infections. Preoperative HALP score can predict the short-term outcome of patients undergoing elective supratentorial neurosurgery.

The quality of recovery following neurosurgery is of utmost significance, and the type of anesthesia used directly impacts it. Previous research on total intravenous anesthesia (TIVA) and inhalation anesthesia yielded mixed results. We used the Quality of Recovery-40 questionnaire (QoR-40) to prove equivalence in quality of recovery between TIVA and balanced anesthesia in patients undergoing elective supratentorial tumor resection. After Institutional Review Board approval, this prospective, single-blinded, single-center, randomized equivalence trial was conducted at a tertiary care hospital in southern India. 93 adults undergoing elective supratentorial craniotomy were randomly allocated into Group A (n = 48) and Group B (n = 45). Group A received TIVA with propofol, while Group B received balanced anesthesia with Sevoflurane. The primary outcome was a QoR-40 score on postoperative days 1, 2, and 3. Secondary endpoints were intraoperative hemodynamics, brain relaxation score, recovery profile, and postoperative analgesia. The global QoR-40 score, measured on the preoperative day, POD1, and POD2 were comparable between Group A (TIVA) and Group B (Sevoflurane Balanced). The POD3 QoR-40 was lower (P = 0.015 95% CL; 18.9-0.8) for Group A (111.8 ± 8.9) versus Group B (116.6 ± 9.7). However, the mean difference in the score between TIVA and the balanced group on the POD1, POD2, and POD3 (-1.8, -2.8, -4.8) was lesser than the minimal clinically significant difference of 6.3. No significant difference was found in secondary outcomes. TIVA and balanced anesthesia provide comparable quality of recovery as assessed with the QoR-40 score in adults undergoing elective supratentorial craniotomy and tumor excision.

Background: Post-craniotomy pain has historically been under-addressed, largely due to the prevailing notion that such pain is typically mild to moderate in intensity. As a result, it has received limited and inconsistent attention in clinical research. This research evaluated and compared the pain-relieving effectiveness of bilateral scalp nerve block (BSNB) versus the traditional use of opioids in cases undergoing supratentorial craniotomy. Aim: Direct: Improve post-operative pain outcome in supratentorial crainotomy and decrease the need for post-operative morphine use. Indirect: Decrease hospital stay time. Methods: A prospective clinical study was conducted with 50 patients scheduled for elective supratentorial craniotomy .The participants were randomly divided into two equal groups. The control group (Group A) received only GA, while the intervention group (Group B) received GA combined with BSNB. Results: Operative time was significantly longer in Group B in contrast with Group A (P<0.001), likely due to the additional time required to perform the nerve block. Postoperative pain scores, assessed at multiple intervals, were significantly diminished in Group B across all measured time points (P<0.001). Additionally, Group A demonstrated a markedly higher requirement for morphine postoperatively (P<0.001), whereas the need for rescue analgesia was significantly reduced in Group B (P<0.001). Conclusion: BSNB provides superior postoperative analgesia in cases undergoing supratentorial craniotomy. Cases who received BSNB experienced significantly diminished pain scores, a longer duration before requiring rescue analgesia, and reduced opioid consumption. Furthermore, the BSNB group exhibited enhanced intraoperative and postoperative hemodynamic stability, indicating a diminished sympathetic response to surgical stimuli and nociceptive stress.

Decompressive craniectomy (DC) remains a primary modality to effectively reduce elevated intracranial pressure (ICP), a correctly performed surgery can prevent cerebral complications and brain injuries caused due to refractory increased ICP. This article compares the safety and efficacy of two surgical techniques-watertight (WT) dural closure and nonwatertight (NWT) dural closure for DC. A prospective randomized comparative study was conducted from May 15, 2021 to April 15, 2022 in the neurosurgery department of a tertiary care hospital. Using the block randomization method, a total of 56 (28 patients per group: group WT including those undergoing WT dural closure and group NWT undergoing NWT dural closure) patients with indication for DC including traumatic brain injury, infarction, aneurysmal subarachnoid hemorrhage, and dural venous sinus thrombosis were included. Fifty-six randomly allocated patients were analyzed for operative characteristics and postoperative complications and for Glasgow Outcome Scale (GOS) outcomes. Compared with group WT, NWT had significantly lesser operative time. Both interventions were effective in managing the patients of traumatic brain injury. The mortality percentage was lesser in the NWT group. Despite fast surgery, the hospital stay in the NWT and WT groups were statistically similar. In the present study, GOS score was determined at 1, 2, and 3 months for determining the outcomes. GOS score improved significantly in both the groups. Statistically, the outcomes were comparable at 1 month ( p = 0.105) and 3 months ( p = 0.188). NWT dural closure had significantly lesser operative time as compared with WT dural closure. However, amount of blood loss, hospital stay, complications, and mortality were similar among the two groups. Even the follow-up outcome response was comparable among the two groups. It can be concluded that in supratentorial craniotomies, adaptive NWT dural closure may be a good, safe, and time-saving alternative.

Hypertonic saline versus mannitol for brain relaxation in supratentorial tumor surgery: a prospective randomized trial.

Supratentorial craniotomy is frequently performed for intracranial pathologies. Two critical aspects of anesthetic management are maintaining hemodynamic stability and controlling postoperative pain. Hypnotic agents and opioids, although commonly used, increase the risk of complications. Scalp block is a simple, safe technique that reduces opioid use and stabilizes perioperative hemodynamics. At our center, four patients undergoing craniotomy for aneurysm or intracranial tumor received selective scalp blocks. Minimal opioids were required, no hypertensive or tachycardic responses were observed, and opioid-related side effects were avoided. Our findings support the complementary role of scalp block alongside routine anesthesia in craniotomy.

Combined opioid free and scalp block enhances the quality of recovery in supratentorial craniotomies done under ERAS protocol: A prospective case series - Post-craniotomy pain is often severe and poorly managed, leading to the exploration of alternatives to opioid-based anaesthesia. While it is a standard practice in neurosurgery, opioid-based anaesthesia can interfere with neurological monitoring and cause side effects. In a case series of ten supratentorial craniotomy patients, we implemented an Enhanced Recovery After Surgery (ERAS) protocol, utilizing opioid-free anaesthesia (OFA) with injections of Magnesium Sulfate and Dexmedetomidine, complemented by a scalp block for a multimodal analgesic approach. The primary outcomes included total postoperative analgesia duration and hemodynamic stability, while secondary outcomes assessed extubation time, rescue analgesic requirements, postoperative nausea and vomiting, sedation levels, and any other complications. The ERAS protocol with opioid-free anaesthesia (OFA) demonstrated excellent recovery outcomes, including rapid extubation, an average analgesia duration of 23 hours, minimal Visual Analog Scale (VAS) scores, low demand for rescue analgesics, minimal sedation, and no postoperative nausea, vomiting, or other complications, highlighting its potential as an effective method for expedited recovery. Keywords: Supratentorial craniotomies, Opioid free anaesthesia, ERAS.

Comparative Evaluation of analgesic efficacy of ketamine and magnesium sulfate as adjuvants to bupivacaine for scalp block in supratentorial Craniotomy: A Randomized, Double-Blind clinical study.

Cortical spreading depolarisation (SD) is a pathological wave of depolarisation in the cortex. SDs occur frequently after severe acute brain injury, and SDs in clusters can contribute to secondary brain damage in patients with severe acute brain injury through hypoperfusion and upregulation of cerebral metabolism in vulnerable brain tissue. Ketamine appears to inhibit SDs both in vitro and in patient series of severe acute brain injury. The KETA-BID trial aims to examine the efficacy and safety of S-ketamine for SDs in severe acute brain injury, as well as the feasibility of the trial design. This randomised, blinded feasibility and pilot trial includes adults (≥ 18 years) undergoing a supratentorial craniotomy or craniectomy for severe acute brain injury (ie, traumatic brain injury, aneurysmal subarachnoid haemorrhage or spontaneous intracerebral haemorrhage). During surgery, an electrocorticography (ECoG) strip is placed adjacent to injured brain tissue. Patients are continuously monitored throughout their stay at the neurointensive care unit and the neurosurgical step-down unit. In the case of an SD, physiological optimisation of intracranial pressure, brain tissue oxygen tension (PbtO2), core temperature and blood glucose is initiated. Participants developing SD clusters are randomised for continuous infusion with S-ketamine or matching placebo in a 1:1 allocation with full blinding of the treatment allocation. Infusion rates (ie, dose) and duration of trial medication are adjusted following a dosing algorithm according to SD occurrence. Surviving participants are followed until 6 months after the injury with recording of functional outcome. The primary outcome is occurrence of SDs per hour of monitoring after randomisation. The Scientific Ethics Committee of the Capital Region of Denmark (H-21056972), the Danish Medicines Agency (EudraCT 2021-003716-12), as well as the Clinical Trials Information System (CTIS 2024-515315-22-00) approved this trial. This trial will provide insight into both SD and the clinical effects of ketamine following severe acute brain injury, presenting a potential new treatment for these patients. The findings will be submitted for publication in peer-reviewed publications. NCT05095857.

BackgroundScalp blocks help attenuate hemodynamic responses and provide analgesia in neurosurgical procedures. Clonidine, an alpha-2 agonist, has been known to enhance the duration of analgesia when used as an adjuvant in peripheral nerve blocks. Our aim was to evaluate the efficacy of adding clonidine 2 mcg/kg to bupivacaine 0.25% versus plain bupivacaine 0.25% in scalp block infiltration in patients undergoing supratentorial craniotomy by comparing the duration of analgesia and perioperative hemodynamic parameters in both groups.MethodsWe enrolled 60 patients in this study based on our inclusion criteria. Patients were divided equally into two groups. Scalp blocks were administered after induction of general anaesthesia. Group A comprised 30 patients and received plain 0.25% bupivacaine infiltration. Group B consisted of 30 patients and received clonidine 2 mcg/kg with 0.25% bupivacaine scalp block infiltration. Heart rate (HR) and mean arterial pressure (MAP) were recorded from application of Mayfield® pins (Integra Lifesciences, Princeton, NJ) every five minutes till the opening of the dura and every five minutes from dura closure up to completion of procedures. Postoperatively, heart rate and MAP were recorded hourly up to four hours. Pain was assessed in terms of a numeric rating scale (NRS) every four hours for the first 24 hours (score 0: no pain; score 10: unbearable pain). A score of 3 was considered a threshold for administration of rescue analgesia. Intraperative hemodynamic complications were noted. ResultsGroup B has significantly lower NRS scores at 4 and 8 hours postoperatively. Group B also had significantly longer time before rescue analgesia at 792 +/- 190.8 minutes (13.2 +/- 3.18 hours) compared to Group A at 415.8 +/- 155.4 minutes (6.93 +/- 2.59 hours, p< 0.001). MAP was significantly lower in group B during the first 30 minutes from the pin application, however, there was no statistical difference in the heart rate between both the groups during this time interval. We observed a significantly lower heart rate in group B from 15 minutes onwards after dura closure, and this continued in the postoperative period. Mean arterial pressure was comparable between the groups until closure. Group B demonstrated a significantly lower MAP from the second hour in the postoperative period. Overall paracetamol consumption in the postoperative period and fentanyl requirement intraoperatively were also significantly higher in group A.Conclusion Addition of clonidine to bupivacaine in scalp blocks significantly (p<0.001) enhanced analgesic efficacy and hemodynamic control in patients undergoing supratentorial craniotomy procedures.