Supratentorial Space-occupying Lesions Research Articles

An Observational Comparative Study to Evaluate the Use of Image-Guided Surgery in the Management and Outcome of Supratentorial Intracranial Space-Occupying Lesions.

The objective of this article is to study the effect of neuronavigation on the outcome of surgery for supratentorial tumors, such as the extent of resection, size of craniotomy, and overall morbidity and mortality by comparing with conventional excision. A total of 50 patients undergoing intracranial surgery for supratentorial space-occupying lesions from 2020 to 2022 were included in the study. One intervention group consisted of patients undergoing surgical resection of supratentorial tumors utilizing image guidance versus the control group, which consisted of patients undergoing surgical excision of supratentorial tumor excision without image guidance. Parameters used to compare the outcome were the extent of resection of the lesions, craniotomy size, and overall morbidity and mortality. There was no significant reduction in craniotomy size or prolongation of operative duration with the use of neuronavigation. There was no significant difference in postoperative hospital stay between the two groups. Neuronavigation-assisted cases did not show any significant reduction in the occurrence of postoperative neurological deficits or any reduction of overall morbidity and mortality.

Enhancing the Reliability of Intraoperative Ultrasound in Pediatric Space-Occupying Brain Lesions

Intraoperative ultrasound (IOUS) may aid the resection of space-occupying brain lesions, though technical limits may hinder its reliability. IOUS (MyLabTwice®, Esaote, Italy) with a microconvex probe was utilized in 45 consecutive cases of children with supratentorial space-occupying lesions aiming to localize the lesion (pre-IOUS) and evaluate the extent of resection (EOR, post-IOUS). Technical limits were carefully assessed, and strategies to enhance the reliability of real-time imaging were accordingly proposed. Pre-IOUS allowed us to localize the lesion accurately in all of the cases (16 low-grade gliomas, 12 high-grade gliomas, eight gangliogliomas, seven dysembryoplastic neuroepithelial tumors, five cavernomas, and five other lesions, namely two focal cortical dysplasias, one meningioma, one subependymal giant cell astrocytoma, and one histiocytosis). In 10 deeply located lesions, IOUS with hyperechoic marker, eventually coupled with neuronavigation, was useful to plan the surgical route. In seven cases, the administration of contrast ensured a better definition of the vascular pattern of the tumor. Post-IOUS allowed the evaluation of EOR reliably in small lesions (<2 cm). In large lesions (>2 cm) assessing EOR is hindered by the collapsed surgical cavity, especially when the ventricular system is opened, and by artifacts that may simulate or hide residual tumors. The main strategies to overcome the former limit are inflation of the surgical cavity through pressure irrigation while insonating, and closure of the ventricular opening with Gelfoam before insonating. The strategies to overcome the latter are avoiding the use of hemostatic agents before IOUS and insonating through normal adjacent brain instead of corticotomy. These technical nuances enhanced the reliability of post-IOUS, with a total concordance to postoperative MRI. Indeed, the surgical plan was changed in about 30% of cases, as IOUS showed a residual tumor that was left behind. IOUS ensures reliable real-time imaging in the surgery of space-occupying brain lesions. Limits may be overcome with technical nuances and proper training.

Cerebral Edema and Elevated Intracranial Pressure.

This article reviews the management of cerebral edema, elevated intracranial pressure (ICP), and cerebral herniation syndromes in neurocritical care. While corticosteroids may be effective in reducing vasogenic edema around brain tumors, they are contraindicated in traumatic cerebral edema. Mannitol and hypertonic saline use should be tailored to patient characteristics including intravascular volume status. In patients with traumatic brain injury who are comatose, elevated ICP should be managed with an algorithmic, multitiered treatment protocol to maintain an ICP of 22 mm Hg or less. Third-line ICP treatments include anesthetic agents, induced hypothermia, and decompressive craniectomy. Recent clinical trials have demonstrated that induced hypothermia and decompressive craniectomy are ineffective as early neuroprotective strategies and should be reserved for third-line management of refractory ICP elevation in severe traumatic brain injury. Monitoring for cerebral herniation should include bedside pupillometry in supratentorial space-occupying lesions and recognition of upward herniation in patients with posterior fossa lesions. Although elevated ICP, cerebral edema, and cerebral herniation are interrelated, treatments should be based on the distinct pathophysiologic process. Focal lesions resulting in brain compression are primarily managed with surgical decompression, whereas global or multifocal brain injury requires a treatment protocol that includes medical and surgical interventions.

Jugular bulb oxygen saturation and the pyruvate lactate ratio are good signals for cerebral metabolism and oxygenation during hypothermia with altered target ventilation

Background The effect of deliberate hypothermia and hypocapnia on brain protection during neurosurgical procedures has been studied for many years, but in this study, the combination of deliberate hypothermia and hypocapnia was analyzed to detect their effects on cerebral oxygenation by the assessment of SjvO 2 and cerebral metabolism by the measurement of both jugular bulb lactate and pyruvate. Patients and methods Sixty patients scheduled for excision of supratentorial space-occupying lesions were randomly allocated into two groups. In group I, hypocapnia was induced combined with hypothermia, and in group II, normocapnia was maintained combined with hypothermia. Hypothermia was induced using a water blanket under the patient controlling the tympanic membrane temperature at 35°C. Jugular bulb venous and arterial blood gas analyses were performed before the induction of hypothermia ± hypocapnia (baseline), and then every 20 min till closure of the dura. The arterio-jugular venous oxygen content difference (AJDO 2 ) and the cerebral oxygen extraction ratio (COER) were calculated. Jugular bulb lactate and pyruvate levels were measured before the induction of hypothermia ± hypocapnia (baseline) and then every 30 min till closure of the dura. Results There was a significant increase in pjH and significant decreases in both PjCO 2 and SjvO 2 in the hypocapnic group after the induction of hypocapnia. SjvO 2 reached 80.32 ± 4.59% in the normocapnic group, whereas it reached 75.3 ± 4.02% in the hypocapnic group. AJDO 2 and COER started to decrease after induced hypothermia in both groups compared with readings before induced hypothermia, but the hypocapnic group had a significantly higher AJDO 2 and COER than the normocapnic group during the period of induced hypothermia (AJDO 2 reached 3.98 ± 0.47 ml/dl and COER reached 25.93 ± 4.13% in comparison with the hypocapnic group, where AJDO 2 reached 4.58 ± 0.51 ml/dl and COER reached 31.96 ± 4.01%).Jugular bulb lactate and pyruvate levels were significantly higher during hypocapnia than during normocapnia. Conclusion Cerebral oxygenation and metabolism were better during hypothermia combined with normocapnia as reflected by relative ͽͽSjvO 2 and ͿͿAJDO 2 and COER as well as ͿͿjugular bulb lactate and pyruvate.

Serum GFAP is a diagnostic marker for glioblastoma multiforme

A serum marker for malignant cerebral astrocytomas could improve both differential diagnosis and clinical management of brain tumour patients. To evaluate whether the serum concentration of glial fibrillary acidic protein (GFAP) may indicate glioblastoma multiforme (GBM) in patients with single supratentorial space-occupying lesions, we prospectively examined 50 consecutive patients with histologically proven GBM, World Health Organization (WHO) grade IV, 14 patients with anaplastic astrocytoma (WHO grade III), 4 patients with anaplastic oligodendroglioma, 13 patients with diffuse astrocytoma (WHO grade II), 17 patients with a single cerebral metastasis and 50 healthy controls. Serum was taken from the patients before tumour resection or stereotactic biopsy. Serum GFAP levels were determined using a commercially available ELISA test and were detectable in 40 out of the 50 GBM patients (median: 0.18 microg/l; range: 0-5.6 microg/l). The levels were significantly elevated compared with those of the non-GBM tumour patients and healthy controls (median: 0 mug/l; range: 0-0.024 microg/l; P < 0.0001, respectively). Non-GBM tumour patients and all healthy subjects showed zero serum GFAP levels. There was a significant correlation between tumour volume (Spearman Rho, CC = 0.47; 95% confidence interval, 0.2-0.67; P < 0.001), tumour necrosis volume (CC = 0.49; 95% confidence interval, 0.2-0.72; P = 0.004), the amount of necrotic GFAP positive cells (CC = 0.61; 95% confidence interval, 0.29-0.81; P = 0.007) and serum GFAP level among the GBM patients. A serum GFAP level of >0.05 microg/l was 76% sensitive and 100% specific for the diagnosis of GBM in patients with a single supratentorial mass lesion in this series. Therefore, it can be concluded that serum GFAP constitutes a diagnostic biomarker for GBM. Future studies should investigate whether serum GFAP could also be used to monitor therapeutic effects and whether it may have a prognostic value.

Transcranial colour-coded sonography for the bedside evaluation of mass effect after stroke.

Repeated cranial computerized tomography scan examination in patients with elevated intracranial pressure is time consuming and requires patient transportation. We prospectively evaluated the diagnostic value of transcranial duplex sonography as a bedside tool for detection of the mass effect after space-occupying ischemic stroke and brain haemorrhage and for evaluating the width and dislocation of the ventricular system and the dislocation of brain mid-line structures. We used transcranial duplex sonography in 21 consecutive patients with space-occupying ischemic middle cerebral artery infarction and brain haemorrhage. The transcranial duplex sonography examinations were performed within 2 h before or after corresponding follow-up cranial computerized tomography scans. We measured the third ventricular width as a parameter for infratentorial and the mid-line shift for supratentorial space-occupying effect. In all patients, mid-line structures could be identified by transcranial duplex sonography. Significant third ventricular dilation was found subsequently in most patients with infratentorial mass effect, and mid-line shift occurred in all patients with supratentorial space-occupying lesions, respectively. The mean difference (absolute values) between transcranial duplex sonography and cranial computerized tomography measurements was 0.8 mm for the ventricular width (standard deviation 1 mm) and 1.1 mm for the mid-line shift (standard deviation: 1.46 mm), with a tendency for these parameters to be underestimated at higher values using transcranial duplex sonography. The linear correlation coefficients were R = 0.97 and R = 0.94, respectively. Transcranial duplex sonography appears to be a sufficiently reliable bedside method for evaluating the width and the lateral displacement of the third ventricle, as validated by cranial computerized tomography scan. Thus, it may be suitable for monitoring the space-occupying effect of both supra- and infratentorial strokes during treatment on critical care and stroke units.

Comparison of Remifentanil and Fentanyl in Patients Undergoing Craniotomy for Supratentorial Space-Occupying Lesions

Comparison of Remifentanil and Fentanyl in Patients Undergoing Craniotomy for Supratentorial Space-Occupying Lesions

Intracranial Pressure and Hemodynamic Effects of Remifentanil Versus Alfentanil in Patients Undergoing Supratentorial Craniotomy

Remifentanil hydrochloride is an ultra-short-acting esterase metabolized mu-opioid receptor agonist. The purpose of this study was to provide preliminary information regarding the effects of this drug on intracranial pressure (ICP) and mean arterial pressure (MAP) in patients scheduled for craniotomy. Twenty-six patients undergoing excision of supratentorial space-occupying lesions were anesthetized with 0.3-0.8 vol% isoflurane in a 2:1 mixture of nitrous oxide:oxygen. Ventilation was adjusted to provide a PaCO2 of <30 mm Hg. After the first burr hole was drilled, patients (n = 5-6 per group) were administered an intravenous infusion of study drug (placebo, remifentanil 0.5 micro gram/kg or 1.0 micro gram/kg, or alfentanil 10 micro gram/kg or 20 micro gram/kg) over 1 min. Epidural ICP and MAP values were recorded at baseline, at completion of infusion, and every minute for the next 10 min. Blood study drug concentrations were measured immediately after completion of infusion. Neither opioid caused a significant increase in ICP. Both drugs were associated with a dose-dependent decrease in MAP. Remifentanil was 31 times more potent than alfentanil for effects on MAP. We conclude that remifentanil produces similar cerebral perfusion pressure effects as does alfentanil. (Anesth Analg 1996;83:348-53)

Combined Radionuclide Circulation and Static Imaging of the Brain

Combined static and dynamic imaging of the brain was performed in 398 patients with suspected space occupying lesions. The imaging findings were analyzed from two points of view: Firstly, the radionuclide results were compared with pathological anatomical findings and, secondly, the diagnostic yield in patients with various symptoms was evaluated. Thus we obtained the number of false positive and false negative results. The findings of the combined imaging procedure were correctly negative in 85% of the patients with non-focal symptoms and false positive in only 1%. The circulation study alone gave false positive results in 7% and so did the static study alone. The combined imaging procedure was pathologic in 46 of 83 cases of space-occupying lesions (55%). There were only three patients in whom a pathologic circulation study was the only indication of a space-occupying lesion (4%). The static study alone gave correct positive findings in 23 more cases (28%). We conclude that a pathologic blood flow study alone is of limited interest. In the presence of a pathologic static study the circulation procedure gives additional information, especially in meningioma and subdural hematoma. In patients with symptoms indicative of supratentorial space-occupying lesions of the brain combined imaging is recommended.

Eine neue topometrische Methode zur Lokalisation der normalen und pathologischen Lage des Angulus venosus der tiefen Hirnvenen im Seitenphlebogramm

A simple topographic method has been developed for the localisation of the venous angle on the lateral cerebral phlebogram. The principle depends on an angular measurement and an estimation of proportions which are statistically independant of each other. The method was tested on 103 phlebograms of adult patients with supratentorial spaceoccupying lesions. It was compared with conventional measurements; a number of advantages were found for using our method and its accuracy is as good as the other, most precise, methods.

Ventriculocisternostomia de Torkildsen no tratamento do hidrocefalo não comunicante: resultados em 67 casos

Sixty-seven cases of non-communicating hydrocephalus treated according to the Torkildsen's procedure are reported. The spinal fluid blockage was caused in 55 cases by supratentorial and in 10 cases by infratentorial tumors; in the remaining cases the spinal fluid interruption was due to non-tumoral causes. Ventriculography was the most important examination performed as far as the local diagnosis was concerned. 15 patients in this series disclosed lethal complications with signs of brain stem lesions. Patient survival was 3.9 years with variation ranging from 1 to 9 years. The following conclusions were drawn: 1) Ventriculocisternostomy is a valious method for the treatment of non-communicating hidrocephalus for it allows a more physiological drainage of the spinal fluid besides favouring the exploration of the posterior fossa in cases of doudtful pre-operative diagnosis. This procedure is of low cost and involves a relatively simple tecnique as compared with other procedures which demand the use of special valves. 2) According to the review of the pertinent literature the best results have been accomplished in cases where there is a non-tumoral aqueduct stenosis as well as in inoperable tumors of the third ventricle. 3) Bilateral drainage is mandatory in cases of bilateral obstruction of Monro's foramina. It has also been indicated in all cases as a precaution due to the possibility of occlusion of one catheter. 4) Ventriculocisternostomy should also be indicated as a prophylactic treatment of non-communicating hydrocephalus in cases of inoperable tumors of the sela or the basal ganglia with compression of the third ventricle but without completly blockage of the ventricle system. 5) Ventriculocisternostomy should be indicated with some reserve in cases of infratentorial tumors as well as in great supratentorial space-occupying lesions. It is however contra-indicated in cases of large tumors and in the inflammatory process involving the posterior fossa. 6) In the present series the obstruction of the draining-system was very uncommon being observed in only three patients. 7) No cases of spinal fluid fistula or meningitis were observed in the present study.

Effect of supratentorial space-occupying lesions on regional intracranial pressure and local cerebral blood flow: an experimental study in baboons.

Cortical blood flow and epidural intracranial pressure have been measured in the two supratentorial compartments of the intracranial space in experimental baboons during the acute expansion of a parieto-occipital epidural balloon. Differential pressures between the two halves of the supratentorial space have been found, and these have been associated with evidence that flow has fallen more quickly in the hemisphere most compressed. The evidence points to a more rapid exhaustion of the autoregulatory capacity in the hemisphere subjected to greater compression, a fall in perfusion pressure to below critical autoregulatory levels occurring slightly before that in the opposite hemisphere, and the establishment of a differential flow pattern for a short time during a critical phase of compression. The displacements induced by inflation of the parieto-occipital balloon have been described.

Pneumoencephalographic studies following complete removal of supratentorial lesions.

Pneumoencephalography, introduced by Dandy, is of paramount importance for the localization of intracerebral lesions. It also has its merits in the study of anatomical changes in vivo, as pointed out by Foerster. In the course of our work we have had the opportunity of studying the changes in the brain, particularly the ventricular system, occurring after the removal of well encapsulated supratentorial space-occupying lesions. In all the cases selected for this purpose the lesions were well delimited and were completely removed. The 10 cases upon which this study is based comprised 5 abscesses, 3 meningiomas, 1 ecchinococcus cyst, and 1 encapsulated tumor which seemed to be a meningioma but proved on histopathologic examination to be an oligodendroglioma. The purpose of the study is to direct attention to the changes in the ventricular system caused by supratentorial space-occupying lesions, and their reversibility as shown by preoperative and postoperative air studies. Case I: S. K., a boy of six and a half years, was admitted on Aug. 16, 1948, because of convulsive seizures of jacksonian type of ten days duration. The boy was known to have congenital heart disease. On examination a right pyramidal and sensory syndrome was found. Pneumoencephalography on Aug. 18 localized the lesion in the left parietal region (Fig. 1A and B). At operation, Aug. 20, a large abscess was completely removed. Recovery ensued. Postoperative pneumoencephalograms, Nov. 12, 1948, are reproduced in Figure 1C and D. Case II: J. G., a 32-year-old woman, was admitted on July 11, 1949, with a history of headache of nine years duration, mental disturbances for the past four years, and complete blindness which had developed in the last few months. On examination, secondary optic atrophy was evident and there were pyramidal tract signs on the left. X-ray examination of the skull revealed complete destruction of the sella turcica. The preoperative ventriculogram (Fig. 2A), obtained on July 26, disclosed a right parieto-occipital space-occupying lesion. At operation on the same day a parasagittal parieto-occipital meningioma weighing 220 gm. was removed. Except for blindness, the patient recovered. A second pneumcencephalographic study was performed on Sept. 16 (Fig. 2B). Case III: S. U., a 36-year-old male, was admitted on March 29, 1950, with severe left frontal headache of ten days duration. Positive neurologic findings were: right central facial weakness and an extensor toe sign on the right. Pneumoencephalography on March 30 showed a left frontal lesion. There were slight distortion of the left frontal horn, some compression of the body of the left ventricle, and depression of the left temporal horn. Air was absent in sulci over the left hemisphere but present over the right. The same day an abscess was evacuated through a left frontal burr hole. Penicillin was administered locally and systemically. On April 10 the capsule of the abscess was enucleated.