Intracranial Tumor Surgery Research Articles

The use of ultrasound in intracranial tumor surgery

As an intraoperative imaging modality, ultrasound is a user-friendly and cost-effective real-time imaging technique. Despite this, it is still not routinely employed for brain tumor surgery. This may be due to the poor image quality in inexperienced hands, and the well-documented learning curve. However, with regular use, the operator issues are addressed, and intraoperative ultrasound can provide valuable real-time information. The aim of this review is to provide an understanding for neurosurgeons of the development and use of ultrasound in intracranial tumor surgery, and possible future advances. A systematic search of the electronic databases Embase, Medline OvidSP, PubMed, Cochrane, and Google Scholar regarding the use of ultrasound in intracranial tumor surgery was undertaken. Intraoperative ultrasound has been shown to be able to accurately account for brain shift and has potential for regular use in brain tumor surgery. Further developments in probe size, resolution, and image reconstruction techniques will ensure that intraoperative ultrasound is more accessible and attractive to the neuro-oncological surgeon. This review has summarized the development of ultrasound and its uses with particular reference to brain tumor surgery, detailing the ongoing challenges in this area.

Trends in cognitive dysfunction following surgery for intracranial tumors.

Background:This study was conducted to prospectively assess the cognitive function of patients with intracranial tumors.Methods:The cognitive status of patients with intracranial tumors were prospectively studied before surgery, and later at 1 and 6 months following surgery, on purposive sampling, using validated post graduate institute (PGI) battery for brain dysfunction (score 0–30) with a higher dysfunction rating score indicating poor cognitive status.Results:Out of 23 patients enrolled, 20 could complete the study. They had substantial cognitive dysfunction before surgery (score 17.1 ± 9.4). Though there was no significant improvement (16.9 ± 9.0) at 1 month, the score improved significantly (10.3 ± 9.2) at 6 months following surgery (P = 0.008). The improvement was relatively subdued in intra-axial, malignant, and radiated tumors. Overall, there was a significant improvement in mental balance (P = 0.048), verbal retention of dissimilar pairs (P = 0.01), and recognition (P = 0.01), while dysfunction persisted in the domains of memory, verbal retention to similar pairs, and visual retention.Conclusion:Patients with intracranial tumors have substantial cognitive dysfunction, which tend to show significant improvement beyond 6 months following surgery, especially among tumors, which were extra-axial, benign, and nonirradiated.

Intra-Operative Fluid Management in Adult Neurosurgical Patients Undergoing Intracranial Tumour Surgery: Randomised Control Trial Comparing Pulse Pressure Variance (PPV) and Central Venous Pressure (CVP).

Fluid management in neurosurgery presents specific challenges to the anaesthesiologist. Dynamic para-meters like Pulse Pressure Variation (PPV) have been used successfully to guide fluid management. To compare PPV against Central Venous Pressure (CVP) in neurosurgical patients to assess hemodynamic stability and perfusion status. This was a single centre prospective randomised control trial at a tertiary care centre. A total of 60 patients undergoing intracranial tumour excision in supine and lateral positions were randomised to two groups (Group 1, CVP n=30), (Group 2, PPV n=30). Intra-operative fluid management was titrated to maintain baseline CVP in Group 1(5-10cm of water) and in Group 2 fluids were given to maintain PPV less than 13%. Acid base status, vital signs and blood loss were monitored. Although intra-operative hypotension and acid base changes were comparable between the groups, the patients in the CVP group had more episodes of hypotension requiring fluid boluses in the first 24 hours post surgery. {CVP group median (25, 75) 2400ml (1850, 3110) versus PPV group 2100ml (1350, 2200) p=0.03} The patients in the PPV group received more fluids than the CVP group which was clinically significant. {2250 ml (1500, 3000) versus 1500ml (1200, 2000) median (25, 75) (p=0.002)}. The blood loss was not significantly different between the groups The median blood loss in the CVP group was 600ml and in the PPV group was 850 ml; p value 0.09. PPV can be used as a reliable index to guide fluid management in neurosurgical patients undergoing tumour excision surgery in supine and lateral positions and can effectively augment CVP as a guide to fluid management. Patients in PPV group had better hemodynamic stability and less post operative fluid requirement.

Etiology of postoperative hyponatremia following pediatric intracranial tumor surgery

OBJECT Cerebral salt wasting (CSW) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH) cause postoperative hyponatremia in neurosurgery patients, can be difficult to distinguish clinically, and are associated with increased morbidity. The authors aimed to determine risk factors associated with CSW and SIADH among children undergoing surgery for intracranial tumors. METHODS This retrospective cohort study included children 0-19 years of age who underwent a first intracranial tumor surgery with postoperative hyponatremia (sodium ≤ 130 mEq/L). CSW was differentiated from SIADH by urine output and fluid balance, exclusive of other causes of hyponatremia. The CSW and SIADH groups were compared with basic bivariate analysis and recursive partitioning. RESULTS Of 39 hyponatremic patients, 17 (44%) had CSW and 10 (26%) had SIADH. Patients with CSW had significantly greater natriuresis compared with those with SIADH (median urine sodium 211 vs 28 mEq/L, p = 0.01). Age ≤ 7 years and female sex were significant risk factors for CSW (p = 0.03 and 0.04, respectively). Both patient groups had hyponatremia onset within the first postoperative week. Children with CSW had trends toward increased sodium variability and symptomatic hyponatremia compared with those with SIADH. Most received treatment, but inappropriate treatment was noted to worsen hyponatremia. CONCLUSIONS The authors found that CSW was more common following intracranial tumor surgery and was associated with younger age and female sex. Careful assessment of fluid balance and urine output can separate patients with CSW from those who have SIADH, and high urine sodium concentrations (> 100 mEq/L) support a CSW diagnosis. Patients with CSW and SIADH had similar clinical courses, but responded to different interventions, making appropriate diagnosis and treatment imperative to prevent morbidity.

NIMG-43DUAL VOLUME VISUALIZATION (3D-DSA AND CROSS-SECTIONAL IMAGING) FOR SURGICAL PLANNING OF INTRACRANIAL MENINGIOMAS

INTRODUCTION: Many techniques about planning for the surgery of intracranial brain tumors have been considered for getting more information about the relationship between tumors and adjacent vasculatures. Especially for the surgery of meningiomas, it is essential to distinguish passing arteries from feeders. It is also very important to preserve venous structures. Dual volume visualization is apt and powerful method to know about these vascular structures. METHODS: Between Feb. 2012 and Dec. 2014, a total of 20 patients underwent brain tumor surgery after undergoing dual volume visualization. The tumors comprised of 1 glioblastoma, 1 medulloblastoma, and 18 meningiomas. The locations of meningiomas were as follows : 6 parasagittal; 4 falx; 2 convexity; 1 tentorial; 1 foramen magnum; 2 sphenoid wing; 1 petroclival; and 1 olfactory groove. RESULTS: In cases involving glioblastoma and medulloblastoma, the boundary between the distinctive tumor mass of the intrinsic tumor and the normal brain is unclear, resulting in post-operative assessments showing greater direct damage done to the normal brain than that caused by vessel injury. Vascular supply and disfiguring observed in preoperative dual volume visualization images closely resembled the actual observations made during the surgery of meningiomas. Three out of eighteen meningioma cases demonstrated new deficits. One case exhibited tumor bed bleeding and perilesional edema leading to aggravation of motor weakness and deterioration. One exhibited venous infarction and a separate delayed hemorrhage leading to motor weakness and deterioration. One developed facial palsy. CONCLUSIONS: The advantages of this technique are as follows: 1. It enables the visualization of arteries and veins, individually; 2. the 3D rotation allows for convenient presurgical orientation; 3. it permits simulating craniotomies. This technique could reduce the incidence of newly developed neurological deficits as a result of identifying which veins to preserve during surgery and predicting the arteries that may shift.

Role of Dexmedetomidine on Hemodynamics and Anesthetic Requirement During Elective Intracranial Tumor Surgery - A Prospective Randomized Double Blind Placebo Controlled Study

Role of Dexmedetomidine on Hemodynamics and Anesthetic Requirement During Elective Intracranial Tumor Surgery - A Prospective Randomized Double Blind Placebo Controlled Study

Second-look surgery for intracranial germ cell tumors.

The role of second-look surgery in intracranial germ cell tumors (GCTs) needs to be reviewed. To present our experience of second-look surgery in patients with intracranial GCTs who showed less than complete response despite normalizing or decreasing tumor markers after chemotherapy. Retrospective review of 7 patients who underwent second-look surgery for an intracranial GCT was performed. Of 23 consecutive patients with newly diagnosed intracranial GCTs treated between August 2003 and August 2013, 7 patients (30%) underwent second-look surgery. The mean age was 9.4 years. The initial diagnoses were mixed germ cell tumor in 5 and immature teratoma in 2. Second-look surgery was performed after 1 to 3 courses of chemotherapy. Magnetic resonance imaging at the surgery demonstrated increasing residual tumor in 4 and stable residual tumor in 3. Tumor markers were normalized in 5 and nearly normalized in 2. Gross total resection was achieved in all patients. Histopathology at second-look surgery revealed mature teratoma in 5, fibrosis with atypical cells in 1, and fibrosis in 1. All patients subsequently underwent additional chemoradiation therapy according to the initial diagnosis. All patients are alive with no evidence of recurrence, with a mean follow-up of 48 months. Second-look surgery plays an important role in the treatment of intracranial GCTs. Surgery may be encouraged at a relatively early phase after chemotherapy when the residual tumor increases or does not change size despite normalized or nearly normalized tumor markers in order to achieve complete resection and improve outcome.

Early Discharge After Surgery for Intra-Axial Brain Tumors

A steady trend in medicine has been discharging patients earlier after surgical procedures, a trend that has been resisted by many in the field of intracranial tumor surgery. Here we demonstrate the feasibility of discharge on postoperative days 1 or 2 for patients undergoing elective intracranial surgery. We conducted a retrospective analysis on all patients undergoing elective intracranial keyhole surgery for tumors, cysts, and other masses between January 2010 and December 2011. During this time period, we used an early discharge plan centered on the clinical appearance of the patient, for which all patients were eligible preoperatively. Patients who met discharge criteria were encouraged to continue recovery at home. Of 313 patients, 213 (68.1%) were discharged on postoperative days 1 or 2. Within this group, 81.6% had supratentorial lesions, 16.9% had infratentorial lesions, and 1.4% had lesions extending above and below the tentorium. High grade gliomas accounted for 38.5% of lesions. No deaths or readmissions for postoperative swelling or hematomas occurred within 28 days of surgery. The overall rate of readmission for postoperative complications was 4.2%, compared with 4.0% for patients discharged on or after postoperative day 3. Readmission rate for repeat surgery addressing complications causing neurological symptoms was 1.9%. Our data suggest that the most serious complications occur within hours of the procedure, not days. The complications requiring readmission that we observed would not have been avoided with longer inpatient courses. Thus, consideration should be given to sending well-looking patients home to recover on postoperative days 1 or 2.

Assessing early unplanned reoperations in neurosurgery: opportunities for quality improvement.

Review of morbidities and mortality has been the primary method used to assess surgical quality by physicians, hospitals, and oversight agencies. The incidence of reoperation has been proposed as a candidate quality indicator for surgical care. The authors report a comprehensive assessment of reoperations within a neurosurgical department and discuss how such data can be integrated into quality improvement initiatives to optimize value of care delivery. All neurosurgical procedures performed in the main operating room or the outpatient surgery center at the Ronald Reagan UCLA Medical Center and UCLA Santa Monica Medical Center from July 2008 to December 2012 were considered for this study. Interventional radiology and stereotactic radiosurgery procedures were excluded. Early reoperations within 7 days of the index surgery were reviewed and their preventability status was evaluated. The incidence of early unplanned reoperation was 2.6% (occurring after 183 of 6912 procedures). More than half of the patients who underwent early unplanned reoperation initially had surgery for shunt-related conditions (34.4%) or intracranial tumor (23.5%). Shunt failure was the most common indication for early unplanned reoperation (34.4%), followed by postoperative bleeding (20.8%) and postoperative elevated intracranial pressure (9.8%). The average time interval (± SD) between the index surgery and reoperation was 3.0 ± 1.9 days. The average length of stay following reoperation was 12.1 ± 14.4 days. This study enabled an in-depth assessment of reoperations within an academic neurosurgical practice and identification of strategic opportunities for department-wide quality improvement initiatives. The authors provide a nuanced discussion regarding the use of absolute reoperations as a quality indicator for neurosurgical patient populations.

A Predictive Model of Unfavorable Outcomes After Benign Intracranial Tumor Resection

Benchmarking of outcomes and individualized risk prediction are central in patient-oriented shared decision making. We attempted to create a predictive model of complications in patients undergoing benign intracranial tumor resection. We performed a retrospective cohort study involving patients who underwent craniotomies for benign intracranial tumor resection during the period 2005-2011 and were registered in the National (Nationwide) Inpatient Sample database. A model for outcome prediction based on individual patient characteristics was developed. There were 19,894 patients who underwent benign tumor resection. The respective inpatient postoperative incidences were 1.3% for death, 22.7% for unfavorable discharge, 4.2% for treated hydrocephalus, 1.1% for cardiac complications, 0.9% for respiratory complications, 0.5% for wound infection, 0.5% for deep venous thrombosis, 2.3% for pulmonary embolus, and 1.5% for acute renal failure. Multivariable analysis identified risk factors independently associated with the above-mentioned outcomes. A model for outcome prediction based on patient and hospital characteristics was developed and subsequently validated in a bootstrap sample. The models demonstrated good discrimination with areas under the curve of 0.85, 0.76, 0.72, 0.74, 0.72, 0.74, 0.76, 0.68, and 0.86 for postoperative risk of death, unfavorable discharge, hydrocephalus, cardiac complications, respiratory complications, wound infection, deep venous thrombosis, pulmonary embolus, and acute renal failure. The models also had good calibration, as assessed by the Hosmer-Lemeshow test. Our models can provide individualized estimates of the risks of postoperative complications based on preoperative conditions and potentially can be used as an adjunct for decision making in benign intracranial tumor surgery.

Is duration of surgery a risk factor for extracranial complications and surgical site infections after intracranial tumor operations?

Duration of surgery has not been much explored as a possible risk factor for complications in neurosurgery. To explore the possible impact of duration of surgery on the risk of developing extracranial complications and surgical site infections following intracranial tumor surgery. Retrospective review of 1,000 consecutive patients who underwent planned surgery for intracranial tumors at a single institution. Complications within 30 days of surgery were registered. Of all patients, 18.6 % acquired extracranial complications, and they were seen in 14.3, 17.7, 22.1 and 37.4 % after operations lasting <2, 2-4, 4-6 and ≥6 h (p = 0.025). In multivariate analyses, duration of surgery per hour [OR 1.14 (1.04-1.25)], ASA 3-4 [OR 1.37 (1.14-1.63)] and acquired neurological deficits [OR 1.47 (1.02-2.11)] were associated with extracranial complications. For surgical site infections, there was a significant association between increased risk and increased duration of surgery (p < 0.001). Duration of surgery together with comorbidity and acquired neurological deficits is an independent risk factor for extracranial complications after brain tumor surgery. Duration of surgery is also associated with surgical site infections. Knowledge about the potential harm of slow surgery should be of interest to neurosurgeons when deciding on various surgical approaches, surgical tools or providing training. Also if acquiring ethical approval or informed consent in technical research projects, the risks associated with prolonging brain surgery should be considered. Special consideration should be warranted in patients with significant comorbidity, planned long surgery and higher risk of acquiring neurological deficits after surgery.

NI-86 * COMBINED AWAKE BRAIN MAPPING AND LOW-FIELD INTRAOPERATIVE MRI FOR BRAIN TUMOR RESECTION

BACKGROUND: Surgery for patients with intraparenchymal brain tumors is often reported as being done with intraoperative MRI guidance or with awake mapping, but rarely with these two methods in tandem. We report our experience performing awake image-guided surgery using a compact iMRI. METHODS: Surgery in 25 patients was done using the PoleStar iMRI system (Medtronic Surgical Technologies). All patients had a glioma in the dominant hemisphere for language. Patients were divided into 4 groups depending on how mapping and imaging effected surgery: Group A: gross total resection (GTR) without imaging; Group B: GTR with the aid of iMRI; Group C: language mapping stopped surgery before further imaging; Group D: language mapping stopped surgery after iMRI revealed residual tumor. RESULTS: The number of iMRI scans acquired ranged from 1 to 5 (mean 2.6), adding an average of 1.4 hours to surgery. There were 7/25 patients in Group A, 6/25 in Group B, 3/25 in Group C, and 9/25 in Group D. Overall, intraoperative imaging led to further resection in 15/25 patients, while language mapping stopped surgery in 12/25. Gross total resection was achieved in 13 patients. A mean follow up of 16.9 months revealed no major new postoperative deficits. Minor deficits of language, calculation, contralateral weakness occurred in 12/25 patients, while language function worsened in 3 patients (12%). CONCLUSIONS: Neurosurgeons should not have to choose between these two modalities, removing the guesswork out of intracranial tumor surgery. Compact iMRI is easily integrated with awake surgery and cortical mapping to ensure accurate resection of gliomas in the dominant hemisphere, while preserving neurological function. In only a small minority of patients with such tumors can a GTR be safely achieved without the use of iMRI and/or language mapping.

Timing, duration, and severity of hyponatremia following pediatric brain tumor surgery*.

To describe the time course, variability, and magnitude of serum sodium changes among children undergoing intracranial tumor surgery. Retrospective cohort study. Tertiary children's hospital in Salt Lake City, UT. Children 0-19 years undergoing first neurosurgical procedure for an intracranial tumor, treated during January 2001 and February 2012. None. Three hundred nineteen patients were placed in three exclusive groups based on the lowest serum sodium measurement during admission: 1) severe hyponatremia: serum sodium less than or equal to 130 mEq/L; 2) mild hyponatremia: 131-135 mEq/L; and 3) normal sodium: more than 135 mEq/L. Timing and severity of sodium perturbations were assessed within each group. Hundred thirty-seven patients (43%) had mild hyponatremia, 39 (12%) had severe hyponatremia, and 143 (45%) had normal sodium. After surgery, sodium decreased in all groups with lower averaged concentrations during postoperative days 0-1 and 5-6, although patients with severe hyponatremia had the greatest decline. Nearly 80% of hyponatremic patients had mild hyponatremia prior to development of severe hyponatremia; median time between mild hyponatremia and severe hyponatremia was 1.6 days (interquartile range, 0.4-5.6). Seventy-five percent of patients manifest mild hyponatremia within two postoperative days; however, severe hyponatremia developed later with 75% of patients manifesting severe hyponatremia within six postoperative days. Nine patients had initial severe hyponatremia between days 6 and 20 after surgery. Patients with severe hyponatremia had greater sodium variability with significantly lower nadirs, greater maximum values, and larger decreases within 24-hour periods compared with other sodium groups. Seventy-five percent of children with severe hyponatremia spent more than 4 days with abnormally low sodium values. Among hyponatremic patients, obstructive hydrocephalus and age less than 3.5 years were significant independent risk factors for severe hyponatremia. Hyponatremia developed in just over half of children. Young children with hydrocephalus have increased risk of severe hyponatremia. Those with severe hyponatremia need frequent and prolonged monitoring because of risk for repeat sodium changes. Further study is needed to evaluate ideal monitoring and treatment of severe hyponatremia after intracranial tumor surgery.

Rate and reasons for elective ventilation in patients undergoing intracranial tumour surgery

Abstract Background: Mechanical ventilation (MV) after neurosurgery is often decided by the preoperative neurological status of the patient. However, there is paucity of information regarding factors responsible for continuation of MV in these patients. This study was carried out to identify the indications and risk factors for elective ventilation after intracranial tumour surgery. Materials and Methods: A prospective observational study was carried out on consecutive adult patients who underwent elective craniotomy for tumour excision, and postoperatively required MV. Data on anaesthesia technique, duration of anaesthesia and surgery, blood loss and transfusion and volume of fluids infused were noted. Intraoperative complications like tight brain, massive blood loss, brainstem handling, cranial nerve handling, haemodynamic instability, cardiac arrhythmias, venous air embolism, electrolyte abnormality and hypothermia were also recorded. Statistical analysis was done using Strata 9.0 software. Categorical data was analysed using Chi-square test or Fisher's exact test and continuous data by Student's t-test. Results: A total of 709 patients enrolled for the study over a period of one year out of which 347 patients (48.9%) required continuation of MV during the postoperative period. The mean duration of MV was 29.7 ± 39.7 hrs. The most common causes for postoperative MV were ‘not responding to commands’ (43.2%), and neurosurgeon's advice (41.8%). The mean ICU and hospital stays were 92.2 ± 134.0 hrs and 13.8 ± 16.5 days, respectively. 47.6% of patients who required postoperative MV on neurosurgeon's advice developed complications whereas it was 33.2% for those ventilated other reasons (P &lt; 0.05). Glasgow outcome scale (GOS) at discharge was poor in 12.4%. On multivariate analysis, intraoperative blood transfusion, tracheostomy and duration of ventilation more than 48 hrs were the independent risk factors associated with poor outcome. Conclusions: Although the neurosurgeon's advice for elective ventilation should not be ignored, but prolonged and avoidable MV may exacerbate the postoperative morbidities apart from increasing the cost of treatment. Hence, a complete understanding of intraoperative events, cerebral physiology and various factors influencing it during the perioperative period may not be overemphasised.

The incidence of postoperative hyponatremia and associated neurological sequelae in children with intracranial neoplasms

Intracranial tumors are common pediatric neoplasms and account for substantial morbidity among children with cancer. Hyponatremia is a known complication of neurosurgical procedures and is associated with higher morbidity among neurosurgical patients. The authors aimed to estimate the incidence of hyponatremia, identify clinical characteristics associated with hyponatremia, and assess the association between hyponatremia and patient outcome among children undergoing surgery for intracranial tumors. This is a retrospective cohort study of children ranging in age from 0 to 19 years who underwent an initial neurosurgical procedure for an intracranial tumor between January 2001 and February 2012. Hyponatremia was defined as serum sodium ≤ 130 mEq/L during admission. Hyponatremia during admission occurred in 39 (12%) of 319 patients and was associated with young age and obstructive hydrocephalus (relative risk [RR] 2.9 [95% CI 1.3-6.3]). Hyponatremic patients were frequently symptomatic; 21% had seizures and 41% had altered mental status. Hyponatremia was associated with complicated care including mechanical ventilation (RR 4.4 [95% CI 2.5-7.9]), physical therapy (RR 4 [95% CI 1.8-8.8]), supplemental nutrition (RR 5.7 [95% CI 3.3-9.8]), and infection (RR 5.7 [95% CI 3.3-9.5]). Hyponatremic patients had a 5-fold increased risk of moderate or severe disability on the basis of their Pediatric Cerebral Performance Category score at discharge (RR 5.3 [95% CI 2.9-9.8]). Obstructive hydrocephalus (adjusted odds ratio [aOR] 3.24 [95% CI 1.38-8.94]) and young age (aOR 0.92 [95% CI 0.85-0.99]) were independently associated with hyponatremia during admission. Hyponatremia was independently associated with moderate or worse disability by Pediatric Cerebral Performance Category score at discharge (aOR 6.2 [95% CI 3.0-13.03]). Hyponatremia was common, particularly among younger children and those with hydrocephalus. Hyponatremia was frequently symptomatic and was associated with more complicated hospital courses. Hyponatremia was independently associated with worse neurological outcome when adjusted for age and tumor factors. This study serves as an exploratory analysis identifying important risk factors for hyponatremia and associated sequelae. Further research into the causes of hyponatremia and the association with poor outcome is needed to determine if prevention and treatment of hyponatremia can improve outcomes in these children.

Patients undergoing surgery of intracranial metastases have different outcomes based on their primary pathology

Objectives:Patients with a variety of different primary cancers can develop intracranial metastases. Patients who develop intracranial metastases are often grouped into the same study population, and therefore an understanding of outcomes for patients with different primary cancers remain unclear.Methods:Adults who underwent intracranial metastatic tumor surgery from 1997–2011 at a single institution were retrospectively reviewed. Primary pathologies were compared using Fisher’s exact and Student’s t-test, and Cox regression analysis was used to identify factors associated with survival.Results:About 708 patients underwent surgery during the reviewed period, where 269 (38%) had non-small cell lung cancer (NSCLC), 106 (15%) breast cancer (BC), 72 (10%) gastrointestinal (GI) cancers, 88 (12%) renal cell cancer (RCC), and 88 (12%) melanoma. The most notable differences were that NSCLC patients were older, BC younger, BC had more primary tumor control, and NSCLC less extracranial spread. BC had longer survival, RCC had longer local progression free survival (PFS), and NSCLC had longer distal PFS. The factors independently associated with survival for NSCLC (female, recursive partitioning analysis (RPA) class, primary tumor control, solitary metastasis, tumor size, adenocarcinoma, radiation, discharge to home), BC (age, no skull base involvement, radiation), GI cancer (age, RPA class, Karnofsky performance scale (KPS), lack of preoperative motor deficit, non-esophageal tumors, non-hemorrhagic tumors, avoidance of new deficits), melanoma (preoperative seizures, solitary metastasis, smaller tumor size, discharge to home, chemotherapy), and RCC (KPS, chemotherapy) were distinctly different.Discussion:These differences between patients with different primary cancers support the fact that patients with intracranial disease are not all the same and should be studied by their primary pathology.

Survival and Recurrence for Patients Undergoing Surgery of Skull Base Intracranial Metastases

Objective Skull base metastases (SBMs) are rare lesions in close proximity to critical neural and vasculature structures. This rarity and complexity have led many to only offer nonsurgical therapies. The surgical outcomes for patients with SBM therefore remain unknown. Design Retrospective, comparison analyses. Setting Johns Hopkins Hospital. Participants All patients who underwent intracranial metastatic tumor surgery. Main Outcome Measure Survival and recurrence. Results Of the 708 patients who underwent intracranial metastatic tumor surgery, 29 (4%) had SBM: 3 (10%) involved the anterior skull base, 7 (24%) the sella, 6 (21%) the orbit, 2 (7%) the sphenoid wing, 3 (10%) the clivus, 4 (14%) the petrous bone, and 4 (14%) the paranasal sinuses. Following surgery, 6 (50%) had improvements in vision and 14 (88%) had improvement and/or maintenance of their cranial nerve symptoms. Three (10%), 0(0%), and 1(3%) developed a new motor, language, and vision deficit, respectively. There were no differences in median survival (10.0 versus 9.2 months, p = 0.48) and local progression-free survival (PFS) (p = 0.52), but there was improved distal PFS (p = 0.04) between patients with and without SBM. Conclusions Patients with SBM are relatively rare. These patients can tolerate surgery with minimal morbidity and mortality, and they have similar prognoses to patients without SBM.

Outcome prediction in intracranial tumor surgery: the National Surgical Quality Improvement Program 2005–2010

Accurate knowledge of individualized risks is crucial for decision-making in the surgical management of patients with brain tumors. Precise delineation of those risks remains a topic of debate. We attempted to create a predictive model of outcomes in patients undergoing craniotomies for tumor resection (CTR). We performed a retrospective cohort study involving patients who underwent CTR from 2005 to 2010 and were registered in the American College of Surgeons National Quality Improvement Project database. A model for outcome prediction based on individual patient characteristics was developed. Of the 1,834 patients, 457 had meningiomas (24.9 %) and 1377 had non-meningioma tumors (75.1 %). The respective 30-day postoperative risks were 2.1 % for stroke, 1.3 % for MI, 2.7 % for death, 2.4 % for deep surgical site infection, and 6.6 % for return to the OR. Multivariate analysis demonstrated that pre-operative tumor-related neurologic deficit, stroke, altered mental status, and weight loss, were independently associated with most outcomes, including post-operative MI, death, and deep surgical site infection. An additive effect of the variables on the risk of all outcomes was observed. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated by the area under the receiver operating characteristic curve, which was 0.687, 0.929, 0.749, 0.746, and 0.679 for postoperative risk of stroke, MI, death, infection, and return to the OR, respectively. Our model can provide individualized estimates of the risks of post-operative complications based on pre-operative conditions, and can potentially be utilized as an adjunct in the decision-making for surgical intervention in brain tumor patients.

MAPK signaling pathway regulates cerebrovascular receptor expression in human cerebral arteries

BackgroundCerebral ischemia results in enhanced expression of contractile cerebrovascular receptors, such as endothelin type B (ETB), 5-hydroxytryptamine type 1B (5-HT1B), angiotensin II type 1 (AT1) and thromboxane (TP) receptors in the cerebral arteries within the ischemic area. The receptor upregulation occurs via activation of the mitogen-activated protein kinases (MAPK) pathway. Previous studies have shown that inhibitors of the MAPK pathway diminished the ischemic area and contractile cerebrovascular receptors after experimental cerebral ischemia. The aim of this study was to examine if the upregulation of contractile cerebrovascular receptors after 48 h of organ culture of human cerebral arteries involves MAPK pathways and if it can be prevented by a MEK1/2 inhibitor. Human cerebral arteries were obtained from patients undergoing intracranial tumor surgery. The vessels were divided into ring segments and incubated for 48 h in the presence or absence of the specific MEK1/2 inhibitor U0126. The vessels were then examined by using in vitro pharmacological methods and protein immunohistochemistry.ResultsAfter organ culture of the cerebral arteries the contractile responses to endothelin (ET)-1, angiotensin (Ang) II and thromboxane (TP) were enhanced in comparison with fresh human arteries. However, 5-carboxamidotryptamine (5-CT) induced decreased contractile responses after organ culture as compared to fresh arteries. Incubation with U0126 diminished the maximum contraction elicited by application of ET-1, Ang II and U46619 in human cerebral arteries. In addition, the MEK1/2 inhibitor decreased the contractile response to 5-CT. Immunohistochemistry revealed that organ culture resulted in increased expression of endothelin ETA, endothelin ETB angiotensin AT2, 5-hydroxytryptamine 5-HT1B and thromboxane A2 receptors, and elevated levels of activated pERK1/2, all localized to the smooth muscle cells of the cerebral arteries. Co-incubation with U0126 normalized these proteins.ConclusionThe study demonstrated that there is a clear association between human cerebrovascular receptor upregulation via transcription involving activation of the MAPK pathway after organ culture. Inhibition of the MAPK pathways attenuated the vasoconstriction mediated by ET, AT and TP receptors in human cerebral arteries and the enhanced expression of their receptors. The results indicate that MAPK inhibition might be a novel target for treatment of cerebrovascular disorders.

The current role of endoscopes in intracranial tumor surgery

The current role of endoscopes in intracranial tumor surgery