Undergoing Brain Tumor Resection Research Articles

The Effect of Hypnotics on Sleep Quality and Cognitive Function in Patients with Brain Tumors

ObjectiveWe investigated the effect of hypnotics on sleep quality, cognitive function, and depressive mood in patients with insomnia following brain tumor resection. MethodsFrom patients who underwent brain tumor resection, we recruited 10 patients with insomnia who received hypnotics for more than 1 week during a 3-week follow-up period (insomnia group). We also recruited 12 control patients with brain tumors but without insomnia (control group). We evaluated sleep quality at baseline and 3 weeks later using the Insomnia Severity Index (ISI), the Pittsburgh Sleep Quality Index (PSQI), the Stanford Sleepiness Scale (SSS), and the Epworth Sleepiness Scale (ESS) and investigated cognitive function and depression using the Computerized Neuropsychological Test and the Beck Depression Inventory (BDI). ResultsAt baseline, SSS, ISI, PSQI, and BDI scores were significantly higher and visual continuous performance test (VCPT) and auditory continuous performance test (ACPT) scores were significantly lower in the insomnia than in the control group. Three weeks later, the patients who had received hypnotics had significantly higher ISI, PSQI, ESS, VCPT, ACPT, visual span forward and backward, and visual recognition test scores, and significantly lower BDI scores. ConclusionQuality of sleep in patients with insomnia following brain tumor resection was initially poor but improved significantly after taking hypnotic medication. Further, the hypnotic medications appeared to contribute to the amelioration of cognitive impairments and depressive moods in patients who previously underwent brain tumor resection. We thus recommend the use of hypnotics for patients with brain tumors with insomnia.

The Impact of Intraoperative Electrocorticography on Seizure Outcome After Resection of Pediatric Brain Tumors: A Cohort Study.

Intraoperative electrocorticography (ECoG) has been utilized in patients with tumor-associated seizures; however, its effectiveness for seizure control remains controversial. To evaluate clinical outcomes in pediatric patients undergoing lesionectomy with or without ECoG. Patients undergoing brain tumor resection at Boston Children's Hospital were examined retrospectively (2005-2014). Inclusion criteria involved diagnosis of a supratentorial tumor,≥2 unequivocal seizures, and≥6 mo follow-up. Patients with isolated cortical dysplasia or posterior fossa tumors were excluded. Logistic regression models evaluated predictors of ECoG use, and the impact of ECoG, gross total resection, and focal cortical dysplasia with tumors on seizure freedom by Engel Class and anti-epileptic drug use (AED). A total of 119 pediatric patients were included (n=69 males, 58%; median age, 11.3 yr). Forty-one patients (34.5%) had ECoG-guided surgery. Preoperative seizure duration and number and duration of AED use were significant predictors for undergoing ECoG. There were no differences in seizure freedom (Engel Class I) or improved Engel Score (Class I-II vs III-IV) in patients who did or did not have ECoG at 30 d, 6 mo, and 1, 2, or 5 yr. Patients undergoing ECoG required a greater number of AEDs at 6 mo (P=.01), although this difference disappeared at subsequent time intervals. Gross total resection predicted seizure freedom at 30 d and 6 mo postsurgery (P=.045). This retrospective study, one of the largest evaluating the use of ECoG during tumor resection, suggests that ECoG does not provide improved seizure freedom compared to lesionectomy alone for children.

Safety and Costs Analysis of a Fast-track Algorithm for Early Hospital Discharge After Brain Tumor Surgery

Abstract INTRODUCTION Until the 1990 s, perioperative care was based on empirical concepts and common practice, in part due to the paucity of scientific evidence. With the need of improving patient outcomes and reducing costs, the concern of developing safe and effective standards in postoperative care emerged. Recently, our institution has adopted a daily algorithm for hospital discharge (DAHD), which is a key point in the concept of Fast-Track Surgery. Thus, we designed a study to evaluate whether there was a difference in length of stay (LOS), rate of complications, and hospital costs after the introduction of the DAHD in the postoperative management of patients who underwent brain tumor resection. METHODS This is a retrospective cohort study. All consecutive patients who underwent brain tumor resection in 2017 by a single neurosurgeon were analyzed. Demographic and procedure-related variables, clinical outcomes, and healthcare costs within 30 d after surgery were collected and compared in patients before (preimplementation) and after (postimplementation) the daily algorithm for hospital discharge (DAHD). RESULTS About 61 patients who had been submitted to brain tumor resection were studied (preimplementation 32, postimplementation 29). The baseline demographic characteristics were similar between the groups. After the DAHD implementation, LOS after surgery in days decreased significantly (median 5 vs 3 days; P = .001). The proportion of patients who were discharged within day 1 or 2 after surgery was significantly higher after DAHD protocol (3.1% vs 44.8%; P < .001). Major and minor complications rates, readmission rate, and unplanned return to hospital in 30-day follow-up were comparable between the groups. There was a significant reduction in the median costs of hospitalization in DAHD group (US$2135 vs US$2765, P = .043), mainly due to a reduction in median ward costs (US$922 vs US$1623, P = .009). CONCLUSION Early discharge after brain tumor surgery was safe, inexpensive, reduced the LOS, and hospitalization costs without increase in readmission rate or postoperative complications.

Inflammatory biomarkers in prognostic analysis for patients with glioma and the establishment of a nomogram.

Being biomarkers that reflect host nutritional and immune status, prognostic nutritional index (PNI) and neutrophil/lymphocyte ratio (NLR) have been identified to be independent prognostic factors in various malignancies. The aim of the present study was to determine the predictive value of these parameters for the prognosis of patients with glioma. Hematological and clinicopathological data were retrospectively analyzed from 128 patients with glioma who underwent brain tumor resection between January 2008 and December 2012. Receiver operating characteristic (ROC) analysis was used to determine the optimal cut-offs for PNI and NLR. Kaplan-Meier survival analysis, and univariate and multivariate analyses based on Cox proportional hazards regression model were used to determine whether NLR and PNI were associated with the prognosis of patients with glioma. R software was used to develop nomograms with all the independent prognostic factors included. Kaplan-Meier analysis followed by log-rank tests indicated that NLR ≥2.8 and PNI <45 were significantly associated with decreased overall survival time. The subsequent multivariate analysis indicated that age ≥50 years [hazard ratio (HR), 2.328; 95% confidence interval (CI), 1.386-3.908; P<0.001], high-grade glioma (HR, 3.088; 95% CI, 1.893-5.037; P<0.001), gross total resection (HR, 0.606; 95% CI, 0.380-0.965; P=0.035) and NLR ≥2.8 (HR, 2.037; 95% CI, 1.264-3.281; P=0.003) were independent prognostic factors. The results of the present study indicated that high NLR was an independent risk factor for overall survival rates in patients with glioma, which indicated its value in improving the current prognostic model.

Monopolar 250–500 Hz language mapping: Results of 41 patients

ObjectivesTo determine whether high-frequency 250–500 Hz monopolar stimulation is effective for mapping cortical and subcortical language structures during brain tumor resection. MethodsUsing high-frequency monopolar stimulation, we mapped the speech areas of 41 awake patients undergoing brain tumor resection in the dominant hemisphere, subject to risk of lesions in the cortical and subcortical speech tracts. Patients were tested for object naming, semantic and other language tasks. ResultsMapping was positive in 22 out of 41 patients. Nine patients presented clinical worsening immediately after surgery. Only one patient did not recover after the 30-day follow-up. Nineteen patients showed negative mapping for language tracts, none of whom exhibited worsening of symptoms at the final evaluation. The applied method showed 89% sensitivity and 56% specificity rates. ConclusionsThe applied method was effective in identifying cortical and subcortical speech areas during the surgical resection of brain tumors. SignificanceDetermining whether monopolar high-frequency stimulation is effective for language mapping is important, since it may be very effective in infiltrating tumor areas and nearby edema region.

PCN9 - BRAIN TUMOR RESECTION SURGERY IN PEDIATRIC PATIENTS; RETROSPECTIVE EPIDEMIOLOGICAL STUDY USING JAPANESE ADMINISTRATIVE DATABASE

Pediatric brain tumor is rare disease with wide range of histopathological classification. Brain tumor is second most common malignancy during childhood. Resection surgery is usually the first step in treating brain tumor in children. However, epidemiological studies of the surgery were scarce. The aim of the present study was to investigate clinical features and outcomes according to hospital surgical volume in pediatric patients who underwent brain tumor resection surgery. We retrospectively analyzed pediatric patients, less than 16 years old, who underwent brain tumor resection surgery from the Japanese Diagnosis Procedure Combination database between April 2012 and March 2016. Patients who with outlier length of stay (>365days) and who with outlier preoperative length of stay (>14days) were excluded. We investigated the patients’ clinical characteristics, major procedures, and in-hospital mortality regarding hospital surgical volume. Subgroup analysis for patients aged 5 and younger was also performed. We identified 1,354 pediatric patients who underwent brain tumor resection surgery after exclusions. About two-fifth of the patients were aged 11-15 years old. Male/female ratio was 53/47. Overall crude in-hospital mortality was 1.8% (N = 24). Seventy-five hospitals provided just one surgery during study period. The crude in-hospital mortality tended to decreases as hospital surgical volume increased (3.3% in the lowest quartile volume, and 0.8% in the highest quartile volume). The tendency becomes more prominent in patients aged 5 years old and younger. The present study implies the volume-outcome relationship in pediatric brain tumor resection surgery although outcome analysis for this kind of surgery is complex due to its heterogeneity. Further centralization of the surgeries should be taken into consideration together with further efforts for risk-adjusted outcome analysis.

Preoperative Mapping of the Supplementary Motor Area in Patients with Brain Tumor Using Resting-State fMRI with Seed-Based Analysis.

The supplementary motor area can be a critical region in the preoperative planning of patients undergoing brain tumor resection because it plays a role in both language and motor function. While primary motor regions have been successfully identified using resting-state fMRI, there is variability in the literature regarding the identification of the supplementary motor area for preoperative planning. The purpose of our study was to compare resting-state fMRI to task-based fMRI for localization of the supplementary motor area in a large cohort of patients with brain tumors presenting for preoperative brain mapping. Sixty-six patients with brain tumors were evaluated with resting-state fMRI using seed-based analysis of hand and orofacial motor regions. Rates of supplementary motor area localization were compared with those in healthy controls and with localization results by task-based fMRI. Localization of the supplementary motor area using hand motor seed regions was more effective than seeding using orofacial motor regions for both patients with brain tumor (95.5% versus 34.8%, P < .001) and controls (95.2% versus 45.2%, P < .001). Bilateral hand motor seeding was superior to unilateral hand motor seeding in patients with brain tumor for either side (95.5% versus 75.8%/75.8% for right/left, P < .001). No difference was found in the ability to identify the supplementary motor area between patients with brain tumors and controls. In addition to task-based fMRI, seed-based analysis of resting-state fMRI represents an equally effective method for supplementary motor area localization in patients with brain tumors, with the best results obtained with bilateral hand motor region seeding.

Surgeon Annual and Cumulative Volumes Predict Early Postoperative Outcomes After Brain Tumor Resection.

Surgeon volume has been previously shown to affect patient outcomes. However, data related to neuro-oncologic surgery are limited and do not include neurologic morbidities as an outcomes measure. In this study, we aimed to determine if 5-year surgeon cumulative and annual volumes predict early postoperative outcomes in patients after brain tumor surgery. A population-based cohort of patients (n=10,258) undergoing brain tumor resection between 2005 and 2014 were included for study using the New York Statewide Planning and Research Cooperation System. Surgeons were categorized by their cumulative and annual surgical volume. Patients treated by high cumulative/high annual (HC/HA) volume surgeons had shorter length of stay (median, 5 days vs. 8 days vs. 8 days vs. 6 days, respectively; P < 0.01), lower charges (median, 70,025 vs. $77,043 vs. $93,715 vs. $77,018 respectively; P < 0.01) and less nonroutine discharge (41% vs. 48% vs. 50.9% vs. 43.9% respectively; P<0.01) compared with patients treated by surgeons from the low cumulative/low annual (LC/LA), LC/HA, HC/LA groups. Similarly, HC/HA volume surgeons also had lower rate of hydrocephalus (9.9% vs. 10.4% vs. 13.7% respectively; P= 0.02), medical complications (6.9% vs. 11.2% vs. 11.5% respectively; P < 0.01), neurologic complications (44.1% vs. 46.8% vs. 48.1% respectively; P=0.03), 30-day reoperation (5.1% vs. 6.9% vs. 7.1% respectively; P < 0.01) and 30-day death (3.3% vs. 5.4% vs. 5.2%; P < 0.01) compared with LC/LA and LC/HA volume surgeons. There is some evidence for improved postoperative outcomes when surgery is performed by HC and HA volume surgeons. This finding suggests that subspecialization in surgical neuro-oncology should be considered.

The Utility of Early Postoperative Head Computed Tomography in Brain Tumor Surgery: A Retrospective Analysis of 755 Cases.

Scheduled early postoperative computed tomography (EPOCT) after craniotomy for brain tumor resection is standard at many institutions. We analyzed utility of preplanned EPOCT after elective craniotomy for brain tumor resection. We retrospectively analyzed 755 brain tumor resections for which EPOCT was performed within 4 hours of surgery. Postoperative clinical neurologic examination results were classified into expected (baseline or predicted postoperative examination), changed (from baseline examination), and unreliable (sedated or baseline comatose patient). Scans were analyzed for unexpected and/or worrisome findings (e.g., hemorrhagic or ischemic stroke). In cases of unexpected findings, management changes were correlated to patient's neurologic examination. Demographic information, tumor histology, and tumor location were analyzed to determine risk factors for unexpected findings. Rate of unexpected EPOCT findings was 4.1%. Patients with expected postoperative examinations were at significantly lower risk of abnormal findings (odds ratio [OR]= 0.074, P < 0.001). Patients with intraventricular tumors (OR= 5.7, P= 0.001) were at higher risk compared with patients with metastatic tumors (OR= 0.24, P= 0.06). No unexpected EPOCT findings led to management changes in patients with expected postoperative neurologic examinations. All unexpected EPOCT findings in patients with changed postoperative neurologic examinations led to management changes. Patients with nonreliable neurologic examinations were at significantly higher risk for unexpected findings on EPOCT (OR= 6.33, P< 0.001) and subsequent management changes. Routine EPOCT is not indicated for patients undergoing brain tumor resection if postoperative neurologic examination is unchanged, as imaging is unlikely to result in management changes. EPOCT should be obtained in all patients with worrisome changes in examination or nonreliable examinations, as both groups have high rates of unexpected findings on imaging that lead to management changes.

A systematic review of perioperative seizure prophylaxis during brain tumor resection: the case for a multicenter randomized clinical trial.

OBJECTIVE The majority of neurosurgeons administer antiepileptic drugs (AEDs) prophylactically for supratentorial tumor resection without clear evidence to support this practice. The putative benefit of perioperative seizure prophylaxis must be weighed against the risks of adverse effects and drug interactions in patients without a history of seizures. Consequently, the authors conducted a systematic review of prospective randomized controlled trials (RCTs) that have evaluated the efficacy of perioperative seizure prophylaxis among patients without a history of seizures. METHODS Five databases (PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL/Academic Search Complete, Web of Science, and ScienceDirect) were searched for RCTs published before May 2017 and investigating perioperative seizure prophylaxis in brain tumor resection. Of the 496 unique research articles identified, 4 were selected for inclusion in this review. RESULTS This systematic review revealed a weighted average seizure rate of 10.65% for the control groups. There was no significant difference in seizure rates among the groups that received seizure prophylaxis and those that did not. Further, this expected incidence of new-onset postoperative seizures would require a total of 1258 patients to enroll in a RCT, as determined by a Farrington-Manning noninferiority test performed at the 0.05 level using a noninferiority difference of 5%. CONCLUSIONS According to a systematic review of major RCTs, the administration of prophylactic AEDs after brain tumor resection shows no significant reduction in the incidence of seizures compared with that in controls. A large multicenter randomized clinical trial would be required to assess whether perioperative seizure prophylaxis provides benefit for patients undergoing brain tumor resection.

The Impact of Race on Discharge Disposition and Length of Hospitalization After Craniotomy for Brain Tumor.

Racial disparities exist in health care, frequently resulting in unfavorable outcomes for minority patients. Here, we use guided machine learning (ML) ensembles to model the impact of race on discharge disposition and length of stay (LOS) after brain tumor surgery from the Healthcare Cost and Utilization Project National Inpatient Sample. We performed a retrospective cohort study of 41,222 patients who underwent craniotomies for brain tumors from 2002 to 2011 and were registered in the National Inpatient Sample. Twenty-six ML algorithms were trained on prehospitalization variables to predict non-home discharge and extended LOS (>7 days) after brain tumor resection, and the most predictive algorithms combined to create ensemble models. Partial dependence analysis was performed to measure the independent impact of race on the ensembles. The guided ML ensembles predicted non-home disposition (area under the curve, 0.796) and extended LOS (area under the curve, 0.824) with good discrimination. Partial dependence analysis showed that black race increases the risk of non-home discharge and extended LOS over white race by 6.9% and 6.5%, respectively. Other, nonblack race increases the risk of extended LOS over white race by 6.0%. The impact of race on these outcomes is not seen when analyzing the general inpatient or general operative population. Minority race independently increases the risk of extended LOS and black race increases the risk of non-home discharge in patients undergoing brain tumor resection, a finding not mimicked in the general inpatient or operative population. Recognition of the influence of race on discharge and LOS could generate interventions that may improve outcomes in this population.

Detection of subclinical vitamin K deficiency in neurosurgery with PIVKA-II

Vitamin K is known for supporting the carboxylation of hepatic coagulation proteins. Levels of proteins induced by vitamin K absence for factor II (PIVKA-II) reflect hypocarboxylated prothrombin and can be used to detect subclinical vitamin K deficiency. The aim of this study was to determine the prevalence of perioperative subclinical vitamin K deficiency among neurosurgical patients using PIVKA-II and investigate the existence of any correlation to standard coagulation assays. Also, the antitumor effects of vitamin K were reviewed. Thirty-five patients undergoing brain tumor resection were included. Blood samples were drawn preoperatively, at the end of surgery and in the morning after surgery. In addition to PIVKA-II, factor II and the Owren and Quick prothrombin times were analyzed. Seventeen of 35 patients had elevated PIVKA-II levels before surgery, which continued to be above normal range postoperatively. Median PIVKA-II and Owren prothrombin time (PT-INR) were increased on the morning day 1 postoperatively compared to before surgery, whereas Quick end-stage prothrombin time (EPT) decreased and factor II was unaffected. Postoperative complications were connected to high PIVKA-II increases. Positive correlations between PIVKA-II and factor II and body mass index (BMI) were found. In conclusion, PIVKA-II was increased in many patients preoperatively and then increased by the morning following surgery. Standard coagulation assays were largely non-pathological. Correlations were demonstrated between PIVKA-II and factor II and BMI. The effect of perioperative treatment with different vitamin K supplements should be investigated in future studies, as well as clinical trials evaluating their antitumor effects.

Intraoperative multi-exposure speckle imaging of cerebral blood flow

Multiple studies have demonstrated that laser speckle contrast imaging (LSCI) has high potential to be a valuable cerebral blood flow monitoring technique during neurosurgery. However, the quantitative accuracy and sensitivity of LSCI is limited, and highly dependent on the exposure time. An extension to LSCI called multi-exposure speckle imaging (MESI) overcomes these limitations, and was evaluated intraoperatively in patients undergoing brain tumor resection. This clinical study (n = 8) recorded multiple exposure times from the same cortical tissue area spanning 0.5–20 ms, and evaluated images individually as single-exposure LSCI and jointly using the MESI model. This study demonstrated that the MESI estimates provided the broadest flow sensitivity for sampling the flow magnitude in the human brain, closely followed by the shorter exposure times. Conservation of flow analysis on vascular bifurcations was used to validate physiological accuracy, with highly conserved flow estimates (<10%) from both MESI and 1 ms LSCI (n = 14 branches). The MESI model had high goodness-of-fit with proper image calibration and acquisition, and was used to monitor blood flow changes after tissue cautery. Results from this study demonstrate that intraoperative MESI can be performed with high quantitative accuracy and sensitivity for cerebral blood flow monitoring.

Magnetic Resonance Imaging Appearance and Mechanism of Action of Five Hemostatic Agents Used in Neurosurgery.

To describe the magnetic resonance (MR) image appearance of 5 hemostatic agents placed in the brain, and to review their clinical application. Descriptive ex vivo and in vivo study. Canine cadavers (n=4), client-owned dogs (n=4). Heads from 4 canine cadavers were used, each with 5 hemostatic agents placed in specific locations in the brain. Hemostatic agents were used in their native form in 2 cadaveric brains, and in 2 others the materials were saturated with fresh whole blood prior to placement to mimic application in a field of active hemorrhage. The heads underwent MR imaging and the images were reviewed. Postoperative MRI images from 4 dogs undergoing brain tumor resection were retrospectively reviewed and compared to the images from the cadavers. All clinical cases and cadaveric specimens underwent surgical closure prior to MR imaging including placement of titanium mesh over the craniotomy defect with a dural graft of porcine small intestinal submucosa (SIS) sealed with Tisseel (fibrin sealant). The SIS and Tisseel used in the dural graft were consistently indistinguishable from the surrounding tissues on MR images. The MR imaging appearance of the remaining 4 hemostatic agents (Gelfoam, Avitene, Surgicel, and Floseal) placed on the surface or in the parenchyma of canine brain, varied with MR sequence weighting and blood saturation. Accurate evaluation of the degree of brain tumor resection on postoperative MR images requires careful differentiation between hemorrhage, residual tumor, and hemostatic agents implanted.

Prophylactic antiepileptic drug administration following brain tumor resection: results of a recent AANS/CNS Section on Tumors survey.

OBJECTIVE Antiepileptic drugs (AEDs) are often administered prophylactically following brain tumor resection. With conflicting evidence and unestablished guidelines, however, the nature of this practice among tumor surgeons is unknown. METHODS On November 24, 2015, a REDCap (Research Electronic Database Capture) survey was sent to members of the AANS/CNS Section on Tumors to query practice patterns. RESULTS Responses were received from 144 individuals, including 18.8% of board-certified neurosurgeons surveyed (across 86 institutions, 16 countries, and 5 continents). The majority reported practicing in an academic setting (85%) as a tumor specialist (71%). Sixty-three percent reported always or almost always prescribing AED prophylaxis postoperatively in patients with a supratentorial brain tumor without a prior seizure history. Meanwhile, 9% prescribed occasionally and 28% rarely prescribed AED prophylaxis. The most common agent was levetiracetam (85%). The duration of seizure prophylaxis varied widely: 25% of surgeons administered prophylaxis for 7 days, 16% for 2 weeks, 21% for 2 to 6 weeks, and 13% for longer than 6 weeks. Most surgeons (61%) believed that tumor pathology influences epileptogenicity, with high-grade glioma (39%), low-grade glioma (31%), and metastases (24%) carrying the greatest seizure risk. While the majority used prophylaxis, 62% did not believe or were unsure if prophylactic AEDs reduced seizures postoperatively. The vast majority (82%) stated that a well-designed randomized trial would help guide their future clinical decision making. CONCLUSIONS Wide knowledge and practice gaps exist regarding the frequency, duration, and setting of AED prophylaxis for seizure-naive patients undergoing brain tumor resection. Acceptance of universal practice guidelines on this topic is unlikely until higher-level evidence supporting or refuting the value of modern seizure prophylaxis is demonstrated.

Effects of Perioperative Acetyl Salicylic Acid on Clinical Outcomes in Patients Undergoing Craniotomy for Brain Tumor

To evaluate the safety of continuing acetyl salicylic acid (ASA) in patients undergoing brain tumor resection. Many patients are on antiplatelet agents that are withheld before elective neurosurgical procedures to reduce bleeding risk. Cessation of ASA in patients with cardiovascular disease is associated with a known increased risk of thrombotic events, especially in patients with coronary stents. The medical records of patients who underwent surgical resection of a brain tumor at the University of Florida from 2010 to 2014 were evaluated. The patients were separated into groups based on preoperative ASA use and whether or not it was stopped before surgery. Patients were evaluated for thrombotic complications, postoperative hemorrhage, estimated blood loss, length of hospital stay, and discharge disposition. Of the 452 patients analyzed, 368 patients were not on chronic ASA therapy, 55 patients had their ASA discontinued before surgery, and 28 patients were continued on ASA perioperatively. The patients on preoperative ASA were comparable on all collected demographic variables. There were no statistical differences detected between the groups for outcomes including bleeding complications, need for reoperation, or thrombotic complications. In this analysis, perioperative low dose ASA use was not associated with increased risk of perioperative complications.

Concurrent neoadjuvant chemotherapy is an independent risk factor of stroke, all-cause morbidity, and mortality in patients undergoing brain tumor resection

Neoadjuvant chemotherapy (NC) may be utilized for treatment of various tumors, and a proportion of patients on active NC may require resection of a primary or secondary brain tumor. The objective of this study is to examine the impact of NC on postoperative neurosurgical outcomes. Elective cranial neurosurgical patient data was obtained from the American College of Surgeons National Surgical Quality Improvement Program database between 2006 and 2012. The impact of NC on 30day stroke, all-cause postoperative morbidity, and mortality were assessed. Adjusted odds ratios (OR) were estimated for stroke, overall morbidity, and mortality using a multivariable logistic regression model, accomplished in stepwise fashion, for patients receiving NC versus those not receiving NC. This study analyzed 3812 patients undergoing elective cranial surgery, with 152 on concurrent NC. NC patients had a complication rate of 23.68%, while patients not receiving NC had a lower complication rate at 17.65% (p=0.057). Multivariable regression analysis revealed that patients who received NC had significantly increased odds of developing a stroke with neurological deficit (OR 3.39; 95% confidence interval [CI] 1.37–8.40) and all-cause postoperative morbidity (OR 1.57; 95% CI 1.04–2.37) over the control group. Finally, the NC cohort demonstrated higher odds of mortality following surgery than their non-NC counterparts (OR 3.81; 95% CI 1.81–8.02). Ninety-two patients (2.41%) died within 30days, of whom 10 (6.58%) were receiving NC versus 82 non-NC (2.24%) patients (p=0.001). Concurrent NC is associated with an increased risk of short-term stroke with neurological deficit, all-cause morbidity, and mortality in patients undergoing brain tumor resection.

Levetiracetam seizure prophylaxis in craniotomy patients at high risk for postoperative seizures

Background:The risk of developing immediate postoperative seizures in patients undergoing supratentorial brain tumor surgery without anti-epileptic drug (AED) prophylaxis is 15-20%. Patients who present with pre-operative seizures and patients with supratentorial meningioma or supratentorial low grade gliomas are at significantly higher risk. There is little data on the efficacy of levetiracetam as a prophylactic AED in the immediate postoperative period (within 7 days of surgery) in these patients.Methods:We conducted a retrospective chart review of 165 adult patients classified as higher risk for postoperative seizures who underwent brain tumor resection at Duke University Hospital between time May 2010 and December 2011. All patients had received levetiracetam monotherapy in doses of 1000-3000 mg/day in the immediate postoperative period.Results:We identified 165 patients with following tumor locations: Frontal 83 (50.3%), Temporal 37 (22.4%), Parietal 30 (18.2%), Occipital 2 (1.2%) and 13 (7.8%) with single lesions involving more than one lobe. Histology revealed: Glioma 98 (59.4%), Meningioma 57 (34.5%) and Brain Metastases 6 (3.6%). Preoperatively, 88/165 (53.3%) patients had presented with seizures. 12/165 patients (7.3%) developed clinical seizures (generalized 10, partial 2) in the immediate post-operative period. Other than somnolence in 7 patients (4.2%), no major side-effects were noted.Conclusions:The incidence of seizures was significantly lower in patients treated with levetiracetam (7.3%) when compared with the expected (15-20%) rate without AED prophylaxis based on the previous literature. Levetiracetam appears effective and safe for seizure prevention in patients undergoing brain tumor resection and who are at significantly higher risk of developing post-operative seizures. These findings warrant confirmation in a prospective randomized trial.

Ambient mass spectrometry for the intraoperative molecular diagnosis of human brain tumors.

The main goal of brain tumor surgery is to maximize tumor resection while preserving brain function. However, existing imaging and surgical techniques do not offer the molecular information needed to delineate tumor boundaries. We have developed a system to rapidly analyze and classify brain tumors based on lipid information acquired by desorption electrospray ionization mass spectrometry (DESI-MS). In this study, a classifier was built to discriminate gliomas and meningiomas based on 36 glioma and 19 meningioma samples. The classifier was tested and results were validated for intraoperative use by analyzing and diagnosing tissue sections from 32 surgical specimens obtained from five research subjects who underwent brain tumor resection. The samples analyzed included oligodendroglioma, astrocytoma, and meningioma tumors of different histological grades and tumor cell concentrations. The molecular diagnosis derived from mass-spectrometry imaging corresponded to histopathology diagnosis with very few exceptions. Our work demonstrates that DESI-MS technology has the potential to identify the histology type of brain tumors. It provides information on glioma grade and, most importantly, may help define tumor margins by measuring the tumor cell concentration in a specimen. Results for stereotactically registered samples were correlated to preoperative MRI through neuronavigation, and visualized over segmented 3D MRI tumor volume reconstruction. Our findings demonstrate the potential of ambient mass spectrometry to guide brain tumor surgery by providing rapid diagnosis, and tumor margin assessment in near-real time.

Impact of remifentanil use on early postoperative outcomes following brain tumor resection or rectal cancer surgery

Remifentanil, a mu-opioid receptor agonist, has important characteristics for neuroanesthesia, but data about its effects on postoperative recovery and mortality are currently lacking. Using the Japanese Diagnosis Procedure Combination database in 2007, we selected patients who underwent elective brain tumor resection with open craniotomy under general anesthesia using either remifentanil or fentanyl and divided them into two categories: remifentanil patients and non-remifentanil patients. After propensity score matching for potential confounders, we compared the in-hospital mortality and postoperative length of stay (LOS) between the two groups. For comparison, the same endpoints were evaluated for patients underwent rectal cancer surgery under general anesthesia with intraoperative epidural anesthesia. In patients who underwent brain tumor resection (936 pairs), remifentanil patients had significantly lower in-hospital mortality (1.5 % vs. 3.0 %; P = 0.029). Logistic regression analysis revealed that the odds ratio for use of remifentanil for in-hospital mortality was 0.47 (95 % confidence interval, 0.25-0.91; P = 0.025). Remifentanil patients also showed earlier discharge from hospital (median LOS, 17 vs. 19 days; hazard ratio, 1.19, 95 % confidence interval, 1.08-1.30; P < 0.001). In contrast, in 2,756 pairs of patients undergoing rectal cancer surgery, no significant difference was seen in either in-hospital morality (1.2 % vs. 1.3 %; P = 0.518) or median LOS (19 vs. 19 days; P = 0.148) between the two groups. Our data suggest a possible association between use of remifentanil and better early postoperative recovery for patients undergoing neurosurgery with craniotomy. Further studies, including a randomized controlled trial, are required to confirm the present results.