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Bernstein Z, Chisango Z, Mannam S, Bray D, Hoang K. Characterizing the association between CSF biomarkers and risk for ventriculoperitoneal shunt following posterior fossa tumor resection in a case-control study. Clin Neurol Neurosurg 2024; 238:108169. [PMID: 38377626 DOI: 10.1016/j.clineuro.2024.108169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/09/2024] [Accepted: 02/05/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Recalcitrant hydrocephalus necessitating permanent cerebrospinal fluid (CSF) diversion is a known complication after resection of a posterior fossa tumor (PFT). Various CSF contents, such as protein and other markers, have been variably correlated with the need for permanent CSF diversion. This study aims to evaluate which CSF laboratory values are associated with permanent CSF diversion following PFT resection in adults. METHODS This study queried our multi-institutional database (Central Nervous System Tumor Outcome Registry at Emory; CTORE) consisting of 617 adult patients with PFT resections from 2006 to 2021. Retrospective data was collected from the 89 patients of this cohort that required EVD placement. Patients were stratified into two groups: those that required a shunt following EVD removal (n = 30) and those that did not (n = 40). CSF variables collected included glucose, protein, nucleated cell count, and presence of infection. An unadjusted logistic regression was performed to assess exposures associated with shunt requirement and unadjusted odds ratios (ORs) and their associated 95 % confidence intervals (CIs) were obtained. RESULTS Immediately following surgery, no CSF variables were significantly associated with shunt placement. Except for post-operative CSF being not-clear (OR: 4.15 (1.47-12.56), p = 0.009) and CSF glucose (OR: 0.97 (1.03-1.07), p = 0.031) all other variables were not significantly associated with shunt at time point 2. CONCLUSION In our retrospective analysis, most routinely collected CSF values were not associated with permanent CSF diversion via a ventriculoperitoneal shunt following PFT resection. Further research is needed to identify other potential predictive markers.
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Affiliation(s)
- Zachary Bernstein
- Emory University School of Medicine, Department of Neurosurgery, Emory University Hospital, 100 Woodruff Circle, Atlanta, GA 30308, United States.
| | - Zvipo Chisango
- Emory University School of Medicine, Department of Neurosurgery, Emory University Hospital, 100 Woodruff Circle, Atlanta, GA 30308, United States
| | - Sai Mannam
- Perelman School of Medicine at the University of Pennsylvania, Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, United States
| | - David Bray
- Emory University School of Medicine, Department of Neurosurgery, Emory University Hospital, 100 Woodruff Circle, Atlanta, GA 30308, United States
| | - Kimberly Hoang
- Emory University School of Medicine, Department of Neurosurgery, Emory University Hospital, 100 Woodruff Circle, Atlanta, GA 30308, United States
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Darshan HR, Sudhir BJ, Singh A, Sreenath R, Easwer HV, Krishnakumar K, Nair P. Analysis of Evolution of Hydrocephalus in Posterior Fossa Tumors and Validation Study of the Modified Canadian Preoperative Prediction Rule for Hydrocephalus in Children and Frankfurt Grading System for Prediction of Cerebrospinal Fluid Diversion in Adults with Posterior Fossa Tumors. World Neurosurg 2023; 180:e91-e98. [PMID: 37683926 DOI: 10.1016/j.wneu.2023.08.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023]
Abstract
OBJECTIVE We sought to analyze the evolution of hydrocephalus and enumerate its predictive factors in posterior fossa tumors in children and adults. We also validated the modified Canadian Preoperative Prediction Rule for Hydrocephalus (mCPPRH) and Frankfurt grading systems as tools to predict cerebrospinal fluid (CSF) diversion in children and adults, respectively. METHODS A retrospective review of patients with posterior fossa tumors operated between 2012 and 2019 was performed. Clinical, radiologic, and operative data were obtained. Validation was performed for both scores via receiver operating characteristic (ROC) curves and evaluation of the area under the curve (AUC). RESULTS We included 116 children and 343 adults in the study. Of the adults, 141 patients had intraaxial tumors and 172 had extraaxial tumors. The insertion of external ventricular drain (EVD), its duration, papilledema was noted to have significant influence on the need for permanent CSF diversion (P < 0.05) in children. The ROC for mCPPRH score was 0.659 (0.501-0.816), Age- 0.496 (0.334-0.658) and Evans index- 0.788 (0.654-0.922). In adults- Intraaxial tumours Age, Frankfurt score, duration of EVD, Diagnosis, Extent of resection and periventricular capping significant predictors and ROC age AUC 0.300 (0.193-0.407), Evans index 0.939 (0.888-0.990), and Frankfurt score 0.908 (0.853-0.964) (P < 0.05), whereas in extraaxial tumors Frankfurt grading, sex, duration of EVD, presence of perilesional edema and extent of resection (P < 0.05) ROC age AUC 0.439 (0.344-0.534), Evans index 0.941 (0.906-0.977), and Frankfurt score 0.847 (0.782-0.912). CONCLUSIONS This is the first external validation study for the 2 predictive systems in use. mCPPRH demonstrated poor predictive accuracy, and Frankfurt grading system demonstrated good accuracy. EVD insertion and its duration was significantly predictive of the need for permanent CSF diversion.
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Affiliation(s)
- Hirisave Ravikumar Darshan
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Bhanu Jayanand Sudhir
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India.
| | - Ajit Singh
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Rajeev Sreenath
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Hariharan Venkat Easwer
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Kesavapisharady Krishnakumar
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | - Prakash Nair
- Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, India
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Liu S, Chen P, Yang H, Xie T, Liu T, Li C, Yang L, Li Z, Huang J, Gao Y, Xie Q, Yu Y, Hu F, Zhang X. Role of endoscopic third ventriculostomy in patients undergoing resection of pulvinar area lesions: Preliminary clinical results. J Clin Neurosci 2023; 117:61-67. [PMID: 37774635 DOI: 10.1016/j.jocn.2023.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Patients with pulvinar area lesions may develop hydrocephalus at any stage. The role of endoscopic third ventriculostomy (ETV) in this setting remains unclear. METHOD We retrospectively enrolled 15 patients with a mean age of 43 years who underwent endoscopic resection of pulvinar area lesions using the supracerebellar infratentorial approach (SCITA). We compared the different modalities of hydrocephalus management and their outcomes. RESULTS Nine of 15 patients (60.0%) had preoperative obstructive hydrocephalus. Five patients underwent ETV before tumor resection, and none developed postoperative hydrocephalus. Four patients underwent one-stage surgery for tumor removal, and one patient with a polymorphous low-grade neuroepithelial tumor of the young required postoperative ETV. Another patient with diffuse astrocytoma and hydrocephalus underwent concurrent lamina terminalis fenestration and endoscopic resection via the SCITA, which resulted in the resolution of hydrocephalus. The preoperative ETV group had no major postoperative complications, while the non-ETV group had three (0/5 vs. 3/4, P = 0.048). The ETV group also had a shorter intensive care unit stay; however, the difference was not significant (1.2 vs. 2.8; P = 0.188). ETV was effective in alleviating symptoms of postoperative hydrocephalus in patients with midbrain-invading tumors. CONCLUSION Endoscopic surgery via the SCITA can address both tumor and hydrocephalus issues in some cases but has a higher surgical risk and postoperative hydrocephalus rate. Preoperative ETV can prevent these complications and improve postoperative outcomes.
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Affiliation(s)
- Shuang Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pin Chen
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hantao Yang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Xie
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tengfei Liu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Li
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liangliang Yang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zeyang Li
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jinlong Huang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yang Gao
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qiang Xie
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong Yu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fan Hu
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaobiao Zhang
- Department of Neurosurgery, Zhongshan Hospital, Fudan University, Shanghai, China; Digital Medical Research Center, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Key Laboratory of Medical Image Computing and Computer-Assisted Intervention, Shanghai, China.
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Guo ZY, Zhong ZA, Peng P, Liu Y, Chen F. A scoring system categorizing risk factors to evaluate the need for ventriculoperitoneal shunt in pediatric patients after brain tumor resection. Front Oncol 2023; 13:1248553. [PMID: 37916175 PMCID: PMC10616891 DOI: 10.3389/fonc.2023.1248553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 10/02/2023] [Indexed: 11/03/2023] Open
Abstract
Objectives To develop a scoring system based on independent predictors of the need for ventriculoperitoneal (VP) shunt after brain tumor resection in pediatric patients. Methods A total of 416 pediatric patients (≤ 14 years old) with brain tumors who underwent surgery were randomly assigned to the training (n = 333) and validation cohorts (n = 83). Based on the implementation of VP shunt, the training cohort was divided into the VP shunt group (n = 35) and the non-VP shunt group (n = 298). Univariate and multivariate logistic analyses were performed. A scoring system was developed based on clinical characteristics and operative data, and scores and corresponding risks were calculated. Results Age < 3 (p = 0.010, odds ratio [OR] = 3.162), blood loss (BL) (p = 0.005, OR = 1.300), midline tumor location (p < 0.001, OR = 5.750), preoperative hydrocephalus (p = 0.001, OR = 7.044), and total resection (p = 0.025, OR = 0.284) were identified as independent predictors. The area under the curve (AUC) of the scoring system was higher than those of age < 3, BL, midline tumor location, preoperative hydrocephalus, and total resection (0.859 vs. 0.598, 0.717, 0.725, 0.705, and 0.555, respectively; p < 0.001). Furthermore, the scoring system showed good performance in the validation cohort (AUC = 0.971). The cutoff value for predictive scores was 5.5 points, which categorized patients into low risk (0-5 points) and high risk (6-14 points) groups. Conclusions Our scoring system, integrating age < 3, BL, midline tumor location, preoperative hydrocephalus, and total resection, provides a practical evaluation. Scores ranging from 6 to 14 points indicate high risk.
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Affiliation(s)
- Zhong-Yin Guo
- Department of Neurosurgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zi-An Zhong
- Department of Neurosurgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Peng Peng
- Department of Neurosurgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Yang Liu
- Department of Neurosurgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Feng Chen
- Department of Neurosurgery, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
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Zhou W, Zhang H, An X, Li C, Gong J, Liu W, Sun T, Zhao F, Tian YJ. A nomogram for predicting post-operative hydrocephalus in children with medulloblastoma. Neurosurg Rev 2023; 46:246. [PMID: 37723329 DOI: 10.1007/s10143-023-02156-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/02/2023] [Accepted: 09/12/2023] [Indexed: 09/20/2023]
Abstract
Post-operative hydrocephalus is common among children with medulloblastoma after initial tumor resection. This study aimed to establish a novel model for predicting the development of post-operative hydrocephalus in children with medulloblastoma. Only pediatric patients who received initial medulloblastoma resection at Beijing Tiantan Hospital between January 2018 and May 2021 were included in this study. The potential risk factors associated with post-operative hydrocephalus were identified based on multivariate logistic regression and the nomogram. Receiver operating characteristic (ROC) curve were used to evaluate the performance of the nomogram model based on an independent cohort of medulloblastoma patients who underwent surgery from June 2021 to March 2022. A total of 105 patients were included in the primary cohort. Superior invasion (P = 0.007), caudal invasion (P = 0.025), and intraventricular blood ≥ 5 mm (P = 0.045) were significantly related to the development of post-operative hydrocephalus and thus were assembled into the nomogram model. The model accurately predicted post-operative hydrocephalus based on the calibration curve. The area under the ROC curves for the primary and validation cohorts was 0.849 and 0.855, respectively. In total, the nomogram we developed may aid clinicians in assessing the potential risk of pediatric patients with MB developing post-operative hydrocephalus, especially those who would otherwise not have received a diversionary procedure at presentation.
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Affiliation(s)
- Wentao Zhou
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heng Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu An
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chunde Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian Gong
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Wei Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tao Sun
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fu Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Department of Neural Reconstruction, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
| | - Yong-Ji Tian
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
- Department of Neural Reconstruction, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China.
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Weller M, Le Rhun E, Van den Bent M, Chang SM, Cloughesy TF, Goldbrunner R, Hong YK, Jalali R, Jenkinson MD, Minniti G, Nagane M, Razis E, Roth P, Rudà R, Tabatabai G, Wen PY, Short SC, Preusser M. Diagnosis and management of complications from the treatment of primary central nervous system tumors in adults. Neuro Oncol 2023; 25:1200-1224. [PMID: 36843451 PMCID: PMC10326495 DOI: 10.1093/neuonc/noad038] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 02/28/2023] Open
Abstract
Central nervous system (CNS) tumor patients commonly undergo multimodality treatment in the course of their disease. Adverse effects and complications from these interventions have not been systematically studied, but pose significant challenges in clinical practice and impact function and quality of life, especially in the management of long-term brain tumor survivors. Here, the European Association of Neuro-Oncology (EANO) has developed recommendations to prevent, diagnose, and manage adverse effects and complications in the adult primary brain CNS tumor (except lymphomas) patient population with a specific focus on surgery, radiotherapy, and pharmacotherapy. Specifically, we also provide recommendations for dose adaptations, interruptions, and reexposure for pharmacotherapy that may serve as a reference for the management of standard of care in clinical trials. We also summarize which interventions are unnecessary, inactive or contraindicated. This consensus paper should serve as a reference for the conduct of standard therapy within and outside of clinical trials.
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Affiliation(s)
- Michael Weller
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Emilie Le Rhun
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Martin Van den Bent
- The Brain Tumour Center at the Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Susan M Chang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Timothy F Cloughesy
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Roland Goldbrunner
- Center of Neurosurgery, Department of General Neurosurgery, University of Cologne, Cologne, Germany
| | - Yong-Kil Hong
- Brain Tumor Center, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Rakesh Jalali
- Neuro Oncology Cancer Management Team, Apollo Proton Cancer Centre, Chennai, India
| | - Michael D Jenkinson
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust & University of Liverpool, Liverpool, UK
| | - Giuseppe Minniti
- Department of Medicine, Surgery and Neurosciences, University of Siena, Policlinico Le Scotte, Siena, Italy
- IRCCS Neuromed, Pozzilli, IS, Italy
| | - Motoo Nagane
- Department of Neurosurgery, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Evangelia Razis
- Third Department of Medical Oncology, Hygeia Hospital, Marousi, Athens, Greece
| | - Patrick Roth
- Department of Neurology, University Hospital and University of Zurich, Zurich, Switzerland
| | - Roberta Rudà
- Division of Neuro-Oncology, Department of Neuroscience, City of Health and Science and University of Turin, Turin, Italy
| | - Ghazaleh Tabatabai
- Department of Neurology & Neuro-Oncology, Hertie Institute for Clinical Brain Research, Center for Neurooncology, Comprehensive Cancer Center, German Cancer Consortium (DKTK), Partner site Tübingen, University Hospital Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Patrick Y Wen
- Center for Neuro-oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, Massachusetts, USA
| | - Susan C Short
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Clinical Oncology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Matthias Preusser
- Division of Oncology, Department of Medicine 1, Medical University, Vienna, Austria
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Eguiluz-Melendez A, Rodríguez-Hernández LA, López-Molina JA, Sangrador-Deitos MV, Mondragón-Soto MG, Gómez-Amador JL, Guinto-Nishimura GY. Obstructive Hydrocephalus Due to Posterior Fossa Tumors in Adults: A Comparative Analysis of 3 Surgical Techniques. World Neurosurg 2023; 175:e593-e600. [PMID: 37054951 DOI: 10.1016/j.wneu.2023.03.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND The main treatments for hydrocephalus due to posterior fossa tumors are tumor resection with or without an external ventricular drain, ventriculoperitoneal shunt (VPS), and endoscopic third ventriculostomy. Although preoperative cerebrospinal fluid diversion by any of these techniques improves clinical outcomes, evidence comparing the efficacy of these techniques is scarce. Therefore, we aimed to retrospectively evaluate each treatment modality. METHODS This single-center study analyzed 55 patients. Treatments were classified as successful (hydrocephalus resolution with a single surgical event) or failed and compared with a χ2 test. Kaplan-Meier curves and log-rank tests were employed. A Cox proportional hazard model was used to determine relevant covariates predicting outcomes. RESULTS Mean patient age was 36.3 years, 43.4% of patients were men, and 50.9% of patients presented with uncompensated intracranial hypertension. Mean tumor volume was 33.4 cm3, and extent of resection was 90.85%. Tumor resection with or without an external ventricular drain was successful in 58.82% of cases, VPS was successful in 100%, and endoscopic third ventriculostomy was successful in 76.19% (P = 0.014). Mean follow-up time was 15.12 months. Log-rank test found statistically significant differences between survival curves of treatments (P = 0.016) favoring the VPS group. Postoperative surgical site hematoma was a significant covariate in the Cox model (hazard ratio = 17; 95% confidence ratio, 2.301-81.872; P = 0.004). CONCLUSIONS This study favored VPS as the most reliable treatment of hydrocephalus due to posterior fossa tumors in adult patient; however, several factors influence clinical outcomes. We proposed an algorithm based on our findings and other authors' findings to facilitate the decision-making process.
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Affiliation(s)
- Aldo Eguiluz-Melendez
- Neurosurgery Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Luis A Rodríguez-Hernández
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Jesús A López-Molina
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Marcos V Sangrador-Deitos
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico.
| | - Michel G Mondragón-Soto
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Juan L Gómez-Amador
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
| | - Gerardo Y Guinto-Nishimura
- Neurosurgery Department, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, Mexico City, Mexico
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Hu SQ, Guo ZY, Wan LJ, Chen ZR, Wan F. Blood Loss in Operation Is Independently Predictive of Postoperative Ventriculoperitoneal Shunt in Pediatric Patients With Posterior Fossa Tumors. Pediatr Neurol 2023; 144:119-125. [PMID: 37244218 DOI: 10.1016/j.pediatrneurol.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 03/21/2023] [Accepted: 04/27/2023] [Indexed: 05/29/2023]
Abstract
BACKGROUND To identify the risk factors for postoperative hydrocephalus and the need for ventriculoperitoneal (VP) shunt after posterior fossa tumor (PFT) resection in pediatric patients and establish a predictive model. METHODS A total of 217 pediatric patients (≤14 years old) with PFTs who underwent tumor resection from November 2010 to December 2020 were divided into a VP shunt group (n = 29) and non-VP shunt group (n = 188). Univariate and multivariate logistic regression were performed. A predictive model was established based on the independent predictors. Receiver operating characteristic curves were generated to determine the cutoff values and areas under the curve (AUCs). The Delong test was performed to compare the AUCs. RESULTS Age less than three years (P = 0.015, odds ratio [OR] = 3.760), blood loss (BL) (P = 0.002, OR = 1.601), and locations at fourth ventricle (P < 0.001, OR = 7.697) were the independent predictors. The predictive model was as follows: total score = age (<3; yes = 2, no = 0) + BL + tumor locations (fourth ventricle; yes = 5, no = 0). The AUC of our model was higher than those of age less than three years, BL, locations at the fourth ventricle, and compound factors (age <3 + locations) (0.842 vs 0.609, 0.734, 0.732, and 0.788, respectively). The cutoff values of the model and BL were 7.5 points and 2.75 U, respectively. CONCLUSIONS BL, age less than three years, and tumors at the fourth ventricle were independent predictors. Model scores over 7.5 points predict a high risk.
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Affiliation(s)
- Sheng-Qi Hu
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhong-Yin Guo
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Li-Jun Wan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zi-Rong Chen
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Feng Wan
- Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China; Department of Neurosurgery, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
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9
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The semi-sitting position in patients with indwelling CSF shunts: perioperative management and avoidance of complications. Acta Neurochir (Wien) 2023; 165:421-427. [PMID: 36502472 PMCID: PMC9922215 DOI: 10.1007/s00701-022-05430-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/17/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Posterior fossa or midline tumors are often associated with hydrocephalus and primary tumor removal with or without perioperative placement of an external ventricular drain (EVD) is commonly accepted as first-line treatment. Shunting prior to posterior fossa surgery (PFS) is mostly reserved for symptomatic cases or special circumstances. There are limited data regarding the anticipated risk for symptomatic pneumocephalus and the perioperative management using the semi-sitting position (SSP) in such a scenario. Here, we therefore assessed the safety of performing PFS in a consecutive series of patients over a period of 15 years to allow the elaboration of recommendations for perioperative management. METHODS According to specific inclusion and exclusion criteria a total of 13 patients who underwent 17 operations was identified. Supratentorial pneumocephalus was evaluated with semiautomatic-volumetric segmentation. The volume of pneumocephalus was evaluated according to age and ventricular size. RESULTS Ten of the 13 patients had a programmable valve (preoperative valve setting range 6-14 cmH20; mean 7.5 cmH20) while 3 patients had non programmable valves. A variable amount of supratentorial air collection was evident in all patients postoperatively (range 3.2-331 ml; mean 122.32 ml). Positive predictors for the volume of postoperative pneumocephalus were higher age and a preoperative Evans ratio > 0.3. In our series, we encountered no cases of tension pneumocephalus necessitating an air replacement procedure as well as no obstruction, disconnection, infection or hardware malfunction of the shunt system. CONCLUSIONS Our findings indicate that a CSF shunt in situ is not a contraindication for performing PFS in the semi-sitting position and it does not increase the pre-existing risk for postoperative tension pneumocephalus. In cases of primary shunting for hydrocephalus associated with posterior fossa tumors a programmable valve set at a medium opening pressure with a gravitational device is a valid option when PFS in the semi-sitting position is opted. In patients with an indwelling shunt diversion system special caution is indicated in order to prevent and detect overdrainage especially in not adjustable valves or shunts without antisiphon devices.
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Pettersson SD, Jabbar R, Popławska M, Och A, Orrego-Gonzalez E, Klepinowski T, Krakowiak M, Sagan L, Radek M, Zakrzewski K, Nowoslawska E, Kwiecien K, Skrzypkowska P, Szmuda T, Miękisiak G, Vega RA. Telovelar versus transvermian approach to tumors of the fourth ventricle and their impact on postoperative neurological complications: A multicenter study. Surg Neurol Int 2023; 14:124. [PMID: 37151430 PMCID: PMC10159312 DOI: 10.25259/sni_167_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 03/15/2023] [Indexed: 05/09/2023] Open
Abstract
Background Tumors of the fourth ventricle are exceedingly rare; however, such lesions are formidable due to the severe postoperative neurological complications (pNCs) which often occur. The adoption of the telovelar approach over the transvermian was created to supposedly mitigate the pNCs; however, there is a lack of sufficient data supporting this theory. Methods Records from six hospitals were reviewed for patients surgically treated for a single tumor within the 4th ventricle from 2016 to 2022. The pNCs which had 10 or more occurrences among the patients were individually assessed as the dependent variable in a binary logistic regression model against covariates which included the surgical approach. Results This study of 67 patients confirms no significant differences in risk for pNCs between the transvermian and telovelar approach. Rather, multivariate analysis identified neurophysiological monitoring (IONM) as a protective factor for postoperative speech and swallowing defects (odds ratio [OR]: 0.076, 95% confidence interval [CI] 0.011-0.525). Furthermore, intraoperative external ventricular drainage (EVD) was a protective factor for postoperative gait and focal motor defects (OR: 0.075, 95% CI 0.009-0.648) and for postoperative hydrocephalus (OR: 0.020, 95% CI 0.002-0.233). A univariate meta-analysis pooling the present study's patients and an additional 304 patients from the three additional studies in the literature confirms no significant differences in risk between the transvermian and telovelar approach for pNCs. Conclusion Intraoperative adjuncts including IONM and EVD may play a significant role in the postoperative outcome. Despite the present study's sample size being a major limitation, the findings may provide great value to neurosurgeons given the scarcity of the current literature.
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Affiliation(s)
| | - Redwan Jabbar
- Department of Neurosurgery, Medical University of Lodz, Lodz, Poland
| | | | - Aleksander Och
- Department of Neurosurgery, Medical University of Gdansk, Gdansk, Poland
| | - Eduardo Orrego-Gonzalez
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States
| | | | - Michał Krakowiak
- Department of Neurosurgery, Medical University of Gdansk, Gdansk, Poland
| | - Leszek Sagan
- Department of Neurosurgery, Pomeranian Medical University, Szczecin
| | - Maciej Radek
- Department of Neurosurgery, Medical University of Lodz, Lodz, Poland
| | | | - Emilia Nowoslawska
- Department of Neurosurgery, Polish Mother Memorial Research Institute, Poland
| | - Katarzyna Kwiecien
- Department of Neurosurgery and Neuro-oncology, Medical University of Lodz, Lodz, Poland
| | | | - Tomasz Szmuda
- Department of Neurosurgery, Medical University of Gdansk, Gdansk, Poland
| | | | - Rafael A. Vega
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States
- Corresponding author: Rafael A. Vega, Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, United States.
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Lee WJ, Choi JW, Kong DS, Nam DH, Lee JI, Seol HJ. Factors Associated with Acute Obstructive Hydrocephalus After Retrosigmoid Approach for Extra-Axial Cerebellopontine Angle Tumors. World Neurosurg 2022; 166:e1-e10. [PMID: 35489600 DOI: 10.1016/j.wneu.2022.04.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/14/2022] [Accepted: 04/15/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND This study aimed to identify the risk factors for acute obstructive hydrocephalus (AOHCP) after extra-axial cerebellopontine angle (CPA) tumor surgery using the retrosigmoid (RS) approach. METHODS This retrospective study assessed 154 patients (100 vestibular schwannomas, 34 CPA meningiomas [MNGs], 9 trigeminal schwannomas, and 11 petroclival MNGs) who underwent surgical resection using the RS approach by a single surgeon between August 2010 and September 2019. AOHCP was defined as postoperative ventricular enlargement due to cerebrospinal fluid flow obstruction caused by surgery-related cerebellar injury within 1 week. The radiological characteristics of the tumors were classified, and the surgical outcomes were reviewed. We analyzed the impact of different factors on the development of AOHCP after surgery. RESULTS AOHCP developed in 17 (11%) patients, all of whom were treated with external ventricular drain insertion. Multivariate analysis showed that CPA MNGs (odds ratio [OR], 37.98), grade of tumor extension beyond the petroclival junction (grade 1: OR, 16.42; grade 2: OR, 17.47), major fourth ventricle compression (OR, 17.77), and surgery-related hemorrhage (OR, 7.64) were associated with AOHCP. Surgery-related hemorrhage was observed in 17 (11%) patients. 9 (6%) patients underwent ventriculoperitoneal shunt surgery because of persistent HCP. CONCLUSIONS An increased risk of AOHCP after the RS approach was observed in patients with extra-axial CPA tumors with clival extension and major fourth ventricle compression. Compulsive and meticulous hemostasis must be achieved because postoperative hemorrhage is associated with AOHCP.
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Affiliation(s)
- Won-Jae Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung-Won Choi
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Doo-Sik Kong
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Do-Hyun Nam
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung-Il Lee
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ho Jun Seol
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
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Zhang C, Zhang T, Ge L, Li Z, Chen J. Management of Posterior Fossa Tumors in Adults Based on the Predictors of Postoperative Hydrocephalus. Front Surg 2022; 9:886438. [PMID: 35722528 PMCID: PMC9198439 DOI: 10.3389/fsurg.2022.886438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThis study aims to identify the predictors of postoperative hydrocephalus in patients with posterior fossa tumors (PFTs) and guide the management of perioperative hydrocephalus.MethodsWe performed a single-institution, retrospective analysis of patients who underwent resection of PFTs in our department over a 10-year period (2011–2021). A total of 682 adult patients met the inclusion criteria and were divided into either a prophylactic external ventricular drainage (EVD) group or a nonprophylactic-EVD group. We analyzed data for the nonprophylactic-EVD group by univariate and multivariate analyses to identify predictors of postoperative acute hydrocephalus. We also analyzed all cases by univariate and multivariate analyses to determine the predictors of postoperative ventriculoperitoneal (VP) shunt placement.ResultsTumor infiltrating the midbrain aqueduct [P = 0.001; odds ratio (OR) = 9.8], postoperative hemorrhage (P < 0.001; OR = 66.7), and subtotal resection (P = 0.006; OR = 9.3) were independent risk factors for postoperative EVD. Tumor infiltrating the ventricular system (P < 0.001; OR = 58.5) and postoperative hemorrhage (P < 0.001; OR = 28.1) were independent risk factors for postoperative VP shunt placement.ConclusionsThese findings may help promote more aggressive monitoring and earlier interventions for postoperative hydrocephalus in patients with PFTs.
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Affiliation(s)
- Chengda Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Department of Neurosurgery, Affiliated Hospital of Hubei University of Medicine, First People’s Hospital of Xiangyang, Xiangyang, China
| | - Tingbao Zhang
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Lingli Ge
- Department of Paediatrics, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Central Hospital of Xiangyang, Xiangyang, China
| | - Zhengwei Li
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Correspondence: Jincao Chen Zhengwei Li
| | - Jincao Chen
- Department of Neurosurgery, Zhongnan Hospital of Wuhan University, Wuhan, China
- Correspondence: Jincao Chen Zhengwei Li
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Salah M, Elhuseny AY, Youssef EM. Endoscopic third ventriculostomy for the management of hydrocephalus secondary to posterior fossa tumors: A retrospective study. Surg Neurol Int 2022; 13:65. [PMID: 35242431 PMCID: PMC8888306 DOI: 10.25259/sni_971_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/05/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Endoscopic third ventriculostomy (ETV) is an effective alternative to ventriculoperitoneal shunting as well as external ventricular drainage for the urgent management of acute hydrocephalus. We performed this study to investigate the efficacy and safety of ETV before tumor resection in managing hydrocephalus in patients with posterior fossa brain tumors (PFBT) in our neurosurgery department. Methods: We conducted this retrospective observational study between February 2018 and February 2020 on all cases diagnosed with PFBT associated with triventricular obstructive hydrocephalus. We retrospectively reviewed the demographic characteristics, operative procedures, and radiological investigations of all cases. During the follow-up period, clinical, as well as radiological success were evaluated. Results: Twenty-two ETV procedures were performed in 22 cases of PFBT (mean age = 22.1 years, SD = 11.4). Of the 22 cases, 8 cases (36.4%) had ependymoma, 7 cases (31.8%) had cerebellar astrocytoma, and 5 cases (22.7 %) had medulloblastoma, while 2 cases (9.1%) had diffuse pontine gliomas. The median follow-up duration was 9 months (range 3–13 months). The most commonly reported clinical presentation was the significant intracranial pressure increase. All operations were performed successfully in all cases. Only two ETV post-tumor resection failures were documented during the follow-up period. Conclusion: Preoperative ETV has shown to be an effective long-term cerebrospinal fluid diversion procedure to manage PFBT-associated hydrocephalus, with a relatively low rate of complications. Further prospective studies are required to assess the regular use of ETV before complete tumor resection.
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Yin X, Duan H, Yi Z, Lu R, Li C, Li L. Clinical characteristics, surgical treatment, and risk factor analysis of postoperative functional outcome in patients with intracranial hemangioblastoma. World Neurosurg 2022; 161:e427-e435. [DOI: 10.1016/j.wneu.2022.02.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 02/04/2022] [Accepted: 02/04/2022] [Indexed: 10/19/2022]
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Bray DP, Saad H, Douglas JM, Grogan D, Dawoud RA, Chow J, Deibert C, Pradilla G, Nduom EK, Olson JJ, Alawieh AM, Hoang KB. Artificial neural networks predict the need for permanent cerebrospinal fluid diversion following posterior fossa tumor resection. Neurooncol Adv 2022; 4:vdac145. [PMID: 36299798 PMCID: PMC9586212 DOI: 10.1093/noajnl/vdac145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Resection of posterior fossa tumors (PFTs) can result in hydrocephalus that requires permanent cerebrospinal fluid (CSF) diversion. Our goal was to prospectively validate a machine-learning model to predict postoperative hydrocephalus after PFT surgery requiring permanent CSF diversion. Methods We collected preoperative and postoperative variables on 518 patients that underwent PFT surgery at our center in a retrospective fashion to train several statistical classifiers to predict the need for permanent CSF diversion as a binary class. A total of 62 classifiers relevant to our data structure were surveyed, including regression models, decision trees, Bayesian models, and multilayer perceptron artificial neural networks (ANN). Models were trained using the (N = 518) retrospective data using 10-fold cross-validation to obtain accuracy metrics. Given the low incidence of our positive outcome (12%), we used the positive predictive value along with the area under the receiver operating characteristic curve (AUC) to compare models. The best performing model was then prospectively validated on a set of 90 patients. Results Twelve percent of patients required permanent CSF diversion after PFT surgery. Of the trained models, 8 classifiers had an AUC greater than 0.5 on prospective testing. ANNs demonstrated the highest AUC of 0.902 with a positive predictive value of 83.3%. Despite comparable AUC, the remaining classifiers had a true positive rate below 35% (compared to ANN, P < .0001). The negative predictive value of the ANN model was 98.8%. Conclusions ANN-based models can reliably predict the need for ventriculoperitoneal shunt after PFT surgery.
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Affiliation(s)
- David P Bray
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Dayton Grogan
- Medical College of Georgia-Augusta University, Augusta, Georgia, USA
| | | | - Jocelyn Chow
- College of Arts and Sciences, Emory University, Atlanta, Georgia, USA
| | - Christopher Deibert
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edjah K Nduom
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali M Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kimberly B Hoang
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Sefcikova V, Loizidou M, Samandouras G. Commentary: Permanent Cerebrospinal Fluid Diversion in Adults With Posterior Fossa Tumors: Incidence and Predictors. Neurosurgery 2022; 90:e15-e16. [PMID: 34982889 DOI: 10.1227/neu.0000000000001761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 08/31/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Viktoria Sefcikova
- UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Maria Loizidou
- UCL Queen Square Institute of Neurology, University College London, London, UK
| | - George Samandouras
- UCL Queen Square Institute of Neurology, University College London, London, UK.,Victor Horsley Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, University College London, London, UK
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Saad H, Bray DP, McMahon JT, Philbrick BD, Dawoud RA, Douglas JM, Adeagbo S, Yarmoska SK, Agam M, Chow J, Pradilla G, Olson JJ, Alawieh A, Hoang K. Permanent Cerebrospinal Fluid Diversion in Adults With Posterior Fossa Tumors: Incidence and Predictors. Neurosurgery 2021; 89:987-996. [PMID: 34561703 DOI: 10.1093/neuros/nyab341] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 07/09/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Posterior fossa tumors (PFTs) can cause hydrocephalus. Hydrocephalus can persist despite resection of PFTs in a subset of patients requiring permanent cerebrospinal fluid (CSF) diversion. Characteristics of this patient subset are not well defined. OBJECTIVE To define preoperative and postoperative variables that predict the need for postoperative CSF diversion in adult patients with PFTs. METHODS We surveyed the CNS (Central Nervous System) Tumor Outcomes Registry at Emory (CTORE) for patients who underwent PFT resection at 3 tertiary-care centers between 2006 and 2019. Demographic, radiographic, perioperative, and dispositional data were analyzed using univariate and multivariate models. RESULTS We included 617 patients undergoing PFT resection for intra-axial (57%) or extra-axial (43%) lesions. Gross total resection was achieved in 62% of resections. Approximately 13% of patients required permanent CSF diversion/shunting. Only 31.5% of patients who required pre- or intraop external ventricular drain (EVD) placement needed permanent CSF diversion. On logistic regression, size, transependymal flow, use of perioperative EVD, postoperative intraventricular hemorrhage (IVH), and surgical complications were predictors of permanent CSF diversion. Preoperative tumor size was only independent predictor of postoperative shunting in patients with subtotal resection. In patients with intra-axial tumors, transependymal flow (P = .014), postoperative IVH (P = .001), surgical complications (P = .013), and extent of resection (P = .03) predicted need for shunting. In extra-axial tumors, surgical complications were the major predictor (P = .022). CONCLUSION Our study demonstrates that presence of preoperative hydrocephalus in patients with PFT does not necessarily entail the need for permanent CSF diversion. We report the major predictive factors for needing permanent CSF diversion.
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Affiliation(s)
- Hassan Saad
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - David P Bray
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | | | | | - Reem A Dawoud
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Segun Adeagbo
- School of Medicine, Emory University, Atlanta, Georgia, USA
| | | | - Matthew Agam
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Jocelyn Chow
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Jeffrey J Olson
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Kimberly Hoang
- Department of Neurosurgery, School of Medicine, Emory University, Atlanta, Georgia, USA
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Donaldson L, Margolin E. Absence of papilledema in large intracranial tumours. J Neurol Sci 2021; 428:117604. [PMID: 34384969 DOI: 10.1016/j.jns.2021.117604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/07/2021] [Accepted: 08/01/2021] [Indexed: 10/20/2022]
Abstract
Papilledema refers to optic disc edema occurring secondary to raised intracranial pressure. In patients with intracranial tumours, tumour size might be the expected predictor of whether or not papilledema will develop, however, this is not the case in clinical practice. We report a series of 5 patients with large intracranial tumours and no evidence of papilledema and discuss the potential factors which may contribute to the lack of optic disc edema in these cases. Development of papilledema depends on both the presence of elevated intracranial pressure and transmission of elevated pressure to the subarachnoid space within the optic nerve sheath and to the optic nerve itself. We discuss how intracranial tumours may influence the physiology of the surrounding tissues, cerebrospinal fluid dynamics and cerebral venous outflow and how individual anatomic variations, particularly within the optic nerve sheath and optic canal, likely play a role in development of papilledema.
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Affiliation(s)
- Laura Donaldson
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada
| | - Edward Margolin
- University of Toronto, Department of Ophthalmology and Vision Sciences, Toronto, Ontario, Canada; University of Toronto, Department of Medicine, Division of Neurology, Toronto, Ontario, Canada.
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Endoscopic third ventriculostomy before surgery of third ventricle and posterior fossa tumours decreases the risk of secondary hydrocephalus and early postoperative complications. Neurosurg Rev 2021; 45:771-781. [PMID: 34291350 PMCID: PMC8827142 DOI: 10.1007/s10143-021-01570-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 05/02/2021] [Accepted: 05/24/2021] [Indexed: 11/27/2022]
Abstract
Endoscopic third ventriculostomy (ETV) is an effective treatment for obstructive hydrocephalus (HCP) at the level of third or fourth ventricle. To date, there is no consensus regarding its role as intervention preceding the operation of tumour removal. The aim of this prospective open-label controlled study is to assess if ETV prevents secondary HCP after tumour removal and if ETV influences the early results of tumour surgery. The study was performed on 68 patients operated for tumours of the third ventricle and posterior fossa. In 30 patients, ETV was performed several days before tumour removal, while in 38 patients, the tumour was removed during a one-stage procedure without ETV. Patients who did not receive ETV before the tumour removal procedure had a higher probability of developing postoperative HCP (n = 12, p = 0.03). They also demonstrated a substantially higher rate of early postoperative complications (n = 20, p = 0.002) and a lower Karnofsky score (p = 0.004) than patients in whom ETV was performed before tumour removal. The performance of external ventricular drainage in the non-ETV group did not prevent secondary HCP (p = 0.68). Postoperative cerebellar swelling (p = 0.01), haematoma (p = 0.04), cerebrospinal fluid leak (p = 0.04) and neuroinfection (p = 0.04) were the main risk factors of persistent HCP. Performance of ETV before tumour removal is not only beneficial for control of acute HCP but also prevents the occurrence of secondary postoperative HCP and may also minimize early postoperative complications.
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Characteristics and management of hydrocephalus in adult patients with cerebellar glioblastoma: lessons from a French nationwide series of 118 cases. Neurosurg Rev 2021; 45:683-699. [PMID: 34195892 DOI: 10.1007/s10143-021-01578-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/19/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Abstract
The characteristics of hydrocephalus associated with cerebellar glioblastoma (cGB) remain poorly known. The objectives were to describe the occurence of hydrocephalus in a French nationwide series of adult patients with cGB, to identify the characteristics associated with hydrocephalus and to analyze the outcomes associated with the different surgical strategies, in order to propose practical guidelines. Consecutive cases of adult cGB patients prospectively recorded into the French Brain Tumor Database between 2003 and 2017 were screened. Diagnosis was confirmed by a centralized neuropathological review. Among 118 patients with cGB (mean age 55.9 years), 49 patients (41.5%) presented with pre-operative hydrocephalus. Thirteen patients (11.0%) developed acute (n=7) or delayed (n=6) hydrocephalus postoperatively. Compared to patients without hydrocephalus at admission, patients with hydrocephalus were younger (52.0 years vs 58.6 years, p=0.03) and underwent more frequently tumor resection (93.9% vs 73.9%, p=0.006). A total of 40 cerebrospinal-fluid diversion procedures were performed, including 18 endoscopic third ventriculostomies, 12 ventriculoperitoneal shunts and 10 external ventricular drains. The different cerebrospinal-fluid diversion options had comparable functional results and complication rates. Among the 89 patients surgically managed for cGB without prior cerebrospinal-fluid diversion, 7 (7.9%) were long-term shunt-dependant. Hydrocephalus is frequent in patients with cGB and has to be carefully managed in order not to interfere with adjuvant oncological treatments. In case of symptomatic hydrocephalus, a cerebrospinal-fluid diversion is mandatory, especially if surgical resection is not feasible. In case of asymptomatic hydrocephalus, a cerebrospinal-fluid diversion has to be discussed only if surgical resection is not feasible.
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ctDNA-Based Liquid Biopsy of Cerebrospinal Fluid in Brain Cancer. Cancers (Basel) 2021; 13:cancers13091989. [PMID: 33919036 PMCID: PMC8122255 DOI: 10.3390/cancers13091989] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 12/18/2022] Open
Abstract
The correct characterisation of central nervous system (CNS) malignancies is crucial for accurate diagnosis and prognosis and also the identification of actionable genomic alterations that can guide the therapeutic strategy. Surgical biopsies are performed to characterise the tumour; however, these procedures are invasive and are not always feasible for all patients. Moreover, they only provide a static snapshot and can miss tumour heterogeneity. Currently, monitoring of CNS cancer is performed by conventional imaging techniques and, in some cases, cytology analysis of the cerebrospinal fluid (CSF); however, these techniques have limited sensitivity. To overcome these limitations, a liquid biopsy of the CSF can be used to obtain information about the tumour in a less invasive manner. The CSF is a source of cell-free circulating tumour DNA (ctDNA), and the analysis of this biomarker can characterise and monitor brain cancer. Recent studies have shown that ctDNA is more abundant in the CSF than plasma for CNS malignancies and that it can be sequenced to reveal tumour heterogeneity and provide diagnostic and prognostic information. Furthermore, analysis of longitudinal samples can aid patient monitoring by detecting residual disease or even tracking tumour evolution at relapse and, therefore, tailoring the therapeutic strategy. In this review, we provide an overview of the potential clinical applications of the analysis of CSF ctDNA and the challenges that need to be overcome in order to translate research findings into a tool for clinical practice.
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Muthukumar N. Hydrocephalus Associated with Posterior Fossa Tumors: How to Manage Effectively? Neurol India 2021; 69:S342-S349. [DOI: 10.4103/0028-3886.332260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Risk factors for hydrocephalus following fourth ventricle tumor surgery: A retrospective analysis of 121 patients. PLoS One 2020; 15:e0241853. [PMID: 33201889 PMCID: PMC7671531 DOI: 10.1371/journal.pone.0241853] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Accepted: 10/21/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND AIM Most patients who present with a fourth ventricle tumor have concurrent hydrocephalus, and some demonstrate persistent hydrocephalus after tumor resection. There is still no consensus on the management of hydrocephalus in patients with fourth ventricle tumor after surgery. The purpose of this study was to identify the factors that predispose to postoperative hydrocephalus and the need for a postoperative cerebrospinal fluid (CSF) diversion procedure. MATERIALS AND METHODS We performed a retrospective analysis of patients who underwent surgery of the fourth ventricle tumor between January 2013 and December 2018 at the Department of Neurosurgery in West China Hospital of Sichuan University. The characteristics of patients and the tumor location, tumor size, tumor histology, and preventive external ventricular drainage (EVD) that were potentially correlated with CSF circulation were evaluated in univariate and multivariate analysis. RESULTS A total of 121 patients were enrolled in our study; 16 (12.9%) patients underwent postoperative CSF drainage. Univariate analysis revealed that superior extension (p = 0.004), preoperative hydrocephalus (p<0.001), and subtotal resection (p<0.001) were significantly associated with postoperative hydrocephalus. Multivariate analysis revealed that superior extension (p = 0.013; OR = 44.761; 95% CI 2.235-896.310) and subtotal resection (p = 0.005; OR = 0.087; 95% CI 0.016-0.473) were independent risk factors for postoperative hydrocephalus after resection of fourth ventricle tumor. CONCLUSION Superior tumor extension (into the aqueduct) and failed total resection of tumor were identified as independent risk factors for postoperative hydrocephalus in patients with fourth ventricle tumor.
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Cerebrospinal fluid circulating tumour DNA as a liquid biopsy for central nervous system malignancies. Curr Opin Neurol 2020; 33:736-741. [DOI: 10.1097/wco.0000000000000869] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The role of external ventricular drainage for the management of posterior cranial fossa tumours: a systematic review. Neurosurg Rev 2020; 44:1243-1253. [PMID: 32494987 DOI: 10.1007/s10143-020-01325-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/20/2020] [Accepted: 05/25/2020] [Indexed: 10/24/2022]
Abstract
Posterior cranial fossa tumours frequently develop hydrocephalus as first presentation in up to 80% of paediatric patients and 21.4% of adults, although it resolves after tumour removal in 70-90% and 96%, respectively. New onset hydrocephalus is reported in about 2.1% of adult and 10-40% of paediatric patients after posterior fossa surgery. There is no consensus concerning prophylactic external ventricular drainage (EVD) placement that is frequently used before posterior fossa lesion removal, as well in those cases without clear evidence of hydrocephalus. The aim of the study was to define the most correct management for patients who undergo posterior fossa tumour surgery, thus identifying cohorts of patients who are at risk of persistent hydrocephalus prior to surgery. A systematic review of literature has been performed, following PRISMA guidelines. Most of the studies reported CSF shunt only in the presence of hydrocephalus, whereas only a few authors suggested its prophylactic use in the absence of signs of ventricular dilatation. Predictive factors for postoperative hydrocephalus has been identified, including young age (< 3 years), severe symptomatic hydrocephalus at presentation, EVD placement before surgery, FOHR index > 0.46 and Evans index > 0.4, pseudomeningocele, CSF leak and infection. The use of pre-resection CSF shunt in case of signs and symptoms of hydrocephalus is mandatory, although it resolves in the majority of cases. As reported by several studies included in the present review, we suggest CSF shunt also in case of asymptomatic hydrocephalus, whereas it is not indicated without evidence of ventricular dilatation.
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Zhao Y, Chen L, Zhang J, You N, Liu Y, Yao A, Zhao K, Zhang J, Xu B. Duraplasty with Cervical Fascia Autograft to Reduce Postoperative Complications of Posterior Fossa Tumor Surgery with Suboccipital Midline Approach. World Neurosurg 2019; 134:e1115-e1120. [PMID: 31785439 DOI: 10.1016/j.wneu.2019.11.106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The suboccipital midline approach is common dealing with posterior fossa tumors but has a high risk of postoperative complications, such as pseudomeningocele, cerebrospinal fluid (CSF) leak, and meningitis. Neurosurgeons used various kinds of method to lower its rate. METHODS A retrospective, single-center review of patients diagnosed with posterior fossa tumor underwent a suboccipital midline approach. Compare the rates of pseudomeningocele, CSF leak, and meningitis between 2 groups (artificial dura mater or cervical fascia autograft). We get the cervical fascia autograft from the superficial layer of deep cervical fascia just above the trapezius. RESULTS Our retrospective review involved 123 patients matching the inclusion criteria between January 2009 and April 2019. The complication rate of pseudomeningocele, CSF leak and meningitis were 8.9%, 4.9%, and 17.9%, respectively. The presence of pseudomeningocele or CSF leak for group "artificial" was 11 of 75 (14.67%) and for group "autograft" it was 3 of 48 (6.25%). The rate of meningitis for group "artificial" (24.0%, 18 of 75) was significantly higher (P = 0.027) than the one for group "autograft" (8.33%, 4 of 48). Multivariate regression analysis suggested that the age was negatively correlated with postoperative pseudomeningocele or CSF leak (P = 0.006), with meningitis (P < 0.001). Using cervical fascia autograft decreased the rate of meningitis (P = 0.021) while showing no statistically significant clinical impact on pseudomeningocele or CSF leak. CONCLUSIONS Applying the cervical fascia autograft to reconstruct the dura during posterior fossa surgery is a simple and effective method to reduce the rate of meningitis as compared with artificial dura mater.
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Affiliation(s)
- Yue Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Li Chen
- Department of Radiology, People's Hospital of Qinghai Province, Xining, Qinghai, China
| | - Jiashu Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Na You
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Yuyang Liu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Anhui Yao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Kai Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Jun Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Bainan Xu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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Crevier-Sorbo G, Atkinson J, Di Genova T, Puligandla P, Dudley RWR. Hydrocephalus-induced neurogenic stunned myocardium and cardiac arrest in a child: completely reversed with CSF diversion. J Neurosurg Pediatr 2019; 24:35-40. [PMID: 31003226 DOI: 10.3171/2019.2.peds18711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 02/28/2019] [Indexed: 01/11/2023]
Abstract
Neurogenic stunned myocardium (NSM) is a potentially fatal cause of sudden cardiogenic dysfunction due to an acute neurological event, most commonly aneurysmal subarachnoid hemorrhage in adults. Only two pediatric cases of hydrocephalus-induced NSM have been reported. Here the authors report a third case in a 14-year-old boy who presented with severe headache, decreased level of consciousness, and shock in the context of acute hydrocephalus secondary to fourth ventricular outlet obstruction 3 years after standard-risk medulloblastoma treatment. He was initially stabilized with the insertion of an external ventricular drain and vasopressor treatment. He had a profoundly reduced cardiac contractility and became asystolic for 1 minute, requiring cardiopulmonary resuscitation when vasopressors were inadvertently discontinued. Over 1 week, his ventricles decreased in size and his cardiac function returned to normal. All other causes of heart failure were ruled out, and his impressive response to CSF diversion clarified the diagnosis of NSM secondary to hydrocephalus. He was unable to be weaned from his drain during his time in the hospital, so he underwent an endoscopic third ventriculostomy and has remained well with normal cardiac function at more than 6 months' follow-up. This case highlights the importance of prompt CSF diversion and cardiac support for acute hydrocephalus presenting with heart failure in the pediatric population.
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Luo W, Xu Y, Yang J, Liu Z, Liu H. Fourth Ventricular Meningiomas. World Neurosurg 2019; 127:e1201-e1209. [PMID: 31004862 DOI: 10.1016/j.wneu.2019.04.097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 04/09/2019] [Accepted: 04/10/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Fourth ventricular meningiomas (FVMs) are extremely rare. Here, we report a series of 11 patients at a single institution. A comprehensive literature analysis is conducted. METHODS Information about 11 patient was extracted from the patient data. Reports of cases in English were obtained from the literature. Including our 11 patients, 71 patients were analyzed in this study. RESULTS The most common age of onset was from the third decade to sixth decade of life. The female/male ratio was about 1.16:1. The most frequent subtype of meningioma was fibrous meningioma. FVMs had specific imaging features, such as calcification (20%), peritumoral edema (30.3%), heterogeneous enhancement (22.5%), cystic formation (4.3%), and hydrocephalus (52.8%). The proportion of total tumor resection was about 94.9%, with 15.3% of postoperative complications. During follow-up, the recurrent rate of FVMs was about 6.8%. There was no significant difference in the analysis of correlation between hydrocephalus and the maximum diameter of tumors, correlation between hydrocephalus and the volume of tumor, or correlation between peritumoral edema and the volume of tumor, as well as correlation between heterogeneous enhancement and the grade of meningiomas. CONCLUSIONS FVMs have their own characteristics in age of onset, gender ratio, histologic types, and imaging features. The recommended treatment is surgical treatment via the telovelar approach with suboccipital craniotomy/craniectomy. Adjuvant therapy is needed in some high-grade meningiomas and in patients undergoing partial resection. The prognosis is relatively good, with fewer postoperative complications and a higher rate of total resection.
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Affiliation(s)
- Wei Luo
- Department of Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yulun Xu
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jun Yang
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongmin Liu
- Department of Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hai Liu
- Department of Neurosurgery, China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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The effect of tumor removal via craniotomies on preoperative hydrocephalus in adult patients with intracranial tumors. Neurosurg Rev 2018; 43:141-151. [PMID: 30120611 DOI: 10.1007/s10143-018-1021-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/23/2018] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
Abstract
The efficacy of tumor removal via craniotomies on preoperative hydrocephalus (HC) in adult patients with intracranial tumors is largely unknown. Therefore, we sought to evaluate the effect of tumor resection in patients with preoperative HC and identify the incidence and risk factors for postoperative VP shunt dependency. All craniotomies for intracranial tumors at Oslo University Hospital in patients ≥ 18 years old during a 10-year period (2004-2013) were reviewed. Patients with radiologically confirmed HC requiring surgery and subsequent development of shunt dependency were identified by cross-linking our prospectively collected tumor database to surgical procedure codes for hydrocephalus treatment (AAF). Patients with preexisting ventriculoperitoneal (VP) shunts (N = 41) were excluded. From 4774 craniotomies performed on 4204 patients, a total of 373 patients (7.8%) with HC preoperatively were identified. Median age was 54.4 years (range 18.1-83.9 years). None were lost to follow-up. Of these, 10.5% (39/373) required permanent CSF shunting due to persisting postoperative HC. The risk of becoming VP shunt dependent in patients with preexisting HC was 7.0% (26/373) within 30 days and 8.9% (33/373) within 90 days. Only secondary (repeat) surgery was a significant risk factor for VP shunt dependency. In this large, contemporary, single-institution consecutive series, 10.5% of intracranial tumor patients with preoperative HC became shunt-dependent post-craniotomy, yielding a surgical cure rate for HC of 89.5%. To the best of our knowledge, this is the first and largest study regarding postoperative shunt dependency after craniotomies for intracranial tumors, and can serve as benchmark for future studies.
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