Risk factors for new-onset shunt-dependency after craniotomies for intracranial tumors in adult patients

Hydrocephalus following Brain Tumor Surgery: Factors Correlating with Occurrence of Postoperative Hydrocephalus and Predictive Scoring Model

Hydrocephalus following brain tumor surgery is found, although cause of hydrocephalus is optimally eradicated. This study aimed to investigate factors associated with development of postoperative hydrocephalus that requires shunt procedure and generate predictive scoring model of this condition. Demographic, clinical, radiographic, treatment, laboratory, complication, and postoperative data were collected. Binary logistic regression was used to investigate final model for generating predictive scoring system of postoperative hydrocephalus. A total of 179 patients undergoing brain tumor surgery were included. Forty-five (25.1%) patients had postoperative hydrocephalus that required shunt surgery. In univariate analysis, several factors were found to be associated with postoperative hydrocephalus. Strong predictors of postoperative hydrocephalus revealed in multivariate analysis included tumor recurrence before surgery (odds ratio [OR], 4.38; 95% confidence interval [CI], 1.28-14.98; p  = 0.018), preoperative hydrocephalus (OR, 6.52; 95% CI, 2.44-17.46; p  < 0.001), glial tumor (OR, 3.76; 95% CI, 1.14-12.43; p  = 0.030), metastasis (OR, 5.19; 95% CI, 1.72-15.69; p  = 0.004), intraventricular hemorrhage (OR, 7.08; 95% CI, 1.80-27.82; p  = 0.005), and residual tumor volume (OR, 1.05; 95% CI, 1.01-1.09; p  = 0.007). A cutoff predictive score with the best area under curve and optimum cutoff point was utilized for discriminating patients with high risk from individuals with low risk in occurrence of postoperative hydrocephalus. This study reported predictive factors strongly associated with development of postoperative hydrocephalus. Predictive scoring system is useful for identifying patients with an increased risk of postoperative hydrocephalus. Patients classified in the high-risk group require closed surveillance of the hydrocephalus.

Management of Posterior Fossa Tumors in Adults Based on the Predictors of Postoperative Hydrocephalus

Objective

This study aims to identify the predictors of postoperative hydrocephalus in patients with posterior fossa tumors (PFTs) and guide the management of perioperative hydrocephalus.

Methods

We 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.

Results

Tumor infiltrating the midbrain aqueduct [P = 0.001; odds ratio (OR) = 9.8], postoperative hemorrhage (P &lt; 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 &lt; 0.001; OR = 58.5) and postoperative hemorrhage (P &lt; 0.001; OR = 28.1) were independent risk factors for postoperative VP shunt placement.

Conclusions

These findings may help promote more aggressive monitoring and earlier interventions for postoperative hydrocephalus in patients with PFTs.

Hydrocephalus Shunting in Supratentorial Glioblastoma: Functional Outcomes and Management

Background

Glioblastoma is the most common and the most challenging to treat adult primary central nervous system tumor. Although modern management strategies modestly improved the overall survival, the prognosis remains dismal associated with poor life quality and the clinical course often dotted by treatment side effects and cognitive decline. Functional deterioration might be caused by obstructive or communicating hydrocephalus but due to poor overall prognosis surgical treatment options are often limited and its optimal management strategies remain elusive. We aimed to investigate risk factors, treatment options and outcomes for tumor-associated hydrocephalus in a contemporary 10 years cohort of glioblastoma patients.

Methods

We reviewed electronic health records of 1800 glioblastoma patients operated at the Department of Neurosurgery, Medical Center – University of Freiburg from 2009 to 2019. Demographics, clinical characteristics and radiological features were analyzed. Univariate analysis for nominal variables was performed either by Fisher’s exact test or Chi-square test, as appropriate.

Results

We identified 39 glioblastoma patients with symptomatic communicating hydrocephalus treated by ventricular shunting (incidence 2.1%). Opening of the ventricular system during a previous tumor resection was associated with symptomatic hydrocephalus (p<0.05). There was also a trend toward location (frontal and temporal) and larger tumor volume. Number of craniotomies before shunting was not considered as a risk factor. Shunting improved hydrocephalus symptoms in 95% of the patients and Karnofsky Performance Score (KPS) could be restored after shunting. Of note, 75% of the patients had a post-shunting oncological treatment such as radiotherapy or chemotherapy, most prevalently chemotherapy. Infection (7.7%) and over- or under drainage (17.9%) were the most common complications requiring shunt revision in ten patients (25.6%), No peritoneal metastasis was found. The median overall survival (OS) was 385 days and the median post shunting survival was 135 days.

Conclusion

Ventricular system opening was identified as a risk factor for communicating hydrocephalus in glioblastoma patients. Although glioblastoma treatment remains challenging, shunting improved hydrocephalus-related functional status and may be considered even in a palliative setting for symptom relief.

Long-term risk of shunt failure after brain tumor surgery

Long-term risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus (HC) after craniotomy for brain tumors are largely unknown. The aim of this study was to establish the overall VP shunt survival rates during a decade after shunt insertion and to determine risks of shunt failure after brain tumor surgery in the long-term period. In this population-based cohort from a well-defined geographical region, all adult patients (> 18 years) from 2004 to 2013 who underwent craniotomies for intracranial tumors leading to VP shunt dependency were included. Our brain tumor database was cross-linked to procedure codes for shunt surgery (codes AAF) to extract brain tumor patients who became VP shunt dependent after craniotomy. The VP shunt survival time, i.e. the shunt longevity, was calculated from the day of shunt insertion after brain tumor surgery until the day of its failure. A total of 4174 patients underwent craniotomies, of whom 85 became VP shunt dependent (2%) afterwards. Twenty-eight patients (33%) had one or more shunt failures during their long-term follow-up, yielding 1-, 5-, and 10-year shunt success rates of 77%, 71%, and 67%, respectively. Patient age, sex, tumor location, primary/repeat craniotomy, placement of external ventricular drainage (EVD), ventricular entry, post-craniotomy hemorrhage, post-shunting meningitis/infection, and multiple shunt revisions were not statistically significant risk factors for shunt failure. Median shunt longevity was 457.5 days and 21.5 days for those with and without pre-craniotomy HC, respectively (p < 0.01). This study can serve as benchmark for future studies.

Perioperative Complications in Endoscopic Endonasal versus Transcranial Resections of Adult Craniopharyngiomas

BACKGROUND

Adult craniopharyngiomas are low-grade tumors of the pituitary infundibulum that can be locally aggressive and frequently present with profound visual deficits and endocrinopathies. Surgical resection remains the preferred initial treatment for these lesions, and recently endoscopic endonasal approaches (EEAs) have become increasingly used. However, minimal data exist comparing these techniques with traditional transcranial (TC) methods. The purpose of this study was to evaluate perioperative differences in EEA and TC approaches for adult craniopharyngiomas over the past several decades.

METHODS

Craniopharyngioma surgeries in the Nationwide Inpatient Sample from 1998 to 2014 were identified. Complication rates, mortality rates, and annual treatment trends were stratified by procedure. Annual caseload was assessed with linear regression, and multivariate logistic regression models were created to determine predictors of inpatient mortality and perioperative complications.

RESULTS

From 1998-2014, a significant increase in EEAs for craniopharyngiomas (+4.36/year, r² = 0.80, P < 0.0001) was observed. In contrast, no increase in TC surgeries for these lesions was seen. In multivariate analysis, EEAs were more likely to experience postoperative cerebrospinal fluid leak (odds ratio = 2.61, P < 0.0001). However, EEAs were protective against all other perioperative complications including diabetes insipidus, panhypopituitarism, visual impairment, and even mortality (odds ratio = 0.41, P = 0.0007).

CONCLUSIONS

Over the past several decades, utilization of EEAs to resect adult craniopharyngiomas has increased. EEAs appear to be associated with lower rates of perioperative mortality and complications. However, long-term, prospective studies controlling for tumor size, location, and preoperative symptomatology are needed to determine when one approach should be used preferentially over the other.

Risk of early failure of VP shunts implanted for hydrocephalus after craniotomies for brain tumors in adults

Risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus after craniotomies for brain tumors are largely unknown. The purpose of this study was to determine the overall timing of VP shunting and its failure after craniotomy for brain tumors in adults. The authors also wished to explore risk factors for early VP shunt failure (within 90 days). A population-based consecutive patient cohort of all craniotomies for intracranial tumors leading to VP shunt dependency in adults (> 18 years) from 2004 to 2013 was studied. Patients with pre-existing VP shunts prior to craniotomy were excluded. The survival time of VP shunts, i.e., the shunt longevity, was calculated from the day of shunt insertion post-craniotomy for a brain tumor until the day of shunt revision requiring replacement or removal of the shunt system. Out of 4774 craniotomies, 85 patients became VP shunt-dependent (1.8% of craniotomies). Median time from craniotomy to VP shunting was 1.9 months. Patients with hydrocephalus prior to tumor resection (N = 39) had significantly shorter time to shunt insertion than those without (N = 46) (p < 0.001), but there was no significant difference with respect to early shunt failure. Median time from shunt insertion to shunt failure was 20 days (range 1–35). At 90 days, 17 patients (20%) had confirmed shunt failure. Patient age, sex, tumor location, primary/secondary craniotomy, extra-axial/intra-axial tumor, ventricular entry, post-craniotomy bleeding, and infection did not show statistical significance. The risk of early shunt failure (within 90 days) of shunts after craniotomies for brain tumors was 20%. This study can serve as benchmark for future studies.

Management of Hydrocephalus in Children: Anatomic Imaging Appearances of CSF Shunts and Their Complications

OBJECTIVE. This article addresses the management of hydrocephalus and the CSF shunts used to treat this entity. CONCLUSION. CSF shunts have a high failure rate. Imaging plays a pivotal role in assessing CSF shunt failure and determining the need for surgical revision. An in-depth knowledge of CSF shunt components, their failure modes, and the corresponding findings on anatomic imaging studies is necessary to ensure timely diagnosis and prevent permanent neurologic damage.

Minimally invasive keyhole temporal lobectomy approach for supramaximal glioma resection: A safety and feasibility study

With a recent trend towards supra-maximal resection for gliomas and minimally invasive techniques, keyhole temporal lobectomies may serve an important role in neurosurgical oncology. Due to their location and proximity to eloquent brain, temporal lobe gliomas offer unique challenges that may limit the extent of resection. Here we describe a modified technique using mini-craniotomies through a keyhole approach for temporal lobectomies in glioma patients. We retrospectively reviewed data from consecutive patients who underwent temporal lobectomies for resection of gliomas from 2012 to 2018. Demographic data, extent of tumor resection, pre and post-op KPS, short term and long term complications, as well as other relevant data were collected. We identified 57 patients who underwent keyhole-mini craniotomy for temporal lobectomies for glioma. Surgical procedures were performed in 12 patients for low-grade glioma (LGG) and 45 patients for high-grade glioma (HGG). Awake craniotomies were performed in 15 of the cases, and 13 cases were for tumor recurrence. Supra-maximal resection (SMR) was achieved in 15 patients, while gross total resection (GTR) and near total resection (NTR) achieved in 32 patients and 10 patients, respectively. Average pre- and post-op KPS were equivalent, and post-operative complications requiring surgical intervention were experienced in 4 patients. Here we show that our modified keyhole craniotomy is both safe and effective in achieving SMR or GTR in glioma patients, with minimal morbidity. This minimally-invasive temporal lobectomy may be an instrumental tool for neurosurgical oncologists transitioning to less invasive techniques.

The effect of tumor removal via craniotomies on preoperative hydrocephalus in adult patients with intracranial tumors

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.