A Predictive Model of Unfavorable Outcomes After Benign Intracranial Tumor Resection

Incidence and Risk Factors of Surgical Site Infection After Cranial Surgery for Patients with Brain Tumors: A Systematic Review and Meta-analysis

BACKGROUND

Surgical site infections after craniotomy (SSI-CRANs) are a serious adverse event given the proximity of the wound to the central nervous system. SSI-CRANs are associated with substantial patient morbidity and mortality. Despite the importance and recognition of this event in other surgical fields, there is a paucity of evidence in the neurosurgical literature devoted to SSI-CRAN specifically in patients after brain tumor surgery.

METHODS

Systematic searches of Medline, Embase, and Cochrane Central were undertaken. The primary outcome was the incidence of SSI-CRAN at 30 and 90 days. Secondary outcomes were risk factors for SSI-CRAN.

RESULTS

Thirty-seven studies reporting 91,907 patients with brain tumors who underwent cranial surgery were included in the meta-analysis. Pooled incidence of SSI-CRAN at 30 and 90 days was 4.03% (95% CI: 2.94%-5.28%, I2 = 97.3) and 6.17% (95% CI: 3.16%-10.07%, I2 = 97.3), respectively. Specifically, incidence of SSI-CRAN following surgery for posterior fossa tumors was the highest at 9.67% (95% CI: 5.98%-14.09%, I2 = 75.5). Overall pooled incidence of readmission within 30 days and reoperation due to SSI-CRAN were 13.9% (95% CI: 12.5%-15.5%, I2 = 0.0) and 16.3% (95% CI: 5.4%-31.3%, I2 = 72.9), respectively. Risk factors for SSI-CRAN included reintervention (risk ratio [RR] 1.58, 95% CI: 1.22-2.04, I2 = 0.0), previous radiotherapy (RR 1.69, 95% CI: 1.20-2.38, I2 = 0.0), longer duration of operation (mean difference 64.18, 95% CI: 3.96-124.40 minutes, I2 = 90.3) and cerebrospinal fluid (CSF) leaks (RR 14.26, 95% CI: 2.14-94.90, I2 = 73.2).

CONCLUSIONS

SSI-CRAN affects up to 1 in 14 patients with brain tumors. High-risk groups include those with reintervention, previous radiotherapy, longer duration of operation, and CSF leaks. Further prospective studies should focus on bundles of care that will reduce SSI-CRAN.

Clinical tool for prognostication of discharge outcomes following craniotomy for meningioma

BACKGROUND

Patients' comorbidities might affect the immediate postoperative morbidity and discharge disposition after surgical resection of intracranial meningioma.

OBJECTIVE

To study the impact of comorbidities on outcomes and provide a web-based application to predict time to favorable discharge.

METHODS

A retrospective review of the prospectively collected national inpatient sample (NIS) database was conducted for the years 2009-2013. Time to favorable discharge was defined as hospital length of stay (LOS). A favorable discharge was defined as a discharge to home and a non-home discharge destination was defined as an unfavorable discharge. Cox proportional hazards model was built. Full model for time to discharge and separate reduced models were built.

RESULTS

Of 10,757 patients who underwent surgery for meningioma, 6554 (60%) had a favorable discharge. The median hospital LOS was 3 days (interquartile range [IQR] 2-5). In the full model, several clinical and socioeconomic factors were associated with a higher likelihood of unfavorable discharge. In the reduced model, 13 modifiable comorbidities were negatively associated with a favorable discharge except for drug abuse and obesity, which are not associated with discharge. Both models accurately predicted time to favorable discharge (c-index:0.68-0.71).

CONCLUSION

We developed a web application using robust prognostic model that accurately predicts time to favorable discharge after surgery for meningioma. Using this tool will allow physicians to calculate individual patient discharge probabilities based on their individual comorbidities and provide an opportunity to timely risk stratify and address some of the modifiable factors prior to surgery.

Solitary fibrous tumors: Clinical and imaging features from head to toe

Solitary fibrous tumors (SFTs) are rare fibroblastic mesenchymal tumors that are usually benign with variable malignant potential. They can develop in any organ due to their spindle cell origin. The exact etiology of solitary fibrous tumors is unknown. The majority of SFTs are benign with 10-30% of them exhibiting aggressive and malignant features. The aggressiveness of this type of tumor is not associated with its histological features, which makes surgical resection the treatment of choice. We will review the clinical and radiological features and possible differential diagnoses of SFTs according to their anatomical sites following the World Health Organization 2020 classification.

Biomarkers of Seizure Activity in Patients With Intracranial Metastases and Gliomas: A Wide Range Study of Correlated Regions of Interest

Introduction: Studies quantifying cortical metrics in brain tumor patients who present with seizures are limited. The current investigation assesses morphometric/volumetric differences across a wide range of anatomical regions, including temporal and extra-temporal, in patients with gliomas and intracranial metastases (IMs) presenting with seizures that could serve as a biomarker in the identification of seizure expression and serve as a neuronal target for mitigation.

Methods: In a retrospective design, the MR sequences of ninety-two tumor patients [55% gliomas; 45% IM] and 34 controls were subjected to sophisticated morphometric and volumetric assessments using BrainSuite and MATLAB modules. We examined 103 regions of interests (ROIs) across eight distinct cortical categories of interests (COI) [gray matter, white matter; total volume, CSF; cortical areas: inner, mid, pial; cortical thickness]. The primary endpoint was quantifying and identifying ROIs with significant differences in z-scores based upon the presence of seizures. Feature selection employing neighborhood component analysis (NCA) determined the ROI within each COI having the highest significance/weight in the differentiation of seizure vs. non-seizure patients harboring brain tumor.

Results: Overall, the mean age of the cohort was 58.0 ± 12.8 years, and 45% were women. The prevalence of seizures in tumor patients was 28%. Forty-two ROIs across the eight pre-defined COIs had significant differences in z-scores between tumor patients presenting with and without seizures. The NCA feature selection noted the volume of pars-orbitalis and right middle temporal gyrus to have the highest weight in differentiating tumor patients based on seizures for three distinct COIs [GM, total volume, and CSF volume] and white matter, respectively. Left-sided transverse temporal gyrus, left precuneus, left transverse temporal, and left supramarginal gyrus were associated with having the highest weight in the differentiation of seizure vs. non-seizure in tumor patients for morphometrics relating to cortical areas in the pial, inner and mid regions and cortical thickness, respectively.

Conclusion: Our study elucidates potential biomarkers for seizure targeting in patients with gliomas and IMs based upon morphometric and volumetric assessments. Amongst the widespread brain regions examined in our cohort, pars orbitalis, supramarginal and temporal gyrus (middle, transverse), and the pre-cuneus contribute a maximal potential for differentiation of seizure patients from non-seizure.

Emergency department evaluation and 30-day readmission after craniotomy for primary brain tumor resection in New York State

OBJECTIVE

Fragmentation of care has been recognized as a major contributor to 30-day readmissions after surgical procedures. The authors investigated the association of evaluation in the hospital where the original procedure was performed with the rate of 30-day readmissions for patients presenting to the emergency department (ED) after craniotomy for primary brain tumor resection.

METHODS

A cohort study was conducted, involving patients who were evaluated in the ED within 30 days after discharge following a craniotomy for primary brain tumor resection between 2009 and 2013, and who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database of New York State. A propensity score–adjusted model was used to control for confounding, whereas a mixed-effects model accounted for clustering at the hospital level.

RESULTS

Of the 610 patients presenting to the ED, 422 (69.2%) were evaluated in a hospital different from the one where the original procedure was performed (28.9% were readmitted), and 188 (30.8%) were evaluated at the original hospital (20.3% were readmitted). In a multivariable analysis, the authors demonstrated that being evaluated in the ED of the original hospital was associated with a decreased rate of 30-day readmission (OR 0.64, 95% CI 0.41–0.98). Similar associations were found in a mixed-effects logistic regression model (OR 0.63, 95% CI 0.40–0.96) and a propensity score–adjusted model (OR 0.64, 95% CI 0.41–0.98). This corresponds to one less readmission per 12 patients evaluated in the hospital where the original procedure was performed.

CONCLUSIONS

Using a comprehensive all-payer cohort of patients in New York State who were evaluated in the ED after craniotomy for primary brain tumor resection, the authors identified an association of assessment in the hospital where the original procedure was performed with a lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.

Does scope of practice correlate with the outcomes of craniotomy for tumor resection in children?

BACKGROUND

The relationship of scope of practice (predominantly adult, versus predominantly pediatric) with the outcomes of brain tumor surgery in children remains uncertain. We investigated the association of practice focus with the outcomes of neurosurgical oncology operations in pediatric patients.

METHODS

We performed a cohort study of all pediatric patients (younger than 18 years old) who underwent craniotomies for tumor resections from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. In order to control for confounding, we used propensity score conditioning with mixed effects analysis to account for clustering at the hospital level.

RESULTS

During the study period, there were 770 pediatric patients who underwent craniotomy for tumor resection and met the inclusion criteria. Of these, 370 (48.1%) underwent treatment by providers with predominantly adult practices and 400 (51.9%) by physicians who operated predominantly on children. Mixed-effects multivariable regression analysis demonstrated lack of association of predominantly adult practice with inpatient mortality (OR, 1.12; 95% CI, 0.48-2.58), and discharge to a facility (OR, 1.25; 95% CI, 0.77-2.03). These associations persisted in propensity-adjusted models.

CONCLUSIONS

In a cohort of pediatric patients undergoing craniotomy for tumor resection from a comprehensive all-payer database, we did not demonstrate a difference in mortality, and discharge to a facility between providers with predominantly adult and predominantly pediatric practices.

A Single-Center Cost Analysis of Treating Primary and Metastatic Brain Cancers with Either Brain Laser Interstitial Thermal Therapy (LITT) or Craniotomy

BACKGROUND

Brain laser interstitial thermal therapy (LITT) under magnetic resonance imaging (MRI) guidance has recently gained US clinical approval for the ablation of soft, neurological tissue. LITT is a minimally invasive alternative to craniotomy.

OBJECTIVE

While safety and efficacy are the focus of most current LITT studies, it is unclear how acute care costs (inpatient care ± aftercare) of LITT compare to craniotomy in an academic medical center. Therefore, the purpose of this analysis is to examine these costs of using brain LITT under MRI guidance compared to craniotomy in complex anatomies.

METHODS

Consecutive patients treated at a single US center from 1 January 2010 to 21 October 2014 were retrospectively evaluated. Patients were included if they had a primary procedure for LITT or craniotomy (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] procedure code 17.61 or ICD-9-CM procedure code 01.59, respectively) and were subgrouped according to their diagnosis of primary brain or metastatic brain cancer (ICD-9-CM 191.0-191.9 or ICD-9-CM 198.3, respectively). Patients were excluded if they had co-morbid conditions such as brain edema (ICD-9-CM 348.5). Patients were matched (LITT vs. craniotomy) based on diagnosis. Appropriate statistical analyses were undertaken to examine the year 2015 costs for care in all settings (acute hospital and post-hospital care, i.e., skilled nursing facility, rehabilitation, and home care) were examined.

RESULTS

In patients treated for a primary brain cancer, there was no statistical difference in the acute and post-care costs of LITT and craniotomy (inverse variance, mean difference [MD], random effects model): MD = -US$1669; 95% confidence interval (CI) -$8192 to $4854; P = 0.62. When examining difficult to access primary malignancies, no difference was found: MD = -US$4719; 95% CI -$12,183 to $2745; P = 0.22. In metastatic brain cancer, LITT was found to be significantly less costly than craniotomy: MD = -US$6522; 95% CI -$11,911 to -$1133; P = 0.02.

CONCLUSIONS

In patients with metastatic brain cancer, LITT is less costly than craniotomy. Patients receiving LITT had a significantly shorter length of hospital stay, were significantly older, and were more likely to be discharged home. The use of LITT may be a reasonable option in bundled episodes of care for brain cancer and may fit into the Bundled Payment for Care Improvement (BPCI) program being evaluated by Medicare and providers.

Association of Prior Falls with Adverse Outcomes After Neurosurgical Operations in the Elderly

BACKGROUND

Despite the increasing number of elderly patients undergoing neurosurgical interventions, there are limited resources for preoperative assessment of frailty in this population. We investigated the association between recent history of falls and surgical outcomes for these patients.

METHODS

We performed a prospective cohort study of all patients, 65 years and older, undergoing elective neurosurgical procedures from 2014-2015 in a tertiary referral medical center. We examined the association of sustaining a fall in the 6 months before the operation with discharge to a facility, readmissions, and complications in the first 30 days after discharge. In order to control for confounding, we used multivariable regression models and propensity score conditioning. Mixed-effects models were used to control for clustering at the surgeon level.

RESULTS

During the study period, 143 elderly patients underwent a neurosurgical procedure and met the inclusion criteria. Of these, 53.1% had a history of falls preoperatively. Mixed-effects multivariable logistic regression analysis demonstrated an association between preoperative falls and discharge to a facility (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.23-1.47), 30-day readmissions (OR, 1.57; 95% CI, 1.36-1.78), and 30-day complications (OR, 1.13; 95% CI, 1.03-1.23). Similar associations were present in propensity score-adjusted models and models stratified by cranial and spinal procedures.

CONCLUSIONS

History of at least 1 fall in the 6 months before a neurosurgical operation was associated with increased risk of discharge to a facility, readmissions, and complications in the first 30 days after discharge. History of prior falls should be taken into account during the preoperative risk assessment of neurosurgical patients.

Risk factors for post-operative respiratory failure among 94,621 neurosurgical patients from 2006 to 2013: a NSQIP analysis

INTRODUCTION

Post-operative respiratory failure can occur after neurosurgical operations. Identification of risk factors for respiratory failure after neurosurgery may help guide clinical decision-making, decrease length of stay, improve patient outcomes, and lower costs.

METHODS

We performed a search of the ACS-NSQIP database for all patients undergoing operations with a neurosurgeon from 2006 to 2013. We analyzed demographics, past medical history, and post-operative respiratory failure, defined as unplanned intubation and/or ventilator dependence for more than 48 h post-operatively.

RESULTS

Of 94,621 NSQIP-reported neurosurgical patients from 2006 to 2013, 2325 (2.5 %) developed post-operative respiratory failure. Of these patients, 1270 (54.6 %) were male, with an overall mean age of 60.59 years; 571 (24.56 %) were current smokers and 756 (32.52 %) were ventilator-dependent. Past medical history included dyspnea in 204 patients (8.8 %), COPD in 198 (8.5 %), and congestive heart failure in 66 (2.8 %). The rate of post-operative respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 (p < 0.001). Of the 2325 patients with respiratory failure, 1061 (45.6 %) underwent unplanned intubation post-operatively and 1900 (81.7 %) were ventilator-dependent for more than 48 h. The rate of both unplanned intubation (p < 0.001) and ventilator dependence (p < 0.001) decreased significantly from 2006 to 2013. Multivariate analysis demonstrated that significant risk factors for respiratory failure included inpatient status (p < 0.001, OR = 0.165), age (p < 0.001, OR = 1.014), diabetes (p = 0.001, OR = 1.489), functional dependence prior to surgery (p < 0.001, OR = 2.081), ventilator dependence (p < 0.001, OR = 10.304), hypertension requiring medication (p = 0.005, OR = 1.287), impaired sensorium (p < 0.001, OR = 2.054), CVA/stroke with or without neurological deficit (p < 0.001, OR = 2.662; p = 0.002, OR = 1.816), systemic sepsis (p < 0.001, OR = 1.916), prior operation within 30 days (p = 0.026, OR = 1.439), and operation type (cranial relative to spine, p < 0.001, OR = 4.344, Table 4).

CONCLUSIONS

Based on the NSQIP database, risk factors for respiratory failure after neurosurgery include pre-operative ventilator dependence, alcohol use, functional dependence prior to surgery, stroke, and recent operation. The overall rate of respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 according to these data.