When the Infection Hits the Wound: Matched Case-Control Study in a Neurosurgical Patient Collective Including Systematic Literature Review and Risk Factors Analysis

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.

The impact of intraoperative MRI on cranial surgical site infections-a single-center analysis

PURPOSE

The use of intraoperative MRI (ioMRI) contributes to an improved extent of resection. Hybrid operating room MRI suites have been established, with the patient being transferred to the MRI scanner. In the present descriptive analysis, we compared the rate of surgical site infections (SSI) after intracranial tumor surgery with and without the use of ioMRI.

METHODS

In this retrospective study, we included 446 patients with open craniotomy performed for brain tumor surgery. One hundred fourteen patients were operated on with the use of ioMRI between June 1, 2018, and June 30, 2019 (group 1). During the same period, 126 patients were operated on without ioMRI (group 2). As an additional control group, we analyzed 206 patients operated on from February 1, 2017, to February 28, 2018 when ioMRI had not yet been implemented (group 3).

RESULTS

The rate of SSI in group 1 (11.4%), group 2 (9.5%), and group 3 (6.8%) did not differ significantly (p = 0.352). Additional resection after ioMRI did not result in a significantly elevated number of SSI. No significant influence of re-resection, prior radio-/chemotherapy, blood loss or duration of surgery was found on the incidence of SSI.

CONCLUSION

Despite the transfer to a non-sterile MRI scanner, leading to a prolonged operation time, SSI rates with and without the use of ioMRI did not differ significantly. Hence, advantages of ioMRI outweigh potential disadvantages as confirmed by this real-life single-center study.

Association of predictive factors and neurosurgical postoperative infections: A retrospective analysis

OBJECTIVE

To identify the factors that predispose neurosurgical patients to surgical site infections (SSI) as well as assess the risk factors attached to infection by a specific microorganism.

METHODOLOGY

A retrospective case-control study was conducted at University College of Medical Sciences and G.T.B. Hospital, Delhi. Adult patients (>18 years) undergoing a neurosurgical procedure with a diagnosis of SSI in the year 2021 having a minimum follow up of 30 days postoperatively or until death if they survived less than 30 days were included. Statistical analysis was performed using the SPSS 16 software with level of significance at 0.05.

RESULTS

An incidence of 3.15% was observed at our center. Mean age of the study population was 39.2 ± 13.07 years (range 22-70 years) with a male: female ratio of 3:1. Having an underlying infection (p = 0.024), ASA score> 2 (p = 0.041), duration of surgery> 4 h (p = 0.025), diabetes (p = 0.027) and preoperative stay at the hospital (p = 0.036) were found to be statistically significant risk factors in the prediction of SSI in neurosurgical patients which were utilised to create a regression model with an accuracy of 70% and AUC of 0.833. Deep infections were found to have a significant association with positive culture on the collected samples (p = 0.035).

CONCLUSIONS

This study is a starting point to identify which factors could predict the presence of a particular organism isolated from the site of infection in neurosurgical patients, thereby minimizing AMR.

Surgical site infections after elective craniotomy for brain tumor: a study on potential risk factors and related treatments

BACKGROUND

Surgical site infection (SSI) is a common complication following craniotomy that increases morbidity, mortality, and medical expenses. The objectives of this study were to determine the relevant risk factors associated with SSI after elective craniotomy for brain tumor and analyse the treatments for SSI.

METHODS

A retrospective nested case‒control study was conducted using data from patients who underwent craniotomy for brain tumor resection at the Neurosurgical Oncology Department No. 6 of Beijing Tiantan Hospital, Capital Medical University, between January 2019 and December 2021. Risk factors for SSI were determined using multivariate logistic regression analysis. We analyzed microbiological and related treatment data for different SSI types.

RESULTS

Among 2061 patients who underwent craniotomy for brain tumor, 31 had SSI (1.50%). In the multivariate logistic regression analysis, body mass index (BMI) and operative duration were identified as independent risk factors for SSI. The most common microorganism isolated from SSIs was Staphylococcus epidermidis (22.9%), and drug sensitivity results showed that gram-positive bacteria were sensitive to linezolid, vancomycin and tigecycline, whereas gram-negative bacteria were sensitive to meropenem, cefepime and ceftazidime. Six of the seven patients who underwent bone flap removal due to osteomyelitis were infected with gram-negative bacteria.

CONCLUSIONS

BMI and operative duration were identified as independent risk factors for SSI. Diabetes mellitus, previous ratio therapy, type of incision, recurrence tumor and other risk factors were not found to be associated with the occurrence of SSI in this study.

Surgical Site Infections in Glioblastoma Patients-A Retrospective Analysis

Surgical site infections (SSIs) after craniotomy lead to additional morbidity and mortality for patients, which are related to higher costs for the healthcare system. Furthermore, SSIs are associated with a longer hospital stay for the patient, which is particularly detrimental in glioblastoma patients due to their limited life expectancy. Risk factors for SSIs have already been described for craniotomies in general. However, there is limited data available for glioblastoma patients. As postoperative radiation influences wound healing, very early radiation is suspected to be a risk factor for SSI. Nevertheless, there are no data on the optimal timing of radiotherapy. To define risk factors for these patients, we analyzed our collective. We performed a retrospective analysis of all operations with histological evidence of a glioblastoma between 2012 and 2021. Open biopsy and tumor removal (gross total resection, subtotal resection) were included. Stereotactic biopsies were excluded. Demographic data such as age and gender, as well as duration of surgery, diameter of the trepanation, postoperative radiation with interval, postoperative chemotherapy, highest blood glucose level, previous surgery, ASA score, foreign material introduced, subgaleal suction drainage, ventricle opening and length of hospital stay, were recorded. The need for surgical revision due to infection was registered as an SSI. A total of 177 patients were included, of which 14 patients (7.9%) suffered an SSI. These occurred after a median of 45 days. The group with SSIs tended to include more men (57.1%, p = 0.163) and more pre-operated patients (50%, p = 0.125). In addition, foreign material and subgaleal suction drains had been implanted more frequently and the ventricles had been opened more frequently, without reaching statistical significance. Surprisingly, significantly more patients without SSIs had been irradiated (80.3%, p = 0.03). The results enable a better risk assessment of SSIs in glioblastoma patients. Patients with previous surgery, introduced foreign material, subgaleal suction drain and opening of the ventricle may have a slightly higher for SSIs. However, because none of these factors were significant, we should not call them risk factors. A less radical approach to surgery potentially involving these factors is not justified. The postulated negative role of irradiation was not confirmed, hence a rapid chemoradiation should be induced to achieve the best possible oncologic outcome.

Treatment of Ventriculitis and Meningitis After Neurosurgery Caused by Carbapenem-Resistant Enterobacteriaceae (CRE): A Challenging Topic

Post-neurosurgical infection is a common complication of neurosurgery, and serious infection can threaten the life of patients. In recent years, the increase in multidrug-resistant bacteria, especially carbapenem-resistant Enterobacteriaceae (CRE), has proved fatal to patients. Although there are a few cases of CRE meningitis and few clinical trials have been carried out, it has attracted increasing attention with the increasing probability of its occurrence, especially considering that there are few successful cases. An increasing number of studies are also looking for the risk factors and clinical symptoms of CRE intracranial infection. In terms of treatment, some new antibiotics are gradually being used in the clinic, but due to the complicated drug-resistant mechanism of CRE and the obstruction of the blood‒brain barrier (BBB), the therapeutic effect is still very poor. In addition, obstructive hydrocephalus and brain abscess caused by CRE meningitis are still important causes of patient death and are also difficult to treat.

Clinical infections in neurosurgical oncology: An overview

Central nervous system (CNS) infections are urgent conditions with high morbidity and mortality. Bacteria, viruses, parasites or fungi can cause them. Intracranial infections after craniotomies are an important complication of treatment, especially in oncological patients that are already immunologically compromised due to the disease and treatment. The consequence of CNS infections in oncological patients includes longer treatment with antibiotics, additional surgical procedures, higher treatment costs and poorer treatment outcomes. Additionally, the management of primary pathology may be prolonged or postponed as a result of the active infection. By introducing new and improved protocols, tightening controls on their implementation, constantly educating the entire team involved in patient treatment and educating both patients and relatives, the incidence of infections can be reduced effectively.

Quality indicators and early adverse in surgery for atypical meningiomas: A 16-year single centre study and systematic review of the literature

Introduction

Atypical meningiomas represent approximately 20% of all intracranial meningiomas and are characterized by distinct histopathological criteria and an increased risk of postoperative recurrence. Recently, quality indicators have been introduced to monitor quality of the delivered care.

Research question

Which quality indicators/outcome measures are being applied in patients being operated for atypical meningiomas? What are risk factors associated with poor outcome? How is the surgical outcome and which quality indicators are reported in the literature?

Material and methods

The primary outcomes of interest were 30-days readmission-, 30-day reoperation-, 30-day mortality-, 30-day nosocomial infection- and the 30-day surgical site infection (SSI) rate, CSF-leakage, new neurological deficit, medical complications, and lengths of stay. The secondary aim was the identification of prognostic factors for the mentioned primary outcomes. A systematic review of the literature was performed screening studies for the mentioned outcomes.

Results

We included 52 patients. 30-days outcomes in terms of unplanned reoperation were 0%, unplanned readmission 7.7%, mortality 0%, nosocomial infection 17.3%, and SSI 0%. Any adverse event occurred in 30.8%. Preoperative C-reactive protein over 5 ​mg/l was independent factor for the occurrence of any postoperative adverse event (OR: 17.2, p ​= ​0.003). A total of 22 studies were included into the review.

Discussion and conclusion

The 30-days outcomes at our department were comparable with reported outcomes in the literature. Currently applied quality indicators are helpful in determining the postoperative outcome but mainly report the indirect outcome after surgery and are influenced of patient, tumor and treatment related factors. Risk adjustment is vital.

Characterization of perioperative glycemic status and dexamethasone use with associated postoperative complications in glioblastoma patients

PURPOSE

Postoperative morbidity in glioblastoma (GBM) patients can be due to the disease course but can also come from postoperative complications. Our objective was to study the association of dexamethasone use and perioperative hyperglycemia with postoperative complications in GBM patients.

METHODS

A single-center, retrospective cohort study was conducted in patients who underwent surgery for primary GBM from 2014-2018. Patients with perioperative fasting blood glucose (FBG) measurements and adequate follow-up to assess for complications were included.

RESULTS

A total of 199 patients were included. More than half (53%) had poor perioperative glycemic control (FBG ≥ 7 mM for ≥ 20% perioperative days). Higher dexamethasone dose (≥ 8 mg) was associated with higher FBG on postoperative days 2-4 and 5 (p = 0.02,0.05,0.004,0.02, respectively). Poor glycemic control was associated with increased odds of 30-day any complication and 30-day infection on univariate analysis (UVA), and 30-day any complication and increased length of stay (LOS) on multivariate analysis (MVA). Higher average perioperative daily dexamethasone dose was associated with increased odds of 30-day any complication and 30-day infection on MVA. Elevated hemoglobin A1c (HgbA1c, ≥ 6.5%) was associated with increased odds of 30-day any complication, 30-day infection, and LOS on UVA. In a multivariate linear regression model, only the diagnosis of diabetes mellitus predicted perioperative hyperglycemia.

CONCLUSIONS

Perioperative hyperglycemia, higher average dexamethasone use and elevated preoperative HgbA1c are associated with increased risk of postoperative complications in GBM patients. Avoiding hyperglycemia and limiting dexamethasone use in postoperative period may decrease the risk of complications. Select HgbA1c screening may allow the identification of a group of patients at higher risk of complications.

Can Currently Suggested Quality Indicators Be Transferred to Meningioma Surgery?-A Single-Center Pilot Study

BACKGROUND

 Risk stratification based on standardized quality measures has become crucial in neurosurgery. Contemporary quality indicators have often been developed for a wide range of neurosurgical procedures collectively. The accuracy of tumor-inherent characteristics of patients diagnosed with meningioma remains questionable. The objective of this study was the analysis of currently applied quality indicators in meningioma surgery and the identification of potential new measures.

METHODS

 Data of 133 patients who were operated on due to intracranial meningiomas were subjected to a retrospective analysis. The primary outcomes of interest were classical quality indicators such as the 30-day readmission, 30-day reoperation, 30-day mortality, 30-day nosocomial infection, and the 30-day surgical site infection rate. Uni- and multivariate analyses were performed. The occurrence of a new postoperative neurologic deficit was analyzed as a potential new quality indicator.

RESULTS

 The overall unplanned readmission rate was 3.8%; 13 patients were reoperated within 30 days (9.8%). The 30-day nosocomial infection and surgical site infection rates were 6.8 and 1.5%, respectively. A postoperative new neurologic deficit or neurologic deterioration as a currently assessed quality feature was observed in 12 patients (9.2%). The edema volume on preoperative scans proved to have a significant impact on the occurrence of a new postoperative neurologic deficit (p = 0.023).

CONCLUSIONS

 Classical quality indicators in neurosurgery have proved to correlate with considerable deterioration of the patient's health in meningioma surgery and thus should be taken into consideration for application in meningioma patients. The occurrence of a new postoperative neurologic deficit is common and procedure specific. Thus, this should be elucidated for application as a complementary quality indicator in meningioma surgery.

Wide Dissection Trans-Sulcal Approach for Resection of Deep Intra-Axial Lesions in Eloquent Brain Areas

Introduction: Resection of intra-axial tumors (IaT) in eloquent brain regions risks major postoperative neurological deficits. Awake craniotomy is often used to navigate these areas; however, some patients are ineligible for awake procedures. The trans-sulcal approach (TScal) was introduced to reduce parenchymal trauma during tumor resection. We report our experiences utilizing TScal for resection of deep IaT located in eloquent areas. Materials and Methods: This is a single-center retrospective analysis of patients who underwent IaT resection in eloquent areas via TScal from January 2013 to April 2021. Seventeen cases were reviewed, and relevant data was collected. Fluorescence-guided surgery with 5-aminolevulinic acid (ALA) and intraoperative ultrasound was performed in some cases. Results: Seventeen patients (10 males, 7 females) averaging 61.2 years-old (range, 21-76) were included in this study. Average length of stay was 4.8 days, and only 2 patients (11.8%) required hospital readmission within 30 days. Gross total resection (GTR) was achieved in 15 patients (88.2%), while subtotal resection occurred in 2 patients (11.8%). Eleven patients (64.7%) reported full resolution of symptoms, 4 patients (23.5%) reported deficit improvement, and 2 patients (11.8%) experienced no change from their preoperative deficits. No patient developed new permanent deficits postoperatively. Discussion: GTR, preoperative deficit reduction, and complications were comparable to awake craniotomy and other TScal studies. Ancillary intraoperative techniques, such as brain mapping, 5-ALA and intraoperative ultrasound, are afforded by TScal to improve resection rates and overall outcomes. Conclusions: TScal can be an option for patients with deep lesions in eloquent areas who are not candidates for awake surgeries.

Risk Prediction of Central Nervous System Infection Secondary to Intraventricular Drainage in Patients with Intracerebral Hemorrhage: Development and Evaluation of a New Predictive Model Nomogram

BACKGROUND

Currently no reliable tools are available for predicting the risk of central nervous system (CNS) infections in patients with intracerebral hemorrhage after undergoing ventriculostomy drainage. The current study sought to develop and validate a nomogram to identify high-risk factors of CNS infection after ventriculomegaly drain placement for intracerebral hemorrhage.

METHODS

A total of 185 patients with intracerebral hemorrhage who underwent ventriculoperitoneal drainage were enrolled to the current study. Patients were divided into a CNS infection group (20 patients) and a non-CNS infection group (165 patients). The baseline data from both groups was used to develop and evaluate a model for predicting the likelihood of developing CNS infection after ventriculoperitoneal drain placement for intracerebral hemorrhage.

RESULTS

The finding showed that operative time, intraventricular drainage duration, postoperative temperature, white blood cell count in cerebrospinal fluid (CSF), neutrophils ratio in CSF, Red blood cell count in CSF, and glucose content in CSF were correlated with CNS infection. A nomogram for predicting the risk of CNS infection was constructed based on these variables. The c-index and the AUC of the ROC curve was 0.961, showing good discrimination. Clinical decision curve analysis indicated that the nomogram clinical application ranged between 1 and 100%. The clinical impact curve was generated to set with a threshold probability of 0.5.

CONCLUSION

The nomogram reported in the current study can be used by clinicians to identify patients likely to have secondary CNS infections, so that clinicians can better treat these patients at earlier stages.

Statistical Approaches for Quantifying the Quality of Neurosurgical Care

BACKGROUND

Quantifying quality of health care can provide valuable information to patients, providers, and policy makers. However, the observational nature of measuring quality complicates assessments.

METHODS

We describe a conceptual model for defining quality and its implications about the data collected, how to make inferences about quality, and the assumptions required to provide statistically valid estimates. Twenty-one binary or polytomous quality measures collected from 101,051 adult Medicaid beneficiaries aged 18-64 years with schizophrenia from 5 U.S. states show methodology. A categorical principal components analysis establishes dimensionality of quality, and item response theory models characterize the relationship between each quality measure and a unidimensional quality construct. Latent regression models estimate racial/ethnic and geographic quality disparities.

RESULTS

More than 90% of beneficiaries filled at least 1 antipsychotic prescription and 19% were hospitalized for schizophrenia during a 12-month observational period in our multistate cohort with approximately 2/3 nonwhite beneficiaries. Four quality constructs emerged: inpatient, emergency room, pharmacologic/ambulatory, and ambulatory only. Using a 2-parameter logistic model, pharmacologic/ambulatory care quality varied from -2.35 to 1.26 (higher = better quality). Black and Latinx beneficiaries had lower pharmacologic/ambulatory quality compared with whites. Race/ethnicity modified the association of state and pharmacologic/ambulatory care quality in latent regression modeling. Average quality ranged from -0.28 (95% confidence interval, -2.15 to 1.04) for blacks in New Jersey to 0.46 [95% confidence interval, -0.89 to 1.40] for whites in Michigan.

CONCLUSIONS

By combining multiple quality measures using item response theory models, a composite measure can be estimated that has more statistical power to detect differences among subjects than the observed mean per subject.

Enhanced Recovery After Surgery (ERAS) for Cranial Tumor Resection: A Review

Enhanced Recovery After Surgery (ERAS) protocols describe a standardized method of preoperative, perioperative, and postoperative care to enhance outcomes and minimize complication risks surrounding elective surgical intervention. A growing body of evidence is being generated as we learn to apply principles of ERAS standardization to neurosurgical patients. First applied in spinal surgery, ERAS protocols have been extended to cranial neuro-oncological procedures. This review synthesizes recent findings to generate evidence-based guidelines to manage neurosurgical oncology patients with standardized systems and assess ability of these systems to coordinate multidisciplinary, patient-centric care efforts. Furthermore, we highlight the potential utility of multimedia, app-based communication platforms to facilitate patient education, autonomy, and team communication within each of the three settings.

Outcome of Patients with Surgical Site Infection after Craniotomy

Background: The management of surgical site infection (SSI) after craniotomy remains challenging with few existing recommendations. Patients and Methods: We reviewed the medical files of patients who underwent surgery between 2009 and 2018 to manage infection after craniotomy at our tertiary hospital. The Cox proportional hazards model and the Renyi test were used to investigate the association between relapse or all-cause mortality and selected variables. We compared infections with and without intra-cranial involvement using the Fisher test and the Wilcoxon rank sum test. Results: Seventy-seven episodes of infection were identified in 58 patients. The proportion of relapse was estimated to be 32.2% (± standard deviation [SD] 6.9) at five years. Intra-cranial infection was present in 15.6% of the cases (n = 12). Bone flap was removed in the majority of cases (93.5%) and the overall median duration of antibiotic therapy was six weeks (interquartile range [IQR] 6-12 weeks). Staphylococcus aureus was associated with a higher risk of relapse (p = 0.037). The administration of parenteral antibiotic agents (p = 0.012) and bone flap removal (p = 0.0051) were correlated with less relapse. In contrast, immunosuppressive drug use and radiotherapy were correlated with a higher risk of relapse (p = 0.014 and p = 0.031, respectively) and a higher all-cause mortality (p = 0.0093 and p < 0.0001, respectively). We found no difference between infections with and without intra-cranial involvement. Conclusions: Bone flap removal and parenteral antibiotic agents remain important in the management of SSI after craniotomy and were associated with less relapse in our study. More studies are needed to better determine the optimal treatment of this infection.

Length of preoperative hospital stay is the dominating risk factor for surgical site infection in neurosurgery: A cohort data-driven analysis

Background:

The number of days of preoperative hospital stay (PHS) is a modifiable variable that has shown contradictory surgical site infection (SSI) risk factor results in neurosurgery. We sought to pinpoint the day of PHS length related with a marked increase of risk of SSI.

Methods:

From a tertiary teaching hospital, January 2015–December 2017, prospectively collected nonpercutaneous neurosurgery procedures with standard antibiotic prophylaxis and 1-year follow-up were evaluated. SSI risk factors were assessed through multiple logistic regression models with different thresholds of PHS.

Results:

A total of 1012 procedures were included in the study. Incidence of SSI was 4.4%. The median PHS was higher in those with SSI than in those without (1 day, interquartile range [IQR]: 7 vs. 0 days, IQR: 1, respectively, P = 0.002). By the amount of six days of PHS, this exposure risk past the threshold of significance for impact on wound infection (OR 2.8; CI 1.23–6.39, P = 0.014). Operative time past 4 h (OR 2.11; CI 1.12-3.98; P = 0.021), and in some models, previous surgery at same admission were also identified by multivariate analysis as increasing postoperative SSI risk.

Conclusion:

The gradual increase of the SSI OR associated with longer PHS days was the highest risk factor of SSI in our cohort of patients. Studies directed to reduce this complication should consider the PHS.

Nonemergent craniotomy surgical site infection: a retrospective cohort study

Background

The incidence of surgical site infection after craniotomy (SSI-CRAN) varies widely and is associated with major consequences. The aim of this study is to estimate the SSI-CRAN rate at the neurosurgery department of a tertiary center and to establish its risk factors.

Methods

All consecutive adult patients who underwent elective craniotomy for tumor resection at a tertiary center from January 2018 to October 2019 were retrospectively assessed. Demographic, clinical, and surgical data were collected. The main outcome of our study was the development of SSI within 30days postsurgery, as defined by the European Centre for Disease Prevention and Control guidelines. Univariate and multivariate analyses were performed to establish risk factors for SSI-CRAN.

Results

From the 271 patients enrolled in this study, 15 (5.5%) developed SSI-CRAN within 30days postsurgery, 11 (73.3%) of which were organ-space. The most common causative microorganisms isolated were gram-positive cocci, particularly Staphylococcus epidermidis (n = 4, 66.7%). In the univariate analysis, absence of normothermia and cerebrospinal fluid (CSF) leak were associated with SSI-CRAN. In the multivariate analysis, normothermia was the only protective factor and CSF leak was the only independent risk factor for SSI-CRAN.

Conclusion

The cumulative incidence of SSI-CRAN within 30days postsurgery was 5.5%. CSF leak and the absence of normothermia were the only independent risk factors for SSI-CRAN. The data provided in this study should be considered in the design of preventive strategies aimed to reduce the incidence of SSI.

Applicability of contemporary quality indicators in vestibular surgery-do they accurately measure tumor inherent postoperative complications of vestibular schwannomas?

Background

Due to rising costs in health care delivery, reimbursement decisions have progressively been based on quality measures. Such quality indicators have been developed for neurosurgical procedures, collectively. We aimed to evaluate their applicability in patients that underwent surgery for vestibular schwannoma and to identify potential new disease-specific quality indicators.

Methods

One hundred and three patients operated due to vestibular schwannoma were subject to analysis. The primary outcomes of interest were 30-day and 90-day reoperation, readmission, mortality, nosocomial infection and surgical site infection (SSI) rates, postoperative cerebral spinal fluid (CSF) leak, facial, and hearing function. The secondary aim was the identification of prognostic factors for the mentioned primary outcomes.

Results

Thirty-day (90-days) outcomes in terms of reoperation were 10.7% (14.6%), readmission 9.7% (13.6%), mortality 1% (1%), nosocomial infection 5.8%, and SSI 1% (1%). A 30- versus 90-day outcome in terms of CSF leak were 6.8% vs. 10.7%, new facial nerve palsy 16.5% vs. 6.1%. Hearing impairment from serviceable to non-serviceable hearing was 6.8% at both 30- and 90-day outcome. The degree of tumor extension has a significant impact on reoperation (p < 0.001), infection (p = 0.015), postoperative hemorrhage (p < 0.001), and postoperative hearing loss (p = 0.026).

Conclusions

Our data demonstrate the importance of entity-specific quality measurements being applied even after 30 days. We identified the occurrence of a CSF leak within 90 days postoperatively, new persistent facial nerve palsy still present 90 days postoperatively, and persisting postoperative hearing impairment to non-serviceable hearing as potential new quality measurement variables for patients undergoing surgery for vestibular schwannoma.

Bifrontal Osteoplastic Flap: An Option to Decrease Infection in Bifrontal Craniotomies with Skull Base Osteotomies

Infection can be a common complication following bifrontal craniotomy with skull base osteotomies given the potential violation of sinuses and entry into the nasal structures. Our objective was to examine our series of patients who underwent a bifrontal craniotomy with skull base osteotomies and describe the infection rate. We propose the bifrontal osteoplastic flap as an adjunct to infection prevention. A retrospective single-center study of a patient database was performed. Twenty patients were identified. Fifty-five percent were male. The mean age was 55.7 ± 13.9 years. The most common indications for surgery were esthesioneuroblastomas (35%) and anterior skull base meningiomas (30%). Six patients (30%) developed an infection, 1 patient (5%) developed a CSF leak, and no patients developed a mucocele. All 6 infected cases had nasal pathology with intracranial extension, they all received chemoradiation post-operatively and were all combined cases with otorhinolaryngology. Eighty-three percent of these patients required a craniectomy and all of them required long-term IV antibiotics. Infection is not uncommon after a bifrontal craniotomy with skull base osteotomies and the use of the bifrontal osteoplastic flap in cases where the risk of infection is high, i.e., esthesioneuroblastomas surgery, may help reduce said risk and lead to better patient outcomes.

Economic impact of a care bundle to prevent surgical site infection after craniotomy: a cost-analysis study

Background

Surgical site infections after craniotomy (SSI-CRAN) significantly impact patient outcomes and healthcare costs by increasing length of stay and readmission and reoperation rates. However, to our knowledge, no study has yet analysed the economic impact of a surgical care bundle for preventing SSI-CRAN. The aim is to analyse the hospital cost saving after implementation of a care bundle for the prevention of SSI-CRAN.

Methods

A retrospective cost-analysis was performed, considering two periods: pre-care bundle (2013–2015) and care bundle (2016–2017). A bottom-up approach was used to calculate the costs associated with infection in patients who developed a SSI-CRAN in comparison to those who did not, in both periods and on a patient-by-patient basis. The derived cost of SSI-CRAN was calculated considering: (1) cost of the antibiotic treatment, (2) cost of length of stay in the neurosurgery ward within the 1-year follow up period, (3) cost of the re-intervention, and (4) cost of the implant for cranial reconstruction, when necessary.

Results

A total of 595 patients were included in the pre-care bundle period and 422 in the care bundle period. Mean cost of a craniotomy procedure was approximately €8000, rising to €24,000 in the case of SSI-CRAN. Mean yearly hospital costs fell by €502,857 in the care bundle period (€714,886 vs. €212,029). Extra costs between periods were mainly due to increased length of hospital stay (€573,555.3 vs. €183,958.9; difference: €389,596.4), followed by the cost of implant for cranial reconstruction (€69,803.4 vs. €9,936; difference: €59,867.4). Overall, implementation of the care bundle saved the hospital €500,844.3/year.

Conclusion

The implementation of a care bundle for SSI-CRAN had a significant economic impact. Hospitals should consider the deployment of this multimodal preventive strategy to reduce their SSI-CRAN rates, and also their costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13756-021-01016-4.

Classical and disease-specific quality indicators in glioma surgery—Development of a quality checklist to improve treatment quality in glioma patients

Background

There is a pressing demand for more accurate, disease-specific quality measures in the field of neurosurgery. Aiming at most adequately measuring and reflecting the quality of glioma therapy, we developed a novel quality indicator bundle in form of a checklist for all patients that are treated operatively for glioma.

Methods

On the basis of possible glioma-specific quality indicators retrieved from the literature and quality guidelines, a multidisciplinary team developed a checklist containing 13 patient-need-specific outcome measures. Subsequently, the checklist was prospectively applied to a total of 78 patients compared with a control group consisting of 322 patients. A score was generated based on the maximum of quality measures achieved.

Results

Significant improvements in quality after prospectively introducing the checklist were achieved for supplemental physical and occupational therapy during inpatient stay (89.4% vs 100%, P = .002), consultation of a social worker during inpatient stay (64% vs 92.3%, P &lt; .001), psycho-oncological screening (14.3% vs 70.5%, P &lt; .001), psycho-oncological consultation (31.1% vs 82.1%, P &lt; .001), and consultation of the palliative care team (20% vs 40%, P = .031). Overall, after introduction of the checklist one-third (n = 23) of patients reached best-practice measures in all categories, and over half of the patients (n = 44) achieved above 90% with respect to the outcome measures.

Conclusions

Aiming at ensuring comprehensive, consistent, and timely care of glioma patients, the implementation of the checklist for routine use in glioma surgery represents an efficient, easily reproducible, and powerful tool for significant improvements.

The evolving role of neurosurgery for central nervous system metastases in the era of personalized cancer therapy

Recent therapeutic advances involving the use of systemic targeted treatments and immunotherapeutic agents in patients with advanced cancers have translated into improved survival rates. Despite the emergence of such promising pharmacological therapies and extended survival, the frequency of metastases in the central nervous system has steadily increased. Effective medical and surgical therapies are available for many patients with brain metastases and need to be incorporated into multi-disciplinary care protocols. The role of neurosurgeons is evolving within these multi-disciplinary care teams. Surgical resection of brain metastases can provide immediate relief from neurological symptoms due to large lesions and provides the histopathological diagnosis in cases of no known primary malignancy. In situations where immunotherapy is part of the oncological treatment plan, surgery may be proposed for expeditious relief of edema to remove the need for steroids. In patients with multiple brain metastases and mixed response to therapeutics or radiosurgery, tumour resampling allows tissue analysis for druggable targets or to distinguish radiation effects from progression. Ventriculo-peritoneal shunting may improve quality of life in patients with hydrocephalus associated with leptomeningeal tumour dissemination and may allow for time to administer more therapy thus prolonging overall survival. Addressing the limited efficacy of many oncological drugs for brain metastases due to insufficient blood-brain barrier penetrance, clinical trial protocols in which surgical specimens are analysed after pre-surgical administration of therapeutics offer pharmacodynamic insights. Comprehensive neurosurgical assessment remains an integral element of multi-disciplinary oncological care of patients with brain metastases and is integral to tumour biology research and therapeutic advancement.

Are preoperative chlorhexidine gluconate showers associated with a reduction in surgical site infection following craniotomy? A retrospective cohort analysis of 3126 surgical procedures

OBJECTIVE

Surgical site infection (SSI) is a complication linked to increased costs and length of hospital stay. Prevention of SSI is important to reduce its burden on individual patients and the healthcare system. The authors aimed to assess the efficacy of preoperative chlorhexidine gluconate (CHG) showers on SSI rates following cranial surgery.

METHODS

In November 2013, a preoperative CHG shower protocol was implemented at the authors' institution. A total of 3126 surgical procedures were analyzed, encompassing a time frame from April 2012 to April 2016. Cohorts before and after implementation of the CHG shower protocol were evaluated for differences in SSI rates.

RESULTS

The overall SSI rate was 0.6%. No significant differences (p = 0.11) were observed between the rate of SSI of the 892 patients in the preimplementation cohort (0.2%) and that of the 2234 patients in the postimplementation cohort (0.8%). Following multivariable analysis, implementation of preoperative CHG showers was not associated with decreased SSI (adjusted OR 2.96, 95% CI 0.67-13.1; p = 0.15).

CONCLUSIONS

This is the largest study, according to sample size, to examine the association between CHG showers and SSI following craniotomy. CHG showers did not significantly alter the risk of SSI after a cranial procedure.

Pedicle Subtraction Osteotomy for Deformity Correction in the Upper Cervical Spine: A Technical Note

BACKGROUND

 Kyphosis is the most common deformity of the cervical spine leading to development of severe disabilities. In case of fused kyphosis, surgical treatment can be demanding and often requires multiple-step procedures for adequate correction. We present a technique of single-stage pedicle subtraction osteotomy (PSO) of C3 to treat a patient with fused kyphosis of C2 and C3 causing spinal stenosis with subsequent myelopathy.

METHODS

 A 53-year-old man presented with progressive myelopathy not able to walk with 6/18 points on the modified Japanese Orthopedic Association scale. Horizontal gaze was lost due to cervical kyphosis. Magnetic resonance imaging (MRI) revealed a cervical kyphosis causing stenosis, cord compression, and kinking; computed tomography (CT) showed substantial anterior and posterior fusion of C2 and C3.

RESULTS

 Surgery included decompression via laminectomy of C2 to C6 in combination with PSO of C3 and additional dorsal instrumentation of C2 to C6. Cervical spinal alignment was corrected, as the C2-C4 Cobb angle was reduced from 48.9 to 20.6 degrees. Horizontal gaze was restored. Postoperative MRI demonstrated full decompression of the cord without kinking of the vertebral arteries. No complications were noted. The patient recovered well with restoration of his ability to walk.

CONCLUSION

 Single-stage pedicle subtraction closing wedge osteotomy in the upper cervical spine, although a demanding surgical procedure, is an alternative treatment option in selected cases of fused and severe cervical kyphosis. In contrast to multiple-step approaches, the single-stage procedure could reduce operating time and may thus decrease complications.

Applications of materials for dural reconstruction in pre-clinical and clinical studies: Advantages and drawbacks, efficacy, and selections

The dura mater provides a barrier to protect the tissue underneath and cerebrospinal fluid. However, dural defects normally cause cerebrospinal fluid leakage and other complications, such as wound infections, meningitis, etc. Therefore, the reconstruction of dura mater has important clinical significance. Current dural reconstruction materials include: homologous, acellular, natural, synthetic, and composite materials. This review comprehensively summarizes the characteristics and efficacy of these dural substitutes, especially in clinical applications, including the advantages and drawbacks of those from different sources, the host tissue response in pre-clinical studies and clinical practice, and the comparison of these materials across different surgical procedures. Furthermore, the selections of materials for different surgical procedures are highlighted. Finally, the challenges and future perspectives in the development of ideal dural repair materials are discussed.

A Care Bundle Intervention to Prevent Surgical Site Infections after a Craniotomy

BACKGROUND

Although surgical site infections after a craniotomy (SSI-CRAN) are a serious problem involving significant morbidity and costs, information on their prevention is scarce. We aimed to assess whether the implementation of a care bundle was effective in preventing SSI-CRANs.

METHODS

A historical control study was used to evaluate the care bundle, which included a preoperative shower with 4% chlorhexidine soap, appropriate hair removal, adequate preoperative systemic antibiotic prophylaxis, the administration of 1 g of vancomycin powder into the subgaleal space before closing, and a post-operative dressing of the incisional surgical wound with a sterile absorbent cover. Patients were divided into 2 groups: pre-intervention (January 2013 to December 2015) and intervention (from January 2016 to December 2017). The primary study endpoint was the incidence of SSI-CRANs within a year post-surgery. Propensity score matching was performed and differences between the two study periods were assessed using Cox regression models.

RESULTS

A total of 595 and 422 patients were included in the pre-intervention and intervention periods, respectively. The incidence of SSI-CRANs was lower in the intervention period (15.3% vs. 3.5%; p < 0.001). Using a propensity score model, 421 pairs of patients were matched. The care bundle intervention was independently associated with a reduced incidence of SSI-CRANs (AOR: 0.23, 95% CI: 0.13-0.40; p < 0.001).

CONCLUSION

The care bundle intervention was effective in reducing SSI-CRAN rates. The implementation of this multimodal preventive strategy should be considered in centers with high SSI-CRAN incidences.

Neurosurgical Post-Operative Wound Infections: A retrospective study on surgical site infections for quality improvement

Despite efforts to maintain a meticulous aseptic environment, wound infection is one of the most common complications following surgery and may be related to dehiscence, haemorrhage, infection, and/or poor surgical technique. With the appearance of new wound closure techniques and suture materials, we felt compelled to perform a retrospective study on our institution's neurosurgical population to determine how our institution compared to others in terms of incidence of surgical site infection (SSI). A retrospective analysis was performed at our single institution for all patients that had cranial or spine surgery by a neurosurgeon for the past 15 years. The data were extracted via Crimson Continuum of Care software program and analysed using χ² and relative risk. The data retrieval software program collected a total of 1184 cranial and spinal surgeries. Of these 1184 cases, 12 resulted in post-operative wound infections. Using these collected values, we compared the results with published values in the literature. Prior studies have shown that up to 33% of surgical cases have post-operative infections. Using this reported value in comparison with our data, χ² testing equals 547.893 with 1 df, P = .0001 (confidence interval = 0.05), which demonstrated statistical significance when compared with surgical literature. The results from this retrospective analysis demonstrated that the rate of neurosurgical post-operative SSI falls within the range consistent with the literature, which has shown rates of infection from <1% up to 15% depending on the type of surgery, surgical technique, and patient characteristics. SSIs can be an unfortunate and costly post-operative complication. Risks factors in the past have been studied, but introspection by each institution is an important metric to ensure accountability and provide optimal patient care in comparison with established data and guidelines. No deviation from current techniques is deemed necessary at our institution based on the results.

Hair-sparing technique using absorbable intradermal barbed suture versus traditional closure methods in supratentorial craniotomies for tumor

BACKGROUND

Hair-sparing techniques in cranial neurosurgery have gained traction in recent years and previous studies have shown no difference in infection rates, yet limited data exists evaluating the specific closure techniques utilized during hair-sparing craniotomies. Therefore, it was the intention of this study to evaluate the rate of surgical site infections (SSIs) and perioperative complications associated with using an absorbable intradermal barbed suture for skin closure in hair-sparing supratentorial craniotomies for tumor in order to prove non-inferiority to traditional methods.

METHODS

A retrospective review of supratentorial craniotomies for tumor by a single surgeon from 2011 to 2017 was performed. All perioperative adverse events and wound complications, defined as a postoperative infection, wound dehiscence, or CSF leak, were compared between three different groups: (1) hair shaving craniotomies + transdermal polypropylene suture/staples for scalp closure, (2) hair-sparing craniotomies + transdermal polypropylene suture/staples for scalp closure, and (3) hair-sparing craniotomies + absorbable intradermal barbed suture for scalp closure.

RESULTS

Two hundred sixty-three patients underwent hair shaving + transdermal polypropylene suture/staples, 83 underwent hair sparing + transdermal polypropylene suture/staples, and 100 underwent hair sparing + absorbable intradermal barbed suture. Overall, 2.9% of patients experienced a perioperative complication and 4.3% developed a wound complication. In multivariable analysis, the use of a barbed suture for scalp closure and hair-sparing techniques was not predictive of any complication or 30-day readmission. Furthermore, the absorbable intradermal barbed suture cohort had the lowest overall rate of wound complications (4%).

CONCLUSIONS

Hair-sparing techniques using absorbable intradermal barbed suture for scalp closure are safe and do not result in higher rates of infection, readmission, or reoperation when compared with traditional methods.

Development and validation of prediction scores for nosocomial infections, reoperations, and adverse events in the daily clinical setting of neurosurgical patients with cerebral and spinal tumors

OBJECTIVE

Various quality indicators are currently under investigation, aiming at measuring the quality of care in neurosurgery; however, the discipline currently lacks practical scoring systems for accurately assessing risk. The aim of this study was to develop three accurate, easy-to-use risk scoring systems for nosocomial infections, reoperations, and adverse events for patients with cerebral and spinal tumors.

METHODS

The authors developed a semiautomatic registry with administrative and clinical data and included all patients with spinal or cerebral tumors treated between September 2017 and May 2019. Patients were further divided into development and validation cohorts. Multivariable logistic regression models were used to develop risk scores by assigning points based on β coefficients, and internal validation of the scores was performed.

RESULTS

In total, 1000 patients were included. An unplanned 30-day reoperation was observed in 6.8% of patients. Nosocomial infections were documented in 7.4% of cases and any adverse event in 14.5%. The risk scores comprise variables such as emergency admission, nursing care level, ECOG performance status, and inflammatory markers on admission. Three scoring systems, NoInfECT for predicting the incidence of nosocomial infections (low risk, 1.8%; intermediate risk, 8.1%; and high risk, 26.0% [p < 0.001]), LEUCut for 30-day unplanned reoperations (low risk, 2.2%; intermediate risk, 6.8%; and high risk, 13.5% [p < 0.001]), and LINC for any adverse events (low risk, 7.6%; intermediate risk, 15.7%; and high risk, 49.5% [p < 0.001]), showed satisfactory discrimination between the different outcome groups in receiver operating characteristic curve analysis (AUC ≥ 0.7).

CONCLUSIONS

The proposed risk scores allow efficient prediction of the likelihood of adverse events, to compare quality of care between different providers, and further provide guidance to surgeons on how to allocate preoperative care.

The rise of quality indicators in neurosurgery: 30-day unplanned reoperation rate evaluated in 3760 patients-a single-center experience

OBJECTIVE

Quality indicators are emerging as tools to evaluate health care outcomes. Few studies have evaluated indicators suitable for neurosurgery so far. Among others, reoperation rate has been suggested as a possible indicator. We aimed to evaluate the reoperation rate in a large neurosurgery adult collective.

METHODS

In this exploratory post hoc analysis, we evaluated all patients operated in our service for elective and emergency surgery between January 2014 and May 2016. Planned and unplanned reoperations were filtered and a quantitative analysis, including uni- and multivariate analyses, was performed.

RESULTS

A total of 3760 patients were included in this evaluation. From 378 reoperated patients within 30 days (10.1%), 51 underwent planned procedures (1.4%). Three hundred twenty-seven patients (8.7%) represented the analyzed collective of patients having undergone unplanned surgical procedures, causing a total of 409 from 4268 additional procedures (9.6%). Early unplanned 7-day reoperation rate was 4.5% (n = 193), occurring in 4.5% of patients (n = 193). Postoperative hemorrhage (n = 107, 26.2%) and external ventricle drainage-associated infections or dislocation (n = 105, 25.7 %) were the most common indication for unplanned surgery.

CONCLUSION

Unplanned re-operation rate of a neurosurgical service can help to internally evaluate health care outcome and improve quality of care. Benchmarking with this indicator however is not recommendable as results can vary distinctly due to the heterogenic patient collective of each institution. We expect unplanned reoperation rates to be higher in large university hospitals and tertiary centers with complex cases, as compared to center with less complex cases treating patients with lower morbidity. In this study, we deliver an authentic portrait of a large neurosurgical center in Germany.

Surgical Closed Suction Drain Use After Craniotomy for Evacuation of Supratentorial Epidural Hematomas: A Case Series of Radiographic and Clinical Outcomes

BACKGROUND

Surgical closed suction drain (SCSDs) are used in a variety of surgical disciplines to prevent postoperative fluid collections. Use of SCSDs has not been well studied in the neurosurgical literature. Practice patterns have varied within our institution with respect to SCSDs after craniotomies for neurotrauma. In this study we describe SCSD use for patients undergoing evacuation of supratentorial epidural hematomas (EDHs) and examine the effect on patient outcomes and length of hospital stay.

METHODS

We performed a retrospective review of craniotomies for supratentorial EDH performed at our Level I trauma center between May 2015 and May 2018. Imaging and clinical data were obtained from chart review.

RESULTS

Fifty-two patients with EDH received operations from 8 attending surgeons. The number of drains used was 0 or 1 in 36 cases and 2 or more in 16 cases. Drain location was subgaleal in 25 cases, epidural in 8 cases, and both subgaleal and epidural in 13 cases. Attending preference (P < 0.001) but not hematoma size was associated with use of an epidural drain and use of 2 or more drains. After controlling for age, initial neurologic exam, and presence of other injuries, use of more drains was associated with longer intensive care unit lengths of stay. Drain use pattern was not associated with patient outcome measures, and no return to the operating room was necessary for residual or recurrent EDH.

CONCLUSIONS

Use of fewer SCSDs did not affect radiographic outcome after evacuation of epidural hematomas but was associated with decreased intensive care unit length of stay.

Intradermal Scalp Closure Using Barbed Suture in Cranial Tumor Surgeries: A Technical Note

BACKGROUND AND IMPORTANCE

Traditional scalp closure technique following elective craniotomy involves placement of staples or a continuous running suture. Despite low complication rates, these techniques are often considered to be disfiguring by patients, contribute to the psychosocial trauma of brain surgery, and are associated with discomfort during postoperative staple or suture removal. Some authors have described scalp closure using intradermal absorbable suture, but this technique likely does not reach the tensile strength of closure using traditional methods, and requires knots at the apices of the incision, which can act as a nidus for infection.

CLINICAL PRESENTATION

We employed a barbed intradermal closure method in supratentorial elective craniotomies for tumor resection. Complication rates were recorded, and cosmetic outcomes were informally assessed. Intradermal closure with barbed sutures was utilized in 76 patients. At the 2-wk postoperative clinic visit, cosmetic outcomes were excellent in all cases. There was 1 superficial wound infection that presented 6 wk after a pterional craniotomy for low-grade glioma. This resolved with superficial wound revision and oral antibiotic therapy.

CONCLUSION

We present a novel scalp closure technique for craniotomies using intradermal barbed Monocryl suture. We have had excellent cosmetic outcomes, and the infection rate of 1.3% compares favorably to published rates. Further studies are required to quantify the improvement in patient satisfaction compared to conventional closure methods.

The use of dehydrated amniotic membrane allograft for augmentation of dural repair in transsphenoidal endoscopic endonasal resection of pituitary adenomas

BACKGROUND

In transsphenoidal endoscopic endonasal surgery (TEES), watertight separation of the sinonasal cavity and intracranial compartment is the primary goal of closure. However, even when meticulous closure technique is implemented, cerebrospinal fluid (CSF) leaks, dural scarring, and meningitis may result. Particularly when intraoperative CSF leak occurs, materials that facilitate the creation of a watertight seal that inhibits disease transition and minimizes inflammatory response after durotomy are sought. Dehydrated amniotic membrane (DAM) allograft appears to confer these attributes as studies have shown it augments epithelialization, facilitates wound healing, and minimizes and impedes bacterial growth. We detail the use of DAM allograft to augment sellar closures after TEES.

METHODS

We conducted a feasibility study, retrospectively reviewing our institution's database of TEES for resection of pituitary adenomas in which DAM was utilized to supplement sellar closure.

RESULTS

One hundred twenty transsphenoidal surgery cases with DAM were used during sellar closure, with a 49.2% intraoperative CSF leak rate. Of this cohort, two patients experienced postoperative CSF leak (1.7%), and no patients developed meningitis. CSF leak rate for TEES-naïve patients was 0.9%.

CONCLUSIONS

This feasibility study demonstrates that dehydrated amniotic membrane allograft can be safely utilized as an adjunct during sellar closures for TEES for pituitary adenoma resection with very low rates of CSF leak and meningitis.

Standard Free Versus Osteoplastic Craniotomy: Assessment of Complication Rates During Intracranial Electroencephalogram Electrode Placement for Seizure Localization

OBJECTIVE

Patients with medically intractable epilepsy often undergo sequential surgeries and are therefore exposed to an elevated risk for infection, resulting in unanticipated returns to the operating room. The goal of our study was to determine whether use of an osteoplastic bone flap technique would reduce the infection rate in these patients.

METHODS

A single-institution, retrospective chart review of patients with medically intractable epilepsy for grid placement was performed. Univariate analyses and linear regression were used to assess primary outcomes, including infection and hematomas requiring surgical evacuation. Secondary outcomes included duration of treatment and other, unanticipated surgeries.

RESULTS

A total of 199 patients were identified, 56 (28%) with osteoplastic flaps. Standard free flaps were associated with an increased rate of infection at the craniotomy site (n = 24, 17%, vs. 0, 0%, P = 0.003), whereas osteoplastic flaps were associated with more returns to operating room for hematoma evacuation (n = 5, 9% vs. 3.2%, P = 0.024). Overall, the rate of return to operating room for unanticipated surgeries was similar, but infectious complications prolonged the duration of treatment (median: 17 days vs. 2 days, χ² = 13.97, P < 0.001).

CONCLUSIONS

Osteoplastic bone flaps markedly decreased the risk of craniotomy infections compared with free flaps in patients undergoing sequential surgeries. This decrease is offset, however, by an increase in intracranial hematoma requiring return to the operating room. Infection appeared to be a more significant complication as it was associated with increased duration of treatment. The osteoplastic technique is especially appealing in those patients likely to undergo multiple surgeries in short succession.

Risk factors for surgical site infection after craniotomy: a prospective cohort study

Background

Although surgical site infection after craniotomy (SSI-CRAN) is a serious complication, risk factors for its development have not been well defined. We aim to identify the risk factors for developing SSI-CRAN in a large prospective cohort of adult patients undergoing craniotomy.

Methods

A series of consecutive patients who underwent craniotomy at a university hospital from January 2013 to December 2015 were prospectively assessed. Demographic, epidemiological, surgical, clinical and microbiological data were collected. Patients were followed up in an active post-discharge surveillance programm e for up to one year after surgery. Multivariate analysis was carried out to identify independent risk factors for SSI-CRAN.

Results

Among the 595 patients who underwent craniotomy, 91 (15.3%) episodes of SSI-CRAN were recorded, 67 (73.6%) of which were organ/space. Baseline demographic characteristics were similar among patients who developed SSI-CRAN and those who did not. The most frequent causative Gram-positive organisms were Cutibacterium acnes (23.1%) and Staphylococcus epidermidis (23.1%), whereas Enterobacter cloacae (12.1%) was the most commonly isolated Gram-negative agent. In the univariate analysis the factors associated with SSI-CRAN were ASA score > 2 (48.4% vs. 35.5% in SSI-CRAN and no SSI-CRAN respectively, p = 0.025), extrinsic tumour (28.6% vs. 19.2%, p = 0.05), and re-intervention (4.4% vs. 1.4%, p = < 0.001). In the multivariate analysis, ASA score > 2 (AOR: 2.26, 95% CI: 1.32–3.87; p = .003) and re-intervention (OR: 8.93, 95% CI: 5.33–14.96; p < 0.001) were the only factors independently associated with SSI-CRAN.

Conclusion

The risk factors and causative agents of SSI-CRAN identified in this study should be considered in the design of preventive strategies aimed to reduce the incidence of this serious complication.

Electronic supplementary material

The online version of this article (10.1186/s13756-019-0525-3) contains supplementary material, which is available to authorized users.

Adverse events in brain tumor surgery: incidence, type, and impact on current quality metrics

BACKGROUND

The aim of the study was to determine pre-operative factors associated with adverse events occurring within 30 days after neurosurgical tumor treatment in a German center, adjusting for their incidence in order to prospectively compare different centers.

METHODS

Adult patients that were hospitalized due to a benign or malignant brain were retrospectively assessed for quality indicators and adverse events. Analyses were performed in order to determine risk factors for adverse events and reasons for readmission and reoperation.

RESULTS

A total of 2511 cases were enrolled. The 30 days unplanned readmission rate to the same hospital was 5.7%. The main reason for readmission was tumor progression. Every 10th patient had an unplanned reoperation. The incidence of surgical revisions due to infections was 2.3%. Taking together all monitored adverse events, male patients had a higher risk for any of these complications (OR 1.236, 95%CI 1.025-1.490, p = 0.027). Age, sex, and histological diagnosis were predictors of experiencing any complication. Adjusted by incidence, the increased risk ratios greater than 10.0% were found for male sex, age, metastatic tumor, and hemiplegia for various quality indicators.

CONCLUSIONS

We found that most predictors of outcome rates are based on preoperative underlying medical conditions and are not modifiable by the surgeon. Comparing our results to the literature, we conclude that differences in readmission and reoperation rates are strongly influenced by standards in decision making and that comparison of outcome rates between different health-care providers on an international basis is challenging. Each health-care system has to develop own metrics for risk adjustment that require regular reassessment.

Second-look strokectomy of cerebral infarction areas in patients with severe herniation

OBJECTIVE

Decompressive craniectomies (DCs) are performed on patients suffering large cerebral infarctions. The efficacy of this procedure has been demonstrated in several trials. In some cases, however, this procedure alone is not sufficient and patients still suffer refractory elevations of intracranial pressure (ICP). The goal of this study was to determine whether resection of infarcted tissue, termed strokectomy, performed as a second-look procedure after DC, improves outcome in selected cases.

METHODS

The authors retrospectively evaluated data of patients who underwent a DC due to a cerebral infarction at their institution from 2009 to 2016, including patients who underwent a strokectomy procedure after DC. Clinical records, imaging data, outcome scores, and neurological symptoms were analyzed, and clinical outcomes and mortality rates in the strokectomy group were compared to those for similar patients in recently published randomized controlled trials.

RESULTS

Of 198 patients who underwent DC due to cerebral infarction, 12 patients underwent strokectomy as a second surgical procedure, with a median National Institutes of Health Stroke Scale (NIHSS) score of 19 for patients with versus 16 for those without secondary strokectomy (p = 0.029). Either refractory increases of ICP > 20 mm Hg or dilated pupils in addition to herniation visible on CT images were triggers for strokectomy surgery. Ten of 12 (83%) patients had infarctions in more than one territory (p < 0.001). After 12 months, 43% of patients had a good outcome according to the modified Rankin Scale (mRS) score (≤ 3). In the subgroup of patients suffering infarctions in more than one vascular territory, functional outcome after 12 months was better (mRS ≤ 3 in 40% of patients in comparison to 9%; p = 0.027). A 1:3 case-control analysis matched to age, side of infarction, sex, and vascular territory confirmed these results (mRS ≤ 3, 42% in comparison to 11%; p = 0.032). Age, NIHSS score on admission, and number of vascular territories involved were identified as risk factors in multivariate analysis (p < 0.05). Patients in the strokectomy group had more infections (p < 0.001). According to these results, the authors developed a scale (Münster Stroke Score, 0-6 points) to predict whether patients might benefit from additional strokectomy. Receiver-operating characteristic (ROC) curve analysis revealed an area under the curve (AUC) of 0.86 (p < 0.001). The authors recommend a Münster Stroke Score of ≥ 3 as a cutoff, with a sensitivity of 92% and specificity of 66%, for predicting benefit from strokectomy.

CONCLUSIONS

In this study in comparison to former studies, mortality rates were lower and clinical outcome was comparable to that of previously published trials regarding large cerebral infarctions. Second surgery including strokectomy may help achieve better outcomes, especially in cases of infarction of more than one vascular territory.

The implementation of an infection prevention bundle reduces surgical site infections following cranial surgery

BACKGROUND

The benefit of an infection prevention bundle made up of five basic procedures to avoid surgical site infections (SSIs) following cranial surgery was evaluated.

METHODS

Data from all patients with first time elective brain surgery from March 2014 till May 2016 were analyzed. In April 2015, an infection prevention bundle was implemented. The rate of SSIs after first time elective cranial surgery of patients operated 1 year before and 1 year after the implementation was compared.

RESULTS

Of the 321 cases operated before the implementation of the infection prevention bundle, 13 cases (4%) developed a SSI. After the implementation, only 6 patients out of 288 were re-operated due to a SSI (2%). The most frequent etiological germ cultivated was Staphylococcus aureus.

CONCLUSION

The implementation of a bundle of 5 basic infection prevention steps leads to a clinical relevant reduction of SSIs.

Conscious sedation with dexmedetomidine compared with asleep-awake-asleep craniotomies in glioma surgery: an analysis of 180 patients

OBJECTIVE

Awake craniotomies have become a feasible tool over time to treat brain tumors located in eloquent regions. Different techniques have been applied in neurooncology centers. Both “asleep-awake-asleep” (asleep) and “conscious sedation” were used subsequently at the authors’ neurosurgical department. Since 2013, the authors have only performed conscious sedation surgeries, predominantly using the α2-receptor agonist dexmedetomidine as the anesthetic drug. The aim of this study was to compare both mentioned techniques and evaluate the clinical use of dexmedetomidine in the setting of awake craniotomies for glioma surgery.

METHODS

The authors retrospectively analyzed patients who underwent operations either under the asleep condition using propofol-remifentanil or under conscious sedation conditions using dexmedetomidine infusions. In the asleep group patients were intubated with a laryngeal mask and extubated for the assessment period. Adverse events, as well as applied drugs with doses and frequency of usage, were recorded.

RESULTS

From 224 awake surgeries between 2009 and 2015, 180 were performed for the resection of gliomas and included in the study. In the conscious sedation group (n = 75) significantly fewer opiates (p < 0.001) and vasoactive (p < 0.001) and antihypertensive (p < 0.001) drugs were used in comparison with the asleep group (n = 105). Furthermore, the postoperative length of stay (p < 0.001) and the surgical duration (p < 0.001) were significantly lower in the conscious sedation group.

CONCLUSIONS

Use of dexmedetomidine creates excellent conditions for awake surgeries. It sedates moderately and acts as an anxiolytic. Thus, after ceasing infusion it enables quick and reliable clinical neurological assessment of patients. This might lead to reducing the amount of administered antihypertensive and vasoactive drugs as well as the length of hospitalization, while likely ensuring more rapid surgery.

The evolution of cranial meningioma surgery-a single-center 25-year experience

BACKGROUND

There have been major developments in diagnostic and surgical and non-surgical techniques used in the management of meningiomas over last three decades. We set out to describe these changes in a systematic manner.

METHOD

Clinical and radiological data, surgical procedures, complications, and outcome of 817 patients who underwent surgery for primarily diagnosed meningioma between 1991 and 2015 were investigated.

RESULTS

Median age at diagnosis increased significantly from 56 to 59 years (p = .042), while tumor location and preoperative Karnofsky performance status did not change during the observation period. Availability of preoperative MRI increased, and rates of angiography and tumor embolization decreased (p < .001, each). Median duration of total, pre-, and postoperative stay was 13, 2, and 9 days, respectively, and decreased between 1991 and 2015 (p < .001, each). Median incision-suture time varied annually (p < .001) but without becoming clearly longer or shorter during the entire observation period. The use of intraoperative neuronavigation and neuromonitoring increased, while the rates of Simpson grade I and III surgeries decreased (p < .001). Rates of postoperative hemorrhage (p = .997), hydrocephalus (p = .632), and wound infection (p = .126) did not change, while the frequency of early postoperative neurological deficits decreased from 21% between 1991 and 1995 to 13% between 2011 and 2015 (p = .003). During the same time, the rate of surgeries for postoperative cerebrospinal fluid leakage slightly increased from 2 to 3% (p = .049). Within a median follow-up of 62 months, progression was observed in 114 individuals (14%). Progression-free interval did not significantly change during observation period (p > .05). Multivariate analyses confirmed the lack of correlation between year of surgery and tumor relapse (HR: 1.1, p > .05).

CONCLUSIONS

Preoperative diagnosis and surgery of meningiomas have been substantially evolved. Although early neurological outcome has improved, long-term prognosis remains unchanged.

The use of dehydrated amniotic membrane allograft for augmentation of dural closure in craniotomies and endoscopic endonasal transphenoidal surgeries

BACKGROUND

Primary watertight dural closure is the preferred method of postcraniotomy dural repair. However, even when ideal technique is implemented, postoperative infection, cerebrospinal fluid (CSF) leaks, pseudomeningoceles, and dural scarring are possible complications. For this reason, materials that augment the dura's ability to create a watertight seal, prevent disease transmission, and inhibit inflammatory response are sought. Dehydrated amniotic membrane (DAM) allograft appears to fulfil these requirements as it has several beneficial properties that aid wound healing, including promotion of epithelialization, scar tissue prevention, and inhibition of bacterial growth. We provide the literature's first description of the use of DAM allograft to supplement dural closures for craniotomies and transsphenoidal surgeries.

METHODS

We conducted a pilot study, retrospectively reviewing our institution's database of craniotomies and transsphenoidal surgeries that utilized DAM to augment dural closure.

RESULTS

One hundred fifty-five cases, including 102 new craniotomies for supratentorial lesions, one re-do craniotomy for supratentorial recurrent glioma, 18 craniotomies for infratentorial lesions, 1 craniotomy for anterior skull base schwannoma, 32 transphenoidal surgeries, and 1 combined craniotomy and transnasal endoscopic surgery, used DAM allograft to augment dural closure. Only one complication occurred (0.6% complication rate), which was a superficial wound infection requiring washout without craniectomy. No CSF leaks occurred.

CONCLUSIONS

This pilot study demonstrates that dehydrated amniotic membrane allograft can be safely utilized as an adjunct during dural closures for craniotomies and transsphenoidal surgeries.

What interventions are performed in daily practice to prevent surgical site infections in neurosurgical patients? Findings from an explorative survey

Aim

The primary aim of the study was to describe the perioperative care ensured on a daily basis to prevent surgical site infection in Italian neurosurgeries; the secondary aim was to explore surgical site infections 30 days after the surgical procedures.

Methods

Patients cared for in 16 neurosurgical units who (a) were ≥18 years of age, (b) underwent neurosurgical procedures, and (c) were willing to participate in the study were taken into account.

Results

A total of 383 patients were included. A preoperative shower was performed in 332 cases (86.7%), shaving in 318 (83%) cases, and antibiotic prophylaxis was administered in 293 (76.5%) cases. Surgical site disinfection was performed mainly with povidone–iodine (344; 89.8%). A surgical site dressing was applied in 376 (98.2%) cases and was changed on average after 37.8h for shaved and 39h for non-shaved patients. Postoperative shampooing was performed only in 74 (19.3%) cases. Surgical site infection at 30 days occurred in three (0.8%) patients. Discussion and conclusions: Perioperative care aimed at preventing surgical site infections is variable across Italian neurosurgical units. More studies aimed at developing evidence capable of supporting decision-making processes in neurosurgery care are strongly recommended.

The Use of Dehydrated Amniotic Membrane Allograft for the Augmentation of Dural Repair in Craniotomies

Background: In cranial neurosurgery, primary watertight dural closure is the standard method of post-craniotomy dural repair. However, cerebrospinal fluid (CSF) leaks, pseudomeningoceles, postoperative infections, and dural scarring are possible complications, even when a meticulous technique is implemented. For this reason, materials that enhance the dura’s ability to create a watertight seal, inhibit the inflammatory response, and prevent disease transmission are sought. Dehydrated amniotic membrane (DAM) allograft appears to facilitate these properties, as studies have shown that it improves wound healing, prevents scar tissue formation, promotes epithelialization, and inhibits bacterial growth. We detail the use of a DAM allograft to augment dural closures for craniotomies.

Methods: We conducted a pilot study, retrospectively reviewing our institution’s database of craniotomies that utilized DAM to supplement dural closure.

Results: A total of 122 cases, including 18 initial craniotomies for infratentorial lesions, 102 initial craniotomies for supratentorial lesions, one re-do craniotomy for supratentorial recurrent glioma, and one craniotomy for an anterior skull base schwannoma used a DAM allograft to augment dural closure. Only one complication occurred (0.8% complication rate), which was a superficial wound infection requiring washout without craniectomy. No CSF leaks occurred.

Conclusions: This pilot study demonstrates that dehydrated amniotic membrane allograft can be safely utilized as an adjunct during dural closures for craniotomies.

Incidence and risk factors of neurosurgical site infections: results of a prospective multicenter cohort study on 6359 surgeries

BACKGROUND

Neurosurgical surgical site infections (SSI) are life-threatening complications, requiring medical treatment and additional surgeries and remain a substantial cause of morbidity. In order to identify the incidence and the main risk factors for SSI, we developed the Prophylaxis with Antibiotic Protocol for Neurosurgical Site Infections Study (PASSIS), a prospective observational multicenter cohort study for examining a large number of neurosurgical procedures.

METHODS

The study PASSIS involved four Italian departments of neurosurgery applying the same antibiotic prophylaxis (ABP) protocol on 6359 consecutive neurosurgical procedures. In high-risk conditions (intra-operative contamination and/or postoperative cerebro-spinal fluid [CSF], and/or subcutaneous drainage and/or postoperative hyperpyrexia) and in presence of wound complication (CSF leak and/or CSF collection and/or wound diastasis), a prolongation protocol was prescribed.

RESULTS

The crude rate of SSI in the whole series was and 1.7% for patient and 1.5% for procedure. Patient related SSI risk factors: Younger patients (≤14 years) had a significantly higher SSI risk compared with older patients (RR: 2.17; 95% CI: 1.13-4.14). Patients underwent two surgeries were at increased SSI risk (RR: 3.80; 95% CI: 2.33-6.18), and the risk increased with the number of surgeries. Surgeries lasting longer than 3 hours (RR: 2.27; 95% CI: 1.15-4.50), undergoing two or more surgeries and the presence of prosthetic implants (RR: 2.40; 95% CI: 1.53-3.77) were procedure related SSI risk factors positively associated with SSI. In high-risk conditions and in wound complication as defined previously, ABP prolongation showed limited efficacy (RR:1.97; 95% CI: 1.21-3.22 and 9.31; 95% CI: 5.90-14.68 respectively).

CONCLUSIONS

The subjects submitted to complicated, repeated, long lasting craniotomies, especially if experiencing postoperative deterioration, display the higher risk of SSIs, as a final life-threatening complication. In order to reduce the SSI rate, further studies should address to design tailored prophylaxis protocols for each high risk situation as hereby defined; the wound complications deserve an increased microbiological surveillance, focusing the attention on the timing and source of infections.

Regression of Pineal Lesions: Spontaneous or Iatrogenic? A Case Report and Systematic Literature Review

BACKGROUND

Tumors arising from the pineal region account for approximately 1% of intracranial neoplasms. We present a case of a previously healthy 5-year-old boy with an acute onset of headache. A magnetic resonance imaging (MRI) scan showed a pineal mass with aqueduct compression. The patient was scheduled for tumor resection. An endoscopic third ventriculostomy was performed in advance for the treatment of hydrocephalus. Afterwards, MRI showed a relevant regression of the pineal mass without specific treatment. Consequently, surgery was cancelled and further MRI follow-up showed a regression of the mass and a constant tumor mass over a period of 30 months. Spontaneous regression of malignant tumors is a rare phenomenon with an incidence of 1 of 60,000-100,000 cases. Only a few cases with spontaneous regression of pineal tumors have been reported.

METHODS

We performed a systematic literature review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines on spontaneously regressing pineal lesions and found 13 cases in the literature.

RESULTS

Six hypotheses for explaining tumor regression were found, comprising treatment with steroids, effects of diagnostic irradiation, treatment of hydrocephalus, pineal apoplexy, surgical trauma, and immunologic mechanisms. None of these mechanisms was evidentiary. However, in all reported cases, some kind of treatment (e.g. treatment of hydrocephalus, application of steroids, and so on) has been performed before tumor regression.

CONCLUSIONS

The clinician has to bear in mind that regression of pineal tumors might be triggered by use of steroids, for example, and in cases of improvement of the patient's presenting symptoms, new MRI scans should be performed.