Clinical impact of early CT scans after lateral skull-base surgery

Routine postoperative computed tomography scan after craniotomy: systematic review and evidence-based recommendations

Over the last few years, the role of early postoperative computed tomography (EPOCT) after cranial surgery has been repeatedly questioned, but there is yet no consensus on the practice. We conducted a systematic review to address the usefulness of EPOCT in association with neurological examination after elective craniotomies compared to the neurological examination alone. Studies were eligible if they provided information about the number of patients scanned, how many were asymptomatic or presented neurological deterioration before the scan and how many of each of those groups had their management changed due to imaging findings. CTs had to be performed in the first 48 h following surgery to be considered early. Eight studies were included. The retrospective studies enrolled a total of 3639 patients, with 3737 imaging examinations. Out of the 3696 CT scans performed in asymptomatic patients, less than 0.8% prompted an intervention, while 100% of patients with neurological deterioration were submitted to emergency surgery. Positive predictive values of altered scans were 0.584 for symptomatic patients and 0.125 for the asymptomatic. The number of altered scans necessary to predict (NNP) one change in management for the asymptomatic patients was 8, while for the clinically evident cases, it was 1.71. The number of scans needed to diagnose one clinically silent alteration is 134.75, and postoperative imaging of neurologically intact patients is 132 times less likely to issue an emergency intervention than an altered neurological examination alone. EPOCT following elective craniotomy in neurologically preserved patients is not supported by current evidence, and CT scanning should be performed only in particular conditions. The authors have developed an algorithm to help the judgment of each patient by the surgeon in a resource-limited context.

International practice variation in postoperative imaging of chronic subdural hematoma patients

OBJECTIVE

The value of CT scanning after burr hole surgery in chronic subdural hematoma (CSDH) patients is unclear, and practice differs between countries. At the Brigham and Women's Hospital (BWH) in Boston, Massachusetts, neurosurgeons frequently order routine postoperative CT scans, while the University Medical Center Utrecht (UMCU) in the Netherlands does not have this policy. The aim of this study was to compare the use of postoperative CT scans in CSDH patients between these hospitals and to evaluate whether there are differences in clinical outcomes.

METHODS

The authors collected data from both centers for 391 age- and sex-matched CSDH patients treated with burr hole surgery between January 1, 2002, and July 1, 2016, and compared the number of postoperative scans up to 6 weeks after surgery, the need for re-intervention, and postoperative neurological condition.

RESULTS

BWH patients were postoperatively scanned a median of 4 times (interquartile range [IQR] 2-5), whereas UMCU patients underwent a median of 0 scans (IQR 0-1, p < 0.001). There was no significant difference in the number of re-operations (20 in the BWH vs 27 in the UMCU, p = 0.34). All re-interventions were preceded by clinical decline and no recurrences were detected on scans performed on asymptomatic patients. Patients' neurological condition was not worse in the UMCU than in the BWH (p = 0.43).

CONCLUSIONS

While BWH patients underwent more scans than UMCU patients, there were no differences in clinical outcomes. The results of this study suggest that there is little benefit to routine scanning in asymptomatic patients who have undergone surgical treatment of uncomplicated CSDH and highlight opportunities to make practice more efficient.

Utility of early postoperative imaging after combined endoscopic and open ventral skull base surgery

PURPOSE

Immediate postoperative imaging is frequently obtained after combined skull base surgery (SBS) with endoscopic endonasal and open transcranial approaches. The importance of early postoperative imaging for detecting complications in these patients is still debatable. In this study, we investigated the clinical utility of early postoperative imaging after combined SBS for determination of postoperative complications.

METHODS

A retrospective chart analysis of 21 cases of combined SBS between 2009 and 2015 was performed. Data on postoperative computed tomography (CT) and magnetic resonance imaging (MRI), and the hospital course were collected. We separated interpretations of postoperative imaging into two groups: (1) when using the radiologist's interpretation alone, and (2) when using the surgeon's knowledge of the case in conjunction with imaging.

RESULTS

Forty-two postoperative scans were obtained (21 CT, 21 MRI) within 48 hours of surgery. There was a significant statistical difference between imaging interpretation by surgeons and radiologists for CT interpretation only. For CT interpretation the true positive (TP), false positive (FP), true negative (TN), and false negative (FN) rates for radiologists (TP, 0/21; FP, 6/21; TN, 11/21; FN, 4/21) slightly deviated from surgeons' interpretation (TP, 1/21 [p = 0.9999]; FP, 0/21 [p = 0.0207]; TN, 17/21 [p = 0.1000]; FN, 3/21 [p = 1.000]). Rates for MRI interpretation by both groups were nearly identical, with no significant difference found. Overall, four patients experienced seven postoperative complications, which led to a complication rate of 19.0% (4/21). The patients exhibited clinical symptoms in all instances of postoperative complications that required further intervention.

CONCLUSION

The benefit of early postoperative imaging to detect complications after combined SBS was limited. In this cohort of patients, positive imaging findings' effects on patient management were dictated by the presence of supporting clinical symptoms.

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

OBJECTIVE

Scheduled early postoperative computed tomography (EPOCT) after craniotomy for brain tumor resection is standard at many institutions. We analyzed utility of preplanned EPOCT after elective craniotomy for brain tumor resection.

METHODS

We retrospectively analyzed 755 brain tumor resections for which EPOCT was performed within 4 hours of surgery. Postoperative clinical neurologic examination results were classified into expected (baseline or predicted postoperative examination), changed (from baseline examination), and unreliable (sedated or baseline comatose patient). Scans were analyzed for unexpected and/or worrisome findings (e.g., hemorrhagic or ischemic stroke). In cases of unexpected findings, management changes were correlated to patient's neurologic examination. Demographic information, tumor histology, and tumor location were analyzed to determine risk factors for unexpected findings.

RESULTS

Rate of unexpected EPOCT findings was 4.1%. Patients with expected postoperative examinations were at significantly lower risk of abnormal findings (odds ratio [OR] = 0.074, P < 0.001). Patients with intraventricular tumors (OR = 5.7, P = 0.001) were at higher risk compared with patients with metastatic tumors (OR = 0.24, P = 0.06). No unexpected EPOCT findings led to management changes in patients with expected postoperative neurologic examinations. All unexpected EPOCT findings in patients with changed postoperative neurologic examinations led to management changes. Patients with nonreliable neurologic examinations were at significantly higher risk for unexpected findings on EPOCT (OR = 6.33, P < 0.001) and subsequent management changes.

CONCLUSIONS

Routine EPOCT is not indicated for patients undergoing brain tumor resection if postoperative neurologic examination is unchanged, as imaging is unlikely to result in management changes. EPOCT should be obtained in all patients with worrisome changes in examination or nonreliable examinations, as both groups have high rates of unexpected findings on imaging that lead to management changes.

The Simpson grading in meningioma surgery: does the tumor location influence the prognostic value?

In meningiomas, location-specific differences of the prognostic value of the Simpson classification are sparsely investigated but can influence strategy of surgery. We therefore compared the prognostic value of the Simpson classification in different tumor locations. Progression was compared with Simpson grade in 826 meningioma patients (median age 58 years, female:male ratio 2.4) in location-specific uni- and multivariate analyses. Simpson grade strongly correlated with tumor location (p < .001). Within a median follow-up of 50 months, recurrence was observed in 107 of 803 patients (13%). In general, increasing Simpson grade (p = .002) and subtotal resection (STR, ≥grade III) were correlated with tumor recurrence [hazard ratio (HR): 1.87; p = .004]. In 268 convexity meningiomas, frequency of tumor recurrence correlated with Simpson grade (p = .034). Risk of recurrence was similar after grade I and II resections, tended to increase after grade III (HR: 2.35; p = .087) but was higher after grade IV resections (HR: 7.35; p = .003). Risk of recurrence was higher after STR (HR: 4.21; p = .001) than after gross total resection (GTR, ≤grade II). Contrarily, increasing Simpson grade and STR were not correlated with progression in 102 falx, 38 posterior fossa and nine intraventricular meningiomas. In 325 skull base lesions, risk of recurrence was similar after GTR and STR (p = .198) and was only increased after grade IV resections (HR: 3.26; p = .017). Simpson grading and extent of resection were not equally prognostic in all locations. Lower impact of extent of resection should be considered during surgery for skull base, posterior fossa and falx meningiomas.

Surgical management and follow-up of lateral skull base tumors: An 8-year review

The purpose of the present article was to describe the diagnostic evaluation of, and surgical approaches to, lateral skull base tumors (LSBTs). The study is a retrospective review of 21 patients diagnosed with tumors that involve lateral skull base (8 with malignant diseases and 13 with benign lesions) who were surgically treated during a 8-year period. The transparotid-transmandibular (38%) was the most commonly performed surgical procedure, followed by the transmandibular (24%), the transmaxillary (24%), the transcervical approach (10%) and the combined approach (4%). The surgical procedures were uneventful and there were no postoperative mortalities. Complications were encountered in 12 cases, and morbidity was not remarkable during the perioperative stages. After an average follow-up of 46 months, only 1 of 14 patients with benign diseases had a recurrence following the resection of a pleomorphic adenoma. Of 7 patients with malignant tumors, 5 are alive with no evidence of disease. The majority of the benign lateral skull base tumors can be removed surgically with a low rate of complications and recurrence. However, malignant neoplasms carry a poor prognosis and a low rate of disease-free survival.

No Routine Postoperative Head CT following Elective Craniotomy--A Paradigm Shift?

Introduction

Patient management following elective cranial surgery often includes routine postoperative computed tomography (CT). We analyzed whether a regime of early extubation and close neurological monitoring without routine CT is safe, and compared the rate of postoperative emergency neurosurgical intervention with published data.

Methods

Four hundred ninety-two patients were prospectively analyzed; 360 had supra- and 132 had infratentorial lesions. Extubation within one hour after skin closure was aimed for in all cases. CT was performed within 48 hours only in cases of unexpected neurological findings.

Results

Four-hundred sixty-nine of the 492 patients (95.3%) were extubated within one hour, 20 (4.1%) within 3 hours, and three (0.6%) within 3 to 10 hours. Emergency CT within 48 hours was performed for 43/492 (8.7%) cases. Rate of recraniotomy within 48 hours for patients with postoperative hemorrhage was 0.8% (n = 4), and 0.8% (n = 4) required placement of an external ventricular drain (EVD). Of 469 patients extubated within one hour, 3 required recraniotomy and 2 required EVD placements. Of 23 patients with delayed extubation, 1 recraniotomy and 2 EVDs were required. Failure to extubate within one hour was associated with a significantly higher risk of surgical intervention within 48 hours (rate 13.0%, p = 0.004, odds ratio 13.9, 95% confidence interval [3.11–62.37]).

Discussion

Early extubation combined with close neurological monitoring is safe and omits the need for routine postoperative CT. Patients not extubated within one hour do need early CT, since they had a significantly increased risk of requiring emergency neurosurgical intervention.

Trial Registration

ClinicalTrials.gov NCT01987648

Is postoperative imaging mandatory after meningioma removal? Results of a prospective study

Background

Routine postoperative imaging (PI) following surgery for intracranial meningiomas is common practice in most neurosurgical departments. The purpose of this study was to determine the role of routine PI and its impact on clinical decision making after resection of meningioma.

Methods

Patient and tumor characteristics, details of radiographic scans, symptoms and alteration of treatment courses were prospectively collected for patients undergoing removal of a supratentorial meningioma of the convexity, falx, tentorium, or lateral sphenoid wing at the authors’ institution between January 1st, 2010 and March 31st, 2012. Patients with infratentorial manifestations or meningiomas of the skull base known to be surgically difficult (e.g. olfactory groove, petroclival, medial sphenoid wing) were not included. Maximum tumor diameter was divided into groups of < 3cm (small), 3 to 6 cm (medium), and > 6 cm (large).

Results

206 patients with meningiomas were operated between January 2010 and March 2012. Of these, 113 patients met the inclusion criteria and were analyzed in this study. 83 patients (73.5%) did not present new neurological deficits, whereas 30 patients (26.5%) became clinically symptomatic. Symptomatic patients had a change in treatment after PI in 21 cases (70%), while PI was without consequence in 9 patients (30%). PI did not result in a change of treatment in all asymptomatic patients (p<0.001) irrespective of tumor size (p<0.001) or localization (p<0.001).

Conclusions

PI is mandatory for clinically symptomatic patients but it is safe to waive it in clinically asymptomatic patients, even if the meningioma was large in size.