Perioperative problems in patients with brainstem tumors and their influence on patient outcome

CLINICAL AND SURGICAL CHARACTERISTICS OF POSTERIOR FOSSA TUMORS IN ADULTS - SINGLE-CENTER EXPERIENCE OF SURGICAL MANAGEMENT

In contrast to tumors in children, between 6% and 20% of all brain tumors in adults arise solitary in the posterior cranial fossa. Given their rarity in adults, as well as the importance and complexity of their treatment, this paper reviews and discusses the clinical and surgical characteristics of such tumors. In a retrospective single-institution observational study, adult patients with posterior fossa tumors treated surgically over a ten-year period were analyzed. The characteristics observed were age and gender distribution, clinical symptoms, histopathologic tumor type, tumor size, location and extent of surgical resection, tumor recurrence and postoperative complications, as well as surgical outcome. Sixty-six patients who underwent surgical treatment were diagnosed with a tumor in the posterior fossa. The mean age was 63 years, and patients were evenly distributed by gender. The most common histopathologic type was metastatic tumor (59.1%), whereas meningioma was the most common primary brain tumor (16.6%) recorded. Most patients presented with vegetative and cerebellar symptoms in general and cranial nerve palsy, especially in the occurrence of vestibular schwannoma. In conclusion, posterior fossa tumors grow in a confined space and therefore may directly threaten vital centers in their immediate vicinity. Thus, it is crucial to schedule an appropriate surgical intervention as soon as possible, as it can significantly improve treatment outcome and prognosis of the disease. If possible, meticulous total tumor resection should be the treatment of choice. In the case of hydrocephalus, a ventriculoperitoneal shunt should be considered as an alternative surgical option after tumor resection.

Surgical considerations for maximal safe resection of exophytic brainstem glioma in the pediatric age group

Background:

Brainstem glioma is the leading cause of morbidity and mortality among all central nervous system tumors, especially in childhood as it represents about 20% of all pediatric brain tumors. Therefore, this study aimed to present our experience in a tertiary center in a developing country with limited resources for the surgical management of exophytic brainstem gliomas.

Methods:

This retrospective study included pediatric patients with brainstem (midbrain, pontine, or medullary) focal or diffuse gliomas whether low or high grade that had dorsal, ventral, or lateral exophytic component who were presented to our hospitals from January 2019 to January 2021. The patients’ data were collected, such as age, sex, preoperative and postoperative clinical condition, radiological data, surgical approach, extent of tumor removal, histopathology, follow-up period, and adjuvant therapy.

Results:

A total of 23 patients were included in this study. The telovelar approach was used in 17 patients, the supracerebellar infratentorial approach in three patients, and the retrosigmoid, transcerebellar, and occipital transtentorial approach once for each patient. Twenty patients underwent near-total excision, and three underwent subtotal excision. Two-thirds of our cases (17 patients) were low-grade gliomas, with the remaining one-third comprising entirely of either anaplastic astrocytoma (five patients) or glioblastoma multiforme (one patient). The follow-up period of the patients extended from 3 months to 24 months.

Conclusion:

Exophytic brainstem glioma surgery can result in good outcomes with minimal complications when near-total excision is attempted through a properly chosen approach and adherence to some surgical techniques and considerations.

Postoperative Neurological Complications after a Cranial Surgery: A Multicentre Prospective Observational Study

Background  Cranial surgery is associated with multiple postoperative complications varying from simple nausea and vomiting to devastating complications such as stroke and death. This multicentre collaborative effort was envisioned to collect observational data regarding postoperative complications in cranial surgeries among the Indian population. The aim of this study was to describe the postoperative neurological complications occurring within the first 24 hours after surgery and to identify the predictive factors.

Methods Data was collected from three participating tertiary care academic institutions. The study was prospective, observational, multicentre design with data collected over a period of two months or 100 cases, whichever is earlier, from each participating institute. A predesigned Microsoft excel sheet was distributed among all three centers to maintain uniformity. All patients aged 18 years and above of both sexes undergoing elective or emergency craniotomies were included in the study. The postoperative neurological complications (within 24 hours) assessed were: (1) Neurological deficit (ND) defined as new focal neurological motor deficit relative to preoperative status. (2) Sensorium deterioration (SD) defined as reduction in Glasgow coma score (GCS) by 2 or more points compared with preoperative GCS. (4) Postoperative seizures (SZs) defined as any seizure activity. All possible variables associated with the above neurological complications were tested using Chi-square/Fisher exact test or Mann–Whitney U test. The predictors, which were statistically significant at p < 0.2, were entered into a multiple logistic regression model. Alpha error of 5% was taken as significant.

Results Data from three institutions was collected with a total of 279 cases. In total, there were 53 (19%) neurological complications. There were 28 patients with new postoperative NDs (10.04%), 24 patients had SD (8.6%), and 17 patients had seizures (6.1%). Neurological deficits were significantly less in institution 2. Diagnosis of traumatic brain injury (TBI) was associated with very low risk of ND, and vascular pathology was associated with higher chance of a ND. The duration of anesthesia was found to be significantly predictive of SD (OR/CI = 1.01 / 1–1.02). None of the factors were predictive of PS.

Conclusion The incidences of postoperative ND, SD and postoperative seizures were 10%, 8.6%, and 6.1%, respectively. Studies with a much larger sample size are required for a better and detailed analysis of these complications.

[Convulsive syndrome as a manifestation of acute cerebral damage due to paradoxical air embolism in neurosurgical patients. Series of clinical cases and literature review]

Introduction

Paradoxical air embolism (PAE) is a rare potentially fatal complication followed by entering of air emboli from the right cardiac chambers and pulmonary artery to large circulation circle.

Objective

To analyze five patients who underwent neurosurgical intervention complicated by PAE and early postoperative convulsive syndrome.

Material and methods

There were five patients who developed early postoperative convulsive syndrome after previous neurosurgery in sitting position complicated by PAE. Convulsive syndrome required intensive care at the ICU. MRI confirmed ischemic foci de novo outside the zone of surgical intervention in all cases. All patients underwent video-EEG monitoring in order to select anticonvulsant therapy and evaluate its effectiveness. The authors were able to match the epileptogenic focus in the cerebral cortex with MRI data. Available literature data devoted to the problem of convulsive syndrome after neurosurgery complicated by PAE were analyzed.

Results

The focus of epileptiform activity coincided with one of the foci of hyperintense MR signal in all cases.

Conclusion

Video-EEG monitoring is advisable in patients with impaired consciousness who underwent neurosurgery complicated by PAE.

Takotsubo cardiomyopathy following resection of a fourth ventricle tumour

Takotsubo cardiomyopathy is a rare disorder associated with catecholamine discharge in response to episodes of stress. We present the case of a 39-year-old patient with no other significant medical history who suffered acute ECG changes, left ventricular dysfunction with regional wall motion abnormalities and raised cardiac enzymes following a period of severe and sustained hypertension and tachycardia associated with resection of tumour from the floor of the fourth ventricle. We believe this to be only the second case of a takotsubo cardiomyopathy related to intracranial surgery. It demonstrates the need for consideration, recognition and diagnosis of takotsubo cardiomyopathy following periods of severe peri-operative stress.

Nationwide analysis of unplanned 30-day readmissions after transsphenoidal pituitary surgery

BACKGROUND

Transsphenoidal pituitary surgery has evolved into a safe procedure with shorter hospitalizations, yet unplanned readmissions remain a quality measure for which there is a paucity of data. We sought to examine rates, timing, etiologic factors, and costs surrounding readmission after transsphenoidal pituitary surgery.

METHODS

The Nationwide Readmissions Database (NRD) was queried for patients who underwent transsphenoidal pituitary between January 2013 and November 2013. Patient, procedure, admission, and hospital-level characteristics were compared for patients with and without unplanned 30-day readmission. Multivariate logistic regression was used to identify readmission predictors. A total of 8546 patients were included in this retrospective study.

RESULTS

A total of 8546 patients with a median age of 54 years and female predominance were identified, with 742 patients experiencing at least 1 unplanned readmission within 30 days of index admission. Hypertension, hypothyroidism, diabetes, and obesity were common comorbidities among readmitted patients. Readmission was most frequently because of nervous system complications, followed by neurohypophyseal or electrolyte disorders, cerebrospinal fluid leak, hemorrhage, and meningitis. Median length and cost of stay of index admission was greater in the readmission group (p < 0.001). Fluid and electrolyte disorders as well as neurologic disease (most commonly epilepsy or convulsions) present on initial admission were predictive of length of initial stay and readmission (p < 0.001). Median readmission cost was $7723 and was expected to occur within 7 days.

CONCLUSION

Approximately 8.7% of patients undergoing transsphenoidal pituitary surgery experience an unplanned readmission within 30 days of discharge. Risk factors identified should be considered to reduce preventable readmissions and identify medically complex patients.

Seizure incidence in the acute postneurosurgical period diagnosed using continuous electroencephalography

OBJECTIVEDelay in diagnosis and subsequent treatment of nonconvulsive seizures can lead to worsened outcomes. The gold standard in detecting nonconvulsive seizures is continuous video-electroencephalography (cEEG). Compared to routine, 30-minute EEG, the use of cEEG increases the likelihood of capturing intermittent nonconvulsive seizures. Studies of critically ill patients in intensive care units demonstrate a particularly high rate of nonconvulsive seizures. Some of these studies included postneurosurgical patients, but often subanalyses of specific populations were not done. In particular, few studies have specifically evaluated postneurosurgical patients by using cEEG in the acute postoperative setting. Therefore, the incidence and predictors of acute postneurosurgical seizures are unclear.METHODSIn this study, the authors focused on patients who were admitted to the neurological critical care unit following neurosurgery and who underwent cEEG monitoring within 72 hours of surgery.RESULTSA total of 105 cEEG studies were performed in 102 patients. Twenty-nine patients demonstrated electrographic (subclinical) seizures, of whom 10 had clinical seizures clearly documented either before or during cEEG monitoring. Twenty-two patients had subclinical seizures only detected on cEEG, 19 of whom did not have clinical seizure activity at any point during hospitalization. Those with seizures were more likely to have had a history of epilepsy (p = 0.006). The EEG studies of patients with seizures were more likely to show lateralized periodic discharges (p = 0.012) and lateralized rhythmic delta activity (p = 0.012). The underlying neuropathological disorders most associated with seizure risk were lobar tumor on presentation (p = 0.048), subdural hematoma (SDH) requiring craniotomy for evacuation (p = 0.002), subarachnoid hemorrhage (SAH) (p = 0.026), and perioperative SAH (p = 0.019). In those undergoing craniotomy, the presence of SDH (p = 0.032), particularly if requiring evacuation (p = 0.003), increased the risk of seizures. In those without preoperative intracranial bleeding, perioperative SAH after craniotomy was associated with a higher incidence of seizures (p = 0.014). There was an additive effect on seizure incidence when perioperative SAH as well as concomitant intraparenchymal hemorrhage and/or stroke were present. The clinical examination of the patient, including the presence or absence of altered mental status and the presence or absence of repetitive movements, was not predictive of subclinical seizures.CONCLUSIONSIn postneurosurgical patients referred for cEEG monitoring, there is a high rate of both clinical and subclinical seizures in the early postoperative period. Seizures are particularly common in patients with SDH or lobar tumor and perioperative SAH. There was an additive effect on seizure incidence when more extensive brain injury was present. As expected, those with a history of epilepsy also demonstrated higher seizure rates. Further studies are needed to evaluate the time period of maximum seizure incidence after surgery, and the effects acute postneurosurgical seizures have on long-term outcomes.