Late neurocognitive sequelae in survivors of brain tumours in childhood

As survival among children treated for cancer continues to improve, more attention is being focussed on the late effects of cancer treatment. In children treated for brain tumours, chronic neurocognitive effects are especially challenging. Deficits in cognitive development have been described most thoroughly among children treated for posterior-fossa tumours, specifically medulloblastomas and ependymomas, which account for about 30% of all newly diagnosed cases of brain tumours in children. Most children who have survived brain tumours have required surgical resection and focal or craniospinal radiotherapy (irradiation of the entire subarachnoid volume of the brain and spine), with or without systemic chemotherapy. Historically, intelligence quotient (IQ) scores have provided a benchmark against which to measure changes in cognitive development after treatment. Observed declines in IQ are most likely a result of failure to learn at a rate that is appropriate for the age of the child, rather than from a loss of previously acquired knowledge. The rate of IQ decline is associated with a several risk factors, including younger age at time of treatment, longer time since treatment, female sex, as well as clinical variables such as hydrocephalus, use of radiotherapy and radiotherapy dose, and the volume of the brain that received treatment. Loss of cerebral white matter and failure to develop white matter at a rate appropriate to the developmental stage of the child could partly account for changes in IQ score. Technical advances in radiotherapy hold promise for lowering the frequency of neurocognitive sequelae. Further efforts to limit neurocognitive sequelae have included design of clinical trials to test the effectiveness of cognitive, behavioural, and pharmacological interventions.

Neurosurgical outcomes in a modern series of 400 craniotomies for treatment of parenchymal tumors

OBJECTIVE

The goals were to critically review all complications resulting within 30 days after craniotomies performed for excision of intra-axial brain tumors relative to factors likely to affect complication rates and to assess the value of these data in predicting the risk of surgical morbidity, particularly for surgery in eloquent brain regions.

METHODS

Neurosurgical outcomes were studied for 327 patients who underwent 400 craniotomies for removal of intra-axial parenchymal brain neoplasms in a 21-month period. Tumors removed included gliomas (206 tumors) and metastases (194 tumors) located both supratentorially (358 tumors) and infratentorially (42 tumors).

RESULTS

The major complication incidence was 13%, and the operative mortality rate was 1.7%. The overall morbidity rate was 32%, but more types of complications were considered than in previous studies. The major neurological morbidity rate was 8.5%. Based on pre- versus postoperative (at 4 wk) Karnofsky Performance Scale scores, 9% of patients deteriorated neurologically, 32% improved, and 58% showed no change. The median postoperative hospital stay was 5 days. Tumors were defined as Grade I, II, or III based on their location relative to brain function, and this tumor functional grade was the most important variable affecting the incidence of any neurological deficit. Patients with tumors in eloquent (Grade III) or near-eloquent (Grade II) brain areas incurred more neurological deficits than did patients with tumors in noneloquent areas (Grade I). Neither repeat surgery for recurrent disease nor extent of surgical resection affected outcome significantly. Although most tumors in this study, including those in eloquent regions, were removed by gross total resection, this did not lead to more major neurological deficits. Regional complications (at the surgical sites) and systemic complications (medical) were more prevalent among older patients (age >60 yr) with lower preoperative Karnofsky Performance Scale scores (< or = 50) and posterior fossa masses. We showed how our data can be used to predict the total risk of surgical morbidity for a given patient, to facilitate patient counseling and surgical decision-making.

CONCLUSION

The finding that gross total resections could be performed in eloquent brain regions with an acceptable level of neurological impairment suggested that the mere presence of a tumor in eloquent brain does not automatically contraindicate surgery. Our results have practical risk-predictive value, and they should aid in the construction of subsequent outcome studies, because we have identified the key areas to monitor.

Outcome of contemporary surgery for chronic subdural haematoma: evidence based review

OBJECTIVE

To evaluate the results of surgical treatment options for chronic subdural haematoma in contemporary neurosurgery according to evidence based criteria.

METHODS

A review based on a Medline search from 1981 to October 2001 using the phrases "subdural haematoma" and "subdural haematoma AND chronic". Articles selected for evaluation had at least 10 patients and less than 10% of patients were lost to follow up. The articles were classified by three classes of evidence according to criteria of the American Academy of Neurology. Strength of recommendation for different treatment options was derived from the resulting degrees of certainty.

RESULTS

48 publications were reviewed. There was no article that provided class I evidence. Six articles met criteria for class II evidence and the remainder provided class III evidence. Evaluation of the results showed that twist drill and burr hole craniostomy are safer than craniotomy; burr hole craniostomy and craniotomy are the most effective procedures; and burr hole craniostomy has the best cure to complication ratio (type C recommendation). Irrigation lowers the risk of recurrence in twist drill craniostomy and does not increase the risk of infection (type C recommendation). Drainage reduces the risk of recurrence in burr hole craniostomy, and a frontal position of the drain reduces the risk of recurrence (type B recommendation). Drainage reduces the risk of recurrence in twist drill craniostomy, and the use of a drain does not increase the risk of infection (type C recommendation). Burr hole craniostomy appears to be more effective in treating recurrent haematomas than twist drill craniostomy, and craniotomy should be considered the treatment of last choice for recurrences (type C recommendation).

CONCLUSIONS

The three principal techniques-twist drill craniostomy, burr hole craniostomy, and craniotomy-used in contemporary neurosurgery for chronic subdural haematoma have different profiles for morbidity, mortality, recurrence rate, and cure rate. Twist drill and burr hole craniostomy can be considered first tier treatment, while craniotomy may be used as second tier treatment. A cumulative summary of data shows that, overall, the postoperative outcome of chronic subdural haematoma has not improved substantially over the past 20 years.

Awake craniotomy with brain mapping as the routine surgical approach to treating patients with supratentorial intraaxial tumors: a prospective trial of 200 cases

OBJECT

Awake craniotomy was performed as the standard surgical approach to supratentorial intraaxial tumors, regardless of the involvement of eloquent cortex, in a prospective trial of 200 patients surgically treated by the same surgeon at a single institution.

METHODS

Patient presentations, comorbid conditions, tumor locations, and the histological characteristics of lesions were recorded. Brain mapping was possible in 195 (97.5%) of 200 patients. The total number of patients sustaining complications was 33 for an overall complication rate of 16.5%. There were two deaths in this series, for a mortality rate of 1%. New postoperative neurological deficits were seen in 13% of the patients, but these were permanent in only 4.5% of them. Complication rates were higher in patients who had gliomas or preoperative neurological deficits and in those who had undergone prior radiation therapy or surgery. No patient who entered the operating room neurologically intact sustained a permanent neurological deficit postoperatively. Of the most recent 50 patients treated, three (6%) required a stay in the intensive care unit, and the median total hospital stay was 1 day.

CONCLUSIONS

Use of awake craniotomy can result in a considerable reduction in resource utilization without compromising patient care by minimizing intensive care time and total hospital stay. Awake craniotomy is a practical and effective standard surgical approach to supratentorial tumors with a low complication rate, and provides an excellent alternative to craniotomy performed with the patient in the state of general anesthesia because it allows the opportunity for brain mapping and avoids general anesthesia.

Outcome of aggressive removal of cavernous sinus meningiomas

Despite recent advances in surgery of the cavernous sinus, meningiomas in that area offer a formidable challenge. The rationale for aggressive surgical removal of cavernous sinus meningiomas is based on the presumption that the extent of removal is inversely related to the rate of recurrence. Over the past 10 years, 41 patients with histologically benign meningiomas involving the cavernous sinus underwent aggressive surgery. Total removal, as confirmed by intraoperative inspection and postoperative radiological studies, was achieved in 31 patients (76%). Twelve patients have been followed for more than 5 years; 10 underwent total tumor removal and only one of these experienced recurrence (5 years after surgery). The other two patients underwent subtotal removal and had symptomatic and radiological evidence of regrowth 3 and 4 years after surgery. Pre-existing cranial nerve deficits improved in only 14% of the patients, remained unchanged in 80%, and worsened permanently in 6%. Seven patients experienced a total of 10 new cranial nerve deficits, four of which involved the nerves subserving ocular motor function. Extraocular muscle function did not worsen in the 25 patients with a seeing eye ipsilateral to the tumor, and no instance of visual worsening occurred. Two patients died 4 months after surgery, one from severe delayed vasospasm and hypothalamic infarction and the other because of a myocardial infarction. Another patient died from a pulmonary embolus on the 9th postoperative day. There were three instances of cerebral ischemia; one was transient, lasting less than 24 hours, while two were related to injury of the middle cerebral artery and resulted in residual hemiplegia. Other complications included three cases of nonfatal pulmonary emboli, two cerebrospinal fluid leaks, and one instance each of exposure keratitis, acute hypothyroidism, and cerebral edema.

Risk factors for neurosurgical site infections after craniotomy: a prospective multicenter study of 2944 patients. The French Study Group of Neurosurgical Infections, the SEHP, and the C-CLIN Paris-Nord. Service Epidémiologie Hygiène et Prévention

OBJECTIVE

To determine the incidence and risk factors of surgical site infections (SSIs) after craniotomy and to test the risk index score proposed by the National Nosocomial Infections Surveillance (NNIS) system, which, to our knowledge, has not been validated in neurosurgery to date.

METHODS

During a 15-month period, every adult patient undergoing craniotomy in 10 neurosurgical units was prospectively evaluated for development and risk factors of SSI. The follow-up period was at least 30 days. SSIs were defined according to the Center for Disease Control definitions. Incidence was calculated per patient. Multivariate analyses were conducted at first to include all significant risk factors of univariate analysis and then only those known preoperatively. Finally, the NNIS risk index was tested in this population.

RESULTS

Of a total of 2944 patients, 117 patients (4%) with SSIs were observed, including 30 with wound infections, 14 with bone flap osteitis, 56 with meningitis, and 17 with brain abscesses. Independent risk factors for SSIs were postoperative cerebrospinal fluid leakage (odds ratio, 145; 95% confidence interval, 72-293) and subsequent operation (odds ratio, 7; 95% confidence interval, 4-12). Independent predictive risk factors were emergency surgery, clean-contaminated and dirty surgery, an operative time longer than 4 hours, and recent neurosurgery. Absence of antibiotic prophylaxis was not a risk factor. The NNIS risk index was effective in identifying at-risk patients.

CONCLUSION

Independent risk factors for SSIs after craniotomy involve postoperative events. However, the NNIS risk index is effective in identifying at-risk patients.

Rebleeding leads to poor outcome in ultra-early craniotomy for intracerebral hemorrhage

BACKGROUND

A modest benefit was previously demonstrated for hematoma evacuation within 12 hours of intracerebral hemorrhage onset. Perhaps surgery within 4 hours would further improve outcome.

METHODS

Adult patients with spontaneous supratentorial intracerebral hemorrhage were prospectively enrolled. Craniotomy and clot evacuation were commenced within 4 hours of symptom onset in all cases. Mortality and functional outcome were assessed at 6 months. This group of patients was compared with patients treated within 12 hours of symptom onset using the same surgical and medical protocols.

RESULTS

The study was stopped after a planned interim analysis of 11 patients in the 4-hour surgery arm. Median time to surgery was 180 minutes; median hematoma volume was 40 mL; median baseline NIH Stroke Scale score was 19 and Glasgow Coma Scale score was 12. Six-month mortality was 36% and median Barthel score was 75 in survivors. Postoperative rebleeding occurred in four patients, three of whom died. A relationship between postoperative rebleeding and mortality was apparent (p = 0.03). Rebleeding occurred in 40% of the patients treated within 4 hours, compared with 12% of the patients treated within 12 hours (p = 0.11). There was a clear correlation between improved outcome and smaller postsurgical hematoma volume (p = 0.04).

CONCLUSIONS

Surgical hematoma evacuation within 4 hours of symptom onset is complicated by rebleeding, indicating difficulty with hemostasis. Maximum removal of blood remains a predictor of good outcome.

Efficacy of Standard Trauma Craniectomy for Refractory Intracranial Hypertension with Severe Traumatic Brain Injury: A Multicenter, Prospective, Randomized Controlled Study

To compare the effect of standard trauma craniectomy (STC) versus limited craniectomy (LC) on the outcome of severe traumatic brain injury (TBI) with refractory intracranial hypertension, we conducted a study at five medical centers of 486 patients with severe TBI (Glasgow Coma Scale score </= 8) and refractory intracranial hypertension. In all 486 cases, refractory intracranial hypertension, caused by unilateral massive frontotemporoparietal contusion, intracerebral/subdural hematoma, and brain edema, was confirmed on a CT scan. The patients were randomly divided into two groups, one of which underwent STC (n = 241) with a unilateral frontotemporoparietal bone flap (12 x 15 cm), and the second of which underwent LC (n = 245) with a routine temporoparietal bone flap (6 x 8 cm). At 6-month follow-up, 96 patients (39.8%) in the STC group had a favorable outcome on the basis of the Glasgow Outcome Scale, including 62 patients who had a good recovery and 34 who showed moderate deficits. Another 145 patients (60.2%) in the STC group had an unfavorable outcome, including 73 with severe deficits, nine with persistent vegetative status, and 63 who died. By comparison, only 70 patients (28.6%) in the LC group had a favorable outcome, including 41 who had a good recovery and 29 who had moderate deficits. Another 175 patients (71.4%) in the LC group had an unfavorable outcome, including 82 with severe deficits, seven with persistent vegetative status, and 86 who died (p < 0.05). In addition to these findings, the incidence of delayed intracranial hematoma, incisional hernia, and CSF fistula was lower in the STC group than in the LC group (p < 0.05), although the incidence of acute encephalomyelocele, traumatic seizure, and intracranial infection was not significantly different in the two groups (p > 0.05). The results of the study indicate that STC significantly improves outcome in severe TBI with refractory intracranial hypertension resulting from unilateral frontotemporoparietal contusion with or without intracerebral or subdural hematoma. This suggests that STC, rather than LC, be recommended for such patients.

Risk factors for neurosurgical site infections after craniotomy: a critical reappraisal of antibiotic prophylaxis on 4578 patients

The objective of this study was to evaluate incidence and risk factors of postoperative infections, with emphasis on antibiotic prophylaxis, in a series of 4578 craniotomies. A prospective database was implemented for surveillance of postcraniotomy infections. During period A, no antibiotic prophylaxis was prescribed for scheduled, clean craniotomies, lasting less than 4 h, whereas emergency, clean-contaminated or long-lasting craniotomies received cloxacillin or amoxicillin-clavulanate. During period B, prophylaxis was given to every craniotomy. The effect of prophylaxis on craniotomy infections, independently of other risk factors, was studied by multivariate analysis. The overall infection rate was 6.6%. CSF leak, male gender, surgical diagnosis, surgeon, early re-operation, surgical duration and absence of prophylaxis were independent risk factors. CSF leak had the highest odds ratio. Antibiotic prophylaxis decreased infection rate from 9.7% down to 5.8% in the entire population (p<0.0001) mainly by decreasing rates in low risk patients from 10.0% down to 4.6% (p<0.0001). Antibiotic prophylaxis in craniotomy is effective in preventing surgical site infections even in low-risk patients.

Extradural temporopolar approach to lesions of the upper basilar artery and infrachiasmatic region

Surgical access to the parasellar, infrachiasmatic, and posterior clinoid regions has traditionally been accomplished through an intradural pterional or subtemporal approach. However, for large or complex lesions in these locations, such traditional trajectories may not afford sufficient exposure for complete obliteration of the pathological process. The authors describe an anterolateral transcavernous approach to this region that includes the following components: 1) extradural removal of the sphenoid wing and exposure of the superior orbital fissure and foramen rotundum; 2) removal of the anterior clinoid process via the anterolateral route; 3) decompression of the optic canal; 4) extradural retraction of the temporal tip; 5) transcavernous mobilization of the carotid artery and third cranial nerve; and 6) removal of the posterior clinoid process. This method results in enhanced exposure with minimal brain retraction and preservation of the temporal tip bridging veins. This approach has been used in 22 patients: 10 with basilar top aneurysms, eight with craniopharyngiomas, one with a tuberculum sellae meningioma, and two with trigeminal neuromas; the last patient had a carotid-cavernous fistula and a concomitant pituitary adenoma. Complete clip ligation was performed for all 10 basilar artery aneurysms, and gross total resection was achieved with preservation of the pituitary stalk in all tumor cases. Microscopic total resection was not possible in two cases of craniopharyngioma due to hypothalamic invasion. Two patients suffered transient postoperative hemiparesis, and one patient has persisting weakness; however, no patient followed for more than 6 months suffered any persistent cranial nerve morbidity. It is concluded that this procedure can serve as an alternative to either the transsylvian or subtemporal approaches when cranial base pathologies are large or complex.

Cranioplasty: cosmetic or therapeutic?

Cranioplasty is among the oldest surgical procedures. Trauma, infections, tumors and compression caused by brain edema are some of the reasons for the removal of bone. The indications for cranioplasty after resolution of the primary process that led to the bone defect were never well defined, and many were the "cosmetic" indications for cranioplasty. However, there are many theories suggesting that an underlying physiological alteration may occur which may require the correction of the bone defect; many patients improve after surgery. We discuss the physiopathological basis of the "syndrome of the trephined" and try to achieve a better understanding of the present status of cranioplasty and its possible therapeutic role.

Risk Factors for Adult Nosocomial Meningitis After Craniotomy Roleof Antibiotic Prophylaxis

OBJECTIVE

To evaluate incidence and risk factors of postoperative meningitis, with special emphasis on antibiotic prophylaxis, in a series of 6243 consecutive craniotomies.

METHODS

Meningitis was individualized from a prospective surveillance database of surgical site infections after craniotomy. Ventriculitis related to external ventricular drainage or cerebrospinal fluid shunt were excluded. From May 1997 until March 1999, no antibiotic prophylaxis was prescribed for scheduled, clean, lasting less than 4 hours craniotomies, whereas emergency, clean-contaminated, or long-lasting craniotomies received cloxacillin or amoxicillin-clavulanate. From April 1999 until December 2003, prophylaxis was given to every craniotomy. Independent risk factors for meningitis were studied by a multivariate analysis. Efficacy of antibiotic prophylaxis in preventing meningitis was studied as well as consequences on bacterial flora.

RESULTS

The overall meningitis rate was 1.52%. Independent risk factors were cerebrospinal fluid leakage, concomitant incision infection, male sex, and surgical duration. Antibiotic prophylaxis reduced incision infections from 8.8% down to 4.6% (P < 0.0001) but did not prevent meningitis: 1.63% in patients without antibiotic prophylaxis and 1.50% in those who received prophylaxis. Bacteria responsible for meningitis were mainly noncutaneous in patients receiving antibiotics and cutaneous in patients without prophylaxis. In the former, microorganisms tended to be less susceptible to the prophylactic antibiotics administered. Mortality rate was higher in meningitis caused by noncutaneous bacteria as compared with those caused by cutaneous microorganisms.

CONCLUSION

Perioperative antibiotic prophylaxis, although clearly effective for the prevention of incision infections, does not prevent meningitis and tends to select prophylaxis resistant microorganisms.

Hardware-related complications of deep brain stimulation: a ten year experience

OBJECTIVE

To analyse the occurrence of hardware-related complications in patients with deep brain stimulation (DBS), over a long period of time.

METHOD

All patients operated on with DBS at our institution between 1993 and 2002 were followed with respect to adverse events related to the implanted hardware.

RESULTS

One hundred and nineteen consecutive patients underwent 139 procedures with implantation of 161 electrodes. The minimum follow-up was 12 months. The follow-up time was 540 electrode-years. The rate of hardware-related complications per electrode-year was 4.3%. In total, 17 patients (15%) had 23 hardware-related complications. These included 8 electrode breakages, 4 electrode migrations, 2 stimulator migrations, 3 erosions, 2 erosions and infections, 2 infections and 2 cases of stimulator malfunction. The majority of these complications occurred during the first four years in our experience.

CONCLUSIONS

DBS is a life-long therapy that requires a life-long follow-up. Increased experience and adaptation of surgical technique are the main determinants for avoidance of hardware-related complications.

Evidence for a hydrostatic mechanism in human neurogenic pulmonary edema

STUDY OBJECTIVES

To identify the relative contribution of hydrostatic and permeability mechanisms to the development of human neurogenic pulmonary edema.

DESIGN

Retrospective review of patients with neurogenic pulmonary edema who had pulmonary edema fluid analysis.

SETTING

University hospital ICU.

PATIENTS

Twelve patients with neurogenic pulmonary edema in whom the associated neurologic condition was subarachnoid hemorrhage (n = 8, 67%), postcraniotomy (n = 2), and stroke (n = 2).

MEASUREMENTS

Protein concentration was measured from pulmonary edema fluid and plasma samples obtained shortly after the onset of clinical pulmonary edema.

RESULTS

The mechanism of pulmonary edema was classified according to the initial alveolar edema fluid to plasma protein concentration ratio. A hydrostatic mechanism (ratio < or = 0.65) was observed in seven patients, none of whom had cardiac failure or intravascular volume overload. Five patients had evidence for increased permeability (ratio > 0.70). Patients with a hydrostatic mechanism had better initial oxygenation (mean +/- SD PaO2/FIO2 [fraction of inspired oxygen] = 233 +/- 132) compared with patients with increased permeability (PaO2/FIo2 = 80 +/- 42), and oxygenation improved more rapidly in the hydrostatic patients. Overall mortality (58%) was high, but it was related to unresolved neurologic deficits, not to respiratory failure.

CONCLUSION

Many of our patients had a hydrostatic mechanism for neurogenic pulmonary edema. This is a novel observation in humans since prior clinical case reports have emphasized increased permeability as the usual mechanism for neurogenic pulmonary edema. These findings are consistent with pulmonary venoconstriction or transient elevation in left-sided cardiovascular pressures as contributing causes to the development of human neurogenic pulmonary edema.

Surgical treatment of primary lung cancer with synchronous brain metastases

OBJECTIVES

The role of surgical resection for brain metastases from non-small cell lung cancer is evolving. Although resection of primary lung cancer and metachronous brain metastases is superior to other treatment modalities in prolonging survival and disease-free interval, resection of the primary non-small cell lung cancer and synchronous brain metastases is controversial.

METHODS

From January 1975 to December 1997, 220 patients underwent surgical treatment for brain metastases from non-small cell lung cancer at our institution. Twenty-eight (12.7%) of these patients underwent surgical resection of synchronous brain metastases and the primary non-small cell lung cancer.

RESULTS

The group comprised 18 men and 10 women. Median age was 57 years (range 35-71 years). Twenty-two (78.6%) patients had neurologic symptoms. Craniotomy was performed first in all 28 patients. Median time between craniotomy and thoracotomy was 14 days (range 4-840 days). Pneumonectomy was performed in 4 patients, bilobectomy in 4, lobectomy in 18, and wedge excision in 2. Postoperative complications developed in 6 (21.4%) patients. Cell type was adenocarcinoma in 11 patients, squamous cell carcinoma in 9, and large cell carcinoma in 8. After pulmonary resection, 17 patients had no evidence of lymph node metastases (N0), 5 had hilar metastases (N1), and 6 had mediastinal metastases (N2). Twenty-four (85.7%) patients received postoperative adjuvant therapy. Follow-up was complete in all patients for a median of 24 months (range 2-104 months). Median survival was 24 months (range 2-104). Survival at 1, 2, and 5 years was 64.3%, 54.0%, and 21.4%, respectively. The presence of thoracic lymph node metastases (N1 or N2) significantly affected 5-year survival (P =.001).

CONCLUSION

Although the overall survival for patients who have brain metastases from non-small cell lung cancer is poor, surgical resection may prove beneficial in a select group of patients with synchronous brain metastases and lung cancer without lymph node metastases.

Analysis of 158 frontal sinus fractures: current surgical management and complications

A retrospective analysis is presented of 158 patients who sustained frontal sinus fractures and were subsequently treated in the Division of Maxillofacial Surgery, University of Turin, from 1987 to 1998. The fractures were subdivided according to involvement of anterior and posterior walls, and of the nasofrontal duct. While treatment involving only the anterior wall is well standardized and without complications, management of anterior plus posterior wall fractures or involving the nasofrontal duct is still controversial. In dislocated posterior wall fractures, cranialization and obliteration of the remaining dead space and of the nasofrontal ducts using bone grafts, combined with the use of a pericranium flap, allow separation of the nasal cavity from the anterior cranial fossa, preventing ascending infections and thus reducing the rate of complications. When the fracture involves the nasofrontal duct with the posterior wall substantially intact, it is better to re-establish patency of the nasofrontal duct with a drainage tube and preserve the function of the sinus. A protocol used in the management of each group of fractures, clinical and radiological results, timing of operation, surgical procedures, outcomes, and long-term complications are all discussed.

Complications of burr-hole craniostomy and closed-system drainage for chronic subdural hematomas: a retrospective analysis of 376 patients

OBJECTIVE

Burr-hole craniostomy with closed-system drainage (BCD) is the most frequently used neurosurgical treatment of chronic subdural hematomas (cSDH). The surgical and medical complications of BCD have seldom been investigated systematically. The objective of this study was to define the frequency of surgical and medical complications following BCD for cSDH.

METHODS

The medical records of 376 patients managed by BCD were reviewed with respect to complications during the hospital stay.

RESULTS

Seventy-seven surgical complications (20.5%) were encountered. The most frequent minor complication after surgery was seizures (n 51, 13.6%). The most frequent major surgical complications were intracerebral hemorrhage and subdural empyema (n 8, 2.1% each). Four patients with intracerebral hemorrhage died, accounting for a surgical mortality rate of 1.1%. Fifty-nine medical complications (15.7%) occurred during the hospital stay. Pneumonia was the most frequent medical complication (n 29, 7.7%). Medical complications were fatal in 24 patients, accounting for a mortality rate of 6.4%. In 22 patients (5.8%), death was not related to a complication, but to the initial brain damage. The overall mortality rate was 13.3%.

CONCLUSION

The rate of complications in patients with cSDH who underwent the BCD is high. The clinical relevance of medical complications has to be emphasized because of their substantial contribution to overall mortality.

Complications of craniofacial resection for tumors involving the anterior skull base

BACKGROUND

A consecutive series of 85 patients undergoing craniofacial resection for malignant tumors involving the anterior cranial base between 1974 and 1992 was reviewed.

RESULTS

There were two (2%) postoperative deaths. Postoperative complications occurred in 33 (39%) patients. Local major complications occurred in 26 (31%) patients, local minor in 7 (8%), and systemic in 5 (6%). More than one complication occurred in a number of patients. Bacterial contamination led to a significant proportion of local, septic complications. Repair of the skull base defect with a pedicled pericranial flap was unsatisfactory and was associated with an increased incidence of local major complications. A local major complication was associated with a dramatic lengthening of hospitalization.

CONCLUSION

Future endeavors for prevention of complications should focus on antibiotic prophylaxis and reconstruction of the cranial base defect with better vascularized flaps.

Incidence and treatment of peripheral venous thrombosis in patients with glioma

The incidence, prevention, and treatment of peripheral venous thrombosis were studied retrospectively in 381 patients with malignant glioma. Of 264 patients who did not receive antithrombotic prophylaxis, 97 (36.7%) developed clinical phlebitis confirmed by venography. Sixty-six cases occurred within 6 weeks of craniotomy. By contrast, only 12 (10%) of 117 patients who received intermittent pneumatic pressure to the calves during craniotomy developed phlebitis (4 patients with 6 weeks of the surgery). Of the 109 patients with venous thrombosis, 103 were treated with anticoagulants. Of the 6 patients treated conservatively, 3 died of pulmonary emboli. Intracranial hemorrhage occurred in 1.9% of the patients taking anticoagulants and in 2.2% of those who did not develop phlebitis. We conclude that patients with malignant gliomas have a high risk of developing peripheral venous thrombosis; that antithrombotic therapy reduces the incidence of thrombosis following craniotomy; and that, in patients who develop phlebitis, anticoagulation reduces the risk of pulmonary emboli without increasing the risk of intracranial hemorrhage.

The subcranial approach for fronto-orbital and anteroposterior skull-base tumors

We describe 78 patients with fronto-orbital and sphenoethmoidal tumors surgically treated with the subcranial approach. This approach was developed by us in 1978 primarily for the treatment of skull-base trauma and craniofacial anomalies. Since 1980, we have extended the indications to include tumor resections. This extended anterior exposure of the anterior fossa skull base, including the sphenoidal and clival planes, enables an en bloc tumor removal obviating the transfrontal approach or lateral rhinotomy. In contrast with the conventional transcranial approach, the anterior subcranial approach provides an extended exposure of these locations, avoiding frontal lobe retraction. Reduction of complications, such as recurrent cerebrospinal fluid leaks, postoperative brain edema, damage to cranial nerves, and infection plus decreased hospitalization, are the major advantages of this procedure.

Extraneural metastases of central nervous system tumors

In the past, extraneural metastasis of central nervous system tumors was considered to be a rare event. However, more recently, a considerable body of literature has accumulated so that to date some 282 patients with extraneural metastases have been reported. Of these reported cases, 40.4% have occurred in children. Although central nervous system tumors can spread spontaneously beyond the confines of the central nervous system, most instances of extraneural metastasis occur after craniotomy or diversionary cerebrospinal fluid shunting. Extraneural metastases are universally fatal. Although it is not curative, chemotherapeutic treatment of metastases may greatly decrease the patient's discomfort and improve the quality and duration of survival. Every effort should be made to prevent this complication by avoiding diversionary cerebrospinal fluid shunting procedures or by incorporating a filtering device if a shunt becomes necessary.

Prospective evaluation of pain and analgesic use following major elective intracranial surgery

OBJECT

Opioid administration after major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect the postoperative neurological examination. The authors conducted a prospective study to evaluate the incidence, severity, and treatment of postoperative pain in patients who underwent major intracranial surgery.

METHODS

One hundred eighty-seven patients (77 men and 110 women, mean age 52 +/- 15 years, mean weight 78.1 +/- 19.9 kg) underwent either supratentorial (129 patients) or infratentorial (58 patients) procedures. Sixty-nine percent of the patients reported experiencing moderate to severe pain (> or =4 on a 0-10 scale) during the 1st postoperative day. Pain scores greater than or equal to 4 persisted in 48% on the 2nd postoperative day. Approximately 80% of patients were treated with acetaminophen on the 1st postoperative day, whereas opioids (primarily intravenous fentanyl) were administered to 58%. Compared with patients who underwent supratentorial procedures, those who underwent infratentorial procedures reported more severe pain at rest (mean score 4.9 +/- 2.2 compared with 3.8 +/- 2.6; p = 0.015) and with movement (mean score 6.3 +/- 2.6 compared with 4.5 +/- 2.7; p < 0.001) on the 1st postoperative day. On both the 1st and 2nd postoperative days, patients who underwent infratentorial procedures received greater quantities of opioid (p < or = 0.019) and nonopioid (p < or = 0.013) analgesics than those who underwent supratentorial procedures. Patients' dissatisfaction with analgesic therapy was significantly associated with elevated pain levels on the first 2 postoperative days (p < 0.001).

CONCLUSIONS

In contrast to prevailing assumptions, the study findings reveal that most patients undergoing elective major intracranial surgery will experience moderate to severe pain for the first 2 days after surgery and that this pain is often inadequately treated.

Tumors of the skull base: outcome and survival analysis of 77 cases

We reviewed our experience with combined approaches to lesions that transcend the bones of the skull base. Seventy-seven skull base procedures were performed on 73 patients during a 10-year period from 1982 to 1992. There were 34 patients (44%) with region lesions (anterior), seven patients (9%) with region II lesions (anterior-lateral), 25 patients (32%) with region III lesions (lateral-posterior), and 11 patients (14%) with lesions that invaded more than one anatomic site. The histopathology in this series was quite variable, with 22 patients (29%) having squamous cell carcinoma and eight patients (10%) having basal cell carcinoma. Forty-one patients had surgery by an anterior approach and 38 patients had lateral approaches, with 18 undergoing an infratemporal approach and 29 undergoing temporal bone resections. Overall, 44% of the patients had a postoperative complication. Survival of this heterogeneous group of patients is 79% at 2 years and 71% at 4 years, with those patients with region II disease having a statistically significant poorer prognosis with no survivors at 4 years.

Hemicraniectomy and moderate hypothermia in patients with severe ischemic stroke

BACKGROUND AND PURPOSE

We compared the clinical course of 36 consecutive patients with severe acute ischemic stroke (more than two thirds of the middle cerebral artery territory) treated with hemicraniectomy (CE; n=17) or moderate hypothermia (MH; n=19) in terms of intracranial pressure control, mortality, and specific treatment parameters.

METHODS

Over a period of 18 months, patients with severe ischemic stroke were treated with CE when the nondominant hemisphere was affected and with MH when the dominant hemisphere was affected. MH (33 degrees C) was induced with either cold blankets and fans (n=11) or endovascular cooling (n=8). Intracranial pressure was monitored invasively in all cases.

RESULTS

Age, sex, cranial CT findings, level of consciousness, and time to treatment were similar between the 2 groups; significant differences were noted in National Institute of Health Stroke Scale (NIHSS) score (20 [range, 18 to 22] and 17 [range, 16 to 18] for MH and CE, respectively) but were not present when NIHSS score was corrected for aphasia (17 [range, 15 to 19] and 17 [range, 16 to 18] for MH and CE, respectively). Mortality was 12% for CE and 47% for MH; 1 patient treated with MH died as a result of treatment complications (sepsis) and 3 of intracranial pressure crises that occurred during rewarming. Duration of mechanical ventilation and of neurological intensive care unit stay did not significantly differ, but duration of catecholamine application and maximal catecholamine dosage were significantly higher in the MH group.

CONCLUSIONS

In patients with severe ischemic stroke, CE results in lower mortality and lower complication rates compared with MH. Both treatment modalities, however, are associated with intensive medical treatment and a prolonged stay in the neurological intensive care unit.