Category: Outcome

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Long-term Outcomes of Patients With Giant Intracranial Arteriovenous Malformations

giant AVM

Neurosurgery 79:116–124, 2016

Giant intracranial arteriovenous malformations (AVMs) are rare cerebrovascular lesions that pose management challenges.

OBJECTIVE: To further clarify outcomes in patients with giant cerebral AVMs managed with conservative or interventional therapies.

METHODS: We performed a retrospective review of all patients diagnosed with AVMs evaluated at our institution from 1990 to 2013. Patients with a single intracranial AVM .6 cm were included. Patients were divided into 2 groups: conservative management or intervention (microsurgery, radiosurgery, or embolization). Functional outcome was assessed with the modified Rankin Scale (mRS) and compared between the 2 groups.

RESULTS: A total of 55 patients with giant AVMs were included, and 35 patients (63.6%) had clinical follow-up with a mean of 11.8 years. Spetzler-Martin grades were as follows: grade III, n = 2 (3.6%); grade IV, n = 15 (27.3%); and grade V, n = 38 (69.1%). Twenty-four patients (43.6%) were conservatively managed. The patients in the conservatively managed group had larger AVMs (P , .05) with more frequent involvement of the temporal lobe (P = .02). Five patients (26.3%) in the conservatively managed group and 5 (31.3%) in the intervention group experienced hemorrhage during follow-up, translating to an annualized risk of 2.7% and 4.1%, respectively. No significant difference in risk of first subsequent hemorrhage was observed (P = .78). Despite comparable mRS scores at presentation, we observed a trend toward better outcomes (mRS , 2) in patients undergoing conservative management (P = .06) compared with the intervention group at last follow-up.

CONCLUSION: This study suggests that interventions for giant AVMs should be considered cautiously because hemorrhagic risk is similar regardless of management strategy and functional outcome is likely to be same or better in the conservatively managed population.

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Low-grade Glioma Surgery in Intraoperative Magnetic Resonance Imaging

Hypnosis for Awake Surgery of Low-grade Gliomas

Neurosurgery 78:775–786, 2016

The ideal treatment strategy for low-grade gliomas (LGGs) is a controversial topic. Additionally, only smaller single-center series dealing with the concept of intraoperative magnetic resonance imaging (iMRI) have been published.

OBJECTIVE: To investigate determinants for patient outcome and progression-freesurvival (PFS) after iMRI-guided surgery for LGGs in a multicenter retrospective study initiated by the German Study Group for Intraoperative Magnetic Resonance Imaging.

METHODS: A retrospective consecutive assessment of patients treated for LGGs (World Health Organization grade II) with iMRI-guided resection at 6 neurosurgical centers was performed. Eloquent location, extent of resection, first-line adjuvant treatment, neurophysiological monitoring, awake brain surgery, intraoperative ultrasound, and fieldstrength of iMRI were analyzed, as well as progression-free survival (PFS), new permanent neurological deficits, and complications. Multivariate binary logistic and Cox regression models were calculated to evaluate determinants of PFS, gross total resection (GTR), and adjuvant treatment.

RESULTS: A total of 288 patients met the inclusion criteria. On multivariate analysis, GTR significantly increased PFS (hazard ratio, 0.44; P < .01), whereas “failed” GTR did not differ significantly from intended subtotal-resection. Combined radiochemotherapy as adjuvant therapy was a negative prognostic factor (hazard ratio: 2.84, P < .01). Field strength of iMRI was not associated with PFS. In the binary logistic regression model, use of high-field iMRI (odds ratio: 0.51, P < .01) was positively and eloquent location (odds ratio: 1.99, P < .01) was negatively associated with GTR. GTR was not associated with increased rates of new permanent neurological deficits.

CONCLUSION: GTR was an independent positive prognostic factor for PFS in LGG surgery. Patients with accidentally left tumor remnants showed a similar prognosis compared with patients harboring only partially resectable tumors. Use of high-field iMRI was significantly associated with GTR. However, the field strength of iMRI did not affect PFS.

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Predictive factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction

Predictive factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction

Acta Neurochir (2016) 158:865–873

The mortality rate of patients with brain oedema after malignant middle cerebral artery (MCA) infarction approaches 80 % without surgical intervention. Surgical treatment with ipsilateral decompressive hemicraniectomy (DHC) has been shown to dramatically improve survival rates. DHC currently lacks established inclusion criteria and additional research is needed to assess the impact of prognostic factors on functional outcome. The aim of this study was to assess the impact of prognostic factors on functional outcome.

Method A retrospective cohort study was carried out including 46 patients who underwent DHC at the Karolinska University Hospital between 2004 and 2014. The maximum time to surgery was 5 days after symptom debut. The primary endpoint was a dichotomised score on the modified Rankin Scale (mRS) 3 months after surgery, with favourable outcome defined as mRS ≤ 4.

Results When the study population was dichotomised according to the primary endpoint, a significant difference between the groups was seen in preoperative Glasgow Coma Score (GCS), blood glucose levels and the infarction’s involvement of the basal ganglia (p <0.05). In a logistic regression model, preoperative GCS contributed significantly with a 59.6 % increase in the probability of favourable outcome for each point gained in preoperative GCS (p=0.035).

Conclusions The results indicate that preoperative GCS, blood glucose and the infarction’s involvement of the basal ganglia are strong predictors of clinical outcome. These factors should be considered when assessing the probable outcome of DHC, and additional research based on these factors may contribute to improved inclusion criteria for DHC.

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Surgical Decompression of Arachnoid Cysts Leads to Improved Quality of Life

Suprasellar Arachnoid Cysts- Toward a New Simple Classification Based on Prognosis and Treatment Modality

Neurosurgery 78:613–625, 2016

There is no previous prospective study on the outcome of surgical decompression of intracranial arachnoid cysts (AC).

OBJECTIVE: To investigate if surgical fenestration for AC leads to change in patients’ health-related quality of life.

METHODS: Prospective study including 76 adult patients operated for AC. Patients responded to Short Form-36 and Glasgow Benefit Inventory quality of life questionnaires, and to visual analogue scales, assessing headache and dizziness pre- and postoperatively. Patient scores were compared with those of a large sample of healthy individuals.

RESULTS: Preoperatively, 84.2% of the patients experienced headache and 70.1% dizziness. Mean pre- versus postoperative Visual Analogue Scale scores for headache and dizziness dropped from 45.6 to 25.7 and from 35.2 to 12.2, respectively. Preoperative Short Form-36 scores were significantly below age norms in all subscales, but improved after surgery into normal range in 7 out of 8 subscales for middle-aged and older patients. Younger patients’ scores remained lower than age norm in 6 out of 8 subscales. A significant postoperative improvement was seen in 3 out of 4 Glasgow Benefit Inventory subscales. Improvement in headache and/or dizziness, but not preoperative cyst size or reduction in cyst volume, correlated with improvement in 6 out of 8 Short Form-36 subscales and 3 out of 4 Glasgow Benefit Inventory subscales. Only 1 patient experienced a severe complication causing permanent invalidity.

CONCLUSION: Surgery for AC can be performed with a fairly low risk of complications and yields significant improvement in quality of life correlated to postoperative improvement in headache and dizziness. These findings may justify a more liberal approach to surgical treatment for AC.

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Advanced MRI may complement histological diagnosis of lower grade gliomas and help in predicting survival

Advanced MRI may complement histological diagnosis of lower grade gliomas and help in predicting survival

J Neurooncol (2016) 126:279–288

MRI grading of grade II and III gliomas may have an important impact on treatment decisions. Occasionally, both conventional MRI (cMRI) and histology fail to clearly establish the tumour grade. Three cMRI features (no necrosis; no relevant oedema; absent or faint contrast enhancement) previously validated in 196 patients with supratentorial gliomas directed our selection of 68 suspected low-grade gliomas (LGG) that were also investigated by advanced MRI (aMRI), including perfusion weighted imaging (PWI), diffusion weighted imaging (DWI) and spectroscopy. All the gliomas had histopathological diagnoses.

Sensitivity and specificity of cMRI preoperative diagnosis were 78.5 and 38.5 %, respectively, and 85.7 and 53.8 % when aMRI was included, respectively. ROC analysis showed that cut-off values of 1.29 for maximum rCBV, 1.69 for minimum rADC, 2.1 for rCho/Cr ratio could differentiate between LGG and HGG with a sensitivity of 61.5, 53.8, and 53.8 % and a specificity of 54.7, 43 and 64.3 %, respectively. A significantly longer OS was observed in patients with a maximum rCBV\1.46 and minimum rADC[1.69 (80 vs 55 months, p = 0.01; 80 vs 51 months, p = 0.002, respectively). This result was also confirmed when cases were stratified according to pathology (LGG vs HGG). The ability of aMRI to differentiate between LGG and HGG and to predict survival improved as the number of aMRI techniques considered increased.

In a selected population of suspected LGG, classification by cMRI underestimated the actual fraction of HGG. aMRI slightly increased the diagnostic accuracy compared to histopathology. However, DWI and PWI were prognostic markers independent of histological grade.

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Preoperative predictive factors for surgical and functional outcomes in chronic subdural hematoma

Subdural Hematoma

Acta Neurochir (2016) 158:135–139

Chronic subdural hematoma (CSDH) is a frequently encountered neurosurgical condition, especially in the elderly. We investigated predictive factors for surgical and functional outcomes after burr-hole drainage (BHD) surgery.

Methods All patients with CSDH treated by BHD between January 2012 and December 2014 were included in this study. All patients were classified by symptom, clinical grade, time, location, hematoma density, midline shift, and other characteristics. Pre- and postoperative CT evaluation was performed at 0, 3, and 6 months. Clinical grades were classified as described in Markwalder et al. Surgical and clinical outcomes were evaluated with the brain expansion rate and modified Rankin Scale (mRS). Brain expansion rate was calculated as the ratio between post- and pre-operative hematoma thickness. Recurrence was defined as the occurrence of symptoms and hematoma on CT within 6 months.

Results This study included 130 patients over 2 years. Among the variable parameters, young age (<75), iso-density of hematoma on CT, and short duration from symptom to surgery were correlated with good brain expansion. Patients with good brain expansion had fewer recurrences. In terms of mRS, young age, iso-density, and good clinical grade were correlated with good functional outcomes.

Conclusions Clinicians should be more aware of general conditions and medical problems, especially in elderly patients. Membranectomy should be considered in patients with a long duration of symptoms or hypo-dense hematomas to promote good brain expansion and good mRS scores.

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Long-term outcomes after supratotal resection of diffuse low-grade gliomas

Long-term outcomes after supratotal resection of diffuse low-grade gliomas

Acta Neurochir (2016) 158:51–58

Total or subtotal surgical resection ofWHO grade II glioma (diffuse low-grade glioma, DLGG) can significantly increase survival. Moreover, a supratotal resection, i.e., an extended resection with a margin beyondMR imaging abnormalities, could decrease the risk of malignant transformation. Here, the goal is to analyze the long-term functional and oncological outcomes following supratotal resection for DLGG.

Methods Sixteen consecutive patients who underwent supratotal resection for a DLGG with a minimum follow-up of 8 years after surgery were included. The resection was continued up to functional cortical and subcortical structures defined by intrasurgical electrical mapping. The extent of resection was evaluated on postoperative FLAIR-weighted MR imaging. Data regarding clinicoradiological features, therapeutic management, and outcomes were analyzed.

Results Seven men and nine women (mean age, 41.3 years, range, 26–63 years) were included (seizure in 15 cases, one incidental discovery). All patients resumed a normal life after surgery (no neurological deficits, no epilepsy). The volume of postoperative cavity was larger than the preoperative tumor volume in the 16 patients. Neuropathological examination confirmed the diagnosis of WHO grade II glioma in all cases. No adjuvant treatment was administrated after resection. The mean duration of postoperative follow-up was 132 months (range, 97–198 months). There was no relapse in eight cases. Eight patients experienced tumor recurrence, with an average time to relapse of 70.3 months (range, 32–105 months), but without malignant transformation. Five of them have been retreated, with a reoperation (two cases), chemotherapy (three cases) and radiotherapy (two cases). All patients continue to enjoy a normal life.

Conclusions This is the first series demonstrating the prolonged impact of supratotal resection on malignant transformation of DLGG. These original data may suggest to remove a margin around the FLAIR-weighted MR imaging abnormalities in a more systematic manner for DLGG not involving eloquent structures.

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Neurocognitive Changes Associated With Surgical Resection of Left and Right Temporal Lobe Glioma

Temporal lobe tumor

Neurosurgery 77:777–785, 2015

Little is known regarding the neurocognitive impact of temporal lobe tumor resection.

OBJECTIVE: To clarify subacute surgery-related changes in neurocognitive functioning (NCF) in patients with left (LTL) and right (RTL) temporal lobe glioma.

METHODS: Patients with glioma in the LTL (n = 45) or RTL (n = 19) completed comprehensive pre- and postsurgical neuropsychological assessments. NCF was analyzed with 2-way mixed design repeated-measures analysis of variance, with hemisphere (LTL or RTL) as an independent between-subjects factor and pre- and postoperative NCF as a within-subjects factor.

RESULTS: About 60% of patients with LTL glioma and 40% with RTL lesions exhibited significant worsening on at least 1 NCF test. Domains most commonly impacted included verbal memory and executive functioning. Patients with LTL tumor showed greater decline than patients with RTL tumor on verbal memory and confrontation naming tests. Nonetheless, over one-third of patients with RTL lesions also showed verbal memory decline.

CONCLUSION: In patients with temporal lobe glioma, NCF decline in the subacute postoperative period is common. As expected, patients with LTL tumor show more frequent and severe decline than patients with RTL tumor, particularly on verbally mediated measures. However, a considerable proportion of patients with RTL tumor also exhibit decline across various domains, even those typically associated with left hemisphere structures, such as verbal memory. While patients with RTL lesions may show even greater decline in visuospatial memory, this domain was not assessed. Nonetheless, neuropsychological assessment can identify acquired deficits and help facilitate early intervention in patients with temporal lobe glioma.

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Intracranial meningioma surgery in the elderly (over 65 years): prognostic factors and outcome

Tuberculum Sellae Meningiomas

Acta Neurochir 157 (9): 1549-1557

Meningiomas are more prevalent in elderly individuals; however, the surgical outcome and prognostic factors in this age group are unclear. This retrospective study aimed to identify the prognostic factors of elderly patients with intracranial meningiomas who underwent surgical resection.

Methods

Eighty-six patients (aged ≥65) diagnosed with an intracranial meningioma were surgically treated at our department. The clinical, radiological, and follow-up data were retrospectively reviewed. Univariate and multivariate logistic analyses were performed to identify relationships between factors [age, sex, neurological condition, concomitant disease, American Society of Anesthesiology (ASA) classification, preoperative Karnofsky Performance Scale (KPS) score, tumor location and size, peritumoral edema, and Simpson resection grade] and outcome.

Results

One patient (1.2 %) died within 30 days of surgery. The morbidity rate was 37.2 %. Postoperative morbidities occurred more frequently in the patients with preoperative neurological deficits than in those without (p = 0.049). Univariate analysis identified significant relationships between a low KPS score (≤70) at discharge and preoperative neurological deficits, low preoperative KPS score (≤70), and critical tumor location (p < 0.001, p < 0.001, and p = 0.04, respectively). In the multivariate logistic analysis, only the preoperative KPS score remained significant for the KPS score at discharge (p = 0.005); there was no significant association with the most recent KPS score.

Conclusion

The outcome of intracranial meningioma resection in elderly individuals is favorable if the preoperative KPS score is >70 and no neurological deficits are present. Treatment decisions should be patient-specific, and additional factors should be considered when operations are performed in patients with a low preoperative KPS score or neurological deficits.

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Aneurysm diameter as a risk factor for pretreatment rebleeding: a meta-analysis

MCA aneurysm

J Neurosurg 122:921–928, 2015

Aneurysmal rerupture prior to treatment is a major cause of death and morbidity in aneurysmal subarachnoid hemorrhage. Recognizing risk factors for aneurysmal rebleeding is particularly relevant and might help to identify the aneurysms that benefit from acute treatment. It is uncertain if the size of the aneurysm is related to rebleeding. This meta-analysis was performed to evaluate whether an association could be determined between aneurysm diameter and the rebleeding rate before treatment. Potentially confounding factors such age, aneurysm location, and the presence of hypertension were also evaluated.

Methods The authors systematically searched the PubMed, Embase, and Cochrane databases up to April 3, 2013, for studies of patients with aneurysmal subarachnoid hemorrhage that reported the association between aneurysm diameter and pretreatment aneurysmal rebleeding. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were used to evaluate study quality.

Results Seven studies, representing 2121 patients, were included in the quantitative analysis. The quality of the studies was low in 2 and very low in 5. Almost all of the studies used 10 mm as the cutoff point for size among other classes, and only one used 7 mm. An analysis was performed with this best unifiable cutoff point. Overall rebleeding occurred in 360 (17.0%) of 2121 patients (incidence range, from study to study, 8.7%–28.4%). The rate of rebleeding in small and large aneurysms was 14.0% and 23.6%, respectively. The meta-analysis of the 7 studies revealed that larger size aneurysms were at a higher risk for rebleeding (OR 2.56 [95% CI 1.62–4.06]; p = 0.00; I2 = 60%). The sensitivity analysis did not alter the results. Five of the 7 studies reported data regarding age; 4 studies provided age-adjusted results and identified a persistent relationship between lesion size and the risk of rebleeding. The presence of hypertension was reported in two studies and was more prevalent in patients with rebleeding in one of these. Location (anterior vs posterior circulation) was reported in 5 studies, while in 4 there was no difference in the rebleeding rate. One study identified a lower risk of rebleeding associated with posterior location aneurysms.

Conclusions This meta-analysis showed that aneurysm size is an important risk factor for aneurysmal rebleeding and should be used in the clinical risk assessment of individual patients. The authors’ results confirmed the current guidelines and underscored the importance of acute treatment for large ruptured aneurysms.

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An evidence-based treatment algorithm for the management of WHO Grade II and III meningiomas

Management of WHO Grade II and III meningiomas

Neurosurg Focus 38 (3):E3, 2015

The management of WHO Grade II “atypical” meningiomas (AMs) and Grade III “malignant” meningiomas (MMs) remains controversial and under-investigated in prospective studies. The roles of surgery, radiation therapy, radiosurgery, and chemotherapy have been incompletely delineated. This has left physicians to decipher how they should treat patients on a case-by-case basis.

In this study, the authors review the English-language literature on the management and clinical outcomes associated with AMs and MMs diagnosed using the WHO 2000/2007 grading criteria. Twenty-two studies for AMs and 7 studies for MMs were examined in detail. The authors examined clinical decision points using the literature and concepts from evidence-based medicine.

Acknowledging the retrospective nature of the studies concerning AM and MM, the authors did find evidence for the following clinical strategies: 1) maximal safe resection of AM and MM; 2) active surveillance after gross-total resection of AM; 3) adjuvant radiation therapy after subtotal resection of AM, especially in the absence of putative radioresistant features; and 4) adjuvant radiation therapy after resection of MM.

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Effects of Hematoma Reduction by Stereotactic Aspiration for Patients With Spontaneous Intracerebral Hemorrhage

Effects of Hematoma Reduction by Stereotactic Aspiration for Patients With Spontaneous Intracerebral Hemorrhage

Neurosurg Q 2015;25:17–23

Spontaneous intracerebral hemorrhage (ICH) is a devastating medical condition associated with significant morbidity and mortality. Whether the hematoma should be surgically removed remains controversial. This study was a retrospective analysis of patients with spontaneous ICH who were treated with computed tomography (CT)-guided stereotactic aspiration. The aim of this study was to investigate whether hematoma volume reduction in deep-seated ICH utilizing this minimally invasive surgical procedure improves clinical outcome.

Methods: Ninety-nine patients who suffered spontaneous ICH provided informed consent and were included in the study. Patients were divided into an operated group that underwent CT-guided stereotactic aspiration, and a nonoperated group that received only medical treatment. CT-guided stereotactic aspiration was performed at least 8 hours after onset of ICH. Using the Leksell stereotactic frame for guidance, a 4-mm-diameter catheter was inserted into the body of the hematoma through a frontal burr hole. Glasgow Coma Scale, motor function, and length of hospital stay were used to assess differences in outcomes between the 2 groups. The correlation between clinical outcome and stereotactic aspiration was evaluated using multivariate regression analysis.

Results: Ninety-nine consecutive patients were entered into this study. Patients in the operated group (n=41) were treated with CT-guided stereotactic hematoma aspiration. The 3-month Glasgow Outcome Scale score in the nonoperated group (n=58) was significantly lower than that in the operated group (2.32±1.26 vs. 3.15±1.33, P<0.001). Patients in the operated group experienced greater motor function recovery than those in the nonoperated group. The average length of hospital stay of the operated group was significantly shorter than that of the nonoperated group (31.2±14.6 vs. 41.7±17.2 d, P=0.002).

Conclusions: Stereotactic aspiration may improve the functional outcome and shorten the hospital stay of patients who have suffered spontaneous ICH. This procedure is minimally invasive and shows promise as a safe and effective treatment method for these patients.

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Factors Predicting Recurrence After Resection of Clival Chordoma

Clivus chordomas

Neurosurgery 76:179–186, 2015

Clival chordomas frequently recur because of their location and invasiveness.

OBJECTIVE: To investigate clinical, operative, and anatomic factors associated with clival chordoma recurrence.

METHODS: Retrospective review of clival chordomas treated at our center from 1993 to 2013.

RESULTS: Fifty patients (56% male) with median age of 59 years (range, 8-76) were newly diagnosed with clival chordoma of mean diameter 3.3 cm (range, 1.5-6.7). Symptoms included headaches (38%), diplopia (36%), and dysphagia (14%). Procedures included transsphenoidal (n = 34), transoral (n = 4), craniotomy (n = 5), and staged approaches (n = 7). Gross total resection (GTR) rate was 52%, with 83%mean volumetric reduction, values that improved over time.While the lower third of the clivus was the least likely superoinferior zone to contain tumor (upper third = 72%/middle third = 82%/lower third = 42%), it most frequently contained residual tumor (upper third = 33%/middle third = 38%/lower third = 63%; P , .05). Symptom improvement rates were 61% (diplopia) and 53% (headache). Postoperative radiation included proton beam (n = 19), cyberknife (n = 7), intensity-modulated radiation therapy (n = 6), external beam (n = 10), and none (n = 4). At last follow-up of 47 patients, 23 (49%) remain disease-free or have stable residual tumor. Lower third of clivus progressed most after GTR (upper/mid/lower third = 32%/ 41%/75%). In a multivariate Cox proportional hazards model, male gender (hazard ratio [HR] = 1.2/P = .03), subtotal resection (HR = 5.0/P = .02), and the preoperative presence of tumor in the middle third (HR = 1.2/P = .02) and lower third (HR = 1.8/P = .02) of the clivus increased further growth or regrowth, while radiation modality did not.

CONCLUSION: Our findings underscore long-standing support for GTR as reducing chordoma recurrence. The lower third of the clivus frequently harbored residual or recurrent tumor, despite staged approaches providing mediolateral (transcranial 1 endonasal) or superoinferior (endonasal 1 transoral) breadth. There was no benefit of proton-based over photonbased radiation, contradicting conventional presumptions.

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Validation of a prognostic score for early mortality in severe head injury cases

Brain_trauma_CT

J Neurosurg 121:1314–1322, 2014

Traumatic brain injury (TBI) represents a large health and economic burden. Because of the inability of previous randomized controlled trials (RCTs) on TBI to demonstrate the expected benefit of reducing unfavorable outcomes, the IMPACT (International Mission on Prognosis and Analysis of Clinical Trials in TBI) and CRASH (Corticosteroid Randomisation After Significant Head Injury) studies provided new methods for performing prognostic studies of TBI. This study aimed to develop and externally validate a prognostic model for early death (within 48 hours). The secondary aim was to identify patients who were more likely to succumb to an early death to limit their inclusion in RCTs and to improve the efficiency of RCTs.

Methods. The derivation cohort was recruited at 1 center, Hospital 12 de Octubre, Madrid (1990–2003, 925 patients). The validation cohort was recruited in 2004–2006 from 7 study centers (374 patients). The eligible patients had suffered closed severe TBIs. The study outcome was early death (within 48 hours post-TBI). The predictors were selected using logistic regression modeling with bootstrapping techniques, and a penalized reduction was used. A risk score was developed based on the regression coefficients of the variables included in the final model.

Results. In the validation set, the final model showed a predictive ability of 50% (Nagelkerke R2), with an area under the receiver operating characteristic curve of 89% and an acceptable calibration (goodness-of-fit test, p = 0.32). The final model included 7 variables, and it was used to develop a risk score with a range from 0 to 20 points. Age provided 0, 1, 2, or 3 points depending on the age group; motor score provided 0 points, 2 (untestable), or 3 (no response); pupillary reactivity, 0, 2 (1 pupil reacted), or 6 (no pupil reacted); shock, 0 (no) or 2 (yes); subarachnoid hemorrhage, 0 or 1 (severe deposit); cisternal status, 0 or 3 (compressed/absent); and epidural hematoma, 0 (yes) or 2 (no). Based on the risk of early death estimated with the model, 4 risk of early death groups were established: low risk, sum score 0–3 (< 1% predicted mortality); moderate risk, sum score 4–8 (predicted mortality between 1% and 10%); high risk, sum score 9–12 (probability of early death between 10% and 50%); and very high risk, sum score 13–20 (early mortality probability > 50%). This score could be used for selecting patients for clinical studies. For example, if patients with very high risk scores were excluded from our study sample, the patients included (eligibility score < 13) would represent 80% of the original sample and only 23% of the patients who died early.

Conclusions. The combination of Glasgow Coma Scale score, CT scanning results, and secondary insult data into a prognostic score improved the prediction of early death and the classification of TBI patients.

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A comparison of lumboperitoneal and ventriculoperitoneal shunting for idiopathic intracranial hypertension

IIH

Neurosurg Focus 37 (5):E4, 2014

Complications following lumboperitoneal (LP) shunting have been reported in 18% to 85% of cases. The need for multiple revision surgeries, development of iatrogenic Chiari malformation, and frequent wound complications have prompted many to abandon this procedure altogether for the treatment of idiopathic benign intracranial hypertension (pseudotumor cerebri), in favor of ventriculoperitoneal (VP) shunting. A direct comparison of the complication rates and health care charges between first-choice LP versus VP shunting is presented.

Methods. The Nationwide Inpatient Sample database was queried for all patients with the diagnosis of benign intracranial hypertension (International Classification of Diseases, Ninth Revision, code 348.2) from 2005 to 2009. These data were stratified by operative intervention, with demographic and hospitalization charge data generated for each.

Results. A weighted sample of 4480 patients was identified as having the diagnosis of idiopathic intracranial hypertension (IIH), with 2505 undergoing first-time VP shunt placement and 1754 undergoing initial LP shunt placement. Revision surgery occurred in 3.9% of admissions (n = 98) for VP shunts and in 7.0% of admissions (n = 123) for LP shunts (p < 0.0001). Ventriculoperitoneal shunts were placed at teaching institutions in 83.8% of cases, compared with only 77.3% of first-time LP shunts (p < 0.0001). Mean hospital length of stay (LOS) significantly differed between primary VP (3 days) and primary LP shunt procedures (4 days, p < 0.0001). The summed charges for the revisions of 92 VP shunts ($3,453,956) and those of the 6 VP shunt removals ($272,484) totaled $3,726,352 over 5 years for the study population. The summed charges for revision of 70 LP shunts ($2,229,430) and those of the 53 LP shunt removals ($3,125,569) totaled $5,408,679 over 5 years for the study population.

Conclusions. The presented results appear to call into question the selection of LP shunt placement as primary treatment for IIH, as this procedure is associated with a significantly greater likelihood of need for shunt revision, increased LOS, and greater overall charges to the health care system.

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Practical surgical indicators to identify candidates for radical resection of insulo-opercular gliomas

Surgical indicators insular gliomas

J Neurosurg 121:1124–1132, 2014

Maximum resection of gliomas with minimum surgical complications usually leads to optimum outcomes for patients. Radical resection of insulo-opercular gliomas is still challenging, and selection of ideal patients can reduce risk and obtain better outcomes.

Methods. This retrospective study included 83 consecutively treated patients with newly diagnosed gliomas located at the insulo-opercular region and extending to the sylvian fissure around the primary motor and somatosensory cortices. The authors selected 4 characteristics as surgical indicators: clear tumor boundaries, negative enhancement, intact lenticulostriate arteries, and intact superior extremity of the central insular sulcus.

Results. Univariate analysis showed that tumors with clear boundaries were associated with higher rates of gross-total resection than were tumors with ambiguous boundaries (75.7% vs 19.6%). Tumors with negative enhancement compared with enhanced tumors were associated with lower frequency of tumor progression (32.0% vs 81.8%, respectively) and lower rates of surgical complications (14.0% vs 45.5%, respectively). Tumors with intact lenticulostriate arteries were associated with higher rates of gross-total resection than were tumors with involved lenticulostriate arteries (67.3% vs 11.8%, respectively). Tumors with intact superior extremity of the central insular sulcus were associated with higher rates of gross-total resection (57.4% vs 20.7%, respectively) and lower rates of surgical complications (18.5% vs 41.4%, respectively) than were tumors with involved anatomical structures. Multivariate analysis showed that clear tumor boundaries were independently associated with gross-total resection (p < 0.001). Negative enhancement was found to be independently associated with surgical complications (p = 0.005), overall survival times (p < 0.001), and progression-free survival times (p = 0.004). Independent associations were also found between intact lenticulostriate arteries and gross-total resection (p < 0.001), between intact lenticulostriate arteries and progression-free survival times (p = 0.026), and between intact superior extremity of the central insular sulcus and gross-total resection (p = 0.043). Among patients in whom all 4 indicators were present, prognosis was good (5- year survival rate 93.3%), resection rate was maximal (gross-total resection 100%), and surgical complication rate was minimal (6.7%). Also among these patients, overall rates of survival (p = 0.003) and progression-free survival (p = 0.005) were significantly higher than among patients in whom fewer indicators were present.

Conclusions. The authors propose 4 simple indicators that can be used to identify ideal candidates for radical resection of insulo-opercular gliomas, improve the outcomes, and promote maximum resection without introducing neurological complications. The indicators are clear tumor boundaries, negative enhancement, intact lenticulostriate arteries, and intact superior extremity of the central insular sulcus.

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Management of Atypical Cranial Meningiomas, Part 2: Predictors of Progression and the Role of Adjuvant Radiation After Subtotal Resection

Meningioma_-_brain_invasion_-_high_mag

Neurosurgery 75:356–363, 2014

The efficacies of adjuvant stereotactic radiosurgery (SRS) and external beam radiation therapy (EBRT) for atypical meningiomas (AMs) after subtotal resection (STR) remain unclear.

OBJECTIVE: To analyze the clinical, histopathological, and radiographic features associated with progression in AM patients after STR.

METHODS: Fifty-nine primary AMs after STR were examined for predictors of progression, including the impact of SRS and EBRT, in a retrospective cohort study.

RESULTS: Twenty-seven patients (46%) progressed after STR (median, 30 months). On univariate analysis, spontaneous necrosis positively (hazard ratio = 5.2; P = .006) and adjuvant radiation negatively (hazard ratio = 0.3; P = .009) correlated with progression; on multivariate analysis, only adjuvant radiation remained independently significant (hazard ratio = 0.3; P = .006). SRS and EBRT were associated with greater local control (LC; P = .02) and progression-free survival (P = .007). The 2-, 5-, and 10-year actuarial LC rates after STR vs STR/EBRT were 60%, 34%, and 34% vs 96%, 65%, and 45%. The 2-, 5-, and 10-year actuarial progression-free survival rates after STR vs STR/EBRT were 60%, 30%, and 26% vs 96%, 65%, and 45%. Compared with STR alone, adjuvant radiation therapy significantly improved LC in AMs that lack spontaneous necrosis (P = .003) but did not improve LC in AMs with spontaneous necrosis (P = .6).

CONCLUSION: Adjuvant SRS or EBRT improved LC of AMs after STR but only for tumors without spontaneous necrosis. Spontaneous necrosis may aid in decisions to administer adjuvant SRS or EBRT after STR of AMs.

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Effect of neoadjuvant temozolomide upon volume reduction and resection of diffuse low-grade glioma

Effect of neoadjuvant temozolomide upon volume reduction and resection of diffuse low-grade glioma

J Neurooncol (2014) 120:155–161

Maximal safe resection is associated with prolonged survival in patients with low-grade glioma (LGG). It has been suggested that neoadjuvant temozolomide may provide sufficient tumor shrinkage to facilitate aggressive surgical debulking. We examined the impact of temozolomide upon volume reduction and resectability of LGG.

We retrospectively identified 20 adult patients with biopsy proven, deemed not totally resectable LGGs, treated initially with temozolomide. Volumetric 3D (calculated from serial FLAIR images) and 2D tumor measurements were obtained prior to treatment and at 3 months post-treatment. The anticipated extent of resection (EOR) at the 2 time points was measured based on anatomical limitations, calculated as: [(total tumor volume – unresectable tumor volume)/total tumor volume] x 100. Eloquent cortex, deep structures and corpus callosum were considered unresectable.

Mean tumor volume was 68.4 cm3 pre-treatment and 49.5 cm3 at 3 months post-treatment. The mean change from baseline to 3 months after treatment was -32.5 % (p\0.001). Mean 2D pre-treatment area was 28.6 and 23.3 cm2 at 3 months post-treatment. The 2D change was also significant, with mean change of -17 % (p\0.001). 5 % had partial response; 40 % minor response; 45 % stable disease; and 10 % progressive disease by RANO criteria. Mean pretreatment anticipated EOR was 67.2 and 71.5 %at 3 months post-treatment. The mean change from baseline was 4.3 % (p = 0.10).

Our findings demonstrate significant volumetric and 2D reduction of LGG with temozolomide. Although this tumor shrinkage might facilitate radical surgical resection in some cases, our data failed to show statistically significant improvement in anticipated EOR.

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Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation

Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation

Neurosurg Rev (2014) 37:653–659

Additional space-occupying intracerebral hematoma (ICH) in patients suffering from subarachnoid hemorrhage (SAH) is a known predictor for poor outcome. Emergent clot evacuation might be mandatory. However, data concerning the influence of ICH location on outcome is scarce. Therefore, we analyzed the influence of ICH location on clinical course and outcome in patients with SAH and additional ICH.

One hundred seventy-four patients were treated with aneurysmal SAH and additional ICH between September 1999 and May 2012. Information including patient characteristics, treatment, and radiological findings were prospectively entered into a database. Patients were stratified according to ICH location and neurological outcome. Neurological outcome was assessed according to modified Rankin Scale (mRS).

ICH location was temporal (58.6 %), frontal (28.7 %), and perisylvian ICH (12.6%); 63.8% presented in poor admission status and favorable outcome was achieved in 35.6 %. In the multivariate analysis, favorable outcome was associated with young age, ICH <50 ml, and good admission status. The location of ICH was not associated with outcome. The current data confirms that a significant number of patients with ICH after aneurysm rupture achieve favorable outcome. Prognostic factor for favorable outcome are “age,” “size of the hematoma,” and “admission status.” The location of the ICH seems not to be associated with outcome.

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Improvement in social function and health-related quality of life after shunt surgery for idiopathic normal-pressure hydrocephalus

HRQOL in iNPH

J Neurosurg 121:776–784, 2014

Object. To investigate the impact of shunt surgery on the activity, participation, autonomy, and health-related quality of life (HRQOL) of patients with idiopathic normal-pressure hydrocephalus (iNPH) as well as the effect on caregiver burden.

Methods. Thirty-seven patients (median age 70 years, range 50–89 years) with iNPH were evaluated before and 6 months after surgery. Symptoms and signs were assessed by the iNPH scale, activities of daily living (ADL) with the Functional Independence Measure (FIM) and Assessment of Motor and Process Skills (AMPS), autonomy and participation with Impact on Participation and Autonomy (IPA), and caregiver burden with the Caregiver Burden Scale (CBS). HRQOL was evaluated with the EQ-5D (EuroQol Group–5 Dimension health survey).

Results. Twenty-four patients (65%) improved clinically (iNPH scale score) and 31 (86%) improved their HRQOL after surgery, almost to the same level as found in the normal population. The patients became more independent in physical and cognitive activities, and participation and autonomy improved. The caregiver burden was decreased among caregivers to male patients but remained unchanged on the overall group level.

Conclusions. After shunt surgery, patients with iNPH showed improvement in most aspects of social life, they became more independent, and their quality of life returned to nearly normal.

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