No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Incidence of Recraniotomy for Postoperative Infections After Surgery for Intracranial Tumors
Abstract
The prevalence rate for all primary brain and central nervous system tumors is estimated to be 130.8 per 100,000 inhabitants (CTBRUS (2008) Statistical report: primary brain tumors in the United States, 2000–2004. http:// www. cbtrus. org/ reports/ / 2007-2008/ 2007report. pdf). The cornerstone of brain tumor treatment is surgery, where the objective is radical surgery within safe limits and to establish an exact tissue diagnosis. However, craniotomies are not without inherent risks, be it surgical mortality, postoperative hematomas or infections. Infections after neurosurgical procedures often present as meningitis, subdural empyema, or cerebral abscess. Although meningitis can often be treated with intravenous antibiotics, cases that involve a bone flap infection, subdural empyema, or cerebral abscess usually require a repeated operation. In a recent large series, 1.5 % of the patients were reoperated for postoperative infection. Of these infections, 59.0 % were extradural. Independent risk factors were male sex and meningioma histopathology. The vast majority of reoperations occurred within 3 months of tumor surgery. The consequences of postoperative infections were generally minor, as 85 % had a good outcome with no or only a mild disability, but within the group of patients reoperated for infection, the mortality rate was 5 %.
Surgical approach selection is one of the main questions in skull base surgery that mostly determines the successful outcome of the surgery.
The objectives of this study are the decision-making tactics for approach selection and the results of the surgical treatment of patients with anterior and middle skull base meningiomas.
Materials and methods: There were performed 245 surgeries of removal anterior and middle skull base meningiomas in the department of neurosurgery of the “Interregional Clinical and Diagnostic Center” (ICDC) with a mortality rate of 2,8% in the period from 2010 to 2020 years.
Results: The decision-making algorithm includes such criteria as the size and location of the tumor, involvement of neural and vascular structures in the tumor’s stroma and safety and efficacy properties of the surgical approach. The common approaches that are used in the department of neurosurgery of ICDC are unilateral subfrontal, transbasal bifrontal, pterional, modified orbitozygomatic, supraorbital eyebrow, and endoscopic transnasal approaches. Thus, the tumor can be attacked by multiple angles with the most effective and safe trajectory. In some cases, it is advisable to stage the tumor removal using approaches with different trajectories or combine transcranial and endoscopic approaches to facilitate the radicalism and safety of the surgery.
In order to weigh the risks of surgery against the presumed advantages, it is important to have specific knowledge about complication rates.
To study the surgical mortality and rate of reoperations for hematomas and infections after intracranial surgery for brain tumors in a large, contemporary, single-institution consecutive series.
All adult patients from a well-defined population of 2.7 million inhabitants who underwent craniotomies for intracranial tumors at Oslo University Hospital from 2003 to 2008 were included (n = 2630). The patients were identified from our prospectively collected database and their charts studied retrospectively. Follow-up was 100%.
The overall surgical mortality, defined as death within 30 days of surgery, was 2.3% (n = 60). The mortality rates for high- and low-grade gliomas, meningiomas, and metastases were 2.9%, 1.0%, 0.9%, and 4.5%, respectively. Age >60 (odds ratio 1.84, P < 0.05) and biopsy compared with resection (odds ratio 4.67, P < 0.01) were significantly positively associated with increased surgical mortality. Hematomas accounted for 35% of the surgical mortality. Postoperative hematomas needing evacuation occurred in 2.1% (n = 54). Age >60 was significantly correlated to increased risk of postoperative hematomas (odds ratio 2.43, P < 0.001). A total of 39 patients (1.5%) were reoperated for postoperative infection. Meningiomas had an increased risk of infections compared with high-grade gliomas (odds ratio 4.61, P < 0.001).
The surgical mortality within 30 days of surgery was 2.3%, with age >60 and biopsy vs resection being the 2 factors significantly associated with increased mortality. Postoperative hematomas caused about one third of the surgical mortality.
A retrospective analysis was performed on 66 patients with anaplastic astrocytoma (AA) and 177 patients with glioblastoma multiforme (GM). The prognostic importance of age, performance status, tumour location, extent of surgery and radiation treatment was studied. Radiation therapy gave a significant improvement in survival in both AA (p less than 0.003) and GM (p less than 0.002), but was given only to patients in a good neurological condition. Both younger age (p less than 0.003), and good preoperative performance status (p less than 0.002) were associated with a longer survival in AA, but not in GM. Extensive surgery was correlated with a better immediate postoperative performance, a lower one-month mortality rate and a longer survival, in both AA and GM. There was no relationship between preoperative neurological function status and the extent of surgery. Because of the retrospective nature of this study, the conclusion is that performing extensive surgery instead of limited surgery does not lead to more deterioration in postoperative neurological function.
In many new clinical trials of patients with malignant gliomas surgical intervention is incorporated as an integral part of tumor-directed interstitial therapies such as gene therapy, biodegradable wafer placement, and immunotherapy. Assessment of toxicity is a major component of evaluating these novel therapeutic interventions, but this must be done in light of known complication rates of craniotomy for tumor resection. Factors predicting neurological outcome would also be helpful for patient selection for surgically based clinical trials.
The Glioma Outcome Project is a prospectively compiled database containing information on 788 patients with malignant gliomas that captured clinical practice patterns and patient outcomes. Patients in this series who underwent their first or second craniotomy were analyzed separately for presenting symptoms, tumor and patient characteristics, and perioperative complications. Preoperative and intraoperative factors possibly related to neurological outcome were evaluated. There were 408 patients who underwent first craniotomies (C1 group) and 91 patients who underwent second ones (C2 group). Both groups had similar patient and tumor characteristics except for their median age (55 years in the C1 group compared with 50 years in the C2 group; p = 0.006). Headache was more common at presentation in the C1 group, whereas papilledema and an altered level of consciousness were more common at presentation in patients undergoing second surgeries. Perioperative complications occurred in 24% of patients in the C1 group and 33% of patients in the C2 group (p = 0.1). Most patients were the same or better neurologically after surgery, but more patients in the C2 group (18%) displayed a worsened neurological status than those in the C1 group (8%; p = 0.007). The Karnofsky Performance Scale score and, in patients in the C2 group, tumor size were important neurological outcome predictors. Regional complications occurred at similar rates in both groups. Systemic infections occurred more frequently in the C2 group (4.4 compared with 0%; p < 0.0001) as did depression (20 compared with 11%; p = 0.02). The perioperative mortality rate was 1.5% for the C1 group and 2.2% for the C2 group (p = not significant). The median length of the hospital stay was 4 days in each group.
Perioperative complications occur slightly more often following a second craniotomy for malignant glioma than after the first craniotomy. This should be considered when evaluating toxicities from intraoperative local therapies requiring craniotomy. Nevertheless, most patients are neurologically stable or improved after either their first or second craniotomy. This data set may serve as a benchmark for neurosurgeons and others in a discussion of operative risks in patients with malignant gliomas.
To investigate the prognostic significance of the volumetrically assessed extent of resection on time to tumor progression (TTP), overall survival (OS), and tumor recurrence patterns, the authors retrospectively analyzed preoperative and postoperative tumor volumes in 102 adult patients from the time of the initial resection of a hemispheric anaplastic astrocytoma (AA).
The quantification of tumor volumes was based on a previously described method involving computerized analysis of magnetic resonance (MR) images. Analysis of contrast-enhancing tumor volumes on T1-weighted MR images was conducted for 67 patients who had contrast-enhancing tumors. Measurements of T2 hyperintensity were obtained for all 102 patients in the study. The presence or absence of preresection enhancement, actual volume of this enhancement, and the percentage of preoperative enhancement as it relates to the total T2 tumor volume did not have a statistically significant relationship to TTP or OS. In addition to age, the volume of residual disease measured on T2-weighted MR images was the most significant predictor of TTP (p < 0.001), and residual contrast-enhancing tumor volume was the most significant predictor of OS (p = 0.003) on multivariate analysis. In contrast to low-grade gliomas, there was no statistically significant relationship between the extent of resection and histological characteristics at the time of recurrence, that is, tumor Grade III compared with Grade IV.
Data from this retrospective analysis of a histologically uniform group of hemispheric AAs treated in the MR imaging era suggest that residual tumor volumes, as documented on postoperative imaging studies, may be a prognostic factor for TTP and OS for this patient population.
Objective. – The aim of this study was to determine the risk factors for postoperative infection after craniotomy, a threat for the vital prognosis, in order to define specific prevention measures.Method and patients. – An open prospective study was made on all adult patients undergoing craniotomy and followed 30 days postoperatively. The infections were defined according to CDCA criteria. The parameters studied were: age, sex, ASA and Glasgow scores, neurosurgical history, the type, the moment and the surface of shaving, antibioprophylaxis, and the type and duration of surgery as well as its emergency level.Results. – One hundred and seventy patients were included. Thirty presented with an infection (17.6%), nine with a skull infection, 13 with meningitis, three with empyema, and two with osteitis. The risk factors identified thanks to a univariate analysis were the emergency level of surgery (P 200 min, and duration of stay in ICU >72 h (P
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.
BACKGROUND
No age-adjusted or histologic-adjusted assessments of the association between extent of resection and risk of either recurrence or death exist for neurosurgical patients who undergo resection of low-grade glioma using intraoperative magnetic resonance image (MRI) guidance.METHODS
The current data included 156 patients who underwent surgical resection of a unifocal, supratentorial, low-grade glioma in the MRI suite at Brigham and Women's Hospital between January 1, 1997, and January 31, 2003. Estimates of disease-free and overall survival probabilities were calculated using Kaplan–Meier methodology. The association between extent of resection and these probabilities was measured using a Cox proportional hazards model. Observed death rates were compared with the expected death rate using age-specific and histologic-specific survival rates obtained from the Surveillance, Epidemiology, and End Results Registry.RESULTSPatients who underwent subtotal resection were at 1.4 times the risk of disease recurrence (95% confidence interval [95% CI], 0.7–3.1) and at 4.9 times the risk of death (95% CI, 0.61–40.0) relative to patients who underwent gross total resection. The 1-year, 2-year, and 5-year age-adjusted and histologic-adjusted death rates for patients who underwent surgical resection using intraoperative MRI guidance were 1.9% (95% CI, 0.3–4.2%), 3.6% (95% CI, 0.4–6.7%), and 17.6% (95% CI, 5.9–29.3%), respectively: significantly lower than the rates reported using national data bases.CONCLUSIONS
The data from the current study suggested a possible association between surgical resection and survival for neurosurgical patients who underwent surgery for low-grade glioma under intraoperative MRI guidance. Further study within the context of a large, prospective, population-based project will be needed to confirm these findings. Cancer 2005. © 2005 American Cancer Society.
Postoperative infection after cranial surgery is a serious complication that requires immediate recognition and treatment. In certain cases such as postoperative meningitis, the patient can be treated with antibiotics only. In cases that involve a bone flap infection, subdural empyema, or cerebral abscess, however, reoperation is often needed. There has been significant disagreement regarding the incidence of postoperative central nervous system (CNS) infections following cranial surgery. In this paper the authors' goal was to perform a retrospective review of the incidence of CNS infection after cranial surgery at their institution. They focused their review on those patients who required repeated surgery to treat the infection.
The authors reviewed the medical records and imaging studies in all patients who underwent a craniotomy or stereotactic drainage for CNS infection over the past 10 years. Subgroup analysis was then performed in patients whose infection was a result of a previous cranial operation to determine the incidence, factors associated with infection, and the type of infectious organism. Patients treated nonoperatively (that is, those who received intravenous antibiotics for postoperative meningitis or cellulitis) were not included. Patients treated for wound infection without intracranial pus were also not included.
During the study period from January 1997 through December 2007, approximately 16,540 cranial surgeries were performed by 25 neurosurgeons. These included elective as well as emergency and trauma cases. Of these cases 82 (0.5%) were performed to treat postoperative infection in 50 patients. All 50 patients underwent their original surgery at the authors' institution. The median age was 51 years (range 2-74 years). There were 26 male and 24 female patients. The most common offending organism was methicillin-sensitive Staphylococcus aureus, which was found in 10 of 50 patients. Gram-negative rods were found in 15 patients. Multiple organisms were identified in specimens obtained in 5 patients. Six patients had negative cultures. Most craniotomies leading to subsequent infection were performed for tumors or other mass lesions (23 of 50 patients), followed by craniotomies for hemorrhage and vascular lesions. Almost half of the patients underwent > 1 cranial operation before presenting with infection.
Postoperative infection after cranial surgery is an important phenomenon that needs immediate recognition. Even with strict adherence to sterile techniques and administration of antibiotic prophylaxis, a small percentage of these patients will develop an infection severe enough to require reoperation.
With recent advances in the adjuvant treatment of malignant brain astrocytomas, it is increasingly debated whether extent of resection affects survival. In this study, the authors investigate this issue after primary and revision resection of these lesions.
The authors retrospectively reviewed the cases of 1215 patients who underwent surgery for malignant brain astrocytomas (World Health Organization [WHO] Grade III or IV) at a single institution from 1996 to 2006. Patients with deep-seated or unresectable lesions were excluded. Based on MR imaging results obtained < 48 hours after surgery, gross-total resection (GTR) was defined as no residual enhancement, near-total resection (NTR) as having thin rim enhancement of the resection cavity only, and subtotal resection (STR) as having residual nodular enhancement. The independent association of extent of resection and subsequent survival was assessed via a multivariate proportional hazards regression analysis.
Magnetic resonance imaging studies were available for review in 949 cases. The mean age and mean Karnofsky Performance Scale (KPS) score at time of surgery were 51 +/- 16 years and 80 +/- 10, respectively. Surgery consisted of primary resection in 549 patients (58%) and revision resection for tumor recurrence in 400 patients (42%). The lesion was WHO Grade IV in 700 patients (74%) and Grade III in 249 (26%); there were 167 astrocytomas and 82 mixed oligoastrocytoma. Among patients who underwent resection, GTR, NTR, and STR were achieved in 330 (35%), 388 (41%), and 231 cases (24%), respectively. Adjusting for factors associated with survival (for example, age, KPS score, Gliadel and/or temozolomide use, and subsequent resection), GTR versus NTR (p < 0.05) and NTR versus STR (p < 0.05) were independently associated with improved survival after both primary and revision resection of glioblastoma multiforme (GBM). For primary GBM resection, the median survival after GTR, NTR, and STR was 13, 11, and 8 months, respectively. After revision resection, the median survival after GTR, NTR, and STR was 11, 9, and 5 months, respectively. Adjusting for factors associated with survival for WHO Grade III astrocytoma (age, KPS score, and revision resection), GTR versus STR (p < 0.05) was associated with improved survival. Gross-total resection versus NTR was not associated with an independent survival benefit in patients with WHO Grade III astrocytomas. The median survival after primary resection of WHO Grade III (mixed oligoastrocytomas excluded) for GTR, NTR, and STR was 58, 46, and 34 months, respectively.
In the authors' experience with both primary and secondary resection of malignant brain astrocytomas, increasing extent of resection was associated with improved survival independent of age, degree of disability, WHO grade, or subsequent treatment modalities used. The maximum extent of resection should be safely attempted while minimizing the risk of surgically induced neurological injury.
The purpose of this study was to determine the incidence rate and risk factors of surgical site infections (SSIs) in neurosurgery for any type of surgery and any American Society of Anesthesiologists class.
The authors undertook an exhaustive 18-month prospective survey including patients who underwent neurosurgery. In particular, a 30-day follow-up was completed in patients whose surgery did not involve placement of a prosthesis or implant, and 1-year follow-up was completed for patients who underwent surgery to place a prosthesis or implant. The Centers for Disease Control definition of SSI was used. Univariate and multivariate analyses were conducted; all dependent variables found in univariate analysis were entered in the multiple regression model. A stepwise multiple logistic regression method was used.
Of the 844 patients studied, 35 SSIs were diagnosed, yielding an incidence rate of 4.1% (95% confidence interval 3.6-4.5). Independent predictive risk factors for infection were cerebrospinal fluid leakage, external shunt, Altemeier class, and further neurosurgery. A lack of antibiotic prophylaxis was not found to be a risk factor.
Infection risk factors occur mainly during the postoperative period.
Meningiomas that occur over the convexity of the brain are the most common meningiomas, but little has been published about their contemporary management. We aimed to analyze a large series of convexity meningiomas with respect to surgical technique, complication rates, and pathological factors leading to recurrence.
We retrospectively reviewed 163 cases of convexity meningiomas operated on in our institution by the senior author (PMB) between 1986 and 2005. The median follow-up time was 2.3 years (range, 1-13 yr).
Convexity tumors represented 22% of all meningiomas operated on. There was a female:male ratio of 2.7:1. Median age was 57 years (range, 20-89 yr). Image-guided surgery was used on all cases in the last 5 years. The 30-day mortality rate was 0%. The incidence of new neurological deficits was 1.7%, and the overall complication rate was 9.4%. The pathology of the tumors was benign in 144 (88.3%), atypical in 16 (9.8%), and anaplastic/malignant in 3 (1.8%). In six of the cases designated "benign," there were borderline atypical features. The 5-year recurrence rate for benign meningiomas was 1.8%, atypical meningiomas 27.2%, and anaplastic meningiomas 50%. The two cases of benign tumor recurrences involved tumors with borderline atypia and high MIB-1 indices. The borderline atypical cases had a 5-year recurrence-free survival rate of only 55.9%, more closely approximating that of tumors designated "atypical."
Convexity meningiomas can be safely removed using modern image-guided minimally invasive surgical techniques with a very low operative mortality. Benign convexity meningiomas having a Simpson Grade I complete excision have a very low recurrence rate. The recurrence rates of atypical and malignant tumors are significantly higher, and borderline atypical tumors should be considered to behave more like atypical rather than benign lesions. Longer-term follow-up data are needed to more accurately determine the recurrence rates of benign meningiomas.
An excellent response by participating institutions was realized in this survey of patterns of care for patients with primary brain tumors. Since the histopathology of the tumor is such a strong predictor of outcome and influences care so greatly, most analyses were performed not only on the overall series of patients but also by World Health Organization histological classification. Several factors that influence outcome were identified: tumor type, patient age, patient Karnofsky rating, tumor location, and therapy. Very few cases were coded as regards the American Joint Committee on Cancer clinical stage, and few potentially eligible cases were placed in investigative protocols. It behooves those centers providing investigative protocol opportunities to develop liaisons with practicing physicians nearby as well as at some distance and to provide an organizational framework that will make participation in these protocols practical for a larger segment of our brain-tumor patient population.
Between 1980 and 1985, the increased use of magnetic resonance imaging in neuroradiology is apparent as well as the increased use of stereotactic biopsy and interstitial radiotherapy. Complications of therapy seem acceptably low. Five-year survival for benign brain tumor is high, while that for the most common primary tumor, glioblastoma multiforme, is only 5.5%.
Some of the findings in this survey confirm those from the literature while others, particularly the pattern of care, represent new data.
A series of 4992 intracranial procedures performed over an 11-year period was evaluated for the occurrence of postoperative hemorrhage. Forty patients (0.8%) experienced postoperative hemorrhage. Twenty-four hemorrhages were intracerebral (60%), 11 were epidural (28%), 3 were subdural (7.5%), and 2 were intrasellar (5.0%). Hematomas in 33 patients occurred at the operative site, and 7 occurred remote from the operative site. Intracranial tumor was the reason for operation in 56% of the patients developing a clot, and meningioma was the most common tumor associated with this complication. The use of the sitting position was not associated with an increased incidence of postoperative hemorrhage. Disturbances of coagulation and hypertension seemed to be potential precipitating factors. Postoperative hemorrhage was recognized within 12 hours of operation in 35% of the patients. An altered level of consciousness was the most frequent clinical finding, present in all patients. There was no clear relationship between the time of recognition and the final clinical outcome. Parenchymal clots carried the worst prognosis, accounting for 8 of the 11 deaths and all 7 patients with poor neurological outcome.
Extensive surgical resection of supratentorial gliomas increases survival. However, some reports suggest that the perioperative morbidity and mortality outweigh the potential benefit of the procedure. We examined prospectively morbidity and mortality in 104 consecutive patients who underwent surgery for supratentorial glioma, as well as other factors that might affect the short-term outcome. To determine if our experience was unusual, we compared these results with those obtained from another academic neurosurgical center by a review of the records of 109 patients also treated surgically for supratentorial glioma. Mortality was 3.3% and the medical plus neurologic morbidity was 31.7%. Functionally significant neurologic worsening occurred in 42 (19.7%) patients. Complications were more frequent in patients with moderate or severe preoperative disabilities than those with mild or no preoperative disability. Patients with complete resection had fewer acute neurologic complications, and no greater risk of being neurologically impaired at 1 week, than patients with biopsy or less extensive procedures. Morbidity and mortality correlated with location: deep-midline lesions had a higher overall rate of perioperative complications (p = 0.032) and mortality (p = 0.019) and bilateral lesions a higher rate of hemorrhage (p = 0.017) and hydrocephalus (p = 0.010). Older patients (greater than 55 years) and those receiving high daily dose of preoperative dexamethasone (greater than or equal to 24 mg) had a significantly higher risk of surgical mortality. Reoperation for recurrent tumor carried no greater risk of mortality, neurologic deterioration, and infection than a first operation.(ABSTRACT TRUNCATED AT 250 WORDS)
A case-control analysis was performed to evaluate the association of 15 potential risk factors with postoperative infection in neurosurgical patients. All infections that developed postoperatively on the neurosurgical service at the University of Minnesota from January, 1970, to March, 1984, were identified. Among the 9202 operations performed during that time, 101 infections occurred for a rate of 1.1%. Three risk factors showed significant association with postoperative infection: cerebrospinal fluid (CSF) leak, concurrent noncentral nervous system (CNS) infection, and perioperative antibiotic therapy. The presence of a CSF leak and a concurrent non-CNS infection increased the estimated relative risk of infection to 13:1 and 6:1, respectively. The use of perioperative antibiotics was associated with a decrease in the risk of infection to approximately 20% of the control level. Three other risk factors (paranasal sinus entry, placement of a foreign body, and use of a postoperative drain) appeared to be associated with increased risk of infection, although statistical significance was not demonstrated. None of the remaining nine risk factors studied showed any suggestion of increased risk of infection.
The files of 1143 neurosurgical patients, operated on between November 1, 1979 and June 4, 1981 were examined for records of post-operative infections. Eighty-three patients had developed infections (7%). In addition there were 33 instances of aseptic meningitis. Patients with a shunt were prone to infection (12%). Bone flap infections accounted for more than half of all infections after supratentorial craniotomy. Bacterial meningitis accounted for more than half of all infections after suboccipital craniotomy and translabyrinthine operations. In these patients bacterial meningitis was six times more common, and aseptic meningitis three times more common than in those who had had supratentorial operations. Shunt infection was more common after repeated shunt operations in quick succession. Craniotomy increased the risk of a shunt becoming infected. Antibiotic prophylaxis should be used not only in shunt operations but in all operations performed on patients with a shunt. If bacteria are recovered in a suspected shunt infection, immediate removal of the shunt is the best treatment. However, if the shunt's removal or replacement is exceptionally difficult intraventricular antibiotic treatment may be tried. The age of the patient, the duration of the operation, the individual surgeon and the number of operations did not affect the rate of infection. Clinical signs and conventional laboratory tests, apart from bacterial culture, cannot differentiate between bacterial and aseptic meningitis, but a drop in the level of consciousness suggests bacterial meningitis.
The rates of survival, tumor recurrence, and tumor progression were analyzed in 225 patients with meningioma who underwent surgery as the only treatment modality between 1962 and 1980. Patients were considered to have a recurrence if their studies verified a mass effect in spite of a complete surgical removal, whereas they were defined as having progression if, after a subtotal excision, there was clear radiological documentation of an increase in the size of their tumor. There were 168 females and 57 males (a ratio of 2.9:1), with a peak incidence of tumor occurrence in the fifth (23%), sixth (29%), and seventh (23%) decades of life. Anatomical locations were the convexity (21%), parasagittal area (17%), sphenoid ridge (16%), posterior fossa (14%), parasellar region (12%), olfactory groove (10%), spine (8%), and orbit (2%). The absolute 5-, 10-, and 15-year survival rates were 83%, 77%, and 69%, respectively. Following a total resection, the recurrence-free rate at 5, 10, and 15 years was 93%, 80%, and 68%, respectively, at all sites. In contrast, after a subtotal resection, the progression-free rate was only 63%, 45%, and 9% during the same period (p less than 0.0001). The probability of having a second operation following a total excision after 5, 10, and 15 years was 6%, 15%, and 20%, whereas after a subtotal excision the probability was 25%, 44%, and 84%, respectively (p less than 0.0001). Tumor sites associated with a high percentage of total excisions had a low recurrence/progression rate. For example, 96% of convexity meningiomas were removed in toto, and the recurrence/progression rate at 5 years was only 3%. Parasellar meningiomas, with a 57% total excision rate, had a 5-year probability of recurrence/progression of 19%. Only 28% of sphenoid ridge meningiomas a second resection, the probability of a third operation at 5 and 10 years was 42% and 56%, respectively. There was no difference in the recurrence/progression rates according to the patients' age or sex, or the duration of symptoms. Implications for the potential role of adjunctive medical therapy or radiation therapy for meningiomas are discussed.
The goal of treating patients with malignant gliomas by intracranial surgery has been to remove as much tumor as possible without causing new neurologic deficits. However, it is still debatable whether the degree of surgical resection correlates with survival times of patients with supratentorial gliomas.
One hundred and one patients with supratentorial malignant gliomas who underwent either a gross total resection, a subtotal resection, and/or a partial resection were examined. A correlation between their length of survival and the degree of surgical resection was determined.
The survival rates of patients who underwent total resections were significantly higher than those of patients who underwent subtotal or partial resections (P < 0.01). However, there was no significant difference in the survival rates between the subtotal and partial resection groups. These results also were confirmed by independent variables, such as age, location of the tumors, and histologic subtypes, with the exceptions of temporal gliomas and those younger than 60 years.
The favorable prognosis of patients with malignant gliomas depends upon the total resection of these tumors. These findings should be of help in designing preoperative surgical intervention strategies.
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.
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.
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.
Independent risk factors for SSIs after craniotomy involve postoperative events. However, the NNIS risk index is effective in identifying at-risk patients.
Intracranial meningiomas are mainly benign lesions amenable for surgical resection. However, removal of an intracranial meningioma carries a higher risk of post-operative hemorrhage compared to surgery for other intracranial neoplasms. Because avoidance of post-operative hematoma is of vital interest for neurosurgical patients, the aim of this retrospective study was to analyze risk factors of post-operative hematoma associated with meningioma surgery. Two hundred and ninety six patients with intracranial meningiomas, operated between June 1998 and June 2002, were included in this study. Patients who developed a space-occupying post-operative intracranial hemorrhage and were treated surgically were identified. Data of patients with and without hematoma were retrospectively analyzed to identify risk factors associated with post-operative hematoma. Variables analyzed included patients' age, invasion of venous sinus by the meningioma, tumor vascularization, arachnoidal infiltration, pre-operative prophylaxis of thromboembolic events, peri-operative coagulation abnormalities, residual tumor, location and histology of the tumor. Outcome of patients with post-operative hematoma was assessed according to the Glasgow Outcome Scale (GOS) at discharge and at three months. 21 patients (7.1 %) of 296 patients developed a post-operative intracranial hematoma requiring surgical evacuation. Age was significantly higher in the hematoma group 62.4 +/- 14.0 years compared to patients without post-operative hematoma 56.1 +/- 12.0 (p < 0.05; t-test). Patients older than 70 years had a six-fold increased risk to develop a post-operative hematoma (Chi2 test, 95% CI 1.949-13.224). Patients with post-operative hemorrhage had significant lower post-operative prothrombin time, fibrinogen and platelets immediately after surgery and lower platelets at day 1. None of the other parameters, including pre-operative routine coagulation values, differed significantly between patients with and without post-operative hemorrhage. Three patients with post-operative hematoma showed platelet dysfunction and three patients showed decreased FXIII activity. Of those patients with post-operative hemorrhage at three months follow up three patients (13%) succumbed from reasons not directly related to hemorrhage, one patient remained GOS 2 (4.3%), four patients (17.4%) were GOS 3 and 15 (65.4%) patients had favorable outcome (GOS 4 [one patient] and GOS5 [14 patients]). Meningioma surgery carries a higher risk for post-operative hematoma in the elderly. Thrombocytopenia and other hemostatic disorders were frequently associated with post-operative hemorrhage after meningioma surgery, while no surgical factors could be defined. Extending coagulation tests and specific replacement therapy may prevent hematoma formation and improve the patients outcome.
The treatment of brain metastasis is generally palliative, with whole brain radiation therapy (WBRT), since the majority have uncontrollable systemic cancer. In certain circumstances, such as single brain metastases, death may be more likely from brain involvement than systemic disease. In this group, surgical resection has been proposed to relieve symptoms and prolong survival.
To assess the clinical effectiveness of surgical resection plus WBRT versus WBRT alone in the treatment of single brain metastasis.
The Cochrane Cancer Network Specialised trials register (July 2003), Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 1 2003), MEDLINE (1966 to July 2003), EMBASE (1980 to July 2003), CANCERLIT (1980 to July 2003), BIOSIS (1985 to July 2003) and SCIENCE CITATION INDEX (1981 to July 2003) were searched. References of identified studies were hand searched, as was the Journal of Neuro-Oncology over the previous 10 years and Neuro-Oncology over the past 2 years, including all conference abstracts. Specialists in neuro-oncology were also contacted.
Randomized controlled trials (RCTs) comparing surgery and WBRT with WBRT alone, in patients with single brain metastasis.
Two reviewers independently assessed trial quality and extracted data.
Three RCTs were identified, with 195 patients in total. No significant difference in survival was noted hazard ratio (HR) 0.74 (95% confidence interval (CI) 0.39 to 1.40, p = 0.35), although there was a high degree of heterogeneity between trials. One trial has shown surgery and WBRT to increase the duration of functionally independent survival (FIS) HR 0.42 (95% CI 0.22 to 0.80, p < 0.008). There is a trend for surgery and WBRT to reduce the number of deaths due to neurological cause odds ratio (OR) 0.57 (95% CI 0.29 to 1.10, p = 0.09). Adverse effects were not found to be statistically more common in any group.
Surgery and WBRT may improve FIS but not overall survival. There is a trend that it may reduce the proportion of deaths due to neurological cause. All these results were in a highly selected group of patients. Operating on metastases does not confer significantly more adverse effects.
To assist in selecting treatment for patients with brain metastases, the current study assessed the risk of adverse outcomes after contemporary resection of metastatic brain tumors in relation to patient, surgeon, and hospital characteristics, with particular attention to the volume of care and trends in outcomes.
A retrospective cohort study of 13,685 admissions from the Nationwide Inpatient Sample between 1988-2000 was performed. Multivariate logistic, ordinal, and loglinear regression were used with endpoints of mortality, discharge disposition, length of stay, and total hospital charges.
The overall in-hospital mortality rate was 3.1% and an additional 16.7% of patients were not discharged directly home. In multivariate analyses, larger-volume centers were found to have lower mortality rates for intracranial metastasis resection (odds ratio [OR], 0.79; 95% confidence interval [95% CI], 0.59-1.03 [P = 0.09]). An adverse discharge disposition also was less likely at higher-volume hospitals (OR, 0.75; 95% CI, 0.65-0.86 [P < 0.001]). For surgeon caseload, mortality was lower with higher-caseload providers (OR, 0.49; 95% CI, 0.30-0.80 [P = 0.004]) and an adverse discharge disposition occurred significantly less frequently (OR, 0.51; 95% CI, 0.40-0.64 [P < 0.001]). The annual number of resections increased by 79% during the study period, from 3900 (1988) to 7000 (2000). In-hospital mortality rates decreased from 4.6% (1988-1990) to 2.3% (1997-2000), a 49% relative decrease. Length of stay was reported to be significantly shorter with higher-volume providers. Hospital charges were not found to be associated significantly with hospital caseload and were found to be significantly lower after surgery that was performed by higher-caseload surgeons.
The results of the current study found that higher-volume hospitals and surgeons provided superior short-term outcomes after resection of intracranial metastasis was performed, with shorter lengths of stay and a trend toward lower charges.
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.
To evaluate incidence and risk factors of postoperative meningitis, with special emphasis on antibiotic prophylaxis, in a series of 6243 consecutive craniotomies.
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.
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.
Perioperative antibiotic prophylaxis, although clearly effective for the prevention of incision infections, does not prevent meningitis and tends to select prophylaxis resistant microorganisms.
Postoperative central nervous system infection (PCNSI) in patients undergoing neurosurgical procedures represents a serious problem that requires immediate attention. PCNSI most commonly manifests as meningitis, subdural empyema, and/or brain abscess. Recent studies (which have included a minimum of 1000 operations) have reported that the incidence of PCNSI after neurosurgical procedures is 5%-7%, and many physicians believe that the true incidence is even higher. To address this issue, we examined the incidence of PCNSI in a sizeable patient population.
The medical records and postoperative courses for patients involved in 2111 neurosurgical procedures at our institution during 1991-2005 were reviewed retrospectively to determine the incidence of PCNSI, the identity of offending organisms, and the factors associated with infection.
The median age of patients at the time of surgery was 45 years. Of the 1587 cranial operations, 14 (0.8%) were complicated by PCNSI, whereas none of the 32 peripheral nerve operations resulted in PCNSI. The remaining 492 operative cases involved spinal surgery, of which 2 (0.4%) were complicated by PCNSI. The overall incidence of PCNSI was 0.8% (occurring after 16 of 2111 operations); the incidence of bacterial meningitis was 0.3% (occurring after 4 of 1587 operations), and the incidence of brain abscess was 0.2% (occurring after 3 of 1587 operations). The most common offending organism was Staphylococcus aureus (8 cases; 50% of infections), followed by Propionibacterium acnes (4 cases; 25% of infections). Cerebrospinal fluid leakage, diabetes mellitus, and male sex were not associated with PCNSI (P>.05).
In one of the largest neurosurgical studies to have investigated PCNSI, the incidence of infection after neurosurgical procedures was <1%--more than 6 times lower than that reported in recent series of comparable numerical size. Cerebrospinal fluid leak, diabetes mellitus, and male sex were not associated with an increased incidence of PCNSI. The results from this study indicate that the true incidence of PCNSI after neurosurgical procedures may be greatly overestimated in the literature and that, in surgical procedures associated with a high risk of infection, prophylaxis for S. aureus and/or P. acnes infection should be of primary concern.
There are not many studies that address the selection of patients harboring malignant brain tumors for open surgery. It is necessary, especially in developing countries, to establish the standards because of their impact not only on the efficacy but also on the cost-effectiveness of surgery. With the concern to add information that may help in future studies about the decision making, we proposed to analyze factors associated with surgical complications and evaluate their influence on the functional status at 30 days after surgery.
A consecutive series of 236 surgeries performed between June 1999 and June 2005 were retrospectively analyzed (168 gliomas, 65 metastases, 3 others). Variables evaluated were age, sex, pre- and postoperative KPS, ASA status, anatomic localization, extent of tumor resection, tumor histology, and number of surgeries.
The incidence of complicated craniotomies was 15.68% and mortality was 2.97%. Postoperatively, 92% of the patients improved or maintained the functional status, whereas 8% worsened. In multivariate analysis, only preoperative KPS (P = .009), ASA status (P = .02), and histology type (P = .03) showed significant association with postoperative complications.
We found that the neurologic and clinical preoperative condition and grade III gliomas were factors related to postoperative complications, whereas age, extent of resection, and number of surgeries were not risk factors. We believe that these conclusions provide an additional benchmark for future multicentric studies that focus on the selection criteria for resection of malignant brain tumors.
Craniotomy for the resection of metastatic brain tumors in the U.S., 1988-2000: decreasing mortality and the effect of provider caseload
- Fg Barker