Gabrielle A. White-Dzuro

Perioperative seizure in patients with glioma is associated with longer hospitalization, higher readmission, and decreased overall survival

OBJECTIVE Seizures are among the most common perioperative complications in patients undergoing craniotomy for brain tumor resection and have been associated with increased disease progression and decreased survival. Little evidence exists regarding the relationship between postoperative seizures and hospital quality measures, including length of stay (LOS), disposition, and readmission. The authors sought to address these questions by analyzing a glioma population over 15 years. METHODS A retrospective cohort study was used to evaluate the outcomes of patients who experienced a postoperative seizure. Patients with glioma who underwent craniotomy for resection between 1998 and 2013 were enrolled in the institutional tumor registry. Basic data, including demographics and comorbidities, were recorded in addition to hospitalization details and complications. Seizures were diagnosed by clinical examination, observation, and electroencephalography. The Student t-test and chi-square test were used to analyze differences in the means between continuous and categorical variables, respectively. Multivariate logistic and linear regression was used to compare multiple clinical variables against hospital quality metrics and survival figures, respectively. RESULTS In total, 342 patients with glioma underwent craniotomy for first-time resection. The mean age was 51.0 ± 17.3 years, 192 (56.1%) patients were male, and the median survival time for all grades was 15.4 months (range 6.2-24.0 months). High-grade glioma (Grade III or IV) was seen in 71.9% of patients. Perioperative antiepileptic drugs were administered to 88% of patients. Eighteen (5.3%) patients experienced a seizure within 14 days postoperatively, and 9 (50%) of these patients experienced first-time seizures. The mean time to the first postoperative seizure was 4.3 days (range 0-13 days). There was no significant association between tumor grade and the rate of perioperative seizure (Grade I, 0%; II, 7.0%; III, 6.1%; IV, 5.2%; p = 0.665). A single ictal episode occurred in 11 patients, while 3 patients experienced 2 seizures and 4 patients developed 3 or more seizures. Compared with their seizure-free counterparts, patients who experienced a perioperative seizure had an increased average hospital (6.8 vs 3.6 days, p = 0.032) and ICU LOS (5.4 vs 2.3 days; p < 0.041). Seventy-five percent of seizure-free patients were discharged home in comparison with 55.6% of seizure patients (p = 0.068). Patients with a postoperative seizure were significantly more likely to visit the emergency department within 90 days (44.4% vs 19.0%; OR 3.41 [95% CI 1.29-9.02], p = 0.009) and more likely to be readmitted within 90 days (50.0% vs 18.4%; OR 4.45 [95% CI 1.69-11.70], p = 0.001). In addition, seizure-free patients had a longer median overall survival (15.6 months [interquartile range 6.6-24.4 months] vs 3.0 months [interquartile range 1.0-25.0 months]; p = 0.013). CONCLUSIONS Patients with perioperative seizures following glioma resection required longer hospital and ICU LOS, were readmitted at higher rates than seizure-free patients, and experienced shorter overall survival. Biological and clinical factors that predispose to the development of seizures after glioma surgery portend a worse outcome. Efforts to identify these factors and reduce the risk of postoperative seizure should remain a priority among neurosurgical oncologists.

Risk of post-operative pneumocephalus in patients with obstructive sleep apnea undergoing transsphenoidal surgery.

Patients undergoing transsphenoidal surgery (TSS) have an anterior skull base defect that limits the use of positive pressure ventilation post-operatively. Obstructive sleep apnea (OSA) can be seen in these patients and is treated with continuous positive airway pressure (CPAP). In our study we documented the incidence of pre-existing OSA and reported the incidence of diagnosed pneumocephalus and its relationship to OSA. A retrospective review was conducted from a surgical outcomes database. Electronic medical records were reviewed, with an emphasis on diagnosis of OSA and documented symptomatic pneumocephalus. A total of 324 patients underwent 349 TSS for sellar mass resection. The average body mass index of the study cohort was 32.5kg/m(2). Sixty-nine patients (21%) had documented OSA. Only 25 out of 69 (36%) had a documented post-operative CPAP plan. Out of all 349 procedures, there were two incidents of pneumocephalus diagnosed. Neither of the patients had pre-existing OSA. One in five patients in our study had pre-existing OSA. Most patients returned to CPAP use within several weeks of TSS for resection of a sellar mass. Neither of the patients with pneumocephalus had pre-existing OSA and none of the patients with early re-initiation of CPAP developed this complication. This study provides preliminary evidence that resuming CPAP early in the post-operative period might be less dangerous than previously assumed.

Risk Factors for Deep Venous Thrombosis Following Orthopaedic Trauma Surgery: An Analysis of 56,000 patients

Background: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are recognized as major causes of morbidity and mortality in orthopaedic trauma patients. Despite the high incidence of these complications following orthopaedic trauma, there is a paucity of literature investigating the clinical risk factors for DVT in this specific population. As our healthcare system increasingly emphasizes quality measures, it is critical for orthopaedic surgeons to understand the clinical factors that increase the risk of DVT following orthopaedic trauma. Objectives: Utilizing the ACS-NSQIP database, we sought to determine the incidence and identify independent risk factors for DVT following orthopaedic trauma. Patients and Methods: Using current procedural terminology (CPT) codes for orthopaedic trauma procedures, we identified a prospective cohort of patients from the 2006 to 2013 ACS-NSQIP database. Using Wilcoxon-Mann-Whitney and chi-square tests where appropriate, patient demographics, comorbidities, and operative factors were compared between patients who developed a DVT within 30 days of surgery and those who did not. A multivariate logistic regression analysis was conducted to calculate odds ratios (ORs) and identify independent risk factors for DVT. Significance was set at P < 0.05. Results: 56,299 orthopaedic trauma patients were included in the analysis, of which 473 (0.84%) developed a DVT within 30 days. In univariate analysis, twenty-five variables were significantly associated with the development of a DVT, including age (P < 0.0001), BMI (P = 0.037), diabetes (P = 0.01), ASA score (P < 0.0001) and anatomic region injured (P < 0.0001). Multivariate analysis identified several independent risk factors for development of a DVT including use of a ventilator (OR = 43.67, P = 0.039), ascites (OR = 41.61, P = 0.0038), steroid use (OR = 4.00, P < 0.001), and alcohol use (OR = 2.98, P = 0.0370). Compared to patients with upper extremity trauma, those with lower extremity injuries had significantly increased odds of developing a DVT (OR = 7.55, P = 0.006). The trend toward increased odds of DVT among patients with injuries to the hip/pelvis did not reach statistical significance (OR = 4.51, P = 0.22). Smoking was not found to be an independent risk factor for developing a DVT (P = 0.1217). Conclusions: This is the largest study to date using the NSQIP database to identify risk factors for DVT in orthopaedic trauma patients. Although the incidence of DVT was low in our cohort, the presence of certain risk factors significantly increased the odds of developing a DVT following orthopaedic trauma. These findings will enable orthopaedic surgeons to target at-risk patients and implement post-operative care protocols aimed at reducing the morbidity and mortality associated with DVT in orthopaedic trauma patients.

Decreased survival in glioblastomas is specific to contact with the ventricular-subventricular zone, not subgranular zone or corpus callosum

The clinical effect of radiographic contact of glioblastoma (GBM) with neurogenic zones (NZ)—the ventricular-subventricular (VSVZ) and subgranular (SGZ) zones—and the corpus callosum (CC) remains unclear and, in the case of the SGZ, unexplored. We investigated (1) if GBM contact with a NZ correlates with decreased survival; (2) if so, whether this effect is associated with a specific NZ; and (3) if radiographic contact with or invasion of the CC by GBM is associated with decreased survival. We retrospectively identified 207 adult patients who underwent cytoreductive surgery for GBM followed by chemotherapy and/or radiation. Age, preoperative Karnofsky performance status score (KPS), and extent of resection were recorded. Preoperative MRIs were blindly analyzed to calculate tumor volume and assess its contact with VSVZ, SGZ, CC, and cortex. Overall (OS) and progression free (PFS) survivals were calculated and analyzed with multivariate Cox analyses. Among the 207 patients, 111 had GBM contacting VSVZ (VSVZ+GBMs), 23 had SGZ+GBMs, 52 had CC+GBMs, and 164 had cortex+GBMs. VSVZ+, SGZ+, and CC+ GBMs were significantly larger in size relative to their respective non-contacting controls. Multivariate Cox survival analyses revealed GBM contact with the VSVZ, but not SGZ, CC, or cortex, as an independent predictor of lower OS, PFS, and early recurrence. We hypothesize that the VSVZ niche has unique properties that contribute to GBM pathobiology in adults.

The Influence of Perioperative Seizure Prophylaxis on Seizure Rate and Hospital Quality Metrics Following Glioma Resection

BACKGROUND Antiepileptic drugs (AEDs) are frequently administered prophylactically to mitigate seizures following craniotomy for brain tumor resection. However, conflicting evidence exists regarding the efficacy of AEDs, and their influence on surgery-related outcomes is limited. OBJECTIVE To evaluate the influence of perioperative AEDs on postoperative seizure rate and hospital-reported quality metrics. METHODS A retrospective cohort study was conducted, incorporating all adult patients who underwent craniotomy for glioma resection at our institution between 1999 and 2014. Patients in 2 cohorts-those receiving and those not receiving prophylactic AEDs-were compared on the incidence of postoperative seizures and several hospital quality metrics including length of stay, discharge status, and use of hospital resources. RESULTS Among 342 patients with glioma undergoing cytoreductive surgery, 301 (88%) received AED prophylaxis and 41 (12%) did not. Seventeen patients (5.6%) in the prophylaxis group developed a seizure within 14 days of surgery, compared with 1 (2.4%) in the standard group (OR = 2.2, 95% CI [0.3-17.4]). Median hospital and intensive care unit lengths of stay were similar between the cohorts. There was also no difference in the rate at which patients presented within 90 days postoperatively to the emergency department or required hospital readmission. In addition, the rate of hospital resource consumption, including electroencephalogram and computed tomography scan acquisition, and neurology consultation, was similar between both groups. CONCLUSION The administration of prophylactic AEDs following glioma surgery did not influence the rate of perioperative seizures, nor did it reduce healthcare resource consumption. The role of perioperative seizure prophylaxis should be closely reexamined, and reconsideration given to this commonplace practice.

Novel Approach to Securing Deep Brain Stimulation Leads: Technique and Analysis of Lead Migration, Breakage, and Surgical Infection

Background: Fixation of the electrode during deep brain stimulation (DBS) surgery is an important aspect of the procedure. We have developed an alternative method for securing leads that utilizes a titanium hemoclip and cement. This technique is described, and the rates of complications are compared to conventional methods of securing leads. Methods: A total of 291 DBS operations performed by a single surgeon were retrospectively analyzed. We reviewed medical records to look for complications. We compared rates of complications based on the technique used. Re sults: 9 patients (3.1%) developed surgical site infections (SSIs), 4 (1.3%) with SSI of the internal pulse generator pocket. Of the 5 SSIs around the leads, none occurred with StimLoc and 5 (1.1%) with the novel technique. Eight patients (2.7%) required surgical readjustment of the DBS leads due to suboptimal clinical benefit; all 8 (1.8%) occurred with the novel technique. Four patients (1.4%) had lead fractures, 2 (2.2%) with StimLoc and 2 (0.5%) with the novel technique. Conclusions: We described a method for securing DBS leads and showed an acceptable incidence of hardware complications when compared to the conventional method. We feel this technique has improved cosmetic results and should be considered as a method for securing DBS leads.

Single Operation to Repair Multifocal Cerebrospinal Fluid Fistulae Following Gunshot Wound: A Case Report

Introduction Traumatic cerebrospinal fluid (CSF) fistulae can be a challenging neurosurgical disease, often requiring complicated surgical intervention. Case Presentation A 54-year-old man presented with a gunshot wound to the head with complex injury to the skull base and significant CSF leakage from multiple sites. A single surgery was performed using a combined Neurosurgery, Neurotology, and Rhinology team, which was successful in repairing the multiple skull base defects and preventing further CSF leak. Discussion Trauma to the skull base is a common inciting factor for the development of CSF fistulae. Endoscopic approaches are often preferred for repairing these defects, but craniotomy remains a viable option that may be required in more complex cases. A combined approach has not been described previously, but was successful for this severe multifocal defect. Conclusion A multidisciplinary approach allowed for a combined intervention that addressed both the anterior and middle fossae fistulae simultaneously. This limited the potential infectious complications of continued CSF leak and allowed for early rehabilitation.