Giyarpuram N. Prashant

Restrictive transfusion threshold is safe in high-risk patients undergoing brain tumor surgery

OBJECTIVEnTo assess the safety of a restrictive threshold for the transfusion of red blood cells (RBCs) compared to a liberal threshold in high-risk patients undergoing brain tumor surgery.nnnPATIENTS AND METHODSnWe reviewed patients who were 50 years of age or older with a preoperative American Society of Anesthesiologists physical status class II to V who underwent open craniotomy for tumor resection and were transfused packed RBCs during or after surgery. We retrospectively assigned patients to a restrictive-threshold (a pretransfusion hemoglobin level <8g/dL) or a liberal-threshold group (a pretransfusion hemoglobin level of 8-10/dL). The primary outcome was in-hospital mortality rate. Secondary outcomes were in-hospital complication rates, length of stay, and discharge disposition.nnnRESULTSnTwenty-five patients were included in the study, of which 17 were assigned to a restrictive-threshold group and 8 patients to a liberal-threshold group. The in-hospital mortality rates were 12% for the restrictive-threshold group (odds ratio [OR] 0.93, 95% confidence interval [CI] 0.07-12.11) and 13% for the liberal-threshold group. The in-hospital complication rates were 52.9% for the restrictive-threshold group (OR 1.13, 95% CI 0.21-6.05) and 50% for the liberal-threshold group. The average number of days in the intensive care unit and hospital were 8.6 and 22.4u2009days in the restrictive-threshold group and 6 and 15u2009days in the liberal-threshold group, respectively (P=0.69 and P=0.20). The rates of non-routine discharge were 71% in the restrictive-threshold group (OR 2.40, 95% CI 0.42-13.60) and 50% in the liberal-threshold group.nnnCONCLUSIONSnA restrictive transfusion threshold did not significantly influence in-hospital mortality or complication rates, length of stay, or discharge disposition in patients at high operative risk.

Dural repair in cranial surgery is associated with moderate rates of complications with both autologous and non-autologous dural substitutes

OBJECTIVEnDuraplasty, a common neurosurgical intervention, involves synthetic or biological graft placement to ensure dural closure. The objective of this study is to advance our understanding of the use of dural substitutes in cranial surgery.nnnMETHODSnThe PubMed database was systematically searched to identify studies published over the past decade (2007-2017) that described duraplasty procedures. Clinical data were disaggregated and analyzed for the comparisons of biological versus synthetic grafts.nnnRESULTSnA total of 462 cases were included in the quantitative synthesis. Overall, the most common indication for duraplasty was tumor resection (53%). Allografts were more frequently used in decompression for Chiari malformations compared with xenografts and synthetic grafts (P < 0.001). Xenografts were more frequently used in decompressive hemicraniectomy procedures for evacuation of acute subdural hematomas over allografts and synthetics (P < 0.001). Synthetic grafts were more frequently used in tumor cases than biological grafts (Pxa0=xa00.002). The cumulative complication rate for dural substitutes of all types was 11%. There were no significant differences in complication rates among the 3 types of dural substitutes.nnnCONCLUSIONSnDural substitutes are commonly used to ensure dural closure in a variety of cranial procedures. This study provides greater insight into duraplasty practices and highlights the moderate complication rate associated with the procedure. Future studies are needed to determine the safety and efficacy of such procedures in larger prospective cohorts.

Planned Subtotal Resection of Vestibular Schwannoma Differs from the Ideal Radiosurgical Target Defined by Adaptive Hybrid Surgery

OBJECTIVEnTo retrospectively compare ideal radiosurgical target volumes defined by a manual method (surgeon) to those determined by Adaptive Hybrid Surgery (AHS) operative planning software in 7 patients with vestibular schwannoma (VS).nnnMETHODSnFour attending surgeons (3 neurosurgeons and 1 ear, nose, and throat surgeon) manually contoured planned residual tumors volumes for 7 consecutive patients with VS. Next, the AHS software determined the ideal radiosurgical target volumes based on a specified radiotherapy plan. Our primary measure was the difference between the average planned residual tumor volumes and the ideal radiosurgical target volumes defined by AHS (dRVAHS-planned).nnnRESULTSnWe included 7 consecutive patients with VS in this study. The planned residual tumor volumes were smaller than the ideal radiosurgical target volumes defined by AHS (1.6 vs. 4.5 cm3, Pxa0= 0.004). On average, the actual post-operative residual tumor volumes were smaller than the ideal radiosurgical target volumes defined by AHS (2.2xa0cm3 vs. 4.5 cm3; Pxa0= 0.02). The average difference between the ideal radiosurgical target volume defined by AHS and the planned residual tumor volume (dRVAHS-planned) was 2.9 ± 1.7 cm3, and we observed a trend toward larger dRVAHS-planned in patients who lost serviceable facial nerve function compared with patients who maintained serviceable facial nerve function (4.7 cm3 vs. 1.9 cm3; Pxa0= 0.06).nnnCONCLUSIONSnPlanned subtotal resection of VS diverges from the ideal radiosurgical target defined by AHS, but whether that influences clinical outcomes is unclear.

End-Stage Liver Disease in Patients with Intracranial Hemorrhage Is Associated with Increased Mortality: A Cohort Study

OBJECTIVEnTo determine if end-stage liver disease (ESLD) in patients with intracranial hemorrhage (ICH) is associated with increased mortality.nnnMETHODSnThis single-center, retrospective cohort study included 53 patients (33 in ESLD cohort and 20 in non-ESLD cohort) who received neurosurgical care between 2006 and 2017. ESLD was defined clinically as severely impaired liver function and at least 1 major complication of liver failure. The primary outcome was mortality.nnnRESULTSnOverall, in-hospital, and 30-day mortality rates were higher in the ESLD cohort versus the non-ESLD cohort (79 vs. 30%, 79 vs. 20%, and 64 vs. 25%, all P ≤ 0.01). We identified a significant difference in overall survival between ESLD and non-ESLD cohorts on Kaplan-Meier analysis (Pxa0= 0.004 with log-rank and Wilcoxon tests). Odds of overall, in-hospital, and 30-day mortality in the ESLD cohort were 8.67 (95% confidence interval [CI], 2.44-30.84), 14.86 (95% CI, 3.75-58.90), and 5.25 (95% CI, 1.53-18.08). Other predictors of overall mortality included primary admission diagnosis of liver disease (odds ratio [OR]xa0= 9.60; 95% CI, 3.75-58.90), higher Child-Pugh (ORxa0= 1.64; 95% CI, 2.66-34.67) and Model for End-Stage Liver Disease (ORxa0= 1.12; 95% CI, 1.04-1.20) scores, lower Glasgow Coma Scale score (ORxa0= 0.73; 95% CI, 0.61-0.88), ICH that developed in the hospital (ORxa0= 4.11; 95% CI, 1.21-13.98), and intraparenchymal hemorrhage (ORxa0= 9.23; 95% CI, 1.72-49.56).nnnCONCLUSIONSnESLD in patients with ICH is associated with increased mortality.

Red Blood Cell Transfusions Following Resection of Skull Base Meningiomas: Risk Factors and Clinical Outcomes

Abstract Objective This article identifies risk factors for and investigates clinical outcomes of postoperative red blood cell transfusion in patients with skull base meningiomas. Design Retrospective cohort study. Setting Single academic medical center. Participants The transfusion group included patients who had skull base meningiomas and who received packed red blood cell (RBC) transfusion within 7 days of surgery. The no transfusion group included patients who had skull base meningiomas but who did not have RBCs transfused within 7 days of surgery. Main Outcome Measures In‐hospital complication rate, length of stay (LOS), and discharge disposition. Results One hundred and ninety‐six patients had a craniotomy for resection of a meningioma at our institution from March 2013 to January 2017. Seven patients had skull base meningiomas and received RBC transfusion within 7 days of surgery (the transfusion group). The skull base was an independent risk factor for transfusion after we controlled for the effect of meningioma size (OR 3.89, 95% CI 1.34, 11.25). Operative time greater than 10 hours was an independent risk factor for prolonged hospital stay (OR 8.84, 95% CI 1.08, 72.10) once we controlled for the effect of transfusion. In contrast, transfusion did not independently impact LOS or discharge disposition once we controlled for the effect of operative time. Conclusions The skull base is an independent predictor of RBC transfusion. However, RBC transfusion alone cannot predict LOS or discharge disposition in patients who undergo surgical resection of a skull base meningioma.

Survival Outcomes After Intracranial Hemorrhage in Liver Disease

BACKGROUNDnSurvival outcomes for patients with liver disease who suffer an intracranial hemorrhage (ICH) have not been thoroughly investigated.nnnOBJECTIVEnTo understand survival outcomes for 3 groups: (1) patients with an admission diagnosis of liver disease (end-stage liver disease [ESLD] or non-ESLD) who developed an ICH in the hospital, (2) patients with ESLD who undergo either operative vs nonoperative management, and (3) patients with ESLD on the liver transplant waitlist who developed an ICH in the hospital.nnnMETHODSnWe retrospectively reviewed hospital charts from March 2006 through February 2017 of patients with liver disease and an ICH evaluated by the neurosurgery service at a single academic medical center. The primary outcome was survival.nnnRESULTSnWe included a total of 53 patients in this study. The overall survival for patients with an admission diagnosis of liver disease who developed an ICH (n = 29, 55%) in the hospital was 22%. Of those patients with an admission diagnosis of liver disease, 27 patients also had ESLD. Kaplan-Meier analysis found no significant difference in survival for ESLD patients (n = 33, 62%) according to operative status. There were 11 ESLD patients on the liver transplant waitlist. The overall survival for patients with ESLD on the liver transplant waitlist who suffered an in-hospital ICH (n = 7, 13%) was 14%.nnnCONCLUSIONnICH in the setting of liver disease carries a grave prognosis. Also, a survival advantage for surgical hematoma evacuation in ESLD patients is not clear.

The Meningioma Vascularity Index: a volumetric analysis of flow voids to predict intraoperative blood loss in nonembolized meningiomas

OBJECTIVEMeningiomas that appear hypervascular on neuroimaging could be amenable to preoperative embolization. However, methods for measuring hypervascularity have not been described, nor has the benefit of preoperative embolization been adjudicated. The objective of this study was to show a relationship between flow void volume (measured on MRI) and intraoperative estimated blood loss (EBL) in nonembolized meningiomas.METHODSThe authors performed volumetric analyses of 51 intracranial meningiomas (21 preoperatively embolized) resected at their institution. Through the use of image segmentation software and a voxel-based segmentation method, flow void volumes were measured on T2-weighted MR images. This metric was named the Meningioma Vascularity Index (MVI). The primary outcomes were intraoperative EBL and perioperative blood transfusion.RESULTSIn the nonembolized group, the MVI correlated with intraoperative EBL when controlling for tumor volume (r = 0.55, p = 0.002). The MVI also correlated with perioperative blood transfusion (point-biserial correlation [rpb] = 0.57, p = 0.001). A greater MVI was associated with an increased risk of blood transfusion (odds ratio [OR] 5.79, 95% confidence interval [CI] 1.15-29.15) and subtotal resection (OR 7.64, 95% CI 1.74-33.58). In the embolized group, those relationships were not found. There were no significant differences in MVI, intraoperative EBL, or blood transfusion across groups.CONCLUSIONSThis study clearly shows a relationship between MVI and intraoperative EBL in nonembolized meningiomas when controlling for tumor volume. The MVI is a potential biomarker for tumors that would benefit from embolization.

Risk factors for platelet transfusion in glioblastoma surgery

The objectives of this study are to identify risk factors for and to evaluate clinical outcomes of platelet transfusion in glioblastoma surgery. The medical records of adult patients who underwent craniotomy for glioblastoma resection at a single academic medical center were retrospectively reviewed. We stratified patients into 2 groups: those who were transfused at least 1 unit of platelets intraoperatively or postoperatively (no more than 7u202fdays after surgery), and those who were not transfused with platelets. Through the use of a 1:3 matched cohort analysis, we compared complications, length of stay, discharge disposition, and mortality, across groups. One hundred and five consecutive adult patients were included in this study. Thirteen patients (12.38%) received platelet transfusions. Prior antiplatelet therapy (odds ratio [OR] 8.21, 95% confidence interval [CI]: 2.36-28.58), preoperative platelet count less than 200,000u202fcells/µL (OR 8.46, 95% CI: 2.16-33.22), and longer operative times (OR 1.73, 95% CI: 1.10-2.72) were significant risk factors for platelet transfusion. There were no significant differences in the outcomes of interest in the matched cohort analysis.

Middle cranial fossa approach for the repair of superior semicircular canal dehiscence is associated with greater symptom resolution compared to transmastoid approach

BackgroundSuperior semicircular canal dehiscence (SSCD) is a disorder of the skull base that is gaining increasing recognition among neurosurgeons. Traditionally, the middle cranial fossa (MCF) approach has been used for the surgical repair of SSCD. However, the transmastoid (TM) approach is an alternative strategy that has demonstrated promising results.MethodsWe performed independent searches of a popular database to identify studies that described outcomes following the surgical repair of SSCD through MCF and TM approaches. The primary outcome was symptom resolution.ResultsOur analysis included 24 studies that described 230 patients that underwent either an MCF (nxa0=xa0148, 64%) approach or a TM (nxa0=xa082, 36%) approach for primary surgical repair of SSCD. A greater percentage of patients in the MCF group experienced resolution of auditory symptoms (72% vs 59%, pxa0=xa00.012), aural fullness (83% vs 55%, pxa0=xa00.049), hearing loss (57% vs 31%, pxa0=xa00.026), and disequilibrium (75% vs 44%, pxa0=xa00.001) when compared to the TM group. The MCF approach was also associated with higher odds of symptom resolution for auditory symptoms (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.14–2.82), aural fullness (OR 4.02, 95% CI 1.04–15.53), hearing loss (OR 2.91, 95% CI 1.14–7.42), and disequilibrium (OR 3.94, 95% CI 1.78–8.73). The mean follow-up was 9xa0months.ConclusionsThe literature suggests that the MCF approach for the repair of SSCDxa0is associated with greater symptom resolution when compared to the TM approach. This information could help facilitate patient discussions.