Craniotomy for supratentorial brain tumors: risk factors for brain swelling after opening the dura mater

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Object. Cerebral swelling often occurs during craniotomy for cerebral tumors. The primary aim in this study was to determine risk factors (intracranial pressure [ICP], patient characteristics, histopathological features, neuroimaging characteristics, anesthetic regimen, and perioperative physiological data) predictive of brain swelling through the dural opening. As a secondary aim the authors attempted to define subdural ICP thresholds associated with brain swelling.

Methods. The study population consisted of 692 patients (mean age 50 ± 15 years) scheduled for elective craniotomy for supratentorial brain tumors. Brain swelling through the dural opening was estimated according to a four-point scale. The patients were dichotomized as those without cerebral swelling (that is, brain below the dura mater [59 patients] or brain at the level of the dura mater [386 patients]) and those with cerebral swelling (that is, moderate brain swelling [205 patients] or pronounced brain swelling [42 patients]). Logistic regression analysis was used to identify subdural ICP (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.72–2.1, p < 0.0001), midline shift (OR 1.06, 95% CI 1.02–1.11, p = 0.008), a diagnosis of glioblastoma multiforme (OR 2.1, 95% CI 1.01–4.3, p = 0.047), and metastasis (OR 2.9, 95% CI 1.3–6.9, p = 0.01) as independent risk factors of intraoperative brain swelling. Thresholds for ICP associated with brain swelling were defined as follows: at an ICP less than 5 mm Hg, brain swelling rarely occurred (5% probability); at an ICP greater than 13 mm Hg, brain swelling occurred with 95% probability; and at an ICP greater than 26 mm Hg, severe brain swelling occurred with 95% probability.

Conclusions. Subdural ICP is the strongest predictor of intraoperative brain swelling. It is possible to define thresholds of cerebral swelling and the authors recommend subdural ICP measurement as a tool to initiate preventive measures to reduce ICP before opening the dura mater.

Article Information

Address reprint requests to: Georg E. Cold, M.D., Ph.D., Department of Neuroanesthesia, Århus University Hospital, 8000 Århus C, Denmark. email: gcold@akh.aaa.dk.

© AANS, except where prohibited by US copyright law.

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Figures

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    Graph demonstrating the logistic regression curve with 95% pointwise CIs depicting the relationship between ICP (x-axis) and the percentage risk of brain swelling (y-axis) in 692 patients. The logistic regression curve is generated using the equation p = p(x1) = exp(b0 + b1 × x1)/[1 + exp(b0 + b1 × x1), where p is the probability of brain swelling, b0 and b1 are the intercept and slope estimates from the logistic regression analysis, and x is ICP.

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    Graph demonstrating the logistic regression curve with 95% pointwise CIs depicting the relationship between ICP (x-axis) and the percentage risk of severe brain swelling (y-axis) in 247 patients with either moderate (205 patients) or severe brain swelling (42 patients). The logistic regression curve is generated using the equation in the Fig. 1 legend.

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