Postoperative ischemic changes following brain metastasis resection as measured by diffusion-weighted magnetic resonance imaging

Clinical article

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Object

Brain metastases occur in 10% to 40% of patients harboring cancer. In cases of neurosurgical metastasis resection, all postoperative neurological deterioration should be avoided. Reasons for postoperative deficits can be direct tissue damage due to resection, hemorrhage, venous congestive infarcts, or arterial ischemic events leading to tissue infarction. The aim of this study was to evaluate whether postoperative ischemic infarctions occur in surgery for brain metastasis and to determine their influence on new postoperative neurological deficits.

Methods

Patients who underwent resection of brain metastases and had preoperative and early postoperative (within 48 hours) MRI scans, including diffusion-weighted imaging sequences and apparent diffusion coefficient maps, between January 2009 and May 2012 were included in this study. Clinical and histopathological data (histopathological results, pre- and postoperative neurological status, and previous tumor-specific therapy) were recorded.

Results

One hundred twenty-two patients (56 male, 66 female) who underwent resection of brain metastases were included. The patients' mean age was 60 years (range 21–89 years). The mean time span from initial tumor diagnosis to resection of brain metastasis was 44 months (range 0–338 months). The mean preoperative Karnofsky Performance Status was 80% (exact mean 76% ± 17% [SD]), and the mean postoperative value was 80% (exact mean 78% ± 17%). Twelve (9.8%) of the 122 patients had postoperative permanent worsening of a neurological deficit or a new permanent neurological deficit; 44 (36.1%) of the 122 patients had postoperative ischemic lesions. When comparing patients with and without previous brain irradiation, 53.8% of patients with previous brain irradiation had ischemic lesions on postoperative imaging compared with 31.3% of patients without previous brain irradiation (p = 0.033). There was a significant association between ischemia and postoperative neurological status deterioration (transient or permanent); 13 (29.5%) of 44 patients with ischemic lesions had deterioration of their neurological status compared with 7 (9%) of the 78 patients who did not have ischemic lesions (p = 0.003).

Conclusions

This study demonstrates a high prevalence of vascular incidents in patients undergoing resection for metastatic brain disease. Patients harboring postoperative ischemic lesions detected by MRI have a higher rate of neurological deficits (transient or permanent). Patients who had previous irradiation therapy are at higher risk of developing postoperative ischemic lesions. A large number of postoperative neurological deficits are caused by ischemic incidents.

Abbreviations used in this paper:ADC = apparent diffusion coefficient; AT = arterial territory; DWI = diffusion-weighted imaging; TB = terminal branch; TE = echo time; TR = repetition time.
Article Information

Contributor Notes

Address correspondence to: Jens Gempt, M.D., Neurochirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, München 81675, Germany. email: Jens.Gempt@tum.de.Please include this information when citing this paper: published online October 11, 2013; DOI: 10.3171/2013.9.JNS13596.

© Copyright 1944-2019 American Association of Neurological Surgeons

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References
  • 1

    Andrews DWScott CBSperduto PWFlanders AEGaspar LESchell MC: Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial. Lancet 363:166516722004

    • Search Google Scholar
    • Export Citation
  • 2

    Arbit EWroński MBurt MGalicich JH: The treatment of patients with recurrent brain metastases. A retrospective analysis of 109 patients with nonsmall cell lung cancer. Cancer 76:7657731995

    • Search Google Scholar
    • Export Citation
  • 3

    Campen CJKranick SMKasner SEKessler SKZimmerman RALustig R: Cranial irradiation increases risk of stroke in pediatric brain tumor survivors. Stroke 43:303530402012

    • Search Google Scholar
    • Export Citation
  • 4

    De Witt Hamer PCRobles SGZwinderman AHDuffau HBerger MS: Impact of intraoperative stimulation brain mapping on glioma surgery outcome: a meta-analysis. J Clin Oncol 30:255925652012

    • Search Google Scholar
    • Export Citation
  • 5

    Duffau H: Awake surgery for incidental WHO grade II gliomas involving eloquent areas. Acta Neurochir (Wien) 154:5755842012

  • 6

    Dützmann SGeßler FBink AQuick JFranz KSeifert V: Risk of ischemia in glioma surgery: comparison of first and repeat procedures. J Neurooncol 107:5996072012

    • Search Google Scholar
    • Export Citation
  • 7

    Galldiks NStoffels GFilss CPPiroth MDSabel MRuge MI: Role of O-(2-(18)F-fluoroethyl)-L-tyrosine PET for differentiation of local recurrent brain metastasis from radiation necrosis. J Nucl Med 53:136713742012

    • Search Google Scholar
    • Export Citation
  • 8

    Gavrilovic ITPosner JB: Brain metastases: epidemiology and pathophysiology. J Neurooncol 75:5142005

  • 9

    Gempt JBuchmann NRyang YMKrieg SKreutzer JMeyer B: Frameless image-guided stereotaxy with real-time visual feedback for brain biopsy. Acta Neurochir (Wien) 154:166316672012

    • Search Google Scholar
    • Export Citation
  • 10

    Gempt JFörschler ABuchmann NPape HRyang YMKrieg SM: Postoperative ischemic changes following glioma resection as measured by diffusion weighted magnetic resonance imaging and their clinical relevance. Clinical article. J Neurosurg 118:8018082013

    • Search Google Scholar
    • Export Citation
  • 11

    Gras-Combe GMoritz-Gasser SHerbet GDuffau H: Intraoperative subcortical electrical mapping of optic radiations in awake surgery for glioma involving visual pathways. Clinical article. J Neurosurg 117:4664732012

    • Search Google Scholar
    • Export Citation
  • 12

    Haddy NMousannif ATukenova MGuibout CGrill JDhermain F: Relationship between the brain radiation dose for the treatment of childhood cancer and the risk of long-term cerebrovascular mortality. Brain 134:136213722011

    • Search Google Scholar
    • Export Citation
  • 13

    Jagannathan JSherman JHMehta GUChin LS: Radiobiology of brain metastasis: applications in stereotactic radiosurgery. Neurosurg Focus 22:3E42007

    • Search Google Scholar
    • Export Citation
  • 14

    Kalkanis SNKondziolka DGaspar LEBurri SHAsher ALCobbs CS: The role of surgical resection in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. J Neurooncol 96:33432010

    • Search Google Scholar
    • Export Citation
  • 15

    Khan RBGutin PHRai SNZhang LKrol GDeAngelis LM: Use of diffusion weighted magnetic resonance imaging in predicting early postoperative outcome of new neurological deficits after brain tumor resection. Neurosurgery 59:60662006

    • Search Google Scholar
    • Export Citation
  • 16

    Korinth MCDelonge CHütter BOGilsbach JM: Prognostic factors for patients with microsurgically resected brain metastases. Onkologie 25:4204252002

    • Search Google Scholar
    • Export Citation
  • 17

    Muacevic AWowra BSiefert ATonn JCSteiger HJKreth FW: Microsurgery plus whole brain irradiation versus Gamma Knife surgery alone for treatment of single metastases to the brain: a randomized controlled multicentre phase III trial. J Neurooncol 87:2993072008

    • Search Google Scholar
    • Export Citation
  • 18

    Neuloh GPechstein USchramm J: Motor tract monitoring during insular glioma surgery. J Neurosurg 106:5825922007

  • 19

    Paek SHAudu PBSperling MRCho JAndrews DW: Reevaluation of surgery for the treatment of brain metastases: review of 208 patients with single or multiple brain metastases treated at one institution with modern neurosurgical techniques. Neurosurgery 56:102110342005

    • Search Google Scholar
    • Export Citation
  • 20

    Patchell RATibbs PAWalsh JWDempsey RJMaruyama YKryscio RJ: A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 322:4945001990

    • Search Google Scholar
    • Export Citation
  • 21

    Raore BSchniederjan MPrabhu RBrat DJShu HKOlson JJ: Metastasis infiltration: an investigation of the postoperative brain-tumor interface. Int J Radiat Oncol Biol Phys 81:107510802011

    • Search Google Scholar
    • Export Citation
  • 22

    Sacco RLBenjamin EJBroderick JPDyken MEaston JDFeinberg WM: American Heart Association Prevention Conference. IV. Prevention and Rehabilitation of Stroke Risk factors. Stroke 28:150715171997

    • Search Google Scholar
    • Export Citation
  • 23

    Smith JSCha SMayo MCMcDermott MWParsa ATChang SM: Serial diffusion-weighted magnetic resonance imaging in cases of glioma: distinguishing tumor recurrence from postresection injury. J Neurosurg 103:4284382005

    • Search Google Scholar
    • Export Citation
  • 24

    Ulmer SBraga TABarker FG IILev MHGonzalez RGHenson JW: Clinical and radiographic features of peritumoral infarction following resection of glioblastoma. Neurology 67:166816702006

    • Search Google Scholar
    • Export Citation
  • 25

    Vogelbaum MASuh JH: Resectable brain metastases. J Clin Oncol 24:128912942006

  • 26

    Wager MDu Boisgueheneuc FPluchon CBouyer CStal VBataille B: Intraoperative monitoring of an aspect of executive functions: administration of the Stroop test in 9 adult patients during awake surgery for resection of frontal glioma. Neurosurgery 72:2 Suppl Operativeons169ons1812013

    • Search Google Scholar
    • Export Citation
  • 27

    Walter JKuhn SAWaschke AKalff REwald C: Operative treatment of subcortical metastatic tumours in the central region. J Neurooncol 103:5675732011

    • Search Google Scholar
    • Export Citation
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