Tormod Selbekk, Ole Solheim and Geirmund Unsgård
Ole Solheim, Asgeir Store Jakola, Sasha Gulati and Øyvind Salvesen
Asgeir S. Jakola, Geirmund Unsgård and Ole Solheim
Outcome following brain tumor operations is often assessed by health professionals using various gross function scales. However, surprisingly little is known about how modern glioma surgery affects quality of life (QOL) as reported by the patients themselves. In the present study the authors aimed to assess changes in QOL after glioma surgery, to explore the relationship between QOL and traditional outcome parameters, and to examine possible predictors of change in QOL.
Eighty-eight patients with glioma were recruited from among those 16 years or older who had been admitted to the authors' department for brain tumor surgery in the period between January 2007 and December 2009. A 3D ultrasonography–based navigation system was utilized in nearly all operations and functional MR imaging data on eloquent lesions were incorporated into the neuronavigation system. Preoperative scores for QOL (EuroQol 5D [EQ-5D]) and functional status (Karnofsky Performance Scale [KPS]) were obtained. The EQ-5D and KPS scores were subsequently recorded 6 weeks postoperatively, as were responses to a structured interview about new deficits and possible complications.
There was no change in the median EQ-5D indexes following surgery, 0.76 versus 0.75 (p = 0.419). The EQ-5D index value was significantly correlated with the KPS score (p < 0.001; rho = 0.769). The EQ-5D index values and KPS scores improved in 35.2% and 24.1% of cases, were equal in 20.5% and 47.2% of cases, and deteriorated in 44.3% and 28.7%, respectively. Thus, both improvement and deterioration were underestimated by the KPS score as compared with the patient-reported QOL assessment. New motor deficits (p = 0.003), new language deficits (p = 0.035), new unsteadiness and/or ataxia (p = 0.001), occipital lesions (p = 0.019), and no use of ultrasonography for resection control (p = 0.021) were independent predictors of worsening QOL in a multivariate model.
The surgical procedures per se may not significantly alter QOL in the average patient with glioma; however, new deficits have a major undesirable effect on QOL. It seems that the active use of intraoperative ultrasonography may be associated with a preservation of QOL. The EQ-5D seems like a good outcome measure with a strong correlation to traditional variables while offering a more detailed description of outcome.
Christina Drewes, Lisa Millgård Sagberg, Asgeir Store Jakola and Ole Solheim
Traditionally, the dominant (usually left) cerebral hemisphere is regarded as the more important one, and everyday clinical decisions are influenced by this view. However, reported results on the impact of lesion laterality are inconsistent in the scarce literature on quality of life (QOL) in patients with brain tumors. The authors aimed to study which cerebral hemisphere is the most important to patients with intracranial tumors with respect to health-related QOL (HRQOL).
Two hundred forty-eight patients with unilateral, unifocal gliomas or meningiomas scheduled for primary surgery were included in this prospective cohort study. Generic HRQOL was measured using the EQ-5D-3L questionnaire preoperatively and after 4–6 weeks. Cross-sectional and longitudinal analyses of data were performed.
Tumor volumes were significantly larger in right-sided tumors at diagnosis, and language or speech problems were more common in left-sided lesions. Otherwise, no differences existed in baseline data. The median EQ-5D-3L index was 0.73 (range −0.24 to 1.00) in patients with right-sided tumors and 0.76 (range −0.48 to 1.00) in patients with left-sided tumors (p = 0.709). Due to the difference in tumor volumes at baseline, histopathology and tumor volumes were matched in 198 patients. EQ-5D-3L index scores in this 1:1 matched analysis were 0.74 (range −0.7 to 1.00) for patients with right-sided and 0.76 (range −0.48 to 1.00) for left-sided lesions (p = 0.342). In the analysis of longitudinal data, no association was found between tumor laterality and postoperative EQ-5D-3L index scores (p = 0.957) or clinically significant change in HRQOL following surgery (p = 0.793).
In an overall patient-reported QOL perspective, tumor laterality does not appear to be of significant importance for generic HRQOL in patients with intracranial tumors. This may imply that right-sided cerebral functions are underestimated by clinicians.
Lisa Millgård Sagberg, Ole Solheim and Asgeir S. Jakola
By exploring longitudinal patient-reported health-related quality of life (HRQoL), the authors sought to assess the quality of survival for patients in the 1st year after diagnosis of glioblastoma.
Thirty unselected patients ≥ 18 years who underwent primary surgery for glioblastoma in the period 2011–2013 were included. Using the generic HRQoL questionnaire EQ-5D 3L, baseline HRQoL was assessed before surgery and at postoperative follow-up after 1, 2, 4, 6, 8, 10, and 12 months.
There was an apparent correlation between deterioration in HRQoL scores and tumor progression. Patients with permanent deterioration in HRQoL early after surgery represented a subgroup with rapid progression and short survival. Both positive and negative changes in HRQoL were more often seen after surgery than after radio- or chemotherapy. Patients with gross-total resection (GTR) reported better and more stable HRQoL. In a multivariable analysis preoperative cognitive symptoms (p = 0.02), preoperative functional status (p = 0.03), and GTR (p = 0.01) were independent predictors of quality of survival (area under the curve for EQ-5D 3L index values).
The results indicate that progression-free survival is not only a surrogate marker for survival, but also for quality of survival. Quality of survival seems to be associated with GTR, which adds further support for opting for extensive resections in glioblastoma patients with good preoperative functional levels.
Asgeir Store Jakola, Geirmund Unsgård, Roar Kloster and Ole Solheim
Ole Solheim, Asgeir Store Jakola, Sasha Gulati and Tom Børge Johannesen
Surgical mortality is a frequent outcome measure in studies of volume-outcome relationships, and the Agency for Healthcare Research and Quality has endorsed surgical mortality after craniotomies as an Inpatient Quality Indicator. Still, the frequency and causes of 30-day mortality after neurosurgical procedures have not been much explored. The authors sought to study the frequency and possible causes of death following primary intracranial tumor operations. They also sought to explore a possible predictive value of perioperative mortality rates from neurosurgical centers in relation to long-term survival.
Using population-based data from the Norwegian cancer registry, the authors identified 15,918 primary operations for primary CNS tumors treated in Norway in the period from August 1955 through December 2008. Patients were followed up until death, emigration, or September 2009. Causes of mortality as indicated on death certificates were studied. Factors associated with an increased risk of perioperative death were identified.
The overall risk of perioperative death after first-time surgery for primary intracranial tumors is currently 2.2% and has decreased over the last decades. An age ≥ 70 years and histopathological entities with poor long-term prognoses are risk factors. Overlapping lesions are also associated with excess risk, indicating that lesion size or multifocality may matter. The overall risk of perioperative death is also higher in biopsy cases than in resection cases. Perioperative mortality rates of the 4 Norwegian neurosurgical centers were not predictive of their respective long-term survival rates.
Although considered surgically related if they occur within the first 30 days of surgery, most early postoperative deaths can happen independent of the handiwork of the operating surgeon or anesthesiologist. Overall prognosis of the disease seems to be a strong predictor of perioperative death—perhaps not surprisingly since the 30-day mortality rate is merely the intonation of the Kaplan-Meier curve. Both referral and treatment policies at a neurosurgical center will therefore markedly affect such early outcomes, but early deaths may not necessarily reflect overall quality of care or long-term results. The low incidence of perioperative death in intracranial tumor surgery also greatly limits the statistical power in comparative analyses, such as between published patient series or between centers and certainly between surgeons. Therefore the authors question the value of perioperative mortality rates as a quality indicator in modern neurosurgery for tumors.
Lisa Millgård Sagberg, Christina Drewes, Asgeir S. Jakola and Ole Solheim
In the absence of practical and reliable prognostic tools in intracranial tumor surgery, decisions regarding patient selection, patient information, and surgical management are usually based on neurosurgeons' clinical judgment, which may be influenced by personal experience and knowledge. The objective of this study was to assess the accuracy of the operating neurosurgeons' predictions about patients' functional levels after intracranial tumor surgery.
In a prospective single-center study, the authors included 299 patients who underwent intracranial tumor surgery between 2011 and 2015. The operating neurosurgeons scored their patients' expected functional level at 30 days after surgery using the Karnofsky Performance Scale (KPS). The expected KPS score was compared with the observed KPS score at 30 days.
The operating neurosurgeons underestimated their patients' future functional level in 15% of the cases, accurately estimated their functional levels in 23%, and overestimated their functional levels in 62%. When dichotomizing functional levels at 30 days into dependent or independent functional level categories (i.e., KPS score < 70 or ≥ 70), the predictive accuracy was 80%, and the surgeons underestimated and overestimated in 5% and 15% of the cases, respectively. In a dichotomization based on the patients' ability to perform normal activities (i.e., KPS score < 80 or ≥ 80), the predictive accuracy was 57%, and the surgeons underestimated and overestimated in 3% and 40% of cases, respectively. In a binary regression model, the authors found no predictors of underestimation, whereas postoperative complications were an independent predictor of overestimation (p = 0.01).
Operating neurosurgeons often overestimate their patients' postoperative functional level, especially when it comes to the ability to perform normal activities at 30 days. This tendency to overestimate surgical outcomes may have implications for clinical decision making and for the accuracy of patient information.
Toril Skandsen, Kjell Arne Kvistad, Ole Solheim, Ingrid Haavde Strand, Mari Folvik and Anne Vik
In this prospective cohort study the authors examined patients with moderate to severe head injuries using MR imaging in the early phase. The objective was to explore the occurrence of diffuse axonal injury (DAI) and determine whether DAI was related to level of consciousness and patient outcome.
One hundred and fifty-nine patients (age range 5–65 years) with traumatic brain injury, who survived the acute phase, and who had a Glasgow Coma Scale (GCS) score of 3–13 were admitted between October 2004 and August 2008. Of these 159 patients, 106 were examined using MR imaging within 4 weeks postinjury. Patients were classified into 1 of 3 stages of DAI: Stage 1, in which lesions were confined to the lobar white matter; Stage 2, in which there were callosal lesions; and Stage 3, in which lesions occurred in the dorsolateral brainstem. The outcome measure used 12 months postinjury was the Glasgow Outcome Scale–Extended (GOSE).
Diffuse axonal injury was detected in 72% of the patients and a combination of DAI and contusions or hematomas was found in 50%. The GCS score was significantly lower in patients with “pure DAI” (median GCS Score 9) than in patients without DAI (median GCS Score 12; p < 0.001). The GCS score was related to outcome only in those patients with DAI (r = 0.47; p = 0.001). Patients with DAI had a median GOSE score of 7, and patients without DAI had a median GOSE score of 8 (p = 0.10). Outcome was better in patients with DAI Stage 1 (median GOSE Score 8) and DAI Stage 2 (median GOSE Score 7.5) than in patients with DAI Stage 3 (median GOSE Score 4; p < 0.001). Thus, in patients without any brainstem injury, there was no difference in good recovery between patients with DAI (67%) and patients without DAI (66%).
Diffuse axonal injury was found in almost three-quarters of the patients with moderate and severe head injury who survived the acute phase. Diffuse axonal injury influenced the level of consciousness, and only in patients with DAI was GCS score related to outcome. Finally, DAI was a negative prognostic sign only when located in the brainstem.
Christina Drewes, Lisa Millgård Sagberg, Asgeir Store Jakola, Sasha Gulati and Ole Solheim
Published outcome reports in neurosurgical literature frequently rely on data from retrospective review of hospital records at discharge, but the sensitivity and specificity of retrospective assessments of surgical morbidity is not known. The aim of this study was to elucidate the sensitivity and specificity of retrospective assessment of morbidity after intracranial tumor surgery by comparing it to patient-reported outcomes at 30 days.
In 191 patients who underwent surgery for the treatment of intracranial tumors, we evaluated newly acquired neurological deficits within the motor, language, and cognitive domains. Traditional retrospective discharge data were collected by review of hospital records. Patient-reported data were obtained by structured phone interviews at 30 days after surgery. Data on perioperative medical and surgical complications were obtained from both hospital records and patient interviews conducted 30 days postoperatively.
Sensitivity values for retrospective review of hospital records as compared with patient-reported outcomes were 0.52 for motor deficits, 0.4 for language deficits, and 0.07 for cognitive deficits. According to medical records, 158 patients were discharged with no new or worsened deficits, but only 117 (74%) of these patients confirmed this at 30 days after surgery. Specificity values were high (0.97–0.99), indicating that new deficits were unlikely to be found by retrospective review of hospital records at discharge when the patients did not report any at 30 days. Major perioperative complications were all identified through retrospective review of hospital records.
Retrospective assessment of medical records at discharge from hospital may greatly underestimate the incidence of new neurological deficits after brain tumor surgery when compared with patient-reported outcomes after 30 days.