E. Antonio Chiocca and Judith A. Schwartzbaum
Thomas J. Semrad, Robert O'Donnell, Ted Wun, Helen Chew, Danielle Harvey, Hong Zhou and Richard H. White
The authors sought to define the incidence of symptomatic venous thromboembolism (VTE) in patients harboring malignant gliomas.
The authors conducted a retrospective analysis of data obtained in all cases of malignant glioma diagnosed in California during a 6-year period; the occurrence of a VTE was identified using linked hospital discharge data. The Cox proportional hazard model was used to analyze the association of specific risk factors with the development of a VTE or death within 2 years of the cancer diagnosis.
Among 9489 cases, the 2-year cumulative incidence of VTE was 7.5% (715 cases), with a rate of 16.1 events per 100 person-years during the first 6 months. Three hundred ninety-one (55%) of these 715 cases were diagnosed within 61 days of major neurosurgery. Risk factors for VTE included older age (hazard ratio [HR] 2.6, confidence interval [CI] 2.0–3.4 for age range 65–74 years compared with ≤ 45 years), glioblastoma multiforme histology (HR 1.7, CI 1.4–2.1), three or more chronic comorbidities (HR 3.5, CI 2.8–4.3 [compared with no comorbidity]), and neurosurgery within 61 days (HR 1.7, CI 1.3–2.3). Patients in whom a VTE was present were at higher risk of dying within 2 years (HR 1.3, CI 1.2–1.4). In a nested case–control analysis of all VTE cases, there was no association between insertion of a vena cava filter and the risk of a recurrent VTE.
In patients harboring a glioma there was a very high incidence of symptomatic VTEs, particularly within 2 months of neurosurgery. The development of a VTE was associated with a 30% increase in the risk of death within 2 years. Further studies are needed to determine if risk stratification and the use of medical prophylaxis after neurosurgery improves outcomes.
Athir H. Morad, Bradford D. Winters, Myron Yaster, Robert D. Stevens, Elizabeth D. White, Richard E. Thompson, Jon D. Weingart and Allan Gottschalk
Opioid administration following major intracranial surgery is often limited by a presumed lack of need and a concern that opioids will adversely affect postoperative outcome and interfere with the neurological examination. Nevertheless, evidence is accumulating that these patients suffer moderate to severe postoperative pain and that this pain is often undertreated. The authors hypothesized that intravenous patient-controlled analgesia (PCA) would safely and more effectively treat postoperative supratentorial craniotomy pain than conventional as needed (PRN) therapy.
Following a standardized course of general anesthesia, adult patients who underwent elective supratentorial intracranial surgery were randomized in the neurosciences intensive care unit to receive either PRN intravenous fentanyl 25–50 μg every 30 minutes or PCA intravenous fentanyl 0.5 μg/kg every 15 minutes (maximum 4 doses/hour). The authors measured pain (self-reported scale score [0–10]), sedation (Ramsay Sedation Scale score), Glasgow Coma Scale score, fentanyl use, and major adverse events (excessive sedation, respiratory depression, pruritus, nausea, or vomiting) hourly.
Sixty-four patients with a mean age of 48 years (range 22–77 years) were randomized to intravenous PCA (29 patients) or PRN fentanyl (35 patients) groups. There were no statistically significant demographic differences between the 2 groups. Patients receiving intravenous PCA had significantly lower pain scores than those receiving intravenous PRN fentanyl (2.53 ± 1.96 vs 3.62 ± 2.11 [p = 0.039]) and received significantly more fentanyl than the PRN group (44.1 ± 34.5 vs 23.6 ± 23.7 μg/hour [p = 0.007]). There were no differences between the 2 groups regarding the number of patients with adverse events.
Intravenous PCA more effectively treats the pain of supratentorial intracranial surgery than PRN fentanyl, and patients in the former group did not experience any untoward events related to the self-administration of opioids.
Aaron A. Cohen-Gadol, Brian G. Wilhelmi, Frederic Collignon, J. Bradley White, Jeffrey W. Britton, Denise M. Cambier, Teresa J. H. Christianson, W. Richard Marsh, Fredric B. Meyer and Gregory D. Cascino
The authors reviewed the long-term outcome of focal resection in a large group of patients who had intractable partial nonlesional epilepsy, including mesial temporal lobe sclerosis (MTS), and who were treated consecutively at a single institution. The goal of this study was to evaluate the long-term efficacy of epilepsy surgery and the preoperative factors associated with seizure outcome.
This retrospective analysis included 399 consecutive patients who underwent epilepsy surgery at Mayo Clinic in Rochester, Minnesota, between 1988 and 1996. The mean age of the patients at surgery was 32 ± 12 years (range 3–69 years), and the mean age at seizure onset was 12 ± 11 years (range 0–55 years). There were 214 female (54%) and 185 male (46%) patients. The mean duration of epilepsy was 20 ±12 years (range 1–56 years). The preceding values are given as the mean ± standard deviation.
Of the 399 patients, 237 (59%) had a history of complex partial seizures, 119 (30%) had generalized seizures, 26 (6%) had simple partial seizures, and 17 (4%) had experienced a combination of these. Preoperative evaluation included a routine and video-electroencephalography recordings, magnetic resonance imaging of the head according to the seizure protocol, neuropsychological testing, and a sodium amobarbital study. Patients with an undefined epileptogenic focus and discordant preoperative studies underwent an intracranial study. The mean duration of follow up was 6.2 ± 4.5 years (range 0.6–15.7 years). Seizure outcome was categorized based on the modified Engel classification. Time-to-event analysis was performed using Kaplan–Meier curves and Cox regression models to evaluate the risk factors associated with outcomes.
Among these patients, 372 (93%) underwent temporal and 27 (7%) had extratemporal resection of their epileptogenic focus. Histopathological examination of the resected specimens revealed MTS in 113 patients (28%), gliosis in 237 (59%), and normal findings in 49 (12%). Based on the Kaplan–Meier analysis, the probability of an Engel Class I outcome (seizure free, auras, or seizures related only to medication withdrawal) for the overall patient group was 81% (95% confidence interval [CI] 77–85%) at 6 months, 78% (CI 74–82%) at 1 year, 76% (CI 72–80%) at 2 years, 74% (CI 69–78%) at 5 years, and 72% (CI 67–77%) at 10 years postoperatively. The rate of Class I outcomes remained 72% for 73 patients with more than 10 years of follow up. If a patient was in Class I at 1 year postoperatively, the probability of seizure remission at 10 years postoperatively was 92% (95% CI 89–96%); almost all seizures occurred during the 1st year after surgery. Factors predictive of poor outcome from surgery were normal pathological findings in resected tissue (p = 0.038), male sex (p = 0.035), previous surgery (p < 0.001), and an extratemporal origin of seizures (p < 0.001).
The response to epilepsy surgery during the 1st follow-up year is a reliable indicator of the long-term Engel Class I postoperative outcome. This finding may have important implications for patient counseling and postoperative discontinuation of anticonvulsant medications.