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Neurosurgical Review Jun 2022Elevated intracranial pressure (ICP) with reduced cerebral perfusion pressure is a well-known cause of secondary brain injury. Previously, there have been some reports... (Meta-Analysis)
Meta-Analysis Review
Elevated intracranial pressure (ICP) with reduced cerebral perfusion pressure is a well-known cause of secondary brain injury. Previously, there have been some reports describing different supra- and infratentorial ICP measurements depending on the location of the mass effect. Therefore, we aimed to perform a systematic review and meta-analysis to clarify the issue of optimal ICP monitoring in the infratentorial mass lesion. A literature search of electronic databases (PUBMED, EMBASE) was performed from January 1969 until February 2021 according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement. Two assessors are independently screened for eligible studies reporting the use of simultaneous ICP monitoring in the supra- and infratentorial compartments. For quality assessment of those studies, the New Castle Ottawa Scale was used. The primary outcome was to evaluate the value of supra- and infratentorial ICP measurement, and the secondary outcome was to determine the time threshold until equalization of both values. Current evidence surrounding infratentorial ICP measurement was found to be low to very low quality according to New Castle Ottawa Scale. Eight studies were included in the systematic review, four of them containing human subjects encompassing 27 patients with infratentorial pathology. The pooled data demonstrated significantly higher infratentorial ICP values than supratentorial ICP values 12 h after onset (p < 0.05, 95% CI 3.82-5.38) up to 24 h after onset (p < 0.05; CI 1.14-3.98). After 48-72 h, both ICP measurements equilibrated showing no significant difference. Further, four studies containing 26 pigs and eight dogs showed a simultaneous increase of supra- and infratentorial ICP value according to the increase of supratentorial mass volume; however, there was a significant difference towards lower ICP in the infratentorial compartment compared to the supratentorial compartment. The transtentorial gradient leads to a significant discrepancy between supra- and infratentorial ICP monitoring. Therefore, infratentorial ICP monitoring is warranted in case of posterior fossa lesions for at least 48 h.
Topics: Animals; Cerebrovascular Circulation; Dogs; Humans; Intracranial Hypertension; Intracranial Pressure; Monitoring, Physiologic; Skull; Swine
PubMed: 35118578
DOI: 10.1007/s10143-022-01746-y -
Cancers Sep 2022The incidence of recurrent metastatic brain tumors is increasing due to advances in local therapy, including surgical and radiosurgical management, as well as improved... (Review)
Review
The incidence of recurrent metastatic brain tumors is increasing due to advances in local therapy, including surgical and radiosurgical management, as well as improved systemic disease control. The management of recurrent brain metastases was previously limited to open resection and/or irradiation. In recent years, laser interstitial thermal therapy (LITT) has become a promising treatment modality. As systemic and intracranial disease burden increases in a patient, patients may no longer be candidates for surgical resection. LITT offers a relatively minimally invasive option for patients that cannot tolerate or do not want open surgery, as well as an option for accessing deep-seated tumors that may be difficult to access via craniotomy. This manuscript aims to critically review the available data regarding the use of LITT for recurrent intracranial brain metastasis. Ten of seventy-two studies met the criteria for review. Generally, the available literature suggests that LITT is a safe and feasible option for the treatment of recurrent brain metastases involving supratentorial and cortical brain, as well as posterior fossa and deep-seated locations. Among all studies, only one directly compared craniotomy to LITT in the setting of recurrent brain metastasis. Prospective studies are needed to better elucidate the role of LITT in the management of recurrent brain metastases.
PubMed: 36139527
DOI: 10.3390/cancers14184367 -
Surgical Neurology International 2022Hypertonic saline (HS) and mannitol are hyperosmolar agents that are usually used to reduce intracranial pressure (ICP) and provide a satisfactory brain relaxation. The... (Review)
Review
BACKGROUND
Hypertonic saline (HS) and mannitol are hyperosmolar agents that are usually used to reduce intracranial pressure (ICP) and provide a satisfactory brain relaxation. The aim of the study was to perform a systematic review and meta-analysis to compare the efficacy of HS and mannitol on brain relaxation intraoperatively in patient undergoing craniotomies for supra-tentorial brain tumors.
METHODS
A systematic review and meta-analysis of randomized control trials. We included randomized control trials that compared equiosmolar HS and mannitol in supratentorial tumors craniotomies and reported at least one of the following outcomes: degree of brain relaxation, ICP, central venous pressure, mean arterial pressure, perioperative fluid input, urine output, Na+ levels, and K+ levels. We searched Medline, Cochrane Central Register of Controlled Trials, and Embase using MESH terms and keywords. The bibliographic references of included studies and trial registries were also searched.
RESULTS
Seven articles were included. The degree brain of relaxation was comparable across the two groups with slight tendency toward HS (RR = 1.13, 95% CI 0.99-1.29; = 0.08). Mannitol was associated with significantly higher urine output (standardized mean difference [SMD] = -1.33, 95% CI -1.56--1.10; < 0.001). Na levels were higher in HS group (SMD = 1.47, 95% CI 0.86-2.09; < 0.001). Mannitol was associated with non-significant decrease in CVP and increase fluid input (SMD = 0.42, 95% CI 0.00-0.85 and SMD = -0.18, 95% CI -0.37-0.02, respectively).
CONCLUSION
Both HS and mannitol are associated with satisfactory brain relaxation with a non-statistically significant tendency for HS to achieve better relaxation scores with mannitol resulting in higher urine output while HS with higher Na levels.
PubMed: 35509546
DOI: 10.25259/SNI_136_2022 -
Neurosurgical Review May 2023Neoadjuvant stereotactic radiotherapy (NaSRT) is a novel strategy for brain metastasis (BM) treatment, promising to achieve good local control, improved survival, and... (Meta-Analysis)
Meta-Analysis Review
Neoadjuvant stereotactic radiotherapy (NaSRT) is a novel strategy for brain metastasis (BM) treatment, promising to achieve good local control, improved survival, and low toxicity. This is a systematic review of available literature and meta-analysis of 8 articles eligible for inclusion after searching MEDLINE via PubMed, Web-of-science, Cochrane Wiley, and Embase databases up to March 2023. A total of 484 patients undergoing NaSRT to treat 507 lesions were included. The median age was 60.9 (IQR 57-63) years, with a median tumor volume of 12.1 (IQR 9-14) cm. The most frequent histology was non-small-cell lung cancer (41.3%), followed by breast (18.8%), and melanoma (14.3%). Lesions had a preferred supratentorial location (77.4%). Most of the studies used a single fraction schedule (91% of patients, n = 440). Treatment parameters were homogeneous and showed a median dose of 18 (IQR 15.5-20.5) Gy at a median of 80% isodose. Surgery was performed after a median of 1.5 (IQR 1-2.4) days and achieved gross-total extent in 94% of cases. Median follow-up was 12.9 (IQR 10-15.7) months. NaSRT showed an overall mortality rate of 58% (95% CI 43-73) at the last follow-up. Actuarial outcomes rates were 60% (95% CI 55-64) for 1-year overall survival (1y-OS), 38% (95% CI 33-43) for 2y-OS, 29% (95% CI 24-34) for 3y-OS; overall 15% (95% CI 11-19) for local failure, 46% (95% CI 37-55) for distant brain failure, 6% (95% CI 3-8) for radionecrosis, and 5% (95% CI 3-8) for leptomeningeal dissemination. The median local progression-free survival time was 10.4 (IQR 9.5-11.4) months, while the median survival without distant failure was 7.4 (IQR 6.9-8) months. The median OS time for the entire cohort was 17 (IQR 14.9-17.9) months. Existing data suggest that NaSRT is effective and safe in the treatment of BMs, achieving good local control on BMs with and low incidence of radionecrosis and leptomeningeal dissemination. Distant control appears limited compared to other radiation regimens.
Topics: Humans; Middle Aged; Carcinoma, Non-Small-Cell Lung; Neoadjuvant Therapy; Lung Neoplasms; Brain Neoplasms; Radiosurgery; Retrospective Studies; Treatment Outcome
PubMed: 37256368
DOI: 10.1007/s10143-023-02031-2 -
Cancers Sep 2022Brain metastases (BMs) carry a high morbidity and mortality burden. Neoadjuvant stereotactic radiotherapy (NaSRT) has shown promising results. We systematically reviewed... (Review)
Review
BACKGROUND
Brain metastases (BMs) carry a high morbidity and mortality burden. Neoadjuvant stereotactic radiotherapy (NaSRT) has shown promising results. We systematically reviewed the literature on NaSRT for BMs.
METHODS
PubMed, EMBASE, Scopus, Web-of-Science, Cochrane, and ClinicalTrial.gov were searched following the PRISMA guidelines to include studies and ongoing trials reporting NaSRT for BMs. Indications, protocols, and outcomes were analyzed using indirect random-effect meta-analyses.
RESULTS
We included 7 studies comprising 460 patients with 483 BMs, and 13 ongoing trials. Most BMs originated from non-small lung cell carcinoma (41.4%), breast cancer (18.7%) and melanoma (43.6%). Most patients had single-BM (69.8%) located supratentorial (77.8%). Patients were eligible if they had histologically-proven primary tumors and ≤4 synchronous BMs candidate for non-urgent surgery and radiation. Patients with primary tumors clinically responsive to radiotherapy, prior brain radiation, and leptomeningeal metastases were deemed non-eligible. Median planning target volume was 9.9 cm (range, 2.9-57.1), and NaSRT was delivered in 1-fraction (90.9%), 5-fraction (4.8%), or 3-fraction (4.3%), with a median biological effective dose of 39.6 Gy10 (range, 35.7-60). Most patients received piecemeal (76.3%) and gross-total (94%) resection after a median of 1-day (range, 1-10) post-NaSRT. Median follow-up was 19.2-months (range, 1-41.3). Actuarial post-treatment rates were 4% (95%CI: 2-6%) for symptomatic radiation necrosis, 15% (95%CI: 12-18%) and 47% (95%CI: 42-52%) for local and distant recurrences, 6% (95%CI: 3-8%) for leptomeningeal metastases, 81% (95%CI: 75-87%) and 59% (95%CI: 54-63%) for 1-year local tumor control and overall survival.
CONCLUSION
NaSRT is effective and safe for BMs. Ongoing trials will provide high-level evidence on long-term post-treatment outcomes, further compared to adjuvant stereotactic radiotherapy.
PubMed: 36077863
DOI: 10.3390/cancers14174328 -
Journal of Neuroimaging : Official... May 2022Angiocentric gliomas (AGs) are epileptogenic low-grade gliomas in young patients. We aimed to investigate the MRI findings of AGs and systematically review previous... (Review)
Review
BACKGROUND AND PURPOSE
Angiocentric gliomas (AGs) are epileptogenic low-grade gliomas in young patients. We aimed to investigate the MRI findings of AGs and systematically review previous publications and three new cases.
METHODS
We searched PubMed, Elsevier's abstract and citation database, and Embase databases and included 50 patients with pathologically proven AGs with analyzable preoperative MRI including 3 patients from our institution and 47 patients from 38 publications (median age, 13 years [range, 2-83 years]; 35 men). Two board-certified radiologists reviewed all images. The relationships between seizure/epilepsy history and MRI findings were statistically analyzed. Moreover, clinical and imaging differences were evaluated between supratentorial and brainstem AGs.
RESULTS
Intratumoral T1-weighted high-intensity areas, stalk-like signs, and regional brain parenchymal atrophy were observed in 23 out of 50 (46.0%), 10 out of 50 (20.0%), and 14 out of 50 (28.0%) patients, respectively. Intratumoral T1-weighted high-intensity areas were observed significantly more frequently in patients with stalk-like signs (positive, 9/10 vs. negative, 14/40, p = .0031) and regional atrophy (13/14 vs. 10/36, p = .0001). There were significant relationships between the length of seizure/epilepsy history and presence of intratumoral T1-weighted high-intensity area (median 3 years vs. 0.5 years, p = .0021), stalk-like sign (13.5 vs. 1 year, p < .0001), and regional atrophy (14 vs. 0.5 years, p < .0001). Patients with brainstem AGs (n = 7) did not have a seizure/epilepsy history and were significantly younger than those with supratentorial AGs (median, 5 vs. 13 years, p < .0001, respectively).
CONCLUSIONS
Intratumoral T1-weighted high-intensity areas, stalk-like signs, and regional brain atrophy were frequent imaging features in AG. We also found that affected age was different between supratentorial and brainstem AGs.
Topics: Adolescent; Atrophy; Brain Neoplasms; Female; Glioma; Humans; Magnetic Resonance Imaging; Male; Neuroimaging; Seizures
PubMed: 35201652
DOI: 10.1111/jon.12983 -
World Neurosurgery May 2023Historically, the occurrence of hemorrhage in the brainstem after an episode of supratentorial intracranial hypertension was described by Henri Duret in 1878.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Historically, the occurrence of hemorrhage in the brainstem after an episode of supratentorial intracranial hypertension was described by Henri Duret in 1878. Nevertheless, to date the eponym Duret brainstem hemorrhage (DBH) lacks systematic evidence regarding its epidemiology, pathophysiology, clinical and radiologic presentation, and outcome.
METHODS
We conducted a systematic literature review and meta-analysis using the Medline database from inception to 2022 looking for English-language articles concerning DBH, in accordance with the PRISMA guidelines.
RESULTS
The research yielded 28 articles for 32 patients (mean age, 50 years; male/female ratio, 3:1). Of patients, 41% had head trauma causing 63% of subdural hematoma, responsible for coma in 78% and mydriasis in 69%. DBH appeared on the emergency imaging in 41% and on delayed imaging in 56%. DBH was located in the midbrain in 41% of the patients, and in the upper middle pons in 56%. DBH was caused by sudden downward displacement of the upper brainstem secondary to supratentorial intracranial hypertension (91%), intracranial hypotension (6%), or mechanical traction (3%). Such downward displacement caused the rupture of basilar artery perforators. Brainstem focal symptoms (P = 0.003) and decompressive craniectomy (P = 0.164) were potential favorable prognostic factors, whereas an age >50 years showed a trend toward a poor prognosis (P = 0.0731).
CONCLUSIONS
Unlike its historical description, DBH appears as a focal hematoma in the upper brainstem caused by the rupture of anteromedial basilar artery perforators after sudden downward displacement of the brainstem, regardless of its cause.
Topics: Humans; Male; Female; Middle Aged; Cerebral Hemorrhage; Hematoma, Subdural; Brain Stem Hemorrhage, Traumatic; Intracranial Hypertension
PubMed: 36868404
DOI: 10.1016/j.wneu.2023.02.110 -
World Neurosurgery Jul 2020Management of incidental asymptomatic brain tumors in children is controversial due to lack of clear evidence-based guidelines. We present this systematic review in an...
OBJECTIVES
Management of incidental asymptomatic brain tumors in children is controversial due to lack of clear evidence-based guidelines. We present this systematic review in an attempt to highlight an optimal treatment paradigm.
METHODS
This systematic review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Databases were searched up to August 2019 using the keywords "incidental," "brain tumor," and "pediatric." Our main focus was on brain lesions suspected for neoplasm, diagnosed incidentally on neuroimaging in an otherwise asymptomatic patient <18 years old. Cystic, vascular, and inflammatory brain lesions were excluded.
RESULTS
Fourteen studies comprising 308 patients were included. All cases were diagnosed using magnetic resonance imaging. The most common indications for imaging were headache (93; 30%) and trauma (72; 23%). Lesion distribution was supratentorial (179; 58%), infratentorial (121; 40%), and intraventricular (8; 3%). Of 308 cases, 243 (79%) were managed with neuroradiological surveillance and 57 (19%) by upfront surgical excision. Of those managed conservatively, 177 (73%) remained stable within a mean follow-up of 30 months, 54 (22%) progressed, and 12 (5%) spontaneously regressed. Meanwhile, upfront excision achieved complete remission in all 57 cases over a mean follow-up of 68.3 months.
CONCLUSION
A small body of evidence has emerged, highlighting the marked heterogeneity and contradictory results between the available studies, limiting our ability to draw solid conclusions. At this point, the decision between surgery and "watchful waiting" should be tailored on an individual patient basis depending on suspicion of malignancy, clinical or radiologic progression, and parental preference.
Topics: Adolescent; Asymptomatic Diseases; Brain Neoplasms; Child; Child, Preschool; Conservative Treatment; Disease Management; Humans; Incidental Findings; Infant; Infant, Newborn; Neurosurgery; Neurosurgical Procedures; Pediatrics; Watchful Waiting
PubMed: 32165344
DOI: 10.1016/j.wneu.2020.02.178 -
Dysphagia Jan 2024Neurological patients frequently have disorders of consciousness, swallowing disorders, or neurological states that are incompatible with extubation. Therefore, they... (Review)
Review
Neurological patients frequently have disorders of consciousness, swallowing disorders, or neurological states that are incompatible with extubation. Therefore, they frequently require tracheostomies during their stay in an intensive care unit. After the acute phase, tracheostomy weaning and decannulation are generally expected to promote rehabilitation. However, few reliable predictive factors (PFs) for decannulation have been identified in this patient population. We sought to identify PFs that may be used during tracheostomy weaning and decannulation in patients with brain injuries. We conducted a systematic review of the literature regarding potential PFs for decannulation; searches were performed on 16 March 2021 and 1 June 2022. The following databases were searched: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, PEDro, OPENGREY, OPENSIGLE, Science Direct, CLINICAL TRIALS and CENTRAL. We searched for all article types, except systematic reviews, meta-analyses, abstracts, and position articles. Retrieved articles were published in English or French, with no date restriction. In total, 1433 articles were identified; 26 of these were eligible for inclusion in the review. PFs for successful decannulation in patients with acquired brain injuries (ABIs) included high neurological status, traumatic brain injuries rather than stroke or anoxic brain lesions, younger age, effective swallowing, an effective cough, and the absence of pulmonary infections. Secondary PFs included early tracheostomy, supratentorial lesions, the absence of critical illness polyneuropathy/myopathy, and the absence of tracheal lesions. To our knowledge, this is the first systematic review to identify PFs for decannulation in patients with ABIs. These PFs may be used by clinicians during tracheostomy weaning.
PubMed: 38189928
DOI: 10.1007/s00455-023-10646-2 -
Child's Nervous System : ChNS :... Jun 2023Intracranial cavernous malformations (CMs) are rare vascular malformations of the central nervous system in children. Infantile patients, being a developmentally... (Review)
Review
INTRODUCTION
Intracranial cavernous malformations (CMs) are rare vascular malformations of the central nervous system in children. Infantile patients, being a developmentally vulnerable age group, pose a special challenge for management of these lesions. We pooled data from infantile patients diagnosed at our institution and individual cases published in the literature to provide input towards therapeutic decision-making.
METHODS
A systematic search of PubMed, MEDLINE, Embase, and Scopus was performed in accordance with PRISMA guidelines to identify all reported cases of intracranial CMs in the literature for infantile patients aged ≤ 2 years. In addition, cases from our institution diagnosed between 2010 and 2020 were also included. Individual cases were pooled and analyzed for clinical presentation, natural history, and outcomes from conservative and surgical management.
RESULTS
A total of 36 cases were included, of which 32 were identified from the literature. Median age at presentation was 14 months (range: 2 days to 24 months) months; 53% (n = 19) were females. Most cavernomas (64%, 23/36) were supratentorial, while 30% (n = 11) were located in brainstem and 5.5% (n = 2) in the cerebellum. With the exception of one patient, all cases were reported to be symptomatic; seizures (n = 15/31, 48.3%) and motor deficits (n = 13/31, 42%) were the most common symptom modalities. A total of 13 patients were managed conservatively upon initial presentation. No symptomatic hemorrhages were observed during 26 total person-years of follow-up. A total of 77% (28/36) underwent surgery; either upfront (23/28, 82%) at initial presentation or following conservative management. Among 12 patients who had preoperative seizures, 11/12 (91.6%) achieved seizure freedom post-resection. Among 7 patients who presented with hemiparesis preoperatively, 5 (71%) demonstrated some improvement, while 1 remained unchanged, and another patient with a brainstem cavernous malformation had worsening of motor function postoperatively. Postoperative recurrence was noted in 3 cases (3/27, 11%).
CONCLUSION
Annual risk of repeat hemorrhage may be low for infantile patients with intracranial cavernous malformations; however, better follow-up rates and higher number of cases are needed to make a definitive assertion. Surgical resection may be associated with high rates of epilepsy cure and provide improvement in neurological function in a select number of cases.
Topics: Child; Female; Humans; Infant, Newborn; Male; Hemangioma, Cavernous, Central Nervous System; Brain Stem; Hemangioma, Cavernous; Seizures; Paresis
PubMed: 36917267
DOI: 10.1007/s00381-023-05903-6