Elsevier

World Neurosurgery

Volume 113, May 2018, Pages e769-e776
World Neurosurgery

Original Article
Early Postoperative Perils of Intraventricular Tumors: An Observational Comparative Study

https://doi.org/10.1016/j.wneu.2018.02.177Get rights and content

Highlights

  • Resected intraventricular tumors have higher rates of critical postoperative events.

  • Acute obstructive hydrocephalus is an important early postoperative complication.

  • Routine intraoperative EVD placement may be justified for this subgroup of patients.

Background

Early postoperative patient surveillance after removal of intraventricular tumors is often hindered by delayed awakening and prolonged somnolence. The objective of this study was to analyze the incidence of early critical postoperative events after elective craniotomy for intraventricular tumors in adults compared with extraventricular lesions.

Methods

An observational comparative study was conducted on adult patients who had undergone first-time elective craniotomy between November 2011 and August 2016. Patients were stratified into extraventricular lesions (group 1) and intraventricular tumors (group 2). The rates of late extubation, early postoperative seizures, emergency head computed tomography (CT) scans, and urgent surgical intervention within 48 hours and mortality within 30 days of surgery were analyzed from a prospective database.

Results

A total of 977 elective craniotomies were analyzed, including 951 (97.3%) in group 1 and 26 (2.7%) in group 2. Emergency CT scans were ordered significantly more frequently in group 2 (34.6% vs. 8.4%; odds ratio, 5.76; 95% confidence interval [CI], 2.49–13.35; P = 0.0002), and the incidence of urgent surgical intervention was significantly higher in group 2 (11.5% vs. 0.8%; odds ratio, 15.38; 95% CI, 3.83–61.72; P = 0.002). The main reason for urgent surgical intervention in group 2 was acute obstructive hydrocephalus. Overall surgical mortality after 30 days was 0.3% (3 cases in group 1, no cases in group 2).

Conclusions

Intraventricular tumors are at significantly higher risk for early emergency head CT and urgent surgical intervention. This patient cohort might benefit from routine intraoperative and early postoperative imaging, as well as intraoperative extraventricular drain placement.

Introduction

Among intracranial mass lesions, intraventricular tumors constitute a rare and heterogeneous subgroup of brain tumors. When planning for surgery selection of the most appropriate and safe approach is of fundamental importance. Due to their deep location and intimate proximity to periventricular eloquent neurovascular structures neurosurgical strategies critically depend on multiple careful microanatomic considerations. Hence, the resection of intraventricular tumors is especially challenging and modern neurosurgery has come a long way since Dandy performed manual removal of a large intraventricular tumor through an open parietal transcortical approach.1 Many anatomic studies and reviews have addressed these surgical matters and have nicely illustrated save microsurgical approaches to the ventricular system with regard to minimizing the risk of injury to eloquent brain matter or perforating arteries.2, 3, 4, 5, 6, 7, 8

We have recently shown that early extubation after elective craniotomy can be safely performed and clinical monitoring of the awakened patient with normal neurologic findings precludes routine early postoperative head computed tomography (CT) scanning.9 Yet in our experience, following craniotomy for intraventricular tumors, patients more often show a tendency for delayed postoperative awakening and might demonstrate a prolonged state of mild confusion and lethargy. Consequently, postoperative neurologic monitoring is challenging, and head CT is frequently ordered to rule out early postoperative complications. It is well accepted that microsurgical removal of a deep-seated intraventricular tumor with interference into cerebrospinal fluid (CSF) circulation more directly impacts early postoperative neurologic function than surgery restricted outside the ventricular system. Yet, to the best of our knowledge, there are no detailed reports in the literature on the incidence of early critical postoperative events for patients operated on for intraventricular tumors.

The objective of this report was to evaluate the incidence of unexpected neurologic worsening, clinically relevant acute obstructive hydrocephalus and urgent surgical intervention in the early postoperative phase after elective craniotomy for intraventricular tumors in adult patients as compared to craniotomy for extraventricular lesions.

Section snippets

Patients and Data Collection

This was a retrospective, observational comparative single center study based on prospectively collected data. The data was obtained from a database on elective craniotomies performed at our institution that was implemented for a previous study and registered at ClinicalTrials.gov.9 Patient data as defined in a case report form was prospectively collected, coded, and entered into a Good Clinical Practice–compliant electronic database. Data included patient demographics, American Society of

Intraventricular Tumors

A total of 977 patients with first-time elective craniotomy were included for final analysis. Primarily extraventricular lesions were found in 951 patients (group 1). A breakdown of these entities is shown in Table 1. Intracranial brain tumors were found in a total of 754 (77.2%) patients, including 26 cases of purely intraventricular tumors (group 2). Demographic patient profiles and clinical features including use of preoperative medication are listed in Table 2. The incidence of

Discussion

Primarily intraventricular tumors are a rare and histopathologically heterogeneous subgroup of brain tumors representing merely 1%–3% of intracranial mass lesions.14, 15, 16, 17 In accordance with these reports, in the present series, intraventricular tumors accounted for just 3.4% of all intracranial tumors and only 2.7% of all included craniotomies. It is well known that intraventricular tumors may present a wide spectrum of possible intra- and postoperative complications. The aim of our

Conclusions

Neurosurgical resection of intraventricular tumors is associated with a significantly higher incidence of urgent head CTs and surgical interventions within the first 48 hours after elective surgery. In the early postoperative phase, acute obstructive hydrocephalus is the main threat for these patients. This selected subgroup might benefit from routine “prophylactic” intraoperative EVD placement, as well as intraoperative or postoperative imaging to detect and instantly treat possible early

References (26)

  • H. Kasowski et al.

    Transcallosal approach for tumors of the lateral and third ventricles

    Neurosurg Focus

    (2001)
  • U. Cikla et al.

    Microsurgical resection of tumors of the lateral and third ventricles: operative corridors for difficult-to-reach lesions

    J Neurooncol

    (2016)
  • R.T. Schär et al.

    No routine postoperative head CT following elective craniotomy: a paradigm shift?

    PLoS One

    (2016)
  • Cited by (1)

    • Large lateral intraventricular tumors – Outcome of radical surgery

      2021, Journal of Clinical Neuroscience
      Citation Excerpt :

      The techniques of tumor debulking and hemostasis have to be learnt and acquired over years of experience. Surgery on intraventricular large tumors has been associated with the range of morbidity and mortality that has been reported to be up to 45%. [1,2] Transcallosal or transcortical approaches are the two possible surgical options [8,9].

    Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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