Predictors and Impact of Postoperative 30-Day Readmission in Glioblastoma.

BACKGROUND: Postoperative 30-day readmissions have been shown to negatively affect survival and other important outcomes in patients with glioblastoma (GBM). OBJECTIVE: To further investigate patient readmission risk factors of primary and recurrent patients with GBM. METHODS: The authors retrospectively reviewed records of 418 adult patients undergoing 575 craniotomies for histologically confirmed GBM at an academic medical center. Patient demographics, comorbidities, and clinical characteristics were collected and compared by patient readmission status using chi-square and Mann-Whitney U testing. Multivariable logistic regression was performed to identify risk factors that predicted 30-day readmissions. RESULTS: The cohort included 69 (12%) 30-day readmissions after 575 operations. Readmitted patients experienced significantly lower median overall survival (11.3 vs 16.4 months, P = .014), had a lower mean Karnofsky Performance Scale score (66.9 vs 74.2, P = .005), and had a longer initial length of stay (6.1 vs 5.3 days, P = .007) relative to their nonreadmitted counterparts. Readmitted patients experienced more postoperative deep vein thromboses or pulmonary embolisms (12% vs 4%, P = .006), new motor deficits (29% vs 14%, P = .002), and nonhome discharges (39% vs 22%, P = .005) relative to their nonreadmitted counterparts. Multivariable analysis demonstrated increased odds of 30-day readmission with each 10-point decrease in Karnofsky Performance Scale score (odds ratio [OR] 1.32, P = .002), each single-point increase in 5-factor modified frailty index (OR 1.51, P = .016), and initial presentation with cognitive deficits (OR 2.11, P = .013). CONCLUSION: Preoperatively available clinical characteristics strongly predicted 30-day readmissions in patients undergoing surgery for GBM. Opportunities may exist to optimize preoperative and postoperative management of at-risk patients with GBM, with downstream improvements in clinical outcomes.

The role of anticoagulation for superior sagittal sinus thrombosis following craniotomy for resection of parasagittal/parafalcine meningiomas.

OBJECTIVE: The safety and efficacy of anticoagulation in managing superior sagittal sinus (SSS) thrombosis remains unclear. The present study investigated the relationship between anticoagulation and cerebrovascular complications in parasagittal/parafalcine meningioma patients presenting with post-surgical SSS thrombosis. METHODS: We analyzed 266 patients treated at a single institution between 2005 and 2020. Bivariate analysis was conducted using the Mann-Whitney U test and Fisher's exact test. Multivariate analysis was conducted using a logistic regression model. Blood thinning medications investigated included aspirin, warfarin, heparin, apixaban, rivaroxaban, and other novel oral anticoagulants (NOACs). A symptomatic SSS thrombosis was defined as a radiographically apparent thrombosis with new headaches, seizures, altered sensorium, or neurological deficits. RESULTS: Our patient cohort was majority female (67.3%) with a mean age ([Formula: see text] SD) of 58.82 [Formula: see text] 13.04 years. A total of 15 (5.6%) patients developed postoperative SSS thrombosis and 5 (1.9%) were symptomatic; 2 (0.8%) symptomatic patients received anticoagulation. None of these 15 patients developed cerebrovascular complications following observation or anticoagulative treatment of asymptomatic SSS thrombosis. While incidence of any other postoperative complications was significantly associated with SSS thrombosis in bivariate analysis (p = 0.015), this association was no longer observed in multivariate analysis (OR = 2.15, p = 0.16) when controlling for patient age, sex, and anatomical location of the tumor along the SSS. CONCLUSIONS: Our single-institution study examining the incidence of SSS thrombosis and associated risk factors highlights the need for further research efforts better prognosticate this adverse outcome. Conservative management may represent a viable treatment strategy for patients with SSS thrombosis.

A novel radiographic marker of sarcopenia with prognostic value in glioblastoma.

OBJECTIVE: Sarcopenia is an important prognostic consideration in surgical oncology that has received relatively little attention in brain tumor patients. Temporal muscle thickness (TMT) has recently been proposed as a novel radiographic marker of sarcopenia that can be efficiently obtained within existing workflows. We investigated the prognostic value of TMT in primary and progressive glioblastoma. METHODS: TMT measurements were performed on magnetic resonance images of 384 patients undergoing 541 surgeries for glioblastoma. Relationships between TMT and clinical characteristics were examined on bivariate analysis. Optimal TMT cutpoints were established using maximally selected rank statistics. Predictive value of TMT upon postoperative survival (PS) was assessed using Cox proportional hazards regression adjusted for age, sex, Karnofsky performance status (KPS), Stupp protocol completion, extent of resection, and tumor molecular markers. RESULTS: Average TMT for the primary and progressive glioblastoma cohorts was 9.55 mm and 9.40 mm, respectively. TMT was associated with age (r = -0.14, p = 0.0008), BMI (r = 0.29, p < 0.0001), albumin (r = 0.11, p = 0.0239), and KPS (r = 0.11, p = 0.0101). Optimal TMT cutpoints for the primary and progressive cohorts were ≤ 7.15 mm and ≤ 7.10 mm, respectively. High TMT was associated with increased Stupp protocol completion (p = 0.001). On Cox proportional hazards regression, high TMT predicted increased PS in progressive [HR 0.47 (95% confidence interval (CI)) 0.25-0.90), p = 0.023] but not primary [HR 0.99 (95% CI 0.64-1.51), p = 0.949] glioblastoma. CONCLUSIONS: TMT correlates with important prognostic variables in glioblastoma and predicts PS in patients with progressive, but not primary, disease. TMT may represent a pragmatic neurosurgical biomarker in glioblastoma that could inform treatment planning and perioperative optimization.

The Prognostic Impact of Nutritional Status on Postoperative Outcomes in Glioblastoma.

OBJECTIVE: The clinical impact and optimal method of assessing nutritional status (NS) have not been rigorously examined in glioblastoma. We investigated the relationship between NS and postoperative survival (PS) in glioblastoma using 4 nutritional indices and identified which index best modeled PS. METHODS: NS was retrospectively assessed for patients with glioblastoma undergoing surgery at our institution from 2007 to 2019 using the albumin level, albumin/globulin ratio (AGR), nutritional risk index (NRI), and prognostic nutritional index (PNI). Optimal cut points for each index were identified using maximally selected rank statistics and previously established criteria. The predictive value of each index on PS was determined using Cox proportional hazards models adjusted for prognostic variables. The best-performing model was identified using the Akaike Information Criterion. RESULTS: Our analysis included 242 patients (64% male) with a mean age of 57.6 years, Karnofsky Performance Status of 77.6, 5-factor modified frailty index of 0.59, albumin level of 4.2 g/dL, AGR of 1.9, NRI of 105.6, and PNI of 47.4. Median PS after index and repeat surgery was 12.7 and 7.8 months, respectively. On multivariable analysis, low albumin level (hazard ratio [HR], 2.09; 95% confidence interval [CI], 1.52-2.89; P < 0.001), mild NRI (HR, 1.61; 95% CI, 1.04-2.49; P = 0.032), moderate/severe NRI (HR, 2.51; 95% CI, 1.64-3.85; P < 0.001), and low PNI (HR, 2.51; 95% CI, 1.78-3.53; P < 0.001), but not low AGR (HR, 1.17; 95% CI, 0.89-1.54; P = 0.270), predicted decreased PS. PNI had the lowest Akaike Information Criterion. CONCLUSIONS: NS predicts PS in glioblastoma. PNI may provide the best model for assessing NS. NS is an important modifiable aspect of brain tumor management that warrants increased attention.

Predicting Postoperative Outcomes in Brain Tumor Patients With a 5-Factor Modified Frailty Index.

BACKGROUND: Frailty indices may represent useful decision support tools to optimize modifiable drivers of quality and cost in neurosurgical care. However, classic indices are cumbersome to calculate and frequently require unavailable data. Recently, a more lean 5-factor modified frailty index (mFI-5) was introduced, but it has not yet been rigorously applied to brain tumor patients. OBJECTIVE: To investigate the predictive value of the mFI-5 on length of stay (LOS), complications, and charges in surgical brain tumor patients. METHODS: We retrospectively reviewed data for brain tumor patients who underwent primary surgery from 2017 to 2018. Bivariate (ANOVA) and multivariate (logistic and linear regression) analyses assessed the predictive power of the mFI-5 on postoperative outcomes. RESULTS: Our cohort included 1692 patients with a mean age of 55.5 yr and mFI-5 of 0.80. Mean intensive care unit (ICU) and total LOS were 1.69 and 5.24 d, respectively. Mean pulmonary embolism (PE)/deep vein thrombosis (DVT), physiological/metabolic derangement, respiratory failure, and sepsis rates were 7.2%, 1.1%, 1.6%, and 1.7%, respectively. Mean total charges were $42 331. On multivariate analysis, each additional point on the mFI-5 was associated with a 0.32- and 1.38-d increase in ICU and total LOS, respectively; increased odds of PE/DVT (odds ratio (OR): 1.50), physiological/metabolic derangement (OR: 3.66), respiratory failure (OR: 1.55), and sepsis (OR: 2.12); and an increase in total charges of $5846. CONCLUSION: The mFI-5 is a pragmatic and actionable tool which predicts LOS, complications, and charges in brain tumor patients. It may guide future efforts to risk-stratify patients with subsequent impact on postoperative outcomes.

Predictors of Nonroutine Discharge Disposition Among Patients with Parasagittal/Parafalcine Meningioma.

OBJECTIVE: Discharge disposition is an important outcome for neurosurgeons to consider in the context of high-quality, value-based care. There has been limited research into how the unique anatomic considerations associated with parasagittal/parafalcine meningioma resection may influence discharge disposition. We investigated the effects of various predictors on discharge disposition within a cohort of patients with parasagittal/parafalcine meningioma. METHODS: A total of 154 patients treated at a single institution were analyzed (2016-2019). Bivariate analysis was conducted using the Mann-Whitney U and Fisher exact tests. Multivariate analysis was conducted using logistic regression. An optimism-corrected C-statistic was calculated using 2000 bootstrap samples to assess logistic regression model performance. RESULTS: Our cohort was mostly female (67.5%) and white (72.7%), with a mean age of 57.29 years. Most patients had tumors associated with the middle third of the superior sagittal sinus (SSS) (60.4%) and had tumors that were not fully occluding the SSS (74.0%). In multivariate analysis, independent predictors of nonroutine discharge disposition included 5-factor Modified Frailty Index score (odds ratio [OR], 2.06; P = 0.0088), Simpson grade IV resection (OR, 4.22; P = 0.0062), and occurrence of any postoperative complication (OR, 2.89; P = 0.031). The optimism-corrected C-statistic of our model was 0.757. CONCLUSIONS: In our single-institution experience, neither extent of SSS invasion nor location along the SSS predicted nonroutine discharge, suggesting that tumor invasion and posterior location along the SSS are not necessarily contraindications to surgery. Our results also highlight the importance of frailty and tumor size in stratifying patients at risk of nonroutine discharge disposition.