Prediction Score for Postoperative Neurologic Complications after Brain Tumor Craniotomy: A Multicenter Observational Study.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Craniotomy for brain tumor displays significant morbidity and mortality, and no score is available to discriminate high-risk patients. Our objective was to validate a prediction score for postoperative neurosurgical complications in this setting. METHODS: Creation of a score in a learning cohort from a prospective specific database of 1,094 patients undergoing elective brain tumor craniotomy in one center from 2008 to 2012. The validation cohort was validated in a prospective multicenter independent cohort of 830 patients from 2013 to 2015 in six university hospitals in France. The primary outcome variable was postoperative neurologic complications requiring in-intensive care unit management (intracranial hypertension, intracranial bleeding, status epilepticus, respiratory failure, impaired consciousness, unexpected motor deficit). The least absolute shrinkage and selection operator method was used for potential risk factor selection with logistic regression. RESULTS: Severe complications occurred in 125 (11.4%) and 90 (10.8%) patients in the learning and validation cohorts, respectively. The independent risk factors for severe complications were related to the patient (Glasgow Coma Score before surgery at or below 14, history of brain tumor surgery), tumor characteristics (greatest diameter, cerebral midline shift at least 3 mm), and perioperative management (transfusion of blood products, maximum and minimal systolic arterial pressure, duration of surgery). The positive predictive value of the score at or below 3% was 12.1%, and the negative predictive value was 100% in the learning cohort. In-intensive care unit mortality was observed in eight (0.7%) and six (0.7%) patients in the learning and validation cohorts, respectively. CONCLUSIONS: The validation of prediction scores is the first step toward on-demand intensive care unit admission. Further research is needed to improve the score's performance before routine use.

Evolution of Prophylaxis Protocols for Venous Thromboembolism in Neurosurgery: Results from a Prospective Comparative Study on Low-Molecular-Weight Heparin, Elastic Stockings, and Intermittent Pneumatic Compression Devices.

BACKGROUND: The incidence of venous thromboembolism (VT) in neurosurgical practice is astonishingly high, representing a major cause of morbidity and mortality. Prophylaxis strategies include elastic stockings, low-molecular-weight heparin (LMWH), and intermittent pneumatic compression (IPC) devices. OBJECTIVE: To assess the safety and efficacy of 2 different VT prophylaxis protocols implemented in a European neurosurgical center. METHODS: All patients admitted for neurosurgical intervention between 2012 and 2016 were stratified as low, moderate, and high risk of VT and received a combination of elastic stockings and LMWH. The protocol was modified in 2014 with the inclusion of perioperative IPC devices for all patients and only in the high-risk group also postoperatively. RESULTS: At time of post-hoc analysis, data obtained from patients included in this study before 2014 (Protocol A, 3169 patients) were compared with those obtained after the introduction of IPC (Protocol B, 3818 patients). Among patients assigned to protocol A, 73 (2.3%) developed deep-vein thrombosis (DVT) and 28 (0.9%) developed pulmonary embolism (PE), 9 of which were fatal (0.3%). Among patients assigned to protocol B, 32 developed DVT (0.8%) and 7 (0.18%) developed PE, with 2 eventually resulting in the death of the patient. A post-hoc analysis confirmed that the use of preoperative LMWH was not associated with a statistically significant greater risk of postoperative bleeding. CONCLUSIONS: This study, despite its limitations of the nonrandomized design, seems to suggest that perioperative IPC devices are a non-negligible support in the prophylaxis of clinically symptomatic DVT and PE.