Dexamethasone in Patients with Glioblastoma: A Systematic Review and Meta-Analysis.

OBJECTIVE: Glioblastomas are the most common primary central nervous system (CNS) tumors. Although modern management strategies have modestly improved overall survival, the prognosis remains dismal, with treatment side effects often impinging on the clinical course. Glioblastomas cause neurological dysfunction by infiltrating CNS tissue and via perifocal oedema formation. The administration of steroids such as dexamethasone is thought to alleviate symptoms by reducing oedema. However, despite its widespread use, the evidence for the administration of dexamethasone is limited and conflicting. Therefore, we aimed to review the current evidence concerning the use and outcomes of dexamethasone in patients with glioblastoma. METHODS: We performed a systematic review and meta-analysis according to the PRISMA-P guidelines. We performed a restricted search using the keywords "Dexamethasone" and "Glioblastoma" on PubMed, Web of Science, Cochrane Library, and Academic Search Premier. We included studies reporting on overall survival (OS) and progression-free survival (PFS) in glioblastoma patients receiving higher or lower dexamethasone doses. The risk of bias was assessed using ROBINS-I. We performed a meta-analysis using a random effects model for OS and PFS. RESULTS: Twenty-two retrospective studies were included. Higher doses of dexamethasone were associated with poorer OS (hazard ratio 1.62, confidence interval 1.40-1.88) and PFS (1.49, 1.23-1.81). OS remained worse even when studies corrected for clinical status (1.52, 1.38-1.67). CONCLUSION: Despite the widespread use of dexamethasone in glioblastoma patients, its use is correlated with worse long-term outcomes. Consequently, Dexamethasone administration should be restricted to selected symptomatic patients. Future prospective studies are crucial to confirm these findings.

Comparison Between Flow-Regulated and Gravitational Shunt Valves in the Treatment of Normal Pressure Hydrocephalus: Flow-Grav Study.

BACKGROUND: Normal pressure hydrocephalus (NPH) is frequently treated with ventriculoperitoneal shunt (VPS) surgery. However, VPS implantation can lead to overdrainage and complications such as headaches, hygroma, and subdural hematoma due to a siphon effect in an upright position. Gravitational valves prevent overdrainage through position-dependent adjustment of valve resistance. Flow-regulated valves that increase resistance in presence of high cerebrospinal fluid flow may provide similar protection against overdrainage and present an alternative to gravitational valves. OBJECTIVE: To compare gravitational and flow-regulated shunt valves in patients with symptomatic NPH. METHODS: We performed a retrospective analysis of 97 patients suffering from NPH who underwent VPS implantation with a gravitational or a flow-regulated valve. The primary endpoint was the occurrence of hygroma or subdural hematoma. Secondary endpoints were neurological outcome (Kiefer score, Stein and Langfitt score, and NPH recovery rate), frequency of valve adjustments, and reoperations. RESULTS: No significant differences in the occurrence of hygroma and subdural hematoma (11.4% for flow-regulated valves vs 5.7% for gravitational valves, P = .462) or response to treatment (77.3% vs 81.1%, P = .802) were found. Patients with flow-regulated valves required fewer valve adjustments (1.12 vs 2.02, P < .001) to reach their optimal neurological outcome and underwent fewer surgical revisions (11.4% vs 28.3%, P = .047). CONCLUSION: Our data suggest that shunt therapy in NPH patients with a flow-regulated instead of a gravitational valve is safe and effective with a comparable clinical outcome and risk of overdrainage complications. Moreover, patients with flow-regulated valves may need fewer valve adjustments and reoperations.

How to avoid pneumocephalus in deep brain stimulation surgery? Analysis of potential risk factors in a series of 100 consecutive patients.

BACKGROUND: Accuracy of lead placement is the key to success in deep brain stimulation (DBS). Precise anatomic stereotactic planning usually is based on stable perioperative anatomy. Pneumocephalus due to intraoperative CSF loss is a common procedure-related phenomenon which could lead to brain shift and targeting inaccuracy. The aim of this study was to evaluate potential risk factors of pneumocephalus in DBS surgery. METHODS: We performed a retrospective single-center analysis in patients undergoing bilateral DBS. We quantified the amount of pneumocephalus by postoperative CT scans and corrected the data for accompanying brain atrophy by an MRI-based score. Automated computerized segmentation algorithms from a dedicated software were used. As potential risk factors, we evaluated the impact of trephination size, the number of electrode tracks, length of surgery, intraoperative blood pressure, and brain atrophy. RESULTS: We included 100 consecutive patients that underwent awake DBS with intraoperative neurophysiological testing. Systolic and mean arterial blood pressure showed a substantial impact with an inverse correlation, indicating that lower blood pressure is associated with higher volume of pneumocephalus. Furthermore, the length of surgery was clearly correlated to pneumocephalus. CONCLUSION: Our analysis identifies intraoperative systolic and mean arterial blood pressure as important risk factors for pneumocephalus in awake stereotactic surgery.

COveRs to impRove AesthetiC ouTcome after Surgery for Chronic subdural haemAtoma by buRr hole trepanation (CORRECT-SCAR): protocol of a Swiss single-blinded, randomised controlled trial.

INTRODUCTION: Outcomes rated on impairment scales are satisfactory after burr hole trepanation for chronic subdural haematoma (cSDH). However, the surgery leads to bony defects in the skull with skin depressions above that are frequently considered aesthetically unsatisfactory by the patients. Those defects could be covered by the approved medical devices (burr hole covers), but this is rarely done today. We wish to assess, whether the application of burr hole covers after trepanation for the evacuation of cSDH leads to higher patient satisfaction with the aesthetical result at 90 days postoperative, without worsening disability outcomes or increasing the complication rate. METHODS AND ANALYSIS: This is a prospective, single-blinded, randomised, controlled, investigator-initiated clinical trial enrolling 80 adult patients with first-time unilateral or bilateral cSDH in Switzerland. The primary outcome is the difference in satisfaction with the aesthetic result of the scar, comparing patients allocated to the intervention (burr hole cover) and control (no burr hole cover) group, measured on the Aesthetic Numeric Analogue scale at 90 days postoperative. Secondary outcomes include differences in the rates of skin depression, complications, as well as neurological, disability and health-related quality of life outcomes until 12 months postoperative. ETHICS AND DISSEMINATION: The institutional review board (Kantonale Ethikkommission Zürich) approved this study on 29 January 2019 under case number BASEC 2018-01180. This study determines, whether a relatively minor modification of a standard surgical procedure can improve patient satisfaction, without worsening functional outcomes or increasing the complication rate. The outcome corresponds to the value-based medicine approach of modern patient-centred medicine. Results will be published in peer-reviewed journals and electronic patient data will be safely stored for 15 years. TRIAL REGISTRATION NUMBER: NCT03755349.

Effect of stroke thrombolysis predicted by distal vessel occlusion detection.

OBJECTIVE: Among ischemic stroke patients with negative CT angiography (CTA), we aimed to determine the predictive value of enhanced distal vessel occlusion detection using CT perfusion postprocessing (waveletCTA) for the treatment effect of IV thrombolysis (IVT). METHODS: Patients were selected from 1,851 consecutive patients who had undergone CT perfusion. Inclusion criteria were (1) significant cerebral blood flow (CBF) deficit, (2) no occlusion on CTA, and (3) infarction confirmed on follow-up. Favorable morphologic response was defined as smaller values of final infarction volume divided by initial CBF deficit volume (FIV/CBF). Favorable functional outcome was defined as modified Rankin Scale score of ≤2 after 90 days and decrease in NIH Stroke Scale score of ≥3 from admission to 24 hours (∆NIHSS). RESULTS: Among patients with negative CTA (n = 107), 58 (54%) showed a distal occlusion on waveletCTA. There was no difference between patients receiving IVT (n = 57) vs supportive care (n = 50) regarding symptom onset, early ischemic changes, perfusion mismatch, or admission NIHSS score (all p > 0.05). In IVT-treated patients, the presence of an occlusion was an independent predictor of a favorable morphologic response (FIV/CBF: ß -1.43; 95% confidence interval [CI] -1.96, -0.83; p = 0.001) and functional outcome (90-day modified Rankin Scale: odds ratio 7.68; 95% CI 4.33-11.51; p = 0.039; ∆NIHSS: odds ratio 5.76; 95% CI 3.98-8.27; p = 0.013), while it did not predict outcome in patients receiving supportive care (all p > 0.05). CONCLUSION: In stroke patients with negative CTA, distal vessel occlusions as detected by waveletCTA are an independent predictor of a favorable response to IVT.

Early Imaging Prediction of Malignant Cerebellar Edema Development in Acute Ischemic Stroke.

BACKGROUND AND PURPOSE: Malignant cerebellar edema (MCE) is a life-threatening complication of acute ischemic stroke that requires timely diagnosis and management. Aim of this study was to identify imaging predictors in initial multiparametric computed tomography (CT), including whole-brain CT perfusion (WB-CTP). METHODS: We consecutively selected all subjects with cerebellar ischemic WB-CTP deficits and follow-up-confirmed cerebellar infarction from an initial cohort of 2635 patients who had undergone multiparametric CT because of suspected stroke. Follow-up imaging was assessed for the presence of MCE, measured using an established 10-point scale, of which scores ≥4 are considered malignant. Posterior circulation-Acute Stroke Prognosis Early CT Score (pc-ASPECTS) was determined to assess ischemic changes on noncontrast CT, CT angiography (CTA), and parametric WB-CTP maps (cerebellar blood flow [CBF]; cerebellar blood volume; mean transit time; time to drain). Fisher's exact tests, Mann-Whitney U tests, and receiver operating characteristics analyses were performed for statistical analyses. RESULTS: Out of a total of 51 patients who matched the inclusion criteria, 42 patients (82.4%) were categorized as MCE- and 9 (17.6%) as MCE+. MCE+ patients had larger CBF, cerebellar blood volume, mean transit time, and time to drain deficit volumes (all with P<0.001) and showed significantly lower median pc-ASPECTS assessed using WB-CTP (CBF, cerebellar blood volume, mean transit time, time to drain; all with P<0.001) compared with MCE- patients, while median pc-ASPECTS on noncontrast CT and CTA was not significantly different (both P>0.05). Receiver operating characteristics analyses yielded the largest area under the curve values for the prediction of MCE development for CBF (0.979) and cerebellar blood volume deficit volumes (0.956) and pc-ASPECTS on CBF (0.935), whereas pc-ASPECTS on noncontrast CT (0.648) and CTA (0.684) had less diagnostic value. The optimal cutoff value for CBF deficit volume was 22 mL, yielding 100% sensitivity and 90% specificity for MCE classification. CONCLUSIONS: WB-CTP provides added diagnostic value for the early identification of patients at risk for MCE development in acute cerebellar stroke.