Radio-chemotherapy feasibility for biopsy-only unresectable IDH wild-type glioblastomas (BO-GBM).

Background: "Biopsy-only" glioblastoma (BO-GBM) is a heterogeneous, understudied group of patients associated with a poor outcome. Our objective was to explore the pattern of care and prognosis associated with BO-GBM in our center. Methods: Patients with IDH wild-type BO-GBM included in a prospective regional cohort initiated in 2014 and closed in 2017 were retrospectively reviewed for patient characteristics, MRI findings, treatment allocation, and delivery. Results: Of 535 patients included in the cohort, 137 patients were included in the present analysis. The median age was 66 years old and the median KPS was 70. Forty-six patients (33.6%) were referred to radiotherapy and chemotherapy (RT-TMZ) regimen, 75 (54.7%), considered unfitted for RT, received chemotherapy upfront (CT) and 16 (11.7%) were referred to palliative care (PC). Regarding the first group, 91% of patients completed the RT-TMZ. In the CT group, 11 of 75 patients (14.7%) underwent radiotherapy after chemotherapy upfront. Median overall survival was 12.3 months (95% CI, 15.30-24.16), 5.7 months (95% CI, 6.22-9.20), and 1.9 months (95% CI, 1.43-5.08) in RT-TMZ, CT, and PC groups, respectively. In multivariate analyses, progression-free survival was impacted by baseline KPS (P < .001) and MGMT status (P = .004). Overall survival was impacted by baseline KPS (P < .001) and age (P = .030). Conclusion: BO-GBM constitute a large and heterogeneous population in which one-third of patients is amenable to the standard of care, with survival outcome close to one of the patients who underwent surgery. Reliable criteria are needed to help select patients for adequate treatment while new strategies are warranted for BO-GBM unfit for RT.

Live Stimulated Raman Histology for the Near-Instant Assessment of Central Nervous System Samples.

Central nervous system tumors encompass many heterogeneous neoplasms with different outcomes and treatment strategies. The current classification of these tumors is based on molecular parameters in addition to histopathology to define tumor entities. This genomic characterization of tumors is also becoming increasingly essential for physicians to identify targeted therapy options. The deployment of such genomic profiling relies on an efficient surgical sampling. To perform an appropriate tumor resection and a correct sampling of the tumor, the neurosurgeon may request an intraoperative pathological consultation. Stimulated Raman histology (SRH), an emerging nondestructive imaging technology, can address this challenge. SRH allows for a rapid and label-free microscopic examination of unprocessed tissues samples in near-perfect concordance with standard histology. In this study we showed that SRH enabled the near-instant microscopic examination of various central nervous system samples without any tissue processing such as labeling, freezing nor sectioning. Since SRH imaging is a nondestructive approach, we demonstrated that the tissue could be readily recovered after SRH imaging and reintroduced into the conventional pathology workflow including immunohistochemistry and genomic profiling to establish a definitive diagnosis.

Radiosurgical Corpus Callosotomy for Intractable Epilepsy: Retrospective Long-Term Safety and Efficacy Assessment in 19 Patients an Review of the Literature.

BACKGROUND: Some patients suffering from intractable epileptic seizures, particularly drop attacks (DAs), are nonremediable by curative techniques. Palliative procedure carries a significant rate of surgical and neurological complications. OBJECTIVE: To propose evaluation of safety and efficacy of Gamma Knife corpus callosotomy (GK-CC) as an alternative to microsurgical corpus callosotomy. METHODS: This study included retrospective analysis of 19 patients who underwent GK-CC between 2005 and 2017. RESULTS: Of the 19 patients, 13 (68%) had improvement in seizure control and 6 had no significant improvement. Of the 13/19 (68%) with improvement in seizures, 3 (16%) became completely seizure-free, 2 (11%) became free of DA and generalized tonic-clonic but with residual other seizures, 3 (16%) became free of DA only, and 5 (26%) had >50% reduction in frequency of all seizure types. In the 6 (31%) patients with no appreciable improvement, there were residual untreated commissural fibers and incomplete callosotomy rather than failure of Gamma Knife to disconnect. Seven patients showed a transient mild complication (37% of patients, 33% of the procedures). No permanent complication or neurological consequence was observed during the clinical and radiological workup with a mean of 89 (42-181) months, except 1 patient who had no improvement of epilepsy and then aggravation of the pre-existing cognitive and walking difficulties (Lennox-Gastaut). The median time of improvement after GK-CC was 3 (1-6) months. CONCLUSION: Gamma Knife callosotomy is safe and accurate with comparable efficacy to open callosotomy in this cohort of patients with intractable epilepsy suffering from severe drop attacks.

Plasma nanoDSF Denaturation Profile at Baseline Is Predictive of Glioblastoma EGFR Status.

Glioblastoma (GBM) is the most frequent and aggressive primary brain tumor in adults. Recently, we demonstrated that plasma denaturation profiles of glioblastoma patients obtained using Differential Scanning Fluorimetry can be automatically distinguished from healthy controls with the help of Artificial Intelligence (AI). Here, we used a set of machine-learning algorithms to automatically classify plasma denaturation profiles of glioblastoma patients according to their EGFR status. We found that Adaboost AI is able to discriminate EGFR alterations in GBM with an 81.5% accuracy. Our study shows that the use of these plasma denaturation profiles could answer the unmet neuro-oncology need for diagnostic predictive biomarker in combination with brain MRI and clinical data, in order to allow for a rapid orientation of patients for a definitive pathological diagnosis and then treatment. We complete this study by showing that discriminating another mutation, MGMT, seems harder, and that post-surgery monitoring using our approach is not conclusive in the 48 h that follow the surgery.

Meningoencephalitis with refractory intracranial hypertension: consider decompressive craniectomy.

The benefits of decompressive craniectomy (DC) have been demonstrated in malignant ischemic stroke and traumatic brain injuries with refractory intracranial hypertension (ICH) by randomized controlled trials. Some reports advocate the potential of DC in the context of ICH due to meningoencephalitis (ME) with focal cerebral edema, but its interest remains controversial especially when there is diffuse cerebral edema. The aim of this study is to assess the benefits of DC in meningoencephalitis with malignant cerebral edema whether it is focal or diffuse. We report two cases successfully treated in our institute, plus we conducted a systematic literature review focused on cases of DC in ME in compliance with Prisma guidelines. The first patient is a 36-year-old woman who suffered from fulminant pneumococcal meningoencephalitis (ME) with refractory ICH following a transsphenoidal removal of pituitary adenoma. The second patient is a 20-year-old man suffering from neuro-meningeal cryptococcosis with refractory ICH. In both cases DC led to major clinical improvement with a GOS-E 8 at one year. These results are consistent with the literature review which reports a favorable outcome in 85% of cases. DC appears to be a promising therapeutic option in cases of ME with refractory ICH. Thus, reliable criteria will have to be defined to guide us in our practice in emergency cases where DC has not been part of the therapeutic arsenal yet.

Postoperative complications in cranial and spine neurosurgery: a prospective observational study.

BACKGROUND: Postoperative complications do occur in all neurosurgical departments, but the way they are defined, and their true incidence vary a lot. The aim of the present study was to objectively assess the morbidity and mortality related to all neurosurgical procedures performed in our department and provide insight on their main causes and identify key factors to reduce their incidence. METHODS: Data were retrieved from a prospectively maintained database regarding all patients undergoing a cranial or spinal neurosurgical procedure between November 2016 and April 2016 in the neurosurgical department in Timone University Hospital (APHM- Marseille). Patients undergoing a functional, pediatric, or interventional neuroradiological procedures were not included. RESULTS: The medical records of a total number of 963 patients were analyzed. A postoperative complication occurred in 208 patients (21.6%) including 115 (26.6%) in the cranial surgery group and 93 (17.5%) in the spinal surgery group. A complication occurred 1.5 more frequently in the cranial than in the spinal surgery group. Cranial surgery is 1.5 times more at risk of complications than spinal surgery (P=0.007). Preoperative comorbidities (ASA Score >3 to 4) were significantly associated with the occurrence of complications (P<0.001). In the cranial group, procedures performed in an emergency setting were 1.8 times more at risk of complications than scheduled surgeries (P<0.001). Conversely, in the spine group, scheduled surgeries were 1.4 times less at risk than emergency procedures (P=0.04). The main complication in both groups was found to be postoperative infection, with an incidence of 9.3% and 11.1% for cranial and spinal surgery respectively. Postoperative mortality reached 4.9% and 1.7% and the average length of stay was 12 and 11 days respectively. CONCLUSIONS: The incidence of complication in our series was found to be relatively high with predominantly infection as the main cause of postoperative complications. Reinforcing good practice measures at every step should help to significantly decrease our complication rate.

Evidence for a critical role of the left inferior parietal lobule and underlying white matter connectivity in proficient text reading.

OBJECTIVE: Reading proficiency is an important skill for personal and socio-professional daily life. Neurocognitive models underlie a dual-route organization for word reading, in which information is processed by both a dorsal phonological "assembled phonology route" and a ventral lexical-semantic "addressed phonology route." Because proficient reading should not be reduced to the ability to read words one after another, the current study was designed to shed light on the neural bases specifically underpinning text reading and the relative contributions of each route to this skill. METHODS: Twenty-two patients with left-sided, diffuse, low-grade glioma who underwent operations while awake were included. They were divided into 3 groups on the basis of tumor location: the inferior parietal lobule (IPL) group (n = 6), inferior temporal gyrus (Tinf) group (n = 6), and fronto-insular (control) group (n = 10). Spoken language and reading abilities were tested in all patients the day before surgery, during surgery, and 3 months after surgery, and cognitive functioning was evaluated before and 3 months after surgery. Text-reading scores obtained before and 3 months after surgery were compared within each group and between groups, correlations between reading scores and both spoken language and cognitive scores were calculated, postoperative cortical-subcortical resection location was estimated, and multiple regression analysis was conducted to examine the relationship between reading proficiency and lesion location. RESULTS: The results indicated that only the patients in the IPL group showed a significant decrease in text-reading scores between periods, which was not associated with lower scores in naming or verbal fluency; patients in the Tinf group showed a slight nonsignificant decrease in text reading between periods, which was associated with a clear decrease in naming and semantic verbal fluency; and patients in the control group showed no differences between preoperative and postoperative reading and spoken language scores. The results of the analysis of these behavioral results and anatomical data (resection cavities and white matter damage) suggest critical roles for the left inferior parietal lobule and underlying white matter connectivity, especially the posterior segment of the arcuate fasciculus, in proficient text reading. CONCLUSIONS: Text-reading proficiency may depend on not only the integrity of both processing routes but also their capacity for interaction, with critical roles for the left inferior parietal lobule and posterior arcuate fasciculus. These findings have fundamental as well as clinical implications.

Genomic analysis of paired IDHwt glioblastomas reveals recurrent alterations of MPDZ at relapse after radiotherapy and chemotherapy.

PURPOSE: We aimed to identify genomic drivers of glioblastoma inevitable recurrence. METHODS: Ten pairs of initial and recurrent frozen IDHwt glioblastoma samples were screened by CGH Array. Next Generation Sequencing (NGS) was then performed on an enriched cohort of 19 pairs. MPDZ alterations were analyzed using TCGA dataset. RESULTS: Nineteen IDHwt glioblastoma patients were included. Median age was 54.5 y/o (37.2-72.8). Using CGH array, unsupervised analysis aggregated the cohort by paired initial and recurrent tumors. Only 44% of CGH Array alterations were conserved at recurrence (amplifications: 55%; deletions: 30%). Two regions (including FPR1, 2 and 3) were lost at relapse: 19q13.33 and 19q13.41. MPDZ and 25 other genes were altered in ≥20% of recurrent tumors. NGS analysis of 29 candidate genes revealed 4 genes with pathogenic mutations: (FPR2, REL, TYRP1 and MPDZ). MPDZ (Multiple PDZ Domain Crumbs Cell Polarity Complex Component) was altered by two pathogenic mutations occurring at relapse. Using TCGA dataset we observed that a lower MPDZ mRNA expression was associated with IDHwt (p < 0.001) and grade IV (p < 0.001) gliomas. Finally, a low mRNA MPDZ expression was significantly correlated to poor overall survival in both IDHwt and IDH mutated gliomas, reinforcing the potential pejorative impact of MPDZ loss. CONCLUSION: Our results suggest that MPDZ is more frequently altered at relapse after radio-chemotherapy in glioblastoma IDHwt patients, suggesting that MPDZ impairment could contribute to the systematic resistance of these tumors opening new therapeutic perspectives.

Plasmatic MMP9 released from tumor-infiltrating neutrophils is predictive for bevacizumab efficacy in glioblastoma patients: an AVAglio ancillary study.

We previously identified matrix metalloproteinase 2 (MMP2) and MMP9 plasma levels as candidate biomarkers of bevacizumab activity in patients with recurrent glioblastoma. The aim of this study was to assess the predictive value of MMP2 and MMP9 in a randomized phase III trial in patients with newly diagnosed glioblastoma and to explore their tumor source. In this post hoc analysis of the AVAglio trial (AVAGlio/NCT00943826), plasma samples from 577 patients (bevacizumab, n = 283; placebo, n = 294) were analyzed for plasma MMP9 and MMP2 levels by enzyme-linked immunosorbent assay. A prospective local cohort of 38 patients with newly diagnosed glioblastoma was developed for analysis of tumor characteristics by magnetic resonance imaging and measurement of plasma and tumor levels of MMP9 and MMP2. In this AVAglio study, MMP9, but not MMP2, was correlated with bevacizumab efficacy. Patients with low MMP9 derived a significant 5.2-month overall survival (OS) benefit with bevacizumab (HR 0.51, 95% CI 0.34-0.76, p = 0.0009; median 13.6 vs. 18.8 months). In multivariate analysis, a significant interaction was seen between treatment and MMP9 (p = 0.03) for OS. In the local cohort, we showed that preoperative MMP9 plasma levels decreased after tumor resection and were correlated with tumor levels of MMP9 mRNA (p = 0.03). However, plasma MMP9 was not correlated with tumor size, invasive pattern, or angiogenesis. Using immunohistochemistry, we showed that MMP9 was expressed by inflammatory cells but not by tumor cells. After cell sorting, we showed that MMP9 was expressed by CD45+ immune cells. Finally, using flow cytometry, we showed that MMP9 was expressed by tumor-infiltrating neutrophils. In conclusion, circulating MMP9 is predictive of bevacizumab efficacy and is released by tumor-infiltrating neutrophils.

Long-term surgical oncological and functional outcome of large petroclival and cerebellopontine angle epidermoid cysts: a multicenter study.

Cranial nerve (CN) disorders are the foremost symptoms in cerebellopontine angle (CPA) and petroclival area (PCA) epidermoid cysts (EC).The aim of this work was to  assess the long-term surgical results on CN function and tumor control in these patients. We performed a retrospective cohort study about 56 consecutive patients operated on for a CPA or PCA EC between January 2001 and July 2019 in six participating French cranial base referral centers. Sixteen patients (29%) presented a PCA EC and 40 a CPA EC (71%). The median clinical and radiological follow-up was 46 months (range 0-409). Preoperative CN disorders were present in 84% of patients (n = 47), 72% of them experienced CN deficits improvement at the last follow-up consultation (n = 34): 60% of cochlear and vestibular deficits (n = 9/15 in both groups), 67% of trigeminal neuralgia (n = 10/15), 53% of trigeminal hypoesthesia (n = 8/15), 44% of lower cranial nerve disorders (n = 4/9), 38% of facial nerve deficits (n = 5/8) and 43% of oculomotor deficits (n = 3/7) improved or were cured after surgery. New postoperative CN deficits occurred in 48% of patients (n = 27). Most of them resolved at the last follow-up, except for cochlear deficits which improved in only 14% of cases (n = 1/7). Twenty-six patients (46%) showed evidence of tumor progression after a median duration of 63 months (range 7-210). The extent of resection, tumor location, and tumor size was not associated with the occurrence of new postoperative CN deficit or tumor progression. A functional nerve-sparing resection of posterior fossa EC is an effective strategy to optimize the results on preexisting CN deficits and reduce the risk of permanent de novo deficits.

Adult H3K27M mutated thalamic glioma patients display a better prognosis than unmutated patients.

BACKGROUND: Adult thalamic gliomas are a rare entity whose management is challenging for physicians. The aim of this study is to describe the characteristics and prognostic factors of thalamic gliomas in adult patients. METHODS: We retrospectively analyzed the clinical, neuro-radiological, histological, and molecular characteristics of all cases of adult thalamic glioma in our regional center. RESULTS: We included 38 adult patients. Median age at diagnosis was 56.5 years old (range, 24-80). Median KPS at diagnosis was 70%. Two-thirds of patients presented with tumor necrosis on MRI. Bithalamic lesions were present in four patients. The median volume of enhancement associated with lesions was relatively small (14 mm3). Two patients had undergone partial surgical resection. All other patients underwent biopsy. Median PFS was 7.1 months (95% CI [3.7-10.5]) and median OS was 15.6 months (95% CI [11.7-19.6]). Among 20 patients with available tumor samples for molecular analyses, only 4 (20%) presented with H3K27M mutation. Patients with H3K27M mutation had longer survival compared to those without. Finally, we identified a long-term survivor population characterized by a younger age, no cognitive impairment, low steroid dose treatment and the presence of H3K27M mutation. CONCLUSION: Thalamic adult glioma differs from bithalamic glioma in children with regards to its clinical, radiological and molecular profiles. Long-term survival is observed in young patients with limited symptoms and H3K27M mutation. A larger prospective cohort is needed to validate these findings.

Fully endoscopic endonasal approach for the treatment of intrasellar arachnoid cysts.

PURPOSE: To report our experience of endoscopic endonasal obliteration of symptomatic sellar arachnoid cyst (SAC). METHODS: From 2002 to 2019, we retrospectively reported the data of 17 cases of SAC operated in Timone University Hospital, Marseille, France. Preoperative clinical findings were collected including main symptoms, visual function and endocrinological assessment. Surgical procedure was homogeneous and consisted in endonasal fully endoscopic surgical obliteration of the cyst cavity with fat graft. Post-operative outcomes, complication and follow-up was reported. RESULTS: Visual disorders and/or headaches were the main symptoms. Our technique provided improvement for 83.3% of the patients suffering from visual disturbance and for 87.5% of those suffering from headaches. We reported 2 cases of cerebrospinal fluid (CSF) leakage (11.8%), but no meningitis. One case of definitive diabetes insipidus occurred and one case of postoperative syndrome of inappropriate antidiuretic hormone secretion was temporary. There was one case of recurrence reported. The mean follow-up was 39 months. CONCLUSION: Patients with symptomatic SAC can be treated successfully by endoscopic endonasal obliteration of the cyst. This simple technique offers true benefits for the patients without craniotomy, but the complication rate remains high especially with the risk of CSF leakage. Special attention to skull base opening and closing could reduce this risk.

Crossed brainstem syndrome revealing bleeding brainstem cavernous malformation: an illustrative case.

BACKGROUND: Since the nineteenth century, a great variety of crossed brainstem syndromes (CBS) have been described in the medical literature. A CBS typically combines ipsilateral cranial nerves deficits to contralateral long tracts involvement such as hemiparesis or hemianesthesia. Classical CBS seem in fact not to be so clear-cut entities with up to 20% of patients showing different or unnamed combinations of crossed symptoms. In terms of etiologies, acute brainstem infarction predominates but CBS secondary to hemorrhage, neoplasm, abscess, and demyelination have been described. The aim of this study was to assess the proportion of CBS caused by a bleeding episode arising from a brainstem cavernous malformation (BCM) reported in the literature. CASE PRESENTATION: We present the case of a typical Foville syndrome in a 65-year-old man that was caused by a pontine BCM with extralesional bleeding. Following the first bleeding episode, a conservative management was decided but the patient had eventually to be operated on soon after the second bleeding event. DISCUSSION: A literature review was conducted focusing on the five most common CBS (Benedikt, Weber, Foville, Millard-Gubler, Wallenberg) on Medline database from inception to 2020. According to the literature, hemorrhagic BCM account for approximately 7 % of CBS. Microsurgical excision may be indicated after the second bleeding episode but needs to be carefully weighted up against the risks of the surgical procedure and openly discussed with the patient. CONCLUSIONS: In the setting of a CBS, neuroimaging work-up may not infrequently reveal a BCM requiring complex multidisciplinary team management including neurosurgical advice.

Ipsilateral vs controlateral approach in tuberculum sellae meningiomas surgery: a retrospective comparative study.

Most of tuberculum sellae meningiomas (TSM) show asymmetric growth. They are usually resected through ipsilateral approaches. The access of the inferior-medial side of the ipsilateral optic nerve might be challenging, which result in increased manipulation of the compromised optic nerve. The contralateral approach has been described to avoid these technical difficulties. Assessing the long-term visual and olfactory outcome, as well as recurrence rate in patients operated for TSM through ipsilateral or contralateral approaches. Single center retrospective cohort study about 94 patients operated on between March 2000 and April 2018. Seventy percent of the preoperative visual acuity loss totally resolved (44%) or showed varying degrees of improvement (26%) after surgery. Seventy-two percent of the preoperative visual field defects evolved favorably (44% recovery, 28% improvement). Eight patients showed aggravated visual disturbances (9%). A contralateral approach seemed to be predictive of visual field defects improvement after surgery (OR = 0.4), with borderline significant results (p = .08). There was a higher rate of postoperative olfactory nerve impairment after a contralateral approach (37% vs 17%, p = .03). Total removal of the tumor fragment entering the optic canal was accomplished in 96% in the contralateral vs 75% in the ipsilateral group (p = .04). The 2-, 5-, and 7-year tumor progression-free survival were 100% in the Simpson grade 2 group, and 85% (n = 17), 74% (n = 11), and 67% (n = 5) in the Simpson grade 4 group, respectively (p = .00). Resection of tuberculum sellae meningiomas through a contralateral approach seems to provide better visual outcome and tumor control at the cost of increased olfactory nerve disorders.

Transfalcine Approach for the Resection of a Bilateral Falx Meningioma: Technical Nuances and Review of Literature.

The tendency to reduce invasive surgeries is gaining more adepts, and the primary goal in meningioma surgery is the maximal safe resection. Falx meningioma is common location for intracranial meningioma, and according to their deep localization, falx meningioma represents a neurosurgical challenge. The objective of the study is to report the feasibility of a transfalcine nontumor dominant side approach for a bilateral falx meningioma. We report a technical note about the surgical approach of a 44-year-old female suffering from an evolutive meningioma of the middle third of the falx. According to the venous drainage anatomy, and the tumor conformation, a contralateral transfalcine approach was done. We described with details this surgical approach, and a reflection about transfalcine approach is proposed, which is a variant of the interhemispheric approach. It permits a good exposure of the medial surface of the contralateral hemisphere thanks to a falx incision. Moreover, a literature review is proposed about 278 articles with a special emphasis on transfalcine approach in meningioma surgery. We report an original minimal invasive approach for an intracranial meningioma, with a complete resection (Simpson I) without any technical complication. This contralateral transfalcine approach brings new technical nuances for the resection of falx or midline intracranial tumors.

SCENITH: A Flow Cytometry-Based Method to Functionally Profile Energy Metabolism with Single-Cell Resolution.

Energetic metabolism reprogramming is critical for cancer and immune responses. Current methods to functionally profile the global metabolic capacities and dependencies of cells are performed in bulk. We designed a simple method for complex metabolic profiling called SCENITH, for single-cell energetic metabolism by profiling translation inhibition. SCENITH allows for the study of metabolic responses in multiple cell types in parallel by flow cytometry. SCENITH is designed to perform metabolic studies ex vivo, particularly for rare cells in whole blood samples, avoiding metabolic biases introduced by culture media. We analyzed myeloid cells in solid tumors from patients and identified variable metabolic profiles, in ways that are not linked to their lineage or their activation phenotype. SCENITH's ability to reveal global metabolic functions and determine complex and linked immune-phenotypes in rare cell subpopulations will contribute to the information needed for evaluating therapeutic responses or patient stratification.

Effective posterior extension of callosotomy by gamma knife surgery.

Drop attacks are the most responsive seizure type to open callosotomy, however, surgical complications can worsen the prognosis. Various less invasive techniques have been explored in an effort to minimize the risk. We present a patient who suffered from life-threatening traumatizing drop attacks in whom previous open anterior callosotomy and vagal nerve stimulation were unsatisfactory. Following posterior extension of the callosotomy by non-invasive gamma knife surgery, the rate of drop attacks declined from 30 a day to once a day, or every few days over a four-month period, without complications. Open callosotomy is an invasive and high risk treatment option for patients with drop attacks. The procedure has a potential for complications and neurological consequences that can worsen the functional capacity of a patient who already suffers with disability. Recently, in an attempt to decrease the invasiveness associated with this technique, additional technical refinements and less invasive procedures have been explored in a few studies. Here, we report a case of refractory epilepsy with life-threatening traumatizing DA, in which the patient was treated by radiosurgical posterior callosotomy after unsatisfactory open anterior callosotomy and vagal nerve stimulation.

Rational use of systematic postoperative CT scans after neurosurgical craniotomy.

BACKGROUND: The aim of this retrospective study was to evaluate the relevance of a systematic postoperative CT scan after neurosurgical craniotomy and to identify predictive factors of complications. METHODS: This retrospective analysis included all the patients at our institution who benefited from a cerebral postoperative CT scan within 24 hours post-craniotomy. Patient characteristics and neuroimaging abnormalities were recorded. Predictive factors were identified using a recursive partitioning analysis. RESULTS: A total of 633 patients were included. Of these, 17.9% of patients suffered from postoperative complications and 7.4% of them required a new surgery. The decision for reoperation was based on the neurological deterioration and the CT scan, but never on the CT scan alone. The mortality rate was 1.1%. The risk to be reoperated was correlated to the occurrence of a new postoperative neurological deficit (P<0.001, HR=4.60) and in situ hemorrhage (P<0.001, HR=4.19). The risk of postoperative hematoma was correlated to the supratentorial location versus infratentorial (P=0.027, HR=2.50). With clinical factors, such as location and etiology of the lesion, schedule type of surgery, and the age of patients, we proposed six classes with the risk to present with hemorrhage or midline shift on postoperative CT scans. CONCLUSIONS: The post-craniotomy CT scan did not impact patient management as an independent decisional tool. We identified several variables associated with the risk of clinical modification that can impact the decision to reoperate and allow establishment of a risk score. This score could be an interesting tool in order to reduce the systematic use of CT scans in the post-surgical period but has to be validated in a prospective study.