Enhanced resection of primary high-grade gliomas using a combination of intraoperative magnetic resonance imaging and intraoperative fluorescence (5-aminolevulinic acid): A single-centre experience.

BACKGROUND: The extent of resection (EOR) of a tumor is a proven prognostic factor in patients undergoing surgery for suspected high grade glioma. A few recent publications have shown the importance of intraoperative magnetic resonance imaging (iMRI) with 5-aminolevulinic acid (5-ALA) fluorescence-guidance in order to maximally increase the EOR. AIM: The objective of our study was to calculate the effect on survival of patients with high grade gliomas of resection using both iMRI and 5-ALA fluorescence-guidance as intraoperative adjuncts. METHODS: Thirty-seven patients with gadolinum-enhancing high gliomas on preoperative MRI undergoing surgical excision were included in a prospective study. Surgeries began under white-light conditions. Intermittently, a blue light filter was switched on to search for remaining tumor tissue not visible to the naked eye. When gross total resection (GTR) was thought to have been achieved, iMRI was done to check for any contrast-enhancing part left behind. Surgery was concluded or resumed based on the iMRI findings. Histopathological examination of the tumor tissue was done. All patients underwent immediate postoperative MRI at the end of the surgery to calculate the EOR. RESULTS: Our results showed that out of the total of 37 patients, 17 patients died during the follow up period and 11 patients were still alive. The mean survival was 587.1 days and median survival was 491 days with a range of 342 to 943 days. When we compared these figures with the average survival in patients with a high grade glioma, i.e., 9 to 14 months, it showed that both the above mentioned modalities were very helpful in increasing the EOR, and in turn, the overall survival. CONCLUSIONS: The use of iMRI as well as fluorescence-guidance are appropriate methods to improve the extent of resection in surgery of contrast-enhancing gliomas. Best results can be achieved by the complementary use of both modalities.

Survival trends in glioma: Experience at a tertiary care centre.

BACKGROUND: Even after decades of research in the field of gliomas, the overall prognosis is still quite dismal. Several factors have been proposed that affect the outcome and survival length of patients with a glioma. Here, we present a series of 471 patients, who underwent surgical resection of their glioma at a tertiary level neurosurgical centre. MATERIALS AND METHODS: We noted retrospective data of patients' age, histological tumor grade, and whether or not intraoperative magnetic resonance imaging (MRI) was used, and assessed the survival length of these patients from the day of surgery. RESULTS: The overall survival in our series was approximately 14 months. Predictably, those with age less than 40 years and those with Karnofsky performance score (KPS) ≥80 had longer survival than those with a higher age and KPS <80; those with World Health Organisation (WHO) grade IV lesions had the shortest survival length compared to all the other grades. However, while comparing survival among other tumor grades, we did not find significant difference. Further, use of intraoperative MRI did not offer any statistically significant difference in survival. CONCLUSION: In addition to the conventional prognostic factors we need more definate ways to accurately predict survival in patients harbouring a glioma. Probably, assessing molecular characteristics of the individual tumors, such as presence of isocitrate dehydrogenase (IDH) mutation versus wild-type IDH, would help us in predicting survival more accurately.

Effects of butorphanol and fentanyl on cerebral pressures and cardiovascular hemodynamics during tunneling phase for ventriculoperitoneal shunt insertion.

PURPOSE: Subcutaneous tunneling for ventriculoperitoneal shunt insertion is the most painful step of this surgery. It is associated with intense hemodynamic response, may influence the intracranial pressure, and thus may worsen the existing intracranial pathology. The purpose of this report is to evaluate the commonly used opioid fentanyl, along with butorphanol, an agonist-antagonist compound. METHODS: Twenty adult patients undergoing ventriculoperitoneal shunt surgery were induced with fentanyl 2-mcg.kg(-1) and thiopentone 4-5 mg.kg(-1). Intubation followed the administration of rocuronium 1 mg.kg(-1). All patients were put on mechanical ventilation to maintain end-tidal carbon dioxide levels of 32 +/- 2 mmHg. Anesthesia was maintained with isoflurane in N2O and O2 (MAC 1.0 +/- 0.2). Routine monitoring, arterial blood pressure and intracranial pressures were measured. Three minutes prior to the tunneling phase, patients received either fentanyl 1 mcg.kg(-1) or butorphanol 1 mg in a randomized manner. Thereafter hemodynamic and intracranial pressure changes were noted during tunneling and each minute in the post-tunneling period for 5 minutes. The duration of the tunneling phase was also noted. Data were presented as number (proportion) or mean +/- SD/median (range) as appropriate. Statistical analysis was done using Wilkoxon ranksum test and the repeated measures of ANOVA. The value of p < 0.05 was considered significant. RESULTS: A significant rise in the intracranial pressure and cerebral perfusion pressure along with the hemodynamic parameters was noted during the tunneling phase in both groups. The changes were of longer clinical duration in the butorphanol group. CONCLUSION: Butorphanol must be used with caution in neurosurgical patients. The ventricular end of the shunt catheter should preferably be put before the tunneling phase to avoid rise in intracranial pressure.