SURG-07. ERAS IN NEURO-ONCOLOGY

BACKGROUND We performed a retrospective study assesses the efficacy and safety of a protocol for the enhanced clinical recovery of neuro-oncology patients undergoing surgery for supratentorial gliomas and metastasis. The protocol developed and applied to the Ca'Foncello Hospital in Treviso starts from the recommendations on the subject that the medical literature reported up to December 2018. Briefly, three main sections:1) preoperative functional status evaluation, preoperative oral carbohydrate loading; 2) minimally invasive surgery, scalp incision anesthesia, nonopioid analgesia; 3) early urinary-catheter removal, standing and feeding resumption within 3-4 hours from surgery. METHODS We collected and analyzed data on 28 patients operated on ERAS protocol and compared them to a control group (22 patients). The main clinical variables are: Charlson comorbidity index; times urinary-catether removal, adherence ambulation, taking food by mouth; hospital long of stay (LOS). We also collected studies from 2016 to 2020 describing data about ERAS and craniotomy and we pooled these into a meta-analysis. RESULTS Times urinary-catheter removal (3.1 vs 25 hours.), adherence to ambulation (4 vs 25 hours) and taking food by mouth (5.25 vs 23.72 hours) were significantly (p< 0.001) reduced in the ERAS group. Median hospital LOS was 2.85 days in the ERAS group and 4.77 days in the control group (p< 0.001). Our results overlapped those of the literature; the same trend was highlighted by our meta-analysis, with postoperative pain rates and hospital LOS significantly lower in ERAS patients (7.9 vs. 2.9 days, p < 0.001). A further important finding was that elderly patients (≥ 65 years) got the same outcomes as younger ones. CONCLUSIONS Our protocol for ERAS in neuro-oncology appears to have significant benefits over conventional management: it may improve patient outcomes, accelerate functional recovery, decrease length of stay, and enable patients to begin adjuvant chemotherapy and/or radiation in a more expeditious manner.

Time to Focus on the Scalp Incision Design for Chronic Subdural Hematoma: Technical Note and Experience

Objective: The scalp incision design in surgery for chronic subdural hematoma (CSDH) is important but is given little attention or is neglected by most neurosurgeons currently. Faulty scalp incision design will affect the ease of surgery, wound healing, and patients’ satisfaction. This study introduces the technique and experience used in our center regarding scalp incision with an adjustable question mark-shaped for CSDH procedures.Methods: A retrospective analysis was conducted of the medical records of patients with CSDH, who underwent surgical treatment that incorporated this incision design from September 2017 through December 2020. The features of concern were intraoperative scalp incision extension and postoperative wound healing. Those patients were followed for occurrences of scalp dysfunction, and their satisfaction with this design.Results: Thirty-seven patients were analyzed. For 2 patients, operative procedures were changed and scalp incisions were extended. All patients had good incision healing without complications. The outpatient or telephone follow-up 6 months after surgery revealed that 36 patients were satisfied with the scalp incision design, one patient experienced widening of incision scar. Six patients (5 women and 1 man) reported cosmetic dissatisfaction, and 7 patients (six women and one man) had mild scalp dysfunction, in daily life.Conclusion: The adjustable question mark-shaped incision used for CSDHs is a fluent curve, with a large angle, and allows a flexible extension. It ensures ease of the operative procedure, good wound healing and meeting patients’ aesthetic needs. The protocol is simple, practical, and worthy of reference by neurosurgeons, especially in primary hospitals.

Diamond-Shaped Mini-Craniotomy: A New Concept in Neurosurgery

Background We describe, step by step, a modified, less invasive, diamond-shaped mini-craniotomy that optimizes dural opening and can be performed in elderly patients affected by acute subdural or intracerebral hematomas, in therapy with antiplatelets or anticoagulants. Methods We retrospectively analyzed the clinical records of 67 patients (mean age of 78.5 years) treated in our institution, during a period of 10 years, with this novel diamond-shaped craniotomy. Seventeen patients were treated for intracerebral hemorrhage and 50 patients for acute subdural hematomas. All the patients were in therapy with antiplatelets or anticoagulants. Results Approach-related complications were not detected. Ten of 67 patients (14.9%) presented temporal muscle atrophy; there was no scar deformity, paresthesia, hyperalgesia, or ramus frontalis palsy around the scalp incision. Thirty-day mortality was 22%. The mean follow-up was 1.3 years. One-month postoperative brain computed tomography scans showed a satisfactory hematoma evacuation in 57 of 67 patients (85%). Conclusions The diamond-shaped mini-craniotomy for acute subdural and intracerebral hematomas is safe and effective, and it should be considered as an alternative to traditional approaches, particularly in elderly patients.

The Retroauricular Incision as an Effective and Safe Alternative Incision for Decompressive Hemicraniectomy

BACKGROUND The reverse question mark (RQM) incision has been traditionally utilized to perform decompressive hemicraniectomies (DHC) to relieve refractory intracranial hypertension. Alternative incisions have been proposed in the literature but have not been compared directly. OBJECTIVE To present the retroauricular (RA) incision as an alternative incision that we hypothesize will increase calvarium exposure to maximize the removal of the hemicranium and will decrease wound-related complications compared to the RQM incision. METHODS This study is a retrospective review of all DHCs performed at our institution over a span of 34 mo, stratified based on the type of scalp incision. The surface areas of the cranial defects were calculated, normalizing to their respective skull diameters. For those patients surviving beyond 1 wk, complications were examined from both cohorts. RESULTS A total of 63 patients in the RQM group and 43 patients in the RA group were included. The average surface area for the RA and RQM incisions was 117.0 and 107.8 cm2 (P = .0009), respectively. The ratio of average defect size to skull size for RA incision was 0.81 compared to 0.77 for the RQM group (P = .0163). Of those who survived beyond 1 wk, the absolute risk for surgical site complications was 14.0% and 8.3% for RQM and RA group (P = .5201), respectively. CONCLUSION The RA incision provides a safe and effective alternative incision to the traditional RQM incision used for DHC. This incision affords a potentially larger craniectomy while mitigating postoperative wound complications.

A novel temporary cranial fixation device for awake cranial surgery: Technical report of 14 cases

Background: Awake craniotomy has become the gold standard in various cranial procedures. As part of the awake technique, three-point pin fixation of the patient’s head is important. One of the issues we encountered is the problem of matching the scalp infiltration site with the final pin position. To overcome this problem, we developed a flat plunger type fixator that adapts to the Mayfield holder. Methods: Our fixator has a 2.5 cm metallic shaft that articulates in a ball and socket joint to allow its concave surfaces to adapt to the patient’s scalp. After placing the patient in the desired position, the head is fixed with the three plungers, circles are drawn around each plunger, and they are then removed for the circles to be infiltrated with bupivacaine. Standard fixation pins are then placed in the Mayfield holder and aimed at the center of the circles. Results: So far, we have operated on 14 patients with this technique. No patient experienced pain during temporary fixation, and the drawn circles ensured that there were no mismatches between the local anesthetic and pin locations. The technique was particularly useful on hairy scalps, where infiltration sites were hidden. We also used only 22.5 mg bupivacaine at the pin sites, freeing a dose for the field block around the scalp incision. Conclusion: The temporary plunger type fixator provided a simple method to economize on local anesthetic use, check the patient’s head position before final fixation, and ensure that the Mayfield pins matched with the anesthetized area.

Moyamoya Disease in Infancy: Application of a Novel Indirect Revascularization Technique for Bihemispheric Cortical Synangiosis

INTRODUCTION Moyamoya disease (MMD) is a rare progressive cerebral arteriopathy characterized by nonatherosclerotic steno-occlusive lesions of the Circle of Willis. Presentation in infancy is rare and usually presents with ischemic stroke. We present a 7-mo old female with bilateral MMD who presented for indirect revascularization after 2 successive strokes in multiple vascular territories. METHODS We demonstrate a novel indirect revascularization technique in infant MMD whereby the patient's multifocal ischemic burden and STA caliber precluded arterial and myosynangiosis. We instead utilized bihemispheric pericranium for revascularization of bilateral oligemic cerebrum. Through a bicoronal scalp incision and inverted T-shaped pericranial incision, large anteriorly-based pericranial flaps were applied to the exposed pial surface using bilateral hemicraniotomies. Synangiosis extended from the frontal pole into parieto-occipital territories. We additionally performed a literature search on bypass approaches used for infant MMD. RESULTS A total of 10 infant MMD cases have been reported in the literature. Our case represents the only use of a pericranial graft in an infant without a combined approach. Pial synangiosis, EDAS, and conservative management represent techniques described in this population. Two case series utilized pericranial flaps with EDAS, however, no infants were included nor did revascularization extend beyond traditional margins. Our patient remains stroke and seizure-free for at least 16-months. She is ambulating independently and meeting her pediatric milestones. CONCLUSION Indirect revascularization is favored in pediatric MMD with approaches primarily utilizing native vessel donor grafts. Bilateral revascularization is performed in a delayed, sequential fashion if indicated. Further, collateralization is limited by the anatomical graft parameters, making hemispheric pathology difficult to comprehensively treat with these approaches. Our case demonstrates the safety and efficacy of utilizing a large bihemispheric pericranial flap on its native pedicle with bilateral hemicraniotomies for revascularization of multiple cerebrovascular territories in severe infant MMD. Our technique also allows for preservation of critical native vessels should the need for reoperation arise.

Hemodynamic and Bispectral Changes During Pin Insertion in Craniotomy – Effect of Locally Infiltrated Bupivacaine

Introduction Cranial pins insertion is a method for head stabilization and together with the scalp incision is one of the biggest noxious stimulus associated with arousal and rapid increase of the blood pressure leading to pathological increase of the intracranial pressure. The aim of this investigation is to study the superiority of the locally infiltrated anesthetic bupivacaine just before the skull pin insertion and the scalp incision in craniotomy under general anesthesia. Methods In the study thirty patients of both genders aged 24-72 years were included. They were categorized as ASA 1 and 2 and divided into two group of 15 patients each, group B (bupivacaine) and group S (saline). We recorded the bispectral (BIS) index, the mean arterial pressure (MAP) and the pulse rate (PR) in five time intervals: t 0-2 min before pin insertion; t 1-2 min after pin insertion; t 2-5 min after; t 3-10 min after and t 4-15 min after. Results Significant difference p<0.05 was achieved in group S for all three followed parameters: blood pressure, heart rate and bispectral index. The difference is present in all four time intervals compared to the initial one before the pin insertion. With further analysis it was demonstrated that the investigated BIS index participates the most in the overall significance in group F. Conclusion The scalp infiltration with local anesthetic bupivacaine results with stable hemodynamic parameters and stable intracranial pressure during the painful procedures as craniotomy.