Research Article: Early prediction of neurological outcome after barbiturate coma therapy in patients undergoing brain tumor surgery

Date Published: April 17, 2019

Publisher: Public Library of Science

Author(s): Jeong-Am Ryu, Wonkyung Jung, Yoo Jin Jung, Do Yeon Kwon, Kina Kang, Hyeok Choi, Doo-Sik Kong, Ho Jun Seol, Jung-Il Lee, Jonathan H. Sherman.

http://doi.org/10.1371/journal.pone.0215280

Abstract

After a difficult brain tumor surgery, refractory intracranial hypertension (RICH) may occur due to residual tumor or post-operative complications such as hemorrhage, infarction, and aggravated brain edema. We investigated which predictors are associated with prognosis when using barbiturate coma therapy (BCT) as a second-tier therapy to control RICH after brain tumor surgery. The study included adult patients who underwent BCT after brain tumor surgery between January 2010 and December 2016. The primary outcome was neurological status upon hospital discharge, which was assessed using the Glasgow Outcome Scale (GOS). In the study period, 4,296 patients underwent brain tumor surgery in total. Of these patients, BCT was performed in 73 patients (1.7%). Among these 73 patients, 56 (76.7%) survived to discharge and 25 (34.2%) showed favorable neurological outcomes (GOS scores of 4 and 5). Invasive monitoring of intracranial pressure (ICP) was performed in 60 (82.2%) patients, and revealed that the maximal ICP within 6 h after BCT was significantly lower in patients with favorable neurological outcome as well as in survivors (p = 0.008 and p = 0.028, respectively). Uncontrolled RICH (ICP ≥ 22 mm Hg within 6 h of BCT) was an important predictor of mortality after BCT (adjusted hazard ratio 12.91, 95% confidence interval [CI] 2.788–59.749), and in particular, ICP ≥ 15 mm Hg within 6 h of BCT was associated with poor neurological outcome (adjusted odds ratio 9.36, 95% CI 1.664–52.614). Therefore, early-controlled ICP after BCT was associated with clinical prognosis. There were no significant differences in the complications associated with BCT between the two neurological outcome groups. No BCT-induced death was observed. The active and timely control of RICH may be beneficial for clinical outcomes in patients with RICH after brain tumor surgery.

Partial Text

Increased intracranial pressure (ICP) generally occurs in patients with brain tumor because of tumor-associated brain edema, tumor per se, or tumor bleeding [1]. Peritumoral edema is a leading cause of morbidity and mortality in patients with brain tumors [2]. Uncontrolled cerebral edema may result in refractory intracranial hypertension (RICH), and also leads to severe neurological deficits and potentially fatal herniation [1,3]. Therefore, treatment for RICH entails medical or surgical interventions. Even when brain tumors are surgically resected, patients should be monitored vigilantly in the intensive care unit, because aggravated brain swelling after tumor resection is not uncommon [1]. In addition, RICH may be caused by residual tumor or post-operative complications such as hemorrhage, infarction, and aggravated brain edema. Therefore, the management of RICH and brain edema are crucial issues in patients undergoing brain tumor surgery. Barbiturate coma therapy (BCT) is currently used as a second-tier therapy to control RICH, and it has been shown to be associated with potential benefits in traumatic brain injury (TBI) or malignant infarction [2,4,5]. Therefore, BCT may be helpful for controlling RICH after brain tumor surgery. However, there have been limited reports on BCT after brain tumor surgery. In addition, it is unknown which factors are important for prognosis if BCT is performed after tumor surgery. The objective of this study was to investigate which predictors are associated with clinical outcomes when BCT is used as a second-tier therapy to control RICH after brain tumor surgery.

In the present study, we evaluated which predictors are associated with clinical outcomes when BCT is used as a second-tier therapy to control RICH after brain tumor surgery. The major findings of this study were as follows: 1) ICPs after BCT were significantly decreased as compared with ICPs before BCT in patients with RICH. 2) The survival rate of patients who underwent BCT after brain tumor surgery was relatively good. After tumor surgery, three-fourths of patients who underwent BCT survived. Furthermore, half of all survivors showed favorable neurological outcome. 3) The early control of ICP after BCT was associated with good clinical prognosis. Controlled RICH (ICP < 22 mm Hg) was an important predictor of survival after BCT, and ICP < 15 mm Hg within 6 h of BCT was particularly associated with favorable neurological outcome. 4) A low incidence of fatal complications after BCT was observed. In addition, there were no significant differences in BCT-induced complications between the two groups with different neurological outcomes. In this study, we found that BCT is a treatment modality with acceptable safety and may thus be a reasonable choice as a last resort to control RICH in patients after brain tumor surgery. The active and timely control of RICH may be beneficial for patients’ outcomes.   Source: http://doi.org/10.1371/journal.pone.0215280

 

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