Hydrocephalus Shunting in Supratentorial Glioblastoma: Functional Outcomes and Management

Ependymal invasion in High-Grade Glioma. Impact on surgical, functional outcomes, and survival rates. Experience in a Latin-American center

OBJECTIVE

Analyze the impact of ependymal invasion in high-grade gliomas (HGG) on surgical, functional outcomes, and survival rates.

MATERIALS AND METHODS

Retrospective, single-center, analytical study of a cohort of adult patients who underwent surgery for HGG at an Argentine center between 2013 and 2023. Patients with Grade IV supratentorial gliomas, with at least 3 months of follow-up and pre-/postoperative volumetric MRI were evaluated for the presence of ependymal invasion and its impact on prognosis.

RESULTS

Out of 591 patients undergoing HGG surgery, 263 met the inclusion criteria, with a mean follow-up of 24.8 months (range 5-141). The mean age was 58.5 years with a predominance of male patients (63%). Glioblastomas accounted for 80% of cases, with frontal (28.5%) and temporal (21.6%) lobes as the most frequent tumor locations. Mean preoperative volume was 27.2 cm³, and the mean KPS at surgery was 82. Ependymal invasion was identified in 83 patients (31.5%) and was associated with significantly worse progression-free survival (PFS) and overall survival (OS). These patients had an increased risk of and earlier onset of multicentricity and leptomeningeal spread. Ependymal invasion also negatively impacted the extent of resection, increasing subtotal resections, and it was also associated with a higher risk of complications such as hydrocephalus and CSF leaks.

CONCLUSION

Ependymal invasion significantly and independently impacts prognosis of patients with HGG. These findings underscore the importance of recognizing ependymal invasion as a key prognostic factor to guide the management and treatment strategies for affected patients.

Ventricular opening in High-Grade Glioma surgery. Impact on surgical, functional outcomes, and survival rates. Experience in a Latin-American center

OBJECTIVE

Analyze the impact of ventricular opening during surgery for High-Grade Glioma (HGG) on surgical, functional outcomes, and survival rates.

MATERIALS AND METHODS

Retrospective, single-center, analytical study of a cohort of patients who underwent surgery for HGG in an Argentine center between 2013 and 2023. Patients with Grade IV supratentorial gliomas, 3 months of minimum follow-up, studied with pre and postoperative volumetric MRI were included. Subsequently, ventricular opening during surgery and its influence on prognosis were analyzed.

RESULTS

A total 263 patients met the inclusion criteria, with a mean follow-up of 24.8 months. Mean age was 58.5 years with a predominance of male patients (63 %) and preoperative mean KPS was 80 (range 40-100). Eighty-eight percent of tumors corresponded to Glioblastomas and the mean preoperative volume was 27.2 cm3. Ventricular opening was identified in 80 patients (30.4 %) in correlation with the number of patients with ependymal invasion. This factor was associated with worse survival rates and risk of multicentricity in univariate analysis. However, when adjusted for covariables, there was a trend towards higher survival and slight increase in resection rates. Opening the ventricles was associated with a higher risk of leptomeningeal spread and complications such as hydrocephalus and CSF leak.

CONCLUSION

Ventricular opening during surgery for HGG did not show to represent an independent prognostic factor for survival rates. It could be considered when ependymal invasion is observed in favor of maximizing EOR. Conversely, it should be avoided as it carries a higher risk for complications and tumor spread.

Risk factors for cerebrospinal fluid shunt infection in pediatrics: A meta-analysis

Background

Placement of cerebrospinal fluid (CSF) shunt for diversion remains a primary treatment for patients with hydrocephalus despite its surgical complications, including shunt infection, that remain high and become a medical and social problem. The meta-analysis was conducted to investigate risk factors of shunt infection in pediatrics.

Methods

Literature was searched on PubMed, Scopus, and the Cochrane Library. The methodology used for this investigation was preferred reporting items for systematic reviews and meta-analysis.

Results

This meta-analysis included five publications. The only significant results were found in ages <6 months with relative risk (RR) of 33.06 (95% confidence interval [CI] 9.27-117,99; P < 0.01), Caucasian race with RR of 15.24 (95% CI 6.77-34.34), and African-American race with RR of 2.37 (95% CI 2.07-2.70). The other results provided were not significant, such as intraventricular hemorrhage (IVH) of prematurity as the etiology of hydrocephalus with RR of 4.71 (95% CI 1.07-20.82), presence of gastrostomy during shunt insertion with RR of 3.80 (95% CI 0.91-15.88), and comorbidity of respiratory diseases with RR of 0.22 (95% CI 0.11-0.43).

Conclusion

Younger age during the shunt placement procedure, Caucasian race, and African-American race have a significantly higher risk of CSF shunt infection. The previously reported higher risk of shunt infection in cohort studies, such as IVH of prematurity and the presence of gastrostomy, were not significant in this study. Primary studies regarding shunt infection are advocated to be performed in a more extensive population with further risk factors included in the analysis.

Communicating hydrocephalus in glioblastoma presenting as chronic hydrocephalus: systematic review and meta-analysis

OBJECTIVE

Communicating hydrocephalus (CH) is an uncommon complication that can affect patients with glioblastoma (GBM). Due to its clinical and radiological findings, it presents as a chronic hydrocephalus. The mechanisms underlying its occurrence and impact on the prognosis of the disease are poorly known, but some studies have suggested that shunting can have a positive impact on the quality of life of these patients.

METHODS

The authors performed a systematic literature review and meta-analysis to identify the possible risk factors that could help to identify CH cases in glioblastoma, using the MEDLINE/PubMed and Cochrane Database of Systematic Reviews databases. The Joanna Briggs Institute critical appraisal tool was used to assess the risk of bias.

RESULTS

Our search yielded 273 studies, but only 9 records were included in the final quantitative analysis. CH in glioblastoma patients was found to be very uncommon (proportion 0.04 out of 1; range 0.03-0.05, p < 0.01, CI:95%) and its occurrence was associated with a previous ventricular opening (0.85 out of 1; range 0.66-0.94, p < 0.01, CI:95%).

CONCLUSION

CH in glioblastoma should be suspected in patients with GBM who have undergone accidental ventricular opening during tumor resection and presenting with chronic hydrocephalus symptoms.

Efficacy and Safety of Carmustine Wafer Implantation After Ventricular Opening in Glioblastomas, Isocitrate Dehydrogenase-Wildtype, in Adults

BACKGROUND AND OBJECTIVES

We assessed the impact of ventricular opening on postoperative complications and survival of carmustine wafer implantation during surgery of newly diagnosed supratentorial glioblastomas, isocitrate dehydrogenase (IDH)-wildtype in adults.

METHODS

We performed an observational, retrospective, single-center cohort study at a tertiary surgical neuro-oncological center between January 2006 and December 2021.

RESULTS

One hundred ninety-four patients who benefited from a first-line surgical resection with carmustine wafer implantation were included. Seventy patients (36.1%) had a ventricular opening. We showed that ventricular opening (1) did not increase overall postoperative complication rates (P = .201); (2) did not worsen the early postoperative Karnofsky Performance Status score (P = .068); (3) did not increase the time interval from surgery to adjuvant oncological treatment (P = .458); (4) did not affect the completion of the standard radiochemotherapy protocol (P = .164); (5) did not affect progression-free survival (P = .059); and (6) did not affect overall survival (P = .142).

CONCLUSION

In this study, ventricular opening during first-line surgical resection did not affect the survival and postoperative complications after use of carmustine wafer implantation in adult patients with a newly diagnosed supratentorial glioblastoma, IDH-wildtype. This warrants a prospective and multicentric study to clearly assess the impact of the ventricular opening after carmustine wafer implantation in glioblastoma, IDH-wildtype.

Clinical course of ventriculoperitoneal shunting for hydrocephalus following glioblastoma surgery: a systematic review and meta-analysis

BACKGROUND

Surgical resection of glioblastoma (GBM) remains a cornerstone in the current treatment paradigm. The postoperative evolution of hydrocephalus necessitating ventriculoperitoneal shunting (VPS) continues to be defined. Correspondingly the objective of this study was to aggregate pertinent metadata to better define the clinical course of VPS for hydrocephalus following glioblastoma surgery in light of contemporary management.

METHODS

Searches of multiple electronic databases from inception to November 2023 were conducted following PRISMA guidelines. Articles were screened against pre-specified criteria. Outcomes were pooled by random-effects meta-analyses where possible.

RESULTS

A total of 12 cohort studies satisfied all selection criteria, describing a total of 6,098 glioblastoma patients after surgery with a total of 261 (4%) of patients requiring postoperative VPS for hydrocephalus. Meta-analysis demonstrated the estimated pooled rate of symptomatic improvement following VPS was 78% (95% CI 66-88), and the estimated pooled rate of VPS revision was 24% (95% CI 16-33). Pooled time from index glioblastoma surgery to VPS surgery was 4.1 months (95% CI 2.8-5.3), and pooled survival time for index VPS surgery was 7.3 months (95% CI 5.4-9.4). Certainty of these outcomes were limited by the heterogenous and palliative nature of postoperative glioblastoma management.

CONCLUSIONS

Of the limited proportion of glioblastoma patients requiring VPS surgery for hydrocephalus after index surgery, 78% patients are expected to show symptom improvement, and 24% can expect to undergo revision surgery. An individualized approach to each patient is required to optimize both index glioblastoma and VPS surgeries to account for anatomy and goals of care given the poor prognosis of this tumor overall.

Postoperative Communicating Hydrocephalus Following Grade 2/3 Glioma Resection: Incidence, Timing and Risk Factors

BACKGROUND

In diffusely infiltrating gliomas, the maximum extent of tumor resection is an important predictor of overall survival, irrespective of histological or molecular subtype or tumor grade. For glioblastoma WHO grade 4 (GBM), it has been shown that resection-related events, such as ventricular opening and ventriculitis, increase the risk for development of communicating hydrocephalus (CH) requiring cerebrospinal fluid (CSF) diversion surgery. Risk factors for the development and the incidence of hydrocephalus following resection of other types of infiltrating gliomas are less well established. In this study, we evaluated the incidence and timing of occurrence of different types of hydrocephalus and potential risk factors for the development of CH following resection of grade 2 and 3 gliomas.

METHODS

346 patients who underwent tumor resection (WHO grade 2: 42.2%; 3: 57.8%) at our department between 2006 and 2019 were analyzed retrospectively. For each patient, age, sex, WHO grade, histological type, IDH mutation and 1p/19q codeletion status, tumor localization, number of resections, rebleeding, ventriculitis, ventricular opening during resection and postoperative CSF leak were determined. Uni- as well as multivariate analyses were performed to identify associations with CH and independent risk factors.

RESULTS

24 out of 346 (6.9%) patients needed CSF diversion surgery (implantation of a ventriculoperitoneal or ventriculoatrial shunt) following resection. Nineteen patients (5.5%) had CH, on median, 44 days after the last resection (interquartile range: 18-89 days). Two patients had obstructive hydrocephalus (OH), and three patients had other CSF circulation disorders. CH was more frequent in grade 3 compared to grade 2 gliomas (8.5 vs. 1.4%). WHO grade 3 (odds ratio (OR) 7.5, p = 0.00468), rebleeding (OR 5.0, p = 0.00984), ventriculitis (OR 4.1, p = 0.00463) and infratentorial tumor localization (OR 6.6, p = 0.00300) were identified as significant independent risk factors for the development of post-resection CH. Ventricular opening was significantly associated with CH, but it was not an independent risk factor.

CONCLUSION

Physicians treating brain tumor patients should be aware that postoperative CH requiring CSF shunting occurs not only in GBM but also after resection of lower-grade gliomas, especially in grade 3 tumors. It usually occurs several weeks after resection. Rebleeding and postoperative ventriculitis are independent risk factors.

Postoperative communicating hydrocephalus following glioblastoma resection: Incidence, timing and risk factors

Introduction

Glioblastoma (GBM) is the most common malignant primary brain tumor. Treatment includes maximally safe surgical resection followed by radiation and/or chemotherapy. However, resection can lead to ventricular opening, potentially increasing the risk for development of communicating hydrocephalus (CH). Complications such as rebleeding and infection may also lead to CH and, eventually, the need for cerebrospinal fluid (CSF) diversion surgery. In this study, we evaluated the incidence of different types of hydrocephalus and potential risk factors for the development of CH following glioblastoma resection.

Methods

726 GBM patients who underwent tumor resection at our department between 2006 and 2019 were analyzed retrospectively. Potential risk factors that were determined for each patient were age, sex, tumor location, the number of resection surgeries, ventricular opening during resection, postoperative CSF leak, ventriculitis, and rebleeding. Uni- as well as multivariate analyses were performed to identify associations with CH and independent risk factors.

Results

55 patients (7.6%) needed CSF diversion surgery (implantation of a ventriculoperitoneal or ventriculoatrial shunt) following resection surgery. 47 patients (6.5%) had CH, on median, 24 days after the last resection (interquartile range: 17-52 days). 3 patients had obstructive hydrocephalus (OH) and 5 patients had other CSF circulation disorders. Ventricular opening (odds ratio (OR): 7.9; p=0.000807), ventriculitis (OR 3.3; p=0.000754), and CSF leak (OR 2.3; p=0.028938) were identified as significant independent risk factors for the development of post-resection CH. Having more than one resection surgery was associated with CH as well (OR 2.1; p=0.0128), and frontal tumors were more likely to develop CH (OR 2.4; p=0.00275), while temporal tumors were less likely (OR 0.41; p=0.0158); However, none of those were independent risk factors. Age, sex, or rebleeding were not associated with postoperative CH.

Conclusion

Postoperative CH requiring CSF shunting is not infrequent following GBM resection and is influenced by surgery-related factors. It typically occurs several weeks after resection. If multiple risk factors are present, one should discuss the possibility of postoperative CH with the patient and maybe even consider pre-emptive shunt implantation to avoid interruption of adjuvant tumor therapy. The incidence of CH requiring shunting in GBM patients could rise in the future.