Sawaya R, Hammoud M, Schoppa D, Hess K R, Wu S Z, Shi W M, Wildrick D M
Department of Neurosurgery, The University of Texas M.D. Anderson Cancer Center, Houston 77030, USA.
Neurosurgery. 1998 May;42(5):1044-55; discussion 1055-6. doi: 10.1097/00006123-199805000-00054.
The goals were to critically review all complications resulting within 30 days after craniotomies performed for excision of intra-axial brain tumors relative to factors likely to affect complication rates and to assess the value of these data in predicting the risk of surgical morbidity, particularly for surgery in eloquent brain regions.
Neurosurgical outcomes were studied for 327 patients who underwent 400 craniotomies for removal of intra-axial parenchymal brain neoplasms in a 21-month period. Tumors removed included gliomas (206 tumors) and metastases (194 tumors) located both supratentorially (358 tumors) and infratentorially (42 tumors).
The major complication incidence was 13%, and the operative mortality rate was 1.7%. The overall morbidity rate was 32%, but more types of complications were considered than in previous studies. The major neurological morbidity rate was 8.5%. Based on pre- versus postoperative (at 4 wk) Karnofsky Performance Scale scores, 9% of patients deteriorated neurologically, 32% improved, and 58% showed no change. The median postoperative hospital stay was 5 days. Tumors were defined as Grade I, II, or III based on their location relative to brain function, and this tumor functional grade was the most important variable affecting the incidence of any neurological deficit. Patients with tumors in eloquent (Grade III) or near-eloquent (Grade II) brain areas incurred more neurological deficits than did patients with tumors in noneloquent areas (Grade I). Neither repeat surgery for recurrent disease nor extent of surgical resection affected outcome significantly. Although most tumors in this study, including those in eloquent regions, were removed by gross total resection, this did not lead to more major neurological deficits. Regional complications (at the surgical sites) and systemic complications (medical) were more prevalent among older patients (age >60 yr) with lower preoperative Karnofsky Performance Scale scores (< or = 50) and posterior fossa masses. We showed how our data can be used to predict the total risk of surgical morbidity for a given patient, to facilitate patient counseling and surgical decision-making.
The finding that gross total resections could be performed in eloquent brain regions with an acceptable level of neurological impairment suggested that the mere presence of a tumor in eloquent brain does not automatically contraindicate surgery. Our results have practical risk-predictive value, and they should aid in the construction of subsequent outcome studies, because we have identified the key areas to monitor.
本研究旨在严格审查在切除脑内轴性肿瘤的开颅手术后30天内出现的所有并发症，并分析可能影响并发症发生率的因素，同时评估这些数据在预测手术致残风险方面的价值，尤其是针对脑功能区手术。
对21个月内接受400次开颅手术以切除脑内实质性肿瘤的327例患者的神经外科手术结果进行研究。切除的肿瘤包括幕上（358例）和幕下（42例）的胶质瘤（206例）和转移瘤（194例）。
主要并发症发生率为13%，手术死亡率为1.7%。总体发病率为32%，但与以往研究相比，纳入考虑的并发症类型更多。主要神经功能障碍发生率为8.5%。根据术前与术后（4周）的卡氏功能状态评分，9%的患者神经功能恶化，32%的患者改善，58%的患者无变化。术后中位住院时间为5天。根据肿瘤相对于脑功能的位置将肿瘤分为I、II或III级，这种肿瘤功能分级是影响任何神经功能缺损发生率的最重要变量。脑功能区（III级）或近脑功能区（II级）肿瘤患者比非脑功能区（I级）肿瘤患者出现更多的神经功能缺损。复发性疾病的再次手术和手术切除范围均未对结果产生显著影响。尽管本研究中的大多数肿瘤，包括脑功能区的肿瘤，均通过全切除，但这并未导致更多的主要神经功能缺损。区域并发症（手术部位）和全身并发症（内科）在术前卡氏功能状态评分较低（≤50）的老年患者（年龄>60岁）和后颅窝肿块患者中更为常见。我们展示了如何利用我们的数据预测特定患者手术致残的总风险，以促进患者咨询和手术决策。
在脑功能区能够进行全切除且神经功能损害程度可接受这一发现表明，仅仅脑功能区存在肿瘤并不必然成为手术禁忌。我们的结果具有实际的风险预测价值，应有助于后续结果研究的构建，因为我们已经确定了关键的监测领域。
