Risk factors of postoperative remote intracerebral hemorrhage after craniotomy for ruptured cerebral aneurysms

Objective@#We aimed to identify the relation between perioperative cerebrospinal fluid (CSF) drain through lumbar drainage (LD) and development of postoperative (POP) remote intracerebral hemorrhage (rICH) in craniotomy to treat ruptured intracranial aneurysms. @*Methods@#We retrospectively reviewed consecutive patients who underwent craniotomy for ruptured cerebral aneurysms at the authors’ institution between 1998 and 2004. We subsequently compared the incidence and characteristics of POP rICH between the patients who had a perioperative LD and those who did not. All statistical analyses were conducted using the software package SPSS 19.0 (SPSS Inc., Chicago, IL, USA). A p value of <0.05 was considered statistically significant. @*Results@#We enrolled 688 patients, of which 80 patients (11.6%) received perioperative LD, and 608 did not. LD and non-LD groups were comparable because although clinical characteristics of the two groups were significantly different considering history of hypertension, timing of surgery, and closed system negative pressure suction drain (SD) placement, none of these three variables was an independent risk factor associated with POP rICH in multivariate analysis. POP rICH incidence was significantly higher in the LD goup (12.5%) than non-LD group (0.8%) (p=0.000) in univariate analysis. LD placement was the only independent risk factor associated with the development of rICH in multivariate logistic regression analysis. @*Conclusions@#POP rICH incidence was significantly higher in patients who were managed with perioperative LD than in those who did not. LD insertion in craniotomy for ruptured intracranial aneurysm, should be closely monitored to address the occurrence of POP rICH.

Does work time limit for resident physician affect short-term treatment outcome and hospital length of stay in patients with spontaneous intracerebral hemorrhage?: a two-year experience at a single training hospital in South Korea

Objective@#To compare short-term treatment outcomes at hospital discharge and hospital length of stay (LOS) in patients with spontaneous intracerebral hemorrhage (sICH) before and after introduction of resident physician work time limit (WTL). @*Methods@#We retrospectively reviewed consecutive patients treated for sICH at our institution between 2016 and 2019. Then we dichotomized these patients into two groups, pre-WTL and post-WTL. We analyzed demographic elements and clinical features, and hospital length of stay (LOS). We evaluated short-term outcome using modified Rankin scale score at hospital discharge and then divided it into “good” and “poor” outcome groups. We subsequently, compared short-term treatment outcome and hospital LOS between the pre-WTL and post-WTL groups. @*Results@#Out of 779 patients, 420 patients (53.9%) were included in the pre-WTL group, and 359 (46.1%) in post-WTL. The mortality rate in sICH patients was higher in the post-WTL group (pre-WTL; 13.6% vs. post-WTL; 17.3%), but there was no statistically significant difference in short-term outcome including mortality (p=0.332) between the groups. The LOS also, was not significantly different between the two groups (pre-WTL; 19.0 days vs. post-WTL; 20.2 days) (p=0.341). The initial Glasgow Coma Scale score, personal stroke history, and mean age were the only independent outcome predicting factors for patients with sICH. @*Conclusions@#Some neurosurgeons may expect poorer outcome for sICH after implementation of the WTL of the K-MHW for resident physician however, enforcement of the WTL did not significantly influence the short-term outcome and hospital LOS for sICH in our hospital. Further well-designed multi-institutional prospective studies on the effects of WTL in sICH patient outcome, are anticipated.

Does work time limit for resident physician affect short-term treatment outcome and hospital length of stay in patients with spontaneous intracerebral hemorrhage?: a two-year experience at a single training hospital in South Korea

Objective@#To compare short-term treatment outcomes at hospital discharge and hospital length of stay (LOS) in patients with spontaneous intracerebral hemorrhage (sICH) before and after introduction of resident physician work time limit (WTL). @*Methods@#We retrospectively reviewed consecutive patients treated for sICH at our institution between 2016 and 2019. Then we dichotomized these patients into two groups, pre-WTL and post-WTL. We analyzed demographic elements and clinical features, and hospital length of stay (LOS). We evaluated short-term outcome using modified Rankin scale score at hospital discharge and then divided it into “good” and “poor” outcome groups. We subsequently, compared short-term treatment outcome and hospital LOS between the pre-WTL and post-WTL groups. @*Results@#Out of 779 patients, 420 patients (53.9%) were included in the pre-WTL group, and 359 (46.1%) in post-WTL. The mortality rate in sICH patients was higher in the post-WTL group (pre-WTL; 13.6% vs. post-WTL; 17.3%), but there was no statistically significant difference in short-term outcome including mortality (p=0.332) between the groups. The LOS also, was not significantly different between the two groups (pre-WTL; 19.0 days vs. post-WTL; 20.2 days) (p=0.341). The initial Glasgow Coma Scale score, personal stroke history, and mean age were the only independent outcome predicting factors for patients with sICH. @*Conclusions@#Some neurosurgeons may expect poorer outcome for sICH after implementation of the WTL of the K-MHW for resident physician however, enforcement of the WTL did not significantly influence the short-term outcome and hospital LOS for sICH in our hospital. Further well-designed multi-institutional prospective studies on the effects of WTL in sICH patient outcome, are anticipated.

In vivo dosimetry and acute toxicity in breast cancer patients undergoing intraoperative radiotherapy as boost

PURPOSE: To report the results of a correlation analysis of skin dose assessed by in vivo dosimetry and the incidence of acute toxicity. This is a phase 2 trial evaluating the feasibility of intraoperative radiotherapy (IORT) as a boost for breast cancer patients. MATERIALS AND METHODS: Eligible patients were treated with IORT of 20 Gy followed by whole breast irradiation (WBI) of 46 Gy. A total of 55 patients with a minimum follow-up of 1 month after WBI were evaluated. Optically stimulated luminescence dosimeter (OSLD) detected radiation dose delivered to the skin during IORT. Acute toxicity was recorded according to the Common Terminology Criteria for Adverse Events v4.0. Clinical parameters were correlated with seroma formation and maximum skin dose. RESULTS: Median follow-up after IORT was 25.9 weeks (range, 12.7 to 50.3 weeks). Prior to WBI, only one patient developed acute toxicity. Following WBI, 30 patients experienced grade 1 skin toxicity and three patients had grade 2 skin toxicity. Skin dose during IORT exceeded 5 Gy in two patients: with grade 2 complications around the surgical scar in one patient who received 8.42 Gy. Breast volume on preoperative images (p = 0.001), ratio of applicator diameter and breast volume (p = 0.002), and distance between skin and tumor (p = 0.003) showed significant correlations with maximum skin dose. CONCLUSIONS: IORT as a boost was well-tolerated among Korean women without severe acute complication. In vivo dosimetry with OSLD can help ensure safe delivery of IORT as a boost.

Feasibility and Outcomes of Hypofractionated Simultaneous Integrated Boost-Intensity Modulated Radiotherapy for Malignant Gliomas: A Preliminary Report

PURPOSE: The aim of this study was to assess the feasibility and efficacy of hypofractionated simultaneous integrated boost-intensity modulated radiotherapy (SIB-IMRT) using three-layered planning target volumes (PTV) for malignant gliomas. MATERIALS AND METHODS: We conducted a retrospective analysis of 12 patients (WHO grade IV-10; III-2) postoperatively treated with SIB-IMRT with concurrent temozolomide. Three-layered PTVs were contoured based on gadolinium-enhanced magnetic resonance imaging as follows; high risk PTV (H-PTV) as the area of surgical bed including residual gross tumor with a 0.5 cm margin; low risk PTV (L-PTV) as the area surrounding the high risk PTV with 1.5 cm margin; moderate risk PTV (M-PTV) as a line at one-third the distance from high risk PTV to low risk PTV. Total dose to high risk PTV was 70 Gy in 8 and 62.5 Gy in 4 patients. RESULTS: The median follow-up time was 52 months in surviving patients. The 2- and 5-year overall survival (OS) rates were 66.6% and 47.6%, respectively. The 2- and 5-year progression-free survival (PFS) rates were 57.1% and 45.7%, respectively. The median OS and PFS were 48 and 31 months, respectively. Six patients (50%) progressed: in-field only in one, out-field or disseminated in 4, and both in one patient. All patients completed planned treatments without a toxicity-related gap. Asymptomatic radiation necrosis was observed in 4 patients at post-radiotherapy 9-31 months. CONCLUSION: An escalated dose of hypofractionated SIB-IMRT using three-layered PTVs can be safely performed in patients with malignant glioma, and might contribute to better tumor control and survival.

The deep inspiration breath hold technique using Abches reduces cardiac dose in patients undergoing left-sided breast irradiation

PURPOSE: We explored whether the deep inspiration breath hold (DIBH) technique using Abches during left-sided breast irradiation was effective for minimizing the amount of radiation to the heart and lung compared to free breathing (FB). MATERIALS AND METHODS: Between February and July 2012, a total of 25 patients with left-sided breast cancer underwent two computed tomography scans each with the DIBH using Abches and using FB after breast-conserving surgery. The scans were retrospectively replanned using standardized criteria for the purpose of this study. The DIBH plans for each patient were compared with FB plans using dosimetric parameters. RESULTS: All patients were successfully treated with the DIBH technique using Abches. Significant differences were found between the DIBH and FB plans for mean heart dose (2.52 vs. 4.53 Gy), heart V30 (16.48 vs. 45.13 cm3), V20 (21.35 vs. 54.55 cm3), mean left anterior descending coronary artery (LAD) dose (16.01 vs. 26.26 Gy, all p < 0.001), and maximal dose to 0.2 cm3 of the LAD (41.65 vs. 47.27 Gy, p = 0.017). The mean left lung dose (7.53 vs. 8.03 Gy, p = 0.073) and lung V20 (14.63% vs. 15.72%, p = 0.060) of DIBH using Abches were not different significantly compared with FB. CONCLUSION: We report that the use of a DIBH technique using Abches in breathing adapted radiotherapy for left-sided breast cancer is easily feasible in daily practice and significantly reduces the radiation doses to the heart and LAD, therefore potentially reducing cardiac risk.