Enhanced Recovery After Surgery (ERAS) for Cranial Tumor Resection: A Review.

Enhanced Recovery After Surgery (ERAS) protocols describe a standardized method of preoperative, perioperative, and postoperative care to enhance outcomes and minimize complication risks surrounding elective surgical intervention. A growing body of evidence is being generated as we learn to apply principles of ERAS standardization to neurosurgical patients. First applied in spinal surgery, ERAS protocols have been extended to cranial neuro-oncologic procedures. This review synthesizes recent findings to generate evidence-based guidelines to manage neurosurgical oncology patients with standardized systems and assess ability of these systems to coordinate multidisciplinary, patient-centric care efforts. Furthermore, we highlight the potential usefulness of multimedia, app-based communication platforms to facilitate patient education, autonomy, and team communication within each of the 3 settings.

Cerebrospinal fluid macrophage migration inhibitory factor: a potential predictor of cerebral vasospasm and clinical outcome after aneurysmal subarachnoid hemorrhage.

OBJECTIVE: In patients with aneurysmal subarachnoid hemorrhage (aSAH), poor outcomes have been shown to be correlated with subsequent cerebral vasospasm (CV) and delayed cerebral ischemia (DCI). The identification of novel biomarkers may aid in the prediction of which patients are vulnerable to developing vasospasm, cerebral ischemia, and neurological deterioration. METHODS: In this prospective clinical study at North Shore University Hospital, patients with aSAH or normal pressure hydrocephalus (NPH) with external ventricular drains were enrolled. The concentration of macrophage migration inhibitory factor (MIF) in CSF was assessed for correlation with CV or DCI, the primary outcome measures. RESULTS: Twenty-five patients were enrolled in the aSAH group and 9 were enrolled in the NPH group. There was a significant increase in aggregate CSF MIF concentration in patients with aSAH versus those with NPH (24.4 ± 19.2 vs 2.3 ± 1.1 ng/ml, p < 0.0002). Incidence of the day of peak MIF concentration significantly correlated with the onset of clinical vasospasm (rho = 0.778, p < 0.0010). MIF concentrations were significantly elevated in patients with versus those without evidence of DCI (18.7 ± 4.93 vs 8.86 ± 1.28 ng/ml, respectively, p < 0.0025). There was a significant difference in MIF concentrations between patients with infection versus those without infection (16.43 ± 4.21 vs 8.5 ± 1.22 ng/ml, respectively, p < 0.0119). CONCLUSIONS: Preliminary evidence from this study suggests that CSF concentrations of MIF are correlated with CV and DCI. These results, however, could be confounded in the presence of clinical infection. A study with a larger patient sample size is necessary to corroborate these findings.

Electroencephalogram Abnormalities During Positional Changes in Brain Sagging Syndrome.

PURPOSE: Brain sagging after craniotomy and clipping of a ruptured aneurysm is a rare complication. Clinical and electrographic changes in patients with a final diagnosis of intracranial hypotension are not well described, and can be mistaken on rare occasions for other entities such as nonconvulsive status epilepticus. There may be resulting delay in the diagnosis and treatment of this potentially life-threatening disorder. METHODS: Case report and imaging. RESULTS: We present a case of intracranial hypotension in which concerning continuous electroencephalogram (cEEG) and quantitative EEG (qEEG) findings were noted during active sagging of the brain, which resolved with supine positioning. During upright seating, cEEG showed high-amplitude bilateral rhythmic 2-Hz slow-wave activity, and bilateral increase of spectral delta power on qEEG, in association with neurologic decline in function. When placed in supine position, the cEEG and qEEG abnormalities resolved in conjunction with the recovery of neurologic function. CONCLUSIONS: Brain sagging can be diagnosed using simple maneuvers such as supine positioning. This case report describes changes seen in cEEG and qEEG monitoring that accompany these maneuvers, which may provide further evidence for the diagnosis of brain sagging. Thus, cEEG and qEEG monitoring may have a role in the early detection and treatment of brain sagging.