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Purpose of the Study: A prospective, randomized, double-blind study was designed to assess differences in brain relaxation between 20% mannitol and 3% hypertonic saline (HS) during elective supratentorial brain tumour surgery in patients with midline shift., Material and Methods: Sixty patients undergoing supratentorial craniotomy for tumour resection were enrolled to receive either 5mL/kg of 20% mannitol (n=30) or 3% HS (n=30) administered at skin incision. P CO2 in arterial blood was maintained within 35-40mmHg and arterial blood pressure was controlled within baseline values ±20%. The primary outcome was the proportion of satisfactory brain relaxation. The surgeon assessed brain relaxation on a four-point scale (1=excellent with no swelling, 2=minimal swelling, 3=serious swelling not requiring treatment, 4=severe swelling requiring treatment). Postsurgical intracranial changes determined by imaging techniques, postoperative complications, PACU and hospital stay, and mortality at 30 days were also recorded. Appropriate statistical tests were used for comparison; P<0.05 was considered as significant. This trial was registered in Eudract.ema.europa.eu (#2021-006290-40)., Results: There was no difference in brain relaxation: 2.00 [1.00-2.00] and 2.00 [1.75-3.00] for patients in mannitol and HS groups, respectively (P=0.804). Tumour size (OR: 0.99, 95% CI: 0.99-1.01; P=0.371), peritumoral oedema classification (OR: 0.57, 95% CI: 0.11-2.84; P=0.493), mass effect (OR: 0.86, 95% CI: 0.16-4.87; P=0.864), anaesthesia (OR: 4.88, 95% CI: 0.82-28.96; P=0.081) and midline shift (OR: 5.00, 95% CI: 0.84-29.70; P=0.077) did not have a significant influence on brain swelling in patients treated with either mannitol or HS. No significant differences in perioperative outcomes, mortality and length of PACU and hospital stay were observed., Conclusions: 5mL/kg of 20% mannitol or 3% HS result in similar brain relaxation scores in patients undergoing craniotomy for supratentorial brain tumour with midline shift., (Copyright © 2022 Sociedad Española de Neurocirugía. Published by Elsevier España, S.L.U. All rights reserved.)

Background: A prospective, randomized, double-blind study was designed to assess differences in brain relaxation between 2 doses of 3% HS during elective supratentorial brain tumour surgery. Methods: 60 patients undergoing supratentorial craniotomy for tumour resection were enrolled to receive either 3 mL/kg (group L) or 5 mL/kg (group H) of 3% HS administered at skin incision. Brain relaxation was assessed after dura opening on a scale ranging 1-4 (1 = perfectly relaxed, 2 = satisfactorily relaxed, 3 = firm brain, 4 = bulging brain). Hemodynamic variables and laboratory values (blood gases, osmolarity, haematocrit, and lactate) were collected before HS infusion and 30, 120 and 360 min after it. Presence of midline shift, postoperative complications, PCU and hospital stay, and mortality after 30 days were also recorded. Results: There was no difference in brain relaxation, with 2.0 (1.0-3.0) and 2.0 (1.0-2.3) ( P  = 0.535) for patients in groups L and H, respectively. If adjusted for the presence of midline shift, 50% of patients had adequate brain relaxation scores (grades 1 and 2) in group L and 61% in group H (OR 0.64, CI = 0.16-2.49, P  = 0.515). No significant differences in perioperative outcome, mortality and length of PCU and hospital stay were observed. Conclusion: 3 mL/kg of 3% HS result in similar brain relaxation scores as 5 mL/kg in patients undergoing craniotomy for supratentorial brain tumour. This study reveals that both high and low doses of 3% HS may be less effective on intraoperative brain relaxation in patients with midline shift.

Background: The authors investigated the effect of equiosmolar, equivolemic solutions of 3% hypertonic saline (HS) and 20% mannitol on blood coagulation assessed by rotational thromboelastometry (ROTEM) and standard coagulation tests during elective craniotomy., Methods: In a prospective, randomized, double-blind trial, 40 patients undergoing elective craniotomy were randomized to receive 5 mL/kg of either 20% mannitol or 3% HS for intraoperative brain relaxation. Fibrinogen, activated partial thromboplastin time, prothrombin time, hemoglobin, hematocrit, and platelet count were simultaneously measured intraoperatively with ROTEM for EXTEM, INTEM, and FIBTEM analysis. ROTEM parameters were: clotting time (CT), clot formation time (CFT), maximum clot firmness (MCF), and α-angle., Results: No significant differences between groups were found in ROTEM variables CT, CFT, MCF, α-angle (EXTEM and INTEM), and MCF (FIBTEM) nor standard coagulation tests. ROTEM parameters did not show changes after administration of hyperosmolar solutions relating to basal values, except for an increase of CFT EXTEM (118±28 vs. 128±26 s) and decrease of CT INTEM (160±18 vs. 148±15 s) with values within normal range. Significant decreases from baseline levels were observed for hematocrit (-7%), platelet count (-10%), and fibrinogen (-13%) after HS infusion, and hematocrit (-9%), platelet count (-13%), and fibrinogen (-9%) after mannitol infusion, but remaining normal., Conclusions: The use of 5 mL/kg of equiosmolar solutions of 3% HS and 20% mannitol applied to reach a brain relaxation during elective craniotomy does not induce coagulation impairment as evidenced by ROTEM and standard coagulation tests.

Background: Hyperosmolar solutions have been used in neurosurgery to reduce brain volume and facilitate surgical exposure. The purpose of this study was to compare the effects of equivolume, equiosmolar solutions of mannitol and hypertonic saline (HS) on brain relaxation, intensive care unit (ICU) and hospital stay, postoperative outcomes and incidence of side-effects in patients undergoing elective supratentorial craniotomy., Methods: In a randomised, prospective, double-blind study, 60 patients undergoing elective supratentorial craniotomy were randomised 1:1 to receive 3 ml/kg of either 20% mannitol or 3% HS. The primary outcome was the surgical condition of the brain assessed by the neurosurgeon using a 4-point scale after opening the dura (1 = relaxed, 2 = satisfactory, 3 = firm and 4 = bulging). Secondary outcomes were electrolytes, blood gases, plasma osmolality and haemodynamic variables measured at 0 min, 30 min, 2 h and 6 h after infusion. Also, predefined postoperative complications, length of ICU and hospital stay were recorded. Appropriate statistical tests were used for comparison; p < 0.05 was considered significant., Results: There was no difference in brain relaxation [mannitol, 1(1-3) versus HS, 1(1.4) points; p = 0.55]. Patients with brain midline shift showed a worse response to hyperosmolar solutions than those without midline shift: 37% versus 8%, respectively; OR = 6.6 (95% CI, 1.54-28.83); p = 0.006. Plasma osmolality increased during the study period (6 h) in both the groups (p < 0.05 compared with baseline). No significant differences in postoperative complications or length of ICU and hospital stay were observed between the groups., Conclusions: Single doses of 3 ml/kg of 20% mannitol and 3% HS are safe and effective for intraoperative brain debulking during elective supratentorial craniotomy, but less effective in patients with pre-existing mass effect and midline shift.

Background: We compared the effect of propofol and sevoflurane combined with remifentanil under comparable bispectral index (BIS) levels on transcranial electric motor-evoked potentials (TceMEPs) and somatosensory-evoked potentials (SSEPs) during brainstem surgery., Materials and Methods: A total of 40 consecutive patients (20 per group) undergoing brainstem surgery were randomly assigned to 2 groups receiving either 0.5 MAC sevoflurane or propofol at an effect-site concentration of 2.5 µg/mL for maintenance of anesthesia. Remifentanil was administered to both groups at a rate of 0.25 to 0.35 μg/kg/min along with cisatracurium (0.03 to 0.04 mg/kg/h). TceMEP recordings were carried out in the abductor pollicis brevis, abductor hallucis, and tibialis anterior muscles, whereas cortical SSEPs were measured with posterior tibial nerve stimulation. Amplitudes and latencies of TceMEPs and SSEPs were recorded at 1, 2, 3, and 4 hours after the induction of anesthesia., Results: BIS values remained in the 45 to 60 range. Amplitudes of TceMEPs were significantly higher in the propofol group than those in the sevoflurane group (P<0.05, at all study time points in abductor pollicis brevis and abductor hallucis muscles and only 4 h after anesthetic induction for tibialis anterior muscle), whereas latencies were shorter in the propofol group than those in the sevoflurane group (P<0.05). No differences were observed in latency and amplitude while recording SSEPs between the 2 anesthetic techniques. None of the patients had TceMEPs and SSEPs amplitude or latency changes, exceeding our set limit., Conclusions: Both sevoflurane and propofol at low dosages combined with remifentanil under comparable BIS values and partial muscle relaxation can be used when monitoring of TceMEPs and SSEPs is required for brainstem surgery.

The role of radiosurgery after multimodality treatment of recurrent desmoplastic adult medulloblastoma is analyzed. The ultra-early clinical and pathological response of this tumor to adjunctive radiosurgery is stressed.

We report the case of a 13-year-old girl with an increased hypophysis that mimicked an adenoma, who developed a partial empty sella on MRI after an acute episode of hydrocephalus. After replacement of a CSF shunt, the intracranial pressure returned to normal and the hypophysis filled up again all the sellar fossa. We discuss the possibility of the involvement by an ischemic atrophy of the adenohypophysis in the development of a primary empty sella with idiopathic chronic raised intracranial pressure that prevents the recovery of the gland volume after restoring the intracranial pressure to normal values. Restitution of empty sella may be an indicator of normal intracranial pressure in these cases.

Objectives: To determine the optimum concentration of bupivacaine administered by continuous epidural infusion, using a Baxter Single Day elastomeric infusor at a rate of 2 ml/h, to treat pain during the first 24 h after lumbar laminectomy., Patients and Methods: Sixty patients undergoing elective repair of a herniated lumbar disk were randomly assigned to three homogeneous groups of 20 each. Group I received epidural infusion of 0.0625% bupivacaine, group II received 0.125% bupivacaine and group III received 0.25% bupivacaine. After surgery each patient was given a 4 mL solution of the local anesthetic being studied, followed by an infusion of the same through an elastomeric infusor at a rate of 2 ml/h throughout the first 24 h after surgery. Ketorolac was delivered through a device for patient controlled analgesia after surgery. Pain was assessed on a visual analog scale (VAS) at rest and during movement. Pain relief was assessed on a simple descriptive scale., Results: Significantly less ketorolac was required during epidural infusion of 0.125% and 0.25% bupivacaine than when the 0.0625% concentration was being infused (29 +/- 16 and 28 +/- 13 mg, respectively, versus 110 +/- 35 mg; p < 0.001). VAS scores were significantly lower during infusion of 0.125% and 0.25% bupivacaine than with 0.0625% bupivacaine. No instances of motor blockade or infection related to catheter insertion were observed in any of the patients., Conclusions: Continuous epidural infusion of 0.125% and 0.25% bupivacaine through an elastomeric infusor gives excellent analgesia during the first 24 h after surgery. Administration of 0.25% bupivacaine is associated with a higher incidence of urinary retention. We therefore think that the most recommendable concentration of bupivacaine for infusion is 0.125%.

Acoustic neurinomas were sequentially extracted with saline and saline-Triton X-100 buffers. Detergent was required to detach the bulk of acetylcholinesterase (AChE), but butyrylcholinesterase (BuChE) was mostly released with saline buffer. Sedimentation analysis and hydrophobic chromatography revealed that neurinomas contain principally amphiphilic AChE tetramers, dimers and monomers, and hydrophilic BuChE tetramers. The AChE dimers and monomers remained amphiphilic after incubation with phosphatidylinositol-specific phospholipase C (PIPLC), after or without prior treatment with alkaline hydroxylamine, which shows that, in contrast to the meningioma AChE dimers and monomers, the neurinoma isoforms are devoid of glycolipid. Neurinoma AChE reacted with the antibodies HR2 and AE1 raised against AChE from human brain or erythrocyte, whereas BuChE bound to a sheep antiserum.