Paper Example on Importance of Following up the Neurological Deficit

Introduction

The importance of preoperative embolisation in meningioma has caught the eyes of several researchers and authors. In different comparative studies between patients who had preoperative embolisation performed and those where it was either not performed or not appropriate, it is shown that preoperative embolisation has several benefits including reduction in blood loss, reduced surgical complications and improved outcome. In this article, we will review different articles on the importance of following up the neurological deficit and preoperative complication in meningioma with preoperative embolisation after craniotomy.

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Preliminary studies by different researchers show that preoperative embolisation could be important in the management of meningioma1-7, 9-11, 13-20, 22-30. Studies after studies have shown that it reduces blood loss, reduces surgical complications, improves surgical outcomes, reduced surgical time, easier resection21-22, and softens tumors during subsequent resection (1-3, 6, 9).

However, the procedure may also come with several risks such as cranial nerve deficit, hemorrhage, ischemic conditions, tumoral edema among others. This then points to the need to follow up on a possible neurological deficit (8).

Nevertheless, the actual benefits of preoperative embolisation still remain very unclear, and the potential harm of any additional procedure is the reason its use has been limited for years. Additionally, with the high cost and risks of embolisation, the value of preoperative embolisation must be reconsidered for all cases of meningioma. With this, it is apparent that neurological deficit and preoperative complications should be followed up in meningioma management.

This is a sensitive procedure; sadly, there have not been any randomized clinical trials on its usefulness in the management of meningiomas. As such, no significant conclusions on the general usefulness of the procedure have been made, and its use as a standard practice is thus still not authorized. As it is today, most researchers and authors are dependent on case series as evidence of its use in meningioma management. In this article, we review the importance of following up on the neurological deficit and preoperative embolisation in the management of meningioma through a craniotomy.

Literature Review

Role of Preoperative Embolisation

There are different reports available on different literature by different authors and researchers on the importance of preoperative embolisation in the management of meningioma through a craniotomy. Researchers through case series have been able to draw meaningful conclusions as to whether or not preoperative embolisation is important in the management of meningiomas. However, lack of randomized clinical trials on the usefulness of the procedure, and a possible high cost has limited its use.

Several researchers report that preoperative embolisation could be beneficial in reducing blood loss and therefore reduce blood transfusions. MacPherson15 shows that when a study is conducted between two groups of patients: one in which preoperative embolisation is done and another in whom it is not done, the blood replacement was less in the embolised group compared to the non-embolised group of patients. This seems to suggest that achieving a complete devascularisation could reduce the blood replacement requirement. This possibly confirms the argument by other authors that preoperative embolisation reduces blood less during the management of meningioma 6,9,13,15, 30-35. Blood loss is one of the implicated causes of complications after craniotomy. If enough studies were to be done on this and a significant conclusion be made on its importance, then possibly it will help in preventing possible post-operative complications after craniotomy.

Preoperative embolisation has also been shown to reduce surgical complications. In a study done by MacPherson15, preoperative embolization seems to reduce the possibility of surgical complications. In the study, 21% of patients who had preoperative embolization performed had surgical complications compared to 54% of patients from the non-embolised group who registered surgical complications15. This suggests that preoperative embolization could be important in preventing surgical complications after craniotomy20-24.

Other authors also have it that preoperative difficulty with bleeding is reduced among patients in whom preoperative embolization is perfomed22-24. In his research, Macpherson15 reports that 25% of patients who had embolization done to them, experienced difficulty with bleeding compared to 62% of those in the group where embolization was not done. Even though there is no much research that has been done in this line, it is apparent that preoperative embolization could reduce preoperative difficulty with bleeding.

Complications

There is a number of literature on the complications of the procedure. Some of the documented complications include hemorrhage, ischemic heart conditions, cranial nerve deficit, tumoral edema among others8, 12, 37.

The table below shows some of the results from different researchers on the role of preoperative embolization in the management of meningiomas and whether or not a follow up on the same and neurological deficit is important:

Author Number of patients Blood loss on embolised group Blood loss on embolised group Surgery time surgery complication Singla et al. Not clear Less high Reduced on the embolised group Reduced Bendszus et al. 60 Reduced high Reduced Reduced Macpherson 52 Reduced high Reduced Reduced Borg et. al. 107 Reduced high Reduced Reduced Indications for Preoperative Embolisation

Before anything else, the most critical consideration is the indication for preoperative embolization in meningiomas. The indications still remain unclear, and this is even made worse with lack of randomized clinical trials on its usefulness. Nevertheless, the surgeon's preference and the healthcare facility practice and standards as been cited by many others as one of the determinants of whether or not the procedure should be performed. Waldron et al16 is appreciated for his exclusion criteria for example history of stroke. Here, Wadron and other researchers apply the standard of practice before performing any procedure: comparing the risk-benefit ratio. Latchaw, a researcher, talks about five circumstances in which preoperative embolization plays a big role in the management of meningiomas13-14, 16-17,19,40. The five circumstances include large tumors, tumors involving the base of the skull, tumor involving scalp, tumor involving sinuses, and tumors next to cortex. According to Latchaw17, the fiver circumstances may influence the decision to perform a preoperative embolization on a patient.

Choice of Embolising Material

There are different embolising agents that are always used in the preoperative embolisation in meningiomas. The agents can either be liquid or solids. Some embolising agents produce temporary effects while others produce permanent effects7,10, 36,39. The embolising agents include PVA particles, cellulose beads, microspheres, fibrin glue among others. Notably, in most cases, PVA particles and microspheres are preferred.

Conclusion

By way of a summary, case series reveals positive impacts of preoperative embolisation in the management of meningiomas. However, lack of randomized clinical trials and therefore unclear usefulness and a possible high cost is limiting its use. Despite of that, preliminary studies have shown that it can reduce blood loss, easier resection, decreased surgical time38, reduce surgery complications, improved outcome among other benefits.

References

1. Nania A, Granata F, Vinci S, Pitrone A, Barresi V, Morabito R, et al: Necrosis score, surgical time, and transfused blood volume in patients treated with preoperative embolization of intracranial meningiomas. Analysis of a single-centre experience and a review of literature. Clin Neuroradiol 24:29-36, 2014

2. Shah AH, Patel N, Raper DM, Bregy A, Ashour R, Elhammady MS, et al: The role of preoperative embolization for intracranial meningiomas. J Neurosurg 119:364-372, 2013

3. Nishiguchi T, Iwakiri T, Hayasaki K, Ohsawa M, Yoneda T, Mitsuhashi Y, et al: Post-embolisation susceptibility changes in giant meningiomas: multiparametric histogram analysis using non-contrast-enhanced susceptibility-weighted PRESTO, diffusion-weighted and perfusion-weighted imaging. Eur Radiol 23:551-561, 2013

4.Manelfe C, Guiraud B, David J, Eymeri JC, Tremoulet M, Espagno J, et al: [Embolization by catheterization of intracranial meningiomas.] Rev Neurol (Paris) 128:339-351, 1973 (Fr)

5.Yang C, Asthagiri AR, Iyer RR, Lu J, Xu DS, Ksendzovsky A, et al: Missense mutations in the NF2 gene result in the quantitative loss of merlin protein and minimally affect protein intrinsic function. Proc Natl Acad Sci U S A 108:4980- 4985, 2011.

6.Mezue WC, Ohaegbulam SC, Ndubuisi CC, Chikani MC, Achebe DS: Intracranial meningiomas managed at Memfys hospital for neurosurgery in Enugu, Nigeria. J Neurosci Rural Pract 3:320-323, 2012.

7. Borg A, Ekanayake J, Mair R, Smedley T, Brew S, Kitchen N, et al: Preoperative particle and glue embolization of meningiomas: indications, results and lessons learned from 117 consecutive patients. Neurosurgery [epub ahead of print], 2013

8.Carli DFM, Sluzewski M, Beute GN, van Rooij WJ: Complications of particle embolization of meningiomas: frequency, risk factors, and outcome. AJNR Am J Neuroradiol 31:152- 154, 2010

9.Gruber A, Killer M, Mazal P, Bavinzski G, Richling B: Preoperative embolization of intracranial meningiomas: a 17-years single center experience. Minim Invasive Neurosurg 43:18- 29, 2000

10.Kai Y, Hamada JI, Morioka M, Yano S, Nakamura H, Makino K, et al: Clinical evaluation of cellulose porous beads for the therapeutic embolization of meningiomas. AJNR Am J Neuroradiol 27:1146-1150, 2006.

11. Kai Y, Hamada JI, Morioka M, Yano S, Todaka T, Ushio Y: Appropriate interval between embolization and surgery in patients with meningioma. AJNR Am J Neuroradiol 23:139- 142, 2002

12.Kallmes DF, Evans AJ, Kaptain GJ, Mathis JM, Jensen ME, Jane JA, et al: Hemorrhagic complications in embolization of a meningioma: case report and review of the literature. Neuroradiology 39:877-880, 1997 13. .

13.Richter HP, Schachenmayr W: Preoperative embolization of intracranial meningiomas. Neurosurgery 13:261-268, 1983

14.Rosen CL, Ammerman JM, Sekhar LN, Bank WO: Outcome analysis of preoperative embolization in cranial base surgery. Acta Neurochir (Wien) 144:1157-1164, 2002

15.Macpherson P: The value of pre-operative embolisation of meningioma estimated subjectively and objectively. Neuroradiology 33:334-337, 1991 .

16.Waldron JS, Sughrue ME, Hetts SW, Wilson SP, Mills SA, McDermott MW, et al: Embolization of skull base meningiomas and feeding vessels arising from the internal carotid circulation. Neurosurgery 68:162-169, 2011

17. Latchaw RE: Preoperative intracranial meningioma embolization: technical considerations affecting the risk-to-benefit ratio. AJNR Am J Neuroradiol 14:583-586, 1993

18.Gruber A, Killer M, Mazal P, Bavinzski G, Richling B: Preoperative embolization of intracranial meningiomas: a 17-years single center experience. Minim Invasive Neurosurg 43:18-29, 2000

19.Oka H, Kurata A, Kawano N, Saegusa H, Kobayashi I, Ohmomo T, et al: Preoperative superselective embolization of skull-base meningiomas: indications and limitations. J Neurooncol 40:67-71, 1998

20.Bendszus M, Rao G, Burger R, Schaller C, Scheinemann K, Warmuth- Metz M, et al: Is there a benefit of preoperative meningioma embolization? Neurosurgery 47:1306-1312, 2000

21.De...