Does midline shift predict postoperative nausea in brain tumor patients undergoing awake craniotomy? A retrospective analysis

Abstract

Background:

The presence of midline shift on neuroradiologic studies in brain tumor patients represents mass effect from the tumor and surrounding edema. We hypothesized that baseline cerebral edema as measured by midline shift would increase postoperative nausea (PON). We studied the incidence of PON in brain tumor patients, with and without midline shift on preoperative magnetic resonance (MRI) or computed tomographic (CT) imaging, undergoing awake craniotomy.

Methods:

After IRB approval, we retrospectively extracted data from perioperative records between January 2005 and December 2010. Post-craniotomy nausea and pain scores were collected. Intraoperative anti-emetic, anesthetic, and analgesic regimens were assessed. Both the rescue anti-emetic and cumulative postoperative analgesic requirements were collected up to 12 hours postoperatively. The amount of midline shift on preoperative neuroimaging was gathered from radiology reports. Univariate comparisons between groups (no midline shift vs. midline shift) were made with t-tests for continuous variables, and chi-square tests for categorical variables. A multivariable analysis was performed to identify predictors of postoperative nausea. Limitations of this study include the retrospective design and the inability to gather accurate data regarding vomiting from the medical record.

Results:

Data from 386 patients were available for analysis. Patients were divided into two groups: no midline shift (n = 283) and midline shift (n = 103). The mean midline shift distance was 5.96 mm (95% CI [5.32, 6.59]). There was no difference in the incidence of nausea or pain scores between the two groups. More malignant brain tumor patients were in the midline shift group, as determined by the postoperative histopathological diagnosis (P < 0.05). Patients in the midline shift group also had longer anesthesia and surgical times (P < 0.05).

Conclusion:

In patients undergoing a standardized anesthetic for awake craniotomy for tumor resection, the presence of preoperative midline shift did not correlate with postoperative nausea.

Keywords::

• Anesthesia
• Awake craniotomy
• Brain tumor
• Cerebral edema
• Craniotomy
• Midline shift
• Postoperative nausea

Transparency

Declaration of funding

This study was funded by the Duke University Department of Anesthesiology.

Declaration of financial/other relationships

M.W.O., B.P.-B., M.L.J., and A.H.F. have disclosed that they have no significant relationships with or financial interests in any commercial companies related to this study or article. D.L.M. is a consultant for Cephalogics Corporation LLC. T.J.G. participates in a speakers’ bureau for Fresenius Kabi and Merck, and has research funding from AcelRx, Pacira, Merck, Acacia Pharma, and Cubist Pharmaceuticals.

CMRO peer reviewers may have received honoraria for their review work. The peer reviewers on this manuscript have disclosed that they have no relevant financial relationships.