Chronic subdural hematomas (CSDH), which are frequently encountered in neurosurgical practice, are, in the majority of cases, ideally treated with surgical drainage. Despite this common practice, there is still controversy surrounding the best surgical procedure. With lack of clear evidence of a superior technique, surgeons are free to base the decision on other factors that are not related to patient care. A retrospective chart review of 119 patients requiring surgical drainage of CSDH was conducted at a large tertiary care center over a three-year period. Of the cases reviewed, 58 patients underwent craniotomy, while 61 patients underwent burr hole washout. The study focused on re-operation rates, mortality, and morbidity, as measured by Glasgow coma scores (GCS), discharge Rankin disability scores, and discharge disposition. Secondary endpoints included length of stay and cost of procedure. Burr hole washout was superior to craniotomy with respect to patient outcome, length of stay and recurrence rates. In both study groups, patients required additional surgical procedures (6.6% of burr hole patients and 24.1% of craniotomy patients) (P = 0.0156). Of the patients treated with craniotomy, 51.7% were discharged home, whereas 65.6% of the burr hole patients were discharged home. Patients who underwent burr hole washout spent a mean of 78.8 minutes in the operating suite while the patients undergoing craniotomy spent 129.4 minutes (P < 0.001). The difference in mean cost per patient, based solely on operating time, was $2,828 (P < 0.001). This does not include the further cost due to additional procedures and hospital stay. The mean length of stay after surgical intervention was 3 days longer for the craniotomy group (P = 0.0465). Based on this retrospective study, burr hole washout is superior for both patients’ clinical and financial outcome; however, prospective long-term multicenter clinical studies are required to verify these findings.

Objective: Traditional neurosurgical practice calls for administration of peri-operative stress-dose steroids for sellar-suprasellar masses undergoing operative treatment. This practice is considered critical to prevent peri-operative complications associated with hypoadrenalism, such as hypotension and circulatory collapse. However, stress-dose steroids complicate the management of these patients. It has been our routine practice to use stress steroids during surgery only if the patient has clinical or biochemical evidence of hypocortisolism pre-operatively. We wanted to be certain that this practice was safe.Methods: We present our retrospective analysis from a consecutive series of 114 operations in 109 patients with sellar and/or suprasellar tumors, the majority of whom were managed without empirical stress-dose steroid coverage. Only patients who were hypoadrenal pre-operatively or who had suffered apoplexy were given stress-dose coverage during surgery. We screened for biochemical evidence of hypoadrenalism as a result of surgery by measuring immediate post-operative AM serum cortisol levels.Results: There were no adverse events related to the selective use of cortisol replacement in this patient population.Conclusion: Our experience demonstrates that selective use of corticosteroid replacement is safe; it simplifies the management of the patients, and has advantages over empiric “dogmatic” steroid coverage.

Summary A recent trial by the MRC Lung Cancer Working Party used physician assessments to compare two palliative schedules of radiotherapy in lung cancer. A prospective study has been undertaken on a subset of these trial patients to see how physician assessments of symptomatic relief and general condition correlate with patient perception of therapeutic response. In 40 patients followed up monthly from presentation until close to death, good agreement was found between doctors and patients on change in specific physical symptoms and overall physical condition. Doctors were poor judges of life quality at presentation but appeared able to identify relative improvement or deterioration in overall quality of life. In conclusion, physician assessments may constitute valid end-points for radiotherapy trials comparing palliative schedules in lung cancer.

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Introduction: Brain metastases occur in 15%-20% of lung cancer patients. Recently, studies have suggested that whole-brain radiotherapy (WBRT) may not prolong survival for a subset of patients, and is associated with significant side-effects. Furthermore, it is hypothesized that radiotherapy is often given near the end-of-life when the potential for benefit is minimal. Therefore, this study investigates how frequently radiotherapy for brain metastases is given near the end-of-life in a population-based cohort.Materials and methods: All lung cancer patients who received radiotherapy in British Columbia for brain metastases in 2014-2015 were identified. Patient and treatment characteristics were collected and analyzed to assess associations with death within 90 days of first radiation treatment.Results: In total, 740 patients were identified, with a total of 826 courses of brain radiation. The 90-day mortality rate was 40% (n=330). Multivariable analysis demonstrated higher odds for age (odds ratio (OR) = 1.04, 95% confidence interval (CI) 1.02-1.05), Eastern Cooperative Oncology Group (ECOG) performance score of 2 or higher (OR = 1.59, 95% CI 1.09-2.31) and squamous cell carcinoma (OR = 2.10, 95% CI 1.13-3.90) and lower odds for initial systemic therapy (OR = 0.48, 95% CI 0.34-0.68), more than five fractions of radiotherapy (OR = 0.25, 95% CI 0.16-0.39) and stereotactic radiation (OR = 0.29, 95% CI 0.13-0.65).Conclusion: In our population-based study, WBRT is given in 86% of radiotherapy courses for brain metastases from lung cancer. Of these patients, 40% received treatment near the end-of-life. We identified several factors associated with shortened survival. Using these factors and already established prognostic tools, WBRT utilization should be decreased in the future, improving individualized treatment for patients with brain metastases from lung cancer.