【Abstract】 Objective To explore the perioperative management measures of elderly patients with brain tumors in order to reduce postoperative complications. Methods The surgical treatment of 140 patients was studied by systematic review. Results Among 140 patients, 37 benign tumors were completely resected in 35 cases and most of them were resected in 4 cases; 103 malignant tumors were completely resected in 85 cases and most of them were resected in 18 cases; symptoms disappeared in 55 cases, improved in 60 cases, and had no change in 25 cases in 2 months after operation; 25 postoperative complications were found in 48 cases, and there were 4 cases of deaths within 1 month after operation. Conclusion Meticulous preoperative preparation and evaluation, active treatment of concomitant diseases, strengthening the observation of complications and giving anticipatory measures as early as possible can significantly reduce postoperative complications and improve the prognosis. Fan Guangming, Department of Neurosurgery, Chaoyang Downtown Hospital, Liaoning Province, China [Keywords] Brain tumor; Elderly; Postoperative complications; Perioperative period Brain tumors can occur at any age, are more common in adults, and less frequent in the elderly, generally accounting for 3% to 8.9% of all intracranial tumors [1], The incidence of perioperative complications in the elderly is significantly higher than that in young adults, and the elderly are more likely to suffer from brain tumors than in young adults [2]. With the development of neurosurgery, the surgical mortality rate has decreased to 0-5%, but surgical complications are still inevitable, and the incidence of poor prognosis after surgery is still high [3]. Elderly patients have poor cardiopulmonary function, reduced compensatory function, often accompanied by lesions in other organs and internal environment disorders, coupled with the impact of general anesthesia craniotomy on the function of the patient’s organs, which is prone to cause a variety of postoperative complications. How to reduce postoperative complications of brain tumors in the elderly has attracted the attention of neurosurgeons. Brain Department of Affiliated Hospital of Armed Police Medical College from August 2005 to July 2009, a total of 251 cases of brain tumors in the elderly (over 60 years old) were admitted, of which 140 cases were treated surgically and diagnosed pathologically, the data of this group of cases are analyzed and summarized as follows, in order to explore the measures of perioperative treatment of brain tumors in elderly people, so as to reduce the postoperative complications. 1 Clinical data 1.1 General data 140 cases in this group, 72 males, 68 females, age 60-88 years old, average (69±6.1) years old. 1.2 Tumor site There were 98 cases of supratentorial tumors, accounting for 70% (including: cerebral hemispheres, 66 cases of parafoveal cerebrum, 2 cases of anterior cranial fossa base, 14 cases of saddle area, middle cranial fossa base, pterygoid crest, 10 cases of lateral ventricle and tricortical ventricle, 2 cases of corpus callosum and 1 case of basal ganglia), and 42 cases of sub-tentorial tumors, accounting for 30% (including: cerebellar vermis and cerebellar hemispheres, 16 cases of pontine commissure, 10 cases of pontine commissure angle, 5 cases of brain stem in occipital foramen magnum area, and 4 cases of quads. (11 cases). Description: 85 cases of glioma (including: 47 cases of cerebral hemisphere, 21 cases of lateral ventricle, tricuspid ventricle, tetraparenchymal ventricle, 2 cases of corpus callosum area, 1 case of basal ganglia area, 10 cases of cerebellum, 4 cases of brainstem); 19 cases of meningioma (including: 9 cases of cerebral hemisphere and parafovea of cerebral fossa, 4 cases of pterionic crest and pallidal area, 1 case of cerebellar vermis, 1 case of cerebellar hemisphere, 2 cases of anterior base of the cranial fossa, 2 cases of middle base of the cranial fossa, and 1 case of the area of the foramen magnum of the occipital bone). 1.3 Nature of tumors 37 cases of benign tumors, accounting for 26.4% (among them, 18 cases of meningiomas, 7 cases of pituitary tumors, 10 cases of nerve sheath tumors, and 2 cases of craniopharyngiomas); 103 cases of malignant tumors, accounting for 73.6% (among them: 85 cases of gliomas, 15 cases of brain metastasis tumors, 1 case of malignant lymphoma, 1 case of aggressive pituitary tumor, and 1 case of malignant meningioma). Description: 85 cases of glioma (14 cases of oligodendroglioma; 22 cases of ventricular meningioma; 18 cases of glioblastoma; 3 cases of medulloblastoma; 28 cases of astrocytoma); 15 cases of brain metastasis (primary foci of the situation: 12 cases of lung cancer, 1 case of gastric cancer, 1 case of thyroid cancer, 1 case of rectal cancer, primary foci of which were under control), 1 case of malignant meningioma, and 1 case of invasive pituitary tumor. 1.4 First symptoms and clinical manifestations Headache and vomiting in 47 cases (33.6%), epilepsy in 35 cases (25.0%), psychiatric symptoms in 27 cases (19.3%), hemiparesis in 19 cases (13.6%), sensory disorder in 18 cases (12.8%), vertigo in 16 cases (11.4%), vision loss in 14 cases (10%), cerebellar symptoms in 10 cases (7.1%) ), hearing loss and tinnitus in 8 cases (5.7%), and cranial nerve symptoms in 6 cases (4.2%) in the latter group. 1.5 Preoperative co-morbidities Hypertension 29 cases (20.7%), coronary heart disease 28 cases (20.0%), chronic bronchitis and emphysema 23 cases (16.4%), diabetes mellitus 18 cases (12.8%), malnutrition 19 cases (13.5%), malignant tumors in other parts 15 cases (10.7%), cerebral infarction 10 cases (7.1%) and renal insufficiency 6 times (accounting for 4.3%), totaling 148 cases, of which: 32 cases were combined with 1 disease, 18 cases were combined with 2 diseases, 16 cases were combined with 3 diseases, and 8 cases were combined with 4 diseases. 2 Surgical results and complications 2.1 Surgery 2.1.1 Of the 37 cases of benign tumors: 35 cases of total excision, 4 cases of major excision. 2.1.2 Of the 103 cases of malignant tumors: 85 cases of total excision, 18 cases of most resection, of which 7 cases of debridement flap decompression. 2.1.3 General anesthesia was used in all cases, and surgical resection was performed under the Leica microscope. 2.1.4 Tumors in the saddle region: 1 case of total excision via subfrontal approach, 3 cases of total excision via pterygoid approach, and 6 cases of total excision via transnasal butterfly approach, all of which achieved the purpose of optic nerve decompression. 2.1.5 Tumors in the pontocerebellar angle region: 8 cases of total resection, 2 cases of major resection. 2.1.6 Meningioma: among 19 cases (18 benign meningiomas, 1 malignant meningioma), 16 cases were total resection, 3 cases were major resection, 6 cases were preoperative cerebral angiography (to know the blood supply), 4 cases were interventional embolization of blood-supplying arteries (to reduce intraoperative bleeding). 2.1.7 Brain metastases: between 2 and 4 tumors (one large tumor and the rest are small tumors), surgical resection of large tumors with occupying effect). 2.2 Complications 2.2.1 Lung infection 15 times (10.7%); stress ulcer bleeding 8 times (5.7%); intracranial hematoma 6 times (4.2%); epilepsy 5 times (3.6%); cerebral infarction 4 times (2.8%); dysphagia and choking 4 times (2.8%); intracranial infection 3 times (2.1%); incisional infection 2 times ( 1.4%); deep vein thrombosis 1 time (accounting for 0.7%). The total number of complications was 25 cases and 48 times. 2.2.2 There were 4 deaths within 1 month after operation (including 2 deaths due to intracranial hematoma, 1 death due to large cerebral infarction and 1 death due to intracranial infection), with a mortality rate of 2.85%. 2.3 Comprehensive treatment and follow-up 2.3.1 Symptoms disappeared in 55 cases, improved in 60 cases, and no change in 25 cases 2 months after operation. 2.3.2 Glioma: among 85 cases, 36 cases were treated with γ-knife at the border of tumor cavity and supplemented with whole-brain radiation therapy and chemotherapy, 24 cases were treated with whole-brain radiation therapy and chemotherapy, 6 cases were treated with chemotherapy only, and the rest of the patients were lost to follow-up. 2.3.3 Brain metastases: γ knife treatment for tumor cavity boundary and small tumors, supplemented by whole brain general radiotherapy and chemotherapy, and active treatment of primary foci at the same time. 2.3.4 2 cases of tumors in bridge cerebellar angle area are treated with auxiliary γ knife after most of them are resected; 3 Discussion 3.1 Analysis of the morbidity characteristics of patients with geriatric brain tumors 3.1.1 Elderly people have different degrees of functional decreases and lesions of various systems and organs of the whole body, poor health condition, poor compensatory ability, and some of the patients can’t withstand the blow of craniotomy. 3.1.2 Elderly brain tumor treatment also before more combined with other diseases, such as hypertension, coronary heart disease, chronic bronchitis, emphysema, diabetes mellitus, malnutrition, renal insufficiency and so on, will prolong the recovery period and increase the risk of complications. 3.2 Analysis of the causes of geriatric brain tumor surgical complications 3.2.1 Infection: the elderly have low immunity and poor resistance, the elderly brain tumor patients with more chronic bronchitis, due to general anesthesia intubation, vomiting and mispriming, and postoperative bedridden and other factors, prone to respiratory infections; some patients with diabetes mellitus and malnutrition are prone to postoperative infection of the incision, delayed healing, non-healing, and may also be complicated with intracranial infections ; intraoperative catheterization is required, and postoperative catheterization may be retained, especially for the elderly male patients with prostatic hyperplasia will increase the chance of urinary tract infection. 3.2.2 Stress ulcer bleeding: stress ulcer is acute gastric mucosal erosion and ulcer caused by severe trauma, burns, surgery and other major diseases, often combined with upper gastrointestinal bleeding and life-threatening. A large number of catecholamines are released in the body under stress, serum gastrin levels increase, gastric acid increases, while gastric mucosal blood flow decreases, resulting in extensive bleeding of the gastrointestinal mucosa, which further causes necrotic ulceration of the mucosa, leading to upper gastrointestinal bleeding [4]. It is more likely to occur postoperatively for brainstem and tetralogy of fallot lesions. Elderly people are more prone to develop peptic stress ulcers because of their frailty and poor ability to fight stress. 3.2.3 Postoperative rebleeding: common causes are: the elderly mostly suffer from vascular sclerosis, poor brittleness; abnormal coagulation mechanism; sudden drop in intracranial pressure; intraoperative hemostasis difficulty or incomplete; intraoperative operative injury; reperfusion injury; intraoperative position is not appropriate; low intracranial pressure before the cranial closure; cephalic nailing breaks the skull; drainage is not smooth, platelet oozing blood; hypertension, vitamin K1 deficiency, platelets are low, etc. [5]. 3.2.4 Cerebral infarction: the elderly mostly suffer from vascular sclerosis, vascular stenosis, the need for postoperative dehydration treatment, blood concentration, and can not expand the blood vessels for treatment, it is easy to complicate acute cerebral infarction, especially the meningioma patients with abnormal coagulation mechanism, it is more likely to complicate acute cerebral infarction. 3.2.5 Epilepsy: the causes of seizure epilepsy are 1. damage to the central anterior and posterior gyrus and the nearby cortex; 2. damage caused by intraoperative stretching, electrocautery and exposure of the cerebral cortex; 3. postoperative cerebral edema and hemorrhage; 4. postoperative neuronal metabolism disorders and so on [6]. Supratentorial tumors are prone to complicate epilepsy, and antiepileptic treatment should be given prophylactically to patients with preoperative seizures or EEG abnormalities. 3.3 Strengthen perioperative treatment and prevent complications 3.3.1 Improve preoperative examination: understand the health status and comorbidities of elderly brain tumor patients, and improve the head imaging examination (e.g., cranial CT, cranial MRI scanning + enhancement) and special examination (e.g., preoperative pure tone audiometry and auditory evoked potentials for auditory neuromas; visual acuity, visual field and visual evoked potentials for pituitary tumors; endocrine examination for pituitary tumors and craniopharyngiomas before operation; and endocrine examination for pituitary tumors and craniopharyngiomas before operation). Pituitary tumor, craniopharyngioma, endocrine examination before surgery, etc.). 3.3.2 Physiological and psychological preparation: those who need to be bedridden after surgery should practice urination and defecation in bed before surgery; for the surgery that may affect the cranial nerves of the posterior group, the patients should be trained in the correct way of coughing, sputum coughing and swallowing; to understand the family’s expectation for the effect of the surgery, explain the condition to the patients and their family members, adjust the psychological state of the patients, so as to enable the patients’ and their family members’ mental status to be prepared and adjusted. Discussion and assessment: adjust the comorbidities, grasp the timing of surgery, for patients suffering from malnutrition, diabetes, malignant tumors, receiving radiation therapy or chemotherapy and long-term use of immunosuppressive drugs, etc. should be corrected for the situation before the operation, to improve the patient’s resistance, preoperative measurements to do a good job of preparation work, plan the borders of the bone window, the design of the most reasonable access, surgical access and position selection to take into account the microscope and the possible intraoperative Problems. 3.3.4 Intraoperative precautions: 1. The operation time should not be too long, otherwise it will lead to increased bleeding and also increase the risk of surgery. Too long anesthesia time may lead to difficulties in resuscitation; 2. Low resistance of the elderly, strict aseptic operation during the operation.3. Intraoperative protection of the functional zone: carefully identify the anatomical markings during the operation to avoid pulling on the functional zone, if the patient is located in or encroaches on the functional zone, according to the situation, weigh the pros and cons of the operation, perform a partial resection or give retention.4. Good communication with the anesthesiologist:If there is a lot of bleeding in the opening of the cranium, the blood pressure can be lowered, and the blood pressure can be appropriately elevated before cranial closure, and there is really no activity. If there is much bleeding during craniotomy, the blood pressure can be lowered, and before cranial closure, the blood pressure can be raised appropriately. If the dural tension is high during cranial closure, hyperventilation can be given appropriately. Notify the anesthesiologist in advance when the surgery is expected to be over soon and reduce the medication, so as to strive for the patient to be awake as soon as possible after the end of the surgery. 3.3.5 Preventive measures for postoperative complications: 1. Timing of tracheal intubation: if the patient can open his eyes, shake hands as instructed, have spontaneous respiration, and Sp02 is normal after surgery, he can be directly intubated; for the deeper anesthesia and hazy consciousness, in order to prevent re-bleeding caused by choking on the tube and fluctuation of blood pressure, he can be appropriately sedated, and return to the ward with the tracheal intubation tube; 2. Preventing intracranial re-bleeding: adjust the blood pressure to the normal range before the surgery, and avoid a sudden drop of intracranial pressure in the surgery, before the cranial closure, properly elevate blood pressure, and avoid a sharp drop of intracranial pressure. The blood pressure should be raised appropriately before cranial closure, and the cranium should be closed after observing no active bleeding for 5 min. Try not to use vasodilator drugs within 8 h after surgery, apply hemostatic drugs appropriately, control blood pressure below the basal level, and avoid external stimuli as much as possible; 3. Prevention of grand mal seizure: patients with epileptic brain tumor are prone to epilepsy, and EEG should be routinely investigated before surgery, and antiepileptic treatment should be given to those who have preoperative epileptic seizure or EEG abnormality. Sodium valproate can be given before waking up from general anesthesia, and maintained for about 24 h after operation, and Valium can be used for 8~10 h in case of severe convulsions. 4. Intracranial pressure (ICP) control: the general method is to control the intracranial pressure at the head of the bed, and the ICP is to control the intracranial pressure at the head of the bed. (4) Control intracranial pressure (ICP): the general method is to elevate the head of the bed by 20°, adjust the number and type of dehydrating drugs (mannitol, tachycardia, albumin, etc.) according to ICP, and add hormones if necessary; those without ICP monitoring should pay attention to indirect evidence of intracranial pressure, such as: does the headache worsen when coughing or when the infusion is fast? Does the headache decrease with dehydration? How long does headache relief last? How many times can the headache be controlled with dehydration drugs; 5, stress ulcer bleeding: brainstem, four ventricles lesions are prone to gastrointestinal stress ulcers after surgery, postoperative prophylactic application of omeprazole sodium and other inhibition of gastric acid secretion, monitoring of gastric fluid PH, so that the PH value is greater than 4 [8]. Neurosurgeons are not surgical surgeons, and surgical treatment is not purely surgical, including preoperative preparation, postoperative treatment and care, and many other aspects, each of which is closely related to the patient’s prognosis and should not be ignored. Meticulous preoperative preparation and evaluation, active treatment of concomitant diseases, enhanced observation of complications and early anticipatory measures can significantly reduce postoperative complications and improve the prognosis.