Postoperative Magnetic Resonance Imaging (MRI) Scans for the Surgical Resection of Cranial Glial Tumors According to National Institute of Health and Care Excellence (NICE) Guidelines: A Single-Center Experience

Background Glial tumours are the most common central nervous system (CNS) neoplastic lesions. They occur in 7 per 100,000 individuals in the United Kingdom (UK) and are categorized into astrocytomas, oligodendrogliomas, and glioblastomas in the adult population. The World Health Organization (WHO) has created a classification system in order to better categorise these lesions, placing them in a range from grade I to grade IV. The higher the grade, the poorer the prognosis. The National Institute of Health and Care Excellence (NICE) in the United Kingdom recommends that all surgical resections of glial brain tumours are followed by a postoperative magnetic resonance imaging (MRI) scan within a 72-hour to establish a baseline for further management. Objective We present a retrospective analysis that assessed the compliance rate with NICE guidelines among patients who underwent surgical resection of glial lesions at the Department of Neurosurgery, Queens Hospital Romford, between January 2022 and September 2023. Materials and methods A retrospective analysis was conducted on 136 glial tumour resections that were performed during the period between January 2022 and September 2023. The total time between the end of the operation and the MRI scan was calculated in hours for each procedure. This was analyzed into two groups with respect to compliance with the NICE guidelines, which are within 72 hours and after 72 hours. The non-compliant group was then further investigated regarding the reason for the delay. The cost related to delays was also determined by discussion with the hospital's finance department. Results All of the procedures were followed by a post-operative MRI scan but only 88% were within the timeframe recommended by NICE guidelines. The amount of delay was calculated in hours and the reasons for these delays were identified. We created two categories for delay: requesting delays and radiology department-related delays with an almost equivalent number of delays resulting from each category. This delay has resulted in approximately £19,845 of extra costs for inpatient stays. Conclusion A retrospective analysis at Queens Hospital, Romford, found good compliance with NICE guidelines for post-operative MRI scans in glial lesion resections from January 2022 to September 2023. Eighty-eight per cent of patients received scans within 72 hours, crucial for baseline assessment. A 12% non-compliance rate revealed areas for improvement, causing £19,845 in extra costs due to longer inpatient stays. Expediting scans to 36 hours could save around £30,876 annually and reduce complications like infections and thromboembolism. Proposed strategies include dedicated MRI slots and policy adjustments for MRI requests.


Introduction
The National Institute of Health and Care Excellence (NICE) in the United Kingdom (UK) has issued guidelines for the optimal management of glial tumours [1].According to these guidelines, all surgical resections of glial brain tumours should be followed by a postoperative magnetic resonance imaging (MRI) scan, which includes both pre-and post-contrast sequences within a 72-hour timeframe of the operation to establish a baseline for further management [1].Gliomas are the most prevalent neoplastic lesion of the central nervous system (CNS) that occur in 7 per 100,000 individuals in the UK [2].Gliomas are further categorized into astrocytomas, oligodendrogliomas, and glioblastomas [3].The World Health Organization (WHO) has classified gliomas into four grades (I, II, III, IV), with Grade I indicating the most favourable prognosis; the prognosis worsens progressively as the grade gets higher [4].NICE guidelines recommend surgical resection in specific cases to obtain histological diagnoses, which can aid in oncological treatment, and to resect as much of the tumour as is safely possible [1].Moreover, the outcomes derived from the postoperative MRI scans can provide valuable insights into the potential for recurrence, advancement, and prognosis [5].The most consequential data often emanates from MRI scans conducted within the timeframe of 24 to 72 hours following the operation [5,6].A retrospective analysis assessed the compliance rate with NICE guidelines among patients who underwent surgical resection of glial lesions at Queens Hospital, Romford, Department of Neurosurgery, between January 2022 and September 2023.The adherence to guidelines significantly influences patient outcomes, as the importance of post-operative MRI is wellestablished in the literature, with studies indicating that accurate assessment of tumour resection extent is crucial for determining prognosis and guiding further treatment [7].Evaluating compliance rates can highlight potential gaps in current practice, identify barriers to guideline adherence, and ultimately lead to enhanced patient care and outcomes.Given the complexity and variability of glial tumours, understanding how closely current practices at Queen's Hospital align with NICE guidelines provides essential insights into the quality of care and can drive improvements in clinical protocols and patient management strategies.

Materials And Methods
Retrospective data derived from a clinical audit done at Queens Hospital, Romford, was systematically collected relating to all patients who underwent surgical resection of gliomas during the period between January 2022 and September 2023.This specific timeframe was chosen to allow for an assessment of compliance with post-operative imaging guidelines, taking into consideration the potential influence of coronavirus disease 2019 (COVID-19) restrictions.The department's operations archive underwent a thorough examination, filtering out surgeries unrelated to intracranial masses.Subsequently, the selected surgical cases underwent further review through operation notes, with a focus on exclusively including cases of surgical resections of intracranial tumours.The final list of cases was carefully selected by reviewing histology reports to ensure that only operations with histological findings of glial tumours were included, explicitly excluding cases limited to tissue biopsy.
The data collected included patient demographics, histopathology findings, surgical procedure dates and times, MRI scan dates and times, as well as the average number of admissions and the average cost of a patient's daily stay.
The data analysis process involved organizing the collected data into a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA, USA).Time intervals, measured in hours, between the conclusion of surgery and the subsequent MRI scan, as recorded in the hospital's system, were calculated.These time intervals were categorized into two groups: those within 72 hours and those beyond 72 hours, serving as a basis for assessing compliance with NICE guidelines [1].Cases with MRI scans falling outside the recommended timeframe were closely examined to determine the likely causes of delay.
Additionally, the average time elapsed between surgery and the MRI scan was calculated using Excel's data processing capabilities.Delay causes were categorized into two groups: radiology departmental delay for scans requested prior to or within 24 hours post-operatively, and requesting delay for scans requested after 24 hours post-operatively.The request time was obtained from the hospital's radiology system, where this information is easily accessible.A retroanalysis of all MRI reports was conducted to identify the number of cases in which a residual was reported and those where it was not reported.
Financial information related to costs was obtained from the financial department at Queens Hospital, Romford.

Results
Over a 21-month span, between January 2022 and September 2023, a total of 136 patients underwent surgical resection of glial tumours at Queens Hospital, Romford (Table 1).

GBM: glioblastoma
Among these patients, there were 89 (65%) males and 47 (35%) females with an average age of 61 years old ranging from 25-79 years old.Astrocytomas were diagnosed in 9 (7%) cases, with 5 falling under WHO Grade II and 4 classified as WHO Grade III [3].Additionally, 5 (4%) patients were diagnosed with oligodendroglioma, with 3 categorized as WHO Grade II and the remaining 2 designated as Grade III [3].The remaining 122 (89%) patients were histologically confirmed to have glioblastoma (GBM), classifying them as WHO Grade IV [3].On average, patients had their post-operative MRI at 56 hours following their surgical procedures.Overall, 119 (88%) patients received their scan within the 72-hour window recommended by the NICE guidelines [1], and the remaining 17 (12%) patients did not meet the 72-hour timeframe with an average delay of 134 hours.Amongst the 17 patients who experienced delays, 9 (53%) were attributed to radiology departmental delay, while 8 (47%) resulted from delayed scan requests (Figure 1).

FIGURE 1: Results Summary
The pie chart shows the results and the percentage of compliance and delays.
Of all 136 MRI scans that were reported, 48 (35%) showed no signs of residual tumour and the remaining 88 (65%) reported varying amounts of residual tumour.The average cost of a neurosurgery bed for 24 hours at our hospital is £470.The accumulative hours of delay were found to be 995 hours, which caused an extra cost of £19,845 for the inpatient stay.

Discussion
Gliomas represent the most prevalent primary central nervous system tumours [2].According to NICE guidelines [1], it is recommended that patients undergoing surgical resection of glial tumours should undergo post-operative MRI scans within a 72-hour timeframe [1].This early post-operative imaging facilitates the establishment of a documented baseline, aiding in the subsequent planning of surgical and oncological interventions [1].The postoperative MRI scan significantly contributes to predicting the likelihood of recurrence and overall survival, particularly when conducted within the recommended timeframe of 72 hours [5,6].To assess compliance with these specific NICE guidelines [1], patient data from the Department of Neurosurgery at Queens Hospital, Romford, was systematically reviewed and analyzed.Instances of delays in post-operative scanning were investigated, with root causes categorized into two groups: radiology department delays and requesting delays.Overall, the analysis revealed a good rate of compliance (88%), subsequently leaving a 12% non-compliance rate.Of the previously mentioned 12%, an almost equivalent number of delays resulted from both requesting delays and radiology department-related delays.These delays could be substantially reduced with minor policy adjustments within both the radiology department and the surgical team.
A feasible option involves the allocation of a dedicated one-hour slot each day within the MRI department for neurosurgical imaging in which these scans can be performed.This allocation should not limit neurosciences imaging to this specific hour, and other scans should continue to be scheduled based on clinical prioritization, as is currently standard practice.
With regard to delays in requesting scans, a change to neurosurgical departmental policy could potentially eliminate any delay in submitting request forms.Assigning responsibility to a designated operating surgeon to attach an MRI request form to the printed operation note and place it in the patient's notes can be an effective measure.A handover from the theatre team to the ward team can then be given that the imaging form needs to be submitted and where a completed form can be found.This would be particularly valuable in cases where a patient is transferred to the intensive therapy unit post-operatively and a breakdown of communication may occur between the neurosurgical junior doctors who may be based on the standard ward.A more substantial change would be the introduction of an electronic requesting system, allowing the operating surgeon to request an MRI concurrently with the creation of an operation note eliminating the delay entirely.However, this requires a significant change in culture and established processes at significant financial and organizational costs.
The neurosurgery department at Queens Hospital averages around 2.5 admissions per day, with the average cost of a neurosurgery bed for a 24-hour stay being £470.A total of 995 hours of delay in imaging were found in the period of study, resulting in approximately £19,845 of extra costs incurred.If the average time for a post-operative MRI scan was reduced to 36 hours from the current 55 hours, around £30,876 could be saved annually.This is also not accounting for the potential savings that could be wrought from non-glial tumours, which remains an area of potential further study.
In addition to the financial consideration, the health aspect is crucial.Extended hospital stay increases the risk of inpatient complications, such as infections and venous thromboembolisms, which might be potentially fatal.Performing an early MRI scan can shorten hospital stays participating in timely patient discharge which can help avoid these complications.
A further area of study that could be of interest and significance is to compare the current findings of this paper with the same methodology applied to a period of 21 months during the COVID-19 pandemic where there were greater restrictions and challenges in place to ensure compliance with national guidelines.
The early identification and quantification of residual tumours, when combined with histology findings, is invaluable for further management, both surgical and oncological management.A further retrospective study specifically quantifying the volume of pre-operative tumour and volume of potential residual postresection with the correlation between prognosis and survival would be of benefit in highlighting the importance of early postoperative MRI.
Several limitations were faced while conducting this study.Firstly, it is important to acknowledge that this study was single-centred, which means that the findings might not be generalizable to broader settings.Secondly, the absence of prior research within the centre posed a challenge as there was no baseline to compare the results.Finally, the scarce existing literature on the subject limited the ability to compare the findings with other centres or countries.

Conclusions
A retrospective analysis at Queens Hospital, Romford, found good compliance with NICE guidelines for post-operative MRI scans in glial lesion resections from January 2022 to September 2023.Eighty-eight per cent (88%) of patients received scans within 72 hours, crucial for baseline assessment.A 12% noncompliance rate revealed areas for improvement, causing £19,845 in extra costs due to longer inpatient stays.Expediting scans to 36 hours could save around £30,876 annually and reduce complications like infections and thromboembolism.Proposed strategies include dedicated MRI slots and policy adjustments for MRI requests can cause improvement in compliance.