Endoscopic Transnasal Transsphenoidal Surgery Research Articles

A prospective-randomized placebo-controlled trial comparing the effects of nebulized dexmedetomidine v/s dexmedetomidine-lignocaine mixture on intraoperative hemodynamics and surgical field quality in patients undergoing endoscopic transnasal transsphenoidal pituitary tumor surgery

Background: During transnasal transsphenoidal pituitary surgery (TNTSS), the primary objective is to maintain stable hemodynamics while ensuring ideal surgical conditions. This study aimed to investigate the effect of nebulized dexmedetomidine on hemodynamic parameters and the quality of the surgical field during TNTSS. Methods: Seventy-five patients scheduled for TNTSS were randomized into three groups of 25 each and received preoperative nebulization with 5 mL of nebulizing fluid consisting of 1.5 μg/kg of dexmedetomidine with saline in dexmedetomidine (D) group; 1.5 μg/kg of dexmedetomidine with 2% lignocaine in dexmedetomidine-lignocaine (DL) group and normal saline in the control (S) group. Heart rate (HR), mean blood pressure, Formmers score, anesthetic requirement, and emergence were evaluated for each group. Results: Group S had significantly higher HR and mean arterial pressure than the other two groups across various time points during surgery (P < 0.01). The total requirements for fentanyl, propofol, sevoflurane, and labetalol and the incidence of delayed emergence were significantly higher in the S group compared to the other two groups (P < 0.01). The D and DL groups exhibited significantly better surgical field conditions than the S group. In all the parameters assessed, patients in the D group outperformed those in the DL group. Conclusion: The administration of nebulized dexmedetomidine, both alone and in combination with lignocaine, resulted in stable hemodynamics, favorable operative conditions, reduced anesthetic requirement, and facilitated prompt emergence during TNTSS. Nebulized dexmedetomidine proved superior to its combination with lignocaine across all evaluated parameters.

Endoscopic transsphenoidal resection of a non-functioning ectopic pituitary adenoma located in the clivus: a case report and literature review

We successfully removed a rare ectopic pituitary adenoma from a 64-year-old female patient initially misdiagnosed with a chordoma. The tumor was located in the slope region and posed a challenge due to its rarity and location. Using neuro-navigation and neuro-endoscopic techniques, we performed a transnasal transsphenoidal resection and confirmed postoperatively that the tumor was a non-functional pituitary adenoma. Although the patient experienced temporary cortisol deficiency after surgery, she recovered well. To accurately diagnose ectopic pituitary adenomas of clivus, doctors must carefully evaluate the patient's imaging results and hormone levels. If necessary, nuclear medicine scans can also aid in diagnosis. Endoscopic transnasal-transsphenoidal surgery is the preferred treatment method, and preoperative multimodal imaging evaluation and intraoperative neuro-navigation technology are essential for a successful surgery.

Morphometry and Intracranial Relations of the Sphenoid Sinus in Context to Endoscopic Transnasal Transsphenoidal Surgery.

Introduction Due to the variable degree of pneumatization, the shape and size of the sphenoid sinus are irregular. An endoscopic intranasal transsphenoidal approach is made in sphenoid sinus pathologies, sphenoid sinusitis, and sellar and parasellar diseases. A diagnostic approach to the sphenoid sinus is also done to get a better MRI scan of the pituitary. The present study aims to describe the variant types of sphenoid sinus, morphometry, anatomy, and relations of sphenoid sinus, which will be helpful to surgeons during an endoscopic approach to the sphenoid sinus. Materials and methods We studied 76 cadaveric sphenoid sinuses that were exposed by taking a sagittal section of 38 formalin-fixed cadaveric heads. After examining the inter-sphenoidal septum, it was removed to observe the inside aspect of the sphenoid sinus. Different dimensions of the sinus were noted down. The bulges inside the sinus due to neurovascular structures in relation to the sinus were observed. Results The most prominent type found was the sellar in 68.4% of cases preceded by the postsellar in 23.7% of cases. Presellar type of pneumatization was seen only in 7.9% of cases and the conchal type was absent.Intersphenoid septum was seen in 92,1% of cases, out of which 11.4% of septums were deficient on the posterior aspect. An internal carotid artery bulge in the sphenoid sinus was seen in 46% of cases. In 27.6% and 19.7% of sphenoid sinuses, bulging of the optic and vidian nerves, respectively, were seen. Some of these structures were dehiscent in the sphenoid sinus. Conclusions To get more space in the sphenoid sinus, the septa in the sinus are removed by surgeons, which may damage the walls of the sphenoid sinus. Knowledge of the relations of neurovascular structures with the sphenoid sinus will be helpful to surgeons during the transsphenoidal endoscopic approach to avoid any injury to these structures.

Preservation versus resection of middle turbinate in endoscopic transnasal transsphenoidal pituitary surgery

BackgroundThe strategic position of the middle turbinate (MT) within the nasal cavity makes it the first kick start to resect pituitary pathology through Endoscopic Transnasal Transsphenoidal Surgery (ETTS). This research aimed to determine if the type of endonasal endoscopic approach, MT resection (MTres) versus MT preservation (MTpre), for pituitary surgery affects olfaction and sinonasal function within a subjective as well as objective manner. Patients & methodsA prospective cohort comparative study was conducted to compare the sinonasal and olfaction outcomes pre and post operatively for both groups. Sinonasal symptoms were evaluated subjectively by Sino-Nasal Outcome Test (SNOT-22), while objectively by Peri-Operative Sinus Endoscope Score (POSE) along with Lund-Mackay radiological scoring system (LMS), and a Sniffin Sticks Identification test (SIT) (Burghart, Germany) was used to measure the olfaction intensity. In both groups were used on a pre-operative period and after one, three, and six months post operatively. Results96 patients were recruited within predetermined criteria. It is found that there are no significant differences in SIT between both groups with a ρ value 0.439 post operatively. The average change in score (delta) was an increase of 0.3, with changes ranging from −3 to +4. There was no significant difference in sinonasal symptoms score among both groups, with ρ 0.07 posts operatively. There was a minor upsurge in POSE score and LMS in the preservation group but without remarkable differences with ρ value 0.1 and 0.2 subsequently. It is found that there are no significant differences in SIT between both groups with a ρ value 0.439 post operatively. ConclusionDespite these amendments to the nasal cavity, we approved that these changes do not affect the sinonasal functions.

Audit of Postoperative Readmissions and Patient Messages following Endoscopic Transnasal Transsphenoidal Surgery.

Objectives The aim of this study was to identify the reasons for patient messages, phone calls, and emergency department (ED) visits prior to the first postoperative visit following discharge after endoscopic transnasal transsphenoidal (eTNTS) surgery. Design This is a retrospective review of patients at a tertiary care academic center who underwent eTNTS for resection of a sellar region tumor between May 2020 and August 2021. Patient, tumor, and surgical characteristics were collected, along with postoperative, postdischarge, and readmission information. Regression analyses were performed to investigate risk factors associated with postdischarge phone calls, messages, ED visits, and readmissions. Main Outcome Measures The main outcomes were the number of and reasons for phone calls, patient messages, and ED visits between hospital discharge and the first postoperative visit. We additionally determined whether these reasons were addressed in each patient's discharge instructions. Results A total of 98 patients underwent eTNTS during the study period. The median length of hospital stay was 2 days (interquartile range [IQR]: 1-4 days), at which point most patients (82%) were provided with eTNTS-specific discharge instructions. First postoperative visit took place 9 days after discharge (IQR: 7-10 days). Within that time, 54% of patients made at least one phone call or sent at least electronic message and 17% presented to the ED. Most common reasons for call/message were nasal care, appointment scheduling, and symptom and medication questions. Conclusion Through this work, we highlight the most common reasons for resource utilization via patient phone calls, messages, and ED visits among our cohort to better understand any shortfall or gap in the discharge process that may reduce these events.

Adjunctive Benefit of High-Field 3 Tesla MRI Guidance in Endoscopic Transsphenoidal Resection of Pituitary Adenoma

Abstract Introduction Pituitary adenomas (PAs) although benign, are difficult to resect intracranial tumors and their residues are associated with morbidity and reduced quality of life. Thus, gross total resection (GTR) is the goal for all PAs. Role of various modalities for better intraoperative visualization and thus improve resection of adenoma have been tested and each have their pros and cons. The aim of this paper is to analyze adjunctive benefit of high-field 3 Tesla intraoperative magnetic resonance imaging (iMRI) in PAs resection by endoscopic transnasal transsphenoidal surgery (eTSS). Materials and Methods A total of 50 patients who underwent iMRI-guided eTSS were included. MRI findings in preoperative, intraoperative, and 3 months postoperative stage were compared. Adjunctive value of iMRI in improving resection rates of adenoma, postoperative endocrinological outcomes, need for adjuvant radiotherapy, and postoperative cerebrospinal fluid leak rates was assessed. Results High-field 3 Tesla iMRI helped us to detect residues in 24 (48%) patients and iMRI-guided second look surgery increased our GTR rates from initial 52 to 80% and also helped us to identify and achieve 100% GTR in intrasellar residues and parasellar residues that were medial to medial carotid tangential line. With better resection rates, need for adjuvant radiotherapy was also reduced and only 2% received adjuvant radiotherapy. Average increase in surgical time with the use of iMRI was 38.78 minutes without any side effects pertaining to prolonged surgery. Conclusion High-field iMRI is a useful adjunct in assessment and improvement in extent of resection of PA by endoscopic transsphenoidal surgery. Also, it was found beneficial in preserving normal anatomical gland and, thus, reducing the need for postoperative adjuvant hormonal and radiation therapy.

Assessing Risk of Severe Complications after Endoscopic Transnasal Transsphenoidal Surgery: A Comparison of Frailty, American Society of Anesthesiologists, and Comorbidity Scores.

Objective This study aimed to improve age-independent risk stratification for patients undergoing endoscopic transnasal transsphenoidal (TNTS) approach to pituitary mass resection by investigating the associations between frailty, American Society of Anesthesiologists (ASA), and comorbidity scores with severe complications following TNTS. Design This study is a retrospective review. Setting This review was conducted utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Participants A total of 680 cases of TNTS identified from 2010 to 2013 were included in this study. Main Outcome Measures The modified frailty index (mFI) was calculated to quantify frailty. ASA and Charlson's comorbidity index (CCI) scores were obtained as physiologic status and comorbidity-based prognostic markers. Severe complications were separated into intensive care unit (ICU)-level complications, defined by Clavien-Dindo grade IV (CDIV) criteria, and mortality. Results Overall, 24 CDIV complications (3.5%) and 6 deaths (0.9%) were recorded. Scores for mFI ( p = 0.01, R 2 = 0.97) and ASA ( p = 0.04., R 2 = 0.87) were significantly correlated with CDIV complications. ASA scores were significantly correlated with mortality ( p = 0.03, R 2 = 0.87), as well as independently associated with CDIV complication by multivariable regression models (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.35-6.83, p < 0.01), while mFI was not. CCI was not significantly associated with CDIV complications or mortality. A multivariable regression model incorporating ASA had a lower Akaike's Information Criteria (AIC; 188.55) than a model incorporating mFI (195.99). Conclusion Frailty and physiologic status, as measured by mFI and ASA scores respectively, both correlate with ICU-level complications after TNTS. ASA scores demonstrate greater clinical utility than mFI scores; however, as they are more easily generated, uniquely correlated with mortality and independently associated with ICU-level complication risk on multivariable regression analysis.

A supervised machine-learning algorithm predicts intraoperative CSF leak in endoscopic transsphenoidal surgery for pituitary adenomas.

Despite advances in endoscopic transnasal transsphenoidal surgery (E-TNS) for pituitary adenomas (PAs), cerebrospinal fluid (CSF) leakage remains a life-threatening complication predisposing to major morbidity and mortality. In the current study we developed a supervised ML model able to predict the risk of intraoperative CSF leakage by comparing different machine learning (ML) methods and explaining the functioning and the rationale of the best performing algorithm. A retrospective cohort of 238 patients treated via E-TNS for PAs was selected. A customized pipeline of several ML models was programmed and trained; the best five models were tested on a hold-out test and the best classifier was then prospectively validated on a cohort of 35 recently treated patients. Intraoperative CSF leak occurred in 54 (22,6%) of 238 patients. The most important risk's predictors were: non secreting status, older age, x-, y- and z-axes diameters, ostedural invasiveness, volume, ICD and R-ratio. The random forest (RF) classifier outperformed other models, with an AUC of 0.84, high sensitivity (86%) and specificity (88%). Positive predictive value and negative predictive value were 88% and 80% respectively. F1 score was 0.84. Prospective validation confirmed outstanding performance metrics: AUC (0.81), sensitivity (83%), specificity (79%), negative predictive value (95%) and F1 score (0.75). The RF classifier showed the best performance across all models selected. RF models might predict surgical outcomes in heterogeneous multimorbid and fragile populations outperforming classical statistical analyses and other ML models (SVM, ANN etc.), improving patient management and reducing preventable morbidity and additional costs.

The Impact of Minimally Invasive Pituitary Surgery on Male and Female Sexual Dysfunction in Patients with Pituitary Adenoma

Introduction: In the present study, we prospectively investigated the impact of endoscopic transnasal trans-sphenoidal surgery (ETTS) on sexual function in male and female patients with pituitary adenoma. Methods: The study included a total of 40 consecutive patients (male, n = 28 and female, n = 12) aged 22–65 years, who underwent ETTS for pituitary adenoma in our center between March 2019 and August 2019. Twenty-seven (67.5%) and 13 (32.5%) patients had functioning and nonfunctioning pituitary adenomas, respectively. Routine preoperative hormone levels were obtained in every patient. The tests were repeated at the postoperative third month. Preoperatively and at the postoperative third month, the 5-item version of the International Index of Erectile Function and the Female Sexual Function Index (FSFI) was used in male and female patients, respectively. Results: Before surgery, 24 (85.7%) men had erectile dysfunction (ED), and 10 (83%) women had female sexual dysfunction. After surgery, all the patients’ abnormal hormone parameters improved. All the male patients’ ED degrees were positively affected by surgery. In women, the FSFI was significantly better than in the preoperative period. Discussion/Conclusion: Our results showed that both males and females with pituitary adenomas benefitted from minimally invasive pituitary surgery in terms of a high-remission rate and improvement in sexual dysfunction.

Cerebrospinal Fluid Leak in Transnasal Transsphenoidal Surgery for Pituitary Adenoma and its Management

Introduction Over the past few decades endoscopic transnasal transsphenoidal (ETNTS) approach has been practised for excision of pituitary tumours which has minimised the rate of complications and morbidity. However, cerebrospinal fluid (CSF) leak remains a frequent complication requiring efficient management. Various skull-base repair techniques have been described in the literature all along, but there is no universal protocol for the same. Our study aims to determine an ideal strategy for skull-base repair following ETNTS surgery and suggest a protocol at the tertiary centre for the same. Materials and Methods In this prospective study, patients with pituitary adenoma undergoing ETNTS excision from January 2017 to May 2019 were included. Data were collected based on the intraoperative findings of grade of CSF leak following excision, surgical method for skull-base repair, biomaterials used, and recurrence of CSF leak postoperatively and its management. Results A total of 141 patients between 10 to 74 years of age (mean age 42.6) underwent ETNTS excision of pituitary adenoma. Intraoperative CSF leak was observed in 30.5% patients with 14.1% of grade I, 8.5% of grade II and 7.8% of grade III and repair was done with fat closure, multilayer closure and with naso-septal flap, respectively. Postoperative recurrence of CSF leak was found in 2.83% of total cases and 9.3% of patient with intraoperative leak, which were managed appropriately. Overall closure rate was 100% with no further recurrence of CSF leak. Conclusion Surgical repair of skull-base in CSF leak is challenging and requires management in careful and graded fashion for favourable outcome.

Cerebrospinal fluid leakage repair of various grades developing during endoscopic transnasal transsphenoidal surgery.

ObjectivesWe describe the strategy used to repair intraoperative leaks of various grades and define factors for preventing postoperative cerebrospinal fluid leakage (CSF) after surgery via the endoscopic endonasal transsphenoidal approach (EETA).Study designRetrospective chart review at a tertiary referral center.MethodsPatients who underwent surgery via EETA from January 2009 to May 2020 were retrospectively reviewed. Intraoperative CSF leakage was graded 0–3 in terms of the dural defect size; various repairs were used depending on the grade.ResultsA total of 777 patients underwent 869 operations via EETA; 609 (70.1%) experienced no intraoperative CSF leakage (grade 0) but 260 (29.9%) did. Leakage was of grade 1 in 135 cases (15.5%), grade 2 in 83 (9.6%), and grade 3 in 42 (4.8%). In 260 patients with intraoperative CSF leakage, a buttress was wedged into the sellar defect site in 178 cases (68.5%) and a pedicled flap was placed in 105 cases (40.4%). Autologous fat (108 cases, 41.5%) and a synthetic dural substitute (91 cases, 35%) were used to fill the dead space of the sellar resection cavity. Postoperative CSF leakage developed in 21 patients: 6 of grade 1, 7 of grade 2, and 8 of grade 3. Buttress placement significantly decreased postoperative leakage in grade 1 patients (p = 0.041). In patients of perioperative leakage grades 2 and 3, postoperative CSF leakage was significantly reduced only when both fat and a buttress were applied (p = 0.042 and p = 0.043, respectively).ConclusionA buttress prevented postoperative CSF leakage in grade 1 patients; both fat and buttress were required by patients with intraoperative leakage of grades 2 and 3.

Long-term olfactory dysfunction after single-nostril endoscopic transnasal transsphenoidal pituitary adenoma surgery

BackgroundOver the past decade, the endoscopic transnasal transsphenoidal approach for pituitary adenomas has been widely adopted among neurosurgeons. However, olfactory disturbances have been observed after this procedure, and few studies on long-term (>6 mo) olfactory disturbance after endoscopic transnasal transsphenoidal pituitary adenoma surgery have been conducted. Although we perform minimally invasive endoscopic surgery, some patients continue to experience hyposmia, with some even experience long-term hyposmia. This impairment results in a considerable loss in quality of life. We present a series of patients who underwent minimally invasive single-nostril TSS for pituitary adenoma, including evaluation of their olfactory function. We further investigated the related risk factors for long-term olfactory dysfunction. MethodsOne hundred sixty-one consecutive patients who met the study criteria underwent the single-nostril endoscopic transsphenoidal approach by the senior author. The Smell Diskettes Olfaction Test was used to evaluate olfactory function. ResultsPostoperative olfactory disturbance in patients treated with endoscopic transnasal TSS is frequent. Of the study population, 67.1% of the patients were hyposmic or anosmic and 14.9% had long-term olfactory dysfunction. We also performed multivariate logistic regression analysis to compare the characteristics of patients with long-term olfactory dysfunction. Nasal symptoms (odds ratio [OR], 6.77) and smoking (OR, 14.77) were associated with long-term olfactory dysfunction after transnasal TSS. ConclusionsSignificant disturbances in olfactory performance occur after single-nostril transnasal TSS for pituitary adenoma. Furthermore, preoperative nasal disease and smoking appear to be risk factors for long-term olfactory dysfunction. Physicians should address clinical findings related to olfactory function and provide appropriate care.

Surgical and clinical outcome in elderly patients affected by non-functional pituitary adenoma treated by endoscopic transnasal transsphenoidal surgery: A monocentric study

Surgical and clinical outcome in elderly patients affected by non-functional pituitary adenoma treated by endoscopic transnasal transsphenoidal surgery: A monocentric study

Diabetes insipidus and syndrome of inappropriate antidiuresis (SIADH) after pituitary surgery: incidence and risk factors.

Electrolyte disorders are relatively frequent and potentially serious complications after pituitary surgery. Both DI (diabetes insipidus) and SIADH (syndrome of inappropriate antidiuresis) can complicate and prolong hospital and intensive care unit stay, and the latter may even be preventable. We aim to assess the incidence of both electrolyte disorders and their risk factors. From a prospective registry of patients who underwent endoscopic transnasal transsphenoidal surgery (TSS) for pituitary adenoma, patients with postoperative DI and SIADH were identified. Univariable and multivariable statistics were carried out to identify factors independently associated with the occurrence of either DI or SIADH. A total of 174 patients were included, of which 73 (42%) were female. Mean age was 54years (range 20-88). During postoperative hospital stay, 13 (7.5%) patients presenting with DI and 11 (6.3%) with SIADH were identified. Patients who developed DI after surgery had significantly longer hospital stays (p = 0.022), as did those who developed SIADH (p = 0.002). Four (2.3%) patients were discharged with a diagnosis of persistent DI, and 2 (1.1%) with the diagnosis of SIADH. At the last follow-up, 5 (2.9%) patients presented with persistent DI, while none of the patients suffered from SIADH. Younger age (odds ratio (OR) 0.97, 95% confidence interval (CI) 0.94-1.01, p = 0.166) and pituitary apoplexy (OR 2.69, 95% CI 0.53-10.65, p = 0.184) were weakly associated with the occurrence of DI. We identified younger age (OR 0.96, 95% CI 0.92-0.99, p = 0.045) and lower preoperative serum sodium (OR 0.83, 95% CI 0.71-0.95, p = 0.008) as independent risk factors for SIADH. Although we found a weak association among age, pituitary apoplexy, and the occurrence of DI, no independent predictor was identified for DI. For postoperative SIADH however, lower age and preoperative serum sodium were identified as significant predictors. None of these findings were sufficiently supported by preexisting literature. Both electrolyte disorders are exquisitely hard to predict preoperatively, and further research into their early detection and prevention is warranted.

Pituitary Apoplexy with raised intracranial pressure

Pituitary apoplexy in pre-existing pituitary adenomas occurs as a consequence of acute hemorrhage or infarction. Patients with pituitary apoplexy present with sudden onset headache, vomiting, clouding of consciousness and visual field defects or total oculomotor palsies without any prior diagnosis of pituitary tumor.&#x0D; In this case report, we report a case of 52 years female who presented to the emergency department with headache throughout her head and periorbital area with vomiting. Investigations revealed sellar cystic lesion suggestive of pituitary apoplexy with normal hormonal profile. She underwent endoscopic trans-nasal trans-sphenoidal surgery with complete resection of pituitary adenoma. Histopathological examination of tumor specimen showed large areas of necrosis with blood surrounded by the adenomatous tissue. Post-operatively she had cerebrospinal fluid rhinorrhea with persistent papilledema and hydrocephalus. Sellar floor repair along with theco-peritoneal shunt lead to good recovery.

Early outcome of endoscopic trans-nasal trans-sphenoidal pituitary surgery in Kano, Nigeria

Endoscopic trans-nasal trans-sphenoidal hypophysectomy is a minimally invasive surgical procedure aimed at resection of pituitary tumors. This technique is widely practiced in developed countries but is presently gaining popularity in our environment. This study was aimed at presenting our preliminary outcomes as it relates to the technique of endoscopic trans-nasal trans-sphenoidal pituitary surgery in Kano, Nigeria. This was a retrospective study of patients with pituitary tumors that presented at a government tertiary and private specialist health institutions from October 2018 to December 2019. They all had excision of varying degrees of pituitary tumors via endoscopic trans-nasal trans-sphenoidal approach under general anesthesia. There were 4 females (66.7%) and 2 males (33.3%) and their ages ranged between 25 – 60 years. They presented with varying degrees of clinical symptoms such as gynaecomastia, galactorrhea, irregular menstruation, infertility, intermittent headache and visual impairment. Four (66.7%) had complete tumor excision and 2 (33.3%) had incomplete excision. Four (66.7%) had complete symptom relief and 2 (33.3%) had significant improvement in symptoms. The complications of surgery were nasal septal adhesion 1(16.7%), CSF leak 1(16.7%) and transient diabetes insipidus 2(33.3%). All complications were resolved during admission and at follow up visits. Histopathological analysis of specimens confirmed 5 cases of pituitary adenoma and a case of pituitary Rathkes cleft cyst. Endoscopic trans-nasal trans-sphenoidal pituitary surgery is feasible and has a favorable outcome in our setting with prospects for improvement to ensure safety. Keywords: Nasal endoscopy, Sinus surgery, Pituitary tumors, Skull base, Hypophysectomy.

Endoscopic Transnasal Transsphenoidal Pituitary Surgery in Acromegaly: Anatomical Variations and Surgical Considerations.

Endoscopic Transnasal Transsphenoidal Pituitary Surgery in Acromegaly: Anatomical Variations and Surgical Considerations.

Neural network-based identification of patients at high risk for intraoperative cerebrospinal fluid leaks in endoscopic pituitary surgery.

Although rates of postoperative morbidity and mortality have become relatively low in patients undergoing transnasal transsphenoidal surgery (TSS) for pituitary adenoma, cerebrospinal fluid (CSF) fistulas remain a major driver of postoperative morbidity. Persistent CSF fistulas harbor the potential for headache and meningitis. The aim of this study was to investigate whether neural network-based models can reliably identify patients at high risk for intraoperative CSF leakage. From a prospective registry, patients who underwent endoscopic TSS for pituitary adenoma were identified. Risk factors for intraoperative CSF leaks were identified using conventional statistical methods. Subsequently, the authors built a prediction model for intraoperative CSF leaks based on deep learning. Intraoperative CSF leaks occurred in 45 (29%) of 154 patients. No risk factors for CSF leaks were identified using conventional statistical methods. The deep neural network-based prediction model classified 88% of patients in the test set correctly, with an area under the curve of 0.84. Sensitivity (83%) and specificity (89%) were high. The positive predictive value was 71%, negative predictive value was 94%, and F1 score was 0.77. High suprasellar Hardy grade, prior surgery, and older age contributed most to the predictions. The authors trained and internally validated a robust deep neural network-based prediction model that identifies patients at high risk for intraoperative CSF. Machine learning algorithms may predict outcomes and adverse events that were previously nearly unpredictable, thus enabling safer and improved patient care and better patient counseling.

Nasal Functions in Three-Dimensional Endoscopic Skull Base Surgery.

Endoscopic transnasal transsphenoidal surgery has become the standard procedure for the majority of skull base diseases, including sellar, parasellar, and clival pathologies. The aim of this study was the objective evaluation of nasal airflow resistances and olfactory function in 3-dimensional (3D) endoscopic transnasal transsphenoidal surgery. One hundred patients who underwent 3D transnasal endoscopic surgery for sellar, parasellar, and clival diseases were enrolled. Active anterior rhinomanometry and Sniffin' Sticks tests were performed before endoscopic surgery and at 3 and 6 months postoperatively. No significant difference about nasal airflow resistance and olfactory function was observed between preoperative and postoperative subjective and objective scores. In the group of patients with sellar and parasellar diseases, a worst nasal respiratory function was seen when crusting was present, and a worst olfactory function was observed in patients with synechiae. Nasal functions returned to previous levels when crusting or synechiae solved. No statistically significant correlation was observed between the evaluated nasal functions and the reconstruction with flaps. The 3D endoscopic transnasal transsphenoidal surgery represents a more and more important tool in skull base surgery. It does not determine nasal respiratory and olfactory alterations after the treatment, without an increase in nasal complaints that could worsen quality of life.

Severe Hypercortisolism with Hypokalemic Alkalosis Mimicking Ectopic Cushing Syndrome in a Patient with Cushing Disease Due to Pituitary Microadenoma.

Severe Hypercortisolism with Hypokalemic Alkalosis Mimicking Ectopic Cushing Syndrome in a Patient with Cushing Disease Due to Pituitary Microadenoma.