Intracranial Surgery Research Articles

Spikes in bispectral index, likely due to seizure activity, during intracranial surgery.

Spikes in bispectral index, likely due to seizure activity, during intracranial surgery.

Tenecteplase: A Review of Its Pharmacology and Uses.

Tenecteplase: A Review of Its Pharmacology and Uses.

Utility of Pre-operative Glasgow Coma Scale and SKALE Scoring System to Predict need for Post-operative Ventilator Support in Intracranial Tumour Patients

Objective: To evaluate the feasibility of GCS and SKALE in predicting post-operative requirement of ventilator support in intracranial tumour patients. Methods: Seventy patients undergoing intracranial tumour resection surgery were assessed pre-operatively using GCS and SKALE scoring systems to predict their post-operative requirement of ventilator support. The data was analysed using SPSS software and ShapiroWilk test and Chi-Square tests were apllied to compare the obtain data. Results: The study included 70 patients, of whom 88.6% had good GCS of 13-15 and 72.9% had good SKALE score of >8. We found that all patients with poor GCS ≤8 required post -operative ventilator support, while only 4 out 62 patients with GCS 13-15 required ventilator support post-operatively (p value <0.05). Patients with SKALE score ≤8 also had higher incidence of post-operative ventilator requirement (31.6%) as against those with SKALE score >8 (11.8%). Conclusion: GCS is a good predictor of post-operative ventilator requirement. SKALE scoring system requires further studies to prove its utility.

Clinical Outcomes of Dexmedetomidine As An Anesthetic Adjuvant in Intracranial Surgery, An Experience from Irfan General Hospital Peshawar: A Prospective Case Series Study

Objective: Neuro anesthesia (most commonly general) is indicated in intracranial surgery, the goal of which is to maintain a stable hemodynamic environment. This study aimed at evaluating the effectiveness of Dexmedetomidine (DEX) when used as an adjuvant in intracranial surgery. Materials And Methods: A prospective design was utilized and the data was collected at the Department of Neurosurgery Irfan General Hospital Peshawar in patients undergoing intracranial. All those patients having a score of 14 or 15 on the Glasgow Coma Scale, and I and II on the American Society of Anesthesiologists (ASA) undergoing intracranial surgery under general anesthesia were included in the study. Results: The majority of patients were males 35 (66%) while 18 (34%) were females. 29(55%) patients were categorized as grade I while 24 (45%) as grade II according to the American Society of Anesthesiologists-Physical status. mean extubation time of our sample of patients undergoing craniotomy was 6.21 ± 2.16 minutes while the time for rescue analgesia was 41.23 ± 23.15 minutes. The heart rate values decreased significantly when noted at different intervals from the baseline. Conclusion: Dexmedetomidine is an effective and safe anesthetic adjuvant when used in intracranial surgery and provides stable hemodynamics both intra and post-operatively. The neuro anesthetic drug also reduces the requirements of other opioids and rescue drugs.

Analysis of Factors Affecting Outcome of Acute Extradural Hematoma—Our Observation in Dhaka Medical College and Hospital

Abstract Background Extradural hematoma (EDH) is a leading cause of death in young population. Timely intervention gives dramatic recovery but often fatal if not treated in time. The surgical outcome of EDH depends on many variables that strongly affect the prognosis of the disease, which are preoperative Glasgow coma scale (GCS), overlying skull fracture, time interval between injury and surgery, other associated intracranial injuries (like cerebral contusion, subdural hematoma, or intracerebral hematoma), pupillary abnormalities (anisocoria), and hematoma volume. But no correlation was found between surgical outcome of EDH and age, sex, etiology, and site of hematoma. Objective We want to identify the factors affecting the surgical outcome of EDH that will help us in preoperative prioritization of the cases for intervention, adequate resuscitation, and counselling the attendant regarding the outcome. Our ultimate goal was to reduce the mortality and morbidity from this disease. Methods This study was conducted on the patients admitted through neuroemergency and diagnosed as EDH by computed tomography scan of head, in the department of Neurosurgery of Dhaka medical college and hospital from January 1, 2017 to December 31, 2019. This is three-year prospective interventional study where all the patients underwent surgical evacuation of EDH on emergency basis and outcome was measured by Glasgow outcome scale (GOS) after 48 hours of admission and at discharge. Results Outcome was divided into good (GOS 4,5) and poor (GOS 1–3) groups. Pre-operative GCS, overlying skull fracture, time interval between injury and surgery, associated intracranial injuries, anisocoria and hematoma volume were the factors affecting the surgical outcome significantly. Conclusion Good surgical outcome is associated with EDH volume less than 40cc, preoperative GCS more than 8, absence of anisocoria, overlying skull fracture, no associated intracranial injury and surgery within 12 hours of injury. But age, sex and site of EDH has no definite correlation with outcome.

Intracranial Neuroendoscopy in Children and Adults: Where Do the Differences Lie?

Intraventricular neuroendoscopy has evolved into an essential adjunct in neurosurgery and is used across all age groups for various indications. However, studies comparing neuroendoscopic procedures between children and adults are scarce. The aim of this study is to compare various aspects between adults and children undergoing neuroendoscopy. We retrospectively analyzed the data from consecutive patients dichotomized into 2 cohorts, pediatric (age <18 years) and adult (age ≥18 years) groups, in whom intracranial neuroendoscopy was performed between 2013 and 2020 (pediatric group) and 2010 and 2020 (adult group). Of 132 patients who underwent intracranial neuroendoscopic surgery, 47 (35.6%) were children and 85 (64.4%) were adults. The most common indications for the children and adults were intraventricular or paraventricular tumors (23.4%) and aqueduct stenosis (40%), respectively. Their clinical condition at the last follow-up was unchanged or improved for 90.5% of the children and 92.1% of the adults. An increased endoscopic third ventriculostomy success score was predictive of endoscopic third ventriculostomy success in the pediatric cohort (odds ratio, 1.073; P= 0.043). The postoperative rates of transient (pediatric, 23.4%; adult, 18.8%) and permanent (pediatric, 0%; adult, 1.2%) complications were comparable. The rate of secondary surgery was higher for the pediatric cohort (38.3%) than for the adult cohort (17.6%). The indications for neuroendoscopy vary between adults and children, although the long-term clinical outcome is comparable. The rate of secondary surgery is significantly higher for pediatric patients, especially for those aged <1 year. Because neuroendoscopy is considerably more frequent in pediatric patients, including pediatric neurosurgeons in adult neuroendoscopic cases could potentially help lower the complication rates and increase the success rates.

Intravenous thrombolysis and mechanical recanalization for acute ischemic stroke in deep brain stimulation patients: a case series

BackgroundIntravenous thrombolysis (IVT) and endovascular mechanical thrombectomy therapy (MT) are well established in the treatment of acute ischemic stroke. It is currently unclear whether these treatments can be applied in patients with previous deep brain stimulation (DBS) surgery and how long the interval to the DBS operation should be.MethodsFour patients with ischemic stroke and IVT or MT were included in this retrospective case series. Data on demographics, genesis, severity and course of the stroke and the DBS indication were extracted and evaluated. Furthermore, a literature review was conducted. Outcomes and hemorrhagic complications after IVT, MT or intra-arterial thrombolysis in patients with prior deep brain stimulation surgery and intracranial surgery were analyzed.ResultsFour patients with acute ischaemic stroke and previous DBS surgery were treated with IVT (2 patients), MT (1) or a combined therapy of IVT and MT (1). The time interval to the previous DBS surgery was between 6 and 135 months. In these four patients, no bleeding complications occurred. The literature review revealed four publications with a total of 18 patients, who were treated with IVT, MT or intra-arterial thrombolysis. Of these 18 patients, only 1 had undergone deep brain stimulation surgery, the other 17 patients had received brain surgery for other reasons. Bleeding complications occurred in four of the 18 reported patients, but not in the DBS case. All four patients with bleeding complications were reported to have died as a result. In three of the four patients with fatal outcome, surgery was less than 90 days before the onset of stroke.ConclusionIVT and MT were tolerated by four patients with ischemic stroke more than 6 months after DBS surgery without bleeding complications.

Postoperative intrakranielle unterdruckassoziierte venöse Kongestion: das "lentiform rim sign"

Postoperative intracranial hypotension-associated venous congestion (PIHV) or pseudohypoxic brain swelling (PHBS), first described in 2003, is a rare but potentially fatal acute complication following otherwise uneventful intracranial or spinal surgery mainly with liquor leakage or use of suction drainage [Van Roost D et al. Neurosurgery 2003; 53: 1315–1322]. The patients suffer from an unexpected impairment of consciousness, seizures, and brainstem dysfunction. It is supposed that a rapid loss of cerebrospinal fluid (CSF) causes brain sagging which may compromise the main intracranial deep venous structures through shear forces. Therefore, venous ischemia, infarction, and bleeding due to venous congestion are likely consequences [Van Roost D et al. Neurosurgery 2003; 53: 1315–1322].

Postoperative delirium after intracranial neurosurgery: A prospective cohort study from a developing nation.

Post-operative delirium (POD) is a major complication after anesthesia and surgery with an incidence varying from 5 to 50%. The incidence of POD after intracranial surgery is likely to be higher due to the pre-existing brain pathology and direct handling of the brain during neurosurgery. The primary objective of this study was to assess the incidence of POD after intracranial neurosurgery and our secondary objective was to identify the potential risk factors for its occurrence. This prospective observational study was conducted after the institutional ethics committee approval between october 2020 and march 2021. We included patients of either gender aged ≥ 18 years and undergoing elective intracranial neurosurgery. Exclusion criteria included patients aged below 18 years, undergoing emergency neurosurgery, patients with impaired consciousness and patients with psychiatric comorbidities or those taking psychotropic medications. We planned to exclude patients from analysis who were transferred to intensive care unit (ICU) or if they were not extubated after surgery. Our study outcome was development of POD as assessed by confusion assessment method (CAM). The overall incidence of POD during the three postoperative days was 19.2% (n=60/313). The incidence of POD on days 1, 2, and 3 were 19.2% (n=60/313), 17.2% (n=50/291), and 16.3% (n=39/239). Preoperative delirium and hyperactive Emergence Delirium were found to be the significant predictors of POD. Every one in five patients undergoing intracranial neurosurgery is vulnerable for the development of POD within first three days after surgery. The incidence of occurrence of POD is time-sensitive and is decremental.

Association of intraoperative lactate elevation and postoperative mortality and morbidity in patients undergoing craniotomy: retrospective analysis.

Intraoperative lactate levels increase in patients undergoing craniotomy, but the reason is not yet fully known. High levels of intraoperative lactate are associated with mortality and morbidity in patients with septic shock and abdominal and cardiac surgery. Investigate whether intraoperative lactate elevation is associated with postoperative systemic and neurological complications and mortality in craniotomy. Retrospective study SETTING: University hospital in Turkey. In this study, we included patients who underwent elective intracranial tumor surgery in our hospital between 1 January 2018, and 31 December 2018. According to the level of intraoperative lactate, patients were divided into two groups: high (≥2.1 mmol/L) and normal (<2.1 mmol/L). The groups were compared by the presence of postoperative new neurological deficits, postoperative surgical and medical complications, mechanical ventilation duration, 30-day mortality, in-hospital mortality, and hospital stay length. Cox regression analysis was performed for the 30-day mortality outcome. Association between intraoperative lactate levels and postoperative 30-day mortality. 163 patients with lactate data. While no significant difference was found between the groups regarding age, gender, ASA score, tumor location, operation time and pathology results, preoperative neurologic deficits were higher in the high intraoperative lactate group (P=.017). No statically significant difference was found between the groups for postoperative neurological deficit, need for prolonged mechanical ventilation, and hospital stay length. The postoperative 30-day mortality rate was higher in the group with high intraoperative lactate (P=.028). High lactate and medical complications were significant in the Cox analysis. Intraoperative lactate elevation was associated with postoperative 30-day mortality in patients undergoing craniotomy. The intraoperative level of lactate is an important mortality predictor in patients undergoing craniotomy. Retrospective design and single-centered, missing most data for several variables. None.

Quantitative Pupillometry in Patients with Surgical Decompression (P11-7.006)

<h3>Objective:</h3> In this study, we aim to describe quantitative pupil reactivity and size characteristics post-surgical decompression. <h3>Background:</h3> Poor pupil reactivity and asymmetry are potential hallmarks of worsening intracranial injury in patients with acute neurological conditions. However, their clinical significance after intracranial surgery, when mass effect is less likely to directly affect midbrain pupillary pathways, is unclear. <h3>Design/Methods:</h3> We performed a retrospective chart review of patients with quantitative pupillometry who received decompressive hemicraniectomy for ischemic stroke, traumatic brain injury (TBI), or intracranial hemorrhage (ICH). We identified clinical and radiological neuroworsening within 1 hour of pupil measurements. We report abnormal pupils, defined as abnormal reactivity (Neurologic Pupil Index (NPi) &lt;3), or asymmetric pupil reactivity (NPi difference ≥ 0.7), or asymmetric size (&gt;1 mm). We also tested abnormal pupil association with clinical and radiographic signs of neuroworsening before and after decompression. <h3>Results:</h3> Of 24 patients, the mean age was 45.29 ± 19.23 years and 16 were male (66.7%). Thirteen patients received hemicraniectomies for stroke (N=7) or ICH (N=6; spontaneous or related to another injury), 9 had hemicraniectomy for acute subdural hemorrhage, and 2 underwent suboccipital craniectomies for posterior circulation ICH. For all patients, pupil abnormalities occurred in 53.82% of post-surgical measurements, as compared to 45.5% of available pre-surgical measurements. Within the subgroup of patients with ≥3 measurements before and after surgery (n=13), the median minimum NPi post-surgery was lower than pre-surgery (3.8 [2.7–3.39] v. 3.9 [2.7–3.51], p &lt; 0.001). Post-surgery, decreased NPi was associated with loss of cranial nerves, motor decline, and refractory intracranial pressure. <h3>Conclusions:</h3> Abnormalities in pupil reactivity and asymmetry occur frequently post-surgical decompression and are affiliated with neuroworsening events. Close quantitative monitoring of pupils may be indicated even after surgical decompression to identify episodes of neuroworsening, but further definitive studies are necessary. <b>Disclosure:</b> Ms. Hupp has nothing to disclose. The institution of Mr. Cronin has received research support from American Heart Association. Mrs. Kim has received personal compensation for serving as an employee of Boston Medical Center. Dr. Ong has nothing to disclose.

3D-Printed Head Model in Patient's Education for Micro-Neurosurgical Aneurysm Clipping Procedures

Computed tomography (CT), Magnetic resonance imaging (MRI), and 3D reconstruction from Digital Subtraction Angiography (DSA) are currently used in clinical consultations for patients diagnosed with intracranial aneurysms; however, they have limitations in helping patients understand the disease and possible treatments. This study investigates the use of a 3D-printed model of the patients' neurosurgical anatomy and vascular pathology as an educational tool in outpatient clinics. A 3D-printed model of a middle cerebral artery aneurysm was created for use during patient consultations to discuss microsurgical treatment of unruptured cerebral aneurysms. In total, 38 patients and 5 neurosurgeons were included in the study. After the consultation, the patients and neurosurgeons received a questionnaire to assess the effectiveness of the 3D-printed model as an educational tool. The 3D model improved the patients' understanding of the diagnosis, the aneurysm's relationship to the parent artery; the treatment process as well as the risks if left untreated. The patients found the 3D model to be an interesting tool (97%). The neurosurgeons were satisfied with the 3D-printed model as a patient encounter tool, they found the model effective during consultation (87%) and better than the conventional education tools used during consultations (97%). Using a 3D model improves communication, enhances the patient's understanding of the pathology and its treatment and potentially facilitates the informed consent process in patients undergoing intracranial aneurysm surgery.

Retrospective Study of the Safety and Efficacy of Intraoperative Methadone for Pain Management in Patients Undergoing Elective Intracranial Surgery

Patients undergoing intracranial surgery experience significant perioperative pain and are typically treated with short-acting opioids. Methadone, with its prolonged half-life and multimodal central nervous system effects, presents a promising option for managing postcraniotomy pain. Despite its proven efficacy in other types of surgeries, the use of methadone in patients undergoing craniotomy has not yet been explored. A retrospective chart review was conducted for 60 adult patients ranging in age from 18 to 81 years who received methadone during intracranial surgeries. The primary outcome of interest was the total opioid consumption in oral morphine milligram equivalents (MMEs) and patient-reported pain scores within 24 hours and up to 72 hours postoperatively. The methadone dosage varied from 5 to 20 mg. In the infratentorial group, the median total MME on postoperative day 1, 2, and 3 was 30.5, 17, and 0.8, respectively, with mean pain scores of 3.56, 3.91, and 2.71. In the supratentorial group, the median total MME on postoperative day 1, 2, and 3 was 17.85, 15.4, and 1.2, with mean pain scores of 2.31, 1.68, and 2.21, respectively. Patients who were chronic opioid users had significantly higher pain scores and average opioid use (P < 0.05). None of the patients required administration of naloxone or airway interventions. Comparison with the historical control showed that our study patients had lower pain scores and MME. The single intraoperative dose of methadone is well tolerated by adult patients undergoing various types of intracranial surgeries, with minimal side effects, including elderly patients aged 65 years or older.

Development and validation of a nomogram for blood transfusion during intracranial aneurysm clamping surgery: a retrospective analysis

PurposeIntraoperative blood transfusion is associated with adverse events. We aimed to establish a machine learning model to predict the probability of intraoperative blood transfusion during intracranial aneurysm surgery.MethodsPatients, who underwent intracranial aneurysm surgery in our hospital between January 2019 and December 2021 were enrolled. Four machine learning models were benchmarked and the best learning model was used to establish the nomogram, before conducting a discriminative assessment.ResultsA total of 375 patients were included for analysis in this model, among whom 108 received an intraoperative blood transfusion during the intracranial aneurysm surgery. The least absolute shrinkage selection operator identified six preoperative relative factors: hemoglobin, platelet, D-dimer, sex, white blood cell, and aneurysm rupture before surgery. Performance evaluation of the classification error demonstrated the following: K-nearest neighbor, 0.2903; logistic regression, 0.2290; ranger, 0.2518; and extremely gradient boosting model, 0.2632. A nomogram based on a logistic regression algorithm was established using the above six parameters. The AUC values of the nomogram were 0.828 (0.775, 0.881) and 0.796 (0.710, 0.882) in the development and validation groups, respectively.ConclusionsMachine learning algorithms present a good performance evaluation of intraoperative blood transfusion. The nomogram established using a logistic regression algorithm showed a good discriminative ability to predict intraoperative blood transfusion during aneurysm surgery.

Involvement of cortical projections to basolateral amygdala in context-induced reinstatement of ethanol-seeking in rats

Ethanol is the most consumed substance of abuse in the world, and its misuse may lead to the development of alcohol use disorder (AUD). High relapse rates remain a relevant problem in the treatment of AUD. Exposure to environmental cues previously associated with ethanol intake could trigger ethanol-seeking behavior. However, the neural mechanisms involved in this phenomenon are not entirely clear. In this context, cortical projections to the basolateral amygdala (BLA) play a role in appetitive and aversive learned behaviors. Therefore, we aimed to evaluate the activation of the cortical projections from the prelimbic (PL), orbitofrontal (OFC), and infralimbic (IL), to the BLA in the context-induced reinstatement of ethanol-seeking. Male Long-Evans rats were trained to self-administer 10% ethanol in Context A. Subsequently, lever pressing in the presence of the discrete cue was extinguished in Context B. After nine extinction sessions, rats underwent intracranial surgery for the unilateral injection of red fluorescent retrograde tracer into the BLA. The context-induced reinstatement of ethanol-seeking was assessed by re-exposing the rats to Context A or B under extinction conditions. Finally, we combined retrograde neuronal tracing with Fos to identify activated cortical inputs to BLA during the reinstatement of ethanol-seeking behavior. We found that PL, but not OFC or IL, retrogradely-labeled neurons from BLA presented increased Fos expression during the re-exposure to the ethanol-associated context, suggesting that PL projection to BLA is involved in the context-induced reinstatement of ethanol-seeking behavior.

Development and first results of a national databank on care and treatment outcome after traumatic brain injury

PurposeIn absence of comprehensive data collection on traumatic brain injury (TBI), the German Society for Neurosurgery (DGNC) and the German Society for Trauma Surgery (DGU) developed a TBI databank for German-speaking countries.MethodsFrom 2016 to 2020, the TBI databank DGNC/DGU was implemented as a module of the TraumaRegister (TR) DGU and tested in a 15-month pilot phase. Since its official launch in 2021, patients from the TR-DGU (intermediate or intensive care unit admission via shock room) with TBI (AIS head ≥ 1) can be enrolled. A data set of > 300 clinical, imaging, and laboratory variables, harmonized with other international TBI data collection structures is documented, and the treatment outcome is evaluated after 6- and 12 months.ResultsFor this analysis, 318 patients in the TBI databank could be included (median age 58 years; 71% men). Falls were the most common cause of injury (55%), and antithrombotic medication was frequent (28%). Severe or moderate TBI were only present in 55% of patients, while 45% suffered a mild injury. Nevertheless, intracranial pathologies were present in 95% of brain imaging with traumatic subarachnoid hemorrhages (76%) being the most common. Intracranial surgeries were performed in 42% of cases. In-hospital mortality after TBI was 21% and surviving patients could be discharged after a median hospital stay of 11 days. At the 6-and 12 months follow-up, a favorable outcome was achieved by 70% and 90% of the participating TBI patients, respectively. Compared to a European cohort of 2138 TBI patients treated in the ICU between 2014 and 2017, patients in the TBI databank were already older, frailer, fell more commonly at home.ConclusionWithin five years, the TBI databank DGNC/DGU of the TR-DGU could be established and is since then prospectively enrolling TBI patients in German-speaking countries. With its large and harmonized data set and a 12-month follow-up, the TBI databank is a unique project in Europe, already allowing comparisons to other data collection structures and indicating a demographic change towards older and frailer TBI patients in Germany.

Association of Preoperative Glycated Hemoglobin and Early Postoperative Infections After Elective Craniotomy: A Retrospective Cohort Study

The prognostic value of preoperative glycated hemoglobin (HbA1c) testing is controversial. The available evidence on the role of preoperative HbA1c in predicting postoperative complications after different surgical procedures has been conflicting. The primary aim of our retrospective observational cohort study was to assess the association between preoperative HbA1c and postoperative infections after elective craniotomy. We extracted and analyzed data from an internal hospital database on 4564 patients who underwent neurosurgical intervention from January 2017 to May 2022. The primary outcome measure of the present study was infections established in the first week after surgery using the Centers for Disease Control and Prevention criteria. The records were stratified by the HbA1c values and intervention types. For patients who had undergone brain tumor removal with a preoperative HbA1c ≥6.5%, the odds of early postoperative infections were increased (odds ratio, 2.08; 95% confidence interval, 1.16-3.72; P= 0.01). We found no association between HbA1c and early postoperative infections for patients who had undergone elective cerebrovascular intervention, cranioplasty, or a minimally invasive procedure. After adjusting for age and gender, the threshold for significant infection risk for neuro-oncological patients increased with an HbA1c ≥7.5% (adjusted odds ratio, 2.97; 95% confidence interval, 1.37-6.45; P= 0.0058). For patients undergoing elective intracranial surgery for brain tumor removal, a preoperative HbA1c ≥7.5% is associated with a higher infection rate within the first postoperative week. Future prospective studies are required to assess the prognostic value of this association for clinical decision-making.

Causes and risk factors of an unplanned second craniotomy in patients with traumatic brain injury

BackgroundThe purpose of this retrospective study was to evaluate the causes and risk factors of an unplanned second craniotomy in patients with traumatic brain injury (TBI).MethodsA total of 219 patients with TBI who underwent initial unilateral intracranial supratentorial surgery between January 2016 to November 2021 were included. We evaluated the causes of an unplanned second craniotomy in 40 patients, and analyzed the risk factors for a contralateral second craniotomy in 21 patients using a multivariate logistic regression analysis.ResultsThe most common cause for an unplanned second craniotomy was delayed or enlarged hematoma in the non-operation area (26/40; 65%), followed by recurrent hematoma in the operation area (8/40; 20%), ipsilateral massive cerebral infarction (3/40; 7.5%), diffuse brain swelling (2/40; 5%) and enlarged cerebral contusion (1/40; 2.5%). Multivariate logistic regression analysis showed that a contralateral craniocerebral injury feature (CCIF) (OR = 13.175), defined on preoperative computerized tomography scanning, was independent risk factor for a contralateral second craniotomy.ConclusionsAn unplanned second craniotomy in patients with TBI was mainly related to delayed or enlarged hematoma. An increased risk of a contralateral second craniotomy occurs in patients with CCIF.

Postoperative Delirium After Intracranial Surgery: A Retrospective Cohort Study.

The clinical relevance of postoperative delirium (POD) in neurosurgery remains unclear and should be investigated because these patients are vulnerable. Hence, we investigated the impact of POD, by means of incidence and health outcomes, and identified independent risk factors. Adult patients undergoing an intracranial surgical procedure in the Erasmus Medical Center Rotterdam between June 2017 and September 2020 were retrospectively included. POD incidence, defined by a Delirium Observation Screening Scale (DOSS) ≥3 or antipsychotic treatment for delirium within 5 days after surgery, was calculated. Logistic regression analysis on the full data set was conducted for the multivariable risk factor and health outcome analyses. After including 2901 intracranial surgical procedures, POD was present in 19.4% with a mean onset in days of 2.62 (standard deviation, 1.22) and associated with more intensive care unit admissions and more discharge toward residential care. Onset of POD was not associated with increased length of hospitalization or mortality. We identified several independent nonmodifiable risk factors such as age, preexisting memory problems, emergency operations, craniotomy compared with burr-hole surgery, and severe blood loss. Moreover, we identified modifiable risk factors such as low preoperative potassium and opioid and dexamethasone administration. Our POD incidence rates and correlation with more intensive care unit admission and discharge toward residential care suggest a significant impact of POD on neurosurgical patients. We identified several modifiable and nonmodifiable risk factors, which shed light on the pathophysiologic mechanisms of POD in this cohort and could be targeted for future intervention studies.

Navigation guidance in neuroendoscopic management of complex hydrocephalus

Patients with multiloculated hydrocephalus have multiple, separate abnormal CSF collections with no communication between them. Causes include complications of neonatal meningitis, germinal matrix hemorrhage in neonates, head trauma, and intracranial surgery. Endoscopic fenestration with shunt insertion is a safe and less invasive technique as the initial treatment. In this video, the authors demonstrate a few cases in which electromagnetic navigation was used with a stylet inserted through the operating endoscope to guide the surgeon. Modalities such as insertion of intraventricular contrast and fluorescein may be used as adjuvants, as demonstrated. The use of navigation helps to identify distorted anatomical landmarks and guides surgery. The video can be found here: https://stream.cadmore.media/r10.3171/2023.1.FOCVID22152.