Postoperative Meningitis Research Articles

Contribution of watertight dural closure to prevention of postoperative cerebrospinal fluid leakage in endoscopic transnasal surgery for intradural lesions.

The goal of this study was to evaluate the efficacy of watertight dural closure (WTDC) in preventing postoperative CSF leakage during extended endoscopic transnasal surgery (ETS) for skull base tumors, while preserving sinonasal quality by omitting the routine use of a nasoseptal flap. This retrospective study included 28 patients who underwent ETS and experienced Esposito grade 3 CSF leakage at a single institution between June 2022 and June 2024. WTDC was performed using fascia lata grafts and various suturing techniques. Surgical videos and electronic medical records were reviewed to assess suturing times and postoperative outcomes. The efficacy of WTDC in preventing CSF leakage was evaluated, and the technical aspects of the procedure were analyzed. Among the 28 patients (14 female, 14 male), WTDC was successfully achieved in 14 cases, with near-watertight closure in the remaining 14. The average suturing time decreased with experience, showing a trend of improved efficiency. No postoperative CSF leaks were observed, and 1 case of postoperative meningitis resolved without sequelae. Despite significant risk factors for CSF leakage, WTDC was effective in all patients without the routine use of lumbar drainage. WTDC in ETS is a reliable method for preventing postoperative CSF leakage, particularly in complex skull base surgeries with high-risk factors. This technique avoids the complications associated with nasoseptal flap use, preserves sinonasal quality, and reduces the need for lumbar drainage, making it a valuable option for skull base reconstruction.

Intra-infundibular Epidermoid Cysts- A Distinct and Rare Entity.

Epidermoid cyst (EC) located completely within the pituitary infundibulum is a rare entity with only seven reported cases. In this study, we have described our experience with resection of intra-infundibular epidermoid cysts (IECs) and reviewed the existing literature highlighting its distinguishing features and operative nuances. Three consecutive cases of IEC operated at our institute was retrospectively studied. PubMed and EMBASE databases were searched, and seven case reports of IEC were found. Relevant clinical, radiological, operative data of ten cases were analyzed. The median age at diagnosis was 53.5 years and six cases were males. Preoperatively, although the average tumor size was only 1.62 cm3, 80% of patients had visual disturbance, and 78% of patients had deficiency in pituitary hormones. Five patients had preoperative diabetes insipidus. Mild diffusion restriction was noted in four out of five cases that mentioned it. The most common differential diagnosis considered was Rathke's cleft cyst and craniopharyngioma. Adhesion of the cyst wall to the stalk and/or the hypothalamus was a common occurrence resulting in residual wall being left behind in 50% cases. Expanded endoscopic endonasal approach was utilized in nine cases and one case underwent fronto-temporal craniotomy with resection via pretemporal approach. Postoperative chemical meningitis was demonstrated in two cases and sterile abscess was noted in another case. IECs are rare tumors that are often misdiagnosed preoperatively. They have different postoperative morbidity profiles compared to other cystic lesions in the infundibulum. This makes it important to recognize this distinct entity.

Clinical Insights and Outcomes in Community-Acquired Acute Bacterial Meningitis versus Postoperative Bacterial Meningitis.

To compare the demographics, clinical characteristics, and in-hospital mortality rates between community-acquired bacterial meningitis cases and postoperative bacterial meningitis. Analytical study. Place and Duration of the Study: Department of Infectious Diseases and Clinical Microbiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkiye, from 2016 to 2022. A total of 153 patients diagnosed with bacterial meningitis were included and categorised into two groups: 95 (62.1%) with community-acquired bacterial meningitis (CABM) and 58 (37.9%) with postoperative bacterial meningitis (POBM). Demographics, clinical features, laboratory, paraclinical findings, treatments, and outcomes of the cases were compared. Data were retrieved using a standard data collection form from the electronic medical records. A substantial portion (58.8%) of all patients had comorbidities. Fever was the common symptom in all groups. Headache, neck stiffness, nausea, and vomiting were more often observed in the CABM group (p <0.001). Upon admission, the CABM exhibited higher levels of white blood cell count, C-reactive protein, and procalcitonin (p = 0.017, p = 0.004, p = 0.007, respectively). Overall 33.1% had positive cerebrospinal fluid cultures. The overall mortality rate was 26.8%. POBM was associated with longer hospital and intensive care unit (ICU) stays (p <0.001). Shorter treatment durations, lower Glasgow coma scale scores (GCS), higher Charlson Comorbidity Index values, and elevated markers of inflammation were related to mortality. This study illuminates the differences in clinical presentations and outcomes between community-acquired and postoperative bacterial meningitis. It also suggests that factors such as lower GCS scores, comorbidities, and elevated inflammation markers at the last follow-up may be associated with unfavourable clinical outcomes in bacterial meningitis. Postoperative meningitis, Central nervous system infection, Cerebrospinal fluid, Antibiotics.

A Reliable Closure Technique for Retromastoid Craniotomy to Avoid Cerebrospinal Fluid Leaks and Meningitis

BACKGROUND AND OBJECTIVES: Postoperative cerebrospinal fluid (CSF) leaks and meningitis are well-known risks of retromastoid craniotomy. Use of abdominal fat grafts, collagen allografts, and rigid or semirigid buttresses have demonstrated efficacy in preventing CSF leaks and meningitis in endoscopic endonasal surgery. This study aims to determine the utility of a similar multilayered reconstruction technique for retromastoid craniotomy. METHODS: We retrospectively reviewed 212 consecutive patients who underwent retromastoid craniotomy for tumor removal or microvascular decompression from 2007 to 2022. Scalp incisions were linear or slightly curved, muscle and facia opening was performed sharply avoiding monopolar cautery; craniotomies had a maximum dimension of 3 cm. A primary water-tight dural closure was rarely achieved favoring collagen sponge overlay often augmented with autologous fat. Clinical factors including pathology, mastoid air cell entry, and reconstruction material were analyzed. Outcomes including postoperative CSF leakage and meningitis were assessed. RESULTS: Of 212 patients (mean age 56 ± 16 years; 60% female; 10% with prior surgery), 148 (70%) had tumor resection and 64 (30%) had microvascular decompression. Mastoid air cells were breached in 67%. Collagen sponge dural overlay was used in 201/212 (95%). A fat graft was placed in 116 (55%) cases: 69% with air cell entry, 27% without air cell entry; 158 (75%) patients had their bone flap replaced, 46 (21%) had titanium mesh cranioplasty, 8 (4%) had no bone flap or titanium mesh. There were no CSF leaks or meningitis. One patient had a lumbar drain placement preoperatively, none postoperatively. Median length of stay was 2 days. CONCLUSION: Retromastoid craniotomy multilayered reconstruction with liberal use of collagen sponge and abdominal fat grafts seems to reliably avoid postoperative CSF leaks and meningitis including in the setting of nonwatertight dural closure and mastoid cell entry. Use of shorter incisions, avoidance of monopolar cautery, and a relatively small craniotomy may contribute to the absence of CSF leaks in this series.

Predictors of length of postoperative stay following endoscopic skull base surgery with intraoperative CSF leak.

Establishing benchmarks for length of stay (LOS) may inform strategies to improve resource efficiency, decrease costs, and advance care quality. In this study, the authors characterize postoperative LOS in endoscopic skull base surgery (ESBS) and elucidate prolonging factors. A retrospective chart review was conducted at a tertiary academic center including consecutive adult patients who underwent intradural ESBS with intraoperative CSF leak during primary repair between July 2018 and March 2024. LOS, calculated as the time between the end of anesthesia until discharge from the hospital, comprised the primary outcome. Categorical and continuous independent study variables were assessed for univariate LOS association via the Mann-Whitney U-test and Kendall's tau-b correlation, respectively, and those with significant associations were included as multiple linear regression inputs. One hundred sixty-three patients were included, with a median LOS of 4.0 (interquartile range [IQR] 2.8-5.8) days. LOS was significantly prolonged in high-flow (n = 82) compared with low-flow (n = 81) CSF leak cohorts (median 4.5 [IQR 3.9-6.5] vs 2.9 [IQR 2.1-4.7] days, p = 0.002). Defects involving the anterior cranial fossa (n = 16, median 4.6 [IQR 3.3-7.5)] days), suprasellar region (n = 94, median 4.4 [IQR 3.2-6.4] days), sella (n = 138, median 3.9 [IQR 2.8-5.8] days), or posterior cranial fossa (n = 17, median 4.5 [IQR 3.9-6.5] days) had variable LOSs. On multiple linear regression, after controlling for numerous patient, surgical, and postoperative factors, lesion diameter (B = 0.16, 95% CI 0.048-0.26), bone defect area (B = 0.008, 95% CI 0.001-0.014), anesthesia time (B = 0.015, 95% CI 0.004-0.026), bed rest length (B = 2.34, 95% CI 1.12-3.56), postoperative CSF leak (B = 11.06, 95% CI 4.11-18.01), postoperative meningitis (B = 11.79, 95% CI 4.83-18.74), postoperative stroke/hemorrhage (B = 25.25, 95% CI 18.43-32.06), and postoperative pneumonia (B = 5.59, 95% CI 0.79-10.38) independently predicted overall prolonged LOS. With healthcare utilization receiving increased attention, mitigating factors that extend LOS are important. Extent of surgery and certain postoperative complications may constitute key factors prolonging LOS following intradural ESBS with intraoperative CSF leak.

Endoscopic Endonasal Reconstruction of Intraoperative Cerebrospinal Fluid Leak in Different Skull Base Regions: Outcomes, Meningitis, and Risk Factors

ObjectiveVarious non-vascularized or vascularized techniques have been adopted in endoscopic endonasal surgery (EES) for repairing intraoperative cerebrospinal fluid (CSF) leaks after tumor resection. Vascularized nasoseptal flaps (VNSF), free nasoseptal grafts (FNSG), free turbinate grafts (FTG), fascia lata and mashed muscle (FLMM) are frequently used. Outcomes of those grafts applied in the defects of different regions need to be clarified. MethodsThe data from a series of 162 patients with skull base tumor who underwent EES that had intraoperative CSF leak between Jan 2012 and Jan 2021 were retrospectively analyzed. The regions included anterior skull base (ASB), sellar region, clivus and infratemporal fossa (ITF). Repair failure rate (RFR), meningitis rate and associated risk factors were assessed. ResultsIn total, 172 reconstructions were performed in 162 patients for the four sites of the skull base. There were 7 cases (4.3%) that had postoperative CSF leaks, which required second repair. The RFR for ASB, sellar region, clivus, and ITF was 2.6%, 2.2%, 16.7%, and 0%, respectively. The clivus defect was an independent risk factor for repair failure (P<0.01). The postoperative meningitis rate was 5.6%. Repair failure was an independent risk factor for meningitis (P < 0.01). ConclusionsVNSF, FNSG, FTG, FLMM are reliable autologous materials for repairing the dural defects in different regions during EES. Clivus reconstruction remains a great challenge, which had a higher RFR and meningitis rate. Repair failure is significantly associated with postoperative meningitis.

Clinical Evaluation of Dural (Spinal) Membrane Repair Materials

To select high-quality and cost-effective dural (spinal) membrane repair materials, in order to reduce the cost of consumables procurement, save medical insurance funds, and optimize hospital operation and management. Taking the BS06B disease group (spinal cord and spinal canal surgery without extremely severe or severe complications and comorbidities, mainly diagnosed as congenital tethered cord syndrome) as an example, a retrospective analysis was conducted on the relevant data of surgical treatment for congenital tethered cord syndrome conducted in our hospital from January 2021 to June 2023. Safety and efficacy indicators in clinical application (incidence of postoperative epidural hemorrhage, incidence of postoperative purulent cerebrospinal meningitis, incidence of cerebrospinal fluid leakage, surgical duration, and postoperative hospital stay) were compared. There was no difference in safety and effectiveness between different brands of dura mater repair materials. For the repair of small incisions in dura mater surgery, high-quality and cost-effective dura mater repair materials can be selected to reduce hospital costs and control expenses for the disease group.

Frontal sinus reconstruction with overlapping sinus mucosa and vascularized pericranial flap Coverage after modified transbasal bifrontal craniotomy: Novel technique and clinical outcomes

BackgroundThe modified transbasal bifrontal craniotomy is a variant of the bifrontal craniotomy with a wider surgical corridor than the standard approach. There are several methods for frontal sinus repair in bifrontal craniotomy. This study reports a novel method for frontal sinus repair in the modified transbasal interhemispheric approach by precisely overlapping the frontal sinus mucosa margin (without frontal sinus mucosa exenteration) with packing the frontal sinus with povidone-soaked gel foam and covering it with a vascularized pericranial flap. MethodsIn this case series, we retrospectively collected the clinical outcomes regarding cerebrospinal fluid (CSF) leakage, meningitis, and mucocele formation of patients who underwent modified transbasal bifrontal craniotomy at Vara Hospital. ResultsFrom January 2016 to December 2021, 65 patients with anterior skull-base lesions were treated with a modified transbasal interhemispheric approach with frontal sinus repair by overlapping frontal sinus mucosa with gel foam packing and vascularized pericranium flap covering. There was no case of postoperative CSF leakage, meningitis, or mucocele formation during the follow-up period of 19.2 months (min 1, max 73). ConclusionsWe demonstrated that the modified transbasal interhemispheric approach with frontal sinus repair using gel foam packing and pericranial flap is effective in preventing postoperative CSF leakage and meningitis.

Impact of the Lumbar Catheter on the Incidence of Postsurgical Meningitis in the Endoscopic Endonasal Approach

Abstract Objectives Endoscopic endonasal approach (EEA) procedures are inherently contaminated due to direct access through the nasopharyngeal mucosa. The reported rate of postoperative meningitis in EEA procedures is between 0.7 and 10%. Lumbar catheters are used in EEA surgeries to prevent cerebrospinal fluid (CSF) fistulae, but their use is associated with increased infection rates. This study investigated whether there is a difference in rates of postoperative meningitis based on lumbar catheter (LC) utilization. Methods We performed a retrospective review of consecutive patients who underwent EEA surgeries between January 2016 and March 2023 at a single institution (Fundación para la Lucha contra las Enfermedades Neurológicas de la Infancia). Main Outcome Incidence of meningitis following EEA surgery with lumbar catheter. Results Seventy-two patients were enrolled, median age was 44 years, and 53% were female. The most frequent surgery performed was craniopharyngioma 46% (26 patients). A LC was used in 28 patients. Meningitis was diagnosed in 11 of 72 patients (15.2%), being higher in the LC group (10 patients). The odds ratio for the development of meningitis in the presence of an LC was 23.38 (95% confidence interval, 2.77–123.78; p &lt; 0.004). There was no statistical difference in the reported incidence of meningitis when CSF leak was present. Conclusions This study demonstrates an extremely high incidence of meningitis (36%) following EEA procedures when an LC is used. The incidence of meningitis was not significantly associated with CSF leak in our cohort.

Periventricular and Intraventricular Tumors in a Low-Income Country: Hard Learning Curve and Outcome of a Young Neurosurgeon from Burkina Faso

Background: Periventricular and Intraventricular processes are life-threatening conditions because of their propensity to obstruct Cerebrospinal fluid pathways and to compress highly functional and vital structures. There are deep-seated lesions requiring rigorous microsurgical technic for their resection. Methods: We retrospectively analyzed the profile and outcome of Periventricular and intraventricular processes operated by the same author since his return in his country in 2015, after graduated abroad in WFNS Rabat training center program 2023. Result: We defined 15 patients operated over 8 years. There were 4 processes in lateral ventricle (26.6%), 1 in third ventricle (6.6%), 2 thalamus processes (13.3%), 4 in fourth ventricle (26.6%) and finally 4 in cerebellar hemisphere and violating the fourth ventricle (26.6%). Various surgical approaches were used, such as contralateral interhemispheric transcallosal, classical interhemispheric transcallosal, Subfrontal transbasal translamina terminalis, Frontal Transcortical, Temporal trans T2, ventriculoperitoneal shunting, endoscopy, cerebellar transcotical approach and Telovelar approach. Surgical procedure duration was more than 10 hours in 12 cases (80%) and one third of the patients have been operated in 2018. When neurosurgical operative microscope was not available, ophthalmologic microscope or binocular with headlight were used to achieve the resection. Pathological examination revealed High-grade glioma, subependymal giant cell astrocytoma (SEGA), central neurocytoma, Subependymoma, Hemangioblastoma, pilocytique astrocytoma, Medulloblastoma, gemiocytic astrocytoma, atypical papilloma of choroid plexus, craniopharygioma and cyst of septum pellucidum. We reported good postoperative outcome in 10 cases (66.6%), moderate postoperative deficit in 1 case and 4 cases of postoperative death (26.6%) among which 3 cases of postoperative meningitis. Conclusion: Periventricular and intraventricular processes can be safely approach in low-income country with acceptable result. However young African Neurosurgeon should be trained to be comfortable with multiple surgical approaches and also with binocular as well as with microscope. WFNS training program is a strong basement for the take-off of young African neurosurgeon. Backing home should be the rule after training, to develop neurosurgery.

502 Endoscopic Versus Microsurgery Resection of Third Ventricle Colloid Cysts: A Single-center Case-series of 140 Consecutive Patients

INTRODUCTION: The resection of colloid cysts of third ventricle can be done with either open microsurgery or endoscopy with each having different cons and pros. METHODS: Data of patients who underwent surgical resection of third ventricle colloid cyst via either endoscopic or microsurgery approach by a single surgeon between 2005-2020 were retrospectively collected. After administration of criteria, 140 records were retrieved (60 through endoscopic and 80 by trans-cranial microsurgery). Clinical and surgical measures were compared between approaches after adjustment for confounders with generalized linear multivariate regression. RESULTS: Length of hospital stay, postoperative meningitis, and operation time, cyst size, and baseline comorbidities did not differ between groups. Gross total resection (GTR) was achieved for all cases in microsurgery group while in endoscopic group it was lower (90% vs 100%; p = 0.005). Intraoperative hemorrhage occurred in 14 (23.3%) of endoscopic patients while for microscopic group it was zero (p &lt; 0.001). Post-operative shunt was required for two patients (one in endoscopic group and the other in microscopic group). Two patients had tumor recurrence, both being in endoscopic group. No mortality was detected in either group. Multivariate analyses were insignificant for the effects of clinical and demographic factors in occurrence of worse surgical outcomes (non-GTR and hemorrhage). CONCLUSIONS: Rate of intra-operative hemorrhage was higher in endoscopic method and GTR was lower, even after adjustment for other factors. This could be due to technologic shortcomings and limited space for resection maneuvers and complication management.

Predictive factors of hydrocephalus development in pediatric patients undergoing hemispherectomy for intractable epilepsy.

Hemispherectomy surgery is an effective procedure for pediatric patients with intractable hemispheric epilepsy. Hydrocephalus is a well-documented complication of hemispherectomy contributing substantially to patient morbidity. Despite some clinical and operative factors demonstrating an association with hydrocephalus development, the true mechanism of disease is incompletely understood. The aim of this study was to investigate a range of clinical and surgical factors that may contribute to hydrocephalus to enhance understanding of the development of this complication and to aid the clinician in optimizing peri- and postoperative surgical management. A retrospective chart review was conducted on all pediatric patients younger than 21 years who underwent hemispherectomy surgery at the Cleveland Clinic between 2002 and 2016. Data collected for each patient included general demographic information, neurological and surgical history, surgical technique, pathological analysis, presence and duration of perioperative CSF diversion, CSF laboratory values obtained while an external ventricular drain (EVD) was in place, length of hospital stay, postoperative aseptic meningitis, and in-hospital surgical complications (including perioperative stroke, hematoma formation, wound breakdown, and/or infection). Outcomes data included hemispherectomy revision and Engel grade at last follow-up (based on the Engel Epilepsy Surgery Outcome Scale). Data were collected for 204 pediatric patients who underwent hemispherectomy at the authors' institution. Twenty-eight patients (14%) developed hydrocephalus requiring CSF diversion. Of these 28 patients, 13 patients (46%) presented with hydrocephalus during the postoperative period (within 90 days), while the remaining 15 patients (54%) presented later (beyond 90 days after surgery). Multivariate analysis revealed postoperative aseptic meningitis (OR 7.0, p = 0.001), anatomical hemispherectomy surgical technique (OR 16.3 for functional/disconnective hemispherectomy and OR 7.6 for modified anatomical, p = 0.004), male sex (OR 4.2, p = 0.012), and surgical complications (OR 3.8, p = 0.031) were associated with an increased risk of hydrocephalus development, while seizure freedom (OR 0.3, p = 0.038) was associated with a decreased risk of hydrocephalus. Hydrocephalus remains a prominent complication following hemispherectomy, presenting both in the postoperative period and months to years after surgery. Aseptic meningitis, anatomical hemispherectomy surgical technique, male sex, and surgical complications show an association with an increased rate of hydrocephalus development while seizure freedom postsurgery is associated with a decreased risk of subsequent hydrocephalus. These findings speak to the multifactorial nature of hydrocephalus development and should be considered in the management of pediatric patients undergoing hemispherectomy for medically intractable epilepsy.

Sellar Reconstruction With a Bioabsorbable Plate After Endoscopic Transsphenoidal Pituitary Adenoma Resection: Safe and Efficacious.

To report outcomes of a large cohort of patients who underwent endoscopic endonasal transsphenoidal surgery (EETS) for resection of a pituitary adenoma with subsequent Resorb-X plate (RXP) sellar reconstruction. A retrospective review of 620 EETS operations performed at a single academic center between 2005 and 2020 was conducted. A total of 215 EETS operations of 208 patients were identified between 2012 and 2020 who underwent reconstruction with the RXP after EETS for pituitary tumor resection with a final pathologic diagnosis of pituitary adenoma. Analysis of pooled data revealed a mean preoperative tumor volume of 6.8 cm3 (range: 0.038-51.03 cm3). Postoperative cerebrospinal fluid leak occurred in 2 patients (0.93%). Postoperative meningitis occurred in 1 patient (0.47%). There were no cases of RXP extrusion. The rate of postoperative CSF leak and meningitis after use of the RXP for sellar reconstruction compares favorably to other methods, including use of autologous grafts and flaps. Use of RXP during EETS is a safe and efficacious method of sellar reconstruction and may obviate the need for autologous tissue reconstruction after pituitary adenoma resection.

Evaluation of surgical treatment strategies and outcome for cerebral arachnoid cysts in children and adults

ObjectiveThe best treatment strategies for cerebral arachnoid cysts (CAC) are still up for debate. In this study, we present CAC management, outcome data, and risk factors for recurrence after surgical treatment, focusing on microscopic/endoscopic approaches as compared to minimally invasive stereotactic procedures in children and adults.MethodsIn our single-institution retrospective database, we identified all patients treated surgically for newly diagnosed CAC between 2000 and 2022. Microscopic/endoscopic surgery (ME) aimed for safe cyst wall fenestration. Stereotactic implantation of an internal shunt catheter (STX) to drain CAC into the ventricles and/or cisterns was used as an alternative procedure in patients aged ≥ 3 years. Treatment decisions in favor of ME vs. STX were made by interdisciplinary consensus. The primary study endpoint was time to CAC recurrence (TTR). Secondary endpoints were outcome metrics including clinical symptoms and MR-morphological analyses. Data analysis included subdivision of the total cohort into three distinct age groups (AG1, < 6 years; AG2, 6–18 years; AG3, ≥ 18 years).ResultsSixty-two patients (median age 26.5 years, range 0–82 years) were analyzed. AG1 included 15, AG2 10, and AG3 37 patients, respectively. The main presenting symptoms were headache and vertigo. In AG1 hygromas, an increase in head circumference and thinning of cranial calvaria were most frequent. Thirty-five patients underwent ME and 27 STX, respectively; frequency did not differ between AGs. There were two (22.2%) periprocedural venous complications in infants (4- and 10-month-old) during an attempt at prepontine fenestration of a complex CAC, one with fatal outcome in a 10-month-old boy. Other complications included postoperative bleeding (2, 22.2%), CSF leaks (4, 44.4%), and meningitis (1, 11.1%). Overall, clinical improvement and significant volume reduction (p = 0.008) were seen in all other patients; this did not differ between AGs. Median follow-up for all patients was 25.4 months (range, 3.1–87.1 months). Recurrent cysts were seen in 16.1%, independent of surgical procedure used (p = 0.7). In cases of recurrence, TTR was 7.9 ± 12.7 months. Preoperative ventricular expansion (p = 0.03), paresis (p = 0.008), and age under 6 years (p = 0.03) were significant risk factors for CAC recurrence in multivariate analysis.ConclusionsIn patients suffering from CAC, both ME and STX can improve clinical symptoms at low procedural risk, with equal extent of CAC volume reduction. However, in infants and young children, CAC are more often associated with severe clinical symptoms, stereotactic procedures have limited use, and microsurgery in the posterior fossa may bear the risk of severe venous bleeding.

Postoperative shunt failure following hemispherectomy in pediatric patients with pre-existing hydrocephalus

ObjectiveThe risk of hydrocephalus following hemispherectomy for drug resistant epilepsy (DRE) remains high. Patients with pre-existing hydrocephalus pose a postoperative challenge, as maintaining existing shunt patency is necessary but lacks a clearly defined strategy. This study examines the incidence and predictors of shunt failure in pediatric hemispherectomy patients with pre-existing ventricular shunts.MethodsWe performed a retrospective chart review at our center to identify pediatric patients diagnosed with DRE who were treated with ventricular shunt prior to their first hemispherectomy surgery. Demographic and perioperative data were obtained including shunt history, hydrocephalus etiology, epilepsy duration, surgical technique, and postoperative outcomes. Univariate analysis was performed using Fisher’s exact test and Pearson correlation, with Bonferroni correction to a = 0.00625 and a = 0.01, respectively.ResultsFive of nineteen (26.3%) patients identified with ventriculoperitoneal shunting prior to hemispherectomy experienced postoperative shunt malfunction. All 5 of these patients underwent at least 1 shunt revision prior to hemispherectomy, with a significant association between pre- and post-hemispherectomy shunt revisions. There was no significant association between post-hemispherectomy shunt failure and valve type, intraoperative shunt alteration, postoperative external ventricular drain placement, hemispherectomy revision, lateralization of shunt relative to resection, postoperative complications, or postoperative aseptic meningitis. There was no significant correlation between number of post-hemispherectomy shunt revisions and age at shunt placement, age at hemispherectomy, epilepsy duration, or shunt duration prior to hemispherectomy.ConclusionsEarlier shunt revision surgery may portend a subsequent need for shunt revision following hemispherectomy. These findings may guide neurosurgeons in counseling patients with pre-existing ventricular shunts prior to hemispherectomy surgery.

Usefulness of cerebrospinal fluid presepsin (soluble CD14 subtype) as a new marker in the diagnosis of neurosurgical postoperative meningitis.

To determine the usefulness of cerebrospinal fluid (CSF) presepsin in the diagnosis of neurosurgical postoperative meningitis (POM). The study included patients admitted to the Department of Neurosurgery, Toho University Medical Center Omori Hospital from May 1, 2020 to March 31, 2022 with suspected meningitis after neurosurgery who clinically required CSF sampling and patients who underwent CSF sampling for examination of idiopathic normal pressure hydrocephalus (iNPH). Participants were divided into a POM and a postoperative non meningitis (PONM) group based on the POM diagnostic criteria established for this study. The control group included patients from whom a CSF sample for iNPH was collected by tap test. A total of 238 CSF samples were collected from 90 patients. There were 39 samples in the POM, 180 samples in the PONM, and 19 samples in the control group. CSF presepsin levels in the POM were significantly higher than in the PONM group (1764.5 and 440.9 pg./mL, respectively; p < 0.0001). The control group had CSF presepsin levels of 95.5 pg./mL. A cutoff value of 669 pg./mL for CSF presepsin in POM and PONM groups had 76.9% sensitivity and 78.3% specificity for the diagnosis of POM. In analyzes including only subarachnoid hemorrhage (SAH) cases (123 samples), CSF presepsin (1251.2 pg./mL) in the POM was significantly higher than in the PONM subgroup (453.9 pg./mL; p < 0.0001). The cutoff value for presepsin in CSF among patients with SAH (669 pg./mL) had 87.5% sensitivity and 76.6% specificity, similar to that of all patients. CSF presepsin is a useful marker in the diagnosis of neurosurgical POM even in patients with blood components, such as SAH. When POM is suspected, measurement of CSF presepsin may be recommended in addition to a general CSF examination.

A novel multilayered membrane repair technique for high-flow cerebrospinal fluid leaks during expanded endoscopic endonasal tumor resection.

Postoperative cerebrospinal fluid (CSF) leak is a life-threatening complication following endoscopic skull base surgery. This study describes a multilayered membrane reconstruction strategy for treating high-flow intraoperative CSF leaks during expanded endoscopic endonasal tumor resection (EEA) and presents the associated outcomes, supplemented by surgical video documentation. A retrospective review was performed on patients who underwent multilayered membrane reconstruction for high-flow CSF leaks during EEA. From January 2019 to June 2023, 15 patients undergoing EEA experienced high-flow intraoperative CSF leaks and received multilayered membrane reconstruction. Tumor pathologies included pituitary adenoma, craniopharyngioma, and meningioma. After a median postoperative follow-up of 13 months, no postoperative CSF leakage, intracranial infection, meningitis, and pneumocephalus was detected. Our preliminary experience indicates that the multilayered membrane reconstruction technique may be a reliable method for achieving a watertight closure of high-flow intraoperative CSF leaks during EEA and warrants further study.

The value of elevated cerebrospinal fluid lactate concentrations in post-neurosurgical bacterial meningitis

Bacterial meningitis is a serious complication after neurosurgery and has a high mortality rate. Early diagnosis and timely treatment are crucial or will have disastrous consequences. The classic triad of bacterial meningitis lacks sensitivity and specificity. Therefore, the diagnosis of post-neurosurgical bacterial meningitis relies on cerebrospinal fluid. But traditional cerebrospinal fluid parameters are not completely reliable in diagnosing post-neurosurgical bacterial meningitis. Previous studies have found that CSF lactate concentration is related to bacterial meningitis. But, after the craniocerebral operation, the cerebrospinal fluid of most patients is bloody. Whether red blood cells interfere with diagnosing PNBM based on lactate concentration is limited. In the current study, we further analysis on whether red blood cells interfere with diagnosing PNBM based on lactate concentration. This study aimed to investigate the value of cerebrospinal fluid lactate concentrations in post-neurosurgical bacterial meningitis. A prospective observational study was performed on 62 patients at Kunshan First People’s Hospital’s intensive care unit affiliated with Jiangsu University. We found that erythrocytes do not affect cerebrospinal fluid lactate, and elevated lactate concentrations can be used as a marker for postoperative bacterial meningitis.

Comparison of prophylactic antibiotics for endonasal transsphenoidal surgery using a national inpatient database in Japan.

The choice of prophylactic antibiotics for use in endonasal transsphenoidal surgery (ETSS) lacks universal standards. This study aimed to investigate the effectiveness of cefazolin, ampicillin and third-generation cephalosporins for preventing postoperative meningitis and secondary outcomes (in-hospital death and the combination of pneumonia and urinary tract infection) in patients who have undergone ETSS. The study used data from the Diagnosis Procedure Combination database in Japan. Data from 10 688 patients who underwent ETSS between April 2016 and March 2021 were included. Matching weight analysis based on propensity scores was conducted to compare the outcomes of patients receiving cefazolin, ampicillin or third-generation cephalosporins as prophylactic antibiotics. Of the 10 688 patients, 9013, 102 and 1573 received cefazolin, ampicillin and third-generation cephalosporins, respectively. The incidence of postoperative meningitis did not significantly differ between the cefazolin group and the ampicillin group (OR, 1.02; 95% CI, 0.14-7.43) or third-generation cephalosporins group (OR, 0.81; 95% CI, 0.10-6.44). Similarly, in-hospital death and the composite incidence of pneumonia and urinary tract infection did not differ between the cefazolin group and the ampicillin or third-generation cephalosporins group. Cefazolin, ampicillin and third-generation cephalosporins as perioperative prophylactic antibiotics for ETSS do not differ significantly in terms of preventing meningitis.

Endoscopic surgery versus craniotomy for spontaneous intracerebral hemorrhage in the late elderly patients

ObjectivesTo compare the prognosis of late elderly patients with spontaneous intracerebral hemorrhage (ICH) treated by endoscopic evacuation and craniotomy Materials and MethodsUsing the Diagnosis Procedure Combination database, we identified patients aged ≥ 75 years who underwent surgery for spontaneous ICH within 48 hours after admission between April 2014 and March 2018. Eligible patients were classified into two groups according to the type of surgery (endoscopic surgery and craniotomy). Propensity-score matching weight analysis was conducted to compare the good neurological outcome modified Rankin Scale (mRS) score (0–4) at discharge as the primary endpoint between the two groups. Secondary endpoints were postoperative meningitis, tracheostomy, reoperation within 3 days and total hospitalization costs. ResultsAmong the 5,396 eligible patients, endoscopic surgery and craniotomy were performed in 895 and 4,501 patients, respectively. In the propensity-score matching weight analysis, all covariates were well balanced. The proportions of patients with a good prognosis (mRS score at discharge: 0–4) did not significantly differ between the surgical procedures (42.1% vs. 42.8%, p = 0.828). The proportions of meningitis, tracheostomy and reoperation were not significantly different between the two groups. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (25,536 vs. 29,603 US dollars, p = 0.012). ConclusionsInhospital outcomes did not differ between endoscopic and open surgeries for spontaneous ICH in the late-stage elderly patients aged ≥75 years. Hospitalization costs were significantly higher in the craniotomy group, suggesting that endoscopic surgery may be more acceptable.