Postoperative Cerebrospinal Fluid Research Articles

Prevalence and Impact of Constipation on Reconstructive Outcomes Following Endoscopic Skull Base Surgery

Abstract Objective Postoperative constipation in endoscopic skull base surgery (ESBS) may provoke undesired straining, which, in theory, may create intracranial pressure shifts and impact skull base reconstruction. The purpose of this study is to assess the prevalence and contributing factors to postoperative constipation after ESBS, and whether this impacts reconstructive outcomes. Methods Patients undergoing ESBS between July 2018 and December 2022 at a single-center, tertiary academic skull base surgery program were retrospectively reviewed. Chart reviews were performed to identify average bowel movements per day, indication for surgery, age, sex, body mass index (BMI), history of chronic pain, length of postoperative bedrest, length of stay (LOS), and postoperative use of opioid analgesics. Additionally, use of a standing stool bowel regimen, as-needed (PRN) stool softeners/laxatives, and enemas were recorded. Constipation was defined as greater than 48 hours without a bowel movement. Results In total, 213 patients (115 with intradural pathologies) were identified, of which 146 (69%) patients had postoperative constipation. Postoperative constipation was associated with longer bedrest (1.86 ± 0.20 vs. 1.06 ± 0.12 days; p = 0.011); increased morphine equivalent dose (MED) during postoperative days 2, 3, 5, and 6 (all p < 0.05); and total postoperative MED (106.70 ± 14.01 vs. 46.88 ± 8.44 mg; p < 0.001). Additionally, postoperative constipation was an independent predictor of LOS (p = 0.009). There were no differences in postoperative cerebrospinal fluid (CSF) leak between the groups (p = 0.622). Conclusion Postoperative constipation rates were high after ESBS and likely causative factors include increased immobilization and postoperative opioid use. Standing bowel regimens should be considered in ESBS patients. However, there was no increased rate of postoperative CSF leaks.

Dural Injury During Spinal Surgery and Postoperative Cerebrospinal Fluid Leakage: A Single-Center Experience

Dural Injury During Spinal Surgery and Postoperative Cerebrospinal Fluid Leakage: A Single-Center Experience

Clinical parameters and postoperative outcomes of pituitary adenomas in children: Analysis according to size of adenomas and adopted surgical procedures.

Pathologies of pediatric pituitary adenomas are uncommon and challenging to diagnose. Pituitary adenomas cause mass effects and neurological disruption in children. Postoperative evaluations of endocrine functions are challenging. The present study categorized adenomas by size and type, and evaluated outcomes based on the surgical procedures adopted. In addition, the present study analyzed the demographic parameters of children as well as the factors supposed to be influencing remission. Clinical characteristics, treatment parameters and postoperative outcomes of curative surgeries in 135 children [80 (59%) females and 55 (41%) males; age 12 (11-13) years at the time of first diagnosis] with pituitary adenomas who underwent curative surgeries operated between 1998 and 2023 in the Yichang Central People's Hospital, (Yichang, China) were included in the present retrospective study. A total of 112 (83%) children had microadenomas (<10 mm adenomas), 6 (4%) had macroadenomas (≥10 mm adenomas) and 17 (13%) had invisible adenomas. Pathological examination revealed that 59 (44%) children had functional adenomas and 10 (7%) had non-functional adenomas. Among functional adenomas, acromegaly (excess secretion of insulin-like growth factor 1) was reported to be the most common [30 (22%)] pediatric adenomas, followed by prolactinomas [prolactin secretion ≥1,000 mIU/l; 20 (15%) and Cushing syndrome (9 (7%)]. A total of 23 (17%), 3 (2%), 4 (3%), 3 (2%) and 3 (2%) children were reported to have remission and underwent re-surgery. These patients (remission) underwent microscopic trans-sphenoidal resection, endoscopic endonasal trans-sphenoidal resection, trans-sphenoidal resection alone, bilateral adrenalectomy and gross total resection adopted curative surgeries initially, respectively. Postoperative diabetes insipidus, adrenal insufficiency and cerebrospinal fluid leaks have been reported in children who have undergone curative surgeries for macroadenomas or Cushing syndrome. Female pediatric patients with clinical manifestations were more likely to have pituitary adenomas. Pediatric patients generally have functional pituitary adenomas, particularly adreno-corticotropin-secreting adenomas. Microscopic trans-sphenoidal resection is associated with a lower risk of under-treatment. Postoperative outcomes and clinical benefits of curative surgeries are based on the complete type of surgical removal and size of the pituitary adenomas mass (Level of Evidence: 3; Technical Efficacy Stage: 4).

Multi-center study on sellar reconstruction after endoscopic transsphenoidal pituitary surgery.

Surgical techniques for sellar reconstruction include no reconstruction, use of synthetic materials, autologous grafts, and/or vascularized flaps. The aim of this study was to conduct a multi-center study comparing the efficacy and postoperative morbidity associated with different sellar reconstruction techniques. A retrospective chart review of patients who underwent endoscopic transsphenoidal surgery for pituitary tumors from five participating sites between January 2021 and March 2023 was performed. The variables included demographics, tumor characteristics, reconstruction technique, postoperative cerebrospinal fluid leak (CSF) leak, and 22-item Sino-Nasal Outcome Test (SNOT-22) scores. Comparisons of postoperative complications, SNOT-22 scores, and duration of surgery by type of onlay reconstruction were evaluated using Fisher's exact test, analysis of variance, and Kruskal‒Wallis test. Five hundred and one patients were identified. The median tumor size was 2.1cm, and 64% were non-functioning. Intraoperative CSF leak was identified in 38% of patients. A total of 89% of patients underwent onlay reconstruction: 49% were reconstructed with mucosal grafts, 35% with nasoseptal flaps, and 5% with other onlay techniques. Nasoseptal flaps were utilized more frequently in the setting of giant pituitary adenomas (>3cm), medial cavernous sinus wall resection, and high-flow intraoperative CSF leaks. Cases who utilized mucosal grafts had an overall shorter operating time (median: 183 min vs. 240 min; p<0.001). Five postoperative CSF leaks were identified, and therefore, statistical analysis could not be performed for this complication. The effectiveness and morbidity of different sellar reconstruction techniques are comparable. Vascularized flaps were utilized more frequently in the setting of larger tumors and high-flow intraoperative CSF leaks.

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.

The hidden risk: Intracranial hemorrhage following durotomies in spine surgery

ObjectiveIntracranial hemorrhage (ICH) after durotomy in elective spine surgery, though rare, can pose a significant risk to patient outcomes. Spine surgeries bear a risk of dural tears (DT) with potential of postoperative cerebrospinal fluid leakage (PCSFL). Excessive PCSFL can precipitate a decrease in intracranial pressure, potentially leading to ICH. Literature on ICH as a postoperative complication is scarce. The aim was to assess the incidence and risk factors of ICH in patients undergoing elective spine surgery. MethodsUtilizing the 2020 National Impatient Sample (NIS) adults (>18 years) were selected by primary procedure category codes for spine fusion, discectomy, spinal cord decompression and cervicothoracic/lumbosacral nerve decompression. Exclusion criteria were trauma and malignancy. The primary outcome was occurrence of ICH. Comparative analysis and a multivariable logistic regression were used to identify independent risk. ResultsIn total, 40,990 patients met our criteria with an incidence of ICH at 0.08%. The ICH-group showed an increased length of stay and higher mortality compared to the control group. Spinal cord decompression, DT and PCSFL were significantly more frequent in patients with ICH. Alcohol, drug abuse and hypertension were significantly more prevalent in patients with ICH. DT, alcohol abuse and hypertension were independent risk factors for ICH. ConclusionsThis study underscores the rarity and severity of ICHs following elective spine surgery, emphasizing awareness and looking for possible preventive measures. Our finding suggests that DT, as a complication of surgical techniques, as well as alcohol abuse and hypertension are significant predictors of ICH.

Endoscopic Transsphenoidal Drainage for Rathke Cleft Cyst With Sellar Xanthogranuloma - Successful Cyst Drainage and Prevention of Postoperative Cerebrospinal Fluid Leakage: 2-Dimensional Operative Video.

The etiology of sellar xanthogranuloma (SXG) remains unclear,1-5 and the surgical strategy for treating SXG is debatable. In this study, we present the surgical case of a symptomatic SXG associated with Rathke cleft cyst. The intraoperative decision to prevent postoperative cerebrospinal fluid (CSF) leakage and secure the drainage route is discussed. A 72-year-old woman presented with severe headaches, visual loss, and gradual enlargement of a cystic lesion on magnetic resonance imaging. The cyst compressed the chiasm upward. The cyst wall was partially thickened and contained a solid mass that was weakly enhanced after gadolinium administration. The endoscopic transsphenoidal cyst was drained, the solid tumor was partially removed for histological diagnosis, and the wide drainage orifice was secured. Intraoperatively, the cyst wall was widely open, but CSF leaked during manipulation of the solid tumor. The sellar floor was partially reconstructed by a multilayer technique to prevent postoperative CSF leakage. The wide cyst drainage route to the sphenoid sinus was also secured. Histologic diagnosis revealed SXG with ciliated columnar epithelium. No postoperative CSF leakage occurred, and the cyst continued to shrink. The patient's visual acuity improved, and pituitary function was preserved. If a CSF leak is identified intraoperatively in a case of secondary SXG associated with Rathke cleft cyst, a cystic fenestration with partial sellar reconstruction may reduce the likelihood of postoperative CSF leakage and ensure continuous drainage. Institutional Review Board approval was not required; The patient consented to the surgery and the publication of her images and surgical video.

Surgical and radiosurgical outcomes for Koos grade 3 vestibular schwannomas.

This study aimed to reveal the preferred initial treatment for Koos grade 3 vestibular schwannomas (VS). We performed a two-institutional retrospective study on 21 patients with Koos grade 3 VS undergoing resection at Yokohama Medical Center and 37 patients undergoing radiosurgery at Yokohama Rosai Hospital from 2010 to 2021. Tumor control, complications, and functional preservation were compared. The median pre-treatment volume and follow-up duration were 2845 mm3 and 57.0 months, respectively, in the resection group and 2127 mm3 and 81.7 months, respectively, in the radiosurgery group. In the resection group, 16 (76.2%) underwent gross total resection, and three patients (14.3%) experienced regrowth; however, no one required additional treatment. In the radiosurgery group, the tumor control rate was 86.5%, and three cases (8.1%) required surgical resection because of symptomatic brainstem compression. Kaplan-Meier analyses revealed that tumors with delayed continuous enlargement and large thin-walled cysts were significantly associated with poor prognostic factors (p = 0.0027, p < 0.001). The pre-radiosurgery growth rate was also associated with the volume increase (p = 0.013). Two cases (9.5%) required additional operation due to complications such as post-operative hematoma and cerebrospinal fluid leaks in the resection group, whereas temporary cranial neuropathies were observed in the radiosurgery group. Two patients (9.5%) had poor facial nerve function (House-Brackmann grading grade 3) in the resection group, while no one developed facial paresis in the radiosurgery group. Trigeminal neuropathy improved only in the resection group.Radiosurgery can be considered for the treatment of Koos grade 3 VS for functional preservation. However, resection may also be considered for patients with severe trigeminal neuropathy or a high risk of volume increments, such as large thin-walled cysts and rapid pre-treatment growth.

Multidisciplinary approach to severe intracranial, intraorbital allergic fungal sinusitis

BackgroundAllergic fungal sinusitis (AFS) is a form of paranasal mycosis that often involves bone destruction and can extend into the orbit and anterior skull base. Intracranial and intraorbital involvement are published but not both in each included patient of a series. The purpose of the present study was to review cases of extensive AFS with orbital or/and skull base erosion, including the presenting symptoms, patient socioeconomic background, imaging features, surgical technique, and post-operative outcomes. MethodsThe records of 30 patients with the histological diagnosis of AFS and both intracranial and intraorbital involvement were reviewed. ResultsThe average age of the patients was 25.2 years. 83 % of patients were male. 70 % were African American. 66 % of patients had Medicaid or were uninsured. Presenting symptoms were headaches (80 %), nasal obstruction (33 %), proptosis (40 %), vision change (23 %), facial pressure (10 %), and decreased sense of smell (7 %). 100 % of patients had bone erosion observed on computerized tomography scans with disease extending intracranially through the anterior skull base or posterior wall of the frontal sinus along with disease that eroded through the lamina papyracea. All patients had failed medical management. All patients underwent surgery by Otolaryngology, Ophthalmology, and Neurosurgery with transnasal endoscopic approaches and orbitotomy. 80 % also underwent a bifrontal craniotomy for removal of intracranial extradural disease with cranialization. 53 % of patients had orbital implants remaining after surgery; 23 % had nasal stents. There were no postoperative cerebrospinal fluid leaks. Average hospital stay was 4.8 days. Preoperatively, 13 % of patients underwent allergy testing. 94 % saw an Allergist postoperatively. 21 % required follow up surgery. ConclusionsA team approach of Otolaryngologists, Ophthalmologists, and Neurosurgeons is recommended for this slowly growing but locally destructive disease. Most patients with AFS will present with headaches and nasal obstruction. While most cases of AFS can be successfully managed with transnasal endoscopic techniques, orbitotomy and craniotomy represents an effective treatment for severe AFS cases with extensive intracranial and intraorbital involvement. This disease is found most commonly in young African American males and in the underinsured.

Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery: Two-center retrospective cohort study.

Over the past two decades, endoscopic endonasal skull base surgery (EESBS) has revolutionized the treatment of skull base tumors by enabling minimal access to resect significant pathologies such as meningiomas, pituitary adenomas, and chordomas. Despite its efficacy, complications such as cerebrospinal fluid (CSF) leak pose significant challenges, with an average incidence of 8.9% following EESBS. Therefore, our study aims to investigate the risk factors associated with postoperative CSF leak after employing an endoscopic endonasal approach for skull base surgery, focusing on patients treated at King Abdul-Aziz Medical City in Jeddah and King Abdullah Medical City in Makkah, Saudi Arabia. A retrospective review of patients who underwent an endoscopic endonasal approach for the resection of intradural skull base pathology between January 2016 and December 2022 was performed with a total of 51 patients. Basic demographic data were collected, along with patient comorbidities, presenting symptoms, tumor pathology, tumor site, the extent of resection, and outcomes. 51 participants were analyzed, with a mean age of 43.41. Male participants comprised (58.8%), while headaches were the most common symptom (74.5%), followed by visual disturbances (51.0%). Nonsecretory tumors predominated, primarily located in the sellar and suprasellar regions (58.8%). Gross total resection was performed in the majority (56.9%), with a 9.8% incidence of postoperative CSF leak. Notably, all four patients with CSF leak experienced preoperative headaches. Hypertension was prevalent in Cases 1 and 4, with Case 4 having a history of neurological disease and radiation therapy. Anterior skull base tumors were most frequent in Cases 3 and 4. The incidence of CSF leakage after surgery in this study was similar to that previously reported. It is worth noting that repeated surgeries may increase the risk of postoperative CSF leakage. Therefore, it is important to carefully evaluate the surgical approach for tumor removal and skull base reconstruction, considering the tumor characteristics and the patient's overall condition.

Dorsal intercostal artery flap; A reliable option for coverage of myelomeningocele defects: A case series.

Meningomyelocele is a common congenital condition and its reconstruction poses a challenge for surgeons. The dorsal intercostal artery (DICA) flap offers a one-stage tension-free closure with adequate results. This study, spanning from January 2019 to September 2022, analyses the outcome of nine DICA flaps for meningomyelocele reconstruction, where the average size of the DICA flap was 6.8 x 4.6 cm for an average defect of 6.33 x 4 cm. Notably, no post-operative blood transfusion was required, nor any complications occurred except for one patient's septic shock-related death. Two had post-operative cerebrospinal fluid (CSF) leak, repaired primarily with one requiring VP shunt. Based on our experience, the DICA flap, with its consistent anatomy, is a reliable option for the reconstruction of meningomyelocele defects.

A phenomenon not to be missed: delayed postoperative cerebrospinal fluid rhinorrhea following no identifiable intraoperative leak in sellar surgery.

A phenomenon not to be missed: delayed postoperative cerebrospinal fluid rhinorrhea following no identifiable intraoperative leak in sellar surgery.

Graftless Primary Dural Closure Following Retrosigmoid Approach: Doing More With less

Achieving watertight dural closure without grafts via the retrosigmoid approach can be challenging, contributing to a significant rate of postoperative cerebrospinal fluid (CSF) leaks. This study describes a dural incision technique for achieving primary dural closure without grafts following the retrosigmoid approach and presents clinical data from the authors' experience. Clinical and surgical data of 227 patients who underwent the dural incision technique following the retrosigmoid approach for various pathologies were retrospectively reviewed. To achieve no-graft watertight dural closure, the dural incision involves two critical steps: a 1 cm transverse incision of the dura parallel to the foramen magnum to drain CSF from the cisterna magna, and a vertical linear opening of the retrosigmoid dura. Dural incisions were closed watertight with vicryl 4/0 running sutures, without the use of grafts, fibrin glue, hemostatic overlays, or dural substitutes. Pre- or postoperative lumbar drainage was not employed. Primary watertight dural closure was successfully achieved in all patients without the use of grafts or duraplasty. The average duration of dura closure was 17.7 minutes. During an average follow-up period of 49.3 months, there were no instances of CSF leaks or meningitis. In the authors' preliminary experience, the linear dural incision described herein was effetcive for achieving a no-graft, watertight primary dural closure in the retrosigmoid approach, with no CSF leaks or meningitis in our series. Validation of these preliminary data in a larger patient cohort is necessary.

Surgical Correction of Orbital Hypertelorism With Absorbable Plate Instead of Frontal and Orbital Bar and Inverted U-Shaped Osteotomy.

The aim of the study is to investigate the effect and feasibility of using absorbable plate instead of frontal and orbital bar and inverted U-shaped osteotomy to correct the widening of orbital distance. The surgical effect and feasibility of using absorbable plate instead of frontal and orbital bridge plus inverted U-osteotomy for orbital widening syndrome in seven cases between January 2019 and February 2022 were retrospectively analyzed. First, the surgical procedure for orbital hypertelorism was inverted U-shaped orbital osteotomy, and a frontal bone flap was removed, exposing the superior orbital margin and the orbital circumference, and the orbital bone was directly cut off by inverted U-shaped osteotomy. The widened bone in the middle of the orbit was removed, and a long absorbable plate was used to replace the orbitofrontal bridge. The two sides of the orbit were fixed on the absorbable plate, and the absorbable plate was fixed on the rear skull. The clinical effect of treatment, complications (such as cerebrospinal fluid leakage and infection), safety, and feasibility of surgery were evaluated. Using absorbable plate instead of fronto-orbital bridge achieved the effect of orbitofrontal bridge, without orbital distance widening, cerebrospinal fluid leakage, and intracranial infection. Operating time was reduced. There was no metal fixation, and there was no risk of a second operation. The effect of replacing the frontal-orbital bridge with an absorbable plate and inverted U-shaped osteotomy is positive, the operation time is short, and the orbital distance is clearly improved. This approach can replace the traditional orbital-distance operation, and the incidence of postoperative cerebrospinal fluid leakage and infection is low. Long-term follow-up results are stable.

Comparative Analysis of Endoscope Obscuration With Utilization of an Endonasal Access Guide for Endonasal Skull Base Surgery.

In endoscopic endonasal approaches (EEAs) for skull base pathologies, endoscope view obscuration remains a persistent, time-consuming, and distracting issue for surgeons and may result in increased operative time. The endonasal access guide (EAG) has been demonstrated as a possible adjunct to minimize these events. However, to date, there have been no comparative studies performed and the potential time savings by using EAGs have yet to be quantified. This cohort study aimed to determine the operative efficiency benefits of the EAG in EEA operations. Analysis of EEA operative videos from an EAG cohort (n = 20) and a control cohort (n = 20) was performed, assessing 12-minute segments in the first, middle, and last third of each operation. The first segment in each cohort was selected before EAG placement, serving as an internal control. Every endoscope lens soiling instance was counted (measured as cleaning actions per minute), timed (obscuration time %), and identified as a withdrawal, irrigation, or other cleaning action. Perioperative variables including skull base repair and postoperative cerebrospinal fluid leakage were assessed. Within the EAG cohort, obscuration time was reduced in the middle and last third compared with the first third (3.73% [CI: 2.39-5.07] vs 12.97% [CI: 10.24-15.70], P < .001; 4.19% [CI: 2.83-5.55] vs 12.97% [CI: 10.24-15.70], P < .001) and cleaning actions were also significantly reduced by EAG (0.69/min [CI: 0.39-0.99] vs 1.67/min [CI: 1.34-2.00], P = .001; 0.66/min [CI: 0.35-0.97] vs 1.67/min [CI: 1.34-2.00], P < .001). Between the control and EAG cohorts, there was no significant difference between obscuration time and cleaning actions in the first third (9.33% vs 12.97%, P = .086; 1.34/min vs 1.67/min, P = .151) or in the middle third (6.24% vs 3.73%, P = .140; 0.80/min vs 0.69/min, P = .335), but there was a significant difference in the last third (9.25% [CI: 6.95-11.55] vs 4.19% [CI: 2.83-5.55], P < .001; 0.95/min [CI: 0.73-1.17] vs 0.66/min [CI: 0.35-0.97], P = .018). EAG significantly reduces lens obscurations and cleaning events, particularly during the intradural portion of operations. This technology may offer a greater time-saving impact with patients undergoing long EEA operations.

Leukocyte- and Platelet-Rich Fibrin versus Commercially Available Fibrin Sealants in Elective Cranial Surgery: A Cost-Minimization Analysis

BackgroundPrevious findings from a clinical trial demonstrated non-inferiority of Leukocyte- and platelet-rich fibrin (L-PRF) compared to commercially available fibrin sealants in preventing postoperative cerebrospinal fluid (CSF) leakage, necessitating intervention. This cost-effectiveness evaluation aims to assess the value-for-money of both techniques for dural closure in supratentorial and infratentorial surgeries. MethodsCost-effectiveness was estimated from a healthcare payer’s perspective alongside a randomized clinical trial comprising 328 patients. The analysis focused on clinical and health-related quality of life (HRQOL) outcomes, as well as direct medical costs including inpatient costs, imaging and laboratory costs, and outpatient follow up costs up to twelve weeks after surgery. ResultsClinical and HRQOL data showed no significant differences between L-PRF (EQ5D 0.75 ± 0.25, SF-36 63.93% ± 20.42) and control (EQ5D 0.72 ± 0.22, SF-36 60.93% ± 20.78) groups. Pharmaceutical expenses during initial hospitalization were significantly lower in the L-PRF group (€190.4, IQR 149.9) than in the control group (€394.4, IQR 364.3), while other cost categories did not show any significant differences, resulting in an average cost advantage of €204 per patient favoring L-PRF. ConclusionThis study demonstrates L-PRF as a cost-effective alternative for commercially available fibrin sealants in dural closure. Implementing L-PRF can lead to substantial cost savings, particularly considering the frequency of these procedures.

Endoscopic endonasal resection of symptomatic Rathke's cleft cysts: outcomes of the strategy to maintain the fenestration open.

The study intends to clarify the optimal endoscopic endonasal surgical strategy for symptomatic Rathke's cleft cysts (RCCs). We retrospectively analyzed patients with RCCs that underwent EEA surgery. The strategy for surgical and reconstruction method selection was presented. Patients were split into groups of fenestration open or closed. Pre- and postoperative symptoms, imaging, ophthalmologic, and endocrinologic exams were reviewed. The incidence of complications and the recurrence rates were determined. The 75 individuals were all received primary operations. The fenestration closed group contained 32 cases, while the fenestration open group contained 43 cases. The median follow-up period was 39 months. The three primary complaints were headache (n = 51, 68.00%), vision impairment (n = 45, 60.00%), and pituitary dysfunction (n = 16, 21.33%). Of the 51 patients with preoperative headaches, 48 (94.12%) reported improvement in their symptoms following surgery. Twenty-three out of 45 patients (51.11%) experienced an improvement in visual impairment. Pituitary dysfunction was found improved in 14 out of 16 individuals (87.50%). There was no discernible difference in the rate of symptom alleviation between both groups. There were three patients (3/75, 4.00%) had cyst reaccumulation. One of them (1/75, 1.33%), which needed reoperation, was healed using pterional approach. In term of complications, cerebral infections occurred in two patients (2/75, 2.67%). Both of them recovered after antibiotic treatment. No postoperative cerebrospinal fluid rhinorrhea occurred. One patient (1/75, 1.33%) in the open group experienced epistaxis. There was no persistent hypopituitarism or diabetes insipidus (DI). Analysis of headache related factors showed that the presence of wax like nodules was related to it. RCC was successfully treated with endoscopic endonasal surgery with few problems when the fenestration was kept as open as feasible. Preoperative identification of T2WI hypointense nodules may be a potential reference factor for surgical indication.

Conventional clinical signs and symptoms are poor predictors of postoperative cerebrospinal fluid leak: A single-centre cohort perspective.

Postoperative cerebrospinal fluid (CSF) leak remains a concerning complication of the endoscopic endonasal approach (EEA) for skull base pathology. Signs and symptoms suggesting CSF leak often trigger additional workup during the postoperative course. We systematically evaluate associations between subjectively reported clinical signs/symptoms noted during the immediate postoperative period and incidence of postoperative CSF leaks. Retrospective chart review was conducted at a tertiary academic medical centre including 137 consecutive patients with intraoperative CSF leak during EEA with primary repair between July 2018 and August 2022. Postoperative CSF leak associations with clinical signs and symptoms were evaluated using positive (PPV) and negative predictive values (NPV), sensitivity, specificity and odds ratio (OR) via univariate logistic regression. Seventy-nine patients (57.7%) had high-flow leaks repaired and 5 (3.6%) developed CSF leaks postoperatively. Of reported symptoms, rhinorrhea was most common (n = 52, 38.0%; PPV [95% CI] = 7.6% [4.8%, 11.9%]), followed by severe headache (n = 47, 34.3%; 6.3% [3.1%, 12.5%]), dizziness (n = 43, 31.4%; 2.3% [0.4%, 12.1%]), salty or metallic taste (n = 20, 14.6%; 9.9% [3.3%, 25.8%]), and throat drainage (n = 10, 7.3%; 9.9% [1.7%, 41.4%]). Nausea or vomiting constituted the most reported sign concerning for CSF leak (n = 73, 53.3%; PPV [95% CI] = 4.1% [2.0%, 8.1%]). On univariate regression, no sign or symptom, including rhinorrhea (OR [95% CI] = 7.00 [0.76-64.44]), throat drainage (3.42 [0.35-33.86]), salty/metallic taste (4.22 [0.66-27.04]), severe headache (3.00 [0.48-18.62]), dizziness (0.54 [0.06-4.94]), fever (3.16 [0.50-19.99]), and nausea/vomiting (1.33 [0.22-8.21]), associated with postoperative CSF leak. A range of subjectively reported symptoms and signs failed to predict postoperative CSF leak. Further investigation is warranted to inform appropriate attention and response.

Extended Endoscopic Endonasal Approach for Giant Pediatric Craniopharyngiomas: Technical Note and Case Series.

Giant pediatric craniopharyngiomas are rare tumors whose clinical and surgical management is extremely challenging. A variety of open transcranial approaches has been used to resect these lesions. Although there has been an increasing acceptance of the endoscopic endonasal approach (EEA) for the resection of pediatric craniopharyngiomas in recent years, many surgeons continue to recommend against the use of the EEA for giant pediatric craniopharyngiomas. This study aimed to evaluate the feasibility of extended EEA for giant craniopharyngiomas in the pediatric population. All consecutive pediatric patients with giant craniopharyngiomas (diameter >4 cm) who underwent endoscopic endonasal surgery at our institution were retrospectively reviewed. Data on demographic information, preoperative assessment, imaging features, surgical results, complications, and recurrences were recorded and analyzed. A total of 16 pediatric patients with an average age of 12 years were identified. The mean maximum diameter and volume of the tumors were 4.35 cm and 24.1 cm3, respectively. Gross total resection was achieved in 13 patients (81.3%) and subtotal resection in 3 patients (18.7%). Postoperatively, partial or complete anterior pituitary insufficiency occurred in 100% of patients, and 62.5% developed new-onset diabetes insipidus. Visual function improved in 9 patients (56.3%) and remained stable in 7 patients (43.7%). Postoperative cerebrospinal fluid leakage occurred in 2 patients and was successfully repaired through the EEA. During a mean follow-up of 44.3 months, 18.8% of patients had a >9% increase in body mass index, and 93.8% of patients successfully returned to school or work. Two patients (12.5%) suffered a recurrence. Disease control was achieved in 16 patients (100%) at final follow-up. The extended EEA allows adequate access to this challenging tumor and enables complete resection and visual improvement with a reasonable approach-related complication rate.

Concept Recognition and Characterization of Patients Undergoing Resection of Vestibular Schwannoma Using Natural Language Processing

Abstract Background Natural language processing (NLP), a subset of artificial intelligence (AI), aims to decipher unstructured human language. This study showcases NLP's application in surgical health care, focusing on vestibular schwannoma (VS). By employing an NLP platform, we identify prevalent text concepts in VS patients' electronic health care records (EHRs), creating concept panels covering symptomatology, comorbidities, and management. Through a case study, we illustrate NLP's potential in predicting postoperative cerebrospinal fluid (CSF) leaks. Methods An NLP model analyzed EHRs of surgically managed VS patients from 2008 to 2018 in a single center. The model underwent unsupervised (trained on one million documents from EHR) and supervised (300 documents annotated in duplicate) learning phases, extracting text concepts and generating concept panels related to symptoms, comorbidities, and management. Statistical analysis correlated concept occurrences with postoperative complications, notably CSF leaks. Results Analysis included 292 patients' records, yielding 6,901 unique concepts and 360,929 occurrences. Concept panels highlighted key associations with postoperative CSF leaks, including “antibiotics,” “sepsis,” and “intensive care unit admission.” The NLP model demonstrated high accuracy (precision 0.92, recall 0.96, macro F1 0.93). Conclusion Our NLP model effectively extracted concepts from VS patients' EHRs, facilitating personalized concept panels with diverse applications. NLP shows promise in surgical settings, aiding in early diagnosis, complication prediction, and patient care. Further validation of NLP's predictive capabilities is warranted.