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Background: Tension pneumocephalus (PMC) is a rare and feared complication following the endonasal endoscopic approach (EEA) to skull base procedures. This is a neurosurgical emergency that requires urgent decompression to avoid catastrophic neurologic damage or death. An avoidable cause is the application of positive pressure ventilation (PPV) in EEA patients for postoperative hypoxia. Our institution implemented a hospital-wide protocol in response to this to identify and manage at-risk patients; this paper aims to identify if this protocol was effective in lowering the rates of tension PMC secondary to PPV., Results: In the 3 years following the implementation of the protocol, 110 patients underwent EEAs, from which 1 case of tension PMC (found to be not secondary to PPV) was identified. This is compared with 2 cases of tension PMC secondary to PPV over the preceding 5 years, out of 406 EEA patients. This constitutes a quantifiable reduction in PPV-related tension PMC in both standard and extended approach EEAs, signifying the effective uptake of the protocol., Conclusions: We found no cases of tension PMC after PPV following EEA skull base surgery in our institution since the implementation of an institution-wide guideline. This underscores the utility of our simple and cost-effective preventative protocol in reducing the overall rates of tension PMC following the inadvertent postoperative application of PPV. Further research is needed to study the comparative risks and benefits of PPV in the post-EEA patient and thus inform future iterations of the protocol., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Intradural lumbar disk herniation (ILDH) is a rare variant and accounts for 0.33%-1.5% of lumbar disk herniations. Although clues exist on preoperative imaging, they remain subtle and most cases of ILDH are diagnosed intraoperatively. Intraoperative ultrasound is a useful adjunct in diagnosing and managing ILDH. We present a case to demonstrate the features of an intradural herniated disk on ultrasound imaging and highlight the utility of intraoperative ultrasonography in establishing diagnosis, guiding dural opening, and confirming adequate nerve root decompression following diskectomy., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Headache is a common symptom in patients with pituitary adenomas. Research on whether resection of pituitary adenomas via the endoscopic endonasal approach (EEA) affects headaches is limited, and the pathophysiology of headaches associated with pituitary adenomas remains unclear. This study aimed to determine if resection of pituitary adenomas via the EEA improves headaches and investigate factors that may be associated with headaches in patients with pituitary adenoma., Methods: A prospectively collected database of 122 patients undergoing resection of pituitary adenoma via the EEA was analyzed. Patient-reported headache severity was collected prospectively using the Headache Impact Test (HIT-6) at preoperative baseline and 4 postoperative time points (3 weeks, 6 weeks, 3 months, and 6 months)., Results: Adenoma size and subtype, cavernous sinus invasion, and hormonal status were not associated with preoperative headache burden. In patients with preoperative headaches (HIT-6 score >36), significant decreases in HIT-6 score were observed postoperatively at 6 weeks (5.5-point improvement, 95% CI 1.27-9.78, P < 0.01), 3 months (3.6-point improvement, 95% CI 0.01-7.18, P < 0.05), and 6 months (7.5-point improvement, 95% CI 3.43-11.46, P < 0.01). The only factor associated with headache improvement was cavernous sinus invasion (P = 0.003). Adenoma size and subtype and hormonal status were not associated with postoperative headache burden., Conclusions: Resection via the EEA is associated with significant improvement in headache-related impact on patient functioning from ≥6 weeks after surgery. Patients with cavernous sinus invasion are more likely to experience improvement in headaches. The mechanism of headaches associated with pituitary adenoma still requires clarification., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Craniopharyngiomas are morbid tumors that significantly reduce patients' quality of life (QoL). The lifelong burden of endocrine, visual, hypothalamic, and limbic dysfunction can have disastrous consequences for the physical and psychosocial health of patients. Elucidating the factors that influence QoL could guide therapeutic interventions to improve patient well-being., Methods: A systematic review was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement using the PubMed and Medline databases. Studies that had reported patient QoL using validated metrics in both adult and pediatric populations were included. Bias and methodological rigor were assessed using the MINORS (methodological index for nonrandomized studies) criteria., Results: A total of 25 studies, including 2025 patients, were available for review. Most studies were small, retrospective, cohort studies with a high risk of bias. The QoL of the patients with craniopharyngioma was lower than that of the general population. Hypothalamic involvement was consistently the strongest predictor of QoL. Endocrinopathy contributed to morbidity but could be ameliorated by hormone replacement therapy. Social and emotional dysregulation and a poor memory are common complaints after surgery, and iatrogenic damage to the infundibulum, hypothalamus, limbic system, and frontal lobes might underlie these concerns. Sleep-wake cycle dysfunction and hypothalamic obesity are serious consequences of hypothalamic damage., Conclusions: An experienced multidisciplinary team is necessary to optimally manage the complex cases of these patients. The poor QoL of patients with craniopharyngioma is multifactorial. However, the contribution of iatrogenesis is not insubstantial. Improved surgical techniques, focusing on hypothalamic preservation, and adjuvant treatment options are required to improve the well-being of these patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Knowledge of anatomy and its variations is the key to safe and efficient surgery. The endoscopic endonasal route to the sella has evolved to become the preferred route to access a wide variety of diseases. We describe the skeletal, vascular, and neural anatomic variations that could be encountered from the nasal phase, through the sphenoid phase, to the sellar phase of the operative exposure. A preoperative checklist is also provided., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Tension pneumocephalus (TP) is a rare but feared complication of endoscopic endonasal skull base surgery. In contrast to simple pneumocephalus, which is common after endoscopic transnasal approaches and managed conservatively, TP represents a neurosurgical emergency and mandates urgent decompression., Case Description: Here we present 2 cases of TP as a consequence of positive pressure ventilation following endoscopic endonasal skull base surgery. Both occurred during resuscitation for postoperative hypoxia. These cases prompted the development of an institution-wide protocol to identify and manage patients at risk of TP after extended skull base approaches., Conclusions: To our knowledge, these are the only such cases of postoperative TP following positive pressure ventilation in the literature., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Sellar arachnoid cysts are a rare occurrence but may impinge on vital parasellar anatomy and thus are often symptomatic. The etiology of sellar arachnoid cysts is contentious, fueled by heterogeneity in cyst wall structure and contents between cases. The "ball-valve" mechanism is 1 of 2 predominant theories describing their formation, which contends that an aperture in the diaphragm allows cerebrospinal fluid to enter the cyst, propelled by pulsatile flow, but its egress is obscured by the pituitary during the ebb of the pressure wave., Case Description: Here we present a case of a 51-year-old female with a symptomatic sellar arachnoid cyst. She underwent an endoscopic transsphenoidal fenestration which alleviated her symptoms., Conclusions: Intraoperative video evidence during arachnoid cyst fenestration supports the "ball-valve" theory of sellar arachnoid cyst development., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The reporting of adverse events (AEs) in neurosurgery uses inconsistent definitions and subjective grading systems. A standardized system for recording and describing AEs would allow valid comparisons to be drawn between different institutions, using different technologies, at different times. The Spinal Adverse Events Severity System - Neuro (SAVES-N) system is a modification of the well-validated SAVES-V2 system that encompasses complications from both cranial and spinal surgery. The objective of this study was to assess the interobserver reliability of SAVES-N in spinal and cranial neurosurgery., Methods: Ten vignettes, including cranial and spinal neurosurgical cases, were assessed by groups of consultant neurosurgeons (n = 5) and neurosurgical registrars (n = 5) using the SAVES-N system. Interobserver reliability for the presence of AEs, the type of AE, and the SAVES severity grade of the AE were calculated using Gwet's AC2 and Fleiss' kappa and were interpreted using the thresholds described by Landis and Koch., Results: Neurosurgeons had almost-perfect agreement (Gwet AC2 = 0.93), whereas registrars had substantial agreement (Gwet's AC2 = 0.74) in determining the presence or absence of AEs. Both neurosurgeons (Fleiss' kappa = 0.78) and registrars (Fleiss' kappa = 0.70) demonstrated substantial agreement within their groups as to the type of AE. Similarly, neurosurgeons (Gwet's AC2 = 0.94) and registrars (Gwet's AC2 = 0.81) both graded the severity of the AE with almost perfect agreement., Conclusions: The results of this study demonstrate that the scope of the well-validated SAVES-V2 system may be broadened to cranial neurosurgical cases by SAVES-N with substantial to almost-perfect interobserver reliability., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Obesity is an important consideration in neurosurgical practice. Of Australian adults, 28.3% are obese and it is estimated that more than two thirds of Australia's population will be overweight or obese by 2025. This review of the effects of obesity on neurosurgical procedures shows that, in patients undergoing spinal surgery, an increased body mass index is a significant risk factor for surgical site infection, venous thromboembolism, major medical complications, prolonged length of surgery, and increased financial cost. Although outcome scores and levels of patient satisfaction are generally lower after spinal surgery in obese patients, obesity is not a barrier to deriving benefit from surgery and, when the natural history of conservative management is taken into account, the long-term benefits of surgery may be equivalent or even greater in obese patients than in nonobese patients. In cranial surgery, the impact of obesity on outcome and complication rates is generally lower. Specific exceptions are higher rates of distal catheter migration after shunt surgery and cerebrospinal fluid leak after posterior fossa surgery. Minimally invasive approaches show promise in mitigating some of the adverse effects of obesity in patients undergoing spine surgery but further studies are needed to develop strategies to reduce obesity-related surgical complications., (Copyright © 2017 Elsevier Inc. All rights reserved.)