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Background: Early extubation, defined as removal of the endotracheal tube at the end of surgery before transfer to a designated postoperative care area, is associated with better outcomes after elective infratentorial craniotomy. The Predicting Infratentorial Craniotomy Extubation (PRICE) project was an international survey designed to estimate the rate of early extubation after elective infratentorial craniotomy, as reported by neuroanesthesiologists, neurosurgeons, and neurocritical care specialists., Methods: Following research ethics board waiver, the 15-question online PRICE survey was circulated to the members of 5 international medical societies over a 15-week period., Results: One hundred and ninety of 5453 society members completed the survey (3.5% response rate). Respondents represented a total of 99 institutions from 92 cities, in 27 countries. While 84 of 188 (44.7%) respondents reported achieving early extubation in more than 95% of cases, 43 of 188 (22.9%) reported extubating fewer than 75% of cases early. The proportion of physicians who reported extubating at least 75% of cases early was greater in high-volume compared with low-volume institutions (73.5% vs. 50.9%, respectively; P =0.003) and among anesthesiologists compared with other specialties (75.6% vs. 45.6%, respectively; P <0.001). Preoperative bulbar dysfunction, preoperative altered consciousness and the course of surgery were the 3 factors with the biggest impact on the decision to extubate early versus late among respondents., Conclusions: The reported rate of early extubation after elective infratentorial craniotomy varies widely between institutions, with respondents from high-volume institutions reporting greater rates of early extubation than those from lower-volume centers. The course of surgery, evidence of bulbar dysfunction, and altered consciousness, appear to affect the decision to extubate early more than other predictors., Competing Interests: N.G. has received consultancy fees from PIPRA AG (Zurich, Switzerland) unrelated to this work. The remaining authors have no conflicts of interest to declare., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Lesions infiltrating the petrous temporal bone are some of the most complex to treat surgically. Many approaches have been developed in order to address these lesions, including endoscopic endonasal, anterior petrosectomy, posterior petrosectomy, and retrosigmoid., Method: We describe in a stepwise fashion the surgical steps of the retrosigmoid intradural inframeatal petrosectomy., Conclusion: The retrosigmoid intradural inframeatal petrosectomy may afford satisfactory exposure with limited drilling and minimal disruption of perilesional anatomical structures. It can provide excellent surgical results, especially for soft tumors, while minimizing surgical morbidity.

The efficacy of tumor removal via craniotomies on preoperative hydrocephalus (HC) in adult patients with intracranial tumors is largely unknown. Therefore, we sought to evaluate the effect of tumor resection in patients with preoperative HC and identify the incidence and risk factors for postoperative VP shunt dependency. All craniotomies for intracranial tumors at Oslo University Hospital in patients ≥ 18 years old during a 10-year period (2004-2013) were reviewed. Patients with radiologically confirmed HC requiring surgery and subsequent development of shunt dependency were identified by cross-linking our prospectively collected tumor database to surgical procedure codes for hydrocephalus treatment (AAF). Patients with preexisting ventriculoperitoneal (VP) shunts (N = 41) were excluded. From 4774 craniotomies performed on 4204 patients, a total of 373 patients (7.8%) with HC preoperatively were identified. Median age was 54.4 years (range 18.1-83.9 years). None were lost to follow-up. Of these, 10.5% (39/373) required permanent CSF shunting due to persisting postoperative HC. The risk of becoming VP shunt dependent in patients with preexisting HC was 7.0% (26/373) within 30 days and 8.9% (33/373) within 90 days. Only secondary (repeat) surgery was a significant risk factor for VP shunt dependency. In this large, contemporary, single-institution consecutive series, 10.5% of intracranial tumor patients with preoperative HC became shunt-dependent post-craniotomy, yielding a surgical cure rate for HC of 89.5%. To the best of our knowledge, this is the first and largest study regarding postoperative shunt dependency after craniotomies for intracranial tumors, and can serve as benchmark for future studies.

Background: Craniotomies carry inherent risks of postoperative complications that may have a negative impact on patients' status. Recognizing and preventing surgical complications is of paramount importance, especially in meningioma surgery, where most of these tumors are benign and current management protocols are effective in terms of disease control and maintenance of higher quality of life. The objective of this study was to describe the early complications after surgery and their predictive factors in patients undergoing resection of intracranial meningiomas., Methods: A partly retrospective, partly prospective review was conducted in a Norwegian population-based cohort of 1469 consecutive cases of meningioma surgery treated at the university hospitals of Oslo, totaling 11,414 patient-years of follow-up., Results: 2.6% of patients had a postoperative hematoma, 2.7% a postoperative infection, 3.9% a postoperative worsening of neurologic status; 5.4% of patients died during a 30-day period after surgery. Predictive factors of increased risk of postoperative complications were patient's age for the hematoma, a non-skull base meningioma for infection, and postoperative hematoma for the risk of neurologic worsening or 30-day mortality., Conclusions: Early postoperative complications in meningioma surgery have a negative impact on patient survival and postoperative neurologic status, in a disease where survival is usually not limited by the meningioma itself. In this study, we identified risk factors for early postoperative complications, the identification of at-risk populations may help to prevent the occurrence of these risk factors., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The risk of developing a de novo shunt-dependent hydrocephalus (HC) after undergoing a craniotomy for brain tumor in adult patients is largely unknown. All craniotomies for intracranial tumors at Oslo University Hospital in adult patients ≥18 years of age during a 10-year period (2004-2013) were included. None were lost to follow-up. Patients who developed a shunt-dependent HC were identified by cross-linking our prospectively collected tumor database to patients with a NCSP surgical procedure code of hydrocephalus (AAF). Patients with pre-existing HC or ventriculoperitoneal (VP) shunts were excluded from the study. A total of 4401 craniotomies were performed. Of these, 46 patients (1.0%) developed de novo postoperative HC requiring a VP shunt after a median of 93 days (mean 115 days, range 6-442). Median age was 62.0 years (mean 58.9 years, range 27.3-80.9) at time of VP shunt surgery. Patients without pre-existing HC had a 0.2% (n = 8/4401) risk of becoming VP shunt dependent within 30 days and 0.5% (n = 22/4401) within 90 days. Age, sex, tumor location, primary/secondary surgery, and radiotherapy were not associated with VP shunt dependency. Choroid plexus tumors and craniopharyngiomas had increased risk of VP shunt dependency. In this large, contemporary, single-institution consecutive series, the risk of postoperative shunt-dependency after craniotomies for brain tumors without pre-existing HC was very low. This is the largest study with regards to de novo postoperative shunt-dependency after craniotomies for patients with intracranial tumors and can serve as a benchmark for future studies.

Object: The aim of this study was to investigate the incidence of CSF disturbances before and after intracranial surgery for pediatric brain tumors in a large, contemporary, single-institution consecutive series., Methods: All pediatric patients (those < 18 years old), from a well-defined population of 3.0 million inhabitants, who underwent craniotomies for intracranial tumors at Oslo University Hospital in Rikshospitalet between 2000 and 2010 were included. The patients were identified from the authors' prospectively collected database. A thorough review of all medical charts was performed to validate all the database data., Results: Included in the study were 381 consecutive craniotomies, performed on 302 patients (50.1% male, 49.9% female). The mean age of the patients in the study was 8.63 years (range 0-17.98 years). The follow-up rate was 100%. Primary craniotomies were performed in 282 cases (74%), while 99 cases (26%) were secondary craniotomies. Tumors were located supratentorially in 249 cases (65.3%), in the posterior fossa in 105 (27.6%), and in the brainstem/diencephalon in 27 (7.1%). The surgical approach was supratentorial in 260 cases (68.2%) and infratentorial in 121 (31.8%). Preoperative hydrocephalus was found in 124 cases (32.5%), and 71 (86.6%) of 82 achieved complete cure with tumor resection only. New-onset postoperative hydrocephalus was observed in 9 (3.5%) of 257 cases. The rate of postoperative CSF leaks was 6.3%., Conclusions: Preoperative hydrocephalus was found in 32.5% of pediatric patients with brain tumors treated using craniotomies. Tumor resection alone cured preoperative hydrocephalus in 86.6% of cases and the incidence of new-onset hydrocephalus after craniotomy was only 3.5%.

Background: Directional intraoperative Doppler (dioDoppler) ultrasonography is well established as a tool in the surgery of intracranial aneurysms and cerebral arteriovenous malformations. The literature provides little information about the possible usefulness of this method during surgery on cranial dural arteriovenous fistulas (dAVFs)., Objective: To present our experience with the use of dioDoppler during surgery on cranial dAVFs., Methods: All patients undergoing craniotomy for cranial dAVF from January 2007 to October 2012 in which dioDoppler was used were included in the study. We reviewed patient records, operating protocols, radiological images, dioDoppler files, and intraoperative videos., Results: During the study period, 12 patients with cranial dAVFs underwent surgical treatment facilitated by dioDoppler. Four patients were operated on acutely for cerebral bleeds, and 8 patients were treated for various cerebral symptoms and the assumption of a significant risk for intracranial bleed. Three advantages of dioDoppler were unequivocal identification of veins with cortical/deep venous reflux from the fistula, verification of completeness of occlusion of the fistula, and identification of dural arterial feeders not visualized under the microscope., Conclusion: Reviewing our experience, we found that dioDoppler sonography is an easy, safe, effective, reliable, and instantaneous tool during surgery on cranial dAVFs.

Background: In order to weigh the risks of surgery against the presumed advantages, it is important to have specific knowledge about complication rates. Contemporary reports on complications following craniotomy for tumor resection in pediatric patients are scarce., Objective: To study the surgical mortality and rate of hematomas, infections, meningitis, infarctions, and cerebrospinal fluid (CSF) leaks, as well as neurological morbidity, after craniotomy for pediatric brain tumors in a large, contemporary, single-institution consecutive series., Methods: All pediatric patients (< 18 years) from a well-defined population of 3.0 million inhabitants who underwent craniotomies for intracranial tumors at Oslo University Hospital, Rikshospitalet, during 2003 to 2009 were included. The patients were identified from our prospectively collected database, and all charts were reviewed to validate the database entries., Results: Included in the study were 273 craniotomies, performed on 211 patients. Mean age was 8.5 years (range, 0-18). Follow-up was 100%. One hundred ninety-nine cases (72.9%) were primary craniotomies, while 74 cases (27.1%) were secondary craniotomies. Surgical approach was supratentorial in 194 (71.1%) and infratentorial in 79 (28.9%). Surgical mortality within 30 days was 0.4% (n = 1). Complication rates were intracerebral hemorrhage 0.4%, chronic subdural hematoma 1.1%, meningitis 1.8%, cerebral infarctions 1.5%, and postoperative CSF leak 7.3%. Neurological deficit rates were no change or improvement 87.2%, minor or moderate new deficits 9.5%, and severe new neurological deficits 2.9%., Conclusion: Overall, the complication rates are low and compare favorably with similar data from adult series. The authors' data could be used as a baseline for future studies.

Background: In order to weigh the risks of surgery against the presumed advantages, it is important to have specific knowledge about complication rates., Objective: To study the surgical mortality and rate of reoperations for hematomas and infections after intracranial surgery for brain tumors in a large, contemporary, single-institution consecutive series., Methods: All adult patients from a well-defined population of 2.7 million inhabitants who underwent craniotomies for intracranial tumors at Oslo University Hospital from 2003 to 2008 were included (n = 2630). The patients were identified from our prospectively collected database and their charts studied retrospectively. Follow-up was 100%., Results: The overall surgical mortality, defined as death within 30 days of surgery, was 2.3% (n = 60). The mortality rates for high- and low-grade gliomas, meningiomas, and metastases were 2.9%, 1.0%, 0.9%, and 4.5%, respectively. Age >60 (odds ratio 1.84, P < 0.05) and biopsy compared with resection (odds ratio 4.67, P < 0.01) were significantly positively associated with increased surgical mortality. Hematomas accounted for 35% of the surgical mortality. Postoperative hematomas needing evacuation occurred in 2.1% (n = 54). Age >60 was significantly correlated to increased risk of postoperative hematomas (odds ratio 2.43, P < 0.001). A total of 39 patients (1.5%) were reoperated for postoperative infection. Meningiomas had an increased risk of infections compared with high-grade gliomas (odds ratio 4.61, P < 0.001)., Conclusion: The surgical mortality within 30 days of surgery was 2.3%, with age >60 and biopsy vs resection being the 2 factors significantly associated with increased mortality. Postoperative hematomas caused about one third of the surgical mortality.

Background: Work-related musculoskeletal disorders (WMSDs) affect a significant percentage of the neurosurgical workforce. The aim of the current questionnaire-based study was to examine the prevalence of WMSDs amongst neurosurgeons, identify risk factors, and study the views of neurosurgeons regarding ergonomics. Methods: From June to August 2020, members of the "European Association of Neurosurgical Societies," the "Neurosurgery Research Listserv," and the "Latin American Federation of Neurosurgical Societies" were asked to complete an electronic questionnaire on the topics of WMSDs and ergonomics. Results: A total of 409 neurosurgeons responded to the survey, with a 4.7 male to female ratio. Most of the surgeons worked in Europe (76.9%) in academic public hospitals. The vast majority of the participants (87.9%) had experienced WMSDs, mainly affecting the shoulder, neck, and back muscles. The most common operations performed by the participants were "Craniotomy for convexity/intrinsic tumors" (24.1%) and "Open lumbar basic spine" (24.1%). Neurosurgeons agreed that ergonomics is an underexposed area in the neurosurgical field (84.8%) and that more resources should be spend (87.3%) and training curricula changes should be made (78.3%) in order to alleviate the burden of WMSDs on neurosurgeons. Univariate analysis did not reveal any associations between the development of WMSDs and age, gender, tenure, average duration of operation, operating time per week, type of operation, and surgical approach. Conclusions: The problem of WMSDs ought to be more closely addressed and managed by the neurosurgical community. More studies ought to be designed to investigate specific ergonomic parameters in order to formulate practice recommendations. [ABSTRACT FROM AUTHOR]

To study improvements in outcomes after surgery for intracranial meningiomas. We performed a longitudinal observational study comparing 1469 patients operated on for intracranial meningioma in 4 consecutive time frames (1990–1994, 1995–1999, 2000–2004, and 2005–2010). Median age at surgery was 58.3 years. Median follow-up was 7 years. Patients in later periods were older than in the earlier ones (odds ratio [OR], 1.19 [1.09–1.32]; P < 0.0005), indicating a trend toward operating on more elderly patients. Before 2000, 42%, 32%, 6%, 19%, and 0.3% achieved Simpson grade (SG) I, II, III, IV, and V, respectively, whereas the SG rates were 35%, 37%, 4%, 23%, and 0.9% after 2000 (OR, 1.18 [1.06–1.30]; P < 0.005). The perioperative mortality (OR, 0.65 [0.46–0.91]; P < 0.05) and worsened neurologic outcome rate (OR, 0.70 [0.60–0.83]; P < 0.0001) were significantly lower in later decades, but the 4 surgical periods were similar regarding postoperative infections and hematomas. Retreatment-free survival (RFS) and overall survival (OS) increased significantly over the 4 time frames (P < 0.05 and P < 0.0001, respectively). Multivariate analysis confirmed the improvement of surgical radicality, neurologic outcome, perioperative mortality, OS, and RFS. Meningioma surgery as well as patient population changed over the 2 decades considered in this study. We observed higher rates of gross total resection in the later period and the perioperative outcomes improved or were unchanged, which signifies better long-term outcomes, RFS, and OS. [ABSTRACT FROM AUTHOR]

Simple Summary: Meningiomas are the most common intracranial tumor [1] and are classified by the World Health Organization (WHO) as grade I (benign), grade II (atypical), or grade III (anaplastic) [2]. Regarding atypical meningiomas, predictors of overall survival (OS) and progression-free survival (PFS) are less well documented compared to their benign counterparts. Moreover, one of the most critical aspects of meningiomas is tumor relapse/progression that may also take place after the complete removal of the lesion. Recurrent lesions pose the question whether it is reasonable to perform second surgery. Alternative approaches include radiotherapy (RT) (stereotactic radiosurgery or conventional fractionated RT). We investigated 77 consecutive patients who underwent craniotomy for intracranial atypical meningiomas to evaluate predictors of OS and retreatment-free survival, and to assess the benefits of surgical retreatment for subsequent recurrences. We concluded that gross total resection (GTR) significantly prolonged retreatment-free survival but had no significant impact on OS. GTR was also associated with improved/stable neurological outcomes at 6–12 months. Age at surgery, preoperative Karnofsky performance scale (KPS), and retreatment were all strong prognostic factors of OS. Time-to-retreatment did not decrease significantly in patients requiring repeated surgical excision. Introduction: Predictors of survival and progression of disease in atypical meningiomas are less well documented in the literature compared to benign meningiomas. Higher grade meningiomas tend to recur often and one of the most critical aspects is how to best deal with relapses. Methods: A total of 77 consecutive patients who underwent craniotomy for atypical meningioma between 1990–2010 at Oslo University Hospital (OUH) were reviewed. Results: Median age at surgery was 62.21 [interquartile range (IQR): 22.87] years. Fifty-one patients (66.2%) had neurological deficits at presentation. Fifty-four patients (70.1%) underwent gross total resection (GTR). Thirty-nine patients (50.7%) had improved/stable neurological outcomes at 6–12 months. Twenty-two patients (28.6%) underwent retreatment, of whom 20 (26.0%) were subjected to resection followed by adjuvant radiotherapy. Overall survival (OS) was significantly longer in patients <65 years (p < 0.001), with preoperative Karnofsky performance scale (KPS) score of ≥ 70 (p = 0.006), and who required no retreatment (p = 0.033). GTR significantly prolonged the retreatment-free survival rate (p < 0.001). STR carried almost a six-fold greater risk of neurological outcome deterioration (p = 0.044). Conclusions: GTR significantly prolonged retreatment-free survival but had no significant impact on OS. STR was a significant risk factor for deteriorated neurological outcome. Age, preoperative KPS, and retreatment were all strong predictors of OS. Median time-to-retreatment (TTR) did not shorten significantly throughout repeated surgeries. [ABSTRACT FROM AUTHOR]

Skull base meningiomas represent a challenge for neurosurgeons, and the procedures are typically performed by experienced neurosurgeons, thus limiting resident training. A new simulation and rehearsal device can be used as an aid for senior surgeons during these operations and serve as a training tool for junior surgeons. Forty patients harboring an anterior/middle fossa meningioma were recruited. Surgical Theater, a rehearsal/simulation platform, was used for preoperative planning and intraoperative 3D navigation on 20 patients (CT-MADE group), while the remaining (control group) underwent a traditional navigation. Qualitative comparisons between the 2 groups were made with regard to surgical procedure and patient outcome. Satisfaction questionnaires were completed by expert neurosurgeons and residents to assess the overall usefulness of the platform. Furthermore, the surface of the simulated craniotomy performed during the planning was compared with the one actually performed during surgery in order to evaluate the reliability of the planning. No differences between the 2 groups were found (surgery duration: P = 0.4; visual impairment: P = 0.56). Both residents and senior neurosurgeons enjoyed using the platform for intraoperative navigation and planning; simulated craniotomies were significantly smaller as compared with the real ones (P = 0.009), probably because it was not intuitive to depict the exact margins of the operculum with the platform. Surgical Theater helped residents to improve their anatomic and procedural comprehension and was deemed as a useful aid to safely perform some demanding neurosurgical procedures, by both senior and junior surgeons. [ABSTRACT FROM AUTHOR]