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Background Little is known on adverse events and their timing after peripheral nerve surgery in extremities. The aim of this study is to identify predictors and typical timing of complications, unplanned readmission, and length of hospital stay for patients undergoing peripheral nerve surgery in the extremities. Methods Data were extracted from the National Surgical Quality Improvement Program (NSQIP) registry from 2005 to 2015. Adult patients undergoing peripheral nerve surgery in the extremities were included. A subgroup analysis was performed for brachial plexus operations. Multivariable logistic regression was performed to identify predictors of any complication, surgical site infection, unplanned readmission, and reoperation. Results A total of 2,840 patients were identified; 628 were brachial plexus operations. Overall complications were 4.4% and 7.0%, respectively. Median time for occurrence of any complication was 8 days. The most common complications were wound-related (1.7%), which occurred at a median of 15 days postoperatively. Reoperation occurred in 1.8% of all cases; most commonly for musculoskeletal repair (16.7%). Unplanned readmissions occurred in 2.3% and were most often due to wound-related problems (24.1%). Preoperatively contaminated wounds, inpatient procedures, and longer operative time seemed to have the most influence on all adverse events. In brachial plexus pathology, insulin-dependent diabetes and emergency cases also negatively affected outcomes. Conclusions Complications usually occur one to two weeks postoperatively. Preoperatively contaminated wounds, inpatient procedures, and longer operative times influence outcome. Anatomical level of operation results in significantly different lengths of hospital stay; brachial plexus pathology has the longest length of stay.

OBJECTIVE The utility of robotic instrumentation is expanding in neurosurgery. Despite this, successful examples of robotic implementation for endoscopic endonasal or skull base neurosurgery remain limited. Therefore, the authors performed a systematic review of the literature to identify all articles that used robotic systems to access the sella or anterior, middle, or posterior cranial fossae. METHODS A systematic review of MEDLINE and PubMed in accordance with PRISMA guidelines performed for articles published between January 1, 1990, and August 1, 2021, was conducted to identify all robotic systems (autonomous, semiautonomous, or surgeon-controlled) used for skull base neurosurgical procedures. Cadaveric and human clinical studies were included. Studies with exclusively otorhinolaryngological applications or using robotic microscopes were excluded. RESULTS A total of 561 studies were identified from the initial search, of which 22 were included following full-text review. Transoral robotic surgery (TORS) using the da Vinci Surgical System was the most widely reported system (4 studies) utilized for skull base and pituitary fossa procedures; additionally, it has been reported for resection of sellar masses in 4 patients. Seven cadaveric studies used the da Vinci Surgical System to access the skull base using alternative, non–TORS approaches (e.g., transnasal, transmaxillary, and supraorbital). Five cadaveric studies investigated alternative systems to access the skull base. Six studies investigated the use of robotic endoscope holders. Advantages to robotic applications in skull base neurosurgery included improved lighting and 3D visualization, replication of more traditional gesture-based movements, and the ability for dexterous movements ordinarily constrained by small operative corridors. Limitations included the size and angulation capacity of the robot, lack of drilling components preventing fully robotic procedures, and cost. Robotic endoscope holders may have been particularly advantageous when the use of a surgical assistant or second surgeon was limited. CONCLUSIONS Robotic skull base neurosurgery has been growing in popularity and feasibility, but significant limitations remain. While robotic systems seem to have allowed for greater maneuverability and 3D visualization, their size and lack of neurosurgery-specific tools have continued to prevent widespread adoption into current practice. The next generation of robotic technologies should prioritize overcoming these limitations.

Background Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo. Objective To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis. Methods A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed. Results Thirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different. Conclusion This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.

Background Quality improvement, value-based care delivery, and personalized patient care depend on robust clinical, financial, and demographic data streams of neurosurgical outcomes. The neurosurgical literature lacks a comprehensive review of large national databases. Objective To assess the strengths and limitations of various resources for outcomes research in neurosurgery. Methods A review of the literature was conducted to identify surgical outcomes studies using national data sets. The databases were assessed for the availability of patient demographics and clinical variables, longitudinal follow-up of patients, strengths, and limitations. Results The number of unique patients contained within each data set ranged from thousands (Quality Outcomes Database [QOD]) to hundreds of millions (MarketScan). Databases with both clinical and financial data included PearlDiver, Premier Healthcare Database, Vizient Clinical Data Base and Resource Manager, and the National Inpatient Sample. Outcomes collected by databases included patient-reported outcomes (QOD); 30-day morbidity, readmissions, and reoperations (National Surgical Quality Improvement Program); and disease incidence and disease-specific survival (Surveillance, Epidemiology, and End Results-Medicare). The strengths of large databases included large numbers of rare pathologies and multi-institutional nationally representative sampling; the limitations of these databases included variable data veracity, variable data completeness, and missing disease-specific variables. Conclusion The improvement of existing large national databases and the establishment of new registries will be crucial to the future of neurosurgical outcomes research.

In this study, we set out to define our institutional criteria for patient eligibility for transsphenoidal resection of parasellar meningiomas, and to report our experience with extended transnasal approaches for these lesions. We aimed to discuss the important considerations of patient selection and risk stratification to optimize outcomes for patients with these difficult lesions, and also include considerations that should be reviewed during surgical approach selection. Medical records from Brigham and Women’s Hospital were retrospectively reviewed for all patients who underwent transsphenoidal surgery for pituitary disease with the senior author from April 2008 to March 2017 (938 procedures). Patients undergoing surgery for anterior skull base meningioma were identified and patient data were collected. Seven patients (four women, three men) underwent transsphenoidal resection (five endoscopic, one microscopic, and one hybrid endoscopic/microscopic) of pathologically-confirmed anterior skull base meningiomas during the study period. Five patients presented with visual field deficits, three presented with headache, two presented with hypopituitarism, and one woman presented with infertility. The median maximum tumor diameter was 1.7 cm (range 1.4–4.2 cm). Six patients underwent subtotal resection, and one underwent gross total resection. The median MIB-1 index was 2.3 (range 1.0–7.6). Complications included two readmissions (one on POD11 for small bowel obstruction, one on POD48 for epistaxis), and the development of new onset thyroid deficiency and transient diabetes insipidus in one patient. Two patients had reoperations by craniotomy for tumor recurrence after 5 and 6 years, respectively. Although more commonly treated transcranially, anterior skull base meningiomas are sometimes amenable to resection transphenoidally. Patient selection is critical, and multiple factors, including tumor size, consistency, and location, patient and surgeon preference, and presenting symptoms each affect the optimum surgical approach. We have developed criteria for patient selection so that transsphenoidal surgery can be used to resect or debulk anterior skull base meningiomas safely and with favorable outcomes.

Epidemiological analyses of many cancers have demonstrated differences in incidence and outcome for patients from different racial backgrounds. The aim of this study was to determine the incidence of non-malignant CNS tumors by race and age to identify incidence variance. Data from the Central Brain Tumor Registry of the United States (CBTRUS) from 2009 to 2013 were used to calculate age-adjusted incidence rates (IR) per 100,000 population and 95% confidence intervals for selected tumors overall, by race, age group, and race stratified by age group. In those aged 0-14 years, Whites had significantly greater IR of neuronal and mixed neuronal-glial tumors (IR = 0.37) compared to Others (IR = 0.26) and Blacks (IR = 0.24). In those 15-39 years, Blacks had significantly greater IR of tumors of the pituitary (IR = 3.80) than Others (IR = 3.29) and Whites (IR = 3.15), and significantly greater IR of grade I meningioma (IR = 1.93) than Whites (IR = 1.59) and Others (IR = 1.21). In those 40 years and older, Blacks had significantly greater IR of grade I meningioma (IR = 19.16) compared to Whites (IR = 15.77) and Others (IR = 15.32), and significantly greater IR of tumors of the pituitary (IR = 10.47) than Others (IR = 5.85) and Whites (IR = 4.99). Others had significantly greater IR of nerve sheath tumors (IR = 4.00) compared to Whites (IR = 3.46) and Blacks (IR = 1.64). The incidence of non-malignant CNS tumors differs significantly by race and age in the USA. These differences may contribute to previously-described health outcome disparities.

PURPOSE The neurologic assessment in neuro-oncology (NANO) scale was developed as a standardized metric to objectively measure neurologic function in brain tumor patients to complement radiographic assessment in defining overall outcome. A multicenter, phase 2 study of pembrolizumab with or without bevacizumab in patients with recurrent glioblastoma incorporated the NANO scale as an exploratory endpoint. METHODS Neurologic examination was evaluated at baseline and MRI assessments using the NANO scale until patients came off study. Statistical descriptive data analysis was performed using R (version 3.4.3). Correlation analysis utilized Fisher’s exact test. RESULTS NANO compliance rate was 94% in 80 patients accrued on the study. Of the 80 patients, 7 were missing NANO at baseline visit and were excluded from analysis for NANO response criteria. Fifteen patients did not have end of treatment NANO evaluation. Of 73 patients, 35 (48%) had a normal neurologic examination at baseline by NANO. Strength and language accounted for the majority of changes in neurologic function over the course of study treatment. Eighteen patients (25%) had neurologic progression by NANO, of whom 2 did not have concurrent radiographic progression. Three patients (pembrolizumab plus bevacizumab cohort) had a neurologic response associated with stable disease on MRI. NANO assessment prior to initiation of cycle 3 correlated with RANO response (p=0.011), change in KPS (p=0.002) and dexamethasone requirement (p=0.007) while those with NANO progression at this assessment had worse overall survival (291 vs 324 days), but this trend did not achieve statistical significance (p=0.2). CONCLUSIONS Evaluation of neurologic function by NANO scale was feasible in a multicenter prospective study in patients with GBM with a high compliance rate. The NANO scale objectively tracked stable neurologic function in most patients throughout the trial period and was associated with a trend for survival.

Background Diabetes insipidus (DI) is a recognized transient or permanent complication following transsphenoidal surgery (TSS) for pituitary tumors. Objective To describe significant experience with the incidence of DI after TSS, identifying predictive characteristics and describing our diagnosis and management of postoperative DI. Methods A retrospective analysis was performed of 700 patients who underwent endoscopic TSS for resection of pituitary adenoma (PA), Rathke cleft cyst (RCC), or craniopharyngioma. Inclusion criteria included at least 1 wk of follow-up for diagnosis of postoperative DI. Permanent DI was defined as DI symptoms and/or need for desmopressin more than 1 yr postoperatively. All patients with at least 1 yr of follow-up (n = 345) were included in analyses of permanent DI. Multivariable logistic regression models were constructed to identify predictors of transient or permanent postoperative DI. Results The overall rate of any postoperative DI was 14.7% (103/700). Permanent DI developed in 4.6% (16/345). The median follow-up was 10.7 mo (range: 0.2-136.6). Compared to patients with PA, patients with RCC (odds ratio [OR] = 2.2, 95% CI: 1.2-3.9; P = .009) and craniopharyngioma (OR = 7.0, 95% CI: 2.9-16.9; P ≤ .001) were more likely to develop postoperative DI. Furthermore, patients with RCC (OR = 6.1, 95% CI: 1.8-20.6; P = .004) or craniopharyngioma (OR = 18.8, 95% CI: 4.9-72.6; P ≤ .001) were more likely to develop permanent DI compared to those with PA. Conclusion Although transient DI is a relatively common complication of endoscopic and microscopic TSS, permanent DI is much less frequent. The underlying pathology is an important predictor of both occurrence and permanency of postoperative DI.

Primary brain tumors account for ~1% of new cancer cases and ~2% of cancer deaths in the United States; however, they are the most commonly occurring solid tumors in children. These tumors are very heterogeneous and can be broadly classified into malignant and benign (or non-malignant), and specific histologies vary in frequency by age, sex, and race/ethnicity. Epidemiological studies have explored numerous potential risk factors, and thus far the only validated associations for brain tumors are ionizing radiation (which increases risk in both adults and children) and history of allergies (which decreases risk in adults). Studies of genetic risk factors have identified 32 germline variants associated with increased risk for these tumors in adults (25 in glioma, 2 in meningioma, 3 in pituitary adenoma, and 2 in primary CNS lymphoma), and further studies are currently under way for other histologic subtypes, as well as for various childhood brain tumors. While identifying risk factors for these tumors is difficult due to their rarity, many existing datasets can be leveraged for future discoveries in multi-institutional collaborations. Many institutions are continuing to develop large clinical databases including pre-diagnostic risk factor data, and developments in molecular characterization of tumor subtypes continue to allow for investigation of more refined phenotypes.Key Point1. Brain tumors are a heterogeneous group of tumors that vary significantly in incidence by age, sex, and race/ethnicity.2. The only well-validated risk factors for brain tumors are ionizing radiation (which increases risk in adults and children) and history of allergies (which decreases risk).3. Genome-wide association studies have identified 32 histology-specific inherited genetic variants associated with increased risk of these tumors.

BACKGROUND: Statins have previously been shown to have protective effects for other cancers, but no prospective studies of statin use and glioma have been conducted. METHODS: We evaluated the association between statin use and risk of glioma in the female Nurses’ Health Study (NHS, n = 114,419) and Nurses’ Health Study II (NHSII, n = 115,813) and the male Health Professionals Follow-up Study (HPFS, n = 50,223). Glioma cases were confirmed by medical record review. Age and multivariable-adjusted hazard ratios of glioma by statin use were estimated using Cox proportional hazards models. RESULTS: In 4,430,700 person-years of follow-up, we confirmed 483 incident cases of glioma. Compared with never-users, ever statin use was associated with borderline increased risk of glioma in the combined cohorts (age-adjusted HR = 1.23, 95% CI 0.99–1.54), as was longer duration of statin use (HR = 1.48, 95% CI 1.08–2.03 comparing > 8 years of use to never use, p-trend = 0.01). We also observed a significant inverse association between hyperlipidemia and glioma in multivariable models (HR = 0.74, 95% CI 0.59–0.93 in combined cohorts), which was attenuated in lagged analyses. Compared to never use, in multivariable-adjusted models, ever statin use (HR = 1.43, 95% CI 1.10–1.86) and statin use duration (HR = 1.72, 95% CI 1.21–2.45, for > 8 years of use, p-trend = 0.003) were each significantly associated with increased glioma risk. CONCLUSION: In contrast to case–control studies reporting inverse associations, we found borderline increased risk of glioma with statin use. Results were strengthened after adjustment for cardiovascular risk factors due to an unexpected inverse association between hyperlipidemia and glioma risk. Further studies of statin use, hyperlipidemia, and glioma risk are warranted.

Pituitary adenomas with positive ACTH staining are derived from the corticotroph lineage. Most corticotroph adenomas are small and secrete ACTH, causing a form of hypercortisolism known as Cushing disease (CD); however, a subset do not secrete ACTH and are referred to as silent corticotroph adenomas (SCA). Rarely, hypercortisolemic patients who undergo surgery are diagnosed with the ill-defined entity of corticotroph hyperplasia (CH). In order to better define CH and compare the clinical, laboratory, and imaging parameters of CD, SCA, and CH, comprehensive chart review was performed for all patients at our institution within the past ten years who underwent transsphenoidal surgery for a pituitary mass showing diffuse ACTH immunostaining in lesional tissue. All cases were re-reviewed by an experienced neuropathologist to confirm the diagnoses. Patients with clinical and biochemical evidence of ACTH-dependent hypercortisolemia and an ACTH-positive adenoma were classified as CD (n=59). Patients without hypercortisolemia but with ACTH-staining adenomas were classified as SCA (n=32). Patients clinically suspected of having Cushing disease whose surgical specimen did not show adenoma but consisted only of abnormally expanded acini with ACTH-positive cells were classified as CH (n=13). Average (± SD) pre-operative cortisol (mcg/dL)/ ACTH (pg/mL) measurements were: CD 23.7±8.1 / 66.4±40.1; SCA 12.7±6.2 / 44.4±38.0; CH 24.5±5.9 / 63.8±35.1. SCA patients had larger tumors and presented with more symptoms of compression whereas both CD and CH patients presented with characteristic features of hypercortisolism: weight gain, hypertension, hirsutism, and skin changes (p

BACKGROUND Although survival statistics in patients with glioblastoma multiforme (GBM) are well-defined at the group level, predicting individual patient survival remains challenging because of significant variation within strata. OBJECTIVE To compare statistical and machine learning algorithms in their ability to predict survival in GBM patients and deploy the best performing model as an online survival calculator. METHODS Patients undergoing an operation for a histopathologically confirmed GBM were extracted from the Surveillance Epidemiology and End Results (SEER) database (2005-2015) and split into a training and hold-out test set in an 80/20 ratio. Fifteen statistical and machine learning algorithms were trained based on 13 demographic, socioeconomic, clinical, and radiographic features to predict overall survival, 1-yr survival status, and compute personalized survival curves. RESULTS In total, 20 821 patients met our inclusion criteria. The accelerated failure time model demonstrated superior performance in terms of discrimination (concordance index = 0.70), calibration, interpretability, predictive applicability, and computational efficiency compared to Cox proportional hazards regression and other machine learning algorithms. This model was deployed through a free, publicly available software interface (https://cnoc-bwh.shinyapps.io/gbmsurvivalpredictor/). CONCLUSION The development and deployment of survival prediction tools require a multimodal assessment rather than a single metric comparison. This study provides a framework for the development of prediction tools in cancer patients, as well as an online survival calculator for patients with GBM. Future efforts should improve the interpretability, predictive applicability, and computational efficiency of existing machine learning algorithms, increase the granularity of population-based registries, and externally validate the proposed prediction tool.

Background The existing body of literature on postoperative neurosurgical infections lacks large multicenter reports on postoperative neurosurgical infections. This is the largest study to date of postoperative neurosurgical infections rates, time to event, and risk factors. Methods Demographics, medical history, and postoperative infections were assessed for all adult patients in the large, randomized, multicenter American College of Surgeons–National Surgical Quality Improvement Program (ACS-NSQIP) database undergoing an operation with a surgeon whose primary specialty was neurological surgery from 2006 to 2014. Results Of 3,723,797 cases from 517 institutions in the NSQIP from 2006 to 2014, 132,063 neurosurgery cases were identified. Within these patients, the 30-day rate of postoperative infections was 5.3%. Postoperatively, 1.8% of patients developed surgical site infections (SSI), and 3.9% developed other infections including pneumonia and urinary tract infections. Superficial SSI had a cumulative incidence of 0.8% at a median of 16 (interquartile range [IQR], 11–22) days. Pneumonia had a cumulative incidence of 1.4% at a median of 5 days (IQR, 2–10 days). Systemic inflammatory response syndrome had a cumulative incidence of 1.6% at a median of 3 days (IQR, 8–16 days). Predictors of postoperative infections on multivariable analysis included female sex, older age, obesity, functionally dependent status before surgery, ventilator dependence, preoperative steroid use, bleeding disorders, hyponatremia, lymphocytosis, anemia, thrombocytosis, emergent case status, wound class II–IV, American Society of Anesthesiologists class 3–5, and longer operative times. Conclusion The overall ACS-NSQIP reported rate of postoperative infections was 5.3% from 2006 to 2014. Multivariable analysis demonstrated several predictive factors for postoperative infections.

The application of stem cell transplants in clinical practice has increased in frequency in recent years. Many of the stem cell transplants in neurologic diseases, including stroke, Parkinson disease, spinal cord injury, and demyelinating diseases, are unproven—they have not been tested in prospective, controlled clinical trials and have not become accepted therapies. Stem cell transplant procedures currently being carried out have therapeutic aims, but are frequently experimental and unregulated, and could potentially put patients at risk. In some cases, patients undergoing such operations are not included in a clinical trial, and do not provide genuinely informed consent. For these reasons and others, some current stem cell interventions for neurologic diseases are ethically dubious and could jeopardize progress in the field. We provide discussion points for the evaluation of new stem cell interventions for neurologic disease, based primarily on the new Guidelines for Stem Cell Research and Clinical Translation released by the International Society for Stem Cell Research in May 2016. Important considerations in the ethical translation of stem cells to clinical practice include regulatory oversight, conflicts of interest, data sharing, the nature of investigation (e.g., within vs outside of a clinical trial), informed consent, risk-benefit ratios, the therapeutic misconception, and patient vulnerability. To help guide the translation of stem cells from the laboratory into the neurosurgical clinic in an ethically sound manner, we present an ethical discussion of these major issues at stake in the field of stem cell clinical research for neurologic disease.

Background Functional gonadotroph adenomas (FGAs) are rare tumors of the pituitary gland that secrete biologically active gonadotropins. Objective To advance clinical understanding of FGAs. Methods We performed a retrospective review of adult patients who underwent resection of a pituitary lesion between August 1997 and October 2014 and remain under care at our center. We identified patients who had pathologic and biochemical confirmation of FGAs, as defined by a lack of serum follicle-stimulating hormone/luteinizing hormone suppression in the setting of elevated gonadal steroids, associated clinical symptoms, or both. Results FGAs were documented in 7 patients (5 men, 2 women) over a 17-year period. Clinical findings at presentation included visual field deficits in 5 patients, headache in 3, sexual dysfunction in 3, and ovarian cysts in both women. Each patient underwent lesion resection (6 via the endonasal transsphenoidal approach and 1 via a craniotomy with transsphenoidal reoperation). Analysis of tumor samples revealed immunopositivity for follicle-stimulating hormone/luteinizing hormone in 5 patients and FSH only in 2 patients. Postoperative follow-up (median, 10 months; range, 4-213 months) indicated remission in 6 of 7 patients. Conclusion An FGA can pose both a diagnostic and a therapeutic challenge. The tumor is often diagnosed as a nonfunctioning macroadenoma after presenting with nonspecific symptoms and is the cause of significant morbidity. An FGA should be considered in the differential diagnosis of patients harboring pituitary adenomas with reproductive dysfunction. Transsphenoidal resection is the initial treatment of choice and can reduce endocrine dysfunction, resolve headaches, improve visual impairment, and provide tissue for detailed analysis. Abbreviations FGA, functional gonadotroph adenomaFSH, follicle-stimulating hormoneLH, luteinizing hormoneTSH, thyroid-stimulating hormone.

Pituitary tumor apoplexy can result from either hemorrhagic or infarctive expansion of pituitary adenomas, and the related mass effect can result in compression of critical neurovascular structures. The time course of recovery of visual field deficits, headaches, ophthalmoparesis, and pituitary dysfunction after endoscopic transsphenoidal surgery has not been well established.Medical records were retrospectively reviewed for all patients who underwent endoscopic transsphenoidal surgery for pituitary tumor apoplexy from April 2008 to November 2014.Of 578 patients who underwent transsphenoidal surgery, pituitary tumor apoplexy was identified in 44 patients (7.6%). Two patients had prior surgery, leaving 42 patients for final analysis. These included infarction-related apoplexy in 7 (14.4%) patients, and hemorrhagic apoplexy in 35 (85.6%) patients. Hemorrhagic adenomas had a larger axial tumor diameter than patients with infarctive adenomas (4.4 ± 4.1 cm vs. 1.8 ± 0.8 cm; P0.01), but were otherwise equivalent. At an average last follow-up of 2.52 years (range, 0.1-6.7 years), resolution of ophthalmoparesis as a result of pituitary tumor apoplexy demonstrated the longest recovery course (range, 2.4 ± 2.2 months) compared with visual field deficits (range, 8.0 ± 9.9 days), headaches (range, 1.9 ± 3.0 days), or pituitary dysfunction (range, 2.0 ± 1.8 weeks; P0.01). All patients who presented with headaches (n = 37) and/or visual disturbances (n = 22) had complete resolution of symptoms at last follow-up, whereas 83.3% of patients who presented with ophthalmoplegia experienced resolution. Endocrinologic dysfunction remained relatively consistent after surgery.Endoscopic transsphenoidal surgery can provide durable resolution of symptoms for patients presenting with pituitary tumor apoplexy. Recovery from headaches, visual, and pituitary dysfunction may be more rapid compared with ophthalmoparesis.

Many studies have implicated operative length as a predictor of post-operative complications, including venous thromboembolism [deep vein thrombosis (DVT) and pulmonary embolism (PE)]. We analyzed the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database from 2006 to 2014, to evaluate whether length of operation had a statistically significant effect on post-operative complications in patients undergoing surgical resection of meningioma. Patients were included for this study if they had a post-operative diagnosis of meningioma. Patient demographics, pre-operative comorbidities, and post-operative 30-day complications were analyzed. Of 3743 patients undergoing craniotomy for meningioma, 13.6 % experienced any complication. The most common complications and their median time to occurrence were urinary tract infection (2.6 %) at 10 days postoperatively (IQR 7-15), unplanned intubation (2.5 %) at 3 days (IQR 1-7), failure to wean from ventilator (2.4 %) at 2.0 days (IQR 2-4), and DVT (2.4 %) at 6 days (IQR 11-19). Postoperatively, 3.6 % developed VTE; 2.4 % developed DVT and 1.7 % developed PE. Multivariable analysis identified older age (third and upper quartile), obesity, preoperative ventilator dependence, preoperative steroid use, anemia, and longer operative time as significant risk factors for VTE. Separate multivariable logistic regression models demonstrated longer operative time as a significant risk factor for VTE, all complications, major complications, and minor complications. Meningioma resection is associated with various post-operative complications that increase patient morbidity and mortality risk. this large, multi-institutional patient sample, longer operative length was associated with increased risk for postoperative venous thromboembolisms, as well as major and minor complications.

Objective Perception of medicolegal risk has been shown to influence defensive medicine behaviors. Canada, South Africa, and the United States have 3 vastly different health care and medicolegal systems. There has been no previous study comparing defensive medicine practices internationally. Methods An online survey was sent to 3672 neurosurgeons across Canada, South Africa, and the United States. The survey included questions on the following domains: surgeon demographics, patient characteristics, physician practice type, surgeon liability profile, defensive behavior—including questions on the frequency of ordering additional imaging, laboratory tests, and consults—and perception of the liability environment. Responses were analyzed, and multivariate logistic regression was used to examine the correlation of medicolegal risk environment and defensive behavior. Results The response rate was 30.3% in the United States ( n = 1014), 36.5% in Canada ( n = 62), and 41.8% in South Africa ( n = 66). Canadian neurosurgeons reported an average annual malpractice premium of $19,110 (standard deviation [SD] = $11,516), compared with $16,262 (SD = $7078) for South African respondents, $75,857 (SD = $50,775) for neurosurgeons from low-risk U.S. states, and $128,181 (SD = $79,355) for those from high-risk U.S. states. Neurosurgeons from South Africa were 2.8 times more likely to engage in defensive behaviors compared with Canadian neurosurgeons, while neurosurgeons from low-risk U.S. states were 2.6 times more likely. Neurosurgeons from high-risk U.S. states were 4.5 times more likely to practice defensively compared with Canadian neurosurgeons. Conclusions Neurosurgeons from the United States and South Africa are more likely to practice defensively than neurosurgeons from Canada. Perception of medicolegal risk is correlated with reported neurosurgical defensive medicine within these countries.

Brain tumor patients undergoing craniotomy generally receive prophylaxis against venous thromboembolism (VTE), but modalities in use differ widely and have been debated in the literature. A systematic review and meta-analysis was conducted to assess the efficacy and safety of VTE prophylaxis among brain tumor patients undergoing craniotomy. Ten randomized controlled trials were included in the final efficacy analysis. The various prophylactic measures employed in these studies reduced the risk for thrombosis compared to controls with an overall risk ratio of 0.61 (95 % CI: 0.47–0.79) in the fixed effect model. Although Cochrane Q-test showed unimportant heterogeneity across studies (p = 0.19) and the I2, a measure of heterogeneity between studies, was reasonably low at 28 %, subgroup analysis indicated that intervention type was a potential effect modifier for efficacy (p = 0.04). Unfractionated heparin alone showed a stronger reduction in VTE risk compared to placebo (RR = 0.27; 95 % CI: 0.10–0.73), and LMWH combined with mechanical prophylaxis showed a lower VTE risk as compared to mechanical prophylaxis alone (0.61; 95 % CI: 0.46–0.82). This meta-analysis demonstrates a statistically significant VTE risk reduction among brain tumor patients receiving prophylaxis, with chemical prophylaxis showing the strongest risk reduction. Five studies were included in the safety analysis, which showed an overall increased risk of bleeding comparing different prophylactic measures to different controls (RR = 2.02; 95 % CI: 1.14–3.58; I2 = 0 %; p = 0.86). Interventions in these studies were associated with an increased risk of post-operative, minor hemorrhage (RR = 2.20; 95 % CI = 1.00; 4.85), while the risk of major hemorrhage was not increased by chemoprophylaxis.

Venous thromboembolism (VTE), incorporating both deep vein thrombosis and pulmonary embolism, is a common, morbid, and potentially fatal condition. Patients undergoing surgery are at increased risk of VTE due to many perioperative factors, and patients undergoing surgery for high-grade glioma (HGG) have been found to be at an even higher risk than general surgical patients. Chemical prophylaxis of VTE during the postneurosurgical period remains one of the major dilemmas in modern neurosurgical practice due to a potential increased risk of devastating intracranial hemorrhage in the setting of anticoagulation. In this review, we aim to summarize the prevalence of VTE in patients with HGG and discuss relevant risk factors for the development of VTE after surgery for this malignancy. We also review options for VTE prophylaxis in the postoperative period and discuss appropriate management of these complex patients.

Introduction We report a contemporary consecutive series of 80 patients operated on for benign pituitary macroadenomas, followed endocrinologically for at least 3 months postoperatively. These patients were systematically evaluated preoperatively by high-resolution magnetic resonance imaging designed to detect the position of normal gland relative to the lesion. The rate of preservation of normal pituitary was critically analyzed using this strategy combined with endoscopic transsphenoidal resection. Methods This is a retrospective review of 46 women and 34 men with mean postoperative follow-up of 14 months (range, 3–30 months). The lesions encountered consisted of 80 pituitary macroadenomas (55 nonfunctioning, 18 acromegaly, 5 prolactinoma, 1 Cushing, one thyroid-stimulating hormone). Pituitary endocrine status was determined preoperatively and at most recent follow-up, and categorized as normal or impaired, based on laboratory studies showing new hormone deficiency or the need for pituitary hormone replacement therapy. Results Fifty-three patients (66.3%) had normal endocrine function preoperatively; 3 (5.7%) had loss of function postoperatively (1 transient). Twenty-seven patients (33.8%) had impaired function preoperatively; postoperatively 20 (74.1%) were unchanged, and 5 (18.5%) were worse; 2 (7.4%) recovered lost pituitary function. Of 80 patients undergoing resection, 5 (6.3%) had worsened pituitary function postoperatively. Patients with recurrent lesions ( n = 5, 6.3%) and those presenting with pituitary tumor apoplexy ( n = 5, 6.3%) were more likely to become further impaired. Other endocrine sequelae included 2 patients with permanent postoperative diabetes insipidus and 3 with transient symptomatic syndrome of inappropriate secretion of antidiuretic hormone. Conclusions The preservation and restoration of hormonal function are essential to assessing the outcome of surgery and to the patient's quality of life. Careful analysis of the anatomy of the pituitary lesions and their effect on the anatomy and physiology of the pituitary gland are crucial to success and allow modern technological advances to provide fewer complications of therapy and improved outcomes for our patients. The benchmarks provided in this article are a stimulus for even better results in the future as we take advantage of technical and conceptual advances and the benefits of multidisciplinary collaboration.

Post-operative respiratory failure can occur after neurosurgical operations. Identification of risk factors for respiratory failure after neurosurgery may help guide clinical decision-making, decrease length of stay, improve patient outcomes, and lower costs. We performed a search of the ACS-NSQIP database for all patients undergoing operations with a neurosurgeon from 2006 to 2013. We analyzed demographics, past medical history, and post-operative respiratory failure, defined as unplanned intubation and/or ventilator dependence for more than 48 h post-operatively. Of 94,621 NSQIP-reported neurosurgical patients from 2006 to 2013, 2325 (2.5 %) developed post-operative respiratory failure. Of these patients, 1270 (54.6 %) were male, with an overall mean age of 60.59 years; 571 (24.56 %) were current smokers and 756 (32.52 %) were ventilator-dependent. Past medical history included dyspnea in 204 patients (8.8 %), COPD in 198 (8.5 %), and congestive heart failure in 66 (2.8 %). The rate of post-operative respiratory failure decreased from 4.1 % in 2006 to 2.1 % in 2013 (p

OBJECT Recent studies have examined the impact of perceived medicolegal risk and compared how this perception impacts defensive practices within the US. To date, there have been no published data on the practice of defensive medicine among neurosurgeons in Canada. METHODS An online survey containing 44 questions was sent to 170 Canadian neurosurgeons and used to measure Canadian neurosurgeons’ perception of liability risk and their practice of defensive medicine. The survey included questions on the following domains: surgeon demographics, patient characteristics, type of physician practice, surgeon liability profile, policy coverage, defensive behaviors, and perception of the liability environment. Survey responses were analyzed and summarized using counts and percentages. RESULTS A total of 75 neurosurgeons completed the survey, achieving an overall response rate of 44.1%. Over one-third (36.5%) of Canadian neurosurgeons paid less than $5000 for insurance annually. The majority (87%) of Canadian neurosurgeons felt confident with their insurance coverage, and 60% reported that they rarely felt the need to practice defensive medicine. The majority of the respondents reported that the perceived medicolegal risk environment has no bearing on their preferred practice location. Only 1 in 5 respondent Canadian neurosurgeons (21.8%) reported viewing patients as a potential lawsuit. Only 4.9% of respondents would have selected a different career based on current medicolegal risk factors, and only 4.1% view the cost of annual malpractice insurance as a major burden. CONCLUSIONS Canadian neurosurgeons perceive their medicolegal risk environment as more favorable and their patients as less likely to sue than their counterparts in the US do. Overall, Canadian neurosurgeons engage in fewer defensive medical behaviors than previously reported in the US.

OBJECTIVEPerioperative management of patients with sellar lesions is complex, requiring input from a multidisciplinary team of specialists for ongoing management of both endocrinological and neurosurgical issues. Here, the authors reviewed the experience of a single multidisciplinary center over 10 years to identify key postoperative practices that ensure positive outcomes for patients with sellar lesions who undergo transsphenoidal surgery.METHODSThe authors performed a retrospective review of all transsphenoidal operations carried out by the senior author at a single center from April 2008 through November 2018. They included only adult patients and recorded perioperative management. They also reviewed the evolution of clinical practices for perioperative care at their institution to identify strategies for ensuring positive patient outcomes, and they reviewed the literature on select related topics.RESULTSIn total, 1023 operations in 928 patients were reviewed. Of these, 712 operations were for pituitary adenomas (69.6%), and 122 were for Rathke cleft cysts (11.9%). The remainder included operations for craniopharyngiomas (3.6%), arachnoid cysts (1.7%), pituitary tumor apoplexy (1.0%), and other sellar pathologies (12.2%). Among the reviewed operations, the median hospital stay was 3 days (IQR 2–3). Patient management details during the pre-, intra-, and postoperative periods were identified, including both shared characteristics of all patients undergoing transsphenoidal surgery and unique characteristics that are specific to certain lesion types or patient populations.CONCLUSIONSPatients with sellar lesions who undergo transsphenoidal surgery require complex, multidisciplinary perioperative care to monitor for common adverse events and to improve outcomes, but there is a dearth of high-quality evidence guiding most perioperative practices. Here, the authors reviewed practices at their institution across more than 1000 transsphenoidal operations that may help ensure successful patient outcomes.

Objective To identify trends in mobility and daily pain levels among a cohort of patients with clinically diagnosed spine disease. Methods Participants with spine disease were enrolled from a general neurosurgical clinic and installed a smartphone application (Beiwe) designed for digital phenotyping to their personal smartphone. This application collected passive meta-data on a minute-to-minute basis, including global positioning system (GPS), WiFi, accelerometer, text and telephone logs, and screen on and off time. The application also administered daily visual analog scale pain surveys. A linear mixed model framework was used to test for associations between self-reported pain and mobility and sociability from the passively collected data. Results A total of 105 patients were enrolled, with a median follow-up time of 94.5 days; 55 patients underwent a surgical intervention during the follow-up period. The weekly pain survey response rate was 73.2%. By the end of follow-up, the mean change in pain for all patients was −1.3 points (4.96 at the start of follow-up to 3.66 by the end of follow-up). Increased pain was significantly associated with reduced patient mobility as measured using 3 daily GPS summary statistics (i.e., average flight length, maximum diameter travelled, total distance travelled). Conclusions Patients with spine disease who reported greater pain had reduced mobility, as measured by the passively collected smartphone GPS data. Smartphone-based digital phenotyping appears to be a promising and scalable approach to assess mobility and quality of life of patients with spine disease.

BACKGROUND Multiple studies have reported higher rates of glioma in areas with higher socioeconomic status (SES) but to the authors' knowledge have not stratified by other factors, including race/ethnicity or urban versus rural location. METHODS The authors identified the average annual age-adjusted incidence rates and calculated hazard ratios for death for gliomas of various subtypes, stratified by a county-level index for SES, race/ethnicity, US region, and rural versus urban status. RESULTS Rates of glioma were highest in counties with higher SES (rate ratio, 1.18; 95% CI, 1.15-1.22 comparing the highest with the lowest quintiles [P

Public pressure for innovation plays a key role in determining the goals of neurosurgical research and practice. Public, philanthropic, and industry funding of research and innovation each have direct and differing effects on the advances achieved in neurosurgical practice, while public advocacy and pressure for specific treatments can shift clinical practice patterns. In this chapter, we will discuss how these varied forms of public pressure for innovation should meet the criteria of beneficence, non-maleficence, autonomy, and justice, just as the care provided by neurosurgeons should.

Conflicts of interest (COI) are formed from competing interests or motivations held by an individual or group. They are ubiquitous in the setting of innovation and collaboration, as these same collaborative ventures are imperative for the advancement of any field. While neurosurgical innovation benefits from the vast collaboration, industry funding, and incentives for innovation, it is important that COI are managed ethically. Financial COI between the medical device industry and physicians is perhaps the most evident example of how COI can affect clinical decisions and innovative practice. Additionally, in the realm of the scientific literature, there have been examples of abuse from the medical device industry, in which COI may have led to poor trial design and incomplete reporting of adverse events. Aside from the influence of industry, even more subtle forms of COI can have a lasting effect. For example, all physicians are subjected to more subtle forms of coercion that could affect judgment, and the effect of these is perhaps amplified given the subjective nature of many clinical decisions and the lack of oversight in innovation of thought. Thus, it is important to promote ethical innovation in order to preserve the quality of the literature and clinical practice and to protect patients.

With billions being spent yearly on medical research and development, a look is warranted into how innovation in medicine is funded. Neurosurgical innovation in particular can cost millions of dollars for the development of new therapies. In the United States, the private sector is by far the largest annual funder of medical research (over $100 billion), with the federal government ($36 billion) contributing less than half as much as private companies. Other sources, such as patient advocacy groups, academic institutions, and state and local government funded a substantial but much smaller amount of research.

Surgical innovation differs significantly from medical innovation, and the ethical discussion about medical innovation and compassionate use cannot necessarily be applied directly to innovation in surgery. It is sometimes considered difficult to meet the high ethical and regulatory standards for medical treatments in a surgical setting, where innovation is constantly occurring in small and incremental ways. Moving from these arguments, many have claimed that access to surgical innovation aligns with patient autonomy and should be permitted in certain circumstances. However, others argue that unrestricted access to innovative treatments can subvert regulation, risks undermining knowledge-generation structures, and poses a serious ethical risk. In this chapter, we will explore both viewpoints and discuss under what circumstances a patient’s right to innovative surgical treatment can be justifiably infringed.

Chimeric antigen receptor T cell therapy has become an important tool in the treatment of relapsed and refractory malignancy; however, it is associated with significant neurological toxicity. We characterized the neurological toxicity associated with chimeric antigen receptor T-cell therapy in a consecutive series of 100 patients up to 2 months post transfusion, 28 of whom were obtained from chart review and the others by prospective observation. The underlying neoplasms were lymphoma (74%), myeloma (14%), leukaemia (10%), and sarcoma (2%). The median age of the cohort was 64.5 years old and 39% of patients were female. The most commonly occurring neurological symptoms were encephalopathy (57%), headache (42%), tremor (38%), aphasia (35%) and focal weakness (11%). Focal neurological deficits are frequently observed after chimeric antigen receptor T-cell therapy and are associated with regional EEG abnormalities, FDG-PET hypometabolism, and elevated velocities on transcranial Doppler ultrasound. In contrast, structural imaging was typically normal. As this form of treatment is more widely adopted, recognition of the frequently encountered symptoms will be of increasing importance for the neurologists and oncologists caring for this growing patient population.

Incidence, prevalence, and survival for brain tumors varies by histologic type, age at diagnosis, sex, and race/ethnicity. Significant progress has been made in identifying potential risk factors for brain tumors, although more research is warranted. The strongest risk factors that have been identified thus far include allergies/atopic disease, ionizing radiation, and heritable genetic factors. Further analysis of large, multicenter, epidemiologic studies, as well as well annotated omic datasets (including genomic, epigenomic, transcriptomic, proteomic, or metabolomics data) can potentially lead to further understanding of the relationship between gene and environment in the process of brain tumor development.

OBJECTIVEThere are limited data on the long-term outcomes for children undergoing surgical revascularization for moyamoya disease (MMD) in North America. The authors present a series of pediatric MMD patients who underwent a standard revascularization procedure, pial synangiosis, more than 20 years previously at a single institution by a single surgical team.METHODSThis study is a retrospective review of all patients aged 21 years or younger treated for MMD at Boston Children’s Hospital who were operated on more than 20 years previously by the senior author (R.M.S.). Radiographic and operative reports, outpatient clinical records, and communications with patients and families were reviewed to document current clinical status, ability to perform daily activities, and concurrent or new medical conditions.RESULTSA total of 59 patients (38 female [64.4%], 21 male [35.6%]; median age at surgery 6.2 years [IQR 0.5–21 years]) were identified who were diagnosed with MMD and underwent surgical revascularization procedures more than 20 years previously. Clinically, all but 2 patients (96.6%) presented with the following symptoms alone or in combination: 43 (73%) presented with stroke, 22 (37%) with transient ischemic attack, 12 (20%) with seizures, 7 (12%) with headache, 3 (5%) with choreiform movements, and 2 (3%) with hemorrhage; MMD was incidentally detected in 2 patients (3%). Five patients had unilateral MMD at presentation, but 3 of these ultimately progressed to develop bilateral MMD after an average of 16 months; therefore, pial synangiosis was ultimately performed in a total of 116 hemispheres during the study period. Clinical follow-up was available at a median interval of 20.6 years (IQR 16.1–23.2 years). Modified Rankin Scale scores were stable or improved in 43 of 50 patients with evaluable data; 45 of 55 are currently independent. There were 6 patient deaths (10.2%; 3 due to intracranial hemorrhage, 2 due to tumor-related complications, and 1 due to pulmonary artery stenosis), 4 of whom had a history of previous cranial radiation. One patient (1.7%) experienced a late stroke. Synangiosis vessels remained patent on all available late MRI and MRA studies. Four patients reported uneventful pregnancies and vaginal deliveries years following their revascularization procedures.CONCLUSIONSRevascularization for MMD by pial synangiosis appears to confer protection from stroke for pediatric patients over long-term follow-up. A history of cranial radiation was present in 4 of the 6 patients who died and in the lone patient with late stroke. Most patients can expect productive, independent lives following revascularization surgery in the absence of significant preoperative neurological deficits and comorbidities.

Cushing’s disease (CD) is a condition characterized by excess glucocorticoid from an ACTH pituitary adenoma. Identifying surgical candidates represents a major diagnostic challenge. We performed a root cause analysis (RCA) of treatment failures for patients with suspected CD. The present study aims to categorize failures in treatment. Medical records were reviewed from 2008 to 2017 for all patients treated surgically for suspected CD. Demographics, past medical history, endocrine outcomes, imaging findings, laboratory studies and clinical features were collected. Eighty-five patients were identified with pre-operative suspicion for CD. Thirty-four (40.0%) had undergone prior surgery confirming ACTH adenoma, leaving 51 (60.0%) for analysis. The average length of follow-up was 18.3 ± 24.1 months, 42 (82.4%) patients had postoperative biochemical remission of hypercortisolism. Forty-three (84.3%) had histologically confirmed CD, two (3.9%) were diagnosed with extracranial ACTH-secreting tumors, four (7.8%) had no obvious tumor upon intraoperative exploration, one (1.9%) had suspected pituitary ACTH hyperplasia, and one (1.9%) had no identifiable pathologic tissue despite apparent gross tumor observed during surgery. Thirty-four (66.7%) patients had remission following surgery alone, four (7.8%) after reoperation, and four (7.81%) after radiosurgery. One patient (1.9%) was found to have an ectopic source of ACTH, and one (1.9%) had immunohistochemically confirmed adrenal tumors. On RCA, we identified six categories of treatment failures. CD is a diagnostic challenge that can be difficult to distinguish from other forms of hypercortisolism. Surgical efficacy can be improved with more accurate patient selection, and perhaps with improved imaging methods.

Stepwise improvements in the imaging of pituitary adenomas in the last 100 years have had a tremendous impact on patient care. Pituitary tumors are now diagnosed earlier in the time course of the disease, improving chances of endocrine and visual recovery. There is improved pre-surgical planning due to a better understanding of the investment of the tumor around important surrounding parasellar structures. Approaches to tumors are now safer due to stereotactic navigation and residual disease can be radiographically followed for a lifetime and treated prior to irreversible neurological damage. Furthermore, adjuvant radiotherapy can be more precisely delivered to the tumor bed with the aid of higher resolution images. Thanks to these incremental improvements previously formidable macroadenomas, which carried a high risk for morbidity and residual disease, can now be treated safely and effectively. Here, we review modern imaging modalities used to diagnose pituitary adenomas, and identify areas for further improvement.

We report the indications and outcomes of awake right hemispheric brain surgery, as well as a rare patient with crossed aphasia. Awake craniotomies are often performed to protect eloquent cortex. We reviewed the medical records for 35 of 96 patients, in detail, who had awake right hemisphere brain operations. Intraoperative cortical mapping of motor and/or language function was performed in 29 of the 35 patients. A preoperative speech impairment and left hand dominance were the main indicators for awake right-sided craniotomies in patients with right hemisphere lesions. Four patients with lesion proximity to eloquent areas underwent awake craniotomies without cortical mapping. In addition, one patient had a broncho-pulmonary fistula, and another had a recent major cardiac procedure that precluded awake surgery. An eloquent cortex representation was identified in 14 patients (48.3%). Postoperatively, seven of 17 patients (41.1%) who presented with weakness, experienced improvements in their motor functions, 11 of 16 (68.7%) with seizures became seizure-free, and seven of nine (77.7%) with moderate to severe headaches and one of two with a visual field deficit improved significantly. There were also improvements in speech and language functions in all patients who presented with speech difficulties. A right sided awake craniotomy is an excellent option for left handed patients, or those with right sided cortical lesions that result in preoperative speech impairments. When combined with intraoperative cortical mapping, both speech and motor function can be well preserved.

Introduction The transsphenoidal approach was initially developed in neurosurgical practice as an operative approach to the pituitary gland. The introduction of the operating endoscope has improved the versatility of the transsphenoidal approach, broadening the spectrum of lesions that can be treated effectively with this operative strategy. Methods We performed a retrospective review of all patients who underwent transnasal, transsphenoidal operations at Brigham and Women's Hospital from April 2008 to February 2015 and categorized each case by pathologic diagnosis. Results A total of 792 transnasal, transsphenoidal operations (512 endoscopic) were performed by 9 neurosurgeons for 33 pathologies over a 7-year period. Pituitary adenomas (535, 67.55%) were the most common impetus for a transsphenoidal operation. Others included Rathke cleft cysts (86, 10.86%), craniopharyngiomas (25, 3.16%), lympocytic hypophysitis/pituitary inflammation (21, 2.65%), arachnoid cysts (8, 1.01%), spindle cell oncocytoma (4, 0.51%), colloid cysts (4, 0.51%), and pituicytoma (2, 0.25%). Pituitary hyperplasia was treated in 9 cases (1.14%) and pituitary apoplexy in 7 (0.88%). Nineteen operations were undertaken for postoperative repairs (2.40%) and 3 for abscesses (0.38%). Other diseases treated transsphenoidally included chordomas (12, 1.52%), metastases (9, 1.14%), meningiomas (5, 0.63%), clival lesions (4, 0.51%), germinomas (3, 0.38%), granulomas (2, 0.25%), dermoid tumors (2, 0.25%), and 1 (0.13%) each of esthesioneuroblastoma, granular cell tumor, Wegener granulomatosis, olfactory neuroblastoma, glioneuronal tumor, chondromyxoid fibroma, epidermoid, meningoencephalocele, aneurysm, neuroendocrine carcinoma, chondrosarcoma, and lymphoma. Conclusions Although initially devised in neurosurgical practice for tumors of the pituitary gland, developments in technology now make the transsphenoidal approach an effective operative strategy for a wide range of anterior skull base lesions.

The US health care system is struggling with rising costs, poor outcomes, waste, and inefficiency. The Patient Protection and Affordable Care Act represents a substantial effort to improve access and emphasizes value-based care. Value in health care has been defined as health outcomes for the patient per dollar spent. However, given the opacity of health outcomes and cost, the identification and quantification of patient-centered value is problematic. These problems are magnified by highly technical, specialized care (eg, neurosurgery). This is further complicated by potentially competing interests of the 5 major stakeholders in health care: patients, doctors, payers, hospitals, and manufacturers. These stakeholders are watching with great interest as health care in the United States moves toward a value-based system. Market principles can be harnessed to drive costs down, improve outcomes, and improve overall value to patients. However, there are many caveats to a market-based, value-driven system that must be identified and addressed. Many excellent neurosurgical efforts are already underway to nudge health care toward increased efficiency, decreased costs, and improved quality. Patient-centered shared value can provide a philosophical mooring for the development of health care policies that utilize market principles without losing sight of the ultimate goals of health care, to care for patients.

Venous thromboembolism (VTE), including deep venous thrombosis (DVT) and pulmonary embolism (PE), frequently complicates the postoperative course of primary malignant brain tumor patients. Thromboprophylactic anticoagulation is commonly used to prevent VTE at the risk of intracranial hemorrhage (ICH). We extracted all patients who underwent craniotomy for a primary malignant brain tumor from the National Surgical Quality Improvement Program (NSQIP) registry (2005-2015) to perform a time-to-event analysis and identify relevant predictors of DVT, PE, and ICH within 30 days after surgery. Among the 7376 identified patients, the complication rates were 2.6, 1.5, and 1.3% for DVT, PE, and ICH, respectively. VTE was the second-most common major complication and third-most common reason for readmission. ICH was the most common reason for reoperation. The increased risk of VTE extends beyond the period of hospitalization, especially for PE, whereas ICH occurred predominantly within the first days after surgery. Older age and higher BMI were overall predictors of VTE. Dependent functional status and longer operative times were predictive for VTE during hospitalization, but not for post-discharge events. Admission two or more days before surgery was predictive for DVT, but not for PE. Preoperative steroid usage and male gender were predictive for post-discharge DVT and PE, respectively. ICH was associated with various comorbidities and longer operative times. This multicenter study demonstrates distinct critical time periods for the development of thrombotic and hemorrhagic events after craniotomy. Furthermore, the VTE risk profile depends on the type of VTE (DVT vs. PE) and clinical setting (hospitalized vs. post-discharge patients).

Background Innovation is a part of the daily practice of neurosurgery. However, a clear definition of what constitutes innovation is lacking and opinions vary from continent to continent, from hospital to hospital, and from surgeon to surgeon. Methods In this study, we distributed an online survey to neurosurgeons from multiple countries to investigate what neurosurgeons consider innovative, by gathering opinions on several hypothetical cases. The anonymous survey consisted of 52 questions and took approximately 10 minutes to complete. Results A total of 355 neurosurgeons across all continents excluding Antarctica completed the survey. Neurosurgeons achieved consensus (>75%) in considering specific cases to be innovative, including laser resection of meningioma, focused ultrasonography for tumor, oncolytic virus, deep brain stimulation for addiction, and photodynamic therapy for tumor. Although the new dura substitute case was not considered innovative, there was consensus among neurosurgeons indicating that institutional review board approval was still necessary to maintain ethical standards. Furthermore, although 90% of neurosurgeons considered an oncolytic virus for glioblastoma multiforme to be innovative, only 78% believed that institutional review board approval was necessary before treatment. Conclusions Our results indicate that innovation is a heterogeneous concept among neurosurgeons that necessitates standardization to ensure appropriate patient safety without stifling progress. We discuss both the ethical drawbacks of not having a clear definition of innovation and the challenges in achieving a unified understanding of innovation in neurosurgery and offer suggestions for uniting the field.

Patients undergoing transsphenoidal pituitary surgery (TSS) are at risk for several serious complications, including the syndrome of inappropriate antidiuretic hormone and subsequent hyponatremia. In this study, we examined the effect of 1 week of post-discharge fluid restriction to 1.0 L daily on rates of post-operative readmission for hyponatremia. We retrospectively analyzed all patients undergoing TSS from 2008 to 2014 and prospectively recorded patient data from 2015 to 2017. Patients were divided into a control cohort (2008–2014), who were discharged with instructions to drink to thirst; and an intervention cohort (2015–2017) who were instructed to drink less than 1.0 L daily for 1 week post-operatively. This study included 788 patients; 585 (74.2%) in the control cohort and 203 (25.8%) in the intervention cohort. Overall, 436 (55.3%) were women, the median age was 47 (range 15–89), and average BMI was 29.4 kg/m2 (range 17.7–101.7). Patients were relatively well matched. Of patients in the intervention group, none was readmitted for hyponatremia (0/203), compared to 3.41% (20/585) in the control group (p = 0.003). Patients in the intervention group also had significantly higher post-operative week one sodium levels (140.1 vs 137.5 mEq/L; p = 0.002). No fluid balance complications occurred in patients who followed this protocol. Hyponatremia can be a life-threatening complication of TSS, and prevention of readmission for hyponatremia can help improve patient safety and decrease costs. Mandatory post-discharge fluid restriction is a simple and inexpensive intervention associated with decreased rates of readmission for hyponatremia and normal post-operative sodium levels.

Objective Rathke cleft cysts (RCC) are benign lesions of the sella that often present with headache. It is not currently well established whether surgical resection of RCC results in resolution of headache. We conducted a meta-analysis to examine the effect of RCC resection on headache resolution. Methods PubMed, EMBASE, and Cochrane databases were searched through June 2017 for articles that evaluated the effect of RCC resection on headache resolution. Pooled effect estimates were calculated using fixed-effects and random-effects models. Results Ten case series with 276 patients were included. Transsphenoidal surgery (TSS) was used to resect RCC in all of the studies. Only 1 patient in 1 study underwent transcranial surgery. Using the fixed effect model, the overall headache resolution prevalence was 71.7% (95% confidence interval [CI] 65.3%, 77.3%) among patients who underwent resection of RCC (I2 = 76.9%; P-heterogeneity Conclusion This meta-analysis demonstrates that the resection of RCC in patients presenting with headache is associated with headache resolution.

Introduction Medicine is rapidly changing, both in the level of collective medical knowledge and in how it is being delivered. The increased presence of administrators in hospitals helps to facilitate these changes and ease administrative workloads on physicians; however, tensions sometimes form between physicians and administrators. Analysis This situation is based on perceptions from both sides that physicians obstruct cost-saving measures and administrators put profits before patients. In reality, increasing patient populations and changes in health care are necessitating action by hospitals to prevent excessive spending as health care systems become larger and more difficult to manage. Recognizing the cause of changes in health care, which do not always originate with physicians and administrators, along with implementing changes in hospitals such as increased physician leadership, could help to ease tensions and promote a more collaborative atmosphere. Ethically, there is a need to preserve physician autonomy, which is a tenet of medical professionalism, and a need to rein in spending costs and ensure that patients receive the best possible care. Conclusion Physicians and administrators both need to have a well-developed personal ethic to achieve these goals. Physicians need be allowed to retain relative autonomy over their practices as they support and participate in administrator-led efforts toward distributive justice.