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We aimed to identify trends in the neurosurgical practice environment in the United States from 2006 to 2013 using the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database, and to determine the complication rate for spinal and cranial procedures and identify risk factors for post-operative complications across this time period. We performed a search of the American College of Surgeons-NSQIP database for all patients undergoing an operation with a surgeon whose primary specialty was neurological surgery from 2006 to 2013. Analysis of patient demographics and pre-operative co-morbidities was performed, and multivariate analysis was used to determine predictors of surgical complications. From 2006 to 2013, the percentage of spinal operations performed by neurosurgeons relative to cranial and peripheral nerve cases increased from 68.0% to 76.8% (p<0.001) according to the NSQIP database. The proportion of cranial cases during the same time period decreased from 29.7% to 21.6% (p<0.001). The overall 30-day complication rate among all 94,621 NSQIP reported patients undergoing operations with a neurosurgeon over this time period was 8.2% (5.6% for spinal operations, 16.1% for cranial operations). The overall rate decreased from 11.0% in 2006 to 7.5% in 2013 (p<0.001). Several predictors of post-operative complication were identified on multivariate analysis., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: The American College of Surgeons National Surgical Quality Improvement Program database aims to reduce 30-day postoperative complications. Reduction of postoperative stroke and coma can decrease length and cost of hospitalization, improve patient functional status, and decrease morbidity and mortality., Methods: We performed a search of the American College of Surgeons National Surgical Quality Improvement Program database for all patients from 2006 to 2013 undergoing an operation with a surgeon whose primary specialty was neurologic surgery., Results: Of 94,546 neurosurgical patients reported, there were 687 (0.73%) cases of postoperative stroke and coma. The annual rate of coma longer than 24 hours decreased from 0.90% in 2006 to 0.002% in 2013 (P < 0.001), and the annual rate of stroke decreased from 1.2% in 2006 to 0.5% in 2013 (P = 0.013). Multivariate analysis showed that inpatient status (P = 0.001; odds ratio [OR], 30.3), age (P = 0.005; OR, 1.012), history of diabetes (P = 0.017; OR, 1.515), ventilator dependence (P < 0.001; OR, 4.379), impaired sensorium (P < 0.001; OR, 2.314), history of coma longer than 24 hours (P < 0.001; OR, 2.655), hemiparesis (P = 0.022; OR, 1.492), cerebrovascular accident/stroke with neurologic deficit (P < 0.001; OR, 2.091), cerebrovascular accident/stroke without neurologic deficit (P = 0.001; OR, 2.44), and tumor involving central nervous system (P < 0.001; OR, 2.928) are significant risk factors for developing postneurosurgical stroke and coma., Conclusions: The rate of postneurosurgical stroke decreased from 1.2% in 2006 to 0.5% in 2013 and the rate of postneurosurgical coma greater than 24 hours decreased from 0.9% in 2006 to 0.002% in 2013. Ten risk factors for developing postneurosurgical stroke and coma were identified using multivariable analysis. These risk factors should be assessed preoperatively and incorporated into clinical decision making so that individuals who are at higher risk for the development of stroke and coma can be appropriately monitored during the postoperative period., (Copyright © 2016 Elsevier Inc. All rights reserved.)

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., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To compare the self-reported liability characteristics and defensive medicine practices of neurosurgeons in Texas with neurosurgeons in Illinois in an effort to describe the effect of medicolegal environment on defensive behavior., Methods: An online survey was sent to 3344 members of the American Board of Neurological Surgery. Respondents were asked questions in 8 domains, and responses were compared between Illinois, the state with the highest reported average malpractice insurance premium, and Texas, a state with a relatively low average malpractice insurance premium., Results: In Illinois, 85 of 146 (58.2%) neurosurgeons surveyed responded to the survey. In Texas, 65 of 265 (24.5%) neurosurgeons surveyed responded. In Illinois, neurosurgeons were more likely to rate the overall burden of liability insurance premiums to be an extreme/major burden (odds ratio [OR] = 7.398, P < 0.001) and to have >$2 million in total coverage (OR = 9.814, P < 0.001) than neurosurgeons from Texas. Annual malpractice insurance premiums in Illinois were more likely to be higher than $50,000 than in Texas (OR = 9.936, P < 0.001), and survey respondents from Illinois were more likely to believe that there is an ongoing medical liability crisis in the United States (OR = 9.505, P < 0.001). Neurosurgeons from Illinois were more likely to report that they very often/always order additional imaging (OR = 2.514, P = 0.011) or very often/always request additional consultations (OR = 2.385, P = 0.014) compared with neurosurgeons in Texas., Conclusions: Neurosurgeons in Illinois are more likely to believe that there is an ongoing medical liability crisis and more likely to practice defensively than neurosurgeons in Texas., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Delayed symptomatic hyponatremia (DSH) is a known complication of transsphenoidal surgery that can lead to prolonged hospital stay, readmission, and in rare cases, death. Many potential predictors for development of DSH have been investigated. A better understanding of DSH risk can lead to better patient outcomes. We performed a systematic review to determine the rates and predictors of DSH after both endoscopic transsphenoidal surgery and microscopic transsphenoidal surgery., Methods: A systematic search of the literature was conducted using MEDLINE/PUBMED, EMBASE, and Cochrane databases. Inclusion criteria were 1) case series with at least 10 cases reported, 2) adult patients who underwent eTSS or mTSS for pituitary tumors, and 3) reported occurrence of DSH (defined as serum sodium level <135 mEq/L with associated symptoms) after postoperative day 3. Data were analyzed using CMA V.3 Statistical Software (2014)., Results: Ten case series satisfied the inclusion criteria for a total of 2947 patients. Various factors including age, gender, cerebrospinal fluid leak, and tumor size were investigated as potential predictors of DSH. DSH event rates for both mTSS and eTSS fell between around 4 and 12 percent and included a variety of proposed predictors., Conclusions: Age, gender, tumor size, rate of decline of blood sodium, and Cushing disease are potential predictors of DSH. By identifying patients at high risk for DSH, preventative efforts can be implemented in the perioperative setting to reduce the incidence of potentially catastrophic hyponatremia following transsphenoidal surgery., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Venous thromboembolism (VTE) is a relatively common and well-described condition, affecting approximately 1-2% of the general population. VTE can lead to significant morbidity and death via pulmonary embolism (PE). During the post-operative period, VTE occurs at higher rates due to natural thrombotic responses to injury and limited post-operative mobility. In general, rates of post-operative VTE are higher in patients undergoing operations for cranial and spinal lesions than for lesions of other types, a phenomenon that is not fully explained. Proposed mechanisms include increased local synthesis of tissue factor in brain tumor patients and a higher rate of paresis in patients undergoing operations on the central nervous system. Several studies have demonstrated that other risk factors for VTE include age, sex, ethnicity, hospital stay length, and coagulation state. Tumor type and size have also been explored as potential risk factors. Despite higher rates of VTE development, neurosurgeons are often hesitant to prescribe post-operative anticoagulants for fear of hemorrhage. Here we review the literature on VTE in brain tumor patients, with a focus on their etiology, diagnosis, treatment, and prophylaxis. In most brain tumor patients, aggressive chemical and mechanical VTE prophylaxis is indicated in the post-operative period to prevent the formation of VTE., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

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., (Copyright © 2015 Elsevier Ltd. All rights reserved.)