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Background: Surgical site infections after craniotomy (SSI-CRAN) significantly impact patient outcomes and healthcare costs by increasing length of stay and readmission and reoperation rates. However, to our knowledge, no study has yet analysed the economic impact of a surgical care bundle for preventing SSI-CRAN. The aim is to analyse the hospital cost saving after implementation of a care bundle for the prevention of SSI-CRAN., Methods: A retrospective cost-analysis was performed, considering two periods: pre-care bundle (2013-2015) and care bundle (2016-2017). A bottom-up approach was used to calculate the costs associated with infection in patients who developed a SSI-CRAN in comparison to those who did not, in both periods and on a patient-by-patient basis. The derived cost of SSI-CRAN was calculated considering: (1) cost of the antibiotic treatment, (2) cost of length of stay in the neurosurgery ward within the 1-year follow up period, (3) cost of the re-intervention, and (4) cost of the implant for cranial reconstruction, when necessary., Results: A total of 595 patients were included in the pre-care bundle period and 422 in the care bundle period. Mean cost of a craniotomy procedure was approximately €8000, rising to €24,000 in the case of SSI-CRAN. Mean yearly hospital costs fell by €502,857 in the care bundle period (€714,886 vs. €212,029). Extra costs between periods were mainly due to increased length of hospital stay (€573,555.3 vs. €183,958.9; difference: €389,596.4), followed by the cost of implant for cranial reconstruction (€69,803.4 vs. €9,936; difference: €59,867.4). Overall, implementation of the care bundle saved the hospital €500,844.3/year., Conclusion: The implementation of a care bundle for SSI-CRAN had a significant economic impact. Hospitals should consider the deployment of this multimodal preventive strategy to reduce their SSI-CRAN rates, and also their costs., (© 2021. The Author(s).)

Objective: We demonstrate the advantages and safety of long, intraorbitally-placed needle electrodes, compared to standard-length subdermal electrodes, when recording lateral rectus electromyography (EMG) during intracranial surgeries., Methods: Insulated 25 mm and uninsulated 13 mm needle electrodes, aimed at the lateral rectus muscle, were placed in parallel during 10 intracranial surgeries, examining spontaneous and stimulation-induced EMG activities. Postoperative complications in these patients were reviewed, alongside additional patients who underwent long electrode placement in the lateral rectus., Results: In 40 stimulation-induced recordings from 10 patients, the 25 mm electrodes recorded 6- to 26-fold greater amplitude EMG waveforms than the 13 mm electrodes. The 13 mm electrodes detected greater unwanted volume conduction upon facial nerve stimulation, typically exceeding the amplitude of abducens nerve stimulation. Except for one case with lateral canthus ecchymosis, no clinical or radiographic complications occurred in 36 patients (41 lateral rectus muscles) following needle placement., Conclusions: Intramuscular recordings from long electrode in the lateral rectus offers more reliable EMG monitoring than 13 mm needles, with excellent discrimination between abducens and facial nerve stimulations, and without significant complications from needle placement., Significance: Long intramuscular electrode within the orbit for lateral rectus EMG recording is practical and reliable for abducens nerve monitoring., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Background: The endoscope-assisted subtemporal key-hole epidural approach (ESKEA) has been recently described. The aim of this study was to measure working volumes and exposure of key areas of the middle cranial fossa provided by this approach., Methods: Four fresh frozen cadaver heads were dissected to analyze 3 modular corridors (1A, 1B, and 2) harvested through ESKEA. A step-by-step dissection was performed, and key anatomic landmarks were recorded. A GTxEyesII-ApproachViewer was used to quantify the working volume and exposure of 4 different regions (sphenoorbital, parasellar, superior petrous apex, and squamopetrous). For each corridor, 3 incremental degrees of temporal dural retraction (5, 10, and 15 mm) were tested., Results: The working volume of all corridors progressively increased with degree of retraction: Corridors 1A, 1B, and 2 showed a gain in working volume of 21%, 27%, and 19% from 5 mm to 10 mm retraction, respectively, and a gain of 40%, 45%, and 44% from 5 mm to 15 mm retraction, respectively. The sphenoorbital area was exposed (27%-45%) through corridor 1A, and exposure significantly increased with the degree of retraction. Corridor 1B provided optimal exposure of parasellar areas (86%-100%) and superior petrous apex (70%-87%) regardless of the degree of retraction. The squamopetrous area was satisfactorily addressed through corridor 2 (88%) only with the highest degree of retraction., Conclusions: ESKEA can be conceived as a modular approach: the 3 surgical corridors have specific working volumes, which are clearly influenced by the degree of temporal lobe retraction, and provide exposure of different middle cranial fossa areas., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Repairing bone defects generated by craniectomy is a major therapeutic challenge in terms of bone consolidation as well as functional and cognitive recovery. Furthermore, these surgical procedures are often grafted with complications such as infections, breaches, displacements and rejections leading to failure and thus explantation of the prosthesis., Objective: To evaluate cumulative explantation and infection rates following the implantation of a tailored cranioplasty CUSTOMBONE prosthesis made of porous hydroxyapatite. One hundred and ten consecutive patients requiring cranial reconstruction for a bone defect were prospectively included in a multicenter study constituted of 21 centres between December 2012 and July 2014. Follow-up lasted 2 years., Results: Mean age of patients included in the study was 42±15 years old (y.o), composed mainly by men (57.27%). Explantations of the CUSTOMBONE prosthesis were performed in 13/110 (11.8%) patients, significantly due to infections: 9/13 (69.2%) (p<0.0001), with 2 (15.4%) implant fracture, 1 (7.7%) skin defect and 1 (7.7%) following the mobilization of the implant. Cumulative explantation rates were successively 4.6% (SD 2.0), 7.4% (SD 2.5), 9.4% (SD 2.8) and 11.8% (SD 2.9%) at 2, 6, 12 and 24 months. Infections were identified in 16/110 (14.5%): 8/16 (50%) superficial and 8/16 (50%) deep. None of the following elements, whether demographic characteristics, indications, size, location of the implant, redo surgery, co-morbidities or medical history, were statistically identified as risk factors for prosthesis explantation or infection., Conclusion: Our study provides relevant clinical evidence on the performance and safety of CUSTOMBONE prosthesis in cranial procedures. Complications that are difficulty incompressible mainly occur during the first 6 months, but can appear at a later stage (>1 year). Thus assiduous, regular and long-term surveillances are necessary., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: Intracranial pressure monitor (ICPm) procedure rates are a quality metric for American College of Surgeons trauma center verification. However, ICPm procedure rates may not accurately reflect the quality of care in TBI. We hypothesized that ICPm and craniotomy/craniectomy procedure rates for severe TBI vary across the United States by geography and institution., Methods: We identified all patients with a severe traumatic brain injury (head Abbreviated Injury Scale, ≥3) from the 2016 Trauma Quality Improvement Program data set. Patients who received surgical decompression or ICPm were identified via International Classification of Diseases codes. Hospital factors included neurosurgeon group size, geographic region, teaching status, and trauma center level. Two multiple logistic regression models were performed identifying factors associated with (1) craniotomy with or without ICPm or (2) ICPm alone. Data are presented as medians (interquartile range) and odds ratios (ORs) (95% confidence interval)., Results: We identified 75,690 patients (66.4% male; age, 59 [36-77] years) with a median Injury Severity Score of 17 (11-25). Overall, 6.1% had surgical decompression, and 4.8% had ICPm placement. Logistic regression analysis showed that region of the country was significantly associated with procedure type: hospitals in the West were more likely to use ICPm (OR, 1.34 [1.20-1.50]), while Northeastern (OR, 0.80 [0.72-0.89]), Southern (OR, 0.84 [0.78-0.92]), and Western (OR, 0.88 [0.80-0.96]) hospitals were less likely to perform surgical decompression. Hospitals with small neurosurgeon groups (<3) were more likely to perform surgical intervention. Community hospitals are associated with higher odds of surgical decompression but lower odds of ICPm placement., Conclusion: Both geographic differences and hospital characteristics are independent predictors for surgical intervention in severe traumatic brain injury. This suggests that nonpatient factors drive procedural decisions, indicating that ICPm rate is not an ideal quality metric for American College of Surgeons trauma center verification., Level of Evidence: Epidemiological, level III; Care management/Therapeutic level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: Sepsis and septic shock are important quality and patient safety metrics. This study examines incidence of Sepsis and/or septic shock (S/SS) after craniotomy for tumor resection, one of the most common neurosurgical operations., Methods: Multicenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify patients undergoing craniotomy for tumor (CPT 61510, 61521, 61520, 61518, 61526, 61545, 61546, 61512, 61519, 61575) from 2012-2015. Univariate and multivariate logistic regression models were used to identify risk factors for S/SS., Results: There were 18,642 patients that underwent craniotomy for tumor resection. The rate of sepsis was 1.35% with a mortality rate of 11.16% and the rate of septic shock was 0.65% with a 33.06% mortality rate versus an overall mortality rate of 2.46% in the craniotomy for tumor cohort. The 30-day readmission rate was 50.54% with S/SS vs 10.26% in those without S/SS. Multiple factors were identified as statistically significant (p <0.05) for S/SS including ascites (OR = 33.0), ventilator dependence (OR = 4.5), SIRS (OR = 2.8), functional status (OR = 2.3), bleeding disorders (OR = 1.7), severe COPD (OR = 1.6), steroid use (OR = 1.6), operative time >310 minutes (OR = 1.5), hypertension requiring medication (OR = 1.5), ASA class ≥ 3 (OR = 1.4), male sex (OR = 1.4), BMI >35 (OR = 1.4) and infratentorial location., Conclusions: The data indicate that sepsis and septic shock, although uncommon after craniotomy for tumor resection, carry a significant risk of 30-day unplanned reoperation (35.60%) and mortality (18.21%). The most significant risk factors are ventilator dependence, ascites, SIRS and poor functional status. By identifying the risk factors for S/SS, neurosurgeons can potentially improve outcomes. Further investigation should focus on the creation of a predictive score for S/SS with integration into the electronic health record for targeted protocol initiation in this unique neurosurgical patient population., Competing Interests: The authors have declared that no competing interests exist.

Traumatic brain injury (TBI) poses a huge public health and societal problem worldwide. Uncertainty exists on how care system and treatment approaches for TBI worked in China may differ from those in Europe. Better knowledge on this is important to facilitate interpretation of findings reported by Chinese researchers and to inform opportunities for collaborative studies. We aimed to investigate concordance and variations in TBI care between Chinese and European neurotrauma centers. Investigators from 52 centers in China and 68 in Europe involved in the Collaborative European Neuro Trauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study were invited to complete provider profiling (PP) questionnaires, which covered the main aspects of care system and treatment approaches of TBI care. Participating Chinese and European centers were mainly publicly funded and academic. More centers in China indicated available dedicated neuro-intensive care than those in Europe (98% vs. 60%), and treatment decisions in the ICU were mainly determined by neurosurgeons (58%) in China while in Europe, (neuro)intensivists often took the lead (61%). The ambulance dispatching system was automatic in half of Chinese centers (49%), whereas selective dispatching was more common in European centers (74%). For treatment of refractory intracranial hypertension, a decompressive craniectomy was more frequently regarded as general policy in China compared with in Europe (89% vs. 45%). We observed both concordance and substantial variations with regard to the various aspects of TBI care between Chinese and European centers. These findings are fundamental to guide future research and offer opportunities for collaborative comparative effectiveness research to identify best practices.

Background: Isolated chronic subdural hematoma (ICSH), as a special rare species, has great controversy over its treatment. A retrospective analysis was performed to compare craniotomy with endoscopic-assisted trepanation drainage (EATD) of ICSH., Methods: The data of ICSH patients for craniotomy or EATD from January 2011 to April 2019 were retrospectively collected and analysed. Of 106 patients, 49 and 57 patients received craniotomy and EATD treatment respectively. Recurrence rate, morbidity and mortality rate were the main outcome., Result: There was no recurrence in both groups. The morbidity rate of the EATD group (2/57, 3.5%) was significantly lower than that of the craniotomy group (17/49, 34.7%, p = 0.0033). There was no death in the EATD group, but 3 cases died of operative produce in the craniotomy group. The average operation time of the craniotomy group (95.3min) was significantly longer than that of the EATD group (66.5min, P =  0.0032). Craniotomy group had more intraoperative blood loss (213.2ml) than EATD group (34.5ml, P = 0.0044). EATD patients had shorter hospital stay and recovered faster., Conclusions: Compared with craniotomy, EATD is a more effective and safer method for the treatment of ICSH., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The growing elderly population in Western societies has led to an increasing number of primary brain tumors occurring in patients beyond the age of 65. The purpose of this study was to assess and compare the safety, efficacy, and outcomes of oncological craniotomy procedures between patients above and below 65 years. We performed a retrospective analysis of the ACS-NSQIP database to identify patients undergoing supratentorial and infratentorial tumor excisions by neurosurgeons between 2008 and 2016. We stratified them based on a cutoff age of 65 years and analyzed for minor and major complications, reoperation, the total length of hospital stay, and mortality within a standardized 30-day follow-up. Among the 30,183 analyzed patients, 9,652 (32%) were elderly (age ≥ 65). The bivariate analysis demonstrated significantly increased risk of complications, including major and minor complications and mortality in patients with metabolic syndrome, preoperative steroid use, and ASA classification ≥3. (p-value ≤ 0.001***). After controlling for confounding variables in our logistic regression models, older age, metabolic syndrome, extended operative time beyond 5 h, dependent functional health status, ASA class ≥3, steroid use pre-operatively, and black/African American race were found to be significant predictors of major and minor complication. Our study provides a comprehensive analysis of perioperative risk factors and predictors of adverse outcomes following craniotomy for supratentorial and infratentorial tumors in elderly patients. We identified increased age as an independent risk factor for minor and major adverse events as well as extended hospitalization., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Object: To investigate the efficacy and safety of four interventions of spontaneous intracerebral hemorrhage simultaneously., Methods: PubMed, EmBase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched for randomized controlled trials (RCTs) investigating endoscopic surgery (ES), minimally invasive puncture surgery (MIPS), conventional craniotomy (CC), and/or conservative medical treatment (CMT). Good functional outcome, death, and hemorrhage recurrence rates were evaluated by a network meta-analysis., Results: 20 RCTs with 3603 patients were included. Compared with CMT, a higher rate of good functional outcome was found after ES (RR=2.21, 95% CI 1.37 to 3.55) and MIPS (RR=1.47, 95% CI 1.24 to 1.73). Both ES (RR=0.62, 95% CI 0.44 to 0.86) and MIPS (RR=0.72, 95% CI 0.58 to 0.90) markedly reduced the rate of death. However, there was no significant difference in efficacy and safety between ES and MIPS. The top ranked P score for the efficacy outcome was for ES (P score=0.9810). ES (P-score=0.0709) ranked lowest for the primary safety outcome. There was a higher risk of hemorrhage recurrence after CC (RR=3.80, 95% CI 1.90 to 7.63) and MIPS (RR=2.86, 95% CI 1.70 to 4.82) compared with CMT whereas no significant difference was found for ES (RR=1.46, 95% CI 0.53 to 4.02)., Conclusions: The results suggest that both ES and MIPS significantly improve neurological function and reduce the risk of death compared with CMT, and there is no significant difference between ES and MIPS. Ranking of P scores revealed that ES may be the most optimal intervention to improve functional outcome and prevent death. This needs to be evaluated further., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Surgical evacuation of intracranial bleeding in pediatric patients due to acquired prothrombin complex deficiency (APCD) is a life-saving surgery when conservative treatment insufficient and impending brain herniation. This study aimed to evaluate the Glasgow outcome scale-extended pediatric (GOS-ePed) score of the pediatric intracranial bleeding patients with APCD after craniotomy and duraplasty., Method: This was a retrospective study in the last 5 years of our experience. All of the pediatric patients with intracranial bleeding due to APCD who needed surgery were investigated. The data were collected from medical records after their parents have given their written informed concern and approved by the Ethics Review Committee, Faculty of Medicine, Universitas Kristen Indonesia. The inclusion criteria were patients who operated on by craniotomy and duraplasty. The patient with a second disease was excluded. Blood tests include hemoglobin, prothrombin time, activated prothrombin time, and platelets were investigated before and after intravenous vitamin K injection, transfusion packed red cells (PRCs), and fresh frozen plasma (FFP) administration. The Glasgow coma scale (GCS) pre- and postoperatively was evaluated using a modified GCS for infants and children. The outcome was evaluated by the GOS-ePed score. All data were analyzed with the normality test and paired t test., Results: There were 5 patients age between 37 and 60 days, and all patients did not get vitamin K prophylaxis after birth. The blood tests of all patients revealed anemia, prothrombin, and activated prothrombin time increased, but platelets were normal. All these values returned to normal after vitamin K injection, transfusion of PRCs, and FFP. The paired t tests were p < 0.05. The GCS of all patients before surgery was 8 or below. After surgery, the GCS of 4 patients was increased become 12 and 15. One patient did not change significantly. The GOS-ePed score showed 4 patients (80%) had upper or lower good recovery, and 1 patient (20%) was in a vegetative state., Conclusions: The GOS-ePed score of the pediatric intracranial bleeding with APCD after craniotomy and duraplasty was mostly in upper or lower good recovery., (© 2020 S. Karger AG, Basel.)

Purpose of Review: Hyperventilation is commonly used in neurological patients to decrease elevated intracranial pressure (ICP) or relax a tense brain. However, the potentially deleterious effects of hyperventilation may limit its clinical application. The aim of this review is to summarize the physiological and outcome evidence related to hyperventilation in neurological patients., Recent Findings: Physiologically, hyperventilation may adversely decrease cerebral blood flow (CBF) and the match between the cerebral metabolic rate and CBF. In patients with severe traumatic brain injury (TBI), prolonged prophylactic hyperventilation with arterial carbon dioxide tension (PaCO2) less than 25 mmHg or during the first 24 h after injury is not recommended. Most patients (>90%) with an aneurysmal subarachnoid hemorrhage undergo hyperventilation (PaCO2 <35 mmHg); however, whether hyperventilation is associated with poor outcomes in this patient population is controversial. Hyperventilation is effective for brain relaxation during craniotomy; however, this practice is not based on robust outcome evidence., Summary: Although hyperventilation is commonly applied in patients with TBI or intracranial hemorrhage or in those undergoing craniotomy, its effects on patient outcomes have not been proven by quality research. Hyperventilation should be used as a temporary measure when treating elevated ICP or to relax a tense brain. Outcome research is needed to better guide the clinical use of hyperventilation in neurological patients.

Background: Various studies suggest that the insular cortex may play an underappreciated role in pediatric frontotemporal/parietal epilepsy. Here, we report on the postsurgical outcomes in 26 pediatric patients with confirmed insular involvement by depth electrode monitoring., Objective: To describe one of the largest series of pediatric patients with medically refractory epilepsy undergoing laser interstitial thermal therapy (LITT) or surgical resection of at least some portion of the insular cortex., Methods: Pediatric patients in whom invasive insular sampling confirmed insular involvement and who subsequently underwent a second stage surgery (LITT or open resection) were included. Complications and Engel Class outcomes at least 1 yr postsurgery were compiled as well as pathology results in the open surgical cases., Results: The average age in our cohort was 10.3 yr, 58% were male, and the average length of follow-up was 2.43 ± 0.20 (SEM) yr. A total of 14 patients underwent LITT, whereas 12 patients underwent open resection. Complications in patients undergoing either LITT or open resection were mostly minimal and generally transient. Forty-three percent of patients who underwent LITT were Engel Class I, compared to 50% of patients who underwent open insular resection., Conclusion: Both surgical resection and LITT are valid management options in the treatment of medically refractory insular/opercular epilepsy in children. Although LITT may be a less invasive alternative to craniotomy, further studies are needed to determine its noninferiority in terms of complication rates and seizure freedom, especially in cases of cortical dysplasia that may involve extensive regions of the brain., (Copyright © 2019 by the Congress of Neurological Surgeons.)

The two most common surgical interventions for spontaneous intracerebral hemorrhage in the basal ganglia of patients more than 65 years old are either minimally invasive puncture and drainage or craniotomy. This study aimed to compare the curative effects of these two procedures in such patients. A retrospective study of patients older than years with spontaneous intracerebral hemorrhage was conducted between January 2012 and December 2015. Of the 86 patients, 47 received minimally invasive puncture and drainage and 39 underwent craniotomy. One year after surgery no statistically significant difference was observed between the two groups with respect to: evacuation rate of the hematoma five days after the operation, volume of residual hematoma, occurrence of rebleeding, development of infectious meningitis, length of hospitalization, fatality, or Glasgow Outcome Scale and Barthel Index scores. However, the amount of blood loss during the procedure (P < 0.001), total cost of hospitalization (P = 0.004), and incidence of epilepsy (P = 0.045) were significantly higher for the craniotomy group than the minimally invasive puncture and drainage group. It was found that, in patients older than 65 years with basal ganglia hemorrhage, minimally invasive puncture and drainage is less invasive, more cost efficient and induces less bleeding during surgery than craniotomy., Competing Interests: The authors declare no competing interests., (©2019 Yang et al. Published by IMR press. All rights reserved.)

Malignant stroke occurs in a subgroup of patients suffering from ischemic cerebral infarction and is characterized by neurological deterioration due to progressive edema, raised intracranial pressure, and cerebral herniation. Decompressive craniectomy (DC) is a surgical technique aiming to open the "closed box" represented by the non-expandable skull in cases of refractory intracranial hypertension. It is a valuable modality in the armamentarium to treat patients with malignant stroke: the life-saving effect has been proven for both supratentorial and infratentorial DC in virtually all age groups. This leaves physicians with the difficult task to decide who will require early or preemptive surgery and who might benefit from postponing surgery until clear evidence of deterioration evolves. Together with the patient's relatives, physicians also have to ascertain whether the patient will have acceptable disability and quality of life in his or her presumed perception, based on preoperative predictions. This complex decision-making process can only be managed with interdisciplinary efforts and should be supported by continued research in the age of personalized medicine.

Background: To study improvements in outcomes after surgery for intracranial meningiomas., Methods: 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)., Results: 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., Conclusions: 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., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The purpose of the Toyota Production System (TPS) Lean 5S methodology project is to improve the efficiency and effectiveness in a process by eliminating identified process waste of (1) defects (errors), (2) overproduction, (3) waiting, (4) confusion, (5) motion/travel, (6) excess inventory, (7) overprocessing, and (8) human potential. The specific aim of this quality improvement project was to evaluate the impact of the TPS 5S tool process, a problem-solving, space-organizing tool, on distractions and interruptions in the neurosurgery operating room (OR) workflow with a goal to decrease neurosurgery craniotomy infection rates in a neurosurgery OR suite within a 3-month period., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To date, no standard surgical procedure has been proven effective for intracerebral hemorrhage (ICH), particularly deep hematomas. This retrospective study evaluated the effectiveness and safety of endoscopic surgery, minimally invasive puncture and drainage, and craniotomy for treating moderate basal ganglia ICH., Methods: Patients with basal ganglia ICH (N = 177) were divided into 3 groups based on therapeutic intervention as follows: endoscopic surgery group (n = 61), minimally invasive puncture and drainage group (n = 60), and craniotomy group (n = 56). Patient characteristics at admission were recorded. Operative time; blood loss during operation; evacuation rate; postoperative complications secondary to perihematomal edema, including rebleeding, infectious meningitis, pulmonary infection, gastrointestinal bleeding, and epilepsy; mortality; and Glasgow Outcome Scale scores were compared among the 3 groups., Results: Minimally invasive puncture and drainage was the least traumatic procedure and had the shortest operative time, but it could not remove the hematoma quickly; moreover, it had the highest rebleeding rate. Craniotomy was effective in removing the hematoma but resulted in marked trauma and had the highest incidence of pulmonary infection. Endoscopic surgery was safer and more effective than the other 2 surgical methods, with greater improvement in neurologic outcomes and no change in mortality., Conclusions: Minimally invasive neuroendoscopic management has the advantages of direct vision, efficient hematoma evacuation, and relatively good results. Endoscopic surgery may be a more promising approach for the treatment of moderate basal ganglia ICH., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Over the last few decades, cerebrovascular surgery has gravitated towards a minimally invasive philosophy without compromising the foundational principles of patient safety and surgical efficacy. Enhanced radiosurveillance modalities and increased average life expectancy have resulted in an increased reported incidence of intracranial aneurysms. Although endovascular therapies have gained popularity in the recent years, microsurgical clipping continues to be of value in the management of these aneurysms owing to its superior occlusion rates, applicability to complex aneurysms and reduced retreatment rates. The concept of keyhole transcranial procedures has advanced the field significantly leading to decreased postoperative neurological morbidity and quicker recovery. The main keyhole neurosurgical approaches include the supraorbital craniotomy (SOC), lateral supraorbital craniotomy (LSOC), mini-pterional craniotomy (MPTC), mini-orbitozygomatic craniotomy and the mini anterior interhemispheric approach (MAIA). As these minimally invasive approaches can have an inherent limitation of a narrow viewing angle and low regional illumination, the use of endoscopic assistance in such procedures is being popularized. Neuroendoscopy can aid in the visualization of hidden neurovascular structures and inspection of the parent arterial segment without undue retraction of the lesion. This review focuses on the historical progression of the surgical management of intracranial aneurysms, the technical details of various minimally invasive approaches, patient selection and clinical outcomes of the anterior circulation aneurysms and useful tenets to avoid complications during these procedures. Meticulous preoperative planning to understand the patient's vascular anatomy, the orientation and relationship of the aneurysm to adjacent structures, use of neuronavigation guidance and endoscopic assistance if needed can lead to an optimal surgical outcome while minimizing neurological morbidity and mortality.

This study aimed to evaluate the safety and effectiveness of an alternative dural substitute using a porcine pericardial graft for duraplasty in a large animal model. Six pigs underwent bilateral craniectomy followed by bilateral duraplasty using either a porcine pericardium patch or a Biodesign® Dural Repair Graft. Intraoperative workability was evaluated for each type of graft. Pigs were euthanized after 1 and 3 months (n = 3 per group). Histological analysis was performed for each case. The Biodesign® Dural Repair Graft showed better workability than the porcine pericardial patch, which was more transparent (p = 0.002). Histological analyses at 1 and 3 months showed no differences between the types of graft. There was no postoperative leakage of cerebrospinal fluid in any case. No grafts showed any adverse reactions in the underlying brain tissues. The porcine pericardial patch as a dural substitute seems to be an acceptable alternative graft to duraplasty using a small intestinal submucosal graft (Biodesign®). Further studies are needed to determine whether porcine pericardial patches provide workable alternatives in clinical practice., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: We aimed to provide a systematic description of our 2-year experience using a standardized bedside, single burr hole approach to intracranial multimodality monitoring (MMM) in patients with severe traumatic brain injury (sTBI), focusing on safety and probe reliability., Methods: We performed this observational cohort study at a university-affiliated, Level I trauma center with dedicated 20-bed neuroscience intensive care unit. We included 43 consecutive sTBI patients who required MMM to guide clinical care based on institutional protocol and had a four-lumen bolt placed to measure intracranial pressure, brain tissue oxygen, regional cerebral blood flow, brain temperature, and intracranial electroencephalography., Results: sTBI patients were aged 41.6 ± 17.5 years (mean ± SD) and 84% were men. MMM devices were placed at a median of 12.5 h (interquartile range [IQR] 9.0-21.4 h) after injury and in non-dominant frontal lobe in 72.1% of cases. Monitoring was conducted for a median of 97.1 h (IQR 46.9-124.6 h) per patient. While minor hemorrhage, pneumocephalus, or small bone chips were common, only one (2.4%) patient experienced significant hemorrhage related to device placement. Radiographically, device malpositioning was noted in 13.9% of patients. Inadvertent device discontinuation occurred for at least one device in 58% of patients and was significantly associated with the frequency of travel for procedures or imaging. Devices remained in place for > 80% of the total monitoring period and generated usable data > 50% of that time., Conclusions: A standardized, bedside single burr hole approach to MMM was safe. Despite some probe-specific recording limitations, MMM provided real-time measurements of intracranial pressure, oxygenation, regional cerebral blood flow, brain temperature, and function.

Objective: This study evaluated the sustainability of teaching awake craniotomy in Indonesia. We explored the factors affecting how awake craniotomy can be taught in a low- to middle-income (LMIC) country and the factors affecting the utilization of awake craniotomy in Indonesia., Methods: This is a prospective mixed-methods study in Indonesia. A questionnaire was administered to 100 neurosurgeons at a conference on their experience with neuro-oncology, awake craniotomy, and teaching missions. Thirty-three physicians participated in semi-structured interviews elaborating on these topics. Data on tumor caseload and resources were collected., Results: Thirty-three of 88 respondents (41.3%) indicated that they still perform awake craniotomy. Although 87.3% felt that it was beneficial for patients and resource sparing, less than a quarter of them felt they had sufficient exposure/training in awake craniotomy. Almost all of them wanted further training and to maintain a relationship with international mentors. Four themes emerged about the factors that affect how we teach awake craniotomy in an LMIC: 1) the sustainability of a teaching mission is dependent on a culture of information sharing and 2) the support of multiple health care providers; 3) hospital structure affects how changes are implemented; and 4) health care professionals in Indonesia value opportunities for international training. Regarding the uptake of awake craniotomy in Indonesia, there are sociocultural factors that affect patients' receptiveness to surgery and the national insurance plan restricts the provision of neurosurgical care., Conclusions: Many factors need to be explored when planning a neurosurgical mission in LMICs to ensure its sustainability., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Outcomes of minimally invasive surgery (MIS) versus conventional craniotomy (CC) for patients with spontaneous supratentorial intracerebral hemorrhage (SICH) have not been compared previously. We reviewed the current evidence regarding the safety and efficacy of MIS compared with CC in patients with SICH., Methods: We conducted a meta-analysis of studies comparing MIS and CC in patients with computed tomography-confirmed SICH published between January 2000 and April 2018 in MEDLINE, Embase, and the Cochrane Controlled Trials Register based on PRISMA inclusion and exclusion criteria. Binary outcomes comparisons between MIS and CC were described using odds ratios (ORs)., Results: Five randomized controlled trials (RCTs) and 9 prospective controlled studies (non-RCTs), involving a total of 2466 patients, met our inclusion criteria. There was a statistically significant difference in mortality rate between MIS and CC (OR, 0.76; 95% confidence interval [CI], 0.60-0.97). MIS was associated with a lower rate of rebleeding (OR, 0.42; 95% CI, 0.28-0.64) and a higher rate of good recovery compared with CC (OR, 2.27; 95% CI, 1.34-3.83)., Conclusions: Patients with SICH may benefit more from MIS than CC. Our study could help clinicians optimize treatment strategies in SICH., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The association between underlying liver disease and poor surgical outcomes has been well documented across a wide variety of surgical disciplines. However, little is known about the importance of liver disease in neurosurgery. In this report, we assess the independent effect of liver disease on perioperative outcomes in patients undergoing craniotomy for tumor., Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients undergoing craniotomy for tumor from 2006 to 2015. Presence and severity of underlying liver disease was assessed with the aspartate aminotransferase-to-platelet ratio index and the Model for End-Stage Liver Disease-Sodium scores, computed from preoperative laboratory values., Results: Among 11,897 patients, mild and advanced disease was identified in 2.4% and 1.9% of patients, respectively. Rates of 30-day mortality were 4.5% and 15.8% in these patients, compared with 3.1% in patients with healthy livers. The 30-day complication rate was 40.3%, 28.0%, and 19.8% in patients with advanced, mild, and no liver disease, respectively. In multivariate analysis, the presence of any liver disease (mild or advanced) was independently associated with mortality (OR = 2.46; 95% confidence interval [CI], 1.68-3.59; P < 0.001), morbidity (OR, 1.49; 95% CI, 1.18-1.87; P = 0.001), and length of hospital stay over 10 days (OR, 1.35; 95% CI, 1.07-1.70; P = 0.012), when compared with 13 covariates. Liver disease showed the strongest independent association with mortality of all risk factors analyzed., Conclusions: Liver disease is an independent predictor of poor 30-day outcomes following craniotomy for tumor. Consideration of underlying liver function can have a role in surgical decision making and postoperative care for these patients., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: Surgical treatment is widely used for haematoma removal in spontaneous intracerebral haemorrhage (ICH) patients, but there is controversy about the selection of surgical methods. The CT angiography (CTA) spot sign has been proven to be a promising factor predicting haematoma expansion and is recommended as an entry criterion for haemostatic therapy in patients with ICH. This trial was designed to evaluate the clinical efficacy of two surgical methods (haematoma removal by craniotomy and craniopuncture combined with urokinase infusion) for patients in the early stage (≤6h from symptom onset) of spontaneous ICH with a moderate haematoma volume (30 ml - 60 ml)., Patients and Methods: From January 2012 to July 2017, 196 eligible patients treated in our institution were enrolled according to the inclusion criteria. The patients were divided into the CTA spot sign positive type and CTA spot sign negative type according to the presence or absence of the CTA spot sign. For each type, the patients were randomly assigned to two groups, i.e., the craniotomy group, in which patients underwent craniotomy with haematoma removal, and the craniopuncture group, in which patients underwent minimally invasive craniopuncture combined with urokinase infusion therapy. Neurological function was evaluated with the Scandinavian Stroke Scale (SSS) at day 14. The disability level and the activities of daily living were assessed using a modified Rankin Scale (mRS) and Barthel Index (BI) at day 90. Case fatalities were recorded at day 14 and 90. Complications were recorded during hospitalization., Results: For the CTA spot sign positive type, the craniotomy group had a higher SSS than that in the craniopuncture group (P < 0.05) at day 14. The rebleeding rate was higher in the craniopuncture group than that in the craniotomy group (P < 0.05) during hospitalization. The craniotomy group had a lower mRS than that in the craniopuncture group (P < 0.01) and had a higher BI than that in the craniopuncture group (P < 0.05) at day 90. There was no statistically significant difference in the fatality rate between the two groups. For the CTA spot sign negative type, there were no significant differences in the SSS, mRS, BI, fatality rate and complication rate between the two groups., Conclusion: ICH can be divided into the CTA spot sign positive and negative type according to the presence or absence of the CTA spot sign. For the CTA spot sign positive type, patients can benefit from craniotomy with haematoma removal, which can reduce the postoperative rebleeding rate and improve the prognosis. For the CTA spot sign negative type, both craniotomy and craniopuncture are applicable. Considering simple procedure and minor surgical injury, craniopuncture can be a more reasonable choice., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Integration of three-dimensional (3D) printing and stereolithography into clinical practice is in its nascence, and concepts may be esoteric to the practicing neurosurgeon. Currently, creation of 3D printed implants involves recruitment of offsite third parties. We explored a range of 3D scanning and stereolithographic techniques to create patient-specific synthetic implants using an onsite, clinician-facilitated approach., Methods: We simulated bilateral craniectomies in a single cadaveric specimen. We devised 3 methods of creating stereolithographically viable virtual models from removed bone. First, we used preoperative and postoperative computed tomography scanner-derived bony window models from which the flap was extracted. Second, we used an entry-level 3D light scanner to scan and render models of the individual bone pieces. Third, we used an arm-mounted, 3D laser scanner to create virtual models using a real-time approach., Results: Flaps were printed from the computed tomography scanner and laser scanner models only in a ultraviolet-cured polymer. The light scanner did not produce suitable virtual models for printing. The computed tomography scanner-derived models required extensive postfabrication modification to fit the existing defects. The laser scanner models assumed good fit within the defects without any modification., Conclusions: The methods presented varying levels of complexity in acquisition and model rendering. Each technique required hardware at varying in price points from $0 to approximately $100,000. The laser scanner models produced the best quality parts, which had near-perfect fit with the original defects. Potential neurosurgical applications of this technology are discussed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To explore the perspective on Decompressive craniectomy (DH) of each of these specialties to establish common grounds for improved clinical practice., Methods: An electronic survey was distributed via email and social media groups to members of these specialties in Kingdom of Saudi Arabia and the Gulf countries. Local practices, common triggers for referral for DH, perceived outcomes of these procedures, individual impression of what constitutes good clinical outcomes were explored., Results: There are 89 physicians participated: 41 (46.1%) neurologists, 34 (38.2%) neurosurgeons, and 14 (15.7%) intensivests. Participants are mostly practicing in intermediate volume centers or high volume centers. Half of the neurosurgeons preferred to be consulted immediately on candidates with large middle cerebral artery (MCA) strokes. The most important referral trigger for DH was clinical changes. The modified Rankin Scale (mRS) cutoff for good clinical outcome was 3 for 73.6% of respondents. There was agreement that DH only improves survival (64.4%). A third of the neurologists considered it to improve functional outcome compared to 15.4% of intensivests and 14.8% of neurosurgeons. There was agreement (66.7%) that patients older than 60 years with involvement of more than one territory should be excluded from DH. Only 7.7% of neurosurgeons excluded patients with dominant hemispheric strokes., Conclusion: Our physicians` views are variable in what`s called acceptable outcome, and further studies are needed to to test the characteristics that helps in decision making such as hemisphere dominancy, time onset of stroke and vital radiological signs. This is seen despite the literature being full of data that supports the DC over medical management in malignant MCA infarction. Better multidisciplinary education initiatives are needed to unify the understanding and help improve the practices in this challenging subset of patients.

Background: Craniocerebral gunshot injury refers to a wound caused by a bullet passing through or lodged in brain tissue, resulting in the loss of function of a certain area or other fatal damage to the human brain. Craniocerebral gunshot injury is usually life-threatening and is very common in modern warfare, accounting for the majority of battle casualties. Most of the patients suffer from acute cerebral infarction caused by vascular injury. Lack of early and solid battlefield emergency medical interference adds to the risk of death among the wounded., Case Presentation: We present a 24-year-old man who was shot with a shotgun from a distance of 15 m in an accidental injury. Forty-seven grapeshots were found on his body surface by physical examination. A computed tomography (CT) scan demonstrated large areas of low-density shadows in his right parietal lobe and right temporal lobe with the midline shifting to the left side 2 days later. Afterwards, the patient was transferred to our emergency medical center at Changzheng Hospital in Shanghai. Cranial computed tomography angiography (CTA) showed a high-density shadow in the initial part of the right middle cerebral artery. The branches after the initial part were obliterated. Prompt medical attention and decompressive craniotomy (DC) surgery contributed to the final recovery from cerebral infarction of this patient., Conclusion: Bullets can penetrate or be lodged in the brain, causing intracranial hypertension. The bullets lodged in the brain can result in stenosis and embolism of a cerebral artery, causing acute cerebral infarction. Combining dura turning-over surgery with DC surgery can not only decrease intracranial pressure, which can increase the blood supply for hypertension-induced vessel stenosis, but also help vessels outside the dura mater grow into ischemic areas of the cerebral cortex. However, this new pattern of surgery needs further support from evidence-based medicine.

Background: Owing to the rising costs of health care delivery, the quality of delivered care has become a central issue across all medical specialties. Consequently, there is increasing pressure to create standardized frameworks for measuring quality of care. In the field of cranial neurosurgery, health care administrators have begun applying quality measures that are easily available but might be inaccurate in measuring the quality of care., Methods: We performed a systematic literature review on quality indicators (QIs) that are presently used in this field, aiming to elucidate which QIs are scientifically founded and thus potentially justifiable as measures of quality. We found a total of 8 QIs, and methodologically evaluated published studies according to the AIRE (Appraisal of Indicators through Research and Evaluation) criteria. These criteria include length of hospital stay, all-cause readmission rate, and unplanned reoperation rate., Results: Our review indicates that these presently used or proposed QIs for neurosurgery lack scientific rigor and are restricted to rudimentary measures, and that further research is necessary., Conclusions: Neurosurgeons need to define their own QIs and actively participate in the validation of these QIs to provide the best possible patient outcomes. More reliable clinical registries, obligatory for all neurosurgical services, should be established as a basis for establishing such indicators, with risk adjustment being an important element of any such indicators., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The relationship of scope of practice (predominantly adult, versus predominantly pediatric) with the outcomes of brain tumor surgery in children remains uncertain. We investigated the association of practice focus with the outcomes of neurosurgical oncology operations in pediatric patients., Methods: We performed a cohort study of all pediatric patients (younger than 18 years old) who underwent craniotomies for tumor resections from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. In order to control for confounding, we used propensity score conditioning with mixed effects analysis to account for clustering at the hospital level., Results: During the study period, there were 770 pediatric patients who underwent craniotomy for tumor resection and met the inclusion criteria. Of these, 370 (48.1%) underwent treatment by providers with predominantly adult practices and 400 (51.9%) by physicians who operated predominantly on children. Mixed-effects multivariable regression analysis demonstrated lack of association of predominantly adult practice with inpatient mortality (OR, 1.12; 95% CI, 0.48-2.58), and discharge to a facility (OR, 1.25; 95% CI, 0.77-2.03). These associations persisted in propensity-adjusted models., Conclusions: In a cohort of pediatric patients undergoing craniotomy for tumor resection from a comprehensive all-payer database, we did not demonstrate a difference in mortality, and discharge to a facility between providers with predominantly adult and predominantly pediatric practices.

Background: The increasing endeavors to make inpatient treatment processes more effective leads to a reduction of the length of stay in hospital and minimization of postoperative monitoring. Therefore, the aim of our study was to determine potential postoperative complications for neurosurgical patients undergoing elective surgery with respect to assessment of the relevance for intensive medical care. Furthermore, our approach was compared with the standard of postoperative care of such patients in Germany., Methods: All 499 patients scheduled for elective craniotomy at our institute from 2010-2013 could be included corresponding to various treatment criteria for vascular diseases, such as aneurysms, arteriovenous malformation (AVM) and cavernous hemangioma as well as supratentorial and infratentorial tumors, transsphenoidally operated pituitary adenomas and stereotactic biopsies. All complications could be collated and categorized according to major and minor complications. Furthermore, a survey was conducted among 155 neurosurgical hospitals and departments with respect to the preferred postoperative monitoring strategy for the named treatment categories., Results: The numbers of major complication were in accordance with data from other studies and although minor complications (13.4% in our collective) are rarely recorded in the literature, they do however indicate an adequate postoperative inpatient monitoring. The results of the survey showed a broad preference for intensive care unit monitoring of patients undergoing elective craniotomy in Germany., Conclusion: The undisputed gold standard of postoperative monitoring of neurosurgical patients undergoing elective surgery is still the intensive care unit. Although more flexible surveillance modalities are available, a cost-driven restructuring of postoperative monitoring and in particular reduction of the length of stay in hospital must be subjected to detailed scrutinization.

Background: Acute subdural hematoma (SDH) is a major cause of morbidity after severe traumatic brain injury. Surgical evacuation of the hematoma, either via craniotomy or craniectomy, is the mainstay of treatment in patients with progressive neurologic deficits or significant mass effect. However, the decision to perform either procedure remains controversial., Methods: A literature search using major online databases and a manual search of references on the topic of craniotomy and craniectomy for evacuation of subdural hematoma until September 2016 was performed. The outcome variables were analyzed which included residual SDH, revision rate, and clinical outcome., Results: Six comparison studies, with a total number of 2006 craniotomy and 451 craniectomy patients, fulfilled the inclusion criteria. Patients who underwent craniectomy scored significantly lower on the Glasgow Coma Scale at the time of initial presentation. Postoperatively, the rate of residual SDH was significantly lower in the craniectomy group than the craniotomy group (P = 0.004), with no difference in the revision rate. The odds of a poor outcome at follow-up was found to be lower in the craniotomy group (50.1% vs. 60.1%, respectively; P = 0.004). Similarly, mortality rates was lower in the craniotomy group than the craniectomy group (P = 0.004)., Conclusions: The safety and efficacy of craniotomy versus decompressive craniectomy in treatment of acute SDH remain controversial. In this study, craniectomy was associated with worse clinical presentation and postoperative outcome compared with craniotomy. However, craniectomy was associated with lower rate of residual SDH after treatment., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: The most painful stages of craniotomy are the placement of the pin head holder and the skin incision. The primary aim of the present study is to compare the effects of the scalp block and the local anesthetic infiltration with bupivacaine 0.5% on the hemodynamic response during the pin head holder application and the skin incision in infratentorial craniotomies. The secondary aims are the effects on pain scores and morphine consumption during the postoperative 24h., Methods: This prospective, randomized and placebo controlled study included forty seven patients (ASA I, II and III). The scalp block was performed in the Group S, the local anesthetic infiltration was performed in the Group I and the control group (Group C) only received remifentanil as an analgesic during the intraoperative period. The hemodynamic response to the pin head holder application and the skin incision, as well as postoperative pain intensity, cumulative morphine consumption and opioid related side effects were compared., Results: The scalp block reduced the hemodynamic response to the pin head holder application and the skin incision in infratentorial craniotomies. The local anesthetic infiltration reduced the hemodynamic response to the skin incision. As well as both scalp block and local anesthetic infiltration reduced the cumulative morphine consumption in postoperative 24h. Moreover, the pain intensity was lower after scalp block in the early postoperative period., Conclusion: The scalp block may provide better analgesia in infratentorial craniotomies than local anesthetic infiltration., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Since awake craniotomy (AC) has become a standard of care for supratentorial tumour resection, especially in the motor and language cortex, determining the most appropriate anaesthetic protocol is very important. The aim of this retrospective study is to compare the effectiveness of conscious sedation (CS) to "awake-asleep-awake" (AAA) techniques for supratentorial tumour resection. Forty-two patients undergoing CS and 22 patients undergoing AAA were included in the study. The primary endpoint was to compare the CS and AAA techniques with respect to intraoperative pain and agitation in patients undergoing supratentorial tumour resection. The secondary endpoint was comparison of the other intraoperative complications. This study results show that the incidence of intraoperative agitation and seizure were lower in the AAA group than in the CS group. Intraoperative blood pressures were significantly higher in the CS group than in the AAA group during the pinning and incision, but the level of blood pressures did not need antihypertensive treatment. Otherwise, blood pressures were significantly higher in the AAA group than in the CS group during the neurological examination and the severity of hypertension needed statistically significant more antihypertensive treatment in the AAA group. As a result of hypertension, the amount of intraoperative bleeding was higher in the AAA group than in the CS group. In conclusion, the AAA technique may provide better results with respect to agitation and seizure, but intraoperative hypertension needed a vigilant follow-up especially in the wake-up period., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

The optimal timing of cranioplasty after decompressive craniectomy has not been well established. The purpose of this study was to evaluate the relationship between timing of cranioplasty and related complications. A systematic search of MEDLINE, Scopus, and the Cochrane databases was performed using PRISMA guidelines for English-language articles published between 1990 and 2015. Case series, case-control and cohort studies, and clinical trials reporting timing and complication data for cranioplasty after decompressive craniectomy in adults were included. Extracted data included overall complications, infections, reoperations, intracranial hemorrhage, extra-axial fluid collections, hydrocephalus, seizures, and bone resorption for cranioplasty performed within (early) and beyond (late) 90days. Twenty-five of 321 articles met inclusion criteria for a total of 3126 patients (1421 early vs. 1705 late). All were retrospective observational studies. Early cranioplasty had significantly higher odds of hydrocephalus than late cranioplasty (Odds Ratio [OR] 2.38, 95% Confidence Interval [CI] 1.25-4.52, p=0.008). There was no difference in odds of overall complications, infections, reoperations, intracranial hemorrhage, extra-axial fluid collections, seizures, or bone resorption. Subgroup analysis of trauma patients revealed a decreased odds of extra-axial fluid collection (OR 0.30, p=0.02) and an increased odds of hydrocephalus (OR 4.99, p=0.05). Early cranioplasty within 90days after decompressive craniectomy is associated with an increased odds of hydrocephalus than with later cranioplasty, but no difference in odds of developing other complications. Earlier cranioplasty in the trauma population is associated with fewer extra-axial fluid collections., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: Intraoperative computed tomography (iCT) is currently used to confirm the target location of the microelectrode (ME) during microelectrode recording (MER) and ultimate location of deep brain stimulation (DBS) leads at our institution. We evaluated whether iCT can be used to predict the trajectory and accuracy of the ME track., Patients and Methods: Intraoperative imaging profiles of ten consecutive patients who had undergone DBS surgery were retrospectively reviewed. We found that cranial iCT, in addition to visualizing the target, also visualizes the extra-cranial segment of the guide tube (ECGT) used to insert the ME. We propose a hypothetical technique that extrapolates the trajectory of only the ECGT down to target depth using planning software. In order to provide a proof of concept analysis of this hypothetical technique, we retrospectively assessed post MER placement iCT studies and used planning software to visualize only the ECGT. An extrapolated vector was drawn along the long axis of the ECGT down to the same depth (z) as the ME. The obtained x and y coordinates were subsequently recorded and compared to the x and y coordinates of the ME tip to validate this technique., Results: The average radial error between ECGT trajectory coordinates and final ME tip coordinates was 0.93±0.1mm (mean±SEM)., Conclusion: The use of iCT to predict accuracy of microelectrode location is feasible. In the future, performing iCT before guide tube penetration of dura can allow for trajectory prediction and if needed, correction of the ME, thereby potentially improving accuracy and reducing the number of MER tracks., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Objectives: To evaluate the value of physical examination as a monitoring tool during subcortical resection in awake craniotomy patients and surgical outcomes., Patients and Methods: Authors reviewed medical records of patients underwent awake craniotomy with continuous physical examination for pathology adjacent to the eloquent area., Results: Between January 2006 and August 2015, there were 37 patients underwent awake craniotomy with continuous physical examination. Pathology was located in the left cerebral hemisphere in 28 patients (75.7%). Thirty patients (81.1%) had neuroepithelial tumors. Degree of resections were defined as total, subtotal, and partial in 16 (43.2%), 11 (29.7%) and 10 (27.0%) patients, respectively. Median follow up duration was 14 months. The reasons for termination of subcortical resection were divided into 3 groups as follows: 1) by anatomical landmark with the aid of neuronavigation in 20 patients (54%), 2) by reaching subcortical stimulation threshold in 8 patients (21.6%), and 3) by abnormal physical examination in 9 patients (24.3%). Among these 3 groups, there were statistically significant differences in the intraoperative (p=0.002) and early postoperative neurological deficit (p=0.005) with the lowest deficit in neuronavigation group. However, there were no differences in neurological outcome at later follow up (3-months p=0.103; 6-months p=0.285). There were no differences in the degree of resection among the groups., Conclusion: Continuous physical examination has shown to be of value as an additional layer of monitoring of subcortical white matter during resection and combining several methods may help increase the efficacy of mapping and monitoring of subcortical functions., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: This retrospective study was designed to evaluate the effectiveness of autoclaving for the prevention of surgical site infection (SSI) after cranioplasty., Methods: Patients who underwent cranioplasty with autologous bone were enrolled. SSI was defined as an infection requiring bone flap removal. Risk factors of SSI, as reported by other researchers, and microbiologic features of SSI were analyzed. All bone flaps were preserved in a deep freezer (-70°C). Autoclaving of the preserved autologous bone flap before cranioplasty was performed for 5 minutes at 135°C in the 26 patients., Results: Eighty patients were enrolled. The mean age was 53.3 years and the male/female ratio was 3:2. Causes of craniectomy included trauma (n = 37) and nontrauma (n = 43). The mean time interval between craniectomy and cranioplasty was 49.7 days. The SSI rate after cranioplasty with autologous bone was 17.5% (n = 14). In univariate analysis, the cranioplasty operation time (P = 0.09) and the use of autoclaved bone (P = 0.00) were supposed to be risk factors for SSI. The use of autoclaved autologous bone was found to be the only risk factor of SSI (P = 0.01; hazard ratio = 8.88) in binary logistic regression analysis. Non-methicillin-resistant Staphylococcus aureus (MRSA) causes were more frequent in the autoclaved group (MRSA, 30%; non-MRSA, 70%) compared with the nonautoclaved group (MRSA, 100%) (P = 0.07). A microscopic examination showed that autoclaving after long-term cryopreservation may result in a loss of bone viability., Conclusions: Autoclaving of autologous bone causes SSI after cranioplasty and it seems to increase the risk of non-MRSA infection by normal skin flora., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Patient safety aspects and the residents' role in spine surgery within a structured training program have recently been investigated. The current work deals with residency training safety aspects for cranioplasty (CP), a standard neurosurgical cranial procedure., Methods: Retrospective 2-center study comparing consecutive patients undergoing CP by a supervised neurosurgery resident (teaching cases) with a consecutive series of patients operated on by a board-certified faculty neurosurgeon (nonteaching cases). The primary end point was occurrence of a postoperative complication. Secondary end points were severity (Ibañez degree) of postoperative complications, surgical site infections requiring CP removal and patients' clinical outcome measured with the modified Rankin Scale., Results: A total of 240 CPs (137 teaching [57.1%] and 103 nonteaching [42.9%] cases) were analyzed. The mean teaching case operation time was longer (129.2 vs. 115.8 minutes; P < 0.001), and there was no difference in the estimated blood loss (mean 243.3 vs. 223.1 mL; P = 0.444). Supervised residents were as likely as board-certified faculty neurosurgeons to have a postoperative complication (odds ratio [OR], 0.77; 95% confidence interval [CI], 0.42-1.39; P = 0.385) and the severity was comparable (Pearson χ(2) = 7.62; P = 0.106). Teaching cases were as likely as nonteaching cases to experience a surgical site infection requiring CP removal (OR, 1.66; 95% CI, 0.69-4.04; P = 0.261). Also, the likelihood for postoperative improvement on the modified Rankin Scale was similar for patients in both groups (OR, 1.11; 95% CI, 0.62-2.00; P = 0.719)., Conclusions: A relatively simple cranial procedure, such as CP, can be safely performed by a supervised neurosurgery resident without increasing complications or compromising patients' outcomes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: To the authors' knowledge, the current study is the first national analysis of the association between preoperative platelet count and outcomes after craniotomy., Methods: Patients who underwent craniotomy for tumor were extracted from the prospective National Surgical Quality Improvement Program registry (2007-2014) and stratified by preoperative thrombocytopenia, defined as mild (125,000-149,000/μL), moderate (100,000-124,000/μL), severe (75,000-99,000/μL), or very severe (<75,000/μL). Cox proportional hazards analysis was used to evaluate the association between thrombocytopenia and 30-day mortality, and multivariable logistic regression with complications and unplanned reoperation. Covariates included patient age, sex, tumor histology, American Society of Anesthesiologists class, functional status, comorbidities, and surgical time., Results: A total of 14,852 patients were included in the current study and thrombocytopenia was classified as mild in 4.4% (646 patients), moderate in 2.0% (290 patients), severe in 0.7% (105 patients), or very severe in 0.4% (66 patients) of patients. The adjusted hazard of 30-day death was significantly higher for patients with moderate (6.6%; hazard ratio [HR], 2.13 [95% confidence interval (95% CI), 1.30-3.49; P =  0.003]), severe (10.5%; HR, 2.33 [95% CI, 1.18-4.60; P =  0.02]), and very severe (10.6%; HR, 3.65 [95% CI, 1.71-7.82; P =  0.001]) thrombocytopenia, compared with patients without thrombocytopenia (2.9%), with an increased effect size noted with greater thrombocytopenia. Likewise, when the platelet count was evaluated continuously, a higher platelet count was associated with a lower hazard of 30-day mortality (HR, 0.987 [95% CI, 0.981-0.993; P<.001]), developing any complication (odds ratio, 0.985 [95% CI, 0.981-0.988; P<.001]), and reoperation (odds ratio, 0.990 [95% CI, 0.983-0.994; P = .003]). Unplanned reoperation was due to intracranial hemorrhage in 53.3% of patients with moderate thrombocytopenia., Conclusions: In this National Surgical Quality Improvement Program analysis, moderate and severe thrombocytopenia were associated with mortality and reoperation after craniotomy for tumor. Cancer 2016;122:1708-17. © 2016 American Cancer Society., (© 2016 American Cancer Society.)

Enhanced recovery after surgery (ERAS) initiatives in the fields of gastrointestinal and pelvic surgery have contributed to improved postoperative functional status for patients and decreased length of stay. A similar comprehensive protocol is lacking for patients undergoing craniotomy for tumor resection. A literature search was performed using PubMed. These references were reviewed with a preference for recent high quality studies. Cohort and retrospective studies were also included if higher levels of evidence were lacking. A literature search was conducted for scalp blocks and minimally invasive craniotomies. Papers were scored using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria for evidence level and recommendation grade. Seventeen ERAS items were reviewed and recommendations made. The current body of evidence is insufficient to create a standardized protocol for craniotomy and tumor resection. However, this initial review of the literature supports pursuing future research initiatives that explore modalities to improve functional recovery and decrease length of stay in craniotomy patients., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The mesial temporal region (MTR) comprises important components of the limbic system, as well as vital neurovascular structures. Because of its important functional role, as much healthy brain tissue as possible must be preserved while targeting resection of MTR lesions., Methods: A frontal minicraniotomy is used to access the MTR through a subfrontal approach. By opening the most medial part of the Sylvian fissure, the uncus-amygdala complex is exposed, and through this, the head of the hippocampus can be reached and removed as well., Conclusions: This approach is extremely suitable for MTR lesions, as it provides the advantage of sparing the most important functional structures of the temporal lobe, the temporal stem, and the limen insulae, as well as the optic radiations and the fronto-occipital connections.

Background: Intraoperative angiography (IOA) is essential in evaluating residual aneurysm following clip ligation, but it does lead to an additional procedure which increases the duration of the procedure as well as increasing room traffic. We examined whether IOA during microsurgery is a risk factor for developing cranial surgical site infection., Materials and Methods: A retrospective cohort study was performed of all patients undergoing craniotomy for aneurysm treatment between 2005 and 2012 at the University of Michigan. IOA was used at the surgeons' discretion. The primary outcome of interest was occurrence of a surgical site infection and the secondary outcome of interest was clip repositioning following IOA. Variables including IOA were tested for their independent association with the occurrence of a surgical site infection., Results: During the study period 676 intracranial aneurysms were treated by craniotomy; IOA was used in 104 of these cases. There were a total of 20 surgical site infections, 2 in the IOA group (1.9%) and 18 in the non-IOA group (3.1%), indicating that IOA was not a statistically significant variable for infection (p=0.50). No additional single variable measured could be shown to have a statistically significant increase in infection, and there were no direct complications related to the use of IOA (stroke, dissection, perforation)., Conclusions: IOA does not increase the risk of developing a surgical site infection. It can be conducted without exposing patients to an undue risk of infection., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Glioblastoma (GBM) occurs more commonly in elderly patients. However, these patients are often excluded from clinical trials. The absence of solid evidence has resulted in a nihilistic view of GBM in the elderly and a traditionally conservative treatment approach. In particular, the safety of surgical resection for both primary and recurrent GBM is poorly understood in elderly patients., Methods: In a retrospective cohort of patients aged ≥65 years, we examined selection for biopsy, surgical resection, and reoperation for recurrent disease. We also analyzed complication rates after initial resection and reoperation for recurrent disease. We identified 319 elderly patients with pathologically proven GBM who underwent a total of 274 craniotomies at our institution between 2000 and 2012. Events were reported according to the methods used in the Glioma Outcomes Project., Results: The overall rate of complications after resection was 21.9%, with a rate of neurological complications of 7.7%. The rates of neurological, regional, and systemic complications were not significantly different after initial craniotomy and reoperation for GBM in elderly patients. Reoperations were not associated with an increased risk of complications. Low cardiovascular risk, improved functional status, and hemispheric GBM were associated with selection for more aggressive surgical treatment. Younger age and improved functional status were associated with a reduced likelihood of complications., Conclusions: We conclude that in select patients, age alone should not preclude the decision to pursue aggressive surgical management., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Neuronavigation is an essential tool in cranial neurosurgery. Despite continuing improvements in the technologies used for neuronavigation, certain events can lead to unacceptable mismatches. To provide the best possible outcome for the patients, surgeons need to do everything possible to reduce mismatches., Methods and Results: Some simple techniques can greatly improve neuronavigation accuracy and patient safety. We describe two simple methods that were developed or refined in the Department of Neurosurgery at Inselspital, Bern, Switzerland: the transdermal navigation landmark and use of bone screws for co-registration., Conclusions: Both techniques are easy to use, do not require expensive additional instruments, and are helpful in procedures involving neuronavigation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The organization of a multicenter survey about chronic subdural hematomas has triggered the discussion on different surgical techniques of burr hole evacuation. Such a standard operation gives neurosurgeons plenty of scope for creating their own way., Methods: The procedure presented is one burr hole with a closed drainage system. In detail, each single step is enrolled: the planning of the burr hole, positioning, direction of skin incision, opening of the dura, drain positioning, channeling through the galea, and postoperative care., Conclusions: We present a thorough summary that could serve as a common standard and as a basis for comparison of future trials.

Introduction: The greater superficial petrosal nerve (GSPN) is especially important in anterior transpetrosal approach (ATPA) as the most reliable superficial landmark of Kawase's triangle. The GSPN can be considered as the superficial lateral border of anterior petrosectomy on the middle fossa to avoid internal carotid artery (ICA) injury. Although experienced operators can find the GSPN, its confirmation is not always easy to achieve., Methods: We introduce our recent GSPN confirmation methods using facial nerve monitoring. In 10 recent cases, antidromic GSPN stimulation and free-running facial muscle electromyography (EMG) monitoring were performed., Results: Facial nerve evoked-EMG by antidromic GSPN stimulation confirmed the location of the GSPN course with precision in all cases. Free-running facial muscle EMG informed the mechanical stress of facial nerves through the GSPN. There was no postoperative facial palsy or dry eye in these cases., Conclusions: GSPN confirmation and preservation are not always easy to achieve. These monitoring methods are useful for the confirmation of the GSPN, which is a landmark for safe extradural anterior petrosectomy, and for the preservation of the GSPN itself.

Background: Lateral orbitotomy can be minimalized using contemporary endoscopy., Methods: Anatomy of the temporal fossa/orbital wall junction is described. The attachment of the temporal fascia is cut off from the orbital rim through a 1.5 cm skin incision in the lateral orbital wrinkle. The temporal muscle is detached from the bone to create a space for the telescope. An appropriate bone opening in the lateral orbital wall is created with the aid of neuronavigation to handle intraorbital pathology., Conclusion: Endoscopic lateral orbitotomy is an original alternative to the microsurgical Krönlein approach and yields good functional and cosmetic results.

Background: Awake craniotomy is a valuable procedure since it allows brain mapping and live monitoring of eloquent brain functions. The advantage of minimizing resource utilization is also emphasized by some physicians in North America. Data on how well an awake craniotomy is tolerated by patients and how much stress it creates is available from different studies, but this topic has not consequently been summarized in a review of the available literature. Therefore, it is the purpose of this review to shed more light on the still controversially discussed aspect of an awake craniotomy., Methods: We reviewed the available English literature published until December 2013 searching for studies that investigated patients' responses to awake craniotomies., Results: Twelve studies, published between 1998 and 2013, including 396 patients with awake surgery were identified. Eleven of these 12 studies set the focus on the perioperative time, one study focused on the later postoperative time. The vast majority of patients felt well prepared and overall satisfaction with the procedure was high. In the majority of studies up to 30 % of the patients recalled considerable pain and 10-14 % experienced strong anxiety during the procedure. The majority of patients reported that they would undergo an awake craniotomy again. A post traumatic stress disorder was present neither shortly nor years after surgery. However, a normal human response to such an exceptional situation can for instance be the delayed appearance of unintentional distressing recollections of the event despite the patients' satisfaction concerning the procedure., Conclusions: For selected patients, an awake craniotomy presents the best possible way to reduce the risk of surgery related neurological deficits. However, benefits and burdens of this type of procedure should be carefully considered when planning an awake craniotomy and the decision should serve the interests of the patient.