Journal of Neurological Surgery Part B: Skull Base最新文献

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Objectives: The use of genomic testing for patients with anterior skull base malignancies has grown dramatically. There are no clear guidelines on indications for testing. As the literature on the subject is still in early stages, there is a need for expert consensus. We conducted a modified Delphi expert consensus process with high-volume North American cranial base surgical programs.

Design setting participants: A modified Delphi consensus approach was used, following the method laid out by the American Academy of Otolaryngology-Head and Neck Surgery, and included 13 high-volume care centers. An otolaryngologist was appointed at each location to serve as the institutional representative.

Main outcome measures: Participant responses to Delphi surveys were tabulated to determine consensus.

Results: Thirteen teams responded comprising 23 otolaryngologists and 10 neurosurgeons. Overall, 11 of 12 institutions reported genomic testing to be fairly or easily available at their location, and 22 of 38 initial statements achieved consensus. Statements achieving consensus focused on primary and recurrent rare tumors without possibility of margin-negative resection, those with family history of anterior skull base malignancies, or rare tumors with distant metastasis. Statements regarding routine genomic sequencing or for primary tumors and cost of care did not achieve consensus.

Conclusion: Expert multidisciplinary teams agreed on several appropriate settings for genomic sequencing in patients with anterior skull base malignancies, including recurrence, distant metastasis, and the inability to achieve a margin-negative resection. Further research is needed to explicitly clarify the role of genomic sequencing in this rare disease group.

Objective: This study aimed to determine the incidence and risk factors for postoperative pulmonary complications (PPCs) following endoscopic endonasal surgery (ESS).

Design: Retrospective review from January 2023 to May 2023.

Setting: Tertiary academic center.

Participants: One hundred EES cases, of which 97 met the inclusion criteria.

Main outcome measures: The primary outcome was the incidence of PPC. Univariable and multivariable analyses were used to assess preoperative variables, demographics, and respiratory comorbidities; intraoperative variables of surgery and duration of intubation, endotracheal tube (ETT) size, estimated blood loss (EBL), gastric tube use during surgery; postoperative cerebrospinal fluid (CSF) leak, and length of hospital stay as predictors of PPC.

Results: Ninety-seven patients met the inclusion criteria. Twenty-nine developed PPC including increased oxygen requirement (14.4%), pneumonia (9.3%), atelectasis (3.1%), respiratory failure (2.1%), and pulmonary embolism (2.1%). Sixty-four percent were clinically significant PPC. PPC was associated with age ( p  < 0.007), longer duration of surgery ( p  < 0.001), longer duration of intubation ( p  < 0.001), postoperative intubation ( p  < 0.001), higher EBL ( p  = 0.022), and longer length of hospital stay ( p  < 0.001). There was no significant association between PPC and sex ( p  = 0.705), body mass index (BMI; p  = 0.403), gastric tube presence ( p  = 0.778), ETT size ( p  = 0.636), and preoperative history of pulmonary disease ( p  = 0.403).

Conclusion: The incidence of PPC in patients undergoing EES is significant. Targeting perioperative risk factors including age ≥65, duration of intubation, postsurgical intubation status, and intraoperative blood loss should have a meaningful impact on decreasing PPC. The contribution of silent intraoperative aspiration during surgery needs to be investigated further in high-risk patient populations.

Introduction: Cerebrovascular bypass surgery is technically demanding, with dozens of modifiable parameters influencing operative decision-making. Thoughtful selection of needle and suture materials is critical to success in these operations.

Methods: Based on the authors' experiences and existing literature, a brief guide to needle and suture selection is provided.

Results: Recommendations for needle and suture have taken into consideration key features of bypass constructs, such as bypass type, vessel caliber, and working space. Specific suture and needle are highlighted from two of the most common industry suppliers.

Conclusion: This guide synthesizes clinical insights and practical guidelines to support neurosurgical trainees and practitioners in mastering cerebrovascular bypass techniques.

Objective: Prolactinomas comprise half of all pituitary adenomas. This study explores the significance of measuring intraoperative (IO) prolactin (PRL) levels in guiding surgical decision-making and predicting operative success.

Methods: Retrospective cohort study design of consecutive patients with prolactinomas who underwent transsphenoidal resection from June 2021 to May 2023. IO PRL was measured after tumor resection was completed. Remission was defined as normalization of PRL levels during follow-up without medication. Outcomes included factors associated with remission, utilizing significance thresholds at p  < 0.05.

Results: Thirteen patients were included with a 5.3-month median follow-up (range, 3-15 months). Most of the tumors were microadenomas (61%), with a median preoperative PRL level of 116 ng/mL (range, 25-471). Gross total resection was achieved in 69% of patients, all of whom attained remission. The median IO PRL was 19.8 ng/mL (range, 1-329), the postoperative day 1 PRL of 3.6 ng/mL (range, 1-203), and the latest PRL at 9.3 ng/mL (range, 1-137). A ≥40% decline in IO PRL from baseline was identified as the optimal cutoff for predicting biochemical remission, with 89% sensitivity, 75% specificity, and 85% accuracy.

Conclusion: Monitoring PRL levels intraoperatively may be a useful biomarker aiding surgeon's assessment of the extent of tumor resection and guide surgical decision-making. Further refinement of the immunoassay assay and clinical testing with more extensive prospective studies are needed.

Objective: The purpose of this study was to introduce a watertight duraplasty with artificial dural grafts for anterior skull base (ASB) reconstruction.

Methods: Between November 2019 and October 2023, we used artificial dural grafts for the ASB reconstruction in 10 cases of recurrent benign cranionasal communicating tumors. Through a transcranial subfrontal approach, the tumor was totally removed and the skull base defect was repaired using the NormalGEN and DuraMax artificial dural grafts. Clinical and imaging follow-ups were conducted to screen for the occurrence of postoperative cerebrospinal fluid (CSF) leakage, intracranial infection, and encephalocele.

Results: Gross total resection of tumor and ASB reconstruction with the artificial dural grafts were achieved in 10 patients. The patients were followed up clinically for 11 to 52 months (mean 26.0 months) and underwent medical imaging follow-up for 6 to 36 months (mean 18.4 months). One patient presented with CSF leakage on day 47 after the operation. Another patient endured intracranial infection without CSF leakage on the fifth day after the operation. Both patients were cured. No encephalocele was observed during the follow-up period. All the patients achieved a favorable recovery.

Conclusion: Following transcranial resection of benign cranionasal communicating tumors, we utilized artificial dural grafts for ASB reconstruction when the frontal pericranium was impaired by tumor invasion or previous surgery. Our initial experience and postoperative follow-up have proven that the method is feasible and reliable in selected cases.

Introduction: Surgical treatment of skull base pathologies is frequently discussed in the context of endoscopic endonasal or transcranial approaches. Combined endoscopic and open approaches have been utilized in a staged or sequential fashion, with the goal of reducing the risk of postoperative cerebrospinal fluid leak, morbidity, wound infection/complication, and failure to achieve adequate reconstruction. However, few studies have described the concurrent use of endoscopic endonasal and transcranial approaches to safely address complex skull base pathologies.

Methods: We treated 13 patients with primary skull base tumors (sinonasal undifferentiated carcinoma/esthesioneuroblastoma), recurrent tumors, infection, and skull base defect/encephalocele. Out of the thirteen patients, eight had undergone prior endoscopic and/or open transcranial approaches for resection of their pathologies. Additionally, 3/13 patients underwent radiation or chemotherapy radiation prior to the combined approach.

Results: The desired clinical outcome (i.e., gross total tumor resection, resolution of infection, and skull base resection/repair) was achieved in 12/13 cases. One case had subtotal resection (Simpson grade III) of an olfactory groove meningioma. Postoperatively, there was one 30-day mortality due to pulmonary infarction, one case with hydrocephalus requiring ventriculoperitoneal shunt placement, and one flap infection due to postoperative cocaine use resulting in revisions and hospice. Importantly, no patients experienced postoperative CSF leaks, including those who underwent postoperative chemotherapy/radiation.

Conclusion: This case series suggests that a concurrent combined endoscopic transcranial approach, in carefully selected patients, can treat a wide range of complex and recurrent skull base pathologies resistant to previous treatment, with a reasonable rate of postoperative wound/leak complications.