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

Objectives Patients undergoing surgery for Cushing's disease may be more likely to be readmitted to the hospital than other patients with pituitary disorders. We investigated rates, causes, and predictors of unplanned readmission following transsphenoidal surgery for Cushing's disease to identify areas for clinical, financial, and administrative improvements.

Design Retrospective cohort study.

Setting Academic pituitary centers in the United States participating in a multicenter surgical outcome registry.

Participants Five hundred and nineteen patients underwent transsphenoidal surgery for treatment of Cushing's disease by 26 surgeons at nine participating institutions from 2003 to 2023.

Main Outcome Measures Unplanned 90-day readmission rates and causes of readmission.

Results Unplanned readmissions occurred in 57/519 patients (11.0%), with hyponatremia in 12/57 (21%), cerebrospinal fluid leak evaluation in 8/57 (14%), epistaxis in 6/57 (10%), deep vein thrombosis in 4/57 (7%), syncope in 3/57 (5%), and headache in 3/57 (5%). Factors including no tumor on initial magnetic resonance imaging, return to the operating room during the index admission, lack of early remission, and inpatient complications were associated with a greater probability of readmission on univariate analysis. However, none remained predictive on multivariate analysis.

Conclusion Our results show that readmission rates after transsphenoidal surgery for Cushing's disease are comparable to previously reported rates for all pituitary-related disorders, with the most common reason being hyponatremia. High-impact clinical protocols focused on preventing delayed hyponatremia may reduce the risk of readmission. Failure to identify significant predictors of readmission, even in this large clinical dataset, underscores the challenge of identifying high-risk clinical cohorts.

Objective Olfactory groove meningiomas (OGM) commonly present with olfactory deficits and compression of the frontal lobes. Given the relationship to dietary behaviors, our objective was to evaluate the relationship between OGMs and postoperative weight loss.

Methods Retrospective review of primary resection of meningiomas between 2017 and 2023 at a single institution was conducted. Neurofibromatosis type 2, pregnancy, weight loss medications, or surgeries were excluded. Data collection included preoperative body mass index (preBMI) and postoperative BMI (poBMI) at 3 to 6 and 12 months. Percent BMI change (pcBMI) was calculated by (poBMI − preBMI/preBMI × 100%). IBM SPSS Statistics (Version 27) was used for descriptive statistics and stepwise multiple linear regression.

Results Ninety-eight patients met inclusion with a mean age of 57.58 years. Three groups were stratified by location: OGM (n = 15), anterior cranial fossa excluding OGM (ACF; n = 24), and other (OTH; n = 59). Olfactory dysfunction was present in 53.8% of the OGMs. OGM presented with significantly larger lesions (57.25 ± 55.98 mm³) and a higher preBMI (34.58 ± 7.41 kg/m²) than ACF and OTH. A greater pcBMI was seen in OGM at both timepoints (−7.74%, −8.73%). OGM location, tumor volume, and preBMI were found significant on univariate analysis (p < 0.05) and included in multiple linear regression. All regression models were significant (p = 0.001). Location significantly added to the prediction at 3 to 6 and 12 months as well as preBMI at 12 months. In a subanalysis of ACF and OGM, OGM location was significantly associated with negative pcBMI at 3 to 6 and 12 months.

Conclusion OGMs are associated with higher preoperative weight and greater weight loss postoperatively compared with other locations.

Introduction Common approaches to remove skull base tumors invading the orbital apex, cavernous sinus, middle fossa, or temporal lobe include orbitozygomatic or fronto-orbital craniotomies. Recently, different types of orbital approaches have been described as alternative minimally invasive techniques.

Objective With this systematic review, we analyzed the typology of intracranial tumors treated through transorbital approaches, especially through the lateral orbital (LO) wall, and analyzing the complication rates and outcomes.

Design A PubMed/Medline search was performed using the criteria: “orbitotomy,” “transorbital,” “transpalpebral,” and “lateral orbitotomy” in combination with “cavernous sinus,” “middle fossa,” and “temporal lobe.”

Main Outcome Measures From these reports, we collected diagnoses, lesion sizes and locations, approaches, outcomes, aesthetic outcomes, postoperative ptosis, postoperative cranial nerve (CN) palsies, length of CN deficits postoperatively, overall complications, and follow-up length.

Results A total of 13 papers and 3 of our own cases matched our inclusion criteria totaling 160 patients. Most patients were treated for meningiomas (135, 84.4%). The approaches included the LO approach (n = 54; 33.8%), deep transorbital (n = 5; 3.1%), mini-LO (n = 91; 56.9%), and modified LO (n = 10; 6.2%). While not all cases reported excision success, the various LO approaches achieved total (n = 42; 26.25%) resection margins. Postoperative ocular complications (including CN palsies, proptosis, or ocular disturbances) totaled 46 (28.8%) new CN palsies, 23 (14.4%) occurrences of vision loss, 1 (1.7%) with worsened proptosis, 5 (3.9%) with worsened enophthalmos, and 42 (26.3%) other complications.

Conclusion Microsurgical LO approaches, especially in the era of radiosurgery, may become a suitable alternative to other more established craniotomies.

Objectives In recent years, the transnasal endoscopic method for transsphenoidal pituitary tumor resection (eTSR), alongside the conventional sublabial microscopic transsphenoidal resection (mTSR) method, has gained popularity due to advancements in imaging and instrumentation. The current study sought to elucidate whether the trend toward eTSR was associated with changes in clinical outcomes at a single institution's multidisciplinary pituitary surgery program.

Setting and Participants The Virginia Commonwealth University (VCU) Brain Tumor Database was queried for patients who underwent either transnasal or sublabial pituitary tumor resection of pituitary tumors between 2009 and 2021.

Design Clinical outcomes were compared between the two groups.

Main Outcome Measures Surgical outcomes like estimated blood loss (EBL), cerebrospinal fluid (CSF) leak rates, hospital length of stay (LOS), and extent of resection were studied.

Results A total of 93 patients (57 mTSR, 36 eTSR) underwent review, revealing that mTSR was associated with a higher average intraoperative blood loss (310.5 ± 48.6 mL) than eTSR (160.0 ± 30.7 mL; p = 0.012). eTSR demonstrated an elevated intraoperative CSF leak incidence (36.1 vs. 15.8%; p = 0.043), but no difference in postoperative CSF leak requiring intervention. Hospital LOS and extent of resection showed no significant differences between the approaches.

Conclusion This single-institution, retrospective study suggests that, in experienced hands, both eTSR and mTSR approaches are effective with comparable risk profiles. The approach may be best determined by the surgical team's evaluation of the tumor's imaging features, paying attention to the patient's preoperative hematologic status due to the greater propensity for blood loss with the microscopic approach.

Introduction Skull base surgery has evolved from fundamental elements into a distinct multidisciplinary specialty. Using bibliometrics, we appraised the literature pertaining to skull base surgery since 1900 and studied the emergence of the specialty as a scholarly field.

Methods We queried Web of Science for all content from past presidents of the North American Skull Base Society (N = 31) and their self-identified forebears, influences, contemporaries, and trainees (N = 115). Statistical and bibliometric analyses were performed using various Python packages on article metadata.

Results Our query returned 28,167 articles. The most pertinent works (N = 15,529), identified algorithmically through an analysis of terms in titles, were published between 1900 and 2024 by 15,286 authors. The field exploded in the latter half of the 20th century, concurrently with increased interdisciplinary and international collaboration, and contemporaneously with the formation of centers of excellence and influential societies. Since 1950, prolific contributors to the field from neurosurgery, otolaryngology, radiology/radiation oncology, plastic surgery, and ophthalmology have increasingly subspecialized in skull base topics. The proportion of female authors in the corpus has grown from <1% in 1980 to 17% in 2023. We identify the articles that comprise the historical roots of modern skull base surgery, map the emergence of fundamental terminology within the corpus, and identify the authors who stand as key nodes of collaboration and influence.

Conclusion The field of skull base surgery was born from pioneering individuals with training in varied disciplines. The coalescence of skull base surgery into a distinct and diversified subspecialty has been powered by dedicated collaborative efforts on a global scale.

Objective Owing to the rarity of skull base chondrosarcomas (CS), much of its natural history and long-term impact on patient quality of life (QoL) are not well studied. This novel study demonstrates QoL among CS patients following radical treatment constituting surgery and postoperative radiotherapy over 2 decades.

Study Design Retrospective review and prospective data collection to obtain patient demographic, tumor characteristics, clinical symptoms, and patient-reported QoL outcomes using the 36-Item Short Form Health Survey (SF-36).

Setting/Participants Patients diagnosed with CS who underwent radical intent surgical resection by the senior author and adjuvant early postoperative proton beam therapy.

Results Twenty-eight skull base CS patients were identified, with 19 patients completing full treatment course. Mean long-term follow-up was 148.9 months. Diplopia symptom resolution was high. No significant deterioration in SF-36 Physical Health Component (PHC) and Mental Health Component (MHC) scores was observed at postoperative and long-term follow-up. General health was stable initially but deteriorated in long term (Δ −18.88, minimal clinically important difference [MCID]: 9.86, p = 0.04). Compared with age-matched Canadian control patients, CS patients reported similar PHC scores at baseline and follow-up. CS patients reported lower MHC scores (45.8 vs. 50.9, p = 0.13) preoperatively, which persisted at follow-up decreasing by 1.9 (43.9 vs. 53.7, p = 0.03); this difference, however, did not reach MCID threshold of Δ 5.9.

Conclusion We present the longest follow-up data on CS demonstrating stable long-term QoL with aggressive surgery. Tumor control was high and preoperative tumor size did not affect long-term QoL. Preoperative QoL was lower among CS compared with Canadian normative data. Postoperatively, only the decline in physical functioning QoL scores exceeded MCID. At long-term follow-up, the decline in physical functioning, social functioning, and general health exceeded MCID. Overall, QoL among CS patients remained lower at long-term follow-up despite absence of tumor progression and resolution of symptoms.

Introduction Skull base neuroanatomy is traditionally learned through two-dimensional anatomical atlases, which while are of unquestionable value, lack the nuanced association of three-dimensional relationships between fundamental anatomical structures relevant to surgical approaches. Surgically focused step-by-step anatomical dissections can augment trainee learning of complex skull base techniques, particularly multistep and nuanced techniques such as translabyrinthine and transcochlear approaches.

Methods Translabyrinthine and transcochlear approaches were performed on six sides of three formalin-fixed latex-injected specimens. The study objective was the completion and photo documentation of the steps involved in the approach in order to provide a comprehensive, intelligible, and anatomically oriented resource for multilevel trainees. Illustrative case examples were prepared to supplement approach dissections.

Results The translabyrinthine and transcochlear approaches offer unique lateral windows through the temporal bone into the posterior fossa, providing excellent access to pathology at the petrous apex, internal auditory canal, Meckel's cave, and anterolateral brainstem. The transcochlear approach, which is an anterior extension of the translabyrinthine, particularly provides excellent exposure of the prepontine region and clivus. Important surgical considerations include patient position, temporal bone drilling and identification of critical landmarks, dural opening and identification of neurovascular structures, and reconstruction/closure techniques.

Conclusion The translabyrinthine and transcochlear approaches are fundamental techniques for lateral skull base and posterior fossa pathologies. Both approaches are hearing-sacrificing but often require minimal to no cerebellar retraction and deliver unique visualization of prepontine neurovascular structures. This step-by-step approach guide provides a unique practical and high-yield surgically oriented learning resource for neurosurgery and otolaryngology trainees.

Objectives To conduct a systematic review of facial nerve hemangiomas (FNH), focusing on patient characteristics, management options, and treatment outcomes.

Design A systematic review was performed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, utilizing PubMed, EMBASE, Scopus, and Cochrane databases from inception to December 31, 2022.

Setting Literature sourced from various databases providing information on FNH cases.

Participants A total of 176 patients with FNH were included in the study, identified from 40 articles meeting inclusion criteria.

Main Outcome Measures Patient demographics, lesion characteristics, preoperative symptoms, surgical approaches, and postoperative outcomes, including House-Brackmann (HB) grades.

Results Among the 1,682 initially identified articles, 40 were included in the final review. From these, a total of 176 patients (mean age = 42.7 ± 12.8, 51.1% male) were included for analysis. Bivariate analysis showed that patients with longer preoperative symptom duration and facial nerve sacrifice had significantly greater postoperative HB Grades (p < 0.001). Additionally, a strong positive correlation was observed between pre- and postoperative HB Grades (Spearman's rho = 0.649). Multivariable linear regression analysis showed that both facial nerve sacrifice (β = 0.86, 95% confidence interval [CI]: 0.38–1.34; p < 0.001) and greater preoperative HB Grades (β = 0.36, 95% CI: 0.20–0.53; p < 0.001) were associated with significantly greater postoperative HB Grades, but preoperative symptom duration did not persist as a significant predictor of postoperative HB Grades.

Conclusions FNHs are rare lesions of the skull base affecting the temporal bone. Our findings highlight the role of preoperative facial nerve function and intraoperative preservation of the facial nerve in predicting postoperative outcomes. Timely resection of lesions that prioritizes facial nerve preservation is critical to achieving optimal patient outcomes.

Background Natural language processing (NLP), a subset of artificial intelligence (AI), aims to decipher unstructured human language. This study showcases NLP's application in surgical health care, focusing on vestibular schwannoma (VS). By employing an NLP platform, we identify prevalent text concepts in VS patients' electronic health care records (EHRs), creating concept panels covering symptomatology, comorbidities, and management. Through a case study, we illustrate NLP's potential in predicting postoperative cerebrospinal fluid (CSF) leaks.

Methods An NLP model analyzed EHRs of surgically managed VS patients from 2008 to 2018 in a single center. The model underwent unsupervised (trained on one million documents from EHR) and supervised (300 documents annotated in duplicate) learning phases, extracting text concepts and generating concept panels related to symptoms, comorbidities, and management. Statistical analysis correlated concept occurrences with postoperative complications, notably CSF leaks.

Results Analysis included 292 patients' records, yielding 6,901 unique concepts and 360,929 occurrences. Concept panels highlighted key associations with postoperative CSF leaks, including “antibiotics,” “sepsis,” and “intensive care unit admission.” The NLP model demonstrated high accuracy (precision 0.92, recall 0.96, macro F1 0.93).

Conclusion Our NLP model effectively extracted concepts from VS patients' EHRs, facilitating personalized concept panels with diverse applications. NLP shows promise in surgical settings, aiding in early diagnosis, complication prediction, and patient care. Further validation of NLP's predictive capabilities is warranted.

Objectives The study aimed to examine the influence of different anesthesia depths monitored by Narcotrend on postoperative cognitive dysfunction (POCD) in elderly patients undergoing radical resection of gastrointestinal malignancies.

Methods Individuals in the control group (n = 40) maintained the Narcotrend index (NTI) at 50 to 59 monitored by Narcotrend, whereas the experimental group at 30 to 39. The mini-mental state examination (MMSE) scale and serum S100β concentration were used to evaluate the cognitive function. Cerebral oxygen metabolism and inflammation were evaluated, presenting as regional oxygen saturations of brain (rSO₂) and cerebral oxygen uptake rate (CERO2), serum tumor necrosis factor-α (TNF-α), and interleukin-6 (IL-6).

Results Experimental group presented prominently high levels of rSO2 and low levels of CERO2 relative to controls, meanwhile with reduced serum TNF-α and IL-6. Individuals receiving deep anesthesia owned low levels of S100β and enhanced MMSE score, which showed negative correlation. Low incidence rate of POCD was detected in the experimental group. Both age (hazard ratio = 5.219, 95% confidence interval = 1.813–15.025) and NTI score (hazard ratio = 3.707, 95% confidence interval = 1.292–10.633) were independent influence factors for the onset of POCD.

Conclusion NTI maintained at 30 to 39 can reduce the incidence of POCD in the early postoperative period for elderly patients receiving gastrointestinal tumors surgery, the contribution might be attributed to the improvement of perioperative cerebral oxygen metabolism and inflammatory stress response.