The Enhanced Recovery After Surgery protocol for the perioperative management of pituitary neuroendocrine tumors/pituitary adenomas.

OBJECTIVE: Enhanced Recovery After Surgery (ERAS) is a multimodal perioperative care pathway that has radically modified the management of patients in multiple surgical specialties. Until now, no ERAS Society guidelines have been formulated for the management of cranial pathologies. During the process of ERAS certification for their neurosurgical department, the authors formulated an ERAS protocol for the perioperative care of patients with pituitary neuroendocrine tumors (PitNET), along with a compliance checklist to monitor the adherence to it and its feasibility. The authors describe the protocol and checklist and report the results, including a cost-minimization analysis, with the application of the ERAS philosophy. METHODS: The steps that led to the development of this ERAS protocol, including items concerning the preoperative, intraoperative, and postoperative period, are detailed. The authors report their preliminary results through the comparison of the care practice of a historical cohort with a consecutive surgical cohort of patients with PitNET who underwent operation after the implementation of this ERAS protocol. A compliance checklist with key performance indicators was useful to monitor the adherence to the protocol and the changes in the perioperative management. RESULTS: Following the introduction of this ERAS protocol, the authors significantly shortened the duration of the antibiotic therapy (p < 0.00001) and increased the use of mechanical (p < 0.00001) and pharmacological measures to prevent deep venous thrombosis (p = 0.002). The median length of hospital stay was significantly shorter for the ERAS group (p = 0.00014), and there was no increase in readmission rate or postoperative complications. The documentation and data tracking strongly improved in the ERAS cohort and the authors were more attentive in pain evaluation (p = 0.001), postoperative hormonal supplementation (p = 0.001) and early feeding and mobilization (p = 0.0008 and p < 0.00001, respectively). More patients were discharged on day 3 after surgery in the ERAS group (p < 0.00001). The compliance to the whole process increased from 64.2% to 89.5% (p = 0.016), and the compliance per patient was also found to have significantly increased (p < 0.00001). CONCLUSIONS: The introduction of a standardized ERAS protocol for the perioperative management of patients with PitNET allowed the authors to improve the multidisciplinary management of these patients. With the application of simple cost-effective interventions and with the avoidance of unnecessary measures, gains were made in terms of early mobilization and feeding, thereby resulting in a shorter in-hospital stay.

Implementation of the Enhanced Recovery After Surgery (ERAS®) program in neurosurgery.

BACKGROUND: Over the past decade, Enhanced Recovery After Surgery (ERAS®) guidelines have been proven to simplify postoperative care and improve recovery in several surgical disciplines. The authors set out to create and launch an ERAS® program for cranial neurosurgery that meets official ERAS® Society standards. The authors summarize the successive steps taken to achieve this goal in two specific neurosurgical conditions and describe the challenges they faced. METHODS: Pituitary neuroendocrine tumors (Pit-NET) resected by a transsphenoidal approach and craniosynostosis (Cs) repair were selected as appropriate targets for the implementation of ERAS® program in the Department of Neurosurgery. A multidisciplinary team with experience in managing these pathologies was created. A specialized ERAS® nurse coordinator was hired. An ERAS® certification process was performed involving 4 seminars separated by 3 active phases under the supervision of an ERAS® coach. RESULTS: The ERAS® Pit-NET team included 8 active members. The ERAS® Cs team included 12 active members. Through the ERAS® certification process, areas for improvement were identified, local protocols were written, and the ERAS® program was implemented. Patient-centered strategies were developed to increase compliance with the ERAS® protocols. A prospective database was designed for ongoing program evaluation. Certification was achieved in 18 months. Direct costs and time requirements are reported. CONCLUSION: Successful ERAS® certification requires a committed multidisciplinary team, an ERAS® coach, and a dedicated nurse coordinator.

Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma.

OBJECTIVE: To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI). METHODS: A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, "primary procedure" and "secondary procedure", was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO2) values as well as the need for additional osmotherapy and CSF drainage. RESULTS: Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average post-surgical ICP values, higher PbO2 values and required less osmotic treatments as compared with those treated with DC alone. CONCLUSION: Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.

Surgical management of craniopharyngiomas in adult patients: a systematic review and consensus statement on behalf of the EANS skull base section.

BACKGROUND AND OBJECTIVE: Craniopharyngiomas are locally aggressive neuroepithelial tumors infiltrating nearby critical neurovascular structures. The majority of published surgical series deal with childhood-onset craniopharyngiomas, while the optimal surgical management for adult-onset tumors remains unclear. The aim of this paper is to summarize the main principles defining the surgical strategy for the management of craniopharyngiomas in adult patients through an extensive systematic literature review in order to formulate a series of recommendations. MATERIAL AND METHODS: The MEDLINE database was systematically reviewed (January 1970-February 2019) to identify pertinent articles dealing with the surgical management of adult-onset craniopharyngiomas. A summary of literature evidence was proposed after discussion within the EANS skull base section. RESULTS: The EANS task force formulated 13 recommendations and 4 suggestions. Treatment of these patients should be performed in tertiary referral centers. The endonasal approach is presently recommended for midline craniopharyngiomas because of the improved GTR and superior endocrinological and visual outcomes. The rate of CSF leak has strongly diminished with the use of the multilayer reconstruction technique. Transcranial approaches are recommended for tumors presenting lateral extensions or purely intraventricular. Independent of the technique, a maximal but hypothalamic-sparing resection should be performed to limit the occurrence of postoperative hypothalamic syndromes and metabolic complications. Similar principles should also be applied for tumor recurrences. Radiotherapy or intracystic agents are alternative treatments when no further surgery is possible. A multidisciplinary long-term follow-up is necessary.

Cognitive changes following surgery in intractable hemispheric and sub-hemispheric pediatric epilepsy.

OBJECTIVES: The objectives were to study the short and longitudinal changes in the cognitive skills of children with intractable epilepsy after hemispheric/sub-hemispheric epilepsy surgery. METHODS: Sixteen patients underwent surgery from September 2005 until March 2009. They underwent detailed presurgical evaluation of their cognitive skills and were repeated annually for 3 years. RESULTS: Their mean age was 6.6 years. Epilepsy was due to Rasmussen's encephalitis (n = 9), Infantile hemiplegia seizure syndrome (n = 2), hemimegalencephaly (n = 2), and Sturge Weber syndrome (n = 3). Fourteen (87.5%) patients underwent peri-insular hemispherotomy and two (12.5%) underwent peri-insular posterior quadrantectomy. The mental and social age, gross motor, fine motor, adaptive, and personal social skills showed a steady increase after surgery (p < 0.05). Language showed positive gains irrespective of the side and etiology of the lesion (p = 0.003). However, intelligence quotient (IQ) remained static on follow-up. Patients with acquired pathology gained more in their mental age, language, and conceptual thinking. Age of seizure onset and duration of seizures prior to surgery were predictive variables of postoperative cognitive skills. CONCLUSIONS: There are short- and long-term gains in the cognitive skills of children with intractable epilepsy after hemispherotomy and posterior quadrantectomy that was better in those patients with acquired diseases. Age of seizure onset and duration of seizures prior to surgery were independent variables that predicted the postoperative outcome.

Obstructive Hydrocephalus in Newborn Due to Cerebral Atrium Diverticulum Formation: Complete Resolution After Subdural Hematoma Evacuation.

BACKGROUND: Cerebral atrium diverticula are focal enlargements of the ventricular system that may develop in the presence of persistent intracranial hypertension, but they are rarely described in cases of acute intracranial hypertension. Here we present a unique case of obstructive hydrocephalus in a newborn due to the formation of a cerebral atrium diverticulum compressing the ventricular system. CASE DISCUSSION: A preterm 38-week-old boy was born with urgent caesarian section due to severe hydrocephalus. Magnetic resonance imaging showed the presence of a subacute right subdural hematoma with secondary obstructive hydrocephalus. The cystic lesion was characterized as a right ventricular atrium diverticulum. The child underwent urgent burr-hole evacuation of the right subdural hematoma with complete regression of the obstructive hydrocephalus and right atrial diverticulum. CONCLUSION: Cerebral atrium diverticula are rare focal dilatations of the ventricular system, and their radiologic diagnosis may be challenging. Accurate diagnosis of atrial diverticula and understanding of the underlying physiopathology is mandatory to establish the appropriate operative strategy.

Intracerebellar hemorrhage caused by developmental venous anomaly, from diagnosis to treatment.

BACKGROUND: Developmental venous anomaly (DVA) is considered a benign and asymptomatic cerebrovascular malformation, and only isolated cases of symptomatic DVAs are described in the literature. Even more rarely will these symptoms come from an intraparenchymal hemorrhage caused by the DVA. METHODS AND RESULTS: We present two symptomatic DVAs by intracerebellar hemorrhage. CONCLUSION: The diagnostic steps regarding the pathophysiology of DVA hemorrhage and the treatment options are discussed.

Peri-insular hemispherotomy: potential pitfalls and avoidance of complications.

Techniques for cerebral hemispherectomy have progressively evolved towards more disconnection and less excision over the last 50 years. Peri-insular hemispherotomy (PIH), as described by the senior author, has the maximal ratio of disconnection to excision among all procedures for hemispheric epilepsy. In this study, we focus on surgical complications and intraoperative anatomical observations during PIH over the last 10 years. Based on this experience, the procedure has undergone some modifications, which we detail herein.

Low-pressure hydrocephalic state complicating hemispherectomy: a case report.

UNLABELLED: Low-pressure hydrocephalic state (LPHS) has only recently been described as a distinct clinical entity occurring in patients with bioatrophic lesions of the brain. We report a patient in whom this syndrome developed after subtotal hemispherectomy for intractable epilepsy. METHODS: A 30-year-old man developed cerebrospinal fluid (CSF) rhinorrhea after subtotal hemispherectomy. After repair of the CSF dural fistula, clinical and radiological features of an LPHS developed. After external ventricular drainage for 26 days, a programmable low-pressure shunt system was instituted. RESULTS: Worsening neurologic status and ventriculomegaly in the face of normal intraventricular pressures is diagnostic of this condition. The clinical status clearly correlated with ventricular size and not ventricular pressure. CONCLUSION: LPHS is a clinically significant perioperative complication that rarely occurs after large brain excisions. Restoration of the baseline brain compliance is critical in the management of this condition.