Early Discharge After Surgery for Intra-Axial Brain Tumors.

OBJECTIVE: A steady trend in medicine has been discharging patients earlier after surgical procedures, a trend that has been resisted by many in the field of intracranial tumor surgery. Here we demonstrate the feasibility of discharge on postoperative days 1 or 2 for patients undergoing elective intracranial surgery. METHODS: We conducted a retrospective analysis on all patients undergoing elective intracranial keyhole surgery for tumors, cysts, and other masses between January 2010 and December 2011. During this time period, we used an early discharge plan centered on the clinical appearance of the patient, for which all patients were eligible preoperatively. Patients who met discharge criteria were encouraged to continue recovery at home. RESULTS: Of 313 patients, 213 (68.1%) were discharged on postoperative days 1 or 2. Within this group, 81.6% had supratentorial lesions, 16.9% had infratentorial lesions, and 1.4% had lesions extending above and below the tentorium. High grade gliomas accounted for 38.5% of lesions. No deaths or readmissions for postoperative swelling or hematomas occurred within 28 days of surgery. The overall rate of readmission for postoperative complications was 4.2%, compared with 4.0% for patients discharged on or after postoperative day 3. Readmission rate for repeat surgery addressing complications causing neurological symptoms was 1.9%. CONCLUSIONS: Our data suggest that the most serious complications occur within hours of the procedure, not days. The complications requiring readmission that we observed would not have been avoided with longer inpatient courses. Thus, consideration should be given to sending well-looking patients home to recover on postoperative days 1 or 2.

Endoscopic approach to colloid cyst: what is the optimal entry point and trajectory?

OBJECTIVES: An optimal entry point and trajectory for endoscopic colloid cyst (ECC) resection helps to protect important neurovascular structures. There is a large discrepancy in the entry point and trajectory in the neuroendoscopic literature. METHODS: Trajectory views from MRI or CT scans used for cranial image guidance in 39 patients who had undergone ECC resection between July 2004 and July 2010 were retrospectively evaluated. A target point of the colloid cyst was extended out to the scalp through a trajectory carefully observed in a 3D model to ensure that important anatomical structures were not violated. The relation of the entry point to the midline and coronal sutures was established. Entry point and trajectory were correlated with the ventricular size. RESULTS: The optimal entry point was situated 42.3 ± 11.7 mm away from the sagittal suture, ranging from 19.1 to 66.9 mm (median 41.4 mm) and 46.9 ± 5.7 mm anterior to the coronal suture, ranging from 36.4 to 60.5 mm (median 45.9 mm). The distance from the entry point to the target on the colloid cyst varied from 56.5 to 78.0 mm, with a mean value of 67.9 ± 4.8 mm (median 68.5 mm). Approximately 90% of the optimal entry points are located 40-60 mm in front of the coronal suture, whereas their perpendicular distance from the midline ranges from 19.1 to 66.9 mm. The location of the "ideal" entry points changes laterally from the midline as the ventricles change in size. CONCLUSIONS: The results suggest that the optimal entry for ECC excision be located at 42.3 ± 11.7 mm perpendicular to the midline, and 46.9 ± 5.7 mm anterior to the coronal suture, but also that this point differs with the size of the ventricles. Intraoperative stereotactic navigation should be considered for all ECC procedures whenever it is available. The entry point should be estimated from the patient's own preoperative imaging studies if intraoperative neuronavigation is not available. An estimated entry point of 4 cm perpendicular to the midline and 4.5 cm anterior to the coronal suture is an acceptable alternative that can be used in patients with ventriculomegaly.

Histopathological features of the outer membrane of chronic subdural hematoma and correlation with clinical and radiological features.

We compared the histopathological features of the outer membrane of a chronic subdural hematoma (CSH) with its clinico-radiological presentation in patients. One hundred and fifty-six patients undergoing surgery for CSH were prospectively included in this study. Histopathological specimens of the outer neomembrane obtained intraoperatively were studied. Histological features were classified into four types and analyzed in relation to the Glasgow Coma Scale (GCS) score at presentation and radiological features. On histopathological examination, there were no cases of type I, 42.3% cases of type II and 34.6% cases of type III and 23.1% cases of types IV CSH neomembranes. Patients presenting with a GCS <13 exclusively had type II neomembranes. Increased radiodensity and thickness of the hematoma correlated with type IV neomembranes. This study may serve as an incentive to investigate the histopathology of CSH membranes in predicting outcomes and the recurrence of subdural hemorrhage after drainage surgery.

Neurenteric cyst: an unusual cause of third nerve palsy.

INTRODUCTION: Neurenteric cysts are a rare cause of central nervous system compression. Pediatric intracranial cysts are even less common. CASE STUDY: We describe the presentation, imaging features, surgical management, and postoperative course of a 5-year-old female with congenital third nerve paresis, worsening headaches, and a cyst of the third nerve. We performed an eyebrow incision and keyhole supraorbital craniotomy for exploration and subsequent resection of a neurenteric cyst that was densely involved with the third nerve at its exit from the midbrain. Postoperatively, she had chemical meningitis and complete third nerve palsy. This entity is extremely rare in this location but should be included in the differential. We summarize the current literature on these lesions and recommend biopsy and fenestration as surgical treatment.

Use of market segmentation to identify untapped consumer needs in vision correction surgery for future growth.

PURPOSE: Market segmentation analysis identifies discrete segments of the population whose beliefs are consistent with exhibited behaviors such as purchase choice. This study applies market segmentation analysis to low myopes (-1 to -3 D with less than 1 D cylinder) in their consideration and choice of a refractive surgery procedure to discover opportunities within the market. METHOD: A quantitative survey based on focus group research was sent to a demographically balanced sample of myopes using contact lenses and/or glasses. A variable reduction process followed by a clustering analysis was used to discover discrete belief-based segments. The resulting segments were validated both analytically and through in-market testing. RESULTS: Discontented individuals who wear contact lenses are the primary target for vision correction surgery. However, 81% of the target group is apprehensive about laser in situ keratomileusis (LASIK). They are nervous about the procedure and strongly desire reversibility and exchangeability. CONCLUSION: There exists a large untapped opportunity for vision correction surgery within the low myope population. Market segmentation analysis helped determine how to best meet this opportunity through repositioning existing procedures or developing new vision correction technology, and could also be applied to identify opportunities in other vision correction populations.