3D-Slicer Software-Assisted Neuroendoscopic Surgery in the Treatment of Hypertensive Cerebral Hemorrhage.

OBJECTIVE: To explore the 3D-slicer software-assisted endoscopic treatment for patients with hypertensive cerebral hemorrhage. METHODS: A total of 120 patients with hypertensive cerebral hemorrhage were selected and randomly divided into control group and 3D-slicer group with 60 cases each. Patients in the control group underwent traditional imaging positioning craniotomy, and patients in the 3D-slicer group underwent 3D-slicer followed by precision puncture treatment. In this paper, we evaluate the hematoma clearance rate, nerve function, ability of daily living, complication rate, and prognosis. RESULTS: The 3D-slicer group is better than the control group in various indicators. Compared with the control group, the 3D-slicer group has lower complications, slightly higher hematoma clearance rate, and better recovery of nerve function and daily living ability before and after surgery. The incidence of poor prognosis is low. CONCLUSION: The 3D-slicer software-assisted endoscopic treatment for patients with hypertensive intracerebral hemorrhage has a better hematoma clearance effect, which is beneficial to the patient's early recovery and reduces the damage to the brain nerve of the patient.

Sheltered Neurosurgery During COVID-19: The Emory Experience.

BACKGROUND: The 2019 novel coronavirus disease (COVID-19) pandemic has directly and indirectly impacted health care systems, including residency programs. Social distancing, cancellation of elective cases, and staff re-deployment have compromised clinical and academic teaching. We describe the neurosurgical experience at Emory University during the COVID-19 pandemic and the impact of COVID-19-related policies on resident experience. METHODS: We retrospectively reviewed all neurosurgical cases performed at Emory University Hospital between March 16, the day cancellation of elective cases was effective, and April 15, 2020, and the same period in the preceding 3 years. For the study period, we collected the number of cases and their distribution by subspecialty along with total hospital charges. RESULTS: Compared with an average of 606 cases performed during the study period over the past 3 years, only 145 neurosurgical cases were performed between March 16 and April 15, 2020, which corresponds to an 80% reduction in case volume and 66% decrease in hospital revenue in 2020. When divided by subspecialty, the most significant reduction was observed in functional (84%; P < 0.01) followed by spine (78%; P < 0.01) surgery, although all subspecialties were significantly impacted. Assessing junior resident experience, we observed a significant reduction in number of neurosurgical admissions (47%; P < 0.01) and bedside procedures (59%; P < 0.01) in the study period in 2020 compared with the past 3 years, with no significant reduction in number of consultations (17%; P > 0.1). CONCLUSIONS: Even at academic centers that were not hugely impacted by the COVID-19 pandemic, prophylactic and preparedness measures still exhibited an unprecedented toll on neurosurgical resident and fellow experience.

Seizure outcome and prognostic factors for surgical management of hypothalamic hamartomas in children.

PURPOSE: Hypothalamic hamartomas (HH) are rare benign lesions frequently associated with gelastic seizures early in life. Epilepsy can progress to multiple seizure types with cognitive impairment and behavioural disturbance, leading in some cases to epileptic encephalopathy. METHODS: We reviewed a retrospective series of 112 children treated in a single center, between 1998 and 2017. RESULTS: According to Delalande's HH classification, type1 was found in 2 patients, type 2 in 67, type 3 in 31, and type 4 in 12 patients. Stereotactic endoscopic disconnection was performed in 92 % of the procedures. Median age at diagnosis was 40 months and 7.6 years at surgery. Median time between diagnosis and surgery was 31 months and median follow up 4.1 years. For all HH types, 77.6 % of the patients had a favourable outcome (Engel I + II outcome score) with 57.1 % seizure-free (Engel I). The best outcome was obtained in patients with type 2 HH, (68.7 % Engel I and 85.1 % Engel I + II). The overall complication rate was 8.3 %, which is in line with previous series. Patients with isolated gelastic seizures had a better outcome (Engel I + II in 90 %), as compared to those with other seizure types (p = 0.07). A short delay between hamartoma diagnosis and surgery was a statistically significant factor for a good outcome (p = 0.03). CONCLUSION: Patients with HH and drug-resistant epilepsy should be early identified in order to propose surgical treatment without delay. Endoscopic disconnection is a safe and efficacious surgical option with good seizure outcome and immediate treatment results.

Endoscopic versus Microscopic Pituitary Adenoma Surgery: A Single-center Study.

BACKGROUND: Transsphenoidal approach became the gold standard in the surgical treatment of pituitary adenomas in the past years, but the comparative efficacy of microscopic and endoscopic transnasal surgery has not been fully studied. AIMS: To compare the microscopic and endoscopic transnasal approaches for the treatment of pituitary adenomas. SETTINGS AND DESIGN: A retrospective analysis was performed, comparing adult patients with pituitary adenomas who had undergone transnasal microscopic surgery between January 2006 and December 2014 with the patients operated on with endoscopic surgery between March 2011 and December 2014 at Hospital Italiano de Buenos Aires. MATERIAL AND METHODS: Imaging, hormonal, and ophthalmological studies as well as complications were analyzed. STATISTICAL ANALYSIS: Due to the existence of dichotomous variables, Fisher's exact test was used for statistical analysis. RESULTS: In all, 259 patients who had undergone microsurgery and 140 patients operated on with endoscopy were included. The pathologies compared were microsurgically resected nonfunctioning adenomas: 38.2% (n = 99) versus endoscopically resected: 42.1% (n = 59), and microsurgically resected functioning adenomas: 61.8% (n = 160) versus endoscopically resected: 57.9% (n = 81). A higher number of patients with invasive macroadenomas were reported in the group operated on with endoscopy (35.5% vs. 56.4%). When the patients with invasive pathology of the cavernous sinus were compared, percentages of total resection and hormonal control were higher for endoscopic surgeries (35% vs. 46.8%; 33.3% vs. 64%); however, this difference was not statistically significant. No statistically significant differences were found when postoperative complications were individually analyzed. CONCLUSION: The microsurgical and endoscopic approaches are safe and effective techniques to treat pituitary adenomas. For invasive adenomas, the endoscopic approach may report better results.

The 50 most cited publications in endoscopic third ventriculostomy: a bibliometric analysis.

OBJECTIVEAlthough endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus was introduced in 1923, the method was relegated to the sidelines in favor of extracranial techniques. Since the 1990s to the beginning of the current century, however, ETV has undergone a remarkable resurgence to become the first-line treatment for obstructive hydrocephalus, and for some groups, the procedure has been applied for communicating hydrocephalus as well. In the present study, the authors identified the top 50 cited ETV works. These articles represent works of significance that document current practices and provide guidance for future inquiry.METHODSThe top 50 cited articles pertaining to ETV were identified using bibliometric data obtained with the Harzing's Publish or Perish software search engine. These high-impact works were evaluated for publication properties including year, country of authorship, category, and journal.RESULTSThe top 50 works were cited an average of 141.02 times with a mean of 9.45 citations per year. Articles published in 2005 were the most numerous in the top 50 group. These top articles were most frequently published in the Journal of Neurosurgery: Pediatrics. Most of the articles were clinical studies reporting on patients in the pediatric age group. The country of most authorship was the US, although many other countries were among the top 50 works.CONCLUSIONSThe present report discusses the bibliometric analysis of the top 50 ETV articles. This list may be useful to those interested in the progress and current status of this procedure.

Outcome of Endoscopic Transsphenoidal Surgery for Acromegaly.

OBJECTIVE: Endoscopic transsphenoidal surgery has recently been introduced in pituitary surgery. We investigated outcomes and complications of endoscopic surgery in 2 referral centers in Korea. METHODS: We enrolled 134 patients with acromegaly (microadenomas, n = 15; macroadenomas, n = 119) who underwent endoscopic transsphenoidal surgery at Seoul National University Hospital (n = 74) and Samsung Medical Center (n = 60) between January 2009 and March 2016. Remission was defined as having a normal insulin-like growth factor-1 and a suppressed growth hormone (GH) <1 ng/mL during an oral glucose tolerance test. RESULTS: Remission was achieved in 73.1% of patients, including 13 of 15 microadenoma patients (86.7%) and 86 of 119 macroadenoma patients (72.3%). A multivariate analysis to determine a predictor of biochemical remission demonstrated that absence of cavernous sinus invasion and immediate postoperative GH levels <2.5 ng/dL were significant predictors of remission (adjusted odds ratio [OR], 5.14; 95% confidence interval [CI], 1.52-17.3 and OR, 9.60; 95% CI, 3.41-26.9, respectively). After surgery, normal pituitary function was maintained in 34 patients (25.4%). Sixty-four patients (47.7%) presented complete (n = 59, 44.0%) or incomplete (n = 5, 3.7%) recovery of pituitary function. Hypopituitarism persisted in 20 patients (14.9%) and worsened in 16 patients (11.9%). Postoperatively, transient diabetes insipidus was reported in 52 patients (38.8%) but only persisted in 2 patients (1.5%). Other postoperative complications were epistaxis (n = 2), cerebral fluid leakage (n = 4), infection (n = 1), and intracerebral hemorrhage (n = 1). CONCLUSIONS: Endoscopic transsphenoidal surgery for acromegaly presented high remission rates and a low incidence of endocrine deficits and complications. Regardless of surgical techniques, invasive pituitary tumors were associated with poor outcome.

A Strategy of Percutaneous Endoscopic Lumbar Discectomy for Migrated Disc Herniation.

OBJECTIVE: Percutaneous endoscopic lumbar discectomy (PELD) with remarkable advancements has led to successful results comparable with open discectomy; however, its application in herniated disc (HD) with migration is still challenging and technically demanding. The purpose of this study is to propose various strategies for PELD according to HD with migration. METHODS: A retrospective review was performed on 434 consecutive patients who had undergone PELD. HD with migration was classified into 4 zones: low-grade up/down and high-grade up/down based on the extent and direction of migration. Clinical outcomes were assessed by visual analogue scale score for back and leg pain, Oswestry Disability Index, and modified Macnab criteria. Endoscopic approaches and techniques were analyzed depending on HD with migration. RESULTS: A total of 149 patients underwent PELD for HD with migration. There were 93 low-grade down HD patients, 13 high-grade down, 11 low-grade up, and 32 high-grade up. High-grade up HDs were removed with the outside or outside-in techniques from L1-2 to L4-5. High-grade down HDs were removed via the outside technique with additional foraminoplasty. Low-grade up/down HDs with disc space continuity were removed with the inside-out technique. Meanwhile, at the L5-S1 level, interlaminar PELD was used to treat high-grade up/down HD with migration. The mean visual analogue scale score for back pain, leg pain, and Oswestry Disability Index were significantly improved after PELD. Favorable outcome was achieved in 90.6% of cases. CONCLUSIONS: An appropriate strategy for PELD is important for successful removal of HD considering the extent of migration and direction.

Minimally Invasive Transforaminal Lumbar Interbody Fusion Versus Percutaneous Endoscopic Lumbar Discectomy: Revision Surgery for Recurrent Herniation After Microendoscopic Discectomy.

BACKGROUND: Most patients with recurrence of microendoscopic discectomy (MED) need to receive revision surgery. Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and percutaneous endoscopic lumbar discectomy (PELD) are common operative methods for MED recurrence, but no study has been made to compare the clinical outcomes of these 2 surgical methods as revision surgery for MED recurrence. METHODS: A total of 105 patients who underwent either MIS-TLIF (58 patients) or PELD (47 patients) for revision of MED recurrence were included in this study. Perioperative outcomes (operation time, blood loss, and hospital stay), total cost, pain and functional scores (visual analog scale, Oswestry Disability Index, 12-item short form health survey) with a 12-month follow-up visit and review of complications and recurrence within 12 months postoperatively were recorded and assessed. RESULTS: No significant difference of clinical outcome over time was observed between these 2 approaches. Compared with MIS-TLIF, PELD was associated with greater satisfaction in the early stage after surgery; this effect was equalized after 3 months postoperatively. PELD brought advantages in terms of shorter operation time, shorter hospital stay, less blood loss, and lower total cost compared with MIS-TLIF; however, PELD was also associated with a higher recurrence rate than MIS-TLIF. CONCLUSIONS: Neither of these 2 surgical methods gave a clear advantage in long-term pain or function scores. Compared with MIS-TLIF, PELD could lead to a better perioperative result and less cost; however, the higher recurrence rate could not be ignored. Taking these characteristics into consideration was instrumental in pursuing personalized treatment for MED recurrence.

Cavum septi pellucidi cysts: a survey about clinical indications and surgical management strategies.

INTRODUCTION: Cavum septi pellucidi (CSP) cysts have a very low incidence (0.04%). Symptomatic patients usually present aspecific symptoms. For this reason, the management of these patients is still debated. MATERIALS AND METHODS: We selected the case of a ten year old patient, with a clinical history of frontal morning headaches and difficulty in concentration. Brain MRI documented a septum pellucidum cyst and a moderate biventricular dilation. We submitted the case, and a questionnaire concerning indications to surgery and management options to an international group of 54 pediatric neurosurgeons, analyzing the results and comparing them with the current literature. RESULTS: The majority of the participants (50%) indicated as appropriate at the early stage only a clinical observation. In case of persistence of clinical symptoms, 58% opted for intracranial pressure (ICP) monitoring, which, if raised, was considered by 91% as an adequate indication to proceed with surgical treatment. A total of 98% of the participants indicated endoscopic fenestration of the cyst as the preferred surgical strategy. CONCLUSIONS: The management of symptomatic patients with CSP cyst is controversial. Our results suggest that in most of the patients with aspecific symptoms, clinical observation and eventually ICP monitoring are adequate to identify patients for surgery.

Endoscopic Versus Microscopic Transsphenoidal Approach for Pituitary Adenomas: Comparison of Outcomes During the Transition of Methods of a Single Surgeon.

OBJECTIVE: The transition from microscopic to fully endoscopic transsphenoidal surgery requires a surgeon to assess how the change in technique will affect the extent of tumor resection (EOR), outcomes, and complications. We compared a single surgeon's experience transitioning from one technique to the other and examined the operative outcomes and EOR between microscopic versus endoscopic transsphenoidal surgery. METHODS: Retrospective data analysis of adult patients who were treated surgically for a pituitary adenoma between August 2005 and May 2015 by a single neurosurgeon, who was originally trained and practiced in the microscopic transsphenoidal approach. Patient demographics, perioperative conditions, tumor characteristics, operative times, volumetric EOR, postoperative outcome, and the endoscopic learning curve were evaluated. RESULTS: One hundred and nine patients underwent microscopic transsphenoidal surgery and 275 patients underwent a fully endoscopic approach. The patient characteristics were similar in the 2 groups. Operative room time was significantly shorter in the endoscopic group than in the microscopic group (180.2 vs. 215.6 minutes; P < 0.001). The endoscopic and microscopic groups had similar volumetric EOR (85.1% vs. 82.8%; P = 0.371) as well as residual tumor volume (1.06 cm3 vs. 1.15 cm3; P = 0.765). The mean length of hospital stay was 2.4 days in the endoscopic group and 3.2 days in the microscopic group (P = 0.03). CONCLUSIONS: During the transition from the microscopic to the endoscopic approach, similar surgical outcomes and EOR were achieved in the 2 cohorts. In our experience, the endoscopic approach offers the advantage of shorter operative times and lengths of hospital stays after the surgeon has developed more experience with the technique.

Endoscopic Endonasal versus Microsurgical Transsphenoidal Approach for Growth Hormone-Secreting Pituitary Adenomas-Systematic Review and Meta-Analysis.

BACKGROUND: The pituitary adenoma causing acromegaly is typically resected through a transsphenoidal approach and visualized with an operating microscope or endoscope. We undertook a systematic review and meta-analysis examining the clinical efficacy of endoscopic and microsurgical approaches. METHODS: Relevant studies using either endoscopic or microscopic transsphenoidal approaches for growth hormone pituitary adenomas were identified until February 2016. Data were extracted and analyzed according to predefined clinical end points. RESULTS: We identified 31 studies, in which 950 patients underwent endoscopic transsphenoidal resection and 2137 patients underwent microsurgical transsphenoidal resection. Patients undergoing microsurgery were less likely to present with hypothyroidism (10.7% vs. 19.1%, P = 0.033, 462 vs. 156 patients) and less likely to have macroadenomas (66.9% vs. 83.8%, P ≤ 0.001, 1484 vs. 884 patients); adenomas with cavernous sinus invasion (21.3% vs. 44.4%, P = 0.036, 592 vs. 558 patients); and a lower mean tumor volume (17.84 vs. 20.54 mm3, P = 0.012, 158 vs. 248 patients). Patients treated via the endoscopic approach were more likely to achieve remission for noninvasive macroadenomas (83.8% vs. 66.9%, P ≤ 0.001, 115 vs. 365 patients). Sinusitis (15.6% vs. 2.6%, P < 0.001, 241 vs. 295 patients) and intraoperative cerebrospinal fluid leak (21.6% vs. 1.0%, P = 0.022, 697 vs. 127 patients) were more common in patients treated endoscopically, and meningitis (0.7% vs. 1.7%, P = 0.027, 511 vs. 1513 patients) was more common in patients undergoing a microsurgical approach. CONCLUSIONS: Our study shows the clinical utility of the endoscopic approach and demonstrates potential benefits including increased remission rates with noninvasive macroadenomas and a lower rate of meningitis.

Long-Term Outcomes of Endoscopic Third Ventriculostomy in Adults.

OBJECTIVE: To describe long-term outcomes of endoscopic third ventriculostomy (ETV) in adults with hydrocephalus. METHODS: Single-institution retrospective review of adults treated with ETV between 1998 and 2006. Patient demographic, treatment, and follow-up data were collected. The patients were divided into 2 groups: primary ETV for patients with previously untreated or newly diagnosed hydrocephalus and secondary ETV for patients with a previous shunt presenting with shunt malfunction. ETV outcome was deemed successful if the patient remained shunt-free after ETV. Multivariate analysis was performed using Cox regression. RESULTS: The study population comprised 190 patients, with a median age of 43 years (range, 16-79 years). The median duration of follow-up was 112 months (range, 1-190 months). The primary ETV group contained 129 patients; the secondary ETV group, 61 patients. Operative complications occurred in 11 patients (6%). A successful outcome was obtained in 139 patients (73%). ETV failure occurred in 51 patients, with a median time to failure of 2 months (range, 0-124 months). Although the majority (86%) of ETV failures occurred within 2 years postoperatively, failure was noted in 3 cases between 5 and 10 years after intervention, including in 1 patient at a 124-month follow-up. In multivariate analysis, only previous shunt was found to influence outcomes (P = 0.021), with shorter ETV survival noted in patients with a previous shunt. Age, indication, and ETV success did not influence outcome. CONCLUSIONS: ETV is a safe procedure with excellent rates of long-term efficacy; however, late failure can occur, and patients should be instructed to seek medical advice if symptoms recur. A previous shunt is associated with a higher ETV failure rate.

Endoscopic Endonasal Transsphenoidal Surgery, A Reliable Method for Treating Primary and Recurrent/Residual Craniopharyngiomas: Nine Years of Experience.

OBJECTIVE: Craniopharyngioma resection is one of the most challenging surgical procedures. Herein, we describe our extended endoscopic endonasal transsphenoidal surgery (EETS) technique, and the results of 9 years of use on primary and recurrent/residual craniopharyngiomas. METHODS: This study reviewed 28 EETSs in 25 patients with craniopharyngiomas between January 2006 and September 2015. The patients were divided into 2 groups, newly diagnosed patients (group A, n = 15), and patients having residual or recurrent tumors (group B, n = 10). There was no significant difference between the groups in terms of the largest tumor diameter (P = 0.495), and all patients underwent EETS. The clinical and ophthalmologic examinations, imaging studies, endocrinologic studies, and operative findings for these cases were reviewed retrospectively. RESULTS: The number of gross total resections in group A was 13/15, and 7/10 in group B. Three of the patients developed postoperative cerebrospinal fluid leakage (all in group A). There were no neurovascular or ophthalmologic complications, and no meningitis or mortality was observed. CONCLUSIONS: There has been a notable increase in the use of EETS in the treatment of craniopharyngiomas during the last decade. Despite its increased use in the treatment of primary craniopharyngiomas, its implementation for recurrent or residual craniopharyngiomas has been viewed with suspicion. In this study, the results have been presented separately for primary and recurrent/residual craniopharyngiomas, so that the results can be compared. Overall, EETS is a reliable and successful surgical treatment method for primary and recurrent/residual craniopharyngiomas.

Extended Transsphenoidal Endoscopic Endonasal Surgery of Suprasellar Craniopharyngiomas.

OBJECTIVE: The endoscopic extended transsphenoidal approach for suprasellar craniopharyngiomas may be a really alternative to the transcranial approach in many cases. The authors present their experience with this technique in 136 patients with craniopharyngiomas. METHODS: From the past 7 years 204 patients with different purely supradiaphragmatic tumors underwent removal by extended endoscopic transsphenoidal transtuberculum transplanum approach. Most of the patients (136) had craniopharyngiomas (suprasellar, intra-extraventricular). The patients were analyzed according to age, sex, tumor size, growth and tumor structure, and clinical symptoms. Twenty-five patients had undergone a previous surgery. The mean follow-up was 42 months (range, 4-120 months). The operation is always performed with the bilateral endoscopic endonasal anterior extended transsphenoidal approach. RESULTS: A gross-total removal was completed in 72%. Improvement of vision or absence of visual deterioration after operation was observed in 89% of patients; 11% had worsening vision after surgery. Endocrine dysfunction did not improve after surgery, new hypotalamopituitary dysfunction (anterior pituitary dysfunction or diabetes insipidus) or worsening of it was observed in 42.6%. Other main complications included transient new mental disorder in 11%, temporary neurological postoperative deficits in 3.7%, bacterial meningitis in 16%, cerebrospinal fluid leaks in 8.8%. The recurrence rate was 20% and the lethality was 5.8%. CONCLUSIONS: Resection of suprasellar craniopharyngiomas using the extended endoscopic approach is a more effective and less traumatic technology, able to provide resection of the tumor along with high quality of life after surgery, and relatively rare postoperative complications and mortality.

Fast Track Recovery Program After Endoscopic and Awake Intraparenchymal Brain Tumor Surgery.

BACKGROUND: There is an increasing drive to deliver a more efficient, cost-effective service leading to shorter stays in hospital. The advent of endoscopic and awake tumor surgery has reduced the morbidity associated with brain tumor resection, allowing patients to mobilize and be discharged earlier. Here, we present the outcomes from a single neurosurgical center in the United Kingdom on a fast track recovery program. METHODS: All consecutive patients undergoing elective endoscopic (n = 65) or awake (n = 10) tumor resection over a 3-year period between 1 December 2011 and 31 January 2015, under a single surgeon, were recruited. Data regarding their length of stay and outcomes were prospectively collated and analyzed. RESULTS: 66.7% of patients could be discharged safely within 1 postoperative day. Of the patients who stayed longer, 76% had a prolonged stay because of either social reasons or failing occupational therapy assessments. Only 6 cases (24%) of prolonged hospital admission were for medical reasons. Patients discharged within 1 day were no more likely to develop postoperative complications compared with those staying for longer (18% vs. 28%; odds ratio, 0.56; 95% confidence interval, 0.18-1.75; P = 0.21). The readmission rates were identical in both groups (16%). The only factor significantly affecting length of stay was World Health Organization performance score, both pre- and postoperative. CONCLUSIONS: An early discharge after endoscopic and awake craniotomy tumor resection is both safe and feasible for most patients and is not associated with increased postoperative morbidity. We recommend that all patients who have good baseline function be offered short stay surgery.

Treatment of Middle Cranial Fossa Arachnoid Cysts: A Systematic Review and Meta-Analysis.

OBJECTIVE: To review the literature and analyze the efficacy and safety of 3 surgical methods (neuroendoscopic fenestration, microsurgical fenestration, and cystoperitoneal shunting) for middle cranial fossa arachnoid cysts (MCFACs). METHODS: We searched MEDLINE, PubMed, and Cochrane Central electronic databases and collected studies of patients with MCFACs treated with 1 of 3 surgical methods. Eligible studies reported the rate of clinical symptoms improvement (RCSI), rate of cyst reduction (RCR), rate of total complications (RTC), rate of short-term complications (RSTC), rate of long-term complications (RLTC), and other parameters. RESULTS: Eighteen studies met the criteria. MCFACs were divided into 3 groups on the basis of surgical method: RCSI in group I (237 patients, neuroendoscopic fenestration) was 90% (95% confidence interval [CI]: 83%-95%); RCR: 76% (95% CI: 67%-84%); RTC: 28% (95% CI: 22%-34%); RSTC: 23% (95% CI: 17%-30%); and RLTC: 6% (95% CI: 3%-11%). RCSI in group II (144 patients, microsurgical fenestration) was 87% (95% CI: 75%-96%); RCR: 87% (95% CI: 70%-97%); RTC: 49% (95% CI: 30%-68%); RSTC: 44% (95% CI: 21%-68%); RLTC: 3% (95% CI: 0%-12%). RCSI in group III (93 patients, cystoperitoneal shunting) was 93% (95% CI: 66%-99%); RCR: 93% (95% CI: 66%-99%); RTC: 20% (95% CI: 5%-42%); RSTC: 10% (95% CI: 0%-31%); RLTC: 15% (95% CI: 9%-23%). RLTC differed significantly between the 3 groups (P = 0.005); RTC and RSTC between group I and group II (P = 0.002). CONCLUSIONS: All 3 surgical methods are effective for MCFACs, but considering safety, neuroendoscopic fenestration may be the best initial procedure.

Nasoseptal Flap Elevation in Patients with History of Septal Surgery: Does It Increase Flap Failure or Cerebrospinal Fluid Leakage?

OBJECTIVE: The nasoseptal flap (NSF) has been shown to be a mainstay in the reconstruction of skull base defects. We evaluated the efficacy and complications of NSF in patients with a history of septal surgery who had the potential risk of tearing and poor vascularity. METHODS: We performed a retrospective chart and video review of patients who underwent NSF for skull base reconstruction between February 2012 and May 2015. Comparison was made between 18 patients (revision group) who had a history of septoplasty and/or transseptal transsphenoidal approach and 88 patients (primary group) without a history of septal surgery. Laceration when raising the flap, vascularity on postoperative magnetic resonance imaging, viability on postoperative endoscopy, and cerebrospinal fluid (CSF) leakage were compared between the revision and primary groups. RESULTS: Laceration of the flap occurred during NSF elevation in 2 patients (11.1%) in the revision group and 4 patients (4.5%) in the primary group (P = 0.269). Poor flap vascularity on magnetic resonance imaging was observed in 2 patients (11.1%) in the revision group and 8 patients (9.1%) in the primary group (P = 0.674). The rate of flap necrosis on endoscopy was 5.6% in the revision group and 1.1% in the primary group (P = 0.312). There was no significant difference in CSF leakage rate between the 2 groups (revision 5.6% and primary 10.2%). CONCLUSIONS: There was no difference in rate of CSF leakage or flap integrity between the 2 groups. Therefore, NSF for skull base reconstruction is feasible in patients with a history of septal surgery.

Neuroendoscopy in Kuwait: Evolution, Current Status, and Future Directions.

An overview of the development of neuroendoscopy at the neurosurgery department, Ibn Sina Hospital in Kuwait, is presented with an outline of difficulties and obstacles faced by the field until it reached its current status. The factors and solutions that helped us overcome these problems are also elaborated on. After a modest beginning few years ago, endoscopic skull base procedures, intraventricular neuroendoscopy, and spinal endoscopy are regularly performed in the department. Although neuroendoscopy is not per se a neurosurgical subspecialty, it is an area that requires special training. Achieving an appropriate level of care necessitates these highly trained neurosurgeons to collaborate together and with other specialties to create teamsgeared towards offering such treatment options topatients. Importantly, a multitude of essential facilities should be available to make such a pattern of practice possible. In our experience, this was made possible through continued efforts that have finally paid off and gradually led to a complete shift of the face of neuroendoscopic practice in our department. Our future endeavors aim at further development of neuroendoscopy in the department to create a center of excellence.

Predictors and Rates of Delayed Symptomatic Hyponatremia after Transsphenoidal Surgery: A Systematic Review [corrected].

BACKGROUND: Delayed symptomatic hyponatremia (DSH) is a known complication of transsphenoidal surgery that can lead to prolonged hospital stay, readmission, and in rare cases, death. Many potential predictors for development of DSH have been investigated. A better understanding of DSH risk can lead to better patient outcomes. We performed a systematic review to determine the rates and predictors of DSH after both endoscopic transsphenoidal surgery and microscopic transsphenoidal surgery. METHODS: A systematic search of the literature was conducted using MEDLINE/PUBMED, EMBASE, and Cochrane databases. Inclusion criteria were 1) case series with at least 10 cases reported, 2) adult patients who underwent eTSS or mTSS for pituitary tumors, and 3) reported occurrence of DSH (defined as serum sodium level <135 mEq/L with associated symptoms) after postoperative day 3. Data were analyzed using CMA V.3 Statistical Software (2014). RESULTS: Ten case series satisfied the inclusion criteria for a total of 2947 patients. Various factors including age, gender, cerebrospinal fluid leak, and tumor size were investigated as potential predictors of DSH. DSH event rates for both mTSS and eTSS fell between around 4 and 12 percent and included a variety of proposed predictors. CONCLUSIONS: Age, gender, tumor size, rate of decline of blood sodium, and Cushing disease are potential predictors of DSH. By identifying patients at high risk for DSH, preventative efforts can be implemented in the perioperative setting to reduce the incidence of potentially catastrophic hyponatremia following transsphenoidal surgery.

Frontobasal Midline Meningiomas: Is It Right To Shed Doubt on the Transcranial Approaches? Updates and Review of the Literature.

BACKGROUND: Traditionally, the surgical removal of tuberculum sellae meningioma (TSM) and olfactory groove meningioma (OGM) requires transcranial approaches and microsurgical techniques, but in the last decade endoscopic expanded endonasal approaches have been introduced: transcribriform for OGMs and transtuberculum-transplanum for TSM. A comparative analysis of the literature concerning the two types of surgical treatment of OGMs and TSM is, however, difficult. METHODS: We conducted a literature search using the PubMed database to compare data for endoscopic and microsurgical techniques in the literature. We also conducted a retrospective analysis of selected cases from our series presenting favorable characteristics for an endoscopic approach, based on the criteria of operability of these lesions as generally accepted in the literature, and we compared the results obtained in these patients with those in the endoscopic literature. RESULTS: We believe that making the sample more homogeneous, the difference between microsurgical technique and endoscopic technique is no longer so striking. A greater radical removal rate, a reduced incidence of cerebrospinal fluid fistula and, especially, the possibility of removing lesions of any size are advantages of transcranial surgery; a higher percentage of improvement in visual outcome and a lower risk of a worsening of a pre-existing deficit or onset of a new deficit are advantages of the endoscopic technique. CONCLUSION: At present, the microsurgical technique is still the gold standard for the removal of the anterior cranial fossa meningiomas of all sizes, and the endoscopic technique remains a second option in certain cases.