Clinical Applicability of the Sellar Barrier Concept in Patients with Pituitary Apoplexy: Is It Possible?

There is evidence of association between sellar barrier thickness and intraoperative cerebrospinal fluid (CSF) leakage, impacting the postoperative prognosis of the patients. The aim of this study is to analyze the clinical applicability of the sellar barrier concept in a series of operated patients with pituitary apoplexy (PA). A retrospective study was conducted including 47 patients diagnosed with PA who underwent surgical treatment through a transsphenoidal approach. Brain magnetic resonance imaging (MRI) of the patients were evaluated and classified utilizing the following criteria: strong barrier (greater than 1 mm), weak barrier (less than 1 mm), and mixed barrier (less than 1 mm in one area and greater than 1 mm in another). The association between sellar barrier types and CSF leakage was analyzed, both pre- and intraoperatively. The preoperative MRI classification identified 10 (21.28%) patients presenting a weak sellar barrier, 20 patients (42.55%) with a mixed sellar barrier, and 17 patients (36.17%) exhibiting a strong sellar barrier. Preoperative weak and strong sellar barrier subtypes were associated with weak (p ≤ 0.001) and strong (p = 0.009) intraoperative sellar barriers, respectively. Strong intraoperative sellar barrier subtypes reduced the odds of CSF leakage by 86% (p = 0.01). A correlation between preoperative imaging and intraoperative findings in the setting of pituitary apoplexy has been observed.

Case Report: Diagnosis of Petrous Apex IgG4-Related Disease by Middle Cranial Fossa Craniotomy and Temporal Bone Biopsy.

Introduction: Primary IgG4-related disease (IgG4-RD) of the temporal bone is a rare condition. Unlike typical petrous apicitis or Gradenigo syndrome, our patient presented exclusively with unilateral cranial nerve VI palsy and symptoms of diplopia. Skull base imaging demonstrated a destructive bony lesion in the petrous apex. Imaging and systemic investigations were insufficient to support a diagnosis. The diagnosis was achieved histologically after acquiring the specimen by middle cranial fossa craniotomy and temporal bone biopsy. This case report is thought to be the first published description of a diagnosis of IgG4-RD proven with the middle cranial fossa approach. Case Report: We describe a 29-year-old female with primary IgG4-RD of the petrous apex of the temporal bone. This patient presented with a few-month history of left-sided headache and recent-onset diplopia due to paralysis of cranial nerve VI. Imaging demonstrated a petrous apex lesion, and comprehensive systemic investigations could not reach a diagnosis. A middle cranial fossa craniotomy and a biopsy of the temporal bone lesion were undertaken to establish the diagnosis. Histological confirmation of IgG4-RD was proven. Following treatment with corticosteroids, the patient experienced complete recovery and resolution of her symptoms. Conclusion: This study describes a case of primary IgG4-RD of the petrous apex of the temporal bone that presented with diplopia and was diagnosed by middle fossa craniotomy and temporal bone biopsy. To the best of our knowledge, this is the first case description where primary diagnosis was made based on middle cranial fossa craniotomy and temporal bone biopsy.

International Defensive Medicine in Neurosurgery: Comparison of Canada, South Africa, and the United States.

OBJECTIVE: Perception of medicolegal risk has been shown to influence defensive medicine behaviors. Canada, South Africa, and the United States have 3 vastly different health care and medicolegal systems. There has been no previous study comparing defensive medicine practices internationally. METHODS: An online survey was sent to 3672 neurosurgeons across Canada, South Africa, and the United States. The survey included questions on the following domains: surgeon demographics, patient characteristics, physician practice type, surgeon liability profile, defensive behavior-including questions on the frequency of ordering additional imaging, laboratory tests, and consults-and perception of the liability environment. Responses were analyzed, and multivariate logistic regression was used to examine the correlation of medicolegal risk environment and defensive behavior. RESULTS: The response rate was 30.3% in the United States (n = 1014), 36.5% in Canada (n = 62), and 41.8% in South Africa (n = 66). Canadian neurosurgeons reported an average annual malpractice premium of $19,110 (standard deviation [SD] = $11,516), compared with $16,262 (SD = $7078) for South African respondents, $75,857 (SD = $50,775) for neurosurgeons from low-risk U.S. states, and $128,181 (SD = $79,355) for those from high-risk U.S. states. Neurosurgeons from South Africa were 2.8 times more likely to engage in defensive behaviors compared with Canadian neurosurgeons, while neurosurgeons from low-risk U.S. states were 2.6 times more likely. Neurosurgeons from high-risk U.S. states were 4.5 times more likely to practice defensively compared with Canadian neurosurgeons. CONCLUSIONS: Neurosurgeons from the United States and South Africa are more likely to practice defensively than neurosurgeons from Canada. Perception of medicolegal risk is correlated with reported neurosurgical defensive medicine within these countries.

Intracranial pressure monitoring as an early predictor of third ventriculostomy outcome.

OBJECTIVES: Endoscopic third ventriculostomy (ETV) is a routinely used alternative to ventriculoperitoneal shunt in patients with obstructive hydrocephalus. We attempted to determine the usefulness of the surgeon's intraoperative impression and postoperative period intracranial pressure monitoring that may help guide clinicians in predicting the early functional outcome of ETV. METHODS: Patients who underwent ETV between 2006 and 2011 were retrospectively reviewed. The sample included 63 patients (23 female and 40 male), between the ages of 13 and 69 years. In each case, the surgeon's intraoperative impression, cerebrospinal fluid (CSF) samplings, and postoperative intracranial pressure (ICP) monitoring (via transduced external ventricular drain for up to 72 hours) was recorded and evaluated in light of functional outcome of ETV at discharge and early follow up (1-2 months). RESULTS: ICP monitoring predicted initial function of the ETV in 51 cases (80.9%) and in 12 cases (19%) suggested ETV failure. Monitoring has a positive predictive value (PPV) of 76.3% and a negative predictive value (NPV) of 100% whereas the surgeon's intraoperative impression of future function had a PPV of 76.5% and NPV of 76.9%. CSF sampling has a much poorer predictive quality because the wide confidence interval and a PPV of 63.6% and NPV 38.2%. In our series the evidence of sepsis as a result of external ventricular drain was found to be 11.67%. Subgroup analysis, removing the patients with posterior fossa tumors, results in increased PPV (85.7%) of ICP monitoring. CONCLUSIONS: ETV is a valuable means of treating obstructive hydrocephalus. By considering the surgeon's intraoperative impression and postoperative ICP monitoring course, some of the uncertainty around its functional outcome can be overcome. The surgeon's impression and the ICP monitoring offer approximately the same predictive quality for ETV outcome.