Pilot Validation of a 3-Dimensional Printed Pituitary Adenoma, Vascular Injury, and Cerebrospinal Fluid Leak Surgical Simulator.

BACKGROUND AND OBJECTIVES: Endoscopic skull base surgery is a subspecialty field which would benefit significantly from high-fidelity surgical simulators. Giving trainees the opportunity to flatten their learning curve by practicing a variety of procedures on surgical simulators will inevitably improve patient outcomes. METHODS: Four neurosurgeons, 8 otolarynologists, and 6 expert course faculty agreed to participate. All participants were asked to perform a transsphenoidal exposure and resection of a pituitary adenoma, repair a cerebrospinal fluid (CSF) leak, control a carotid injury, and repair a skull base defect. The content, face, and construct validity of the 3-dimensional printed model was examined. RESULTS: The heart rate of the participants significantly increased from baseline when starting the carotid injury simulation (mean 90 vs 121, P = .029) and significantly decreased once the injury was controlled (mean 121 vs 110, P = .033, respectively). The participants reported a significant improvement in anxiety in facing a major vascular injury, as well as an increase in their confidence in management of major vascular injury, resecting a pituitary adenoma and repair of a CSF leak using a 5-point Likert scale (mean 4.42 vs 3.58 P = .05, 2 vs 3.25 P < .001, 2.36 vs 4.27 P < .001 and 2.45 vs 4.0 P = .001, respectively). The mean Objective Structured Assessment of Technical Skills score for experienced stations was 4.4, significantly higher than the Objective Structured Assessment of Technical Skills score for inexperienced stations (mean 3.65, P = .016). CONCLUSION: We have demonstrated for the first time a validated 3-dimensional printed surgical simulator for endoscopic pituitary surgery that allows surgeons to practice a transsphenoidal approach, surgical resection of a pituitary adenoma, repair of a CSF leak in the diaphragma sellae, control of a carotid injury, and repair of skull base defect.

Neuronavigation in endoscopic skull base surgery and the accuracy of different MRI sequences.

OBJECTIVE: Neuronavigation is common technology used by skull base teams when performing endoscopic endonasal surgery. A common practice of MRI imagining is to obtain 3D isotopic gadolinium enhanced T1W magnetisation prepared rapid gradient echo (MPRAGE) sequences. These are prone to distortion when undertaken on 3 T magnets. The aim of this project is to compare the in vivo accuracy of MRI sequences between current and new high resolution 3D sequences. The goal is to determine if geometric distortion significantly affects neuronavigation accuracy. METHODS: Patients were scanned with a 3D T1 MPRAGE sequence, 3D T1 SPACE sequence and a CT stereotactic localisation. Following general anaesthesia, patients were registered on the Stealth Station (Medtronic, USA) using a side mount emitter for Electromagnetic navigation. A variety of surgically relevant anatomical landmarks in the sagittal and coronal plane were selected with real and virtual data points measured. RESULTS: A total of 10 patients agreed be enrolled in the study with datapoints collected during surgery. The distance between real and virtual datapoints trended to be lower in SPACE sequences compared to MPRAGE. Paired t test did not demonstrate a significant difference. CONCLUSION: We have demonstrated that navigational accuracy is not significantly affected by the type of MRI sequence selected and that current corrective algorithms are sufficient. Navigational accuracy is affected by many factors, with registration error likely playing the most significant role. Further research involving real time imaging such as endoscopic ultrasound may hopefully address this potential error.

Proton beam therapy for clival chordoma: Optimising rare cancer treatments in Australia.

With the anticipated launch of the Australian Bragg Centre for Proton Therapy and Research (ABCPTR) in Adelaide, Australia, proton therapy will become a significant addition to existing cancer treatment options for Australians. The anticipated benefits will be particularly evident in rare cancers such as clival chordomas, a challenging tumour entity due to the anatomical relationship with critical structures, and proven radio-resistance to conventional radiation therapy. The article synthesises key findings from major studies and evaluates the current evidence supporting various management strategies for clival chordomas. It also considers the influence of institutional volume and multidisciplinary team management on patient outcomes and outlines how high-quality care can be effectively delivered within the Australian healthcare system, emphasising the potential impact of proton therapy on the treatment paradigm of clival chordomas in Australia.

An infratentorial dural arteriovenous fistula mimicking cervical myelopathy: A case report.

Dural arteriovenous fistulas may have insidious clinical presentations and are often challenging to diagnose. A small number of cases have been associated with perimedullary venous congestion and cord oedema, mimicking common pathologies, such as cervical myelopathy. We describe a case report of a patient presenting with a constellation of symptoms and radiological signs mimicking C5/6 cervical myelopathy secondary to disc herniation. The patient was managed with anterior cervical discectomy and fusion, with postoperative neurological deterioration unresponsive to steroid therapy. This prompted further investigation of other pathologies. An infratentorial Cognard 5 and Borden type 3 dural arteriovenous fistula was diagnosed on 6-vessel DSA and managed with onyx embolization. Marked improvement of neurological symptoms, notably bilateral lower limb weakness, was achieved postoperatively. In summary, this case demonstrates the importance of considering alternative, less common pathologies that involve the cervical spinal cord when neurological improvement is not achieved following decompressive surgery for cervical myelopathy.

Management of frontoethmoidal osteoma causing pneumocephalus and cerebrospinal fluid leakage with minimally invasive techniques: illustrative cases.

BACKGROUND: Osteoid osteoma is a common benign bone tumor frequently seen in the frontoethmoid region. However, involvement of the skull base is rare, with few cases previously reported. OBSERVATIONS: The authors report two cases of spontaneous, symptomatic frontoethmoidal osteoma: one presented with neurological deficit secondary to tension pneumocephalus and the other with cerebrospinal fluid leakage. The first case was managed with a transfrontal sinus craniotomy and pneumocephalus decompression with osteoma resection and skull base reconstruction. The second case was managed with a uninaral endoscopic endonasal approach to the anterior skull base with osteoma resection and reconstruction. LESSONS: Given the paucity of cases with associated tension pneumocephalus described in the literature, it was relevant to describe the authors' experience with surgical decision-making and the expected outcomes among patients with this pathology when using minimally invasive techniques.

'What's in a name', a systematic review of the pterional craniotomy for aneurysm surgery and its many modifications with a proposal for simplified nomenclature.

BACKGROUND: The pterional or frontosphenotemporal craniotomy has stood the test of time and continues to be a commonly used method of managing a variety of neurosurgical pathology. Already described in the beginning of the twentieth century and perfected by Yasargil in the 1970s, it has seen many modifications. These modifications have been a normal evolution for most neurosurgeons, tailoring the craniotomy to the patients' specific anatomy and pathology. Nonetheless, an abundance of variations have appeared in the literature. METHODS: A search strategy was devised according to the 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. To identify articles investigating the variations in the pterional approach, the following search terms were applied: (pterional OR minipterional OR supraorbital) AND (approach OR craniotomy OR technique). RESULTS: In total, 3552 articles were screened with 74 articles being read in full with 47 articles being included for review. Each article was examined according the name of the technique, temporalis dissection technique, craniotomy technique and approach. CONCLUSION: This systematic review gives an overview of the different techniques and modifications to the pterional craniotomy since it was initially described. We advocate for the use of a more standardised nomenclature that focuses on the target zone to simplify the management approach to supratentorial aneurysms.

The Learning Curve for Endoscopic Endonasal Transsphenoidal Pituitary Surgery: Evaluating Endocrine Outcomes.

OBJECTIVE: In South Australia endoscopic endonasal approach (EEA) pituitary surgery has been practiced since 2006, largely by two neurosurgeons with a small fellowship-trained otolaryngology team. The aim of this cohort study was to determine if a "learning curve" can be established over this time period, as represented by structural and endocrine patient outcomes. METHOD: Retrospective cohort study of patients undergoing EEA surgery between 2006 and 2021 in Adelaide, South Australia at three tertiary teaching hospitals.. Cases were divided by each surgeon and split into groups of sequential 40 cases. Endocrine assessment pre- and post-operatively involved static pituitary and end-organ hormones, with dynamic tests as required, assessed by an pituitary endocrinologist. Each hormonal axis (gonadal, cortisol, thyroid, prolactin and growth hormone) was documented preoperatively and at an early and long term follow up at 1-2 and 12 months, respectively. RESULTS: The study included a cohort of 443 pituitary adenomas managed with endoscopic endonasal transsphenoidal surgery in a consecutive fashion between two neurosurgeons over 16-years. Gross tumour resection but not visual visual outcomes improved with surgical experience but this outcome may be neurosurgeon dependent. Endocrine outcomes were not consistently improved with experience, but lower rates of hypopituitarism were seen with experience with one neurosurgeon. Average follow up was approximately 5 years, and a minimum follow up of 12 months for all patients. CONCLUSIONS: We present long term endocrine follow up for patients with functional and non-functional adenomas. Improved rates of gross tumour resection were evident with with surgical experience. However, there was no apparent change in post-operative endocrine outcomes.

The learning curve for endoscopic endonasal pituitary surgery: a systematic review.

Recent literature demonstrates that a learning curve exists for endoscopic pituitary surgery. However, there is significant variability in the way these studies report their outcomes. This study aims to systematically review the literature regarding outcomes for endoscopic pituitary surgery and how this may be related to a surgical learning curve. An electronic search of the databases Medline, Scopus, Embase, Web of Science and Cochrane Library databases was performed and data extracted according 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. Ten articles were included in the review as they examined the following: rates of gross total resection, average operative time, CSF leak rate, visual outcomes, endocrine outcomes and how these results were influenced by surgical experience. We have demonstrated that a learning curve exists for some outcome variables for endoscopic pituitary surgery. However, there is significant heterogeneity in the current body of literature which makes clear comparisons difficult.

Olfaction preservation in olfactory groove meningiomas: a systematic review.

Olfactory groove meningiomas (OGM) are a skull base neoplasm that represents between 8 and 13% of all intracranial meningiomas. Approach selection focuses on achieving frontal lobe decompression, gross total resection and vision preservation. Recently, there has been a focus on olfaction and considering its preservation as a quality-of-life outcome measure. An electronic search of the databases Medline, Scopus, Embase, Web of Science and Cochrane library databases was performed and data extracted according 2020 Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) statement. Six articles were selected for inclusion mainly based due to reporting quantitative outcomes for olfaction assessed by a smell identification test (e.g. sniffin' sticks). Objective olfaction preservation can be achieved with a variety of surgical approaches. More research which includes objective assessment of olfactory function and ideally as well QoL outcome measures is needed to further optimize the treatment pathways in OGM patients.

The use of antiepileptic medication in early post traumatic seizure prophylaxis at a single institution.

BACKGROUND: Current international guidelines for traumatic brain injury (TBI) recommend the use of phenytoin for the prevention of early post traumatic seizures (PTS) when the benefits are thought to outweigh the risks. In practice however, alternative antiepileptic drugs (AEDs) such as levetiracetam and valproate are being used as they are believed to have a more favourable risk profile. This is despite there being insufficient evidence to support their efficacy. The purpose of this study was to identify which AED was prescribed to patients presenting with a TBI at a single institution, and to determine the rate of early PTSs. METHODS: This was a retrospective case-note review study done at the Flinders Medical Centre including patients admitted from May 2013 to June 2017. All patients with traumatic intracranial haematomas were included. Patients were excluded if they had seizures prior to presentation to hospital or died within 24 h of injury. The primary outcomes were rate of early PTSs and the type of prophylactic AED prescribed. RESULTS: During this study period, 610 patients presented with a mild, moderate or severe traumatic brain injury. Overall, 16% of patients were prescribed an AED, with more than 90% of these patients being prescribed levetiracetam. Overall, the rate of early PTSs for patients prescribed AEDs was 2.9% compared with 3.5% for patients not prescribed AEDs (OR 0.83 CI 0.24-2.85 p = 1). CONCLUSIONS: This study showed that levetiracetam was the most commonly prescribed AED. It also demonstrated no statistically significant difference in the rate of early PTSs in patients with TBI, with or without prophylactic AEDs. This is in keeping with other contemporary studies, and therefore the routine administration of prophylactic AEDs may need to be re-examined.

Stereoscopic Three-Dimensional Neuroanatomy Lectures Enhance Neurosurgical Training: Prospective Comparison with Traditional Teaching.

OBJECTIVE: Stereoscopic three-dimensional (3D) imaging is increasingly used in the teaching of neuroanatomy and although this is mainly aimed at undergraduate medical students, it has enormous potential for enhancing the training of neurosurgeons. This study aims to assess whether 3D lecturing is an effective method of enhancing the knowledge and confidence of neurosurgeons and how it compares with traditional two-dimensional (2D) lecturing and cadaveric training. METHODS: Three separate teaching sessions for neurosurgical trainees were organized: 1) 2D course (2D lecture + cadaveric session), 2) 3D lecture alone, and 3) 3D course (3D lecture + cadaveric session). Before and after each session, delegates were asked to complete questionnaires containing questions relating to surgical experience, anatomic knowledge, confidence in performing procedures, and perceived value of 3D, 2D, and cadaveric teaching. RESULTS: Although both 2D and 3D lectures and courses were similarly effective at improving self-rated knowledge and understanding, the 3D lecture and course were associated with significantly greater gains in confidence reported by the delegates for performing a subfrontal approach and sylvian fissure dissection. CONCLUSIONS: Stereoscopic 3D lectures provide neurosurgical trainees with greater confidence for performing standard operative approaches and enhances the benefit of subsequent practical experience in developing technical skills in cadaveric dissection.

Dual lumbar bronchogenic and arachnoid cyst presenting with sciatica and left foot drop.

INTRODUCTION: Spinal bronchogenic cysts are rare findings, with only four cases of lumbar bronchogenic cysts reported in the literature. All of these bronchogenic cysts involved the conus medullaris. We present the first case of a lumbar bronchogenic cyst and arachnoid cyst arising from the cauda equina in a 68-year-old male. Uniquely, this bronchogenic cyst also contained components of an arachnoid cyst. METHODS: Magnetic resonance imaging (MRI) demonstrated a compressive cystic lesion at the level of the L3 vertebra splaying the cauda equina. An L3/L4 laminectomy was performed with marsupialisation of the cyst. RESULTS: Histological examination revealed pseudostratified ciliated columnar epithelium confirming the diagnosis of a bronchogenic cyst, as well as a pleated fibrovascular tissue lined by sparsely spaced small monomorphic arachnoidal cells, indicating an arachnoid cyst. CONCLUSION: We demonstrate that bronchogenic cysts can be successfully treated with marsupialisation.

Metastatic Neuroendocrine Carcinoma of Unknown Origin Arising in the Femoral Nerve Sheath.

BACKGROUND: Metastatic neuroendocrine carcinoma of unknown origin is a rare condition, usually presenting with lesions in the liver and/or lung. We present the first reported case of a metastatic neuroendocrine carcinoma of unknown origin arising in the femoral nerve sheath. CASE DESCRIPTION: Magnetic resonance imaging demonstrated what was thought to be a schwannoma in the left femoral nerve sheath in the proximal femoral triangle, immediately inferior to the anterior inferior iliac spine. At the time of operation, the tumor capsule was invading surrounding tissue, as well as three trunks of the femoral nerve. The patient underwent a subtotal resection, preserving the integrity of the residual functioning femoral nerve trunks. Histologic evaluation determined that the tumor had features consistent with a metastatic neuroendocrine carcinoma of unknown primary origin. The patient recovered well postoperatively, and subsequent radiologic evaluation failed to demonstrate a potential primary site. Unfortunately, the patient re-presented with disease progression and was subsequently referred to palliative care. CONCLUSIONS: We recommend that there is a definite role for surgery in the management of solitary neuroendocrine carcinoma of unknown origin.

The Effect of 3-Dimensional Simulation on Neurosurgical Skill Acquisition and Surgical Performance: A Review of the Literature.

OBJECTIVE: In recent years, 3-dimensional (3D) simulation of neurosurgical procedures has become increasingly popular as an addition to training programmes. However, there remains little objective evidence of its effectiveness in improving live surgical skill. This review analysed the current literature in 3D neurosurgical simulation, highlighting remaining gaps in the evidence base for improvement in surgical performance and suggests useful future research directions. DESIGN: An electronic search of the databases was conducted to identify studies investigating 3D virtual reality (VR) simulation for various types of neurosurgery. Eligible studies were those that used a combination of metrics to measure neurosurgical skill acquisition on a simulation trainer. Studies were excluded if they did not measure skill acquisition against a set of metrics or if they assessed skills that were not used in neurosurgical practice. This was not a systematic review however, the data extracted was tabulated to allow comparison between studies RESULTS: This study revealed that the average overall quality of the included studies was moderate. Only one study assessed outcomes in live surgery, while most other studies assessed outcomes on a simulator using a variety of metrics. CONCLUSIONS: It is concluded that in its current state, the evidence for 3D simulation suggests it as a useful supplement to training programmes but more evidence is needed of improvement in surgical performance to warrant large-scale investment in this technology.

Paclitaxel-coated balloon reduces target lesion revascularization compared with standard balloon angioplasty.

OBJECTIVE: Peripheral arterial disease (PAD) is a highly prevalent condition that contributes significantly to the morbidity and mortality of affected patients. PAD creates a significant economic burden on health care systems around the world. We reviewed all available literature to provide a meta-analysis assessing the outcome of patients treated with drug-eluting balloons (DEBs) compared with percutaneous transluminal balloon angioplasty (PTA) through measuring the rate of target lesion revascularization (TLR). METHODS: An electronic search of the MEDLINE, Scopus, Embase, Web of Science, and Cochrane Library databases was performed. Articles reporting randomized controlled trials that compared treatment with DEBs vs PTA were selected for inclusion. A meta-analysis was performed by pooling data on rates of TLR, binary restenosis (BR), and late lumen loss (LLL). RESULTS: The 10 included articles comprised a sample size of 1292 patients. Meta-analysis demonstrated the rate of TLR in DEB-treated patients was significantly lower compared with patients treated with PTA at 6 months (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.11-0.53; P = .0004), 12 months (OR, 0.28; 95% CI, 0.13-0.62; P = .002), and 24 months (OR, 0.25; 95% CI, 0.10-0.61; P = .002). Decreased LLL and BR was demonstrated at 6 months in patients treated with DEBs compared with patients treated with PTA (mean difference, -0.74; 95% CI, -0.97 to -0.51; P = .00001; OR, 0.34; 95% CI, 0.23-0.49; P = .00001). CONCLUSIONS: This meta-analysis demonstrates that treatment with DEBs compared with PTA results in reduced rates of reintervention in patients with PAD. Comparison of DEBs to other emerging treatments to determine which method results in the lowest reintervention rates and in the greatest improvement in quality of life should be the focus of future trials.