Comparing neuroendocrine recovery between surgical and conservative management in pituitary apoplexy patients: a propensity score-matched analysis.

Pituitary apoplexy is a rare and potentially life-threatening clinical syndrome. Patients may present with severeneuro-ophthalmologic or endocrine symptoms. Current evidence is unclear whether conservative or surgicalmanagement leads to the best neuroendocrine outcomes. This study aimed to compare neuroendocrine outcomesbetween surgical and conservative treatments in a single center. Cases of patients with pituitary apoplexy whoreceived transsphenoidal surgery or conservative management in Songklanagarind Hospital between January 1,2005 and December 31, 2022 were retrospectively reviewed. A propensity score matching method was used toadjust bias from treatment selection (surgery or conservative treatment). Differences in visual field, visual acuity,cranial nerve, and endocrine outcomes between the surgical and conservative treatment groups were analyzedusing logistic regression analysis. This study included 127 patients, with 98 and 29 patients in the surgical and theconservative treatment group, respectively. The optimal matching method was used for propensity score matching.Compared to the conservative group, the surgically treated patients had a significantly higher rate of visual fieldrecovery (odds ratio (OR): 12.89, P = 0.007). However, there were no statistical differences in the recovery rate ofpreoperative visual acuity, cranial nerve, and endocrine deficits between the groups. Transsphenoidal surgery wasassociated with a higher rate of visual field recovery when compared to the conservative treatment for pituitaryapoplexy patients. Careful selection of appropriate treatment based on the patient's presentation andneuroendocrine status will result in the best outcomes while avoiding unnecessary surgical intervention.

Factors predicting outcomes of endoscopic endonasal approach in craniopharyngioma patients.

Objectives: Endoscopic endonasal approach (EEA) is commonly used for resection of craniopharyngioma (CP). Treatment outcomes of EEA for CP were related to numerous factors; however, they have been evaluated in few studies. The objective of this study is to investigate factors associated with the outcomes of CP following this operation. Materials and Methods: The records of patients with CP, who underwent EEA at our institution from January 2014 to June 2022, were retrospectively reviewed. Surgical outcomes, including the extent of resection, visual recovery, and endocrinological outcomes, were reported. Clinical and radiographic factors were analyzed for their associations with treatment outcomes using logistic regression analyzes. Results: This study cohort consisted of 28 patients with CP. Gross total resection (GTR) was achieved in 12 patients (43%). Post-operative visual status improved, stabilized, and deteriorated in 89%, 6%, and 6% of the patients, respectively. There were no patients recovered from pre-operative pituitary dysfunctions, while post-operative hypoadrenalism, hypothyroidism, and hypogonadism were found in 9 (36%), 11 (42%), and 4 (22%) patients, respectively. Post-operative permanent diabetic insipidus was found in 13 patients (50%). Greater suprasellar extension of the tumor was associated with a lower rate of GTR (P = 0.011). Diabetes mellitus (DM) was associated with poor visual recovery (P = 0.022). Larger tumor size and Puget grade 2 were associated with postoperative hypoadrenalism (P = 0.01 and 0.023, respectively). In addition, Puget grade 2 was associated with post-operative hypothyroidism (P = 0.017). Conclusion: For EEA in CP, the extent of resection could be determined by suprasellar extension of the tumor. DM was a poor predicting factor for visual recovery, while larger tumors and Puget grade 2 had a higher risk of post-operative hypopituitarism.

Economic impact of a machine learning-based strategy for preparation of blood products in brain tumor surgery.

BACKGROUND: Globally, blood donation has been disturbed due to the pandemic. Consequently, the optimization of preoperative blood preparation should be a point of concern. Machine learning (ML) is one of the modern approaches that have been applied by physicians to help decision-making. The main objective of this study was to identify the cost differences of the ML-based strategy compared with other strategies in preoperative blood products preparation. A secondary objective was to compare the effectiveness indexes of blood products preparation among strategies. METHODS: The study utilized a retrospective cohort design conducted on brain tumor patients who had undergone surgery between January 2014 and December 2021. Overall data were divided into two cohorts. The first cohort was used for the development and deployment of the ML-based web application, while validation, comparison of the effectiveness indexes, and economic evaluation were performed using the second cohort. Therefore, the effectiveness indexes of blood preparation and cost difference were compared among the ML-based strategy, clinical trial-based strategy, and routine-based strategy. RESULTS: Over a 2-year period, the crossmatch to transfusion (C/T) ratio, transfusion probability (Tp), and transfusion index (Ti) of the ML-based strategy were 1.10, 57.0%, and 1.62, respectively, while the routine-based strategy had a C/T ratio of 4.67%, Tp of 27.9%%, and Ti of 0.79. The overall costs of blood products preparation among the ML-based strategy, clinical trial-based strategy, and routine-based strategy were 30, 061.56$, 57,313.92$, and 136,292.94$, respectively. From the cost difference between the ML-based strategy and routine-based strategy, we observed cost savings of 92,519.97$ (67.88%) for the 2-year period. CONCLUSION: The ML-based strategy is one of the most effective strategies to balance the unnecessary workloads at blood banks and reduce the cost of unnecessary blood products preparation from low C/T ratio as well as high Tp and Ti. Further studies should be performed to confirm the generalizability and applicability of the ML-based strategy.

Risk Factors for Intraoperative Hypotension During Decompressive Craniectomy in traumatic Brain Injury Patients.

BACKGROUND: Decompressive craniectomy (DC) is an important therapy for treating intracranial pressure elevation following traumatic brain injury (TBI). During this procedure, about one-third of patients become complicated with intraoperative hypotension (IH), which is associated with abruptly decreasing sympathetic activity resulting from brain decompression. This study aimed to identify factors associated with IH during DC procedures and the mortality rate in these patients. METHODS: The records of adult TBI patients aged 18 years and older who underwent DC at Songklanagarind Hospital between January 2014 and January 2021 were retrospectively reviewed. Using logistic regression analysis, various factors were analyzed for their associations with IH during the DC procedures. RESULTS: This study included 83 patients. The incidence of IH was 54%. Multivariate analysis showed that Glasgow Coma Scale motor response (GCS-M) 1-3 (vs. 4-6), higher preoperative heart rate (PHR), and larger amount of intraoperative blood loss were significantly associated with IH (P = 0.013, P < 0.001, and P < 0.001, respectively). Patients with GCS-M 1-3 and PHR ≥ 75 bpm had the highest chance of IH (77%), while patients with neither of these risk factors had the lowest chance (29%). The in-hospital mortality rate in the IH and non-IH groups was 44% and 26%, respectively (P = 0.138). CONCLUSIONS: GCS-M 1-3, higher PHR, and larger amount of intraoperative blood loss were the risk factors associated with IH during DC procedure in TBI patients. Patients who have these risk factors should be closely monitored and the attending physician be ready to apply prompt resuscitation and treatment for IH.

Factors Predicting Neuroendocrine Recovery Following Transsphenoidal Surgery in Pituitary Apoplexy Patients.

BACKGROUND: Pituitary apoplexy is a rare clinical syndrome. Only a few studies have examined factors associated with recovery of neuroendocrine functions following transsphenoidal surgery. This study aimed to identify factors associated with neuroendocrine recovery following surgery for pituitary apoplexy. METHODS: The records of pituitary apoplexy patients who underwent transsphenoidal surgery at Songklanagarind Hospital between January 2005 and December 2020 were retrospectively reviewed. The primary outcomes were the recoveries of preoperative visual acuity (VA), visual field, cranial nerve function, and pituitary hormone deficits. Using logistic regression analysis, various factors were analyzed for their associations with recovery of neuroendocrine functions. RESULTS: The study included 98 patients. Multivariate analysis showed that older age and greater suprasellar extension were associated with no recovery of VA (P = 0.042 and P = 0.018, respectively). Only 33% of patients aged >55 years and suprasellar extension of lesion ≥25 mm gained recovery of VA, while 100% of patients with neither of these factors had recovery. Underlying hypertension was associated with no recovery of preoperative visual field defect (P = 0.027). Wilson-Hardy classification-invasion grades 3-4 and lower preoperative serum prolactin level were associated with no recovery from preoperative hypoadrenalism and hypothyroidism (P = 0.016 and P = 0.007, respectively). CONCLUSIONS: Older age, higher suprasellar extension, and hypertension were poor prognostic factors for visual recovery. Wilson-Hardy inferior invasion grade 3-4 and lower preoperative serum prolactin level were poor prognostic factors for recovery from hypopituitarism. Stratifying patients according to these prognostic factors may assist in selecting patients for surgery.

Development and internal validation of a nomogram to predict massive blood transfusions in neurosurgical operations.

Objectives: A massive blood transfusion (MBT) is an unexpected event that may impact mortality. Neurosurgical operations are a major operation involving the vital structures and risk to bleeding. The aims of the present research were (1) to develop a nomogram to predict MBT and (2) to estimate the association between MBT and mortality in neurosurgical operations. Material and Method: We conducted a retrospective cohort study including 3660 patients who had undergone neurosurgical operations. Univariate and multivariate logistic regression analyses were used to test the association between clinical factors, pre-operative hematological laboratories, and MBT. A nomogram was developed based on the independent predictors. Results: The predictive model comprised five predictors as follows: Age group, traumatic brain injury, craniectomy operation, pre-operative hematocrit, and pre-operative international normalized ratio and the good calibration were observed in the predictive model. The concordance statistic index was 0.703. Therefore, the optimism-corrected c-index values of cross-validation and bootstrapping were 0.703 and 0.703, respectively. Conclusion: MBT is an unexpectedly fatal event that should be considered for appropriate preparation blood components. Further, this nomogram can be implemented for allocation in limited-resource situations in the future.

Surgical outcomes of patients after treatment of ruptured anterior communicating artery aneurysms: "real-world" evidence from southern Thailand.

BACKGROUND: Anterior communicating artery (AComA) aneurysm rupture is the most common cause of subarachnoid hemorrhage worldwide. In this study, we aimed to determine the factors associated with a poor clinical outcome in patients with ruptured AComA aneurysms undergoing microsurgical clipping. METHODS: We retrospectively reviewed the clinical and radiologic features as well as clinical outcomes of 150 consecutive patients with ruptured AComA aneurysm who underwent surgical clipping during the 11-year study period. Logistic regression analysis was performed to identify independent factors associated with unfavorable clinical outcomes (defined as a modified Rankin scale score of 3-6). RESULTS: The study included 83 male and 67 female patients, with a mean age of 51.3 ± 11.5 years. At admission, most of the patients had good neurological status, including 97 (64.7%) patients with a Hunt and Hess grade of 1 or 2 and 109 (72.6%) patients with a World Federation of Neurosurgical Societies grade of 1 or 2. Unfavorable outcomes at 6 months were observed in 23 (22.0%) patients, and the 6-month mortality rate was 8.0%. Multivariate analysis showed that preoperative intraventricular hemorrhage (odds ratio [OR], 19.66; 95% confidence interval [CI], 5.10-75.80; P < 0.001), A1 hypoplasia (OR, 8.90; 95% CI, 2.82-28.04; P < 0.001), and postoperative cerebral infarction (OR, 3.21; 95% CI, 1.16-8.88; P = 0.025) were strong independent risk factors for unfavorable outcomes. CONCLUSIONS: Proper management of preoperative intraventricular hemorrhage, A1 hypoplasia, and intensive care for postoperative brain infarction are warranted for improved surgical outcomes in patients with ruptured AComA aneurysm undergoing surgical clipping.

Prognostic Factors of Acromegalic Patients with Growth Hormone-Secreting Pituitary Adenoma After Transsphenoidal Surgery.

BACKGROUND: Acromegaly is a rare, chronic disorder that mostly results from growth hormone (GH)-secreting pituitary adenoma. Transsphenoidal surgery is the first-line treatment of this adenoma. This study aimed to identify factors associated with remission outcome in patients with GH-secreting pituitary adenomas following transsphenoidal surgery. METHODS: Patients with GH-secreting pituitary adenomas who underwent transsphenoidal surgery for tumor removal at Songklanagarind Hospital between January 2003 and December 2019 were retrospectively reviewed. The primary outcome was the remission of disease at the last follow-up using 2000 and 2010 consensus criteria. Using logistic regression analysis, various factors were analyzed for association with disease remission outcome. RESULTS: This study included 51 patients. The remission rate of GH-secreting pituitary microadenomas and macroadenomas following transsphenoidal surgery were 100% and 43.75%, respectively. Multivariate analysis showed that preoperative insulin-like growth factor 1 index ≥2.5 and Knosp classification grade 3-4 were significantly associated with nonremission outcome (P < 0.001 and P = 0.012, respectively). Patients with both of these factors had poor outcomes and never achieved remission after treatment, while patients with neither of these factors had high remission rates (87.5%) following surgery. Four of 6 (66.7%) patients who underwent repeat surgery gained remission. CONCLUSIONS: Preoperative insulin-like growth factor 1 index ≥2.5 and Knosp classification grade 3-4 were important prognostic factors that determined remission outcome after treatment. Patients who have both of these poor prognostic factors should be aggressively treated with surgery, medication, and probably radiation to optimally control the disease.

Machine learning applications for the prediction of surgical site infection in neurological operations.

OBJECTIVE: Surgical site infection (SSI) following a neurosurgical operation is a complication that impacts morbidity, mortality, and economics. Currently, machine learning (ML) algorithms are used for outcome prediction in various neurosurgical aspects. The implementation of ML algorithms to learn from medical data may help in obtaining prognostic information on diseases, especially SSIs. The purpose of this study was to compare the performance of various ML models for predicting surgical infection after neurosurgical operations. METHODS: A retrospective cohort study was conducted on patients who had undergone neurosurgical operations at tertiary care hospitals between 2010 and 2017. Supervised ML algorithms, which included decision tree, naive Bayes with Laplace correction, k-nearest neighbors, and artificial neural networks, were trained and tested as binary classifiers (infection or no infection). To evaluate the ML models from the testing data set, their sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), as well as their accuracy, receiver operating characteristic curve, and area under the receiver operating characteristic curve (AUC) were analyzed. RESULTS: Data were available for 1471 patients in the study period. The SSI rate was 4.6%, and the type of SSI was superficial, deep, and organ/space in 1.2%, 0.8%, and 2.6% of cases, respectively. Using the backward stepwise method, the authors determined that the significant predictors of SSI in the multivariable Cox regression analysis were postoperative CSF leakage/subgaleal collection (HR 4.24, p < 0.001) and postoperative fever (HR 1.67, p = 0.04). Compared with other ML algorithms, the naive Bayes had the highest performance with sensitivity at 63%, specificity at 87%, PPV at 29%, NPV at 96%, and AUC at 76%. CONCLUSIONS: The naive Bayes algorithm is highlighted as an accurate ML method for predicting SSI after neurosurgical operations because of its reasonable accuracy. Thus, it can be used to effectively predict SSI in individual neurosurgical patients. Therefore, close monitoring and allocation of treatment strategies can be informed by ML predictions in general practice.

Diagnostic Yield and Complication of Frameless Stereotactic Brain Biopsy.

BACKGROUND: With the advancement of neuronavigation technologies, frameless stereotactic brain biopsy has been developed. Previous studies proved that frameless stereotactic brain biopsy was as effective and safe as frame-based stereotactic brain biopsy. The authors aimed to find the factors associated with diagnostic yield and complication rate of frameless intracranial biopsy. MATERIALS AND METHODS: Frameless stereotactic brain biopsy procedures, between March 2009 and April 2017, were retrospectively reviewed from medical records including imaging studies. Using logistic regression analysis, various factors were analyzed for association with diagnostic yield and postoperative complications. RESULTS: Eighty-nine frameless stereotactic brain biopsy procedures were performed on 85 patients. The most common pathology was primary central nervous system lymphoma (43.8%), followed by low-grade glioma (15.7%), and high-grade glioma (15%), respectively. The diagnostic yield was 87.6%. Postoperative intracerebral hematoma occurred in 19% of cases; however, it was symptomatic in only one case. The size of the lesion was associated with both diagnostic yield and postoperative intracerebral hematoma complication. Lesions, larger than 3 cm in diameter, were associated with a higher rate of positive biopsy result (P = 0.01). Lesion 3 cm or smaller than 3 cm in diameter, and intraoperative bleeding associated with a higher percentage of postoperative intracerebral hematoma complications (P = 0.01). CONCLUSIONS: For frameless stereotactic brain biopsy, the size of the lesion is the essential factor determining diagnostic yield and postoperative intracerebral hematoma complication.

Outcome of Ruptured Posterior Communicating Artery Aneurysm Treatment Comparing Between Clipping and Coiling Techniques.

BACKGROUND: Very few data stratify the functional outcome of ruptured posterior communicating artery (PCoA) aneurysm treatment based on each treatment strategy. Therefore, the authors aimed to evaluate the outcome of PCoA aneurysm treatment to compare the clipping and coiling techniques and find the factors that determined the treatment outcomes. METHODS: Patients with ruptured PCoA aneurysm at Songklanagarind Hospital between November 2002 and March 2018 were retrospectively reviewed and classified into the clipping group or the coiling group. The primary outcome was the modified Rankin Scale (mRS) at 6 months after treatment, and the patients were stratified into "good outcome" (mRS 0-2) and "poor outcome" (mRS 3-6). Using logistic regression analysis, various factors were analyzed for association with the treatment outcome. RESULTS: This study included 189 patients: 104 and 85 patients in the clipping and coiling groups, respectively. Patients in the coiling group were significantly older, with more underlying diseases. However, the treatment outcomes at 6 months were not significantly different between the 2 groups. The percentages of poor outcomes in the clipping and coiling groups were 28% and 31%, respectively (P = 0.734). Older age, seizure, higher Hunt and Hess grade, deterioration before aneurysm obliteration, an aneurysm on the left side, and a medially projected PCoA aneurysm were statistically significantly correlated with poor outcomes. CONCLUSIONS: Neurosurgical clipping and endovascular coiling are effective treatments for aneurysm obliteration in ruptured PCoA aneurysm. An aneurysm on the left side and a medially projected PCoA aneurysm were the factors correlated with poor outcome.