Predictive Score of Adverse Events After Carotid Endarterectomy: The NSQIP Registry Carotid Endarterectomy Scale.

Background The goal of this study was to create a comprehensive, integer-weighted predictive scale of adverse events after carotid endarterectomy (CEA), which may augment risk stratification and patient counseling. Methods and Results The targeted carotid files from the prospective NSQIP (National Surgical Quality Improvement Program) registry (2011-2013) comprised the derivation population. Multivariable logistic regression evaluated predictors of a 30-day adverse event (stroke, myocardial infarction, or death), the effect estimates of which were used to build a weighted predictive scale that was validated using the 2014 to 2015 NSQIP registry release. A total of 10 766 and 8002 patients were included in the derivation and the validation populations, in whom 4.0% and 3.7% developed an adverse event, respectively. The NSQIP registry CEA scale included 14 variables; the highest points were allocated for insulin-dependent diabetes mellitus, high-risk cardiac physiological characteristics, admission source other than home, an emergent operation, American Society of Anesthesiologists' classification IV to V, modified Rankin Scale score ≥2, and presentation with a stroke. NSQIP registry CEA score was predictive of an adverse event (concordance=0.67), stroke or death (concordance=0.69), mortality (concordance=0.76), an extended hospitalization (concordance=0.73), and a nonroutine discharge (concordance=0.83) in the validation population, as well as among symptomatic and asymptomatic subgroups (P<0.001). In the validation population, patients with an NSQIP registry CEA scale score >8 and 17 had 30-day stroke or death rates >3% and 6%, the recommended thresholds for asymptomatic and symptomatic patients, respectively. Conclusions The NSQIP registry CEA scale predicts adverse outcomes after CEA and can risk stratify patients with both symptomatic and asymptomatic carotid stenosis using different thresholds for each population.

Prolactinomas and nonfunctioning adenomas: preoperative diagnosis of tumor type using serum prolactin and tumor size.

OBJECTIVE: Prolactinoma and nonfunctioning adenoma (NFA) are the most common sellar pathologies, and both can present with hyperprolactinemia. There are no definitive studies analyzing the relationship between the sizes of prolactinomas and NFAs and the serum prolactin level. Current guidelines for serum prolactin level cutoffs to distinguish between pathologies are suboptimal because they fail to consider the adenoma volume. In this study, the authors attempted to describe the relationship between serum prolactin level and prolactinoma volume. They also examined the predictive value that can be gained by considering tumor volume in differentiating prolactinoma from NFA and provide cutoff values based on a large sample of patients. METHODS: A retrospective analysis of consecutive patients with prolactinomas (n = 76) and NFAs (n = 217) was performed. Patients were divided into groups based on adenoma volume, and the two pathologies were compared. RESULTS: A strong correlation was found between prolactinoma volume and serum prolactin level (r = 0.831, p < 0.001). However, there was no significant correlation between NFA volume and serum prolactin level (r = -0.020, p = 0.773). Receiver operating characteristic curve analysis of three different adenoma volume groups was performed and resulted in different serum prolactin level cutoffs for each group. For group 1 (≤ 0.5 cm3), the most accurate cutoff was 43.65 µg/L (area under the curve [AUC] = 0.951); for group 2 (> 0.5 to 4 cm3), 60.05 µg/L (AUC = 0.949); and for group 3 (> 4 cm3), 248.15 µg/L (AUC = 1.0). CONCLUSIONS: Prolactinoma volume has a significant impact on serum prolactin level, whereas NFA volume does not. This finding indicates that the amount of prolactin-producing tissue is a more important factor regarding serum prolactin level than absolute adenoma volume. Hence, volume should be a determining factor to distinguish between prolactinoma and NFA prior to surgery. Current serum prolactin threshold level guidelines are suboptimal and cannot be generalized across all adenoma volumes.

Abdominal Fat Graft for Sellar Reconstruction: Retrospective Outcomes Review and Technical Note.

BACKGROUND: The transsphenoidal approach is the standard of care for the treatment of pituitary adenomas and is increasingly employed for many anterior skull base tumors. Persistent postoperative cerebrospinal fluid (CSF) leaks can result in significant complications. OBJECTIVE: To analyze our series of patients undergoing abdominal fat graft repair of the sellar floor defect following transsphenoidal surgery, describe and investigate our current, routine technique, and review contemporary and past methods of skull base repair. METHODS: A recent consecutive series (2008-2017) of 865 patients who underwent 948 endonasal procedures for lesions of the sella and anterior skull base was retrospectively reviewed. Three hundred eighty patients underwent reconstruction of the sellar defect with an abdominal fat graft. RESULTS: The diagnoses of the 380 patients receiving fat grafts were the following: 275 pituitary adenomas (72.4%), 50 Rathke cleft cysts (13.2%), 12 craniopharyngiomas (3.2%), and a variety of other sellar lesions. Fourteen patients had persistent postoperative CSF leak requiring reoperation and included: 5 pituitary adenomas (1.3%), 4 craniopharyngiomas (1.1%), 2 arachnoid cysts (0.53%), 2 prior CSF leaks (0.53%), and 1 Rathke cleft cyst (0.26%). Four patients (1.1%) developed minor abdominal donor site complications requiring reoperation: 1 hematoma, 2 wound complications, and 1 keloid formation resulting in secondary periumbilical infection. CONCLUSION: Minimizing postoperative CSF leaks following endonasal anterior skull base surgery is important to decrease morbidity and to avoid a prolonged hospital stay. We present an evolved technique of abdominal fat grafting that is effective and safe and includes minimal morbidity and expense.

The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas-a meta-analysis.

OBJECT: In the past decade, the endonasal transsphenoidal approach (eTSA) has become an alternative to the microsurgical transcranial approach (mTCA) for tuberculum sellae meningiomas (TSMs) and olfactory groove meningiomas (OGMs). The aim of this meta-analysis was to evaluate which approach offered the best surgical outcomes. METHODS: A systematic review of the literature from 2004 and meta-analysis were conducted in accordance with the PRISMA guidelines. Pooled incidence was calculated for gross total resection (GTR), visual improvement, cerebrospinal fluid (CSF) leak, intraoperative arterial injury, and mortality, comparing eTSA and mTCA, with p-interaction values. RESULTS: Of 1684 studies, 64 case series were included in the meta-analysis. Using the fixed-effects model, the GTR rate was significantly higher among mTCA patients for OGM (eTSA: 70.9% vs. mTCA: 88.5%, p-interaction < 0.01), but not significantly higher for TSM (eTSA: 83.0% vs. mTCA: 85.8%, p-interaction = 0.34). Despite considerable heterogeneity, visual improvement was higher for eTSA than mTCA for TSM (p-interaction < 0.01), but not for OGM (p-interaction = 0.33). CSF leak was significantly higher among eTSA patients for both OGM (eTSA: 25.1% vs. mTCA: 10.5%, p-interaction < 0.01) and TSM (eTSA: 19.3%, vs. mTCA: 5.81%, p-interaction < 0.01). Intraoperative arterial injury was higher among eTSA (4.89%) than mTCA patients (1.86%) for TSM (p-interaction = 0.03), but not for OGM resection (p-interaction = 0.10). Mortality was not significantly different between eTSA and mTCA patients for both TSM (p-interaction = 0.14) and OGM resection (p-interaction = 0.88). Random-effect models yielded similar results. CONCLUSION: In this meta-analysis, eTSA was not shown to be superior to mTCA for resection of both OGMs and TSMs.

The extended, transnasal, transsphenoidal approach for anterior skull base meningioma: considerations in patient selection.

PURPOSE: In this study, we set out to define our institutional criteria for patient eligibility for transsphenoidal resection of parasellar meningiomas, and to report our experience with extended transnasal approaches for these lesions. We aimed to discuss the important considerations of patient selection and risk stratification to optimize outcomes for patients with these difficult lesions, and also include considerations that should be reviewed during surgical approach selection. METHODS: Medical records from Brigham and Women's Hospital were retrospectively reviewed for all patients who underwent transsphenoidal surgery for pituitary disease with the senior author from April 2008 to March 2017 (938 procedures). Patients undergoing surgery for anterior skull base meningioma were identified and patient data were collected. RESULTS: Seven patients (four women, three men) underwent transsphenoidal resection (five endoscopic, one microscopic, and one hybrid endoscopic/microscopic) of pathologically-confirmed anterior skull base meningiomas during the study period. Five patients presented with visual field deficits, three presented with headache, two presented with hypopituitarism, and one woman presented with infertility. The median maximum tumor diameter was 1.7 cm (range 1.4-4.2 cm). Six patients underwent subtotal resection, and one underwent gross total resection. The median MIB-1 index was 2.3 (range 1.0-7.6). Complications included two readmissions (one on POD11 for small bowel obstruction, one on POD48 for epistaxis), and the development of new onset thyroid deficiency and transient diabetes insipidus in one patient. Two patients had reoperations by craniotomy for tumor recurrence after 5 and 6 years, respectively. CONCLUSIONS: Although more commonly treated transcranially, anterior skull base meningiomas are sometimes amenable to resection transphenoidally. Patient selection is critical, and multiple factors, including tumor size, consistency, and location, patient and surgeon preference, and presenting symptoms each affect the optimum surgical approach. We have developed criteria for patient selection so that transsphenoidal surgery can be used to resect or debulk anterior skull base meningiomas safely and with favorable outcomes.

The Changing Health Care Landscape and Implications of Organizational Ethics on Modern Medical Practice.

INTRODUCTION: Medicine is rapidly changing, both in the level of collective medical knowledge and in how it is being delivered. The increased presence of administrators in hospitals helps to facilitate these changes and ease administrative workloads on physicians; however, tensions sometimes form between physicians and administrators. ANALYSIS: This situation is based on perceptions from both sides that physicians obstruct cost-saving measures and administrators put profits before patients. In reality, increasing patient populations and changes in health care are necessitating action by hospitals to prevent excessive spending as health care systems become larger and more difficult to manage. Recognizing the cause of changes in health care, which do not always originate with physicians and administrators, along with implementing changes in hospitals such as increased physician leadership, could help to ease tensions and promote a more collaborative atmosphere. Ethically, there is a need to preserve physician autonomy, which is a tenet of medical professionalism, and a need to rein in spending costs and ensure that patients receive the best possible care. CONCLUSION: Physicians and administrators both need to have a well-developed personal ethic to achieve these goals. Physicians need be allowed to retain relative autonomy over their practices as they support and participate in administrator-led efforts toward distributive justice.

Safety of remifentanil in transsphenoidal surgery: A single-center analysis of 540 patients.

Although some studies have examined the efficacy and safety of remifentanil in patients undergoing neurosurgical procedures, none has examined its safety in transsphenoidal operations specifically. In this study, all transsphenoidal operations performed by a single author from 2008 to 2015 were retrospectively reviewed to evaluate the safety of remifentanil in a consecutive series of patients. During the study period, 540 transsphenoidal operations were identified. Of these, 443 (82.0%) patients received remifentanil intra-operatively; 97 (18.0%) did not. The two groups were well-matched with regard to demographic categories, comorbidities, and pre-operative medications (p>0.05), except pre-operative tobacco use (p=0.021). Patients were also well-matched with regard to radiographic features and surgical techniques. Patients who received remifentanil were more likely to harbor a macroadenoma (78.1% vs. 67.0%, p=0.025), and had slightly longer anesthesia time on average (269.2minvs. 239.4min, p=0.024). All pathologic diagnoses were well-matched between the two groups, except that patients receiving remifentanil were more likely to harbor a non-functioning adenoma (46.5% vs. 26.8%, p<0.001). Analysis of post-operative complications showed no significant difference between patients who received remifentanil and those who did not, and length of stay and prevalence of ICU stay did not differ between the two groups. In a well-matched series of 540 patients undergoing transsphenoidal surgery, remifentanil was found to be a safe anesthetic adjunct. There were no significant differences in post-operative hospital course or complications in patients who did and did not receive intra-operative remifentanil.

Time Course of Resolution of Hyperprolactinemia After Transsphenoidal Surgery Among Patients Presenting with Pituitary Stalk Compression.

BACKGROUND: Primary lactotroph disinhibition, or stalk effect, occurs when mechanical compression of the pituitary stalk disrupts the tonic inhibition by dopamine released by the hypothalamus. The resolution of pituitary stalk effect-related hyperprolactinemia postoperatively has not been studied in a large cohort of patients. We performed a retrospective review to investigate the time course of recovery of lactotroph disinhibition after transsphenoidal surgery. METHODS: Medical records were retrospectively reviewed for all patients undergoing transsphenoidal surgery with the senior author from April 2008 to November 2014. RESULTS: Of 556 pituitary adenomas, 289 (52.0%) were eliminated: 77 (13.9%) had an immunohistochemically confirmed prolactinoma, 119 (21.4%) patients had previous surgery, 93 (16.7%) had incomplete medical records, leaving 267 patients (48.0%) for final analysis. Of these patients, 72 (27.0%) had increased serum prolactin levels (≥23.3 ng/mL), suggestive of pituitary stalk effect (maximum prolactin level = 148.0 ng/mL). Patients with stalk effect were more likely than those with normal serum prolactin levels to present with menstrual dysfunction (29.7% vs. 19.4%; P < 0.01) and galactorrhea (11.1% vs. 2.1%; P < 0.01). Patients with lactotroph disinhibition were more likely to harbor macroadenomas than were patients who did not show lactotroph disinhibition (81.9% vs. 70.2%; P = 0.06). Among patients with increased preoperative prolactin, 77.8% experienced normalization of serum prolactin postoperatively, galactorrhea improved in 100%, sexual dysfunction resolved in 66.6%, and menstrual dysfunction among premenopausal females normalized in 73.3% at last follow-up (mean, 5.35 years; range, 0.1-10 years). CONCLUSIONS: Transsphenoidal surgery can provide durable normalization of serum prolactin levels and related symptoms caused by pituitary stalk compression-related lactotroph disinhibition.

Time Course of Symptomatic Recovery After Endoscopic Transsphenoidal Surgery for Pituitary Adenoma Apoplexy in the Modern Era.

BACKGROUND: Pituitary tumor apoplexy can result from either hemorrhagic or infarctive expansion of pituitary adenomas, and the related mass effect can result in compression of critical neurovascular structures. The time course of recovery of visual field deficits, headaches, ophthalmoparesis, and pituitary dysfunction after endoscopic transsphenoidal surgery has not been well established. METHODS: Medical records were retrospectively reviewed for all patients who underwent endoscopic transsphenoidal surgery for pituitary tumor apoplexy from April 2008 to November 2014. RESULTS: Of 578 patients who underwent transsphenoidal surgery, pituitary tumor apoplexy was identified in 44 patients (7.6%). Two patients had prior surgery, leaving 42 patients for final analysis. These included infarction-related apoplexy in 7 (14.4%) patients, and hemorrhagic apoplexy in 35 (85.6%) patients. Hemorrhagic adenomas had a larger axial tumor diameter than patients with infarctive adenomas (4.4 ± 4.1 cm vs. 1.8 ± 0.8 cm; P < 0.01), but were otherwise equivalent. At an average last follow-up of 2.52 years (range, 0.1-6.7 years), resolution of ophthalmoparesis as a result of pituitary tumor apoplexy demonstrated the longest recovery course (range, 2.4 ± 2.2 months) compared with visual field deficits (range, 8.0 ± 9.9 days), headaches (range, 1.9 ± 3.0 days), or pituitary dysfunction (range, 2.0 ± 1.8 weeks; P < 0.01). All patients who presented with headaches (n = 37) and/or visual disturbances (n = 22) had complete resolution of symptoms at last follow-up, whereas 83.3% of patients who presented with ophthalmoplegia experienced resolution. Endocrinologic dysfunction remained relatively consistent after surgery. CONCLUSIONS: Endoscopic transsphenoidal surgery can provide durable resolution of symptoms for patients presenting with pituitary tumor apoplexy. Recovery from headaches, visual, and pituitary dysfunction may be more rapid compared with ophthalmoparesis.

United States neurosurgery annual case type and complication trends between 2006 and 2013: An American College of Surgeons National Surgical Quality Improvement Program analysis.

We aimed to identify trends in the neurosurgical practice environment in the United States from 2006 to 2013 using the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database, and to determine the complication rate for spinal and cranial procedures and identify risk factors for post-operative complications across this time period. We performed a search of the American College of Surgeons-NSQIP database for all patients undergoing an operation with a surgeon whose primary specialty was neurological surgery from 2006 to 2013. Analysis of patient demographics and pre-operative co-morbidities was performed, and multivariate analysis was used to determine predictors of surgical complications. From 2006 to 2013, the percentage of spinal operations performed by neurosurgeons relative to cranial and peripheral nerve cases increased from 68.0% to 76.8% (p<0.001) according to the NSQIP database. The proportion of cranial cases during the same time period decreased from 29.7% to 21.6% (p<0.001). The overall 30-day complication rate among all 94,621 NSQIP reported patients undergoing operations with a neurosurgeon over this time period was 8.2% (5.6% for spinal operations, 16.1% for cranial operations). The overall rate decreased from 11.0% in 2006 to 7.5% in 2013 (p<0.001). Several predictors of post-operative complication were identified on multivariate analysis.

Neurosurgical Defensive Medicine in Texas and Illinois: A Tale of 2 States.

OBJECTIVE: To compare the self-reported liability characteristics and defensive medicine practices of neurosurgeons in Texas with neurosurgeons in Illinois in an effort to describe the effect of medicolegal environment on defensive behavior. METHODS: An online survey was sent to 3344 members of the American Board of Neurological Surgery. Respondents were asked questions in 8 domains, and responses were compared between Illinois, the state with the highest reported average malpractice insurance premium, and Texas, a state with a relatively low average malpractice insurance premium. RESULTS: In Illinois, 85 of 146 (58.2%) neurosurgeons surveyed responded to the survey. In Texas, 65 of 265 (24.5%) neurosurgeons surveyed responded. In Illinois, neurosurgeons were more likely to rate the overall burden of liability insurance premiums to be an extreme/major burden (odds ratio [OR] = 7.398, P < 0.001) and to have >$2 million in total coverage (OR = 9.814, P < 0.001) than neurosurgeons from Texas. Annual malpractice insurance premiums in Illinois were more likely to be higher than $50,000 than in Texas (OR = 9.936, P < 0.001), and survey respondents from Illinois were more likely to believe that there is an ongoing medical liability crisis in the United States (OR = 9.505, P < 0.001). Neurosurgeons from Illinois were more likely to report that they very often/always order additional imaging (OR = 2.514, P = 0.011) or very often/always request additional consultations (OR = 2.385, P = 0.014) compared with neurosurgeons in Texas. CONCLUSIONS: Neurosurgeons in Illinois are more likely to believe that there is an ongoing medical liability crisis and more likely to practice defensively than neurosurgeons in Texas.