Management of external ventricular drain: to wean or not to wean?

PURPOSE: External ventricular drain (EVD) is one of the most frequent procedures in neurosurgery and around 15 to 30% of these patients require a permanent cerebrospinal fluid (CSF) diversion. The optimal EVD weaning strategy is still unclear. Whether gradual weaning compared to rapid closure, reduces the rate of permanent CSF diversion remains controversial. The aim of this trial is to compare the rates of permanent CSF diversion between gradual weaning and rapid closure of an EVD. METHODS: This was a single-center, retrospective cohort study including patients between 2010 to 2020. Patients were divided into a weaning (WG) and non-weaning (NWG) group. The primary outcome was permanent CSF diversion rates, secondary outcomes included hospitalization time, EVD-related morbidity, and clinical outcome. RESULTS: Out of 412 patients, 123 (29.9%) patients were excluded due to early death or palliative treatment. We registered 178 (61.6%) patients in the WG and 111 (38.4%) in the NWG. Baseline characteristics were comparable between groups. The VPS rate was comparable in both groups (NWG 37.8%; WG 39.9%, p = 0.728). EVD related infection (13.5% vs 1.8%, p < 0.001), as well as non-EVD related infection rates (2.8% vs 0%, p < 0.001), were significantly higher in the WG. Hospitalization time was significantly shorter in the NWG (WG 24.93 ± 9.50 days; NWG 23.66 ± 14.51 days, p = 0.039). CONCLUSION: Gradual EVD weaning does not seem to reduce the need for permanent CSF diversion, while infection rates and hospitalization time were significantly higher/longer. Therefore, direct closure should be considered in the clinical setting.

Pituitary germinoma after resection of a mature third ventricular teratoma: illustrative case.

BACKGROUND: Metachronous intracranial germ cell tumors (iGCTs)-unrelated, histologically different iGCTs occurring at different time points-occurring within the same patient remain a rarity. Herein, the authors report such a case and discuss the literature and potential pathophysiological mechanisms leading to this phenomenon. OBSERVATIONS: A 9-year-old boy presented with new-onset impaired balance, headaches, nausea, visual disturbances, and left facial paresis. Magnetic resonance imaging (MRI) scans revealed a suspected pineal region teratoma originating from the pineal gland with consecutive obstructive hydrocephalus. A mature teratoma was diagnosed and resected. Postoperative recovery was good, and the patient could return to his normal daily activities. However, a new, slowly progressive lesion in the sellar region with an enlarged infundibular stalk was detected on follow-up MRI 3.5 years after initial pineal region teratoma resection. Biopsy revealed a newly developed pure germinoma. The patient was treated with radiotherapy plus chemotherapy and remained relapse free at the last follow-up. Sixteen other cases have reported a surgically resected primary mature teratoma, wherein patients developed metachronous germinomas during follow-up. Different theories try to elaborate this phenomenon, yet none can completely account for it. LESSONS: Although rare, metachronous iGCT is a phenomenon neurosurgeons should be aware of. In patients treated for iGCT, close long-term clinical, imaging, and laboratory follow-up is recommended. https://thejns.org/doi/10.3171/CASE2443.

Management of Recurrent Cerebrospinal Fluid Rhinorrhea Caused by Sequential, Anatomically Separated Skull Base Defects-A Case-Based Systematic Review.

OBJECTIVE: Recurrent cerebrospinal fluid (CSF) rhinorrhea caused by sequential, anatomically separated skull base defects is rarely reported in the literature. Neither management nor etiology has been sufficiently investigated. We present an illustrative case and a systematic review of the literature regarding etiology, diagnostics, and management of this rare phenomenon. METHODS: A systematic literature search looking for articles reporting sequential CSF leaks with multiple skull base defects was performed. Data from included articles were descriptively reported, and the quality of the included studies was assessed with Grading of Recommendations Assessment, Development and Evaluation. RESULTS: A 71-year-old woman with posttraumatic CSF rhinorrhea and left-sided CSF otorrhea due to a left-sided horizontal fracture of the petrous bone presented at our institution. After initial surgical repair and a 10-week symptom-free interval, CSF rhinorrhea recurred. Imaging revealed a preexisting contralateral meningoencephalocele of the lateral sphenoid recess causing recurrent CSF rhinorrhea most likely after initial traumatic laceration. The defect was successfully treated. A literature search identified 366 reports, 6 of which were included in the systematic review with a total of 10 cases. Quality was deemed good in 8 of 10 cases. The most common location for primary and sequential CSF leaks was along the sphenoid bone (4/10 and 5/10 patients, respectively). All publications except one reported the presence of a meningo (encephalo)cele as cause of the sequential CSF leak. CONCLUSIONS: Occurrence of recurrent CSF rhinorrhea due to an anatomically separated sequential skull base lesion remains a rare phenomenon. Reassessment of imaging studies and a structured diagnostic workup to detect sequential CSF leaks independent of the primary lesion should is recommended.

Patient-Reported Neurocognitive Outcome After Endoscopic Ventricular Surgery.

BACKGROUND: Endoscopic ventricular surgery (EVS) shows overall reduced morbidity compared to open craniotomy, but carries, however, the risk for neurocognitive impairment caused by fornix-, hypothalamus-, and injuries other structures adjacent to the ventricular system. Objective or subjective neurocognitive impairment after EVS is rarely reported. The aim of this study was to assess the subjective neurocognitive outcome in patients undergoing EVS for various pathologies. METHODS: We conducted a retrospective cohort study in adult patients undergoing EVS at our institution between 2010 and 2021. The primary outcome was subjective neurocognitive outcome after EVS measured by patient-reported outcomes (PROs). Secondary outcomes were objective neurocognitive outcome, return-to-work rate, subjective quality of life and satisfaction with surgery. Descriptive and comparative statistics were conducted for all outcome parameters. RESULTS: Fifty-one patients (median age 48 years, 62.7% female) were included. Patients commonly presented with subjective neurocognitive impairment (54.9%) and hydrocephalus was the most common indication for surgery (54.9%). Worse long-term subjective neurocognitive outcome was observed in 5 (21.7%) patients while 18 (78.3%) patients improved. Worse long-term objective neurocognitive outcome was seen in 2 cases (10.5%), of which 1 patient became worse trough surgery while 15 (78.9%) patients improved. Improved subjective and objective neurocognitive outcome correlated in 73.8% of the cases (r = 0.363, P = 0.018). Return to work was possible for 70% of the patients and subjective quality of life was improved or unchanged in 88.1% of the patients. CONCLUSIONS: Subjective neurocognitive outcome and quality of life improvement are often achieved after EVS and permanent neurocognitive impairment is rare. Further well-designed trials on subjective and objective neurocognitive outcome after EVS are warranted.

Characteristics, Progression, and Output of Randomized Platform Trials: A Systematic Review.

Importance: Platform trials have become increasingly common, and evidence is needed to determine how this trial design is actually applied in current research practice. Objective: To determine the characteristics, progression, and output of randomized platform trials. Evidence Review: In this systematic review of randomized platform trials, Medline, Embase, Scopus, trial registries, gray literature, and preprint servers were searched, and citation tracking was performed in July 2022. Investigators were contacted in February 2023 to confirm data accuracy and to provide updated information on the status of platform trial arms. Randomized platform trials were eligible if they explicitly planned to add or drop arms. Data were extracted in duplicate from protocols, publications, websites, and registry entries. For each platform trial, design features such as the use of a common control arm, use of nonconcurrent control data, statistical framework, adjustment for multiplicity, and use of additional adaptive design features were collected. Progression and output of each platform trial were determined by the recruitment status of individual arms, the number of arms added or dropped, and the availability of results for each intervention arm. Findings: The search identified 127 randomized platform trials with a total of 823 arms; most trials were conducted in the field of oncology (57 [44.9%]) and COVID-19 (45 [35.4%]). After a more than twofold increase in the initiation of new platform trials at the beginning of the COVID-19 pandemic, the number of platform trials has since declined. Platform trial features were often not reported (not reported: nonconcurrent control, 61 of 127 [48.0%]; multiplicity adjustment for arms, 98 of 127 [77.2%]; statistical framework, 37 of 127 [29.1%]). Adaptive design features were only used by half the studies (63 of 127 [49.6%]). Results were available for 65.2% of closed arms (230 of 353). Premature closure of platform trial arms due to recruitment problems was infrequent (5 of 353 [1.4%]). Conclusions and Relevance: This systematic review found that platform trials were initiated most frequently during the COVID-19 pandemic and declined thereafter. The reporting of platform features and the availability of results were insufficient. Premature arm closure for poor recruitment was rare.

Neurosurgical Treatment and Outcome of Pediatric Skull Base Lesions: A Case Series and Review of the Literature.

INTRODUCTION: Pediatric skull base lesions occur rarely and are of various etiologies. Traditionally, open craniotomy has been the treatment of choice; however, nowadays, endoscopic approaches are increasingly applied. In this retrospective case series, we describe our experience in treating pediatric skull base lesions and provide a systematic overview of the literature on the treatment and outcome of pediatric skull base lesions. METHODS: We conducted a retrospective data collection of all pediatric patients (<18 years) treated for a skull base lesion at the Division of Pediatric Neurosurgery, University Children's Hospital Basel, Switzerland, between 2015 and 2021. Descriptive statistics and a systematic review of the available literature were additionally conducted. RESULTS: We included 17 patients with a mean age of 8.92 (±5.76) years and nine males (52.9%). The most common entity was sellar pathologies (n = 8 47.1%), with craniopharyngioma being the most common pathology (n = 4, 23.5%). Endoscopic approaches, either endonasal transsphenoidal or transventricular, were used in nine (52.9%) cases. Six patients (35.3%) suffered from transient postoperative complications, while in none of the patients these were permanent. Of the nine (52.9%) patients with preoperative deficits, two (11.8%) showed complete recovery and one (5.9%) partial recovery after surgery. After screening 363 articles, we included 16 studies with a total of 807 patients for the systematic review. The most common pathology reported in the literature confirmed our finding of craniopharyngioma (n = 142, 18.0%). The mean PFS amongst all the studies included was 37.73 (95% CI [36.2, 39.2]) months, and the overall weighted complication rate was 40% (95% CI [0.28 to 0.53] with a permanent complication rate of 15% (95% CI [0.08 to 0.27]. Only one study reported an overall survival of their cohort of 68% at five years. CONCLUSION: This study highlights the rarity and heterogeneity of skull base lesions in the pediatric population. While these pathologies are often benign, achieving GTR is challenging due to the deep localization of the lesions and eloquent adjacent structures, leading to high complication rates. Therefore, skull base lesions in children require an experienced multidisciplinary team to provide optimal care.

Minimally invasive image-guided endoscopic evacuation of intracerebral haemorrhage: How I Do it.

BACKGROUND: Minimally invasive endoscopic hematoma evacuation (MEHE) is an emerging surgical technique for treating spontaneous supratentorial intracerebral haemorrhage (SSICH). Multiple studies, analysing whether the outcome after such a procedure is improved, are still ongoing. METHOD: We herein present the indications, advantages, and perioperative considerations for the surgical technique of MEHE applied at our institution. CONCLUSION: MEHE with a view through a transparent brain access device is a valid and safe approach for the surgical evacuation of SSICH.

Endoscopic surgery for spontaneous supratentorial intracerebral haemorrhage: A systematic review and meta-analysis.

Introduction: Treatment for spontaneous supratentorial intracerebral haemorrhage (SSICH) is limited and consist of either best medical treatment (BMT) or surgical hematoma evacuation. Treatment methods and choice of surgical technique are debated, and so far, no clear advantage of endoscopic surgery (ES) over conventional craniotomy (CC) or BMT was shown. The aim of this systematic review and meta-analysis was to investigate the differences in outcome, morbidity, and mortality between ES and CC or BMT. Methods: We systematically searched Embase and PubMed databases for randomised controlled trials comparing ES to CC or BMT. The primary outcome was favourable functional outcome after 6 months. Secondary outcomes were morbidity and mortality rates and duration of surgery. Results: Seven articles were eligible for the outcome analysis with 312 subjects in the control (216 CC, 96 BMT) and 279 in the treatment group (ES). Compared to BMT, ES showed significantly improved favourable functional outcome (RR 1.93 [1.12; 3.33], p = 0.02) and mortality rates (RR 0.63 [0.44; 0.90], p = 0.01). No significant difference in favourable functional outcome and mortality was seen in ES compared to CC (RR 2.13 [0.01; 737], p = 0.35; RR 0.42 [0.17; 1.05], p = 0.06). ES showed significantly lower morbidity (RR 0.41 [0.29; 0.58], p < 0.01), and overall infection rates (RR 0.33 [0.20; 0.54], p < 0.01) compared to CC. Duration of surgery was significantly shorter for ES compared to CC (SMD -3.17 [-4.35; -2.00], p < 0.01). Conclusion: ES showed significantly improved favourable functional outcome and mortality rates compared to BMT while showing reduced length of surgery and lower complication rates compared to CC. Therefore, ES appears a promising approach for treatment of SSICH justifying further prospective trials. Systematic review registration: PROSPERO, identifier: CRD42020181018.