Neuroradiological features of contrast-induced neurotoxicity: A systematic review and pooled analysis.

BACKGROUND: Contrast-induced neurotoxicity (CIN), is an increasingly recognised complication of endovascular procedures, presenting as a spectrum of neurological symptoms that mimic ischaemic stroke. The diagnosis of CIN remains a clinical challenge, and stereotypical imaging findings are not established. This study was conducted to characterise the neuroimaging findings in patients with CIN, to raise diagnostic awareness and improve decision making. METHODS: We performed a systematic review of PubMed and Embase databases from inception (1946/1947) to June 2023 for reports of CIN following administration of iodinated contrast media. Studies with a final diagnosis of CIN, which provided details of neuroimaging were included. All included cases were pooled and descriptive analysis was conducted. RESULTS: A total of 84 patients were included, with a median age of 64 years. A large proportion of patients had normal imaging (CT 40.8 %, MRI 53.1 %). CT abnormalities included cortical/subarachnoid hyperattenuation (42.1 %), cerebral oedema/sulcal effacement (26.3 %), and loss of grey-white differentiation (7.9 %). Frequently reported MRI abnormalities included brain parenchymal MRI signal change (40.8 %) and cerebral oedema (12.2 %), most commonly observed on FLAIR sequences (26.5 %). Characterisation of imaging findings according to anatomical location and clinical symptoms has been conducted. CONCLUSIONS: Neuroimaging is an essential part of the diagnostic workup of CIN. Analysis of the anatomical location and laterality of imaging abnormalities may suggest relationship between radiological features and actual clinical symptoms, although this remains to be confirmed with dedicated study. Radiological abnormalities, particularly CT, appear to be transient and reversible in most patients.

Tension Pneumocephalus Secondary to Positive Pressure Ventilation Following Endoscopic Endonasal Skull Base Surgery: Three-Year Follow-Up After Implementation of an Institutional Protocol.

BACKGROUND: Tension pneumocephalus (PMC) is a rare and feared complication following the endonasal endoscopic approach (EEA) to skull base procedures. This is a neurosurgical emergency that requires urgent decompression to avoid catastrophic neurological damage or death. An avoidable cause is the application of positive pressure ventilation (PPV) in EEA patients for postoperative hypoxia. Our institution implemented a hospital-wide protocol in response to this to identify and manage at-risk patients; the present paper aims to identify if this protocol was effective in lowering the rates of tension PMC secondary to PPV. RESULTS: In the 3 years following the implementation of the protocol, 110 patients underwent EEAs, from which 1 case of tension PMC (found to be not secondary to PPV) was identified. This is compared to 2 cases of tension PMC secondary to PPV over the preceding 5 years, out of 406 EEA patients. This constitutes a quantifiable reduction in PPV-related tension PMC in both standard and extended approach EEAs, signifying the effective uptake of the protocol. CONCLUSION: We found no cases of tension PMC after PPV following EEA skull base surgery in our institution since the implementation of an institution-wide guideline. This underscores the utility of our simple and cost-effective preventative protocol in reducing the overall rates of tension PMC following the inadvertent postoperative application of PPV. Further research is needed to study the comparative risks and benefits of PPV in the post-EEA patient and thus inform future iterations of the protocol.

Quality of life in Prolactinoma: A systematic review.

BACKGROUND: Prolactinomas are common tumours that significantly reduce quality-of-life (QOL) due to sellar mass effect, secondary hypogonadism, and the peripheral effects of prolactin. Understanding the factors that influence QOL would provide insights into therapeutic targets to optimise patient outcomes and improve wellbeing in prolactinoma. METHODS: A systematic review was performed in accordance with the PRISMA statement. Studies that reported patient QoL using validated metrics were included. Bias and methodological rigour were assessed using the MINORS criteria. RESULTS: A total of 18 studies were identified studies were available for review, comprising 877 patients. Most were small cross-sectional studies at high risk of bias. Prolactinoma exhibit worse QOL than healthy controls, particularly mental and psychosocial wellbeing. QOL is also worse than patients with non-functional adenomas, but better than those with Cushing's disease and acromegaly. QOL correlates with prolactin levels, and approaches population baseline with prolonged biochemical control. Dopamine agonists and surgery both improve overall QOL, however improvements are more rapid with surgery. CONCLUSION: Poor quality of life in prolactinoma is multifactorial, related to biochemical control, side effects of therapy, and sellar mass effect. Targeting persistent symptoms, reducing healthcare costs, and reducing side-effects of therapy are avenues to improving QOL in patients with prolactinoma.

Preoperative coil localization for spinal surgery is accurate, safe and effective: a single-centre initial experience.

OBJECTIVE AND STUDY DESIGN: This is a retrospective, descriptive study of consecutive patients undergoing novel preoperative pushable coil localization for spinal surgery, in order to evaluate its feasibility, safety and accuracy. METHODS: Consecutive patients who underwent pre-operative coil marking for spinal surgery at our institution from May 2018 to July 2021 were included. Data were collected for coil placement, accuracy, complications and fluoroscopy usage. Patient demographic and relevant perioperative and procedural data were also collected. RESULTS: A total of 34 patients were identified of which 32 (94%) had complete data and imaging at last clinical follow up, with a mean duration of 13.9 months. There were no incorrect level surgeries performed. There were no coil-related complications found in our cohort. CONCLUSIONS: Preoperative coil placement is an accurate, safe and well-tolerated method for level localization in spinal surgeries.

Clinical management of contrast-induced neurotoxicity: a systematic review.

BACKGROUND: Contrast-induced neurotoxicity (CIN) is an increasingly recognised complication following endovascular procedures utilising contrast. It remains poorly understood with heterogenous clinical management strategies. The aim of this review was to identify commonly employed treatments for CIN to enhance clinical decision making. METHODS: A systematic search of Embase (1947-2022) and Medline (1946-2022) was conducted. Articles describing (i) patients with a clinical diagnosis of CIN, (ii) with radiological exclusion of other pathologies, (iii) detailed report of treatments, and (iv) discharge outcomes, were included. Data relating to demographics, procedure, symptoms, treatment and outcomes were extracted. RESULTS: A total of 73 patients were included, with a median age of 64 years. The most common procedures were cerebral angiography (42.5%) and coronary angiography (42.5%), and the median volume of contrast administered was 150 ml. The most common symptoms were cortical blindness (38.4%) and reduced consciousness (28.8%), and 84.9% of patients experienced complete resolution at the time of discharge. Management included intravenous fluids to dilute contrast in the cerebrovasculature (54.8%), corticosteroids to reduce blood-brain barrier damage (47.9%), antiseizure (16.4%) and sedative (16.4%) medications. Mannitol (13.7%) was also utilised to reduce cerebral oedema. Intensive care admission was required for 19.2% of patients. No statistically significant differences were observed between treatment and discharge outcomes. CONCLUSIONS: The clinical management of CIN should be considered on a patient-by-patient basis, but may consist of aggressive fluid therapy alongside corticosteroids, as well as other supportive therapy as required. Further examination of CIN management is required to define best practice.

Effects of a comprehensive brain computed tomography deep learning model on radiologist detection accuracy.

OBJECTIVES: Non-contrast computed tomography of the brain (NCCTB) is commonly used to detect intracranial pathology but is subject to interpretation errors. Machine learning can augment clinical decision-making and improve NCCTB scan interpretation. This retrospective detection accuracy study assessed the performance of radiologists assisted by a deep learning model and compared the standalone performance of the model with that of unassisted radiologists. METHODS: A deep learning model was trained on 212,484 NCCTB scans drawn from a private radiology group in Australia. Scans from inpatient, outpatient, and emergency settings were included. Scan inclusion criteria were age ≥ 18 years and series slice thickness ≤ 1.5 mm. Thirty-two radiologists reviewed 2848 scans with and without the assistance of the deep learning system and rated their confidence in the presence of each finding using a 7-point scale. Differences in AUC and Matthews correlation coefficient (MCC) were calculated using a ground-truth gold standard. RESULTS: The model demonstrated an average area under the receiver operating characteristic curve (AUC) of 0.93 across 144 NCCTB findings and significantly improved radiologist interpretation performance. Assisted and unassisted radiologists demonstrated an average AUC of 0.79 and 0.73 across 22 grouped parent findings and 0.72 and 0.68 across 189 child findings, respectively. When assisted by the model, radiologist AUC was significantly improved for 91 findings (158 findings were non-inferior), and reading time was significantly reduced. CONCLUSIONS: The assistance of a comprehensive deep learning model significantly improved radiologist detection accuracy across a wide range of clinical findings and demonstrated the potential to improve NCCTB interpretation. CLINICAL RELEVANCE STATEMENT: This study evaluated a comprehensive CT brain deep learning model, which performed strongly, improved the performance of radiologists, and reduced interpretation time. The model may reduce errors, improve efficiency, facilitate triage, and better enable the delivery of timely patient care. KEY POINTS: • This study demonstrated that the use of a comprehensive deep learning system assisted radiologists in the detection of a wide range of abnormalities on non-contrast brain computed tomography scans. • The deep learning model demonstrated an average area under the receiver operating characteristic curve of 0.93 across 144 findings and significantly improved radiologist interpretation performance. • The assistance of the comprehensive deep learning model significantly reduced the time required for radiologists to interpret computed tomography scans of the brain.

Pathophysiology of Contrast-Induced Neurotoxicity: A Narrative Review of Possible Mechanisms.

BACKGROUND: Contrast-induced neurotoxicity (CIN) is an increasingly observed event following the administration of iodinated contrast. It presents as a spectrum of neurological symptoms that closely mimic ischaemic stroke, however, CIN remains a poorly understood clinical phenomenon. An appreciation of the underlying pathophysiological mechanisms is essential to improve clinical understanding and enhance decision-making. METHODS: A broad literature search of Medline (1946 to December 2022) and Embase (1947 to December 2022) was conducted. Articles discussing the pathophysiology of CIN were reviewed. SUMMARY: The pathogenesis of CIN appears to be multifactorial. A key step is likely blood-brain barrier (BBB) breakdown due to factors including ischaemic stroke, uncontrolled hypertension, and possibly contrast agents themselves, among others. This is followed by passage of contrast agents across the BBB, leading to chemotoxic sequelae on neural tissue. KEY MESSAGES: This review provides a clinically oriented review on the pathophysiology of CIN to enhance knowledge and improve decision-making among clinicians.

Current knowledge and perspectives of contrast-induced neurotoxicity: A survey of Australian clinicians.

BACKGROUND: Contrast-induced Neurotoxicity (CIN) is an increasingly recognised complication following endovascular procedures. It remains a relatively unexplored clinical entity, and we sought to characterise clinician perspectives towards CIN, as well as identify gaps in knowledge and provide directions for future research. METHODS: An online survey was distributed to members of the Australian and New Zealand Society of Neuroradiology, as well as several Australian tertiary hospitals. Questions related to clinical exposure to CIN, diagnosis, management and pathophysiology were explored. Descriptive analysis was conducted on survey responses, and statistical analysis was performed using Chi-square and Fisher's exact test as appropriate. RESULTS: A total of 95 survey responses were recorded (26.8% response rate). Only 28.4% of respondents were comfortable in diagnosing CIN, and even fewer (24.2%) were comfortable in independently managing CIN patients. Based on clinician opinion, symptoms including impaired consciousness and cortical blindness were thought to be most associated with CIN, whilst the radiological findings of parenchymal oedema and cortical enhancement were considered to be most indicative of CIN. Most clinicians agreed that further investigation is required related to pathophysiology (86.3%), diagnosis (83.2%), and treatment (82.1%). CONCLUSION: CIN is a poorly understood complication following endovascular procedures. Significant gaps in clinical understanding are evident, and further investigation is vital to improve diagnosis and management.

Headache Improvement Following Endoscopic Resection of Pituitary Adenomas.

BACKGROUND: Headache is a common symptom in patients with pituitary adenomas. Research on whether resection of pituitary adenomas via the endoscopic endonasal approach (EEA) affects headaches is limited, and the pathophysiology of headaches associated with pituitary adenomas remains unclear. This study aimed to determine if resection of pituitary adenomas via the EEA improves headaches and investigate factors that may be associated with headaches in patients with pituitary adenoma. METHODS: A prospectively collected database of 122 patients undergoing resection of pituitary adenoma via the EEA was analyzed. Patient-reported headache severity was collected prospectively using the Headache Impact Test (HIT-6) at preoperative baseline and 4 postoperative time points (3 weeks, 6 weeks, 3 months, and 6 months). RESULTS: Adenoma size and subtype, cavernous sinus invasion, and hormonal status were not associated with preoperative headache burden. In patients with preoperative headaches (HIT-6 score >36), significant decreases in HIT-6 score were observed postoperatively at 6 weeks (5.5-point improvement, 95% CI 1.27-9.78, P < 0.01), 3 months (3.6-point improvement, 95% CI 0.01-7.18, P < 0.05), and 6 months (7.5-point improvement, 95% CI 3.43-11.46, P < 0.01). The only factor associated with headache improvement was cavernous sinus invasion (P = 0.003). Adenoma size and subtype and hormonal status were not associated with postoperative headache burden. CONCLUSIONS: Resection via the EEA is associated with significant improvement in headache-related impact on patient functioning from ≥6 weeks after surgery. Patients with cavernous sinus invasion are more likely to experience improvement in headaches. The mechanism of headaches associated with pituitary adenoma still requires clarification.

Glucocorticoids and Water Balance: Implications for Hyponatremia Management and Pituitary Surgery.

Water balance is fundamental to all homeostasis. The hypothalamic-pituitary-adrenal axis influences water balance through the effects of corticotropin-releasing hormone and cortisol on arginine vasopressin secretion and the peripheral effects of cortisol on hemodynamics and renal water handling. In this review, we explored the complex interplay of glucocorticoids with water balance, with particular attention to hyponatremia and pituitary surgery.

The utility of internal spinal marking for intraoperative localisation: A systematic review.

BACKGROUND: Incorrect level spinal surgery is an avoidable complication, with significant ramifications. Several pre-operative spinal marking techniques have been described to aid intraoperative localisation. METHODS: A systematic search of Ovid MEDLINE, and EMBASE was performed from inception to July 2022. All publications describing cases of internal spinal marking were included for further analysis. 22 articles describing 503 patients satisfied our eligibility criteria. RESULTS: A number of localisation techniques, including endovascular coiling (n = 16), fiducials (n = 177), dye (n = 109), needle/fixed wire (n = 199), cement (n = 4), and gadolinium tubes (n = 1) were described. The highest rates of technical success were observed with endovascular coiling, fiducials, cement and dye (100 %), and complication rates were lowest with endovascular coiling, fiducials and cement (0 %). CONCLUSIONS: Overall, internal spinal marking was effective and safe. When considering practicality and efficacy, fiducial marking appears the optimal technique, as it can be performed in the outpatient setting under local anaesthesia. This review demonstrates the need for more targeted investigation into localisation methods in spinal surgery.

Quality of life and surgical outcomes in incidental pituitary adenomas undergoing endoscopic endonasal resection.

OBJECTIVE: Incidental, asymptomatic pituitary adenomas require nuanced, shared decision-making, which is limited by a poor understanding of their natural history and effects on quality of life (QOL). A greater understanding of the effects of surgery would inform evidence-based care. METHODS: A multicenter review of consecutive pituitary adenomas resected via an endoscopic endonasal approach (EEA) between late 2016 and mid-2021 was performed, with prospective, longitudinal QOL assessment (at 3 and 6 weeks and at 3, 6, and 12 months) postoperatively using the 35-item Anterior Skull Base Questionnaire. RESULTS: Of 366 adenomas resected during the study period, 52 (14.2%) were incidentally discovered, of which 51 (98.1%) were macroadenomas. Preoperative QOL in patients with these incidentalomas was better than in those with adenomas presenting with endocrinopathy (p < 0.01), visual failure (p = 0.02), or headache (p = 0.03). Surgery was performed due to visual field deficits (13.5%, n = 7); ophthalmoplegia (1.9%, n = 1); radiological compression or contact of the optic apparatus (63.5%, n = 33); functional status (growth hormone-secreting tumor) (5.8%, n = 3); and clinically significant growth (15.4%, n = 8). Surgical outcomes were excellent, with vision improved in 100% (7/7) and complete resection in 84.6% (44/52). There were 2 (3.8%) cases of new cortisol deficiency, 3 (5.8%) cases of transient postoperative diabetes insipidus, and 4 (7.7%) cases of postoperative hyponatremia. There were no perioperative complications and no cases of postoperative CSF leakage. QOL transiently decreased during the first 3 weeks after surgery, then improved to above baseline levels by 3 months (p = 0.03) and continued to improve throughout the first postoperative year (p = 0.03). All surgical indications demonstrated an overall mean improvement in QOL at 3 months. QOL benefits were not affected by age or tumor size. CONCLUSIONS: Resection of pituitary adenomas via the EEA provided a tangible benefit for patients within 3 months. Surgery via the EEA is safe, effective, and beneficial for patients with pituitary incidentalomas meeting accepted criteria for intervention.

The HACKD Score-Predicting Extent of Resection of Pituitary Macroadenomas Through an Endoscopic Endonasal Transsphenoidal Approach.

BACKGROUND: Predicting extent of resection before pituitary surgery is imperative for operative planning and patient counseling. In the era of endoscopic endonasal transsphenoidal surgery (EEA), a specific, reliable tool for predicting resection of macroadenomas would have widespread applications. OBJECTIVE: To identify factors that predict resection of pituitary macroadenomas through the EEA. METHODS: A prospectively maintained, multicenter database of 277 consecutive macroadenomas resected through the EEA was analyzed. Multivariate logistic regression identified predictors of gross total resection (GTR). A simple scoring system, the Hardy, Age, Clival, Knosp, Depth (HACKD) Score, was developed and tested. RESULTS: GTR was achieved in 82.3% (228/277) of cases. Older than 50 years (odds ratio [OR] 2.96, P = .01), clival extension (OR 5.87, P < .01), Hardy grade C or D suprasellar extension (OR 3.91, P = .01), Knosp grade 3 or 4 cavernous sinus invasion (OR 7.62, P < .01), and tumor depth >20 mm (OR 5.14, P < .01) were all associated with subtotal resection. The HACKD score, awarding 1 point each for Hardy grade C or D, and older than 50 years, and 2 points each for clival extension, Knosp grades 3 or 4, and tumor depth >20 mm, demonstrated excellent discriminative ability (AUROC 0.887, 95% CI: 0.839-0.934). The rate of GTR progressively decreased with a higher HACKD score. Rates of GTR were 95.8% (182/190) for low (HACKD ≤2), 59.5% (44/74) for moderate (HACKD 3-5), and 15.4% (2/13) for high (HACKD 6+) HACKD scores. CONCLUSION: The HACKD score is a simple and accurate tool based on the largest study analyzing predictors of GTR in pituitary macroadenomas operated through the EEA.

Validation of the anterior skull base questionnaire 35 in endoscopic pituitary adenoma surgery.

Patient quality of life (QOL) is an important metric of surgical success. To guide therapeutic advances in pituitary adenoma surgery, a validated, comprehensive instrument to quantify QOL is required. We aim to evaluate the validity of the 35 item anterior skull base questionnaire (ASBQ-35) in patients undergoing pituitary adenoma surgery. A total of 168 patients undergoing endoscopic resection of pituitary adenomas underwent longitudinal QOL assessment using the ASBQ-35 and the 22-item Sinonasal Outcomes Test (SNOT-22) over the first postoperative year. Validity of the ASBQ-35 was assessed by internal consistency, test-retest reliability, responsiveness to clinical change, and concurrent validity with the SNOT-22. Internal consistency of the ASBQ-35 was excellent, with a Cronbach's alpha > 0.95 across all timepoints. Test-retest reliability between 3 and 6 months (ICC = 0.82, p < 0.001) and 6 months and 12 months (ICC = 0.78, p < 0.001) was robust. Concurrent validity with SNOT-22 was strong across all timepoints (absolute Pearson r ≥ 0.63, p < 0.001). Mean ASBQ-35 scores were significantly worse at 3 weeks compared to preoperative baseline (mean difference - 0.28, p < 0.01); however, by 12 months, scores had significantly improved (mean difference + 0.24, p < 0.01), indicating that the scale is responsive to clinical change. Each of the 6 domains of the ASBQ, and all 35 component questions, contributed to the discriminative of the ASBQ to measure QOL during the first postoperative year. The ASBQ-35 is a valid, comprehensive tool for assessing QOL after endoscopic pituitary adenoma surgery. Each component of the ASBQ-35 contributed to the overall assessment of QOL during the first postoperative year.

Postoperative fluid restriction to prevent hyponatremia after transsphenoidal pituitary surgery: An updated meta-analysis and critique.

BACKGROUND: Hyponatremia is a common and potentially dangerous complication of transsphenoidal surgery. Prophylactic postoperative fluid restriction has been trialled as a method to reduce the incidence of postoperative hyponatremia. METHODS: A systematic review of the literature was performed in accordance with the PRISMA statement. Risk of bias was assessed using the MINORS criteria. Meta-analysis was performed using the random-effects model. RESULTS: A total of 6 retrospective cohort studies were available for analysis. Fluid restriction was commonly between 1000 and 1500 ml/day and limited to the first postoperative week. Overall, the rate postoperative hyponatremia was fourfold less in the fluid restricted cohorts (3.4 % vs 11.2 %, OR 0.24 (95 %CI 0.15-0.38), p < 0.01). There was no difference in readmission rates (1.4 % vs 3.9 %, OR 0.32 (95 %CI 0.09-1.13), p = 0.08) or postoperative diabetes insipidus (14.5 % vs 18.6 %, OR 0.82 (95 %CI 0.50-1.36), p = 0.45) between fluid restricted and control cohorts. CONCLUSION: Prophylactic postoperative fluid restriction is a cheap, easily implemented intervention that appears to reduce the rate of postoperative hyponatremia, but not necessarily re-admission rates. Whether these prevented cases of hyponatremia are clinically significant remains to be demonstrated.

Predictors of improvement in quality of life at 12-month follow-up in patients undergoing anterior endoscopic skull base surgery.

BACKGROUND: Patients with pituitary lesions experience decrements in quality of life (QoL) and treatment aims to arrest or improve QoL decline. OBJECTIVE: To detect associations with QoL in trans-nasal endoscopic skull base surgery patients and train supervised learning classifiers to predict QoL improvement at 12 months. METHODS: A supervised learning analysis of a prospective multi-institutional dataset (451 patients) was conducted. QoL was measured using the anterior skull base surgery questionnaire (ASBS). Factors associated with QoL at baseline and at 12-month follow-up were identified using multivariate logistic regression. Multiple supervised learning models were trained to predict postoperative QoL improvement with five-fold cross-validation. RESULTS: ASBS at 12-month follow-up was significantly higher (132.19,SD = 24.87) than preoperative ASBS (121.87,SD = 25.72,p<0.05). High preoperative scores were significantly associated with institution, diabetes and lesions at the planum sphenoidale / tuberculum sella site. Patients with diabetes were five times less likely to report high preoperative QoL. Low preoperative QoL was significantly associated with female gender, a vision-related presentation, diabetes, secreting adenoma and the cavernous sinus site. Top quartile change in postoperative QoL at 12-month follow-up was negatively associated with baseline hypercholesterolemia, acromegaly and intraoperative CSF leak. Positive associations were detected for lesions at the sphenoid sinus site and deficient preoperative endocrine function. AdaBoost, logistic regression and neural network classifiers yielded the strongest predictive performance. CONCLUSION: It was possible to predict postoperative positive change in QoL at 12-month follow-up using perioperative data. Further development and implementation of these models may facilitate improvements in informed consent, treatment decision-making and patient QoL.

Relationship between herniated intervertebral disc fragment weight and pain in lumbar microdiscectomy patients.

OBJECTIVE: The relationship between lumbar disc herniation (LDH) size and the severity of preoperative pain and its impact on postoperative recovery is incompletely understood. This study was conducted to investigate the association between herniated disc fragment weight and pain before and after microdiscectomy. METHODS: A consecutive series of patients from an ongoing randomised controlled trial (ACTRN12616001360404) were included in this study. Included patients were aged between 18 and 75, had a clinical diagnosis of radiculopathy, and MRI evidence of a concordant single-level lumbar disc herniation. All patients underwent standard microdiscectomy without aggressive discectomy or curettage of the endplates. Disc fragment weight was measured intraoperatively. RESULTS: A total of 122 patients with a mean age of 49.5 ± 12.8 years, were included. The median weight of disc fragment was 0.545 g (95% CI 0.364 - 0.654 g). There was no relationship between disc weight and the duration of symptoms (p = 0.409) severity of preoperative leg pain (p = 0.070) or preoperative back pain (p = 0.884). Disc fragment weight was demonstrated to have no correlation with clinically significant postoperative leg pain improvement (p = 0.535) or back pain (p = 0.991). Additional LDH factors, including radiological percentage of canal compromise (p = 0.714), herniation classification (p = 0.462), and vertebral level (p = 0.788) were also shown to have no effect on leg pain outcomes. CONCLUSIONS: Disc fragment weight had no effect on the severity of pain at presentation or after microdiscectomy. Patients benefit from surgery equally, regardless of the size of LDH.

Quality of Life in Craniopharyngioma: A Systematic Review.

BACKGROUND: Craniopharyngiomas are morbid tumors that significantly reduce patients' quality of life (QoL). The lifelong burden of endocrine, visual, hypothalamic, and limbic dysfunction can have disastrous consequences for the physical and psychosocial health of patients. Elucidating the factors that influence QoL could guide therapeutic interventions to improve patient well-being. METHODS: A systematic review was performed in accordance with the PRISMA (preferred reporting items for systematic reviews and meta-analyses) statement using the PubMed and Medline databases. Studies that had reported patient QoL using validated metrics in both adult and pediatric populations were included. Bias and methodological rigor were assessed using the MINORS (methodological index for nonrandomized studies) criteria. RESULTS: A total of 25 studies, including 2025 patients, were available for review. Most studies were small, retrospective, cohort studies with a high risk of bias. The QoL of the patients with craniopharyngioma was lower than that of the general population. Hypothalamic involvement was consistently the strongest predictor of QoL. Endocrinopathy contributed to morbidity but could be ameliorated by hormone replacement therapy. Social and emotional dysregulation and a poor memory are common complaints after surgery, and iatrogenic damage to the infundibulum, hypothalamus, limbic system, and frontal lobes might underlie these concerns. Sleep-wake cycle dysfunction and hypothalamic obesity are serious consequences of hypothalamic damage. CONCLUSIONS: An experienced multidisciplinary team is necessary to optimally manage the complex cases of these patients. The poor QoL of patients with craniopharyngioma is multifactorial. However, the contribution of iatrogenesis is not insubstantial. Improved surgical techniques, focusing on hypothalamic preservation, and adjuvant treatment options are required to improve the well-being of these patients.

Charting the potential of brain computed tomography deep learning systems.

Brain computed tomography (CTB) scans are widely used to evaluate intracranial pathology. The implementation and adoption of CTB has led to clinical improvements. However, interpretation errors occur and may have substantial morbidity and mortality implications for patients. Deep learning has shown promise for facilitating improved diagnostic accuracy and triage. This research charts the potential of deep learning applied to the analysis of CTB scans. It draws on the experience of practicing clinicians and technologists involved in development and implementation of deep learning-based clinical decision support systems. We consider the past, present and future of the CTB, along with limitations of existing systems as well as untapped beneficial use cases. Implementing deep learning CTB interpretation systems and effectively navigating development and implementation risks can deliver many benefits to clinicians and patients, ultimately improving efficiency and safety in healthcare.