Comparison Between Ventricular and Spinal Infusion Tests in Suspected Normal Pressure Hydrocephalus.

Idiopathic normal pressure hydrocephalus (iNPH) is an often-overlooked or misdiagnosed brain disorder characterized by overt ventriculomegaly and associated with gait disturbances, cognitive impairment, and urinary incontinence. If correctly diagnosed, it is considered the only form of dementia treatable with surgery, namely through a ventriculoperitoneal or ventriculoatrial shunt with programmable valves.Among the 856 spinal and ventricular infusion tests performed from 2001 to 2017 at our institution, we analyzed 106 cases selected for suspected normotensive hydrocephalus. In all cases, Intracranial Elastance Index (IEI) and outflow resistance (Rout) values were calculated: 52 of these patients underwent Spinal Katzman Test (SKT), and the remaining 54 underwent an intraventricular infusion test (IVKT). Of the 40 patients in the SKT group with pathological elastance (71%), 17 also had a Rout >12 mmHg and 23 a Rout <12 mmHg. Of the 50 patients in the IVKT group with pathological elastance (92%), 38 also had a Rout >12 mmHg and 12 a Rout <12 mmHg.IVKT and SKT to date represent two useful tools in the diagnosis of normal pressure hydrocephalus. Despite being more invasive, IVKT, including both the intracranial elastance index (IEI) and Rout analysis, could be considered more reliable than SKT and therefore could be reserved for the most controversial cases.

Clinical and radiological outcomes following open door laminoplasty: a single center evolution of the technique.

BACKGROUND: The aim of the present study was to compare and describe clinical and radiological outcomes after two different variants of open door laminoplasty for cervical spondylotic myelopathy (CSM). METHODS: Fifty-five patients underwent cervical laminoplasty for CSM. Between 2005 to 2009, 32 patients underwent open-door laminoplasty (Group A) performed with a monolateral exposure with contralateral "green stick" laminar fracture. A technical variant consisting in bilateral exposure, spinous process removal and symmetrical muscular closure was applied in the other 23 (Group B), from 2009 to 2016. A retrospective analysis of surgical results between the two groups was performed. RESULTS: In group B, the mean operative time was longer, and the mean volume of intraoperative blood loss was much higher than in group A. Both differences were not significant (P=0.1601 and P=0.0884, respectively). The average hospitalization was non-significantly longer in group B (7.3±1.8 vs. 6.5±1.6 d; P=0.0947). Postoperatively, axial neck pain was more severe in group A at last follow-up than preoperatively (P>0.05). mJOA scores and Nurick grades improved significantly in both groups at last follow-up; in group A, the mean recovery rates were 41.5% by mJOA scores and 29.4% by Nurick grades, whereas in group B they were 52.7% and 36.8%, respectively. CONCLUSIONS: Applying some few variations to a standard monolateral approach, although slightly more time and blood consuming, could reduce the incidence of long-term axial symptoms and, in our experience, are not burdened by worsening of outcomes. A prospective, multicentric study with a longer follow-up should be conducted in order to confirm our findings.

Impact of 4K ultra-high-definition endoscope in pituitary surgery: analysis of a comparative institutional case series.

BACKGROUND: Trans-sphenoidal endoscopic surgery has drawn huge benefits from advances in surgical visualization. The Ultra-HD "4K" endoscope has improved 4-fold image resolution compared with HD, but its actual advantages are unclear. Aim of the present study was to assess its usefulness in the early outcome of trans-sphenoidal surgery. METHODS: We analyzed a series of 199 trans-sphenoidal pituitary adenoma procedures performed by an experienced team using alternatively HD (N.=102) or 4K (N.=97) endoscopes. We evaluated extent of resection both subjectively, based on intraoperative surgeon's impression, and objectively based on postoperative MR scan. RESULTS: Baseline patients' characteristics were balanced. Objective near-total and total resection rates were comparable between 4K and HD groups (91.5% vs. 86.3% and 64.9% vs. 56.9%, respectively). 4K endoscope slightly improved resection rate in recurrent adenoma. At multivariate analysis, the only independent prognosticator of total resection was cavernous sinus invasion. Importantly, 4K endoscope enhanced the reliability of intraoperative judgement on extent of resection, significantly reducing unexpected residuals (12.8% vs. 33.3% for HD). Operative features and clinical outcomes were similar. CONCLUSIONS: The HD endoscope remains the standard-of-care for pituitary surgery. The 4K enhanced, "immersive" visualization significantly improved the reliability of surgeon's judgment on resection and might be useful in surgically difficult cases.

Reappraising the Role of Trans-Sphenoidal Surgery in Prolactin-Secreting Pituitary Tumors.

BACKGROUND: Prolactinomas represent a unique challenge for endocrinologists and neurosurgeons. Considering recent innovations in surgical practice, the authors aimed to investigate the best management for prolactinomas. METHODS: A retrospective, cross-sectional and monocentric study was designed. Consecutive patients affected by prolactinomas were enrolled if treated with a first-line treatment with a dopamine agonist (DA) or trans-sphenoidal surgery (TSS). Patients carried giant prolactinomas, and those with a follow-up <12 months were excluded. RESULTS: Two hundred and fifty-nine patients were enrolled. The first treatment was DA for 140 patients and TS for 119 cases. One hundred and forty-six of 249 patients (58.6%) needed a second therapy. The mean follow-up was 102.2 months (12-438 months). Surgery highly impacted on the cure rate-in particular, in females (p = 0.0021) and in microprolactinomas (p = 0.0020). Considering the multivariate analysis, the female gender and surgical treatment in the course of the clinical history were the only independent positive predictors of a cure at the end of 5 years follow-up (p = 0.0016, p = 0.0005). The evaluation of serum prolactin (24 hours after TSS) revealed that 86.4% of patients with postoperative prolactin (PRL) ≤10 ng/mL were cured at the end of the follow-up (p < 0.0001). CONCLUSIONS: According to our experience, surgery allows a high cure rate of prolactinomas, particularly in females with microadenoma, with a good safety profile. TSS for prolactinomas should be considered as a concrete option, during the multidisciplinary evaluation, in centers of reference for pituitary diseases.

Galectin-3 and Estrogen Receptor Alpha as Prognostic Markers in Prolactinoma: Preliminary Results From a Pilot Study.

Introduction: Prolactin-secreting pituitary tumors (PRL-omas) are generally benign neoplasia. However, a percentage of cases show aggressive behavior. Prognostic markers may allow for the identification of aggressive cases. In this study, we investigated the prognostic role of galectin-3 and the estrogen receptor alpha (ERα), as predictive biomarkers of aggressiveness and poor prognosis. Patients and Methods: A mono-centric and retrospective study was conducted on consecutive cases of PRL-omas that underwent first line treatment with surgery and were followed-up for at least five years. The immunohistochemical expression of ERα and galectin-3 was investigated in each case. Results: 36 patients were enrolled. Galectin-3 resulted positive in 11 patients (30.6%). The median expression of ERα was 85% (IQR: 37). Among the group of 21 patients who underwent radical surgery (58.3%), recurrence occurred in 12 cases (33.3%). 27 patients were treated post-surgery with a dopamine agonist (DA) (12 for recurrence and 22 for a history of partial surgery). 13 patients (48.1%) were responsive to DA. Six of 11 cases positive for galactin-3 underwent partial surgery (54.5%, p<0.001). Recurrence occurred in all five cases that underwent radical surgery, which were also positive for galectin-3 (p=0.03). Galectin-3 resulted positive in 9 patients resistant to DA treatment (81.1%, p=0.01). ERα expression was lower in tumors positive for galectin-3 (p<0.001), with mitotic activity (p=0.012), with higher Ki67 Li (p<0.001), and in males with post-surgical recurrence (p<0.001). Conclusion: Galectin-3 and ERα play as markers of aggressiveness and prognosis in PRL-omas and may be tested to identify the aggressive forms of the disease.

Intraventricular infusion test accuracy in predicting short- and long-term outcome of iNPH patients: a 10-year update of a three-decade experience at a single institution.

OBJECTIVE: In a previous work, we found that an Intracranial Elastance Index (IEI) ≥0.3 at ventricular infusion test had a high accuracy in predicting shunt response at 6 and 12 months in idiopathic normal pressure hydrocephalus (iNPH). The aim of this study was to verify the accuracy of IEI to predict response to shunt at both short- and long-term follow-up. METHODS: Retrospective evaluation of 64 patients undergoing ventriculo-peritoneal shunting for iNPH between 2006 and 2015 based on a positive ventricular infusion test (IEI≥0.3). Patients were classified according to Krauss scale and mRS preoperatively, at 1-year and at last follow-up. An improvement of at least one point at Krauss score or at mRS was considered as a good outcome; unchanged or worsened patients were grouped as poor outcome. RESULTS: Mean follow-up was 6.6 years. Improvement at Krauss scale was seen in 62.5% and 64.3% of patients at 1-year and last follow-up, respectively. Patients in good functional status (mRS≤2) increased from 25 in the preoperative period to 57% at both 1-year and last follow-up. IEI was significantly associated with Krauss (p=0.041) and mRS (p=0.036) outcome at last follow-up. Patients with worse preoperative Krauss and mRS had higher chance to improve but higher overall scores after treatment. At ROC curves, IEI showed a good long-term prediction of change in mRS from first year to last follow-up. CONCLUSIONS: IEI≥0.3 predicts outcomes at both short- and long-term, with more than 50% of patients being able to look after themselves after 6 years from treatment.

Long-standing Overt Ventriculomegaly in Adults and Endoscopic Third Ventriculostomy, the Perfect Treatment for the Proper Diagnosis.

OBJECTIVE: Long-standing overt ventriculomegaly in adults (LOVA) is form of hydrocephalus that develops during childhood, manifesting its symptoms during adulthood. Only a small number of LOVA case series have been published, and controversies regarding optimal management still exist. The authors collected a series of symptomatic LOVA patients treated successfully using endoscopic third ventriculostomy (ETV), aiming to strengthen what has been reported in the literature on ETV's role in both neurologic and neurocognitive outcomes. METHODS: Between 2002 and 2020, we collected 40 case studies of patients treated using an ETV. Associated pathologies were documented in 14 cases. All patients underwent magnetic resonance scans preoperatively and postoperatively while only 29 patients were submitted during follow-up to neurocognitive assessment. RESULT: At a mean follow-up of 6 years, 36 patients (90%) reported either an improvement or a stabilization of their presenting symptoms. Headache improved subjectively in 11 patients (27.5%), balance and gait disturbances improved in all patients, urinary incontinence improved in 24 patients (60%), memory disturbances subjectively improved in 21 patients (52.5%), and visual deficits improved in 5 patients (12.5%). Four patients (10%) had symptom progression, which occurred 6 to 24 months after surgery with radiologic evidence of ETV failure. CONCLUSIONS: LOVA is a form of hydrocephalus that must be correctly identified. A correct magnetic resonance study and comprehensive neuropsychologic assessment are crucial to identify it in order to define proper management. From our analysis, ETV represents the gold standard treatment granting rewarding results that are maintained in a long-term follow-up.

Do antiplatelet and anticoagulant drugs modify outcome of patients treated for chronic subdural hematoma? Still a controversial issue.

BACKGROUND: Anticoagulants (ACs) and antiplatelet aggregation agents (AAAs) seem to be correlated to a higher incidence of chronic subdural hematoma (CSDH) but whether or not they contribute to its recurrence is debated. Few data are available on clinical outcomes and indications for the management of this therapy are not so well defined. We investigated the role of ACs and AAAs in modifying patients' clinical outcomes treated for CSDH, especially for re-bleedings. METHODS: This retrospective study, enrolled patients treated for CSDH. Patients characteristics were recorded including drugs used (antiplatelet/anticoagulant) and clinical conditions (Modified Rankin Scale [mRS]) upon admission. Patients underwent surgery (burrhole vs. minicraniectomy) with subdural drainage positioning. Clinical/radiological follow-ups were performed at one and six months. Chi-square/Fisher's Exact test were used to compare variables and stepwise backward logistic regression analysis was used for defining their impact on complications, risk of re-bleeding and reoperation. RESULTS: Overall, 230 patients (45 on ACs, 76 on AAAs and nine on both) were enrolled. Higher mRS scores were significantly associated with a higher risk of general complications (OR=3.78, 95% CI: 1.66-8.62, P=0.002), higher risk of rebleeding (OR =15.82, 95% CI: 4.33-57.90, P<0.001) and re-operation (OR=11.39, 95% CI: 3.35-37.56, P<0.0001). No statistically significant association was found between AAAs or ACs and complications or re-bleedings or risk of reoperation. CONCLUSIONS: AAAs and ACs alone do not seem to worsen the clinical outcome or increase re-bleedings. mRS may be a predicting factor, since patients with higher scores showed a worse outcome and an increased risk of re-bleeding, general complications and reoperation.

Usefulness of Brain Positron Emission Tomography with Different Tracers in the Evaluation of Patients with Idiopathic Normal Pressure Hydrocephalous.

Idiopathic normal pressure hydrocephalus (iNPH) is the only form of dementia that can be cured by surgery. Its diagnosis relies on clinical and radiological criteria. Identifying patients who can benefit from surgery is challenging, as other neurological diseases can be concomitant or mimic iNPH. We performed a systematic review on the role of positron emission tomography (PET) in iNPH. We retrieved 35 papers evaluating four main functional aspects with different PET radiotracers: (1) PET with amyloid tracers, revealing Alzheimer's disease (AD) pathology in 20-57% of suspected iNPH patients, could be useful in predictions of surgical outcome. (2) PET with radiolabeled water as perfusion tracer showed a global decreased cerebral blood flow (CBF) and regional reduction of CBF in basal ganglia in iNPH; preoperative perfusion parameters could predict surgical outcome. (3) PET with 2-Deoxy-2-[18F]fluoroglucose ([18F]FDG ) showed a global reduction of glucose metabolism without a specific cortical pattern and a hypometabolism in basal ganglia; [18F]FDG PET may identify a coexisting neurodegenerative disease, helping in patient selection for surgery; postsurgery increase in glucose metabolism was associated with clinical improvement. (4) Dopaminergic PET imaging showed a postsynaptic D2 receptor reduction and striatal upregulation of D2 receptor after treatment, associated with clinical improvement. Overall, PET imaging could be a useful tool in iNPH diagnoses and treatment response.

Tumour-infiltrating cytotoxic T lymphocytes in somatotroph pituitary neuroendocrine tumours.

INTRODUCTION: Somatotroph pituitary tumours are often resistant to first-generation somatostatin analogues and can invade the surrounding structures, limiting the chances of curative surgery. Recent studies suggested that the immune microenvironment and pro-angiogenic factors can influence neuroendocrine tumour prognosis. In this study, we aimed to investigate the prognostic role of immune cell-specific markers and endocan, a proteoglycan involved in neoangiogenesis and cell adhesion, in a cohort of acromegaly patients who underwent pituitary surgery as first-line treatment. SUBJECTS AND METHODS: Sixty four eligible subjects were identified. CD4+, CD8+ and CD68+ cells and endocan expression were evaluated by immunohistochemistry and results correlated with clinical and neuroradiological findings. Responsiveness to somatostatin analogues was assessed in patients with persistent disease following surgery. RESULTS: The number of CD8+ lymphocytes was significantly lower in tumours with cavernous sinus invasion (median 0.2/HPF, IQR: 2.2) compared with those without cavernous sinus invasion (median 2.4/HPF, IQR: 2.3; P = 0.04). Tumours resistant to first-generation somatostatin analogues had lower CD8+ lymphocytes (median 1/HPF, IQR: 2.4) compared with responders (median 2.4/HPF, IQR: 2.9; P = 0.005). CD4+ lymphocytes were observed sporadically. The number of CD68+ macrophages and the endothelial or tumour cell endocan expression did not differ based on tumour size, cavernous sinus invasion or treatment responsiveness. CONCLUSIONS: Our study suggests that a lower number of CD8+ lymphocytes is associated with cavernous sinus invasion and resistance to treatment with first-generation somatostatin analogues in acromegaly patients. These results highlight a potential role of the tumour immune microenvironment in determining the prognosis of somatotroph pituitary tumours.

Pasireotide and Pegvisomant Combination Treatment in Acromegaly Resistant to Second-Line Therapies: A Longitudinal Study.

CONTEXT: The treatment of acromegaly resistant to first- and second-line therapies can be extremely challenging. DESIGN: We have described six patients who were successfully treated with a combination therapy of pasireotide and pegvisomant and compared them with a control group of patients resistant to conventional somatostatin analogs (SSAs), whose disease was controlled with other treatment, such as pasireotide (as monotherapy) or pegvisomant (as monotherapy or combined with conventional SSAs). RESULTS: In these six patients, acromegaly was controlled with combined pasireotide and pegvisomant treatment after failure of all other treatments. Compared with the 49 patients in the control group, these six patients had giant and invasive pituitary adenomas (at both the cavernous sinus and other structures). Although not statistically significant, higher growth hormone levels, more elevated Ki-67 expression, greater somatostatin receptor (SSTR) subtype 5 expression, and lower SSTR subtype 2 expression at the diagnosis of acromegaly were detected in patients receiving combination treatment with pasireotide and pegvisomant compared with the control group. CONCLUSION: Our data have reinforced the importance of personalized treatment of patients with acromegaly according to the clinical, biochemical, molecular, and morphological disease markers and suggest that combined treatment with pasireotide and pegvisomant can induce disease control in tumors with low SSTR2 expression, resistant to conventional SSAs (alone or combined with pegvisomant) and to new-generation SSAs alone (pasireotide).

Short- and long-term responsiveness to low dose growth hormone (GH) in adult GH deficiency: Role of GH receptor polymorphism.

In patients with growth hormone (GH) deficiency (GHD), low doses of recombinant human GH (rhGH) have a similar or better long-term clinical effect than higher doses. Pharmacogenetic studies suggest that GH receptor (GHR) polymorphism only influences some metabolic parameters. Nonetheless, there is no clear scientific evidence proving the effects of lower rhGH dose regimens on metabolic parameters. The aim of our prospective study was to evaluate the effects of GHR polymorphism in adult GHD patients treated with low rhGH dose during short- (6 and 12 months) and long-term (5 years) follow-up. Sixty-nine GHD adult patients were studied, before and during treatment with rhGH, using a standardised low-dose protocol calculated on the basis of body weight (0.01-0.03 mg kg-1  week-1 ) and monitored by an insulin-like growth factor (IGF)-I plasma assay, as well as anthropometric and metabolic parameters. The GHR genotype (flfl, fld3 or d3d3) was determined from the peripheral blood. d3-GHR carriers showed a more effective short- and long-term response to low rhGH dose with respect to low-density lipoprotein reduction, body composition and blood pressure (homozygous patients only); d3-GHR homozygosity is related to a significant IGF-I increase during short-term follow-up. Regression analysis demonstrated that rhGH dose, age at diagnosis and GHR genotype are the major determinants of IGF-I increase at 6 and 12 months of replacement therapy. The d3d3-GHR genotype may influence some metabolic effects during the short- and long-term follow-up of low rhGH dose and could be an independent determinant of the increase of IGF- I during short-term follow-up.

Bullough's Lesion: An Unexpected Diagnosis After the Resection of a Slowly Growing Osseous-Like Retroauricular Bump-Case Report and Review of the Literature.

We describe the case of a 33-year-old woman with a history of over 15 years of a slow growing firm osseous-like right retroauricular mass. Surgical resection was easily performed using a sharp technique, because of a clear cleavage plane. The histologic diagnosis was a rare, unexpected, protuberant fibro-osseous lesion named "Bullough lesion." Only few cases of this benign pathologic entity have been described in English literature. Clinical differential diagnosis must be done with osteoma, periosteal chondroma, and other fibro-osseous lesions such as fibrodysplasia and ossifying fibroma. Because of the paucity of data, the natural history of this lesion is unknown and serial clinical and radiological follow-up is advised.

Comparison of Endoscopic Versus Microsurgical Resection of Pituitary Adenomas with Parasellar Extension and Evaluation of the Predictive Value of a Simple 4-Quadrant Radiologic Classification.

BACKGROUND: The amount of parasellar extension is a known limitation for gross total resection (GTR) of pituitary adenomas. Endoscopic technique seems to improve resection of adenomas extending laterally. Knosp classification is used to evaluate the extent of parasellar invasion: increasing Knosp grades correspond with lower rates of GTR. The 4-quadrant method could help to estimate the risk of partial resection in adenomas with parasellar extension. The objective of this study was to compare the rate of GTR between microsurgical and endoscopic techniques in pituitary adenomas with parasellar extension. The secondary aim was to compare the predictive value of Knosp classification and of the 4-quadrant classification regarding GTR. METHODS: This was a retrospective comparison of GTR in different Knosp grades and per quadrant in 55 consecutive patients who underwent microsurgical (n = 28, 2001-2008) or endoscopic (n = 27, 2008-2016) resection of a pituitary adenoma with parasellar extension. RESULTS: The endoscopic group (19/27 patients) had a significant higher rate of GTR than the microsurgical group (8/28 patients) (P = 0.005). This was evident in all patients but those with Knosp grade 4. Using the quadrant classification, the endoscopic group had a significantly higher rate of GTR than the microsurgical group in all but the inferolateral quadrant. The 2 classifications showed similar sensitivity in predicting subtotal resection (78% quadrant vs. 82% Knosp), with limited specificity (both 25%). CONCLUSIONS: GTR of macroadenomas with parasellar extension is significantly enhanced by the endoscopic approach. The 4-quadrant classification appears as sensitive as the Knosp classification and could be a simple adjunct to predict surgical radicality, in particular in cases of inferolateral quadrant invasion.

Hypofractionated stereotactic radiotherapy for oligometastatic patients: developing of a response predictive model.

OBJECTIVES: Treatment of oligometastatic patients is a current challenge in radiation oncology. Aim of this study is to define a dose-response relationship for hypofractionated radiotherapy of oligometastases. METHODS: Retrospective analysis of metastases treated by hypofractionated stereotactic radiotherapy was performed. Delivered dose was calculated both as biological effective dose (BED10), and as ratio between BED10 and the logarithm of metastasis volume (BED10 logVolume Ratio, BVR). Two dose-response models were defined by logistic regression. The fitted outcome was the Metastases Complete Response (MCR). Performances of the models were assessed by area under the receiver operating curve (AUC) and by bootstrap calibration of original data. BED10 and BVR impact on survival outcomes has been evaluated. RESULTS: Fifty-three patients with 79 metastases were analyzed. AUC and calibration of BVR-based logistic model showed better accuracy in predicting MCR with respect to BED10-based model. No significant difference between the two ROCs was observed (De Long test p value > 0.05), but significant discordance in calibration resulted in the BED10 model (p value < 0.05 in Hosmer-Lemeshow Goodness of fit test). BVR returned also better results in multivariate analyses for survival outcomes. CONCLUSIONS: The ratio between BED10 and the logarithm of metastasis volume (BVR), as a corrective factor for fitting the probability of metastases response to stereotactic radiotherapy, could be a tool for evaluating and prescribing treatments for oligometastatic disease. BVR can be useful for producing more reliable survival statistics too.

What Is the Best Timing of Repeated CT Scan in Mild Head Trauma with an Initially Positive CT Scan?

BACKGROUND: Mild traumatic brain injury (MTBI) is among the most common causes of emergency admission. Current guidelines have clearly evidenced risk factors and neurologic signs that should suggest computed tomography (CT) of the head at admission and indications for the first repeated CT scan. However, the role and frequency of further repeated CT scans after an initially positive scan are still unclear. METHODS: We retrospectively analyzed 222 patients admitted in our hospital for clinical observation after an MTBI and a positive initial scan. Repeated CT scans were categorized according to timing from the first scan. All the scans were evaluated for the presence of posttraumatic lesions. We classified the data in 3 groups according to the timing of CT scans: A (CT scans at t0-t12-t24), B (t0-t12-t48), and C (t0-t24-t48). Differences in worsening or stability of posttraumatic lesions were compared by the χ2 test. RESULTS: 146 CT scans were performed at t12, 81 at t24, and 143 at t48. The initial CT scan was positive for epidural hematoma in 17 cases, subdural hematoma in 106, subdural hygroma in 10, intracerebral contusion in 110, subarachnoid hemorrhage in 109, and intraventricular hemorrhage in 12. None of the posttraumatic lesions showed significant worsening or at the first or second CT scan in any of the 3 groups. CONCLUSIONS: The treatment of patients in clinically stable condition with an MTBI and posttraumatic intracranial lesions at initial CT scan has been shown to minimally benefit from repeated CT scans. Given neurologic stability, a control scan can be safely delayed up to 48 hours to avoid unnecessary scans.

Chronic subdural hematoma in patients aged 80 years and older: A two-centre study.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a common condition in the elderly, and the ageing of population will increase the number of "superaged" patients presenting this pathology for the years to come. Few studies investigating the outcome of superaged patients surgically treated for CSDH are available, and study populations are generally small. The outcome of surgically treated patients and risk factors are not completely clear. Aim of the work is to identify the risk factors which may influence the outcome of patients aged 80 years and older surgically treated for CSDH. PATIENTS AND METHODS: This is a retrospective two-centre study including 151 surgically treated patients. A univariate (Fisher exact test) and multivariate (logistic regression) analysis of possible risk factors influencing outcome was performed. Outcome was expressed as: 6-month clinical outcome, 6-month mortality, complications and length of hospital stay. RESULTS: Univariate analysis showed an association between Charlson Comorbidity Index (CCI) and 6-month clinical outcome (p = 0,048), complications (p = 0,034) and 6-month mortality (p = 0,007). Antithrombotic drugs were associated with longer hospital stay (p < 0,001). Logistic regression analysis showed an association between CCI and complications (p = 0,016, HR = 3,18) and 6-month mortality (p = 0,034, HR = 11,71), and between antithrombotic drugs and longer hospital stay (p = 0,002, HR = 3,07). CONCLUSIONS: Age alone is not a predictor of bad outcome for patients aged 80 years and older surgically treated for CSDH. Charlson Comorbidity Index (CCI) may prove a valuable outcome predicting tool in these patients, and a longer hospital stay may be anticipated for patients under antithrombotic agents.

Learning curve of endoscopic pituitary surgery: Experience of a neurosurgery/ENT collaboration.

For neurosurgeons, who are accustomed to the binocular microscope, there is a new learning curve that must be overcome for monocular endoscopic pituitary surgery. Different studies describe a learning curve between 15 and 200 procedures, after which both operative time and complications stabilize. In this retrospective study, we evaluate the endoscopic learning curve of our group, already trained in microsurgical transsphenoidal surgery, with the assistance of ear, nose, and throat (ENT) surgeons. From 2010 to 2015, a total of 95 patients with pituitary adenomas were treated with a purely endoscopic approach. The latest 48 patients treated with the endoscope (L group) were compared with the 47 initial patients treated with the endoscope (E group) and with 43 patients treated with the microscope (M group), in terms of surgical time, complications, and tumor removal rate. The complication rate was similar in all the groups, as was the rate of total adenoma resection. Mean surgical time was shorter in the L group than in the E group (115±36min vs. 157±46 min, p<0.001); the average operative time was also shorter in the L group than in the M group (135±43min). The estimated reduction in duration of surgery per 10 patients was 9min (p<0.001). Over time, blood transfusions discrepantly increased from the E group to the L group (11% vs. 31%). Because of the pivotal role of ENT in the transnasal stage of 50 endoscopic procedures, we obtained an operative time comparable to that of microscopic procedures, with similar complication rate and gross total resections. Neurosurgical-ENT combined follow-up proved to be a fundamental protection from late complications.