A systematic review and meta-analysis of major blood protein biomarkers that predict unfavorable outcomes in severe traumatic brain injury.

INTRODUCTION: Severe traumatic brain injury (TBI) presentation and late clinical outcomes are usually evaluated by the Glasgow Outcome Scale-Extended (GOS-E), which lacks strong prognostic predictability. Several blood biomarkers have been linked to TBI, such as Tau, GFAP, UCH-L1, S-100B, and NSE. Clinical values of TBI biomarkers have yet to be evaluated in a focused multi-study meta-analysis. We reviewed relevant articles evaluating potential relationships between TBI biomarkers and both early and 6-month outcomes. METHODS: All PubMed article publications from January 2000 to November 2023 with the search criteria "Protein Biomarker" AND "Traumatic Brain Injury" were included. Amongst all comparative studies, the sensitivity means and range values of biomarkers in predicting CT Rotterdam scores, ICU admission in the early period, or predicting GOS-E < 4 at the 6-month period were calculated from confusion matrices. Sensitivity values were modeled for each biomarker across studies and compared statistically for heterogeneity and differences. RESULTS: From the 65 articles that met the criteria, 13 were included in this study. Six articles involved early-period TBI outcomes and seven involved 6-month outcomes. In the early period TBI outcomes, GFAP had a superior sensitivity to UCH-L1 and S-100B, and similar sensitivity to the CT Rotterdam score. In the 6-month period TBI outcomes, total Tau and NSE both had significant interstudy heterogeneity, making them inferior to GFAP, phosphorylated Tau, UCH-L1, and S-100B, all four of which had similar sensitivities at 75 %. This sensitivity range at 6-month outcomes was still relatively inferior to the CT Rotterdam score. Total Tau did not show any prognostic advantage at six months with GOS-E < 4, and phosphorylated Tau was similar in its sensitivity to other biomarkers such as GFAP and UCH-L1 and still inferior to the CT Rotterdam score. CONCLUSION: This data suggests that TBI protein biomarkers do not possess better prognostic value with regards to outcomes.

Cerebral arterial vasospasm complicating supratentorial meningioma resection: illustrative cases.

BACKGROUND: Cerebral arterial vasospasm is a rare complication after supratentorial meningioma resection. The pathophysiology of this condition may be similar to vasospasm after aneurysmal subarachnoid hemorrhage, and treatment options may be similar. OBSERVATIONS: The authors present two cases of cerebral vasospasm after supratentorial meningioma resection and perform a systematic literature review of similar cases. LESSONS: Cerebral arterial vasospasm after supratentorial meningioma resection may be associated with significant morbidity due to cerebral ischemia if not addressed in a timely manner. Treatment paradigms may be adopted from the management of arterial vasospasm associated with subarachnoid hemorrhage.

Evaluation of Retrospective Patient Preference on Extent of Resection of Nonfunctioning Pituitary Adenomas.

BACKGROUND: Neurosurgeons treat nonfunctioning pituitary adenomas by surgical resection. Based on the adherence of the tumor to the normal pituitary gland, operative risks may include hormone replacement therapy for postoperative hypopituitarism with gross total resection that injures the gland or recurrent tumor with subtotal resection and purposeful avoidance of gland manipulation. None of the patients presented in this article had a preoperative preference regarding extent of resection. This study aimed to evaluate postoperative patient preferences regarding extent of resection. METHODS: Adult patients who underwent resection of adenomas between 2015 and 2023 were retrospectively reviewed and surveyed. After surgery, participating patients were asked for their preference regarding 100% tumor resection with lifelong daily hormone replacement therapy versus 90% tumor resection with a chance of recurrence in the hypothetical situation where the neurosurgeon encounters tumor adherent to the normal gland. RESULTS: Of the 73 patients included, 54 (74.0%) responded to the survey, with the majority (36 [66.7%]) preferring 90% resection with the chance of tumor recurrence. Tumor recurrence (odds ratio 2.3, 95% confidence interval 2.1-2.5, P = 0.03) and steroid avoidance (odds ratio 2.2, 95% confidence interval 2.0-2.4, P = 0.04) were the 2 variables that were significant predictors of patient preference in multivariate regression analysis. CONCLUSIONS: Although patients may not have the preoperative insight or experience to have a strong conviction regarding the extent of adenoma resection, the consequences following surgery clearly influence their preference. Most patients in our study, including patients with gross total resection and especially patients who experienced side effects of steroid therapy, preferred subtotal resection with the chance of tumor recurrence over hormone replacement therapy.

Posters Presented at North American Skull Base Society 2016-2018: What Factors Influence Their Publication?

Objective Research productivity impacts an individual's academic credentials and serves to advance the field of neurosurgery at large. Poster presentations allow researchers to share preliminary results with respected colleagues; however, more critical is the ability to publish peer-reviewed articles. Key factors that lead posters to journal publication are not well understood and difficult to quantify. This study investigates the association between bibliometrics of authors who presented posters at the North American Skull Base Society (NASBS) meeting and odds of journal publication. Methods Posters from the 2016 to 2018 NASBS archive were reviewed. Hirsch-index (h-index) of first (FH) and senior (SH) authors, research type, research topic, and number of poster authors (nAuthPost) were collected. For posters published as journal articles, number of days from poster presentation to publication (nDays), number of authors in published articles (nAuthArt), and journal impact factor (JIF) were recorded. Results One-hundred sixty-nine of 481 posters (35.1%) were published as articles. Median FH and SH for published versus unpublished posters were 7 versus 5 ( p = 0.01) and 29 versus 19 ( p < 0.001), respectively. When adjusted with multivariate regression, only SH ( p < 0.001) and nAuthPost ( p = 0.001) were significantly associated with odds of publication. Median (interquartile range [IQR]) nDays was 361 (394). Increased authors from poster to article ( p = 0.017) and lower FH ( p = 0.08) were correlated with increased time to publication. Median (IQR) JIF for all publications was 1.723 (1.068). Conclusions Bibliometrics such as h-index and number of authors from posters can help objectively characterize and predict future success in research productivity.

MGMT Methylated High Grade Glioma with Distant Recurrence and Stable Original Tumor Site: Case Series.

We present three cases of O6-Methylguanine-DNA Methyl-transferase (MGMT) methylated high grade gliomas with distant recurrence. All three patients had a radiographic stability of original tumor site at time of distant recurrence indicating impressive local control with Stupp protocol in patients with a MGMT methylated tumors. All patients had a poor outcome after distant recurrence. For one patient Next Generation Sequencing (NGS) was available for both original and recurrent tumor and did not reveal any difference other than high tumor mutational burden in the distant recurrent tumor. Understanding risk factors of distant recurrence in MGMT methylated tumors and investigating correlations between recurrences will help plan therapeutic strategies to prevent distant recurrence and improve survival of these patients.

Effect of Extent of Resection on Survival of Patients with Glioblastoma, IDH-Wild-Type, WHO Grade 4 (WHO 2021): Systematic Review and Meta-Analysis.

BACKGROUND: In light of the recently updated World Health Organization (WHO) 2021 central nervous system tumor classifications, the aim of the present study was to establish the effect of the resection extent on overall survival (OS) and progression-free survival (PFS) for patients who met the current diagnostic criteria for glioblastoma, isocitrate dehydrogenase (IDH)-wild-type (WT), WHO grade 4. METHODS: A systematic literature search was performed using the following databases: PubMed, Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews and ClinicalTrials.gov to identify studies that had compared OS and PFS after gross total resection (GTR) versus subtotal resection (STR) or biopsy for glioblastoma IDH-WT. RESULTS: We identified 1439 studies, of which 9 met the inclusion and/or exclusion criteria. Of the 2023 patients, 788 had undergone GTR. The meta-analysis showed a significant increase in the OS and PFS duration after GTR for glioblastoma IDH-WT, with a median OS of 20 months (95% confidence interval [CI], 17-25) after GTR versus 12 months (95% CI, 9-15) after STR (P < 0.0001). The median PFS was 11 months (95% CI, 9-12) after GTR versus 7 months (95% CI, 5-7) after STR (P < 0.0001). GTR was associated with a 51% reduction in the mortality risk (hazard ratio, 0.49; 95% CI, 0.36-0.65) and a 42% reduction in the progression risk (hazard ratio, 0.58; 95% CI, 0.39-0.88) compared with STR. CONCLUSIONS: The results from our systematic review suggest that GTR is associated with improved OS and PFS compared with STR for glioblastoma, IDH-WT, WHO grade 4 (WHO 2021). However, our findings were limited by the various study designs and significant clinical and methodologic heterogeneity among the studies.

K i -67/MIB-1 and Recurrence in Pituitary Adenoma.

Objectives K i -67/MIB-1 is a marker of cellular proliferation used as a pathological parameter in the clinical assessment of pituitary adenomas, where its expression has shown utility in predicting the invasiveness of these tumors. However, studies have shown variable results when using K i -67/MIB-1 association with recurrence. The purpose of this study is to determine if a high K i -67/MIB-1 labeling index (LI) is predictive of recurrence in pituitary adenomas. Methods A retrospective chart review was performed for patients undergoing pituitary adenoma resection with at least 1 year of follow-up. Additionally, systematic data searches were performed and included studies that correlated recurrence rate to K i -67/MIB-1 LI. Our institutional data were included in a synthesis with previously published data. Results Our institutional review included 79 patients with a recurrence rate of 26.6%. We found that 8.8% of our patients had a high K i -67/MIB-1 LI (>3%); however, high K i -67/MIB-1 was not associated with recurrence. The systematic review identified 244 articles and 49 full-text articles that were assessed for eligibility. Quantitative analysis was performed on 30 articles including our institutional data and 18 studies reported recurrence by level of K i -67/MIB-1 LI. Among studies that compared K i -67/MIB-1 ≥3 vs. <3%, 10 studies reported odds ratios (OR) greater than 1 of which 6 were statistically significant. A high K i -67/MIB-1 had higher odds of recurrence via the pooled odds ratio (OR = 4.15, 95% confidence interval [CI]: 2.31-7.42). Conclusion This systematic review suggests that a high K i -67/MIB-1 should prompt an increased duration of follow-up due to the higher odds of recurrence of pituitary adenoma.

Rathke's cleft cyst marsupialization and repair with a free mucosal graft - Video case report and literature review.

Rathke's cleft cysts (RCCs) are sellar or suprasellar cystic lesions arising from the remnants of the embryological Rathke's pouch. When symptomatic, RCCs are usually treated surgically via marsupialization. Free mucosal graft (FMG) repair has shown promise in decreasing recurrence versus marsupialization alone. The authors present a case report with operative video of a patient with visual and endocrinological symptoms with a RCC treated with FMG following marsupialization. A search of the PubMed database from July 1997 through April 2022 was conducted using the terms 'Rathke's cleft cyst', 'Rathke's cleft cyst management', 'Rathke's cleft cyst repair', 'mucosal graft', 'mucosal coupling', 'transsphenoidal', and 'endoscopic endonasal'. Clinical and pathological aspects of the case presented were compared with information obtained from literature review. A 25-year-old female presented with a six-year history of amenorrhea, one-year history of anemia, headaches, and progressive visual loss. Imaging revealed an RCC. The patient underwent surgical treatment via an endoscopic endonasal approach. Marsupialization was achieved with placement of an FMG to help prevent restenosis. Post-operative examination revealed that the patient's OD vision returned to normal, although her OS vision was only slightly improved. Our review of the English literature resulted in 35 full-length articles that were published between 1997 and 2022. The literature suggests that FMG prevents scar formation by allowing for adequate epithelialization, thus decreasing the recurrence rate and being well tolerated by patients. Our findings support the utility of the FMG as a superior surgical treatment option for RCC management.

Treatment of tegmen dehiscence using a middle fossa approach and autologous temporalis fascia graft: Outcomes from a single center.

INTRODUCTION: Although bony defects of the tegmen surface are relatively common, the majority of dehiscences are asymptomatic. For those who experience symptoms, there is a wide spectrum of relatively benign manifestations such as hearing loss and otorrhea to potentially more serious but rare sequelae such as epilepsy and meningitis. Surgical management of tegmen dehiscences (TDs) can help prevent these symptoms. In this manuscript, we present one of the largest reported single team experiences of using a temporal craniotomy with middle cranial fossa approach and temporalis fascia graft in the treatment of tegmen defects. METHODS: We retrospectively reviewed every case of a TD surgically repaired by the same neurosurgeon/otolaryngologist team at Loyola University Medical Center from May 2015 to January 2022. In our chart review, we identified 44 patients with 48 cases of tegmen defect repair. We analyzed patient characteristics, operative details, and postoperative outcomes. RESULTS: 44 patients met inclusion criteria for the presence of TD (mean age 55 years, 55% male, and average body mass index 35.6). 89% of these patients had no clear etiology for the dehiscence. Commonly reported symptoms were hearing loss (89%) and CSF otorrhea (82%). The least reported presenting signs and symptoms were seizures (5%) and meningitis (2%). Most defects were repaired with both temporalis fascial and calvarial bone grafts (63%), while a minority were treated with temporalis fascia only (33%), temporalis fascia with muscle (2%), or fascia lata (2%). Every patient in our sample experienced resolution of CSF otorrhea after tegmen repair and 81% of the sample reported subjective hearing improvements after surgery. 6% of our sample had post-operative infections and 8% of patients underwent repeat unilateral surgery for a surgical complication. CONCLUSION: Craniotomy for middle fossa approach using autologous temporalis fascial grafts is a safe and effective method for the treatment of TD. These procedures should be performed by experienced and multidisciplinary teams.

LXR agonist improves peripheral neuropathy and modifies PNS immune cells in aged mice.

BACKGROUND: Peripheral neuropathy is a common and progressive disorder in the elderly that interferes with daily activities. It is of importance to find efficient treatments to treat or delay this age-related neurodegeneration. Silencing macrophages by reducing foamy macrophages showed significant improvement of age-related degenerative changes in peripheral nerves of aged mice. We previously demonstrated that activation of the cholesterol sensor Liver X receptor (LXR) with the potent agonist, GW3965, alleviates pain in a diet-induced obesity model. We sought to test whether LXR activation may improve neuropathy in aged mice. METHODS: 21-month-old mice were treated with GW3965 (25 mg/Kg body weight) for 3 months while testing for mechanical allodynia and thermal hyperalgesia. At termination, flow cytometry was used to profile dorsal root ganglia and sciatic nerve cells. Immune cells were sorted and analyzed for cholesterol and gene expression. Nerve fibers of the skin from the paws were analyzed. Some human sural nerves were also evaluated. Comparisons were made using either t test or one-way ANOVA. RESULTS: Treatment with GW3965 prevented the development of mechanical hypersensitivity and thermal hyperalgesia over time in aged mice. We also observed change in polarization and cholesterol content of sciatic nerve macrophages accompanied by a significant increase in nerve fibers of the skin. CONCLUSIONS: These results suggest that activation of the LXR may delay the PNS aging by modifying nerve-immune cell lipid content. Our study provides new potential targets to treat or delay neuropathy during aging.

Primary Intradural Extramedullary Sporadic Spinal Hemangioblastomas: Case Report and Systematic Review.

BACKGROUND: Hemangioblastomas are benign vascular neoplasms of the central nervous system that may occur sporadically or in association with Von Hippel-Lindau disease. A minority of these lesions can occur in the spine, mostly as intramedullary masses. The authors present a rare case of primary sporadic spinal hemangioblastoma occurring as an intradural extramedullary (IDEM) lesion. Diagnostic workup and surgical management of the patient are described. METHODS: A systematic MEDLINE search was conducted using the keywords "hemangioblastoma" and "intradural extramedullary," "extramedullary," or "cauda equina." Clinicopathological characteristics and outcomes of the present case were reviewed and compared with those in the literature. RESULTS: A 72-year-old man was found to have an IDEM lesion in his cervical spine after presenting with neck and shoulder pain. Gross total resection was successfully performed with sacrifice of an involved dorsal nerve rootlet. Screening for Von Hippel-Lindau was negative. Thirty-three additional patients with sporadic IDEM hemangioblastomas are reported in the literature. There was a slight male preponderance (54%) with a median age of 52 years. Patients presented with pain (54%), radiculopathy (33%), or myelopathy (32%). The majority of lesions were located in the lumbosacral spine (56%). All patients underwent maximal safe resection with stable or improved clinical status. CONCLUSION: Primary IDEM hemangioblastomas are a rare entity. Differential diagnosis includes other IDEM lesions, such as schwannomas, meningiomas, or some vascular malformations. Resection of these sporadic tumors can be safely performed and result in improvement of neurologic deficits associated with mass effect from the tumor with low likelihood of recurrence.

Long-Term Outcomes of Pituitary Gland Preservation in Pituitary Macroadenoma Apoplexy: Case Series and Review of the Literature.

Introduction For patients presenting with neurological changes from pituitary tumor apoplexy, urgent surgical intervention is commonly performed for diagnosis, tumor resection, and optic apparatus decompression. Although identification and preservation of the pituitary gland during the time of surgery can be challenging, it may lead to improve endocrine outcomes. Methods A retrospective case series of all patients with macroadenomas presenting with apoplexy at Loyola University Medical Center from 2016 to 2018 was studied. Demographic, radiographic, and intraoperative characteristics were collected including age, gender, comorbidities, presenting symptoms, preoperative size of pituitary adenoma, Knosp's grade, Hardy's grade, identification and/or preservation of the gland, pre- and postoperative hormonal levels, intraoperative and/or postoperative complications, and follow-up time. Results A total of 68 patients underwent endoscopic endonasal surgery for resection of a macroadenoma. Among them, seven (10.2%) presented with apoplexy; five patients were male and two were female and presenting symptoms and signs included headache (100%), endocrinopathies (57%), visual acuity deficit (71%), visual field deficit (71%), and oculomotor palsy (57%). A gross-total resection rate was achieved in 86% of patients. Among them, 71% of patients obtained complete symptomatic neurological improvement. A statistically significant difference between gender and endocrine function was found, as no females and all males required some form of postoperative hormonal supplementation ( p = 0.047) . Conclusion Endoscopic endonasal resection of macroadenomas with sparing of the pituitary gland in the setting of apoplexy is safe and effective. Preservation of the normal gland led to no posterior pituitary dysfunction, and a statistically significant difference between gender and postoperative endocrinopathy was identified. Further studies with larger samples sizes are warranted.

Transsphenoidal Resection of Pituitary Tumors in the United States, 2009 to 2011: Effects of Hospital Volume on Postoperative Complications.

Introduction Higher surgical volumes correlate with superior patient outcomes for various surgical pathologies, including transnasal transsphenoidal (TNTS) pituitary tumor resection. With the introduction of endoscopic approaches, there have been nationwide shifts in technique with relative declines in microsurgery. We examined the volume-outcome relationship (VOR) for TNTS pituitary tumor surgery in an era of increasingly prevalent endoscopic approaches. Methods Patients who underwent TNTS pituitary tumor resection between 2009 and 2011 were retrospectively identified in the State Inpatient Database subset of the Healthcare Cost and Utilization Project. Generalized linear mixed-effect models were used to assess odds of various outcome measures. Institutions were grouped into quartiles by case volume for analysis. Results A total of 6,727 patients underwent TNTS pituitary tumor resection between 2009 and 2011. White or Asian American patients and those with private insurance were more likely to receive care at higher volume centers (HVC). Patients treated at HVC (>60 cases/year) were less likely to have nonroutine discharges (3.9 vs. 1.9%; p = 0.002) and had shorter length of stay (LOS; 4 vs. 2 days; p = 0.001). Overall, care at HVC trended toward lower rates of postoperative complications, for example, a 10-case/year increase correlated with a 10% decrease in the rate of iatrogenic panhypopituitarism (odds ratio [OR] = 0.90, 95% confidence interval [CI]: 0.81-0.99; p = 0.04) and 5% decrease in likelihood of diabetes insipidus (OR = 0.95, 95% CI: 0.90-0.99; p = 0.04) on multivariable analysis. Conclusions Our analysis shows that increased case volume is related to superior perioperative outcomes for TNTS pituitary tumor resections. Despite the recent adoption of newer endoscopic techniques and concerns of technical learning curves, this VOR remains undisturbed.

Fetal Bovine Collagen Grafts for Repair of Tegmen Defects and Encephaloceles Via Middle Cranial Fossa Approach.

To evaluate the use of commercially available allogenic dural graft materials made of fetal bovine collagen, we present an analysis of our case series with use of autologous and allogenic graft materials. Patients who underwent surgical repair of a tegmen tympani defect associated with ipsilateral conductive hearing loss and cerebrospinal fluid (CSF) otorrhea using a middle cranial fossa (MCF) approach from 2004 to 2018 at Loyola University Medical Center were included. Resolution of CSF otorrhea, audiologic outcomes, facial nerve preservation, and surgical complications was analyzed. Thirty-three patients with an average age of 55.3 years (range: 21-78, standard deviation [SD]: 12.9) and body mass index of 34.4 (range: 22-51, SD: 7.4) underwent an MCF repair of a tegmen and dural defect. All patients presented with CSF otorrhea and conductive hearing loss ipsilateral to the defect. Repairs were made with combinations of allograft and autograft in 17 cases, allograft only in 15 cases, and autograft only in 5 cases. Improvement in hearing was noted in 33 cases, and resolution of CSF otorrhea was noted in 36 cases; one patient required repeat surgery which resolved CSF otorrhea. Three patients had minor complications; all these were in the autograft group. The MCF approach coupled with the use of fetal bovine collagen grafts is a safe and viable method to repair tegmen tympani and associated dural defects with salutary outcomes and low morbidity.

The Utility of Using Preoperative MRI as a Predictor for Intraoperative Pituitary Adenoma Consistency and Surgical Resection Technique.

Objective Most pituitary adenomas are of soft consistency and can be resected during surgery with routine suction instruments. However, fibrous adenomas may require more aggressive techniques. The ability to predict consistency on magnetic resonance imaging (MRI) would improve preoperative preparation and may have implications on the extent of resection. Design A retrospective review of MRI and tumor histology of 50 consecutive patients who underwent endoscopic endonasal resection for nonfunctional adenomas was performed. Methods An intensity ratio was calculated based on quantitative MRI signal intensity of the adenoma and pons. Intraoperatively, a sequentially graded technique required for resection ranged from suction (R1) for softer tumors, curettes (R2) for tumors with intermediate consistency, and aspirators and/or other microinstruments (R3) for firmer tumors. Fibrotic content was determined from histologic collagen percentage, and rates of gross total resection (GTR) were calculated from postoperative imaging. Statistical analyses were performed to determine if resection classification could be predicted by intensity ratio or collagen percentage, calculate ratio of cut-off points for clinical use, and assess for correlation between intensity ratios and collagen percentage. Results Tumors with ratios < 1.6 on the T2-weighted coronal image and collagen content > 5.3% were likely to have required a more aggressive resection technique. Statistically significant lower rates of GTR and higher rates of perioperative complications were seen with such tumors. Conclusion Preoperative MRI analyses can be helpful but not definitive in predicting adenoma consistency. Fibrous adenomas, associated with higher collagen content, are more difficult to resect and have higher rates of subtotal resection.

Endoscopic Endonasal Resection of Meckel's Cave Epidermoid Cysts: Case Discussion and Literature Review.

Meckel's cave (MC) epidermoid cysts are relatively uncommon lesions. In cases where surgical excision is indicated, resection is often carried out via a frontosphenotemporal craniotomy from an anterolateral approach or a temporal craniotomy with or without a petrosectomy for a lateral corridor; both of these routes are associated with brain retraction and potential neurovascular injury. The anterior location of MC in the middle cranial fossa makes safe access via posterior fossa-based approaches-such as the retrosigmoid approach-challenging as well. Here, we present the cases of two patients diagnosed with epidermoid cysts in MC who underwent surgical resection via an endoscopic endonasal transpterygoid approach. Near-total resection was achieved in both cases, with only mild transient neurologic disturbances postoperatively. Radiographically, no evidence of residual disease was noted in either patient. We further review the nuances of an extended endoscopic endonasal approach to these lesions.

Lower-dose perioperative steroid protocol during endoscopic endonasal pituitary adenoma resection.

BACKGROUND: Perioperative steroid management for pituitary adenoma resections is multifaceted due to possible hypothalamic-pituitary-adrenal (HPA) axis disruption. Although many different strategies have been proposed, there is no standard protocol for prophylaxis of potential hypocortisolemia. METHODS: We performed a retrospective analysis of consecutive endoscopic endonasal pituitary adenoma resections. Before March 2016, patients received ≥100 mg of hydrocortisone intraoperatively followed by 2 mg of dexamethasone immediately postoperatively in most of the patients. Subsequently, patients received only 50 mg of hydrocortisone intraoperatively. A morning cortisol level was checked on postoperative day (POD) 2, and if it was <10 mcg/dL, patients remained on maintenance hydrocortisone. At 6 weeks, serum cortisol was redrawn and low-dose therapy was weaned when indicated. RESULTS: Of those who received ≥100 mg of hydrocortisone, 8 of 24 (33.3%) were discharged on hydrocortisone compared to 1 of 14 (7.1%) who received 50 mg. 18 of 24 (75%) of ≥100 mg group received dexamethasone on POD 1, and of those, 8 (44.4%) were discharged on hydrocortisone. Of those who received ≥100 mg and were on outpatient steroid therapy initially, 3 of 8 (37.5%) required continuation after 6 weeks compared to none who received 50 mg. There was an association between patient's intraoperative/immediate postoperative steroid use and steroid continuation at discharge. CONCLUSION: Through our experience, we hypothesize that ≥100 mg of hydrocortisone intraoperatively followed by postoperative dexamethasone may be overly suppressive in patients with otherwise normally functioning HPA. A 50 mg intraoperative dose alone may be considered to lower rates of unnecessary steroid regimens postoperatively.