Streamlining the External Ventricular Drain and Intracranial Pressure Monitor Procedural Setup: A Quality Improvement Initiative.

OBJECTIVE: External ventricular drain (EVD) and intracranial pressure (ICP) monitor placements are among the most common critical care procedures for severe brain injury. Quality improvement initiatives have streamlined similar processes. The aim of the project was to decrease the time to collect supplies for EVD or ICP monitor placement by 25% by April 1, 2021. METHODS: The project followed the define-measure-analyze-improve-control 6 sigma framework. Several quality gaps were identified: equipment stored separately, delays in replacing faulty items, and wasted resources. The team defined the process using the suppliers-inputs-processes-outputs-customers + requirements method, measured time to collect supplies, and analyzed data with an Ishikawa/fishbone diagram. The improve phase included a kaizen burst to generate solutions and an impact/effort grid to evaluate options. The team concluded that the optimal plan was to stock a mobile EVD cart and an ICP monitor pole with disposable go-bags. RESULTS: The average time for nurses to collect EVD placement supplies decreased from 411 to 63 seconds (7-1 minute), and the average time for nurses to collect ICP monitor placement supplies decreased from 418 to 53 seconds (7-<1 minute). Residents decreased the time to obtain EVD placement supplies from 330 to 56 seconds (6-<1 minute) and ICP monitor supplies from 489 to 77 seconds (8-1 minute). Feedback was overwhelmingly positive and focused on improved process efficiency and reduced waste. CONCLUSIONS: The time reduction and enthusiasm are likely associated with the simplicity and comprehensiveness of the intervention design. Including key stakeholders in decision-making and succinct communications reduced resistance to change.

Carotid Artery Injury during Transsphenoidal Pituitary Surgery: Lessons from a 15-Year Modern Microsurgery Cohort.

Background Internal carotid artery (ICA) injury is a rare but potentially catastrophic complication of transsphenoidal resection (TSR) of pituitary tumors, potentially resulting in a host of deficits due to the risk of hemorrhage, ischemia, or even death. The endoscopic endonasal approach (EEA) has gained considerable popularity in the modern era, with few busy neurosurgeons remaining committed to practicing transnasal pituitary microsurgery. Our objective was therefore to characterize the overall incidence of ICA injury in a large, longitudinal, single-surgeon microscopic TSR series conducted during the modern EEA era. Methods Retrospective case series. Results Overall TSR volume by the senior author (F.B.M.) was 817 pituitary tumors during the study period, 2002 to 2017. Within that cohort, two instances of ICA injury were identified (0.2%), including one each with Cushing's disease and acromegaly, both of whom ultimately recovered without residual neurologic deficit. No pediatric injuries were identified. Conclusion Vascular injury is an exceedingly rare complication of transsphenoidal pituitary surgery. Adjuncts to prevent this complication include careful review of the coronal magnetic resonance imaging, identification of the midline, as needed use of the Doppler, and initial caudal opening of the sellar dura. Although potentially disastrous, good neurologic outcomes may be obtained, with immediate judicious packing followed by immediate digital subtraction angiography to assess vessel patency and secondary complications such as pseudoaneurysm.

Resection of Massive "Tarry" Intra/Extra-ventricular Prepontine Colloid Cyst: 2-Dimensional Operative Video.

Colloid cysts are typically slow-growing lesions that account for approximately 1% of primary intracranial neoplasms and predominantly exist intraventricularly. These benign lesions typically can exist symptom-free for years and do not require surgical intervention. However, if the location of the colloid cyst is symptomatic, surgical debulking may be indicated. In this intraoperative video, we illustrate the case of an 8 cm, intra/extra-ventricular colloid cyst that appeared as a craniopharyngioma on preoperative imaging, but upon resection via a trans-middle temporal gyrus approach, was found to be very atypically filled with a thick, "tarry" substance, which we hypothesize is due to serial, subacute lesional hemorrhages. After debulking and piecemeal resection of the majority of the mass with ultrasonic aspiration and microsurgical tools, a hard, calcified nodule was left tenaciously adherent to the superior cerebellar artery to prevent damage to this vascular structure.

Ecthyma Gangrenosum Secondary to Pseudomonal Sepsis Complicated by Acute Respiratory Distress Syndrome Following Craniotomy for Resection of a Metastasis.

Ecthyma gangrenosum is a rare physical exam finding pathognomonic for severe bacteremia and typically associated with pseudomonal sepsis. The characteristic skin lesions appear as ring-shaped hemorrhagic pustules that evolve into necrotic ulcers. In the present case, a 62-year-old woman with a pulmonary adenocarcinoma treated with surgical resection and adjuvant chemotherapy developed three symptomatic brain masses. The lesions were presumed metastatic and initially treated with stereotactic radiosurgery; however, follow-up imaging identified treatment failure of a cerebellar lesion, and the patient was subsequently taken to surgery on an elective basis for suboccipital craniotomy and tumor resection. Although her initial postoperative course was unremarkable, on postoperative day two, she experienced a rapidly progressive neurologic and hemodynamic decline. During this period, numerous ring-shaped, necrotic cutaneous lesions rapidly appeared, consistent with ecthyma gangrenosum. In spite of multi-modality critical care treatment and resuscitation, including milrinone, multiple vasopressors, anti-pseudomonal antibiotics, and prone positioning, the patient progressed to cardiorespiratory failure and died.

Emergent Decompression of Intracranial Abscess in Eisenmenger Syndrome.

BACKGROUND: Eisenmenger syndrome is a rare sequela of uncorrected congenital heart disease complicated by pulmonary hypertension, from which reversal of the pathologic left-to-right cardiovascular shunt and cyanosis follow. Right-to-left shunting can lead to paradoxical cerebral emboli-increasing the risk of spontaneous or iatrogenic stroke and cerebral abscess. CASE DESCRIPTION: A 38-year-old man presented with new focal seizures due to a brain abscess. Ventricular septal defect and pulmonary hypertension were identified. Despite dexamethasone and broad-spectrum antibiotics, he developed hemiparesis and altered mental status and required emergent stereotactic abscess drainage. Despite the anesthetic hazards of Eisenmenger syndrome, the procedure was successful and the patient recovered completely. CONCLUSIONS: Noncardiac perioperative mortality in Eisenmenger syndrome is historically reported up to 19%, and risks are further increased with prolonged case duration or hypotension, mandating vigilant attention to volume status. Correspondingly, shorter- or lower-risk procedures such as stereotactic drainage are recommended. Procedures should be performed only at centers with expertise in management of Eisenmenger syndrome and cardiac-specialized anesthesiologists whenever possible. Although a conservative approach with early, aggressive medical management is preferred, operative intervention may be required in the setting of progressive deterioration and excellent postoperative outcomes are achievable.

Pediatric Pituitary Adenoma: Case Series, Review of the Literature, and a Skull Base Treatment Paradigm.

Background Pediatric pituitary adenoma is a rare skull base neoplasm, accounting for 3% of all intracranial neoplasms in children and 5% of pituitary adenomas. Compared with pituitary tumors in adults, secreting tumors predominate and longer disease trajectories are expected due to the patient age resulting in a natural history and treatment paradigm that is complex and controversial. Objectives The aims of this study were to describe a large, single-institution series of pediatric pituitary adenomas with extensive long-term follow-up and to conduct a systematic review examining outcomes after pituitary adenoma surgery in the pediatric population. Methods The study cohort was compiled by searching institutional pathology and operative reports using diagnosis and site codes for pituitary and sellar pathology, from 1956 to 2016. Systematic review of the English language literature since 1970 was conducted using PubMed, MEDLINE, Embase, and Google Scholar. Results Thirty-nine surgically managed pediatric pituitary adenomas were identified, including 15 prolactinomas, 14 corticotrophs, 7 somatotrophs, and 4 non-secreting adenomas. All patients underwent transsphenoidal resection (TSR) as the initial surgical treatment. Surgical cure was achieved in 18 (46%); 21 experienced recurrent/persistent disease, with secondary treatments including repeat surgery in 10, radiation in 14, adjuvant pharmacotherapy in 11, and bilateral adrenalectomy in 3. At the last follow-up (median 87 months, range 3-581), nine remained with recurrent/persistent disease (23%). Thirty-seven publications reporting surgical series of pediatric pituitary adenomas were included, containing 1,284 patients. Adrenocorticotropic hormone (ACTH)-secreting tumors were most prevalent (43%), followed by prolactin (PRL)-secreting (37%), growth hormone (GH)-secreting (12%), and nonsecreting (7%). Surgical cure was reported in 65%. Complications included pituitary insufficiency (23%), permanent visual dysfunction (6%), chronic diabetes insipidus (DI) (3%), and postoperative cerebrospinal fluid (CSF) leak (4%). Mean follow-up was 63 months (range 0-240), with recurrent/persistent disease reported in 18% at the time of last follow-up. Conclusion Pediatric pituitary adenomas are diverse and challenging tumors with complexities far beyond those encountered in the management of routine adult pituitary disease, including nuanced decision-making, a technically demanding operative environment, high propensity for recurrence, and the potentially serious consequences of hypopituitarism with respect to fertility and growth potential in a pediatric population. Optimal treatment requires a high degree of individualization, and patients are most likely to benefit from consolidated, multidisciplinary care in highly experienced centers.