Augmented Reality in Neurosurgery: A New Paradigm for Training.

Augmented reality (AR) involves the overlay of computer-generated images onto the user's real-world visual field to modify or enhance the user's visual experience. With respect to neurosurgery, AR integrates preoperative and intraoperative imaging data to create an enriched surgical experience that has been shown to improve surgical planning, refine neuronavigation, and reduce operation time. In addition, AR has the potential to serve as a valuable training tool for neurosurgeons in a way that minimizes patient risk while facilitating comprehensive training opportunities. The increased use of AR in neurosurgery over the past decade has led to innovative research endeavors aiming to develop novel, more efficient AR systems while also improving and refining present ones. In this review, we provide a concise overview of AR, detail current and emerging uses of AR in neurosurgery and neurosurgical training, discuss the limitations of AR, and provide future research directions. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 386 articles were initially identified. Two independent reviewers (GH and AC) assessed article eligibility for inclusion, and 31 articles are included in this review. The literature search included original (retrospective and prospective) articles and case reports published in English between 2013 and 2023. AR assistance has shown promise within neuro-oncology, spinal neurosurgery, neurovascular surgery, skull-base surgery, and pediatric neurosurgery. Intraoperative use of AR was found to primarily assist with surgical planning and neuronavigation. Similarly, AR assistance for neurosurgical training focused primarily on surgical planning and neuronavigation. However, studies included in this review utilize small sample sizes and remain largely in the preliminary phase. Thus, future research must be conducted to further refine AR systems before widespread intraoperative and educational use.

When should we measure surgical site infection in patients undergoing a craniotomy? A consideration of the current practice.

Introduction: Surgical site infection (SSI) is a common postoperative complication that causes significant morbidity, particularly in patients undergoing cranial neurosurgery. The treatment of SSI can attract a significant cost by way of increasing length of stay, readmission and reoperation in some cases. Cranial neurosurgical cases without implant surgery are recommended by the centre for disease control to be surveyed for SSI for a 30-day period. The number and proportion of SSI cases that present outside of this 30-day period is unknown.Method: All cranial, neurosurgical procedures at Salford Royal Foundation NHS Trust (SRFT) between October 2011 and April 2015 (n = 3513) were identified and followed up prospectively. The number of SSIs detected, the length of time following operation, microbiological organisms cultured and the need for further neurosurgical procedure was recorded. Mean length of time from operation to detection of SSI was calculated and a hazard function analysis was undertaken.Results: Of the 3531 cases (m = 1903, f = 1628) that underwent cranial neurosurgery included in this series 86 cases of SSI were noted. The mean number of days at which SSI was first clinically diagnosed in this series was 53 days. The time period in which 75% of cases were identified to be SSI was 49 days from the date of the surgical procedure, with 32 cases (37%) presenting outside of the 30-day period of surveillance. Over half of cases required some degree of operative intervention to treat SSI.Conclusion: A longer period of surveillance in cranial neurosurgical procedures is likely to detect a truer rate of SSI in addition to the identification of a notable number of cases that require surgical intervention. We recommend a period of at at least 50 days.

C-reactive protein kinetics post elective cranial surgery. A prospective observational study.

Introduction: Post cranial surgery readmission, largely caused by surgical site infection (SSI), is a marker of patient-care quality requiring comprehensive discharge planning. Currently, discharge assessment is based on clinical recovery and basic laboratory tests, including C-reactive protein (CRP). Although CRP kinetics have been examined postoperatively in a handful of papers, the validity of CRP as a standalone test to predict SSI is yet to be explored.Methods: A prospective observational study was performed on adult patients undergoing elective cranial surgery over a 3-month period. Laboratory data; CRP, white cell count (WCC), neutrophil cell count (NCC), and clinical data were assessed pre and post-operatively and were evaluated as predictors for safe discharge. Readmission rates within 1 month were recorded.Results: In this study, 68 patients were included. About 8.6% were readmitted due to SSI. A postoperativepeak in CRP was seen on day 2 with a value of 57 in the non-readmitted group, and 115 in the readmitted group. CRP dropped gradually to normal levels by day 5 in the non-readmitted group. A secondary CRP rise at day 5 was noted in the readmitted group with a sensitivity, specificity, and negative predictive value of 71%, 90%, and 96%, respectively. Interestingly, our ROC analysis indicates that a CRP value of less than 65 predicts safe discharge with a sensitivity of 86%, specificity of 89% and negative predictive value of 98% of safe discharge (area under the curve, AUC: 0.782). No significant difference in other inflammatory markers was found between both groups.Conclusions: CRP increases postoperatively for 4-5 d which could be a physiological response to surgery, however, prolonged elevation or a secondary increase in CRP may indicate an ongoing infection. Our data validate the potential use of CRP levels to predict SSI. A multicentre study is warranted to investigate the role of CRP in predicting SSI.

Surgical-site infection surveillance in cranial neurosurgery.

INTRODUCTION: Surgical-site infection (SSI) is associated with significant morbidity and mortality. Public Health England or PHE has published guidance on its surveillance, which is now mandatory in some specialities. We review how appropriate their programme is for monitoring SSI in cranial neurosurgery [CN]. METHOD: SSI data on all patients [N = 2375] undergoing CN, over two years, at Salford Royal Foundation NHS Trust or SRFT were prospectively recorded. SSI was defined as arising within 30 days of operation or 1 year where an implant(s) remains. Follow-up, by a dedicated SSI nurse, was at 30 days using inpatient, outpatient clinic or telephone consultation, or post-discharge postal questionnaires [PDpQ] and by monitoring for readmissions. A descriptive analysis was performed looking at the follow-up process and SSI rate. RESULTS: Thirty-day follow-up data was obtained in 1776 patients (74.8%). Overall, 82 (3.5%) patients had a confirmed SSI. 22/82 (27%) were identified as inpatients [median time from operation: 14.5 days, inter-quartile range (IQR): 16] and 60/82 (73%) as readmissions [median time from operation: 31.5 days, IQR: 186.5]. No SSIs were identified via PDpQ. CONCLUSIONS: These data suggest that active outpatient follow-up is not necessary and that monitoring of inpatients and readmissions is enough for a cranial neurosurgical SSI programme.

Integration of Augmented Reality Into Glioma Resection Surgery: A Case Report.

Augmented reality (AR) is an exciting technology that has garnered considerable attention in the field of neurosurgery. Despite this, clinical use of this technology is still in its infancy. An area of great potential for this technology is the ability to display 3D anatomy overlaid with the patient to assist with presurgical and intraoperative decision-making. A 39-year-old woman presented with headaches and was experiencing what was described as a whooshing sound. MRI revealed the presence of a large left frontal mass involving the genu of the corpus callosum, with heterogeneous enhancement and central hemorrhagic necrosis, confirmed to be a glioma. She underwent a craniotomy with intraoperative MRI for resection. An augmented reality system was used to superimpose 3D holographic anatomy onto the patient's head for surgical planning. This report highlights a new AR technology and its immediate application to cranial neurosurgery. It is critical to document new uses of this technology as the field continues to integrate AR as well as other next-generation technologies into practice.

Risk assessment of early therapeutic anticoagulation following cranial surgery: an institutional case series.

OBJECTIVE: Postoperative thrombotic complications represent a unique challenge in cranial neurosurgery as primary treatment involves therapeutic anticoagulation. The decision to initiate therapy and its timing is nuanced, as surgeons must balance the risk of catastrophic intracranial hemorrhage (ICH). With limited existing evidence to guide management, current practice patterns are subjective and inconsistent. The authors assessed their experience with early therapeutic anticoagulation (≤ 7 days postoperatively) initiation for thrombotic complications in neurosurgical patients undergoing cranial surgery to better understand the risks of catastrophic ICH. METHODS: Adult patients treated with early therapeutic anticoagulation following cranial surgery were considered. Anticoagulation indications were restricted to thrombotic or thromboembolic complications. Records were retrospectively reviewed for demographics, surgical details, and anticoagulation therapy start. The primary outcome was the incidence of catastrophic ICH, defined as ICH resulting in reoperation or death within 30 days of anticoagulation initiation. As a secondary outcome, post-anticoagulation cranial imaging was reviewed for new or worsening acute blood products. Fisher's exact and Wilcoxon rank-sum tests were used to compare cohorts. Cumulative outcome analyses were performed for primary and secondary outcomes according to anticoagulation start time. RESULTS: Seventy-one patients satisfied the inclusion criteria. Anticoagulation commenced on mean postoperative day (POD) 4.3 (SD 2.2). Catastrophic ICH was observed in 7 patients (9.9%) and was associated with earlier anticoagulation initiation (p = 0.02). Of patients with catastrophic ICH, 6 (85.7%) had intra-axial exploration during their index surgery. Patients with intra-axial exploration were more likely to experience a catastrophic ICH postoperatively compared to those with extra-axial exploration alone (OR 8.5, p = 0.04). Of the 58 patients with postoperative imaging, 15 (25.9%) experienced new or worsening blood products. Catastrophic ICH was 9 times more likely with anticoagulation initiation within 48 hours of surgery (OR 8.9, p = 0.01). The cumulative catastrophic ICH risk decreased with delay in initiation of anticoagulation, from 21.1% on POD 2 to 9.9% on POD 7. Concurrent antiplatelet medication was not associated with either outcome measure. CONCLUSIONS: The incidence of catastrophic ICH was significantly increased when anticoagulation was initiated within 48 hours of cranial surgery. Patients undergoing intra-axial exploration during their index surgery were at higher risk of a catastrophic ICH.

A Case of Trigeminal Neuralgia in an Adult Patient With Lambdoid Synostosis.

Trigeminal neuralgia (TN) is characterized by sudden, brief intense pain in the distribution of the unilateral trigeminal nerve (TGN). Neurovascular compression (NVC) of the TGN is the most common cause of TN. Recent studies have suggested that a structural anomaly of the posterior cranial fossa might be involved in the development of TN, and several studies have documented the association between NVC-related TN and congenital posterior cranial deformities in adults. We present the case of a 56-year-old woman with NVC-related TN and unilateral lambdoid synostosis (ULS), along with a literature review, to investigate the relationship between TN and structural anomalies of the posterior fossa. This is the first report of TN in an adult with ULS. Mild and asymptomatic cases of lambdoid synostosis might have a higher incidence of NVC-related TN in association with posterior cranial fossa deformities.

Tranexamic Acid Demonstrates Efficacy without Increased Risk for Venous Thromboembolic Events in Cranial Neurosurgery: Systematic Review of the Evidence and Current Applications in Nontraumatic Pathologies.

BACKGROUND: The cautionary stance normally taken towards tranexamic acid (TXA) is rooted in concerns regarding its complication profile, namely its purported risk for venous thromboembolic events (VTEs). In the present review, we intend to bring increased attention to TXA as a remarkably valuable tool that does not appear to increase the risk for VTE when used as indicated in select patients. METHODS: We queried three databases to identify reporting use of TXA during nontraumatic cranial neurosurgery procedures (excluded traumatic brain injury). Data gathered included VTE complications, deep venous thrombosis, use of allogeneic blood transfusions, estimated blood loss, and operative duration. RESULTS: Twenty-eight studies were deemed eligible for inclusion in the present meta-analysis, including nine studies on surgical resection of intracranial neoplasms, ten studies on aneurysmal subarachnoid hemorrhage, and nine studies on craniosynostosis. In brain tumor surgery, TXA appears to successfully reduce blood loss without predisposing patients to VTE or seizure (P < 0.01). However, it does not appear to reduce rates of vasospasm in aneurysmal subarachnoid hemorrhage (P = 0.27), and its administration is not associated with clinically meaningful differences in long term neurological outcomes. For pediatric patients undergoing craniosynostosis procedures, TXA similarly reduces blood loss (P < 0.01). Nonetheless, low dosing protocols should be used because they appear effective and the effects of high dose TXA in children have not been studied. CONCLUSIONS: TXA is an effective hemostatic agent that can be administered to reduce blood loss and transfusion requirements for a wide range of neurosurgical applications in a broad spectrum of patient populations.

Methods of Hemostasis in Cranial Neurosurgery: An Anatomy-Based Stepwise Review.

BACKGROUND: Hemostasis is crucial in preventing hemorrhage during cranial neurosurgical procedures and maintaining visualization of the surgical field. There is significant variation in the availability of hemostatic methods across different settings and hemostatic techniques are being continuously developed over the decades of practicing neurosurgery. The aim of this article is to provide an outline of the potential methods to achieve hemostasis based on the sequential operative anatomy of a cranial operation. METHODS: A systematic review was conducted following the PRISMA guidelines. The PubMed database was searched from inception of the database to July 18, 2023. A total of 64 studies were identified fulfilling predefined inclusion criteria, and the risk of bias was assessed using the Joanna Briggs Institute checklists. RESULTS: Seventy-one hemostatic agents, techniques, tools, and devices were identified, which were then categorized according to the operative phase for which they are indicated. Nine operative anatomic targets were addressed in the sequence in which they are involved during a cranial procedure. For each anatomic target, the following number of hemostatic techniques/agents were identified: 11 for scalp, 3 for periosteum, 10 for skull bone, 11 for dura mater, 9 for venous sinuses, 5 for arteries, 6 for veins, 12 for brain parenchyma, and 4 for cerebral ventricles. CONCLUSIONS: Depending on the phase of the surgery and the anatomic structure involved, the selection of the appropriate hemostatic method is determined by the source of bleeding. Surgeon awareness of all the potential techniques that can be applied to achieve hemostasis is paramount, especially when faced with operative nuances and difficult-to-control bleeding during cranial neurosurgical procedures.

Association between patient characteristics and dissatisfaction after cranial neurosurgery: A prospective observational study.

Objectives: Patient satisfaction is an indicator of the quality of healthcare. It can improve treatment adherence and health outcomes. This study aimed to determine the incidence, predictive factors, and impact of post-operative patient dissatisfaction with perioperative care after cranial neurosurgery. Materials and Methods: This was a prospective observational study conducted in a tertiary care academic university hospital. Adult patients undergoing cranial neurosurgery were assessed for satisfaction 24 h after surgery using a five-point scale. The data regarding patient characteristics that may predict dissatisfaction after surgery were collected along with ambulation time and hospital stay. Shapiro-Wilk test was used to assess normality of data. Univariate analysis was performed using Mann-Whitney U-test and significant factors were entered into binary logistic regression model for identifying predictors. The level of significance was set at P < 0.05. Results: Four hundred and ninety-six adult patients undergoing cranial neurosurgery were recruited into the study from September 2021 to June 2022. Data of 390 were analyzed. The incidence of patient dissatisfaction was 20.5%. On univariate analysis, literacy, economic status, pre-operative pain, and anxiety were associated with post-operative patient dissatisfaction. On logistic regression analysis, illiteracy, higher economic status, and no pre-operative anxiety were predictors of dissatisfaction. The patient dissatisfaction did not impact ambulation time or duration of hospital stay after the surgery. Conclusion: One in five patients reported dissatisfaction after cranial neurosurgery. Illiteracy, higher economic status, and no pre-operative anxiety were predictors of patient dissatisfaction. Dissatisfaction was not associated with delayed ambulation or hospital discharge.

Association of Do-Not-Resuscitate orders and in-hospital mortality among patients undergoing cranial neurosurgery.

BACKGROUND: Previous studies identified pre-existing DNR orders as a predictor of mortality after surgery. We sought to evaluate mortality of patients receiving cranial neurosurgery with DNR orders placed at the time of, or within 24 h of admission. METHODS: We performed a retrospective cohort study using the California State Inpatient Database, January 2018 to December 2020. We used International Classification of Diseases, 10th Revision (ICD-10) codes to identify emergent hospitalizations with principal diagnosis of brain injury, including traumatic brain injury [TBI], ischemic stroke [IS], intracerebral hemorrhage [ICH], subarachnoid hemorrhage [SAH], or malignant brain tumor [mBT]. We used procedure and Diagnosis Related Group codes to identify cranial neurosurgery. Patients with DNR were one-to-one matched to non-DNR controls based on diagnosis (exact matching), age, sex, Elixhauser comorbidity index, and organ failure (coarsened matching). The primary outcome was inpatient mortality. RESULTS: In California, 30,384 patients underwent cranial neurosurgery, 2018-2020 (n = 3,112, 10% DNR). DNR patients were older, more often female, more often White, with greater comorbidity and organ system dysfunction. There were 2,505 patients with DNR orders 1:1 matched to controls. Patients with DNR had greater inpatient mortality (56% vs. 23%, p < 0.001; Hazard Ratio 3.11, 95% CI 2.50-3.86), received tracheostomy (Odds Ratio [OR] 0.37, 95% CI 0.24-0.57) and gastrostomy less (OR 0.48, 95% CI 0.39-0.58) compared to controls. Multivariable analysis of the unmatched cohort demonstrated similar results. CONCLUSION: Patients undergoing cranial neurosurgery with early or pre-existing DNR have high inpatient mortality compared to clinically similar non-DNR patients; 1 in 2 died during their hospitalization.

Glioblastoma Multiforme in a Patient With Alpha-1-Antitrypsin Deficiency.

Alpha-1 antitrypsin (A1AT) is a common genetic disease caused by a mutation in the SERPINA1 gene, predisposing patients to severe premature lung and liver disease. Higher expression of SERPINA1 has been associated with a poor prognosis in patients with high-grade glioblastoma. We present a woman in her 70s with a history of A1AT deficiency treated with weekly plasma-purified A1AT infusions, who presented with metabolic encephalopathy. A CT scan of the brain obtained during admission revealed a left frontal lobe mass measuring 1.1 cm. A craniotomy and resection of the lesion were performed, and the pathology studies revealed a glioblastoma multiforme, WHO grade IV. She is currently healing and awaiting treatment with temozolomide with concomitant radiation and tolerating treatment well.

Postoperative Diabetes Insipidus Mimicking Radiological Findings and Symptoms of Intracranial Hypotension: A Case Report.

Endocrine disturbances such as diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) are recognized complications of craniopharyngioma surgery, which occur due to damage to structures that produce or store antidiuretic hormone (ADH). Intracranial hypotension is a clinical syndrome that presents with headache and typical radiological features and can occur due to a leak of cerebral spinal fluid (CSF) in operations that involve the opening of the arachnoid (e.g., craniopharyngioma surgery). We describe a patient presenting with headache, radiological evidence of intracranial hypotension, and chronic DI after craniopharyngioma surgery. This occurred in the absence of evidence of a CSF leak. The headache and radiological findings resolved after the identification and treatment of DI. Intracranial hypotension may have occurred secondary to dehydration in chronic DI. A 48-year-old woman presented with progressive visual field loss due to cystic recurrence of a craniopharyngioma. She underwent redo (second) extended endoscopic transsphenoidal surgery, having previously undergone an uncomplicated debulking procedure two years prior. Her redo operation was uneventful, and her vision improved postoperatively. A lumbar drain was placed preoperatively to protect the skull base repair and was removed after 48 hours. In the initial postoperative period, she developed a clinical (polyuria) and biochemical picture consistent with DI, subsequently reverting to a SIADH, after which fluid and sodium homeostasis appeared to normalize, and she was discharged. Two months after discharge, she re-presented with new headaches eased by lying flat. Magnetic resonance imaging (MRI) brain showed bilateral convexity subdural effusions and diffuse pachymeningeal enhancement, suggesting intracranial hypotension and raising concern for postoperative CSF leak. MRI spine did not show a CSF fistula at the site of the previous lumbar drain. Transsphenoidal examination under anesthesia showed a well-healed skull base repair and no evidence of CSF leak. She concurrently reported polyuria and polydipsia. A formal water deprivation test confirmed central DI. Treatment with desmopressin improved her headache, and a follow-up MRI brain showed resolution of the previous stigmata of intracranial hypotension. This case report reminds physicians and neurosurgeons that systemic disorders (such as dehydration) can cause intracranial hypotension.

Early outcomes of supratentorial cranial surgery for tumor resection in older patients.

With longevity increasing in the United States, more older individuals are presenting with supratentorial brain tumors. Despite improved perioperative management, there is persistent disparity in surgical resection rates among patients aged 65 years or older. We aim to assess the effects of advanced age (≥65 years) on 30-day outcomes in patients with supratentorial tumors who underwent craniotomy for supratentorial tumor resection. Data obtained in adults who underwent supratentorial tumor resections was extracted from the prospectively-collected American College of Surgeons: National Surgical Quality Improvement Program (NSQIP; 2012-2018) database. Using multivariate regression, we compared odds of major and minor complications; prolonged length-of-stay (LOS); discharge anywhere other than home; and 30-day readmission, reoperation, and mortality rates between patients aged 18-64 years (the control cohort) and those 65-74 years or ≥75 years of age. Of the 14,234 patients who underwent craniotomy for supratentorial tumors and met inclusion criteria, 30.7% were ≥65 years of age; 71.4% of these were 65-74 years and 28.6% were ≥75 years old. Compared to the control group, both older subpopulations had more medical comorbidities. Both older subgroups had increased odds of major complications and prolonged LOS relative to the control group. Older patients had greater odds of mortality at 30 days. Advanced age, defined as ≥65 years, was significantly associated with higher odds of complications, prolonged LOS, and mortality within the 30-day post- operative period after adjusting for potential confounders. Age is one important consideration when prospectively risk-stratifying patients to minimize and mitigate suboptimal perioperative outcomes.

The Use of a Novel Perfusion-Based Human Cadaveric Model for Simulation of Dural Venous Sinus Injury and Repair.

BACKGROUND: Dural sinus injuries are potentially serious complications associated with acute blood loss. It is imperative that neurosurgery trainees are able to recognize and manage this challenging scenario. OBJECTIVE: To assess the feasibility of a novel perfusion-based cadaveric simulation model to provide the fundamentals of dural sinus repair to neurosurgical trainees. METHODS: A total of 10 perfusion-based human cadaveric models underwent superior sagittal sinus (SSS) laceration. Neurosurgery residents were instructed to achieve hemostasis by any method in the first trial and then repeated the trial after watching the instructional dural flap technique video. Trials were timed until hemostasis and control of the region of injury was achieved. Pre- and post-trial questionnaires were administered to assess trainee confidence levels. RESULTS: The high-flow extravasation of the perfusion-based cadaveric model mimicked similar conditions and challenges encountered during acute SSS injury. Mean ± standard deviation time to hemostasis was 341.3 ± 65 s in the first trial and 196.9 ± 41.8 s in the second trial (P < .0001). Mean trainee improvement time was 144.4 s (42.3%). Of the least-experienced trainees with longest repair times in the initial trial, a mean improvement time of 188.3 s (44.8%) was recorded. All participants reported increased confidence on post-trial questionnaires following the simulation (median pretrial confidence of 2 vs post-trial confidence of 4, P = .002). CONCLUSION: A perfusion-based human cadaveric model accurately simulates acute dural venous sinus injury, affording neurosurgical trainees the opportunity to hone management skills in a simulated and realistic environment.

Infection Rate after Cranial Neurosurgical Procedures: A Prospective Single-Center Study.

OBJECTIVE: To determine infection rate (IR) and to identify modifiable risk factors (RF) in cranial neurosurgery in a neurosurgical department for tertiary referral as part of an infection control surveillance to reduce surgical site infections (SSI). METHODS: A prospective SSI incidence cohort study from February 2013 to January 2014 was performed in a tertiary-care neurosurgical teaching hospital and referral center. All consecutive adults undergoing any cranial neurosurgical procedure were included. Data were collected by a trained member of the infection control staff during the twice-weekly visits of the hospitalized patients. Follow-up was 30 days (procedures without implant) and 1 year (procedures involving permanent implants). SSI was diagnosed according to criteria of CDC. RESULTS: A total of 317 patients undergoing 333 index procedures were included. The median age was 61 years (range, 17-91 years) and 46% were female. Survival in patients with completed follow-up was 76% (196/258). Overall, IR was 7.2% (24/333 index procedures); in 96% (23/24), a neurosurgical implant was involved. The IR of extraventricular drainage (EVD) was 12.5% (13.1/1000 EVD days). The main causative pathogens were Staphylococcus aureus followed by coagulase-negative staphylococci and Propionibacterium acnes. Independent RF for neurosurgical SSI were EVD as part of the index operation and body mass index >25 kg/m2. CONCLUSIONS: IR was in accordance with recent prospective single-center studies (reported IR between 1.6% and 9%). EVD placement was identified as the strongest modifiable RF for SSI in cranial neurosurgical procedures. The need for standard infection control procedures for the insertion and maintenance of EVDs to avoid their contamination is reinforced.

Correlation of Subjective Hospital Compare Metrics With Objective Outcomes of Cranial Neurosurgical Procedures in New York State.

Background: Public reporting is at the forefront of health care reform. Objective: To investigate whether patient satisfaction as expressed in a public reporting platform correlates with objective outcomes for cranial neurosurgery patients. Methods: We performed a cohort study involving patients undergoing cranial neurosurgery from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System database. This cohort was merged with the corresponding data from the Centers for Medicare and Medicaid Services Hospital Compare website. The association of patient satisfaction metrics with outcomes was examined with the use of a propensity-adjusted regression model. Results: Overall, 19 591 patients underwent cranial neurosurgery during the study. Using a propensity-adjusted multivariable regression analysis, we demonstrated that hospitals with a greater percentage of patient-assigned "high" scores had decreased mortality (OR, 0.60; 95% CI, 0.53-0.67), rate of discharge to rehabilitation (OR, 0.93; 95% CI, 0.88-0.98), length of stay (adjusted difference, -1.29; 95% CI, -1.46 to -1.13), and hospitalization charges (adjusted difference, -23%; 95% CI, -36% to -9%) after cranial neurosurgery. Similar associations were identified for hospitals with a higher percentage of patients, who would recommend these institutions to others. Conclusion: In a Centers for Medicare and Medicaid Services Hospital Compare-Statewide Planning and Research Cooperative System merged dataset, we observed an association of higher performance in patient satisfaction measures with decreased mortality, rate of discharge to rehabilitation, hospitalization charges, and length of stay.

Preoperative Frailty Score for 30-Day Morbidity and Mortality After Cranial Neurosurgery.

BACKGROUND: Evaluating preoperative frailty is critical for guiding shared surgical decision-making. The purpose of this study was to develop a novel preoperative frailty index for classification of adverse outcomes following cranial neurosurgery procedures. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all cranial neurosurgery cases from 2006 to 2014. Sequential univariate and multivariate testing was used to identify significant independent predictors of 30-day mortality. Frailty scores were computed by summating across weighted predictors. Receiver operating characteristic curve analysis quantified the discriminative capacity of the frailty score for classifying mortality and other major adverse outcomes. RESULTS: List-wise exclusion of patients with incomplete datasets yielded a final sample of 27,098 patients (mortality rate = 3.9%). Multivariate regression testing identified 19 independent predictors of 30-day mortality. Receiver operating characteristic curve analysis revealed impressive outcome discrimination (area under the curve = 0.87, P < 0.001, optimal classification accuracy = 83.0%). Patients in the "high-risk" group (score ≥4, n = 5155) had significantly increased risk for mortality (15.4%) and major adverse outcomes (32.0%) compared with patients in the "low-risk" group (n = 21,943, mortality = 1.2%, major adverse outcomes = 4.0%). The frailty score remained highly discriminative across all age groups examined. CONCLUSIONS: Neurosurgical patients undergo extensive preoperative evaluation, but the field currently lacks a robust bedside scoring system for quantifying patient frailty. In this study, we introduced a novel preoperative frailty index capable of classifying 30-day morbidity and mortality outcomes following cranial neurosurgeries.

VITOM 3D: Preliminary Experience in Cranial Surgery.

BACKGROUND: Optimal vision and ergonomics are important factors contributing to achievement of good results during neurosurgical interventions. The operating microscope and the endoscope have partially filled the gap between the need for good surgical vision and maintenance of a comfortable posture during surgery. Recently, a new technology called video-assisted telescope operating monitor or exoscope has been used in cranial surgery. The main drawback with previous prototypes was lack of stereopsis. We present the first case report of cranial surgery performed using the VITOM 3D, an exoscope conjugating 4K resolution view and three-dimensional technology, and discuss advantages and disadvantages compared with the operating microscope. CASE DESCRIPTION: A 50-year-old patient with vertigo and headache linked to a petrous ridge meningioma underwent surgery using the VITOM 3D. Complete removal of the tumor and resolution of symptoms were achieved. The telescope was maintained over the surgical field for the duration of the procedure; a video monitor was placed at 2 m from the surgeons; and a control unit allowed focusing, magnification, and repositioning of the camera. CONCLUSIONS: VITOM 3D is a video system that has overcome the lack of stereopsis, a major drawback of previous exoscope models. It has many advantages regarding ergonomics, versatility, and depth of field compared with the operating microscope, but the holder arm and the mechanism of repositioning, refocusing, and magnification need to be ameliorated. Surgeons should continue to use the technology they feel confident with, unless a distinct advantage with newer technologies can be demonstrated.

A systematic review of 30-day readmission after cranial neurosurgery.

OBJECTIVE The 30-day readmission rate has emerged as an important marker of the quality of in-hospital care in several fields of medicine. This review aims to summarize available research reporting readmission rates after cranial procedures and to establish an association with demographic, clinical, and system-related factors and clinical outcomes. METHODS The authors conducted a systematic review of several databases; a manual search of the Journal of Neurosurgery, Neurosurgery, Acta Neurochirurgica, Canadian Journal of Neurological Sciences; and the cited references of the selected articles. Quality review was performed using the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) criteria. Findings are reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. RESULTS A total of 1344 articles published between 1947 and 2015 were identified; 25 were considered potentially eligible, of which 12 met inclusion criteria. The 30-day readmission rates varied from 6.9% to 23.89%. Complications arising during or after neurosurgical procedures were a prime reason for readmission. Race, comorbidities, and longer hospital stay put patients at risk for readmission. CONCLUSIONS Although readmission may be an important indicator for good care for the subset of acutely declining patients, neurosurgery should aim to reduce 30-day readmission rates with improved quality of care through systemic changes in the care of neurosurgical patients that promote preventive measures.