Assessment of multimodal treatment options in recurrent and persistent acromegaly: a systematic review and meta-analysis.

PURPOSE: In patients with acromegaly, secondary treatment options in cases of hormonal non-remission or tumor progression include repeat transsphenoidal surgery (TSS), radiation-based treatment (RT), or medical therapy (MT). In this study, we aim to evaluate the clinical effectiveness of various second-line treatment options for acromegaly. METHODS: Using the PRISMA guideline, a systematic review was performed by searching MEDLINE (PubMed), Web of Science, Scopus, and Cochrane electronic bibliographic databases from conception to the end of 2022. Outcomes of interest included hormonal remission rate, complications, and mortality associated with each treatment modality for refractory acromegaly. RESULTS: A total of 79 studies including 3,208 refractory acromegaly patients (44.90% males) were analyzed, with a mean patient age of 43.89 years. There was a statistically significant difference between various therapeutic modalities in terms of remission rate, with MT offering the highest remission rate (62.55%), followed by RT (50.15%) and TSS (37.39%). Subgroup analysis of radiotherapeutic and medical modalities did not show a significant difference in remission rate between different kinds of sub-modalities in each treatment approach. Recurrence following secondary treatment was not different in patients treated with reoperation TSS compared to other modalities. CONCLUSIONS: The management of persistent and recurrent acromegaly optimally requires a multimodal approach. In different scenarios of refractory acromegaly based on previous treatment, secondary treatments may vary in terms of remission rate and complications. Medical agents provide considerable effectiveness as a second-line therapy for recurrent or persistent disease. In selected cases, however, reoperation still provides an opportunity for cure or freedom from medications. The findings of this study may help clinicians to prioritize varying options involved in this multifaceted decision-making process.

Recurrent acromegaly: a systematic review on therapeutic approaches.

BACKGROUND AND OBJECTIVE: Management of recurrent acromegaly is challenging for both neurosurgeons and endocrinologists. Several treatment options including repeat surgery, medical therapy, and radiation are offered for such patients. The efficacy of these modalities for the treatment of recurrence has not been studied previously in the literature. In this study, we aim to systematically review the existing cases of recurrence and come to a conclusion regarding the appropriate treatment in such cases. METHOD: A systematic review was performed through PubMed, Scopus, Web of Science, and Cochrane database to identify studies reporting the treatment outcome of recurrent acromegaly patients. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the included studies were reviewed for primary and secondary treatment, complications, and outcomes of the secondary treatment. RESULTS: The systematic review retrieved 23 records with 95 cases of recurrent acromegaly. The mean time of recurrence was 4.16 years after the initial treatment. The most common primary treatment was surgery followed by radiotherapy. The remission rate was significantly higher in medical and radiotherapy compared to surgical treatment. CONCLUSION: In cases of recurrent acromegaly, the patient may benefit more from radiotherapy and medical therapy compared to surgery. As the quality of evidence is low on this matter feature studies specifically designed for recurrent patients are needed.

When the nerve keeps firing: an institutional experience and systematic review on delayed response after microvascular decompression for trigeminal neuralgia.

BACKGROUND: This study aimed to investigate the occurrence of delayed response following microvascular decompression (MVD) in patients with trigeminal neuralgia (TN) and identify potential contributing factors. Additionally, we present two cases with delayed relief observed at our institution. METHOD: Two TN patients with delayed response and clear intra-operative arterial findings are presented in this study. Furthermore, we conducted a systematic review by searching electronic bibliographic databases, including MEDLINE (PubMed), Web of Science, Scopus, and Embase, from inception to 2022. RESULTS: We identified a total of 28 full-text articles involving 322 TN patients who experienced delayed pain relief. Out of these, only 11 studies provided sufficient evidence and were included in the final analysis. Among the patients, 73.46% were female. The mean incidence rate of delayed response after MVD treatment for TN was 10.5%, with a range of 0.95 to 57.14% across different studies. The mean age of these patients was 59.86 years. The reported time to pain relief in the existing reports was at least 4 days post-surgery. In 72.88% of the reported cases, right-side dominance was observed. The majority of delayed cases experienced pain relief within 3 months, with a median time of 1 month. CONCLUSIONS: A thorough examination of the probability of delayed pain relief after MVD for TN and understanding the characteristics of this phenomenon can offer surgeons valuable post-operative guidance and aid in decision-making regarding potential immediate reoperation.

A primer to vascular anatomy of the brain: an overview on anterior compartment.

PURPOSE: Knowledge of neurovascular anatomy is vital for neurosurgeons, neurologists, neuro-radiologists and anatomy students, amongst others, to fully comprehend the brain's anatomy with utmost depth. This paper aims to enhance the foundational knowledge of novice physicians in this area. METHOD: A comprehensive literature review was carried out by searching the PubMed and Google Scholar databases using primary keywords related to brain vasculature, without date restrictions. The identified literature was meticulously examined and scrutinized. In the process of screening pertinent papers, further articles and book chapters were obtained through analysis and additional assessing of the reference lists. Additionally, four formalin-fixed, color latex-injected cadaveric specimens preserved in 70% ethanol solution were dissected under surgical microscope (Leica Microsystems Inc, 1700 Leider Ln, Buffalo Grove, IL 60089 USA). Using microneurosurgical as well as standard instruments, and a high-speed surgical drill (Stryker Instruments 1941 Stryker Way Portage, MI 49002 USA). Ulterior anatomical dissection was documented in microscopic images. RESULTS: Encephalic circulation functions as a complex network of intertwined vessels. The Internal Carotid Arteries (ICAs) and the Vertebral Arteries (VAs), form the anterior and posterior arterial circulations, respectively. This work provides a detailed exploration of the neurovascular anatomy of the anterior circulation and its key structures, such as the Anterior Cerebral Artery (ACA) and the Middle Cerebral Artery (MCA). Embryology is also briefly covered, offering insights into the early development of the vascular structures of the central nervous system. Cerebral venous system was detailed, highlighting the major veins and tributaries involved in the drainage of blood from the intracranial compartment, with a focus on the role of the Internal Jugular Veins (IJVs) as the primary, although not exclusive, deoxygenated blood outflow pathway. CONCLUSION: This work serves as initial guide, providing essential knowledge on neurovascular anatomy, hoping to reduce the initial impact when tackling the subject, albeit the intricate vasculature of the brain will necessitate further efforts to be conquered, that being crucial for neurosurgical and neurology related practice and clinical decision-making.

Posterior vascular anatomy of the encephalon: a comprehensive review.

PURPOSE: This article presents a comprehensive exploration of neurovascular anatomy of the encephalon, focusing specifically on the intricate network within the posterior circulation and the posterior fossa anatomy; enhancing understanding of its dynamics, essential for practitioners in neurosurgery and neurology areas. METHOD: A profound literature review was conducted by searching the PubMed and Google Scholar databases using main keywords related to neurovascular anatomy. The selected literature was meticulously scrutinized. Throughout the screening of pertinent papers, further articles or book chapters were obtained through additional assessment of the reference lists. Furthermore, four formalin-fixed, color latex-injected cadaveric specimens preserved in 70% ethanol solution were dissected under surgical microscope (Leica Microsystems Inc, 1700 Leider Ln, Buffalo Grove, IL 60089, USA), using microneurosurgical as well as standard instruments, and a high-speed surgical drill (Stryker Instruments 1941 Stryker Way Portage, MI 49002, USA). Ulterior anatomical dissection was performed. RESULTS: Detailed examination of the basilar artery (BA), a common trunk formed by the union of the left and right vertebral arteries, denoted a tortuous course across the basilar sulcus. Emphasis is then placed on the Posterior Inferior Cerebellar Artery (PICA), Anterior Inferior Cerebellar Artery (AICA) and Superior Cerebellar Artery (SCA). Each artery's complex course through the posterior fossa, its divisions, and potential stroke-related syndromes are explored in detail. The Posterior Cerebral Artery (PCA) is subsequently unveiled. The posterior fossa venous system is explained, categorizing its channels. A retrograde exploration traces the venous drainage back to the internal jugular vein, unraveling its pathways. CONCLUSION: This work serves as a succinct yet comprehensive guide, offering fundamental insights into neurovascular anatomy within the encephalon's posterior circulation. Intended for both novice physicians and seasoned neuroanatomists, the article aims to facilitate a more efficient clinical decision-making in neurosurgical and neurological practices.

Thrombosis in Cushing's disease; raising the flag of concern.

Cushing's disease (CD) is associated with an increased risk of venous thromboembolic events. The purpose of this review is to discuss preventive strategies for post-operative thrombosis in CD patients and their impact on patient outcomes. A systematic review under PRISMA guidelines was conducted within PubMed, Embase, Web of Science, and Cochrane databases through July 2022. Of the 3207 papers retrieved, seven articles were included in this systematic review. Four hundred forty-eight patients were presented in the reviewed studies and the overall reported mortality was 2.67% (12/448). Three studies utilized prophylaxis methods including graduated compression stockings (GCS) and early ambulation (EA) while the remaining four studies only used anticoagulation medicine. Only 20 patients received pre-operative prophylactic treatment, while 366 patients received post-operative prophylaxis which was delivered either immediately after surgery or at different time intervals within 2 days following the surgery. Thrombotic events mainly occurred within two to 3 months after surgery. Overall, a higher frequency of thromboembolic events and mortality was observed in the control groups in comparison to groups receiving prophylaxis. A combination of anticoagulation, EA, and GCS might reduce thrombotic events and mortality in CD patients after treatment. Although the early commencement of a prophylactic anticoagulation regimen on the same day of surgery and continuing up to 3 months seems beneficial, the application of a prophylactic regimen should be utilized with caution since the number of included studies was insufficient to draw a strong conclusion, as well as neither prospective study nor randomized controlled trials existed.

Healthcare disparities in pituitary surgery: a systematic review.

OBJECTIVE: Pituitary surgery is a frequent neurosurgical procedure for the management of pituitary adenomas, but little research has been done on the impact of healthcare disparities on surgical results. Healthcare inequity/disparity in terms of race and socioeconomic status (SES), in addition to age and gender, was evaluated in this study to see if they affect the results of pituitary surgery. METHODS: A systematic literature search was carried out utilizing the MEDLINE (PubMed), Web of Science, Scopus, and Embase electronic databases from conception to 2023. The Newcastle-Ottawa Scale was used for quality assessment of the included studies. RESULTS: Twenty-one studies yielded a total of 381,643 patients, and removal of the studies with temporal overlap resulted in 134,832 patients with a mean ± SD age of 51.52 ± 0.41 years. Based on the available data, 46.63% of patients were male. Black patients were more likely to be recommended against surgery, while Asian or Pacific Islander patients were more likely to be recommended for surgery. Postoperative course and outcome showed mixed results, with some studies reporting higher rates of transient diabetes insipidus and stroke in racial minority populations. Private hospitals admitted more White patients, and certain racial groups had reduced access to high-volume centers. SES disparities were assessed in terms of insurance and income. Patients with government insurance or without insurance were more likely to be recommended active surveillance instead of definitive treatment. Furthermore, high SES was associated with a higher likelihood of receiving surgical treatment, better treatment outcomes, and better access to high-volume centers. In terms of age and gender disparity, older patients and females were less likely to be recommended for surgical treatment. Age and gender did not consistently impact postoperative course and treatment outcomes, with varying results across studies. No significant age and gender disparities were observed in hospital admissions and charges. CONCLUSIONS: This study revealed the presence of disparities in pituitary adenoma surgery based on race, SES, age, and gender. These disparities highlight the need for further research and interventions to ensure equitable access to appropriate surgical treatment and improved outcomes for all patients with pituitary adenomas.

Safety of craniotomy for brain tumor resection in octogenarians and older patients - a matched - cohort analysis.

INTRODUCTION: The incidence of brain tumors has increased in elderly population overtime. Their eligibility to a major surgery remains a questionable subject. This study evaluated prognostic factors and 30-days morbidity and mortality in octogenarian population who underwent craniotomy for resection of brain tumor. MATERIALS AND METHODS: A total of 154 patients were divided into two different groups: patients above 80 years old and patients below 65 years old. In both groups, patients were stratified based on diagnosis with benign tumors [meningioma] and malignant tumors [high-grade gliomas and metastases]. Multivariable logistic regression model with backward elimination method was utilized to identify the independent risk factors for 30-days readmission and post-operative complications. RESULTS: The analysis revealed no significant difference in 30-day readmission (p = 0.7329), 30-day mortality (0.6854) or in post-operative complication (p = 0.3291) between age ≥ 80 and age ≤ 65 groups. A longer length of stay (LOS) was observed in the older patients (p = 0.0479). There was a significant difference in the pre-post KPS between the two groups (p < 0.0001). ASA (p = 0.0315) and KPS (p = 0.071) were found as important prognostic factors associated with post-operative mortality in both groups. CONCLUSION: Octogenarians can withstand craniotomy without any significant increase in 30-day readmission, 30-day mortality and post-operative complications as compared to patients younger than age 65. The ASA score (>3) and/or KPS (<70) were the most important prognostic factors for 30-days readmission and mortality.

MRI-negative Cushing's Disease: Management Strategy and Outcomes in 15 Cases Utilizing a Pure Endoscopic Endonasal Approach.

BACKGROUND: Cushing's disease (CD) is among the most common etiologies of hypercortisolism. Magnetic resonance imaging (MRI) is often utilized in the diagnosis of CD, however, up to 64% of adrenocorticotropic hormone (ACTH)-producing pituitary microadenomas are undetectable on MRI. We report 15 cases of MRI negative CD who underwent surgical resection utilizing a purely endoscopic endonasal approach. METHODS: Endoscopic endonasal transsphenoidal surgery (EETS) was performed on 134 CD cases by a single surgeon. Fifteen cases met inclusion criteria: no conclusive MRI studies and no previous surgical treatment. Data collected included signs/symptoms, pre- and post-operative hormone levels, and complications resulting from surgical or medical management. Data regarding tumor diameter, location, and tumor residue/recurrence was obtained from both pre- and post-operative MRI. Immunohistochemistry was performed to assess for tumor hormone secretion. RESULTS: Aside from a statistically significant difference (P = 0.001) in histopathological results between patients with negative and positive MRI, there were no statistically significant difference between these two groups in any other demographic or clinical data point. Inferior petrosal sinus sampling (IPSS) with desmopressin (DDAVP®) administration was performed on the 15 patients with inconclusive MRIs to identify the origin of ACTH hypersecretion via a central/peripheral (C/P) ratio. IPSS in seven, five and three patients showed right, left, and central side lateralization, respectively. With a mean follow-up of 5.5 years, among MRI-negative patients, 14 (93%) and 12 patients (80%) achieved early and long-term remission, respectively. In the MRI-positive cohort, over a mean follow-up of 4.8 years, 113 patients (94.9%) and 102 patients (85.7%) achieved initial and long-term remission, respectively. CONCLUSIONS: Surgical management of MRI-negative/inconclusive Cushing's disease is challenging scenario requiring a multidisciplinary approach. An experienced neurosurgeon, in collaboration with a dedicated endocrinologist, should identify the most likely location of the adenoma utilizing IPSS findings, followed by careful surgical exploration of the pituitary to identify the adenoma.

Percutaneous balloon compression technique using intraoperative contrasted DynaCT for the treatment of refractory trigeminal neuralgia: initial experience.

OBJECTIVE: Percutaneous balloon compression (BC) is a well-established technique that can provide immediate relief to patients suffering from trigeminal neuralgia (TN). The general procedure of BC uses fluoroscopy imaging to guide the needle through the foramen ovale (FO). The aim of this study was to describe our experience with a novel technique using intraoperative contrast-enhanced DynaCT as an adjunct for more accurate and safer guidance of the needle to the FO. METHODS: In this study, DynaCT was used to perform BC in 20 TN cases. The three-dimensional path of the needle was pre-planned using DynaCT obtained during the administration of IV contrast. The FO was accessed in a single pass along the path pre-determined from the DynaCT images, avoiding any major arteries and veins. DynaCT was also used for confirmation of the final position of the needle prior to insertion of the balloon as well as for confirmation of the position of the balloon after inflation. RESULTS: Intravenous contrast-enhanced DynaCT-guided percutaneous BC allowed precise advancement and positioning of the needle within the FO. It facilitated cannulation of the FO along a pre-determined path that avoided any major vascular structures. Clinical outcomes were excellent-all patients had a quick postoperative recovery, and there were no complications. CONCLUSIONS: The advantages of the contrast-enhanced DynaCT-guided technique include a single precise needle pass and avoidance of vessel injury. Precise placement of the balloon into different aspects of the FO can target trigeminal branches more selectively and allow for a better outcome.

Frontotemporal Orbitozygomatic Transcavernous Approach: Stepwise Cadaveric Dissection for a Safe Corridor.

Background Advances in skull base surgery have increased the need for a detailed understanding of skull base anatomy and its intrinsic relationship to surrounding structures. This has resulted in an improvement in patient outcomes. The frontotemporal orbitozygomatic (FTOZ) transcavernous approach (TCA) is an excellent option for treating complex lesions involving multiple compartments of the skull base, including the sellar and parasellar, third ventricle, orbit, and petroclival region. Objective This article aimed to provide a detailed cadaveric dissection accompanying a thorough procedure description, including some tips and pitfalls of this technique. Methods Microsurgical dissection was performed in four freshly injected cadaver heads at the Cranial Base Neuroanatomy Laboratory, Cleveland Clinic Florida. The FTOZ TCA was performed on both sides of the four specimens. The advantages and disadvantages were discussed based on the anatomic nuances of this approach. Results The FTOZ TCA represented a wide access to the anterior, middle, and posterior fossa. When combined with an anterior clinoidectomy, it allowed for significant and safe internal carotid artery mobilization. This approach created numerous windows, including opticocarotid, carotid-oculomotor, supratrochlear, infratrochlear, anteromedial, anterolateral, and posteromedial triangles. The only drawback was the length of the dissection and the level of surgical acumen required to perform it. Conclusion Despite its technical difficulty, the FTOZ TCA should be considered for the surgical management of basilar apex aneurysms and tumors surrounding the cavernous sinus, sellar/parasellar, retrochiasmatic, and petroclival region. Continuous training and dedicated time in the skull base laboratory can help achieve the necessary skills required to perform this approach.

Correlation Between Pituitary Adenoma Surgery and Anxiety Disorder: Systematic Review and Meta-Analysis.

OBJECTIVE: This study aims to evaluate the impact of surgical intervention on anxiety levels in patients with various types of pituitary adenoma (PA). METHOD: A systematic review was conducted following PRISMA guidelines until October 2022, searching Embase, PubMed, Web of Sciences, and Scopus. RESULTS: A total of 32 studies were included, encompassing 2,681 patients with the mean age of 53.33 ± 6.48 years (43.4% male). Among all subtypes, 664 diagnosed with Cushing's disease (25.8%), 612 with acromegaly (23.8%), 282 with prolactinoma (10.9%), and 969 with nonfunctional pituitary adenomas (37.6%). Pituitary insufficiency was the most common complication. Considering therapeutic modalities, 515 patients (29.8%) underwent endoscopic trans-sphenoidal surgery, while 222 (12.9%) underwent microscopic trans-sphenoidal surgery. The type of trans-sphenoidal surgery was not specified in 977 (56.6%) patients. A total of 17 studies including 1510 patients which mostly assessed anxiety using the Hospital Anxiety and Depression Scale (HADS) and Zung Self-Rating Anxiety Scale (SAS) were included in the meta-analysis. Preoperative evaluation using Hospital Anxiety and Depression Scale (HADS) questionnaire showed a pooled score of 8.27 (95%CI 4.54-12.01), while postoperative evaluation yielded a pooled score of 6.49 (95%CI 5.35-7.63), indicating no significant difference. Preoperative SAS assessment resulted in a pooled score of 50.43 (95%CI 37.40-63.45), with postoperative pooled score of 55.91 (95%CI 49.40-62.41), showing no significant difference. CONCLUSIONS: Our analysis revealed no significant difference in anxiety scores pre- and postoperatively. While our findings suggest stability in anxiety levels following surgical intervention, it is imperative to recognize the limitations of the current evidence base. The observed lack of consensus may be influenced by factors such as the heterogeneous nature of the patient population, variations in the characteristics of pituitary adenomas, diverse therapeutic approaches, and potential confounding variables such as pre-existing mental health conditions and coping mechanisms. Further research is warranted to elucidate the nuanced relationship between surgical intervention for PA and anxiety outcomes, considering these complex interactions and employing rigorous methodologies to address potential sources of bias.

Chiari Malformation Type 1 and Semi-Sitting Position-A Suitable Alternative for Patients with High BMI.

OBJECTIVE: Chiari I malformation results from a mismatch between the posterior fossa bones and neural components. Management usually relies on surgical treatment. Despite being the most common assumed positioning, the prone position can be challenging in high body mass index (BMI) patients (>40 kg/m2). METHODS: Between February 2020 and September 2021, 4 consecutive patients with class III obesity underwent posterior fossa decompression. The authors describe nuances of the positioning and perioperative details. RESULTS: No perioperative complications were reported. These patients are at a lower risk of bleeding and increased intracranial pressure as a consequence of low intra-abdominal pressure and venous return. In this context, the semi-sitting position, with the aid of accurate monitoring for venous air embolism, seems to be an advantageous surgical position in this group of patients. CONCLUSIONS: We present our results and technical nuances on positioning high BMI patients for posterior fossa decompression using a semi-sitting position.

Trigeminal Neuralgia-Step-by-Step DYNA-Computed Tomography-Assisted Balloon Compression Rhizotomy.

Trigeminal nerve balloon compression (TNBC)1-3 can provide immediate therapeutic relief to patients suffering from trigeminal neuralgia. This is a particularly effective treatment option for patients who are not eligible for surgical procedures (i.e., elderly patients or patients with multiple comorbidities) or for patients who have had an insufficient response to microvascular decompression. TNBC can also be used as a bridge treatment before stereotactic radiosurgery. Use of intraoperative computed tomography-like images using a C-arm system (DYNA-CT) imaging facilitates the TNBC procedure.4,5 Three-dimensional DYNA-CT imaging with needle guidance allows for precise needle advancement and insertion through the foramen ovale. DYNA-CT enables the direct visualization and avoidance of vascular structures such as the carotid or internal maxillary arteries and results in decreased procedure times and complications. The authors present a step-by-step video demonstrating the use of intraoperative DYNA-CT needle guidance for TNBC (Video 1). A Siemens Artis Zee Biplane system is used for the procedure. A comprehensive description of all elements of the procedure is provided including balloon preparation, needle trajectory planning, needle advancement, 3-dimensional confirmation of the needle's depth and path, balloon placement, balloon inflation, and balloon removal. Tips and optimal strategies are presented. Advantages of using DYNA-CT for needle guidance include the reduction of fluoroscopy dose and fluoroscopy time. The average dose area product during conventional percutaneous balloon compression in prior studies was 1137 mGycm2, with a mean fluoroscopic time of 62 seconds.6 In our experience, the mean fluoroscopy dose is 274 mGycm2 and the total fluoroscopic time is about 45 seconds. Furthermore, during the DYNA-CT acquisition, the neurointerventional team stays outside the room during the DYNA-CT, which reduces the cumulative radiation to the operator. DYNA-CT needle guidance facilitates precise advancement of the needle into the foramen ovale and positioning of the balloon in the Meckel cave during TNBC. It is a safe and feasible technique that allows for the visualization and avoidance of important structures such as the internal carotid artery or the internal maxillary artery, resulting in decreased procedure times and complications.

Enhanced recovery after surgery in patients with normal pressure hydrocephalus undergoing ventriculoperitoneal shunting procedures.

OBJECTIVE: Patients with idiopathic normal pressure hydrocephalus (iNPH) who undergo ventriculoperitoneal shunt (VPS) placement often belong to an older demographic, putting them at increased risk of postoperative delirium and related complications. Recent literature documenting the use of Enhanced Recovery After Surgery (ERAS) protocols in various disciplines of surgery has shown improved clinical outcomes, faster discharge, and lower readmission rates. Early return to a familiar environment (i.e., discharged home) is a well-known predictor of reduced postoperative delirium. However, ERAS protocols are uncommon in neurosurgery, especially intracranial procedures. We developed a novel ERAS protocol for patients with iNPH undergoing VPS placement to gain further insight regarding postoperative complications, specifically delirium. METHODS: We studied 40 patients with iNPH with indications for VPS. Seventeen patients were selected at random to undergo the ERAS protocol, and twenty-three patients underwent the standard VPS protocol. The ERAS protocol consisted of measures to reduce infection, manage pain, minimize invasiveness, confirm procedural success with imaging, and shorten the length of stay. Pre-operative American Society of Anesthesiologists (ASA) grade was collected for each patient to indicate baseline risk. Rates of readmission and postoperative complications, including delirium and infection, were collected at 48 h, 2 weeks, and 4 weeks postoperatively. RESULTS: There were no perioperative complications among the 40 patients. There was no postoperative delirium in any of the ERAS patients. Postoperative delirium was observed in 10 of 23 non-ERAS patients. There was no statistically significant difference between the ASA grade between the ERAS and non-ERAS groups. CONCLUSIONS: We described a novel ERAS protocol for patients with iNPH receiving VPS focusing on an early discharge. Our data suggest that ERAS protocols in VPS patients might reduce the incidence of delirium without increasing the risk of infection or other postoperative complications.

Intraoperative Ultrasonography in Pituitary Surgery Revisited: An Institutional Experience and Systematic Review on Applications and Considerations.

OBJECTIVE: The primary objective of this systematic review is to evaluate the effectiveness of intraoperative ultrasound (IOUS) in improving outcomes in patients undergoing pituitary surgery. METHODS: A systematic review was performed by searching MEDLINE (PubMed), Web of Science, Scopus, and Embase electronic bibliographic databases from conception to 2022. RESULTS: The included studies yielded a total of 660 patients, with 488 patients undergoing IOUS. Outcome were available for 341 patients treated with IOUS and 157 patients who were treated without the IOUS application, and the remission rates following surgery were 76% and 59%, respectively. Only 2 studies reported remission rates for both groups, and meta-analysis for these studies showed significant superiority of intraoperative ultrasonography (Random effect, odds ratio 4.99, P < 0.01). Regarding extent of resection, IOUS resulted in 71% gross total resection, while absence of IOUS yielded a gross total resection rate of 44%. Among studies with available follow-up on IOUS, the recurrence rate was 3%. Pituitary dysfunction (34%), cerebrospinal fluid leak (31%), and central nervous system infection (8%) were the most common complications in the IOUS group. The mean follow-up was 19.97 months in studies reporting follow-up time. CONCLUSIONS: The application of the IOUS is both safe and effective and could improve the outcome of pituitary surgeries. IOUS can assist surgeons in the identification of pituitary tumors and their surrounding anatomy and can help minimize the risk of complications associated with this complex surgical procedure.

Anatomical Description and Literature Review of the Endoscopic Endonasal Transclival Transodontoid Approach Combined with Endoscopic Transoral Decompression to the Anterior Craniovertebral Junction: A New Strategy.

OBJECTIVE: To describe and evaluate the steps required to perform a combined endoscopic endonasal/transoral transclival transodontoid approach for anterior decompression of the craniovertebral junction. METHODS: The endoscopic endonasal transclival transodontoid approach combined with endoscopic transoral decompression was performed on 4 cadaveric specimens. Evaluation of this combined technique; a review of the literature; and the nuances, advantages, and pitfalls are reported. RESULTS: Adequate wide anterior decompression was achieved in all specimens. This combined approach allowed the preservation of the anterior arch of C1 without injuring the eustachian tube anatomy and avoiding internal carotid artery manipulation. CONCLUSIONS: Mastery of both techniques allows for a safe and comfortable surgical corridor. The transoral and transnasal approaches should not be considered as either/or techniques, but rather as a complement to each other. However, as with all new or developing techniques, there is a steep learning curve, which requires ample training in the skull base laboratory.

Endoscopic endonasal optic nerve sheath decompression (EONSD) for idiopathic intracranial hypertension: Technical details and meta-analysis.

BACKGROUND: The neurosurgical management of idiopathic intracranial hypertension (IIH) remains controversial. Although shunting and newer endovascular stenting techniques are part of the neurosurgical armamentarium to treat medically refractory IIH symptoms, optic nerve sheath fenestration has traditionally been performed by ophthalmologists. OBJECTIVE: We present a detailed cadaveric dissection that simulates the endoscopic endonasal optic nerve sheath decompression (EONSD) technique along with the literature review. METHODS: EONSD was performed in four freshly injected cadaveric specimens. Additionally, a systematic review from different electronic databases has been done. RESULTS: Bilateral EONSD was performed in all specimens without significant technical difficulties. Based on our experience, there is no need to expose the periorbita or orbital apex. The primary anatomic landmarks were the optic canal, the lateral opticocarotid recess, the tuberculum, the limbus, and the clinoid segment of the internal carotid artery. Based on the systematic review, 68 patients (77.9% female) underwent EONSD, with a mean age of 33.4 ± 6.9 years in adult patients. Follow-up ranged from 3 to 58 months across different studies. The pooled meta-analysis showed headache, papilledema, and visual disturbance improvement in 78% [95%CI 0.65-0.90], 72% [95%CI 0.61-0.83], and 88% [95%CI 0.80-0.96] of cases who underwent EONSD, respectively. The subgroup analysis showed there was no statistically significant difference between unilateral and bilateral EONSD in terms of different measured outcomes. CONCLUSION: EONSD is a feasible surgical procedure that may obviate the need for shunting in patients with IIH. Although clinical studies showed that EONSD is a safe and effective technique, further studies are required to establish the preferences of either unilateral or bilateral approaches.

Debilitating trigeminal neuralgia secondary to idiopathic intracranial hypertension.

Idiopathic intracranial hypertension (IIH) is characterized by raised intracranial pressure with unknown etiology. The most common neurological manifestations are headache and visual loss. Often, other cranial nerve impairments are also found, most commonly in the VI nerve. Trigeminal neuralgia (TN) is a debilitating condition that is most frequently caused by neurovascular pathology, but TN secondary to IIH is a rare and poorly described topic. Possible explanations of TN in these patients include the distortion of the local anatomy at CN entry zones and fluid displacement causing distortion of the Meckel's cave. In the case below we describe the clinical course of an obese female patient with TN-like pain who underwent a ventriculoperitoneal shunt to treat IIH and experienced complete resolution of both conditions.

Recurrent Cushing Disease: An Extensive Review on Pros and Cons of Different Therapeutic Approaches.

OBJECTIVE: Recurrent Cushing disease (CD) is characterized by the reappearance of clinical and hormonal aspects of hypercortisolism that occur more than 6 months after an initial post-treatment remission. METHODS: We performed a systematic review and meta-analysis to synthesize the evidence about remission and complication rates after transsphenoidal surgery (TSS) radiotherapy (RT) and medical therapy (MT) in recurrent CD patients. A quantitative systematic review was performed. Article selection was performed by searching MEDLINE (using PubMed), and Cochrane electronic bibliographic databases through 2020. RESULTS: We noted 61 articles described therapeutic management of recurrent CD patients with representative outcome. A total of 723 patients received different therapeutic modality for their recurrent CD. The remission rates were 0.65 (95% confidence interval [CI] 0.60-0.70), 0.57 (95% CI 0.51-0.63), and 0.75 (95% CI 0.60-0.86) in the TSS, RT, and MT subgroups, respectively. The total remission rate after therapeutic approaches on recurrent CD patients was 0.64 (95% CI 0.60-0.68). A test for subgroup differences revealed there was a statistically significant difference between different subgroups (P = 0.01). The post hoc test showed that in comparison with RT, TSS (P = 0.0344) and MT (P = 0.0149) had a higher rate of remission. However, there was no statistically significant difference between separate therapeutic modalities in terms of complications including diabetes insipidus (P = 1.0) and hypopituitarism (P = 0.28). CONCLUSIONS: Compared MT and TSS, RT has a statistically lower rate of remission. Although there is robust superiority of surgery over RT, interpretation of MT data must considered with caution due to the small number of included cases and wide CI range.