Pseudocapsule-Based Resection for Pituitary Adenomas via the Endoscopic Endonasal Approach

IntroductionThe endoscopic endonasal approach (EEA) is a safe and effective treatment for pituitary adenomas (PAs). Since extracapsular resection (ER) of PAs improves tumor resection and endocrine remission rates, the interface between the pseudocapsule and gland draws increasing attention. However, it is difficult to precisely dissect the tumor along the exact boundary, and complete removal of the tumor increases the risks of normal tissue damage and cerebrospinal fluid (CSF) leakage. In this study, we investigated the extracapsular resection as well as the pseudocapsule histology to evaluate the effectiveness and safety of pseudocapsule-related surgical interventions.MethodsFrom December 2017 to December 2019, 189 patients of PAs via EEA in our single center were analyzed retrospectively. The images, operative details, and clinical follow-up of patients were collected. Sixty-four patients underwent pseudocapsule-based ER, and 125 patients also underwent traditional intracapsular resection (IR) with or without intensive excision for FPAs. The clinical characteristics, tumor resection, endocrinological outcomes, and postoperative morbidities of the two groups were compared. Informed consent for publication of our article was obtained from each patient. Histological examination of pseudocapsule was performed using hematoxylin and eosin and reticulin staining.ResultsThe gross total recession was 62 (96.9%) in the ER group and 107 (85.6%) cases in the IR group, whereas the endocrine remission rate was 29/31 (93.5%) and 40/53 (75.5%) cases, respectively. Anterior pituitary functions were not aggravated postoperatively in any patient, but transient diabetes insipidus (DI) occurred more in the IR group (64.0%) than in ER (48.4%). Pseudocapsule specimens were obtained in 93 patients, and clusters of small cell aggregation were detected in 11 pseudocapsule specimens (11.8%) whereas other patients showed no remarkable developed pseudocapsule. Intraoperative CSF leak occurred more in the ER group (28.1%) than in the IR group (13.6%), but no difference was seen between two groups postoperatively. No case of intracranial hematoma or pituitary crisis occurred in both groups. After a mean follow-up of 22.8 months, tumor recurrence was observed in 4 (2.1%) cases.ConclusionPseudocapsule-based extracapsular resection of PAs via EEA is an effective and safe procedure to achieve complete resection with high and sustained endocrine remission and without deteriorating pituitary function.

A retrospective study to analyze treatment of post traumatic cerebro spinal fluid rhinorrhea and role of trans cranial pedicled pericranial repair in present day context

: Skull base fractures are a major cause of morbidity and mortality in head injury. Anterior cranial Fossa (ACF) skull base fracture, leading to Cerebro Spinal Fluid (CSF) Rhinorrhea is one of the most commonly encountered presentation in ACF base fractures. The key to successful management of such cases lies in early diagnosis and surgical management before it leads to meningitis and avoidable mortality.To evaluate the cases of post traumatic CSF rhinorrhea and analyze the parameters utilized to guide the management strategies. An attempt was made to come up with guidelines for its management in a tertiary care hospital.This was a retrospective study in which all cases of traumatic CSF Rhinorrhea admitted to Tertiary care hospital were included. Patients were divided into three groups. First group was conservatively managed in which the rhinorrhea and serial imaging findings showed favourable response.In thesecond group patients were subjected to endoscopic repair by the ENT surgeon based on anatomical considerations. The third group included patients who were had failed the trial of conservative management and the site of leak did not favor endoscopic repair.The outcomes in all these groups were analyzed and conclusions drawn.A total of 54 patients were included in the study which was conducted between Jan 2014 to 2020. 24 were successfully managed conservatively,10 were managed with endoscopic repair and 20 were managed by bifrontal craniotomy and pedicled pericranial ACF Base repair. There was one case from the first group who developed CSF leak after one month necessitating ACF base repair. There was no recurrence reportedin the cases managed endoscopically, whereas one case subjected to craniotomy had recurrence requiring lumbar drain placement. With each transcranial surgery there was a refinement in the technique further minimizing complications. We have elaborated on the surgical nuances to ensurebetter outcomes. : Pedicledpericranial flap ACF base repair is an elegant approach which requires an understanding of the mechanism of CSF leak from skull base fractures. This procedure can easily be mastered and when performed correctly provides best results for cases where there are multiple ACF defects, those not accessible by endoscope and also in those cases where imaging is not able to localize the exact site of defect leading to CSF rhinorrhea. Anosmia is an in evitable complication of this procedure. However, the trade off between mortality resulting from meningitis versus anosmia makes it a viable and attractive treatment option.

Anterior Skull Base Meningioma: Surgical approach and complication avoidance

Background: Endoscopic endonasal approach (EEA) and keyhole transcranial approaches are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective: We compare tumor resection rates and complication profiles of EEA and supraorbital key hole approach (SOKHA) against conventional transcranial approaches (TCA). Methods: Fifty-four patients with ASBM [olfactory groove (OGM), n=19 and planum sphenoidale/tuberculum sellae (PS/TSM), n=35) operated at a single centre over 7 years were retrospectively analyzed. Results: The overall rate of GTR was higher in OGM (15/19, 78.9%) than PS-TSM group (23/35, 65.7%, p=0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death (n=1) following medical complication (TCA) and CSF leak requiring re-exploration (n=2, one each in TCA and EEA) accounted for the major complications in OGM. For the PS/TSM group, the GTR rates were 73.3% (n=11/15), 53.8% (n=7/13) and 71.4% (n=5/7) with TCA, EEA and SOKHA respectively. Seven patients (20%) of PS-TSM developed major postoperative complications including 4 deaths (one each in TCA, SOKHA and 2 in EEA group) and 3 visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PS-TSM especially if the tumor has encased intracranial arteries. Conclusions: No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma related problems. SOKHA may be a good alternative to TCA in selected PS-TSMs while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PS-TSM.

Incidence and perioperative risk factors for surgical site infections in neurosurgery: prospective observational study

Background Surgical site infections (SSI) represent a burden on the health care system especially in developing countries with significant morbidity and mortality. In Egypt, especially in our institution, there is no registry for the SSI rate or the contributing factors with no clear guidelines regarding the regimen of perioperative antibiotic prophylaxis. Our study was conducted to assess the local practice and to calculate the rate and risk factors of SSI. Patients and methods A prospective registry was established at the Neurosurgery Department, Demerdash teaching hospital Ain Shams University, Cairo, Egypt. All patients who underwent elective neurosurgical procedures were included in this study. Trauma patients were excluded. Patients were followed-up for incident SSI for 1 month postoperatively. SSIs were identified based on CDC criteria and a standardized data collection form predictor variables including patient characteristics, preoperative, intraoperative, and postoperative factors along with the pattern of antimicrobial prophylaxis. Results The study included 248 patients with 1-month postoperative follow-up. An SSI rate of 19% was recorded being mainly in patients below 10 years of age. Postoperative CSF leak was noticed to be the most significant risk factor of SSI in our study (p value < 0.01). Sixty five percent of culture results showed infection with gram-negative bacilli with the predominance of Acinetobacter. Conclusion Prolonged use of perioperative antibiotics does not seem to have an added benefit in SSI prevention. Tailoring of the used antibiotic regimen is highly recommended according to the latest antimicrobial prophylaxis guidelines and the local culture and sensitivity results.

Outcome Comparison of Endoscopic (Endonasal Trans-Sphenoidal) Repairs of CSF Leak vs. Transcranial Approach

OBJECTIVES: To compare the effectiveness of Endoscopic (endonasal transsphenoidal) repair of CSF leak with transcranial approach in terms of post-operative complications. METHODOLOGY: This study was conducted in the Department of Neurosurgery, Lady Reading Hospital, Peshawar. Total of 40 patients diagnosed according to inclusion criteria were enrolled and were divided into two groups. One group was treated with endonasal trans-sphenoidal repair, and another was treated with a trans-cranial approach. All patients were followed for 1 year. RESULTS: The mean age of enrolled patients was 35.4±11.6 years. There were 62.5% male and 37.5% female. In the endoscopic group the recurrence rate was observed in 3 (15%) of the patients while in the trans-cranial group the recurrence rate was observed in 2 (10%) of the patients. The overall recurrence and success rate was 8% and 92% respectively. About 4 patients developed an infection, which was treated successfully. CONCLUSION: It is concluded that the endoscopic approach is safe and effective. The endoscopic approach should be considered as standard procedure for treatment.

Management of Frontal Bone Fracture in a Tertiary Neurosurgical Care Center—A Retrospective Study

Aim We present our experience in the management of frontal bone fractures using the previously described radiologic classification of frontal bone fractures. Methodology A retrospective study was conducted, which reviewed the medical records and computed tomographic (CT) scan images of patients with frontal bone fracture from January 2016 to February 2019. Patients with complete medical records and a follow-up of minimum 1 year were included in the study. Demographic details, mechanism of injury, associated intracranial injuries, maxillofacial fractures, management, and complications were analyzed. CT scan images were used to classify the frontal bone fractures using the novel classification given by Garg et al (2014). The indications for surgical treatment were inner table frontal sinus fracture with cerebrospinal fluid (CSF) leak, intracranial hematoma with significant mass effect requiring surgical evacuation, and outer table comminuted fracture that is either causing nasofrontal duct obstruction or for cosmetic purpose. Results A total of 55 patients were included in the study. Road traffic accidents as the commonest cause of frontal bone fractures. The most common fracture pattern was type 1 followed by type 5 and depth B followed by depth A. Four patients presented with CSF rhinorrhea. CSF rhinorrhea was more frequent with fracture extension to the skull base (depth B, C, D), which was statistically significant (p < 0.001). Conclusion Frontal bone fracture management has to be tailor-made for each patient based on the extent of the fracture, presence of CSF leak, and associated intracranial and maxillofacial injuries.

In-Hospital Costs Associated With an Expanded Endonasal Approach to Anterior Skull Base Tumors

Objective: To determine in-hospital costs associated with performing an EEA to anterior skull base pathology and to identify drivers of cost variability for patients undergoing endoscopic anterior skull base surgery. Methods: All endoscopic anterior skull base surgeries performed over a period from January 1st, 2015 to October 24th, 2017 were evaluated. The electronic medical record was reviewed for patient factors, tumor characteristics, and cost variables associated with each hospital stay and univariate analysis was performed using Stata software. Results: An EEA was associated with an average total in-hospital cost of $44 545. Compared to patients undergoing a transsphenoidal approach to pituitary tumor resection, EEA patients incurred higher in-hospital costs across all variables including a total cost increase of $15 921 (95% confidence interval $5720-26 122, P = .002). Univariate analysis of all endoscopic anterior skull base surgery patients showed a cost increase of $30 616 associated with post-operative cerebrospinal fluid (CSF) leak ($10 420-50 811, P = .004), $14 610 with post-operative diabetes insipidus (DI) ($4610-24 609, P = .004), and $11 522 with African-American patients relative to Caucasian patients ($3049-19 995, P = .008). Conclusions: Patients who undergo endoscopic EEA for resection of anterior skull base tumors typically incur greater in-hospital costs than patients undergoing a standard TSA. Post-operative complications such as CSF leak and DI, as well as ethnicity, are significant drivers of cost-variability.

Critical Appraisal of Minimally Invasive Keyhole Surgery for Intracranial Meningioma

Purpose Minimally invasive meningioma removal through transcranial and endoscopic endonasal keyhole routes remain controversial. Herein we detail results of keyhole meningioma removal defined as use of a minimally invasive “retractorless” approach for which a traditional larger approach is often used instead. Methods Retrospective analysis from 2008-2021 of consecutive patients undergoing keyhole meningioma removal through one of six approaches: extent of resection, complications, endoscopy use, MRI FLAIR/T2 changes. Surgical goal was maximal safe removal including conservative(subtotal) removal for some invasive locations. Results Of 329 patients, keyhole approaches were utilized in 193(59%) patients (mean age 59±13; 30(15.5%) prior surgery) who underwent 213 operations; 205(96%) were skull base location. Approaches included: endoscopic endonasal(n=74,35%), supraorbital(n=73,34%), retromastoid(n=38,18%), mini-pterional(n=20,9%), suboccipital(n=4,2%), and contralateral transfalcine(n=4,2%). Primary outcomes: Gross total/near total(>90%) resection: 125(59%); (5% for petroclival, cavernous sinus/Meckel’s cave, spheno-cavernous locations vs 77% other locations). Complications included: permanent neurological worsening12(6%); CSF leak 2(1%); meningitis 2(1%); no patients sustained DVT, PE, MI, or 30-day mortality. Median LOS was 3 days with 94% discharged home and 96% with favorable 90-day KPS. Secondary outcomes: Small persistent FLAIR/T2 changes: 11(5.2%) patients. Endoscopy use: 87/139(63%) of craniotomies, facilitating additional tumor removal in 55%. Tumor progression was observed in 26(13%) patients(mean follow-up 42±36 months). Conclusion This analysis suggests keyhole meningioma removal can be associated with reasonable resection rates, low complication rates, short hospitalizations and high 90-day performance scores. Subtotal removal may be appropriate for invasive/adherent meningiomas to avoid complications. With careful patient selection and requisite experience, these approaches may be considered alternatives to traditional approaches.