Faculty Bibliography

BACKGROUND/UNASSIGNED:Craniopharyngiomas are rare parasellar tumors, and papillary craniopharyngiomas (PCPs) represent 8 to 20% of cases. DESIGN/UNASSIGNED:Interim analysis of retrospective data collected from the Registry of Adenomas of the Pituitary and Related Disorders (RAPID). SETTING/UNASSIGNED:Fourteen U.S.-based academic skull base centers between 2011 and 2023. PARTICIPANTS/UNASSIGNED:Patients with PCPs. MAIN OUTCOME MEASURES/UNASSIGNED:Demographic, imaging, surgical, and outcome variables. RESULTS/UNASSIGNED: CONCLUSIONS/UNASSIGNED:RAPID consortium enabled the largest real-world clinical information dataset for PCPs. Early findings support that GTR and stalk preservation are important to outcomes. Iterative analysis and discussion of data led to the generation of a framework for future studies to fully leverage the capabilities of multicenter registries.

BACKGROUND/UNASSIGNED:Advances in endoscopic endonasal approaches in ventral skull base surgery have led to increasingly complex resections and reconstructions. This study investigates differences in postoperative outcomes, including postoperative cerebrospinal fluid (CSF) leak and infection, following anterior skull base surgery and reconstruction, as a function of the type of nasal packing (absorbable vs. nonabsorbable) used to bolster the skull base reconstruction. METHODS/UNASSIGNED:A retrospective chart review was performed at a single tertiary care institution. Patients who underwent ventral skull base surgery with placement of nasal packing between January 1, 2020, and December 1, 2023, were included. We included only patients of a single rhinologist (S.L.) involved. Outcome measures included postoperative CSF leaks and postoperative infection. RESULTS/UNASSIGNED: = 0.309) between these two cohorts of patients. CONCLUSION/UNASSIGNED:While no significant differences were found in the rate of postoperative CSF leak or infection, additional patient factors should be taken into consideration when choosing between absorbable and nonabsorbable nasal packing for ventral skull base reconstruction. LEVEL OF EVIDENCE/UNASSIGNED:4.

OBJECTIVES/UNASSIGNED:To develop and study a novel means of imaging auditory brainstem implant (ABI) paddle placement utilizing postoperative MRI images to determine correlation between ABI performance and ideal paddle placement properties. DESIGN/UNASSIGNED:Single-center retrospective review and image analysis. SETTING/UNASSIGNED:Tertiary referral center. PARTICIPANTS/UNASSIGNED:Patients >18 years old who received an ABI from 2009 to 2023 and had subsequent MRI and auditory performance testing completed. MAIN OUTCOME MEASURES/UNASSIGNED:ABI paddle angulation and insertion depth measure, in addition to categories of auditory performance (CAP) score. RESULTS/UNASSIGNED: = 0.049) once patients with large tumor burden were excluded. Insertion depth and axial angulation showed a negative correlation, in which higher insertion depth was associated with a decrease in axial angulation value, although not statistically significant. CONCLUSION/UNASSIGNED:We present a novel means of measuring ABI paddle placement utilizing MRI to improve the objectivity of paddle placements assessments. Multicenter collaboration to increase the number of patients studied with this new measurement scheme will be required before stronger measurement associations can be determined.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Little is known about how accelerated discharge strategies compare with established enhanced recovery pathways after endoscopic endonasal surgery (EES). This study aimed to evaluate the efficacy and safety of an accelerated discharge protocol after EES. METHODS:This was a retrospective analysis of adults who underwent EES for pituitary adenomas at a single academic center between 2012 and 2025. Patients were managed under 1 of 4 postoperative pathways dependent on year of surgery: (1) No institutional protocol; (2) First-generation recovery protocol; (3) Enhanced recovery after surgery (ERAS); and (4) Expedited one-day discharge. Demographic and clinical variables were extracted from the electronic medical record using automated natural-language-processing methods. Primary outcomes were length of stay (LOS) and 30-day all-cause readmission or reoperation. All data processing, visualization, and statistical analyses were performed using Python version 3.12. RESULTS:Six hundred patients who underwent 630 surgeries were included. Median LOS was 3 days, with a 30-day readmission rate of 14.3% and a 30-day postdischarge reoperation rate of 2.5%. LOS differed significantly across protocol eras, with progressively shorter hospital stays observed over time and the shortest median stay occurring under the expedited discharge protocol (P < .0001). Readmission rates were highest in the preprotocol (16.2%) and initial protocol periods (17.2%), declining to 8.3% under the ERAS protocol and 10.0% under the expedited discharge protocol (P = .039). 30-day postdischarge reoperation rates did not statistically differ across protocols. In multivariate analyses, both the ERAS (rate ratio = 0.899, P = .021) and expedited discharge protocols (rate ratio = 0.819, P = .024) demonstrated significantly shorter hospital stays compared with the preprotocol era, without differences in 30-day readmission or reoperation rates. CONCLUSION/CONCLUSIONS:The expedited discharge protocol safely shortened hospital stays without increasing 30-day readmissions or reoperations. These findings support the feasibility of accelerated postoperative pathways after EES. Broad adoption has the potential to produce substantial resource savings without compromising patient safety.

OBJECTIVE:Frailty is a known predictor of adverse outcomes in pituitary surgery, yet its impact regarding craniopharyngioma remains unclear. The authors assessed preoperative frailty, measured by the 11-factor modified frailty index (mFI-11), and its association with perioperative morbidity among adult patients undergoing craniopharyngioma surgery. METHODS:Using the Registry for Adenomas of the Pituitary and Related Disorders (RAPID) database, the authors performed a retrospective cohort study of the records of patients ≥ 18 years of age who underwent craniopharyngioma surgery between June 2007 and November 2024. Patients were stratified into the following categories according to their numeric mFI-11 score: fit (scores 0 and 1), managing well (scores 2 and 3), and mildly frail (scores 4-6). Primary outcomes included hospital length of stay (LOS) and discharge disposition. Secondary outcomes included 90-day readmission, surgical outcomes, and complications. Multivariable analyses were performed to identify independent predictors of hospital LOS and non-home discharge, adjusting for age, surgeon experience, American Society of Anesthesiologists class, complications, and surgical approach. RESULTS:Among 278 patients (221 fit, 43 managing well, 14 mildly frail), higher-frailty patients were older (mean age 47.8 ± 16.1 years in fit vs 60.1 ± 12.5 years in managing well vs 67.6 ± 8 years in mildly frail, p < 0.001) and more likely to present urgently (24.2% vs 36.4% vs 78.6%, p = 0.001). Gross-total resection was achieved less frequently in frail patients (44.8% vs 24.3% vs 23.1%, p = 0.030). Overall complication rates were similar; however, increasing frailty was associated with higher rates of postoperative mortality (0% vs 2.8% [1/36] vs 7.7% [1/13], p = 0.018), pneumonia (0.5% [1/195] vs 2.8% [1/36] vs 15.4% [2/13], p = 0.006), and reintubation (2.6% [5/195] vs 2.8% [1/36] vs 30.8% [4/13], p = 0.002). Higher frailty was associated with a stepwise rise in median [IQR] LOS (5 [3-8] days vs 7 [4-12] days vs 13 [6.5-21.8] days, p < 0.001) and remained an independent predictor of extended LOS on multivariable analysis (β = 1.729 per point, p = 0.006). Rates of non-home discharge showed a similar pattern (9.2% vs 30.0% vs 64.3%, p < 0.001), with frailty independently predicting non-home discharge (OR 2.352, 95% CI 1.527-3.822). Unplanned 90-day readmission rates were significantly higher in the mildly frail cohorts (22.5% vs 45.7% vs 53.8%, p = 0.002). CONCLUSIONS:The mFI-11 scores independently predicted perioperative morbidity following craniopharyngioma resection. Incorporating frailty screening into preoperative screening may improve risk stratification, family and patient counseling, and discharge planning.

PURPOSE/OBJECTIVE:This multicenter, multi-surgeon retrospective study aimed to identify risk factors for postoperative cerebrospinal fluid (CSF) leak following endonasal resection of craniopharyngioma, while evaluating the "perception gap" through a surgeon survey. METHODS:A retrospective review was conducted on 416 patients who underwent endoscopic transsphenoidal surgery (ETS) for craniopharyngioma from 20 institutions. Factors were compared between patients with and without postoperative CSF leak, and between Early (2007-2015) and Late (2016-2025) Epochs. Complementing the clinical data, a survey of 19 neurosurgeons captured expert perspectives on risk stratification and management strategies. RESULTS:Overall postoperative CSF leak rate was 13.5% (56/416 patients). Univariate analysis identified predominantly cystic tumors (34% vs. 21%, p = 0.034) and intraoperative lumbar drain (LD) use (p < 0.028) as associated with postoperative CSF leak. BMI (p = 0.587), prior surgery (p = 0.576), and tumor size (p = 0.363) were not significant. In the multivariable analysis, LD use was associated with a higher postoperative CSF leak rate (OR 1.91, 95% CI 1.06-3.46; p = 0.030). Between Epochs, nasoseptal flap (NSF) utilization increased from 70.7% to 87.6% (p < 0.001). NSF was protective (OR 0.28, 95% CI 0.07-0.92; p = 0.037) in the Early Epoch; no factors were significant in the Late Epoch. The surgeons' survey identified prior surgery and intraoperative high flow leaks as primary risks; however, their LD protocols diverged from clinical data. CONCLUSION/CONCLUSIONS:Postoperative CSF leak in Craniopharyngioma has evolved. The study highlights a significant divergence between expert perception and clinical data regarding lumbar drains.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Transsphenoidal pituitary surgery has evolved substantially since its first description over 100 years ago, necessitating systematic characterization of its development. We conducted bibliometric analyses of the transsphenoidal surgery literature to map the field's growth, identify thematic shifts, and highlight gaps in the modern evidence base. METHODS:Publications related to the transsphenoidal surgical approach were identified from the Web of Science database. The data set was screened for irrelevant publications using an automated regular-expression natural language processing approach. Bibliometric analyses and visualizations were performed using open-source Python libraries. RESULTS:The final data set consisted of 4167 primarily English-language works published since 1910. Most articles were original research and were concentrated within a small subset of journals. Although research output was concentrated among the United States, China, and Japan, collaboration networks were dense and globally distributed. Pathology mapping showed episodic surges across diagnoses, with major pituitary adenoma subtypes dominating total output. Microscopic terminology surged beginning in the 1960s but declined after the introduction of endoscopy, which rose sharply after the early 1990s and became the dominant approach by 2003. Simultaneously, higher-level evidence designs (prospective studies, randomized trials, and systematic reviews) have steadily increased since the 1980s and were over-represented among highly cited works. Despite a sharp rise in publication volume since the early 1990s, the share of publications related to pediatric populations has steadily decreased. Critically, despite near-universal clinical practice of preoperative Staphylococcus aureus decolonization and surgical site preparation, their documentation and study in the existing literature remain minimal. CONCLUSION/CONCLUSIONS:This analysis details a century of transsphenoidal surgery research, demonstrating rapid expansion of the literature, a definitive shift from microscopic to endoscopic techniques, and a maturation of evidence quality. By identifying specific evidence gaps concerning infection prophylaxis and pediatric populations, these findings provide a structured baseline for prioritizing future research efforts.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Perioperative protocols facilitate earlier discharge without compromising safety in nonfunctioning pituitary adenomas, but no large multicenter studies in the United States have investigated protocols regarding Cushing disease (CD). We sought to characterize perioperative protocols and how their implementation influences clinical outcomes in patients with CD. METHODS:A retrospective analysis was conducted using data from the Registry of Adenomas of the Pituitary and Related Disorders consortium comprising 13 US academic pituitary centers. Institutions were surveyed regarding perioperative procedures for patients undergoing transsphenoidal tumor resection for CD. The impacts of institutional procedures and approaches to implementation on length of stay (LOS) and unplanned 90-day readmission were evaluated. RESULTS:Thirteen institutions contributed survey responses and clinical data for a total of 832 patients meeting inclusion criteria. Ten (76.9%) institutions reported having a postoperative protocol, 9 (69.2%) used a formal document to outline their protocol, and 3 (23.1%) had protocols implemented into hospital policy. Mean LOS was significantly reduced in centers with an established protocol (3.14 vs 3.42 days, P = .032), and more so with a formal document (3.10 vs 3.48 days, P = .001) or hospital policy (2.72 vs 3.36 days, P < .001). Patients treated after protocol implementation experienced shorter LOS (P < .001). Other factors associated with reduced LOS were presence of a separate CD pathway, intraoperative checklist specific to pituitary surgery, non-narcotic pain regimen, Foley removal order, dedicated outpatient advanced practice provider follow-up, and target discharge date ≤2 days. Intraoperative checklist (P = .045), non-narcotic pain regimen (P = .048), nasal packing (P = .005), and 1-day target discharge date (P = .032) were important factors against readmission. Compared with microscopic surgery, endoscopic surgery was associated with shorter LOS but increased readmission odds. CONCLUSION/CONCLUSIONS:This is the first multicenter study to illustrate that implementation of perioperative protocols is associated with a reduction in LOS and readmission risk in patients with CD.

BACKGROUND/UNASSIGNED:Pituitary hyperemia and gland enlargement can be cardinal features of intracranial hypotension secondary to cavernous sinus and epidural venous plexus distention. This phenomenon can therefore complicate radiographic interpretation of sellar lesions when both diagnoses co-exist. We report a unique case of a rapidly enlarging pituitary macroadenoma in the setting of a thoracic cerebrospinal fluid (CSF)-venous fistula causing symptomatic intracranial hypotension. CASE DESCRIPTION/UNASSIGNED:A 53-year-old female with no prior neurosurgical history presented with recurrent orthostatic headache. Magnetic resolution imaging revealed a pituitary lesion along with pathopneumonic signs of intracranial hypotension. The tumor grew rapidly on surveillance imaging, prompting consideration of surgery. Further work-up, however, revealed a thoracic CSF-venous fistula. Endovascular embolization of the fistula led to near-complete resolution of her symptoms and durable radiographic tumor regression. CONCLUSION/UNASSIGNED:Pituitary macroadenomas are susceptible to local hemodynamic changes occurring as a sequelae of occult CSF leak. Identification and treatment of the underlying etiology were sufficient to induce tumor regression.