Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:Despite growing interest in how patient frailty affects outcomes (eg, in neuro-oncology), its role after transsphenoidal surgery for Cushing disease (CD) remains unclear. We evaluated the effect of frailty on CD outcomes using the Registry of Adenomas of the Pituitary and Related Disorders (RAPID) data set from a collaboration of US academic pituitary centers. METHODS:Data on consecutive surgically treated patients with CD (2011-2023) were compiled using the 11-factor modified frailty index. Patients were classified as fit (score, 0-1), managing well (score, 2-3), and mildly frail (score, 4-5). Univariable and multivariable analyses were conducted to examine outcomes. RESULTS:Data were analyzed for 318 patients (193 fit, 113 managing well, 12 mildly frail). Compared with fit and managing well patients, mildly frail patients were older (mean ± SD 39.7 ± 14.2 and 48.9 ± 12.2 vs 49.4 ± 8.9 years, P < .001) but did not different by sex, race, and other factors. They had significantly longer hospitalizations (3.7 ± 2.0 and 4.5 ± 3.5 vs 5.3 ± 3.5 days, P = .02), even after multivariable analysis (β = 1.01, P = .007) adjusted for known predictors of prolonged hospitalization (age, Knosp grade, surgeon experience, American Society of Anesthesiologists grade, complications, frailty). Patients with mild frailty were more commonly discharged to skilled nursing facilities (0.5% [1/192] and 4.5% [5/112] vs 25% [3/12], P < .001). Most patients underwent gross total resection (84.4% [163/193] and 79.6% [90/113] vs 83% [10/12]). No difference in overall complications was observed; however, venous thromboembolism was more common in mildly frail (8%, 1/12) than in fit (0.5%, 1/193) and managing well (2.7%, 3/113) patients ( P = .04). No difference was found in 90-day readmission rates. CONCLUSION/CONCLUSIONS:These results demonstrate that mild frailty predicts CD surgical outcomes and may inform preoperative risk stratification. Frailty-influenced outcomes other than age and tumor characteristics may be useful for prognostication. Future studies can help identify strategies to reduce disease burden for frail patients with hypercortisolemia.

OBJECTIVE:The current neurosurgical treatment for intraventricular hemorrhage (IVH) of prematurity resulting in posthemorrhagic hydrocephalus (PHH) seeks to reduce intracranial pressure with temporary and then permanent CSF diversion. In contrast, neuroendoscopic lavage (NEL) directly addresses the intraventricular blood that is hypothesized to damage the ependyma and parenchyma, leading to ventricular dilation and hydrocephalus. The authors sought to determine the feasibility of NEL in PHH. METHODS:The records of patients with a diagnosis of grade III or IV IVH were reviewed between September 2022 and February 2024. The Papile grade was determined on cranial ultrasonography. Demographic information collected included gestational age, birth weight, weight at the time of surgical intervention, infection confirmed with CSF, and rehemorrhage. Standard local guidelines for temporary (CSF reservoir) and permanent (shunt or endoscopic third ventriculostomy [ETV]) CSF diversion were implemented. Warmed lactated Ringer's was utilized for NEL. The primary outcome was the need for permanent CSF diversion (shunt or ETV). RESULTS:Twenty consecutive patients with grade III or IV IVH complicated by PHH were identified. Twelve patients underwent CSF reservoir placement and NEL, 4 underwent CSF reservoir placement only, 1 underwent shunt placement only, and 3 did not require neurosurgical intervention. Of the 12 patients who underwent reservoir placement and NEL, 8 (67%) ultimately met criteria for permanent CSF diversion compared with 2 of 4 (50%) who underwent CSF reservoir placement only. The mean gestational age at birth, birth weights, and age/weight at time of temporary CSF diversion were similar across groups. The average time interval between temporary and permanent CSF diversion was longer in patients who underwent NEL (2.5 months for shunt and 6.5 months for ETV) compared with CSF reservoir placement only (1.1 months). CONCLUSIONS:NEL is an innovative alternative for the treatment of PHH of prematurity. The authors established an endoscopic lavage program at their institution and herein report the first published account in the United States of the feasibility of NEL for PHH.

BACKGROUND:Aneurysmal bone cysts (ABCs) are slow-growing, expansile bone tumors most often observed in the long bones and lumbar and thoracic spine. Anterior column ABCs of the spine are rare, and few cases have described their surgical management, particularly for lesions with extension into the odontoid process and the bilateral C2 pedicles. In the present case, the authors describe a two-stage strategy for resection of a symptomatic 2.3 × 3.3 × 2.7-cm C2 ABC with cord compression in a 13-year-old patient. OBSERVATIONS/METHODS:Initial tumor debulking was completed via a transoral approach, and resection of the involved region spanning the odontoid process to the C2-3 disc space was continued until visualization of the posterior longitudinal ligament. After appropriate decompression was confirmed, the patient was repositioned prone for removal of the residual tumor among the bilateral C2 pedicles. Posterior instrumentation was placed from the occiput to C4, with an autologous rib graft to encourage fusion. The postoperative recovery was uneventful, and 2-month imaging demonstrated postsurgical changes, resolution of compression, and a stable position of the instrumentation and graft material. LESSONS/CONCLUSIONS:The transoral approach facilitates sufficient exposure for the resection of large odontoid ABCs, and posterior stabilization can reduce the risk of postsurgical cervical subluxation. https://thejns.org/doi/10.3171/CASE2485.

Neuroendoscopic lavage (NEL) is a time-limited neurosurgical intervention that removes intraventricular blood in post-hemorrhagic hydrocephalus (PHH). Preterm neonates are medically complex and fragile, often precluding neurosurgical procedures due to concerns such as extubation risk and body temperature instability during even routine clinical care. In addition, transportation to the operating room can be difficult and risky. Given these factors, our institution developed and implemented a bedside technique to facilitate safe and timely NEL in the neonatal intensive care unit for the treatment of PHH.

BACKGROUND AND OBJECTIVES/OBJECTIVE:To address the lack of a multicenter pituitary surgery research consortium in the United States, we established the Registry of Adenomas of the Pituitary and Related Disorders (RAPID). The goals of RAPID are to examine surgical outcomes, improve patient care, disseminate best practices, and facilitate multicenter surgery research at scale. Our initial focus is Cushing disease (CD). This study aims to describe the current RAPID patient cohort, explore surgical outcomes, and lay the foundation for future studies addressing the limitations of previous studies. METHODS:Prospectively and retrospectively obtained data from participating sites were aggregated using a cloud-based registry and analyzed retrospectively. Standard preoperative variables and outcome measures included length of stay, unplanned readmission, and remission. RESULTS:By July 2023, 528 patients with CD had been treated by 26 neurosurgeons with varying levels of experience at 9 academic pituitary centers. No surgeon treated more than 81 of 528 (15.3%) patients. The mean ± SD patient age was 43.8 ± 13.9 years, and most patients were female (82.2%, 433/527). The mean tumor diameter was 0.8 ± 2.7 cm. Most patients (76.6%, 354/462) had no prior treatment. The most common pathology was corticotroph tumor (76.8%, 381/496). The mean length of stay was 3.8 ± 2.5 days. The most common discharge destination was home (97.2%, 513/528). Two patients (0.4%, 2/528) died perioperatively. A total of 57 patients (11.0%, 57/519) required an unplanned hospital readmission within 90 days of surgery. The median actuarial disease-free survival after index surgery was 8.5 years. CONCLUSION/CONCLUSIONS:This study examined an evolving multicenter collaboration on patient outcomes after surgery for CD. Our results provide novel insights on surgical outcomes not possible in prior single-center studies or with national administrative data sets. This collaboration will power future studies to better advance the standard of care for patients with CD.

BACKGROUND:Idiopathic intracranial hypertension (IIH) can cause debilitating symptoms and optic nerve ischemia if untreated. Cerebrospinal fluid diversion is often necessary to reduce intracranial pressure; however, current ventriculoperitoneal and lumboperitoneal shunting techniques have high failure rates in patients with IIH. OBJECTIVE:To describe our experience treating IIH with a novel stereotactic-guided transcerebellar cisternoperitoneal shunt (SGTC-CPS) technique that places the proximal shunt catheter in the posterior cisterna magnum. METHODS:Retrospective perioperative and postoperative data from all patients who underwent SGTC-CPS placement for IIH from March 1, 2015, to December 31, 2020, were analyzed. Patients were positioned as for ventriculoperitoneal shunt placement but with the head turned farther laterally to adequately expose the retrosigmoid space. Using neuronavigation, an opening was made near the transverse-sigmoid junction, and the proximal catheter was inserted transcerebellarly into the posterior foramen magnum. RESULTS:Thirty-two patients underwent SGTC-CPS placement (29 female; mean body mass index, 36.0 ± 7.5; 14 with prior shunt failures). The mean procedure time for shunt placement was 145 minutes. No intraoperative complications occurred, and all patients were discharged uneventfully. At the 6-month follow-up, 81% of patients (21 of 26) had relief of their presenting symptoms. Shunt survival without revision was 86% (25 of 29) at 1 year and 67% (10 of 15) at 3 years, with no infections. CONCLUSION:The SGTC-CPS offers an alternative solution for cerebrospinal fluid diversion in patients with IIH and demonstrates a lower failure rate and more durable symptom relief compared with ventriculoperitoneal or lumboperitoneal shunt placement. Using proper techniques and equipment promotes safe and facile placement of the proximal catheter.

OBJECTIVE:Transcranial anterior petrosectomy (AP) is a classic approach; however, it is associated with adverse consequences. The endoscopic endonasal approach (EEA) has been developed as an alternative. We describe surgical techniques for AP and EEA and compare the anatomic exposures of each. METHODS:Ten cadaveric heads (20 sides) were dissected. Specimens were divided into 4 groups: 1) AP, 2) EEA for medial petrosectomy (MP), 3) EEA for inferior petrosectomy (IP), and 4) EEA for inferomedial petrosectomy (IMP). Outcomes were areas of exposure, angles of attack to neurovascular structures, and bone resection volumes. RESULTS:AP had a greater area of exposure than did MP and IP (P = 0.30, P < 0.01) and had a higher angle of attack to the distal part of the facial nerve-vestibulocochlear nerve (cranial nerve [CN] VII/VIII) complex than did IP and IMP (P < 0.01). MP had a lower angle of attack than IMP to the midpons (P = 0.04) and to the anterior inferior cerebellar artery (P < 0.01). Compared with IMP, IP had a lower angle of attack to the proximal part of the CN VII/VIII complex (P < 0.01) and the flocculus (P < 0.01). The bone resection volume in AP was significantly less than that in MP, IP, and IMP (P < 0.01). CONCLUSIONS:AP and all EEA techniques had specific advantages for each specific area. We suggest AP for the ventrolateral pons and the anterior superior internal auditory canal, MP for the midline clivus, IP for the ventrolateral brainstem, and IMP to enhance the lateral corridor of the abducens nerve.