Faculty Bibliography

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.

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: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.

OBJECTIVE:A comprehensive quality improvement (QI) program aimed at all aspects of patient care after pituitary surgery was initiated at a single center. This initiative was guided by standard quality principles to improve patient outcomes and optimize healthcare value. The programmatic goal was to discharge most elective patients within 1 day after surgery, improve patient safety, and limit unplanned readmissions. The program is described, and its effect on patient outcomes and hospital financial performance over a 5-year period are investigated. METHODS:Details of the patient care pathway are presented. Foundational elements of the QI program include evidence-based care pathways (e.g., for hyponatremia and pain), an in-house research program designed to fortify care pathways, patient education, expectation setting, multidisciplinary team care, standard order sets, high-touch postdischarge care, outcomes auditing, and a patient navigator, among other elements. Length of stay (LOS), outcome variability, 30-day unplanned readmissions, and hospital financial performance were identified as surrogate endpoints for healthcare value for the surgical epoch. To assess the effect of these protocols, all patients undergoing elective transsphenoidal surgery for pituitary tumors and Rathke's cleft cysts between January 2015 and December 2019 were reviewed. RESULTS:A total of 609 adult patients who underwent elective surgery by experienced pituitary surgeons were identified. Patient demographics, comorbidities, and payer mix did not change significantly over the study period (p ≥ 0.10). The mean LOS was significantly shorter in 2019 versus 2015 (1.6 ± 1.0 vs 2.9 ± 2.2 midnights, p < 0.001). The percentage of patients discharged after 1 midnight was significantly higher in 2019 versus 2015 (75.4% vs 15.6%, p < 0.001). The 30-day unplanned hospital readmission rate decreased to 2.8% in 2019 from 8.3% in 2015. Per-patient hospital profit increased 71.3% ($10,613 ± $19,321 in 2015; $18,180 ± $21,930 in 2019), and the contribution margin increased 42.3% ($18,925 ± $19,236 in 2015; $26,939 ± $22,057 in 2019), while costs increased by only 3.4% ($18,829 ± $6611 in 2015; $19,469 ± $4291 in 2019). CONCLUSIONS:After implementation of a comprehensive pituitary surgery QI program, patient outcomes significantly improved, outcome variability decreased, and hospital financial performance was enhanced. Future studies designed to evaluate disease remission, patient satisfaction, and how the surgeon learning curve may synergize with other quality efforts may provide additional context.