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INTRODUCTION: Surgical treatment for tethered cord syndrome (TCS) involves a laminotomy for intradural lysis of filum terminale (LFT), with the goal of releasing excess tension on the conus medullaris by dividing the filum terminale. While LFT alleviates clinical symptoms, it is associated with risks and complications, including cerebrospinal fluid (CSF) leak and infection, either superficial or deep. Some risks and complications of LFT relate to efficiency and quality of primary dural closure and its downstream effects. We sought to assess the utility of nonpenetrating titanium clips (TC) for primary dural closure with a particular focus on operative duration, associated costs, and complication profiles in a series of pediatric patients undergoing LFT, hypothesizing that TC utilization leads to more efficient closure and therefore potentially lower costs and potentially associated anesthetic length and risks. METHODS: A 4-surgeon, single institution series of 28 pediatric patients underwent LFT with subsequent dural closure performed with either the AnastoClip® nonpenetrating titanium clips or traditional suture technique between July 2022 and May 2023. In order to compare the safety, efficacy, and cost-effectiveness between the two dural closure techniques, relevant data were collected including patient demographics and rates of CSF leak, infection at three-month follow-up, and reoperation. Operative durations and times from beginning to end of dural closure were recorded. RESULTS: A total of 28 pediatric patients (mean age: 5.9 years, 43% female, range: 0.71-17 years) with TCS underwent LFT. All patients underwent procedures involving intradural surgery of the lumbar region. Dural closure was performed using traditional suturing in 19 patients (67.9%) and TC in 9 (32.1%). With respect to duration of dural closure, the average time to closure using traditional suturing techniques was 1271 s (or 21 min and 11 s), while the average time for TC was 265 s (or 4 min and 25 s). At three-month follow-up, one case of cerebrospinal fluid (CSF) leak or infection was observed in the suture cohort and required reoperation. CONCLUSION: Clinical outcomes in the TC group were excellent, consistent with previous reports; our findings further suggest that TCs result in more efficient dural closure than traditional suturing techniques. Our findings suggest that TC may be a safe, efficacious, and more efficient alternative to traditional suture for achieving dural closure in pediatric patients with TCS undergoing LFT surgery.

Microscopic microvascular decompression(M-MVD) is considered the gold standard treatment for primary trigeminal neuralgia and presents excellent long-term pain control rates. Despite the effectiveness of M-MVD, the use of endoscopy in these procedures has proven to be a promising approach. To evaluate the safety and efficacy of purely endoscopic microvascular decompression (E-MVD). A systematic review of the literature was performed using the PubMed, Scopus, Embase, and Cochrane databases. The primary outcome was satisfactory pain relief in short-term (0–30 days), mid-term (mean follow-up >/= 12 months) and long-term (mean follow-up >/= 24 months). Secondary outcomes were CSF leak, facial weakness, hearing loss, facial numbness, the rate of intraoperative identification of the offending vessel(s), mortality, length of stay and operative time. Inclusion criteria were studies including only patient submitted to E-MVD. Exclusion were secondary trigeminal neuralgia and mean follow-up < 12 months. Statistical analysis was performed using RStudio 2024.04.1 + 748. Heterogeneity was assessed using I² statistics. Sensitivity analysis was performed with leave-one-out test. Thirteen articles met the inclusion criteria, comprising a total of 1336 patients. Patients submitted to E-MVD had mean satisfactory pain relief rates of 92.93% (95% CI: 89.52–96.34% I2 = 86%), 88.54% (95% CI: 83.73–93.54% I2 = 87%) and 83.38% (95% CI: 76.58–90.17% I2 = 83%) in the short-term, mid-term and long-term follow-ups, respectively. Furthermore, the incidence of postoperative complications was low, including CSF leak (1.29% (95% CI: 0.32–2.26% I2 = 20%)), facial weakness (0.50% (95% CI: 0.00-1.79% I2 = 60%)), hearing loss (0.81% (95% CI: 0.05–1.57% I2 = 7%)) and facial numbness (3.84% (95% CI: 1.95–6.20% I2 = 54%)). There was no mortality related to the procedure (0% (95% CI: 0–0%; I2 = 0%)). The offending vessel(s) were identified in 99.57% of the cases (95% CI: 98.17–100.00% I2 = 67%)). Our meta-analysis revealed that E-MVD is a safe and effective procedure for the treatment of primary trigeminal neuralgia. Further studies are necessary to compare its usefulness to the traditional M-MVD approach. [ABSTRACT FROM AUTHOR]

Background: Neuronal intranuclear inclusion disease (NIID) is a rare neurodegenerative disorder characterized by the presence of inclusions within the nuclei of various cell types. The clinical manifestations of patients with NIID are diverse. Here, we present the case of a patient with NIID whose clinical presentation and magnetic resonance features closely resembled those of hydrocephalus. Case presentation: The patient was 71-year-old woman with no significant family history. Seven years previously, she began to experience tremors in both hands, which occurred at rest and while holding objects; this was accompanied by urinary incontinence. Four years previously, she developed weakness in both lower limbs, an unstable gait, and dizziness. Over the past year, she noticed stiffening at the root of her tongue, cognitive decline, and slower reaction times compared to her previous state. Upon admission, cranial magnetic resonance imaging (MRI) revealed hydrocephalus-like changes. A cerebrospinal fluid drainage test returned negative results. The patient presented with tremors and urinary incontinence. Physical examination indicated pupillary constriction, and electromyography suggested peripheral neuropathy. Genetic testing revealed 91 GGC repeats in the NOTCH2NLC gene, indicating abnormal expansion. The final diagnosis was NIID. We provided symptomatic treatment for the tremor and cognitive impairment, but there was no significant improvement in the clinical symptoms. Conclusions: Our case suggests that when a patient presents with clinical symptoms and MRI findings resembling hydrocephalus, the possibility of NIID should be considered, especially in the presence of tremors and autonomic symptoms. [ABSTRACT FROM AUTHOR]

Pyogenic ventriculitis (PV) is a severe and challenging infection with high morbidity, commonly associated with neurosurgical procedure. Conventional treatment involves prolonged antibiotic therapy and cerebrospinal fluid drainage but is associated with poor outcome. Neuro-endoscopic lavage (NEL) is a promising technique allowing direct reduction of bacterial load, which can potentially improve patient outcomes. This study aims to address the safety and efficacy of NEL. A retrospective cohort study was conducted on 22 patients with PV treated at West China Hospital from December 2019 to March 2024. Patients were divided into two groups: one receiving conventional therapy and the other undergoing NEL in addition to standard treatment. Primary and secondary outcomes, including clinical cure rate, mortality, and CSF sterilization, were analyzed. NEL significantly improved the clinical cure rate (83.33% vs. 40.00%, P = 0.0480). Although the 6-month mortality rate was not significantly different (P = 0.3233), NEL showed a trend toward faster recovery and a higher CSF sterilization rate. Neuro-endoscopic lavage significantly improves clinical outcomes in patients with pyogenic ventriculitis and represents a safe, preferred treatment option. [ABSTRACT FROM AUTHOR]

Background and Aims: Post-dural puncture headache is a complication of spinal anaesthesia, theorised to be triggered by a lowering in intracranial pressure due to the cerebrospinal fluid leak through the dural puncture. Our objective was to evaluate whether there is a decrease in optic nerve sheath diameter (ONSD) with a reduction in intracranial pressure after spinal anaesthesia. Methods: Patients were randomised by a computer-generated randomisation table to receive spinal anaesthesia (Group S) or peripheral nerve block (Group P) after assessing their eligibility for the anaesthesia procedure as per the protocol. The ONSD was measured in the preoperative period and again at 4 h and 24 h after the anaesthetic, both in the supine and sitting positions, along with haemodynamic parameters. Continuous variables such as age, height, weight, mean arterial pressures, and ONSD were expressed as mean [standard deviation (SD)] [95% confidence interval (CI)] and compared using the student's t -test. Repeated measure ANOVA and Bonferroni were used to compare intra-group parameters. Results: The mean decrease in the ONSD from a baseline mean of 3.95 (SD: 0.17) (95%CI: 3.87, 4.02) to 3.89 (SD: 0.26) (95%CI: 3.78, 4.007) mm at 4 h and 3.94 (SD: 0.12) (95%CI: 3.89, 4.0) mm at 24 h after spinal anaesthesia was statistically significant. The changes in the ONSD measurements in Group P were not statistically significant. Headache was not reported at 24 h or in the follow-up at postoperative day 5. Conclusion: Measurement of ONSD is an easy, economical method for identifying decreased intracranial pressure after spinal anaesthesia. Further research could identify cut-off values to prognosticate PDPH in high-risk individuals. [ABSTRACT FROM AUTHOR]

Background Transpterygoid approaches to the skull base require dissection of the sphenopalatine artery, potentially compromising the option to harvest an ipsilateral nasoseptal flap (NSF) for reconstruction. In cases where other reconstructive options are limited, it may be necessary to utilize a NSF ipsilateral to the transpterygoid approach. Here, we describe the technique of NSF pedicle preservation with reconstruction outcomes. Methods This was a retrospective single-institution review of all expanded endonasal skull base cases utilizing a NSF ipsilateral to a transpterygoid approach. Reconstruction outcomes collected include intraoperative fluorescence with indocyanine green (ICG), postoperative magnetic resonance imaging (MRI) gadolinium enhancement, endoscopic assessment, and reconstruction-related complications. Results Twenty-one cases were included in this study (mean age 51.0 ± 20.6 years, 61.9% female). Indications for NSF ipsilateral to the transpterygoid approach included: bilateral transpterygoid approach (52.4%), revision reconstruction (23.8%), or significant septal deviation (19.0%). Twelve of 14 (85.7%) flaps demonstrated intraoperative perfusion with ICG, 15 of 15 (100%) enhanced on postoperative MRI, and 21 of 21 (100%) flaps had a healthy, viable appearance on postoperative endoscopy. There were no instances of flap necrosis or postoperative cerebrospinal fluid leaks. Technical keys to optimize mobilization of the pedicle include wide decompression of the sphenopalatine foramen and release of neurovascular tethering points of the pterygopalatine fossa. These steps allow for wide skull base exposure with preservation of the sphenopalatine artery. Conclusion With this technique, the transpterygoid approach can be performed in a manner that preserves the pedicle for an ipsilateral NSF and achieve an excellent reconstructive outcome. [ABSTRACT FROM AUTHOR]

Background We aimed to determine the incidence and risk factors for development of diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone secretion (SIADH) after transsphenoidal hypophysectomy (TSH) for resection of a pituitary adenoma. Methods This was a retrospective study of 403 adult patients undergoing TSH for pituitary adenoma. Clinical variables, tumor characteristics, and operative factors were collected. Incidences of DI and SIADH were determined, including timing in the perioperative period. Independent predictors of developing DI and SIADH were identified using multivariable logistic regression. Results Following TSH, 21.3% of patients developed DI at a mean 2.6 days and 7.4% developed SIADH at a mean 4.7 days. DI was negatively associated with older age (odds ratio [OR] = 0.98, 95% confidence interval [CI]: 0.96–0.99, p = 0.029). DI was positively associated with female sex (OR = 2.26, 95% CI: 1.24–4.11, p = 0.008), increase in anteroposterior tumor size (OR = 1.54, 95% CI: 1.11–2.13, p = 0.010), intraoperative cerebrospinal fluid (CSF) leak (OR = 2.29, 95% CI: 1.25–4.19, p = 0.008), and every 100 mL of estimated blood loss (EBL) (OR = 1.18, 95% CI: 1.01–1.39, p = 0.046). Development of SIADH was positively associated with intraoperative CSF leak (OR = 3.56, 95% CI: 1.24–10.21, p = 0.018) on multivariate analysis. Conclusion DI and SIADH occur in the minority of patients undergoing TSH, but vigilance for their development must be maintained for days after the surgery. Development of DI after TSH is multifactorial, having possible patient-specific risk factors and risk related to the complexity of surgical dissection, reflected by tumor size, intraoperative CSF leak, and EBL. Development of SIADH could be associated with intraoperative CSF leak occurrence. [ABSTRACT FROM AUTHOR]

Prior studies characterizing surgically managed frontal sinus fractures are small, institutional studies from major trauma centers (1–5). The current study characterizes the concomitant injuries and complications following open treatment of frontal sinus fractures across the United States. Patients who underwent open treatment for a frontal sinus fracture between 2010 and 2022 were identified in a United States administrative database. Patients <18 years old and with <90 days of follow-up were excluded. Type of fracture (simple or complex), frontal sinus obliteration and concomitant fractures (facial, vertebral, extremity) were identified. 90-day surgical site infection, sinusitis, meningitis, brain abscess and cerebrospinal fluid leak were identified, as well as mucocele any time after surgery. There were 1492 adult patients with open treatment of frontal sinus fractures: 654 (44%) with simple fractures and 838 (56%) with complex fractures. There were 157 (11%) patients with frontal sinus obliteration. Concomitant fractures included facial (715 patients, 48%), vertebral (55, 4%), upper extremity (40, 3%) and lower extremity (53, 4%). Within 90 days of surgery, 155 (10%) patients had a complication: surgical site infection (42, 2.8%), sinusitis (29, 1.9%), meningitis (25, 1.7%), brain abscess (23, 1.5%), and cerebrospinal fluid leak (63, 4.2%). There were 11 (0.7%) patients who developed a mucocele, and <11 (<0.7%) underwent reduction of contour deformity. On multivariate analysis, complex frontal sinus fracture and concomitant vertebral/extremity fracture were associated with increased likelihood of a complication. Over the last thirteen years, complication rates are low following surgically managed frontal sinus fractures. Comminuted fractures and those involving the posterior table increase the likelihood of a complication, likely due to increased injury severity. The results of the current study generally align with the published single-institution studies on complications of frontal sinus fractures treated with surgery. These findings from a large, nationwide cohort strengthen prior conclusions and increase the generalizability of reported complication rates. [ABSTRACT FROM AUTHOR]

Purpose: Treatment strategies for space-occupying/symptomatic pineal cysts (PC) are still up for debate. In this study we present PC management, outcome data and risk factors for recurrence after surgery, focusing on microscopic/endoscopic procedures vs. stereotactic catheter implantation as alternative treatment concept to permanently drain PC into ventricles/cisterns. Methods: This monocentric retrospective analysis included clinical data from all consecutive PC patients treated surgically between 2000 and 2022. Postoperative neurological and functional outcomes, along with perioperative complications, as well as time to PC recurrence and MR-morphological data were evaluated. Results: 39 patients (median age 32.6 years, range: 5.1–71.6 years) were analyzed. Main presenting symptoms were headaches, visual impairment, and epileptic seizures. In 18 patients (46.2%) an enlarged ventricular system was preoperatively found with 7 patients (18.0%) suffering from occlusive hydrocephalus. 14 patients underwent microscopic/endosocopic surgery, in 25 cases stereotaxy was preferred. No complication was seen in the microsurgery/endoscopy group compared to one intracystic postoperative bleeding (2.6%) and two CSF leaks (5.1%) after stereotaxy (p = 0.5). Overall, clinical improvement and significant cyst volume reduction (p < 0.0001) was seen in all patients. Recurrent PC were seen in 23.1%, independent of surgical procedure (p = 0.2). In cases of recurrence, TTR was 25.2 ± 31.2 months. Male gender (p = 0.01), longer surgery time (p = 0.03) and preoperatively increased Evans index (EI) (p = 0.007) were significant risk factors for PC recurrence in multivariate analysis. Conclusion: In patients suffering from PC, microsurgical and stereotactic approaches can improve clinical symptoms at low procedural risk, with equal extent of volume reduction. However, preoperative ventricular enlargement and EI values should be considered for optimal treatment planning to reduce recurrence. [ABSTRACT FROM AUTHOR]

Pituitary Neuroendocrine Tumors (PitNETs), often treated via endonasal transsphenoidal resection, present a risk for postoperative surgical site infections (SSIs), including intracranial infections such as meningitis. Identifying the risk factors associated with these infections is crucial for improving surgical outcomes and patient care. A retrospective study was conducted at a medical center from June 2020 to June 2023. The study included 20 patients with postoperative intracranial infections and 50 controls without infections. Inclusion criteria involved adult patients diagnosed with PitNETs who underwent standard endonasal transsphenoidal surgery and provided informed consent. Exclusion criteria included previous neurosurgical procedures, preoperative infections, concurrent severe diseases, or alternative surgical approaches. Diagnostic criteria for intracranial infections were based on clinical, hematological, cerebrospinal fluid, radiological, and microbiological findings. Statistical analyses were performed using IBM SPSS, focusing on univariate and multivariate logistic regression analyses. Univariate analysis showed no significant association of intracranial infections with factors like smoking history, previous craniotomy, operation time, hypertension, preoperative sphenoid sinusitis, BMI, and age. However, postoperative CSF leaks, intracranial pneumocephalus, diabetes mellitus, and tumor extension to the third ventricle were significantly associated with infections. Multivariate logistic regression further confirmed these findings, with significant odds ratios for these factors. The study reveals a significant correlation between postoperative CSF leaks, intracranial pneumocephalus, diabetes mellitus, and tumor extension to the third ventricle with the occurrence of SSIs following endonasal transsphenoidal resection of PitNETs. Microbial analysis revealed Escherichia coli as the most prevalent pathogen in post-surgery infections, with notable antibiotic resistance patterns observed in key bacteria, necessitating careful antibiotic selection. Tailored clinical treatment strategies addressing these risk factors are essential to reduce the incidence of postoperative SSIs and enhance patient safety. [ABSTRACT FROM AUTHOR]

The dura trauma or large defects due to neurosurgical procedures can result in potential complications. Dural replacements have proven effective to reduce the risk of seizures, meningitis, cerebrospinal fluid leakage, cerebral herniation, and infection. Although various artificial dural patches have been developed, addressing iatrogenic infections and cerebral adhesions resulting from patches implantation remains a challenge. This study employed a network interpenetration modification strategy to introduce super-hydrophilic and super-lubricity zwitterionic hydrogel coatings on polyurethane Neuro-Patch® (NP®) dura mater patch. The successful modification with the hydrogel coating preserved the intrinsic properties of the NP®, such as their anti-leakage and tensile strength capabilities, while effectively reducing biofouling on the surface of the patches. Additionally, by constructing subdural implantation for each dura mater substitute in rabbits, we observed that artificial dura mater patches modified with the hydrogel coating effectively reduced the incidence of postoperative cerebral adhesions and infections. This suggests a promising application prospect of the hydrogel coating in dural repair. The development of dural substitutes with anti-leakage, anti-adhesion and anti-infection functions is the key to the treatment of dural defects and cerebrospinal fluid leakage during trauma or neurosurgery. In this study, the amphoteric ionic hydrogel coating was firmly modified on the surface of polyurethane with a mild modification process to give the patch super-hydrophilic and super-lubricating properties. The adhesion of non-specific proteins and bacteria is effectively reduced. The rabbit dural defect repair model showed that the introduction of zwitterionic hydrogel coating effectively reduced the occurrence of postoperative infection, and no tissue adhesion was observed. Taken together, this study offers a promising way to enhance the performance of artificial dural patches, potentially benefiting patients undergoing neurosurgery. [Display omitted] [ABSTRACT FROM AUTHOR]

Microvascular decompression is considered a first-line treatment in classical trigeminal neuralgia. Teflon is the material commonly used. The use of autologous muscle has been occasionally reported. Failure may result from insufficient nerve decompression, inflammatory reaction to Teflon or late displacement of the offending vessel. In this paper, we illustrate an MVD technique that involves a modified muscle insertion method. In a series of 57 consecutive patients who underwent microvascular decompression, the trigeminal nerve was coated circumferentially with a substantial amount of autologous muscle graft. The coverage was extended well beyond the site of neurovascular conflict to create a cushioned environment and protect the nerve. Pain intensity was assessed using the Barrow-Neurological-Institute (BNI) grading scale. The mean follow-up period was 28.8 months (range: 12 to 75 months). Preoperatively, all patients experienced typical pain that was scored as BNI V. No postoperative mortality was observed. After surgery two patients developed incomplete facial nerve palsy, which resolved over 6-months and one patient experienced hearing loss (the only permanent complication). Ten patients (17.5%) developed mild hemifacial numbness, as detailed in the postoperative data and pain outcome section. There were no infections or cerebrospinal fluid leakages. Immediately after surgery, all patients achieved satisfactory pain control: 55 cases (96.5%) scoring as BNI grade I and 2 cases (3.5%) scoring as BNI grade II. At the latest follow-up, three patients (5.3%) experienced symptoms controlled by medications (grade III). Recurrence of pain BNI IV to V was observed in two cases (3.5%). Circumferential nerve wrapping using abundant autologous muscle resulted in immediate pain control in all patients treated, with a low recurrence rate. [ABSTRACT FROM AUTHOR]

Post-dural puncture headache (PDPH) is a debilitating complication of neuraxial anesthesia, particularly prevalent in obstetric patients, usually characterized by a postural headache. PDPH is hypothesized to result from cerebrospinal fluid leakage through a dural puncture, triggering symptoms like neck stiffness and subjective hearing changes. While conservative measures are common for treatment, more refractory cases may require invasive interventions such as an epidural blood patch (EBP). Recent studies have shown promise in using nebulized dexmedetomidine (nDEX) for PDPH, offering a non-invasive alternative to EBP. Two case presentations illustrate the efficacy of nDEX in resolving PDPH symptoms rapidly and completely. These cases underscore the need for exploring novel therapeutic options, especially in obstetric patients where safe and prompt relief is essential for maternal and newborn well-being. While the EBP remains the gold standard, its limitations of accessibility and invasiveness highlight the significance of investigating alternatives like nDEX. [ABSTRACT FROM AUTHOR]

Background: Microvascular decompression (MVD) is the gold-standard surgical treatment for cranial nerve compression disorders, including trigeminal neuralgia (TN), hemifacial spasm (HFS), and glossopharyngeal neuralgia (GPN). This review synthesizes historical milestones, recent advances, and evolving techniques in MVD, with a primary focus on these conditions. Methods: A comprehensive literature review was conducted using databases such as PubMed, SpringerLink, Google Scholar, BioMed Central, Scopus, and ScienceDirect. Studies published between 1970 and 2024 were analyzed, emphasizing surgical techniques, clinical outcomes, and technological innovations in MVD. Articles addressing TN, HFS, GPN, and other cranial nerve disorders treated with MVD were selected for detailed evaluation. Results: MVD demonstrates high efficacy, with 80–90% of patients achieving immediate symptom relief. Nevertheless, 15–25% of patients experience symptom recurrence, though long-term outcomes remain favorable. Fully endoscopic MVD has shown potential for enhanced intraoperative visualization, particularly in complex anatomical regions; however, its impact on surgical precision and clinical outcomes is still under investigation. Moreover, innovations in visualization technologies, including three-dimensional exoscopic systems and artificial intelligence-assisted surgery, continue to improve procedural safety and outcomes. Despite these advancements, complications such as hearing loss (1–2%) and cerebrospinal fluid leakage (2–4%) persist, highlighting the need for continuous refinement of techniques. Conclusions: MVD is evolving with the integration of cutting-edge technologies, resulting in improved clinical outcomes and reduced complication rates. Emerging innovations such as robotic-assisted MVD and gene therapies for cranial nerve disorders, including TN and GPN, promise even greater efficacy and precision. However, further research is necessary to standardize surgical protocols and address disparities in healthcare systems globally. [ABSTRACT FROM AUTHOR]

A 19-year-old male patient with a history of congenital left oval window defect has had recurrent admissions to a children's hospital for bacterial meningitis since the age of 7. Investigations revealed a left-sided type 1 incomplete partition deformity of the left ear with a congenital oval window defect, leading to communication between the cranium and the middle ear. The patient underwent a left canal wall down mastoidectomy and oval window defect repair, remaining well for 3 years. He experienced two more episodes of bacterial meningitis as he got older, prompting repeated exploratory tympanotomy and repair of the cerebrospinal fluid (CSF) leak after each episode. Recently, he was referred again for recurrent meningitis. Investigations showed a recurrent oval window defect. After undergoing left external ear canal transection, mastoid and middle ear obliteration, and left Eustachian tube obliteration, he remained well without further leaks or meningitis. Congenital oval window defect is rare and may present with recurrent bacterial meningitis secondary to spontaneous CSF leak via the oval window. Radiology plays a crucial role in identifying the source of the CSF leak, facilitating more precise preoperative counseling and surgical intervention. [ABSTRACT FROM AUTHOR]

Background: Orthostatic headache (OH) is a common feature of various conditions, including spontaneous intracranial hypotension (SIH), but no precise definition currently exists outlining the typical OH characteristics. This ambiguity risks misdiagnosis with unnecessary investigations and delay in institution of treatment. The present study aimed to carry out structured phenotyping of OH in patients with SIH with the aim of outlining its typical characteristics. Methods: Eligible patients with clinico-radiological confirmed SIH underwent a structured interview, after which a specialist interest group utilised the modified Delphi process to analyse the data and achieve consensus on defining the typical characteristics of OH in SIH. Results: In total, 137 patients were recruited. OH was present in 75.9%. Typical OH characteristics in SIH were defined as having a baseline severity (lying flat) on waking up of ≤3 (0–10, verbal response scale), headache onset-time of ≤4.5 h on becoming upright, time to peak severity of ≤7.5 h and an offset to baseline severity within 1.5 h of recumbency. Intra-individual consistency in the onset and offset-time was deemed a necessary characteristic. Conclusions: Defining typical OH characteristics has the potential of enhancing SIH diagnostics and management, at the same time as minimising unwarranted invasive procedures. [ABSTRACT FROM AUTHOR]

Introduction: Penetrating spinal cord injuries present unique clinical scenarios with high variability in presentation and management. These injuries are rare, accounting for 0.8% of annual penetrating spine injuries in the United States, with knives being the most common penetrating object. Retention of the knife blade further complicates management, with greater risk of infection and progressive neurologic injury. Given the rarity and variability of such injuries, preferred management for penetrating-knife spinal cord injuries (PKSCI), especially those with retained knife blades, remains contested. Furthermore, the management of PKSCI with concurrent lung injury is poorly described within the literature. Case Report: Here we discuss a unique case of a neurologically intact adult male who suffered a large lower thoracic PKSCI with complete dural transection and lung involvement. The patient arrived with the blade in situ while maintaining full neurologic function. Emergent imaging revealed the blade trajectory passing through the T8 lamina exiting the spinal canal at the costovertebral junction with involvement of the lung parenchyma and associated pneumorrhachis and pneumothorax. The patient was brought to the operating room where the blade was removed under direct visualization, the dura was repaired, and pneumothorax was stabilized. Conclusion: We describe in this case the choice of imaging, method of blade removal, cerebrospinal fluid leak management, dural repair, and concurrent lung injury management that afforded a favorable, ASIA class E outcome with complete preservation of neurologic function. [ABSTRACT FROM AUTHOR]

The article discusses the use of an Endoscopic Integrated Multipoint Laser System (EIMLS) to measure anterior skull base defects with precision. The study found that EIMLS can provide quick, precise, and objective measurements of these defects, showing promise for use in endoscopic surgical techniques. However, further refinement of the measurement technique is needed before implementing it in clinical practice. The technology has the potential to be valuable in otorhinolaryngology and broader endoscopic surgical applications. [Extracted from the article]

Background: This report analyzes traumatic anterior skull base CSF leaks following nasopharyngeal swab testing for detection of SARS-CoV-2 in the largest case series to date, combined with a systematic literature review. Methods: Retrospective multi-institutional case-series of traumatic anterior skull base CSF leak with clear antecedent history of COVID-19 swab was completed. A comprehensive search of databases was performed for the systematic literature review. Results: Thirty-four patients with traumatic CSF leak after COVID-19 nasopharyngeal swab testing were identified. Women were more than twice as likely to experience a CSF leak, as compared to men. The majority of patients (58.8%) had no reported predisposing factor in their clinical history. Common defect sites included the cribriform plate (52.9%), sphenoid sinus (29.4%), and ethmoid roof (17.6%). Four patients (11.8%) presented with meningitis. The median time between the traumatic COVID swab and the detection of CSF leak was 4 weeks (IQR 1–9). Patients with meningitis had a median leak duration of 12 weeks (IQR 8–18). The average leak duration was significantly longer in patients with meningitis compared to without meningitis (p = 0.029), with a moderate effect size (r = − 0.68). Most cases (92.9%) managed with endoscopic endonasal surgical repair were successful. Conclusions: This report clarifies the presentation, risk factors, and management of CSF leaks attributable to diagnostic nasopharynx swabbing procedures in the COVID-19 era. Timely surgical repair is the recommended management option for such leaks. [ABSTRACT FROM AUTHOR]

Introduction: In the management of sinonasal malignancies treatment‐induced morbidity and mortality is gaining relevance both for surgical approaches (endoscopic and open resection) and non‐surgical therapies. The aim of this multicenter study is to assess complications associated with endoscopic surgery and non‐surgical treatments (neoadjuvant and/or adjuvant) for malignant sinonasal tumors. Methods: All patients with nasoethmoidal malignancies treated with curative intent with endoscopic or endoscopic‐assisted surgery at three referral centers with uniform management policies were included. Neo‐ and/or adjuvant (chemo)radiotherapy was administered according to histology and pathological report. Demographics, treatment characteristics, and complications related both to the surgical and non‐surgical approaches were retrieved. The data were analyzed with univariate and multivariate statistics to assess independent predictors of complications. Results: Nine hundred and forty patients were included, 643 males (68%) and 297 females (32%). A total of 225 complications were identified in 187 patients (19.9%): cerebrospinal fluid (CSF) leak (3.5%), mucocele (2.3%), surgical site bleeding (2.0%), epiphora (2.0%), and radionecrosis (2.0%) were the most common. Treatment‐related mortality was 0.4%. Variables independently associated with complications at multivariate analysis were principally dural resection (OR 1.92), cranioendoscopic or multiportal resection (OR 2.93), dural repair with multilayer technique with less than three layers (OR 2.17), and graft different from iliotibial tract (OR 3.29). Conclusion: Our study shows that modern endoscopic treatments and radiotherapy for sinonasal malignancies are associated with limited morbidity and treatment‐related mortality. CSF leak and radionecrosis, although rare, remain the most frequent complications and should be further addressed by future research efforts. [ABSTRACT FROM AUTHOR]

Background The majority of patients with spontaneous intracranial hypotension (SIH) are symptomatic. Some patients are discovered incidentally. The proportion of asymptomatic SIH has never been defined. This article reports our institution's rate of asymptomatic cases among all of our patients with high/intermediate Bern scores on brain MRI, etiology of leak in asymptomatic cases, complications of asymptomatic leaks, and evolution of imaging before and after treatment. Methods We retrospectively analyzed data from the Cerebrospinal Fluid (CSF) Dynamics clinic spanning September 2020 to July 2023. Bern score was calculated from all available brain MRIs in patients with confirmed leaks. Patients with iatrogenic leaks or no brain MRI were excluded. The charts of asymptomatic patients were reviewed to obtain MRI indications, SIH progression, complications, leak type, and treatment outcomes. Results Some 8.6% (7/81) patients with high/intermediate Bern scores were asymptomatic at the time of imaging. Two patients declined myelography. Four of seven asymptomatic patients were found to have CSF-venous fistulas and underwent embolization with radiographic improvement. Complications of asymptomatic leaks in this population included subdural hematoma and superficial siderosis. Conclusions Asymptomatic but clearly present spinal CSF leaks were not uncommon in our group. These results highlight the possibility of a presymptomatic phase in patients with CSF leaks. In our sample, myelography was readily positive for etiology of the leak, and leaks promptly responded to targeted treatment. [ABSTRACT FROM AUTHOR]

The article discusses the outcomes of using autologous versus synthetic inlay grafts for skull base reconstruction in patients with high-flow defects. The study involved a multicenter case-control analysis and found comparable rates of postoperative cerebrospinal fluid leaks between the two types of grafts. The research highlights the importance of meticulous technique over specific tissue type and emphasizes the need to balance the availability and cost of synthetic materials with donor site morbidity in autologous grafts. The study provides valuable insights for surgeons performing skull base reconstructions. [Extracted from the article]

Cerebrospinal fluid (CSF) leaks commonly occur due to trauma or surgical procedures. Here we review CSF leak diagnosis and management in Low- and Middle-Income Countries (LMICs). A systematic review of the CSF leak management in LMICs was conducted using PubMed, Google Scholar, Embase and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eighteen articles with 3,596 patients (mean age = 39.58 years) were analyzed. Of these patients, 31.37% (1,128/3,596) were reported to have developed cranial CSF leaks. The predominant presentation of CSF leak included symptoms of rhinorrhea, headache, meningitis, and visual impairment. The primary etiology of CSF leak was complications from endoscopic surgery (482 patients), followed by spontaneous origin (46 patients), craniotomy (44 cases), and trauma from motor vehicle accidents (43 cases). Computed tomography (CT) scans (10 retrospective, 15 case, and 1 comparative study) and magnetic resonance imaging (MRI) (6 retrospective, 11 case, and 2 comparative studies) were identified as the most utilized diagnostic modalities. The endoscopic endonasal technique emerged as the predominant surgical approach for managing CSF leak (5 retrospective, 13 case, and 1 comparative study). Moreover, both acellular dermal matrix and turbinate flaps demonstrated comparable repair rates in the management of CSF rhinorrhea (95.23% and 96.00%, respectively). Additionally, porcine-derived fibrin sealant exhibited enhanced success rates for repairs in craniotomies, increasing from 49.21% to 97.81%. This study demonstrates progress in the diagnosis, treatment, and management of cerebrospinal fluid (CSF) leaks within LMICs, including the noteworthy advancement from traditional microscope utilization to the endoscopic endonasal technique. [ABSTRACT FROM AUTHOR]

Background: Surgery for tumors in the cerebellopontine angle is always a significant challenge due to the densely packed neurovascular structures, the narrow deep location, and the complex relationship between the lesions and surrounding neurovascular structures. Recently, great attention has been given to the neuroendoscope for its exclusive advantages, which have added a new dimension to many classical microscopic surgeries. However, the feasibility and advisability of fully endoscopic neurosurgery for cerebellopontine angle tumors remain to be further evaluated. Methods: We retrospectively collected the clinical outcomes and endoscopic surgical experience of 12 patients with tumors in the cerebellopontine angle (CPA) from January 2022 to April 2024 in our department. We analyzed patients' records, radiological neuroimaging, tumor-related variables, surgical procedures, and postoperative outcomes in detail. All patients were regularly followed up with neurological examinations and magnetic resonance imaging (MRI)/computed tomography (CT). Results: The pathology of the series included five cases of acoustic neuroma, six cases of meningioma, and one case of teratoma. The mean largest diameter of the lesion was 29.5 mm ±8.5 mm. Headache, hearing loss, and dizziness were the top three most common symptoms. All tumors were resected using the hand technique. No hemorrhage, cerebrospinal fluid leaks, or intracranial infections occurred. All patients with meningioma achieved Simpson grade II resection, and the remaining tumors underwent gross total resection, confirmed by both intraoperative and postoperative imaging. Overall, 91.7% of patients maintained normal facial nerve function postoperatively (HB1). One patient with acoustic neuroma experienced transient facial paralysis after surgery (HB2), which resolved during follow-up at 3 months postoperation. Clinical symptoms of all the other patients were resolved or ameliorated after surgery, with no new neurological deficits. The Karnofsky Performance Scale (KPS) scores remained unchanged or improved for all patients postoperatively. Conclusions: With the accumulation of experience and technological progress, the fully endoscopic retrosigmoid approach could enable safe and effective resection of cerebellopontine angle tumors, providing a panoramic view and illumination of deep-seated structures. [ABSTRACT FROM AUTHOR]

Background: The main surgical interventions for chronic subdural hematoma (CSDH) include craniotomy for hematoma evacuation, neuroendoscopic hematoma evacuation, and burr hole drainage.However, elderly patients often present with significant comorbidities, which limit their ability to tolerate general anesthesia and invasive surgical procedures.Minimally invasive soft-channel drainage under local anesthesia has emerged as a viable alternative, particularly suitable for elderly patients or those with high surgical risk.This study aims to evaluate the clinical outcomes and complication rates of minimally invasive soft-channel drainage assisted by 3D Slicer software for the treatment of CSDH. It also aims to provide new clinical evidence to help improve and optimize treatment protocols for this condition. Methods: A retrospective analysis was conducted involving 83 patients with CSDH treated in our department between January 2021 and December 2023. Patients were categorized into two groups based on the surgical intervention: the control group (burr-hole drainage, n = 42) and the intervention group (minimally invasive soft-channel drainage, n = 41).Baseline characteristics, anesthesia methods, perioperative metrics, and complications were compared. Clinical outcomes were evaluated using the Barthel Index and the modified Rankin Scale (mRS) preoperatively and three months postoperatively. Results: The drainage retention duration, operative time, and hospitalization period in the intervention group were significantly reduced compared to the control group, with reduced intraoperative blood loss (all P < 0.05). There was no significant difference in residual hematoma volume between the groups on postoperative day one (P > 0.05). The incidence of postoperative complications, including pulmonary infection, recurrent subdural hemorrhage, cerebrospinal fluid leakage, and intracranial pneumatosis, was significantly lower in the intervention group compared to the control group (all P < 0.05). No intracranial infections were observed in either group, and there was no statistically significant difference in hematoma recurrence rates (P > 0.05). Similarly, no significant differences were observed in the preoperative and three-month postoperative Barthel Index and mRS scores between groups (all P > 0.05). However, both groups demonstrated significant improvement in mRS and Barthel Index scores at three months postoperatively compared to preoperative levels(all P < 0.001). Conclusion: Both minimally invasive soft-channel drainage assisted by 3D Slicer and burr-hole drainage are safe and effective interventions for CSDH. Nevertheless, the minimally invasive approach provides significant benefits in terms of reducing intraoperative blood loss, shortening operative time, minimizing surgical trauma, and reducing the rate of complications. This approach is only advantageous for patients with well-liquefied hematomas and those with relative contraindications to general anesthesia. [ABSTRACT FROM AUTHOR]

Mechanical damage to the meninges, which protect the spinal cord from blunt external forces, can cause idiopathic cerebrospinal fluid (CSF) leakage. This is probably because even a small meningeal failure leads to the leakage of CSF out of the subarachnoid space. However, the dura mater, the outermost layer of the meninges, is especially resilient and structurally tough. Moreover, CSF leakage can be caused by daily activities, including coughing, sneezing, and falling. Because of these contradicting facts, the essential mechanism of CSF leakage is difficult to understand. Recently, extensive efforts have been made to elucidate the mechanism of traumatic and impact-related injuries through computational simulations. It is crucial to comprehend the actual failure mode of biological materials under in vivo-like injurious loading conditions to enhance the accuracy of injury prediction. Therefore, in this study, we focused on the relationship between the intrinsic shape of wrinkles formed on the dural surface and the mechanical failure mode of the spinal dura mater. We found that a generated crack runs along the microscopic wrinkles in the longitudinal direction even when the spinal dura mater is statically pressurized. [ABSTRACT FROM AUTHOR]

Objective: The burr-hole technique is a minimally invasive transcranial approach designed to minimize the surgical incision size and reduce disruption to brain tissue. We aimed to share our experience with the burr-hole technique for removing brain lesions and to evaluate its effectiveness in treating appropriately sized intra-axial brain lesions. Methods: In this retrospective cohort study, we analyzed the clinical features, radiological characteristics, surgical techniques, and outcomes of patients who underwent burr-hole surgery for intra-axial brain lesions between January 2019 and December 2023. Results: A total of 81 patients were included in the study. Gross total resection was achieved in 74 patients (91.4%), whereas subtotal resection was performed in 7 patients (8.6%). There were no perioperative deaths, cerebrospinal fluid leaks, or wound infections. The median follow-up duration was 40.5 months (range, 4.1–63.7 months). At the end of the follow-up period, 14 patients (17.3%) experienced recurrence, including 6 with glioma and 8 with primary cerebral lymphoma. Among these patients, 10 died due to lesion recurrence. Conclusions: The burr-hole approach using a retractable tubular device is a safe and effective method for the removal of brain lesions. As a novel minimally invasive technique, it significantly facilitates and accelerates the evolution of microsurgical outcomes. [ABSTRACT FROM AUTHOR]

Objective Methods Results Interpretation Frontotemporal dementia (FTD) sagging brain syndrome is a disabling condition. An underlying spinal Cerebrospinal fluid leak can be identified in only a minority of patients and the success rate of non‐directed treatments is low. Some of these patients have a remote history of craniectomy/cranioplasty and we report a positive response to custom implant cranioplasty revision many years after their initial cranioplasty.We reviewed medical records and imaging studies of 61 consecutive patients with FTD sagging brain syndrome. A SIH Disability Assessment Score (SIHDAS) questionnaire was completed to assess the severity of the symptoms before and after custom implant cranioplasty. Pre‐ and post‐operative brain MRI was obtained to assess degree of brain sagging.Eight (13.1%) of the 61 patients had a history of craniectomy/cranioplasty 1.5–13.5 years prior to onset of symptoms of FTD sagging brain syndrome. The mean age of the one woman and seven men at the time of presentation to our medical center was 50 years (range, 26–68 years). None had sinking scalp flap syndrome. Prior treatments included epidural blood patching and dural reduction surgery. Custom cranial implant surgery was performed in four patients and resulted in prompt and remarkable improvement of symptoms in three patients (SIHDAS: very severe disability to no or mild disability) and mild improvement in one patient. Brain MRI showed improvement of brain sagging.A disproportionate number of patients with FTD sagging brain syndrome have a remote history of supratentorial craniectomy/cranioplasty and revision cranioplasty should be considered. [ABSTRACT FROM AUTHOR]

Background Method Results Discussion Patients with spontaneous intracranial hypotension (SIH) report difficulties in concentration and memory. To objectify these deficits, we implemented standard cognitive tests into our routine SIH workup.Retrospective, single‐center report of cognitive standard tests among patients with SIH consecutively admitted from May to July 2023. Cognitive testing involved the Montreal Cognitive Assessment (MoCA©, alternate versions, 0–30 points, 30 points for best performance, ≤26 indicating mild cognitive impairment at age >64 years), and the Trail Making Test, part B (TMT B, z‐scores adjusted to age and education) to test for executive function. Both were administered at admission, and within 36–72 h after surgical repair of the spinal cerebrospinal fluid (CSF) leak.A total of 18 patients with an active spinal CSF leak were tested at admission (seven with ventral, three with lateral leak, and eight with CSF‐venous fistula). There was no profound brain sagging as described in brain sagging dementia. The mean (standard deviation [SD]) age was 53.6 (11) years. Bern scores ranged between 0 and 9, median 6.5. The mean (SD) MoCA score at admission was 26.5 (2) points, with five patients (28%) scoring <26 points indicative of mild cognitive impairment. Performance in the TMT B was impaired in nine patients (50%, z‐score ≥2). Upon targeted treatment of the CSF leak, the mean (SD) MoCA score immediately improved to 28.5 (1), p = 0.001 (n = 14), as did performance on the TMT B (mean [SD] 2.1 [2] vs. 1.1 [1], p = 0.015, n = 13).Spontaneous intracranial hypotension with an active spinal CSF leak is associated with cognitive impairment and surgical closure of the leak led to rapid improvement. We conclude that there may be a causal relationship between cognitive dysfunction and spinal CSF loss. We suggest considering spinal CSF leaks as a treatable cause in patients with mild cognitive impairment and with pre‐dementia. This may ultimately necessitate thorough screening of brain and spine magnetic resonance images in patients with mild cognitive impairment. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective Methods Results Conclusion Trial Registration Surgery to correct the cervicothoracic kyphotic deformity in ankylosing spondylitis (AS) can be associated with serious neurovascular risks. According to the literature, there are no clinical reports documenting the use of vertebral column decancellation (VCD) in the treatment of cervicothoracic kyphotic deformity in patients with AS. The purpose of the present study was to retrospectively analyze and evaluate the effect of VCD on cervicothoracic kyphotic deformity in patients with AS.Records of eight patients with cervicothoracic kyphotic deformity who underwent VCD at C7 in our institution were retrospectively reviewed. The mean duration of clinical follow‐up after surgery was 19 months. The cervical lordosis (CL) and C2–C7 sagittal vertical axis (SVA) were meticulously measured on full‐length spine radiographs. The chin‐brow vertical angle (CBVA) was measured on clinical photographs. Outcome measures utilized included the Neck Disability Index (NDI), the Japanese Orthopaedic Association (JOA) Score, and a Visual Analog Scale (VAS) for neck pain. The data analysis was performed using SPSS version 26.0 for Windows. For paired data adhering to a normal distribution, we utilized paired sample t‐tests to analyze preoperative and postoperative imaging parameters. Statistical significance was established at a p value threshold of < 0.01.All eight patients successfully completed the surgery. With an average VCD osteotomy angle of 47.6° ± 8.1° (±SD), the mean preoperative CBVA was 81.1° ± 17.6° (±SD), while the immediate postoperative value was 19.9° ± 5.7° (±SD). The overall average correction was 61.2° ± 18.9°. The mean preoperative cervical sagittal imbalance was 93.4 ± 27.3 mm (±SD), while the immediate postoperative value was 40.2 ± 18.9 mm (±SD). The overall average correction was 53.2 ± 28.1 mm. None of the eight patients experienced intraoperative complications, including nerve or vascular injury, cerebrospinal fluid leakage, or any other related complications. In the cohort of eight patients, the mean values for estimated blood loss, surgical time, and hospital stay were 1313 mL, 248 min, and 18 days, respectively. In comparison to preoperative scores, statistically significant improvement was noted in all patients in the postoperative period with regard to NDI, JOA, and VAS (p < 0.01, using a paired t‐test).The VCD procedure proves to be a dependable and efficient approach for addressing cervicothoracic kyphotic deformities. It achieves remarkable corrections in cervical kyphosis and CBVA.Chinese Clinical Trial Registry: 2400090375 [ABSTRACT FROM AUTHOR]

Objective: This study aimed to evaluate the feasibility and efficacy of one-piece resection for the treatment of ventral intradural extramedullary spinal meningiomas (VIESMs). Methods: Between January 2017 and December 2023, all patients who underwent one-piece resection for VIESMs were retrospectively reviewed with their demographic, intraoperative and postoperative data being recorded. In addition, postoperative neurological status based on the modified McCormick functional schema (mMFS), along with radiological manifestations on the magnetic resonance imaging (MRI) were assessed and compared with that before the operation. Results: A total of 27 cases (7 men and 20 women) with an average age of 63.37 ± 10.48 years old were included in the present study with the operation time, blood loss, length of hospital stay, and follow-up periods being 292.41 ± 42.64 min, 286.85 ± 47.03 ml, 10.37 ± 1.69 days, and 16.81 ± 10.79 months, respectively. Postoperatively, one case experienced cerebrospinal fluid leakage without neurological deterioration. At the final follow-up, the mMFS scores were unchanged in seven (25.93%) cases while they improved in the remaining 20 (74.07%) cases. Finally, the MRI examinations showed that one-piece resection was successfully performed for each VIESM without a recurrence. Conclusion: One-piece resection was a feasible, safe and effective procedure for treating VIESMs. Partial removal of the ipsilateral pedicle, facet joint, and even posterior vertebral wall to establish a wide surgical corridor and vision, resection of the dentate ligaments to minimize spinal cord traction, and meticulous coagulation of the dural attachment to reduce recurrence were the key technical points. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the surgical outcomes of delayed microsurgical clipping for ruptured intracranial aneurysms (RICAs) of anterior circulation. Methods: This retrospective, cross-sectional study assessed the surgical outcomes of 50 patients who underwent surgical clipping for "ruptured aneurysms" with subarachnoid haemorrhage after the 21st post-bleed day, from May 01, 2022, till May 01, 2023, at the Department of Neurosurgery, Punjab Institute of Neurosciences, Lahore, Pakistan. Results: The mean age of patients was 49.66 ± 6.231 years with a female preponderance of 54%. Out of 50 cases, 21 were midline aneurysms (42%), followed by left-sided laterality in 16 cases (32%). Aneurysm of the anterior communicating artery was the most common accounting for 42% of the patients. Forty-nine patients returned home after first postoperative week without deficits, with a success rate of 98%. Seizures, surgical site infection and cerebrospinal fluid leak were noted in 6%, 4% and 2% patients, respectively. Conclusion: Delayed clipping in RICAs after the 21st post-bleed day is advocated, especially in resource-constrained settings. Meticulous surgical technique and asepsis are responsible for great postoperative outcomes. [ABSTRACT FROM AUTHOR]

Objectives: To determine the incidence of postoperative cerebrospinal fluid (CSF) leaks after endoscopic endonasal transsphenoidal surgery (EETS) for pituitary adenomas without sellar floor reconstruction (SFR). Methods: This retrospective observational study was conducted at Department of Neurosurgery, Punjab Institute of Neurosciences (PINS), Lahore, Pakistan from January, 2018 to December, 2022. It is a non-probability based consecutive case series. A total of 316 patients meeting the inclusion criteria were selected. Results: Among the 316 patients, 102 (32.3%) were male, while 214 (67.7%) were female. Mean age was 40.98±7.8 SD (range 23 to 65 years). Regarding size of pituitary adenomas, 19 (6%) were microadenomas and 297 (94%) were macroadenomas. Overall postoperative CSF (poCSF) leak in our patients was 2.8%. Among cases with poCSF leak, 4 (3.9%) were male and five were female (2.3%) with the P-value of 0.477. Regarding size of pituitary adenomas, only one (5.3%) microadenoma had poCSF leak whereas 8 (2.7%) macroadenomas had poCSF leak with the P-value of 0.432. Conclusion: Pituitary adenomas can be successfully treated with EETS without SFR in patients who do not experience intraoperative CSF leak. [ABSTRACT FROM AUTHOR]

Introduction. Cervical compressive myelopathy manifests mainly as spastic paralysis, exaggerated reflexes, and clumsiness of the hand, with/without gait disturbances. It mainly results from degenerative changes in cervical spine along with infolding of the ligamentum flavum, the presence of spondylolisthesis, the development of osteophytes, and the hypertrophy of facet joints. Though the recent pathology appears to be facetal instability, hence facetal fixation with or without laminectomy in these patients should be advocated. Materials and Methods. 25 patients with cervical compressive myelopathy were operated with transfacet cervical spine fixation with or without laminectomy, decided on the basis of clinical symptomatology and MRI features. Results. All patients with laminectomy showed improved power and significant lightness in limbs post-surgery. In two patients, there was CSF leak, which was stopped by suture re-enforcing of the wound, and one patient required a lumbar drain to be kept for five days. One patient had a temporary deterioration of power in the left upper limb. Among patients undergoing only transfacet fixation, one patient had no change in symptoms, and three patients had a significant lightness in limbs. Conclusion. The decision to perform transfacet fixation with laminectomy versus transfacet fixation alone is based on the severity and type of spinal cord compression and the clinical presentation of the patient. [ABSTRACT FROM AUTHOR]

Background/Objectives: To evaluate the outcomes of anterior skull base (ASB) reconstruction using single versus double vascularized flap techniques following multiportal cranio-endoscopic approaches (CEA), based on a 12-year experience. Methods: A retrospective analysis was conducted on 46 patients who underwent ASB reconstruction after a CEA at our department between 2010 and 2022. Patients were divided into two groups: Group 1 received a pericranial flap (PF) reinforced with a fascia graft, while Group 2 underwent multiple flap reconstruction with PF, fascia graft, and nasoseptal flap (NSF). The primary outcome measured was the incidence of cerebrospinal fluid (CSF) leakage and the impact of adjuvant radiotherapy (RT) on reconstruction. Results: Group 1 (86.9%) demonstrated no significant postoperative CSF leaks, showing that the PF, combined with multilayer techniques (including underlay sealing matrix and overlay fascia graft), effectively repaired ASB defects. Group 2 (13.1%), employing both PF and NSF, showed similar outcomes, with the dual flap approach particularly beneficial in cases of post-traumatic fistulas or when the nasal septum was spared by disease. No significant differences were observed in complications or flap necrosis, even in patients receiving adjuvant RT. Conclusions: The PF is a reliable and versatile option for ASB reconstruction, often sufficient as a single-flap technique. The addition of an NSF can be beneficial in specific cases, particularly in post-traumatic conditions or tumors with unilateral endonasal invasion. However, PF alone, when combined with a multilayer approach, minimizes the risk of CSF leakage and long-term flap necrosis, underscoring the importance of tailored surgical strategies for optimal outcomes. [ABSTRACT FROM AUTHOR]

Background and Objectives: The temporoparietal fascia flap (TPFF) has recently emerged as an option for skull base reconstruction in endoscopic transnasal surgery when vascularized nasal flaps are not available. This study provides a systematic literature review of its use in skull base surgery and describes a novel cohort of patients. Methods: PRISMA guidelines were used for the review. Patients undergoing skull base reconstruction with TPFF in our center from May 2022 to April 2024 were retrospectively included. Data were collected on pre- and post-operative clinical and radiological features, histology, surgical procedures, and complications. Results: Sixteen articles were selected, comprising 42 patients who underwent TPFF reconstruction for treatment of complex skull base pathologies. In total, 5 of 358 patients (0.9%) who underwent tumor resection via endoscopic transanal surgery in the study period in our institution required TPFF. All had been previously treated with surgery and radiation therapy for different pathologies (three chordomas, one giant pituitary neuroendocrine tumor (PitNET), and one sarcoma). Post-operative complications included CSF leak, which resolved after flap revision, and an internal carotid artery pseudoaneurysm requiring endovascular embolization. Conclusions: TPFF is an effective option for skull base reconstruction in complex cases and should be part of the armamentarium of the skull base surgeon. [ABSTRACT FROM AUTHOR]

BACKGROUND: The endoscopic-assisted approach for intracerebral hemorrhage minimizes traumatization of the brain and allows direct access to hematoma. The study aimed to compare the results of the endoscopic-assisted evacuation for supratentorial hemorrhage versus conventional craniotomy. METHODS: A retrospective study analyzed medical records of patients with supratentorial intracerebral hemorrhage treated at our Neurosurgical Department between January 2015 and December 2023. The study included 91 patients who underwent either neuronavigational-assisted neuroendoscopy (n=25) or conventional craniotomy treatment (n=66). RESULTS: For conventional craniectomy procedures, the average residual volume was 10.1 ml, representing an average 82.1% hematoma evacuation efficacy. After endoscopically assisted procedures, the average residual volume was 3.9 ml, achieving a 92.5% hematoma evacuation efficacy. After the endoscopically assisted procedure, fewer than 10% of patients were revised for early or late complications (2 out of 25 patients), whereas after the craniectomy procedure, revision or the introduction of lumbar drainage for cerebrospinal fluid leakage was performed on 35% of patients (20 patients). CONCLUSIONS: The endoscopic-assisted evacuation of supratentorial intracerebral hemorrhage is becoming preferred because of its efficacy, a small number of complications, and minor trauma for the patient (Tab. 1, Fig. 3, Ref. 16). Text in PDF www.elis.sk [ABSTRACT FROM AUTHOR]

[Display omitted] The majority of surgical training is conducted in real-world operations. High-fidelity surgical simulators may provide a safer environment for surgical training. However, the extent that it reflects real-world operations and surgical ability is often poorly characterized. (1) Assess the validity and fidelity of a surgical simulator; (2) Examine the quantitative relationship between simulation performance and markers of real-world ability; (3) Establish thresholds for surgical expertise, and estimate their external validity and accuracy. A cohort study of surgeons at a British neurosurgical center. Ten early-career "novice" surgeons and 8 board-certified "expert" neurosurgeons. (1) Face and content validity, and visual and haptic fidelity; (2) Construct validity; (3) Predictive and discriminative utility of quantitative performance thresholds. Participants performed unilateral lumbar decompressions on high-fidelity spinal simulators that replicate the bony and soft tissue anatomy along with physiological processes such as bleeding and CSF leaks. Operating times, measured from first surgical action to either self-perceived satisfactory decompression or the end of allocated time, were recorded. The performance was also assessed independently by 2 blinded spinal subspecialist neurosurgeons using OSATS, a validated surgical assessment tool that utilizes 5-point scales on a variety of technical domains to grade the overall technical proficiency. Validity and fidelity were assessed by expert neurosurgeons using quantitative questionnaires. Construct validity was assessed by ordinal regression of simulation performance against real-world surgical grade and portfolio. Thresholds of expert status by simulation performance was established, and their predictive and discriminative utility assessed by crossvalidation accuracy and AUC-ROC. Operating time and expert assessments of simulation performance (OSATS) were strong and significant prdictors of surrogate markers of real-world surgical ability. The thresholds for expert status were operating time of 15 minutes and modified OSATS score of 15/20. These thresholds predicted expert status with 84.2% and 71.4% accuracy respectively. Strong discriminative ability was demonstrated by AUC-ROC of 0.95 and 0.83 respectively. All expert surgeons agreed that RealSpine simulators demonstrate high face validity, and high visual and haptic fidelity, with overall scores showing statistically significant agreement on these items (all scores at least 4/5, p<.0001). There was less consensus on content validity, but with still significant overall agreement (average score: 3.75/5, p=.023). Real-world surgical ability and experience can be accurately predicted by defining objective quantitative thresholds on high-fidelity simulations. The thresholds established here, along with other data presented in this paper, may inform objectives and standards to be established in a spinal surgical training curriculum. [ABSTRACT FROM AUTHOR]

The nomenclature, classification, and surgical approaches for spinal dural cysts (SDCs) remain a subject of controversy. The present study proposes a novel subtype classification system and corresponding surgical strategies, with the aim of enhancing comprehension of this entity and standardizing surgical treatment. A retrospective review. A total of 104 patients with SDCs underwent novel subtype classification and corresponding surgical strategies from January 2015 to December 2021. Fifty-four patients who underwent conventional surgery from January 2012 to December 2014 as the control group for preliminary validation. The outcomes are categorized into 4 levels: excellent, good, unchanged, and deteriorated, based on neurological improvement and pain relief. Grades of excellent and good were identified as improvements. Follow-up magnetic resonance imaging and complications were also evaluated. Based on the shared pathogenic factor of dural defects, the dural-associated cysts in the spinal canal are uniformly referred to as SDCs. They are further classified into Type 1 (no nerve roots) and Type 2 (containing nerve roots), with 4 additional subtypes based on the shape of the leak and the flow of leakage. The fissure-shaped leak of Type 1a SDCs is directly sutured, whereas the aperture-shaped leak of Type 1b is repaired using a patch. Low-flow leakage of Type 2a is directly sealed using a combination of adipose tissue and fibrin glue, whereas high-flow Type 2b necessitates suturing at the end of the leak to attenuate cerebrospinal fluid flow prior to sealing. The follow-up period averaged 23.8 months. Excellent or good outcomes were achieved in 100%, 88.9%, 100%, and 97.3% for the 4 subtypes respectively. The overall improvement rate of SDCs was 97.1%, which was significantly higher than that of the conventional surgery group (85.2%, p=.008). MRI follow-up showed a significant reduction in cyst size of 100%, 100%, 97.8%, and 97.3% for the 4 subtypes, respectively. The primary complications included pseudomeningocele in 4 cases (3.8%) and delayed wound healing in 5 cases (4.8%). The complication rate was also significantly lower than that of the control group (8.7% vs 24.1%, p=.008). Subtyping SDCs based on the variation of leaks and leakage can enable more targeted surgical strategies, which are helpful for improving treatment effectiveness and reducing complications. [ABSTRACT FROM AUTHOR]

Durotomy is an intraoperative complication in lumbar surgery, which can result in refractory cerebrospinal leakage. Therefore, intraoperative durotomy in lumbar surgery should be appropriately repaired. The aim of the study was to describe our method to repair intraoperative durotomy using the Gore Preclude MVP Dura Substitute (MVP). The MVP is an artificial dural substitute of three layers. Its surfaces are composed of expanded polytetrafluoroethylene, and the intermittent layer is made of a proprietary fluoroelastomer. After an incidental durotomy during surgery, the MVP was cut and designed bigger than the size of the durotomy site. The MVP was inserted into the space between the dura and the arachnoid membrane. The MVP was unfolded in the inserted space and fixed to the dura using four nodes of 6–0 nylon yarn. Intraoperative dural repair was achieved, and cerebrospinal fluid leakage did not persist. No complications were observed. Our method to repair intraoperative durotomy using the MVP can be simple and useful. [ABSTRACT FROM AUTHOR]