Hair-sparing technique using absorbable intradermal barbed suture versus traditional closure methods in supratentorial craniotomies for tumor.

BACKGROUND: Hair-sparing techniques in cranial neurosurgery have gained traction in recent years and previous studies have shown no difference in infection rates, yet limited data exists evaluating the specific closure techniques utilized during hair-sparing craniotomies. Therefore, it was the intention of this study to evaluate the rate of surgical site infections (SSIs) and perioperative complications associated with using an absorbable intradermal barbed suture for skin closure in hair-sparing supratentorial craniotomies for tumor in order to prove non-inferiority to traditional methods. METHODS: A retrospective review of supratentorial craniotomies for tumor by a single surgeon from 2011 to 2017 was performed. All perioperative adverse events and wound complications, defined as a postoperative infection, wound dehiscence, or CSF leak, were compared between three different groups: (1) hair shaving craniotomies + transdermal polypropylene suture/staples for scalp closure, (2) hair-sparing craniotomies + transdermal polypropylene suture/staples for scalp closure, and (3) hair-sparing craniotomies + absorbable intradermal barbed suture for scalp closure. RESULTS: Two hundred sixty-three patients underwent hair shaving + transdermal polypropylene suture/staples, 83 underwent hair sparing + transdermal polypropylene suture/staples, and 100 underwent hair sparing + absorbable intradermal barbed suture. Overall, 2.9% of patients experienced a perioperative complication and 4.3% developed a wound complication. In multivariable analysis, the use of a barbed suture for scalp closure and hair-sparing techniques was not predictive of any complication or 30-day readmission. Furthermore, the absorbable intradermal barbed suture cohort had the lowest overall rate of wound complications (4%). CONCLUSIONS: Hair-sparing techniques using absorbable intradermal barbed suture for scalp closure are safe and do not result in higher rates of infection, readmission, or reoperation when compared with traditional methods.

Minimally invasive keyhole temporal lobectomy approach for supramaximal glioma resection: A safety and feasibility study.

With a recent trend towards supra-maximal resection for gliomas and minimally invasive techniques, keyhole temporal lobectomies may serve an important role in neurosurgical oncology. Due to their location and proximity to eloquent brain, temporal lobe gliomas offer unique challenges that may limit the extent of resection. Here we describe a modified technique using mini-craniotomies through a keyhole approach for temporal lobectomies in glioma patients. We retrospectively reviewed data from consecutive patients who underwent temporal lobectomies for resection of gliomas from 2012 to 2018. Demographic data, extent of tumor resection, pre and post-op KPS, short term and long term complications, as well as other relevant data were collected. We identified 57 patients who underwent keyhole-mini craniotomy for temporal lobectomies for glioma. Surgical procedures were performed in 12 patients for low-grade glioma (LGG) and 45 patients for high-grade glioma (HGG). Awake craniotomies were performed in 15 of the cases, and 13 cases were for tumor recurrence. Supra-maximal resection (SMR) was achieved in 15 patients, while gross total resection (GTR) and near total resection (NTR) achieved in 32 patients and 10 patients, respectively. Average pre- and post-op KPS were equivalent, and post-operative complications requiring surgical intervention were experienced in 4 patients. Here we show that our modified keyhole craniotomy is both safe and effective in achieving SMR or GTR in glioma patients, with minimal morbidity. This minimally-invasive temporal lobectomy may be an instrumental tool for neurosurgical oncologists transitioning to less invasive techniques.

Imaging Characteristics of a Hypervascular Pituitary Spindle Cell Oncocytoma on Magnetic Resonance Imaging and Digital Subtraction Angiography.

BACKGROUND: Spindle cell oncocytomas (SCOs) are rare neuroendocrine tumors of the posterior pituitary that are often misdiagnosed as nonfunctional pituitary tumors. Fewer than 50 cases of SCOs have been described in the literature, and many of these reports have documented the tumors to be hypervascular on imaging or histology. CASE DESCRIPTION: We present the first cerebral angiography imaging findings of an SCO before primary resection. The discovery of a prominent tumor blush, enlarged meningohypophyseal feeders bilaterally, and prominent tumor draining veins aided in preoperative planning and subsequent successful endoscopic transsphenoidal surgical resection. CONCLUSIONS: Despite being a rare entity, SCOs should be included in the differential diagnosis when working up a hypervascular sellar tumor. Flow voids may be present on initial magnetic resonance imaging evaluation. Subsequent digital subtraction angiography can be used to further investigate abnormal vasculature and aid in surgical planning.

The use of dehydrated amniotic membrane allograft for augmentation of dural repair in transsphenoidal endoscopic endonasal resection of pituitary adenomas.

BACKGROUND: In transsphenoidal endoscopic endonasal surgery (TEES), watertight separation of the sinonasal cavity and intracranial compartment is the primary goal of closure. However, even when meticulous closure technique is implemented, cerebrospinal fluid (CSF) leaks, dural scarring, and meningitis may result. Particularly when intraoperative CSF leak occurs, materials that facilitate the creation of a watertight seal that inhibits disease transition and minimizes inflammatory response after durotomy are sought. Dehydrated amniotic membrane (DAM) allograft appears to confer these attributes as studies have shown it augments epithelialization, facilitates wound healing, and minimizes and impedes bacterial growth. We detail the use of DAM allograft to augment sellar closures after TEES. METHODS: We conducted a feasibility study, retrospectively reviewing our institution's database of TEES for resection of pituitary adenomas in which DAM was utilized to supplement sellar closure. RESULTS: One hundred twenty transsphenoidal surgery cases with DAM were used during sellar closure, with a 49.2% intraoperative CSF leak rate. Of this cohort, two patients experienced postoperative CSF leak (1.7%), and no patients developed meningitis. CSF leak rate for TEES-naïve patients was 0.9%. CONCLUSIONS: This feasibility study demonstrates that dehydrated amniotic membrane allograft can be safely utilized as an adjunct during sellar closures for TEES for pituitary adenoma resection with very low rates of CSF leak and meningitis.

PAX8 Expression Variability in Cerebellar Hemangioblastoma: Case Series and Review of the Literature.

Hemangioblastomas are benign tumors of undetermined origin, and account for up to 2.5% of all intracranial tumors. They may occur either sporadically or as a manifestation of von Hippel-Lindau (VHL) syndrome. Central nervous system (CNS) hemangioblastomas are pathologically diagnosed by gross and microscopic morphology, with further support of the diagnosis conferred by a characteristic immunohistochemistry profile including PAX8 negativity. Although renal hemangioblastomas have previously been reported to be PAX8 positive, CNS hemangioblastoma positive PAX8 expression has never been reported. We reviewed 11 cases of cerebellar hemangioblastoma from our institution over a 7-year period (2010 to 2017). Tissue was stained for PAX8 to determine immunohistochemical labeling. Of 11 reviewed cases of cerebellar hemangioblastoma, 7 exhibited PAX8 immunohistochemical expression. A review of the literature found no previously reported cases of positive PAX8 labeling in cerebellar hemangiomas. PAX8 negativity is not as specific for cerebellar hemangioblastoma as previously thought, and caution must be used when relying solely on a panel of PAX2, PAX8, and inhibin A for pathologic diagnosis.

Laser Interstitial Thermal Therapy as a Primary Treatment for Deep Inaccessible Gliomas.

BACKGROUND: Treatment strategies for deep intracranial gliomas remain limited to stereotactic biopsy in many cases due to the morbidity of aggressive surgical resection. Since no cytoreductive therapy is offered, outcomes have been demonstrably poor compared to patients who are able to undergo primary surgical resection. OBJECTIVE: To present our practice, in an effort to reduce morbidity and still offer cytoreductive treatment, of offering the possibility of laser interstitial thermal therapy (LITT) for the primary treatment of intracranial deep gliomas that would be otherwise unamenable for resection. METHODS: From 2010 to 2017, 74 patients were identified from a single surgeon at a single tertiary care referral center who had been treated with LITT. We conducted an exploratory cohort study on patients (n = 6) who have undergone contemporaneous biopsy and laser ablation for the treatment of deep gliomas with a mean tumor volume of 10.9 cc (range 4.2-52 cc). RESULTS: In our cohort, mean extent of ablation (EOA) was 98.5% on postoperative MRI; mean progression-free survival was 14.3 mo, and 5 patients (83%) remained alive at mean follow-up time of 19.7 mo without any complications. Additionally, there was a negative linear relationship between preoperative lesion size and EOA (P < .04) when analyzed with previously reported series. CONCLUSION: Although our series is small, we suggest that LITT can be a safe alternative cytoreductive therapy for deep surgically inaccessible gliomas. Given the known benefit of near gross total resection for high-grade gliomas, we believe LITT may improve survival for these patients and complement adjuvant treatments if patients are appropriately selected.

Transsphenoidal Approach for Pituitary Adenomas in Elderly Patients.

INTRODUCTION: With a rapidly expanding elderly population in the United States, the incidence of pituitary adenomas in elderly will continue to rise. In this study, we aim to evaluate the safety and efficacy of transsphenoidal endoscopic endonasal resection for pituitary adenomas in the elderly population. METHODS: A retrospective review of 131 consecutive patients who underwent transsphenoidal endoscopic endonasal resection for pituitary adenomas at the University of Miami Hospital between 2012 and 2016 was performed. Preoperative, intraoperative, and surgical outcomes were analyzed in elderly (>70 years) versus nonelderly (<70 years) patients. RESULTS: Of the 131 patients, 23 of them were >70 years (18%), of which 14 were septuagenarians and 9 were octogenarians. Elderly patients were more likely to present with vision loss (80.8% vs. 56.6%; P = 0.013) and larger tumors on imaging (2.7 ± 1.0 cm vs. 2.4 ± 1.3 cm; P = 0.042). Overall surgical and endocrinologic outcomes between the 2 groups were similar. However, patients <70 years old were more likely to have a gross total resection (86.7% vs. 65.4%; P = 0.011), as well as transient diabetes insipidus (54.3% vs. 26.9% P = 0.012) and intraoperative cerebrospinal fluid leak (83.5% vs. 58.5%; P = 0.013). However, permanent postoperative complication rates were similar including rate of permanent diabetes insipidus (4.3% elderly vs. 12.1% adult), cerebrospinal fluid leak (8.7% elderly vs. 8.4% adult), and meningitis (4.3% elderly vs. 2.8% adult). There were no medical complications or deaths in our cohort. CONCLUSION: The transsphenoidal endoscopic endonasal approach can be a safe and effective technique for resection of pituitary adenomas in patients >70 years old with appropriate patient selection.

Use of Tubular Retractor for Resection of Colloid Cysts: Single Surgeon Experience and Review of the Literature.

BACKGROUND: Colloid cysts are challenging lesions to access. Various surgical approaches are utilized which all require brain retraction, creating focal pressure, local trauma, and potentially surgical morbidity. Recently, tubular retractors have been developed that reduce retraction pressure by distributing it radially. Such retractors may be beneficial in colloid cyst resection. OBJECTIVE: To retrospectively review a single neurosurgeon's case series, as well as the literature, to determine the efficacy and safety profile of transtubular colloid cyst resections. We also aim to describe our operative technique for this approach. METHODS: We conducted a retrospective review of colloid cyst resections using either ViewSite Brain Access System (Vycor Medical, Boca Raton, Florida) or BrainPath (NICO, Indianapolis, Indiana) tubular retractors performed by a single neurosurgeon from 2015 to 2017 (n = 10). A literature review was performed to find all published cases of transtubular colloid cyst resections. RESULTS: Gross total resection was achieved in all patients. Early neurologic deficit rate was 10% (n = 1), and permanent neurologic deficit rate was 0%. There were no postoperative seizures or venous injuries. Average hospital stay was 2.0 d. There was no evidence of recurrence at average follow-up length of 13.6 mo. A literature review demonstrated nine studies (n = 77) with an overall complication rate of 7.8%. CONCLUSION: Tubular retractors offer an attractive surgical corridor for colloid cyst resections, avoiding much of the morbidity of interhemispheric approaches, while minimizing damage to normal cortex. There were no permanent complications in our series of ten cases, and a literature review found a similarly benign safety profile.

Nasoethmoid Schwannoma with Intracranial Extension: A Case Report and Comprehensive Review of the Literature.

We describe all cases of nasoethmoid schwannomas with intracranial extension reported in the literature, including an original case report describing the successful gross total resection of a nasoethmoid schwannoma with intracranial extension. Ten cases of nasoethmoid schwannoma with intracranial extension have previously been reported. These lesions most often appear in the second through fourth decades of life and commonly present with anosmia, headache, and visual deficits. Bifrontal craniotomy was the predominantly implemented surgical approach and gross total resection was achieved in all cases, except for one. In conclusion, nasoethmoid schwannoma with intracranial extension is a rare disease entity that is most often benign and is most commonly treated by gross total resection using a bifrontal craniotomy approach.

Preliminary Experience on Laser Interstitial Thermal Ablation Therapy in the Treatment of Extra-axial Masses: Indications, Imaging Characterization and Outcomes.

Laser thermal ablation is a novel minimally invasive neurosurgical technique that has proven to be beneficial in the treatment of a select group of neurosurgical conditions such as primary brain neoplasms, brain metastases, radiation necrosis, and epileptogenic lesions such as cortical dysplasia and mesial temporal sclerosis. The applicability of laser thermal ablation and its utility in the treatment of extra-axial (EA) brain neoplasms, mainly meningioma, is another novel use of this technique. Our article discusses the use and benefits of this technique in this particular clinical scenario. We describe our experience in a group of symptomatic patients from our institution with EA masses, mainly recurrent meningiomas, that failed previous more conventional treatment therapies such as surgery and radiotherapy. Our paper emphasizes patient selection, indications for the procedure, and post-treatment imaging characteristics of the ablated lesions.

Accuracy of frame-based and frameless systems for deep brain stimulation: A meta-analysis.

Deep brain stimulation (DBS) is an effective treatment for movement disorders. It relies on the accurate placement of leads within small nuclei in the basal ganglia. Traditionally, this has been done with great success using frame-based stereotaxy. More recently, frameless systems have been introduced, and several studies have investigated whether they can achieve a similar accuracy. The objective of this meta-analysis was to assess the difference in targeting accuracy between frameless and frame-based systems in deep brain stimulation, using prior studies reporting error in all cardinal directions. We recorded the mean error and standard deviation, and calculated the composite mean difference in error between frame-based and frameless methods using standard difference of means. A total of 76 papers were screened, 25 papers were further assessed, and 5 papers were included in the meta-analysis for a total of 425 DBS electrode placements evaluated. Standard difference of means analysis revealed a statistically significant benefit to frame-based stereotaxy for the x and y coordinates with p = 0.036 and p = 0.0025, respectively. There was no significant difference in the z coordinate. However, the mean differences between frame-based and frameless stereotaxy was small and the composite mean differences were found to be 0.3037 mm, 0.0305 mm, and 0.1630 mm in the x, y and z direction. Our analysis shows that frameless systems represent a reasonable alternative to frame-based methods. Though there was a statistically significant loss of accuracy with frameless methods, the size of this effect was very small and of questionable clinical significance.

The use of dehydrated amniotic membrane allograft for augmentation of dural closure in craniotomies and endoscopic endonasal transphenoidal surgeries.

BACKGROUND: Primary watertight dural closure is the preferred method of postcraniotomy dural repair. However, even when ideal technique is implemented, postoperative infection, cerebrospinal fluid (CSF) leaks, pseudomeningoceles, and dural scarring are possible complications. For this reason, materials that augment the dura's ability to create a watertight seal, prevent disease transmission, and inhibit inflammatory response are sought. Dehydrated amniotic membrane (DAM) allograft appears to fulfil these requirements as it has several beneficial properties that aid wound healing, including promotion of epithelialization, scar tissue prevention, and inhibition of bacterial growth. We provide the literature's first description of the use of DAM allograft to supplement dural closures for craniotomies and transsphenoidal surgeries. METHODS: We conducted a pilot study, retrospectively reviewing our institution's database of craniotomies and transsphenoidal surgeries that utilized DAM to augment dural closure. RESULTS: One hundred fifty-five cases, including 102 new craniotomies for supratentorial lesions, one re-do craniotomy for supratentorial recurrent glioma, 18 craniotomies for infratentorial lesions, 1 craniotomy for anterior skull base schwannoma, 32 transphenoidal surgeries, and 1 combined craniotomy and transnasal endoscopic surgery, used DAM allograft to augment dural closure. Only one complication occurred (0.6% complication rate), which was a superficial wound infection requiring washout without craniectomy. No CSF leaks occurred. CONCLUSIONS: This pilot study demonstrates that dehydrated amniotic membrane allograft can be safely utilized as an adjunct during dural closures for craniotomies and transsphenoidal surgeries.

The Use of Dehydrated Amniotic Membrane Allograft for the Augmentation of Dural Repair in Craniotomies.

BACKGROUND: In cranial neurosurgery, primary watertight dural closure is the standard method of post-craniotomy dural repair. However, cerebrospinal fluid (CSF) leaks, pseudomeningoceles, postoperative infections, and dural scarring are possible complications, even when a meticulous technique is implemented. For this reason, materials that enhance the dura's ability to create a watertight seal, inhibit the inflammatory response, and prevent disease transmission are sought. Dehydrated amniotic membrane (DAM) allograft appears to facilitate these properties, as studies have shown that it improves wound healing, prevents scar tissue formation, promotes epithelialization, and inhibits bacterial growth. We detail the use of a DAM allograft to augment dural closures for craniotomies. METHODS: We conducted a pilot study, retrospectively reviewing our institution's database of craniotomies that utilized DAM to supplement dural closure. RESULTS: A total of 122 cases, including 18 initial craniotomies for infratentorial lesions, 102 initial craniotomies for supratentorial lesions, one re-do craniotomy for supratentorial recurrent glioma, and one craniotomy for an anterior skull base schwannoma used a DAM allograft to augment dural closure. Only one complication occurred (0.8% complication rate), which was a superficial wound infection requiring washout without craniectomy. No CSF leaks occurred. CONCLUSIONS: This pilot study demonstrates that dehydrated amniotic membrane allograft can be safely utilized as an adjunct during dural closures for craniotomies.

Prospective Study of Nonbeneficial Care in Neurocritical Care Unit.

OBJECTIVE: We sought to determine whether a set of simple criteria can identify patients in the neuroscience intensive care unit (NICU) at high risk of poor outcome and delivery of nonbeneficial care early in the course of their illness. Secondarily, factors affecting limitation of care protocols were assessed. METHODS: We prospectively identified patients who were admitted to the NICU with partial loss of brainstem reflexes persisting for >24 hours due to an intrinsic lesion of the brain (trauma, stroke, hemorrhage, etc.). RESULTS: The study included 102 patients. Seventy-two of them died after a mean of 16 days (median: 8 days), and 23 remained comatose, locked-in, or in a vegetative state. Four were conscious and following commands, while 3 were minimally conscious, episodically obeying simple commands. Three out of 4 conscious patients were young males with traumatic brain injuries. Patients who remained full code spent a mean of 22.2 days in the NICU, compared with 10.4 for those who had withdrawal of care (P = 0.022) and 11.9 for patients who received a do-not-resuscitate order (P = 0.045). Time to death did not differ significantly between the groups. Overall, institution of various limitations of care protocols correlated positively with older age (odds ratio [OR] = 1.07, P = 0.0008), being treated on the neurology service (OR = 4.4, P = 0.043), and having health insurance (OR = 5.4, P = 0.03). CONCLUSIONS: We identified simple criteria that can be used to identify patients in the NICU setting for whom continued aggressive care is likely nonbeneficial. Our analysis revealed demographic, social, and economic factors correlating with proxies' willingness to consider limitation of care.

Postoperative Seizure Rate After Transcortical Resection of Subcortical Brain Tumors and Colloid Cysts: A Single Surgeon's Experience.

When deciding on a surgical route to reach subcortical brain tumors and colloid cysts, many surgeons advocate the use of transcallosal, transsulcal, or skull base approaches over transcortical approaches due to a high reported incidence of postoperative seizures. We have retrospectively analyzed all patients operated upon by a senior neurosurgeon (Ricardo J. Komotar) who undertook transcortical approaches for the resection of subcortical brain tumors and colloid cysts. We have also performed a comprehensive review of the literature to estimate postoperative seizure risk after transcortical approaches for the resection of deep tumors and colloid cysts. Of 27 patients who underwent transcortical approaches for the resection of subcortical brain tumors and colloid cysts, zero had postoperative seizures. A comprehensive review of the literature shows an 8.3% postoperative risk of seizures after the transcortical approach. Our institution has never experienced a postoperative seizure following the transcortical approach for the resection of deep tumors and colloid cysts. For this reason, we advocate selecting a surgical approach that obtains adequate lesion exposure and minimizes the violation and retraction of eloquent cortex, venous structures, and white matter tracts, rather than on presumed postoperative seizure risk.

Intradermal Scalp Closure Using Barbed Suture in Cranial Tumor Surgeries: A Technical Note.

BACKGROUND AND IMPORTANCE: Traditional scalp closure technique following elective craniotomy involves placement of staples or a continuous running suture. Despite low complication rates, these techniques are often considered to be disfiguring by patients, contribute to the psychosocial trauma of brain surgery, and are associated with discomfort during postoperative staple or suture removal. Some authors have described scalp closure using intradermal absorbable suture, but this technique likely does not reach the tensile strength of closure using traditional methods, and requires knots at the apices of the incision, which can act as a nidus for infection. CLINICAL PRESENTATION: We employed a barbed intradermal closure method in supratentorial elective craniotomies for tumor resection. Complication rates were recorded, and cosmetic outcomes were informally assessed. Intradermal closure with barbed sutures was utilized in 76 patients. At the 2-wk postoperative clinic visit, cosmetic outcomes were excellent in all cases. There was 1 superficial wound infection that presented 6 wk after a pterional craniotomy for low-grade glioma. This resolved with superficial wound revision and oral antibiotic therapy. CONCLUSION: We present a novel scalp closure technique for craniotomies using intradermal barbed Monocryl suture. We have had excellent cosmetic outcomes, and the infection rate of 1.3% compares favorably to published rates. Further studies are required to quantify the improvement in patient satisfaction compared to conventional closure methods.

Use of Tubular Retractor for Resection of Deep-Seated Cerebral Tumors and Colloid Cysts: Single Surgeon Experience and Review of the Literature.

INTRODUCTION: Brain retraction is often required to develop a surgical corridor during the resection of deep-seated intracranial lesions. Traditional blade retractors distribute pressure asymmetrically and may case local tissue damage. Tubular retractors minimize this pitfall by distributing pressure evenly, which has been shown to translate to significant safety and efficacy data. Further qualified reports regarding the use of tubular retractors are of interest. METHODS: We performed a retrospective analysis of 1 surgeon's experience with 20 cases of minimally invasive resection with the ViewSite Brain Access System (n = 7) and BrainPath (n = 13) systems. In addition, a comprehensive review of all published cases of tubular retractor systems used for resection of subcortical neoplastic, cystic, infectious, vascular, and hemorrhagic lesions was conducted. RESULTS: Of the 20 cases analyzed, gross total resection was achieved in 18, with an associated 10% immediate postoperative complication rate and 5% long-term complication rate. A comprehensive review of the literature showed 30 articles describing 536 cases of resection of deep neoplastic or colloid cysts with an overall complication rate of 9.1%. CONCLUSIONS: Tubular retractor systems have a favorable safety profile and are an important tool in the armamentarium of a neurosurgeon for the resection of deep intracranial lesions.

Extradural clinoidectomy for resection of clinoidal meningioma.

Extradural anterior clinoidectomy is a versatile technique to increase exposure of the sellar and parasellar region. It is of particular use in the resection of clinoidal meningiomas, as sphenoidal and clinoidal hyperostosis can cause compression of the optic nerve. Extradural clinoidectomy follows a series of steps, consisting of (1) unroofing of the superior orbital fissure, (2) unroofing of the optic canal, (3) removal of the optic strut, and (4) removal of the anterior clinoid process. The authors show these steps in detail, as well as their application to the resection of a large clinoidal meningioma. The video can be found here: https://youtu.be/O1Fcef29ETg .