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ObjectiveThis paper assesses the clinical and imaging characteristics, histopathological findings, and treatment outcomes of patients with Rathke’s cleft cyst (RCC), as well as identifies potential risk factors for preoperative visual and pituitary dysfunction, intraoperative cerebrospinal fluid (CSF) leak, and recurrence. Through analyzing these factors, the study aims to contribute to the current understanding of the management of RCCs and identify opportunities for improving patient outcomes.MethodsWe performed a retrospective analysis of 45 RCC patients between ages 18–80 treated by Endoscopic Endonasal Approach (EEA) and cyst marsupialization between 2010 and 2022 at a single institution.ResultsThe median patient age was 34, and 73% were female. The mean follow-up was 70 ± 43 months. Preoperative visual impairment correlated with cyst diameter (OR = 1.41, 95% CI = 1.07 to 1.85, p-value = 0.01) and older age (OR = 1.06, 95% CI = 1.01 to 1.11, p-value = 0.02). Intraoperative CSF leaks were 11 times more likely for cysts ≥ 2 cm (OR = 11.3, 95% CI = 1.25 to 97.37, p-value = 0.03), with the odds of leakage doubling for every 0.1 cm increase in cyst size (OR = 1.41, 95% CI = 1.08 to 1.84, p-value = 0.01). Preoperative RCC appearing hypointense on T1 images demonstrated significantly higher CSF leak rates than hyperintense lesions (OR = 122.88, 95% CI = 1.5 to 10077.54, p-value = 0.03). Preoperative pituitary hypofunction was significantly more likely in patients with the presence of inflammation on histopathology (OR = 20.53, 95% CI = 2.20 to 191.45, p-value = 0.008 ) and T2 hyperintensity on magnetic resonance imaging (MRI) sequences (OR = 23.2, 95% CI = 2.56 to 211.02, p-value = 0.005). Notably, except for the hyperprolactinemia, no postoperative improvement was observed in pituitary function.ConclusionCarefully considering risk factors, surgeons can appropriately counsel patients and deliver expectations for complications and long-term results. In contrast to preoperative visual impairment, preoperative pituitary dysfunction was found to have the least improvement post-surgery. It was the most significant permanent complication, with our data indicating the link to the cyst signal intensity on T2 MR and inflammation on histopathology. Earlier surgical intervention might improve the preservation of pituitary function.

Variations in the biomechanical stiffness of brain tumors can not only influence the difficulty of surgical resection but also impact postoperative outcomes. In a prospective, single-blinded study, we utilize pre-operative magnetic resonance elastography (MRE) to predict the stiffness of intracranial tumors intraoperatively and assess the impact of increased tumor stiffness on clinical outcomes following microsurgical resection of vestibular schwannomas (VS) and meningiomas. MRE measurements significantly correlated with intraoperative tumor stiffness and baseline hearing status of VS patients. Additionally, MRE stiffness was elevated in patients that underwent sub-total tumor resection compared to gross total resection and those with worse postoperative facial nerve function. Furthermore, we identify tumor microenvironment biomarkers of increased stiffness, including αSMA + myogenic fibroblasts, CD163 + macrophages, and HABP (hyaluronic acid binding protein). In a human VS cell line, a dose-dependent upregulation of HAS1-3 , enzymes responsible for hyaluronan synthesis, was observed following stimulation with TNFα, a proinflammatory cytokine present in VS. Taken together, MRE is an accurate, non-invasive predictor of tumor stiffness in VS and meningiomas. VS with increased stiffness portends worse preoperative hearing and poorer postoperative outcomes. Moreover, inflammation-mediated hyaluronan deposition may lead to increased stiffness.

In recent years, there has been a significant surge in discussions surrounding artificial intelligence (AI), along with a corresponding increase in its practical applications in various facets of everyday life, including the medical industry. Notably, even in the highly specialized realm of neurosurgery, AI has been utilized for differential diagnosis, pre-operative evaluation, and improving surgical precision. Many of these applications have begun to mitigate risks of intraoperative and postoperative complications and post-operative care. This article aims to present an overview of the principal published papers on the significant themes of tumor, spine, epilepsy, and vascular issues, wherein AI has been applied to assess its potential applications within neurosurgery. The method involved identifying high-cited seminal papers using PubMed and Google Scholar, conducting a comprehensive review of various study types, and summarizing machine learning applications to enhance understanding among clinicians for future utilization. Recent studies demonstrate that machine learning (ML) holds significant potential in neuro-oncological care, spine surgery, epilepsy management, and other neurosurgical applications. ML techniques have proven effective in tumor identification, surgical outcomes prediction, seizure outcome prediction, aneurysm prediction, and more, highlighting its broad impact and potential in improving patient management and outcomes in neurosurgery. This review will encompass the current state of research, as well as predictions for the future of AI within neurosurgery.

BACKGROUND:Injuring the internal carotid artery (ICA) is a feared complication of endoscopic endonasal approaches. OBJECTIVE:To introduce a comprehensive ICA classification scheme pertinent to safe endoscopic endonasal cranial base surgery. METHODS:Anatomic dissections were performed in 33 cadaveric specimens (bilateral). Anatomic correlations were analyzed. RESULTS:Based on anatomic correlations, the ICA may be described as 6 distinct segments(1) parapharyngeal (common carotid bifurcation to ICA foramen); (2) petrous (carotid canal to posterolateral aspect of foramen lacerum); (3) paraclival (posterolateral foramen lacerum to the superomedial aspect of the petrous apex); (4) parasellar (superomedial petrous apex to the proximal dural ring); (5) paraclinoid (from the proximal to the distal dural rings); and (6) intradural (distal ring to ICA bifurcation). Corresponding surgical landmarks included the Eustachian tube, the fossa of Rosenmüller, and levator veli palatini for the parapharyngeal segment; the vidian canal and V3 for the petrous segment; the fibrocartilage of foramen lacerum, foramen rotundum, maxillary strut, lingular process of the sphenoid bone, and paraclival protuberance for the paraclival segment; the sellar floor and petrous apex for the parasellar segment; and the medial and lateral opticocarotid and lateral tubercular recesses, as well as the distal osseous arch of the carotid sulcus for the paraclinoid segment. CONCLUSION:The proposed endoscopic classification outlines key anatomic reference points independent of the vesselʼs geometry or the sinonasal pneumatization, thus serving as (1) a practical guide to navigate the ventral cranial base while avoiding injury to the ICA and (2) further foundation for a modular access system. ABBREVIATIONS:DOA, distal osseous archEEA, expanded endoscopic approachICA, internal carotid arteryLOCR, lateral opticocarotid recessLTR, lateral tubercular recessMOCR, medial opticocarotid recessSOF, superior orbital fissure

The endonasal route may be feasible for the resection of anterior cranial base tumors that abut the paranasal sinuses. There are several case reports and mixed case series discussing this approach. Other than pituitary adenomas, there is a lack of literature describing the outcomes of endonasal approaches for single-tumor types such as meningiomas. In this study, we describe our current endoscopic endonasal technique and demonstrate the feasibility of using it to access anterior cranial base meningiomas from the back wall of the frontal sinus to the sella and laterally to the region of the midorbit. After this discussion, which includes key technical considerations and nuances, we address safety and efficacy by reporting the outcomes of our early experience with endoscopic endonasal resection of 35 anterior cranial base meningiomas. A total of 35 patients underwent endoscopic endonasal resection of anterior cranial base meningiomas from October 2002 to October 2005. Degree of resection by tumor location was as follows: 10 of the 12 (83%) patients with olfactory groove meningiomas planned for complete resection underwent gross total (seven of 12) or near-total (>95%) (three of 12) resection (67% of all 15 olfactory tumors); 12 of 13 patients (92%) with tuberculum meningiomas underwent gross (11 of 13) or near (>95%) (one of 13) total resection; five patients diagnosed with petroclival meningiomas had successful resection of the parasellar portion of their tumors with relief of visual symptoms (no patients underwent complete resection of their tumors via the endoscopic, endonasal approach); two giant petroclival meningiomas were debulked with 63 and 89% resection, respectively.All patients experienced resolution or improvement of visual symptoms. No patient experienced permanent worsening of vision after surgery. Only one (3%) patient without preoperative endocrine dysfunction experienced a new, permanent pituitary deficit, diabetes insipidus. One (3%) patient experienced a new neurological deficit after experiencing a hemorrhage 3 weeks after surgery. The postoperative cerebrospinal fluid leak rate was 40% (14 of 35) and varied by tumor location. All leaks were resolved without craniotomy. There were no cases of bacterial meningitis. One patient developed a superinfection of a sterile granuloma from a sinusitis 2 years after surgery. There were two cases of deep venous thrombosis and one pulmonary embolus. There were no operative or perioperative deaths. Cranial base meningiomas can be successfully managed via a purely endoscopic endonasal approach with acceptable morbidity and mortality rates. The extent of resection is guided by patient factors and symptoms, not by approach. This series had a high cerebrospinal fluid leak rate. With the evolution of new reconstruction techniques, these rates have been substantially reduced.

Background Excelsior knowledge of endoscopic anatomy and techniques to remove the natural barriers preventing full endonasal access to the interpeduncular and prepontine cisterns determines the ease of transposing the pituitary gland (hypophysiopexy) preserving the glandular function without manipulating the optic apparatus and the oculomotor nerves. Methods Throughout stepwise cadaveric dissections, we describe the expanded endonasal approach (EEA) to the interpeduncular and prepontine cisterns with special references to the intricate anatomy of the region and techniques for hypophysiopexy and posterior clinoidectomies. Conclusion This article illustrates sellar-diaphragmatic dural incisions and various “pituitary gland transpositions” techniques performed via extradural (lifting the gland still covered by both dural layers), interdural (transcavernous), and intradural (between the medial wall of the cavernous sinus and the pituitary tunica) to access the prepontine and interpeduncular cisterns.

Anterior skull base (ASB) malignancies are rare entities characterized by delayed diagnosis and comprise a variety of distinct histological types. Their treatment involves clinical and surgical management, with the latter encompassing open and, more recently, endoscopic approaches. The craniofacial resection, as an open approach, has revolutionized the treatment of such diseases and is the gold standard, although significant morbidity and facial scars are a shortcoming. Seeking a less invasive alternative, many surgeons have approached these pathologies using the endoscopic endonasal approach, with the theoretical advantage of reduced morbidity and no facial scars. In this manuscript, we aim to review the current state-of-art in the surgical management of the ASB malignancies. As such, indications, limitations and future perspectives of different surgical techniques are discussed.

Over the past 10 years, significant anatomic, technical, and instrumentation advances have facilitated the exposure and resection of intradural lesions via a fully endoscopic expanded endonasal approach (EEA). The vascularized nasoseptal flap (based on the posterior nasoseptal artery) has become our primary endoscopic reconstructive technique. The goals of this study are to prospectively evaluate the nasoseptal flap and high-risk cerebral spinal fluid (CSF) leak variables. Prospective evaluation was performed of EEA patients with intraoperative high-flow leaks (either a cistern or ventricle open to nasal cavity during tumor dissection) who underwent nasoseptal flap reconstruction. Seventy consecutive nasoseptal flaps for high-flow intraoperative leaks were evaluated prospectively by the primary author. Twelve risk factors were then graded at the time of the operations and correlated to CSF leak outcomes. The overall postoperative CSF leak rate was 5.7% (4/70). All four postoperative leaks were successfully managed with endoscopic repair and CSF diversion. A multivariate analysis of all 12 risk factors is detailed. Pediatric patients, large dural defects, and radiation therapy were noted to be factors in reconstructive failure. One flap death occurred in a patient with prior surgery and proton therapy, this leak was managed with a temporoparietal flap and endonasal repair. The nasoseptal flap is an excellent anterior skull base reconstructive technique. Patients with high-flow intraoperative CSF leaks had a 94% successful reconstruction rate. Patients with skull base proton radiation therapy are at higher risk for flap failure and preparation for nonradiated tissue reconstruction should be discussed with the patient.

ContextThe development of diabetes insipidus (DI) following transsphenoidal resection of pituitary adenomas has been associated with higher postsurgical morbidity and longer hospitalizations. Identifying these patients promptly and efficiently can lead to improved health care outcomes.ObjectiveWe evaluated our institution’s incidence of DI following pituitary adenoma resection and assessed for preoperative risk factors that were associated with postoperative DI.DesignA retrospective review of 271 patients who underwent endoscopic endonasal resection of a pituitary adenoma between July 2010 and December 2016 by a single neurosurgical provider was completed.SettingAll cases were from a single-center, academic institution.PatientsPatients with a pituitary adenoma diagnosis confirmed on histology were included in the study. Those with previous surgery by a different provider were excluded.ResultsThe incidence of DI at our institution was 16.6% (45 of 271 patients), with only 4% (11 patients) having permanent DI. The presence of visual abnormalities (CI 1.29 to 4.75), suprasellar extension (CI 1.36 to 6.88), and maximal tumor diameter (1.02 to 1.08) was significantly associated with an increased incidence of postoperative DI (P < 0.05). Hyperprolactinemia, tumor functionality, and cerebrospinal fluid exposure were not associated with higher rates of postoperative DI (P > 0.05).ConclusionPituitary adenoma patients presenting with visual abnormalities, suprasellar extension, or large tumors are at higher risk of developing DI postoperatively. These patients warrant closer postoperative monitoring as well as adequate preoperative counseling to decrease their postsurgical morbidity.A review of a single center’s experience with postoperative DI following resection of pituitary adenomas identified tumor size, suprasellar extension, and visual changes as predictors of DI.