Prediction of diabetes insipidus occurrence after endoscopic endonasal removal of sellar lesions using MRI-based radiomics and machine learning

BACKGROUND

Pituitary adenomas and craniopharyngiomas are the most common lesions of the sellar region. These tumors are responsible for invasion or compression of crucial neurovascular structures. The involvement of the pituitary stalk warrants high rates of both pre- and post- operative diabetes insipidus. The aim of our study was to assess the accuracy of machine learning analysis from preoperative MRI of pituitary adenomas and craniopharyngiomas for the prediction of DI occurrence.

METHODS

All patients underwent MRI exams either on a 1.5- or 3-T MR scanner from two Institutions, including coronal T2-weighted (T2-w) and contrast-enhanced T1-weighted (CE T1-w) Turbo Spin Echo sequences. Feature selection was carried out as a multi-step process, with a threshold of 0.75 to identify robust features. Further feature selection steps included filtering based on feature variance (threshold >0.01) and pairwise correlation (threshold <0.80). A Bayesian Network model was trained with 10-fold cross validation employing SMOTE to balance classes exclusively within the training folds.

RESULTS

Thirty patients were included in this study. In total 2394 features were extracted and 1791 (75%) resulted stable after ICC analysis. The number of variant features was 1351 and of non-colinear features was 125. Finally, 10 features were selected by oneR ranking. The Bayesian Network model showed an accuracy of 63% with a precision of 77% for DI prediction (0.68 area under the precision-recall curve).

CONCLUSIONS

We assessed the accuracy of machine learning analysis of texture-derived parameters from preoperative MRI of pituitary adenomas and craniopharyngiomas for the prediction of DI occurrence.

Transorbital and supraorbital uniportal multicorridor approach to the orbit, anterior, middle and posterior cranial fossa: Anatomic study

Introduction

The transorbital route has been proposed for addressing orbital and paramedian skull base lesions. It can be complemented by further marginotomies, as per "extended-transorbital approach" and combined with others ventro-basal approaches featuring the concept of "multiportal surgery". Nevertheless, it cannot address some anatomical regions like the clinoid, carotid bifurcation and the Sylvian fissure. Therefore, we propose a combined transorbital and a supraorbital approach, attainable by a single infra-brow incision, and we called it "Uniportal multicorridor" approach.

Research question

The aim of our study is to verify its feasibility and deep anatomical targets through a cadaveric study.

Materials and methods

Anatomic dissections were performed at the Laboratory of ICLO Teaching and Research Center (Verona, Italy) on four formalin-fixed cadaveric heads injected with colored neoprene latex (8 sides). A stepwise dissection of the supraorbital and transorbital approaches (with an infra-brow skin incision) to the anterior tentorial incisura, clinoid area, lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure is described.

Results

We analyzed the anatomic areas reached by the transorbital corridor dividing them as follow: lateral wall of the cavernous sinus, middle temporal fossa, posterior fossa, and Sylvian fissure; while the anatomic areas addressed by the supraorbital craniotomy were the clinoid area and the anterior tentorial incisura.

Conclusions

The described uniportal multi-corridor approach combines a transorbital corridor and a supraorbital craniotomy, providing a unique intra and extradural control over the anterior, middle, and posterior fossa, tentorial incisura and the Sylvian fissure, via an infra-brow skin incision.

Novelties for increased safety in cranio-vertebral surgery: a review

The cranio-vertebral junction (CVJ) was formerly considered a surgical "no man's land" due to its complex anatomical and biomechanical features. Surgical approaches and hardware instrumentation have had to be tailored in order to achieve successful outcomes. Nowadays, thanks to the ongoing development of new technologies and surgical techniques, CVJ surgery has come to be widely performed in many spine centers. Accordingly, there is a drive to explore novel solutions and technological nuances that make CVJ surgery safer, faster, and more precise. Improved outcome in CVJ surgery has been achieved thanks to increased safety allowing for reduction in complication rates. The Authors present the latest technological advancements in CVJ surgery in terms of imaging, biomaterials, navigation, robotics, customized implants, 3D-printed technology, video-assisted approaches and neuromonitoring.

Endoscopic endonasal treatment of craniopharyngiomas: current management strategies and future perspectives

INTRODUCTION

Craniopharyngiomas are locally aggressive disembryogenetic tumors presenting mostly in childhood and late adulthood. They are often burdened by an unfavorable clinical course due to close relationships with nearby critical neurovascular structures and high risk of recurrences. The aim of our paper is to provide a systematic review of the literature regarding current strategies and future perspectives for the treatment of craniopharyngiomas, focusing on the role of endoscopic endonasal surgery.

EVIDENCE ACQUISITION

A comprehensive literature search of three databases (PubMed, Ovid Medline, and Ovid Embase) has been conducted to identify papers addressing the management strategies in adult and pediatric craniopharyngioma patients.

EVIDENCE SYNTHESIS

Twenty-two articles have been included, providing data for 560 adult and 215 pediatric patients. Mean follow-up was 40.29 months for the adult and 58.05 months for pediatric population. GTR rate was 60.97% and 82.52% in adult and pediatric patients, respectively. Adjuvant radiotherapy was delivered in 20.99% of adult and 8.25% of pediatric cases; 89% of adult patients and 94.11% of pediatric patients receiving radiotherapy had previously undergone NTR, STR or partial resection. The recurrence rate was 19.32% and 18.61% for adult and pediatric population, respectively. Recurrences occurred mostly in patients receiving incomplete resection without adjuvant radiotherapy (72.87% in adults and 51.28% in children); 86.69% and 87.12% of adult and pediatric patients reported improvement of their previous ophthalmologic deficit; 40% of the adult population and 41.86%% of pediatric patients worsened or developed endocrinological disturbances. CSF leak rate was 16.4% in adults and 13.95%% in children.

CONCLUSIONS

Modern policy of craniopharyngioma management is represented by the combination of a "maximum safe" allowed surgical removal plus radiotherapy. In this scenario, the endoscopic endonasal technique proved to be a valid approach for removing these lesions, providing satisfactory outcomes with lower morbidity.

Cervical spine arachnoid cyst complicated by spontaneous intracystic hemorrhage: Case report and review of the literature

Background:

Spinal intradural extramedullary arachnoid cysts represent about 1–3% of all primary spinal space-occupying lesions often causing spinal cord and/or radicular nerve compression. Spontaneous intralesional hemorrhages are extremely rare and are typically found within intracranial arachnoid cysts. Here, a 55-year-old female presented with a spontaneous hemorrhage into a cervical spine arachnoid cyst warranting surgical intervention (i.e., fenestration/excision/occlusion).

Case Description:

A 55-year-old female presented with 3 weeks of dull pain in the cervicothoracic region. She subsequently developed paresthesias and progressive lower extremity weakness with (urinary incontinence. The cervical magnetic resonance revealed a right anterolateral intradural extramedullary “cystic” lesion extending from C7 to T2; it contained a heterogeneous signalon T2W sequences, and a fluid-fluid level was documented on the T2-GRE and FLAIR sequences. At surgery, consisting of a laminectomy, two hemorrhagic cystic lesions were identified and removed. Histological findings were consistent with hemorrhagic into an arachnoid cyst.

Conclusion:

Only rarely hemorrhages develop in intraspinal intradural extramedullary spinal arachnoid cysts.

Eyebrow incision with a crescent-shaped orbital rim craniotomy for microscopic and endoscopic transorbital approach to the anterior and middle cranial fossa: A cadaveric study and case presentation

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The transorbital approach combining eyebrow incision and crescent-shaped craniotomy increases the surgical freedom to access the anterior and middle skull-base.

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The technic allows the use of both endoscope and microscope.

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The concept is at the crossroad between the supraorbital keyhole and endoscopic trans-orbital approach.

Multidisciplinary management of osteoporotic vertebral fractures. An overview

Vertebral fractures represent the most frequent complication associated with osteoporosis. Patients harboring a vertebral fracture complain physical impairment including low back pain and spine balance alteration, i.e., kyphosis, leading to subsequent systemic complication, with an increase in morbidity and mortality risk. Different strategies are available in the management of osteoporotic vertebral fractures: medical therapy acts as a prevention strategy while surgical vertebral augmentation procedures, when correctly indicated, aim to reduce pain and to restore the physiological vertebral height. Considering the growing prevalence and incidence of this condition and its socio-economic burden, prevention, diagnosis and treatment of osteoporotic vertebral fractures are of utmost importance. Our aim is to review the current strategies for the management of osteoporotic vertebral fractures providing an integrated multidisciplinary endocrinological, radiological and neurosurgical point of view.

Pericranial and scalp rotation flaps for occipitocervical hardware exposure with CSF leak in rheumatoid arthritis patient: A case report and review of the literature

Background:

There are several etiologies of craniocervical junction instability (CCJI); trauma, rheumatoid arthritis (RA), infections, tumors, congenital deformity, and degenerative processes. These conditions often require surgery and craniocervical fixation. In rare cases, breakdown of such CCJI fusions (i.e., due to cerebrospinal fluid [CSF] leaks, infection, and wound necrosis) may warrant the utilization of occipital periosteal rescue flaps and scalp rotation flaps to achieve adequate closure.

Case Description:

A 33-year-old female with RA, cranial settling, and high cervical cord compression underwent an occipitocervical instrumented C0–C3/C4 fusion. Two months later, revision surgery was required due to articular screws pull out, CSF leakage, and infection. At the second surgery, the patient required screws removal, the application of laminar clamps, and sealing the leak with fibrin glue. However, the CSF leak persisted, and the skin edges necrosed leaving the hardware exposed. The third surgery was performed in conjunction with a plastic surgeon. It included operative debridement and covering the instrumentation with a pericranial flap. The resulting cutaneous defect was then additionally reconstructed with a scalp rotation flap. Postoperatively, the patient adequately recovered without sequelae.

Conclusion:

A 33-year-old female undergoing an occipitocervical fusion developed a postoperative persistent CSF leak, infection, and wound necrosis. This complication warranted the assistance of plastic surgery to attain closure. This required an occipital periosteal rescue flap with an added scalp rotation flap.