To the Editor: Nonabsorbable suture is considered the standard of care for the closure of surgical wounds following cranial procedures. However, the removal of sutures requires an additional medical appointment for patients after discharge. This appointment is associated with the exposure of patients to situations where they are at risk of being infected with COVID-19 or spreading it to other patients. NEUROSURGERY STUDIES We performed a literature search for studies that included neurosurgical patients. Prospective randomized clinical trials, prospective study of cases (with and without controls), and retrospective reviews of cases were included. Additionally, studies were ranked according to the number of patients studied. We identified 6 articles addressing this issue.
BackgroundRecently, it was defined that the sellar barrier entity could be identified as a predictor of cerebrospinal fluid (CSF) intraoperative leakage. The aim of this study is to validate the application of the sellar barrier concept for predicting intraoperative CSF leak in endoscopic endonasal surgery for pituitary adenomas with a machine learning approach.MethodsWe conducted a prospective cohort study, from June 2019 to September 2020: data from 155 patients with pituitary subdiaphragmatic adenoma operated through endoscopic approach at the Division of Neurosurgery, Università degli Studi di Napoli “Federico II,” were included. Preoperative magnetic resonance images (MRI) and intraoperative findings were analyzed. After processing patient data, the experiment was conducted as a novelty detection problem, splitting outliers (i.e., patients with intraoperative fistula, n = 11/155) and inliers into separate datasets, the latter further separated into training (n = 115/144) and inlier test (n = 29/144) datasets. The machine learning analysis was performed using different novelty detection algorithms [isolation forest, local outlier factor, one-class support vector machine (oSVM)], whose performance was assessed separately and as an ensemble on the inlier and outlier test sets.ResultsAccording to the type of sellar barrier, patients were classified into two groups, i.e., strong and weak barrier; a third category of mixed barrier was defined when a case was neither weak nor strong. Significant differences between the three datasets were found for Knosp classification score (p = 0.0015), MRI barrier: strong (p = 1.405 × 10−6), MRI barrier: weak (p = 4.487 × 10−8), intraoperative barrier: strong (p = 2.788 × 10−7), and intraoperative barrier: weak (p = 2.191 × 10−10). We recorded 11 cases of intraoperative leakage that occurred in the majority of patients presenting a weak sellar barrier (p = 4.487 × 10−8) at preoperative MRI. Accuracy, sensitivity, and specificity for outlier detection were 0.70, 0.64, and 0.72 for IF; 0.85, 0.45, and 1.00 for LOF; 0.83, 0.64, and 0.90 for oSVM; and 0.83, 0.55, and 0.93 for the ensemble, respectively.ConclusionsThere is a true correlation between the type of sellar barrier at MRI and its in vivo features as observed during endoscopic endonasal surgery. The novelty detection models highlighted differences between patients who developed an intraoperative CSF leak and those who did not.
Introducción Los meningiomas de la fosa posterior comprenden el 20% del total de los tumores de la línea meníngea, estando asociada cada localización a un abordaje y una morbi-mortalidad particular. Una debilidad detectada en la mayoría de las clasificaciones es el sesgo de una visión centrada en el sitio de implante, desprovista de una perspectiva combinada con los aspectos quirúrgicos que pueda orientar al neurocirujano joven en la formulación de estrategias y abordajes para su resolución. Objetivos Presentar una clasificación de los meningiomas de la fosa posterior con una visión anatomo-quirúrgica incluyendo la presentación de casos. Materiales y métodos Se estableció una nomenclatura considerando reportes previos, el criterio anatómico y la experiencia quirúrgica de los autores. Se presentaron casos revisando las historias clínicas y los archivos de imágenes correspondientes a cada subtipo en particular de la clasificación propuesta. Resultados Representamos a la fosa posterior como un compartimento con 3 anillos: el superior se divide en medial, lateral-anterior y lateral-posterior; el anillo medio se divide en 6 variantes: clivales puros, esfeno-petro-clivales, petrosos anteriores, petrosos posteriores y de la convexidad suboccipital medial y lateral; el anillo inferior se divide en anterior, lateral derecho, lateral izquierdo y posterior. Conclusión Los meningiomas del anillo superior pueden resolverse mediante una vía suboccipital o suboccipital lateral; los meningiomas del anillo medio tienen un espectro de opciones más diverso; mientras que los meningiomas del anillo inferior -siguiendo el esquema de división en cuadrantes de un reloj- pueden resolverse por medio de un abordaje suboccipital medial o extremolateral.
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