John G. Golfinos

BACKGROUND AND OBJECTIVES: Little is known about how accelerated discharge strategies compare with established enhanced recovery pathways after endoscopic endonasal surgery (EES). This study aimed to evaluate the efficacy and safety of an accelerated discharge protocol after EES. METHODS: This was a retrospective analysis of adults who underwent EES for pituitary adenomas at a single academic center between 2012 and 2025. Patients were managed under 1 of 4 postoperative pathways dependent on year of surgery: (1) No institutional protocol; (2) First-generation recovery protocol; (3) Enhanced recovery after surgery (ERAS); and (4) Expedited one-day discharge. Demographic and clinical variables were extracted from the electronic medical record using automated natural-language–processing methods. Primary outcomes were length of stay (LOS) and 30-day all-cause readmission or reoperation. All data processing, visualization, and statistical analyses were performed using Python version 3.12. RESULTS: Six hundred patients who underwent 630 surgeries were included. Median LOS was 3 days, with a 30-day readmission rate of 14.3% and a 30-day postdischarge reoperation rate of 2.5%. LOS differed significantly across protocol eras, with progressively shorter hospital stays observed over time and the shortest median stay occurring under the expedited discharge protocol ( P < .0001). Readmission rates were highest in the preprotocol (16.2%) and initial protocol periods (17.2%), declining to 8.3% under the ERAS protocol and 10.0% under the expedited discharge protocol ( P = .039). 30-day postdischarge reoperation rates did not statistically differ across protocols. In multivariate analyses, both the ERAS (rate ratio = 0.899, P = .021) and expedited discharge protocols (rate ratio = 0.819, P = .024) demonstrated significantly shorter hospital stays compared with the preprotocol era, without differences in 30-day readmission or reoperation rates. CONCLUSION: The expedited discharge protocol safely shortened hospital stays without increasing 30-day readmissions or reoperations. These findings support the feasibility of accelerated postoperative pathways after EES. Broad adoption has the potential to produce substantial resource savings without compromising patient safety.

Objective To demonstrate magnetic resonance imaging’s (MRI’s) utility in investigating auditory brainstem implant (ABI) performance degradation. Design Case study. Setting Academic medical center. Participant This report presents a patient with neurofibromatosis type 2 and an ABI with durable, limited open-set speech who developed nonauditory side effects and a complete lack of auditory perception. ABI paddle placement was assessed with 1.5 Tesla (T) Siemens MRI, and device function was assessed utilizing integrity tests. Main Outcome Measure The etiology of ABI performance degradation utilizing 1.5 T Siemens MRI. Results On initial postoperative 1.5 T Siemens MRI, the ABI paddle approximated the cochlear nucleus. Approximately 1 year later, the patient experienced ABI performance degradation and dizziness. Although ABI device integrity testing was normal, follow-up 1.5 T Siemens MRI revealed lateral ABI paddle migration from the foramen of Luschka toward the flocculus, likely due to observed fat atrophy from the prior craniotomy reconstruction, suggesting a possible etiology for the observed ABI degradation. Conclusion This report presents MRI’s ability to successfully delineate postoperative fat atrophy, ABI paddle migration in relation to the brainstem, and residual tumor in a patient with ABI degradation.

To better understand the implications of tumor size on auditory brainstem implant (ABI) categories of auditory performance (CAP) score to facilitate more precise patient counselling.Single-center retrospective chart review.Tertiary referral center.Patients > 18 years old with neurofibromatosis type 2 who underwent ABI placement between the years 2009 and 2023 were included. Patients with prior surgical resection were excluded to reduce the potential of previous cochlear nucleus trauma confounding results.Ipsilateral tumor volume was measured from the preoperative MRI, and the primary endpoint was the 1-year CAP score.Fourteen patients were included for analysis, with an average age of 35.3 years. The average preoperative ipsilateral tumor volume was 22.8 cm3 (± 22.4). The average postoperative CAP score was 2.7 (± 2). A negative association was found between ipsilateral tumor size prior to treatment and CAP score (slope = − 0.058, p = 0.010) utilizing a linear regression model. The model accounted for 43.7% of the variance in outcome (R 2 = 0.437, adjusted R 2 = 0.390), with a significant overall model fit (F [1, 12] = 9.31, p = 0.010).Increased tumor size has a negative correlation with ultimate ABI performance. There were patients in this study with larger tumor sizes who still benefited from ABI placement. While larger tumor size should not be a contraindication for ABI placement, understanding the role tumor size can have on performance variation can serve to improve tumor management strategies and preoperative counselling.

To develop and study a novel means of imaging auditory brainstem implant (ABI) paddle placement utilizing postoperative MRI images to determine correlation between ABI performance and ideal paddle placement properties. Single-center retrospective review and image analysis. Tertiary referral center. Patients >18 years old who received an ABI from 2009 to 2023 and had subsequent MRI and auditory performance testing completed. ABI paddle angulation and insertion depth measure, in addition to categories of auditory performance (CAP) score. Inclusion criteria were met by 21 patients with neurofibromatosis type 2 (NF2) who underwent ABI placement. The average insertional depth into the foramen of Luschka was 1.0 cm (Stdev 0.4), with average axial paddle angulation of 62.7 degrees (Stdev 29.7 degrees), average sagittal paddle angulation of 108.7 degrees (Stdev 44.4 degrees), and average coronal paddle angulation of −14.5 degrees (Stdev 62.4 degrees). Single variable linear regression showed a statistically significant negative relationship between insertion depth and CAP score (p = 0.049) once patients with large tumor burden were excluded. Insertion depth and axial angulation showed a negative correlation, in which higher insertion depth was associated with a decrease in axial angulation value, although not statistically significant. We present a novel means of measuring ABI paddle placement utilizing MRI to improve the objectivity of paddle placements assessments. Multicenter collaboration to increase the number of patients studied with this new measurement scheme will be required before stronger measurement associations can be determined.

Background: Pituitary neuroendocrine tumors (PitNETs) are the most common intracranial neuroendocrine tumors. PitNETs can be challenging to classify, and current recommendations include a large immunohistochemical panel to differentiate among 14 WHO-recognized categories. Methods: In this study, we analyzed clinical, immunohistochemical, and DNA methylation data of 118 PitNETs to develop a clinicomolecular approach to classifying PitNETs and identifying epigenetic classes. Results: CNS DNA methylation classifier has an excellent performance in recognizing PitNETs and distinguishing the 3 lineages when the calibrated score is ≥ 0.3. Unsupervised DNA methylation analysis separated PitNETs into 2 major clusters. The first was composed of silent gonadotrophs, which form a biologically distinct group of PitNETs characterized by clinical silencing, weak hormonal expression on immunohistochemistry, and simple copy number profile. The second major cluster was composed of corticotrophs and Pit1 lineage PitNETs, which could be further classified using DNA methylation into distinct subclusters that corresponded to clinically functioning and silent tumors and are consistent with transcription factor expression. Analysis of promoter methylation patterns correlated with lineage for corticotrophs and Pit1 lineage subtypes. However, the gonadotrophic genes did not show a distinct promoter methylation pattern in gonadotroph tumors compared to other lineages. Promoter of the NR5A1 gene, which encodes SF1, was hypermethylated across all PitNETs clinical and molecular subtypes including gonadotrophs with strong SF1 protein expression indicating alternative epigenetic regulation. Conclusion: Our findings suggest that classification of PitNETs may benefit from DNA methylation for clinicopathological stratification.

Skull base surgery is a highly innovative, multidisciplinary field that brings together teams of neurosurgeons, otolaryngology-head and neck surgeons (OHNS), plastic surgeons, ophthalmologists, radiation oncologists, and others. However, not long ago, the nascent field was instead characterized by isolated individual brilliance. This paper explores the contributions of several key players toward breaking silos and transforming the field into what it is today. Our analysis centers on the formation of the North American Skull Base Society (NASBS), and the instrumental role that it played in the development of skull base surgery. We interviewed 12 past presidents of the NASBS and 2 prominent figures in skull base surgery. The contents of those 20 hours and 38 minutes of interviews and documents from initial NASBS meetings were analyzed. Key moments were segmented into short video clips, which complement this manuscript and are available on the NASBS website. A compelling narrative of collaboration, mentorship, and tenacity emerged from our analysis. In the 20th century, the field of skull base surgery was characterized mainly by courageous but isolated efforts by neurosurgeons and OHNS surgeons. Through mentorship, collaboration, and incredible innovation, it has since grown into a multidisciplinary, cutting-edge specialty that utilizes the strengths of several medical specialties. This transformation was largely facilitated by the formation of the NASBS in 1989, which enabled worldwide communication and collaboration among those dedicated to advancing the field. The growth of skull base surgery in North America and the instrumental role of the NASBS highlight the power of collaboration and innovation. It is important to recognize and celebrate the key players who facilitated the creation and success of the NASBS, which continues to unite young members across countless disciplines under one banner.

Background: Accurate intraoperative diagnosis is crucial for differentiating between primary central nervous system (CNS) lymphoma (PCNSL) and other CNS entities, guiding surgical decision-making, but represents significant challenges due to overlapping histomorphological features, time constraints, and differing treatment strategies. We combined stimulated Raman histology (SRH) with deep learning to address this challenge. Methods: We imaged unprocessed, label-free tissue samples intraoperatively using a portable Raman scattering microscope, generating virtual H&E-like images within <3 min. We developed a deep learning pipeline called RapidLymphoma based on a self-supervised learning strategy to (1) detect PCNSL, (2) differentiate from other CNS entities, and (3) test the diagnostic performance in a prospective international multicenter cohort and 2 additional independent test cohorts. We trained on 54 000 SRH patch images sourced from surgical resections and stereotactic-guided biopsies, including various CNS neoplastic/nonneoplastic lesions. Training and test data were collected from 4 tertiary international medical centers. The final histopathological diagnosis served as ground truth. Results: In the prospective test cohort of PCNSL and non-PCNSL entities (n = 160), RapidLymphoma achieved an overall balanced accuracy of 97.81% ± 0.91, non-inferior to frozen section analysis in detecting PCNSL (100% vs. 77.77%). The additional test cohorts (n = 420, n = 59) reached balanced accuracy rates of 95.44% ± 0.74 and 95.57% ± 2.47 in differentiating IDH-wildtype diffuse gliomas and various brain metastasis from PCNSL. Visual heatmaps revealed RapidLymphoma’s capabilities to detect class-specific histomorphological key features. Conclusions: RapidLymphoma proves reliable and valid for intraoperative PCNSL detection and differentiation from other CNS entities. It provides visual feedback within 3 min, enabling fast clinical decision-making and subsequent treatment strategy planning.

To characterize treatment and hearing outcomes for cerebellopontine angle (CPA) meningiomas with inherent risks of hearing loss and identify predictors of hearing loss for surgically treated lesions.Retrospective chart review.Tertiary care medical center.Adult patients with CPA meningiomas impinging upon cranial nerve VIII and/or pretreatment hearing loss managed with microsurgery or stereotactic radiosurgery (SRS) with Gamma Knife at our center between 2012 and 2023.Hearing preservation rate was determined from analysis of patients with pretreatment serviceable hearing for whom hearing-preserving treatment was attempted. Surgical patients were further analyzed using multivariable Cox proportional hazards regression models to identify factors predictive of postoperative hearing loss.We identified 80 patients with CPA meningiomas meeting inclusion criteria who were managed with either microsurgery (43, 54%) or radiosurgery (37, 46%). Following SRS, hearing was preserved in 88% of cases. Following microsurgery, hearing was preserved in 71% of patients—all patients who lost hearing had tumors involving the internal auditory canal (IAC). Among surgical patients only, multivariable analysis accounting for preoperative hearing, recurrence status, lesion size, and patient age, the preoperative imaging finding that the CPA meningioma surrounded the vestibulocochlear nerve was significantly associated with hearing loss (hazard ratio: 10.3, 95% confidence interval: 1.3–81.4, p = 0.02).Most patients with meningiomas of the CPA can experience preservation of hearing, even when there is risk of hearing loss based on pretreatment evaluation. IAC invasion and surrounding of eighth nerve by tumor may portend poorer hearing outcomes in surgically managed patients.

Supplemental Table S1. MRI acquisition parameters

Supplemental Table S4. Multivariate Cox proportional hazards model for histologic grade 2 IDH-mutant astrocytomas