{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,14]],"date-time":"2026-10-14T10:35:00Z","timestamp":1791974100189,"version":"4.4.0"},"reference-count":30,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2020,8]]},"abstract":"<jats:sec><jats:title>OBJECTIVE<\/jats:title><jats:p>Although rates of postoperative morbidity and mortality have become relatively low in patients undergoing transnasal transsphenoidal surgery (TSS) for pituitary adenoma, cerebrospinal fluid (CSF) fistulas remain a major driver of postoperative morbidity. Persistent CSF fistulas harbor the potential for headache and meningitis. The aim of this study was to investigate whether neural network\u2013based models can reliably identify patients at high risk for intraoperative CSF leakage.<\/jats:p><\/jats:sec><jats:sec><jats:title>METHODS<\/jats:title><jats:p>From a prospective registry, patients who underwent endoscopic TSS for pituitary adenoma were identified. Risk factors for intraoperative CSF leaks were identified using conventional statistical methods. Subsequently, the authors built a prediction model for intraoperative CSF leaks based on deep learning.<\/jats:p><\/jats:sec><jats:sec><jats:title>RESULTS<\/jats:title><jats:p>Intraoperative CSF leaks occurred in 45 (29%) of 154 patients. No risk factors for CSF leaks were identified using conventional statistical methods. The deep neural network\u2013based prediction model classified 88% of patients in the test set correctly, with an area under the curve of 0.84. Sensitivity (83%) and specificity (89%) were high. The positive predictive value was 71%, negative predictive value was 94%, and F1 score was 0.77. High suprasellar Hardy grade, prior surgery, and older age contributed most to the predictions.<\/jats:p><\/jats:sec><jats:sec><jats:title>CONCLUSIONS<\/jats:title><jats:p>The authors trained and internally validated a robust deep neural network\u2013based prediction model that identifies patients at high risk for intraoperative CSF. Machine learning algorithms may predict outcomes and adverse events that were previously nearly unpredictable, thus enabling safer and improved patient care and better patient counseling.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2019.4.jns19477","type":"journal-article","created":{"date-parts":[[2019,6,29]],"date-time":"2019-06-29T00:44:03Z","timestamp":1561769043000},"page":"329-335","source":"Crossref","is-referenced-by-count":39,"title":["Neural network\u2013based identification of patients at high risk for intraoperative cerebrospinal fluid leaks in endoscopic pituitary surgery"],"prefix":"10.3171","volume":"133","author":[{"given":"Victor E.","family":"Staartjes","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland;"},{"name":"Amsterdam UMC, Vrije Universiteit Amsterdam, Neurosurgery, Amsterdam Movement Sciences, Amsterdam, The Netherlands; and"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Costanza M.","family":"Zattra","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin","family":"Akeret","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nicolai","family":"Maldaner","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giovanni","family":"Muscas","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Tuscany School of Neurosurgery, University of Firenze, Firenze, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christiaan Hendrik","family":"Bas van Niftrik","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jorn","family":"Fierstra","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Regli","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland;"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carlo","family":"Serra","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland;"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1","series-title":"Neurosurgery","first-page":"425","article-title":"Segments of the internal carotid artery: a new classification","volume":"38","author":"Bouthillier A","year":"1996","unstructured":"Bouthillier A, van Loveren HR, Keller JT: Segments of the internal carotid artery: a new classification. Neurosurgery 38:425\u2013433, 19968837792"},{"key":"b2","series-title":"J Artif Intell Res","doi-asserted-by":"publisher","first-page":"321","DOI":"10.1613\/jair.953","article-title":"SMOTE: Synthetic Minority Over-sampling Technique","volume":"16","author":"Chawla NV","year":"2002","unstructured":"Chawla NV, Bowyer KW, Hall LO, Kegelmeyer WP: SMOTE: Synthetic Minority Over-sampling Technique. J Artif Intell Res 16:321\u2013357, 200210.1613\/jair.953"},{"key":"b3","series-title":"Acta Neurochir (Wien)","doi-asserted-by":"publisher","first-page":"2193","DOI":"10.1007\/s00701-017-3318-6","article-title":"Microsurgical versus endoscopic transsphenoidal resection for acromegaly: a systematic review of outcomes and complications","volume":"159","author":"Chen CJ","year":"2017","unstructured":"Chen CJ, Ironside N, Pomeraniec IJ, Chivukula S, Buell TJ, Ding D, : Microsurgical versus endoscopic transsphenoidal resection for acromegaly: a systematic review of outcomes and complications. Acta Neurochir (Wien) 159:2193\u20132207, 201710.1007\/s00701-017-3318-6"},{"key":"b4","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"861","DOI":"10.3171\/2017.11.JNS172141","article-title":"Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients","volume":"130","author":"Conger A","year":"2018","unstructured":"Conger A, Zhao F, Wang X, Eisenberg A, Griffiths C, Esposito F, : Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. J Neurosurg 130:861\u2013875, 201810.3171\/2017.11.JNS17214129749920"},{"key":"b5","series-title":"World Neurosurg","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1016\/j.wneu.2016.08.088","article-title":"Cavernous sinus invasion in pituitary adenomas: systematic review and pooled data meta-analysis of radiologic criteria and comparison of endoscopic and microscopic surgery","volume":"96","author":"Dhandapani S","year":"2016","unstructured":"Dhandapani S, Singh H, Negm HM, Cohen S, Anand VK, Schwartz TH: Cavernous sinus invasion in pituitary adenomas: systematic review and pooled data meta-analysis of radiologic criteria and comparison of endoscopic and microscopic surgery. World Neurosurg 96:36\u201346, 20162759109810.1016\/j.wneu.2016.08.088"},{"key":"b6","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"1311","DOI":"10.3171\/2012.2.JNS111837","article-title":"Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery","volume":"116","author":"Dlouhy BJ","year":"2012","unstructured":"Dlouhy BJ, Madhavan K, Clinger JD, Reddy A, Dawson JD, O\u2019Brien EK, : Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. J Neurosurg 116:1311\u20131317, 201210.3171\/2012.2.JNS11183722443502"},{"issue":"4 Suppl 2","key":"b7","series-title":"Neurosurgery","first-page":"295","article-title":"Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery","volume":"60","author":"Esposito F","year":"2007","unstructured":"Esposito F, Dusick JR, Fatemi N, Kelly DF: Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Neurosurgery 60 (4 Suppl 2):295\u2013304, 2007"},{"key":"b8","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"709","DOI":"10.1227\/01.NEU.0000325725.77132.90","article-title":"Pituitary hormonal loss and recovery after transsphenoidal adenoma removal","volume":"63","author":"Fatemi N","year":"2008","unstructured":"Fatemi N, Dusick JR, Mattozo C, McArthur DL, Cohan P, Boscardin J, : Pituitary hormonal loss and recovery after transsphenoidal adenoma removal. Neurosurgery 63:709\u2013719, 20081898188110.1227\/01.NEU.0000325725.77132.90"},{"key":"b9","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"1066","DOI":"10.3171\/2016.12.JNS1694","article-title":"Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery","volume":"128","author":"Fraser S","year":"2018","unstructured":"Fraser S, Gardner PA, Koutourousiou M, Kubik M, Fernandez-Miranda JC, Snyderman CH, : Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery. J Neurosurg 128:1066\u20131071, 201810.3171\/2016.12.JNS169428598276"},{"key":"b10","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"67","DOI":"10.3171\/2014.3.JNS131532","article-title":"Morbidity of repeat transsphenoidal surgery assessed in more than 1000 operations","volume":"121","author":"Jahangiri A","year":"2014","unstructured":"Jahangiri A, Wagner J, Han SW, Zygourakis CC, Han SJ, Tran MT, : Morbidity of repeat transsphenoidal surgery assessed in more than 1000 operations. J Neurosurg 121:67\u201374, 201410.3171\/2014.3.JNS13153224834943"},{"key":"b11","series-title":"World Neurosurg","doi-asserted-by":"publisher","first-page":"e513","DOI":"10.1016\/j.wneu.2013.06.005","article-title":"Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein","volume":"82","author":"Jakimovski D","year":"2014","unstructured":"Jakimovski D, Bonci G, Attia M, Shao H, Hofstetter C, Tsiouris AJ, : Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein. World Neurosurg 82:e513\u2013e523, 20142381106810.1016\/j.wneu.2013.06.005"},{"key":"b12","series-title":"Int Forum Allergy Rhinol","doi-asserted-by":"publisher","first-page":"1117","DOI":"10.1002\/alr.21783","article-title":"Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery","volume":"6","author":"Karnezis TT","year":"2016","unstructured":"Karnezis TT, Baker AB, Soler ZM, Wise SK, Rereddy SK, Patel ZM, : Factors impacting cerebrospinal fluid leak rates in endoscopic sellar surgery. Int Forum Allergy Rhinol 6:1117\u20131125, 20162755230310.1002\/alr.21783"},{"key":"b13","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"480","DOI":"10.3171\/2012.8.JNS121702","article-title":"Lumbar drains in transsphenoidal surgery","volume":"118","author":"Laws ER","year":"2012","unstructured":"Laws ER, de los Reyes K, Rincon-Torroella J: Lumbar drains in transsphenoidal surgery. J Neurosurg 118:480\u2013481, 2012 (Letter)10.3171\/2012.8.JNS12170223176337"},{"key":"b14","series-title":"Nature","doi-asserted-by":"publisher","first-page":"436","DOI":"10.1038\/nature14539","article-title":"Deep learning","volume":"521","author":"LeCun Y","year":"2015","unstructured":"LeCun Y, Bengio Y, Hinton G: Deep learning. Nature 521:436\u2013444, 20152601744210.1038\/nature14539"},{"key":"b15","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"1299","DOI":"10.3171\/2012.3.JNS112160","article-title":"Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas","volume":"116","author":"Mehta GU","year":"2012","unstructured":"Mehta GU, Oldfield EH: Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas. J Neurosurg 116:1299\u20131303, 201210.3171\/2012.3.JNS11216022482793"},{"key":"b16","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"803","DOI":"10.3171\/2014.12.JNS141083","article-title":"Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification","volume":"122","author":"Micko ASG","year":"2015","unstructured":"Micko ASG, W\u00f6hrer A, Wolfsberger S, Knosp E: Invasion of the cavernous sinus space in pituitary adenomas: endoscopic verification and its correlation with an MRI-based classification. J Neurosurg 122:803\u2013811, 20152565878210.3171\/2014.12.JNS141083"},{"key":"b17","series-title":"J Neurol Surg B Skull Base","doi-asserted-by":"publisher","first-page":"413","DOI":"10.1055\/s-0037-1603649","article-title":"Rater reliability of the Hardy classification for pituitary adenomas in the magnetic resonance imaging era","volume":"78","author":"Mooney MA","year":"2017","unstructured":"Mooney MA, Hardesty DA, Sheehy JP, Bird CR, Chapple K, White WL, : Rater reliability of the Hardy classification for pituitary adenomas in the magnetic resonance imaging era. J Neurol Surg B Skull Base 78:413\u2013418, 20172887512010.1055\/s-0037-1603649"},{"key":"b18","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"1714","DOI":"10.3171\/2016.3.JNS153044","article-title":"Interrater and intrarater reliability of the Knosp scale for pituitary adenoma grading","volume":"126","author":"Mooney MA","year":"2017","unstructured":"Mooney MA, Hardesty DA, Sheehy JP, Bird R, Chapple K, White WL, : Interrater and intrarater reliability of the Knosp scale for pituitary adenoma grading. J Neurosurg 126:1714\u20131719, 20172736724110.3171\/2016.3.JNS153044"},{"key":"b19","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"728","DOI":"10.1093\/neuros\/nyx328","article-title":"Big data research in neurosurgery: a critical look at this popular new study design","volume":"82","author":"Oravec CS","year":"2018","unstructured":"Oravec CS, Motiwala M, Reed K, Kondziolka D, Barker FG 2nd, Michael LM II, : Big data research in neurosurgery: a critical look at this popular new study design. Neurosurgery 82:728\u2013746, 201810.1093\/neuros\/nyx328"},{"key":"b20","series-title":"Otolaryngol Head Neck Surg","doi-asserted-by":"publisher","first-page":"952","DOI":"10.1177\/0194599818756272","article-title":"Risk factors for intraoperative and postoperative cerebrospinal fluid leaks in endoscopic transsphenoidal sellar surgery","volume":"158","author":"Patel PN","year":"2018","unstructured":"Patel PN, Stafford AM, Patrinely JR, Smith DK, Turner JH, Russell PT, : Risk factors for intraoperative and postoperative cerebrospinal fluid leaks in endoscopic transsphenoidal sellar surgery. Otolaryngol Head Neck Surg 158:952\u2013960, 20182940588510.1177\/0194599818756272"},{"key":"b21","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"889","DOI":"10.3171\/2016.3.JNS152735","article-title":"Primary versus revision transsphenoidal resection for nonfunctioning pituitary macroadenomas: matched cohort study","volume":"126","author":"Przybylowski CJ","year":"2017","unstructured":"Przybylowski CJ, Dallapiazza RF, Williams BJ, Pomeraniec IJ, Xu Z, Payne SC, : Primary versus revision transsphenoidal resection for nonfunctioning pituitary macroadenomas: matched cohort study. J Neurosurg 126:889\u2013896, 20172720314210.3171\/2016.3.JNS152735"},{"key":"b22","series-title":"Otolaryngol Head Neck Surg","doi-asserted-by":"publisher","first-page":"564","DOI":"10.1177\/019459989210700409","article-title":"Complications of lumbar spinal fluid drainage","volume":"107","author":"Roland PS","year":"1992","unstructured":"Roland PS, Marple BF, Meyerhoff WL, Mickey B: Complications of lumbar spinal fluid drainage. Otolaryngol Head Neck Surg 107:564\u2013569, 1992143718810.1177\/019459989210700409"},{"issue":"3","key":"b23","series-title":"Neurosurg Focus","doi-asserted-by":"publisher","first-page":"E17","DOI":"10.3171\/2015.12.FOCUS15564","article-title":"Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging","volume":"40","author":"Serra C","year":"2016","unstructured":"Serra C, Burkhardt JK, Esposito G, Bozinov O, Pangalu A, Valavanis A, : Pituitary surgery and volumetric assessment of extent of resection: a paradigm shift in the use of intraoperative magnetic resonance imaging. Neurosurg Focus 40(3):E17, 20162692605710.3171\/2015.12.FOCUS15564"},{"key":"b24","series-title":"Pituitary","doi-asserted-by":"publisher","first-page":"654","DOI":"10.1007\/s11102-017-0830-x","article-title":"The changing sella: internal carotid artery shift during transsphenoidal pituitary surgery","volume":"20","author":"Serra C","year":"2017","unstructured":"Serra C, Maldaner N, Muscas G, Staartjes V, Pangalu A, Holzmann D, : The changing sella: internal carotid artery shift during transsphenoidal pituitary surgery. Pituitary 20:654\u2013660, 20172882872210.1007\/s11102-017-0830-x"},{"key":"b25","series-title":"Acta Neurochir (Wien)","doi-asserted-by":"publisher","first-page":"2255","DOI":"10.1007\/s00701-018-3690-x","article-title":"Predicting extent of resection in transsphenoidal surgery for pituitary adenoma","volume":"160","author":"Serra C","year":"2018","unstructured":"Serra C, Staartjes VE, Maldaner N, Muscas G, Akeret K, Holzmann D, : Predicting extent of resection in transsphenoidal surgery for pituitary adenoma. Acta Neurochir (Wien) 160:2255\u20132262, 201810.1007\/s00701-018-3690-x"},{"key":"b26","series-title":"J Mach Learn Res","first-page":"1929","article-title":"Dropout: a simple way to prevent neural networks from overfitting","volume":"15","author":"Srivastava N","unstructured":"Srivastava N, Hinton G, Krizhevsky A, Sutskever I, Salakhutdinov R: Dropout: a simple way to prevent neural networks from overfitting. J Mach Learn Res 15:1929\u20131958, 2014"},{"issue":"5","key":"b27","series-title":"Neurosurg Focus","doi-asserted-by":"publisher","first-page":"E12","DOI":"10.3171\/2018.8.FOCUS18243","article-title":"Utility of deep neural networks in predicting gross-total resection after transsphenoidal surgery for pituitary adenoma: a pilot study","volume":"45","author":"Staartjes VE","year":"2018","unstructured":"Staartjes VE, Serra C, Muscas G, Maldaner N, Akeret K, van Niftrik CHB, : Utility of deep neural networks in predicting gross-total resection after transsphenoidal surgery for pituitary adenoma: a pilot study. Neurosurg Focus 45(5):E12, 201810.3171\/2018.8.FOCUS1824330453454"},{"key":"b28","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"425","DOI":"10.3171\/2017.4.JNS162451","article-title":"Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients","volume":"129","author":"Strickland BA","year":"2018","unstructured":"Strickland BA, Lucas J, Harris B, Kulubya E, Bakhsheshian J, Liu C, : Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients. J Neurosurg 129:425\u2013429, 201810.3171\/2017.4.JNS162451"},{"key":"b29","series-title":"Pituitary","doi-asserted-by":"publisher","first-page":"89","DOI":"10.1007\/s11102-005-5351-3","article-title":"Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis","volume":"7","author":"van Aken MO","year":"2004","unstructured":"van Aken MO, Feelders RA, de Marie S, van de Berge JH, Dallenga AHG, Delwel EJ, : Cerebrospinal fluid leakage during transsphenoidal surgery: postoperative external lumbar drainage reduces the risk for meningitis. Pituitary 7:89\u201393, 20041576165710.1007\/s11102-005-5351-3"},{"key":"b30","series-title":"Clinical Management of Pituitary Disorders","first-page":"335","article-title":"Neurosurgical management of large and invasive pituitary tumors","author":"Wilson CB","year":"1979","unstructured":"Wilson CB: Neurosurgical management of large and invasive pituitary tumors, in Tindall GT, Collins WF (eds): Clinical Management of Pituitary Disorders. New York: Raven Press, 1979, pp 335\u2013342"}],"container-title":["Journal of Neurosurgery"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/133\/2\/article-p329.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/133\/2\/article-p329.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg\/133\/2\/article-p329.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,3,26]],"date-time":"2023-03-26T19:36:35Z","timestamp":1679859395000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg\/133\/2\/article-p329.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,8]]},"references-count":30,"journal-issue":{"issue":"2"},"URL":"https:\/\/doi.org\/10.3171\/2019.4.jns19477","relation":{},"ISSN":["0022-3085","1933-0693"],"issn-type":[{"value":"0022-3085","type":"print"},{"value":"1933-0693","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,8]]}}}