Neural network–based identification of patients at high risk for intraoperative cerebrospinal fluid leaks in endoscopic pituitary surgery

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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–based models can reliably identify patients at high risk for intraoperative CSF leakage.


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.


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–based 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.


The authors trained and internally validated a robust deep neural network–based 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.

ABBREVIATIONS AUC = area under the curve; CSF = cerebrospinal fluid; EOR = extent of resection; F1 score = harmonic mean of PPV and sensitivity; GTR = gross-total resection; NPV = negative predictive value; PA = pituitary adenoma; PPV = positive predictive value; R ratio = ratio between the maximum horizontal adenoma diameter and the minimum intercarotid distance at the horizontal C4 segment of the internal carotid artery; TSS = transsphenoidal surgery; 3T-iMRI = high–field strength intraoperative 3-Tesla MRI.

Supplementary Materials

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Contributor Notes

Correspondence Carlo Serra: University Hospital Zurich, Switzerland. WHEN CITING Published online June 21, 2019; DOI: 10.3171/2019.4.JNS19477.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.


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