Journal of Korean Neurosurgical Society最新文献

Cement-augmented pedicle screw instrumentation is a widely accepted method for managing osteoporotic fractures, but it carries inherent risks, particularly related to cement leakage and embolism. This study aimed to analyze a clinical case of complications following cement fixation and provide a detailed review of relevant literature. A 70-year-old patient underwent transpedicular screw instrumentation from L2-L4 with polymethyl methacrylate augmentation, which resulted in cement leakage into the spinal canal and subsequent pulmonary embolism. After revision surgery and conservative treatment for the embolism, the patient's condition stabilized, demonstrating that conservative measures can be effective in managing cement embolism. To complement this case, a comprehensive literature review was conducted to explore the causes, prevention, and treatment of complications related to cement augmentation. The findings support that while cement-augmented pedicle screw instrumentation remains a leading technique for osteoporotic fractures, the associated risks are manageable with proper treatment protocols. This study holds practical significance for healthcare professionals by highlighting both the risks and solutions associated with cement fixation, thus contributing to improved patient outcomes and the development of standardized treatment guidelines.

Objective: Clazosentan is a recently approved endothelin receptor antagonist indicated for the prevention of vasospasm and related complications following aneurysmal subarachnoid hemorrhage (aSAH). To date, no direct, head-to-head comparison between clazosentan and nimodipine has been conducted. In this study, we indirectly assessed the efficacy and safety of these two drugs in preventing vasospasm and its associated outcomes after aSAH.

Methods: Participants from six randomized clinical trials of clazosentan were reclassified into three subgroups based on their concomitant use of oral nimodipine: (1) a clazosentan subgroup (without nimodipine), (2) a nimodipine subgroup (without clazosentan), and (3) a placebo subgroup (receiving neither clazosentan nor nimodipine). Data from participants who received the approved dose of clazosentan 10 mg/h was analyzed. To account for heterogeneities among the analyzed studies, we performed within-study comparisons of subgroups and pooled data from the same subgroup. To further balance the three groups, we conducted a propensity score-matching and compared the outcomes among subgroups. The outcomes measured were angiographic vasospasm within 14 days after aSAH and vasospasm-related morbidity and all-cause mortality (MM) within 6 weeks, defined as death, vasospasm-related new cerebral infarcts, delayed ischemic neurological deficits, or initiation of rescue therapy. Incidence and relative risk reduction (RRR) were analyzed across subgroups, and overall safety was reviewed.

Results: The pooled data from within-study comparisons demonstrated that clazosentan significantly reduced the risk of vasospasm (RRR 0.48 [95 % CI: 0.35, 0.58]) and MM (RRR 0.47 [95 % CI: 0.30, 0.60]) compared to placebo, whereas nimodipine did not. In the propensity score-matched analysis, clazosentan demonstrated a significant risk reduction in outcomes when compared to nimodipine (RRR 0.63 [95% CI: 0.46, 0.75] for vasospasm; RRR 0.29 [95% CI: 0.04, 0.48] for MM) and placebo (RRR 0.59 [95% CI: 0.40, 0.72] for vasospasm; RRR 0.41 [95% CI: 0.21, 0.56] for MM).The overall safety results were comparable across the three subgroups and consistent with the expected range for endothelin receptor antagonists.

Conclusion: Clazosentan at 10 mg/h significantly reduced the incidence of cerebral vasospasm and MM following aSAH, compared to both placebo and nimodipine. Further clinical studies are warranted to compare the efficacy of clazosentan and nimodipine to optimize treatment strategies for aSAH.

The endoscopic transsphenoidal approach is a common approach used in skull base neurosurgery to reach the sellar region. One of the intraoperative risks of this approach is intraoperative bleeding out of the carotid artery. Gentle drilling can prevent carotid artery injury. However, injury to smaller branches, such as the McConnell's capsular artery, which is located within the surgical corridor, is more difficult to prevent. If such an injury is within the junction to the main trunk of the carotid artery, there will be a small circular defect in this area. This can result in massive blood loss and should be closed surgically immediately. We describe a clinical case of intraoperative bleeding from the McConnell's artery originating from the carotid arterial segment (C4) in a 78-year-old female patient operated on for planum sphenoidale meningioma via endoscopic transsphenoidal approach, as well as provide a technical note on a possible technique for bleeding control in such cases. Pinpoint carotid bleeding as a result of intraoperative injury can be stopped by wedging a bone fragment in the carotid canal and fixing it in that position with histoacryl glue at the defect site.

Persistent trigeminal artery (PTA) is the most common residual manifestation of persistent carotid-vertebrobasilar anastomosis, with the medial-type (intrasellar or sphenoidal) PTA being exceptionally rare. Aneurysms originating from the PTA trunk are not common. We present a unique case of an aneurysm located at the trunk of the medial-type PTA in a patient presenting with trigeminal neuralgia who successfully received endovascular treatment. Furthermore, we discuss the anatomical features of this aneurysm and relevant reports, and examine the possible pathomechanism of the associated pain.

Objective: The leptomeningeal ivy sign is a distinctive finding of moyamoya disease (MMD), characterized by a linear high signal intensity along the cortical sulci on contrast-enhanced T1 magnetic resonance imaging (MRI) and fluid-attenuated inversion-recovery MRI. We recently identified a similar linear enhancement along the cortical sulci using gadolinium-enhanced vessel wall MRI (VWMR) in patients with MMD. The aim of this study was to introduce the concept of the "VWMR ivy sign (VIS)".

Methods: Eighteen MMD patients underwent gadolinium-enhanced VWMR. We identified the VIS in gadolinium-enhanced VWMR, represented by a linear high intensity along the cortical sulci. The VIS was assessed by comparing pre and postcontrast T1 black blood sequences on VWMR and was investigated in the precentral, central, and postcentral sulci. "VIS scores" were calculated by the sum of VIS in the three sulci, ranged from 0 to 3. We compared the VIS scores according to different stroke presentations (non-stroke, ischemic stroke, and hemorrhagic stroke). The inter-modality agreement for identifying VIS and fluid-attenuated inversion-recovery (FLAIR)/cortical sulci on contrast-enhanced T1 MRI (CEMR) ivy sign was determined using Cohen's kappa statistics.

Results: The VIS scores were significantly different among the three groups (P = 0.004). The VIS scores in both the ischemic and hemorrhagic groups were significantly higher than those in the non-stroke group (ischemic vs. non-stroke, P = 0.009; hemorrhagic vs. non-stroke, P = 0.004). After adjusting for age and sex using the non-stroke group as a reference group, the VIS scores were significantly higher in the ischemic and hemorrhagic groups (P=0.046, OR 8.27, 95% CI 1.03-66.19 and P=0.039, OR 7.78, 95% CI 1.11-54.48, respectively). Inter-modality agreement between VIS and FLAIR ivy sign was substantial, perfect, and substantial in the precentral, central, and postcentral sulci, respectively (precentral sulcus, κ=0.609, 95% CI=0.213-1; central sulcus, κ=1; and postcentral sulcus, κ=0.769, 95% CI=0.475-1). Inter-modality agreement between the VIS and CEMR ivy sign was substantial in the precentral, central, and postcentral sulci, respectively (precentral sulcus, κ=0.727, 95% CI=0.384-1; central sulcus, κ=0.609, 95% CI=0.384-1; and postcentral sulcus, κ=0.649, 95% CI=0.310-0.998).

Conclusion: This preliminary series introduces the concept of VIS, possibly indicating slow and retrograde flow of sulcal vessels via leptomeningeal collaterals. Future studies are needed to develop an optimal scoring system for VIS and establish its clinical correlation with stroke presentations in MMD patients.

Objective: Primary intraventricular hemorrhage (PIVH) is a rare type of neurologic disorder and remains a challenge for cerebrovascular surgeons. This study intended to investigate the factors associated with neurosurgical intervention and its impact on outcome after PIVH.

Methods: We retrospectively included consecutive patients with PIVH admitted to at a single tertiary academic medical center in China. Conservative treatment or neurosurgical intervention options (including endovascular therapy, craniotomy, stereotactic radiotherapy, endoscopic surgery or external ventricular drain) were assessed. Multivariable logistic regression was applied to determine associations.

Results: In total, 174 patients with PIVH were included in our analysis. There were 79 (45.4%) patients underwent surgery, which was associated with younger age (P = 0.004), higher Baseline Graeb score (P = 0.001), acute hydrocephalus (P = 0.02) and underlying cerebrovascular diseases (P < 0.001) in an adjusted model. In multivariable logistic regression analysis, significant predictors of external ventricular drain after PIVH were higher Baseline Graeb score (P = 0.04), and acute hydrocephalus (P< 0.001). Furthermore, after adjustment for confounders, our analysis showed that neurosurgical intervention could decrease 90-day mortality after PIVH (P = 0.04).

Conclusion: After PIVH, younger patients with higher Baseline Graeb score, acute hydrocephalus and underlying cerebrovascular diseases were more likely to undergo neurosurgical intervention. Surgical treatment of PVIH patients should be optimized to decrease mortality. However, further clinical trials are still needed to determine which patients would benefit from neurosurgical intervention.

Objective: Traumatic optic neuropathy (TON) refers to a pathological condition caused by direct or indirect injury to the optic nerves. In the case of patients with traumatic brain injury, adequate vision evaluation is difficult in many cases due to altered mentality. In order to address this problem, we investigated preoperative pupillary light reflex in TON patients as a predictive factor of surgical outcomes after optic nerve decompression.

Methods: From April 2020 to September 2022, we enrolled patients who were diagnosed with TON and underwent endoscopic optic nerve decompression at our institution. Vision and pupil reflex tests were performed by an ophthalmologist before and after surgery.

Results: Seven patients were enrolled. Their ages ranged from 9 to 78 years and all were male. Among the seven patients, the patient whose pupillary light reflex was sluggish with 6 mm-sized pupil and absent with 7 mm-sized pupil before surgery showed no improvement in vision. Patients with some response to direct reflex or contralateral indirect reflex testing preoperative showed vision improvement after operation.

Conclusion: Direct and indirect pupillary reflexes can be important factors determining treatment outcome for TON. In unconscious patients with a fracture involving the optic canal, timely surgical intervention based on pupillary reflex can prevent permanent loss of vision.

Objective: This study aimed to evaluate the clinical effects of medial branch blocks (MBBs) C2 and C3 in treating patients with medically intractable headaches.

Methods: The medical records of 81 patients with medically intractable headaches who underwent a C2/3 MBB between January 2019 and March 2022 were retrospectively reviewed. The degrees of pain were evaluated using a Visual analogue scale (VAS) score (rating 0-10) on baseline and after procedures. To evaluate patients' satisfaction for the treatment, self-reporting measurements were examined and were categorized as excellent (>90% pain relief), good (50-90% pain relief), fair (10-50% pain relief), and none (<10% pain relief).

Results: The total number of MBB procedure was 107. The average baseline VAS score was 7.4±1.5, which improved significantly to 2.6±2.3, 3.6±2.6, and 4.5±3.2 on 1-3 days, 3-7 days, and 3 months after the procedure, respectively (Wilks' lambda within group test, p<0.001). For the subjective feeling of pain relief, percentages of "excellent" response in the self-reporting measurements were significantly decreased over time (chi-square test; p=0.001).

Conclusion: This study demonstrates clinical effectiveness of C2/3 MBB in patients with medically intractable headaches, with both early and prolonged benefits.

Objective: To evaluate the effect of ventricular opening (VO) on recurrence patterns in patients with newly diagnosed glioblastoma (GBM) treated with bis-chloroethyl-nitrosourea (BCNU) wafer implantation.

Methods: This single-center retrospective study included 40 patients with newly diagnosed GBM who received BCNU wafer implantation after tumor resection between March 2013 and February 2022. The patients were categorized into two groups based on whether VO occurred during the GBM resection. While 18 patients had VO, 22 did not have VO. In cases with VO, the ventricular wall defect is closed with gelatin or oxidized regenerated cellulose and fibrin glue before BCNU wafer implantation. Recurrence patterns-classified as local, diffuse, distant, or multifocal-and time to recurrence were compared between patients with and without VO.

Results: The median follow-up period for the entire cohort was 32.2 months (interquartile range, 16.7-38 months). Median survival time was comparable between patients with VO and patients without VO (38 vs. 26 months, p=0.53). Recurrence occurred in 31/40 patients (77.5%) in entire cohort. The incidence of recurrence was comparable between patients with VO and patients without VO (14 [77.8%] vs. 17 [77.3%], p=1.0). No significant differences were seen between the two groups in time to recurrence (p=0.59) or recurrence patterns (p=0.35).

Conclusion: Ventricular opening during surgery with BCNU wafer implantation does not seem to influence the recurrence patterns. Ventricular opening does not induce distant recurrence if appropriate ventricular closure is performed.