Journal of neurosurgical sciences最新文献

Introduction: Traumatic brain injury (TBI) is a critical condition where the management of oxygen levels plays a pivotal role in patient outcomes. While hypoxemia is known to worsen outcomes, the impact of hyperoxemia on mortality and neurological outcomes remains controversial. This systematic review and meta-analysis aims to evaluate the effects of hyperoxemia on these outcomes in TBI patients.

Evidence acquisition: This study followed PRISMA guidelines and was registered with PROSPERO (registration number: CRD42024537543). A comprehensive search was conducted across MEDLINE, Embase, and SCOPUS databases, identifying relevant studies on hyperoxemia and its impact on mortality and neurological outcomes in TBI patients. Both observational studies and randomized controlled trials were included, and data were synthesized and analyzed using a random-effects model.

Evidence synthesis: Fifteen studies including 38,718 patients were included in the qualitative synthesis, with 13 studies included in the quantitative meta-analysis. Hyperoxemia was not significantly associated with mortality (pooled OR=0.88 [0.66-1.16]; P=0.36; I²=86%) or with unfavorable neurological outcomes (pooled OR=1.04 [0.83-1.29]; P=0.75; I²=67%). Sensitivity analyses limited to studies with low or low/moderate risk of bias showed a statistically significant association between hyperoxemia and reduced mortality, although with high heterogeneity (OR=0.65 [0.48-0.88]; P=0.005; I²=82%). A subgroup analysis of studies assessing neurological outcome at 6 months suggested a trend toward improved functional outcomes with early moderate hyperoxemia (OR=1.32 [0.99-1.75]; P=0.06). An explorative meta-regression did not show a significant linear association between PaO2 thresholds and outcomes.

Conclusions: This systematic review and meta-analysis do not provide sufficient evidence to discourage the use of moderate hyperoxemia in TBI patients. Exploratory analyses suggesting potential benefits from early moderate hyperoxemia require further validation in selected patients. High-quality prospective studies are urgently needed to determine the optimal use of oxygen therapy in TBI.

Introduction: Giant intracranial aneurysms are rare vascular lesions consisting of cerebral aneurysms measuring ≥25 mm in diameter. Their formation is the result of multiple factors including their association with a unique genomic landscape, pathophysiologic processes associated with the pathognomonic, histopathological changes observed within the arterial wall, the physical effects of the cerebral vasculature's unique fluid dynamics, and slow growth rates. Because giant intracranial aneurysms are considered among the most complex to manage, we herein perform a systematic review of the extant evidentiary base found within the neurosurgical literature with the goal of profiling multimodality management strategies for these lesions. Additionally, we will highlight the importance of integrating neuroendovascular surgery into microsurgical treatment regimens for giant cerebral aneurysms.

Evidence acquisition: To this end, we performed a systematic review of the literature through the PubMed, Scopus and Web of Science databases according to PRISMA guidelines. By using predefined search terms, we intended to identify prior reports involving multimodality management of giant intracranial aneurysms. Specifically, we sought to highlight the integral role of both neuroendovascular and microsurgical interventions in treatment of these rare vascular lesions.

Evidence synthesis: Ten studies reporting outcomes for 91 patients met criteria for inclusion in the present meta-analysis. Within this cohort of patients, mean age varied from 39.0 to 60.1 years. Among the giant aneurysms in the present review, many were found extending off of the supraclinoid ICA, which is one of the most common sites for giant intracranial aneurysms to form. In 1988, Batjer described the earliest combined intervention included in the present study. Since then, two common approach type themes involved in multimodal management have evolved: combined strategies often consist of 1) an endovascular approach to vessel occlusion, such as embolization, and 2) a microsurgical method capable of eliminating the aneurysm following control of blood flow. In other words, achieving obliteration via clipping, bypass surgery, clip reconstruction, wrapping, and Hunterian ligation (among others). Review of the literature indicated an overall mortality rate associated with multimodal management of 5.4%. Radiographic obliteration rates were reported in three of ten studies. One of the studies reported an 82.9% rate of successful obliteration. Rates of good outcomes (mRS 0-2, GOS 4-5) ranged from 60% up to a maximum of 87.5%.

Conclusions: Combined, multimodality endovascular and microsurgical treatments appear to be most successful for the treatment of giant aneurysms because of their adaptability, the flexibility they confer, and the synergistic effect of combining the strengths of multiple modalities.

Background: The Italian Association of Neuro-Oncology (AINO) and the Italian Society of Neurosurgery (SINch) promoted a national survey to explore how the 2021 WHO molecular diagnostic criteria for gliomas have been implemented into clinical practice.

Methods: A survey containing 38-item multiple-choice questions was sent to members of the AINO and SINch from January 2022 to March 2022.

Results: We collected 152 answers. Participants from non-academic vs. academic hospitals were 78 (51.3%) and 74 (48.7%). Assessment of IDH mutations and 1p/19q codeletion was reported by 140 (92.1%) and 88 (57.9%) responders, respectively. MGMTp methylation, either at diagnosis or at second surgery, was reported by 110 (72.4%) and 82 (53.9%) responders, respectively. CDKN2A/B homozygous deletion in IDH-mutant astrocytomas was investigated according to 53 (34.9%) responders. Assessment of either EGFR amplification or pTERT mutation or +7-10 chromosome changes in IDH-wild type astrocytomas was reported by 76 (50.0%), 43 (28.3%), and 16 (10.5%) responders, respectively. Academic vs. non-academic hospitals had a higher availability of molecular markers, including CDKN2A/B deletion (34/70, 48.6% vs. 19/82, 23.2%, P=0.001), MGMTp at second surgery (48/69, 69.6% vs. 34/72, 47.2%, P=0.008), EGFR/pTERT/+7-10 (46/70, 65.7% vs. 32/77, 41.6%, P=0.003), BRAF mutation (14/70, 20.0% vs. 4/82, 4.9%, P=0.002), NTRK fusion (14/70, 20.0% vs. 2/81, 2.5%, P<0.001).

Conclusions: The availability of molecular markers for gliomas is widespread among Italian centers. The implementation of the molecular criteria for diagnostic and prognostic purposes in gliomas according to WHO 2021 Classification needs to be improved. Moreover, a critical issue for the future will be the search for rare actionable mutations, which is continuously evolving, in light of the use of targeted therapy.

Introduction: Traumatic brain injury (TBI) impacts over 69 million people annually worldwide and causes significant disability. Gastrointestinal (GI) dysfunction is becoming increasingly recognized as post-TBI sequelae, however best practices for their detection and management remain lacking. The current review aimed to improve the understanding of the epidemiology, pathophysiology, risk factors, and interventions of GI disorders after TBI in order to advance clinical diagnosis and treatment.

Evidence acquisition: A comprehensive literature search was conducted using the PubMed database between 1996 and 25 January 2025 pertaining to post-TBI GI disorders. Special focus was given to relevant reports on the pathophysiology, epidemiology, risk factors, and management for GI disorders.

Evidence synthesis: Post-TBI GI dysfunction occurs primarily due to autonomic dysfunction, increased intracranial pressure, and systemic inflammation, causing intestinal dysmotility and malabsorption, which commonly present as feeding intolerance and malnutrition. Proposed diagnostic criteria include increased gastric residual volume (with/without concurrent GI symptoms), decreased weight, body mass index, and albumin. Standardized nutritional screening methodologies, prokinetic agents, and small bowel and transpyloric feeding have shown benefits in symptomatic management and recovery of GI function, and represent targets for formal study in prospective trials.

Conclusions: Post-TBI GI dysfunction is prevalent and can progress to further systemic injuries, impairment, and long-term disability. Early recognition of autonomic and GI system dysfunction, early implementation of formalized nutritional support and multidisciplinary consultation, and inclusion of prokinetic medications and autonomic nervous system modulators are promising avenues for prevention and treatment of post-TBI feeding intolerance, dysmotility, and malnutrition to improve outcomes.

Background: Proximal junctional kyphosis (PJK) is a common complication following adult spinal deformity (ASD) surgery and puts patients at an increased risk for neurological injury. As reoperation continues to be the mainstay treatment, there is utility in identifying independent preoperative risk factors for PJK development. The aim of this study was to determine whether a history of anterior cervical discectomy and fusion (ACDF) predicts increased incidence of PJK after ASD correction.

Methods: Data was retrospectively collected from the medical record of patients who underwent ASD long-segment spinal fusion between 10/2015 and 9/2020. Patients were divided into cohorts based on whether they had previously undergone ACDF. Demographic, radiographic, perioperative, complication, and patient-reported outcomes measures (PROMs) were analyzed. The primary outcome measure was the development of PJK by the 2-year postoperative timepoint.

Results: Eighty-six patients met inclusion criteria, 14 of which had previously undergone ACDF. Patients with prior ACDF demonstrated a significantly higher risk of developing PJK by 2 years after ASD surgery. The prior ACDF cohort also showed significantly greater proximal junctional sagittal cobb angles (PJCA) from the upper instrumented vertebra (UIV) to UIV+2 at 2-years postoperatively, greater pre- to postoperative changes in PJCA at 1-year postoperatively, and less absolute global sagittal flexibility than the no prior ACDF cohort. No differences were seen in demographic, comorbidity, complication, or PROM data between groups.

Conclusions: These retrospective data demonstrate that a history of ACDF may independently predict the development of PJK after ASD correction and should be considered in the operative decision-making for these patients.

Background: Traditional neurosurgical training involves a steep learning curve. The introduction of advanced simulation technologies, like virtual reality, provides an alternative method for skill acquisition, allowing for repeated practice and objective assessment. This study focuses on evaluating the learning curve associated with lumbar pedicle Kirschner wire insertion using a virtual fluoroscopic simulator among neurosurgical residents.

Methods: Eighteen neurosurgery residents and two interns participated in this study. Participants' initial skill levels were assessed through a questionnaire. Performance metrics, including insertion accuracy, time, and the number of virtual X-ray scans, were recorded across multiple attempts until a "practical learning plateau" was reached. Statistical analyses were conducted to model learning curves, assess the correlation between pre-training experience and performance.

Results: The average number of attempts required to stabilize performance was 5.61. Learning rates varied, with some residents showing rapid improvement while others progressed more slowly. Higher accuracy in wire placement correlated with reduced usage on X-rays over time. However, experienced residents did not necessarily learn faster, indicating potential challenges in adapting to new simulation-based methods. Post-training feedback highlighted the simulator's utility in increasing confidence and skill levels, although some limitations in anatomical accuracy were noted.

Conclusions: This study demonstrates the potential of virtual simulation to enhance neurosurgical training by providing a controlled environment for repeated practice and objective feedback. Simulation-based training can effectively complement traditional methods, though individualized approaches may be necessary to accommodate varying learning rates among residents. Further refinement of simulation tools and their integration into standard training curricula are recommended.

Background: While intraoperative transcranial motor evoked potential (tcMEP) monitoring is widely used in spinal and brain surgery, it is sometimes not used because it can exhibit low specificity and give false-positive results.

Methods: We studied 1833 muscles in 477 patients and 482 muscles in 206 patients without preoperative paralysis of manual muscle test of 2/5 or less in whom spinal and brain surgery, respectively, was performed under tcMEP monitoring. A receiver operating characteristic (ROC) analysis was used to calculate the cutoff point of amplitude relative values that cause postoperative paralysis, and the sensitivity and specificity of tcMEP monitoring with or without compound muscle action potential (CMAP) normalization after peripheral nerve stimulation.

Results: In spinal surgery, the rate of tcMEP amplitude reduction resulting in postoperative paralysis was 54.0% without CMAP normalization and 73.9% under CMAP normalization, with a sensitivity of 92.3% with or without CMAP normalization, a specificity of 95.8% without CMAP normalization vs. 97.4% under CMAP normalization, and this difference was significant by Fisher's exact probability test (two-tailed P=0.0133, one-tailed P=0.0067). In brain surgery, the percentage of tcMEP amplitude reduction resulting in postoperative paralysis was 55.0% without CMAP normalization vs. 68.1% under CMAP normalization, with a sensitivity of 87.0% without vs. 91.3% with CMAP normalization, and a specificity of 91.3% without vs. 95.6% with CMAP normalization, and these values were significantly different by Fisher's Exact Probability Test (two-tailed P=0.0225, one-tailed P=0.0112).

Conclusions: CMAP normalization after peripheral nerve stimulation may significantly increase specificity in intraoperative tcMEP monitoring during spinal and brain surgery.

Introduction: Dysplastic cerebellar gangliocytoma (DCG) is a rare cerebellar tumor glioneuronal and neuronal tumor with phosphatase and tensin homolog (PTEN) identified as a key altered gene. The aim of this study is to establish DCG diagnostic and outcome trends over a six-decade and present cases from our institution.

Evidence acquisition: A literature review of online databases was performed using relevant terms (January 1970-October 2024). Our institution pathology database was queried for patients with DCG (2000-2024). Data was extracted and dichotomized in adult and pediatric cases.

Evidence synthesis: We report three new DCG cases in addition to the 170 DCG cases reported across 97 articles over seven decades, with 52% of articles published since 2010. DCG predominantly occurred in adults (>18 years, 82%), women (59%), at mean age 9.0±6.3 years and 38.1±13.7 years in pediatric and adult patients, respectively. Balance/coordination deficit, headache and visual deficit were the most common presenting symptoms. MRI "tiger-stripe" pattern was present in 67%. Surgical resection was the treatment of choice for >97% of patients. Association with Cowden Syndrome (CS) was confirmed in 67% of patients. PTEN mutations identified in 48.3% of cases, primarily affecting chromosome 10 (10q23.3). Progression-free survival was experienced by 74% of patients and reoperation for progression needed in 3.5% of cases.

Conclusions: DCG is a rare tumor associated with PTEN mutations. MRI aids in diagnosis and surgery ensures favorable outcomes. Standardized genetic screening and targeted therapies require further study, as they hold promise for refining diagnosis and long-term management.

Background: The Calabria Decree (Law No. 145 of 2018) and its subsequent amendments introduced reforms aimed at improving the employment and training conditions of medical residents in Italy. Notably, the decree allowed for the early hiring of residents, starting from their second year of specialization, with permanent contracts upon completion of their training. This study explores the impact of these reforms on neurosurgery residents, specifically examining the effects on their professional development, education, and well-being.

Methods: A survey was conducted by the Italian Society of Neurosurgery (SINCH) and distributed to neurosurgery residents, as well as heads of university and non-university hospital departments. The survey gathered data on residents' demographic information, satisfaction with their employment contracts, preparedness for clinical responsibilities, and perceived effects on their training, particularly in terms of surgical and academic activities. Hospital and university leaders were asked to share their perspectives on the impact of early employment on resident training, research activities, and the overall functioning of healthcare institutions.

Results: A total of 32 neurosurgery residents participated in the survey. Half of the respondents were employed under fixed-term contracts, while the other half had permanent contracts. Residents expressed high satisfaction with surgical activities, with 71.9% feeling well-prepared for managing surgical emergencies. However, 28.1% reported concerns over a perceived loss of essential training, particularly in research. From the university perspective, 86% of institutions viewed early employment as detrimental to resident education, particularly in academic and research activities. In contrast, hospitals reported positive effects, especially regarding human resource management, patient care, and resident enthusiasm.

Conclusions: Early employment under the Calabria Decree has several advantages, particularly in terms of clinical exposure and operational efficiency in hospitals, however, it raises concerns about the potential impact on academic training and scientific research. To ensure comprehensive training, it is essential to foster collaboration between universities and hospitals, emphasizing the importance of maintaining a strong academic foundation alongside clinical practice. The study highlights the need for ongoing adjustments to the training structure to achieve a balance between practical and theoretical education for neurosurgery residents.