Journal of neurosurgical sciences最新文献

Introduction: This meta-analysis aimed to evaluate the safety and efficacy of direct endovascular therapy (EVT) and bridging therapy (EVT with preceding intravenous thrombolysis i.e. IVT), in acute anterior circulation, large vessel occlusion stroke.

Evidence acquisition: Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, Cochrane CENTRAL, SCOPUS and ClinicalTrials.gov. Outcomes of interest were measured by the modified Rankin Scale (mRS), and included: no disability (mRS0), no significant disability despite some symptoms (mRS1), slight disability (mRS2), moderate disability (mRS3), moderately severe disability (mRS4), severe disability (mRS5), mortality (mRS6). Additionally, we inspected patients having excellent outcome, functional independence outcome, and poor outcome, along with successful reperfusion and intracranial hemorrhage. We calculated pooled risk ratios (RRs) and their corresponding 95% confidence intervals (CI).

Evidence synthesis: A total of seven RCTs involving 2,392 patients were finally included. The chances of achieving successful reperfusion were significantly more with IVT+EVT as compared to EVT alone (RR: 0.97; 95% CI: 0.94, 1.00; P=0.03) (I²=0%). There was no significant difference in the number of patients having outcomes ranging from mRS0 to mRS6, excellent outcome, functional independence, poor outcome or incidence of intracranial hemorrhage, who underwent either EVT alone or IVT+EVT.

Conclusions: Additional trials are needed to determine if the absence of significant differences is due to insufficient sample size or if the combination therapy is truly not beneficial.

The retro-sigmoid approach (RA), widely used during different neurosurgical procedures, is burdened by the risk of injuries of the nerves that cross that region contributing to possible postoperative complications. By using, anatomage table (AT), a novel 3D anatomical visualization system, we described the nerves passing through the retromastoid area including the great occipital nerve (GON), the lesser occipital nerve (LON) and the great auricular nerve (GAN), and their courses from the origins, till terminal branches. Moreover, using dedicated software, we measured distances between the nerves and well-recognizable bony landmarks. After identifying the nerves and their distances from bony landmarks, we observed that the safest and risk-free skin incision should be made in an area delimited, superiorly from the superior nuchal line (or slightly higher), and inferiorly from a plane passing at 1-1.5 cm above the mastoid tip. The lateral aspect of such an area should not exceed 9.5-10 cm from the inion, while the medial one should be more than 7 cm far from the inion. This anatomical information has been useful in defining anatomical landmarks and reducing the risk of complications, mainly related to nerve injury, in RA. In-depth neuroanatomic knowledge of the cutaneous nerves of the retromastoid area is essential to minimize the complications related to their injury during different neurosurgical approaches. Our findings suggest that the AT is a reliable tool to enhance understanding of the anatomy, and thus contributing to the refinement of surgical techniques.

Posterior communicating artery aneurysms (PcomAs) present with oculomotor nerve (OMN) palsy in 20-30% of cases, and the sudden onset of OMN palsy has to raise the suspicion of rupture, until proven otherwise. The surgical technique is described in a stepwise fashion. An illustrative case is reported: a 57-year-old female was admitted to our department with the diagnosis of a right sided-PcomA. Three months before the admission, when she harbored with the acute onset of complete ptosis, diplopia, orbital pain, impairment of the medial, upward, and downward gaze, with no pupil dysfunction. The origin of the Pcom and the neck of the aneurysm were easily identified and the aneurysm was clipped. Then, we followed the OMN and cut for less than 4 mm the above-lying anterior petroclinoid ligament (APL) to obtain nerve release. Although few cases are described in the literature, and ours represents a single case, we support that this maneuver should be introduced in the clinical practice of expert neurosurgeons dealing with vascular pathologies, such as the opening of the falciform ligament occurs for the decompression of the optical nerve.

Background: This study aimed to determine whether the presence of distinct glioma margins on preoperative imaging is correlated with improved intraoperative identification of tumor-brain interfaces and overall improved surgical outcomes of non-enhancing gliomas.

Methods: This is a retrospective study of all primary glioma resections at our institution between 2000-2020. Tumors with contrast enhancement or with final pathology other than diffuse infiltrative glial neoplasm (WHO II or WHO III) were excluded. Tumors were stratified into two groups: those with distinct radiographical borders between tumor and brain, and those with ill-defined radiographical margins. Multivariate analysis was performed to determine the impact of clear preoperative margins on the primary outcome of gross-total resection.

Results: Within the study period, 59 patients met inclusion criteria, of which 31 (53%) had distinct margins. These patients were predominantly younger (37.6 vs. 48.1 years, P=0.007). Tumor and other patient characteristics were similar in both cohorts, including gender, laterality, size, location, tumor type, grade, and surgical adjuncts utilized (P>0.05). Multivariate regression identified that distinct preoperative margins correlated with increased rates of gross total resection (P=0.02). Distinct margins on preoperative neuroimaging also correlated positively with surgeon identification of intra-operative margins (P<0.0001), fewer deaths over the study period (P=0.01), and longer overall survival (P=0.03).

Conclusions: Distinct glioma-parenchyma margins on preoperative imaging are associated with improved surgical resection for diffuse gliomas, as distinct margins may correlate with distinguishable glioma-brain interfaces intraoperatively. Further prospective studies may discover additional clinical uses for these findings.

Background: The aim of this paper was to understand the role of prophylaxis with levetiracetam at skin incision in preventing convulsive intraoperative seizures (IOS) during neurosurgical procedures with and without intraoperative neuromonitoring (IONM).

Methods: Authors retrospectively reviewed the Institutional database for cases of supratentorial brain tumors undergoing surgical resection performed from January 2021 to October 2022. Patients were operated on both under general anesthesia and awake, using motor-evoked potentials (MEP) and direct cortical stimulation for cortical mapping. 1000 mg ev of Levetiracetam before skin incision in case of a history of seizures was administrated. We excluded all infratentorial cases.

Results: Three hundred fisty three consecutive cases were retrieved. IOS occurred in 22 patients (6.2%). Prophylaxis with Levetiracetam was administered in 149 patients, and IOS occurred in 16 cases (10.7%) in this group of patients. The IOS rate in the case of no Levetiracetam prophylaxis administration (3.5%) was significantly lower (P<0.001, OR=3.38 [1.35-8.45], RR=3.12 [1.32-7.41]). The Penfield technique stimulation evoked seven of all 22 IOS reported (31.8%) (P=0.006, RR 5.4 [1.44 -20.58], OR 21 [2.3-183.9]), and the train-of-five technique stimulation caused two of all registered IOS (8.7%) (P=0.2, RR 2.3 [0.99-5.67], OR 6.5 [0.55-76.17]). Transcranial MEPs evoked no IOS.

Conclusions: Under levetiracetam prophylaxis, the IOS rate was not significantly lower than in the group of patients without Levetiracetam prophylaxis, regardless of the histology of the tumor and IONM. Neither the transcranial stimulation (MEP) nor train-of-five technique stimulation increases the risk of convulsive IOS, as Penfield technique stimulation does.

In recent years navigated transcranial magnetic stimulation (nTMS) has emerged as a useful tool for the preoperative mapping of brain cortical areas surrounding neoplastic tissues allowing for maximal safe tumor resection and minimizing new postoperative permanent neurological deficits. Three patients presenting with an intrinsic brain tumor (one metastasis from mammary carcinoma, one high-grade glioma, and one low-grade glioma) located within or in close relationship to the central sulcus were enrolled for this study. The MRI-based morphological and nTMS mapping of the central sulcus of the intact hemisphere was complemented by the examination of the contralateral region harboring the lesion. The findings were independently compared, in search of evidence of tumor-induced neuroplasticity and/or signs of parenchymal dislocation/infiltration caused by the tumor. An individual description of each mapping session is provided. Significant discrepancies were observed between morphological MRI and functional nTMS mapping in two patients, demonstrating a tumor-induced shift of distinct cortical areas controlling hand and/or facial movements. In the cases of gliomas, a lower MT was detected in the lesioned hemisphere, possibly due to increased electrical excitability caused by the tumor itself. The integration of MRI-based morphological mapping of the central sulcus with the detection of its somatomotor representations through nTMS can assist neurosurgeons when planning the resection of a motor-eloquent tumor, stratifying the risks of secondary neurological deficits. The combination of the two preoperative techniques is able to disclose tumor-induced neural plasticity subsequently guiding a more precise resection.