Journal of neurosurgical sciences最新文献

Background: The purpose of this study was to evaluate the technical efficacy and safety of transvenous Onyx embolization for dural arteriovenous fistulas (DAVFs) with concomitant transvenous balloon protection of the venous sinus when transarterial route failed or was not feasible.

Methods: Between September 2010 and December 2016, thirty-six patients presenting with intracranial DAVFs underwent transvenous balloon-assisted Onyx embolization. The technical efficacy, treatment-related complications, and angiographic and clinical outcomes were reviewed from our prospectively maintained DAVF database.

Results: According to the Cognard Classification, 11 patients presented with clinically symptomatic Cognard type I; 11 cases with Cognard type IIa; 10 cases with Cognard type IIb; and 4 cases with Cognard type IIa+b. Complete angiographic occlusion of the DAVFs at the latest follow-up (mean 18 months after transvenous embolization) was achieved in 28 patients (77.8%), near-complete angiographic occlusion with minimal residual fistula in 5 patients (13.9%) and significant flow reduction of the DAVF in 2 patients (5.6%) and residual fistula for further treatment in 1 (2.8%) patient. Total clinical cure or remission of the pretreatment symptoms was achieved in 31 patients (31/36, 86.1%; 26 and 5 cases respectively). Affected venous sinus was preserved in 28 patients, intentionally occluded in 7 patients and gradually occluded in 1 patient. There were no immediate or long-term persistent complications after treatment.

Conclusions: Transvenous Onyx embolization of dural arteriovenous fistulas with combined transvenous balloon protection of the venous sinus is safe and effective in achieving high occlusion rate, low embolization-related complications and satisfactory clinical outcomes.

Background: The aim of this study was to explore the effect and mechanism of miR-16-5p on neuron apoptosis and inflammatory response induced by spinal cord injury (SCI).

Methods: Allen's weight-drop method and Basso Bcattie Bresnahan (BBB) rating scale were used to establish SCI rat model and assess locomotor function, respectively. Histopathology of SCI rats and Sham-operated rats was validated by hematoxylin and eosin (H&E) staining. After intravenous injection of miR-16-5p agomir, miR-16-5p antagomir, pcDNA3.1-Apelin-13 or negative controls into SCI rat tails, neuron apoptosis and the expression of miR-16-5p, Apelin-13, apoptotic proteins, inflammatory response-related proteins, and ERK1/2 pathway-related protein were detected. Dual luciferase reporter gene assay was applied for identifying the binding between miR-16-5p and Apelin-13.

Results: SCI rats had locomotor impairment with markedly edema and hemorrhage. Upregulated miR-16-5p expression and downregulated Apelin-13 expression were presented in SCI rats. Intravenous injection of miR-16-5p antagomir or/and pcDNA3.1-Apelin-13 could increase the expression of antiapoptotic proteins (Bcl-2 and Mcl-1) and p-ERK1/2 expression while decrease the expression of proapoptotic proteins (cleaved caspase-3 and Bax) and inflammatory response-related proteins (TNF-α, IL-1β and IL-6). The reverse pattern was shown in rats injected with miR-16-5p agomir. MiR-16-5p targeted Apelin-13. Promotion of miR-16-5p agomir on SCI was attenuated by injection of agomir + pcDNA3.1-Apelin-13.

Conclusions: Downregulation of miR-16-5p could upregulate Apelin-13 expression to activate ERK1/2 pathway, thus alleviating SCI-induced neuron apoptosis and inflammatory response.

Background: Evidence-based indications for intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI) are lacking. The aim of this study was to analyze the main factors that guided the decision-making of invasive ICP monitoring in a large cohort of TBI patients from our institution.

Methods: This is a retrospective, single centre, observational study including adult TBI patients consecutively admitted to our Neurointensive Care Unit over 20 years. Logistic regression analyses were performed to identify potential factors associated with the decision for ICP monitor insertion. A decision tree was developed to identify the combination of factors with the highest statistical power to predict the decision for ICP monitor insertion.

Results: A total of 857 adult patients were included in the analysis. The decision to monitor ICP was strongly related to different factors, including Glasgow Coma Scale (GCS), computed tomography (CT) scan classification, pupils' reactivity, and patients' prognosis at the admission calculated by the International Mission on Prognosis in Traumatic Brain Injury (IMPACT) score (P<0.01). Results from the decision tree showed an overall ability of the 72% in the prediction of ICP monitoring and that, among the factors analyzed, CT findings had the primarily and strongest discrimination power.

Conclusions: The decision to insert an invasive ICP monitoring in patients with TBI is multifactorial. Among the different factors analysed in our cohort of TBI patients, prognostication factors as for IMPACT score and in particular CT findings could potentially explain the decision making for ICP monitoring.

Background: Recent primary central nervous system lymphoma (PCNSL) literature indicates that younger patients benefit from improved survival; however, this benefit is not shared by those 70+ years of age. The purpose of this study was to examine mortality trends in PCNSL patients 70+ years of age to better understand why improved prognosis has not yet reached this rapidly growing population subset.

Methods: Two thousand seventy-five cases (1973-2012, age at diagnosis 70+ years) within the Surveillance, Epidemiology, and End Results (SEER) database were included in Kaplan-Meier and multivariate Cox Regression analyses. Variables include age at diagnosis, decade of diagnosis (1=1973-1982, 2=1983-1992, 3=1993-2002, 4=2003-2012), sex, race and surgery.

Results: Before stratification, both univariate and multivariate analyses agreed that patients aged 70-74 years at diagnosis lived the longest, while those 85+ years lived the shortest (median±SD; 6.0±0.5 months vs. 2.0±0.2 months, respectively, P<0.0005); women lived longer than men (5.0±0.3 months vs. 4.0±0.3 months, respectively, P=0.01); patients who received surgery (6.0±0.5 months) lived longer than those who did not (contraindicated=1.0±0.5 months, P<0.0005; not performed=4.0±0.3 months, P<0.0005). Univariate analysis showed decade 4 lived longer than only decade 3 (4.0±0.3 vs. 4.0±0.5, respectively, P=0.008), while multivariate analysis showed decade 4 lived longer than both 2 (5.0±0.8 months, P=0.03) and 3 (P<0.0005). Following stratification, decade and sex no longer influenced survival. Race did not influence survival.

Conclusions: Minimal clinically meaningful improvements in elderly PCNSL patient all-cause and tumor-specific mortality have been made since 1973, while the best predictors of longevity include younger age and surgery.

Background: This pilot study in post-stroke patients evaluated the effects of supplementation with Pycnogenol^® on alterations in cognitive functions (COFU) over a period of 6 months, starting 4 weeks after the stroke.

Methods: The effects of supplementation - possibly acting on residual brain edema, on global cognitive function, attention and on mental performance - were studied. A control group used standard management (SM) and the other group added Pycnogenol^®, 150 mg daily to SM.

Results: 38 post-stroke patients completed the 6-month-study, 20 in the Pycnogenol^® group and 18 in the control group. No side effects were observed with the supplement. The tolerability was very good. The patients included into the two groups were comparable for age, sex and clinical distribution. There were 2 dropouts in the control group, due to non-medical problems. Main COFU parameters (assessed by a cognitive questionnaire) were significantly improved (all single items) with the supplement compared to controls (P<0.05). Additional observations indicate that Pycnogenol^® patients experienced significantly less mini-accidents (including falls) than controls (P<0.05). The incidences of (minor) psychotic episodes or conflicts and distress and other problems including rare occurrence of minor hallucinations, were lower with the supplementation than in controls (P<0.05). Single observations concerning daily tasks indicated a better effect of Pycnogenol^® compared to controls (P<0.05). Plasma free radicals also decreased significantly with the supplement in comparison to controls (P<0.05). Globally, supplemented subjects had a better recovery than controls.

Conclusions: In post-stroke subjects, Pycnogenol^® supplementation resulted in better recovery outcome and faster COFU 'normalization' after the stroke in comparison with SM; it can be considered a safe, manageable post-stroke, adjuvant management possibly reducing local brain edema. Nevertheless, more patients and a longer period of evaluation are needed to confirm these results.

Background: Pathway activating models try to describe stimulation spread in deep brain stimulation (DBS). Volume of tissue activated (VTA) models are simplified model variants allowing faster and easier computation. Our study aimed to investigate, how VTA visualization can be integrated into a clinical workflow applying directional electrodes using a standard clinical DBS planning system.

Methods: Twelve patients underwent DBS, using directional electrodes for bilateral subthalamic nucleus (STN) stimulation in Parkinson's disease. Preoperative 3T magnetic resonance imaging was used for automatic visualization of the STN outline, as well as for fiber tractography. Intraoperative computed tomography was used for automatic lead detection. The Guide XT software, closely integrated into the DBS planning software environment, was used for VTA calculation and visualization.

Results: VTA visualization was possible in all cases. The percentage of VTA covering the STN volume ranged from 25% to 100% (mean: 60±25%) on the left side and from 0% to 98% (51±30%) on the right side. The mean coordinate of all VTA centers was: 12.6±1.2 mm lateral, 2.1±1.2 mm posterior, and 2.3±1.4 mm inferior in relation to the midcommissural point. Stimulation effects can be compared to the VTA visualization in relation to surrounding structures, potentially facilitating programming, which might be especially beneficial in case of suboptimal lead placement.

Conclusions: VTA visualization in a clinical planning system allows an intuitive adjustment of the stimulation parameters, supports programming, and enhances understanding of effects and side effects of DBS.

Background: Osteoporotic vertebral compression fracture (OVCF) is usually treated by percutaneous kyphoplasty (PKP) which has limitations. We aimed to evaluate the effects of PKP combined with zoledronic acid (ZOL) injection on OVCF and bone metabolism indices.

Methods: A total of 600 OVCF patients admitted from June 2015 to June 2020 were randomly divided into group A (PKP alone), group B (PKP combined with ZOL 1 month later) and group C (PKP concurrently combined with ZOL) (N.=200). Before as well as 1 month (before ZOL treatment in group B) and 1 year after PKP, the pain degree, physical function and self-care ability in daily life were assessed, the height and kyphosis Cobb angle of vertebral body with compression fracture and bone mineral densities (BMDs) at different parts were measured, the clinical efficacy, adverse reactions and recurrence of vertebral fractures during 3 years of follow-up were observed, and the serum levels of BAP, BGP, β-CTx and TP1NP were detected.

Results: Compared with groups A and B, group C had significantly reduced visual analogue scale (VAS) and Oswestry disability index (ODI) scores and raised activity of daily living (ADL) score 1 month after PKP (P<0.05). Groups A-C had successively lowered VAS and ODI scores and elevated ADL Score 1 year after PKP (P<0.05). Compared with before PKP, the height of vertebral body with compression fracture significantly increased, and the kyphosis Cobb angle decreased in the three groups 1 month and 1 year after PKP (P<0.05). In group A, the height was lower whereas the angle was larger 1 year after PKP than those 1 month after PKP (P<0.05). One month after PKP, the height was significantly higher and the angle was smaller in group C than those of groups A and B (P<0.05). One year after PKP, the height significantly increased and the angle decreased successively in groups A-C (P<0.05). BMDs at different parts were significantly higher in group C than those of groups A and B 1 month after PKP (P<0.05). One year after PKP, BMDs were highest in group C and lowest in group A (P<0.05). The overall response rate was significantly higher in group C than that in group A (P<0.05). The recurrence rate of fractures was significantly higher in group A than those of groups B and C (P<0.05). The BAP, BGP, β-CTx and TP1NP levels were significantly lower in group C than those of groups A and B 1 month after PKP (P<0.05), and declined successively in groups A-C 1 year after PKP (P<0.05).

Conclusions: PKP concurrently combined with ZOL exert the most significant therapeutic effects on OVCF, with the lowest recurrence rate of fractures. It relieves pain and improves the physical function and self-care ability in daily life probably by reducing bone metabolism indices, increasing BMD, and maintaining the height and kyphosis Cobb angle of recovered vertebral body.

Background: Giant calcified thoracic disk herniation (GCTD) is an uncommon event, which requires surgical treatment in less than 1% of patients. GCDTs are a specific subgroup of herniated thoracic disks occupying more than 40% of the spinal canal showing calcifications associated with a certain degree of ossification. In this paper, we are reporting our whole experience in the surgical management of GCTDs through anterior approaches. We believe that they present characteristics that associate them to the circumscribed type of ossified posterior longitudinal ligament (OPLL) with a possible common pathophysiology consisting in the dural violation.

Methods: Twenty-three consecutive patients with GCDTs were managed through anterior approaches during the period 1996-2019 at the Niguarda Hospital, Milan, Italy. Clinical data, radiological features, surgical reports, histological findings, and outcomes were reviewed.

Results: There was no mortality, whereas permanent morbidity consisted of 1 case of worsened paraparesis due to accidental spinal cord contusion. One patient required reoperation to repair a postoperative cerebrospinal fluid (CSF) leakage. All patients underwent postoperative MRI which showed excellent decompression of cord and dural sac in all cases. Histological study of en-bloc removed GCTD showed typical calcification patterns of the PLL.

Conclusions: GCDTs may be assimilated to the so-called "circumscribed type" of OPLL. The GCDTs may show the same radiological CT and MRI pattern of OPLL. The anterior accesses now represent the standard of care for GCTDs. The use of operative microscope and intraoperative monitoring is mandatory. The risk of CSF leakage can be markedly reduced by meticulous reconstruction of the dura and the placement of spinal drainage. Adequate exposition may sometimes require one or two levels of corpectomy with consequent vertebral body reconstruction and fixation of anterior column of the spine.