Journal of neurosurgical sciences最新文献

Introduction: Chronic subdural hematoma (CSDH) is a frequent neurological problem, especially in older adults. It often presents headache as a primary symptom. The optimal approach to managing CSDH through invasive treatments is still debated, with various procedures available. We conducted a systematic review of randomized clinical trials, based on the most recent available literature, to assess the efficacy and safety of invasive interventions for the treatment of CSDH.

Evidence acquisition: A comprehensive search of major databases was performed according to PRISMA guidelines with an extensive consultation with experts that independently conducted study selection, data extraction, and bias assessment. The GRADE approach and RoB 2 tool were used to assess evidence quality and risk of bias.

Evidence synthesis: It was identified 4 studies (N.=579) meeting the inclusion criteria. Invasive interventions included burr hole craniostomy, twist drill craniostomy, and subdural drainage systems. Findings varied across studies. A Chinese study suggested shorter hospital stays with twist drill craniostomy compared to simple burr hole craniostomy. A Denmark study showed that the 48-hour drainage has a significantly higher volume of postoperative drain production compared to the 24-hour group. An Iranian study suggested fewer hematomas with burr hole irrigation without drainage compared to with drainage.

Conclusions: Evidence on invasive interventions for CSDH is limited. Treatment decisions should be individualized based on patient factors and potential risks/benefits. Large-scale randomized controlled trials are needed to provide clearer guidelines for CSDH treatment.

Background: The acquisition of fine motor skills crucial for neurosurgical bypasses relies heavily on repetition. While conventional practice models adequately prepare surgeons for superficial anastomoses, they fall short when it comes to deep bypasses through skull base corridors, and realistic training setups are complex and expensive. In this study, we present a novel training concept that combines realism and simplicity, enabling virtually unlimited practice of deep anastomoses.

Methods: Our training setup comprised a binocular microscope, inexpensive microsurgical instruments, vessels sourced from chicken wings, and a commercially available 3D brain-skull model not originally intended for microanastomosis training. By securing "recipient" chicken vessels to the plastic vessels within the model and employing standard techniques to anastomose them with "donor" chicken vessels in the surgical field, we created a simulation of deep neurosurgical bypasses.

Results: With minimal preparation, we successfully replicated complex neurosurgical bypasses such as STA-PCA, PCA-SCA, and A1-graft-MCA. To our knowledge, no comparable training method in terms of realism, simplicity, and affordability exists in the literature.

Conclusions: We present a cost-effective, straightforward, and realistic training approach that facilitates individual practice of deep bypasses at a high frequency. Its simplicity makes it replicable even in resource-limited settings.

Background: The treatment of choice for orbital cavernous hemangiomas (OCHs) is surgical resection, and multiple approaches have been proposed for these challenging deep-seated lesions of the orbit. In the latest years, endoscopic approaches, as the endonasal (EEA) or the transorbital (ETA), have been suggested as minimally invasive alternatives for these tumors, but few large works in literature are reported. In this article, the experience of three Italian referral centers with the endoscopic treatment of OCHs is described.

Methods: All patients with OCHs operated with an endoscopic approach since January 2015 to January 2024 in 3 Italian referral centers were retrospectively collected. Patients' characteristics and symptoms, OCHs localization and type of endoscopic approach were reported. Postoperative complications, clinical outcome and cosmetic results (evaluated with Clavien-Dindo Classification and Scar Cosmesis Assessment and Rating Scale) at follow-up were assessed.

Results: Thirty-four patients were included, 16 were females. ETA was preferred in 19 patients and EEA in 15. All OCHs of the lateral quadrants were treated with ETA. 14/18 cases located in the medial quadrants were treated with EEA, since in 4 of the supero-medial quadrants lesions, an ETA was preferred. Finally, the orbital apex lesion was treated with EEA. Complete resection was achieved in 31 (91.2%) cases. Complications were transient and consisted in 3 cases of diplopia, 1 of medial rectus palsy and 1 of supraorbital neuralgia, all spontaneously regressed at follow-up. An optimal cosmetic outcome was achieved in all patients both after an EEA and an ETA.

Conclusions: Endoscopic approaches for the treatment of OCHs are a safe and valid surgical option, allowing a complete resection avoiding any brain manipulation. Thanks to their less invasiveness, endoscopic approaches guarantee limited neurological and functional sequalae. Moreover, they resulted well tolerated and ensured good cosmetic outcomes.

Background: Clinicians are well-versed in the classical symptoms of low vs. high intracranial pressure (ICP). However, symptoms may not be as predictable of ICP state in shunted patients with chronic symptoms. In this study, we assess whether clinicians can predict high vs. low ICP state in chronically symptomatic shunted patients without any diagnostic clues.

Methods: A detailed retrospective analysis was performed on 259 patients undergoing ICP monitoring. A total of 17 patients who had a ventriculoperitoneal shunt were identified, with a suspected chronic abnormal ICP state based only on clinical symptoms. Patients with investigations guiding towards a likely pressure state were excluded, e.g., imaging or ophthalmological findings suggestive of ICP state.

Results: Clinical suspicion of ICP state was incorrect in 16 out of 17 cases (P<0.05). The symptoms described by patients were suggestive of abnormal ICP states; however, 13 out of 17 cases demonstrated ICP within the normal range (-1.3 to 5.3 mmHg). Three patients with occipital headaches worse on standing, typical of low-pressure symptoms, were in fact shown to have ICP above 10.0 mmHg.

Conclusions: This study casts doubt on the utility of classic symptoms in diagnosing abnormal ICP state in chronically symptomatic shunted patients with equivocal adjuncts. Additionally, it highlights the importance of ICP monitoring for this patient group.

Background: The aim of this study was to assess health-related quality of life (HRQOL) before and after treatment for intracerebral low-grade glioma.

Methods: Patients with low-grade glioma who underwent surgical tumor removal between 2012 and 2018 were eligible for this study. All individuals and their closest relatives received thorough preoperative (

Results: A total of 25 patients were referred for further analysis, after adjustment to the 2021 WHO classification for central nervous system tumors. Compared to the values of a healthy reference population, the patients expressed significant limitations in several SF36 items, both before and after treatment. Under treatment, there were no significant changes in the SF36 items, but the ALQI questionnaire indicated decreasing HRQOL over time. Data derived from relatives revealed a high degree of concordance with the rating results of the patients. Univariate analysis identified neurological deterioration and ongoing epileptic seizures as predictors for unfavorable HRQOL after one year.

Conclusions: Low-grade glioma disease has a significant impact on HRQOL and treatment might contribute to further deterioration. New-onset neurological deficits and ongoing epileptic seizures are predictors of limitations in quality of life. Since the results are based on a small cohort with limited follow-up time, the generalizability of these statements is limited and further studies are required.

Idiopathic normal pressure hydrocephalus (iNPH) represents a nosographic entity characterized by phenotypic variability. In this context, the need arises to differentiate iNPH from neurological conditions characterized by impairment in mobility and cognition, including atypical and secondary parkinsonism, with which it shares several common aspects. In this review we will discuss clinical evidence supporting different iNPH clinical phenotypes mimicking Parkinson's disease and secondary/atypical parkinsonism, indicating iNPH as a neurological condition that should be considered by movement disorders specialists. We will also propose a preliminary diagnostic algorithm combining clinical, imaging and biological markers leading to a multidimensional diagnosis of iNPH associated with parkinsonism.

Introduction: Idiopathic normal pressure hydrocephalus (iNPH) is a treatable neurodegenerative disorder characterized by a triad of gait disturbance, cognitive impairment, and urinary incontinence. Early diagnosis and timely intervention are crucial for optimal outcomes. However, the diagnosis of iNPH remains challenging due to its variable presentation and overlap with other neurological conditions.

Evidence acquisition: A comprehensive review of the literature was conducted to identify current diagnostic criteria and treatment strategies for iNPH. Based on this review, a novel, six-step algorithm was developed to streamline the diagnostic process and improve patient outcomes.

Evidence synthesis: The proposed algorithm includes the following six steps: 1) suspect diagnosis of iNPH: Identification of core clinical features (gait disturbance, cognitive impairment, and urinary incontinence) and radiological evidence of ventricular enlargement; 2) investigate probable iNPH: detailed neuropsychological assessment, gait analysis, and urodynamic studies to confirm the diagnosis; 3) high-volume lumbar puncture: evaluation of the clinical response to CSF drainage, including improvements in gait, cognition, and urinary function; 4) evaluation after HVLP: assessment of the duration and magnitude of symptom improvement after lumbar puncture; 5) shunt surgery: indication for shunt surgery in patients with a positive response to CSF drainage; 6) infusion test and intracranial pressure measurement: alternative diagnostic tools for cases where the diagnosis remains uncertain.

Conclusions: The proposed algorithm provides a structured approach to the diagnosis and management of iNPH. By combining clinical, radiological, and neurophysiological assessments, clinicians can improve diagnostic accuracy and optimize patient outcomes. Further research is needed to validate this algorithm in larger patient populations and to develop more sensitive and specific biomarkers for iNPH.

Introduction: Normal pressure hydrocephalus (NPH) can be caused by acquired events - e.g. subarachnoid hemorrhage, meningitis, or trauma - or can be "idiopathic" (iNPH) when no clear cause is identifiable. The entity and nosology of iNPH has received renewed attention and has recently gone through scrutiny and academic debate.

Evidence acquisition: Authors searched PubMed using the following keywords: "adult hydrocephalus," "alfa synuclein," "Alzheimer's disease," "beta-amyloid," "cerebrospinal fluid," "cilia," "CSF," "genes," "hydrocephalus," "idiopathic," "Lewy Body Dementia," "phosphorylated tau," "shunt responsiveness".

Evidence synthesis: During the past decades several studies have reshaped our view of iNPH, examples are the identification of monogenic forms of iNPH caused by genes involved in the structure and function of cilia or the discovery of the glymphatic system. This review will discuss the causes of iNPH and particularly the relationship with neurodegeneration in terms of: 1) coincidental association; 2) iNPH predisposing to neurodegeneration, 3. neurodegeneration predisposing to iNPH, and 4. independent processes (genetic and environmental) predisposing to both. Based on the gathered evidence, a unified model is then presented, characterized by three sequential events: impairment of CSF dynamic, occurrence of reversible signs, occurrence of irreversible signs.

Conclusions: Almost 70 years after its description, a growing literature on its basic mechanisms is clarifying that iNPH is a syndrome with pathogenetic mechanisms arising from different causes. The paradigm shift has been recognizing that iNPH is not just a CSF disorder but rather a brain disorder expressing with ventriculomegaly. Finally, the better understanding of what causes iNPH support the proposal of changing its name into "Hakim's disease."

Background: Management of unruptured intracranial aneurysms (UIAs) is complex, balancing the risk of rupture and risk of treatment. Therefore, prediction scores have been developed to support clinicians in the management of UIAs. We analyzed the discrepancies between interdisciplinary cerebrovascular board decision-making factors and the results of the prediction scores in our cohort of patients who received microsurgical treatment of UIAs.

Methods: Clinical, radiological, and demographical data of 221 patients presenting with 276 microsurgically treated aneurysms were collected, from January 2013 to June 2020. UIATS, PHASES, and ELAPSS were calculated for each treated aneurysm, resulting in subgroups favoring treatment or conservative management for each score. Cerebrovascular board decision-factors were collected and analyzed.

Results: UIATS, PHASES, and ELAPSS recommended conservative management in 87 (31.5%) respectively in 110 (39.9%) and in 81 (29.3%) aneurysms. The cerebrovascular board decision-factors leading to treatment in these aneurysms (recommended to manage conservatively in the three scores) were: high life expectancy/young age (50.0%), angioanatomical factors (25.0%), multiplicity of aneurysms (16.7%). Analysis of cerebrovascular board decision-making factors in the "conservative management" subgroup of the UIATS showed that angioanatomical factors (P=0.001) led more frequently to surgery. PHASES and ELAPSS subgroups "conservative management" were more frequently treated due to clinical risk factors (P=0.002).

Conclusions: Our analysis showed more aneurysms were treated based on "real-world" decision-making than recommended by the scores. This is because these scores are models trying to reproduce reality, which is yet not fully understood. Aneurysms, which were recommended to manage conservatively, were treated mainly because of angioanatomy, high life expectancy, clinical risk factors, and patient's treatment wish. The UIATS is suboptimal regarding assessment of angioanatomy, the PHASES regarding clinical risk factors, complexity, and high life expectancy, and the ELAPSS regarding clinical risk factors and multiplicity of aneurysms. These findings support the need to optimize prediction models of UIAs.