Journal of neurosurgical sciences最新文献

Introduction: Postoperative cerebrospinal fluid (CSF) leaks and related complications are a major concern after intradural spinal surgeries. The role of prolonged bed rest in reducing the incidence of these complications has been debated. This meta-analysis aimed to evaluate whether early versus late mobilization affects the incidence of CSF leak-related complications (CLRC) after intradural spinal surgery.

Evidence acquisition: Following PRISMA guidelines, we conducted a systematic review and meta-analysis of comparative studies on early ambulation (EA) versus prolonged bed rest (PBR) in patients undergoing intradural spinal surgery. Studied considered for inclusion defined EA as mobilization on postoperative day 1, while PBR as mobilization on postoperative day 3. The primary outcome was the incidence of CLRC, defined as pseudomeningocele, durocutaneous fistula, or wound dehiscence. Secondary outcome was the incidence of medical complications.

Evidence synthesis: Three retrospective comparative studies with a total of 949 patients were included in the analysis. No significant difference was found in the incidence of CLRC between the EA and PBR groups. Length of hospital stay (LOS) and postoperative medical complications incidence were significantly lower in the EA group.

Conclusions: This meta-analysis found that EA does not increase the risk of CLRC compared to PBR, while shortening LOS and reducing medical complications occurrence. These findings suggest that early mobilization could be a safe and effective postoperative strategy, reducing hospital stay and complication rates.

Background: Surpass Evolve Flow Diverter (SE-FD; Stryker Neurovascular, Kalamazoo, MI, USA) was launched in 2019 as a new generation FD of Surpass Streamline. The aim of this study was to report the effectiveness and safety of SE-FD insertion for unruptured intracranial aneurysm at one-year follow-up.

Methods: Between November 2019 and October 2021, a total of 106 patients with 108 aneurysms were treated with FD in single institution. Of these, SE-FD insertion was performed in 40 patients with 41 aneurysms. At one-year follow-up, clinical and angiographic outcomes were retrospectively evaluated from electronic medical record and aneurysm database.

Results: There were 12 male and 28 female patients (mean age 59.1 years, 95% CI: 55.3-62.9). Fusiform aneurysm dissection was 46.3% (19/41). Mean maximum aneurysm diameter was 13.2 mm (SD 5.53), and 34.1% (14/41) of aneurysms were 15 mm or bigger. Among 41 aneurysms, complex aneurysm (recurred, thrombosed, or branch artery-incorporated) was accounted for 41.5% (17/41). All procedures were successfully conducted with 7.3% (3/41) of procedure-related complications. At one-year follow-up (N.=40), neurologic morbidity was noted in 2 cases (5.0%; both with modified Rankin Scale [mRS] 1) without any mortality. At one-year follow-up (N.=41), radiologic outcomes were adequate occlusion in 33 (80.5%) and complete occlusion in 29 (70.7%). There was no retreatment in our cohort.

Conclusions: Surpass Evolve Flow Diverter seemed to be safe and effective for the treatment of dissecting/fusiform or complex aneurysms at one-year follow-up. However, further study is needed to evaluate long term results.

Background: Restoring lumbar lordosis is one of the main goals in lumbar spinal fusion surgery. The Mazor X-Align^™ software allows for the prediction of postoperative segmental lumbar lordosis based on preoperative imaging. There is limited data on the accuracy of this preoperative prediction, especially in patients undergoing short segment lumbar fusion. The objective of our study was to determine the accuracy of predicted postoperative segmental lumbar lordosis using the Mazor X-Align^™ software in patients requiring short segmental fusion.

Methods: Retrospective analysis of adult patients undergoing pedicle screw spinal instrumentation of not more than four levels using the Mazor X^™ Robot (Medtronic Inc., Minneapolis, MN, USA) between July 2017 to June 2020. The robotic guidance software, Mazor X-Align^™ (Medtronic Inc., Minneapolis, MN, USA) was used to calculate the predicted segmental lumbar lordosis based on preoperative CT-imaging and the plan was executed under intraoperative robotic guidance. Predicted segmental lumbar lordosis was compared to achieved segmental lumbar lordosis on 1-month postoperative x-rays using the Cobb angle methodology.

Results: A total of 15 patients (46.6% female) with a mean age of 61.5±10.9 years were included. All patients underwent posterior lumbo-sacral spinal fusion with the Mazor X^™ robotic system with 11 patients (73.3%) undergoing anterior column reconstruction prior to posterior fixation. Instrumentation was performed across a mean of 2.6 levels per case. Preoperative, the mean segmental lumbar lordosis was 30.2±13.6 degrees. The mean planned segmental lumbar lordosis was 35.5±17.0 degrees while the mean achieved segmental lumbar lordosis was 35.8±16.7 degrees. There was no significant mean difference between the planned and achieved segmental lumbar lordosis (P=0.334).

Conclusions: The Mazor X^™ intraoperative robotic planning and guidance is accurate in predicting postoperative segmental lumbar lordosis after short segmental fusion. Our findings may assure surgical decision making and planning.

Background: Treatment of small vestibular schwannomas (VS) depends on size, growth pattern, age, symptoms, co-morbidities. Watchful waiting, stereotactic radiosurgery and microsurgery are three valid options of treatment.

Methods: We reviewed clinical sheets, surgical data and results of 100 consecutive patients with Koos Grade I-II VS, operated at our department via a retrosigmoid microsurgical approach between September 2010 and July 2021. Extent of resection was assessed as total, near-total or subtotal. The course of facial nerve (FN) around the tumor was classified as anterior (A), anterior-inferior (AI), anterior-superior (AS) and dorsal (D). FN function was assessed according to House-Brackmann (HB) Scale and hearing level according to AAO-HNS Classification.

Results: Mean tumor size was 1.52 cm. FN course was mainly AS (46.0%) in the overall cohort; in Koos I VS, FN was AS in 83.3%. Postoperative FN function was HB I in 97% and HB II in 3% of cases. Hearing preservation (AAO-HNS class A-B) was possible in 63.2% of procedures. Total/near-total removal was achieved in 98%. Postoperative mortality was zero. Transient complications were observed in 8% of patients; permanent complications never occurred. Tumor remnant progression was observed in one case, 5 years after subtotal removal.

Conclusions: Microsurgery represents a valid option for management of VS, including Koos I-II grades, with an acceptable complication rate. In particular, in small VS long-term FN facial outcome, HP and total/near-total removal rate are favorable.

Chronic subdural hematoma (cSDH) presents a multifaceted challenge in contemporary neurological practice, necessitating innovative therapeutic strategies. This comprehensive review explores the convergence of two promising interventions: statins and middle meningeal artery (MMA) Embolization. With cSDH incidence on the rise, particularly among the aging population and those with long-term anticoagulant usage, the traditional surgical avenues face limitations in recurrence rates and associated risk factors. Statins, heralded for their anti-inflammatory, vasculogenic, and angiogenic properties, are emerging as potential allies in cSDH management. Concurrently, MMA embolization offers a nuanced approach to target the neomembrane's blood supply, with evidence supporting its efficacy and safety. However, the synthesis of MMA embolization with statins remains relatively unexplored, presenting a complex interplay between inflammation modulation and blood supply interruption.

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.