Journal of neurosurgery最新文献

Objective: The pathophysiological distinctions and modifiable risk factors underlying ischemic versus hemorrhagic conversion in moyamoya disease (MMD) remain incompletely characterized, hindering subtype-specific management. This study aimed to delineate subtype-specific risk patterns and validate biomarkers for asymptomatic progression.

Methods: The authors analyzed the medical records of 774 adult MMD patients from Nanjing Jinling Hospital (2010-2020) and Nanjing Drum Tower Hospital (2013-2020). MMD was stratified as asymptomatic (n = 139), ischemic (n = 450), or hemorrhagic (n = 185). Multivariable logistic regression and Cox proportional hazards models were used to evaluate metabolic profiles, angiographic features (posterior cerebral artery [PCA] involvement and choroidal and lenticulostriate anastomoses), and longitudinal outcomes.

Results: Symptomatic patients demonstrated higher PCA involvement prevalence versus asymptomatic patients (p < 0.001). Ischemic MMD was independently associated with male sex (OR 2.00, 95% CI 1.30-3.07; p = 0.002), hypertension (OR 2.30, 95% CI 1.49-3.54; p < 0.001), hypertriglyceridemia (OR 1.36, 95% CI 1.01-1.83; p = 0.04), hyperglycemia (OR 1.22, 95% CI 1.03-1.45; p = 0.02), and PCA involvement (OR 2.43, 95% CI 1.40-4.20; p = 0.001). Hemorrhagic MMD correlated with BMI (OR 0.88 per kg/m2, 95% CI 0.81-0.97; p = 0.007), hypercholesterolemia (OR 1.53, 95% CI 1.14-2.07; p = 0.005), choroidal anastomosis formation (OR 2.38, 95% CI 1.21-4.70; p = 0.01), and PCA involvement (OR 3.41, 95% CI 1.76-6.61; p < 0.001). During the median 44-month follow-up, asymptomatic patients with PCA involvement (adjusted hazard ratio [HR] 4.86, 95% CI 1.07-22.14; p = 0.04) or choroidal anastomosis (adjusted HR 5.92, 95% CI 1.27-27.62; p = 0.02) exhibited an elevated risk of symptomatic conversion.

Conclusions: Ischemic MMD was independently associated with male predominance, hypertension, and dyslipidemia, while hemorrhagic transformation correlated with lower BMI, hypercholesterolemia, and choroidal anastomosis. PCA involvement and choroidal anastomosis emerged as critical biomarkers for asymptomatic risk stratification.

Objective: During endoscopic endonasal surgery (EES), inferolateral trunk (ILT) sacrifice may be required to efficiently and safely achieve tumor resection within the lateral compartment (LC) of the cavernous sinus (CS). The authors investigated the surgical anatomy and variations of the ILT, aiming to provide practical information to safely expose, coagulate, and transect this artery during EES.

Methods: In this anatomical study, 24 postmortem, lightly embalmed, colored silicone-injected human head specimens were dissected and 41 sides were examined. The origin, course, branching pattern, and relation of the ILT with surrounding structures were investigated. Clinical charts of patients surgically treated for pituitary adenomas (PAs) with LC invasion from July 2018 to April 2023 at the authors' institution were also retrospectively analyzed. Illustrative cases are provided.

Results: The ILT was found in 93% (38/41) of sides, mainly arising from the inferolateral aspect (91%, 30/33 sides) of either the middle or posterior third (82%, 27/33 sides) of the horizontal segment of the internal carotid artery. After a short common trunk (mean length 3 mm), the artery divided into 2 (21%, 8/38) or, more frequently, 3 (74%, 28/38) branches, supplying blood to cranial nerves (CNs) III, IV, V1, V2, V3, and VI and the Gasserian ganglion. While the sympathetic plexus was always located anterior to the ILT, CN VI was found anterior to the ILT in 82% (31/38) of sides. The lateral parasellar ligament (LPL) enwrapped the ILT and its branches in 43% (15/35) of sides. In the coronal plane, the ILT origin was found at the level of the sellar floor (0 ± 1 mm) and the LPL (0 ± 2 mm), both of which can serve as surgical landmarks during lateral transcavernous EES. In the case series of 25 EESs for PAs with LC invasion, the ILT was sacrificed in 5 cases (20%) without any permanent postoperative CN deficits.

Conclusions: This study served as a detailed anatomical investigation of the ILT, which is crucial when accessing the LC of the CS. The authors proposed two reliable landmarks to identify the ILT intraoperatively: the sellar floor and the LPL. Furthermore, investigations confirmed that the ILT can be sacrificed without causing permanent CN deficits given the existence of a collateral supply.

Objective: In patients with low-grade gliomas (LGGs), reallocations of cortical functions (i.e., plasticity) evolve over the course of the disease, allowing serial resections while preserving patients' neurological status. This study aimed to capture evolving patterns of LGG-induced plasticity by means of longitudinal measures of cortical functions based on serial intrasurgical direct electrical stimulation (DES) mappings and navigated transcranial magnetic stimulation (nTMS) mapping. It further assessed nTMS prediction accuracy using DES measures as a reference.

Methods: In patients with confirmed LGG, cortical functional remodeling was assessed through initial intraoperative awake DES mapping (DESI) and DES remapping (DESII), typically spaced several years apart. An additional session of nTMS mapping mirroring intrasurgical functional testing was performed before DESII. In particular, nTMS mapping was guided by preexistent DESI functional maps to maximize stimulation coverage in areas susceptible to presenting with functional reorganizations. Probabilistic functional maps accounting for functional and nonfunctional responses were computed through a multistep voxelwise approach to measure cortical reallocations between DESI and DESII and nTMS prediction accuracy.

Results: Eight patients were prospectively enrolled (median DESI-DESII time interval 7.0 years). Overall, 2268 nTMS and 244 DES cortical sites were recorded. DESII systematically highlighted evolving plasticity. The nTMS functional convergence index, based on comparisons with DESII results, was heterogeneous across cortical structures. Converging nTMS/DESII measures were associated with nonfunctional nTMS responses (91.13%). Evolving patterns of plasticity were effectively revealed by nonfunctional nTMS mapping, except within the ventral premotor cortex (vPMC). Further, nTMS prediction accuracy was high within the pars triangularis, supramarginal gyrus, and supplementary motor area (R2 = 0.50) and low within the vPMC (R2 = 0.0005).

Conclusions: These results provide a unique overview of evolving patterns of cortical plasticity in LGG patients. Although nTMS may help provide longitudinal metrics of plasticity in brain tumor patients, several challenges must be addressed before routine clinical applications.

Objective: The extended approach and the development of pedicled flaps represented major advancements of the endoscopic endonasal approach (EEA) for skull base lesion removal. However, resection of normal nasal structures to expand the working corridor and harvesting such flaps can result in significant nasal morbidity, prompting the exploration of less invasive strategies. The authors aimed to evaluate their experience with the minimally invasive chopsticks mononostril technique using sphenoid sinus cranialization with septal mucosa suturing for skull base lesions. Outcomes were compared with those of the traditional extended EEA using the nasoseptal flap (NSF).

Methods: The authors conducted a retrospective cohort study involving 82 consecutive patients who underwent EEA for paraclival and craniovertebral junction lesions. Forty-one consecutive patients were treated using the chopsticks mononostril approach using the sphenoid sinus cranialization technique (SSCT) and septal mucosa suturing and were compared with 41 consecutive patients treated previously using the extended EEA with the NSF technique (NSFT). Surgical outcomes and postoperative results were compared between the groups, with a particular focus on health-related quality of life (HRQOL), assessed using the Endoscopic Endonasal Sinus and Skull Base Surgery Questionnaire (EES-Q).

Results: Demographics of the two groups were broadly similar. Skull base chordoma was the most common indication (70.7% in the SSCT group vs 58.5% in the NSFT group), followed by chondrosarcoma located at the petrosphenoidal suture (14.6% vs 22.0%), craniopharyngioma (4.9% vs 12.2%), and meningioma (7.3% vs 2.4%). The incidence of postoperative CSF leaks (12.2% [n = 5] in the SSCT group vs 9.8% [n = 4] in the NSFT group) was not significantly different between the groups. Gross-total resection or subtotal resection was achieved in 97.6% of SSCT patients compared with 85.4% in the NSFT group (p = 0.11). Importantly, patients who underwent SSCT reported significantly lower EES-Q scores overall (p = 0.004), with better outcomes in both the physical (p < 0.001) and psychological (p = 0.006) domains.

Conclusions: The chopsticks mononostril approach with SSCT and septal mucosa suturing provides a valuable minimally invasive alternative to the traditional extended EEA, which typically relies on a pedicled flap for skull base reconstruction. By using angled endoscopes to navigate around corners rather than removing them, this technique preserves the endonasal anatomy and provides a less invasive option, ultimately contributing to the preservation of the patient's HRQOL.

Objective: The primary aim of this Italian multicenter study was to determine the incidence of complications associated with pituitary neuroendocrine tumor (PitNET) removal in the modern era of endoscopic pituitary surgery. The secondary objective was to evaluate the influence of surgical experience, patients, and tumor features on the occurrence of each specific complication, as well as options for management and avoidance.

Methods: This retrospective study included the contributions of 10 Italian neurosurgical departments. Respondents were asked to provide the number of endoscopic endonasal approaches (EEAs) performed for PitNET removal from 2013 to 2023 and to identify any surgical complications observed. Main tumor and surgical features associated with the occurrence of surgical complications were evaluated. Respondents were placed into 3 surgical experience groups, based on the number of endoscopic PitNET removals performed during the study period.

Results: From a total of 3356 operations for PitNET removal via an EEA, the incidence of surgical complications was 11.92% (400/3356). Worsening of anterior pituitary function (4.80%) and permanent diabetes insipidus (2.32%) were the complications that occurred the most often. Postoperative CSF leak occurred in 50 cases (1.49%). Other significant complications, such as carotid artery injury, epistaxis, sphenoid sinusitis, septal perforation, residual tumor hemorrhage, intracranial hematoma, vasospasm, subarachnoid hemorrhage, cranial nerve injuries, visual worsening, meningitis, and tension pneumocephalus occurred with incidence rates between 0.06% and 0.89%. Among 350 patients experiencing at least one surgical complication, 58.86% harbored a nonfunctioning adenoma and 17.71% a recurrent tumor. The overall rate of postoperative complications in relation to surgical experience exhibited a U-shaped progression, with a significantly higher rate (p < 0.001) in centers performing fewer than 200 procedures (117/654, 17.89%) compared to centers performing 200-500 operations (88/900, 9.78%) and those with caseloads exceeding 500 (195/1802, 10.82%).

Conclusions: This study demonstrated a reduced overall rate of complications in EEAs for PitNET removal related to advancements in surgical technique, technological progress, and surgeon experience, which have allowed an expansion of indications to more complex cases. Within the U-shaped relationship between surgical experience and complication rate, likely due to the prevalence of PitNETs at higher risk of surgical morbidity in centers with more experience, CSF leakage was found to be the only complication continuously improving with surgical experience.

Objective: Methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-susceptible S. aureus (MSSA) are known to colonize various bodily locations and present unique challenges in the prevention and treatment of deep surgical site infections (SSIs). The aim of this study was to determine if preoperative colonization testing and decolonization protocols reduce the rate of SSIs in patients undergoing surgical neuromodulation procedures.

Methods: Using a prospectively maintained database, a single-surgeon, single-facility, retrospective study identified 513 spinal cord stimulation (SCS) procedures, 1050 deep brain stimulation (DBS) procedures, and 414 intrathecal baclofen (ITB) pump procedures performed between June 2013 and June 2024. These procedures were performed in 361 patients receiving SCS devices, 375 patients receiving DBS devices, and 308 patients receiving ITB pumps. Preoperative S. aureus nasal swab results, postoperative superficial and deep SSIs requiring device removal, and patient-related comorbidities were analyzed. Patients were monitored for at least 6 months postoperatively for deep SSIs. Different perioperative colonization screening, decolonization, and antibiotic protocols were assessed.

Results: Approximately 20% of all patients undergoing implantation of SCS/DBS devices and 25% of patients undergoing implantation of ITB devices had positive results for S. aureus. MSSA colonization was 14 times more common than MRSA colonization in patients who underwent SCS procedures, 9 times more common in those who underwent DBS procedures, and 3 times more common in those who underwent ITB pump procedures. MRSA colonization was 3 times more common in patients who underwent ITB pump procedures than in those who underwent SCS/DBS procedures. There were no deep SSIs in the SCS group. Patients in the ITB pump group had a decrease in infection rate from 8% down to < 2% after implementation of preoperative decolonization protocols.

Conclusions: This study represents the most comprehensive report to date analyzing the prevalence of preoperative MRSA and MSSA colonization in patients undergoing a wide array of surgical neuromodulation procedures. These data support the recommendation that patients receiving neuroimplantable devices, specifically patients undergoing ITB pump procedures, be 1) screened for both MRSA and MSSA, as screening for MRSA alone will not reveal a large fraction of S. aureus colonization; and 2) considered for decolonization protocols prior to surgery. Following these procedures significantly reduced SSIs in patients who underwent ITB pump implantation procedures and might have reduced SSIs for SCS and DBS implantation procedures as well.

Objective: Focused ultrasound (FUS) is a minimally invasive treatment option for essential tremor and tremor-dominant Parkinson's disease. Because thermal lesions are irreversible, it is critical to understand how lesion placement relates to patient outcomes. The aim of this study was to determine whether patient outcomes can be predicted using real-time estimation of heating and the accumulated thermal dose derived from MR temperature imaging (MRTI).

Methods: MRTI, tremor control, and side effects were analyzed from 547 FUS thalamotomy treatments (481 patients, median age 74 years). Previously described methods were used to estimate the heating from 2D MRTI in different orientations and to generate phase maps from the MRTI data. After registration to an MRI atlas, we compared the thermal dose deposition of patients who reported side effects with that of patients who did not report side effects at time points ranging from 1 day to 1 year after FUS. Logistic regression and voxel-wise frequency mapping were used to compare the size and spatial extent of heating, thermal dose, and lesion segmentations to the frequency of different side effects and complete tremor control.

Results: Relationships between the frequency of side effects and tremor control were similar for thermal dose contours and lesion segmentations. Weakness and imbalance were more frequent when heating, dose contours, and lesions extended inferolaterally into the internal capsule. Sensory deficits and dysgeusia were more frequent with increased posterior extent, and dysarthria was more frequent with superior/medial/anterior extent. While most areas associated with complete tremor response overlapped with those associated with side effects, a small anterior region was identified in which complete tremor response without side effects was more frequent. Increased lesion area resulted in more side effects and complete tremor response at early and late time points, but the corresponding areas for dose contours were only related to side effects and only at 1 day after FUS.

Conclusions: MRTI can provide similar results as lesion segmentations after estimating heating and the thermal dose in different orientations. Combining this approach with visualization of anatomy around the thalamus using filtered phase maps of MRTI is useful for real-time monitoring and optimization of FUS treatments.