Journal of neurosurgery最新文献

Objective: To optimize neurosurgical tumor resection, tissue types and borders must be appropriately identified. Authors of this study established the use of a nondestructive laser-based endogenous fluorescence spectroscopy device, "TumorID," to almost immediately classify a specimen as glioma, meningioma, pituitary adenoma, or nonneoplastic tissue in the operating room, utilizing a machine learning algorithm.

Methods: TumorID requires only 0.5 seconds to collect data, without the need for any dyes or tissue manipulation, and utilizes a 100-mW, 405-nm laser that does not damage the tissue. The system was used in the operating room to scan ex vivo specimens from 46 patients (mean age 52 years) with glioma (8 patients), meningioma (10 patients), pituitary adenoma (23 patients), and nonneoplastic tissue resected during an epilepsy operation (5 patients). A support vector machine algorithm was trained to distinguish between these lesions and classify them in near real time. Statistical significance was determined through a generalized estimating equation on the area under the known fluorophore emission regions for free reduced nicotinamide adenine dinucleotide (NADH), bound NADH, flavin adenine dinucleotide, and neutral porphyrins.

Results: Ultimately, the machine learning model showed a high degree of classification power with a multiclass area under the receiver operating characteristic curve of 0.809 ± 0.002. The areas under the curve for neutral porphyrins were found to be statistically significant (p < 0.001) and to have the largest impact on model output.

Conclusions: This initial ex vivo clinical study demonstrated the ability of TumorID to rapidly differentiate and classify various pathologies and surrounding brain in a configuration that can be easily translated to scan in vivo. This classification power could allow TumorID to augment surgical decision-making by enabling rapid intraoperative tissue diagnostics and border delineation, potentially improving patient outcomes by allowing for a more informed and complete resection.

Objective: Cribriform plate dural arteriovenous fistula (DAVF) is a rare lesion associated with a high risk of bleeding. Transarterial embolization (TAE) has been widely recognized as the first-line treatment. However, limited data exist regarding the safety and efficacy of transvenous embolization (TVE). The aim of this study was to report on a cohort of patients with cribriform plate DAVFs who underwent endovascular treatment (EVT), detailing both clinical and angiographic outcomes.

Methods: This single-center case series was conducted from January 2016 to June 2024, including 26 cases in which cribriform plate DAVFs were treated with EVT. A retrospective review of clinical and radiological data was performed. The safety and efficacy of TAE and TVE were compared and further analyzed by including results from the literature published over the past decade.

Results: A total of 25 patients (mean age 60.2 ± 8.3 years; all male) in 26 cases were included in this study. The immediate postoperative total embolization rates were 53.8% (7/13) and 100% (13/13) for TAE and TVE, respectively, resulting in an overall success rate of 76.9% (20/26). TVE demonstrated a significantly higher success rate than that of TAE (p = 0.015). Three TAE cases had surgical complications, including microcatheter fracture (2/3) and thromboembolism (1/3). The TVE group experienced no symptomatic complications. Similar results were observed in the literature review.

Conclusions: TVE might be considered as a preferential strategy for cribriform plate DAVFs in select cases. For optimal safety, it is crucial to navigate microcatheters into the cortical vein using the wire-loop technique. Further studies are required to validate its safety and efficacy.

Objective: In low-grade glioma (LGG), although awake surgery (AS) with intraoperative functional mapping helps to minimize neurological and cognitive deficits, its impact on artistic abilities has received less attention. This study is the first to assess the capacity of professional or semiprofessional artists to resume various art activities following AS for LGG.

Methods: Artists who underwent AS for an IDH-mutated WHO grade 2 glioma with connectome-based resection using cortico-subcortical electrostimulation were consecutively selected. Real-time, tailored multitasking was performed throughout the resection, but no additional tasks related to artistic abilities were introduced.

Results: Nineteen patients were included, consisting of 15 professional artists (5 architects, 2 comedians, 2 musicians, 2 dancers, 1 sculptor, 1 plastic artist, 1 writer, and 1 art professor) and 4 semiprofessional artists-2 musicians (1 professor of chemistry, 1 informatician), 1 poet (theater administrator), and 1 painter (social worker). This consecutive cohort included 10 men (52.6%) and 9 women (47.4%) who underwent AS for LGG. Of the 19 patients, 16 were right-handed, the mean age was 36.8 ± 9.7 years, and the mean Karnofsky Performance Scale score was 94.7 ± 6.9. There were 11 left-sided and 8 right-sided tumors distributed across the 5 lobes (mean preoperative volume 52.8 ± 39.4 cm3). All patients were fully active before surgery, except for 1 architect with intractable epilepsy. Postoperatively, no permanent deficits were observed, except 1 case of voluntary induced hemianopia (5.3%). The mean Karnofsky Performance Scale score was 95.7 ± 5 at 3 months after surgery. All patients returned to their artistic practice at the semiprofessional or professional level, and none reported a subjective loss of creativity. The mean extent of resection was 91.2% ± 8.6% (mean residual tumoral volume 5 ± 5.8 cm3). There were 12 astrocytomas and 7 oligodendrogliomas. Only 1 patient received immediate adjuvant therapy. Five patients (26.3%) underwent subsequent AS. The mean follow-up duration was 7.6 ± 3.1 years since the initial AS. All patients except 3 (84.2%) were still alive at the last follow-up (1 died from an unrelated cause). There were no significant differences between professional and semiprofessional artists, except for a higher rate of reoperation in the latter subgroup (p = 0.037).

Conclusions: These original data show that AS with intraoperative continuous multitasking enabled semiprofessional and professional artists with LGG to resume their artistic work following surgery. This suggests that, although artistic creativity should be more systematically considered in surgical neuro-oncology, even for nonprofessional artists, there is nonetheless no need to introduce specific tests during surgery.

Objective: The traditional freehand insertion of a ventricular catheter using surface anatomical landmarks is a basic procedure for neurosurgeons. However, this procedure involves considerable uncertainty and frequently requires multiple placement attempts. This also periodically results in improper positioning of the catheter tip. The aim of this study was to evaluate the accuracy of ventricular catheter insertion using real-time ultrasound images acquired with a burr hole-compatible transducer and to compare it with freehand insertion.

Methods: This retrospective cohort study included all patients at a single institution who underwent a ventricular catheter insertion operation, including external ventricular drainage, ventriculoperitoneal shunt placement, and Ommaya reservoir insertion through a new burr hole, between January 2015 and March 2022. The data collected for each patient included age, sex, diagnosis, antiplatelet or anticoagulant use within 24 hours before or after the procedure, use of intraoperative real-time ultrasound with a burr hole-compatible transducer, site and side of the ventricular catheter placement, number of attempts required to achieve successful insertion, postoperative parenchymal bleeding, and symptomatic complications related to inaccurate catheter insertion. The Evans index was acquired from preoperative CT images, and the accuracy of ventricular catheter placement was evaluated using postoperative CT.

Results: A total of 136 procedures were included in this study; 81 ventricular catheters were inserted using the freehand technique, and 55 were inserted using the real-time ultrasound technique. The number of catheter placement attempts was significantly lower using the real-time ultrasound technique than the freehand technique (p < 0.001), and the accuracy of the real-time ultrasound technique was significantly higher (p < 0.001). The difference in accuracy between the ultrasound and freehand techniques was augmented in posterior horn punctures (100% and 74.1%, respectively, p = 0.01).

Conclusions: The real-time ultrasound-guided ventricular catheter insertion technique is significantly more accurate than the traditional surface anatomical landmark-based freehand technique and results in a reduced number of puncture attempts.

Objective: The aim of this study was to evaluate the cortical nonenhancing tumor infiltration (CONTIN) sign as a predictive imaging biomarker for IDH-mutant gliomas, including diffuse gliomas with and without contrast enhancement.

Methods: Imaging data were collected from patients with diffuse gliomas (grades 2-4) at Beijing Tiantan Hospital (BTH) from January 2019 to December 2021 (training set, n = 526) and from the University of California, San Francisco, preoperative diffuse glioma MRI dataset (UCSF PDGM; validation set, n = 501). Two independent reviewers assessed the CONTIN sign and other radiological features to develop a diagnostic strategy.

Results: Interrater agreement for the CONTIN sign was almost perfect (κ = 0.812). In the BTH cohort, the prevalence of the CONTIN sign in IDH-mutant gliomas was 90.1% overall, with a rate of 92.2% (106/115) in contrast-enhancing gliomas and 88.9% (168/189) in nonenhancing gliomas. In the UCSF PDGM cohort, the overall prevalence was 85.4%, with 81.4% in contrast-enhancing gliomas and 88.3% in nonenhancing gliomas. In contrast-enhancing gliomas, the CONTIN sign significantly improved sensitivity compared with the T2-FLAIR mismatch (T2FMM) sign, with an increase from 14.8% to 92.2% in the BTH cohort and from 23.3% to 81.4% in the UCSF PDGM cohort. Additionally, the CONTIN sign had a high specificity (82.8% in the BTH cohort, 87.4% in the UCSF PDGM cohort) and negative predictive value (94.6% in the BTH cohort, 97.6% in the UCSF PDGM cohort). By integrating the CONTIN sign with T2FMM, contrast enhancement, age at diagnosis, and other features, a reliable diagnostic protocol for IDH-mutant gliomas was established.

Conclusions: The CONTIN sign was a robust imaging biomarker for identifying IDH mutation status in diffuse glioma, particularly for those with contrast enhancement. Preoperative knowledge of IDH mutation status can enhance patient counseling and inform treatment decision-making.

Objective: Filter specifications for visualizing 5-aminolevulinic acid (5-ALA) tumor fluorescence are incorporated in neurosurgical wide-field microscopes. Novel exoscopes offer modified visualization technologies that should be comparable to older systems to prevent over- or underresection. In this technical note, the authors compare the fluorescence visualization technologies of three exoscopes.

Methods: Images of 73 tissue samples with heterogeneous fluorescence signals were acquired using the Aeos, ORBEYE, and Kinevo exoscope. Fluorescent areas as determined by six raters were calculated and compared with the gold standard, i.e., BLUE 400. Intraclass correlation coefficients (ICCs) were calculated to assess the reliability of the results. Protoporphyrin IX (PpIX) decay under continuous blue-light illumination was determined to assess photobleaching.

Results: The extent of fluorescence was significantly larger under the Aeos. There was no significant difference using the ORBEYE and the Kinevo exoscope. ICCs showed excellent (Kinevo exoscope and Aeos) and good (ORBEYE) reliabilities. The Aeos had the fastest PpIX decay rate.

Conclusions: The ORBEYE and the Kinevo exoscope are safe alternatives to the gold standard. The Aeos seems to be more sensitive regarding fluorescence visualization; however, it remains unclear whether this is at the expense of specificity. The photobleaching effect is stronger in novel exoscopes.

Objective: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. To identify patients with BCVI who were undetected using the classic criteria, researchers designed the expanded Denver screening criteria. The aim of this study was to evaluate adherence to the classic and expanded screening protocols. The authors then assessed the impact of this transition on the identification of BCVI and the development of ischemic brain injuries.

Methods: Patients with moderate to severe traumatic brain injury (TBI) admitted to the authors' center between 2014 and 2021 were retrospectively reviewed. Patient characteristics, adherence to the screening protocol, the incidence of BCVI detected by CT angiography (CTA) or digital subtraction angiography, and the development of ischemia in patients admitted before (2014-2018) and after (2019-2021) the implementation of the expanded Denver criteria were compared. Comparisons in qualitative and quantitative variables between periods were performed using the chi-square test and Mann-Whitney U-test, respectively. Which individual criterion was most associated with adherence to the protocol and incidence of BCVI according to multivariate logistic regression analysis was also determined. The performance of each screening protocol was determined using the C-statistic.

Results: Of the 648 patients with TBI identified during the study period, 397 were recruited in the classic period (2014-2018) and 251 in the expanded period (2019-2021). The rate of adherence to the screening protocol was 58.9% in the classic period and 78.1% in the expanded period (p < 0.001). BCVIs were detected in 38 patients (9.6% incidence) in the classic period and 20 patients (8% incidence) in the expanded period. If the classic criteria had been used in the 2019-2021 period, 14 CT angiograms would not have been performed. During the classic period, 27 patients (6.8%) developed ischemia. In 5 (18.5%) of these 27 patients, ischemia could not be prevented because they were not screened through CTA despite fulfilling the criteria. In the expanded period, 24 patients (9.6%) developed ischemia, with no CTA performed in just 1 patient (4.2%), despite meeting the criteria for screening (p = 0.125).

Conclusions: Despite the improvement in adherence and the enhanced diagnosis of BCVI following training and the implementation of the expanded Denver criteria, the study failed to find a significant reduction in delayed ischemia, while acknowledging the potential for other contributing factors. Further endeavors should be conducted to ensure protocol adherence and early diagnosis of patients at risk of BCVI.