Journal of neurosurgery最新文献

Objective: Postoperative surgical site infections (SSIs) following brain tumor surgery frequently necessitate wound revision and bone flap removal. However, data on subsequent cranial reconstruction in this context remain limited. The aim of this study was to characterize patients undergoing bone flap removal due to SSI, determine the proportion who proceed to cranioplasty, and evaluate surgical strategies, complication rates, and risk factors for implant failure.

Methods: In this multicenter observational study, patients who underwent bone flap removal due to SSI following brain tumor surgery from 2008 to 2022 at four Swedish neurosurgical centers were included. Clinical, radiological, and surgical data were collected retrospectively. Risk factors for implant removal were evaluated with logistic regression and Kaplan-Meier survival analyses. Functional outcome was assessed using the modified Rankin Scale (mRS).

Results: Of 260 patients included in the analysis, 223 (86%, median age was 56 years) underwent cranioplasty and 37 (14%, median age 66 years) did not, primarily due to short life expectancy, poor medical condition, or wound concerns. Among patients who underwent cranioplasty, the most common tumor type was meningioma (75%) and the median cranial defect size was 35 cm2. Synthetic implants were used for all reconstructions. The overall implant removal rate was 21%, primarily due to wound dehiscence and infection. WHO grade 4 tumors and a cranial defect size > 64.5 cm2 were associated with an increased risk of implant removal (p < 0.05). Variables such as age, smoking, and diabetes did not predict complications. Functional outcome, as assessed by the mRS, remained unchanged postoperatively for most patients (87%).

Conclusions: Cranioplasty after bone flap removal due to SSI following brain tumor surgery was associated with a substantial risk of implant failure despite reconstruction of relatively small cranial defects. Predictive factors for implant failure were limited, suggesting that unmeasured variables, such as soft tissue conditions, might play a significant role in these procedures. Given the high rate of implant removal and limited survival among patients with high-grade tumors, careful patient selection and individualized decision-making are essential.

Objective: For more than 4 decades, stereotactic radiosurgery (SRS) has been a standard procedure for brain arteriovenous malformation (AVM). Nonetheless, this procedure has been implicated in postobliteration intracranial hemorrhage (ICH) and delayed cyst formation (DCF). In this study, the authors investigated the long-term outcomes of SRS treatment for AVM.

Methods: Authors of this retrospective study reviewed the medical records of all patients who underwent SRS for brain AVM at a single academic medical center between January 1995 and October 2014 and whose clinical follow-up was at least 5 years. Analysis focused on clinicodemographic profiles, treatment parameters, and imaging phenotypes.

Results: The final study cohort consisted of 380 patients with a mean age of 34.2 years and mean follow-up of 11.5 years. There was a slight preponderance of males in the cohort (201:179). A total of 154 patients (40.5%) experienced ICH prior to SRS treatment. The mean maximum AVM diameter was 3.3 cm, and most malformations were supratentorial (n = 325, 85.5%). Stratification based on Spetzler-Martin grade was as follows: grade I, 35 cases (9.2%); grade II, 104 cases (27.4%); grade III, 136 cases (35.8%); grade IV, 83 cases (21.8%); and grade V, 22 cases (5.8%). The median interval between SRS and complete AVM obliteration was 48.4 months. Chronic encapsulated intracerebral hematoma (CEIH) was noted in 16 patients (mean latency 14.6 years after SRS), and DCF was noted in 24 patients (mean latency 9.6 years after SRS). Among these 40 patients, 14 (35.0%) required craniotomy and 3 (7.5%) required stereotactic aspiration due to symptomatic mass effect. An analysis of risk factors revealed early radiation-induced change (RIC), infratentorial location, and prior hemorrhage as predictive of CEIH. Early RIC alone was predictive of DCF.

Conclusions: Even after angiographic obliteration, long-term clinical and radiological surveillance is warranted due to the risk of CEIH (2.1%) and delayed cysts (3.2%) more than a decade after SRS.

Objective: The aim of this study was to evaluate the long-term visual outcomes following optic nerve decompression in patients with CSF flow disturbances and to propose a mechanistic framework for surgical qualification based on infusion testing and orbital MRI, independent of idiopathic intracranial hypertension (IIH) diagnostic criteria.

Methods: This retrospective study analyzed 30 eyes in 26 patients with progressive visual impairment and evidence of CSF flow abnormalities. All patients underwent standardized lumbar infusion testing to quantify CSF outflow resistance, pressure-volume index, and opening pressure. Orbital MRI was used to assess perioptic CSF collections or optic canal narrowing. On the basis of these data, patients underwent either optic nerve sheath fenestration (ONSF) or endoscopic optic nerve sheath decompression (EONSD). Visual function was evaluated using mean deviation of the visual field, visual evoked potentials, and optical coherence tomography of the retinal nerve fiber layer (RNFL) thickness at baseline and 6 and 24 months.

Results: Mean deviation of the visual field improved by a median of +1.89 dB (p < 0.05), and P100 latency (i.e., the time between a visual stimulus and the visual cortex's response) decreased by -5 msec at 24 months. Papilledema resolved in 87.5% of affected eyes. RNFL thickness remained stable or modestly increased across the cohort, with a trend toward greater thickening following EONSD (+9 µm at both 6 and 24 months) compared with ONSF (minimal change at 6 months [+1 µm] and slight thinning at 24 months [-2 µm]), although the differences were not statistically significant. No significant differences in functional outcomes were observed between the procedures. Patients were stratified into 3 CSF pathophysiological subgroups: 1) IIH with elevated intracranial pressure (ICP), 2) abnormal hydrodynamics without raised ICP, and 3) normal ICP and hydrodynamics with MRI-confirmed perioptic CSF collection. Visual improvement occurred across all subgroups, including groups 2 and 3.

Conclusions: The authors found that optic nerve decompression guided by CSF infusion testing and orbital MRI effectively stabilizes or improves visual function in patients with CSF-related optic neuropathy, including those without elevated ICP. A mechanism-based classification into three surgical phenotypes enables individualized treatment beyond syndromic definitions. This approach may redefine surgical eligibility and expand access to vision-preserving interventions in CSF-mediated optic nerve dysfunction.

Objective: Advancements in endovascular devices and techniques have improved cure rates for selected brain arteriovenous malformations (AVMs). However, data on angiographic and treatment-related complications remain limited. This study presents a 12-year single-center experience with curative endovascular treatment (EVT), along with comparative insights from previously published cohorts.

Methods: Data from all brain AVMs treated with curative intent EVT between 2010 and 2022 were reviewed for baseline demographic characteristics, angioarchitectural features, treatment techniques (single arterial, double arterial, venous, arterial and venous, and transvenous embolization with selective temporary flow arrest [TFATVE]), complications, and clinical and angiographic outcomes. Hemorrhagic and ischemic complications were assessed with postprocedural MRI. Ischemic volumes were semiautomatically calculated on apparent diffusion coefficient maps using regions of interest segmentation by two independent readers. Univariate and multivariate analyses were performed to identify predictors of cure and complications.

Results: A total of 193 patients (54% male, mean ± SD age 38.7 ± 15.9 years) with 193 AVMs (60.6% ruptured) were included. The following techniques were included: single arterial (37.8%), double arterial (26.4%), arterial and venous (19.7%), TFATVE (8.3%), and single venous (7.8%). Intraprocedural complications occurred in 10.4% of cases. Both hemorrhagic and symptomatic ischemic complications occurred in 15.5% of patients. Mean ischemic volume was 9.4 ± 15.1 cm3 and was significantly higher in symptomatic cases. Overall minor and major complications rates were 14% and 3.1%, respectively. The mortality rate was 4.7% and was lower in unruptured AVMs though these had a higher complication rate. The overall angiographic cure rate was 80.3%, increasing to 93%-100% in cases treated with advanced approaches. On multivariate analysis, AVM in an eloquent brain location was associated with lower cure rates (OR 0.3, p = 0.023), while advanced techniques involving TVE were associated with higher cure rates (OR 7.9, p < 0.001).

Conclusions: This large, single-center experience adds to the growing evidence that curative EVT can be a valuable option, especially when advanced techniques are used for low-grade and ruptured deep AVMs. At the same time, higher complication rates in unruptured or higher grade (Spetzler-Martin [SM] grade IV-V) lesions highlight the importance of cautious patient selection. Larger, multicenter prospective studies in high-volume centers are needed to better define the role of curative EVT.

Objective: Although dopamine agonist (DA) therapy still represents the standard of care for prolactinomas, a reconsideration of the role of transsphenoidal surgery has been promoted in recent years. The aim of this multicenter retrospective study was to assess the short- and long-term results of the endoscopic endonasal approach (EEA) for prolactinomas, analyzing which factors have a favorable prognostic role.

Methods: All consecutive prolactinomas operated on in 12 Italian neurosurgical centers between 2013 and 2023 were included. For each case, preoperative clinical and neuroradiological features were considered, as well as surgical complications and short- and long-term results.

Results: The series included 215 patients (44.2% males, mean age 39.7 [SD 16.6] years), accounting for 4.5% of all pituitary surgeries in these centers. The majority of prolactinomas (67.9%) were macroprolactinomas. Radical tumor resection was achieved in 171 patients (79.5%), and 3-month biochemical remission in 154 patients (71.6%). The most common surgical complication was postoperative CSF leak (2.8%). Endocrinological sequelae consisted of new onset of anterior hypopituitarism in 10.7% of cases, transient diabetes insipidus (DI) in 3.3%, and permanent DI in 2.3%. Long-term remission (mean follow-up 33.5 [SD 25.0] months) was achieved in 75.4% of patients, 14 patients (6.5%) presented with tumor recurrence/progression, and 1 (0.5%) demonstrated tumor evolution to carcinoma.

Conclusions: The EEA is a valid option for the treatment of prolactinomas, with better results for micro tumors and regular macro tumors. This study found that preoperative prolactin values < 184 ng/ml were associated with higher chances of biochemical remission, as was larger pituitary surgery center volume. Currently, the most common surgical indications for prolactinomas are represented by cases that are not responsive or intolerant to DAs. However, interesting future perspectives considering EEA as a possible co-first-line therapy in selected patients have been recently proposed.

Objective: The aim of this study was to compare 3 electrode designs-a novel 22-contact circular grid, standard 6-contact strip, and high-density (HD) grid between 32 and 64 contacts-for the detection of epileptiform activity during awake craniotomy.

Methods: This study included patients who underwent functional brain mapping with and without direct electrical stimulation during awake craniotomy. Demographic, clinical, and electrocorticography (ECoG) data were collected.

Results: A total of 194 patients were included, with 264 instances of electrode use: 113 circular grid, 96 strip electrode, and 55 HD grid. The HD grid (15%) was used less to record ECoG during direct electrical stimulation than the circular grid (80%, p < 0.001) and strip electrodes (69%, p < 0.001). Sporadic interictal epileptiform activity was better detected with circular (45%, p < 0.001) and HD (40%, p = 0.006) grids compared with strip electrodes (16%). Spontaneous seizures were recorded more frequently with the circular grid (16%, p = 0.018) compared with the strip electrode (9.4%) and HD grid (1.8%). Afterdischarges were more frequently detected by the circular grid (69%, p = 0.031) and with circular and HD grids (combined) compared with strip electrodes (67% vs 48%, p = 0.024), at lower median intensity (3 mA vs 5 mA, p < 0.001). Multivariable analyses demonstrated circular grids (p < 0.001) to be more sensitive in detecting spontaneous epileptiform activity than strip and HD grid electrodes, and grids (circular and HD) to be better in recording stimulus-induced epileptiform activity (p = 0.01).

Conclusions: This study demonstrates a higher rate of detection of epileptiform activity with circular and standard grids when compared with strip electrodes. The standard HD grid was used less during electrical stimulation, demonstrating the importance of both the number of contacts and design array when considering optimal conditions for ECoG and functional brain mapping.

Objective: Achieving submillimetric accuracy in stereotactic neurosurgery remains critical for safely targeting deep brain structures. Current workflows rely on intraoperative CT to register stereotactic frames to preoperative imaging, but this introduces additional radiation exposure, cost, and workflow complexity. Three-dimensional surface scanning (3DSS) potentially offers a fast radiation-free alternative capable of capturing detailed craniofacial anatomy and frame geometry. Therefore, the aim of this cadaveric study was to evaluate the feasibility, accuracy, and navigational compatibility of integrating 3DSS into stereotactic workflows as a potential replacement for intraoperative CT.

Methods: A human cadaveric head was imaged with both thin-slice CT and structured-light 3DSS after mounting stereotactic frame components. CT, 3DSS, and computer-aided design (CAD) models were registered using a multistep point cloud alignment pipeline involving the fast point feature histogram, the random sample consensus method, and the iterative closest point algorithm. Accuracy was assessed using surface deviation error, root mean square error (RMSE), and fiducial registration error within a commercial neuronavigation platform.

Results: Fusion of the 3D facial scan with CT provided a mean surface deviation error of approximately 0.4 mm. Registration of the 3DSS-derived N-bar localizer to its CAD reference model produced a frame alignment RMSE of 1.3 mm. Within the navigation system, the 3DSS-based workflow achieved a mean fiducial registration error of 0.14 mm (range 0.02-0.20 mm), outperforming the conventional CT-based method (mean error 0.20 mm, range 0.09-0.40 mm).

Conclusions: The 3DSS-based method enabled precise submillimetric stereotactic registration without the need for intraoperative CT, reducing radiation exposure and operative complexity. This workflow is fully compatible with existing navigation systems and could serve as a practical radiation-free alternative in stereotactic neurosurgery. Future work will focus on automating frame detection, incorporating artificial intelligence-driven fusion methods, and validating this approach in live surgical settings.

Objective: Complicated mild traumatic brain injury (cmTBI) is a common emergency consultation in trauma care at community and tertiary hospitals. While neurosurgical evaluation is typically required, actual neurosurgical intervention is rare. The aim of this study was to evaluate the adoption, safety, and effectiveness of a telemedicine-based neurosurgery consultation program (tele-TBI) in reducing unnecessary interhospital transfers of patients with cmTBI.

Methods: A multidisciplinary team implemented the tele-TBI program at 4 community hospitals. Patients with cmTBI who were eligible to receive telehealth consultations over the first 2 years of the program were retrospectively analyzed. The program's impact on reducing interhospital transfers, disposition outcomes, and safety were assessed.

Results: Of 179 eligible patients (94 female, mean age 75 years) reviewed, 117 underwent tele-TBI consultation and 62 did not. Among the patients with tele-TBI consultations, 15 (13%) were transferred to tertiary centers, with 2 (1.7%) admitted to the ICU, 10 (8.5%) admitted to the floor, and 3 (2.6%) managed in the emergency department. Most patients (87%) who underwent tele-TBI consultation were effectively managed at community hospitals; 90 (77%) were observed in the emergency department then discharged and 12 (10%) were admitted. In contrast, all 62 patients without tele-TBI consultation were transferred to tertiary hospitals, of whom 10 (16%) were admitted and 52 (84%) were observed in the emergency department and then discharged. Multivariate analysis revealed that subdural hematoma (OR 2.90, 95% CI 1.53-5.51) and age < 80 years (OR 0.25, 95% CI 0.11-0.56) significantly influenced the likelihood of transfer.

Conclusions: The tele-TBI program reduced unnecessary interhospital transfers. Notably, most patients with tele-TBI consultation were successfully managed in their community hospital. Moreover, nearly 4 of 5 patients without tele-TBI consultation were transferred, only to be discharged directly from the tertiary referral center's emergency department.

Objective: Stereoelectroencephalography (sEEG) was introduced in Europe and has since been widely adopted throughout the United States during the past decade. Given the short history of its use in the United States, most neurosurgeons have not received dedicated sEEG training during residency. Instead, the majority learn sEEG techniques and practices as faculty and attendings. Because of the positively reported safety and efficacy profile of sEEG, it is a valuable tool for discerning epileptogenic foci. However, there are no consensus statements regarding surgical techniques and common intra-/perioperative practices. Here, the authors present the results of a survey of epilepsy neurosurgeons, providing data on current practices. They describe both comparable and contrasting results, indicative of a lack of standardized practice, and offer new insights not previously reported.

Methods: A digital survey with 49 questions was distributed to pediatric and adult epilepsy neurosurgeons via three different forums. The survey addressed multiple topics, including training; planning; techniques; perioperative use of antibiotics, steroids, and antiseizure medications (ASMs); and return-to-work or return-to-school protocols.

Results: Fifty-four epilepsy neurosurgeons completed the survey. Consistent with previous surveys, most respondents (67.4%) reported a total of 1-25 sEEG procedures conducted at their institution annually, with the majority (93.6%) using a robotic system for electrode placement. There is typically a 1- to 6-month waiting period between sEEG and therapeutic procedures, such as placement of a responsive neurostimulation device, laser ablation, or open resection (85.7%, 77.5%, and 73.3% of respondents, respectively). Eighty percent of respondents reported that post-sEEG asymptomatic hemorrhage occurs 25% or less of the time, and 80% reported that post-sEEG infection never occurs, consistent with the literature. This survey is distinguished from others by reporting data on perioperative antibiotic, steroid, and ASM use, revealing substantial variability in antibiotic prescription schedules. Most respondents (77.3%) do not prescribe postoperative steroids, and 40% of respondents typically do not instruct patients to stop or decrease ASMs before admission (25% or less of the time). More than half of respondents (53.3%) reported instructing their patients to return to work or school between 1 week and 1 month post-procedure.

Conclusions: Stereo-EEG has seen a rapid increase in use during the past decade. However, widespread consensus surrounding techniques and practices is still lacking. This survey contributes new insights and data to the limited existing literature, enhancing understanding of important decision-making processes within the sEEG community.