Journal of neurosurgery最新文献

Objective: Cranial bone flap fixation is typically achieved by using titanium plates and screws (TPS), which are the standard of care. However, the use of hardware to achieve long-term bone fixation and healing across a kerf line poses challenges and potential complications, including infection, nonunion, loosening, cranial flap bone resorption, pain, cosmetic deformity, and CSF leakage. The use of a tetracalcium phosphate and phosphoserine (TTCP-PS) regenerative bone adhesive to fixate cranial flaps has been previously shown to be advantageous compared to TPS in an in vivo ovine model and a human cadaveric model. However, the potential impact of TTCP-PS on the underlying brain has not been previously studied. To investigate the local tissue effects of TTCP-PS bone adhesive compared to TPS, a clinically relevant sheep craniotomy model was developed.

Methods: Twelve skeletally mature crossbred sheep were used in this study. All craniotomies and surgical procedures were performed by an experienced, US-trained, licensed, and practicing attending neurosurgeon. Bilateral parietal craniotomies were created using a Medtronic Midas Rex craniotome and perforator. Durotomy was performed and repaired in half of the subjects. Craniotomies were repaired with TPS or the TTCP-PS bone adhesive. CT scans were performed postoperatively and at 12 weeks. Histopathology was performed on the brain and cranial bone.

Results: All sheep reached the study endpoint. Histopathological changes in underlying cerebral cortical tissue were comparable in magnitude and incidence between groups (minimal superficial cortical deformation/loss and/or malacia/loss). The magnitude of microgliosis and astrogliosis related to the cortical changes was comparable between groups (minimal/mild and minimal, respectively). Histopathological findings were procedural in nature, associated with the craniotomy model, and unrelated to the bone flap fixation method. The histological changes did not result in clinically adverse effects.

Conclusions: TTCP-PS was safe, producing no significant difference in adverse effects on local tissues compared to standard craniotomy with plate and screw fixation. This is the first study to quantify histological changes in the underlying cerebral cortex due to standard craniotomy technique.

Objective: The objective of this study was to describe the long-term efficacy of single-fraction stereotactic radiosurgery (SRS) for the primary treatment of sporadic vestibular schwannoma.

Methods: Adult (≥ 18 years of age) patients with sporadic vestibular schwannoma who underwent SRS from 2000 through 2022 were included.

Results: A total of 749 patients met inclusion criteria, the majority (n = 566, 76%) of whom had tumors extending into the cerebellopontine angle at SRS. The median patient age at SRS was 62 years, half (50%) of the patients were women, and 744 (99%) exhibited House-Brackmann grade I facial nerve function at SRS. A total of 42 patients experienced radiosurgical failure and underwent salvage treatment; the median duration of follow-up for the patients who did not undergo salvage treatment was 7.0 years. Overall tumor control rates (95% CI, number still at risk) at 1, 3, 5, 10, and 15 years after SRS were 100% (100%-100%, 718), 98% (97%-99%, 589), 96% (94%-97%, 464), 92% (90%-95%, 258), and 91% (89%-94%, 125), respectively. Patient age (hazard ratio [HR] for a 10-year increase of 0.92, 95% CI 0.71-1.19; p = 0.5), presence of a macrocystic tumor (HR 0.59, 95% CI 0.14-2.46; p = 0.5), and treated tumor volume (HR for a 1-cm3 increase of 1.02, 95% CI 0.88-1.18; p = 0.8) were not significantly associated with the risk of salvage. Three distinct post-SRS tumor behavior patterns were observed, with 13% of patients demonstrating tumor pseudoprogression, all but 4 of whom demonstrated pseudoprogression by year 5 post-SRS.

Conclusions: SRS demonstrates durable tumor control through 15 years of follow-up in most patients (91%); however, a minority are found to still experience SRS failure even beyond 10 years of surveillance. Although occurring in only a minority of patients, tumor pseudoprogression can be evident out to 5 years or longer post-SRS.

Objective: Wait-and-scan surveillance is now commonly employed for initial management of small- and medium-sized vestibular schwannomas. Although small differences in tumor size are unlikely to impact outcomes significantly, treatment with either radiosurgery or microsurgery is usually recommended following radiological detection of tumor growth. The objective of the current study was to identify potential inflection points in vestibular schwannoma tumor size, where the risks of treatment with single-fraction stereotactic radiosurgery (SRS) accelerate to inform timing of intervention.

Methods: Adult (≥ 18 years old) patients with sporadic vestibular schwannoma who underwent SRS from 2000 through 2022 were included.

Results: A total of 749 patients with a median age at SRS of 62 years were studied, the majority (n = 566 [76%]) of whom had tumors extending into the cerebellopontine angle (CPA) at SRS. The optimal tumor size cut point to predict SRS failure and need for salvage treatment was 4 mm or more of CPA extension (c-index 0.59, HR 3.60, p = 0.01). The optimal tumor size cut point to predict the outcome of facial nerve paresis was 13 mm or more of CPA extension, resulting in a c-index of 0.63 (HR 2.88, p = 0.01). Among patients with at least 3 months of surveillance before SRS, those with a tumor growth rate ≥ 2.5 mm/year were more likely to undergo salvage treatment than those with a growth rate < 2.5 mm/year, although this difference did not achieve statistical significance (HR 1.82, p = 0.18).

Conclusions: The risk of SRS failure requiring salvage treatment and the risk of post-SRS facial nerve paralysis increase at sizes of approximately 4 and 13 mm extension into the CPA, respectively, providing a size threshold anchor to help guide treatment decision-making regarding timing of SRS. Furthermore, rapid tumor growth during the initial wait-and-scan period may be associated with an increased risk of radiosurgical failure, which may influence choice of treatment.

Objective: Choroidal anastomosis (ChA) is considered a key indicator of increased hemorrhagic risk in adult moyamoya disease (MMD); however, its clinical course remains unclear. The aim of this study was to identify potential predictors of ChA rupture.

Methods: Retrospective evaluation of clinical and radiological data from 132 ChA-positive hemispheres (86 patients with MMD) treated at a single institution from March 2019 to March 2024 was conducted on a hemisphere-by-hemisphere basis. Two independent raters investigated the morphological characteristics of the ChA, including the lumen area (LA), branching pattern, and presence of a ChA-related pseudoaneurysm, using high-resolution vessel wall imaging. The primary endpoint was subsequent ChA-related hemorrhage, indicating ChA rupture. The secondary endpoint was any hemorrhagic stroke. A multivariate Cox proportional hazards model was used to evaluate the predictors of each endpoint.

Results: Thirteen hemorrhagic strokes occurred in 12 hemispheres (12 patients) during a mean follow-up period of 35.2 months. Nine ChA-related hemorrhages were observed in 9 hemispheres. The predictors for ChA rupture (primary endpoint) were LA of the ChA (per 1-mm2 increase; HR 36.4, 95% CI 4.50-294; p = 0.001), complex-type ChA (HR 4.64, 95% CI 1.08-19.9; p = 0.039), ChA-related pseudoaneurysm (HR 31.6, 95% CI 2.10-474; p = 0.013), and revascularization surgery (HR 0.12, 95% CI 0.02-0.79; p = 0.028). The predictors for any hemorrhagic stroke (secondary endpoint) were hemorrhagic presentation (HR 4.86, 95% CI 1.20-19.6; p = 0.026), LA of the ChA (per 1-mm2 increase; HR 24.9, 95% CI 3.43-180; p = 0.001), complex-type ChA (HR 4.42, 95% CI 1.19-16.3; p = 0.026), ChA-related pseudoaneurysm (HR 46.3, 95% CI 4.94-433; p = 0.001), and revascularization surgery (HR 0.14, 95% CI 0.03-0.64; p = 0.012).

Conclusions: In ChA-positive hemispheres, a larger LA of the ChA, complex-type ChA, and the presence of ChA-related pseudoaneurysms were significant predictors of subsequent ChA rupture and hemorrhagic stroke, whereas revascularization surgery can reduce the risk of subsequent ChA rupture and hemorrhagic events.

Objective: Cervical dystonia (CD) is the most common focal dystonia, characterized by abnormal head postures and pain, often refractory to botulinum toxin therapy. Selective peripheral denervation (SPD) remains a key surgical option, but long-term outcomes in large cohorts are underreported. The purpose of this study was to evaluate the long-term outcomes of SPD in patients with botulinum toxin-refractory CD, focusing on symptom severity, pain, and head posture improvement.

Methods: This retrospective study included 160 adults (mean ± SD age 54 ± 12.0 years, 46% male) with refractory CD who underwent SPD at a single center by a single surgeon from January 2005 to July 2023. Outcomes were assessed using subjective clinical measures and the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), which was calculated retrospectively from clinical records. The modified Bertrand technique involved selective denervation and myotomies tailored to each patient's dystonic pattern. TWSTRS scores were analyzed at baseline, 3 months, 1 year, and final follow-up (mean ± SD 10.3 ± 9.0 months). Time to minimal clinically important difference (MCID) (≥ 12-point TWSTRS drop) was evaluated with covariate-adjusted Kaplan-Meier modeling (ever vs never revised, evaluated with the log-rank test) and a counting-process Cox model with revision as a time-dependent covariate.

Results: Among 160 patients (mean follow-up duration 21.6 ± 35.6 months), TWSTRS improved by 73.5% at 3 months and 61.3% at last follow-up (p < 0.001). Median time to MCID was 3.0 months for never revised patients versus 22.0 months for ever revised patients (log-rank chi-square statistic = 19.09, p < 0.0001). In a time-dependent Cox model, revision surgery was significantly associated with higher likelihood of achieving MCID (HR 2.31, p < 0.005). Pain relief and improved head posture were reported in over 50% of patients. Complications were minimal, and recurrence was observed in 4.2% of cases. Outcomes were consistent with or exceeded those reported in the literature with either SPD or deep brain stimulation (DBS).

Conclusions: SPD is an effective and durable surgical option for refractory CD, significantly improving pain, posture, and quality of life. Although revision surgery delayed time to improvement, it significantly increased the likelihood of achieving meaningful clinical improvement. Overall efficacy aligns with the existing literature, reinforcing its role as a first-line surgical intervention. Further studies should explore strategies to enhance long-term outcomes and delineate the role of SPD relative to DBS.

Objective: Internal carotid artery (ICA) bifurcation (ICAB) aneurysms carry high rupture risk, treatment challenges, and recurrence due to complex morphology and origination patterns. Given their relatively low incidence, research on ICAB morphology is limited. This study analyzed ICAB morphology in aneurysmal, contralateral, and healthy bifurcations, highlighting bilateral differences, anterior cerebral artery (ACA) dominance, and deviations from the vascular optimality principle (VOP).

Methods: A total of 194 angiographic volumes (40 aneurysmal, 28 contralateral, 126 healthy) were evaluated. ICAB morphology included parent/daughter vessel diameters and angle between the ICA and middle cerebral artery (MCA; ФMCA), angle between the ICA and ACA (ФACA), total ICAB angle (ФICAB; ФMCA + ФACA). Aneurysm characteristics (size, neck, origination) and VOP parameters (radius ratio [RR] and junction exponent [n]) were evaluated. Bilateral analysis accounted for ACA dominance.

Results: Compared with controls, aneurysmal ICABs exhibited wider ΦMCA (57.22° ± 12.22° vs 43.74° ± 9.41°, p < 0.001; area under the curve [AUC] = 0.83) and ΦICAB (160.27° ± 16.16° vs 143.66° ± 10.74°, p < 0.001; AUC = 0.79), but not ΦACA, in univariate, multivariate (AUC = 0.85), and bilateral analyses. Angle thresholds of 51.7° for ΦMCA and 152.4° for ΦICAB were identified. Aneurysms originated predominantly off the apex (65%) and ACA (30%). Most occurred on ICABs with dominant (31%) and codominant (58%) A1 segments. Aneurysm neck, but not size, correlated with ΦMCA and ΦICAB, but not ΦACA. In controls, ΦMCA was larger and ΦACA smaller on the dominant A1 side, with no ΦICAB difference. There was no statistically significant difference in RR and n values regardless of aneurysm presence and dominance status.

Conclusions: Aneurysmal ICABs have wider bifurcation angles that are more predominant on the MCA side compared with healthy controls. Only 10% of the aneurysms were found to occur on ICABs with the nondominant A1 segment. A1 dominance status influences bifurcation morphology not only in aneurysmal ICABs but also in healthy controls. These findings underline the importance of ICAB morphology for the likelihood of aneurysm presence, an association that can inform clinical decisions and may serve in predictive analytics.

Objective: Craniopharyngiomas (CPs) pose significant surgical challenges due to their proximity to critical neurovascular structures and their high recurrence rates. The endoscopic endonasal approach (EEA) has emerged as a reliable alternative to craniotomy, offering unique advantages. This study aimed to summarize management experience by analyzing the largest single-team cohort of the EEA for CPs, providing insights for optimizing treatment and guiding surgical decision-making.

Methods: A retrospective analysis of 604 patients with CP (ages 2-76 years) treated via the EEA from 2019 to 2023 was conducted. A new tumor classification based on the relationship between the tumor and key anatomical interfaces in the EEA (sellar diaphragm and third ventricle floor) was proposed. Three surgical corridors were used: chiasm-pituitary, suprachiasmatic translamina terminalis, and transclival. Intraoperative visual evoked potential (VEP) monitoring was assessed for visual protection. Risk factors for complications and progression-free survival (PFS) were analyzed.

Results: Gross-total resection (GTR) was achieved in 89.7% of cases (93.7% in primary vs 78.8% in recurrent tumors). CSF leak rates declined from 7.35% in 2019 to 1.63% in 2023, with hypoalbuminemia and larger dural defects emerging as independent risk factors in adults. VEP monitoring reduced visual deterioration (6.74% vs 12.62%, p = 0.015). Recurrent tumors (odds ratio [OR] 5.397, 95% CI 2.984-9.763; p < 0.001), larger tumor volume (OR 1.038, 95% CI 1.018-1.06; p < 0.001), Puget grade II (OR 2.35, 95% CI 1.249-4.42; p = 0.008), and massive calcification (OR 2.541, 95% CI 1.333-4.841; p = 0.005) were independent risk factors for non-GTR (NGTR). Multivariate Cox analysis showed that NGTR (hazard ratio [HR] 9.181, 95% CI 5.143-16.392; p < 0.001), Puget grade I (HR 3.306, 95% CI 1.385-7.895; p = 0.007), Puget grade II (HR 2.918, 95% CI 1.260-6.755; p = 0.012), cystic tumor (HR 1.794, 95% CI 1.065-3.021; p = 0.028), and calcification (HR 2.249, 95% CI 1.206-4.195; p = 0.011) were independently associated with decreased PFS. Pediatric patients had higher GTR and lower CSF leak incidence rates than adults.

Conclusions: The EEA could be considered the first-line surgical treatment modality for most adult and pediatric patients with CP. For large CPs invading the hypothalamus, the EEA allows for sharp dissection of the tumor from the hypothalamus under direct visualization, enabling complete resection while minimizing hypothalamic damage. Intraoperative VEP monitoring aids in reducing visual deterioration. The proposed tumor classification and experience can enhance surgical quality, reduce complications, and guide patient counseling.

Objective: Gunshot wounds to the head (GSWH) are devastating injuries associated with high rates of morbidity and mortality. Poor outcomes in these patients necessitate identifying which patients may benefit the most from aggressive clinical and surgical management. The Baylor score uses patient age, pupil reactivity, Glasgow Coma Scale (GCS) score, and bullet trajectory at initial presentation to prognosticate mortality and Glasgow Outcome Scale (GOS) score at 6 months. In this cohort of patients with GSWH, the authors aimed to demonstrate internal validation of the Baylor score, which was recently externally validated by a distinct patient cohort at a different level I trauma center.

Methods: Data were obtained from the trauma registry at a high-volume level I trauma center. Patients with penetrating cranial gunshot wounds from January 2008 to May 2022 were identified and retrospectively analyzed. Patient demographics, GCS score, pupillary response, and bullet trajectory on CT scan were reviewed, and the Baylor score was calculated for each patient. GOS score was determined for each patient at last follow-up. The validity of the Baylor score to predict mortality and good functional outcomes was assessed using receiver operating characteristic curves and areas under the curve (AUCs) as performance measures.

Results: Over the 14-year study period, 404 patients met the inclusion criteria (mean age 31.5 [SD 12.9] years, 88.9% male). A total of 227 (56.2%) patients died, while 139 (34.4%) had good functional outcomes defined as GOS score 4 or 5 (moderate disability or good recovery, respectively). The Baylor score demonstrated good prognostication of both mortality (AUC 0.91) and good functional outcomes (AUC 0.93). Baylor scores of 0-2 underestimated good functional outcomes, and scores of 3-5 underestimated mortality. Patients older than 35 years with nonreactive pupils and low GCS score (3 or 4) had 100% mortality.

Conclusions: The Baylor score is a useful and accurate tool for clinicians to estimate mortality and functional outcomes in patients with GSWH. The score may be valuable in guiding patient- and family-centered discussions regarding prognosis early in the treatment course.

Objective: Waste accounts for up to 25% of United States healthcare expenditures. Many sterilized surgical instruments remain unused during procedures, contributing to this burden. Reducing the quantity of unused surgical instrumentation presents an opportunity to decrease costs while improving operating room efficiency. This study aimed to characterize instrument utilization patterns and implements a novel, systematic, replicable protocol to eliminate excess sterile instrumentation.

Methods: This prospective, single-center study investigated sterile instrumental utilization rates (IURs) across and within procedures. Craniotomy for tumor was used to characterize instrument utilization patterns on a per-surgeon, per-surgery, and per-instrument level. A novel 3-phase protocol was designed to systematically reduce sterile surgical waste. In phase 1, IURs were calculated by dividing the instruments used during a procedure by the number provided. Instruments used in fewer than 20% of cases were removed in phase 2. Streamlined instrument kits were demoed while the original kit remained at hand, and instruments were replaced as requested. Phase 3 represented full integration of the reduced kits with removal of the original kits. IURs and the number of instruments used were compared before and after protocol implementation. The protocol was implemented in 17 additional surgical procedures. Follow-up data were collected over 1 year after instrument kit reduction.

Results: The authors observed 69 cases across 6 procedures. Procedural IURs ranged from 11.3% to 38.4%. Most instrument types remained infrequently used (< 20%) across procedures. In craniotomy for tumor, IUR among the pilot instrument kit ranged from 30.6% to 35.3% (median 33.4%) with no significant variation in the number of instruments used per case (p = 0.88). Following protocol implementation, craniotomy instrument kits were reduced from 157 to 99 instruments. IUR increased to 55.2% (p < 0.001) with no change in the number of instruments used per case (mean 52.2 ± 5.4 preintervention vs 54.4 ± 5.0 postintervention, p = 0.43). The number of infrequently used instruments decreased from 38 to 10. Applied to 18 procedure types across 11 surgical specialties, the protocol reduced kit sizes by 21%-60% (median 38%). No changes to reduced instrument kits were requested following implementation.

Conclusions: Instrument utilization is consistent between surgeons and cases. The systematic elimination of unused sterile surgical instrumentation can therefore reduce surgical waste through a replicable protocol without impacting surgeon instrument selection.

Objective: The risk of hemorrhage during stereoelectroencephalography (SEEG) is low but not negligible. The planning of avascular trajectories together with the accuracy of the implantation technique plays an important role for the reduction of this risk. The aim of this study was to compare vessel visualization using dedicated MR arteriography-venography (MRAV) versus frequently used contrast-enhanced T1-weighted MRI for the planning of avascular SEEG trajectories.

Methods: Among 93 patients with drug-resistant epilepsy, 100 SEEG schemes from 100 consecutive SEEG procedures (86 patients with single SEEG and 7 patients with 2 SEEG explorations) with 1525 electrodes were included in this study. Every SEEG scheme was a result of a multidisciplinary discussion and aimed to test a hypothesis for the localization of the epileptogenic zone based on the results of previous noninvasive investigations. All patients had dedicated MRI for SEEG planning including the following 3D sequences/techniques: T1-weighted, FLAIR, T2-weighted, MRAV, and T1-weighted with a double dose of contrast (T1+2C). Avascular planning was based on the individual SEEG scheme with 10-22 trajectories (mean 15 trajectories). A distance of 2.5 mm from the trajectory to the closest vessel on the pial surface was considered as an obligatory safety margin. All vessels closer than this safety margin on the pial surface were considered dangerous. Two neurosurgeons planned independently all the 100 SEEG schemes on T1+2C or MRAV. The same neurosurgeons performed cross-checking with the alternative vascular sequence while looking for dangerous vessels (i.e., T1+2C was checked with MRAV and MRAV was checked with T1+2C). Finally, the rate of detection of dangerous vessels on T1+2C after planning on MRAV and the rate of detection of dangerous vessels on MRAV after planning on T1+2C were calculated and compared.

Results: MRAV visualized a dangerous vessel at the pial entry point in 96 of 100 SEEG explorations that were first planned on T1+2C. The number of dangerous vessels found on MRAV after T1+2C planning ranged from 0 to 5, most frequently 4 dangerous vessels per planning. Overall, 291 of 1525 trajectories (19.1%) were found in 100 SEEG procedures in which MRAV visualized a vessel in the safety zone after SEEG was initially planned on T1+2C. In contrast, there was no vessel visualized on T1+2C in the safety zone when the SEEG was initially planned on MRAV.

Conclusions: These findings indicate that MRAV allowed better vessel visualization than T1+2C during SEEG planning.