Journal of neurosurgery最新文献

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.

Objective: Lesions of the cerebellopontine angle (CPA) and petroclival region represent a challenging surgical target due to the complex anatomy of the involved neurovascular structures. In this scenario, cranial nerve (CN) VI is particularly exposed to potential injuries due to its deep-seated location and absence of a bony foramen that serves as a reference of its most distal cisternal point, especially when it is encased or displaced by large lesions. This study aimed to provide reliable operative guidance for preventing injuries to CN VI during the retrosigmoid approach to address CPA and petrotentorial lesions.

Methods: Four formalin-fixed, latex-injected anatomical specimens were dissected to highlight and investigate the relevant anatomy of the CPA and petroclival region during the retrosigmoid approach. Additionally, 50 sides of noninjected formalin-fixed specimens were dissected for morphometric evaluation. Correlations between the petrotentorial junction (PTJ), porus acusticus (PA), and trigeminal impression (TI) with the entry point of CN VI into Dorello's canal were evaluated. An illustrative clinical case and a 3D anatomical model generated through the photogrammetry scanning technique were described.

Results: In the sagittal plane, CN VI entrance into Dorello's canal was found in a trajectory parallel to the PTJ, passing through the inferior aspect of the PA and 21.5 ± 1.3 mm anteriorly. In the coronal plane, the entry point of CN VI into Dorello's canal was estimated at 6.2 ± 1.2 mm from the anterior edge of the TI in a trajectory perpendicular to the PTJ in 47 (81%) specimens.

Conclusions: The obtained results demonstrated two surgical strategies to locate Dorello's canal within the retrosigmoid route: 1) approximately 20 mm anterior along the inferior edge of the PA parallel to the PTJ; and 2) approximately 6 mm inferior to the anterior edge of the TI, perpendicular to the PTJ. The defined operative strategies provide reliable anatomical guidance to locate the entrance of CN VI into Dorello's canal within the retrosigmoid route, potentially reducing the risk of abducens nerve palsy and improving patient outcomes.

Objective: Postoperative ischemia is a major complication of neurosurgical procedures. Perforator territory ischemia has been related to poor postoperative neurological outcome. This study aimed to investigate the incidence and clinical severity of postoperative perforator territory ischemia in patients with intra-axial or extra-axial tumors.

Methods: Between 2019 and 2022, records of all patients who underwent craniotomies for intra-axial or extra-axial tumors at the authors' brain tumor center were retrospectively reviewed. Patient and disease characteristics, abnormalities identified on early postoperative MRI diffusion-weighted imaging (DWI) sequences, and neurological status measured using the full-scale National Institutes of Health Stroke Scale (NIHSS) at the preoperative time and postoperative follow-up were extracted. Groups were compared based on NIHSS score deterioration at discharge and were stratified for intra-axial tumor subtypes and extra-axial tumor locations. Postoperative DWI abnormality assessment was divided into different territories (perforator territory, cortex, insular, white matter, and multiple locations). The authors distinguished between "anticipated" ischemia directly bordering the resection cavity and iatrogenic injury related to vessel injuries. Multivariable linear regression analyses were performed with full-scale NIHSS scores at discharge as the dependent variable while adjusting for preoperative NIHSS scores and the territories where DWI abnormalities were detected.

Results: In total, 1012 patients underwent craniotomies at the authors' institution. Ultimately, 548 patients with intra-axial tumors and 188 patients with extra-axial tumors were included. The overall incidence of DWI abnormalities in the perforator territory in patients with intra-axial tumors was 14% (n = 74). In the intra-axial group, multivariable linear regression analysis showed that patients with postoperative perforator territory DWI abnormalities (β coefficient 0.72, 95% CI 0.18-1.27; p = 0.01), insular ischemia (β coefficient 0.95, 95% CI 0.08-1.81; p = 0.03), or cortical ischemia (β coefficient 0.43, 95% CI 0.06-0.81; p = 0.02) on DWI had a higher total NIHSS score at discharge. The overall incidence of perforator territory DWI abnormalities in patients with extra-axial tumors was 12% (n = 22). No association was found between NIHSS score at discharge and the territories showing DWI abnormalities.

Conclusions: The overall incidence of perforator territory DWI abnormalities suggesting ischemia was found to be around 13% in both patients with intra-axial and extra-axial tumors. Patients with intra-axial tumors, who had postoperative perforator territory or insular DWI abnormalities, performed worse neurologically at discharge, compared with patients with cortical and/or white matter ischemia.

Objective: Over the past decade, medical therapy has been the gold standard for patients with symptomatic low-grade cervical carotid artery stenosis. Recent advances in imaging techniques for diagnosing unstable plaques have led to evolving and innovative endovascular treatments. The aim of this study was to investigate the efficacy of carotid artery stenting (CAS) and examine differences in outcomes between medical therapy alone versus with CAS.

Methods: Consecutive patients with ischemic stroke due to low-grade carotid artery stenosis (< 50% per North American Symptomatic Carotid Endarterectomy Trial criteria) treated from April 2017 to January 2024 at a single center were analyzed in this retrospective study. Patients received either medical therapy alone or medical therapy followed by CAS. The majority of CAS procedures (98%) were performed with closed-cell stents using the flow-reversal method. Patient medical records were reviewed and plaque features were assessed using multiple imaging modalities. Factors associated with recurrence of ischemic stroke after each treatment were also evaluated. Multivariable Cox regression and Kaplan-Meier analyses were performed to assess differences between treatment groups.

Results: Eighty-four patients (70 male, median age 77 years) were included in this analysis; 44 received medical therapy alone and 40 underwent CAS following medical therapy. In the medical therapy alone group, 27 patients (61%, 26%/patient-year) had new lesions on diffusion-weighted imaging, including 20 (45%, 21%/patient-year) with recurrent symptomatic stroke at the midterm follow-up (median 23 months, IQR 7.9-51 months). Factors associated with recurrence after medical therapy alone included dyslipidemia (HR 5.1) and intraplaque hemorrhage (HR 5.5). In the CAS group, 1 patient (2.5%, 0.8%/patient-year) had a stroke due to an in-stent plaque 4 years after CAS. Kaplan-Meier analysis of recurrent stroke showed a significantly lower rate in the CAS group compared with the medical therapy alone group (p < 0.001).

Conclusions: CAS has potential as a safe and valid treatment option for symptomatic low-grade carotid artery stenosis. The treatment strategy should be carefully considered in patients with dyslipidemia and unstable plaques with a high T1PMR on MRI.

Objective: Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive sarcomas commonly associated with neurofibromatosis type 1 (NF1), whose occurrence in schwannomatosis remains poorly understood. This study aimed to characterize MPNSTs in NF type 2 (NF2)- and SMARCB1-related schwannomatosis through a systematic review and meta-analysis of survival outcomes.

Methods: A comprehensive search of the PubMed, Embase, Scopus, SEER (Surveillance, Epidemiology, and End Results), and Web of Science databases was conducted from database inception through January 2024. Clinical, radiological, histopathological, and treatment data were extracted. Primary endpoints included overall survival (OS) and progression-free survival (PFS). Predictors of outcomes were analyzed using Kaplan-Meier survival curves and Cox proportional hazards models.

Results: A total of 39 cases were identified. NF2-related disease accounted for 67% of cases, while 28% were SMARCB1 related. The mean age at MPNST diagnosis was 33 years (range 9-79 years). Pain (41%) and weakness (26%) were the most common presenting symptoms. The mortality rate was 72.9%. No tumors were associated with LZTR1 mutations. Tumor locations varied widely, with involvement of the pelvis, thigh, skull base, forearm/hand, and cranial nerves. Trends suggested improved survival in the absence of S100 loss, gross-total resection, and a known schwannoma precursor. Conversely, having an intracranial or intraspinal lesion or having NF2 in the setting of prior radiation therapy were found to be associated with decreased survival and increased progression. A risk stratification tool predicted OS (HR 28.0, p < 0.0001) and PFS (HR 12.1, p < 0.0001).

Conclusions: MPNSTs, although rare in schwannomatosis, can arise even in the absence of prior radiation exposure and may mimic benign schwannomas. A preliminary risk stratification tool may aid in identifying high-risk patients and optimizing treatment approaches, although validation is needed. Given the aggressive nature of MPNSTs and their potential for delayed diagnosis due to their rarity, vigilant monitoring and individualized treatment strategies are crucial. Future research should focus on refining risk prediction models and exploring targeted therapies for schwannomatosis-associated MPNSTs to improve patient outcomes.

Objective: The objective of this study was to determine the efficacy of topical vancomycin application on the rates of surgical site infection (SSI) in craniotomy and noninstrumented spinal procedures.

Methods: In total, 1103 patients randomly received either topical vancomycin at the surgical site in addition to standard systemic antibiotic prophylaxis (n = 552) or standard antibiotic prophylaxis alone (n = 551). Symptoms of SSI were assessed via standardized patient surveys for SSI symptoms at postoperative day 30. Univariate, multivariate, and sensitivity analyses were used to determine the effect of topical vancomycin on SSI rate while accounting for demographic and procedural characteristics.

Results: Likely SSI rates did not vary between the treatment and control groups overall (3.94% vs 4.10%; risk difference -0.0016 [95% CI -0.027 to 0.024]; p = 0.90), nor when adjusted for known confounders. Stratification by procedure type showed different baseline rates of SSI, but in no group did topical vancomycin significantly reduce SSI rates. Sensitivity analysis based on various SSI classification schemes also showed no significant reduction due to topical vancomycin. Topical vancomycin use was not associated with significant systemic absorption or significant adverse events.

Conclusions: Topical vancomycin did not result in any significant reduction in SSI compared to the current standard of care. The authors believe that further research is needed to determine the role of topical vancomycin in neurosurgery, and that its use should not be established as the standard of care in the absence of clear evidence of its superiority over current prophylactic treatments.