Journal of neurosurgery最新文献

Objective: There is a paucity of studies on the optimal thresholds for neurointensive care (NIC) targets such as intracranial pressure (ICP) and cerebral perfusion pressure (CPP) in spontaneous intracerebral hemorrhage (sICH). There is also a need to clarify the role of cerebral pressure autoregulatory disturbances (pressure reactivity index [PRx]) and to determine if the autoregulatory CPP target (optimal CPP [CPPopt]) is superior to traditional fixed CPP targets in sICH. In this study, the authors aimed to explore the role of ICP, PRx, CPP, and CPPopt insults in sICH patients treated in the NIC unit.

Methods: In this observational study, 184 adults with sICH with intracerebral hemorrhage (ICH) volume above 10 ml who received > 12 hours of ICP monitoring during the first 7 days at the authors' NIC unit, Uppsala University Hospital, Sweden, between 2010 and 2019 (10 years) were included. Demographic characteristics, admission status, radiological examination, and clinical outcome were evaluated. Favorable outcome was defined as conscious at discharge, while unfavorable outcome as unconscious or deceased. ICP, CPP, PRx, and CPPopt during the first 7 days were analyzed in relation to outcome.

Results: In total, 138 (75%) patients recovered favorably at discharge. Lower percentage of good monitoring time with ICP above 25 mm Hg was independently associated with favorable outcome. CPP above 80 mm Hg was frequent and independently associated with favorable outcome. Median PRx did not differ between the outcome groups, but there was a trend toward worse outcome when PRx exceeded +0.5. Furthermore, when PRx was analyzed together with the concurrent ICP and CPP values, higher values increased the ICP and CPP interval associated with unfavorable outcome. Lastly, there was no independent correlation between CPP deviation from CPPopt and outcome.

Conclusions: Avoiding ICP elevations above 20 to 25 mm Hg and maintaining CPP above 80 mm Hg may be beneficial in sICH patients with large bleeding volume who require NIC. PRx was not independently associated with outcome, but higher values appeared to narrow the safe zones of ICP and CPP.

Objective: Superior canal dehiscence is a pathological aperture of the otic capsule overlying the superior semicircular canal. Currently, two disease subtypes are recognized by experts: frank dehiscence (FD) and near dehiscence (ND). This investigation compares the clinical manifestation and surgical outcomes between patients with FDs and those with NDs, in hopes of delineating their distinctions in pathophysiology and optimal management strategies.

Methods: The authors conducted a cohort study of consecutive middle cranial fossa repairs performed at their institution between 2011 and 2022. FDs were defined as clear dehiscence of the otic capsule, and NDs were defined as focal dehiscence or very thin bony labyrinth (< 0.1 mm) on CT imaging. Multivariable regression models were constructed to assess the relationship of dehiscence subtype with audiometric and symptomatologic baseline presentation and postrepair outcomes. Models were adjusted for demographics, history factors, and follow-up duration.

Results: Among 421 repairs included, 100 (24%) were for NDs and 321 (76%) were for FDs. At 250 Hz, FDs and NDs had a comparable baseline air-bone gap (ABG) (adjusted mean 23.8 dB vs 11.1 dB; adjusted β [aβ] 12.8, 95% CI -0.4 to 25.9) and exhibited a similar degree of narrowing postrepair (-11.7 vs -5.5; aβ -6.2, 95% CI -16.8 to 4.5). At 500 Hz, FDs had a wider baseline ABG (15.4 vs 6.4; aβ 9.1, 95% CI 4.3-13.8) but exhibited numerically greater narrowing postrepair (-6.1 vs 1.1; aβ -7.2, 95% CI -11.4 to -3.0). Despite similar baseline symptomatology, patients with FDs reported lower resolution rates of hearing loss (adjusted OR [aOR] 0.43, 95% CI 0.20-0.94) and higher postoperative onset rates of dizziness (aOR 5.12, 95% CI 1.06-24.76) and vertigo (aOR 8.56, 95% CI 1.11-66.16). Resolution rates for autophony and hyperacusis were similarly high (> 60%) among both cohorts.

Conclusions: Compared to patients with NDs, those with FDs presented with a wider low-frequency ABG but similar symptom profile at baseline. Postsurgery, patients with FDs demonstrated numerically greater ABG narrowing but reported higher rates of dizziness, vertigo, and persistent hearing loss. Nevertheless, surgery yielded objective and subjective benefits among both patients with FDs and those with NDs.

Objective: Patients with autosomal dominant polycystic kidney disease (ADPKD) have been identified to have a significantly increased risk of developing intracranial aneurysms (IAs). These patients are diagnosed at younger ages and are also at increased risk for IA rupture. The objective of this systematic review and meta-analysis was to identify risk factors associated with IA detection during screening of asymptomatic ADPKD patients.

Methods: The authors searched for studies reporting the prevalence of IA among patients with ADPKD screened using MRA, CTA, or DSA on PubMed, Embase, Google Scholar, Scopus, Web of Science, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov prior to August 2023 by using individualized standardized search strategies. Eligibility of all retrieved studies was assessed according to the PRISMA guidelines. Risk of bias of the included observational studies was assessed using the Newcastle-Ottawa Scale. Meta-analysis was performed using a random-effects model.

Results: Twenty-four observational studies involving 5907 patients with ADPKD were identified for quantitative analysis. The authors observed an overall prevalence of IA of 12.6%. They identified several risk factors for IA with statistically significantly increased odds for unruptured IA (UIA) detection, including female sex (18 studies, OR 1.63, 95% CI 1.37-1.94, I2 = 0%), family history of either IA or subarachnoid hemorrhage (SAH) (12 studies, OR 2.17, 95% CI 1.68-2.81, I2 = 0%), family history of SAH (3 studies, OR 2.67, 95% CI 1.25-5.71, I2 = 66.0%), stage 3 or greater chronic kidney disease (CKD) (4 studies, OR 2.55, 95% CI 1.84-3.54, I2 = 0%), and hypertension (13 studies, OR 1.41, 95% CI 1.04-1.91, I2 = 34%). Age > 45 years, family history of ADPKD, smoking status, and presence of liver cysts did not reach statistical significance as risk factors during this meta-analysis.

Conclusions: The results of the authors' meta-analysis suggest increased risk of UIA detection in screening of ADPKD patients who are female, have a family history of IA or SAH, have hypertension, or have moderate or more severe CKD. Given the increased prevalence of IA in ADPKD patients with these risk factors, these patients may stand to benefit from screening for IA early in treatment or at time of diagnosis, even if neurologically asymptomatic.

Objective: Tumor mutational burden (TMB) has been proposed as a prognostic biomarker in patients with metastatic cancer, as well as in patients who receive immune checkpoint inhibitor (ICI) therapy. However, the role of TMB as a biomarker for progression after resection of brain metastases, as well as perioperative ICI treatment response, is less defined. This study examined the impact of TMB on local CNS progression events in patients who underwent resection of a brain metastasis, as well as in those who received postoperative ICI treatment.

Methods: This was a single-center, retrospective cohort study of adult patients with clinical and molecular data available who underwent resection of a brain metastasis from 2019 to 2022. TMB was derived from next-generation sequencing based on a Clinical Laboratory Improvement Amendments (CLIA)-certified clinical oncogene panel. Local progression was the primary endpoint. Kaplan-Meier curves and Cox proportional hazards regression analysis were used to assess the relationship between the primary endpoint and TMB. Thresholds for high and low TMB were obtained from recursive partitioning analysis (RPA).

Results: The cohort consisted of 82 patients with multiple primary cancer types with a median follow-up time of 7 months. Twelve patients (15%) experienced local progression. According to RPA, a threshold for low TMB (< 5.2 mutations/Mb) was identified, which was associated with more rapid local progression (p < 0.001) according to the Kaplan-Meier analysis. On multivariate Cox proportional hazards regression analysis, low TMB was associated with shorter freedom from local recurrence (HR 13.6, 95% CI 1.80-103, p = 0.011). Among the patients who received postoperative ICI (n = 34), low TMB trended toward shorter freedom from local recurrence on Kaplan-Meier analysis (p = 0.062).

Conclusions: Lower TMB was associated with shorter freedom from local recurrence in resected CNS metastases. Among patients who receive postoperative ICI treatment, lower TMB also trended toward more rapid local progression.

Objective: Both direct and indirect surgical revascularization techniques are commonly applied for the treatment of moyamoya disease and syndrome; however, responses can be heterogeneous and efficacy in the context of ischemic disease is not yet formally known from randomized clinical trials. Here, a prospective, longitudinal interventional study was performed to test the hypothesis that presenting 1) parenchymal cerebrovascular reactivity (CVR) and 2) CVR response times portend hemodynamic improvements after direct and indirect revascularization.

Methods: Catheter angiography and hypercapnic blood oxygenation-weighted 3-T MRI (spatial resolution 3.5 × 3.5 × 3.5 mm, repetition time 2000 msec) were acquired before and 11.0 ± 7.9 months and 12.6 ± 6.9 months after surgery, respectively. In response to a 5% fixed-inspired CO2 respiratory challenge, time regression analyses were utilized to quantify maximal cerebrovascular reactivity (CVRmax) and time to reach maximal cerebrovascular reactivity (CVRdelay) to test the overarching hypothesis that presurgical measures predicted postsurgical CVRmax increases and CVRdelay reductions. Age, sex, surgical type, and preoperative impairment were considered as relevant explanatory variables in the regression analysis (significance criterion p < 0.05).

Results: A total of 47 operative hemispheres (32 indirect-only and 15 direct or combined direct-indirect revascularization) from 30 adult patients (median [range] age 43 [20-59] years) were evaluated. Direct/combined versus indirect revascularized brain hemispheres were matched for age (44.1 ± 11.1 vs 44.7 ± 13.8 years, p = 0.864), prior infarct (92.9% vs 92.6%, p = 0.976), and Suzuki stage within 1 stage on the 6-point staging scale (4.1 ± 0.7 vs 3.4 ± 0.6). Across all hemispheres and surgical procedures, CVRmax increased (p = 0.022) and CVRdelay decreased (p = 0.009) after surgery; however, responses varied considerably across hemispheres and surgical procedures. On multiple regression analysis, extent of preoperative impairment, quantified as preoperative CVRmax and moderated by the type of surgery performed, was an indicator of intervention-induced outcome in hemodynamics (p = 0.015). No effect of preoperative CVRdelay or age was found for outcomes.

Conclusions: The findings confirm heterogeneous CVR responses approximately 1 year after revascularization across patients, albeit moderated by type of revascularization. Of the variables considered, lower presurgical CVR provided the most significant indicator of the likelihood of postsurgical hemodynamic improvement.

Objective: Intracranial pressure monitoring (ICPM) is a cornerstone procedure in the management of severe traumatic brain injury (TBI). Yet, its implementation is low and the impact on outcomes debated. The authors' objective was to determine the association between ICPM and 1-year mortality in severe TBI.

Methods: The authors performed a retrospective cohort study utilizing data from the Israel National Trauma Registry (INTR) of severe TBI patients admitted to level I trauma centers from 2015 to 2021. Multivariable logistic regressions were performed to calculate the odds ratio (OR) of 1-year mortality, adjusted for age, Glasgow Coma Scale (GCS) score, other severe injuries (nonhead Abbreviated Injury Scale [AIS] score ≥ 4), hypotension, and surgical decompression. The main outcome was 1-year mortality.

Results: Of 2202 patients, 36.8% underwent insertion of ICPM. ICPM patients had a lower 1-year mortality rate (28.12% vs 33.60%, p = 0.015). Compared with ICPM, the adjusted odds of 1-year mortality of no ICPM were increased 1.2-fold (OR 1.21, 95% CI 0.96-1.54). The effect size was greater among patients with head AIS score 5-6 and age 18-64 years (OR 1.57, 95% CI 1.13-2.20) and age ≥ 65 years (OR 1.92, 95% CI 1.04-3.55); the effect size of no ICPM in those with head AIS score 3-4 was decreased (OR 0.49, 95% CI 0.26-0.93).

Conclusions: A significant association between ICPM and lower 1-year mortality in the most severe TBI patients (head AIS score 5-6) who were ≥ 18 years of age was observed. The authors' study supports the use of ICPM in severe TBI. The authors recommend more detailed reporting to best inform quality improvement programs on a national scale. This research contributes to the academic dialogue on TBI and the considerations for enhancing patient care.

Low-pressure hydrocephalus (LPH) is the presence of persistent ventriculomegaly with low to normal intracranial pressure. Patients with LPH respond to subzero drainage, which consists of external ventricular drainage at levels below the external auditory meatus. Multiple treatment modalities have been described in the literature, but due to low intracranial pressures, weaning the external ventricular drain can take weeks to even months. This poses a relevant gap in the knowledge of treatment for LPH. The authors describe a new technique of placing a programmable differential pressure valve below the clavicle as an effective and feasible way to treat LPH. The authors present their experience with 3 patients with LPH who required prolonged subzero drainage and had a shunt valve placed below the clavicle as an effective treatment for LPH. Three patients were diagnosed with LPH and underwent subzero drainage, and drain weaning trials were unsuccessful. All 3 patients received a programmable valve below the clavicle that enabled an expedited discharge with return to baseline. A shunt valve placed caudal to the clavicle is a feasible and effective long-term treatment option for LPH.

Objective: Prematch research productivity is a heavily utilized metric in evaluating neurosurgery residency applicants. With the rise in research output by successfully matched candidates and the so-called publication arms race, there is a growing interest in understanding the quality and impact of the research conducted by medical students who secure neurosurgery residency positions. This study aimed to characterize the research output of medical students who matched into neurosurgery in 2023, identify predictors of research productivity, and explore the implications of research output on match outcomes.

Methods: First-year neurosurgery residents from the 2023 match were identified via program websites. Research output data were collected from the PubMed and Scopus databases, excluding publications released after the 2023 National Resident Matching Program deadline. Predictive analyses were conducted using multiple linear regression models.

Results: Data were obtained for 242 1st-year neurosurgery residents and 2519 PubMed-indexed publications. The median numbers of total and first author publications were 7 (range 0-73) and 2 (range 0-25), respectively. The median number of citations was 28 (range 0-1010), with a median impact factor of 3.1 (range 0-30.43). Most publications represented retrospective clinical research (n = 839). Of the neurosurgery-related publications, spine-related research was most common (n = 410), while peripheral nerve research was the least common (n = 20). Factors associated with higher publication output included attending a top 20-ranked U.S. News & World Report medical school (p = 0.00044), international medical graduate status (p = 1.95e-6), and obtaining a doctor of philosophy degree (p = 0.00582). Applicants who published more than 30 papers averaged 4.16 citations per paper, whereas residents who published fewer than 30 papers averaged 8.34 citations per paper (p = 0.0006).

Conclusions: This study characterizes the research output of successfully matched neurosurgery applicants and identifies medical school ranking and degree status as predictors of research productivity. Interestingly, only the rank of the medical school attended predicted better match outcomes despite an overall shift to utilizing research as a metric of merit in residency applications in reaction to an increase in pass/fail medical school curriculums and changes in United States Medical Licensing Examination Step 1 grading systems. These findings also demonstrate that residents who published the most papers published the lowest-impact research, which aligns with the notion that there is an increased emphasis on publication quantity rather than publication quality.