Journal of neurosurgery最新文献

Objective: Maximizing extent of resection (EOR) for language-eloquent high-grade glioma (HGG) must be balanced against the risk of neurological deficit. Predictors of postoperative decline in language remain poorly characterized. This study aimed to evaluate intraoperative predictors of postoperative language decline, along with predictors of subsequent temporal recovery.

Methods: The authors conducted a single-center study of patients undergoing awake craniotomy for the resection of language-eloquent HGG utilizing diffusion tractography, 5-aminolevulinic acid (5-ALA), and subcortical stimulation (SCS) with intraoperative language testing. Cases were reviewed between January 2017 and November 2024. Data assessing intraoperative language function, SCS parameters, EOR, along with language deficit at the 48-hour, 2-week, and 3-month follow-ups were collected. Receiver operating characteristic curves and Youden's Index were used to identify optimal subcortical stimulatory thresholds predicative of postoperative deficit in respective language domains for individual fiber tracts, including the inferior fronto-occipital fasciculus (IFOF), arcuate fasciculus (AF) and superior longitudinal fasciculus (SLF), and inferior longitudinal fasciculus (ILF).

Results: A total of 130 patients (78 male, 52 female; mean age 57.1 years) were included. Postoperatively, a new or worsened language deficit was observed in 69 patients (53.1%). This was permanent (> 3 months) in 12 cases (9.2%). Clinical deterioration during awake language testing was a significant predictor of short-term (< 3 months) decline in language domains including semantic processing (IFOF) (RR 3.47, p = 0.0002), reading (ILF) (RR 21.4, p = 0.0025), and auditory naming/repetition (AF/SLF) (RR 6.98, p = 0.001). Factors associated with permanent postoperative language decline were the presence of preoperative speech deficit (RR 2.65, p = 0.020), intraoperative deterioration in ILF-related reading function (RR 8.92, p = 0.0407), and positive SCS of multiple white matter language tracts. Individual stimulation thresholds predictive of functional decline are presented for IFOF, AF, and ILF.

Conclusions: This study evaluated multimodal resection of language-eloquent HGGs using awake mapping, 5-ALA, and tractography. It highlights the significant risk of transient decline in language function following eloquent tumor resection, particularly if a patient has an existing language deficit. The posterior ILF with its associated reading function appears to be most sensitive to decline and shows the least propensity for functional recovery. Deficits correlated with specific white matter tract involvement, especially when multiple tracts were affected. Proposed stimulation thresholds offer a novel guide for safer resections, supporting a multimodal strategy to balance maximal tumor removal with language preservation.

Objective: Iatrogenic ischemic injury is believed to be one of the major causes of postoperative neurological deterioration after resection for diffuse low-grade glioma (dLGG). Epidemiological data on ischemic injury following glioma surgery are limited. The aim of this study was to explore the incidence of postoperative ischemia in a population-based cohort and investigate any correlation with postoperative neurological deterioration.

Methods: In this retrospective study, ischemic lesions following dLGG resections, performed at 9 hospitals in Sweden and Norway between 2012 and 2017, were identified on diffusion-weighted MRI and volumetrically segmented. The association between the incidence, size, or type of ischemic lesion (rim lesions, limited to the resection border, or sector lesions, extending further into the brain tissue) and postoperative neurological deficits was analyzed.

Results: A total of 286 patients were eligible for study inclusion. A postoperative ischemic lesion was found in 245 (85.7%) cases. In 87 (30.4%) patients, lesions were classified as the rim type; 158 (55.2%) patients had the sector type. Larger ischemic lesions were observed among patients with permanent major deficits (4.2 vs 1.6 cm3, p = 0.022). Sector-shaped ischemic lesions were more often associated with transient neurological deterioration than the rim lesions. The use of advanced imaging, intraoperative monitoring, or other specific neurosurgical techniques and tools did not affect the incidence of ischemic lesions.

Conclusions: The authors found postoperative ischemic lesions to be common after the resection of dLGG. Large and sector-shaped, but not rim-shaped, lesions were associated with measured postoperative neurological deficits. Preventing or limiting the extent of these ischemic injuries is important for improving functional results in dLGG surgery.

Objective: The aim of this study was to evaluate the role of hemodynamic parameters in predicting the efficacy of microvascular decompression (MVD) in patients with classic trigeminal neuralgia (CTN) using computational fluid dynamics (CFD).

Methods: Patients with unilateral CTN were recruited from May 2022 to December 2023. Preoperative time-of-flight MR angiography was used to identify neurovascular compression sites. CFD simulations were performed to analyze hemodynamic parameters such as peak systolic flow (PSF), peak systolic pressure drop (PSPD), maximum wall shear stress (WSS), and oscillatory shear index (OSI). Logistic regression analysis was used to develop predictive models for MVD efficacy.

Results: Fifty-six patients were included (28 in the effective MVD group and 28 in the ineffective MVD group). The effective group exhibited significantly lower PSF (mean 0.202 [SD 0.136] vs 0.306 [SD 0.142] ml/sec, p = 0.007) and higher PSPD (mean 33.239 [SD 20.122] vs 22.864 [SD 15.624] Pa, p = 0.036), maximum WSS (median 3.231 [interquartile range (IQR) 2.084-4.359] vs 2.197 [IQR 1.592-3.445] Pa, p = 0.024), and OSI (median 0.001 [IQR 0.001-0.002] vs 0.001 [IQR 0.001-0.001], p = 0.029). Logistic regression analysis identified PSF and maximum WSS as significant predictors of MVD efficacy. The developed prediction models showed high accuracy, with model 2 (using the backward logistic regression method) achieving an area under the receiver operating characteristic curve of 0.920 and both sensitivity and specificity of 90%.

Conclusions: Hemodynamic parameters, particularly PSF and maximum WSS, significantly predict MVD efficacy in CTN. Integrating these parameters into clinical practice could improve surgical outcomes and guide personalized treatment strategies.

Objective: Patients experiencing ischemic strokes typically develop substantial cognitive decline. Intracranial atherosclerotic disease (ICAD) is a common stroke etiology that exposes patients to high and prolonged risks of recurrence. The ERSIAS-PC (Encephaloduroarteriosynangiosis revascularization for symptomatic intracranial atherosclerotic steno-occlusive performance criterion) phase II trial showed a lower risk of recurrent stroke in patients who underwent encephaloduroarteriosynangiosis (EDAS) plus intensive medical management (IMM). In the current study, the authors evaluate factors contributing to cognitive decline in patients with symptomatic ICAD treated with EDAS revascularization.

Methods: ERSIAS-PC patients without aphasia who had completed at least 1 year of follow-up were included this post hoc analysis. Cognitive function was evaluated using the Montreal Cognitive Assessment (MoCA) at baseline and each follow-up and was classified as improved/preserved or worsened. Classification and regression tree (CART) analysis was used to identify factors associated with changes in cognitive function. The factors considered were age, sex, stenosis versus occlusion, baseline modified Rankin Scale score, good collateralization, and compliance with diabetes mellitus (DM), hypertension, and hyperlipidemia (HLD) treatments.

Results: Of the 52 ERSIAS-PC patients, 39 were included in this subgroup analysis. The median age was 46 (IQR 37.0-56.0) years, and 27 (69.2%) patients were female. The mean MoCA score was 22.4 ± 4.9 at baseline and 23.9 ± 4.9 at the 1-year follow-up among the 52 patients in the ERSIAS-PC trial population. Among the 39 patients in this subgroup analysis, the MoCA score improved or remained stable in 33 (84.6%) and declined in 6 (15.4%). CART analysis indicated that the most relevant factor for an improved MoCA score after surgery was compliance with DM treatment (94.5% yes vs 74.2% no, p = 0.02). Other factors indicating a nominal though not statistically significant influence were HLD treatment (83.3% yes vs 60.5% no, p = 0.2) and stenosis (99.1% vs 80.9% occlusion, p = 0.6).

Conclusions: Compliance with DM treatment was significantly associated with cognitive preservation in patients with symptomatic ICAD treated with EDAS. The study findings emphasize the importance of the IMM of stroke risk factors in patients with intracranial atherosclerosis, even after surgical revascularization.

Objective: Carotid blowout syndrome is a constellation of clinical presentations involving injury to the extracranial carotid system. It is frequently secondary to postradiation effects or direct invasion from head and neck cancers and is often managed via endovascular therapy (EVT). However, intracranial internal carotid artery blowout syndrome (ICABS) is a less described entity, has no predefined management algorithms, and can be difficult to manage due to the inherent anatomical limitations of the intracranial carotid. The aim of this study was to perform an individual participant data meta-analysis and present an institutional case series to describe the clinical course of ICABS, as well as to provide a treatment algorithm for this rare syndrome.

Methods: A search for all reported ICABS cases was performed using PubMed, Embase, Scopus, Web of Science, and Google Scholar until June 30, 2024. Additional cases from our institution were added. The primary outcomes were hemorrhagic control, postoperative complications, and all-cause mortality.

Results: The database search yielded 31 studies, and with the addition of 8 patients from the study institution, 80 patients (median age was 55 years) with ICABS were analyzed. The most common injury type was acute blowout (53.8%) and the most commonly affected segment was the petrous internal carotid artery (43.8%). The most frequent underlying diagnosis was head and neck cancer (52.5%). Radiation therapy (37.5%) and surgery (37.4%) were the most common preceding interventions. Overall bleeding control after individualized therapy was attained in 81.2% of patients, with most requiring parent vessel sacrifice (41.2%). The overall postoperative complication rate was 35%. The overall mortality rate was 27.5%, with mortality occurring predominantly in the conservative treatment group (60%) compared with the EVT (27.6%) and surgery (17.6%) groups.

Conclusions: ICABS is rare and often fatal. It frequently occurs after radiation therapy for head and neck cancer or iatrogenically during transsphenoidal surgery. First-line treatment for acute ICABS is often EVT, as it offers a rapid means of halting further hemorrhage. Emerging technologies have allowed for more vessel-preserving strategies and warrant further investigation. Herein, an evidence-based algorithm is provided to help guide management. Systematic review registration no.: CRD42022385494 (www.crd.york.ac.uk/prospero/).

Objective: Electrical stimulation mapping is a widely used technique to determine functional localization for medically refractory epilepsy. Sites where stimulation interferes with naming are often focal regions of the frontal and temporal cortex. The extent to which these crucial sites remain in the same location over time in an individual adult patient has not yet been established. The aim of this study was to determine whether cortical naming sites identified using stimulation mapping are stable in their anatomical location over time in adult patients with medically refractory epilepsy.

Methods: Twenty-two patients who underwent electrical stimulation mapping for medically refractory epilepsy during surgical interventions separated by more than 1 year between 1967 and 2005 were included. A median of 8.35 years elapsed between mappings. The mean age at the first operation was 27.7 (range 10-39) years. Fourteen patients were female. Mapping occurred under two different conditions: intraoperatively in procedures conducted under local anesthesia or extraoperatively through implanted grid electrodes. A Bayesian hierarchical model of language site locations across repeated interventions was used to assess the stability of locations of stimulation-evoked interference in language naming.

Results: Sites where electrical stimulation interferes with language naming were separated by a median of 0.6 cm between the 2 mappings. Eighty-six percent of the mapped sites related to language naming at the second operation were within 1.5 cm of a site identified at the first operation, 61% within 1 cm, and 36% within 0.5 cm. However, in 2 patients, none of the identified language naming sites at the second operation were within 1.5 cm of the sites from the first operation.

Conclusions: This unique, long-term series of neurosurgical mappings reveals that language naming sites in the cortex of adult patients with epilepsy show substantial long-term stability over many years. However, rare relocation of these sites does occur in some patients over many years.

Objective: The aim of this study was to introduce the visuo-operative angle (VOA) as a novel neuroanatomical metric for quantifying surgical exposure and visibility in skull base microsurgery. The VOA measures the alignment between surgical trajectories and target exposure areas in 3D space. Additionally, the authors explored its implementation in 3D photogrammetry of cadaveric models and 3D-segmented presurgical imaging models to assess the feasibility of VOA in experimental and clinical settings.

Methods: Five latex-injected human cadaveric specimens were used to evaluate various endoscopic and microscopic approaches. The VOA was calculated as the angle formed by the surgical trajectory line and the plane of the target exposure area. Photogrammetry was used to generate high-resolution 3D models of the dissected regions and replicate the measurement virtually. Finally, a clinical exploratory trial was conducted in a patient undergoing an endoscopic endonasal approach for a pituitary neuroendocrine tumor (PitNET) with clival erosion. Three-dimensional-rendered preoperative imaging was used to define and measure the target clival region and its VOA, and intraoperative neuronavigation validated the measurement.

Results: VOA showed excellent interrater agreement across 36 target areas (bias ≤ 1°, within-subject coefficient of variation 1%-6%). Endoscopic and microscopic findings were consistent with prior literature using different exposure metrics and expert opinion while adding surgically relevant detail on trajectory visibility and instrument direction toward deep targets (e.g., an endoscopic transorbital approach [ETOA] vs a transmaxillary approach to Meckel's cave and the anterolateral triangle; subtemporal vs translabyrinthine/retrosigmoid approaches to the internal acoustic canal; frontotemporal-orbitozygomatic approach vs ETOA at the clinoid triangle). Photogrammetry yielded measurements highly concordant with cadaveric data. Presurgical estimates (VOA approximately 52.7°) aligned with intraoperative values (53.5°), supporting the feasibility of the VOA as an analytical tool for approach analysis and modeling.

Conclusions: The VOA is a simple, reproducible geometrical metric (in degrees) that relates the surgeon's line of sight and instrument path to the target plane, adding directional detail not captured by conventional metrics. Integrated with photogrammetry and 3D-segmented imaging, the VOA enables the quantitative comparison of corridors and approach variants, as well as supporting regional anatomy modeling. Early results are promising, but larger cadaveric series and multicase clinical studies are needed to establish the accuracy, robustness, and applicability of this metric across anatomical research, surgical planning, and intraoperative calculations.