Journal of neurosurgery最新文献

Objective: Given the challenges of interpreting preictal- and ictal-phase stereoelectroencephalography (SEEG), a complementary approach of examining interictal activity could be of value. High-frequency oscillations (HFOs), recorded at frequencies greater than 80 Hz in SEEG, are often pronounced in but not unique to the epileptogenic zone (EZ) compared with normal cortex. The aim of this study was to assess a novel HFO rate ratio to identify the EZ using region-specific interictal HFO rates, and to estimate the optimal threshold for the HFO rate ratio for both ripples and fast ripples to localize the EZ.

Methods: Patients with epilepsy who underwent resective surgery following SEEG at a single institution (January 2017-December 2022) and had available postoperative MRI with at least 12 months of follow-up were included. A region-specific normative HFO database was retrospectively constructed using interictal physiological HFO detected from nonresected brain areas of 37 patients who remained seizure free after epilepsy surgery. The optimal HFO rate ratio was estimated by finding the ratio that best matched the resection volume that defines the EZ in seizure-free patients. Then an optimal HFO rate ratio was used to detect region-specific pathological HFOs.

Results: Sixty-three patients (32 female, mean age 25 years) with 7512 bipolar SEEG recordings who underwent surgery for epilepsy were analyzed. The HFO rate ratio method accurately localized the EZ in 92% of patients with seizure freedom and identified pathological HFO rates in 80% of patients with persistent seizures, both within (19%) and outside (35%) the resected areas. The optimal threshold for the ripple HFO rate ratio to accurately localize the EZ was 5.8 times the normative value and 2.7 times that of fast ripples, with sensitivity and specificity greater than 85%.

Conclusions: These findings provide evidence that differentiating physiological and pathological interictal HFO rates are helpful in localizing the EZ, with potential utility in patient-specific surgical planning. Further prospective validation of this methodology is warranted.

Objective: Infradiaphragmatic craniopharyngiomas (ICs) are anatomically distinct lesions bounded by an elevated diaphragma sellae (DS). While endoscopic endonasal surgery (EES) has emerged as their primary treatment, achieving complete resection remains challenging due to frequent tumor-DS adhesions, potentially contributing to higher recurrence rates. Authors of this retrospective study evaluated the efficacy and safety of DS resection (DSR) during EES for IC.

Methods: The data for patients with ICs treated with EES between March 2011 and December 2024 were retrospectively reviewed. According to their intraoperative DSR status, patients were classified into the DSR group or non-DSR group. Comprehensive analyses were performed to compare demographics, clinical characteristics, and surgical and long-term outcomes between the resection groups, with additional comparison to contemporary published series.

Results: Forty-six patients with IC were included in the final cohort, with 29 in the DSR group and 17 in the non-DSR group. The DSR group tended to have larger tumor volumes (p = 0.050) and a significantly higher proportion had endocrine dysfunction (p = 0.022) and preoperative hypothalamic involvement (p = 0.002). Forty-three patients (93.5%) underwent complete tumor resection. There was no significant difference in the extent of resection (p = 0.628), endocrine outcomes, visual outcomes, and postoperative hypothalamic involvement (p = 0.258) between the 2 groups, whereas DSR increased the rate of pituitary stalk transection (p = 0.001) and operation times (p < 0.001). DSR did not significantly increase the risk of CSF leakage (p = 0.451), electrolyte imbalance (p = 0.108), or intracranial infections (p = 0.524). During a median 60.5 months of follow-up (IQR 27.8-90.3 months), the recurrence rate and hypothalamic syndrome rate were 4.3% and 6.5%, respectively, for the whole cohort, and they were not significantly different between the 2 resection groups.

Conclusions: As the first dedicated analysis of DSR in the EES era, this study demonstrates that intentional DSR facilitates optimal tumor removal without substantially increasing complication risks. These findings support selective DSR use for ICs demonstrating significant DS adhesion, potentially improving long-term disease control while maintaining an acceptable safety profile.

Objective: The aim of this randomized, controlled, double-blind multicenter trial was to compare the safety and efficacy of globus pallidus internus (GPi) and subthalamic nucleus (STN) deep brain stimulation (DBS) in patients with Meige syndrome (MeS). Additionally, the authors explored the optimal site of DBS and identified predictors of clinical outcomes.

Methods: The primary outcome was improvement in motor function as assessed by the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). The secondary outcomes included mood, global cognitive function, and quality of life (QOL). The optimal stimulation site for DBS was investigated using Lead-DBS.

Results: A total of 62 patients with MeS were randomized to receive GPi-DBS (n = 31) or STN-DBS (n = 31), and all completed the 1-year follow-up. In the GPi-DBS group, the mean improvement rates in BFMDRS movement scores were 54.9%, 57.3%, and 59.7% at 3, 6, and 12 months, respectively. In the STN-DBS group, the corresponding rates were 57.1%, 59.0%, and 59.9%. There was no significant difference in the efficacy of motor symptoms, depression, anxiety, and QOL between the two groups during follow-up. The total electrical energy delivered in the GPi-DBS group was significantly greater than that in the STN-DBS group. The adverse event rates were comparable between the GPi-DBS (16.1%) and STN-DBS (12.9%) groups (p > 0.99). The "sweet spot" for GPi-DBS was found to be located in the posterolateral dorsal pallidum (ρ = 0.76, p = 0.001), while the sweet spot for STN-DBS was found to be situated in the dorsal subthalamic nucleus (ρ = 0.66, p = 0.005). Preoperative BFMDRS movement subscores for speech/swallowing were identified as an independent predictor negatively associated with DBS efficacy (p = 0.025).

Conclusions: GPi-DBS and STN-DBS demonstrate comparable safety and efficacy in patients with MeS. STN-DBS requires lower stimulation parameters than GPi-DBS. The optimal stimulation sites are the posterolateral dorsal GPi and the dorsal STN. Greater preoperative speech/swallowing impairment predicts poorer outcomes.

Objective: The optimal surgical approach for trigeminal schwannomas (TSs), particularly between the endoscopic endonasal approach (EEA) and endoscopic transorbital approach (ETOA), remains unclear. This study aimed to analyze radiological factors influencing surgical outcomes and establish criteria to guide approach selection.

Methods: A retrospective review of the records of TS patients treated with the EEA or ETOA at three tertiary centers from 2015 to 2023 was conducted. The authors introduced the orbito-ovale line (OOL) to classify tumors as low-lying or high-lying. A scoring system (range 0-5 points) incorporating five key radiological factors was developed, categorizing tumors as having a low score (0-2 points) or high score (3-5 points).

Result: Among 74 patients, 54 (73.0%) underwent the ETOA, 19 (25.7%) the EEA, and 1 (1.4%) a combined approach. Gross- or near-total resection was achieved in 86.5% of cases. The ETOA consistently achieved favorable outcomes across both low- and high-score groups, while the EEA showed superior results in high-score cases but underperformed in low-score cases. High-lying tumors involving the middle cranial fossa (MCF) were predominantly treated with the ETOA, whereas low-lying tumors with extracranial involvement were managed with the EEA. The scoring system significantly correlated with outcomes in the EEA group (p = 0.018), with higher scores predicting better results. Surgical morbidity was low, with transient trigeminal neuropathy being the most common complication.

Conclusions: Radiological features, particularly tumor location relative to the OOL and internal carotid artery displacement, significantly influence approach selection and surgical outcomes. The proposed scoring system provides a structured framework for optimizing preoperative decision-making and patient selection. While the ETOA demonstrated superior outcomes for MCF tumors, the EEA remains essential for cases with extracranial involvement.

Objective: As the neurosurgery residency application process grows increasingly reliant on strategy, applicants must weigh relationship-building efforts against academic metrics. This study evaluated how program-specific engagement influences match outcomes and how its importance has evolved following the adoption of United States Medical Licensing Examination (USMLE) Step 1 pass/fail (P/F) grading and program signaling.

Methods: The authors analyzed survey responses from 465 US MD applicants to neurosurgery programs, corresponding to 2637 applications submitted between 2022 and 2025 using the Texas Seeking Transparency in Applications to Residency (TexasSTAR) database. Multivariable logistic regression models evaluated the association between relationship-building variables (away rotation, program signaling, geographic connection, and regional preference) with match success. Stratified models examined interactions with USMLE Step 2 clinical knowledge (CK) score and publication count. One-way ANOVA assessed temporal changes in predictor importance. A random forest machine learning model was developed to identify dominant factors in obtaining an interview.

Results: Away rotation was the strongest independent predictor of match success (adjusted OR [aOR] 8.48, p < 0.001) and interview offer (aOR 23.6, p < 0.001), followed by program signaling (aOR 2.17, p < 0.001; interview aOR 2.15, p < 0.001), and geographic connection (aOR 3.47, p < 0.001). Preferred region was not significantly associated with either outcome. Stratified analyses revealed that relationship variables (away rotation, geographic connection, program signaling) had stronger predictive value for applicants with lower academic metrics (e.g., Step 2 CK score < 244, < 5 publications). Following Step 1 P/F grading transition and program signaling in 2022, applicants submitted fewer applications (p < 0.001) and attended fewer interviews (p = 0.001), while reliance on program-specific engagement increased. Step 2 CK score and number of publications declined in predictive power after 2022. Random forest modeling (89% accuracy) identified away rotation, program signaling, geographic connection, and Step 2 CK score as the strongest interview predictors.

Conclusions: Program-specific engagement strategies are the strongest predictors of obtaining an interview in neurosurgery residency matching. Their growing importance after the transition to USMLE Step 1 P/F grading suggests applicants gain more from targeted connections than broad application volume. Declining application and interview count further reflect a trend toward more strategic engagement.

Objective: The aim of this study was to access vagus nerve stimulation (VNS) parameters for the management of drug-resistant epilepsy (DRE) and to implement a pilot quality improvement initiative to ensure that uniform and consistent literature-supported parameters are used for optimal seizure control in patients with DRE.

Methods: A single-institution retrospective analysis was performed to assess VNS parameters of patients with DRE who underwent implantation from 2013 to 2022, before the intervention was introduced (group 1). Patients who underwent implantation from 2023 to 2024 comprised the postintervention group (group 2), with intervention that included activating VNS intraoperatively and titration to a therapeutic dose of 1.5 mA within 12 weeks. Parameters between groups were compared. Statistical control charts were used to assess process stability. An interrupted time series (ITS) analysis was conducted to assess the impact of the intervention over time, adjusting for preintervention trends.

Results: Eighty-six patients (50% female, mean age 25.4 [SD 15.4] years) were included. Group 1 (n = 62) had delays in initiation of VNS therapy following implantation (median 15 [IQR 10.75] days) and achieving the therapeutic threshold (median 57.5 [IQR 72.93] weeks). Group 2 (n = 24) showed no delay to initiation (median 0 [IQR 0] days) and reached the therapeutic threshold early (median 10 [IQR 6] weeks) compared with group 1 (p < 0.001). Patients for whom the therapeutic threshold was reached during the clinical course increased from 80.65% in group 1 to 91.67% in group 2. Among them, the proportion reaching that threshold within 12 weeks of implantation increased significantly from 14% (7/50) in group 1 to 68.18% (15/22) in group 2 (p < 0.001). Individual and moving range charts, assessed using Levene's test for variance, showed greater process stability and consistency in group 2. ITS analysis showed that the intervention had a sustained and significant impact; the proportion of patients with timely therapeutic parameters increased by 13.26 percentage points every 3 months (p = 0.029). Logistic regression analyses showed the postintervention group and use of scheduled programming had greater odds of achieving timely therapeutic parameters (OR 6.58 [p = 0.001] and 56.77 [p < 0.001], respectively).

Conclusions: Substantial practice variability in VNS parameter settings with suboptimal utilization of therapy existed, which improved following introduction of the pilot intervention. Standardized protocols can ensure timely delivery of therapeutic parameters. These strategies have been underutilized in earlier studies, likely overestimating the time to response from VNS therapy.