Journal of neurosurgery最新文献

Objective: Epilepsy affects nearly 50 million individuals worldwide, with one-third of cases resistant to antiseizure medications. For these patients, surgical intervention offers a potential path to seizure freedom. While resective surgery has been the gold standard, laser interstitial thermal therapy (LITT) has emerged as a minimally invasive alternative. The aim of this study was to evaluate the efficacy and safety of LITT versus resective surgery in patients with nontumoral epilepsy.

Methods: A systematic review and meta-analysis were conducted using PubMed, Embase, and Scopus, including studies comparing seizure freedom rates, complications, and procedural outcomes between LITT and open surgery in nontumoral epilepsy. Eleven studies met the inclusion criteria, comprising 389 LITT and 557 open surgery patients with varying epilepsy etiologies, including temporal lobe epilepsy, focal cortical dysplasia, and tuberous sclerosis. Statistical analysis was performed using a random-effects model to assess seizure freedom, complications, and reoperation rates.

Results: Open surgery demonstrated higher rates of complete seizure freedom, although not reaching significance (68.1% vs 53.7%, RR 0.81, p = 0.07). This outcome was sensitive to influential analysis and reached significance in the epileptogenic zone-directed resection subgroup analysis. Although adequate seizure freedom was comparable between the groups (LITT: 63.0% vs open: 74.0%, RR 0.90, p = 0.11), the open surgery group had higher rates of control in the pediatric and non-temporal lobe epilepsy subgroups. Complication rates were significantly higher in the open surgery group (30.0% vs 18.3%, RR 0.55, p < 0.01). LITT patients had significantly shorter hospital stays (3.4 vs 6.8 days, standardized mean difference -0.93, p < 0.01). Reoperation rates were comparable between groups (13.1% for LITT vs 13.4%, RR 1.59, p = 0.26).

Conclusions: While LITT offers a less invasive approach with reduced hospitalization and morbidity, open surgery remains slightly superior in achieving long-term seizure freedom. Patient selection remains critical, and further studies are needed to refine decision-making criteria based on epilepsy subtype and lesion characteristics.

Objective: The minimal important difference (MID) and minimal important change (MIC) are two metrics that bridge the gap between statistical significance and clinical relevance and are critical to managing clinical decisions and conducting clinical research. The objective of this study was to define MIDs to evaluate cross-sectional differences among groups and to define MICs to evaluate longitudinal within-patient changes for the Mayo Clinic Vestibular Schwannoma Quality of Life (VSQOL) Index.

Methods: Anchor-based methods were used to define MIDs and MICs for the VSQOL Index domain scores, which range from 0 to 100 points, for a national cohort of 1050 patients with sporadic vestibular schwannoma, 644 of whom completed the VSQOL Index twice approximately 1 year apart.

Results: The median of the MID estimates for the VSQOL Index domains were: hearing problems (17, IQR 12.5-21); dizziness and imbalance (21, IQR 18-23); pain, discomfort, and tinnitus (19.5, IQR 15-23.5); problems with face or eyes (18, IQR 17-28); impact on physical, emotional, and social well-being (19.5, IQR 14.5-23.5); difficulty with thinking and memory (23.5, IQR 18.5-28.5); global quality of life (12, IQR 8-16); and satisfaction or regret (13.5, IQR 7-17). MIC estimates for the hearing problems and satisfaction and regret domains were not obtained because the correlations between these domain scores and their associated anchors were not sufficiently strong. The MIC estimates (minimum and maximum) for the remaining domains were: dizziness and imbalance (7.2 and 8.3); pain, discomfort, and tinnitus (8.3 and 8.5); problems with face or eyes (7.0 and 7.4); impact on physical, emotional, and social well-being (2.1 and 8.0); and difficulty with thinking and memory (12.9 and 15.0). The median of the MIC estimates for global quality of life was 5.2 (IQR 3.7-5.6).

Conclusions: The MIDs and MICs reported herein provide a framework to interpret quality-of-life benefit or harm cross-sectionally among groups and longitudinally within patients. Moving forward, these values should be considered when interpreting studies using the VSQOL Index to assess disease-specific quality of life in patients with sporadic vestibular schwannoma.

Objective: This study aimed to provide an anatomical description of the endoscopic transorbital (ETO) transconjunctival approach to the pterygopalatine fossa (PPF).

Methods: Five formalin-fixed, silicone-injected human cadaver heads were studied at the Rhoton Anatomy Laboratory, Bahçeşehir University Faculty of Medicine, Istanbul, Turkey. By using the ETO transconjunctival route, the authors performed dissections on 10 PPFs (both orbits of each specimen). A 0° Olympus endoscope, along with a fiberoptic system, light source, camera, and digital video recording, was used for documentation.

Results: The procedure consisted of three main stages. 1) In the orbital conjunctival stage, a transconjunctival incision was made in the infraorbital region, followed by posterior subperiosteal dissection. 2) In the orbitomaxillary stage, osteotomy of the infraorbital floor was performed using posterior compression, exposing the orbitomaxillary segment of the infraorbital nerve (ION) and providing access to the maxillary sinus. 3) In the pterygopalatine stage, removal of the posterior maxillary wall allowed visualization of the PPF. The pterygopalatine segment of the ION and other regional structures were identified. The mean ± SD distance from the inferior orbital rim to the distal infraorbital canal was 21.8 ± 1.6 mm. The trajectory of the ION and maxillary branch of the trigeminal nerve (CN V2) to the foramen rotundum was mean ± SD 47.3 ± 4.4 mm. The minimal amount of posterior maxillary wall removed to access the ION-to-CN V2 transition measured 12.7 ± 3.5 mm vertically and 11.9 ± 1.5 mm horizontally.

Conclusions: The ETO transconjunctival approach offers a viable alternative for accessing the PPF in selected cases, with potential benefits of reduced complication risk and a more straightforward approach compared to other methods. Further anatomical studies are warranted due to limited existing data.

Objective: Despite advances in technical approaches, microsurgical resection remains the gold standard for treating drug-resistant mesial temporal lobe epilepsy (MTLE). However, current multicenter data on the risk of new focal neurological deficits following MTLE surgery and on factors predicting the likelihood of seizure freedom postsurgery are limited. This study aimed to evaluate the safety and efficacy of surgery by providing reliable data on the predictors of favorable postoperative outcomes.

Methods: The authors conducted a retrospective multicenter analysis across 20 epilepsy centers on 5 continents. Detailed standardized clinical data were collected, encompassing the preoperative status of patients, presurgical diagnostics, surgical techniques, complications, and neurological outcomes. Predictive factors for postoperative neurological deficits and a satisfactory response to surgery (defined as International League Against Epilepsy [ILAE] classes 1 and 2) were analyzed using a logistic regression model. Additionally, the authors assessed the relationship between neurological deficits, seizure outcomes, and neuropsychological performance.

Results: A total of 1167 patients were included in this study. Postoperative new neurological deficits were observed in 22.2% of cases, with new quadrantanopia being the most common (11.2%). No in-hospital mortality or 30-day mortality was recorded. Surgical revision was necessary in 4.3% of cases within the 1st year. A younger age and surgical intervention on the nondominant brain hemisphere were associated with a reduced risk of postoperative neurological deficits. After 1 year, 74.2% of patients achieved seizure outcomes classified as ILAE class 1 or 2. Known positive predictors of seizure outcomes, such as identifiable MRI lesions and a history of febrile seizures, were supported by data. Furthermore, even after adjusting for preoperative MRI findings, hemisphere dominance, occurrence of bilateral tonic-clonic seizures, age, and sex, anterior temporal lobe resection was linked to improved seizure outcomes.

Conclusions: This study offers extensive multicenter data on outcomes following MTLE surgery from a large international patient cohort. The authors' analysis indicates a strong safety profile and high efficacy for epilepsy surgery in this patient group. The comprehensive breakdown of results facilitates the assessment of individual success prospects and improves informed patient counseling.

Objective: The cause of perimesencephalic subarachnoid hemorrhage (pmSAH) is unclear but has historically been attributed to a venous source. The authors hypothesized that high-resolution cone-beam CT (CBCT) during angiography could better identify pmSAH etiology.

Methods: All patients with pmSAH treated at the authors' institution between January 2023 and December 2024 were retrospectively analyzed. Patients were excluded if CBCT was not performed as part of the digital subtraction angiography (DSA), if CBCT source data were not available for review, or if the images were deemed to be low quality. All images were reviewed by 2 neuroangiographers with extensive neurovascular imaging experience and discussed until consensus agreement. Data were recorded as counts and percentages.

Results: Among 152 patients who presented with spontaneous SAH in 2023-2024, 22 had a pmSAH defined according to the Rinkel criteria. These 22 patients had a catheter angiogram performed on 1 of 2 biplane machines. Thirteen of those patients had high-quality CBCT data available for review, 8 (61%) of whom were found to harbor a basilar perforator focal outpouching consistent with a site of rupture. All patients with pmSAH, including the 8 found to have a basilar perforator aneurysm, achieved an excellent neurological recovery with resolution of the basilar perforator finding on follow-up DSA with CBCT and without experiencing a re-rupture event or clinically significant vasospasm.

Conclusions: In the setting of pmSAH, high-resolution CBCT acquired as part of catheter angiography frequently identifies a basilar perforator pseudoaneurysm. Conservative management was associated with excellent outcomes in this series. The authors propose that in the setting of pmSAH, a high suspicion of an arterial etiology should be considered until proven otherwise.

Objective: Orbital metastases (OMs) are a rare complication of cancer that can result in visual impairment. Treatment options include surgery and radiotherapy. However, the optimal treatment for OM is unclear. The current evidence for stereotactic radiosurgery (SRS) is limited. The aim of this study was to examine the efficacy and safety of SRS in patients with OM.

Methods: The clinical and radiological outcomes of patients with OM treated with SRS between April 2006 and November 2023 were retrospectively reviewed. Tumor response was categorized as stable disease (SD), partial response (PR), or complete response (CR) on follow-up imaging by RECIST (Response Evaluation Criteria in Solid Tumours) criteria. A review of the literature was also conducted in accordance with the PRISMA guidelines.

Results: The authors included 15 patients with 17 OM lesions, 9 (60%) of whom were females. The median patient age was 62 years (range 21-82 years). The mean overall survival after treatment was 13.5 months (95% CI 2.34-24.66 months). All patients were treated with SRS using CyberKnife technology. The most common fractionation schedule was 24 Gy in 3 fractions (n = 4). The median lesion diameter was 21 mm (range 11-72 mm). The median volume treated was 2.89 cm3 (range 0.12-56.11 cm3). At the last follow-up, 13 tumors (76.5%) showed SD, 2 tumors (11.8%) showed PR, 2 tumors (11.8%) showed CR, and no tumor (0%) showed progressive disease. The median follow-up was 24.5 months (range 0.5-126 months). The local control rates were 100% at 6 months and 12 months. No immediate or long-term radiation-induced side effects were reported. The literature review yielded 10 studies with 63 patients treated with SRS who had at least one follow-up imaging study.

Conclusions: This study presents the largest series of OMs treated with CyberKnife SRS in the literature. The authors observed an excellent local tumor control with no immediate or long-term radiation-induced necrosis, optic nerve injuries, or xerophthalmia.

Objective: Early discharge following uncomplicated endonasal resection of pituitary adenoma has been described as safe and feasible. Discharge on postoperative day (POD) 1 is not a widely implemented practice in the United States. This study aimed to evaluate the safety of routine POD1 discharges by assessing postoperative unplanned medical care rates compared with those of patients discharged on POD 2 or later (POD2+). The secondary endpoint was to identify predictors of delayed discharge in the POD2+ cohort.

Methods: A retrospective database review of the medical records of 534 patients who underwent endonasal resection of pituitary adenoma at the Mayo Clinic was performed. Relevant demographics, tumor characteristics, and perioperative metrics were abstracted from the medical record, including intraoperative CSF leakage, postoperative complications, emergency department visits, or inpatient readmissions within 30 days. Descriptive, univariate, and multivariate analyses were performed.

Results: In comparison to 422 (79%) patients discharged on POD1, 112 (21%) patients discharged on POD2+ had a higher unplanned medical care rate (13% vs 5.5%, p = 0.019). There were significantly more men in the POD1 group (48%) than in the POD2+ group (37%) (p < 0.04). The most common reasons for POD1 unplanned care were endocrine dysfunction (2.4%), split evenly between syndrome of inappropriate antidiuretic hormone and adrenal insufficiency, whereas the most frequent reason in the POD2+ cohort was medical (0.06%). Univariate analyses indicated that female sex, higher BMI, intensive care unit (ICU) admission, obstructive sleep apnea, continuous positive airway pressure dependence, intraoperative CSF leakage, and diabetes insipidus (DI) increased the likelihood of POD2+ discharge. The reduced logistic regression model demonstrated a higher likelihood of POD2+ discharge with older age, ICU admission, intraoperative CSF leakage, and DI (p < 0.001). Common factors contributing to discharge after POD1 included endocrine (n = 66, 35%) and/or medical (n = 65, 34%) reasons.

Conclusions: Routine patient discharge on POD1 following uncomplicated endonasal resection of pituitary adenoma is a safe practice, as evidenced by the significantly lower rates of unplanned medical care and complications compared with those of patients discharged on POD2 or later. Delayed discharge was associated with older age, ICU admission, intraoperative CSF leakage, and DI. The most frequent reasons for POD1 readmission were endocrine versus medical reasons for POD2+. Preoperative identification of risk factors for delayed discharge and preemptive management of endocrine and medical complications may reduce the length of stay and return to medical care.

Objective: The aim of this study was to determine the clinical and health economic impact of the British Antibiotic and Silver Impregnated Catheters for ventriculoperitoneal Shunts (BASICS) trial on UK shunt surgery practice and shunt infection rates.

Methods: This retrospective study used UK Shunt Registry data to compare antibiotic and standard shunt use in patients undergoing the first insertion of a ventriculoperitoneal shunt during pre-BASICS (January 2004 to June 2013) and post-BASICS (January 2018 to December 2021) periods. Patients of any age with hydrocephalus who underwent a primary ventriculoperitoneal shunt insertion were included. The percentage of antibiotic shunts inserted was the primary outcome, and the revision rate for infection was the secondary outcome. A budget impact analysis was performed to estimate the cost savings from reduced shunt infection.

Results: Across the study period, 12,476 patients (22% pediatric patients) underwent primary shunt insertions with 1226 revisions across 36 centers. Antibiotic shunt use increased from 36.9% in pediatric patients and 20.5% in adults in 2004, to 99.2% in pediatric patients and 96.8% in adults in 2021. The largest change was from 2018 to 2019 (year of BASICS reporting), with a 14.9% and 27.2% increase for pediatric and adult patients, respectively. Compared with standard shunts, the infection rate for antibiotic shunts was significantly lower in both pediatric (5.1% vs 1.9%, p < 0.001) and adult (1.5% vs 0.9%, p = 0.031) patients. Antibiotic shunts saved the NHS an estimated £1,004,572 (95% CI £738,496-£1,270,648) per year.

Conclusions: BASICS has been followed by evident change in UK neurosurgical practice. Antibiotic shunts are the first choice for patients, with reduced infection and cost savings of approximately £1 million per year.