Journal of neurosurgery最新文献

Objective: Stereotactic radiosurgery (SRS) offers excellent tumor control for pituitary adenoma (PA); however, treatment failure occasionally necessitates salvage surgery. Comprehensive studies on salvage surgical outcomes for recurrent PA after SRS remain scarce. This study aimed to elucidate the outcomes of salvage endonasal transsphenoidal surgery (sETS) for progressive PA failing SRS.

Methods: This retrospective, two institution-based cohort study analyzed data from patients who underwent sETS for progressive PA failing SRS. Progression-free survival (PFS), disease-specific survival (DSS), and neurological and endocrinological outcomes in the sETS group were analyzed and compared with those in the primary ETS (pETS) group after propensity score matching using the following variables: age at surgery, maximum tumor diameter, highest Knosp-Steiner classification, and tumor type.

Results: Thirteen sETS patients (8 males [62%], median age at surgery of 56 years) with 5 nonfunctioning (39%), 6 corticotropic (46%), and 2 other functioning (15%) PAs who received median (range) follow-up of 125 ( 23-169) months were included. None of the patients experienced new neurological deficits or death after sETS. The median (range) tumor resection rate was 90% (80%-100%). The 5-year PFS and DSS rates were 55% and 77%, respectively. All 4 patients (31%) who experienced recurrence after sETS had corticotropic tumors. In the matched cohort analysis between the sETS group with 12 patients and the pETS group with 12 patients, no significant differences were observed in surgical outcomes. PFS rates were marginally higher in the sETS group than in the pETS group (80% vs 49% at 3 years, p = 0.216, log-rank test), and DSS was similar between the two groups (p = 0.543, log-rank test).

Conclusions: The authors' results indicate that ETS can be safely performed as a salvage treatment after failed SRS with low complication rates and satisfactory tumor control in treatment-resistant PA.

Objective: The Flow-Redirection Endoluminal Device X (FRED X) is a newer generation flow diverter with surface modifications aimed at minimizing thrombogenicity. At present, data on its long-term efficacy are limited. This multicenter study presents the largest series within the United States describing the device's efficacy, safety, and long-term outcomes in treating cerebral aneurysms of varying morphology.

Methods: Patients treated with the FRED X for a cerebral aneurysm between February 2022 and February 2024 at 6 high-volume centers across the United States were included. Data were collected regarding demographics, clinical presentation, and procedural efficacy. Angiographic and clinical follow-up outcomes were assessed at 6 and 12 months.

Results: A total of 154 patients with 162 aneurysms were treated with 164 FRED X devices over the study period. Overall, 81.8% of the cohort was female with a mean age of 56.8 years. The authors observed satisfactory rates (≥ 99.3%) of device deployment and good wall apposition and neck coverage. One hundred forty-seven (95.5%) patients were functionally independent at discharge (modified Rankin Scale scores 0-2). Rates of adequate occlusion (Raymond-Roy Occlusion Scale score I or II) increased from 84.2% at 6 months to 83.5% at the 12-month follow-up, while rates of in-stent stenosis decreased. All patients (100%) who underwent follow-up were functionally independent at 6 months, and 95.9% were functionally independent at 12 months.

Conclusions: This multicenter cohort study demonstrates the ease of FRED X deployment with an adequate safety profile, with low rates of procedural complications and favorable outcomes on follow-up. Rates of aneurysm occlusion increased over time, with a subsequent decrease in stent-associated complications.

Objective: The war in Ukraine has resulted in a large number of penetrating head wounds with concomitant neurovascular injuries. The aim of this report was to review these patients and demonstrate a multimodal treatment approach used for these complex injuries. This entails a combination of early endovascular and open surgical treatment for optimal outcome.

Methods: This is a prospective study from a single civilian clinical center near the combat frontlines in Dnipro, Ukraine (Mechnikov Dnipropetrovsk Regional Clinical Hospital [MDRCH]). All injuries were sustained during Russia's invasion. Data were collected for a 28-month period from February 24, 2022, to June 24, 2024. The patients with intracranial neurovascular injuries were evaluated and their management and outcomes were documented and analyzed.

Results: Within the study period, 1310 patients with head and neck injuries underwent invasive angiography and, of these, 20 patients (1.5%) were diagnosed with intracranial arterial traumatic injury including traumatic intracranial aneurysms or arteriovenous fistulas. On admission, the Glasgow Coma Scale score ranged from 5 to 15 (median 10). A total of 15 patients (75.0%) were diagnosed with traumatic intracranial aneurysm(s), 2 (10.0%) with traumatic direct carotid cavernous fistulas, and 3 patients (15.0%) had traumatic dural arteriovenous fistulas. In 8 patients (40.0%), there was concurrent damage to the paranasal sinuses. Autologous tissue was used for skull base reconstruction in all cases. Endovascular intervention was performed in 14 patients (70.0%). Surgical intervention immediately followed angiography or endovascular intervention in 14 patients (70.0%). The length of stay at the MDRCH ranged from 3 to 20 days (mean 8.6 days). The Glasgow Coma Scale score at the time of discharge ranged from 8 to 15 (median 13). There was 1 death (5.0%) due to sequelae of severe vasospasm. The Glasgow Outcome Scale score at 1 month after the injury in the other 19 patients ranged from 2 to 5 (median 4).

Conclusions: Early angiographic diagnosis of traumatic neurovascular complications after penetrating head injury allows for their effective management and treatment. The authors propose early comprehensive endovascular and surgical intervention for penetrating craniocerebral injuries. This case series demonstrates that this approach may optimize outcomes in wartime neurovascular injuries.

Objective: There is a lack of data regarding the benefit-risk ratio and therapeutic value of brain biopsy in very elderly patients with brain tumors. This study aimed to evaluate the safety of stereotactic biopsy in patients aged ≥ 80 years and assess the impact of the procedure on subsequent therapeutic management and overall survival (OS).

Methods: The authors retrospectively analyzed the medical records of all patients aged ≥ 80 years who underwent stereotactic biopsy for a newly diagnosed intracerebral tumor during a 15-year period at a single institution.

Results: During the period, 2350 stereotactic brain biopsies were performed, with 209 biopsies (8.9%) in 208 patients aged ≥ 80 years. Histological diagnosis was obtained in 96.2% of cases. Biopsy results differed from the suspected diagnosis in 23 patients (11.1%). After biopsy, 1.9% of the patients experienced persistent neurological deficit. After histopathological diagnosis, 80.7% of the cases received adjuvant treatment. Only a Karnofsky Performance Status (KPS) score ≥ 70% was a significant predictor of receiving complete adjuvant treatment (OR 24.3, 95% CI 7.0-84.1; p < 0.001). The median OS from biopsy was 5.6 months (IQR 2.4-13.5 months). Grade 4 glioma, KPS score < 70%, and tumor contrast enhancement on MRI predicted a shorter OS. Receiving complete first-line adjuvant therapy predicted a longer OS. In patients with grade 4 glioma, those exhibiting a methylated O 6-methylguanine-DNA methyltransferase (MGMT) promoter demonstrated significantly prolonged survival compared with patients with an unmethylated MGMT promoter (p < 0.001).

Conclusions: Stereotactic biopsy for very elderly patients with brain tumors has a high diagnostic yield and a favorable safety profile, ultimately impacting patients' therapeutic management and OS. Nonetheless, it is crucial to consider the patient's prebiopsy condition. Specifically, a KPS score ≥ 70% was identified as a key factor in the decision-making process for biopsy in this population.

Objective: The role of the cerebellum in cognitive function and psychiatric symptoms is poorly understood and particularly understudied in patients with cerebellar pathologies such as Chiari malformation type I (CM-I). Additionally, it is unclear if interventions targeted toward the cerebellum might impact these life-altering symptoms. The authors sought to characterize pre- and postoperative cognitive and psychiatric function in CM-I patients as evidence for targeted cerebellar treatment for some cognitive and psychiatric conditions.

Methods: This prospective study included surgical patients with CM-I who reported cognitive or psychiatric dysfunction. Patients completed a preoperative assessment and a parallel assessment 6 months following surgery. Neuropsychological evaluations included a 90-minute standardized assessment of cognitive function across multiple domains and a self-reported assessment of psychiatric symptoms. This clinical sample consisted of 54 patients (mean age 34.17 years, median 14.15 years). Any patient demonstrating preoperative performance below 3.5 SDs within any cognitive domain was excluded (n = 1). All patients underwent preoperative neuropsychological assessment comprising standard clinical tests of processing speed, attention, memory, executive function, and psychiatric symptoms.

Results: Preoperatively, CM-I patients performed significantly worse than a representative normative sample on measures of executive function and visuospatial memory and reported more psychiatric symptoms across all domains. On postoperative assessment, 89% of patients showed clinically significant improvements (> 1 SD) in cognitive and/or psychiatric domains.

Conclusions: The authors demonstrate significant, often unrecognized, impairments in cognitive function and psychiatric symptoms in a cohort of CM-I patients. Following targeted surgical posterior fossa decompression, these symptoms improved, suggesting that at least in a subgroup of symptomatic CM-I patients, these symptoms may be treatable. This study highlights the potential role of the cerebellum in cognitive and psychiatric dysfunction.

Objective: Blister aneurysms of the internal carotid artery (ICA) have high associated mortality rates and are challenging due to their friable wall and poorly defined neck. Microsurgical and endovascular treatment options have been suggested, including bypass of the parent vessel to exclude the aneurysm. The goal of this study was to evaluate the safety and efficacy of microsurgical versus endovascular interventions. Additionally, for patients treated with open surgery, the outcomes of bypass were compared to nonbypass techniques.

Methods: Three databases were systematically queried for primary studies comparing microsurgery to endovascular therapy and assessing bypass versus nonbypass treatment modalities for blister aneurysms of the ICA. All relevant studies published between 2000 and 2023 were eligible for inclusion. All articles were screened against title and abstract by 2 authors, as were those eligible for full-text assessment. Ultimately, relevant data from all included studies were pooled for meta-analysis in which the Mantel-Haenszel method with random-effects modeling was used.

Results: Among the 504 cases reported across 24 studies, 182 (35.1%) blister aneurysms of the ICA were surgically treated, whereas 337 (64.9%) involved endovascular treatment. There were 235 (46.6%) female patients in the cohort. Functional outcomes were comparable between groups, with 83% of surgically treated patients and 85% of endovascularly treated patients achieving a favorable outcome (p > 0.05). Among the 7 studies (178 patients) comparing bypass to nonbypass microsurgery, rates of postoperative bleeding, ischemic infarct, vasospasm, recurrence, favorable outcomes, and mortality were comparable for bypass (n = 54, 30.3%) and nonbypass groups (n = 124, 69.7%).

Conclusions: Blister aneurysms of the ICA are rare intracranial aneurysms that are difficult to treat with microsurgical and endovascular techniques. Considering only patients treated with open surgery, there appears to be no significant difference in complication profile or functional outcomes between patients undergoing bypass or alternative microsurgical techniques. However, it must be noted that the complex nature of bypass procedures means that much of the data granularity is lost on meta-analysis, suggesting that additional investigations comparing bypass to other open microsurgical techniques may be merited. Similarly, future studies should determine the limitations of dual antiplatelet therapy in endovascular treatment and the efficacy of different numbers and types of overlapping, flow-diverting devices.

Objective: Giant pituitary adenomas (GPAs) are challenging skull base tumors due to their size and proximity to critical neurovascular structures. Achieving gross-total resection (GTR) can be difficult, and residual tumor burden is commonly reported. This study evaluated the ability of convolutional neural networks (CNNs) to predict the extent of resection (EOR) from preoperative MRI with the goals of enhancing surgical planning, improving preoperative patient counseling, and enhancing multidisciplinary postoperative coordination of care.

Methods: A retrospective study of 100 consecutive patients with GPAs was conducted. Patients underwent surgery via the endoscopic endonasal transsphenoidal approach. CNN models were trained on DICOM images from preoperative MR images to predict EOR, using a split of 80 patients for training and 20 for validation. The models included different architectural modules to refine image selection and predict EOR based on tumor-contained images in various anatomical planes. The model design, training, and validation were conducted in a local environment in Python using the TensorFlow machine learning system.

Results: The median preoperative tumor volume was 19.4 cm3. The median EOR was 94.5%, with GTR achieved in 49% of cases. The CNN model showed high predictive accuracy, especially when analyzing images from the coronal plane, with a root mean square error of 2.9916 and a mean absolute error of 2.6225. The coefficient of determination (R2) was 0.9823, indicating excellent model performance.

Conclusions: CNN-based models may effectively predict the EOR for GPAs from preoperative MRI scans, offering a promising tool for presurgical assessment and patient counseling. Confirmatory studies with large patient samples are needed to definitively validate these findings.

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.