Journal of neurosurgery最新文献

Objective: The aim of this study was to evaluate outcomes of deep brain stimulation (DBS) for Meige syndrome, compare the efficacy of globus pallidus internus (GPi) and subthalamic nucleus (STN) as targets, and identify potential outcome predictors.

Methods: The PubMed, Embase, and Web of Science databases were systematically searched to collect individual data from patients with Meige syndrome receiving DBS. Outcomes were assessed using the Burke-Fahn-Marsden Dystonia Rating Scale motor (BFMDRS-M) and disability (BFMDRS-D) scores. Data were analyzed using pooled meta-analysis. The study is registered in the PROSPERO database.

Results: The analysis included 233 patients from 26 studies, with significant publication bias (p = 0.008, Egger's test), but showed significant improvements in BFMDRS-M (65.09% ± 26.65%) and BFMDRS-D (53.48% ± 42.44%) scores at the final follow-up (mean duration 27.10 ± 33.64 months). No significant differences were observed in BFMDRS-M score improvement (mean difference -2.58%, 95% CI -15.84% to 10.69%; p = 0.430) or risk difference for response (-0.97%, 95% CI -10.08% to 8.15%; p = 0.835) between the GPi and STN target groups at the final follow-up across all follow-up periods (0 to ≤ 6, > 6 to ≤ 12, > 12 to ≤ 24, > 24 to ≤ 36, and > 36 months). Multiple regression analysis revealed a negative correlation between disease duration and treatment efficacy and a positive correlation between preoperative BFMDRS score and treatment outcome.

Conclusions: DBS significantly improves motor symptoms and disability in patients with Meige syndrome, with GPi and STN targets providing comparable efficacy. The efficacy of DBS diminishes with longer disease duration, underscoring the importance of early intervention.

Objective: Craniopharyngiomas are rare, benign brain tumors that are primarily treated with surgery. Although the extended endoscopic endonasal approach (EEEA) has evolved as a more reliable surgical alternative and yields better visual outcomes than traditional craniotomy, postoperative visual deterioration remains one of the most common complications, and relevant risk factors are still poorly defined. Hence, identifying risk factors and developing a predictive model for postoperative visual deterioration is indeed necessary. However, there is still a lack of research on these topics. Therefore, the authors used the largest known case series of EEEA for craniopharyngioma to determine pertinent risk factors and develop a nomogram for the noninvasive preoperative prediction of visual outcome.

Methods: A total of 483 cases of craniopharyngioma (338 in the training cohort, 145 in the validation cohort) between January 2019 and March 2023 were retrospectively reviewed, and related risk factors were identified. In total, 851 radiomic features from the MR images of each case were extracted. The least absolute shrinkage and selection operator algorithm was used to select features and construct the radiomic score (Rad-score). A support vector machine (SVM) classifier was adopted to construct a radiomic model. Moreover, a clinical-radiomic nomogram was built by multivariable logistic regression. The performance of the nomogram was assessed by its discrimination, calibration, and clinical utility.

Results: The overall incidence of postoperative visual deterioration was 9.1%. A lack of intraoperative visual evoked potential (VEP) monitoring (OR 0.221, p = 0.001), larger maximum tumor diameter (OR 1.052, p = 0.014), and tight adherence (OR 2.963, p = 0.044) were demonstrated as independent risk factors for postoperative visual deterioration. The radiomic model using the SVM based on 8 selected features exhibited good discrimination in predicting adhesion strength in the training and validation cohorts (area under the receiver operating characteristic curve [AUC] 0.85 vs 0.80). Moreover, the nomogram incorporating the Rad-score and clinical factors showed AUCs of 0.827 and 0.808 in the training and validation sets, respectively, fitting well in calibration curves. Decision curve analysis further confirmed the clinical usefulness of the nomogram.

Conclusions: Intraoperative VEP monitoring was proven to help reduce postoperative visual deterioration, while tight adherence and larger maximum tumor diameter were confirmed as independent risk factors. The radiomic model allowed a noninvasive prediction of the adherence strength between the optic nerves and craniopharyngioma. The nomogram showed a promising performance for noninvasively predicting postoperative visual deterioration and may serve as a useful tool for clinical decision-making and patient counseling.

Objective: The pathophysiology of delayed cerebral ischemia (DCI) is not fully elucidated. The lack of accurate diagnostic tools increases the probability of delayed diagnosis and timely treatment. The authors assessed the relationship of 8-iso-prostaglandin F2α (F2-IsoP) and oxidative stress biomarkers, nitric oxide synthase 3 (NOS3) and nicotinamide adenine dinucleotide phosphate (NADPH), with DCI after aneurysmal subarachnoid hemorrhage (aSAH).

Methods: The authors assessed 65 aSAH patients for F2-IsoP, NOS3, and NADPH concentrations using commercial ELISA on days 2, 4, and 6 after aSAH. The authors examined the correlations of plasma F2-IsoP, NOS3, and NADPH concentrations and clinical variables with DCI onset.

Results: F2-IsoP, NOS3, and NADPH are important laboratory predictors of DCI. Of the clinical predictors, modified Fisher grade, Hunt and Hess grade, and tobacco smoking were the most significant predictors. In patients with DCI, plasma F2-IsoP and NOS3 concentrations were higher, and NADPH concentrations were lower, than in those without DCI (p < 0.01). Plasma F2-IsoP concentration on day 2, and NADPH and NOS3 concentrations on day 6, correlated with DCI occurrence (p < 0.01).

Conclusions: The authors observed decreased antioxidant capacity in patients with DCI, which may be explained by increased F2-IsoP and decreased NADPH. Assessment of F2-IsoP, NOS3, and NADPH may improve the diagnostic accuracy of DCI. Further work is required to determine the role of F2-IsoP, NOS3, and NADPH in clinical practice and DCI pathophysiology.

Objective: The complex mix of factors, including hemodynamic forces and wall remodeling mechanisms, that drive intracranial aneurysm growth is unclear. This study focuses on the specific regions within aneurysm walls where growth occurs and their relationship to the prevalent hemodynamic conditions to reveal critical mechanisms leading to enlargement.

Methods: The authors examined hemodynamic models of 67 longitudinally followed aneurysms, identifying 88 growth regions. These regions (of enlargement) were pinpointed through alignment and distance mapping between baseline and follow-up models. Aneurysm wall subdivisions were created based on saccular anatomy and flow-related characteristics, which were used to assess local hemodynamics. The distribution of growing regions across these subdivisions was then studied and stratified by aneurysm location and morphology to reveal distinct growth patterns. Statistical significance was evaluated using the Kruskal-Wallis and Mann-Whitney tests.

Results: Growth predominantly occurred in the body (p < 0.0001) of aneurysms, with anterior communicating artery (ACom) (p < 0.0001) and lateral (p = 0.002) aneurysms showing a significantly greater tendency for growth in this region. In comparison, middle cerebral artery (MCA) (p < 0.0001) and bifurcation (p = 0.0001) aneurysms demonstrated growth in both the dome and the body. Notable differences in growth distribution across saccular regions included ACom versus MCA (neck, p = 0.038), bifurcation versus lateral (neck, p = 0.008), and so forth. The central flow region saw the most growth (p < 0.0001); although not significant, ACom (p = 0.196) and lateral (p = 0.218) aneurysms showed a tendency for growth in inflow and central zones, while MCA (p = 0.001) and bifurcation (p < 0.0001) aneurysms were more likely to grow in the central flow region.

Conclusions: Two primary mechanisms seem to influence aneurysm growth: high-flow impingement jets in the neck, body, and inflow zones leading to wall degeneration/thinning, mainly in ACom aneurysms; and slow, oscillatory flow conditions in the dome and central flow zones promoting wall remodeling/thickening, mainly in MCA aneurysms. This latter mechanism is also observed as secondary flows in ACom aneurysms. These findings emphasize the need to understand the distinct and sometimes concurrent mechanisms of aneurysm growth, advocating for targeted monitoring and interventions that mitigate rupture risks by considering the unique hemodynamic environments within different aneurysm regions and locations.

Objective: The present study aimed to investigate the association between pituitary adenoma (PA) consistency and other measurable tumor characteristics, extent of resection (EOR), postoperative complications, and outcomes.

Methods: In total, 507 PA resections were intraoperatively assigned a consistency grade from 1 (cystic/hemorrhagic tumors) to 5 (calcified tumors) based on intraoperative tumor characteristics. Tumor consistency was analyzed in tertiles (grades 1 and 2, grade 3, and grades 4 and 5) to determine associations with tumor characteristics, EOR, recurrence, postoperative outcomes, and complications.

Results: The cohort in this study included primarily macroadenomas (93.3%) comprised mostly of nonfunctional PAs (NFPAs) (79.5%), with 77.1% showing suprasellar extension, 16.6% showing infrasellar invasion, and 46.4% showing cavernous sinus invasion (CSI). PA consistency grades were as follows: grade 1 or 2 (40.6%), grade 3 (39.3%), and grade 4 or 5 (20.1%). Compared with grade 1 or 2, higher-consistency PAs were more common in men (p = 0.001) and trended toward lower rates of gross-total resection (GTR) (67.6% vs 53.5%, p = 0.06). Higher PA consistency was predictive of any postoperative complication (OR 1.23, 95% CI 1.05-1.43; p = 0.009), specifically including transient diabetes insipidus (DI) (OR 1.45, 95% CI 1.12-1.85; p = 0.004) and cranial nerve (CN) paresis (OR 3.45, 95% CI 1.56-7.69; p = 0.002). Higher consistency was a strong predictor of CN palsy (OR 3.33, 95% CI 1.52-7.30; p = 0.004) for NFPAs. Higher-consistency PAs were more frequently adrenocorticotropic hormone-positive in both univariable (OR 1.33, 95% CI 1.11-1.60; p = 0.002) and multivariable (OR 1.38, 95% CI 1.11-1.69; p = 0.004) analyses. Higher consistency was associated with lower rates of GTR on stratification by CSI for Knosp grade 3 (p < 0.001) and grade 4 (p < 0.001) PAs, but not in low-grade (Knosp grades 1 and 2) PAs.

Conclusions: Tumor consistency is an important consideration for the resection strategy, particularly for PAs with CSI, and a predictor of intraoperative CSF leaks and perioperative complications and outcomes, including EOR, CN paresis, and transient DI.

Objective: Recent voxel-based lesion symptom mapping (VLSM) studies have identified a critical region for picture naming, located 3.4 to 6.1 cm from the temporal pole. Its resection during left temporal lobe epilepsy surgery led to postoperative decline in picture naming. However, postoperative anomia has been reported after classic left temporal lobectomy, which rarely extends so posteriorly. The aim of the present study was to evaluate patients' postoperative picture naming outcome on the basis of their precise surgical cavities in light of the recent findings from VLSM studies.

Methods: In this monocentric retrospective study, the authors analyzed picture naming outcome and the surgical cavities of 34 patients who underwent surgery for left temporal lobe epilepsy. The authors evaluated their cohort's surgical cavities on the basis of the critical regions identified by VLSM studies as essential to picture naming.

Results: The surgical cavities of patients were anterior to the critical regions for picture naming identified by VLSM studies in the literature. Eight of 11 patients with postoperative lexical access decline at 18 months had a posterior limit of the lesioned voxels that did not reach the critical region identified by VLSM studies. Only 3 of 11 patients with a postoperative picture naming decline had surgical cavities reaching these critical regions. Conversely, 3 of 23 patients with stable or improved postoperative picture naming had surgical cavities reaching these critical regions.

Conclusions: Keeping a surgical cavity anterior to the limits identified by recent VLSM studies does not protect patients from postoperative picture naming decline. Interindividual anteroposterior variability of the basal temporal language area could complete the explanation offered by VLSM.

Objective: Epilepsy is a common neurological disease affecting nearly 1% of the global population, and temporal lobe epilepsy (TLE) is the most common type. Patients experience recurrent seizures and chronic cognitive deficits that can impact their quality of life, ability to work, and independence. These cognitive deficits often extend beyond the temporal lobe and are not well understood. It has been proposed in the extended network inhibition hypothesis that repeated spread of seizure activity to the ascending reticular activating system (ARAS) may contribute to these deficits. Disease duration has been associated with other network changes in patients with TLE, but few studies have investigated the relationship between disease duration, ARAS connectivity, and cognitive deficits in TLE. Furthermore, epilepsy surgery can result in seizure freedom and cognitive improvement in some patients, but it is unclear how the surgery affects ARAS connectivity.

Methods: Resting-state functional MRI data were collected for patients with TLE (preoperatively in 40 and postoperatively in 25), and for 40 age-matched healthy controls. Functional connectivity was computed between all regions. Functional connectivity and segregation, a graph-theory measure of network isolation, were compared across the age spectrum in patients and controls. These same measures were evaluated as a function of epilepsy duration by controlling for age using a linear model built on healthy control data.

Results: The authors found that increases in epilepsy duration were associated with greater segregation of the ARAS and decreased functional connectivity between the pedunculopontine tegmental nucleus and the frontoparietal association cortex. Furthermore, patients with impaired neurocognitive function were noted to have longer epilepsy duration and higher ARAS segregation compared to patients with spared neurocognition. After surgery, completely seizure-free patients demonstrated ARAS connectivity patterns that resembled those found in controls, whereas patients with residual seizures had persistent abnormal connectivity.

Conclusions: These findings suggest that recurrent seizures may contribute to isolation of critical subcortical activating structures, possibly impacting cognitive function. Furthermore, some ARAS functional connectivity abnormalities can be reversed if seizure freedom is achieved after epilepsy surgery. These results provide support for the extended network inhibition hypothesis, may lend insight into the progressive effect of recurrent seizures on arousal networks, and may lead to improved interventions to halt or reverse network impairments in patients with TLE.

Objective: An MRI protocol for germinoma surveillance after complete remission has not been established. Moreover, the standard treatment for recurrent or refractory germinoma has not been determined. In this study, the authors explored the imaging characteristics of recurrent germinoma and discuss their institution's experience with multidisciplinary treatment of this malignancy.

Methods: The medical records of 16 patients (14 male, 2 female) with recurrent germinoma and 62 patients (52 male, 10 female) without recurrence who were treated at the authors' institution between 1989 and 2023 were retrospectively examined. Data including diagnostic imaging, tumor markers, treatment at diagnosis and recurrence, and overall survival were collected from patients' medical records and statistically analyzed.

Results: No patients with recurrence received craniospinal irradiation (CSI) as an initial therapy, and local irradiation was a significant risk factor of recurrence (p = 0.0072). The period between the start of first-line treatment and confirmation of the first recurrence ranged from 4.2 to 272 months (median 66.8 months). Among the recurrences, 13 tumors occurred outside the radiation field, including 6 cases of spinal cord/canal recurrence. One-third of patients did not exhibit elevated tumor marker levels in the serum. Fourteen patients had contrast-enhanced recurrent lesions. In the 2 patients with non-contrast-enhanced lesions, recurrence was detected by high signal intensity on diffusion-weighted imaging (DWI) and elevated tumor marker levels in CSF. Fifteen patients received chemotherapy for the first recurrence, and 14 received radiation therapy, with 9 receiving CSI. The patients who received CSI survived without further recurrence during the study period. However, the median progression-free survival and overall survival after the first recurrence among patients who did not undergo CSI were 12.2 and 37.4 months, respectively, which were shorter than those for patients treated with CSI (both p < 0.01, log-rank test).

Conclusions: Spinal MRI for surveillance in patients with recurrent germinoma, especially for those who do not receive CSI, is recommended. DWI might be useful for detecting recurrent germinoma. Aggressive treatment at the time of recurrence is crucial, and even if remission is achieved with chemotherapy, CSI for consolidation is important to prevent further recurrence.

Objective: This study aimed to investigate the extent of gender disparities in financial interactions between neurosurgeons and the medical device industry, examining the differences in the number, amount, and types of payments made to male and female neurosurgeons.

Methods: Utilizing data from the Centers for Medicare & Medicaid Services Open Payments database covering 2016-2022, the authors conducted a comprehensive analysis of industry payments to neurosurgeons. This methodology included univariate and multivariate analyses to examine the disparities in payments, with a focus on identifying significant differences in compensation across genders.

Results: An analysis of 24,074 industry transactions totaling $388,916,456.88 underscored pronounced gender disparities, with female neurosurgeons involved in merely 2.47% of these transactions and receiving just 0.91% of the overall financial value. The data revealed significant discrepancies in compensation between genders across all contributing companies. Male neurosurgeons engaged in a higher average number of annual transactions compared with their female counterparts (4.60 vs 2.75, p < 0.001), across various financial interactions. This included a greater participation in royalties and licenses (1.49 vs 0.31, p < 0.001), consulting fees (2.16 vs 1.63, p = 0.024), and acquisitions (0.01 vs 0.00, p = 0.006). On average, female neurosurgeons were compensated $16,303.66, starkly lower than the $75,523.20 average received by their male counterparts (p < 0.005). This gap was especially significant in royalties and licenses, where females earned an average of $5168.57 compared with $61,898.47 for males (p = 0.004). Additionally, in acquisitions, female neurosurgeons received no payments at all, whereas males averaged $2153.43 (p = 0.042). Several of these disparities remained significant even after accounting for potential confounding factors, highlighting a systematic bias in compensation and industry engagement against female neurosurgeons.

Conclusions: The study underscores a significant gender-based disparity in the financial interactions between neurosurgeons and the medical device industry. These disparities highlight the need for systemic changes to address the underlying factors contributing to inequity in compensation and industry collaboration opportunities. Implementing equitable compensation structures, mentorship programs, and inclusive policies is a crucial step toward achieving gender parity in neurosurgery and ensuring the field benefits from the diverse skills and perspectives of all its members.