Journal of neurosurgery最新文献

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.

Objective: While numerous studies have evaluated cranioplasty outcomes after decompressive craniectomy, most rely on heterogeneous cohorts with insufficient follow-up. The aim of this near-nationwide multicenter study was to review 15 years of cranial reconstructions in Sweden to establish the rates of complications and shunt dependence, as well as the extent of functional recovery, and to characterize the factors associated with these outcomes.

Methods: Patients treated with primary cranioplasty after decompressive craniectomy from January 2008 to December 2022 were included. Patient medical records were reviewed for demographic and technical details, as well as surgical outcomes and shunt dependency. Functional recovery was determined before surgery and 6 months after cranioplasty using the modified Rankin Scale. Multivariable regression models (adjusted for confounders) were used to evaluate outcome predictors.

Results: Among 725 patients (median age 49 years [IQR 33-59 years]) who underwent cranioplasty, autologous bone was used in 74%. The median follow-up duration was 80 months and 31% of patients underwent at least 1 reoperation. Long-term cranioplasty failure rates were significantly lower with synthetic implants, primarily due to a 15% revision rate caused by bone flap resorption in autologous cranioplasties. Resorption was most pronounced in patients younger than 40 years of age, while infection rates were comparable across different implant materials. One hundred patients (14%) received a permanent shunt, which was associated with the nature of the primary brain injury, cranial defect size, and external brain herniation prior to cranioplasty. Functional improvement was observed in 26% of patients following cranioplasty, and significantly more frequently in younger patients with fewer comorbidities, those who underwent earlier cranioplasty, and those with a history of malignant middle cerebral artery infarction or subarachnoid hemorrhage.

Conclusions: Cranioplasty outcomes after decompressive craniectomy were benchmarked and several outcome predictors were identified. Particularly, reoperation rates remain at alarming levels and suggest that a change in policy from an autograft- to alloplast-first strategy should be considered.

Objective: Deep brain stimulation (DBS) is emerging as an additional surgical option for refractory, multifocal epilepsy. Four-lead DBS systems can be used when seizure onset is poorly localized, generalized, or involves multiple targetable circuits. The goal of this study was to assess preliminary outcomes and complication rates in 4-lead DBS systems for treating epilepsy.

Methods: A consecutive series of 32 patients with 4-lead DBS implants who had at least 6 months of follow-up was reviewed, and demographics, outcomes, and complications were abstracted.

Results: Thirty-two patients implanted with 4 DBS leads (including off-label use) were included. The median age at surgery was 28.5 years, the median age at epilepsy diagnosis was 7.5 years, and 18 patients (56%) were women. The median epilepsy duration prior to implantation was 21 years. The most common seizure localization was frontotemporal (53%), followed by generalized (28%) and parietoccipital (13%). Prior vagus nerve stimulation had been trialed in 20 patients (63%), and an invasive stereotactic EEG recording was performed in 17 patients (59%). Eight patients had prior epilepsy surgery (25%). DBS targets included the anterior thalamic nucleus in combination with the centromedian thalamic nucleus, hippocampus, pulvinar nucleus, cingulate, insula, and globus pallidus. The median surgical duration was 5 hours 22 minutes, with a median operating room time of 8 hours 21 minutes. The median postoperative follow-up was 27 (interquartile range 17-41) months. Three patients experienced transient neurological deficits and 2 patients required intraoperative lead repositioning. There were no infections or hemorrhages. Most patients benefited from stimulation (22% Engel class I, 22% class II, 28% class III, and 28% class IV). The median patient-reported seizure reduction rate was 70%, with a responder rate of 72%. One patient elected to have the system explanted.

Conclusions: Four-lead DBS is safe and can achieve meaningful improvement in challenging cases of multifocal epilepsy with a low complication rate.

Objective: Biologically effective dose (BED)-oriented planning is emerging as a potential key consideration in future planning strategies, aiming to achieve the best, most personalized radiosurgery treatment plans possible. In this study, planning parameters and BED variations in previously treated patients were investigated to determine the factors that affect the treatment results in order to achieve better patient outcomes.

Methods: A highly refined cohort of 191 idiopathic, type 1 trigeminal neuralgia (TN) patients who underwent stereotactic radiosurgery (SRS) with 80 Gy as a first-line invasive treatment were investigated. Follow-up data were obtained from the retrospective analysis of a prospectively maintained database.

Results: As the shot distance from the root entry zone (REZ) increased by each millimeter, the hazard ratio (HR) for relapse increased by 16.3%, and the HR was reduced by 4% for every 10% increase in the BED that the REZ received. The odds of being medication free at the end of follow-up were reduced by 21.5% for every millimeter that the shot was positioned more distally. On the other hand, multivariate analysis showed that the maximum BED applied to the nerve was a positive predictor of new numbness, when corrected for pain duration before SRS, plugging, and age at treatment.

Conclusions: For patients with TN, positioning the shot closer to the REZ and applying a higher BED to this area provides better pain control in the long term compared to more distally placed shots. As expected, a higher maximum BED applied to the nerve was associated with an increased risk of developing facial numbness.