Journal of neurosurgery最新文献

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.

Objective: The physical consistency of pituitary adenomas (PAs) is highly variable, ranging from soft/cystic to firm/calcified. The association between PA consistency and surgical/endocrinological outcomes has been well established, with firm tumors demonstrating poorer outcomes and higher complication rates. However, to date, no reliable means to determine PA consistency preoperatively exist, although T2- and diffusion-weighted imaging show early promise. As such, this study aimed to quantitatively analyze the value of normalized T2-weighted imaging (T2WI) and diffusion-weighted imaging ratios in the preoperative prediction of PA consistency.

Methods: The authors reviewed a prospectively maintained database of all patients undergoing PA resection at a single institution between 2011 and 2024. Inclusion criteria included the following: 1) a PA with a minimum diameter ≥ 20 mm in at least one dimension; 2) a consistency grade assigned at the time of surgery using a previously validated grading scale; and 3) preoperative MRI performed prior to surgery. Normalized tumor to cerebellar T2-weighted imaging intensity (TCTI) ratios were calculated using 10-mm2 regions of interest. Data were analyzed using Kruskal-Wallis tests, multivariable ordinal logistic regression models, and receiver operating characteristic (ROC) curve analyses with 4-fold cross-validation.

Results: A total of 189 patients (mean age 55.4 years, 49.2% female) were included, of whom 77 (40.7%) had PAs with a consistency grade of 1+2, 76 with a consistency grade of 3 (40.2%), and 36 (19%) with a consistency grade of 4+5. When using mean T2WI intensity measurements, TCTI ratios were lower for grade 4+5 tumors (1.48 ± 0.24, p < 0.001) than for grade 3 tumors (1.77 ± 0.44) and grade 1+2 tumors (2.16 ± 1.10, p = 0.001). When using maximum T2WI measurements, TCTI ratios were also lower for grade 4+5 tumors (1.50 ± 0.24, p < 0.001) compared with grade 3 tumors (1.79 ± 0.45), and grade 1+2 tumors (2.15 ± 0.81, p < 0.001). No association between apparent diffusion coefficient values and tumor consistency was observed. In the ROC analysis, comparing soft (grade 1+2) with firm (grade 4+5) tumors, an area under the curve of 0.877 was observed when using maximum signal intensity measurements within the ROI. A TCTI ratio cutoff of 1.682 was associated with a sensitivity of 80.6% and specificity of 85.7% in predicting firm tumors (grade 4+5) versus all other grades in the test dataset.

Conclusions: The T2WI TCTI ratio is predictive of PA consistency where higher ratios are associated with softer tumors. Preoperative prediction of PA consistency using the TCTI ratio might improve patient selection and outcome predication, and guide the excision technique.

Objective: The spinal accessory nerve (SAN) is frequently used as a donor for reinnervation of the suprascapular nerve (SSN) in the reconstruction of brachial plexus injuries (BPIs). This procedure can be performed using either the anterior or posterior approach. However, no studies have compared the postoperative outcomes between these two approaches in adult patients with complete BPI. Thus, this study aimed to compare postoperative shoulder functional outcomes following the anterior and posterior approaches.

Methods: Between 2017 and 2022, 48 adult patients with complete palsy following a closed BPI underwent surgery. Inclusion criteria were surgery performed at least 9 months after injury, patient age between 16 and 60 years, and a minimum follow-up period of 2 years. A total of 38 patients met these criteria. The anterior approach was performed in 18 patients, and the posterior approach was used in 20. Shoulder function was assessed at the 2-year follow-up, including shoulder abduction strength and range of motion (ROM), and external rotation (ER) strength and ROM.

Results: The posterior approach group demonstrated significantly greater shoulder abduction strength and ER strength compared with the anterior approach group. The median shoulder abduction ROM in the posterior approach group was 53° (IQR 38°-75°), which was significantly greater than that of the anterior approach group (median 35°, IQR 10°-45°). The median shoulder ER ROM of the posterior approach group was 15° (IQR 0°-35°), which was also significantly greater than that of the anterior approach group (median 0°, IQR 0°-10°).

Conclusions: The posterior approach in SAN-to-SSN transfer resulted in superior shoulder function outcomes compared with the anterior approach. These findings suggest that the posterior approach might be preferable for optimizing shoulder function recovery in adult patients with complete BPI.

Objective: The objective was to define anatomical landmarks for the parapharyngeal segment of the internal carotid artery (ICA) relevant to the endoscopic endonasal approach (EEA).

Methods: A technique was developed through laboratory investigation and demonstrated in a nasopharyngectomy.

Results: A transpterygoid approach revealed the foramen lacerum, the parasellar and paraclival ICA was exposed, and the lingual process removed. Drilling proceeded through the mandibular strut and adjacent petrous base along the inferolateral surface of the horizontal petrous ICA (hpICA) up to the vertical petrous ICA (vpICA). The medial jugular tubercle was drilled, and the eustachian tube was disconnected and removed. Dissection was performed from superior to inferior using the vpICA to locate the carotid foramen and parapharyngeal ICA (ppICA). The inferior petrous carotid (IPC) triangle was identified and delineated by the ventral hpICA, vpICA, and the line connecting the carotid foramen to the lacerum cartilage. Its importance lies in providing access for an anteroinferior petrosectomy, which is obstructed by the hpICA in an open approach, while its inferior apex marks the depth of the ppICA and enables safer parapharyngeal space dissection.

Conclusions: The mandibular strut and IPC triangle serve as valuable landmarks for tracing the petrous ICA, facilitating reliable craniocaudal localization of the ppICA during EEA.

Objective: Penetrating brain injuries (PBIs) involving the sella region are rare, anatomically complex, and associated with high morbidity due to the proximity of critical neurovascular structures. Herein, the authors introduce a novel trajectory-based classification system derived from wartime injuries sustained during the conflict in Ukraine, aiming to improve the diagnostic framework, guide management strategies, and support prognostication in this unique population.

Methods: The authors conducted a retrospective analysis of all PBIs involving an anatomically defined critically important sellar injury zone (CRISIZ) treated at a tertiary care center over a 2.5-year period (February 2022-August 2024). Injuries were classified into 2 main categories based on projectile trajectory to the CRISIZ: transbasal (TB) and transcortical (TC). Each category was further subdivided into 4 anatomical subtypes. Clinical presentation, imaging characteristics, complications, treatment modalities, and outcomes were compared across subgroups. The primary outcome was the Glasgow Outcome Scale (GOS) score at 6 months.

Results: A total of 29 patients with PBIs involving the CRISIZ were identified (mean patient age 38 years). TB injuries were more common than TC by a factor of 1.6 (18 vs 11; 62.1% vs 37.9%). TB subtypes included transnasal, transorbital, transmaxillary, and infratemporal trajectories; TC subtypes included transfrontal, transtemporal, transventricular, and transoccipital. TB injuries had a higher prevalence of multiple projectile fragments (88.9% vs 45.5%, p < 0.05) and CSF rhinorrhea (66.7% vs 18.2%, p < 0.05). TC injuries were associated with significantly higher rates of intracranial vascular injury (81.8% vs 22.2%, p < 0.01), subarachnoid hemorrhage, intraventricular hemorrhage, and coma on admission (54.5% vs 11.1%, p < 0.05). Overall, in-hospital mortality was 10.3%, and 75.9% of patients achieved favorable outcomes (GOS scores > 3) at 6 months.

Conclusions: Projectile trajectory is a critical determinant of injury pattern and clinical course in PBIs involving the CRISIZ. TC injuries are associated with a higher incidence of neurovascular complications, while TB injuries more commonly involve CSF leaks. Early identification and management of these complications are critical for optimizing outcomes. The proposed classification scheme provides a practical framework to guide evaluation and management in this high-risk patient population.

Objective: Patients with internal carotid artery occlusion (ICAO) present with a heavy thrombosis burden and bad lateral circulation, which are associated with unfavorable outcomes following endovascular therapy (EVT). In this study, authors explored the risk factors associated with poor outcomes in patients with ICAO undergoing EVT and developed and validated a dynamic nomogram for predicting poor outcomes.

Methods: Five hundred seventy-seven patients from the multicenter, randomized, double-blind, placebo-controlled MARVEL (Methylprednisolone as Adjunctive to Endovascular Treatment for Acute Large Vessel Occlusion) trial were included in the current retrospective study. The patients, all of whom had ICAO and received EVT between February 2022 and June 2023, were split into training (60%) and internal validation (40%) cohorts. Additionally, 281 patients from the Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke registry (ACTUAL registry) served as the external validation cohort. Least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analyses were applied to identify risk factors to establish a dynamic nomogram prediction model.

Results: Five risk factors were independently associated with poor outcome, including age (OR 0.951, 95% CI 0.935-0.968, p < 0.001), baseline Alberta Stroke Programme Early CT Score (OR 1.176, 95% CI 1.075-1.286, p < 0.001), baseline National Institutes of Health Stroke Scale score (OR 0.850, 95% CI 0.801-0.901, p < 0.001), baseline American Society of Interventional and Therapeutic Neuroradiology and Society of Interventional Radiology grade (OR 1.646, 95% CI 1.388-1.951, p < 0.001), and baseline glucose levels (OR 0.891, 95% CI 0.827-0.959, p = 0.002). The prediction model, based on these five factors, showed moderate performance with an area under the curve of 0.786 (95% CI 0.728-0.844) in the internal validation and 0.795 (95% CI 0.743-0.847) in the external validation, with the calibration curve closely aligning with the ideal diagonal line.

Conclusions: This predictive model can accurately forecast poor outcomes for patients with ICAO undergoing EVT, serving as a useful adjunct in operative decision-making for both physicians and patient families.

Objective: Deep brain stimulation (DBS) of the centromedian nucleus (CM) of the thalamus is a promising treatment for drug-resistant epilepsy, Tourette syndrome, disorders of consciousness, and chronic pain, particularly when other surgical options are not feasible. However, the CM is challenging to visualize on routine MRI and atlas-based targeting often results in inaccurate electrode placement, affecting surgical outcomes. Furthermore, inability to visualize and directly target the CM is a barrier to CM-DBS in a resource-limited setting. The aim of this study was to develop and test machine learning (ML) models that could predict target coordinates of the CM using multiple datapoints available from conventional T1-weighted MRI.

Methods: Four ML models-linear regression (LR), k-nearest neighbor (KNN), support vector regression (SVR), and deep neural network (DNN)-were developed and optimized using 100 MR images obtained in healthy individuals and validated in a separate dataset of 20 patients with generalized epilepsy, which is an indication for CM-DBS. Models were trained to predict the stereotactic coordinates of the CM using input features, which were x, y, and z coordinates of readily identifiable points from T1-weighted MRI.

Results: The DNN model demonstrated the highest accuracy in predicting CM coordinates, with a mean Euclidean error of 0.88 ± 0.41 mm in the healthy dataset, and 1.12 ± 0.44 mm in the epilepsy dataset. The LR, SVR, and KNN models all performed similarly, although with higher error rates.

Conclusions: These findings indicate that ML models, particularly DNNs, can accurately predict CM coordinates using standard T1-weighted MRI. This approach reduces dependency on advanced imaging techniques, making CM-DBS more accessible.