Journal of neurosurgery最新文献

Objective: The purpose of this study was to present a newly designed 3D-printed personalized model (3D PPM) of a radiofrequency needle guide with a maxillary fixation for gasserian ganglion (GG) puncture.

Methods: Implementation of 3D CT-guided radiofrequency therapy of the GG with and without use of 3D PPM was analyzed. The following parameters were assessed: radiation time, dose area product, air kerma reference point, pain severity during the puncture needle insertion, prosopalgia regression degree (according to visual analog scale) and the severity of facial numbness (according to the Barrow Neurological Institute scale) in the early postoperative period, and postpuncture complications.

Results: Pain severity reduction was equivalent in both groups, and postoperative facial numbness was not observed. A statistically significant difference in radiation exposure parameters was revealed: radiation time was 181.67 ± 2.99 and 310.50 ± 18.46 seconds (p < 0.001); dose area product was 950.97 ± 115.41 and 1545.48 ± 135.04 µGy*m2 (p < 0.005); and the air kerma reference point was 114.53 ± 16.81 and 190.88 ± 17.48 mGy (p < 0.005) in groups 1 and 2, respectively. The severity of pain during a puncture needle insertion was assessed as mild in 62.5% and 25%, moderate in 37.5% and 41.6%, and severe in 0% and 33.3% of patients in groups 1 and 2, respectively. No serious perioperative complications were observed.

Conclusions: The use of 3D PPM allows for controlled needle insertion, reducing the radiation dose to the patient and medical staff, reducing pain during a puncture needle insertion into the area of the foramen ovale, and minimizing the risk of postoperative complications.

Objective: This study focuses on epidermal growth factor receptor-mutated lung adenocarcinoma, known for frequent brain metastasis. It aimed to compare the clinical outcomes and cost-effectiveness of combining Gamma Knife radiosurgery (GKRS) with tyrosine kinase inhibitors (TKIs) (GKRS+TKI group) versus TKIs alone (TKI group) for the treatment of patients with newly diagnosed brain metastasis in this condition.

Methods: Study characteristics of the two groups were matched using inverse probability of treatment weighting (IPTW). In the incremental cost-utility ratio (ICUR) model, a healthcare provider perspective, a 1-month cycle length, a 5-year time horizon, and a discount rate of 2% per year for both effectiveness and costs were adopted. Probabilistic and one-way sensitivity analyses were also conducted to demonstrate the robustness of the findings. Statistical analysis was performed using IBM SPSS version 23.0, and cost-effectiveness analysis was conducted using TreeAge Pro software.

Results: After applying IPTW, the GKRS+TKI group included 205 patients, and the TKI group consisted of 102 patients, with no statistically significant differences in whole confounders. The GKRS+TKI group demonstrated significantly prolonged median progression-free survival (37.5 months vs 10.6 months, p < 0.001) and median overall survival (55.1 months vs 30.8 months, p < 0.001) compared with the TKI group. The GKRS plus TKI strategy achieved an ICUR of $30,532.25 per quality-adjusted life year relative to the TKIs at the willingness-to-pay threshold of US$33,059 (Taiwan's per capita gross domestic product).

Conclusions: The use of GKRS plus TKIs not only reduces disease recurrence and improves prognosis but also demonstrates a higher level of cost-effectiveness. These findings offer valuable guidelines for clinicians and inform healthcare authorities in optimizing resource allocation for improved medical care.

Objective: Aneurysmal subarachnoid hemorrhage (SAH) is associated with high morbidity and mortality rates. In particular, functional outcomes of SAH caused by large or giant (≥ 10 mm) ruptured intracranial aneurysms are worsened by high procedure-related complication rates. However, studies describing the risk factors for poor functional outcomes specific to ruptured large/giant aneurysms are sparse. In addition, high recurrence and rebleeding rates following treatment of such aneurysms remain a concern. This study aimed to clarify the specific risk factors for poor short-term outcomes and long-term durability of SAH due to ruptured large/giant intracranial aneurysms using a multicenter observational database in Japan.

Methods: Data were obtained from 8 institutions participating in a multicenter repository of aneurysmal SAH in Japan. Among 5095 consecutive registered patients with SAH patients, 416 patients with SAH caused by ruptured large/giant (≥ 10 mm) saccular intracranial aneurysms were included. The authors investigated the risk factors for poor functional outcomes in patients with such aneurysms using multivariable analyses and subsequently investigated the interaction between these risk factors. The association between the treatment modality (direct surgery or endovascular therapy) and functional outcomes were finally analyzed using a propensity score-based method. The long-term durability of the treated aneurysms was evaluated by analyzing rebleeding.

Results: Poor functional outcomes (modified Rankin Scale score ≥ 3) at discharge were observed in 251 (60.3%) patients. Increasing aneurysm size was significantly associated with poor functional outcomes (OR 1.13, 95% CI 1.04-1.22; p = 0.003) by a multivariable logistic regression analysis, and such negative effects were more prominent in younger patients, those with a good initial neurological grade, and those treated with direct surgery by interaction analyses. Propensity score-based analysis revealed that patients treated with endovascular therapy had a higher chance of better functional outcomes (OR 1.56, 95% CI 1.41-1.71; p = 0.03). Rebleeding 1 year after treatment was more frequent in the endovascular therapy (4.8%) than in the direct surgery (0.0%) group by survival analysis (p = 0.008, log-rank test).

Conclusions: Increasing aneurysm size was identified as a risk factor for poor functional outcomes after SAH due to large/giant aneurysms and was affected by the interaction with other conventional risk factors. Endovascular therapy was more likely to be associated with better short-term outcomes; however, a higher delayed rebleeding rate after 1 year was a concern.

Objective: The objective was to comprehensively investigate the clinical, molecular, and imaging characteristics and outcomes of H3 K27-altered diffuse midline glioma (DMG) in adults.

Methods: Retrospective chart and imaging reviews were performed in 111 adult patients with H3 K27-altered DMG from two tertiary institutions. Clinical, molecular, imaging, and survival characteristics were analyzed. Characteristics were compared between adult and 365 pediatric patients from a previous multicenter meta-analysis dataset. Cox analyses were performed to determine predictors of overall survival (OS) in adult patients.

Results: The median (range) age of adult patients was 40 (18-75) years, and 64 males and 47 females were included. Adults had a higher male proportion (57.7% vs 45.3%, p = 0.023), lower proportion of histological grade 4 (41.4% vs 74.0%, p < 0.001), and different tumor locations (p < 0.001) compared with pediatric patients; adults commonly showed a thalamus location (41.5%) followed by the spinal cord (27.0%), whereas pediatric patients predominantly showed a pons location (64.9%). The OS of adults was longer than that of pediatric patients (30.3 vs 12.0 months, p < 0.001, log-rank test). Older age at diagnosis (HR 0.96, p = 0.001), histologically lower grade (HR 0.25, p = 0.003), and gross-total resection of nonenhancing tumor (HR 0.15, p = 0.003) were independent favorable prognostic factors.

Conclusions: Adult patients with H3 K27-altered DMG showed distinct clinical, histological, and imaging characteristics compared to pediatric counterparts, with a significantly better prognosis. The authors' results suggest that aggressive surgery should be pursued when deemed feasible for better survival outcomes.

Objective: Endovascular treatment (EVT) is an effective treatment for patients with acute vertebrobasilar artery complex occlusion (VBAO). However, the benefit of bridging thrombolysis prior to EVT remains controversial. The purpose of the present study is to explore the best treatment strategy between bridging treatment (BT) and direct EVT in patients with acute VBAO.

Methods: Patients with acute VBAO who underwent EVT within 24 hours of estimated occlusion in a nationwide retrospective registry at 65 stroke centers in 15 provinces in China from December 2015 to June 2022 were retrospectively analyzed. The outcomes of the BT and direct EVT groups were compared using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). The primary outcome was favorable functional outcome, defined as a 90-day modified Rankin Scale (mRS) score of 0-3. Secondary outcomes included 90-day functional independence (mRS score 0-2), mRS score shift, in-hospital mortality, successful reperfusion, and symptomatic intracranial hemorrhage (sICH). In addition, a meta-analysis integrating currently available evidence was performed to make a systematic comparison between the two treatment strategies.

Results: A total of 2353 patients were ultimately included; 447 of these patients received BT and 1906 received direct EVT. In both the original cohort and in the 1:1 PSM analysis, patients in the BT group had a significantly higher rate of favorable functional outcome (adjusted odds ratio [aOR] 1.41, 95% CI 1.14-1.76 for the original cohort and aOR 1.44, 95% CI 1.07-1.92 for 1:1 PSM). Regarding secondary outcomes, patients with BT had a significantly lower rate of in-hospital mortality (aOR 0.67, 95% CI 0.51-0.88 for the original cohort and aOR 0.69, 95% CI 0.48-0.99 for 1:1 PSM) and a shift toward better outcomes on the mRS (aOR 1.35, 95% CI 1.12-1.63 for the original cohort and aOR 1.31, 95% CI 1.03-1.69 for 1:1 PSM). However, there were no significant differences in functional independence, successful reperfusion, and sICH between the two groups. A meta-analysis, which included 22 studies involving 6579 patients, also revealed the superiority of BT over direct EVT on favorable functional outcome (OR 1.19, 95% CI 1.03-1.37, I2 = 0.00%; p = 0.02).

Conclusions: This matched-control study and meta-analysis suggest that compared with direct EVT, BT may be associated with better functional outcomes in patients with acute VBAO treated within 24 hours of estimated occlusion.

Objective: Tumor consistency, or fibrosity, affects the ability to optimally resect meningiomas, especially with recent trends evolving toward minimally invasive approaches. The authors' team previously validated a practical 5-point scale for intraoperative grading of meningioma consistency. The impact of meningioma consistency on surgical management and outcomes, however, has yet to be explored. This study aimed to determine associations between meningioma consistency and presenting symptoms, tumor characteristics, and postoperative outcomes.

Methods: A total of 209 surgically resected meningiomas were intraoperatively assigned a consistency grade according to a previously validated 5-point scale, ranging from extremely soft, suctionable tumors (grade 1) to firm/calcified tumors (grade 5). Presenting symptoms, tumor characteristics, postoperative complications, and surgical outcomes for these patients were prospectively collected. Tumor consistency was analyzed in three categories (grades 1 and 2, grade 3, and grades 4 and 5), using ANOVA, chi-square or Fisher's exact tests, and univariable logistic regression to evaluate associations between consistency and perioperative characteristics.

Results: The study cohort included 209 patients, of whom 48 (23%) were males with a mean age of 55.0 ± 13.7 years. Meningioma consistency distribution was as follows: grades 1 and 2 (n = 23, 11.0%), grade 3 (n = 88, 42.1%), and grades 4 and 5 (n = 98, 46.9%). The majority of meningiomas were skull base tumors (n = 144, 68.9%). Higher-consistency tumors were associated with lower rates of gross-total resection (OR 0.24, 95% CI 0.13-0.46; p < 0.001), increased invasiveness (OR 4.73, 95% CI 1.53-14.60; p = 0.007), tumor recurrence following resection (OR 3.30, 95% CI 1.25-8.66; p = 0.016), reoperation (OR 3.08, 95% CI 1.16-8.14; p = 0.024), and increased complication rates (OR 2.08, 95% CI 1.05-4.15; p = 0.037). No significant associations were identified with preoperative symptoms, tumor size (mean 4.04 ± 1.50 cm), or duration of surgery (mean 4.26 ± 1.60 hours) (all p > 0.05).

Conclusions: Tumor consistency is associated with important meningioma characteristics and perioperative outcomes. A prior knowledge pertaining to meningioma consistency and tumor characteristics using advanced imaging is a priority and may provide surgeons with meaningful data to guide resection strategy and anticipate postoperative outcomes and complications.

Objective: Focused ultrasound (FUS)-mediated blood-brain barrier (BBB) opening is safe and potentially beneficial in patients with Alzheimer's disease (AD) for the removal of amyloid-beta (Aβ) plaques. However, the optimal BBB opening intervals and number of treatment sessions for clinical improvement remain undefined. Therefore, the aim of this study was to evaluate the safety and benefits of repeated and more extensive BBB opening alone.

Methods: In this open-label prospective study, 6 patients with AD were enrolled from June 2022 to July 2023. FUS-mediated BBB opening was performed three times at 2-month intervals targeting the bilateral frontal lobes. 18F-florbetaben positron emission tomography (FBB-PET) was performed before the first procedure and after the third procedure. Patients were administered neuropsychological and neuropsychiatric evaluations.

Results: All 6 participants completed the study without any acute treatment-related adverse events. An extensive area of BBB opening (mean 43.1 cm3), more than twice as large as the opening volume (mean 20 cm3) in the authors' previous study, was confirmed by contrast-enhanced MRI. FBB-PET scans demonstrated a 14.9-Centiloid average decrease in Aβ plaques in 4 of the 6 participants (67%), but the Aβ plaques increased in 2 participants after BBB opening, compared with baseline. No significant changes were observed in the Korean version of the Mini-Mental State Examination in either group. Caregiver-Administered Neuropsychiatric Inventory scores improved in 5 of 6 participants (83%), indicating an improvement in neuropsychiatric symptoms.

Conclusions: This study confirmed the safety and efficacy of more frequent and extensive bilateral frontal BBB opening over multiple sessions in patients with AD. Furthermore, this is the first clinical trial to demonstrate improvement in neuropsychiatric symptoms through BBB opening alone, without concurrent administration of antibody medications.

Objective: Deep brain stimulation (DBS) is an effective neurosurgical option for patients with treatment-resistant obsessive-compulsive disorder (OCD). Despite being more costly than neuroablative procedures of comparable efficacy, DBS has gained popularity over the years for its reversibility and adjustability. Although the cost-effectiveness of DBS has been investigated extensively in movement disorders, few economic analyses of DBS for psychiatric disorders exist. In this study, the authors present the first cost-effectiveness analysis of DBS for treatment-resistant OCD in the United States.

Methods: The authors developed four decision analytical models to compare the cost-effectiveness of DBS with treatment as usual (TAU) for OCD, varying either the device type (i.e., nonrechargeable or rechargeable) or the time horizon (i.e., 3 or 5 years) in each model. Treatment response and complication rates were based on a literature review. Published algorithms were used to convert Yale-Brown Obsessive Compulsive Scale scores into utility scores reflecting improvements in quality of life. Costs were approached from the healthcare sector perspective and were drawn primarily from Medicare facility and physician reimbursement rates. For each model, a Monte Carlo simulation (n = 100,000) and probabilistic sensitivity analysis were performed to estimate the incremental cost-effectiveness ratio (ICER) in US dollars per quality-adjusted life year (QALY).

Results: Data from 249 and 265 treatment-resistant OCD patients from the published literature who received DBS and had sufficient follow-up in 3- and 5-year models, respectively, were included. When conventional US willingness-to-pay (WTP) thresholds were used, nonrechargeable DBS models were less cost-effective (3-year ICER: $108,431/QALY; 5-year ICER: $203,202/QALY) and rechargeable DBS models were more cost-effective (3-year ICER: $49,363/QALY; 5-year ICER: $41,495/QALY) than TAU. At a WTP threshold of $100,000/QALY, rechargeable DBS devices were moderately more cost-effective than TAU at 3 and 5 years in 100% of iterations. At a WTP threshold of $50,000/QALY, rechargeable DBS devices were definitively more cost-effective than TAU at 3 and 5 years in 54% and 89% of iterations, respectively. When using WHO WTP conventions, 3- and 5-year nonrechargeable models were cost-effective in 100% and 84% of iterations, and 3- and 5-year rechargeable models were highly cost-effective in 99% and 100% of iterations, respectively.

Conclusions: Rechargeable DBS models were cost-effective for treatment-resistant OCD compared with TAU. Nonrechargeable DBS models may be cost-effective, especially with improvement in battery longevity and changes in accepted WTP thresholds.