Journal of neurosurgery最新文献

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.

Objective: The objective of this study was to propose fiber insertion strategies for MRI-guided laser interstitial thermal therapy (MRgLITT) tailored to anatomical subtypes of insulo-opercular focal cortical dysplasia (FCD), as previously defined, and to evaluate the safety and efficacy of these strategies.

Methods: The authors retrospectively reviewed patients with insulo-opercular FCD who underwent LITT at Beijing Tiantan Hospital between January 2020 and November 2024. Lesions were classified as insular, peri-insular, or opercular subtypes on the basis of anatomical criteria previously established by their group, and individualized fiber trajectories were planned accordingly. Seizure outcomes were assessed using the Engel classification. Additionally, the authors evaluated the effects of laser-induced thermal injury on adjacent motor fiber tracts and arterial structures.

Results: Sixteen patients (6 females) were included: 5 insular, 4 peri-insular, and 7 opercular subtypes. The median age at the time of LITT was 16 years, and 75% (12/16) of the patients underwent stereoelectroencephalography (SEEG). At a median follow-up of 2 years, 75% (95% CI 53.8%-96.2%) achieved Engel class IA outcomes. Transient neurological deficits occurred in 6 patients (37.5%, 95% CI 14.0%-61.0%), with no permanent morbidity. In insular cases, a thermal-blocking effect involving the external capsule or putamen was observed, while the posterior limb of the internal capsule remained intact. Postoperative imaging confirmed preserved perfusion of the adjacent M2-M3 segments of the middle cerebral artery (MCA), with no ischemic lesions detected on follow-up MRI.

Conclusions: Fiber insertion strategies for LITT based on anatomical subtypes of insulo-opercular FCD are both safe and effective. This approach enables precise ablation of epileptogenic tissue while minimizing the risk of injury to motor fiber tracts and adjacent vasculature.

Objective: This study evaluated the utility of routine versus symptom-driven MRI to detect hemorrhage in patients with sporadic cerebral cavernous malformations (CCMs) and assessed associated radiographic changes at the first clinical follow-up.

Methods: The authors analyzed a prospective, single-center cohort of patients with sporadic, brain-only CCMs who underwent at least 1 follow-up MRI after diagnosis. Clinical and radiological data were obtained from a longitudinal registry. Follow-up findings included lesion growth (≥ 3 mm), changes in Zabramski classification, persistent T1-weighted hyperintensity, edema, and hemorrhage. MRI indications were categorized as routine surveillance or symptom driven (e.g., new or worsening focal neurological deficit [FND], headache, or seizure). Univariate and multivariate analyses were performed to assess predictors of symptomatic hemmorhage (SH).

Results: Of 236 included patients, 59.3% were female, and 39.8% initially presented with SH. At the first follow-up MRI, radiographic hemorrhage was observed in 13 of 68 patients (19.1%) imaged for new or worsening neurological symptoms (FND, headaches, or seizures), compared to 2 of 168 patients (1.2%) during routine or non-CCM-related surveillance. Among these 168 patients, 17 (10.1%) showed radiological progression-including lesion growth (n = 11 [6.5%]), a change to a more aggressive Zabramski type (n = 10 [6.0%]), and radiological evidence of acute hemorrhage (n = 2 [1.2%]). Most of these events (88.2%) occurred within 2 years. SH was characterized by lesion growth, moderate-to-severe T1-hyperintensity, and edema. Baseline lesion size and location did not predict hemorrhage. New or worsening FND predicted hemorrhage, whereas seizure and headache alone did not. In the multivariate analysis, only the presence of new or worsening FND remained independently associated with hemorrhage (OR 13.73, p < 0.001).

Conclusions: In patients with known CCM, MRI should be performed in case of new or worsening FND, as this was the strongest predictor of hemorrhage. Routine surveillance had limited diagnostic yield in asymptomatic patients but may be appropriate in select cases.