Journal of neurosurgery最新文献

Objective: Because there is no reliable method on admission to predict whether a patient will require neurosurgical intervention in the future, the general approach remains to treat each patient with mild traumatic brain injury (mTBI) and subdural hematoma (SDH) as if they will require such an intervention. Consequently, there is a growing population of patients with mTBI and SDH that is overtriaged despite having a low probability of needing neurosurgical intervention. This study aimed to train and validate a predictive rule-out tool for neurosurgical intervention in patients with mTBI and SDH.

Methods: This was a retrospective cohort study of all trauma patients admitted to six level I trauma centers in three states. Patients were included if they met the following criteria: admitted between 2016 and 2020, ≥ 18 years of age, ICD-10 diagnosis of isolated SDH, initial head imaging available, initial Glasgow Coma Scale score of 13-15, and arrived within 48 hours of injury. Exclusion criteria included skull fracture, intracranial hemorrhage other than an SDH, and no neurosurgical consultation. Prediction variables included 34 demographic, clinical, and radiographic variables. The study outcome was neurosurgical intervention within 48 hours of hospital admission. Seventy-five percent of the data were used for training, and 25% for testing. Multivariable logistic regression with fivefold cross-validation was used on the training set to identify covariates with the highest specificity while holding sensitivity at 100%. Results were validated on the testing set.

Results: In total, 1000 patients were in the training set and 333 in the testing set. The overall neurosurgical intervention rate was 8.8%. For the fivefold cross-validation process, three variables were selected that maximized specificity while holding sensitivity at 100%: maximum hematoma thickness, initial Glasgow Coma Scale score, and preinjury antithrombotic use (sensitivity 100%, specificity 56%, area under the receiver operating characteristic curve 0.94). With a cutoff probability of neurosurgical intervention set at 1.88%, the final model was validated to predict neurosurgical intervention with a sensitivity of 100% (95% CI 88.4%-100%) and specificity of 55.1% (95% CI 49.3%-60.8%).

Conclusions: In this study, the largest of its kind to date, the authors successfully developed and validated a new tool for ruling out the necessity of neurosurgical intervention in patients with mTBI and isolated SDH. By successfully identifying more than half of patients who are unlikely to require neurosurgery within the first 2 days of admission, this tool can be used to improve treatment efficiency and provide patients and clinicians with valuable prognostic information.

Objective: Mastery of the posterior clinoidectomy technique is of utmost importance for neurosurgeons who specialize in endoscopic endonasal approaches, because the posterior clinoid process (PCP) is commonly involved in chondroid tumor resection. Three main techniques for posterior clinoidectomy have been developed: intradural, extradural, and transcavernous interdural. The authors introduce here a novel technical variant in which the transcavernous approach is extended to the dorsal clinoidal space after transection of the caroticoclinoid ligament, and they elaborate on its clinical application on the basis of anatomical dissections and radiological studies.

Methods: The authors reviewed CT angiography images and 3D reconstruction of the PCP in 50 adults to analyze the height and presence of ossified ligament attachments. In addition, endoscopic endonasal posterior clinoidectomy was performed in 20 lightly embalmed postmortem human heads. Three techniques, including extradural, transcavernous, and extended transcavernous posterior clinoidectomy, were performed sequentially, and anatomical landmarks and areas exposed with each technique were investigated and compared.

Results: Using radiological studies, the authors categorized the PCPs as 1 of 2 types: 1) normal, defined as less than or equal to 8 mm high with no ossified ligament attachments; or 2) complex, defined as greater than 8 mm high with or without an ossified ligament attachment. Compared with extradural (exposed PCP height 4.7 ± 0.5 mm) and transcavernous (exposed PCP height 7.3 ± 0.8 mm) posterior clinoidectomies, the extended transcavernous posterior clinoidectomy provided the maximally exposed PCP height (9.6 ± 0.4 mm; p < 0.0001).

Conclusions: This report details the extended transcavernous posterior clinoidectomy as a novel technical variant for achieving maximal exposure of the PCP in endoscopic endonasal surgery. In addition, the positive results establish the importance of preoperative skull base imaging for surgical planning.

Objective: Many patients recruited in the Treatment of Brain Arteriovenous Malformations Study (TOBAS) are managed conservatively. The aim of this study was to monitor what happened to those patients.

Methods: TOBAS comprises two randomized controlled trials and multiple prospective registries. All patients with brain arteriovenous malformations (AVMs) can participate. This report concerns patients selected for conservative management. The primary trial outcome measure is related death or dependency (modified Rankin Scale [mRS] score > 2) at 10 years. Secondary outcomes include intracranial hemorrhages, nonhemorrhagic neurological events, and serious adverse events (SAEs). For this report, outcome results are presented using patient-years, Kaplan-Meier survival curves, and Cox log-rank tests. There was no blinding.

Results: From June 2014 to May 2021, 1010 patients were recruited, of whom 498 (49%) were proposed the prospective observation registry. After exclusions, 434 (87%) patients remained for analysis. The majority of patients had unruptured AVMs (378/434 [87%]), of which 195 (52%) were low grade (Spetzler-Martin grade I or II). During a mean follow-up period of 3.2 years (total 1368 patient-years), the primary outcome occurred in 23 of 434 (5%) patients, corresponding to an incidence of 1.7 (95% CI 1.1-2.5) per 100 patient-years. For unruptured AVMs the incidence was 1.1 (95% CI 0.7-1.9) per 100 patient-years, and for low-grade unruptured AVMs it was 0.6 (95% CI 0.2-1.7) per 100 patient-years. Poor outcomes were more frequent in patients with a history of rupture (HR 5.6 [95% CI 2.4-13.0], p < 0.001), infratentorial AVMs (HR 2.9 [95% CI 1.1-7.3], p = 0.027), and age ≥ 55 years (HR 3.2 [95% CI 1.4-7.6], p = 0.007). Major intracranial hemorrhage occurred in 35 of 434 (8%) patients (incidence of 2.6 [95% CI 1.9-3.6] per 100 patient-years; 2.0 [95% CI 1.3-2.9] per 100 patient-years for unruptured AVMs and 1.3 [95% CI 0.6-2.6] per 100 patient-years for low-grade unruptured AVMs). Major AVM hemorrhages were more frequent in ruptured (HR 4.4 [95% CI 2.1-8.9], p < 0.001), large (HR 2.6 [95% CI 1.1-6.6], p = 0.039), and high-grade (HR 2.5 [95% CI 1.2-5.3], p = 0.013) AVMs and those with deep venous drainage (HR 2.1 [95% CI 1.1-4.2], p = 0.032). SAEs occurred in 48 of 434 (11%) patients (incidence of 3.6 [95% CI 2.7-4.8] per 100 patient-years). For unruptured AVMs the incidence was 2.8 (95% CI 2.0-4.0) per 100 patient-years, and for low-grade unruptured AVMs it was 1.8 (95% CI 1.0-3.2) per 100 patient-years.

Conclusions: Nearly half of TOBAS participants were observed. Rates of untoward neurological events were within expected boundaries.

Objective: Morphological changes such as angulation and torsion of the trigeminal nerve have been reported to cause trigeminal neuralgia (TN). The authors sought to quantify and objectively evaluate the morphological changes of the trigeminal nerve and to elucidate the cause of TN.

Methods: The authors retrospectively analyzed the cases of patients with primary TN who had undergone microvascular decompression at a single facility between January 2016 and December 2022 and had both single-artery compression and a good postoperative outcome. The authors performed segmentation of the trigeminal nerve by using the patients' pre- and postoperative high-resolution MR images, and they then created a 3D model. The centerline of the trigeminal nerve was obtained using volume skeletonization, and the authors created multiple cross-sectional images by reslicing the 3D model perpendicular to the centerline. The parameters analyzed were as follows: the 1) centerline length; 2) centerline curvature; 3) centerline torsion; 4) cross-sectional area; 5) cross-sectional flattening ratio; and 6) cross-sectional long-axis angle. Comparisons were made for each parameter between the affected and unaffected side and between preoperative and postoperative trigeminal nerve findings.

Results: After exclusions, 70 of the 127 patients who underwent microvascular decompression during the study period were included in the analysis. In the preoperative images, the trigeminal nerve on the affected side had a significantly longer centerline length (p = 0.0003), greater curvature (p = 0.0012), smaller cross-sectional area (p < 0.0001), and greater flattening ratio (p = 0.0059) than the unaffected side. On the affected side, the preoperative trigeminal nerve had a significantly longer centerline length (p < 0.0001), greater curvature (p = 0.0028), and smaller cross-sectional area (p < 0.0001) compared to the postoperative trigeminal nerve.

Conclusions: It is possible to analyze the morphological changes of the trigeminal nerve by using this method. In the preoperative trigeminal nerve on the affected side, the centerline is long and curved, and the cross-sectional area is small and flat. Further analyses may help clarify the pathophysiology, aid in diagnoses, and predict the efficacy of treatment.

Objective: Hospitals use rapid response systems (RRSs) to identify and treat patients whose conditions rapidly worsen after admission. However, no study has examined the effects of RRS deployment on the clinical outcomes of patients undergoing cranial neurosurgery. Thus, the authors investigated whether use of RRS affects clinical outcomes in these patients.

Methods: This nationwide, retrospective, population-based cohort study included adult patients who underwent cranial neurosurgery in South Korea between January 1, 2019, and December 31, 2021. The authors classified patients admitted to hospitals that operated RRS into the RRS group and those admitted to hospitals that did not operate RRS into the non-RRS group.

Results: Overall, 73,600 hospitalized patients who underwent cranial neurosurgery were included in this study. These patients were divided into 2 groups: 38,544 (52.4%) were included in the RRS group and 35,066 (47.6%) in the non-RRS group. After propensity score matching, 40,058 patients (20,029 in each group) remained. The in-hospital mortality rate was 10.1% (2022/20,029) for the non-RRS group and 8.9% (1792/20,029) for the RRS group. In the logistic regression analysis, the in-hospital mortality rate of the RRS group was 12% (OR 0.88, 95% CI 0.82-0.94, p < 0.001) lower than that of the non-RRS group. The 1-year all-cause mortality rate was 26.5% (5300/20,029) in the non-RRS group and 24.6% (4921/20,029) in the RRS group. In the Cox regression analysis, the 1-year all-cause mortality rate of the RRS group was 9% (HR 0.91, 95% CI 0.88-0.95; p < 0.001) lower than that of the non-RRS group.

Conclusions: This population-based cohort study revealed that implementing RRS was associated with enhanced short- and long-term survival outcomes in patients who underwent cranial neurosurgery. The authors' findings indicate that the introduction of RRS can enhance patient survival rates after cranial neurosurgery.

Objective: Visual acuity (VA) constitutes an important outcome measure in surgery for medial sphenoid wing meningioma (SWM). This study aimed to assess the recovery of tumor-associated impairment of VA and its impact on patient-reported outcome measures (PROMs) as an indication of vision-related quality of life in patients who had undergone surgery for medial SWM.

Methods: From 2009 to 2018, 153 consecutive patients with medial SWM underwent surgical treatment at the authors' institutions. Tumor-associated VA was evaluated both on admission and during postoperative follow-up examinations, using Snellen charts. Multivariable analysis was performed to identify independent predictors for postoperative improvement of VA. PROMs were collected based on the National Eye Institute 25-Item Visual Function Questionnaire.

Results: Of patients with medial SWM, 53 of 153 (35%) experienced preoperative impairment of VA. The median preoperative duration of visual symptoms was 12 (IQR 3-17) months for the entire study cohort. Multivariable analysis revealed a preoperative duration of visual symptoms ≤ 4 months to be independently associated with postoperative improvement of VA (p = 0.009). Evaluation of PROMs indicated a superior postoperative qualitative extent in the overall health (p = 0.027) and activities of daily living (p = 0.031) categories if preoperative duration of visual impairment was ≤ 4 months.

Conclusions: The overall preoperative duration of tumor-related visual impairment significantly correlates to the extent of postoperative visual improvement as well as vision-related PROMs in medial SWM surgery. These results might aid in preoperative patient counseling and help optimize decision-making and preoperative estimation of long-term visual outcome.

Objective: Long-standing overt ventriculomegaly in adults (LOVA) is a chronic form of hydrocephalus that can lead to cognitive deficits. Data on the cognitive profile of patients with LOVA and cognitive outcomes of endoscopic third ventriculostomy (ETV) are, however, scarce and mostly qualitative.

Methods: Twenty-three consecutive patients with LOVA hydrocephalus underwent ETV surgery, and their cognitive status was assessed before surgery, immediately after surgery, and at the 5-month follow-up. Cognitive function was assessed using a neuropsychological battery measuring 6 cognitive domains: general cognitive status, attention/executive function, language, visuospatial skills, short-term memory, and long-term memory. Cognitive reserve was also estimated through a measure of premorbid IQ to assess its potential influence together with other clinical and demographic variables.

Results: Patients with LOVA did not experience general cognitive decline but rather selective long-term memory (p < 0.001) and visuospatial skills (p = 0.001) deficits alone. Moreover, ETV surgery led to significant immediate postoperative improvement in both domains (p = 0.002 and p < 0.001 respectively), that persisted at follow-up (p < 0.001 for both). However, improvement was observed only in patients with higher premorbid IQ (p < 0.001), while the others did not improve (p > 0.532).

Conclusions: These findings confirm the effectiveness of ETV surgery and highlight the role of cognitive reserve in promoting plasticity of brain and cognitive functions thus fostering and predicting cognitive recovery.

Objective: Optimal management of the pituitary stalk during craniopharyngioma resection remains a controversial subject. This meta-analysis aimed to evaluate the effect of pituitary stalk preservation on postoperative diabetes insipidus (DI), anterior pituitary function (PF), extent of resection, and recurrence.

Methods: Medline was searched via Ovid for relevant articles from inception to September 2, 2022. Studies reporting the rates of DI or anterior PF postoperatively or at last follow-up, extent of resection, or tumor recurrence at last follow-up were eligible for inclusion. The risk ratio (RR) for each outcome was calculated. Random-effects meta-analyses were performed with additional stratification by age. To assess for risk of bias across studies, funnel plots and the Egger's test were utilized.

Results: In total, 3488 abstracts and 150 full-text articles were reviewed, resulting in 33 studies with a total of 2366 patients for inclusion. In the comparative meta-analysis, pituitary stalk preservation significantly decreased the risk of DI postoperatively (17 studies, RR 0.67, 95% CI 0.55-0.81, I2 = 75%), DI at last follow-up (6 studies, RR 0.54, 95% CI 0.41-0.72, I2 = 20%), and abnormal anterior PF postoperatively (15 studies, RR 0.78, 95% CI 0.69-0.89, I2 = 49%) but not abnormal anterior PF at last follow-up (4 studies, RR 0.38, 95% CI 0.09-1.63, I2 = 64%). There were no significant differences in the rates of incomplete resection (12 studies, RR 1.59, 95% CI 0.77-3.28, I2 = 68%) or tumor recurrence (9 studies, RR 1.18, 95% CI 0.92-1.51, I2 = 0%) between the preservation and sacrifice groups. However, subgroup analysis of pediatric patients revealed a higher risk of incomplete resection (RR 3.29, 95% CI 1.17-9.26, I2 = 70%) in the stalk preservation group.

Conclusions: Pituitary stalk preservation was demonstrated to confer protective benefit on PF, although the benefit persisted on long-term follow-up for posterior PF only. Stalk preservation in pediatric patients should be given careful consideration, as it is associated with higher rates of incomplete resection. These results should be interpreted with caution due to inclusion of small studies and inadequate reporting of outcomes in the literature.

Objective: Frailty is recognized as an important predictor of neurointerventional outcomes. MRI-guided focused ultrasound (MRgFUS) thalamotomy is a treatment option for patients with refractory essential tremor (ET) and tremor-dominant Parkinson's disease (TdPD). The aim of this study was to evaluate whether frailer MRgFUS thalamotomy patients had worse tremor outcomes or more complications.

Methods: The authors performed a cohort analysis of patients treated with MRgFUS between 2020 and 2023. Inclusion criteria were unilateral MRgFUS thalamotomy for ET or TdPD with available follow-up data (minimum 3-month follow-up). Frailty was assessed using the 11-item modified frailty index (mFI-11), which includes 11 medical comorbidities. Tremor outcomes were assessed using the Clinical Rating Scale for Tremor Part B. Complications assessed included disturbances of sensation, speech and swallowing, balance and gait, and strength.

Results: In total, 169 eligible patients were identified, including 135 (79.9%) ET and 34 (20.1%) TdPD patients. Frailty did not result in significant differences in tremor outcomes in the combined (p = 0.833), ET (p = 0.902), or TdPD (p = 0.501) cohort, or in any adverse events at the last follow-up (all p > 0.05). The combined mean follow-up was 10.3 ± 5.8 months (range 3-24 months), with cohort-specific mean follow-ups of 10.8 ± 6.0 months for ET and 8.6 ± 4.6 months for TdPD. Between the ET and TdPD cohorts, no significant differences existed in age, sex, handedness, side treated, skull density ratio, number of sonications, peak and average temperatures, energy delivered, BMI, or American Society of Anesthesiologists classification. For medical comorbidities, only hypertension was significantly different (65.9% ET, 47.1% TdPD; p = 0.043). The ET patients were significantly frailer overall, with 20.7% ET and 35.3% TdPD patients considered robust (mFI-11 score of 0), 14.8% ET and 32.4% TdPD patients prefrail (mFI-11 score of 1), 25.9% ET and 8.8% TdPD patients frail (mFI-11 score of 2), and 38.5% ET and 23.5% TdPD patients severely frail (mFI-11 score ≥ 3) (p = 0.007).

Conclusions: Increasing frailty is not associated with worse outcomes, suggesting that MRgFUS may be appropriate even for frailer patients. ET patients are frailer than TdPD patients selected for MRgFUS.