Journal of neurosurgery最新文献

Objective: For patients with language-eloquent brain tumors, surgeons must maximize the extent of resection while minimizing neurological morbidity. Despite the extensive use of noninvasive brain mapping techniques, it remains unclear how to preoperatively localize brain regions essential for sustaining language function in a data-driven manner. Here the authors investigate the clinical utility and functional relevance of regions mapped by functional MRI (fMRI), transcranial magnetic stimulation (TMS), and diffusion tensor imaging (DTI).

Methods: This study included 71 consecutive patients undergoing resection of language-eloquent gliomas from July 1, 2017, to August 1, 2023. A nonlinear coregistration algorithm was used to overlay the postoperative resection cavity onto the preoperative MRI. The resection of preoperative cortical and subcortical localizations was correlated with long-term linguistic outcomes. Fiber tracts were localized by seeding DTI tractography with different cortical features: TMS points (TMS tracts), the fMRI blood oxygen level-dependent (BOLD) signal (fMRI tracts), and a peritumoral 1-cm grid (grid tracts). Multiple fractional anisotropy (FA) thresholds were used for each cortical seed structure. Fiber tracts were normalized to Montreal Neurological Institute space to identify group-level characteristics.

Results: The majority of patients were male (n = 42, 59%) and younger than 60 years of age (n = 46, 65%). Forty-one patients (58%) had high-grade gliomas, while 30 patients (42%) had low-grade gliomas. The authors found that the resection of preoperatively identified cortical language regions does not predict long-term aphasic decline. However, the resection of tracts localized by the TMS points and grid at the 75% normalized FA threshold significantly predicted language outcomes (OR 51, p < 0.001 and OR 5.0, p = 0.04, respectively). Tracts localized by the fMRI BOLD signal did not predict language outcomes at any FA threshold (OR 0.29-5.32, p = 0.42-0.94). Tracts localized by all three cortical seed structures recapitulated normative patterns of subcortical connectivity by colocalizing with and sharing group-level features with language-associated normative tracts derived from the Human Connectome Project. Functional tracts that predicted linguistic outcomes (TMS and grid tracts) demonstrated shared features at a group-level distinct from the nonpredictive fMRI tracts.

Conclusions: The resection of cortical language regions mapped preoperatively by fMRI and TMS did not predict aphasic surgical deficits. In contrast, resecting white matter tracts localized by cortical TMS points and a peritumoral cortical grid significantly predicted aphasic decline, while resecting tracts localized by the fMRI BOLD signal as seeds did not predict linguistic outcomes.

Objective: Cervical dystonia (or spasmodic torticollis) is a neurological condition that results in abnormal movements and head posture, for which initial surgical intervention typically involves selective denervation of the sternocleidomastoid (SCM) and paraspinal muscles. However, muscle reactivation of the distal SCM stump can result in recurrent symptoms. In this study, the authors present their preliminary experience with distal SCM stump resection following selective denervation, with the aim of evaluating the effectiveness of the procedure and identifying patients who may benefit from this technique.

Methods: This is a retrospective single-center cohort study of patients who underwent SCM stump resection as revision surgery for cervical dystonia.

Results: A total of 18 patients (10 males [56%]) were included with a median (range) age of 54 (40-70) years. All patients received selective denervation of the SCM at the authors' institution prior to SCM stump resection at a median (range) time of 12 (3-198) months between surgical procedures. At preoperative baseline, 13 patients (72%) possessed a rotational torticollis component to their head deviation, 12 (67%) possessed a laterocollis component, and 2 (11%) possessed a retrocollis component. At the most recent follow-up (median [range] 16 [4-119] months), 6 patients had complete resolution of their cervical dystonia (33%), while 10 had residual deviation (56%) and 2 had recurrent deviation (11%). However, compared to their post-selective denervation head position, 12 patients experienced improvement in their head position (67%), 4 patients had no change in their head position (22%), and 2 had worsening of their cervical dystonia (11%) following SCM stump resection. Importantly, 12 patients experienced improvement in their pain following SCM stump resection (67%). Patients who had a history of other movement/spasmodic disorders were more likely to have improvement in head position and improvement in pain after SCM stump resection, though neither of these results achieved statistical significance (p = 0.054). Additionally, patients who experienced full resolution of their cervical dystonia had shorter time between initial selective denervation surgery and SCM stump resection, though this result also did not achieve statistical significance (p = 0.068).

Conclusions: Distal SCM stump resection following selective denervation is a simple, safe, and effective option for many patients in treating refractory cervical dystonia. Patients with more severe preoperative presentations may experience greater benefit from SCM stump resection, though additional investigations are needed.

Objective: Semisitting or lounging patient positions offer several advantages in neurosurgical procedures, particularly for the resection of large and highly vascularized posterior fossa lesions. However, concerns persist regarding potentially severe complications such as tension pneumocephalus (TP) and venous air embolisms. The aim of this study was to assess the extent and distribution of postoperative pneumocephalus and to identify risk factors of TP.

Methods: This retrospective analysis included consecutive patients who underwent posterior fossa surgery in the lounging position from January 2010 to November 2020 at a single center. Postoperative cranial CT scans acquired within 24 hours after surgery were registered and normalized to the common Montreal Neurological Institute space to measure intraventricular, subdural, and total intracranial air using voxel-based volumetry. TP was defined as intracranial air associated with reduced consciousness, and its treatment was typically performed via external ventricular drain (EVD) placement or subdural air exchange through mini burr hole trepanation. Patient characteristics, surgical details, and clinical outcome were evaluated.

Results: Overall, 836 patients (462 female, mean age 48.7 years) were included. The indication for surgery was resection of a posterior fossa tumor (96.1%, n = 803), vascular pathology (2.6%, n = 22), malformation (1.1%, n = 9), or other pathology (0.2%, n = 2). Lateral suboccipital and midline suboccipital approaches were performed in 93.8% (n = 784) and 6.2% (n = 52) of patients, respectively. Intracranial air was detected in all patients, with a mean volume of 74 ± 59 mL. The volumetric analysis revealed significantly higher mean volumes of intracranial air (midline: 94 ± 72 mL, lateral: 73 ± 58 mL) [t(828) = 2.44, p = 0.008 (95% CI 4-38)] and intraventricular air (midline: 29 ± 32 mL, lateral: 3 ± 14 mL) [t(828) = 11.36, p < 0.001 (95% 21-30)] in midline approaches compared with lateral approaches. TP occurred in 3.0% of patients, with higher rates (15.4%) in those who underwent midline craniotomies compared with lateral approaches (2.0%) [χ2(1) = 31.14, p < 0.001]. Patients with TP required longer ventilation, intensive care unit stays, and hospitalizations, although Karnofsky Performance Status scores did not differ significantly at follow-up. The logistic regression analysis identified surgical approach, age, duration of surgery, and sex as independent predictors of TP [χ2(4) = 41.34, p < 0.001]. The area under the curve (AUC) analysis indicated that intraventricular air volumes ≥ 27.6 mL were associated with EVD placement (AUC = 0.92, sensitivity = 0.90, specificity = 0.95). TP was managed effectively in all cases, with no long-term sequelae.

Conclusions: These findings suggest that the lounging position can be performed safely with careful monitoring for TP, particularly in old

Objective: Nonfunctioning pituitary adenomas (NFPAs) often present with associated mild hyperprolactinemia, described in literature as "stalk effect." The presence of preoperative hyperprolactinemia caused by tumor compression of the pituitary stalk and endocrinological outcomes has been noted; however, a detailed investigation on the impact on perioperative endocrinological outcome is lacking. The authors aimed to determine whether elevated preoperative serum prolactin concentrations are associated with increased risk of perioperative pituitary dysfunction in patients with NFPAs undergoing endonasal transsphenoidal surgery (ETS).

Methods: The authors conducted a single-center retrospective cohort study of patients who underwent ETS for NFPAs between January 2013 and April 2023. Patients were divided into two groups based on preoperative prolactin concentrations: normal or hyperprolactinemic (prolactin values above upper limit of reference range, adjusted for sex). Outcomes included perioperative endocrinological function and surgical outcomes. Multivariable analysis was conducted to identify factors associated with perioperative endocrinological function outcomes.

Results: Of 244 patients (140 [57%] males; median age 59 years) with a median follow-up of 65 months, 131 (54%) had hyperprolactinemia. Compared with patients with normal preoperative prolactin levels (n = 113), the hyperprolactinemia group had similar tumor size (median diameter 2.5 cm vs 2.3 cm, p = 0.102) but higher rates of cavernous sinus invasion (99% vs 91%, p = 0.035), pituitary stalk deviation (95% vs 74%, p = 0.001), stalk bending (14% vs 1%, p = 0.001), preoperative secondary hypothyroidism (39% vs 22%, p = 0.005), and adrenal insufficiency (AI; 34% vs 22%, p = 0.048). Postoperatively, the hyperprolactinemia group showed higher rates of new secondary hypothyroidism (16% vs 7%, p = 0.048) and new permanent AI (16% vs 6%, p = 0.046). Multivariable analysis revealed preoperative high prolactin as an independent predictor of preoperative secondary hypothyroidism (OR 1.83, 95% CI 1.17-3.44; p = 0.046) and its postoperative deterioration (OR 2.65, 95% CI 1.02-7.69; p = 0.042). Maximum tumor diameter was also a significant predictor of various endocrinological dysfunctions both pre- and postoperatively.

Conclusions: Preoperative hyperprolactinemia in patients with NFPA is associated with higher risks of specific perioperative endocrinological dysfunction and pronounced pituitary stalk deviation. These findings highlight the utility of preoperative prolactin levels as a biomarker for predicting postoperative endocrinological outcomes, potentially enhancing risk assessment and guiding personalized perioperative management.

Objective: The Brain Injury Guidelines (BIG) were modified in 2020 to improve efficiency and safety in triage decision-making. The aim of this study was to present characteristics and in-hospital outcomes of patients classified under category 1 of the modified BIG (mBIG 1).

Methods: A retrospective review of patients presenting with acute traumatic brain injury (TBI) to a level 1 trauma center between 2019 and 2023 was performed. Patients meeting clinical and radiographic criteria for mBIG 1 were identified. An additional cohort of patients was identified who were taking 81 mg of aspirin once daily (ASA81) before the hospital, but who otherwise met mBIG 1 criteria. Summary statistics and univariate analyses were performed.

Results: Three hundred three patients were identified and classified as mBIG 1. The mean patient age was 54.45 (SD 1.17) years and 41.3% were female. There were 144 patients (47.5%) who transferred from an outside hospital. The median admission Glasgow Coma Scale score was 15 (interquartile range [IQR] 15-15). Patients underwent an average of 2.28 (SD 0.03) CT scans. There were 123 (40.6%), 18 (5.9%), and 126 (41.6%) patients with subdural hematoma, intraparenchymal hemorrhage, and subarachnoid hemorrhage, respectively, with 36 patients (11.9%) presenting with multiple hemorrhages. Eleven patients (3.6%) experienced hemorrhage progression. No patient underwent neurosurgical intervention. The mean Injury Severity Score was 13.12 (SD 7.04). The median hospital length of stay (LOS) was 1.01 (IQR 0.37-4.56) days, 75.2% of patients were discharged home, 24.1% were discharged to rehabilitation, and 0.7% died in the hospital. An additional 25 patients were identified who were taking ASA81 prehospital, but otherwise met mBIG 1 criteria. None of these patients underwent neurosurgical intervention and there were no in-hospital deaths. One patient (4.0%) taking ASA81 experienced progression of their hemorrhage but still met mBIG 1 criteria. When compared to the mBIG 1 cohort, the aspirin cohort was significantly older (p < 0.001), but otherwise showed no differences in demographic, clinical, or radiographic variables. The combined mBIG 1 + aspirin cohort was stratified by hemorrhage progression (n = 12). Hospital LOS was significantly greater in the progression cohort (p = 0.017) and fewer patients were discharged home (p = 0.001). There was no difference in age, hypertension, admission mean arterial pressure, platelet count, international normalized ratio, partial thromboplastin time, hemorrhage pattern, and aspirin use between the groups.

Conclusions: Hemorrhage progression was rare, including cases in which patients were receiving prehospital low-dose aspirin therapy. More data are needed that evaluate the role of low-dose aspirin in the triage of patients with mild TBI.

Objective: Surgical management of large vestibular schwannoma (VS; Koos grades III and IV) requires a balance between the maximum extent of resection and the best functional preservation. The primary objective of this study was to determine the volumetric threshold of the VS residual tumor at risk of progression after incomplete resection. The secondary objective was to identify other risk factors of regrowth after incomplete resection.

Methods: This retrospective study included patients who underwent incomplete resection of sporadic VS at a single center from January 2008 to December 2018. The inclusion criteria were: adult age, large single sporadic VS, incomplete resection, and follow-up of > 5 years. Quantitative 3D volumetry was assessed on pre- and postoperative contrast-enhanced T1-weighted MRI using semiautomated segmentation. The volumetric criteria for residual tumor were < 250 mm3 for near-total resection (NTR) and < 2 cm3 for subtotal resection (STR). Univariate and multivariate logistic regression analyses were performed to assess predictors of regrowth after incomplete resection. A residual volume cutoff for risk of regrowth was determined using the Youden index via area under the curve analysis.

Results: The cohort included 119 patients (60 female, median age 58 years) who were categorized into 3 subgroups based on the residual VS according to 3D volumetry: NTR, STR, and partial resection (PR). NTR achieved the best long-term tumor control. Kaplan-Meier progression-free survival rates at 2, 5, and 10 years were 98%, 97%, and 95% for the NTR group; 69%, 56%, and 56% for the STR group; and 20%, 0%, and 0% for the PR group, respectively (p < 0.0001). The cutoff residual volume at risk of growth was 200 mm3, with sensitivity of 95% (95% CI 74%-99%) and specificity of 77% (95% CI 68%-85%, p < 0.001). Moreover, good facial nerve outcomes (House-Brackmann grades I and II) were best achieved with PR (100%), followed by STR (96%) and NTR (90%). In the univariate analysis, the risk factors for regrowth of residual tumor were cystic morphology, residual volume, and residual location (internal auditory canal, cisternal segment, and brainstem combined). The multivariate model identified the volume and location of residual as risk factors (p < 0.0001).

Conclusions: These findings suggest that limited NTR (< 250 mm3) offered an excellent compromise, with long-term tumor control comparable to that of radical resection while preserving superior functional preservation. The authors hope to stimulate discussion toward a unified volumetrically established classification of incomplete resections, allowing for cooperation in future multicenter studies.

Objective: In adult patients with moyamoya disease (MMD), insufficient postoperative collateral formation is usually seen after combined bypass surgery. The arachnoid membrane, a critical anatomical barrier between extracranial and intracranial vascular systems, has an unclear role in postoperative angiogenesis. The aim of this study was to investigate whether intraoperative arachnoid membrane opening enhances angiogenesis in adult patients undergoing combined bypass surgery for MMD.

Methods: This multicenter, prospective, randomized controlled trial (Membrane Opening to Promote Angiogenesis in Adult MMD [MOPOAM]) was conducted across 8 institutions in China. Between June 2022 and August 2023, 104 patients diagnosed with MMD through digital subtraction angiography were randomly assigned to two groups: one group underwent arachnoid opening (n = 51), while the other group had arachnoid preservation (n = 53). The primary endpoint was the rate of good angiogenesis (Matsushima grade A and B) assessed 6-12 months postoperatively, and the secondary endpoint was the incidence of surgical complications within 1 month postsurgery.

Results: All 104 patients completed the study. The rate of good angiogenesis was 54.9% in the arachnoid opening group and 64.2% in the arachnoid preservation group, with no significant difference between groups (OR 1.470, 95% CI 0.669-3.229; p = 0.337). Postoperative complications were observed in 2 patients (3.9%) in the arachnoid opening group and in 5 patients (9.4%) in the arachnoid preservation group, showing no significant difference (OR 2.552, 95% CI, 0.472-13.796; p = 0.276). No significant association between arachnoid opening procedures and functional recovery (assessed by modified Rankin Scale scores) was found during the 6- to 12-month follow-up period (p = 0.831).

Conclusions: In adults with MMD, arachnoid membrane opening during combined bypass surgery did not significantly improve postoperative angiogenesis rates or increase perioperative complications.