Journal of neurosurgery最新文献

Objective: Glioblastoma is an aggressive brain tumor that is more common and has a worse outcome in males. Recently, the observed sex differences have been linked to tumor biology, prominently highlighting fundamental differences in gene expression programs. Here, the authors advance this concept to epigenome-based DNA methylation patterns across primary and recurring glioblastoma.

Methods: The authors leveraged their 614 publicly available DNA methylation datasets comprising 252 female and 362 male patients with glioblastoma. They applied a joint and individual variation explained analysis to explore clusters among tumors in males and females in an unsupervised way. Their prognostic association was explored using Kaplan-Meier analysis and a Cox proportional hazards model. Their findings were validated using The Cancer Genome Atlas (TCGA) dataset.

Results: Clustering of the individual, sex-specific components yielded two distinct clusters in males and females, which were predictive of overall survival in males (p = 0.0098). Among differentially regulated genes in males, the 20 most consistently altered genes resulted in a targeted panel, which predicted overall survival in males and females at the first surgery (p < 0.0001 and p = 0.013) but not at recurrence (p = 0.3 and p = 0.85, respectively). These findings were validated in TCGA dataset. The authors translated the observed differences in survival to networked pathways prominently highlighting protein metabolism in males and oxidative phosphorylation in females.

Conclusions: In summary, the authors report sex-specific differences in DNA methylation patterns among male and female cases of glioblastoma that converge on a set of 20 genes that have a prognostic impact in both sexes at the first surgery. Sex-specific networks of pathways suggest prominent roles for protein processing and antigen presentation in males and metabolism in females. The study findings provide new insights in sex-specific tumor biology to further improve individual gender-based patient management and estimation of disease prognosis.

Objective: The definitive influence of prestroke disability on outcomes in patients with a low Alberta Stroke Program Early CT Score (ASPECTS) treated with endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) remains unknown. This study aimed to investigate the impact of prestroke disability on outcomes in this specific population.

Methods: Data from 32 international centers for AIS-LVO patients with a low ASPECTS who underwent EVT between January 2013 and December 2022 were analyzed retrospectively. Low ASPECTS and prestroke disability were defined as ASPECTS values of 2-5 and prestroke modified Rankin Scale (mRS) score ≥ 2. The primary outcome was a return to the prestroke mRS score at 90 days. Secondary outcomes were independent ambulation (mRS scores of 0-3) or a return to the prestroke mRS score at 90 days, good functional outcome (mRS scores of 0-2) or a return to the prestroke mRS score at 90 days, successful recanalization, and 90-day mortality. Safety outcomes were any intracranial hemorrhage or symptomatic intracranial hemorrhage. A symptomatic intracranial hemorrhage was defined as an intracranial hemorrhage with an associated worsening of ≥ 4 points in the National Institutes of Health Stroke Scale score. Outcomes were compared between patients with and without prestroke disability.

Results: Of 293 patients, 50 (17.1%) had a prestroke disability. Of 50 patients, 20 (40.0%), 24 (48.0%), and 6 (12.0%) had prestroke mRS scores of 2, 3, and 4, respectively. The primary outcome showed no significant difference between the two groups. Compared with patients without prestroke disability, those with prestroke disability had a significantly smaller proportion of independent ambulation or return to prestroke mRS score (adjusted OR 0.13, 95% CI 0.03-0.53) and good functional outcome or return to prestroke mRS score (adjusted OR 0.21, 95% CI 0.05-0.91). Other secondary and safety outcomes showed no significant difference between the two groups.

Conclusions: The present study indicated that prestroke disability was not associated with a return to the prestroke mRS score at 90 days or intracranial hemorrhage. Physicians should not routinely exclude AIS-LVO patients with a low ASPECTS who have prestroke disability from EVT based on prestroke disability alone.

Objective: Although trigeminal neuralgia (TN) is initially managed conservatively, approximately half of all patients will eventually undergo surgery. Despite this outcome, there is limited understanding of the relationship between preoperative length of conservative management and pain outcomes after microvascular decompression (MVD). In this study, the authors aimed to describe the relationship between the duration of preoperative conservative management and postoperative outcomes in patients undergoing MVD for TN.

Methods: The electronic medical records of 381 patients with TN who underwent primary MVD at the authors' institution between 2007 and 2023 were reviewed. Patients were dichotomized based on whether the duration of conservative management, defined as the duration of anticonvulsant use, was greater than, or less than or equal to, the median duration of conservative management for the entire cohort. For adjusted analysis, duration of conservative management was also assessed as a continuous variable. Demographic information, comorbidities, clinical TN characteristics, pain recurrence, and pre- and postoperative modified Barrow Neurological Institute (BNI) pain and numbness scale scores were recorded and compared between groups. Differences in pain outcomes were assessed via multivariate ordinal regression, Kaplan-Meier analysis, and Cox proportional hazards analysis.

Results: The median preoperative duration of conservative management was 1.74 years. Patients with a prolonged duration of conservative management were significantly more likely to be male (p = 0.028) and less likely to preoperatively use opioids (p = 0.037). At final follow-up, those with a prolonged duration of conservative management had significantly higher reported BNI pain scores (p = 0.021) and higher rates of pain recurrence (p = 0.021). On multivariable ordinal regression analysis, younger age (p < 0.001) and prolonged duration of conservative management, which was assessed as both a dichotomized (p = 0.002) and continuous variable (p = 0.011), were associated with higher BNI pain scores at final follow-up. Patients with a longer duration of conservative management also had a significantly shorter time to pain recurrence, as assessed by Kaplan-Meier survival analysis (p = 0.0037) as well as Cox proportional hazards analysis (p = 0.001, dichotomized; p = 0.008, continuous).

Conclusions: In the setting of primary MVD for patients with TN, a longer duration of preoperative conservative management was associated with higher postoperative BNI pain scores and increased risk of pain recurrence. These findings suggest a potential beneficial role for early surgical intervention.

Objective: The aim of this study was to investigate the long-term outcomes and clinical predictors for seizure freedom in patients with hypothalamic hamartomas (HHs) undergoing radiofrequency thermocoagulation (RFTC) guided by stereo-electroencephalography (SEEG).

Methods: The authors enrolled 30 patients with HH-related epilepsy who underwent SEEG-guided RFTC and were followed up for at least 3 years. Seizure outcomes were assessed using the International League Against Epilepsy (ILAE) classification, with classes 1 and 2 defined as seizure freedom. Considering the observed time to relapse, the authors defined postoperative follow-up within 1 year as short-term follow-up. They analyzed lesion features, epileptic characteristics, and SEEG patterns for their relationship with short-term and long-term seizure freedom separately. Long-term complications were also reported.

Results: The mean follow-up was 69.2 months (range 36-107 months) since the first RFTC. At the last follow-up, 20 patients (66.7%) achieved seizure freedom (ILAE classes 1 and 2). Regarding different seizure types, freedom was achieved in 81.8% of patients (18/22, after 2 cases relapsed) with gelastic seizures (GS) and in 52.9% patients (9/17, after 4 cases relapsed) with other types of seizures (i.e., nongelastic seizures [NGS]). Seizures characterized by focal low-voltage fast activity recorded by SEEG were more likely to achieve freedom both in the short term (p = 0.021) and the long term (p = 0.022). A history of HH resection might negatively impact a patient's outcome at long-term follow-up, whereas lesion location, volume, seizure types, or the seizure duration showed no significant influence on both short-term and long-term outcomes. Weight gain was the most common long-term complication (26.7%).

Conclusions: The SEEG signal can guide HH ablation and serve as an important predictor for favorable seizure outcomes in both the short term and long term, a capability not exhibited by other factors thus far. Patients with a history of HH resection but who still experience NGSs should be considered carefully, as there may be a speculated mechanism of an NGS network re-forming, which can partly explain the outcome difference between patients with GSs and those with NGSs, as well as the progression of secondary epileptogenesis.

Objective: Arteriovenous malformations (AVMs) of the brain are a leading cause of stroke in the young and carry a lifetime risk of intracerebral hemorrhage. The management options for high-grade AVMs are limited. Resection is often associated with high rates of postoperative morbidity, and the results of stereotactic radiosurgery (SRS) for these lesions thus far have been mixed. The aim of this study was to summate the published data on the outcomes of SRS for high-grade AVMs in order to better inform the management of these otherwise untreatable lesions.

Methods: A search of four online databases for literature pertaining to the use of SRS to treat high-grade (Spetzler-Martin grades IV-VI) AVMs was performed. Data pertaining to AVM obliteration, incidence of adverse radiation effects (AREs), and posttreatment hemorrhage were extracted, and a meta-analysis of proportions was performed. The study protocol was prospectively registered with PROSPERO.

Results: Fifteen studies describing the results of SRS treatment of 562 high-grade AVMs were analyzed. The overall rate of AVM obliteration during a median follow-up period of 50 months was 34.2% (95% CI 27.0%-42.1%, I2 = 65.1%). The pooled rate of hemorrhage following SRS treatment was 12.2% (95% CI 7.8%-18.7%, I2 = 25%). For previously ruptured AVMs, the rate of hemorrhage was 12.7% (95% CI 8.5%-18.7%, I2 = 0%) compared with 5.2% (95% CI 1.0%-23.1%, I2 = 0%) for unruptured AVMs. The overall incidence of AREs was 9.3% (95% CI 5.2%-15.9%, I2 = 0%).

Conclusions: SRS for high-grade AVMs is associated with a modest rate of obliteration and is complicated by AREs in 9% of cases. Patients harboring previously ruptured AVMs or lesions with high-risk angioarchitectural features may be more likely to benefit from this treatment.

Objective: This study aimed to investigate the effects of bilateral globus pallidus internus (GPi) deep brain stimulation (DBS) on both motor and nonmotor symptoms in patients with Meige syndrome and to further explore prognostic factors for postoperative outcomes based on the long-term follow-up results.

Methods: The authors retrospectively reviewed the medical records of a consecutive cohort of patients with refractory Meige syndrome who underwent GPi-DBS at their center from January 2016 to October 2023. Motor function, quality of life, neuropsychological status, and emotional state were assessed using standardized scales at baseline and every 3-6 months thereafter. Univariate and multivariate linear regression analyses were performed to identify independent risk factors affecting long-term motor function after GPi-DBS in patients with steady-state (stable) Meige syndrome.

Results: Fifty steady-state patients were ultimately included and assessed, with a mean follow-up duration of 62.9 ± 24.8 months. At the final postoperative evaluation, Burke-Fahn-Marsden Dystonia Rating Scale movement and disability scores showed improvements of 69% (p < 0.001) and 61% (p < 0.001), respectively. A significant improvement from baseline was observed in postoperative scores on the 36-item Short-Form General Health Survey. Throughout continuous neurostimulation, global cognitive function, neuropsychological status, and mood remained stable. Multivariate linear regression analysis revealed that longer disease duration (standardized β-coefficient -0.375, 95% CI -0.033 to -0.011; p < 0.001) and reduced volume of activated tissue within the sensorimotor subregion of the GPi (standardized β-coefficient 0.597, 95% CI 0.002-0.003; p < 0.001) were independently associated with worse long-term motor performance.

Conclusions: Bilateral GPi-DBS is an effective, safe, and promising treatment option for intractable Meige syndrome and provides sustained benefits in motor function and quality of life without inducing cognitive or mood-related side effects. Early intervention and accurate electrode placement in the sensorimotor subregion of the GPi are essential for optimizing long-term therapeutic outcomes.