Journal of neurosurgery最新文献

Objective: Cerebral cavernous malformations (CCMs) are a cluster of abnormal vessels of the brain. CCMs have a low risk for intracerebral hemorrhage and appear increasingly often as incidental findings on MRI. Zabramski classification has been used to describe the radiological features of CCMs. How the Zabramski classification associates with the clinical symptoms at presentation and clinical course of the disease is not well established.

Methods: The authors reviewed the medical records of conservatively managed and surgically treated CCM patients over a 20-year period treated in Kuopio and Tampere University Hospitals. Both clinical and radiological data were analyzed. The modified Rankin Scale (mRS) was used to score the symptoms.

Results: Altogether, 775 CCM patients were identified. In both cohorts, most patients were asymptomatic (53% in the Kuopio University Hospital [KUH] cohort and 64% in the Tampere University Hospital [TAUH] cohort). Most CCMs were located supratentorially (77%, 661/858), and most patients presented with epileptic seizures. Of the infratentorial CCMs, most were located in the cerebellum (61%, 121/198). The most common symptoms caused by these CCMs were double vision, sensory deficits, and impaired balance. The median mRS score for symptoms in all CCMs was 0, and if only symptomatic CCMs were accounted for, it was 2. Most CCMs were Zabramski type II, and these CCMs were relatively asymptomatic, similar to Zabramski type III CCMs. Zabramski type I CCMs were mostly symptomatic, whereas Zabramski type IV CCMs were completely asymptomatic. Of patients with type I CCMs, approximately 15% developed new symptoms within 1 year, and in the long-term follow-up 26% had new symptoms. In radiological follow-up, 81% of the type I CCMs regressed to type II or III. Of type II or III CCMs, 2.3% changed over time to type I. Age was associated with the Zabramski classification (p < 0.001 in the TAUH cohort and p = 0.034 in the KUH cohort).

Conclusions: Most CCMs are asymptomatic, incidental findings, in particular, nearly all Zabramski type IV CCMs. If symptoms are present, they are mainly associated with Zabramski type I CCMs and occasionally with Zabramski type II or III CCMs. Although most Zabramski type I CCMs will regress to type II or III and remain asymptomatic, over long-term follow-up, up to one-quarter develop new symptoms.

Objective: Tobacco smoking is among the factors known to significantly augment the risk of untreated intracranial aneurysm (IA) growth and rupture. Smoking appears to have a variable effect on different endovascular treatment modalities. The impact of smoking on the safety, efficacy, and outcomes of Woven EndoBridge (WEB) device use for wide-neck IAs has not been evaluated. This study aimed to investigate the outcomes of WEB devices by smoking status.

Methods: A retrospective multicenter analysis was conducted on the data of patients from 36 sites worldwide treated with the WEB device for intracranial saccular aneurysms. Patients were stratified based on smoking status (current, former, and never smokers). The Student t-test and chi-square test were performed for continuous and categorical variables, respectively. Multivariable logistic regression was used to adjust for confounders.

Results: Of 1376 patients with available smoking status, 504 were current smokers, 358 were former smokers, and 514 were never smokers. Upon adjusting for significant confounders, no association was found between smoking and recurrence outcomes (OR 1.39, 95% CI 0.69-2.80; p = 0.36), thromboembolic and hemorrhagic complications, and mortality among IAs treated with the WEB device. There was no statistically significant difference in outcomes between former and never smokers (OR 1.23, 95% CI 0.70-2.18; p = 0.46). The location of aneurysms differed between smoking groups, with former smokers having more anterior circulation aneurysms compared with current and never smokers (99.0% vs 96.9% vs 95.3%; p = 0.01). In terms of clinical symptoms, headache and dizziness were more common in the never smokers compared with current and former smokers (13.9% vs 8.9% vs 7.7%, p = 0.01).

Conclusions: This large-scale study suggests no significant correlation between smoking and the recurrence of IAs treated with the WEB device. Biological studies are warranted to better understand the biological impact of smoking on the growth and rupture of treated IAs.

Objective: Implanted neuromodulatory devices are important for the surgical management of pain, epilepsy, movement disorders, and spasticity. These devices are surgically implanted, but many must be periodically explanted and replaced as batteries deplete or devices fail. Replacement surgery risks further infections that require device explantation, incur large financial costs, and reduce patient quality of life. To reduce infection rates, a single surgeon began using vancomycin-impregnated absorbable calcium sulfate delayed-response beads with neuromodulatory device and intrathecal pump primary implantations and replacements. The infection rates when using vancomycin-impregnated beads were compared with previously published rates from the same surgeon.

Methods: Patients were identified who underwent primary placement or replacement of an implanted neuromodulatory control device (pumps, generators, and stimulators) with vancomycin-impregnated absorbable calcium sulfate beads between 2019 and 2022. Control data were obtained from patients who underwent surgery prior to the start of using antibiotic beads (2016-2019). Postoperative infection status as well as de-identified demographic and clinical data were extracted from electronic health records. Patients were stratified by use of antibiotic beads, device type, and whether they had an infection within 1 year requiring explantation. Statistical comparisons were made using independent t-tests, Fisher's exact test, and the chi-square test, with α set at 0.05. Effect size was calculated using Cohen's h statistic.

Results: A total of 665 surgeries were included for 611 patients who received antibiotic beads with device implantation, compared to 393 surgeries for 379 patients without antibiotic beads. The postoperative wound infection rate was 1.5% (n = 10 patients) versus 3.6% (n = 14 patients) for antibiotic beads versus controls (p = 0.03). When stratified by device type, a significant reduction in infection rate was found only with deep brain stimulation (DBS) generators (3.4% for controls vs 0.2% for beads, p = 0.002), which corresponds to a small to medium effect size (h = 0.27).

Conclusions: The use of vancomycin-impregnated absorbable calcium sulfate beads was associated with a reduced rate of postoperative infection rates with implantable devices, and specifically for DBS primary implantation and replacement surgeries.

Objective: Patients with meningiomas require serial MRI for surveillance of tumor size and growth rate. The cost and resource requirements for contrast-enhanced MRI include intravenous cannulation, the contrast agent, risk of adverse reaction, and the time needed to acquire, review, and report the additional sequences. With repeated doses, gadolinium is known to accumulate in neural tissues. The authors compared the correlation and accuracy of axial T2-weighted imaging (T2WI) sequences alone for assessing tumor growth, dimensions, and dural venous sinus invasion compared with the current clinical practice of assessing both contrast-enhanced T1-weighted imaging (CE-T1WI) and T2WI sequences.

Methods: The authors retrospectively identified 136 adult patients (65 patients with treated and 71 patients with untreated meningiomas) with two MRI scans obtained at least 6 months apart. For each patient, the two CE-T1WI sequences separated by time were paired, as were the two T2WI sequences, and assessed independently. The paired scans were assessed by a neuroradiologist and advanced radiology trainee blinded to clinical data. Tumor location, dimensions, growth, and venous invasion were evaluated. Peritumoral edema was assessed on T2WI only. Agreement between assessments on both CE-T1WI and T2WI sequences compared with T2WI alone was evaluated using Cohen's kappa (κ), the intraclass correlation coefficient (ICC), and Bland-Altman plots.

Results: Growth was detected in 36 tumors on T2WI compared with 39 when both CE-T1WI and T2WI were assessed. Growth assessed on T2WI alone showed near-perfect agreement with growth assessed on CE-T1WI and T2WI together (κ = 0.945). T2WI alone had an accuracy of 97.8%, specificity of 100%, and sensitivity of 92.3%. Interrater correlation between the radiologists for tumor dimensions was good to excellent (ICC > 0.843). Intrarater agreement between T2WI and CE-T1WI measurements of anteroposterior and transverse tumor dimensions was good (ICC > 0.883 for observer 1, > 0.767 for observer 2). There was substantial agreement between venous invasion on T2WI and both CE-T1WI and T2WI (κ = 0.771). Subgroup analysis for skull base (58.1%), treated (47.8%), and large (> 20-mm diameter; 38.2%) meningiomas did not show any significant difference in agreement between T2WI only and CE-T1WI and T2WI assessments of growth, venous invasion, or tumor dimension.

Conclusions: In patients with treated and untreated meningiomas, unenhanced T2WI can assess tumor dimensions, detect growth, and detect venous invasion with comparable reliability and accuracy to the current clinical practice of using both CE-T1WI and T2WI.

Continued advancement of the neurological surgery specialty depends on health policy engagement aimed at advocating for and protecting neurosurgeons and their patients. Dr. Ann R. Stroink, born in Seattle, Washington, and former president of the American Association of Neurological Surgeons (2022-2023), is an exemplar pioneer and role model in neurosurgery and advocacy. She has held numerous significant leadership positions in grassroots and national efforts to improve neurosurgical care and compensation, including serving as chair of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Washington Committee, the Neurosurgery Delegation to the American Medical Association, and the Council of State Neurosurgical Societies. This brief historical vignette highlights the qualities of a pioneer advocate in neurosurgery who rose to be a successful leader while overcoming the challenges of practicing in a rural setting and within a historically male-dominated profession. Dr. Stroink's legacy serves as a beacon of inspiration, reminding us that through perseverance and advocacy we can pave the way for a brighter future in neurosurgery and beyond.

Objective: The objective of this study was to determine the prevalence of diversity, equity, and inclusion (DEI) information on neurosurgery residency program websites and examine the association between program size, ranking, and DEI information presence.

Methods: A cross-sectional review of 115 US neurosurgery residency program websites was conducted from January 1 to March 2, 2024. Websites were evaluated based on six DEI criteria: 1) diversity commitment in mission/leadership statements, 2) separate diversity mission statement, 3) rotations/fellowships for underrepresented minority students, 4) diversity initiatives, 5) diversity page/section, and 6) appointed diversity leadership positions. Associations between program size, ranking, and DEI information were analyzed.

Results: Among the 115 programs, only 35 (30.43%) met at least one DEI criterion. Specifically, 18.26% had a separate diversity mission statement and 15.65% included a DEI statement in mission/leadership messages. Programs with more than 13 residents were significantly more likely to meet at least one DEI criterion (OR 2.96, 95% CI 1.16-7.56; p = 0.022) and to include a DEI statement in mission/leadership messages (OR 5.38, 95% CI 1.71-24.72; p = 0.018). Top 25-ranked programs by U.S. News & World Report were more likely to have diversity initiatives (OR 6.23, 95% CI 1.78-23.97; p = 0.007). Programs meeting any DEI criterion had a higher percentage of female (29.67% vs 22.55%, p = 0.013) and Black (7.85% vs 4.49%, p = 0.019) residents. There was no statistically significant difference in the percentage of White residents (p = 0.206) across programs, and programs with a mention of DEI in the mission statement had a lower percentage of Asian residents (24.08% vs 33.29%, p = 0.042).

Conclusions: Most US neurosurgery residency programs lack DEI information on their websites. Larger programs and those with higher rankings are more likely to include DEI content, particularly standalone statements. Programs meeting DEI criteria tend to have a higher representation of female and Black residents. These findings highlight the need for greater transparency and commitment to DEI in neurosurgery residency programs, ensuring prospective applicants have access to comprehensive DEI information.

Objective: Inflammation contributes to morbidity following subarachnoid hemorrhage (SAH). The authors of this study evaluate how applying noninvasive transauricular vagus nerve stimulation (taVNS) can target this deleterious inflammatory response following SAH and reduce the rate of radiographic vasospasm.

Methods: In this prospective, triple-blinded, randomized controlled trial, 27 patients were randomized to taVNS or sham stimulation. Serial blood and CSF samples were collected every 3 days to quantify inflammatory markers. Radiographic cerebral vasospasm severity and functional outcomes (modified Rankin Scale scores) were analyzed.

Results: No adverse events occurred. Radiographic vasospasm was significantly reduced (p = 0.018), with serial vessel caliber measurements demonstrating a more rapid return to normal than in the sham-treated group (p < 0.001). In the taVNS group, tumor necrosis factor-α was significantly reduced in both plasma (days 7 and 10) and CSF (day 13); interleukin-6 was also significantly reduced in plasma (day 4) and CSF (day 13) (p < 0.05). Patients receiving taVNS had higher rates of favorable outcomes at discharge (38.4% vs 21.4%) and first follow-up (76.9% vs 57.1%). Patients treated with taVNS had significant improvement in modified Rankin Scale scores from admission to first follow-up (p = 0.014), unlike patients in the sham-treated group (p = 0.18). The taVNS group had a significantly lower rate of discharge to a skilled nursing facility or hospice (p = 0.04).

Conclusions: taVNS is a noninvasive method of neuro- and systemic immunomodulation. This trial supports the finding that taVNS following SAH can mitigate the inflammatory response, reduce radiographic vasospasm, and potentially improve functional and neurological outcomes.