Journal of neurosurgery最新文献

Objective: Vertebrobasilar dolichoectatic aneurysms are a rare type of intracranial aneurysm and are generally associated with a poor prognosis due to high rates of morbidity and mortality secondary to ischemic stroke, mass effect, and intracerebral hemorrhage (ICH) or subarachnoid hemorrhage from rupture. When symptomatic, these lesions often mandate treatment. The aim of this study was to explore the most cost-effective management strategy for dolichoectatic aneurysms.

Methods: A decision algorithm was built with a Markov model to compare immediate treatment versus regular follow-up at different intervals (6-month and 1- and 2-year intervals) for dolichoectatic aneurysms. Input data for the model were extracted from the current literature. Costs, effects, incremental cost-effectiveness ratios, and net monetary benefits (NMBs) were analyzed. Deterministic sensitivity analysis and probabilistic sensitivity analysis with Monte Carlo simulation were performed to evaluate the robustness of the model.

Results: On base case analysis, early treatment for dolichoectatic aneurysms, either through open surgery or endovascular procedure, is the most cost-effective strategy (cost $388,946.24, effectiveness 11.0 quality-adjusted life years), showing the highest NMB. The conclusion remains robust in deterministic sensitivity analysis as well as in Monte Carlo simulation with near 97% cost-effectiveness acceptability. When annual risks of stroke, ICH, growth, and rupture are all very low, a strategy of follow-up every 6 months or annually can be considered.

Conclusions: The cost-effectiveness of MR angiography (MRA) surveillance is only observed in scenarios with an annual ischemic risk < 3.3%, with 6-month follow-up MRA being more cost-effective than that at 1- or 2-year intervals. In contrast, preventive treatment consistently offers a higher NMB when risk increases. The risk of treatment based on patient and aneurysm specific factors should also be considered in the decision to treat.

Objective: Brainstem cavernous malformations (BSCMs) are rare neurovascular lesions, and they are especially rare during pregnancy. Pregnancy was not considered in the international consensus on patient-related factors that influence surgical treatment decisions for BSCMs. Therefore, the authors sought to analyze the association between pregnancy and surgical outcomes of BSCMs.

Methods: The authors retrospectively identified women who were pregnant and underwent microsurgical treatment for a BSCM during a period of 37 years. Pregnant women who underwent surgery antepartum were compared with those who underwent surgery postpartum. Demographics, clinical presentation, BSCM characteristics, gestational age, mode of delivery, neurological outcomes, and obstetric and fetal complications were assessed. Primary maternal outcomes were classified as favorable (modified Rankin Scale [mRS] score ≤ 2) or unfavorable (mRS score > 2) and stable, improved, or worse relative to baseline. A systematic review of the literature was also performed to identify all pregnant women with BSCMs who underwent surgical treatment.

Results: The study identified 11 pregnant women with BSCMs. BSCMs were low grade (Lawton grade 0-II) in 7 of 9 (78%) pregnant women and intermediate grade (III-V) in 2 of 9 (22%). Seven of 11 (64%) pregnant women had ≥ 2 bleeds, and 4 of 11 (36%) had 1 bleed. Seven (64%) patients underwent surgery antepartum and 4 (36%) postpartum; all had favorable final and stable or improved outcomes (p > 0.05). Twelve additional pregnant women with BSCMs who underwent surgical treatment were identified in the literature.

Conclusions: Based on these findings, the authors argue that pregnancy poses no additional risk for poor neurological outcome after surgical treatment of BSCM. Surgical treatment decisions for women with BSCMs should include Lawton BSCM grade, number of symptomatic hemorrhages, and presence of severe or progressive neurological deficits rather than pregnancy status.

Objective: Stereotactic radiosurgery (SRS) is a well-established treatment for brain arteriovenous malformations (bAVMs). However, data on radiation-induced neoplasms (RINs) following SRS in patients with bAVMs remain limited. In this study, authors aimed to evaluate the incidence of newly developed intracranial RINs following SRS for bAVMs.

Methods: The authors retrospectively analyzed anonymized data for patients who underwent SRS for bAVMs between 1990 and 2019 at 18 Gamma Knife centers in Japan. Patients with fewer than 3 years of radiological follow-up, prior radiotherapy, or genetic tumor predisposition were excluded. Newly developed tumors were classified as in field (within the 2-Gy isodose line) or out of field. Annual incidence rates were calculated based on total patient-years of follow-up.

Results: During a median radiological follow-up of 100 months, new intracranial tumors developed in 12 (0.27%) of the 4376 patients included in the study. In-field malignant tumors occurred in 5 patients (0.11%), with a median latency of 13.3 years. Out-of-field tumors were observed in 7 patients (0.16%), including malignant (n = 3) and benign (n = 4) neoplasms, with a median latency of 17.4 years. The cumulative incidence of in-field tumors at 10, 15, and 20 years was 0.08%, 0.16%, and 0.16%, respectively. The corresponding incidence of out-of-field tumors was 0.11%, 0.11%, and 0.58%, respectively. In terms of tumor histology, the cumulative incidence of new intracranial brain tumors at 10, 15, and 20 years was 0.15%, 0.24%, and 0.40% for malignant tumors and 0.03%, 0.03%, and 0.34% for nonmalignant tumors, respectively. Across 43,950.3 patient-years of radiological follow-up, the overall annual incidence was 0.027%, increasing from 0.005% within 5 years to 0.046% after 5 years. The annual incidence of in-field tumors was 0.011% (0% within and 0.021% after 5 years) and 0.016% for out-of-field tumors (0.005% within and 0.025% after 5 years). Malignant tumors had an annual incidence of 0.018% (0.005% within and 0.030% after 5 years), whereas benign tumors occurred only out of field with an annual incidence of 0.009% (0% within and 0.017% after 5 years).

Conclusions: The incidence of radiation-induced malignancies after SRS for bAVMs is extremely low but potentially fatal. Although the current risk is acceptable compared to the mortality associated with microsurgical resection, the possibility of late-onset malignancies, especially in younger patients, warrants caution. As more patients are treated and follow-up periods become extended, this risk may increase. Therefore, long-term surveillance is essential for accurately assessing and managing the potential for RINs over time.

Objective: Endovascular therapy (EVT) has proven to be beneficial in patients with acute large-vessel occlusion (LVO) and a large infarct. The authors aimed to investigate the outcomes of EVT across different thrombus burdens indicated by the clot burden score (CBS).

Methods: This is a post hoc analysis of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT) trial, which, between October 2, 2020, and May 18, 2022, enrolled patients with acute LVO within 24 hours of symptom onset who had an Alberta Stroke Programme Early Computed Tomography Score (ASPECTS) of 3-5 or 0-2 and an infarct-core volume of 70-100 mL. Patients were divided into 2 groups according to the CBS: 0-6 versus 7-9. The primary outcome was the 90-day modified Rankin Scale score ordinal distribution. Safety outcomes were symptomatic intracranial hemorrhage and 90-day mortality.

Results: This study included 429 patients. Among them, 354 (82.5%) patients had a CBS of 0-6, and 75 (17.5%) had a CBS of 7-9. Compared with medical management, EVT was associated with a significant shift toward a better functional outcome at 90 days in the CBS 0-6 subgroup (generalized OR 1.394, 95% CI 1.120-1.736, p = 0.003). However, no significant treatment effect of EVT was observed in the CBS 7-9 subgroup (common OR 1.155, 95% CI 0.517-2.580, p = 0.725). No interaction effect was found between the 2 CBS subgroups (p for interaction = 0.307).

Conclusions: In patients with LVOs and large infarcts, EVT improves functional outcomes in those with a higher thrombus burden but not in those with a lower burden. The CBS has a potential role in selecting candidates for EVT.

Objective: Skull base tumors are difficult to approach because of their deep location and their entrapment by cranial nerves (CNs), arteries, and veins. CN trajectories can be challenging to describe by conventional MRI when they are deformed by skull base tumors. High-resolution (HR) T2-weighted MRI (T2) has been able to depict normal CN cisternal paths; however, tractography has demonstrated value in CN reconstruction when the nerves are displaced by skull base tumors. In the present study, the authors aimed to compare HR T2 to tractography in the detection of CNs displaced by skull base tumors.

Methods: From a case series of various complex skull base tumors managed between July 2015 and December 2023 in a single department, HR T2 scans were acquired, as were diffusion images with dedicated postprocessing, including distortion correction, region of interest design, probabilistic fiber tracking, and three-plane visualization. The positions of CNs displaced by skull base tumors were then compared between HR T2 and tractography.

Results: A total of 132 patients were included in the study. They presented with various skull base tumors: vestibular schwannomas (n = 47), cerebellopontine angle (CPA) meningiomas (n = 46), CPA epidermoid cysts (n = 12), cavernous sinus schwannomas (n = 8), cavernous sinus meningiomas (n = 3), and 16 less frequent histological types. A total of 442 CNs were identified as being displaced by skull base tumors. Of these nerves, 236 (53.4%) were identifiable using HR T2, and 358 (81.0%) were successfully reconstructed using tractography (p < 0.001, McNemar test), although not significantly for the abducens nerve, lower nerves, and hypoglossal nerve. Interestingly, the identification rate of the abducens nerve was higher on HR T2 than tractography (43.5% vs 34.8%).

Conclusions: The present study revealed that tractography is more effective in predicting the position of most nerves displaced by skull base tumors, whereas HR T2 can identify the smallest CNs such as the abducens nerve.

Objective: Tentorial dural arteriovenous fistulas (TDAVFs) are uncommon, high-risk intracranial vascular malformations characterized by severe clinical courses. Transarterial embolization (TAE) has been widely recognized as the primary treatment modality. Nevertheless, limited data exist regarding the safety and efficacy of transvenous embolization (TVE). The current study reports a comparative analysis of TAE and TVE in a consecutive TDAVF cohort, providing detailed insights into both clinical and angiographic outcomes.

Methods: A retrospective cohort analysis was conducted on 53 patients with TDAVFs treated at the authors' institution between January 2016 and March 2024. Patients were categorized into TAE and TVE groups based on the specific procedure performed on each individual.

Results: A total of 53 patients who underwent 59 procedures were included in this study. Onyx served as the exclusive liquid embolic agent in all procedures. TVE demonstrated superior immediate complete occlusion rates compared to TAE (92.3% vs 56.8%, p = 0.04), with sustained long-term occlusion at follow-up (100% vs 65.7%, p = 0.04). Complication rates were comparable (15.4% for TVE vs 6.8% for TAE, p = 0.69), with no permanent neurological deficits. Multivariate analysis identified TVE (adjusted OR 0.096, p = 0.048) and fewer feeding arteries (adjusted OR 0.688, p = 0.009) as independent predictors of immediate occlusion.

Conclusions: In TDAVFs characterized by accessible venous routes, TVE exhibits superior angiographic outcomes compared to TAE, while maintaining comparable complication profiles. The wire-loop technique and dual-microcatheter strategy are essential for achieving reliable venous access. Although TAE remains effective for the majority of TDAVFs, TVE may be a promising initial strategy for lesions with favorable venous accessibility.

Objective: Epilepsy affects nearly 50 million individuals worldwide, with one-third of cases resistant to antiseizure medications. For these patients, surgical intervention offers a potential path to seizure freedom. While resective surgery has been the gold standard, laser interstitial thermal therapy (LITT) has emerged as a minimally invasive alternative. The aim of this study was to evaluate the efficacy and safety of LITT versus resective surgery in patients with nontumoral epilepsy.

Methods: A systematic review and meta-analysis were conducted using PubMed, Embase, and Scopus, including studies comparing seizure freedom rates, complications, and procedural outcomes between LITT and open surgery in nontumoral epilepsy. Eleven studies met the inclusion criteria, comprising 389 LITT and 557 open surgery patients with varying epilepsy etiologies, including temporal lobe epilepsy, focal cortical dysplasia, and tuberous sclerosis. Statistical analysis was performed using a random-effects model to assess seizure freedom, complications, and reoperation rates.

Results: Open surgery demonstrated higher rates of complete seizure freedom, although not reaching significance (68.1% vs 53.7%, RR 0.81, p = 0.07). This outcome was sensitive to influential analysis and reached significance in the epileptogenic zone-directed resection subgroup analysis. Although adequate seizure freedom was comparable between the groups (LITT: 63.0% vs open: 74.0%, RR 0.90, p = 0.11), the open surgery group had higher rates of control in the pediatric and non-temporal lobe epilepsy subgroups. Complication rates were significantly higher in the open surgery group (30.0% vs 18.3%, RR 0.55, p < 0.01). LITT patients had significantly shorter hospital stays (3.4 vs 6.8 days, standardized mean difference -0.93, p < 0.01). Reoperation rates were comparable between groups (13.1% for LITT vs 13.4%, RR 1.59, p = 0.26).

Conclusions: While LITT offers a less invasive approach with reduced hospitalization and morbidity, open surgery remains slightly superior in achieving long-term seizure freedom. Patient selection remains critical, and further studies are needed to refine decision-making criteria based on epilepsy subtype and lesion characteristics.

Objective: The minimal important difference (MID) and minimal important change (MIC) are two metrics that bridge the gap between statistical significance and clinical relevance and are critical to managing clinical decisions and conducting clinical research. The objective of this study was to define MIDs to evaluate cross-sectional differences among groups and to define MICs to evaluate longitudinal within-patient changes for the Mayo Clinic Vestibular Schwannoma Quality of Life (VSQOL) Index.

Methods: Anchor-based methods were used to define MIDs and MICs for the VSQOL Index domain scores, which range from 0 to 100 points, for a national cohort of 1050 patients with sporadic vestibular schwannoma, 644 of whom completed the VSQOL Index twice approximately 1 year apart.

Results: The median of the MID estimates for the VSQOL Index domains were: hearing problems (17, IQR 12.5-21); dizziness and imbalance (21, IQR 18-23); pain, discomfort, and tinnitus (19.5, IQR 15-23.5); problems with face or eyes (18, IQR 17-28); impact on physical, emotional, and social well-being (19.5, IQR 14.5-23.5); difficulty with thinking and memory (23.5, IQR 18.5-28.5); global quality of life (12, IQR 8-16); and satisfaction or regret (13.5, IQR 7-17). MIC estimates for the hearing problems and satisfaction and regret domains were not obtained because the correlations between these domain scores and their associated anchors were not sufficiently strong. The MIC estimates (minimum and maximum) for the remaining domains were: dizziness and imbalance (7.2 and 8.3); pain, discomfort, and tinnitus (8.3 and 8.5); problems with face or eyes (7.0 and 7.4); impact on physical, emotional, and social well-being (2.1 and 8.0); and difficulty with thinking and memory (12.9 and 15.0). The median of the MIC estimates for global quality of life was 5.2 (IQR 3.7-5.6).

Conclusions: The MIDs and MICs reported herein provide a framework to interpret quality-of-life benefit or harm cross-sectionally among groups and longitudinally within patients. Moving forward, these values should be considered when interpreting studies using the VSQOL Index to assess disease-specific quality of life in patients with sporadic vestibular schwannoma.