Journal of neurosurgery最新文献

Objective: While the relationship between smoking and subarachnoid hemorrhage is well established, data regarding the probability of detecting unruptured intracranial aneurysms (UIAs) in smokers remain sparse. The aim of this systematic review and meta-analysis is to provide a comprehensive understanding of the relationship between smoking and the likelihood of identifying UIAs in healthy asymptomatic patients who underwent brain imaging for indications unrelated to UIAs.

Methods: A systematic review was conducted following the PRISMA guidelines. The PubMed and Scopus databases were searched for studies published before March 2024 that reported on the presence of UIAs in healthy asymptomatic patients who had undergone brain imaging for indications unrelated to UIAs. Three independent reviewers assessed the eligibility of all retrieved studies. Risk of bias for the included observational studies was assessed using the methodological index for non-randomized studies. Data on UIA prevalence, smoking status, and patient and aneurysm characteristics were extracted. The association between smoking and the presence of UIA was studied. A prevalence proportional meta-analysis was conducted across the included studies. A meta-analysis was performed with a random-effects model by using summary statistics from the included studies.

Results: Six studies involving 47,788 patients who had undergone brain imaging were identified for quantitative analysis. The pooled UIA prevalence in the sample was 3.07% (95% CI 2.27%-4.16%). Patients who smoked had higher rates of aneurysm detection than the patients who did not smoke (pooled prevalence of 2.96%, 95% CI 2.68%-3.27% vs 2.23%, 95% CI 2.08%-2.39%). Although the relation between the two was not statistically significant (p = 0.06), smoking was associated with higher odds for UIA detection, yielding an OR of 1.34 (95% CI 1.07-1.67) with an I2 value of 53%.

Conclusions: This study suggests a potentially higher risk of UIAs in patients who smoked than in those who never smoked. However, the results of this meta-analysis revealed that smoking was not statistically associated with higher UIA detection. This result could be explained by the limited number of studies published on this topic. If these findings reach statistical significance in future larger studies, it could justify revising guidelines to include cigarette smokers in intracranial aneurysm screening.

Objective: The objective was to evaluate the etiology, natural history, and impact of surgical intervention on outcomes of left ventricular assist device (LVAD) patients presenting with intracranial hemorrhage (ICH).

Methods: The authors completed a retrospective review of LVAD patients who presented with ICH at 2 centers between 2013 and 2022. Patients were reviewed for demographic, clinical, and radiographic variables. LVAD patients were followed for 9.5 years from implantation and 1 year after ICH. The primary outcome was 90-day functional independence defined as modified Rankin Scale (mRS) score 0-2. Secondary outcomes included mortality and rehemorrhage.

Results: Among 1339 LVAD patients, 111 (8.3%) had ICH (mean age 53 years and 65% male). ICH occurred within a median of 18 months from LVAD implantation. Neurosurgery was performed on 16 patients. The inpatient and 90-day mortality rates were 32% and 51%, respectively, which did not differ among hemorrhage types. The rate of functional independence at 90 days was 29%. Rehemorrhage occurred in 16% of patients. The median cost for inpatient hospitalization was $27,000. Predictors of mortality included admission Glasgow Coma Scale (GCS) score and presence of operative indication. Neurosurgery did not predict either functional independence or mortality after controlling for presenting variables.

Conclusions: ICH as a complication of LVAD placement is increasing in frequency. GCS score on presentation best predicted mortality at 90 days. Neurosurgical intervention did not impact outcomes in the authors' study, which warrants further investigation in prospective cohorts.

Objective: Patients with sellar lesions compressing the optic nerve sometimes perceive visual improvement after lesion resection, despite the absence of visual impairment on preoperative ophthalmological examination. This study investigated the indicators of latent visual impairment in patients with sellar lesions.

Methods: Forty-five patients who underwent surgery for sellar lesions compressing the optic nerve with no preoperative visual abnormalities and no change in visual assessment between pre- and postoperative ophthalmological examinations were divided into two groups: 1) patients who perceived recovery of visual function after lesion resection (the improved group), and 2) patients who did not (the unaffected group). Four assessments of optic nerve bending were compared between the groups: 1) coronal optic nerve bending height (CONBH), defined as the vertical distance between the highest apex of the bending optic chiasm and the line connecting the endpoints of the optic nerve on the coronal image; 2) coronal optic nerve bending angle (CONBA), defined as the internal angle formed by the intersection of lines parallel to the left and right optic nerves at the greatest bending section of the optic chiasm on the coronal image; 3) sagittal optic nerve bending height (SONBH), defined as the vertical distance between the highest apex of the bending optic chiasm and the extension line of the optic nerve course in the optic canal on the sagittal image; and 4) sagittal optic nerve bending angle (SONBA), defined as the internal angle formed by the intersection of the line connecting the optic canal entrance level and the highest apex of the bending optic chiasm and the extension line of the optic nerve course in the optic canal on the sagittal image.

Results: Of the 45 patients, 21 were assigned to the improved group and 24 to the unaffected group. CONBH, CONBA, SONBH, and SONBA showed significant differences between the groups (all p < 0.001). Multivariate logistic regression analysis revealed that only SONBA was a significant independent predictor of perceived visual recovery after resection of sellar lesions (OR 2.29, 95% CI 1.03-5.10; p = 0.042). The optimal cutoff point of SONBA for perceiving visual recovery was identified as 30° (specificity 1.000, sensitivity 0.952).

Conclusions: Angle assessment of optic nerve bending due to compression caused by sellar lesions on the sagittal image may be useful in identifying sellar lesions with latent visual impairment.

Objective: Dolichoectatic vertebrobasilar aneurysms (DVBAs) are expansions of arterial tissue leading to aneurysmal formations without an obvious neck. Their natural history is poorly understood; usually patients are admitted with thromboembolic complications and/or neurological symptoms from the mass effect. There have not been international collective data, and correct timing for highly risky treatments has been under discussion. The goal of this study was to define the natural history of DVBA by long-term follow-up in an international population of patients with DVBA.

Methods: The authors collected data in 382 patients with DVBAs from 11 centers in Europe, the US, and Japan. The patients were followed until new ischemic or hemorrhagic stroke, symptomatic compression of the brainstem or cranial nerves, decline in modified Rankin Scale score, or death. Treatment excluded patients from further analysis. Demographic and radiological characteristics of patients were collected and a new classification was created based on the radiological characteristics of the DVBA. In total 223 patients were treated conservatively in the first phase of treatment. The data required for natural history calculations were available for 221 patients, with a cumulative follow-up of 622.3 patient-years. Kaplan-Meier and Cox regression analyses were used to assess risk factors with an influence on patient outcomes.

Results: In total, 21.5% of patients were admitted due to the mass effect, and there were 67 (30%) patient deaths during follow-up, 45 (20.2%) of which were related to aneurysms. The annual mortality and morbidity were 10.8% and 1.6%, respectively. Most of the patients with DVBAs were male, although sex did not affect prognosis when compared to the radiological characteristics of the lesion. The natural history of DVBAs was also impacted by a new classification, in which an age 50 years and older predicted mortality. Furthermore, a DVBA's maximum diameter was directly proportional to adverse events.

Conclusions: This study verifies the malignancy of DVBAs and encourages invasive treatment in the early phase of disease progression based on radiological characteristics and patient age when a treatment option is considered suitable. This also stresses the need for continued investigations to develop new therapeutics with acceptable safety profiles.

Objective: Endovascular intracranial aneurysm (IA) management has significantly evolved over the last 2 decades. Despite these advancements, the aneurysm recanalization rate after coil embolization remains a concern. Statins have been found to affect vascular repair and remodeling; therefore, the authors hypothesized that patients receiving statin therapy at the time of coil embolization would have lower aneurysm recurrence and retreatment rates compared with patients not receiving statin therapy.

Methods: A post hoc analysis was conducted of the primary data from patients enrolled in the Hydrogel Endovascular Aneurysm Treatment Trial focusing on the impact of statin use on the recurrence rates of 3- to 14-mm IAs after endovascular coiling. The primary outcome measured included aneurysm recurrence over 18-24 months using the Raymond-Roy Occlusion Classification. Secondary outcomes included major and minor recurrence rates and retreatment rates. Propensity score matching based on patient and aneurysm characteristics was performed to mitigate selection bias.

Results: A total of 577 patients with data on statin use were eligible for this analysis. Of these, 178 (30.8%) patients were using statins and 399 (69.2%) were not. After propensity score matching, 156 (39.2%) patients were included in the statin group and 242 (60.8%) in the nonstatin group. The recurrence rate was 3.8% (6/156) in the statin group and 10.7% (26/242) in the nonstatin group (p = 0.013). In a subgroup analysis, statin use significantly reduced recurrence in patients with unruptured aneurysms (1.6% vs 9.7%, p = 0.005), but not in those with ruptured aneurysms (12.5% vs 13.6%, p = 0.876).

Conclusions: Statin use was associated with a reduced rate of aneurysm recurrence in patients who underwent endovascular coiling for IAs with a decreased rate of retreatment during the follow-up period. Statins are a relatively low-risk treatment and may be an effective therapy to reduce recanalization of IAs, although further prospective studies are warranted to validate these findings.

Objective: The median household income is a useful metric for healthcare disparity assessment. New England holds the highly diverse, densely populated Boston metropolitan area, which is known for having one of the highest living wages in the US. To the authors' knowledge, there is no published data on the effects of optimal versus suboptimal median household income on the surgical treatment of patients with traumatic brain injury (TBI). The authors sought to evaluate the disparities of an optimal versus suboptimal median household income-stratified population of patients with TBI who underwent surgical treatment at a single level I trauma center with a high safety-net burden in a major US metropolitan area.

Methods: Demographic, clinical, and outcome data of patients who underwent surgery for TBI between 2015 and 2021 were collected and stratified based on optimal (≥ $80,000) and suboptimal (< $80,000) median residential household income. One-to-one tight caliper (0.01) propensity score matching was performed to balance the groups for comparative analysis.

Results: From the initial 144 patients in the optimal and 140 patients in the suboptimal income groups, 53 patients were included in each group after propensity matching. The suboptimal income group was significantly more ethnically diverse (p = 0.02), with significantly more ethnic minority patients (p = 0.05). Significantly more patients in the optimal income group presented as transfers from other hospitals (p < 0.001). Insurance status, injury mechanism, type and location, imaging features, length of ICU stay, and distribution of disposition destinations, as well as the follow-up time and outcome measures were not significantly different between the two groups after propensity matching.

Conclusions: Although the suboptimal income group is significantly more ethnically diverse, median household income does not seem to affect TBI outcomes and discharge disposition. Patients in the optimal income group more frequently presented as transfers from other facilities, potentially indicating fair high-level care at a specialized trauma center with a high safety-net burden adapted to a diverse patient population.

Objective: The floor of the third ventricle and the interpeduncular and prepontine regions represent challenging surgical targets. The expanded endoscopic endonasal approach (EEA) with pituitary gland (PG) transposition has been proposed to provide direct access to these anatomical regions. Through the years, different endoscopic PG transposition techniques have been studied and presented. The goal of this study was to compare the techniques, relevant anatomy, and surgical exposure of extradural, intradural, and interdural PG transposition techniques.

Methods: Six formalin-fixed, latex-injected cadaveric head specimens were used to perform the EEA with extradural, unilateral interdural, and unilateral intradural PG transpositions. The interpeduncular and prepontine regions and the neurovascular structures located within these cisterns were carefully exposed and analyzed. The maximal cranial, caudal, and lateral accessible points within the surgical field were identified for each approach. Consequently, the relative craniocaudal and horizontal surgical axes were measured to quantify the extent of accessibility of each approach.

Results: The extradural PG transposition technique provided the largest horizontal extensions and bilateral access to structures within the interpeduncular and prepontine regions; the mean horizontal axis was 17.9 (range 13.9-20.4) mm. The unilateral interdural PG transposition provided wider vertical exposure, with a mean craniocaudal axis of 16.2 (range 13.0-20.9) mm. In this approach, the surgical field was extended cranially above the ipsilateral mammillary body (MB). The unilateral intradural PG transposition provided a similar surgical exposure to the interdural approach, with a mean craniocaudal axis of 14.7 (range 12.9-15.8) mm. The approach required significant manipulation of the PG after opening both periosteal and meningeal dura layers.

Conclusions: The extradural PG transposition is indicated for lesions of the upper clivus region that extend bilaterally and do not have a cranial extension beyond the MBs. The inter- and intradural PG transpositions are beneficial for unilateral lesions that extend cranially to the MBs. Both techniques require coagulation of the ipsilateral inferior hypophyseal artery. The intradural technique requires more manipulation of the PG, while the interdural technique requires opening and access to the cavernous sinus. If needed, the intra- and interdural techniques can also be performed bilaterally.

Objective: The authors report on a broad range of microsurgical procedures in which the suboccipital median technique was used to treat craniocervical junction arteriovenous fistulas. Their aim was to evaluate the efficacy of the suboccipital posteromedian approach and to assess the associated clinical outcomes.

Methods: The authors extracted information on the fistula site, clinical manifestation, and structural characteristics of arterial and venous vessels by retrospectively evaluating cases from a neurointerventional database spanning 10 years.

Results: In this study, 52 patients (median age 62 years; 23.1% female) were examined, with subarachnoid hemorrhage (SAH)/intracranial hemorrhage (61.6%) and myelopathy (34.6%) as prevalent presentations. Forty craniotomies (76.9%) were performed using the suboccipital median approach. Six craniotomies (11.5%) were performed using the far-lateral approach. Five patients (9.6%) underwent embolization, resulting in a residual lesion in 1. The C1 radicular artery served as the main feeding artery (78.9%). During the operation, the fistulas were mainly located near the C1 dural nerve root sleeve (ventrolateral and dorsolateral to the spinal cord). After the lesion was located, the dentate ligament was severed. Patients with SAH demonstrated a more favorable prognosis (modified Rankin Scale score 0-2, 93.8%) compared to those without SAH (modified Rankin Scale score 0-2, 70%), with a statistically significant difference (p = 0.02).

Conclusions: The suboccipital posteromedian approach is suitable for resections of nearly all craniocervical junction dural arteriovenous fistulas. The prognosis of the patients with SAH was better than that of the patients without it.