Journal of neurosurgery最新文献

Objective: Glioblastoma (GBM) is an aggressive brain tumor with a poor prognosis despite standard treatments. Emerging innovations, including photodynamic therapy (PDT), offer new hope by improving local tumor control and survival. The aim of this review was to systematically assess the clinical benefits of PDT as an adjunct to surgery for patients with GBM.

Methods: A systematic review was conducted in September 2024 using PubMed, Scopus, Embase, and Web of Science, following PRISMA guidelines. Comparative cohort studies evaluating the safety and efficacy of PDT in patients with GBM were included. Oncological outcomes were assessed by comparing progression-free survival (PFS), overall survival (OS), and the difference in 1-year survival rates between the PDT and control groups. Statistical analysis was performed using a random-effects model, while study quality was evaluated with the ROBINS-I tool for nonrandomized studies.

Results: This review included 8 retrospective studies involving 772 patients with GBM (281 in the PDT group and 491 in the control group). Talaporfin sodium (TS) was used in 5 studies, while 5-aminolevulinic acid (5-ALA) was used in 3 studies. The analysis showed that PDT significantly improved the PFS (hazard ratio [HR] 0.66, 95% CI 0.50-0.86; p = 0.003) and OS (HR 0.57, 95% CI 0.46-0.70; p < 0.001) rates, leading to a notable increase of 25% in the 1-year survival rate compared with controls (95% CI 10%-40%, p = 0.001). There was no significant difference between TS and 5-ALA regarding OS outcomes (p = 0.32). Additionally, complication rates were similar between PDT-treated patients and controls (RR 1.28, 95% CI 0.66-2.46; p = 0.46), with transient cerebral edema reported in approximately one-tenth of treated patients.

Conclusions: PDT significantly improved tumor control and extended survival for patients with GBM without increasing major complications. These findings support PDT as a promising adjunctive treatment during surgery. However, further randomized clinical trials are needed to validate its long-term efficacy and to optimize treatment protocols.

Objective: Trapped temporal horn syndrome (TTH) is a rare form of obstructive hydrocephalus that frequently occurs after intraventricular tumor resection. Effective long-term management remains challenging. This study evaluated the long-term outcomes and complication management of refined temporal-to-frontal horn shunting (RTFHS) in patients with TTH.

Methods: This retrospective case series included 53 consecutive patients with imaging-confirmed TTH treated at Beijing Tiantan Hospital of Capital Medical University and Beijing Fengtai Hospital between January 2018 and January 2025. Patients presented with symptoms such as headache, cognitive decline, or motor deficits and had a history of brain tumor surgery. All underwent RTFHS, with follow-up durations ranging from 1 month to 6 years. Of the 53 patients, 28 had follow-up over 6 months and 18 over 1 year. All patients received RTFHS with ipsilateral, contralateral, or bilateral shunting approaches. Primary outcomes included symptom improvement and temporal horn volume reduction. Secondary outcomes included management of complications such as high-protein CSF, infection, or suspected shunt catheter intolerance.

Results: The initial shunt patency rate was 86.8%, and the overall success rate reached 98.1%. Mean temporal horn volume reduction was 30.0% on the day of surgery and 60.3% at 3 months. Locally weighted scatterplot smoothing (LOWESS) regression revealed a rapid decrease in the 1st week, a slower decline from 1 week to 3 months, and stabilization thereafter. Long-term follow-up showed no recurrence or re-enlargement in most patients. Complications were effectively managed in nearly all cases.

Conclusions: RTFHS is a safe, adaptable, and effective surgical option for managing TTH. It offers favorable long-term outcomes and may be a valuable alternative to a ventriculoperitoneal shunt in selected patients. This study provides useful insights into the prevention and management of perioperative issues.

Objective: The goal of this study was to examine how race, socioeconomic status, and geography interact to affect the likelihood of epilepsy surgery within a local academic health system in order to inform the development of future interventions to improve access to epilepsy surgery in Minnesota.

Methods: For this retrospective case-control study, a number of variables, including demographics, comorbidities, insurance status, and geographic location, were extracted from the University of Minnesota's M Health Fairview internal electronic health record dataset. They were then combined with publicly available datasets, including the area deprivation index (ADI). Multivariable logistic regression analysis was performed to identify variables that were associated with surgical intervention. Geospatial information systems (GIS) analysis was then used to explore the relationship between race, ADI, and geography and the likelihood of undergoing epilepsy surgery.

Results: Of 6552 unique inpatients with a primary admitting diagnosis of epilepsy, 132 patients underwent epilepsy surgery. Univariable analysis showed significant differences in race, age, sex, and geography of surgical patients. On multivariable analysis, Black patients were less likely to undergo epilepsy surgery (OR 0.46, 95% CI 0.22-0.96; p = 0.04). Patients from the most deprived areas were more likely to receive surgery (ADI quartile 4: OR 2.32, 95% CI 1.10-4.91; p = 0.03). GIS analysis showed that these high ADI quartile patients were located primarily in micropolitan regions and were predominantly White. Insurance status and comorbidities were not significant factors.

Conclusions: Race, ADI, and geography all impacted utilization of epilepsy surgery within the authors' institution, but the results in this study differed from those seen in national datasets. Overall, these findings highlight the need for local data to improve health disparities and demonstrate specific pathways for local institutions to improve disparities in epilepsy surgery.

Objective: The Brain Injury Guidelines (BIG) provide neurosurgical consultation and imaging protocols by stratifying patients with traumatic brain injury (TBI) according to injury severity. However, the effect of concomitant blunt cerebrovascular injury (BCVI) on clinical progression and surgical intervention within this framework has not been investigated. The aim of this study was to determine whether the Biffl grade for BCVI evaluation should be incorporated into the BIG criteria to help determine clinical care, follow-up imaging, and treatment decisions for these patients.

Methods: Adult patients (age ≥ 18 years) with TBI who were transferred to a level 1 trauma center from 2019 to 2023 were retrospectively analyzed. For analysis, patients were stratified by BIG category and propensity matched (1:1) by age, sex, BIG classification, and frailty index. Clinical outcomes were compared between patients with and without BCVI. Multivariable logistic regression analysis was performed to identify predictors of clinical progression (radiographic injury progression or clinical neurological deterioration) or the need for neurosurgical intervention, both in the overall cohort and in the BCVI subgroup.

Results: Overall, 999 patients (648 male, mean age 53.5 years) were included in this analysis, and 103 patients (10.3%) presented with BCVI in addition to TBI. The presence of BCVI was not independently associated with progression or the need for neurosurgical intervention in the overall cohort of patients with TBI or the matched cohort (103 patients with BCVI and 103 patients without BCVI). However, among patients with BCVI, both the presence of intracranial hemorrhage (OR 3.04, 95% CI 1.01-9.37) and an injury classified as Biffl grade > I (OR 4.00, 95% CI 1.46-10.96) significantly predicted progression or the need for intervention.

Conclusions: For patients with TBI, BCVI alone did not predict clinical progression or the need for neurosurgical intervention. However, higher Biffl grades and intracranial hemorrhage among patients with BCVI were associated with a greater risk of clinical progression or the need for neurosurgical intervention. These findings support the integration of BCVI-specific factors into triage models and highlight the need for refined clinical pathways that supplement BIG classification when BCVI is present.

Objective: Ventriculoperitoneal shunt (VPS) placement remains the primary treatment for hydrocephalus. However, the literature on this topic is heterogeneous, with studies assessing and reporting surgical and clinical outcomes in different ways, lacking standardization. The authors aimed to evaluate the quality of these studies and propose a reporting guideline focusing on essential elements to ensure reproducibility and comparability.

Methods: Following PRISMA guidelines, the authors systematically searched PubMed, Embase, Web of Science, and the Cochrane Library databases. Eligible studies were observational or randomized, reported clinical and/or surgical outcomes related to the treatment of hydrocephalus with VPS placement, included more than 200 patients, and were published in the English language between January 1, 2000, and June 1, 2024. Studies were assessed and focused on 6 key domains: 1) baseline characteristics of the patient sample; 2) study methodology and reporting guidelines; 3) patient comorbidities and clinical status; 4) valve and shunt characteristics; 5) shunt failure, revision, and infection; and 6) postsurgical outcomes and complications.

Results: Forty-five studies comprising 95,597 patients were included. The authors' assessment revealed substantial gaps in the literature on VPS placement, including deficiencies across all domains. A VPS reporting guideline was developed, consisting of 50 items distributed across 6 domains, focusing on key surgical and clinical outcomes.

Conclusions: This review identified important gaps in methodological rigor and reporting across VPS studies for hydrocephalus, limiting the comparability and reproducibility of current evidence. To address these issues, the authors propose the VPS Reporting Guideline, a practical framework to enhance transparency, reproducibility, and comparability in future research, ultimately supporting better evidence synthesis and building of cumulative evidence.

Objective: Nerve injuries can have devastating effects on patients' quality of life. However, the clinical results of direct nerve repair, which is commonly performed for peripheral nerve injury, are often unsatisfactory because of undesirable tension at the repair site. Previous studies have suggested that using a nerve conduit as a connector could provide outcomes that are equivalent to, or potentially better than, direct suture repair. Therefore, the aim of this study was to investigate the underlying mechanisms of peripheral nerve regeneration through a short gap encapsulated in a conduit using transgenic mice.

Methods: Sixty-four transgenic mice (Thy1 yellow fluorescent protein [YFP]-16), in which all axon fibers of the motor and sensory nerves constitutively express YFP, were used in this study. The sciatic nerve of each mouse underwent transection to artificially create an injury. Two weeks later, two types of repair operations were performed: 1) direct epineurial suture (direct repair [DR] group); and 2) repair using an artificial nerve (a polyglycolic acid conduit) as a nerve connector (connector repair [CR] group). Recovery was monitored by serial in vivo imaging of axonal growth and was assessed through histomorphometric measurements such as the axon number, myelinated fiber diameter, myelin sheath thickness, and g-ratio. Functional recovery was evaluated by calculating the area of anterior tibialis muscle fibers and using the von Frey filament test. Gene expression at the repair site was also analyzed.

Results: Although regeneration was slower in the CR than the DR group, the muscle area at week 6 was significantly higher in the CR group, indicating better motor recovery. Moreover, sensory recovery was similar between the CR and DR groups at the final 12-week examination.

Conclusions: These findings indicate that repair using an artificial nerve as a connector achieved better, albeit slow, functional recovery than repair using a direct epineural suture.

Objective: Brain metastases significantly impact neurocognitive function and overall survival. Stereotactic radiosurgery (SRS) is a cornerstone of treatment for patients with limited metastases and expected survival beyond 3 months. Despite current guidelines, up to 20% of patients with brain metastases undergoing SRS have been reported to die within 90 days. This study retrospectively evaluated prognostic factors associated with 90-day survival after SRS, aiming to improve patient selection.

Methods: The authors retrospectively analyzed a cohort of 1546 patients who underwent Gamma Knife SRS for brain metastases at their institution between 2015 and 2023. One hundred seventy patients who survived less than 90 days after SRS were identified and case matched to 170 patients who survived over 90 days. Measured variables included patient demographic characteristics, tumor characteristics, treatment history, functional status, and control of the primary cancer. The authors modeled post-SRS 90-day survival using binomial and multivariate logistic regression.

Results: Multivariate analysis highlighted Karnofsky Performance Score (KPS) < 70 (OR 17.4, p < 0.001), prior whole-brain radiation (OR 6, p = 0.004), and focal neurological deficits (OR 3.02, p = 0.003) as significant predictors of poor survival, whereas CNS progression before SRS (OR 0.22, p < 0.001) and control of systemic cancer (OR 0.556, p = 0.002) were associated with survival < 90 days. The predictive model demonstrated acceptable performance with an area under the curve (AUC) of 0.85, accuracy of 80%, sensitivity of 87%, and specificity of 71%.

Conclusions: Key predictors of 90-day survival after SRS for brain metastases include functional status (KPS), control of systemic cancer, CNS progression status, and focal neurological deficits. These findings are complementary factors that can assist in making decisions and SRS patient selection.

Objective: Core outcome sets (COSs) are needed to promote data consistency across studies as well as data synthesis and comparability. The aim of the current study was to use a modified Delphi process to develop a COS for lateral femoral cutaneous neuropathy (LFCN), hereafter COS-LFCN.

Methods: A 5-stage approach was used to develop the COS-LFCN: 1) consortium development, 2) literature review to identify potential outcome measures, 3) Delphi survey to develop consensus on outcomes for inclusion, 4) Delphi survey to develop definitions, and 5) consensus meeting to finalize the COS and definitions. This study followed the Core Outcome Set - STAndards for Development, (COS-STAD) recommendations.

Results: The Core Outcomes in Nerve Surgery (COINS) Consortium comprised 25 participants, all neurological surgeons, representing 14 countries. The final COS-LFCN consisted of 41 factors and outcomes covering domains of demographics, diagnostics, patient-reported outcomes, motor/sensory outcomes, and complications. Appropriate instruments, methods of testing, and definitions were set. The consensus minimum duration of follow-up was 12 months, with the consensus optimal time points for assessment being preoperatively and 3, 6, and 12 months postoperatively.

Conclusions: The COINS Consortium developed a consensus COS for LFCN and provided definitions, methods of implementation, and time points for assessment. The COS-LFCN should serve as the minimum data to be collected in all future neurosurgical studies on LFCN. Incorporation of this COS will help improve consistency in reporting, data synthesis and comparability, and minimize outcome reporting bias.