Journal of neurosurgery最新文献

Objective: As endovascular interventions become safer and their use more prevalent for treating extracranial pseudoaneurysms, fewer pseudoaneurysms are treated with medical therapy alone. This study aimed to assess the indications for intervention and the safety of medical management.

Methods: A dual-center retrospective analysis was conducted on patients diagnosed with extracranial carotid and vertebral pseudoaneurysms between December 2006 and June 2023.

Results: Of 145 pseudoaneurysms, 121 (83%) received medical therapy, 22 (15%) were treated endovascularly, and 2 (1.4%) were treated with open surgery. In the medical group, there were 2 (1.9%) complications, one unrelated to the pseudoaneurysm. In the intervention group, there were 3 (16%) complications, with 1 patient requiring two retreatments and sacrifice of the vessel. Major trauma (OR 4.0, 95% CI 1.3-14; p = 0.02), use of digital subtraction angiography as the initial imaging modality (OR 9.8, 95% CI 2.5-42; p < 0.01), and a maximum lesion diameter > 6 mm (OR 5.3, 95% CI 1.4-25; p = 0.03) proved to be significant in the decision to intervene. At a median follow-up of 18.1 months, 94.7% of the lesions treated with intervention healed completely compared with 19% of aneurysms in the medical group. Among those medically managed that did not resolve, the median change in diameter was -0.4 mm (IQR -1.8 to 0.4 mm). Age ≤ 50 years and aneurysm maximum diameter ≤ 6 mm predicted healing at follow-up in the medical group with 92% specificity and 65% sensitivity (area under the curve 0.87). At follow-up, 98% of patients were functionally independent (modified Rankin Scale score ≤ 2).

Conclusions: Medical management alone is safe for most extracranial pseudoaneurysms, resulting in significantly fewer complications than endovascular intervention. Maximum diameter ≤ 6 mm and age ≤ 50 years were significant predictors of pseudoaneurysm resolution with medical therapy alone. Lesions that do not heal do not cause further symptoms or require additional intervention.

Objective: Advances in surgical technology and microneurosurgery have led to increased utilization of so-called minimally invasive approaches, including the supraorbital eyebrow (SE) and minipterional (MPT) approaches for lesions involving the interpeduncular region. This study aimed to describe and compare anatomical landmarks, along with highlighting the advantages and disadvantages of the SE and MPT approaches to the interpeduncular region.

Methods: Ten formalin-fixed, latex-injected cadaveric specimens were used to perform bilateral SE and MPT approaches to the interpeduncular region. The operative depth of each approach to key anatomical landmarks was measured. Forty-five axial thin-slice computed tomography studies were reviewed to calculate the operative angles, with consideration of the midline as a reference. A 3D interactive anatomical model generated through the photogrammetry scanning technique was described.

Results: The depths of the operative corridors of the SE and MPT approaches to the interpeduncular fossa were 83.4 ± 1.8 mm and 67.7 ± 3.2 mm, respectively (p < 0.001). The mean angle of the MPT approach to the interpeduncular fossa was significantly wider than the one provided by the SE approach (39.9° ± 5.1° vs 28.4° ± 3.6°, p < 0.001). The interpeduncular region can consistently be accessed through the carotid-oculomotor triangle with the SE approach, as well as with the MPT approach. Furthermore, the SE route offered adequate access to the interpeduncular fossa through the opticocarotid triangle. The MPT route provided direct access to the upper prepontine cistern and anterior mesencephalic zone (AMZ).

Conclusions: The MPT approach provides a wider and shorter operative corridor and can be employed for lesions in the interpeduncular region with extension to the prepontine cistern and ventrolateral midbrain lesions requiring access through the AMZ. The SE approach is better suited for ventromedial midbrain lesions requiring access via the interpeduncular fossa safe entry zone. Additional studies analyzing these approaches in a clinical setting will help to delineate their reliability and efficacy.

Objective: In this study, the authors assessed an algorithm for the diagnosis and management of idiopathic intracranial hypertension (IIH) in patients who had undergone surgical repair of skull base meningoencephaloceles presenting with spontaneous cerebrospinal fluid (sCSF) leakage.

Methods: The authors conducted an institutional retrospective review of patients surgically treated for skull base sCSF leaks between 2014 and 2021. Opening pressure (OP) measurements were taken intraoperatively. The algorithm recommended a ventriculoperitoneal shunt (VPS) for high-risk patients (OP ≥ 30 cm H2O), 4 weeks of acetazolamide plus a 2-week washout and repeat lumbar puncture (LP) at 6 weeks for intermediate-risk patients (OP = 20-29 cm H2O), and repeat LP at 4-6 weeks for low-risk patients (OP < 20 cm H2O). Demographics, radiographic characteristics, management adherence, and outcomes were analyzed.

Results: Eighty patients with sCSF leakage were identified. The mean age was 51.9 years, and the mean body mass index was 36.3 kg/m2. The median follow-up was 8.3 months (IQR 3.3-19.7 months). The overall VPS rate was 15.0%. Three patients (3.8%) experienced acute recurrent leakage, and 3 (3.8%) developed remote recurrent leaks (mean time of 48.1 months). For the 50 patients with both intra- and postoperative OPs, the mean OPs were not significantly different (23.3 vs 23.0 cm H2O, respectively, p = 0.82). The mean variability between the two measurements was an absolute difference of 6.6 cm H2O. While 13 patients (26.0%) moved to a higher-risk category based on postoperative OP, 18 patients (36.0%) moved to a lower-risk category.

Conclusions: Utilizing an algorithm of direct meningoencephalocele repair and selective shunting, acute and remote CSF leak recurrence rates were each 3.8%, and the VPS rate was 15.0%. These data provide further insight into CSF dynamics in this population and argue against the theoretical concern that CSF pressure will increase postrepair. Significant intraindividual variability suggests multiple LPs may be necessary before committing to invasive IIH treatment. Further work is necessary to determine the optimal IIH management strategy.

Objective: The lateral spread response (LSR) is an important electrophysiological sign that predicts successful decompression in patients undergoing microvascular decompression (MVD) for hemifacial spasm (HFS). However, LSRs do not consistently correlate with clinical outcomes, and there are cases in which LSRs are absent. In this study, the authors identified a unique pattern on facial nerve electromyography (EMG) when the root exit zone (REZ) is touched. This distinctive EMG pattern, which the authors coined the "Sang-ku sign" (SKS), could aid in identifying the offending vessel on the REZ, even in the absence of LSRs.

Methods: Between November 2022 and August 2023, the authors analyzed EMG findings from 185 patients undergoing MVD for HFS. Bipolar stimulation electrodes were placed at the marginal mandibular branch, and recordings were obtained from the frontalis and orbicularis oris muscles. Additionally, stimulation electrodes were placed at the temporal branch, and recordings were obtained from the oris and mentalis muscles. The authors statistically analyzed the presence of SKS and its association with demographic, surgical, clinical outcomes, and anatomical factors.

Results: The authors observed a brief, burst-like wave pattern arising from all recorded muscle branches when Teflon felt was placed between the REZ and the facial nerve. This EMG pattern, the SKS, was found in 164 patients (88.6%). Among the factors analyzed, only patient age showed a significant association with the presence of the SKS in univariate analysis (p = 0.007). The presence of the SKS was significantly associated with predicting the disappearance of LSRs (p = 0.045). Clinical outcomes were favorable (99% at the last follow-up) in all cases; thus, no positive correlation was observed in the existence of the SKS and LSRs.

Conclusions: The SKS could serve as an excellent guide for the facial nerve REZ during surgery. Given that HFS results from abnormal vascular contact on the REZ, this finding plays a crucial role in ensuring surgical success. Alongside LSRs, the SKS could provide valuable insights for neurosurgeons.

Objective: The oculomotor cistern (OMC) is a meningeal cuff filled with CSF that contains the oculomotor nerve (cranial nerve [CN] III) at the level of the lateral wall of the cavernous sinus. Only a few studies have investigated the involvement of the OMC by pituitary adenomas (pituitary neuroendocrine tumors [PitNETs]), mainly with relatively small case series. The aim of this study was to perform a histomorphological description of the OMC and systematically analyze its involvement by PitNETs from radiological, clinical, and surgical perspectives.

Methods: Ten hemisellae from formalin-fixed specimens were studied with 3-µm sections. Digital image analysis software was used for morphological and quantitative assessments. Clinical, radiological, surgical, and histological data of patients undergoing endoscopic transsphenoidal surgery for PitNETs at the University of Brescia, Italy, between 2014 and 2021 were recorded. OMC involvement was graded as not compressed, compressed, and invaded. The same surgical team operated on all patients.

Results: The OMC had an elliptical shape with an average area of 3.1 mm2 and a length of 5.5 mm. No cisternal points of weakness were recognized in the histomorphological study. Of 315 patients, 246 had complete data: apoplexy and CN III palsy were documented in 6.9% and 8.5%, respectively. OMC compression and invasion were recorded in 106 (43.1%) and 23 (9.3%) patients. Significant associations between OMC involvement and PitNET dimensions (p < 0.001), Knosp grade (p < 0.001), preoperative oculomotor palsy (p < 0.001), Ki-67 percentage (p = 0.009), and recurrence/progression of residual tumor (p = 0.008) were found. A new postoperative CN III palsy was evident in 2%: transient in 4 cases, and persistent in 1 patient treated for a recurrent PitNET who experienced a local infection complication. Preoperative CN III palsy improved in 10 cases.

Conclusions: Significant OMC involvement by PitNETs might be underrecognized, but it can be treated using the endoscopic transsphenoidal approach, and it affects patient outcomes.

Objective: Because gliomas have poorly defined tumor margins, the ability to achieve maximal resection is limited. To better discern these margins, fluorescence-guided surgery has been used to aid maximal safe resection. The authors describe their experience with the simultaneous use of intraoperative fluorescein sodium (FNa) confocal laser endomicroscopy (CLE) and operating microscope 5-aminolevulinic acid (5-ALA) fluorescence imaging for glioma resection to improve CLE use for better margin discrimination.

Methods: FNa CLE and 5-ALA wide-field imaging were used in 33 patients with gliomas. CLE imaging was enhanced with the use of a telesurgical pathology software platform that enables real-time conversation between the operating neurosurgeons and the pathologists located remotely. CLE was used for imaging tumor regions that were subjectively regarded as tumor margins under normal visualization with the operative microscope. After FNa CLE imaging, 5-ALA wide-field imaging was performed in the same regions. Tissue was biopsied at imaging locations, and interpretations of FNa CLE and 5-ALA wide-field imaging were compared to those of permanent histological sections.

Results: Eighty-eight deep- and superficial-margin regions of interest (ROIs) were imaged with FNa CLE and 5-ALA imaging. Most of the ROIs interpreted by the neuropathologist as infiltrative glioma based on FNa CLE imaging lacked 5-ALA-induced fluorescence. Permanent histological sections from the corresponding regions were concordant with the interpretation of FNa CLE images in 57 of 88 (65%) ROIs and with the interpretation of 5-ALA imaging in 43 of 88 (49%) ROIs. The sensitivity and specificity of FNa CLE for the interpretation of tumor margins were 73% and 41%, respectively, and those of 5-ALA were 38% and 82%, respectively. Positive and negative predictive values for CLE were 79% and 33%, respectively, and those for 5-ALA were 86% and 31%, respectively.

Conclusions: Conventional intraoperative evaluation of tumor margins, based on MRI and wide-field fluorescence imaging, can underestimate the invasiveness of gliomas. FNa CLE showed higher accuracy in detecting regions with infiltrating tumors than intraoperative 5-ALA imaging. Future considerations should include more rigorous comparisons of FNa CLE imaging and 5-ALA-guided resections on a larger cohort of patients.

Objective: Indication for treatment of unruptured intracranial aneurysms (UIAs) is based on several factors, such as patient age, previous medical history, and UIA location and size. For patients harboring UIAs initially managed noninvasively, the treatment strategy during follow-up (FU) can be changed to include surgical or endovascular intervention. This study aims to identify characteristic patterns and potential predictors of UIAs that require revision of the initial management strategy.

Methods: The authors identified intracranial aneurysm (IA) cases newly diagnosed between 2006 and 2022 and initially assigned conservative management. These cases were retrospectively reviewed for 1) patient and UIA characteristics at the time of diagnosis (patient age, comorbidities, previous medical history, potential risk factors, as well as UIA angioarchitecture, location, and size), and 2) any changes in treatment strategy (reason for change, time until intervention, modality of intervention).

Results: Among 1041 IA cases diagnosed in the study period, 144 were initially assigned conservative management. In 10 (6.9%) of these 144 cases, the treatment indication was modified to microsurgical clipping (n = 6) or endovascular embolization (n = 4) after a median FU of 26 months (IQR 8.5-64.5 months). In these 10 cases, the indication for intervention was attributable to IA growth (n = 7), a change in IA configuration (n = 2), or both (n = 1). Exploratory analyses of the effects of UIA size on diagnosis in terms of the hazard for a change of decision suggested an effect starting from 3 mm. No conservatively managed UIAs (n = 144) ruptured during the study period (median FU 24.5 months, IQR 7.75-55.75 months).

Conclusions: The likelihood of a shift to invasive UIA treatment is relatively low if a conservative therapeutic strategy was initially established. However, for cases with changes to the treatment strategy, the change is most often attributable to UIA growth over time. UIAs measuring < 3 mm at initial diagnosis are less likely to be later treated interventionally than those > 3 mm at diagnosis. Therefore, conservatively managed patients with UIAs should be closely monitored with regular radiographic FUs, particularly if the UIA measured > 3 mm at the time of diagnosis.

Objective: Anterior cranial fossa (ACF) dural arteriovenous fistulas (DAVFs) are notoriously malignant vascular abnormalities, and their drainage into the cortical vein poses a high risk of intracranial hemorrhage (ICH). Stereotactic radiosurgery (SRS) is increasingly seen as an alternative to microsurgery or embolization for the treatment of DAVFs; however, researchers have yet to report on its applicability to ACF DAVFs. This paper summarizes the authors' experience in the use of SRS for ACF DAVFs. The authors' objective was to gain a preliminary overview of SRS outcomes in the treatment of ACF DAVFs.

Methods: This retrospective study examined all patients who underwent SRS for ACF DAVFs at a single academic medical center between November 2000 and November 2023. Demographic data, DAVF characteristics, and clinical outcomes were obtained from medical records.

Results: A total of 12 patients diagnosed with ACF DAVFs were treated using SRS. One patient was lost to follow-up. The mean age was 54.8 years and men comprised 82% of the cohort. The most common presenting symptoms included headache (n = 5), ocular symptoms (n = 3), seizure (n = 2), anosmia (n = 1), and tinnitus (n = 1). Two patients were asymptomatic. Four patients (36%) initially presented with ICH. Nine patients exhibited DAVF Cognard type IV, and 2 patients exhibited Cognard type III. DAVF obliteration in 7 of the 11 patients (64%) was confirmed by brain MR angiography (n = 4) or digital subtraction angiography (n = 3). No post-SRS episodes of ICH were reported. Most of the patients (10 of 11) reported improvements in clinical symptoms.

Conclusions: SRS appears to be a viable alternative treatment for ACF DAVFs, particularly for patients who are not suitable candidates for surgery or those with an unfavorable angioarchitecture.

Objective: Establishing benchmarks for length of stay (LOS) may inform strategies to improve resource efficiency, decrease costs, and advance care quality. In this study, the authors characterize postoperative LOS in endoscopic skull base surgery (ESBS) and elucidate prolonging factors.

Methods: A retrospective chart review was conducted at a tertiary academic center including consecutive adult patients who underwent intradural ESBS with intraoperative CSF leak during primary repair between July 2018 and March 2024. LOS, calculated as the time between the end of anesthesia until discharge from the hospital, comprised the primary outcome. Categorical and continuous independent study variables were assessed for univariate LOS association via the Mann-Whitney U-test and Kendall's tau-b correlation, respectively, and those with significant associations were included as multiple linear regression inputs.

Results: One hundred sixty-three patients were included, with a median LOS of 4.0 (interquartile range [IQR] 2.8-5.8) days. LOS was significantly prolonged in high-flow (n = 82) compared with low-flow (n = 81) CSF leak cohorts (median 4.5 [IQR 3.9-6.5] vs 2.9 [IQR 2.1-4.7] days, p = 0.002). Defects involving the anterior cranial fossa (n = 16, median 4.6 [IQR 3.3-7.5)] days), suprasellar region (n = 94, median 4.4 [IQR 3.2-6.4] days), sella (n = 138, median 3.9 [IQR 2.8-5.8] days), or posterior cranial fossa (n = 17, median 4.5 [IQR 3.9-6.5] days) had variable LOSs. On multiple linear regression, after controlling for numerous patient, surgical, and postoperative factors, lesion diameter (B = 0.16, 95% CI 0.048-0.26), bone defect area (B = 0.008, 95% CI 0.001-0.014), anesthesia time (B = 0.015, 95% CI 0.004-0.026), bed rest length (B = 2.34, 95% CI 1.12-3.56), postoperative CSF leak (B = 11.06, 95% CI 4.11-18.01), postoperative meningitis (B = 11.79, 95% CI 4.83-18.74), postoperative stroke/hemorrhage (B = 25.25, 95% CI 18.43-32.06), and postoperative pneumonia (B = 5.59, 95% CI 0.79-10.38) independently predicted overall prolonged LOS.

Conclusions: With healthcare utilization receiving increased attention, mitigating factors that extend LOS are important. Extent of surgery and certain postoperative complications may constitute key factors prolonging LOS following intradural ESBS with intraoperative CSF leak.