Journal of neurosurgery最新文献

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.

Objective: The objective of this study was to describe the long-term efficacy of single-fraction stereotactic radiosurgery (SRS) for the primary treatment of sporadic vestibular schwannoma.

Methods: Adult (≥ 18 years of age) patients with sporadic vestibular schwannoma who underwent SRS from 2000 through 2022 were included.

Results: A total of 749 patients met inclusion criteria, the majority (n = 566, 76%) of whom had tumors extending into the cerebellopontine angle at SRS. The median patient age at SRS was 62 years, half (50%) of the patients were women, and 744 (99%) exhibited House-Brackmann grade I facial nerve function at SRS. A total of 42 patients experienced radiosurgical failure and underwent salvage treatment; the median duration of follow-up for the patients who did not undergo salvage treatment was 7.0 years. Overall tumor control rates (95% CI, number still at risk) at 1, 3, 5, 10, and 15 years after SRS were 100% (100%-100%, 718), 98% (97%-99%, 589), 96% (94%-97%, 464), 92% (90%-95%, 258), and 91% (89%-94%, 125), respectively. Patient age (hazard ratio [HR] for a 10-year increase of 0.92, 95% CI 0.71-1.19; p = 0.5), presence of a macrocystic tumor (HR 0.59, 95% CI 0.14-2.46; p = 0.5), and treated tumor volume (HR for a 1-cm3 increase of 1.02, 95% CI 0.88-1.18; p = 0.8) were not significantly associated with the risk of salvage. Three distinct post-SRS tumor behavior patterns were observed, with 13% of patients demonstrating tumor pseudoprogression, all but 4 of whom demonstrated pseudoprogression by year 5 post-SRS.

Conclusions: SRS demonstrates durable tumor control through 15 years of follow-up in most patients (91%); however, a minority are found to still experience SRS failure even beyond 10 years of surveillance. Although occurring in only a minority of patients, tumor pseudoprogression can be evident out to 5 years or longer post-SRS.

Objective: Cranial bone flap fixation is typically achieved by using titanium plates and screws (TPS), which are the standard of care. However, the use of hardware to achieve long-term bone fixation and healing across a kerf line poses challenges and potential complications, including infection, nonunion, loosening, cranial flap bone resorption, pain, cosmetic deformity, and CSF leakage. The use of a tetracalcium phosphate and phosphoserine (TTCP-PS) regenerative bone adhesive to fixate cranial flaps has been previously shown to be advantageous compared to TPS in an in vivo ovine model and a human cadaveric model. However, the potential impact of TTCP-PS on the underlying brain has not been previously studied. To investigate the local tissue effects of TTCP-PS bone adhesive compared to TPS, a clinically relevant sheep craniotomy model was developed.

Methods: Twelve skeletally mature crossbred sheep were used in this study. All craniotomies and surgical procedures were performed by an experienced, US-trained, licensed, and practicing attending neurosurgeon. Bilateral parietal craniotomies were created using a Medtronic Midas Rex craniotome and perforator. Durotomy was performed and repaired in half of the subjects. Craniotomies were repaired with TPS or the TTCP-PS bone adhesive. CT scans were performed postoperatively and at 12 weeks. Histopathology was performed on the brain and cranial bone.

Results: All sheep reached the study endpoint. Histopathological changes in underlying cerebral cortical tissue were comparable in magnitude and incidence between groups (minimal superficial cortical deformation/loss and/or malacia/loss). The magnitude of microgliosis and astrogliosis related to the cortical changes was comparable between groups (minimal/mild and minimal, respectively). Histopathological findings were procedural in nature, associated with the craniotomy model, and unrelated to the bone flap fixation method. The histological changes did not result in clinically adverse effects.

Conclusions: TTCP-PS was safe, producing no significant difference in adverse effects on local tissues compared to standard craniotomy with plate and screw fixation. This is the first study to quantify histological changes in the underlying cerebral cortex due to standard craniotomy technique.

Objective: Wait-and-scan surveillance is now commonly employed for initial management of small- and medium-sized vestibular schwannomas. Although small differences in tumor size are unlikely to impact outcomes significantly, treatment with either radiosurgery or microsurgery is usually recommended following radiological detection of tumor growth. The objective of the current study was to identify potential inflection points in vestibular schwannoma tumor size, where the risks of treatment with single-fraction stereotactic radiosurgery (SRS) accelerate to inform timing of intervention.

Methods: Adult (≥ 18 years old) patients with sporadic vestibular schwannoma who underwent SRS from 2000 through 2022 were included.

Results: A total of 749 patients with a median age at SRS of 62 years were studied, the majority (n = 566 [76%]) of whom had tumors extending into the cerebellopontine angle (CPA) at SRS. The optimal tumor size cut point to predict SRS failure and need for salvage treatment was 4 mm or more of CPA extension (c-index 0.59, HR 3.60, p = 0.01). The optimal tumor size cut point to predict the outcome of facial nerve paresis was 13 mm or more of CPA extension, resulting in a c-index of 0.63 (HR 2.88, p = 0.01). Among patients with at least 3 months of surveillance before SRS, those with a tumor growth rate ≥ 2.5 mm/year were more likely to undergo salvage treatment than those with a growth rate < 2.5 mm/year, although this difference did not achieve statistical significance (HR 1.82, p = 0.18).

Conclusions: The risk of SRS failure requiring salvage treatment and the risk of post-SRS facial nerve paralysis increase at sizes of approximately 4 and 13 mm extension into the CPA, respectively, providing a size threshold anchor to help guide treatment decision-making regarding timing of SRS. Furthermore, rapid tumor growth during the initial wait-and-scan period may be associated with an increased risk of radiosurgical failure, which may influence choice of treatment.