Journal of neurosurgery最新文献

Objective: Research output among neurosurgery residency applicants has increased in recent years. The authors sought to quantify the publication quantity of board-certified US neurosurgeons and to determine how publication quantity has changed over time.

Methods: Publication data were extracted from Scopus for all neurological surgeons listed as board certified since 1980 by the American Board of Neurological Surgery. Distributions were analyzed on a decade-to-decade as well as continuous basis. Pre-board certification quantity of publication (general and first/senior author) was analyzed using multivariable regression. Univariate regression of pre-board certification rates was used to predict post-board certification rates.

Results: For each decade since 1980, neurosurgeons have published more before receiving board certification than the decade prior, both in total as well as first/senior author publications. Neurosurgeons have also been publishing earlier as well as with increased coauthor counts (p < 0.001). A more recent date of board certification remains a significant and independent predictor of publication count when corrected for time since first publication and average coauthor counts (p < 0.001). Finally, the pre-board certification publication rate is an independent and significant predictor for the post-board certification publication rate (p < 0.001).

Conclusions: This study suggests that neurosurgeons have consistently published earlier in their careers and in increasingly higher quantities over time. This finding is in line with similar trends for neurosurgery applicants, showcasing increasing output across career stages, which has important impacts on the field.

Objective: Digital enhancement and visualization technologies, such as augmented reality (AR), are increasingly used in surgery. Rapid and accurate patient registration with minimal device confinements enables AR systems to increase efficiency, safety, and effectiveness, especially in urgent/emergency and/or bedside scenarios. The aim of this study was to quantitatively compare an AR headset-based neuronavigation system with a standard-of-care reference array-based neurosurgical stereotactic navigation system in a real-world setting.

Methods: This clinical validation trial included adult patients undergoing cranial neurosurgery with stereotactic navigation at a single center from February 2024 to July 2024. Preoperative CT and MR images were acquired and used for construction of a 3D hologram model that included surface-based target fiducial markers for comparison. Preoperative images were stereotactically registered to the patient's head using standard techniques. The registration coordinates for the fiducial markers (control) and registration time were recorded. The AR system was then deployed to create a separate stereotactic registration to the same preoperative images. A second set of registration coordinates for the fiducial markers (experimental) were acquired using the AR system, and the time for this process was also recorded. The Wilcoxon signed-rank test was used to assess differences in registration time, and a linear mixed-effects model (LMM) was used to conduct equivalence testing of coordinates between the control and experimental data.

Results: Twenty patients (mean age ± SD 50.05 ± 14.38 years) were included in the trial. The mean baseline validation error of the control system was 0.73 ± 0.29 mm (range 0-1.0 mm). Using the control system as ground truth, the mean registration accuracy of the AR system was 2.16 ± 0.12 mm. LMM equivalence testing, conducted with margins of 3 mm and 2.5 mm, demonstrated statistical equivalence between the ground truth and AR system coordinates (p < 0.001 and p < 0.003, respectively). The time required for patient model registration using the AR system was a mean of 45.98 ± 15.00 seconds, which was significantly shorter compared with the control system (228.86 ± 100.06 seconds, p < 0.001).

Conclusions: The AR navigation system provided statistically similar registration accuracy and significantly faster patient model registration compared with the standard-of-care stereotactic neuronavigation system. AR navigation was accurate, fast, and had a minimal footprint, offering new opportunities to incorporate stereotaxis in low-resource, bedside, and urgent/emergency settings.

Objective: Cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) is associated with a poor prognosis. Since 2022, clazosentan has become available for clinical use in Japan and has shown potential in improving clinical outcomes for patients with aSAH. However, whether clazosentan alone is sufficient to achieve optimal results or combination therapy is required remains unclear. In this study, the authors aimed to assess the efficacy of combining clazosentan and cilostazol for treating cerebral vasospasm following aSAH due to a ruptured cerebral aneurysm.

Methods: This retrospective multicenter study was conducted using repository data from April 2023 to March 2024 from across 20 institutes. Patients who underwent coil embolization or surgical clipping within 48 hours of aSAH and had a preoperative modified Rankin Scale (mRS) score of 0-2 were eligible for inclusion in the study. Patients who received clazosentan plus fasudil were excluded. The patients were divided into two groups: those who received clazosentan plus cilostazol (cilostazol combination group) and those who did not receive cilostazol (noncilostazol group). Outcomes were measured based on discharge mRS scores (primary) and complications (secondary), including cerebral vasospasm, delayed cerebral ischemia (DCI), pulmonary complications, hypotension, cerebral edema, and de novo intracranial hemorrhage.

Results: In total, 161 patients were included in this study, with 94 and 67 patients in the cilostazol combination and noncilostazol groups, respectively. No significant difference was observed between the two groups in terms of optimal outcomes at discharge (mRS score 0-2). However, the cilostazol combination group tended to experience a lower rate of poor outcomes than the noncilostazol group (11.7% vs 14.9%, respectively, OR 0.36, 95% CI 0.11-1.2, p = 0.095). The incidence rate of DCI was significantly lower in the cilostazol combination group than in the noncilostazol group (0.0% vs 7.5%, p = 0.02). No significant differences were found between the two groups with respect to other complications.

Conclusions: The combination of clazosentan and cilostazol may reduce the incidence of DCI, although its impact on functional outcomes remains unclear. Further research is warranted to explore effective pharmacological strategies for improving the prognosis of aSAH.

Objective: The objective was to develop and validate a proof-of-concept, low-cost, noninvasive device capable of continuously monitoring CSF in external ventricular drainage systems in order to enable earlier detection of infections.

Methods: The authors designed BOSoMetre (CSF-o-Meter), a device that uses a microcontroller and TCS3200 color sensor housed in a 3D-printed chamber for continuous CSF monitoring. The system captures real-time optical measurements across red, green, blue, and clear channels through the external ventricular drain (EVD) tube. Between October 2024 and January 2025, the authors prospectively enrolled 20 patients requiring EVD placement for obstructive hydrocephalus or infection, with 15 included in the final analysis. CSF samples were classified according to Infectious Diseases Society of America 2017 guidelines. The authors processed approximately 4.8 million sensor readings and applied machine learning algorithms using two validation approaches: the subspace k-nearest neighbors (KNN) classifier with 80-20 split validation, and random forest with leave-one-patient-out cross-validation (LOOCV).

Results: The subspace KNN classifier with 80-20 split validation yielded 90.4% accuracy with 92% sensitivity and 90.4% specificity (area under the curve [AUC] 0.968). The more stringent random forest with LOOCV approach achieved 81.1% accuracy with 71.5% sensitivity and 89.2% specificity (AUC 0.736). The device successfully distinguished between clean and infected CSF samples, with particularly high specificity in identifying noninfected samples.

Conclusions: BOSoMetre shows promise as a low-cost (< €100), open-source tool for continuous CSF monitoring and early infection detection, especially for resource-limited settings. The high specificity could potentially reduce unnecessary CSF sampling and associated iatrogenic infection risks. Although the initial results are encouraging, further validation in larger cohorts is needed to confirm clinical utility and overcome the technical limitations identified in this proof-of-concept study.

Objective: Stroke is a leading cause of global death and disability, with mechanical thrombectomy remaining the optimal treatment approach for large-vessel occlusion (LVO) ischemic stroke. Despite endovascular recanalization, nearly half of patients experience poor functional outcomes, a phenomenon termed "futile recanalization." The cerebral glymphatic system has emerged as a potential, yet underexplored, therapeutic target. The aim of this study was to use glymphatic diffusion tensor analysis on post-thrombectomy MRI to evaluate the association between glymphatic flow, clinical outcomes, and futile recanalization in patients with LVO ischemic stroke.

Methods: In this retrospective study, 133 patients with anterior LVO ischemic stroke and available post-thrombectomy MRI at a single center from 2017 to 2021 were identified. Futile recanalization was defined by a modified Rankin Scale score > 2 at 90 days despite achieving complete or near-complete angiographic recanalization (modified thrombolysis in cerebral infarction grades 2b-3). Diffusion tensor imaging along the perivascular space was used to evaluate glymphatic function in patients with futile recanalization and patients with functional independence at 90 days. Spearman's rank correlation was used to examine associations between the along the perivascular space index and clinical variables. Effect sizes were calculated and reported using Cohen's d.

Results: Fifty-five patients (24 male, mean age 73.9 years) with anterior circulation LVO ischemic stroke and adequate post-thrombectomy MRI were included for analysis. Overall, glymphatic clearance was lower on the infarcted side compared with the contralateral side (p = 0.035). Patients with futile recanalization had lower glymphatic flow compared with those with functional independence at 90 days (p = 0.049). Additionally, glymphatic flow was significantly associated with the presenting National Institutes of Health Stroke Scale score (ρ = -0.46, p = 0.002).

Conclusions: These findings suggest that patients with futile recanalization have comparatively worse glymphatic clearance. Further research is required to clarify the relationship between futile recanalization and the glymphatic system, which could facilitate the development of therapeutic adjuncts.

Objective: Wall calcification in unruptured intracranial aneurysms (UIAs) increases the risk of complications of microsurgical aneurysm treatment. Therefore, information on wall calcification is important in deciding on the indication and modality of preventive treatment. However, wall calcification is often not visible on MR angiography. The authors studied risk factors for aneurysm wall calcifications to identify patients who should undergo preprocedural CT imaging to detect wall calcifications.

Methods: From two international cohorts of patients with single or multiple UIAs, data were collected on age, sex, smoking status, hypertension, aneurysm location, aneurysm size, and morphological parameters associated with increased risk for rupture (i.e., at-risk morphology = aspect ratio > 1.6, size ratio > 3, presence of lobulations, and/or irregular shape). Logistic regression was used to calculate odds ratios (ORs) with corresponding 95% confidence intervals (CIs) to investigate risk factors for wall calcification. Using receiver operating characteristic analysis in one cohort, a size cutoff value was determined for ruling out aneurysm wall calcification, which was validated in the other cohort.

Results: Two hundred fifty-five patients with 306 UIAs were included. In univariable analyses, risk factors of aneurysm wall calcification were aneurysm size (OR 1.2, 95% CI 1.1-1.3), hypertension (OR 2.1, 95% CI 1.1-4.5), and at-risk morphology (OR 2.4, 95% CI 1.3-4.4). In multivariable analysis, independent risk factors for wall calcification were aneurysm size (OR 1.2, 95% CI 1.1-1.3) and hypertension (OR 2.8, 95% CI 1.2-6.6), but not at-risk morphology (OR 1.3, 95% CI 0.7-2.7). Aneurysm wall calcification could be ruled out in more than 90% of aneurysms smaller than 6 mm in both the derivation and validation cohorts.

Conclusions: Aneurysm size and hypertension are independent risk factors of aneurysm wall calcification. The authors recommend preprocedural CT imaging in patients with a UIA ≥ 6 mm.

Objective: Progestin exposure, such as with cyproterone acetate (CPA), could increase the risk of developing osteomeningiomas (OMs). This study investigated the volumetric dynamics of the meningeal and intraosseous components of these tumors and their correlation following CPA discontinuation.

Methods: This retrospective study included 17 patients with 21 OMs diagnosed during ongoing CPA treatment. Volumes of the meningeal and intraosseous components of the OMs were measured at multiple time points. Volume dynamics over time were modeled using linear, exponential, power, and Gompertz tumor growth models. Hormone receptor expression in both components was evaluated via immunohistochemical analysis in the 4 tumors on which surgery was performed.

Results: The Gompertz tumor growth model was the most accurate in fitting the data. After CPA cessation, the meningeal component showed volume reduction in 95% of tumors (a substantial decrease in 40% and a modest decrease in 55% of tumors). The intraosseous component exhibited sustained growth in all cases, characterized by three distinct dynamics: slowing growth (40%), linear growth (45%), and pseudo-exponential growth (15%). A significant correlation was observed between the volumetric courses in the two components (rho = 0.49, p = 0.03). Hormone receptor analysis revealed no differences in expression between the two components.

Conclusions: While the meningeal and intraosseous components of OMs respond differently to CPA withdrawal, their growth dynamics remain correlated.

Objective: To date, no studies have focused on the fresh frozen plasma (FFP)-to-red blood cell (RBC) transfusion ratio in patients with severe traumatic brain injury (TBI). Herein, the authors investigated the relationship between the FFP-to-RBC ratio and neurological outcomes, including mortality, in patients with severe TBI (Glasgow Coma Scale [GCS] score < 9).

Methods: This multicenter, retrospective, observational study used data from the Japan Trauma Data Bank from 2019 to 2023. The study included patients aged ≥ 18 years with severe TBI (defined as a GCS score < 9 and an Abbreviated Injury Scale [AIS] score > 2) without severe extracranial injury (AIS score > 2). The high-ratio group was defined as having an FFP-to-RBC ratio > 1, and the low-ratio group was defined as having a ratio of 1 or less. The association between the FFP-to-RBC ratio and outcomes was evaluated using propensity score-based inverse probability of treatment weighting. The primary outcome was in-hospital mortality, and the secondary outcome was a poor neurological outcome at discharge (defined as a Glasgow Outcome Scale score of 1-3).

Results: A total of 1007 patients were included in the analysis. Compared with the low-ratio group, the high-ratio group showed no significant differences in in-hospital mortality (adjusted odds ratio [aOR] 0.91, 95% CI 0.69-1.22) or poor neurological outcome (aOR 1.12, 95% CI 0.76-1.64).

Conclusions: The authors found no association between FFP-to-RBC transfusion ratio and neurological outcomes, including in-hospital mortality, in severe TBI.

Objective: The aim of this study was to incorporate biomarkers into an inflammatory score to improve risk prediction of coagulopathy and hemorrhagic progression of a contusion (HPC) in patients with traumatic intraparenchymal hemorrhage (tIPH), and to further explore the interaction and mediation effects within the chain of events.

Methods: In this retrospective study, the medical records of patients with tIPH who received treatment at two centers from January 2019 to December 2021 were reviewed. Machine learning algorithms were applied for biomarker selection, and an inflammatory score was constructed. Multivariate logistic regression was used to assess the association between the inflammatory score, coagulopathy, and HPC. Measures on multiplicative and additive scales, as well as mediation effects, were subsequently estimated. Finally, by incorporating the inflammatory score, a hybrid model of HPC occurrence was established and validated.

Results: A total of 451 patients (median age 54 years [IQR 45-66 years]) with tIPH were included in this study. The inflammatory score was developed using a combination of parameters, including the mean platelet volume, lactate dehydrogenase level, pan-immune-inflammation value, hemoglobin-to-red blood cell distribution width ratio, and C-reactive protein-to-albumin ratio. The multivariate analysis confirmed that the inflammatory score was independently associated with both coagulopathy and HPC. Additionally, the effect of a high inflammatory score on HPC occurrence was partially mediated by coagulopathy, demonstrating both direct mediation and mediated interaction effects. As a key mediator, coagulopathy accounted for 9.6% of the positive associations. Furthermore, incorporating the inflammatory score into the hybrid model demonstrated significant incremental predictive value across the training, internal, and external test sets.

Conclusions: The inflammatory score was significantly associated with HPC, and this relationship was partially mediated by coagulopathy, with a potential synergistic interaction observed. The hybrid model improved HPC risk prediction.