Journal of neurosurgery最新文献

Objective: Extracranial-intracranial (EC-IC) bypass has been well described in chronic vaso-occlusive cerebrovascular diseases, including both moyamoya disease (MMD) and atherosclerotic disease (AD). This study aimed to compare factors associated with bypass occlusion between these two diseases.

Methods: An institutional database of 357 patients with intracranial bypass procedures performed between August 2001 and May 2022 was retrospectively reviewed. Patients with MMD and AD were selected for study. Baseline characteristics, surgical technique, and flow-related measurements were compared in relation to the outcome of bypass occlusion.

Results: A total of 232 patients met inclusion criteria (AD, n = 108; MMD, n = 124). The average age and sex differed significantly between groups (AD 57.2 years, 56.5% male; MMD 36.6 years, 31.5% male; p < 0.001). The modified Rankin Scale scores at surgery and at follow-up were higher in the AD group (p = 0.004 and p < 0.001, respectively), showing a slightly worse baseline functional status, and higher rates of stroke were observed in the AD group by last follow-up (p = 0.005). Patients with AD also were more likely to require an interpositional graft (p < 0.001). At last follow-up, rates of occlusion did not differ between AD and MMD groups (25.2% vs 25.4%, respectively). Of occluded bypasses, the AD group had more occlusions within 1 week compared to MMD (51.9% vs 35.5%, p = 0.176), although the difference was not significant. In patients with more than 1 year of follow-up and in those with more than 2 years of follow-up, MMD tended to have higher rates of occlusion (31.2% vs 26.1% [p = 0.558], and 26.4% vs 20.7% [p = 0.564]). Flow measurements did not differ between AD and MMD groups, but in subgroup analyses of patients with AD and those with MMD, both bypass flow and cut flow index predicted occlusion in both groups.

Conclusions: Despite different disease etiologies treated with bypass, rates of occlusion at last follow-up did not vary between groups, although short-term follow-up would suggest earlier bypass failure in AD, and extended follow-up trended toward higher occlusion rates in MMD. Additionally, patients with AD were more likely to have further occurrences of stroke by last follow-up. Importantly, the bypass flow and cut flow index at the time of surgery predicted occlusion in both AD and MMD.

Objective: In vitro trials have demonstrated that oversized stents are associated with reduced metal coverage and increased porosity. However, the relationship between stent selection and aneurysm outcome is inconclusive, and determination of this was the authors' purpose in conducting this study.

Methods: This was a single-center retrospective study. Patients who underwent Pipeline embolization device treatment at the authors' center between January 1, 2018, and June 15, 2023, were enrolled. The authors constructed multiple logistic regression models and restricted cubic spline plots to examine the effect of the difference in diameters between the stent and parent artery (Dd) on aneurysm outcome. The authors also performed stratified analyses. Then, Dd was included in the logistic regression analysis as a categorical variable. The cutoff value for Dd was determined according to the principle of the maximum Youden's index.

Results: In total, 302 patients were included in this study. The median Dd was 0.52 mm. With a median follow-up time of 7 months, the aneurysm occlusion rate was 80.1%. The restricted cubic spline plots showed a decreasing aneurysm occlusion rate as Dd increased. After stratification by age and adjunctive embolization, the restricted cubic splines aligned with the results of the main analysis. Compared with the group with a smaller Dd (Dd < 0.3625 mm), the group with a larger Dd showed an OR of 0.439 (p = 0.026). Additionally, patients with diabetes mellitus (OR 0.306, p = 0.018), age ≥ 65 years (OR 0.968, p = 0.03), aneurysm incorporation with a branch (OR 0.253, p < 0.001), and aneurysm neck ≥ 4 mm (OR 0.872, p = 0.003) were independent predictors of aneurysm persistence, whereas Pipeline embolization device plus coiling (OR 4.949, p < 0.001) and smoking history (OR 5.86, p = 0.025) were predictors of aneurysm occlusion.

Conclusions: The authors' retrospective analysis demonstrated that the aneurysm occlusion rate declined when Dd increased within a certain range. The authors suggested that Dd with an interval of -0.25 to 0.5 mm may be proper in clinical practice.

Objective: The overall benefit of employing a sitting/semisitting position for neurosurgical procedures remains under criticism due to concerns for additional risk, especially the risk of intraoperative venous air embolism (VAE). The aim of this single-center cohort study was to evaluate the frequency and severity of VAEs and associated complications in patients undergoing neurosurgery in the lounging position.

Methods: From 2010 to 2020, 1000 patients, including 172 patients with a patent foramen ovale, underwent surgery in the lounging position for different neurosurgical pathologies. All patients were monitored intraoperatively using continuous transesophageal echocardiography (TEE). The anesthesia team documented any observed incidences of VAEs and scored their severity according to the Tuebingen classification system (TCS) for VAE (TCS-VAE). The patients' clinical condition, radiological findings, and hospital course were subsequently analyzed to assess complications in a retrospective analysis of prospectively collected data.

Results: In the cohort of 1000 patients, 5 underwent cervical spine surgery and 995 underwent suboccipital craniotomy. VAE was detected by TEE in 51.4% (95% CI 48.4%-54.5%) of patients, with synchronous changes in end-tidal CO2 (grade 2-5 TCS-VAE) noted in 10.2% (95% CI 8.3%-12.3%). None of the patients presented with hemodynamic instability (grade 5 TCS-VAE). Patients with high-grade VAEs were significantly older (p = 0.02) and had lower BMIs (p = 0.001) than the respective mean value of the cohort. VAE grade was not associated with any of the outcome measures such as Karnofsky Performance Scale score, duration of ventilation, length of intensive care unit stay, and length of hospital stay. Postoperative acute respiratory distress syndrome (ARDS) was diagnosed in 0.3% (95% CI 0.0%-0.7%, n = 3) of all cases, and ARDS was associated with perioperative VAE grade (p = 0.001). No patient suffered a new permanent neurological deficit due to a paradoxical VAE.

Conclusions: In this large cohort, the risk of an intraoperative VAE during neurosurgery in the lounging position was assessed, and contrary to the general perception in the field, no permanent sequelae or fatal adverse events attributable to VAEs were observed. Furthermore, the overall incidence of ARDS was very low. This study clearly establishes that experienced interdisciplinary teams can safely use the lounging position for neurosurgical procedures.

Objective: Craniopharyngiomas (CPs) in adults are rare benign epithelial tumors, and few contemporary studies have explored outcomes after surgical treatment in elderly patients, especially with regard to endoscopic endonasal surgery (EES).

Methods: A retrospective cohort study was conducted on patients aged ≥ 18 years with CP who were treated with EES from 2013 to 2022. The cohort was divided into nonelderly (18-64 years) and elderly (≥ 65 years) groups based on age. Various parameters, including patient and tumor characteristics, surgical outcomes, complications, and follow-up, were compared between the two age groups.

Results: A total of 193 patients met the inclusion criteria, with 161 (83.4%) patients in the nonelderly group and 32 (16.6%) patients in the elderly group. Preoperatively, older patients were more likely to have memory impairment (4.3% vs 18.8%, p = 0.010), fatigue or decreased energy (9.3% vs 34.4%, p = 0.001), hypopituitarism (68.7% vs 90.6%, p = 0.012), or hydrocephalus (18% vs 40.6%, p = 0.005), and they were more likely asymptomatic (1.2% vs 9.4%, p = 0.033) and less likely to experience headache (57.8% vs 31.3%, p = 0.006). Patients in the elderly group had a longer symptom duration (median [IQR] 5 [10] months vs 9.5 [13] months, p = 0.001) and higher comorbidity scores (p < 0.001). Postoperatively, gross-total resection was achieved in 145 (90.1%) and 28 (87.5%) patients in the nonelderly and elderly groups, respectively. Older patients were more likely to develop pneumonia (5% vs 21.9%, p = 0.004). There were no significant differences in the extent of resection (p = 0.541), pathological subtypes (88.2% vs 75.0% adamantinomatous, p = 0.089), operation time (mean ± SD 307.8 ± 68.3 minutes vs 323.5 ± 86.0 minutes, p = 0.257), estimated blood loss (median [IQR] 300 [200] ml vs 300 [238] ml, p = 0.594), length of stay (median [IQR] 15 [8] days vs 15 [22] days, p = 0.964), perioperative mortality (2.5% vs 3.1%, p > 0.99), or postoperative severe hypothalamic dysfunction (37.9% vs 50.0%, p = 0.237) between the groups. Multivariate Cox regression analysis demonstrated that tumor calcification (HR 3.406, 95% CI 1.859-27.233, p = 0.038) and preoperative hydrocephalus (HR 3.688, 95% CI 1.310-10.386, p = 0.013) were independently associated with decreased survival. The median follow-up period in the elderly group was shorter (71 months vs 44 months, p = 0.001), and no recurrence was observed (7.1% vs 0%, p = 0.132).

Conclusions: This study demonstrates that EES is a viable treatment option for older CP patients. With appropriate perioperative management, EES does not significantly increase mortality and, in selected populations, is well tolerated by patients.

Objective: The migration of distal catheter after ventriculoperitoneal shunt placement is a rare but significant complication. Especially in a case of cardiac migration, open-heart surgery or catheter intervention may be required. The authors encountered a case of cardiac migration that fortunately could be treated by withdrawal. A systematic review of cardiac migration was performed to clarify when and how migration was diagnosed and why invasive treatments were required. Based on the collected cases, a Weibull analysis of the latency until diagnosis was performed to examine whether cardiac migration is caused by an initial factor and to compare the result with the other migration sites such as gastrointestinal tract or urinary tract.

Methods: A qualitative systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. A database of case reports was created by searching PubMed and Scopus with the keywords "ventriculoperitoneal AND shunt AND migration" (last search date: April 2022). Whether the occurrence rate of migration is constant over time was examined by fitting a Weibull distribution.

Results: A total of 339 articles of all migration sites were identified. Among them, 36 articles reporting 38 cases of cardiac migration were considered eligible. A total of 39 cases including the authors' case were reviewed qualitatively. When classifying the cases by their latency to diagnosis, the rates of pulmonary thrombosis and of cardiac adhesion were higher in the delayed group (≥ 1 year) than in the early group (≤ 1 month). The rate of open chest surgery was higher in the delayed, intermediate, and early groups, in that order. In the Weibull analysis, the shape parameter (β) was less than 1, indicating that the occurrence rate of cardiac migration was initially high, followed by a decline. The finding supports the hypothesis that migration results from an intraoperative vascular injury. Note that these findings are subject to bias given that they are derived from case reports.

Conclusions: In light of the previous reports, the latency until diagnosis of cardiac migration was associated with the rate of thrombosis and adhesion, which resulted in escalation to invasive treatment. Early diagnosis will prevent invasive treatment because most cases are caused by initial factors, as the Weibull analysis showed.