Journal of neurosurgery最新文献

Objective: Gunshot wounds to the head (GSWH) are devastating injuries associated with high rates of morbidity and mortality. Poor outcomes in these patients necessitate identifying which patients may benefit the most from aggressive clinical and surgical management. The Baylor score uses patient age, pupil reactivity, Glasgow Coma Scale (GCS) score, and bullet trajectory at initial presentation to prognosticate mortality and Glasgow Outcome Scale (GOS) score at 6 months. In this cohort of patients with GSWH, the authors aimed to demonstrate internal validation of the Baylor score, which was recently externally validated by a distinct patient cohort at a different level I trauma center.

Methods: Data were obtained from the trauma registry at a high-volume level I trauma center. Patients with penetrating cranial gunshot wounds from January 2008 to May 2022 were identified and retrospectively analyzed. Patient demographics, GCS score, pupillary response, and bullet trajectory on CT scan were reviewed, and the Baylor score was calculated for each patient. GOS score was determined for each patient at last follow-up. The validity of the Baylor score to predict mortality and good functional outcomes was assessed using receiver operating characteristic curves and areas under the curve (AUCs) as performance measures.

Results: Over the 14-year study period, 404 patients met the inclusion criteria (mean age 31.5 [SD 12.9] years, 88.9% male). A total of 227 (56.2%) patients died, while 139 (34.4%) had good functional outcomes defined as GOS score 4 or 5 (moderate disability or good recovery, respectively). The Baylor score demonstrated good prognostication of both mortality (AUC 0.91) and good functional outcomes (AUC 0.93). Baylor scores of 0-2 underestimated good functional outcomes, and scores of 3-5 underestimated mortality. Patients older than 35 years with nonreactive pupils and low GCS score (3 or 4) had 100% mortality.

Conclusions: The Baylor score is a useful and accurate tool for clinicians to estimate mortality and functional outcomes in patients with GSWH. The score may be valuable in guiding patient- and family-centered discussions regarding prognosis early in the treatment course.

Objective: Waste accounts for up to 25% of United States healthcare expenditures. Many sterilized surgical instruments remain unused during procedures, contributing to this burden. Reducing the quantity of unused surgical instrumentation presents an opportunity to decrease costs while improving operating room efficiency. This study aimed to characterize instrument utilization patterns and implements a novel, systematic, replicable protocol to eliminate excess sterile instrumentation.

Methods: This prospective, single-center study investigated sterile instrumental utilization rates (IURs) across and within procedures. Craniotomy for tumor was used to characterize instrument utilization patterns on a per-surgeon, per-surgery, and per-instrument level. A novel 3-phase protocol was designed to systematically reduce sterile surgical waste. In phase 1, IURs were calculated by dividing the instruments used during a procedure by the number provided. Instruments used in fewer than 20% of cases were removed in phase 2. Streamlined instrument kits were demoed while the original kit remained at hand, and instruments were replaced as requested. Phase 3 represented full integration of the reduced kits with removal of the original kits. IURs and the number of instruments used were compared before and after protocol implementation. The protocol was implemented in 17 additional surgical procedures. Follow-up data were collected over 1 year after instrument kit reduction.

Results: The authors observed 69 cases across 6 procedures. Procedural IURs ranged from 11.3% to 38.4%. Most instrument types remained infrequently used (< 20%) across procedures. In craniotomy for tumor, IUR among the pilot instrument kit ranged from 30.6% to 35.3% (median 33.4%) with no significant variation in the number of instruments used per case (p = 0.88). Following protocol implementation, craniotomy instrument kits were reduced from 157 to 99 instruments. IUR increased to 55.2% (p < 0.001) with no change in the number of instruments used per case (mean 52.2 ± 5.4 preintervention vs 54.4 ± 5.0 postintervention, p = 0.43). The number of infrequently used instruments decreased from 38 to 10. Applied to 18 procedure types across 11 surgical specialties, the protocol reduced kit sizes by 21%-60% (median 38%). No changes to reduced instrument kits were requested following implementation.

Conclusions: Instrument utilization is consistent between surgeons and cases. The systematic elimination of unused sterile surgical instrumentation can therefore reduce surgical waste through a replicable protocol without impacting surgeon instrument selection.

Objective: The risk of hemorrhage during stereoelectroencephalography (SEEG) is low but not negligible. The planning of avascular trajectories together with the accuracy of the implantation technique plays an important role for the reduction of this risk. The aim of this study was to compare vessel visualization using dedicated MR arteriography-venography (MRAV) versus frequently used contrast-enhanced T1-weighted MRI for the planning of avascular SEEG trajectories.

Methods: Among 93 patients with drug-resistant epilepsy, 100 SEEG schemes from 100 consecutive SEEG procedures (86 patients with single SEEG and 7 patients with 2 SEEG explorations) with 1525 electrodes were included in this study. Every SEEG scheme was a result of a multidisciplinary discussion and aimed to test a hypothesis for the localization of the epileptogenic zone based on the results of previous noninvasive investigations. All patients had dedicated MRI for SEEG planning including the following 3D sequences/techniques: T1-weighted, FLAIR, T2-weighted, MRAV, and T1-weighted with a double dose of contrast (T1+2C). Avascular planning was based on the individual SEEG scheme with 10-22 trajectories (mean 15 trajectories). A distance of 2.5 mm from the trajectory to the closest vessel on the pial surface was considered as an obligatory safety margin. All vessels closer than this safety margin on the pial surface were considered dangerous. Two neurosurgeons planned independently all the 100 SEEG schemes on T1+2C or MRAV. The same neurosurgeons performed cross-checking with the alternative vascular sequence while looking for dangerous vessels (i.e., T1+2C was checked with MRAV and MRAV was checked with T1+2C). Finally, the rate of detection of dangerous vessels on T1+2C after planning on MRAV and the rate of detection of dangerous vessels on MRAV after planning on T1+2C were calculated and compared.

Results: MRAV visualized a dangerous vessel at the pial entry point in 96 of 100 SEEG explorations that were first planned on T1+2C. The number of dangerous vessels found on MRAV after T1+2C planning ranged from 0 to 5, most frequently 4 dangerous vessels per planning. Overall, 291 of 1525 trajectories (19.1%) were found in 100 SEEG procedures in which MRAV visualized a vessel in the safety zone after SEEG was initially planned on T1+2C. In contrast, there was no vessel visualized on T1+2C in the safety zone when the SEEG was initially planned on MRAV.

Conclusions: These findings indicate that MRAV allowed better vessel visualization than T1+2C during SEEG planning.

Objective: Certain neurological conditions can be treated by delivering therapeutics to the thalamus, but intrathalamic perfusion properties and methods have not been tested in humans. Therefore, the aim of this study was to define the properties of intrathalamic convective gene therapy delivery by analyzing findings among patients with frontotemporal dementia (FTD) associated with granulin (GRN) mutation who underwent image-guided perfusion of adeno-associated virus serotype 9 (AAV9) expressing GRN.

Methods: Consecutive patients with FTD associated with GRN mutations were enrolled in the ASPIRE-FTD clinical trial. Patients underwent real-time MRI-guided convective co-infusion of the bilateral thalami (1200 µL per thalamus divided equally between the anterior and posterior thalami at an infusion rate up to 15 µL/min) with AAV9-GRN and gadolinium-based contrast material (1 mM). Patient and infusion characteristics were assessed.

Results: Three patients (mean age 53.0 ± 18.2 years) underwent a total of 12 thalamic infusions (mean follow-up 6.0 ± 3.0 months). Real-time MRI demonstrated increasing tissue volume of distribution (Vd) with increasing volume of infusion (Vi) (mean Vd-to-Vi ratio of 2.3 ± 0.1, R2 = 0.97). The mean total Vd per side was 2.8 ± 1.4 cm3 (range 2.6-3.2 cm3). The mean thalamic coverage was 39.1% ± 7.5%. Infusion shaping by varying the infusion rate and cannula position permitted excellent intrathalamic distribution (mean perfusion within the thalamus of 87.2% ± 5.4%). There were no surgical complications.

Conclusions: This investigation of real-time MRI-guided convective delivery provided new insights into thalamic gene therapy perfusion properties. The isotropic tissue composition, low propensity for perivascular leakage, and broad interconnectedness make the thalamus an ideal gene therapy target for a wide variety of neurological disorders.

Objective: The rapid development of artificial intelligence (AI) presents an opportunity to streamline the peer-review process and provide key information to guide academic journals, editorial staff, and reviewers, as well as authors. This study aimed to fine-tune several standard large language and transformer models (LLMs) on the basis of the text of peer-reviewer comments and editorial outcome decisions to find text-based associations with journal decisions for acceptance versus rejection.

Methods: This study, with participation from the Journal of Neurosurgery Publishing Group (JNSPG), included anonymized final decision and reviewer comments to all article submissions made to the Journal of Neurosurgery (JNS) and subsidiary journals from 2021 to 2023. All final decisions were grouped as binary (acceptance/revision vs rejection/transfer). Leading words (i.e., "acceptance" or "rejection") were removed from textual reviewer comments, which were then analyzed using various machine learning and LLMs, including BERT, GPT-2, GPT-3, GPT-4o, and GRU variants, to predict the final manuscript decision outcome. Performance was measured using receiver operating characteristic (ROC) curves. Shapley Additive Explanations (SHAP) analysis was conducted to evaluate the impact of individual words on model predictions.

Results: In the ROC analysis, the fine-tuned GPT-4mini and GPT-3 models achieved the highest area under the curve (AUC) values of 0.91, followed by BERT and GPT-2 with AUC values of 0.84. These were followed by bidirectional GRU and GPT-3 (untrained) with AUC values of 0.75 and 0.70, respectively. Unidirectional GRU and GPT-4o (untrained) demonstrated the lowest AUC values of 0.68 and 0.67, respectively. In the SHAP analysis, the logistic regression model identified words like future," "interesting," and "written" as significant positive predictors of acceptance, whereas "clear," "unclear," and "does" were associated with rejections. The GRU model identified "study," "useful," and "journal" as significant positive predictors, and "unclear," "reading," and "incidence" as negative predictors.

Conclusions: This proof-of-concept study demonstrates that fine-tuned AI models, particularly GPT-3, can predict manuscript acceptance with reasonable accuracy using only textual reviewer comments. Emerging themes that lend weight to article outcome include article clarity, utility, suitability, cohort size, and diligence in addressing reviewer queries. These findings suggest that, when fine-tuned, AI modeling holds significant potential in assisting and facilitating the peer-review process.

Objective: Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is a major source of morbidity and mortality following firearm-related penetrating brain injury (PBI). Standard pharmacological prophylaxis against VTE includes the use of low-molecular-weight heparin (LMWH) or unfractionated heparin (UH). However, the comparative effectiveness of LMWH versus UH to prevent VTE in this population remains unclear.

Methods: A retrospective analysis was conducted using data from the Trauma Quality Improvement Program (2017-2019) to evaluate the effectiveness of LMWH versus UH in patients with PBI. Adult patients (age ≥ 16 years) with an isolated firearm-related PBI treated at a level I or II trauma center were included. The primary outcome was the occurrence of VTE. Secondary outcomes were the need for late neurosurgical decompression and in-hospital mortality. Hierarchical logistic regression models were used to evaluate the association between prophylaxis type and the outcomes, adjusting for patient baseline and injury characteristics, as well as timing of VTE prophylaxis initiation. Effect modification was evaluated to determine whether the observed associations varied between types of early neurosurgical intervention: craniotomy/craniectomy, intracranial monitor/drain placement, or no intervention.

Results: Among 2012 patients with isolated firearm-related PBI, LMWH was associated with 51% decreased odds of VTE compared with UH (OR 0.49, 95% CI 0.32-0.77) after risk adjustment. Subgroup analysis showed that LMWH, compared with UH, was associated with reduced odds of VTE in patients who underwent early craniotomy/craniectomy (OR 0.42, 95% CI 0.23-0.74) or no intervention (OR 0.41, 95% CI 0.21-0.79). The type of pharmacological VTE prophylaxis was not associated with the occurrence of late neurosurgical decompression or in-hospital mortality.

Conclusions: In patients with firearm-related PBI, LMWH appears to be significantly more effective at preventing VTE compared with UH, without increasing the risk of neurosurgical intervention. These findings support the use of LMWH as the preferred agent for VTE prophylaxis after PBI.

Objective: Authors of this study aimed to characterize the neuropsychological profile of survivors of aneurysmal subarachnoid hemorrhage (aSAH) and identify clinical variables associated with poor cognitive outcomes.

Methods: This retrospective observational study included patients with an aSAH diagnosis from 2009 to 2024. Cognitive outcomes were assessed at least 6 months after aSAH using the 22-item Montreal Cognitive Assessment (MoCA-22), Digit Span Test Forward (DST-F), Digit Span Test Backward (DST-B), and Verbal Fluency Test (VFT). Poor cognitive outcomes were defined as an MoCA-22 score < 25th percentile for population norms. Multivariable logistic regression was used to identify factors associated with poor cognitive outcomes. A subset of patients also completed the Beck Depression Inventory II, Stroke-Specific Quality of Life Scale, and Iowa Scales of Personality Change.

Results: A total of 156 patients were included. Fifty-three patients (34%) had an MoCA-22 score < 25th percentile, even though 79% of them had a modified Rankin Scale score ≤ 2 at discharge. Moderate and severe deficits (z-score < 1 SD) were observed in 11% of patients (17/156) on the DST-F, 27% (42/156) on the DST-B, and 9% (14/156) on the VFT. A modified Fisher grade 4 on admission (36/53, 68% vs 45/103, 44%) and infarction during hospitalization (16/53, 30% vs 11/103, 11%) were significantly associated with poor cognitive outcomes (adjusted odds ratio [aOR] 2.43, IQR 1.17-5.16, p = 0.018; and aOR 2.71, IQR 1.10-6.79, p = 0.029, respectively). Infarction also negatively impacted work productivity (OR 0.69, p = 0.015) and social relationships (OR 0.72, p = 0.029). Additionally, 27% of patients (12/44) reported at least mild depressive symptoms and 64% (29/45) acquired a personality disturbance.

Conclusions: Survivors of aSAH can experience neuropsychological deficits, particularly those affecting executive function and working memory, despite good functional recovery. In this study, a modified Fisher grade 4 and new radiological infarction during hospitalization were associated with poor cognitive outcomes.

Objective: Giant craniopharyngiomas (GCPs) (diameter > 4 cm) are rare tumors that present significant surgical challenges due to their tendency to invade multiple compartments. To date, no studies have directly compared the expanded endoscopic endonasal approach (EEA) with the traditional transcranial approach (TCA) for the resection of GCPs. This study aimed to compare the safety and efficacy of these two surgical approaches within a single institution.

Methods: A retrospective cohort study was conducted on the medical records of patients with GCP who underwent surgery at the authors' institution between February 2011 and October 2023. Patients were divided into two groups based on the surgical approach received: EEA and TCA. The groups were compared on various parameters, including patient and tumor characteristics, surgical outcomes, perioperative complications, and long-term results.

Results: Seventy-three patients were included in the analysis, of whom 42 underwent expanded EEA and 31 underwent TCA. Patient and tumor characteristics were comparable between the two groups. The extent of resection and the rate of pituitary stalk preservation were similar in both groups (p = 0.55 and p = 0.16, respectively). Postoperative CSF leaks occurred exclusively in the EEA group, but the difference was not statistically significant (14.3% vs 0.0% in the TCA group, p = 0.08). EEA was associated with superior visual improvement (52.4% vs 22.6% in the TCA group, p = 0.01) and better hypothalamic function (p = 0.04). Postoperative panhypopituitarism (67.7% vs 42.9%, p = 0.04), progression from partial hypopituitarism to panhypopituitarism (48.4% vs 21.4%, p = 0.02), and permanent diabetes insipidus (51.7% vs 26.8%, p = 0.03) occurred more frequently in the TCA group compared with the EEA group. There were no significant differences in tumor recurrence (9.8% for the EEA group and 13.8% for the TCA group, p = 0.89), median BMI gain (1.0 kg/m2 and 1.6 kg/m2, respectively; p = 0.33), long-term hormone replacement (46.3% and 69.0%, respectively; p = 0.06), return to school/work (90.2% and 82.8%, respectively; p = 0.58), or progression-free survival (p = 0.273) between the groups at the last follow-up.

Conclusions: Expanded EEA is associated with a similar gross-total resection rate, greater visual improvement, and better hypothalamic and endocrinological function compared with traditional TCA. Although not statistically significant, EEA was associated with a higher risk for postoperative CSF leaks. These data favor the view that EEA is a safe and effective surgical modality, providing a viable alternative to TCA for GCPs.