Journal of neurosurgery最新文献

Objective: Several case series have investigated the use of laser interstitial thermal therapy (LITT) to treat cavernous malformations (CMs), for either seizure control or reduction of neurological symptoms and future hemorrhage risk. However, pooled outcomes are largely unknown. The authors aimed to quantify posttreatment seizure freedom, symptomatic progression or hemorrhage, perioperative complications, and imaging outcomes from the available literature.

Methods: This study was a PRISMA-compliant systematic review and individual patient-level data meta-analysis of studies reporting LITT ablation of CMs. For patients with epilepsy, the pooled Engel seizure freedom rate was calculated. The rate of symptomatic progression or hemorrhage was calculated for all patients. Fixed-effects logistic regression models were used to test for predictors of seizure freedom and postoperative complications. Linear regression models were used to obtain pooled estimates of the percent CM volume ablated.

Results: A total of 39 patients (28 with epilepsy) underwent LITT for the treatment of 45 CMs (37 cortical, 8 subcortical) at six centers. Among patients with epilepsy, 88.0% (95% CI 68.7%-96.1%) were seizure free at the last follow-up (median 30.0 months, range 12.0-49.0 months). Six patients (15.4%) experienced immediate postoperative neurological deficits. No perioperative hemorrhage was reported, and no patients experienced subsequent hemorrhage or symptomatic progression during follow-up (median 26.0 months, range 2.0-53.0 months). There was no difference in the odds of seizure freedom or adverse events based on preoperative characteristics. Nonepileptogenic CMs (mean volume 2.5 cm3) were significantly larger than epileptogenic CMs (mean volume 0.8 cm3; p = 0.002). LITT was associated with a mean CM volume reduction of 73.7% (95% CI 64.1%-83.2%, p < 0.0001) for epileptogenic CMs and 53.8% (95% CI 14.2%-93.3%, p < 0.023) for nonepileptogenic CMs (p = 0.14).

Conclusions: LITT is a promising therapy for CMs with the goal of seizure control or prevention of symptomatic progression or hemorrhage. While there is a notable risk of immediate postablation neurological deficit, most were transient and nondisabling, and this risk must be weighed against that of continued observation or open resection. Considering the limited number of studies, small number of patients, and limited follow-up time available, additional experience and research with larger patient cohorts and longer-term follow-up will be necessary to validate these findings.

Objective: Mesial temporal lobe epilepsy (mTLE) and neocortical epilepsy (NE) have different anatomo-clinical characteristics. The authors hypothesized that this may be reflected in the different functional connectivity of the epileptogenic zone between mTLE and NE. The authors, therefore, examined preoperative resting-state functional connectivity MRI with regional global connectivity (rGC) analysis for surgically treated patients. The goal of this study was to detect the different functional networks associated with the epileptogenic zone between mTLE and NE.

Methods: Twenty-four patients (12 with mTLE and 12 with NE) who underwent surgery were included in the study. All patients received resting-state functional MRI preoperatively. The mean rGC and number of high-rGC or low-rGC voxels were calculated using preoperative MRI in various regions of interest including the resected area.

Results: The ratio of mean rGC in the resected area to that of the whole brain was significantly lower in mTLE patients than in NE patients. Mean rGC was significantly lower than that of the contralateral counterpart of the resected area in mTLE patients, although it was not significantly different in NE patients. Low rGC was more frequently observed in the resected area in mTLE patients than NE patients, and high rGC more frequently observed in NE than mTLE. Multivariate analysis showed that the etiology of hippocampal sclerosis, the ratio of mean rGC in the resected area to that in the whole brain, and the ratio of the number of low- and high-rGC voxels relative to the whole brain were significant factors to distinguish mTLE from NE.

Conclusions: The authors revealed a distinct brain network structure between mTLE and NE based on rGC analysis with resting-state functional MRI. The authors' unique functional connectivity analysis may be helpful for providing landmarks for lateralization or epileptogenic zones in mTLE and NE.

Objective: The aim of this study was to describe the role and long-term outcomes of high-definition fiber tractography (HDFT) in the surgical management of brainstem cavernomas.

Methods: The authors performed a retrospective evaluation of their database at the HDFT laboratory in a single academic institution.

Results: The authors identified 11 patients with brainstem cavernomas who had HDFT for preoperative workup and underwent microsurgical resection. The mean patient age was 39 years (range 20-76 years), and the mean follow-up was 75.2 months (range 37-149 months). Four cavernomas were located anterolaterally in the pons (2 right and 2 left), 2 were left pontomesencephalic, 1 was thalamomesencephalic, 1 was in the posterior midbrain (right superior colliculus), and 3 were in the posterior pontine/floor of the fourth ventricle. Gross-total resection was achieved in 8 patients (72.7%) and subtotal resection in 3 patients (27.3%). Although 5 patients (45.5%) experienced transient worsening of preoperative symptoms or new deficits, all fully improved within 3 months. None of the patients developed new permanent neurological deficit. Preoperative symptoms improved partially in 8 patients (72.7%) and completely in 3 patients (27.3%). There was one asymptomatic new hemorrhage, and another patient had a symptomatic hemorrhage with a recurrence of his presenting symptoms 15 months after his initial surgery. This patient underwent a re-resection of his residual cavernoma, with no improvement in his preoperative symptoms.

Conclusions: HDFT provides critical anatomical information guiding an optimal surgical corridor and more importantly defining eloquent perilesional boundaries. In this preliminary experience, preoperative planning with HDFT appeared to decrease morbidity in patients who underwent microsurgical resection of their brainstem cavernoma.

Objective: The mission of NeurosurGen, Inc., is to compile and maintain genealogical data on every neurosurgeon in the US and, eventually, the world.

Methods: NeurosurGen's data were compiled from professional organizations, the internet, and historical neurosurgery archives.

Results: The NeurosurGen database (https://www.NeurosurGen.com/) meticulously records the lineage and demographic characteristics of over 8800 neurosurgeons, unveiling a pronounced male dominance at 92.96% and cataloging a rich ethnic tapestry with 3399 neurosurgeons identified as White, Asian, Black, and Hispanic. Harvey W. Cushing's monumental influence is evident, with his name recurring 426 times, anchoring the academic roots of many in the field. Data analysis underscores the pivotal role of institutions such as Brigham and Women's Hospital, Columbia University, Massachusetts General Hospital, Montral Neurological Institute, and Johns Hopkins University in molding neurosurgical leaders, reflecting their historical and contemporary impact on the discipline. Moreover, the project shines a light on the strides toward inclusivity within neurosurgical education, spotlighting institutions that stand out for their contributions to diversifying the field by training significant numbers of female, Asian, Black, and Hispanic neurosurgeons, marking a progressive shift toward a more inclusive neurosurgical community.

Conclusions: NeurosurGen offers a myriad of benefits, including the preservation of the rich history of neurosurgery and the fostering of camaraderie among its practitioners.

Objective: Gamma Knife radiosurgery (GKRS) is a treatment option for refractory trigeminal neuralgia (TN). However, there is a paucity of data regarding the effectiveness of GKRS for relapsing TN following microvascular decompression (MVD). The aim of this study was to characterize the response rate, complications, pain relief durability, and predictors of pain relapse for salvage GKRS following MVD for TN.

Methods: A retrospective study of all patients who received GKRS for Burchiel type 1 TN (TN1) or type 2 TN (TN2) pain at Wake Forest University School of Medicine was conducted. Pain was measured using the Barrow Neurological Institute (BNI) pain intensity score. After an initial pain response of BNI scores I-III, a BNI score of IV or V constituted relapse. Durability of pain relief was characterized using the Kaplan-Meier estimator. Predictors of relapse were investigated using Cox regression models. Statistical significance was set at p < 0.05.

Results: Of 2065 patients with TN1 or TN2, 59 had GKRS post-MVD. Forty-nine (83.1%) of these patients experienced a BNI pain score of I-III at the first follow-up post-GKRS. The median time to relapse was 1.75 years; freedom rates from relapse were 77%, 45.9%, and 30.7% at 1, 2, and 5 years, respectively. Radiofrequency ablation prior to MVD significantly decreased the likelihood of an initial response to salvage GKRS (Fisher's exact test, p = 0.02). After controlling for baseline and clinical characteristics, facial numbness significantly decreased the likelihood of pain relapse (Cox regression, HR 0.15, 95% CI 0.03-0.73; p = 0.01). Conversely, a worse initial pain response significantly increased the likelihood of pain relapse (Cox regression, HR 3.64, 95% CI 1.02-12.95; p = 0.04). Pain relapse within 24 months of the original MVD did not predict durability of pain relief following salvage GKRS (Cox regression, HR 0.94, 95% CI 0.40-2.22; p = 0.89). The overall toxicity rate of salvage GKRS was 35.6%.

Conclusions: Salvage GKRS presents an effective, noninvasive option for recurring TN after MVD, with a comparable response rate to primary GKRS or MVD, and a favorable complications profile relative to salvage MVD. Patients with postoperative facial numbness and a better initial pain response may experience more durable pain relief following salvage GKRS.

Objective: The inferior hypophyseal arteries (IHAs) are intimately related to pituitary and cavernous sinus (CS) lesions. There is still no anatomical study specifically analyzing the IHAs. The aim of this study was to investigate the surgical anatomy and variations of the IHA, and to translate this knowledge into surgical practice.

Methods: Twenty anatomical specimens with vascular injection were used for endoscopic and transcranial dissection. The origin, arrangement patterns of the meningeal hypophyseal trunk (MHT), segmentation, trajectory, branching pattern in each segment, and dominance of the IHAs were investigated.

Results: The IHA was identified in all 40 sides (100%). The IHA originated from the MHT in 37 sides (92.5%) and directly from the cavernous internal carotid artery in 3 sides (7.5%). According to the relationship of the IHA with the MHT, dorsal meningeal artery (DMA), and tentorial artery (TA), the authors classified five patterns of IHA origin: type A (common trunk) was found in 16 sides (40%), type B (IHA-DMA branch trunk) was found in 8 sides (20%), type C (IHA-DMA stem trunk) was found in 7 sides (17.5%), type D (IHA-TA trunk) was found in 6 sides (15%), and type E (independent type) was found in 3 sides (7.5%). All IHAs could be divided into proximal (cavernous) and distal (glandular) segments. Four branching patterns of the proximal segment were observed: 0 branches (12.5%), 1 branch (42.5%), 2 branches (40%), and 3 branches (5%). Three patterns of the distal IHA were noticed: 1) single (25%), 2) bifurcation (65%), and 3) trifurcation (10%). The IHAs entered the posterior third of the medial wall of the CS in 75%, intermediate third in 17.5%, and anterior third in 7.5%. The proximal IHA ran in close relation with the lower third of the posterior clinoid process (PCP) in 80%, middle third in 15%, and upper third in 5%.

Conclusions: The IHA can be divided into proximal and distal segments. Its proximal segment is most often found crossing the CS at the level of the lower third of the PCP and entering the posterior third of the medial wall of the CS. A detailed understanding of the surgical anatomy of the IHA and its variability will help surgeons dealing with challenging lesions within the CS and when performing transcavernous approaches, interdural posterior clinoidectomies, and pituitary gland transpositions.

Objective: Determining the value of a neurosurgeon is complex. Services provided by neurosurgeons have a range of interested parties-from a patient's singular health interest to a community catchment area rendering on-call emergency services. Such complexity makes it difficult to determine and define value. As healthcare reimbursement changes continue to transition further toward value-based/bundled payments, such determinations remain difficult and confusing. Given these factors, now more than ever before, neurosurgeons need to be active participants in the evolving discussions surrounding healthcare advocacy, value, and compensation in an ever-evolving and convoluted system. The objective of this study was to review and present current trends within the evolving landscape of healthcare economics and their impacts on the perceived value of neurosurgical services.

Methods: A systematic review regarding payments and compensation within neurosurgery was performed using a key term search. Additionally, a neurosurgical value model for hospitals was created using Medicare reimbursement methods to attempt to determine the financial contribution of a single neurosurgeon to a hospital system. Furthermore, Internal Revenue Service (IRS) form 990 tax filings from 5380 organizations were examined for comparative trends in profits and revenue on a hospital-wide basis.

Results: Mean and median annualized excess hospitalization revenue from a neurosurgeon over the same number of equal medical admissions was $5,120,533 and $5,141,160, respectively. For private practice groups, the annualized mean and median yearly hospital revenue over a comparable medical admission was calculated to be $1,539,704 and $1,902,555, respectively. For hospital-employed neurosurgeons, the respective addition of Medicare part B payments increased the mean and median values to $2,249,552 and $2,612,403, respectively. Analysis of nonprofit hospital IRS form 990 filings revealed a substantial increase in executive compensation and hospital revenue since 2011. Neurosurgeon median earnings over a similar period, reported through surveys, exhibited varied increases, but significant reporting variation exists.

Conclusions: Medical compensation continues to evolve toward more value-driven methods. Value created as a neurosurgeon is complex, but it should not be underestimated as a key driver of hospital revenue, with up to $2.6 million created annually from neurosurgical hospital admissions. Further discussion is needed to elucidate alternative innovative payment strategies to ensure physicians remain active in the evolving structure of our healthcare system.