Journal of neurosurgery最新文献

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.

Objective: Brain metastases can cause focal neurological deficits that significantly impact quality of life. While resection can lead to deficit recovery, it remains unclear how patient and tumor characteristics at presentation predict postoperative improvement. This retrospective cohort study aimed to examine the impact of cystic features on time to improvement of preoperative neurological deficits.

Methods: Retrospective chart review was performed for adults who underwent resection for one or more brain metastases at a single institution from 2004 to 2022. Patient and tumor variables were compared between cystic and noncystic metastases using the Wilcoxon rank-sum test, Pearson's chi-square test, or Fisher's exact test. Local and distant progression-free survival and time to deficit resolution were compared using the Kaplan-Meier method and Cox proportional hazards regression.

Results: In total, 464 tumors from 444 patients were included, with median clinical and imaging follow-up durations of 9.7 and 6.6 months, respectively. Cystic features were present in 134 tumors and absent in 330. While cystic and noncystic metastases had similar rates of deficit recovery, cystic metastases had a shorter time to deficit recovery (median 1 month, 95% CI 0-4) compared to noncystic (median 8 months, 95% CI 5-23, p = 0.012, log-rank test), with recovery plateauing at 6 months and 2 years, respectively. There were no differences in progression-free survival. Older age (HR 0.98, 95% CI 0.96-0.99, p = 0.005) and tumor in an eloquent cortex (HR 0.62, 95% CI 0.39-0.98, p = 0.041) were associated with slower neurological recovery, while cystic features (HR 1.50, 95% CI 1.02-2.20, p = 0.039) and adjuvant radiotherapy (HR 1.59, 95% CI 1.05-2.42, p = 0.029) were associated with faster recovery.

Conclusions: Patients with cystic brain metastases experience quicker resolution of preoperative neurological deficits after resection but have similar rates of deficit recovery. Older age and tumor presence in eloquent cortex were associated with slower deficit improvement, while cystic features and adjuvant radiotherapy were associated with faster improvement.

Objective: Postoperative meningitis (PM) is a severe complication following skull base tumor surgery, often resulting in prolonged hospitalization and increased morbidity. However, predicting the duration of PM remains challenging. This study aimed to identify prognostic factors influencing the duration of PM and to develop a predictive nomogram to guide individualized management and antibiotic therapy.

Methods: The authors conducted a retrospective cohort study of patients diagnosed with PM after skull base tumor surgery at a high-volume neurosurgical center between December 2018 and August 2024. Patients who received antibiotic treatment were included. Logistic regression analysis was performed to identify independent predictors of prolonged meningitis duration (> 7 and > 14 days). Based on these factors, predictive nomograms were developed and validated to estimate the probability of extended recovery times.

Results: Among 629 patients with PM, 240 (38%) experienced meningitis > 7 days and 69 (11%) had durations > 14 days. Multivariate analysis identified fever duration (> 38.5°C), highest CSF white blood cell (WBC) count, lowest CSF glucose level, highest blood WBC count, highest blood neutrophilic granulocyte proportion, repeat operation, and surgical approach as independent predictors of prolonged meningitis. The nomogram demonstrated good predictive performance, with concordance indices of 0.80 (95% CI 0.74-0.83) for the 7-day model and 0.79 (95% CI 0.70-0.85) for the 14-day model in the training cohort. Calibration curves and decision curve analyses further confirmed the accuracy and clinical utility of the models.

Conclusions: The authors successfully developed and validated a prognostic nomogram to predict the duration of PM following skull base tumor surgery. This tool enables individualized risk stratification, informs the optimal duration of antibiotic therapy, and supports improved postoperative management. Prospective studies are warranted to further validate these findings across broader clinical settings.

Objective: The US neurosurgical workforce faces growing demand driven by an aging population and rising prevalence of neurological conditions. This study projects workforce supply and demand from 2022 to 2037, highlighting potential shortages and geographic disparities.

Methods: Workforce projections (2022-2037) were obtained from the Health Resources & Services Administration's National Center for Health Workforce Analysis Dashboard, using the Health Workforce Simulation Model to estimate supply and demand by specialty, year, and location. Supply, measured in full-time equivalents (FTEs), accounted for new entrants, retirements, and attrition. Demand was projected under two scenarios: 1) status quo and 2) reduced barriers, reflecting improved access for underserved populations. Workforce adequacy (supply-to-demand ratio) was assessed, with descriptive statistics and state-level heat maps generated using Excel and Python in Google Colab.

Results: The neurosurgery workforce is projected to grow slightly from 7060 FTEs in 2022 to 7230 FTEs by 2037 (+2.4%). Under the status quo scenario, demand rises from 7060 to 8310 FTEs (+18%), while the reduced barriers scenario shows an increase from 9280 to 11,830 FTEs (+27%). Workforce adequacy decreases across both scenarios, with national adequacy dropping from 100% to 87% under the status quo and from 72% to 61% under reduced barriers. Metropolitan areas maintain higher adequacy compared with nonmetropolitan areas but still face shortages over time. State-level disparities persist through 2037, with adequacy ranging from 400% in the District of Columbia to 33% in Delaware. By then, neurosurgery ranks 18th under the status quo and 33rd under reduced barriers among 37 specialties.

Conclusions: Significant neurosurgical workforce shortages are projected through 2037, with growing demand outpacing modest supply increases, particularly under the reduced barriers scenario. Targeted strategies are needed to address geographic disparities and ensure adequate neurosurgical care nationwide.