Journal of neurosurgery最新文献

Objective: Trigeminal neuralgia (TN) is a debilitating condition often associated with multiple sclerosis (MS), in which the presence of demyelinating plaques in the pons can impact the trigeminal nerve. Microvascular decompression (MVD) is the gold-standard surgical treatment for classic TN but is traditionally contraindicated in TN-MS patients due to limited efficacy and concerns over neurovascular compression as the sole etiology. This systematic review aimed to evaluate the outcomes of MVD in TN-MS patients, focusing on pain relief and complications.

Methods: A systematic search of the PubMed, Embase, Scopus, and Web of Science databases was conducted in June 2024, adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies reporting on MVD outcomes in TN-MS patients were included. Data on demographics, clinical characteristics, surgical outcomes, and complications were extracted. The primary outcome was long-term pain-free status (Barrow Neurological Institute [BNI] score of I) at the final follow-up. A meta-analysis of proportions was performed using a random-effects model. Risk of bias was assessed using the Methodological Index for Non-Randomized Studies tool.

Results: From 523 unique records, 30 studies were included, consisting of 429 TN-MS patients treated with MVD, with 265 unique patients. Neurovascular compression was identified in 96.6% of the patients. The pooled success rate of MVD, defined as achieving a BNI score of I, was 30.2% (95% CI 24.2%-36.9%). Heterogeneity was low (I2 = 0%-25%) across analyses. The most common complication reported after MVD was transient facial numbness. Publication bias was not significant in the included studies.

Conclusions: MVD is less effective in TN-MS patients than in those with classic TN, with approximately 30% achieving long-term pain-free outcomes. However, MVD may still offer meaningful relief, particularly in patients with neurovascular compression. Given these findings, MVD should not be categorically excluded as a treatment option for TN-MS. Further prospective studies are needed to refine patient selection and optimize outcomes.

Objective: The aim of this study was to evaluate the safety of unruptured intracranial aneurysm (UIA) treatment by assessing postprocedural ischemic lesions using MRI diffusion-weighted imaging (DWI) and correlating these findings with clinical outcomes.

Methods: This investigator-initiated, single-center study prospectively enrolled consecutive patients undergoing UIA treatment at Helsinki University Hospital between December 2022 and August 2024. Postprocedural brain MRI was performed within 3 days, and clinical outcomes (modified Rankin Scale [mRS] score, neurological symptoms, and return to work) were assessed at 3 months. The authors compared the incidence of DWI lesions between treatment modalities and assessed the association between DWI lesions and outcome metrics.

Results: A total of 169 consecutive UIA patients were included, of whom 120 (71%) were treated endovascularly and 49 (29%) surgically. At 3 months, 98% of patients had an mRS score of 0 or 1, 6% had a worsening of their mRS score, and 4% had new neurological symptoms. The incidence of a new DWI lesion was 63%, with no difference between the groups (endovascular 63% vs surgical 63%, p = 0.993). Endovascular patients more often had ≥ 6 DWI lesions (14% vs 0%, p = 0.012), while surgical patients more frequently had lesions ≥ 10 mm (20% vs 8%, p = 0.016). The majority (85%, 91/107) of DWI lesions were asymptomatic, but the presence of a lesion was associated with an increased risk of new neurological symptoms (15% vs 2%, p = 0.006 [59% of symptoms being transient]). There was no association between the presence of any DWI lesion and mRS score (mRS score 0 or 1: 96% with lesions vs 100% without, p = 0.298) or mRS score worsening (7% with lesions vs 5% without, p = 0.747). However, lesions ≥ 10 mm were associated with poorer mRS outcomes (mRS score 0 or 1 16/19 [84%] vs 149/150 [99%], p = 0.005) and an increased risk of mRS score worsening (4/19 [21%] vs 1/150 [1%], p = 0.016). Overall, 97% of patients who were working before treatment returned to work within 3 months.

Conclusions: New DWI lesions are frequent after UIA treatment, despite excellent clinical and mRS outcomes. The mRS score alone might not fully capture the neurological impact of treatment-related ischemia. DWI assessment can provide valuable additional information when evaluating the quality of modern neurovascular care. Clinical trial registration no.: NCT06147102 (ClinicalTrials.gov).

Objective: The Wada test, an intracarotid amobarbital procedure, is the gold standard for preoperative evaluation of postoperative memory decline in patients with drug-resistant epilepsy. However, it has certain limitations including false negatives due to insufficient hippocampal inhibition and false positives due to extrahippocampal disorders such as aphasia. This study examined the utility of posterior cerebral artery (PCA) selective anesthesia for functional evaluation (SAFE) as an alternative approach to avoid aphasia and assessed its predictive value for postoperative verbal memory decline.

Methods: The authors conducted a single-center retrospective study of patients with drug-resistant epilepsy between May 2018 and December 2023, who subsequently underwent PCA SAFE before anterior temporal lobe resection. The SAFE protocol includes comparable memory tasks before and immediately after anesthetic infusion. Preinfusion assessments established baseline memory function, whereas postinfusion assessments evaluated brain function under selective anesthesia. Patients were required to memorize 8 words, 8 pictures, and 5 figures. After the anesthetic effects subsided, recognition tasks were performed for all presented stimuli. The memory score was calculated by subtracting the number of recognized items encoded under anesthesia from the baseline. Word recognition represented verbal memory, whereas figure recognition represented visual memory. A memory score ≥ 2 points on the side of the epileptic focus or no difference between left and right PCA SAFE was classified as a high risk of postoperative memory decline. A decline of ≥ 15 points in postoperative memory scores on the Wechsler Memory Scale-Revised was defined as significant memory decline.

Results: The authors included 11 patients (focus side: left in 8 patients and right in 3 patients). Five patients were classified as having a high risk and 6 as having a low risk for verbal memory decline. All 5 high-risk patients revealed significant postoperative verbal memory decline, whereas 5 of the 6 low-risk patients did not. The sensitivity was 83.3%, and the specificity was 100%. No patients had a significant decline in postoperative visual memory.

Conclusions: PCA SAFE was shown to predict postoperative verbal memory decline with high accuracy. This study highlights the utility of PCA SAFE in reducing aphasic interference in verbal memory, leading to a more accurate evaluation of surgical candidacy in patients with drug-resistant epilepsy.

Objective: Postoperative surgical site infections (SSIs) following brain tumor surgery frequently necessitate wound revision and bone flap removal. However, data on subsequent cranial reconstruction in this context remain limited. The aim of this study was to characterize patients undergoing bone flap removal due to SSI, determine the proportion who proceed to cranioplasty, and evaluate surgical strategies, complication rates, and risk factors for implant failure.

Methods: In this multicenter observational study, patients who underwent bone flap removal due to SSI following brain tumor surgery from 2008 to 2022 at four Swedish neurosurgical centers were included. Clinical, radiological, and surgical data were collected retrospectively. Risk factors for implant removal were evaluated with logistic regression and Kaplan-Meier survival analyses. Functional outcome was assessed using the modified Rankin Scale (mRS).

Results: Of 260 patients included in the analysis, 223 (86%, median age was 56 years) underwent cranioplasty and 37 (14%, median age 66 years) did not, primarily due to short life expectancy, poor medical condition, or wound concerns. Among patients who underwent cranioplasty, the most common tumor type was meningioma (75%) and the median cranial defect size was 35 cm2. Synthetic implants were used for all reconstructions. The overall implant removal rate was 21%, primarily due to wound dehiscence and infection. WHO grade 4 tumors and a cranial defect size > 64.5 cm2 were associated with an increased risk of implant removal (p < 0.05). Variables such as age, smoking, and diabetes did not predict complications. Functional outcome, as assessed by the mRS, remained unchanged postoperatively for most patients (87%).

Conclusions: Cranioplasty after bone flap removal due to SSI following brain tumor surgery was associated with a substantial risk of implant failure despite reconstruction of relatively small cranial defects. Predictive factors for implant failure were limited, suggesting that unmeasured variables, such as soft tissue conditions, might play a significant role in these procedures. Given the high rate of implant removal and limited survival among patients with high-grade tumors, careful patient selection and individualized decision-making are essential.

Objective: For more than 4 decades, stereotactic radiosurgery (SRS) has been a standard procedure for brain arteriovenous malformation (AVM). Nonetheless, this procedure has been implicated in postobliteration intracranial hemorrhage (ICH) and delayed cyst formation (DCF). In this study, the authors investigated the long-term outcomes of SRS treatment for AVM.

Methods: Authors of this retrospective study reviewed the medical records of all patients who underwent SRS for brain AVM at a single academic medical center between January 1995 and October 2014 and whose clinical follow-up was at least 5 years. Analysis focused on clinicodemographic profiles, treatment parameters, and imaging phenotypes.

Results: The final study cohort consisted of 380 patients with a mean age of 34.2 years and mean follow-up of 11.5 years. There was a slight preponderance of males in the cohort (201:179). A total of 154 patients (40.5%) experienced ICH prior to SRS treatment. The mean maximum AVM diameter was 3.3 cm, and most malformations were supratentorial (n = 325, 85.5%). Stratification based on Spetzler-Martin grade was as follows: grade I, 35 cases (9.2%); grade II, 104 cases (27.4%); grade III, 136 cases (35.8%); grade IV, 83 cases (21.8%); and grade V, 22 cases (5.8%). The median interval between SRS and complete AVM obliteration was 48.4 months. Chronic encapsulated intracerebral hematoma (CEIH) was noted in 16 patients (mean latency 14.6 years after SRS), and DCF was noted in 24 patients (mean latency 9.6 years after SRS). Among these 40 patients, 14 (35.0%) required craniotomy and 3 (7.5%) required stereotactic aspiration due to symptomatic mass effect. An analysis of risk factors revealed early radiation-induced change (RIC), infratentorial location, and prior hemorrhage as predictive of CEIH. Early RIC alone was predictive of DCF.

Conclusions: Even after angiographic obliteration, long-term clinical and radiological surveillance is warranted due to the risk of CEIH (2.1%) and delayed cysts (3.2%) more than a decade after SRS.

Objective: The aim of this study was to evaluate the long-term visual outcomes following optic nerve decompression in patients with CSF flow disturbances and to propose a mechanistic framework for surgical qualification based on infusion testing and orbital MRI, independent of idiopathic intracranial hypertension (IIH) diagnostic criteria.

Methods: This retrospective study analyzed 30 eyes in 26 patients with progressive visual impairment and evidence of CSF flow abnormalities. All patients underwent standardized lumbar infusion testing to quantify CSF outflow resistance, pressure-volume index, and opening pressure. Orbital MRI was used to assess perioptic CSF collections or optic canal narrowing. On the basis of these data, patients underwent either optic nerve sheath fenestration (ONSF) or endoscopic optic nerve sheath decompression (EONSD). Visual function was evaluated using mean deviation of the visual field, visual evoked potentials, and optical coherence tomography of the retinal nerve fiber layer (RNFL) thickness at baseline and 6 and 24 months.

Results: Mean deviation of the visual field improved by a median of +1.89 dB (p < 0.05), and P100 latency (i.e., the time between a visual stimulus and the visual cortex's response) decreased by -5 msec at 24 months. Papilledema resolved in 87.5% of affected eyes. RNFL thickness remained stable or modestly increased across the cohort, with a trend toward greater thickening following EONSD (+9 µm at both 6 and 24 months) compared with ONSF (minimal change at 6 months [+1 µm] and slight thinning at 24 months [-2 µm]), although the differences were not statistically significant. No significant differences in functional outcomes were observed between the procedures. Patients were stratified into 3 CSF pathophysiological subgroups: 1) IIH with elevated intracranial pressure (ICP), 2) abnormal hydrodynamics without raised ICP, and 3) normal ICP and hydrodynamics with MRI-confirmed perioptic CSF collection. Visual improvement occurred across all subgroups, including groups 2 and 3.

Conclusions: The authors found that optic nerve decompression guided by CSF infusion testing and orbital MRI effectively stabilizes or improves visual function in patients with CSF-related optic neuropathy, including those without elevated ICP. A mechanism-based classification into three surgical phenotypes enables individualized treatment beyond syndromic definitions. This approach may redefine surgical eligibility and expand access to vision-preserving interventions in CSF-mediated optic nerve dysfunction.

Objective: Advancements in endovascular devices and techniques have improved cure rates for selected brain arteriovenous malformations (AVMs). However, data on angiographic and treatment-related complications remain limited. This study presents a 12-year single-center experience with curative endovascular treatment (EVT), along with comparative insights from previously published cohorts.

Methods: Data from all brain AVMs treated with curative intent EVT between 2010 and 2022 were reviewed for baseline demographic characteristics, angioarchitectural features, treatment techniques (single arterial, double arterial, venous, arterial and venous, and transvenous embolization with selective temporary flow arrest [TFATVE]), complications, and clinical and angiographic outcomes. Hemorrhagic and ischemic complications were assessed with postprocedural MRI. Ischemic volumes were semiautomatically calculated on apparent diffusion coefficient maps using regions of interest segmentation by two independent readers. Univariate and multivariate analyses were performed to identify predictors of cure and complications.

Results: A total of 193 patients (54% male, mean ± SD age 38.7 ± 15.9 years) with 193 AVMs (60.6% ruptured) were included. The following techniques were included: single arterial (37.8%), double arterial (26.4%), arterial and venous (19.7%), TFATVE (8.3%), and single venous (7.8%). Intraprocedural complications occurred in 10.4% of cases. Both hemorrhagic and symptomatic ischemic complications occurred in 15.5% of patients. Mean ischemic volume was 9.4 ± 15.1 cm3 and was significantly higher in symptomatic cases. Overall minor and major complications rates were 14% and 3.1%, respectively. The mortality rate was 4.7% and was lower in unruptured AVMs though these had a higher complication rate. The overall angiographic cure rate was 80.3%, increasing to 93%-100% in cases treated with advanced approaches. On multivariate analysis, AVM in an eloquent brain location was associated with lower cure rates (OR 0.3, p = 0.023), while advanced techniques involving TVE were associated with higher cure rates (OR 7.9, p < 0.001).

Conclusions: This large, single-center experience adds to the growing evidence that curative EVT can be a valuable option, especially when advanced techniques are used for low-grade and ruptured deep AVMs. At the same time, higher complication rates in unruptured or higher grade (Spetzler-Martin [SM] grade IV-V) lesions highlight the importance of cautious patient selection. Larger, multicenter prospective studies in high-volume centers are needed to better define the role of curative EVT.

Objective: Although dopamine agonist (DA) therapy still represents the standard of care for prolactinomas, a reconsideration of the role of transsphenoidal surgery has been promoted in recent years. The aim of this multicenter retrospective study was to assess the short- and long-term results of the endoscopic endonasal approach (EEA) for prolactinomas, analyzing which factors have a favorable prognostic role.

Methods: All consecutive prolactinomas operated on in 12 Italian neurosurgical centers between 2013 and 2023 were included. For each case, preoperative clinical and neuroradiological features were considered, as well as surgical complications and short- and long-term results.

Results: The series included 215 patients (44.2% males, mean age 39.7 [SD 16.6] years), accounting for 4.5% of all pituitary surgeries in these centers. The majority of prolactinomas (67.9%) were macroprolactinomas. Radical tumor resection was achieved in 171 patients (79.5%), and 3-month biochemical remission in 154 patients (71.6%). The most common surgical complication was postoperative CSF leak (2.8%). Endocrinological sequelae consisted of new onset of anterior hypopituitarism in 10.7% of cases, transient diabetes insipidus (DI) in 3.3%, and permanent DI in 2.3%. Long-term remission (mean follow-up 33.5 [SD 25.0] months) was achieved in 75.4% of patients, 14 patients (6.5%) presented with tumor recurrence/progression, and 1 (0.5%) demonstrated tumor evolution to carcinoma.

Conclusions: The EEA is a valid option for the treatment of prolactinomas, with better results for micro tumors and regular macro tumors. This study found that preoperative prolactin values < 184 ng/ml were associated with higher chances of biochemical remission, as was larger pituitary surgery center volume. Currently, the most common surgical indications for prolactinomas are represented by cases that are not responsive or intolerant to DAs. However, interesting future perspectives considering EEA as a possible co-first-line therapy in selected patients have been recently proposed.

Objective: The aim of this study was to compare 3 electrode designs-a novel 22-contact circular grid, standard 6-contact strip, and high-density (HD) grid between 32 and 64 contacts-for the detection of epileptiform activity during awake craniotomy.

Methods: This study included patients who underwent functional brain mapping with and without direct electrical stimulation during awake craniotomy. Demographic, clinical, and electrocorticography (ECoG) data were collected.

Results: A total of 194 patients were included, with 264 instances of electrode use: 113 circular grid, 96 strip electrode, and 55 HD grid. The HD grid (15%) was used less to record ECoG during direct electrical stimulation than the circular grid (80%, p < 0.001) and strip electrodes (69%, p < 0.001). Sporadic interictal epileptiform activity was better detected with circular (45%, p < 0.001) and HD (40%, p = 0.006) grids compared with strip electrodes (16%). Spontaneous seizures were recorded more frequently with the circular grid (16%, p = 0.018) compared with the strip electrode (9.4%) and HD grid (1.8%). Afterdischarges were more frequently detected by the circular grid (69%, p = 0.031) and with circular and HD grids (combined) compared with strip electrodes (67% vs 48%, p = 0.024), at lower median intensity (3 mA vs 5 mA, p < 0.001). Multivariable analyses demonstrated circular grids (p < 0.001) to be more sensitive in detecting spontaneous epileptiform activity than strip and HD grid electrodes, and grids (circular and HD) to be better in recording stimulus-induced epileptiform activity (p = 0.01).

Conclusions: This study demonstrates a higher rate of detection of epileptiform activity with circular and standard grids when compared with strip electrodes. The standard HD grid was used less during electrical stimulation, demonstrating the importance of both the number of contacts and design array when considering optimal conditions for ECoG and functional brain mapping.