Journal of neurological surgery. Part A, Central European neurosurgery最新文献

Background:  Chronic subdural hematoma (cSDH) is a common pathology in daily practice of neurosurgery. Surgical management usually offers a significant clinical recovery. However, the recurrence rate is still high. Several studies have suggested various factors associated with hematoma recurrence with no univocal results. The aim of this study was to determine the prognostic value of early postoperative computed tomography (CT) examination to predict the need for reoperation.

Methods:  A retrospective review of 115 cSDH patients was performed. Clinical findings and pre- and early postoperative CT scan data were recorded. Univariable and bivariable analyses were performed to determine which of the studied factors were associated with an increased risk of reoperation. Their prognostic abilities were assessed using receiver operating characteristic curves.

Results:  Overall, 21 of 115 patients required a surgical revision. Among the comorbidities, diabetes mellitus represented the only factor related with hematoma recurrence (66.76 vs. 23.40%, p = 0.001). Preoperative hematoma density and postoperative residual hyperdensity on early CT scan emerged as significant predictors of cSDH recurrence (recurrence: 18/21, 85.7% vs. nonrecurrence: 17/94, 18.1%, p = 0.001). The ratios of post- and preoperative hematoma thickness (P) and post- and preoperative midline shift (Q) and their sum (K) were statistically higher in the recurrence group with cutoff values of 0.745, 0.555, and 1.135, respectively.

Conclusions:  Systematic early postoperative CT scan after cSDH evacuation may predict hematoma recurrence. In the present study, we found postoperative hyperdensity on CT scan and degree of hematoma variation after surgical evacuation to be the strongest predictors of the need for reoperation.

Background:  The aim of this study was to evaluate the risk factors contributing to early-onset adjacent level fractures (ALFs) occurring within 1 month following either balloon kyphoplasty (BKP) or SpineJack kyphoplasty (SJ) for the treatment of thoracolumbar vertebral compression fractures (TLVCFs).

Methods:  This retrospective analysis enrolled patients with single-level TLVCFs (T11-L2) who underwent either BKP or SJ between July 2013 and June 2019. We recorded the ALF occurrences within 1 month. Age, osteoporosis, severity and shape of TLVCFs, and surgical type were compared between patients with and without early-onset ALFs.

Results:  Altogether, 106 TLVCF patients were enrolled, comprising 64 BKP and 42 SJ cases. We observed 19 early-onset ALFs, with 9 and 10 cases in the BKP and SJ, respectively. Patients with early-onset ALFs have significantly more severe TLCVFs (severe vs. mild, 25 vs. 0%, p = 0.055), and wedge-shaped TLVCFs (26.47 vs. 2.63%, p = 0.002), older age (81.05 vs. 73.34 years, p < 0.001), and kyphoplasty performed within 1 month are risk factors for early-onset ALFs (26.92 vs. 9.26%, p = 0.018). Univariable analysis showed that kyphoplasty timing within 1 month (odds ratio [OR]: 0.193; p = 0.008), wedge-shaped TLVCFs (OR: 5.358; p = 0.036), and advanced age (OR: 1.119; p = 0.001) are significant risk factors for early-onset ALFs.

Conclusions:  The occurrence rate of early-onset ALFs between BKP or SJ techniques in treating TLVCFs does not differ. Preoperative wedge-shaped TLVCFs, advanced age, and early treatment within 1 month are the risk factors for early-onset ALFs following kyphoplasty for TLVCFs.

Background:  Hemimasticatory spasm (HMS) is an uncommon movement disorder of the trigeminal motor rootlet characterized by unilateral, involuntary, and paroxysmal contractions of the muscles of mastication. The mechanisms for HMS are still unclear, and an efficient treatment strategy still needs to be developed. This study aims to investigate the clinical features and surgical treatment of HMS.

Methods:  Twelve patients with HMS were included in our study. The patient data regarding clinical characteristics, neuroimaging presentations, intraoperative findings, and treatment outcomes were analyzed retrospectively. Highly selective trigeminal motor root rhizotomy (HSTR) combined with microvascular compression was performed in nine cases with neurovascular conflict, whereas three patients without vascular compression underwent HSTR only.

Results:  Intraoperative findings showed that there were two patients with six branches, two patients with five branches, and the remaining patients with three to four branches of the trigeminal motor roots. Seven patients had two motor branches severed, three patients had one motor branch severed, and two patients each had three motor branches severed. Nine patients recovered uneventfully and showed no signs of spasms, and the remaining two patients experienced complete disappearance of symptoms within 3 months after surgery. In one patient, the symptoms disappeared immediately after surgery but recurred 2 years later.

Conclusion:  The surgical procedures of HSTR can significantly alleviate the clinical symptoms of patients with HMS without serious complications.

Background:  Absent pupillary reaction occasionally heralds a poor prognosis following severe head injury. The purpose of the study was to evaluate the outcome of all patients who underwent acute evacuation of epidural hematoma (EDH) despite absent bilateral pupillary reaction.

Methods:  The Trauma Quality Improvement Program (TQIP) database for the calendar years 2017 and 2018 was accessed for the study. Adult patients ≥18 years of age who sustained severe traumatic brain injury (TBI) with the diagnosis of EDH and underwent evacuation of the hematoma were included in the study. The patients' characteristics, injury severity score (ISS), Glasgow Coma Scale (GCS) score, midline shift, and comorbidities were compared between patients who had absence of both pupillary reaction (ABPR) and those who presented with presence of both pupillary reaction (PBPR). The primary outcome of the study was in-hospital mortality. Propensity score matching analyses were performed for the study.

Results:  No significant differences were found between the ABPR and PBPR groups regarding the median age (37 years [interquartile range (IQR): 26-53] vs. 40 years [IQR: 28-55]), gender (males; 81.9 vs. 79.5%), median ISS (29 [25.5-34] vs. 27 [25-33]), GCS score (3 [3-4] vs. 3 [3-3], presence of significant midline shift (75.9 vs. 79.5%), and comorbidities. The patients who presented with ABPR had a significantly higher mortality (34.9 vs. 10.8%; p = 0.002). A higher number of patients were discharged to skilled nursing and rehabilitation facilities (16.7 vs. 10.8% and 46.3 vs. 41.9%, respectively; p = 0.045).

Conclusion:  Approximately 65% of severe TBI patients survived after the evacuation of the EDH despite the absence of pupillary reaction.

Background:  In the recent years, three-dimensional (3D) printing technology has emerged as a transformative tool, particularly in health care, offering unprecedented possibilities in neurosurgery. This review explores the diverse applications of 3D printing in neurosurgery, assessing its impact on precision, customization, surgical planning, and education.

Methods:  A literature review was conducted using PubMed, Web of Science, Embase, and Scopus, identifying 84 relevant articles. These were categorized into spine applications, neurovascular applications, neuro-oncology applications, neuroendoscopy applications, cranioplasty applications, and modulation/stimulation applications.

Results:  3D printing applications in spine surgery showcased advancements in guide devices, prosthetics, and neurosurgical planning, with patient-specific models enhancing precision and minimizing complications. Neurovascular applications demonstrated the utility of 3D-printed guide devices in intracranial hemorrhage and enhanced surgical planning for cerebrovascular diseases. Neuro-oncology applications highlighted the role of 3D printing in guide devices for tumor surgery and improved surgical planning through realistic models. Neuroendoscopy applications emphasized the benefits of 3D-printed guide devices, anatomical models, and educational tools. Cranioplasty applications showed promising outcomes in patient-specific implants, addressing biomechanical considerations.

Discussion:  The integration of 3D printing into neurosurgery has significantly advanced precision, customization, and surgical planning. Challenges include standardization, material considerations, and ethical issues. Future directions involve integrating artificial intelligence, multimodal imaging fusion, biofabrication, and global collaboration.

Conclusion:  3D printing has revolutionized neurosurgery, offering tailored solutions, enhanced surgical planning, and invaluable educational tools. Addressing challenges and exploring future innovations will further solidify the transformative impact of 3D printing in neurosurgical care. This review serves as a comprehensive guide for researchers, clinicians, and policymakers navigating the dynamic landscape of 3D printing in neurosurgery.

Background:  Vagal nerve stimulation (VNS) is an adjunctive therapy to pharmacologic treatment in patients with drug-resistant epilepsy. This study aimed to assess the efficacy of VNS therapy for seizure frequency reduction and improving the quality-of-life (QOL) measures in children with refractory epilepsy and to evaluate the correlation between the perspectives of families and those of the treating team.

Methods:  This was a prospective cohort study conducted at Abha Maternity and Children's Hospital, Saudi Arabia, from 2018 to 2022. A total of 21 pediatric patients who completed 1 year of follow-up after VNS implantation were included. Patients were aged between 2 and 14 years, with a mean age of 8.14 ± 3.92 years; 11 (52.4%) patients were females. Family and physician assessments were collected blinded to each other using the Clinical Global Impression of Improvement (CGI-I) scores and QOL assessments to evaluate the correlation between the families' and treating team's perspectives on VNS outcomes.

Results:  In this study, VNS showed significant efficacy in reducing the frequency of seizures. VNS significantly reduced the number of seizures per week from a baseline median of 35 to a median of 0.25 at the end of the follow-up period, representing a dramatic reduction of 99.3% (p < 0.001). The number of emergency department visits per year decreased from a baseline median of 12 to a median of 2, a reduction of 83.3% (p < 0.001), while the number of hospital admissions per year decreased from a baseline median of 3 to a median of 1, a 66.7% decrease (p < 0.001). The number of antiepileptic medications taken decreased from a median of four to three (p < 0.001). Notably, 28.57% of the patients achieved complete seizure freedom, and 38% exhibited significant improvement, with at least 50% reduction in seizure frequency. Importantly, none of the patients experienced an increase in seizure frequency following VNS treatment. The family and physician assessments showed varying degrees of alignment in perceptions, with "concentration" exhibiting a significant positive correlation (r = 0.498, p = 0.022), indicating noteworthy agreement, whereas verbal communication did not show a substantial correlation (r = - 0.062, p = 0.791), indicating a divergence of views.

Conclusion:  VNS is a promising and well-tolerated therapy for individuals with intractable seizures, offering clinical benefits and potential enhancements in various aspects of QOL. The varying perceptions between family and physician assessments highlight the importance of considering multiple perspectives when evaluating treatment outcomes.

Background:  Neurogenic pulmonary edema (NPE) following subarachnoid hemorrhage (SAH) is still one of the most catastrophic complications with high morbidity and mortality rates. Systemic sympathetic hyperactivity has been considered in the pathogenesis, but it has not been clarified. In this study, we investigate the relationship between the degeneration of the T3 dorsal root ganglion (DRG) and the development of NPE following spinal SAH.

Methods:  The study was conducted on 23 rabbits. Five rabbits were used as the control group, 5 as the sham group (n = 5), and 13 as the study group. The correlation between the degenerated neuronal densities of the T3 nerve axons and neurons in the DRG and NPE scores was analyzed statistically.

Results:  A correlation between the neuronal degeneration of the T3 nerve, its DRG, and high NPE scores was found in the study group and the sham group. Massive NPE was detected in the study group along with neural degeneration of T3 axons and ganglia.

Conclusion:  The present study indicates that NPE and pulmonary artery vasospasm can be prevented by reducing T3 DRG degeneration.

Background:  A choristoma is defined as the accumulation of normal tissue in an abnormal location. Salivary gland choristomas are a rare entity that is most frequently described in the middle ear. However, there are a few reported cases of salivary gland choristomas in other locations like the pituitary gland and the optic nerve dural sheath. To the best of our knowledge, we present the first case of a patient with an intraconal salivary gland choristoma. A brief but comprehensive review of literature is offered, additionally.

Methods:  A 19-year-old male patient presented with disturbance of ocular motility, ptosis, and exophthalmos of the right eye. The subsequent imaging by magnetic resonance imaging (MRI) demonstrated an intraconal lesion that infiltrated the lateral and medial rectal muscles of the right eye. The lesion showed intensive gadolinium enhancement in T1-weighted sequence and the fluid-attenuated inversion recovery (FLAIR) sequence showed no intracranial edema. The interdisciplinary neuro-oncologic tumor board recommended a biopsy and partial removal of the lesion.

Results:  Partial resection of the choristoma was successfully performed via lateral orbitotomy. No new neurologic or visual deficits occurred postoperatively. During the 2-week follow-up examination, the exophthalmos had completely regressed and the patient only reported a slight retrobulbar pressure sensation. The histopathologic examination of the tissue revealed seromucous glandular tissue.

Conclusion:  Salivary gland choristomas have been occasionally described intracranially before, but this is the first case of an intraconal accumulation of salivary gland tissue. Partial resection was achieved, resulting in complete recovery of the ophthalmologic symptoms.

Background:  Chronic subdural hematoma (cSDH) is a common neurosurgical condition of growing importance due to the aging population and increasing use of antithrombotic agents. Due to the lack of guidelines, great variability is observed in the treatment of cSDH. We conducted a multicenter, nationwide survey to assess the differences in treatment across Germany in the context of surgical practices discussed in the literature.

Methods:  A web-based survey was designed using the REDCap electronic data capture tool hosted at the Charité - Universitätsmedizin Berlin. The survey was divided into four parts: preoperative management and indication for surgery, perioperative management of medication, surgical technique, and postoperative management. The survey was distributed to German neurosurgical departments through the newsletter of the German Society of Neurosurgery and direct e-mail contact and could be answered by one member of each department between March 1 and May 31, 2023.

Results:  Overall, representatives of 46 German neurosurgical departments completed the survey. Participants needed a mean time of 16:25 minutes (standard deviation [SD] ± 27:47 minutes) to complete the survey. The mean caseload of the participating departments was 1,831.5 (range: 300-6,000; SD ± 1,130.7) operations per year, including 87.8 procedures for cSDH (range: 15-300; SD ± 73.6). Evidence found in the literature regarding the performance of a burr hole craniotomy, use of a drain, passive drainage, removal of the drain 48 hours after surgery, and early mobilization after surgery was consistently implemented in the management of the surveyed departments. On the contrary, recommendations regarding the performance of surgery under local anesthesia, use of subgaleal drains, postoperative Valsalva maneuvers, and avoidance of postoperative computed tomography (CT) if possible were not universally implemented.

Conclusion:  This survey indicates that there is no consensus on the treatment of cSDH in Germany and that the steadily increasing evidence from clinical trials must be implemented in national and international guidelines. The development of tailored treatment strategies for older patients with multiple risk factors and comorbidities is of particular importance.