Neurosurgical Review最新文献

We reviewed the efficacy and safety of intravenous administration of tranexamic acid (TXA) in randomized trials involving patients undergoing intracranial meningioma resection surgery, with special emphasis on the effects of different dosages. A comprehensive search was conducted in the following databases: Cochrane, PubMed, Embase, Scopus, Lilacs, and Web of Science. Two reviewers independently screened titles and abstracts, reviewed the full texts and collected data. Efficacy outcomes analyzed included intraoperative blood loss, blood transfusion rate, duration of surgery, and length of hospital stay. The safety outcomes evaluated included postoperative complications such as seizures, thromboembolic events, and hematoma. A subgroup analysis was performed based on the dosage and timing of administration. Six randomized controlled trials (RCTs) were included, covering 881 patients. Meta-analysis of the data demonstrated that the use of TXA resulted in a significant reduction in intraoperative blood loss (Mean Difference [MD] = -270.26 ml, 95% CI [-422.84, -117.67], p < 0.01, I² = 99%), blood transfusion rate (Relative Risk [RR] = 0.60, 95% CI: [0.46, 0.78], p < 0.01, I² = 3%), duration of surgery (MD = -19.76 min, 95% CI: [-41.74, 2.23], p < 0.01, I² = 75%), and length of hospital stay (MD: -0.48 days, 95% CI: [-0.93, -0.04], p < 0.01, I² = 32%). No significant differences were found in the postoperative complications assessed. In the dosage analysis, the preoperative 20 mg/kg regimen, along with the intraoperative maintenance dose of 1 mg/kg/h, was more effective in reducing intraoperative blood loss in the TXA group, although not statistically significant (323.64 ml vs. 145.54 ml, p = 0.29). The administration of TXA in patients undergoing intracranial meningioma resection surgery showed beneficial results in all efficacy outcomes evaluated, without increasing postoperative complications. However, further studies, especially multicenter ones, are needed to confirm our results.

Transcranial neurosurgery assisted by endoscopy and intraoperative ultrasound (IOUS) has become an effective approach for real-time visualization and guidance during tumor resection. This study explores the application of these techniques in falcine meningioma (FM) resection, assessing their feasibility and safety. Eleven FM patients underwent transcranial endoscopic resection with IOUS assistance. Preoperative neuroimaging, including magnetic resonance (MR) imaging, computed tomography, MR angiography, and MR venography, guided surgical planning. IOUS provided real-time tumor localization, boundary visualization, adjacent structure assessment, and guidance throughout the resection. Tumors were located in the anterior, middle, and posterior falx in 4, 5, and 2 patients, respectively. Of the 11 cases, 8 involved unilateral falx tumors and 3 involved bilateral falx tumors. Simpson grade 1 resection was achieved in 12 patients; one case involved a deeply located tumor closely associated with the deep venous plexus. Pathologically, 10 patients had World Health Organization (WHO) grade 1 meningiomas, and 1 had a WHO grade 3 anaplastic meningioma. Postoperative complications included temporary contralateral hemiplegia in one patient and pulmonary infection in another. The average follow-up period was 19.3 months, with all patients achieving Karnofsky Performance Status scores of > 90. In conclusion, endoscopic resection with IOUS assistance is both feasible and safe for FM patients.

Loss of cervical lordosis (LOCL) is the most common postoperative cervical deformity. This study aimed to identify the predictors of LOCL by investigating the relationship between various factors and LOCL development after surgery for cervical spinal cord tumors. A retrospective analysis was conducted on 51 patients who underwent cervical spinal tumor resection at a single center. Data on the patients' cervical sagittal alignment parameters were collected both pre- and postoperatively to analyze the association between pre- and postoperative cervical sagittal alignment parameters, age, sex, pathological type of tumor, tumor location, tumor length, and likelihood of developing LOCL following cervical spinal cord surgery. Multiple logistic regression analysis revealed significant differences Pre-T1s (p = 0.005) and Post-CL (p = 0.009) angles. Additionally, ROC curves indicated a significant relationship between Post-CL and LOCL (p = 0.008, AUC = 0.718), with a Post-CL threshold value of 9.5°, and a relationship between Pre-T1s and LOCL (p = 0.025, AUC = 0.687). Tumor location, clinical staging, age, sex, and length of the segments involved in the tumor were not significantly associated with LOCL. Patients with a post-CL of less than 9.5° or Pre-T1s of more than 24.5° had a noticeably higher risk of developing LOCL. Active intervention in conjunction with surgical follow-up may be required for patients experiencing significant discomfort and associated functional impairment.

Aneurysmal Subarachnoid Hemorrhage (aSAH), resulting from ruptured aneurysms, is a major contributor to stroke-related mortality and morbidity. Despite advances in healthcare, aSAH remains severe and often leads to complications such as cerebral vasospasm (CV), cerebral infarction, and delayed ischemic neurological deficits (DIND). Clazosentan, an endothelin receptor antagonist, has demonstrated potential in alleviating vasospasm and its associated outcomes, although evidence of its efficacy remains unclear. A systematic review and meta-analysis was conducted following the PRISMA guidelines, including randomized controlled trials (RCTs) that compared clazosentan with placebo in adult patients with aSAH. Primary outcomes were vasospasm-related cerebral infarction and DIND. Secondary outcomes included the incidence of vasospasm, mortality, and adverse effects. Data were analyzed using Review Manager 5.3, and meta-regression was employed to assess moderators, including aneurysm treatment modality. Eight RCTs, involving 3,186 participants, were included in the analysis. Clazosentan significantly reduced vasospasm-related cerebral infarction (RR = 0.56, 95% CI: 0.42-0.76, p = 0.0002) and DIND (RR = 0.67, 95% CI: 0.55-0.80, p < 0.0001). Dosages of 10 mg and 15 mg were found to be the most effective. However, clazosentan had no effect on the overall mortality (p = 0.48) and was associated with an increased risk of hypotension, pulmonary edema, and pleural effusion. Clazosentan significantly reduced vasospasm-related cerebral infarction and DIND in patients with aSAH, particularly at higher doses. Nonetheless, its use is linked to notable adverse effects, highlighting the need for careful assessment of its risk-benefit profile in clinical practice.

Glioma is characterized by high heterogeneity and poor prognosis. Attempts have been made to understand its diversity in both genetic expressions and radiomic characteristics, while few integrated the two omics in predicting survival of glioma. This study was intended to investigate the connection between glioma imaging and genome, and examine its predictive value in glioma mortality risk and tumor immune microenvironment (TIME). Clinical, transcriptomics and radiomics data were obtained from public datasets and patients in our center. Correlation analysis between gene expression and radiomic feature (RF) was performed, followed by survival analysis to select RF-related genes (RFRGs) and gene expression-related RFs (GRRFs). After that, RFRGs and GRRFs were used to construct mortality risk prediction model of all glioma and isocitrate dehydrogenase (IDH) wild type (WT) glioma. The association between RFRGs and TIME was explored. Six cohorts composed of 1,754 glioma patients were included. Thirty-five genes and eighty-two RFs demonstrated high correlation with each other. Gene score based on RFRGs was independent predictor of both glioma (P < 0.05) and IDH-WT glioma (P < 0.05). Same score based on GRRFs was also able to stratify risk of both glioma (P < 0.0001) and IDH-WT glioma (P < 0.0001), with nomograms constructed separately. The TIME of gliomas predicted with RFRGs' score found mismatched risk of death with immune response. RFRGs and GRRFs were able to predict glioma mortality risk and TIME. Further studies could validate our results and explore this genome-imaging interactions.

Spinal cord ischemia and injury pose significant challenges in spinal surgery and traumatic events. Cerebrospinal drains are considered a potential intervention to mitigate these risks, although their efficacy and safety are uncertain. We conducted a comprehensive systematic review and meta-analysis to evaluate the efficacy and safety of cerebrospinal drains in preventing and managing spinal cord ischemia and injury. We systematically searched multiple electronic databases including PubMed, Scopus, Web of Science, and the Cochrane Library to identify relevant studies. Eligible studies included randomized controlled trials, cohort studies, and observational studies assessing the use of cerebrospinal drains in patients undergoing aortic surgeries. Data extraction and quality assessment were independently performed by two reviewers. The systematic review identified 34 studies meeting the inclusion criteria. The meta-analysis conducted using open meta-analyst software revealed a significant effect of cerebrospinal drains on preventing spinal cord ischemia spinal cord injury The pooled odds ratio (OR) in double-arm studies was estimated to be 0.457 (95% CI: 0.275, 0.760). Additionally, the pooled estimate of single-arm studies was estimated to be 0.050 (95% CI: 0.036, 0.065). However, minimal heterogeneity was observed across studies.Cerebrospinal drains may play a role in preventing and managing spinal cord ischemia and injury, but further research is required to confirm their efficacy and safety. Additional well-designed studies are needed to determine the optimal use of cerebrospinal drains in clinical practice.

Resection is often the primary treatment for large brain tumors but is less practical for multiple brain metastases (BM). Current guidelines recommend stereotactic radiosurgery (SRS) for untreated BMs or following the surgical removal of a solitary BM to reduce the risk of local tumor recurrence. Preoperative SRS (pre-SRS) shows promise with fewer complications and more precise targeting, but it lacks tissue diagnosis and may hinder wound healing. This study aims to compare the safety and efficacy of pre-SRS and postoperative SRS (post-SRS) for BM treatment. A comprehensive literature search was conducted in PubMed, Embase, Scopus, and Cochrane Library. Studies were selected based on PICO criteria, including patients with metastatic intracranial lesions undergoing preoperative or postoperative radiosurgery. Data related to outcomes and complications were extracted. Meta-analysis was performed, employing the fixed effect model due to study design similarities and limited patient numbers. Four studies encompassing 616 BM patients (221 preoperative, 405 postoperative) were included. Patient characteristics, including age, gender, cancer source, and lesion location, were similar between groups. Radiosurgery modalities included LINAC and Gamma Knife, with hypofractionated treatments more common postoperatively. Outcomes showed comparable overall survival (p = 0.07), local failure (p = 0.26), and distant failure rates (p = 0.84) between groups. The preoperative group had lower risks of radiation necrosis (p = 0.02) and leptomeningeal disease (p = 0.03) in 1-year follow-up, with significantly better composite outcomes (p = 0.04). No significant difference in wound issues was observed (p = 0.98). This review reveals pre- and post-SRS for BM have similar outcomes for LF, DF, and OS. Pre-SRS potentially lowers RN and LMD risks, with better tumor targeting and less radiation to healthy tissue, while post-SRS targets residual disease but with higher complication risks. Future research should optimize SRS protocols.

Treatment of neuropathic pain in patients with spinal cord injury (SCI) and cauda equina injury (CEI) remains challenging. Dorsal root entry zone lesioning (DREZL) or DREZotomy is a viable surgical option for refractory cases. This study aimed to compare DREZL surgical outcomes between patients with SCI and those with CEI and to identify predictors of postoperative pain relief. We retrospectively analyzed 12 patients (6 with SCI and 6 with CEI) with intractable neuropathic pain who underwent DREZL. The data collected were demographic characteristics, pain distribution, and outcomes assessed by numeric pain rating scores. Variables and percentages of pain improvement at 1 year and long-term were statistically compared between the SCI and CEI groups. The demographic characteristics and percentage of patients who experienced pain improvement at 1 year postoperatively did not differ between the groups. Compared with the SCI group, the CEI group presented significantly better long-term pain reduction (p = 0.020) and favorable operative outcomes (p = 0.015). Patients with border zone pain had significantly better long-term pain relief and outcomes than did those with diffuse pain (p = 0.008 and p = 0.010, respectively). Recurrent pain after DREZL occurred in the SCI group but not in the CEI group. DREZL provided superior pain relief in patients with CEI. The presence of border zone pain predicted favorable outcomes. CEI patients or SCI patients with border zone pain are good surgical candidates for DREZL, whereas SCI patients with below-injury diffuse pain are poor candidates.

Postoperative neurological deterioration due to brain compression by the swollen temporal muscle pedicle used in encephalo-myo-synangiosis (EMS) is a potential complication of combined revascularization for Moyamoya disease (MMD). However, the factors contributing to this phenomenon remain poorly understood. This study aimed to identify factors associated with postoperative temporal muscle swelling following combined revascularization. A total of 37 consecutive combined revascularization using temporal muscle pedicle performed between 2021 and 2023 were analyzed. Postoperative temporal muscle volume was measured through serial CT scans on postoperative days (POD) 0, 1, 7, 14, and 30. Multiple regression analysis was performed to assess factors contributing to swelling, including RNF213 p.R4810K variant, a known genetic risk for Asian MMD. Surgical outcomes and collateral vessel development were also examined. Results showed a significant increase in muscle pedicle volume on POD 1 and 7 across all 37 hemispheres, followed by a marked decrease by POD 30, compared to POD 0. These chronological volume changes were significant in adults (n = 31) but not in pediatric patients (n = 6). Multiple regression analysis identified the RNF213 p.R4810K as sole significant factor positively associated with maximal muscle volume (regression coefficient 0.485, P = 0.0078). Favorable surgical outcomes were achieved in 36 of 37 cases (97.3%) over a mean follow-up of 2.2 years, with indirect collateral development confirmed in 27 adult (87%) and 6 pediatric (100%) hemispheres. Results suggest the RNF213 p.R4810K variant is associated with increased postoperative temporal muscle swelling after combined revascularization, especially in adult MMD patients, indicating a potential genetic influence on this complication.

Rathke's cleft cysts (RCCs) are benign, cystic lesions that account for less than 5% of cases in the pediatric population. While asymptomatic RCCs often require only conservative management, symptomatic cases may necessitate surgical intervention. Advances in surgical techniques have improved the safety of these procedures. This comprehensive review and single-arm meta-analysis evaluates the outcomes of surgical management in pediatric patients. PubMed, Embase, and Web of Science were systematically searched for studies documenting RCC resection in pediatric patients (< 18 years). Outcomes of interest included symptomatic improvement (headache, visual impairment, endocrinopathy), postoperative complications, postoperative diabetes insipidus (DI), recurrence, and reoperation rate. Heterogeneity was assessed using I² statistics, and a random-effects model was adopted. Twelve studies were included in the final analysis. The pooled proportion of headache improvement was 84% (95% CI: 73%-91%), with 65% of patients achieving complete resolution. Improvement of visual symptoms occurred in 87% of cases (95% CI: 63%-96%). The rate of improvement of endocrinopathy after surgery had an overall pooled rate of 48% (95% CI: 29%-69%). The rate of postoperative complications was 8% (95% CI: 4%-13%), and the incidence of new postoperative DI was 28% (95% CI: 18%-40%). The pooled incidence of cyst recurrence was 16% (95% CI: 11%-23%), while the incidence of reoperation was 14% (95% CI: 8%-24%).Surgery for RCC in pediatric patients offers high rates of symptomatic improvement for headaches and visual impairments, though improvement for endocrinopathy tends to be moderate. The procedure generally has a low risk of postoperative complications, but the incidence of new-onset DI is notable. While many patients experienced complete headache resolution, surgery should not be solely indicated for headache management. Surgical decisions must prioritize objective clinical factors, such as cyst characteristics, neurological impact, and endocrine dysfunction. Additionally, recurrence and reoperation rates are observed, highlighting the need for careful consideration of potential risks and individualized treatment planning. Future research should focus on refining surgical techniques and assessing long-term outcomes to optimize treatment strategies for pediatric RCC patients.