Neurosurgical Review最新文献

Introduction: Carotid endarterectomy (CEA) is an established procedure for stroke prevention in patients with carotid artery stenosis. While CEA is considered safe in younger patients, perioperative risks in octogenarians remain debated, with current guidelines classifying the procedure as "high-risk" in this patient population. This study aimed to evaluate short-term outcomes of CEA across age groups and to assess whether comorbidity burden better predicts outcomes than chronological age.

Methods: The ACS-NSQIP database (2013-2020), was used to identify patients eligible for inclusion. The cohort was stratified based on age < 60, 60-80, and > 80 years. Propensity score matching and multivariable logistic regression were used to compare outcomes across age groups and assess predictors of 30-day complications, readmission, reoperation, non-home discharge, and mortality. Interaction analyses were performed to evaluate the combined impact of age, functional status and comorbidity (ASA classification) on outcomes.

Results: Of 82,427 patients, 15,111 (18%) were > 80 years. Octogenarians had significantly higher 30-day complication, readmission, reoperation, non-home discharge, and mortality rates compared with patients aged 60-80 (all p < 0.001), even after propensity matching. Logistic regression confirmed increased risk in octogenarians (aOR 1.34, 95% CI 1.27-1.42), but comorbidity burden and functional dependency were stronger predictors; severe comorbidity (ASA 4-5; aOR 2.17, 95% CI 1.91-2.47) and full dependency (aOR 2.61, 95% CI 1.89-3.59). Interaction analysis demonstrated that octogenarians with low comorbidity had risks comparable to younger patients with moderate comorbidity.

Conclusions: CEA is associated with a worse risk profile among octogenarians. Nonetheless, comorbidity burden and functional status are stronger predictors of adverse outcomes, as compared to age alone. CEA can be performed safely in carefully selected octogenarians with low to moderate comorbidity, whereas severe comorbidity or dependency may represent relative contraindications. Surgical candidacy should be guided by physiological reserve and function rather than chronological age alone.

Intracranial hemorrhage (ICH) is one of the most serious complications of deep brain stimulation (DBS). Reported incidence varies widely due to differences in surgical technique, patient selection, and definitions of hemorrhagic events. This meta-analysis provides an updated estimation of ICH risk in modern DBS practice, focusing on data from high-volume centers published within the last decade. Following PRISMA 2020 principles, we searched PubMed/MEDLINE and Scopus for studies published between June 30, 2014, and June 30, 2024. Eligible studies were single-center cohorts or case series including more than 100 patients undergoing DBS for neurological, movement, or psychiatric disorders. Thirty studies comprising 9634 patients and 17,517 implanted electrodes met inclusion criteria. Pooled proportions were calculated using random-effects models. Subgroup analyses examined the effect of surgical technique (MER vs. non-MER), hemorrhage laterality, and symptomatic versus asymptomatic events. Meta-regression assessed the association between annual electrode volume and ICH risk. The pooled incidence of ICH was 2.74% per patient, 1.49% per electrode, and 2.35% per procedure. MER-based procedures showed a slightly higher ICH rate (2.89%) than non-MER (2.16%), although the difference was not statistically significant (p = 0.706). Unilateral hemorrhages accounted for 83% of all ICHs, and symptomatic events represented 54.4% of cases. Higher annual electrode volume was significantly associated with lower hemorrhage rates (p < 0.001). Modern DBS is associated with a relatively low risk of intracranial hemorrhage, particularly in experienced, high-volume centers. The predominance of unilateral and symptomatic events highlights the importance of careful perioperative monitoring.

Although limited to case report, the role of extracranial-intracranial bypass without aneurysm trapping in resolving complex intracranial aneurysms (CIAs) remained unclear. The aim was to investigate clinical and hemodynamic features of CIAs underwent cerebral revascularization without aneurysm trapping. To the authors' knowledge, this was the first and largest series reported to date. The author prospectively recruited patients with CIAs not passing balloon occlusion test (BOT) or harboring important perforators from Jan. 2019 to Dec 2022. Cerebral revascularization without aneurysm trapping was performed, of which four-dimensional flow (4D-flow) MRI and computational fluid dynamics (CFD) based on CT angiography were utilized. The patients' demographic information and clinical course were obtained from reviewing medical records. Of 15 cases enrolled, CIAs disappeared, unchanged, and enlarged in 4, 8, and 3 cases. The 4D-flow results showed donor vessel had a trend of first increasing and then decreasing in flow and velocity after bypass, with a turning point (TP) that might occur one week after revascularization. The velocity and flow of parent artery (PA) after TP was discrepant with a decrease tendency for aneurysm disappeared, but an increase tendency for aneurysm enlarged. For cases with aneurysm disappeared, CFD analysis revealed postoperative streamline velocity and wall shear (WS) of aneurysm decreased significantly compared to preoperative values. Otherwise, streamline velocity and WS of aneurysm still existed or even increased. Cerebral revascularization without aneurysm trapping was not an ideal option for CIAs, achieving hemodynamic TP of postoperative one week and an uncertain future.

Background: Bone flap replacement restores cranial protection and contour in neurosurgery. Accidental intraoperative contamination, particularly dropped bone flaps, poses risks of infection. Management strategies are heterogeneous and lack standardized guidelines.

Objective: To systematically review reported strategies for managing dropped cranial bone flaps, focusing on surgical context, decontamination methods, operative impact, antibiotic use, and outcomes.

Methods: A systematic review was conducted in accordance with PRISMA guidelines. Relevant databases were searched from inception to September 2025. Eligible studies described strategies for intraoperative bone flap decontamination and reported at least one clinical outcome. Data extracted included study type, sample size, surgical context, decontamination strategy and duration, post-operative antibiotic regimen, follow-up period, and outcomes.

Results: Three retrospective series comprising 48 cases met the inclusion criteria. Flaps were dropped during elevation, transfer, drilling, reinsertion, and plating. Chemical decontamination-typically saline irrigation, povidone iodine ± hydrogen peroxide, and antibiotic soak-was most common, adding 15-30 min to surgery, with no post-operative infections reported. Autoclaving ensured sterility but prolonged the operative time (37 min), and carried the risk of partial flap resorption. Discarding the flap with immediate cranioplasty was reserved for non-salvageable cases, incurring the longest delay (39 min).

Conclusion: Dropped cranial bone flaps are rare but have clinically significant implications. Available evidence, limited to small series and surveys, show comparable outcomes between chemical decontamination, autoclaving, and discarding the flap followed by cranioplasty. Standardized, evidence-based guidelines are lacking, underscoring the need for multicenter prospective studies.