Neurosurgical Review最新文献

Several radiological signs have been recognized as valuable adjuncts to clinical criteria in the diagnosis of normal pressure hydrocephalus (NPH). Certain magnetic resonance imaging (MRI) findings may also provide information on postoperative outcomes following ventricular shunting. However, the evidence remains inconclusive. We conducted a retrospective cohort study including patients from our institution's Clinical Care Center for NPH. Preoperative MRI findings-specifically Evan's Index (EI), callosal angle (CA), disproportionately enlarged subarachnoid space hydrocephalus (DESH), and periventricular white matter hyperintensities (PWMH)-were analyzed in relation to pre- and postoperative clinical status. The median age was 80 years (IQR 75-85), and 68.3% of patients were males. All patients exhibited gait disturbances, 93.3% cognitive impairment, and 83.3% urinary symptoms. Median EI was 0.35 (IQR 0.33-0.37) and median CA was 85.2° (IQR 80-90). DESH was present in 60% of patients, while PWMH were detected in 48.3%. At 1-month follow-up, gait improvement was observed in 66.6%, urinary improvement in 75.6%, and cognitive improvement in 83.0%; sustained at 12 months in 63.8%, 63.8%, and 69.0%, respectively. PWMH correlated with gait improvement (p = 0.04), and DESH with cognitive improvement at 12 months (p = 0.02). DESH and PWMH demonstrated domain-specific prognostic value in idiopathic NPH, whereas EI and CA showed limited predictive utility. Imaging parameters should be interpreted in conjunction with clinical evaluation for outcome prediction.

Background: Traumatic brain injury-induced coagulopathy (TBI-IC) in the elderly is a severe complication of traumatic brain injury (TBI) that leads to unfavorable outcomes. Currently, there are no reliable machine learning (ML) models available for early identification. This study comprehensively assessed routine clinical characteristics at admission to develop a robust, generalizable, and explainable ML model for estimating TBI-IC risk in the elderly and to identify modifiable factors.

Methods: This study included two cohorts: a derivation cohort (n = 484) from the Medical Information Mart for Intensive Care IV (MIMIC-IV) and a validation cohort from the eICU Collaborative Research Database (eICU-CRD) (n = 788). Feature selection utilized the Boruta algorithm, followed by the implementation of a distinctive ML framework incorporating 12 ML algorithms to establish a consensus prediction model (TBI-IC index). The model and feature variable assessments were conducted using multiple analytical methods. Model interpretation and feature quantification relied on the Shapley additive explanation (SHAP) methodology for visualization purposes.

Results: Through Boruta algorithm selection, 17 characteristics were identified across two cohorts and incorporated into 12 ML methodologies, generating 113 permutations and an optimal algorithm for identifying TBI-IC. The TBI-IC index demonstrated strong diagnostic capabilities, achieving a mean area under curve (AUC) of 0.801 across both cohorts, along with notable discriminatory power, model fit, and clinical utility. Multivariate logistic regression and subgroup evaluations confirmed the stability and broad applicability of the TBI-IC model. SHAP explains the importance of ranking features and visualizes global and individual TBI-IC risk predictions. Restricted cubic spline (RCS) regression and threshold effect analysis suggested a nonlinear link between the model features and TBI-IC, and generated inflection points for the features.

Conclusion: An optimized explainable model (TBI-IC index) incorporating several modifiable parameters was established and confirmed to deliver an economical, readily available, and accurate diagnostic tool, along with preventive guidance for TBI-IC among elderly patients, with potential applications in TBI clinical management.

Cluster headache (CH) is a highly disabling primary headache disorder, and a subset of patients remain refractory to medical or neuromodulatory therapies. Stereotactic radiosurgery (SRS) has been explored as a minimally invasive alternative, but reported outcomes are inconsistent. A systematic review and meta-analysis was performed following PRISMA guidelines. A comprehensive search of PubMed, Embase, Scopus, and Web of Science from inception to September 15, 2025, identified eligible studies. Treatment techniques varied across studies, including radiosurgical targeting of the gasserian ganglion or the trigeminal nerve at different locations, with or without concomitant targeting of the sphenopalatine ganglion (SPG). Across five studies involving 51 patients, SRS showed a notable early benefit. The initial complete pain-free rate was 60.1% (95% CI: 24.4-91.3%), and the initial adequate relief rate was 80% (95% CI, 67.0-91.0%). At last follow-up before salvage, complete relief decreased to 28.8% (95% CI: 0-89.3%), and adequate relief to 41.7% (95% CI: 0.01-91.8%), demonstrating limited durability. The pain-recurrence rate was 59.8% (95% CI: 22.9-92.1%), and salvage therapy was required in 19% (95% CI: 7-34%). Adverse radiation effects (AREs) were common, and studies with longer follow-up reported high rates of permanent trigeminal sensory deficits, including anesthesia dolorosa, whereas studies with shorter follow-up likely underestimated late toxicity. SRS may provide early pain reduction in selected patients with medically refractory CH; however, the literature demonstrates a high rate of permanent trigeminal nerve injury, warranting cautious and highly selective use. SRS may serve as a selective or temporizing option when neuromodulatory therapies are not feasible. Limitations include small sample sizes, heterogeneous targets and dosimetry, and inconsistent definitions of outcomes. Future studies should employ prospective multicenter designs, standardized outcome metrics, optimized target planning, and extended follow-up to enhance patient selection.

Brain metastases occur in up to 50% of patients with HER2-positive breast cancer, posing significant therapeutic challenges due to the limited penetration of systemic therapies across the blood-brain barrier and the constraints of radiation therapy (RT). While small-molecule tyrosine kinase inhibitors (TKIs) show promise for crossing the blood-brain barrier and local RT provides initial control, optimal combination strategies remain unclear. This study assesses the safety and efficacy of RT combined with TKIs for HER2-positive breast cancer brain metastases (BCBM), aiming to identify optimal strategies and synergistic benefits. A comprehensive search was conducted through February 12, 2025, for studies on HER2-positive BCBM patients treated with combined RT and TKI versus either alone. Pairwise meta-analyses were conducted using a random-effects model. Bayesian network meta-analysis (NMA) was conducted to integrate direct and indirect comparisons, addressing the lack of head-to-head trials. Eleven studies (2 RCTs, 9 retrospective; 826 patients) evaluated four treatment strategies: pyrotinib + RT, pyrotinib alone, RT alone, and lapatinib + RT. Pairwise meta-analyses showed pyrotinib + RT demonstrated a significantly superior overall response rate (ORR) compared to pyrotinib alone (OR = 3.10, 95% CI = 1.86-5.18) and improved intracranial progression-free survival (PFS) over pyrotinib alone (HR = 0.61, 95% CI = 0.38-0.99) and RT alone (HR = 0.33, 95% CI = 0.12-0.89). Lapatinib + RT was associated with significantly higher severe adverse events (SAEs) than RT alone (OR = 6.13, 95% CI = 2.17-17.27). Bayesian NMA further revealed pyrotinib + RT had superior ORR compared to lapatinib + RT (logOR = 2.18, 95% CI = 0.07-4.58). Ranking probabilities from the Bayesian NMA confirmed pyrotinib + RT as most effective for ORR (97.05%) and DCR (88.57%), with lapatinib + RT associated with the highest SAE risk (95.38%). Based on the available evidence, pyrotinib + RT may represent a promising therapeutic approach, associated with improved ORR and intracranial PFS compared to monotherapies and a favorable safety profile. In contrast, lapatinib + RT appeared to offer limited benefit and a higher risk of SAEs. Further randomized controlled trials are needed to validate these findings.

Cavernous malformations (CMs) are vascular lesions that can lead to seizures or hemorrhage. Although pregnancy involves hormonal and circulatory changes that might influence CM behavior, whether it increases the risk of bleeding is unclear. We performed a systematic review using PubMed/MEDLINE and Scopus of published reports describing pregnant women diagnosed with cerebral or spinal CMs. The study question was framed using the PEO strategy, with pregnant women with cavernous angioma as the population, hemorrhage as the exposure, and clinical outcomes as the endpoints. The search was updated to July 12th, 2025 with no time restrictions. This review followed the PRISMA 2020 guidelines. Thirty-two studies were selected accounting for 94 patients. Most lesions were localized in the brainstem and supratentorial regions. Among patients that were symptomatic during gestation, hemorrhage occurred in 70.9% and seizures in 34.1%. However, a secondary analysis limited to comparative studies consistently showed a low hemorrhage rate during pregnancy, ranging from 0.9% to 3%. Most patients were managed conservatively. Surgical intervention was reserved for cases with acute neurological deterioration or persistent hemorrhage, located below the tentorium. Although, more on prudence than evidence, cesarean delivery was frequently chosen. The secondary analysis on the larger cohorts confirms that pregnancy does not increase the risk of bleeding. Treatment, however, must be postponed after delivery. Nonetheless, in cases where early intervention is unavoidable, due to topography and severity of maternal symptoms, surgery might be an option. Additionally, close monitoring in the early postpartum period remains indispensable.

To explore the clinical outcomes of coaxial endoscopic lumbar interbody fusion (CELIF) with three distinct fusion methods in the treatment of lumbar degenerative diseases. We retrospectively analyzed clinical data of patients who underwent CELIF surgery to treat lumbar degenerative diseases from January 2018 to January 2020. Patients were divided into three groups as follows: patients with the deproteinized and demineralized bovine bone fusion cage (heterogeneous compact internal fixators (HCIF) cage) and bilateral pedicle screw (BPS) fixation were included in Group HCIF-four (n = 23); patients with HCIF cage and unilateral pedicle screw, combined with contralateral translaminar facet screw (UPS + TLFS) fixation, were included in Group HCIF-three (n = 28); and patients with height-adjustable metal fusion cage and BPS fixation were included in Group metal-four (n = 26). Clinical symptoms were evaluated using the Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI). In addition, radiological outcomes were assessed via intervertebral height (IH), neuroforamen height (NH), and segmental angle (SA) prior to surgery, 7 days after surgery, and at the last follow-up. All patients demonstrated significant improvement in symptoms and imaging findings after surgery. At the last follow-up, the VAS, ODI, and imaging indices of Group metal-four were significantly better than those of Group HCIF-three (P < 0.05), whereas Group HCIF-four values were intermediate. The interbody fusion rates for Groups metal-four, HCIF-three, and HCIF-four were 88.46%, 71.43%, and 82.61%, respectively (P = 0.009 < 0.05), and the satisfaction rates were 96.15%, 71.43%, and 82.61%, respectively (P = 0.078 > 0.05). CELIF is a safe and effective minimally invasive surgical intervention for the treatment of lumbar degenerative diseases. Among the three analyzed groups, the height-adjustable metal fusion cage combined with BPS fixation may provide superior clinical and fusion outcomes. HCIF cage combined with UPS + TLFS may be associated with lower fusion rates and higher subsidence, although further prospective studies are needed to confirm these findings.

While technological progress increases precision and reduces invasiveness of stereotactic brain biopsies (BB), biopsy related hemorrhage (BBH) is still a key risk. This study identifies risk factors and uses voxel-based lesion symptom mapping (VLSM) to analyse the spatial distribution of BBH. We analyzed 450 frame-based and robotic-assisted BB. Patients' preoperative MR and postoperative CT imaging were registered and normalized to the standard MNI space enabling volumetry and inter-subject comparison of BBH location. Binary logistic regression analysis was performed to determine significant BBH predictors. Additionally, we performed VLSM to evaluate the exact spatial profile of BBH in relation to the functional outcome. BBH was noted radiographically in 80 cases (18%) with a mean volume of 1.9 ± 19.0 ml. 19/450 (4%) of all BB presented symptomatic BBH characterized mainly by sensorimotor deficits (13/450,3%) and/or reduced vigilance (5/450,1%). 7/450 (2%) cases required surgical evacuation of BBH and 10/450% (2%) patients suffered from persistent neurological deficits. High-grade glioma, patient age and target location were main BBH predictors. VLSM determined frontal trajectories targeting deep-seated lesions in the basal ganglia to be significantly associated with a higher BBH risk. BBH within the posterior aspect of the basal ganglia, insula and capsula interna emerged as significant predictors for neurological deterioration after surgery. While asymptomatic hemorrhages are quite common after brain biopsies, neurological deterioration is rare. BBH risk is influenced by both spatial factors and non-spatial factors. BB targeting basal ganglia were linked to a higher risk of hemorrhage, particularly symptomatic BBH with somatosensory deficit.