Neurosurgical focus最新文献

Objective: Gamma Knife radiosurgery (GKRS) is an important neurosurgical intervention most commonly used for pathologies such as meningiomas, acoustic neuromas, paragangliomas, arteriovenous malformations, and trigeminal neuralgia. While the widespread availability of GKRS in developed countries makes it ubiquitous in neurosurgical research, there is a huge disparity in research in lower-middle-income countries (LMICs). This study aimed to quantify research undertaken by authors in LMICs on GKRS.

Methods: The authors systematically reviewed PubMed for research articles that reported on GKRS from LMICs. Studies reporting on neurosurgically treated pathologies in which either the first or corresponding author was affiliated with an institution in an LMIC were included.

Results: A total of 190 papers from LMICs met the criteria; 142 articles were from Asia and 48 were from Africa. India had the highest number of papers, whereas no papers from LMICs in South America or Oceania met the criteria for inclusion. The most frequently published type of study was retrospective, tumors were the most common pathologies studied, and arteriovenous malformations were the single most studied individual pathology. There was no significant difference in the mean number of each article type or for neoplastic, vascular, or functional pathologies per country between Asia and Africa. Articles were most often published in Neurology India, and 24 studies had a female first author, whereas 22 had a female corresponding author.

Conclusions: This study reveals the relatively low number of studies providing high-quality evidence from LMICs such as randomized controlled trials and meta-analyses, as well as gender inequities and very high disparities among LMICs in GKRS research.

Objective: The global need for neurosurgical care is significant and often unmet. Building partnerships between high-income countries (HICs) and lower-middle-income countries (LMICs) can help bridge the gap. Six features of sustainable global surgical partnerships have been identified; however, their application in neurosurgery has not been studied. The authors analyzed how the 6 pillars of sustainability are applied to neurosurgical partnerships established by the Neurosurgery Outreach Foundation (NOF) with hospitals in LMICs in Asia.

Methods: NOF is an all-volunteer, nonprofit US foundation with the mission to advance neurosurgical care in underserved communities through education, service, and support. The authors examined the NOF programs and identified the characteristics associated with the 6 pillars of sustainability, which are community engagement, multidisciplinary collaboration, education and training, outcome measurement, multisource funding, and bilateral authorship. The authors discuss how these pillars contribute to the establishment of sustainable partnerships.

Results: From 2010 to 2024, NOF has established partnerships at 4 sites: Cebu, Manila, and Davao, the Philippines; and Ulaanbaatar, Mongolia. Partnerships were established with tertiary or quaternary government hospitals to develop neurosurgical programs tailored to the needs of each site and remained sustained and active. Educational surgical missions were in-person outreach activities conducted annually or biennially and were supplemented with online or remote collaboration. The 5 pillars of sustainable partnerships present at all sites include community engagement, multidisciplinary collaboration, education and training, outcome measurement, and multisource funding. The sixth pillar, bilateral authorship, was present at University of the Philippines-Philippine General Hospital in Manila.

Conclusions: Using the 6 pillars of sustainable global partnerships, neurosurgical partnerships can be developed and maintained by all-volunteer nonprofit organizations such as NOF. Incorporating these pillars during the planning and executing of global neurosurgical partnerships are essential for long-term success.

Objective: Unmet global neurosurgical needs pose a significant challenge, as do unequal opportunities for neurosurgical education and training across the globe. Mission:BRAIN is a nonprofit organization working to provide neurosurgical expertise and resources to both patients and healthcare providers in underserved areas. It operates globally, with local chapters involving primarily medical students. Its presence in Europe has expanded in the last few years with initiatives that contribute to shaping an international approach to global neurosurgery challenges. The authors aim to investigate the impact of student-led organizations, such as Mission:BRAIN, on global neurosurgery, with a focus on low-income countries and low- to middle-income countries, while also assessing the changes observed within the European group during its initial 2 years.

Methods: Quantitative and qualitative analyses were employed to investigate changes in the number of chapters, members, and events. The perceived impact was evaluated using a Likert scale survey administered to European members.

Results: Between 2022 and 2023, the number of European chapters increased by 150% (n = 10) and memberships doubled. Of the 102 survey respondents, 56.9% were female and 42.2% were male. Similarly, the number of events grew by 240%, with a significant increase in educational events (325%, p = 0.007). Participation in events increased by 10.13%, reflecting growing interest and engagement. For most members (72.6%), the activities in the European region have increased global awareness of the importance of neurosurgical care in underserved areas; for 45.1% of them, outreach events have effectively communicated the importance of neurosurgical care to nonmedical audiences. For 67.6% of the members, European chapters have contributed to fostering collaboration and knowledge sharing among medical students and healthcare providers. Furthermore, 59% agreed that Mission:BRAIN initiatives have contributed to addressing disparities in neurosurgical care and education.

Conclusions: Mission:BRAIN's growth in Europe showcases the pivotal role of medical students. The impact of the organization's activities demonstrates the students' potential to contribute to the overarching effort of bridging worldwide gaps in healthcare and education and calls for their active participation and recognition.

Objective: Postoperative rehabilitation is crucial for neurosurgical patients' rehabilitation, but access in low- and middle-income countries (LMICs) is often limited. Telerehabilitation offers a cost-effective, accessible alternative by providing remote therapy through digital platforms. This study compared telerehabilitation with traditional methods in LMICs, focusing on cost-effectiveness, clinical outcomes, and patient satisfaction.

Methods: A systematic review was conducted using PRISMA guidelines, with searches across PubMed, Embase, IEEE Xplore, and Web of Science. Studies were included if they focused on telerehabilitation for neurosurgical patients in LMICs and assessed cost-effectiveness or cost savings, along with clinical outcomes. Data extraction and quality assessments were performed using Covidence, with risk of bias evaluations conducted with the ROBINS-I tool.

Results: The authors' review included 20 studies with 40,537 neurosurgical patients, demonstrating telemedicine's role in patient care, from initial consultations to postoperative follow-ups. Cost analysis revealed specific savings such as $61.80 per patient in India for neurosurgical follow-ups, $888 to $1501 per visit in the US for patients from underserved areas, and $3.8 million in stroke and injury care in France. Patient satisfaction showed an average rate of 97% (95% CI 94%-98%, p = 0.06). Additionally, the combined analysis estimated an 88% probability of achieving a favorable outcome (95% CI 68%-96%, p < 0.01). Intervention efficiency revealed a rate of 97% (95% CI 96%-99%, p < 0.0001).

Conclusions: Telerehabilitation in neurosurgical care for LMICs offers a transformative solution, dramatically reducing healthcare costs, improving access, and maintaining the quality of care. With proven effectiveness across large patient populations, telemedicine bridges critical gaps in neurosurgical treatment, highlighting an urgent global need to scale its implementation. This technology could revolutionize healthcare in resource-limited settings, mitigating the geographic, financial, and infrastructural barriers that have long hindered equitable neurosurgical care worldwide.

Objective: The COVID-19 pandemic posed significant global challenges, particularly in its disruption of surgical education, training, and research. The University of Wisconsin (UW)-Madison Microneurosurgery Laboratory, an internationally recognized training center, had to rapidly adapt to continue its mission amid pandemic restrictions. In this study the authors evaluated their laboratory's response during and after the pandemic, focusing on the challenges encountered, innovative strategies used, and their impact on ongoing operations and global neurosurgery outreach.

Methods: A retrospective review was conducted of the UW-Madison Microneurosurgery Laboratory's operations and global neurosurgery outreach efforts from the onset of the COVID-19 pandemic to the present, focusing on the challenges encountered and the innovations implemented. An online survey was also conducted to gather data on fellows' experiences in the post-COVID-19 era. Descriptive and inferential statistical analyses were used to evaluate the data.

Results: The review revealed that the COVID-19 pandemic significantly impacted the laboratory's operations and global outreach, prompting adaptations to maintain training continuity. From March 2020 to April 2021, strict restrictions limited in-person activities, but innovative solutions such as remote teaching, virtual courses, and distributed training kits helped sustain microsurgical education. After restrictions eased, the authors' laboratory resumed hands-on training and expanded outreach efforts.

Conclusions: The COVID-19 pandemic prompted transformative innovations in surgical training at the UW-Madison Microneurosurgery Laboratory, including the adoption of remote teaching, home training kits, and the Madison Objective Self-Assessment Tool. These adaptations ensured training continuity and expanded global access, particularly in low- and middle-income countries. The lessons learned have shaped a sustainable hybrid training approach that continues to enhance neurosurgical education and address barriers to access.

Objective: Traumatic spinal injuries (TSIs) represent significant global health challenges, particularly in low- and middle-income countries (LMICs). In a cohort of patients with TSI from a major East African center, the authors sought to address long-term outcomes after hospital discharge through the following objectives: 1) describe who was successfully contacted after hospital discharge, 2) report posthospital complications, and 3) assess predictors of successful posthospital contact and posthospital complications.

Methods: An institutional TSI registry of patients treated from 2016 to 2021 was the source of patients and contact methods. Telephone calls were made to the primary telephone number between June 2022 and May 2023, and a subjective neurological assessment was performed using a questionnaire. The study outcomes were successful posthospital contact and postdischarge complications. Predictors of each outcome were assessed through univariable and multivariable logistic regression.

Results: Of the 466 TSI patients treated from 2016 to 2021, 40.6% were successfully contacted at a median follow-up period of 29 months. Their median age was 34 years, and most patients were male (n = 400, 85.8%). Among those contacted, 84.8% experienced postdischarge complications, including muscle spasticity (n = 89, 61.4%), pressure ulcers (n = 52, 35.9%), and death (n = 39, 21.2%). Most patients reported a perceived improvement in their neurological status. Key factors predicting successful contact included undergoing surgery, involvement in road traffic accidents, and more recent hospital admission dates following TSI (2019-2021). Employment postinjury was associated with fewer complications (OR 0.20, 95% CI 0.04-0.76; p = 0.029). American Spinal Injury Association Impairment Scale (AIS) grade A at discharge was associated with a significantly increased mortality risk compared with AIS grades B-E (OR 15.58, 95% CI 5.80-50.46; p < 0.001).

Conclusions: This is one of few studies to report on posthospital follow-up using telephone contact for TSI in an LMIC. Among the contactable patients, there were high rates of morbidity and mortality and low rates of employment, showing the considerable medical, social, and economic impact of TSI in this young population and the need for rehabilitation and support services postdischarge.

Objective: Understanding racial and socioeconomic disparities in mechanical thrombectomy (MT) for acute ischemic stroke (AIS) is crucial to addressing these critical healthcare challenges. The authors aimed to evaluate racial and socioeconomic disparities in MT usage for patients with AIS.

Methods: The authors performed a comprehensive search of four electronic databases for studies assessing racial and socioeconomic disparity in MT utilization among Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, Native American, and Other race groups. Outcomes were measured by calculating proportions and 95% CIs for each study using a random-effects model due to expected clinical and methodological heterogeneity.

Results: A total of 11,583,329 patients from 11 studies were included in this systematic review and meta-analysis. The racial breakdown involved 1,864,453 Asian, 2,260,026 NHB, 2,070,186 Hispanic, 5,239,707 NHW, 23,724 Native American, and 125,233 Other patients. Although MT utilization was highest in NHW (2.55%, 95% CI 1.0%-4.8%) and lowest in Native American (0.87%, 95% CI 0.0%-6.8%) patients, the subgroup analysis showed no statistically significantly difference (p = 0.71). Additionally, there was no significant difference in intravenous tissue-type plasminogen activator (IV-tPA) usage rate (p = 0.14) among the races. The MT utilization rate was significantly different in patients who were in the first (p < 0.00001), second (p < 0.0001), third (p < 0.0001), and fourth (p < 0.00001) income quartiles. Among insurance types, disparity in thrombectomy usage was not significantly different in patients with Medicaid (p = 0.99) and Medicare (p = 0.99), while it was significant in patients with private (p < 0.0001) or self-pay (p < 0.0001) insurance.

Conclusions: Although our findings showed no disparity in thrombectomy and IV-tPA utilization, there is still a significant disparity in accessibility to thrombectomy based on insurance types and income quartiles. This study offers future directions for healthcare providers and state legislators to address racial and socioeconomic disparities.

Objective: This study evaluated the effectiveness of various dural closure and bone reconstruction techniques in preventing CSF leakage following retrosigmoid craniotomy for cerebellopontine angle (CPA) tumors. The goal was to identify whether newer combinations of reconstructive materials offer any advantage in reducing CSF leaks and improving surgical outcomes.

Methods: The authors conducted a retrospective review of 225 patients who underwent a retrosigmoid craniotomy for CPA neoplasms between January 2018 and August 2024. Patient demographics, intraoperative reports, and postoperative complications were analyzed. Various reconstructive methods, including the use of TachoSil, HydroSet, autologous or heterologous dural patches, and bone flap repositioning, were compared. CSF-related complications such as CSF leakage, infections, and postoperative hydrocephalus were systematically evaluated.

Results: CSF leakage occurred in 31% of cases (n = 69), while CSF infections and postoperative hydrocephalus were noted in 6% and 7% of patients, respectively. HydroSet combined with bone flap repositioning significantly reduced CSF leakage (p = 0.008), as did the combination of HydroSet and heterologous dural patches (p = 0.007). TachoSil did not show a significant reduction in CSF leakage. Craniectomy with titanium mesh or heterologous cranioplasty was not associated with any CSF leaks. No other single or combined techniques showed significant associations with CSF leakage.

Conclusions: HydroSet in combination with bone reconstruction and heterologous patches demonstrated superior outcomes in reducing CSF leaks. TachoSil did not significantly affect leakage rates, with less definite results. Refining surgical techniques and selecting appropriate materials for dural and bone reconstruction may help reduce complications and improve patient outcomes in CPA tumor surgeries using the retrosigmoid approach.

Objective: Persistent CSF leakage and symptomatic pseudomeningocele formation are a primary concern following intradural posterior fossa and spinal surgeries, with rates approaching 23.7% and 10%, respectively. These complications occur at a higher rate in cases in which a watertight primary closure cannot be attained. In such cases, various dural substitutes and sealants are at the surgeon's disposal and often require suturing a dural substitute to the existing dura. Herein, the authors describe a novel sutureless inlay-onlay fibrin-coated collagen fleece (TachoSil) "sandwich" closure technique for dural reconstruction and closure.

Methods: The authors retrospectively reviewed posterior fossa and intradural spinal cases performed by the senior author from January 1, 2021, to August 30, 2024, which used the described novel closure technique when primary closure without expansion could not be attained. Primary outcomes were rates of postoperative CSF leakage, symptomatic pseudomeningocele formation, CSF diversion, infection, and revision surgery.

Results: A total of 13 patients (8 craniotomies, 2 craniectomies, and 3 spinal cases) were identified with a mean age of 61.3 ± 14.0 years. Surgical indications included intra-axial and extra-axial tumors, acute cerebellar infarcts, an unruptured aneurysm, and a ruptured arteriovenous malformation. One patient (7.7%) who underwent emergency craniectomy for acute cerebellar infarct developed a postoperative CSF leak and symptomatic pseudomeningocele with suspicion of pseudotumor cerebri, ultimately requiring CSF diversion. There were no complications among patients receiving craniotomy or intradural spinal surgery. No postoperative infections or revision surgeries occurred.

Conclusions: The TachoSil sandwich technique represents an effective means of cranial and spinal dural reconstruction and closure in cases in which watertight primary dural closure cannot be achieved.

Objective: Bifrontal craniotomy often involves the bony opening and mucosal disruption of the frontal sinus (FS), which can lead to cerebrospinal fluid (CSF) leakage and meningitis. These complications are particularly associated with surgical treatments for skull base tumors and anterior cerebral artery aneurysms. The authors initially reported on the basic technique in 2014 with 51 cases. This study presents a detailed description of their technique and postoperative management for sealing the exposed FS during bifrontal craniotomy, including long-term follow-up results and outcomes. To objectively evaluate the effectiveness of suturing FS mucosa in preventing CSF leakage during bilateral frontal craniotomy, the authors focused only on anterior cerebral artery aneurysms. This limitation was necessary as other conditions, like extensive tumors or trauma, might lack intact FS mucosa or require its removal due to infection.

Methods: The records of 34 consecutive patients (median age 62.0 years, mean 60.4 years, range 33-78 years) who underwent bifrontal craniotomy for anterior cerebral artery aneurysms between January 2014 and December 2023 were retrospectively analyzed. All patients had bony opening and mucosal injury of the FS (with exposure to the nasal cavity) that required mucosal suturing. This technique for sealing the exposed FS involves careful dissection of the mucosa from the entire sinus, sterilization with iodine-soaked surgical cotton, and preparation for closure. After the microsurgical procedure is completed, the exposed mucosa is sealed with 6-0 nylon sutures and further secured with fibrin glue-soaked Gelfoam. The bony exposure is covered with an autologous bone flap created from the inner table of the craniotomy bone flap. Finally, the frontal periosteal flap is sutured to the frontal base dura mater. Patients were instructed not to blow their noses for 2 months postoperatively.

Results: Two patients experienced transient non-CSF leakage from the nasal cavity, likely due to irrigation fluid, which resolved within 2 days postoperatively. No recurrence was observed during a mean follow-up period of 52.8 ± 41.7 months (median 49 months, range 3-127 months). No cases of meningitis or other intracranial infections were reported.

Conclusions: The long-term results demonstrate the sustained effectiveness of this technique in preventing postoperative complications related to FS exposure during bifrontal craniotomy.