Neurosurgical focus最新文献

Objective: Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure without an identifiable cause, commonly affecting young obese women. While transverse sinus stenosis (TSS) and empty sella are frequent radiological findings in IIH, the relationship between the severity of empty sella and the extent of TSS remains poorly understood.

Methods: In this retrospective study, authors analyzed patients with IIH diagnosed by established criteria in 2013-2023 and healthy controls matched for age, sex, and BMI. All patients underwent 3T brain MRI with contrast-enhanced T1-weighted sequences and MR venography within 3 months of IIH diagnosis. Volumetric analysis was performed using FreeSurfer software. Pituitary and sella turcica areas were manually segmented on midsagittal T1-weighted images, and the pituitary/sella turcica (PS) ratio was calculated. TSS severity was assessed using the Farb scoring system (0-8, with lower scores indicating greater stenosis). Statistical analysis included linear regression and receiver operating characteristic (ROC) curve analysis.

Results: Patients with IIH (n = 69) demonstrated a significantly lower pituitary volume (48.9 vs 63.3 mm2, p = 0.0023), larger sella turcica area (116 vs 73.1 mm2, p < 0.0001), and reduced PS ratio (0.44 vs 0.86, p < 0.0001) compared to those in healthy controls (n = 15). A significant association was found between a declining PS ratio and increasing TSS severity (R = 0.26, p = 0.03) and normalized total brain volume (R = 0.24, p = 0.044). ROC analysis revealed that the PS ratio had 92.8% sensitivity and 100% specificity in differentiating patients with IIH from healthy controls (area under the curve = 0.981).

Conclusions: The PS ratio correlates significantly with TSS severity and brain volume in patients with IIH, suggesting that both findings reflect CSF and interstitial fluid dyshomeostasis. The PS ratio is highly sensitive and specific for IIH and may serve as a noninvasive imaging biomarker for assessing the severity of venous sinus stenosis and intracranial pressure elevation in IIH, particularly useful in settings where MR venography is unavailable. Further research is needed to explore the causative relationship between venous stenosis and empty sella formation.

Objective: Cerebral encephaloceles are being recognized as an etiology of drug-resistant epilepsy (DRE). Neuroimaging suggests a link between idiopathic intracranial hypertension (IIH), dural sinus stenosis (DSS), and encephaloceles. One hypothesis is that pulsatile CSF forces, secondary to elevated intracranial pressure, contribute to forming prominent arachnoid villi, which create pockets of CSF and develop encephaloceles. The impact of DSS and IIH management with stent placement for seizure control in patients with DRE and encephaloceles remains poorly understood. In this study, the authors explored the clinical outcomes in this patient population.

Methods: This single-center case series retrospectively analyzed seizure frequency in 12 patients with DRE due to encephaloceles associated with IIH who underwent cerebral venous sinus stent placement between 2018 and 2024 at the University of Kansas Medical Center. Seizure burden was assessed after stent placement.

Results: Twelve patients with encephaloceles and DRE met the inclusion criteria. The mean age was 49 years, and 9 patients were female. The mean BMI was 36.7 kg/m2. The mean age of seizure onset was 42.1 years. All patients had signs of IIH on MRI of the brain: empty sella (n = 8), transverse sinus stenosis (n = 12), and enlarged arachnoid granulations (n = 5). Seven patients underwent lumbar puncture with a mean opening pressure of 27.25 cm H2O. All patients had unilateral temporal lobe epilepsy and encephaloceles involving a sphenoid wing. One patient (8.3%) had an additional lesion in the basal temporal lobe, and another patient (8.3%) had bilateral cerebellar encephaloceles. The mean pre-stent venous pressure gradient was 14.25 mm Hg, and the mean post-stent gradient was 1.25 mm Hg; 50% of patients had a post-stent pressure gradient of 0 mm Hg. Following venous sinus stent insertion and additional surgical interventions, the mean seizure frequency decreased to 0.9 seizures per month. Eleven patients (91.7%) experienced > 50% reduction in seizure frequency postprocedure.

Conclusions: The impact of endovascular stent placement for DSS and IIH on seizure burden was investigated. Seizure frequency reduction was observed in all patients. This study demonstrates a prominent role of endovascular stent insertion in patients with encephaloceles and DRE that warrants further exploration.

Objective: The presence of dural venous stenosis in idiopathic intracranial hypertension (IIH) is well recognized. However, the complex interplay between intracranial and extracranial factors contributing to pathological intracranial venous congestion remains poorly understood. In this study, the authors explored venous sinus characteristics in cohorts with elevated central venous pressure (eCVP; ≥ 8 mm Hg) and normal CVP (nCVP; < 8 mm Hg).

Methods: The authors retrospectively reviewed medical records for adult patients who underwent invasive venography with manometry for a suspected or confirmed diagnosis of IIH between January 2017 and December 2024. Venous dimensions and pressure profiles were compared between eCVP and nCVP cohorts.

Results: Ninety-eight patients had recorded CVP measurements. The eCVP group (n = 46) exhibited elevated pressures throughout the venous sinuses compared with the nCVP group (n = 52), but opening pressures (OPs), venous sinus dimensions, and pressure gradients did not differ. Post hoc receiver operating characteristic curve analysis identified an internal jugular vein (IJV) pressure cutoff of ≥ 10.5 mm Hg as predictive of eCVP (sensitivity 65.2%, specificity 88.5%, area under the curve 0.835). Applying this threshold, all 268 patients who underwent cerebral venography with manometry were stratified into having an eCVP or eCVP-like effect (n = 96; IJV ≥ 10.5 mm Hg) versus nCVP-like effect (n = 172; IJV < 10.5 mm Hg) on intracranial venous sinus hemodynamics for a strengthened power analysis. Compared with patients with an nCVP-like effect, patients with an eCVP or eCVP-like effect demonstrated higher lumbar puncture OPs (p = 0.05) and narrower sagittal, transverse, and sigmoid sinuses (all p < 0.05), along with the previously observed elevation of venous pressures throughout the sinuses. Furthermore, scatterplots evaluating the relationship between venous sinus dimensions and pressure gradients, stratified by eCVP and nCVP, revealed delayed onset of pressure gradients with increasing OP, higher pressure gradients, and narrower sinus diameters in patients with eCVP compared with patients with nCVP at similar OPs suggested increased dural venous wall compliance.

Conclusions: The authors demonstrate the variability in venous sinus dimensions and pressure gradient profiles with increasing OP, stratified by eCVP versus nCVP. Although eCVP initially protected against gradient development, it ultimately resulted in higher venous pressures, which hindered CSF resorption to a greater extent than nCVP, thereby increasing OP to a greater extent, which eventually resulted in greater stenosis and a higher gradient before plateauing. Patients with eCVP demonstrated more compliant dural venous sinus walls, which could influence long-term effectiveness of stenting and chances of progressive adjacent venous sinus stenosis.

Objective: Venopathic intracranial hypertension (VIH) is a condition of elevated intracranial pressure (ICP) associated with venous sinus stenosis. Venous sinus stenting (VSS) can reconstitute outflow, yet physiological biomarkers to aid patient selection and assess treatment response remain limited. This study assessed intraoperative transcranial Doppler ultrasonography (TCD) and quantitative angiography as tools for detecting cerebral hemodynamic changes during VSS in patients with VIH.

Methods: The authors retrospectively analyzed 11 consecutive patients with VIH who underwent VSS using intraoperative TCD monitoring and quantitative angiographic assessment. Bilateral middle cerebral arteries (MCAs) were insonated via transtemporal windows to record the mean flow velocity (MFV) and pulsatility index (PI) before and after stent placement. In a subset of 5 patients, time to peak (TTP) contrast opacification was measured in the internal carotid artery (ICA), anterior cerebral artery (ACA), and MCA using standardized injection parameters. One-sample, 1-tailed t-tests compared pre- and postoperative changes against zero to determine significance.

Results: The median patient age was 37 (IQR 29.5-40) years, 90.9% were female, and the median BMI was 33.9 kg/m2. Stenosis was most common in the transverse-sigmoid sinus junction (72.7%). After stenting, MFV increased in all patients (left MCA: mean +6.73 [SD 10.45] cm/sec, p = 0.029; right MCA: mean +7.44 [SD 10.61] cm/sec, p = 0.021). PI decreased in most patients (left MCA: mean -0.058 [SD 0.101], p = 0.053; right MCA: mean -0.071 [SD 0.169], p = 0.109) but without statistical significance. The quantitative angiography analysis demonstrated variable mean TTP changes, with reductions in the ICA (-0.32 seconds, p = 0.178) and ACA (-0.48 seconds, p = 0.197), and a slight change in the MCA (+0.21 seconds, p = 0.666). Limitations of the study included patient-specific physiology and procedural factors, including region-of-interest measurements, bone overlay, and potential interference from TCD probes.

Conclusions: Consistent patterns of MFV increase after VSS, suggesting that TCD may be a robust modality for real-time assessment of arterial inflow hemodynamics in VIH. In contrast, the quantitative angiography analysis revealed heterogeneous arterial transit changes, potentially limited by sensitivity to imaging conditions. These findings support the potential complementary use of TCD and quantitative angiography for physiological monitoring in venous outflow disorders, favoring TCD as the more reliable modality. Both methods are promising, low-risk clinical tools for prospective studies seeking to refine patient selection strategies in VSS.

Objective: Venous sinus stent placement is an increasingly common endovascular technique for treating medically refractory symptoms related to idiopathic intracranial hypertension (IIH). Given that data suggest that a considerable number of patients experience symptom relapse or recurrence, understanding prognosticators of treatment failure is of particular interest.

Methods: The authors performed a single-center retrospective review of the medical records of surgically naive patients with IIH who underwent unilateral transverse sinus stent (TSS) placement. Pre-stent clinical, anatomical, and manometric variables were evaluated against post-stent outcomes to determine significant predictors of unfavorable outcomes after treatment.

Results: Forty-two surgically naive patients with IIH underwent unilateral TSS insertion between April 2011 and February 2024. At a mean follow-up of 41 months, 47.6% had ongoing symptoms, 38.1% received escalated medical therapy, 23.8% underwent stent restenosis, and 23.8% underwent procedural retreatment. Younger age at the time of initial stent insertion was associated with post-stent operative retreatment (OR 1.15, p = 0.04), while lower pre-stent BMI predicted resolution of papilledema (OR 0.84, p = 0.003). Higher pre-stent BMI and lower pre-stent pressure gradients were associated with several unfavorable outcomes.

Conclusions: Modifiable and unmodifiable risk factors may impact TSS durability for IIH. Larger multicenter studies are warranted to stratify risk for futile TSS outcomes and characterize the ideal IIH candidate for therapy.

Objective: Idiopathic intracranial hypertension (IIH) is a complex disorder characterized by chronically elevated intracranial pressure (ICP) resulting in headaches and the threat of vision loss. In patients with refractory symptoms despite standard treatments, invasive ICP monitoring (ICPm) may provide critical physiological insights to guide management. However, data on the clinical utility of ICPm in IIH remain limited. This study aimed to evaluate the clinical utility of ICPm in IIH patients with refractory symptoms.

Methods: The authors performed a retrospective analysis of the medical records of 158 adults with IIH who underwent intraparenchymal ICPm for refractory headaches from 2016 to 2023. ICP data were classified into patterns of normal, high, low, or mixed pressure. Multilevel binomial regression models were used to assess predictors of symptom improvement, adjusting for ICPm indication, final diagnosis, and intervention type. Symptom changes were evaluated at follow-up.

Results: The cohort was predominantly female (89.9%), with a mean age of 38.9 ± 10.9 years. All patients presented with chronic headaches, with 35.4% reporting positional headaches, 54.4% visual disturbances, and 24.7% auditory symptoms. Indications for ICPm included shunt dysregulation (52.5%), suspected CSF leakage (36.1%), and elevated ICP (11.4%). Prior to ICPm, 63.9% of patients had CSF shunts in place. ICPm revealed normal pressure in 55.0%, high pressure in 10.8%, low pressure in 22.2%, and mixed patterns in 12.0% of patients. Based on ICPm findings, 42.4% of patients underwent shunt-related interventions, 6.3% received medical therapy, and 34.2% were referred to relevant clinics. Symptom improvement was observed in 46.2% of patients with headaches and > 70% with visual and auditory symptoms. Multivariable analysis showed that older age (OR 0.69, 95% CI 0.48-1.00; p = 0.05) and non-ICP-directed treatments (symptomatic management and referral, both p < 0.02) were associated with lower odds of headache improvement, while the presence of an empty sella on imaging correlated with higher odds of improvement (OR 2.82, 95% CI 1.07-7.46; p = 0.04). ICPm indications had comparable odds of improvement. Referrals and non-ICP-modifying treatments were associated with lower odds of symptom improvement.

Conclusions: ICPm is a valuable tool in managing IIH patients with refractory symptoms, providing diagnostic clarity, guiding management decisions, and potentially avoiding unnecessary interventions. These findings underscore the heterogeneity of ICP dynamics in IIH and support ICPm as an important adjunct in complex cases.

Objective: Spontaneous CSF leaks are traditionally managed with surgical repair. However, a growing body of evidence suggests that some of these leaks may result from idiopathic intracranial hypertension (IIH) and/or elevated intracranial pressure (ICP) due to underlying venous sinus stenosis-an association that remains underrecognized. Venous sinus stenting (VSS) may address CSF leaks by restoring normal venous outflow and reducing ICP. However, few series have evaluated VSS as a primary or adjunctive treatment for CSF leaks. Herein, the authors present a case series highlighting the role of VSS in both contexts.

Methods: The authors performed a retrospective review of the medical records of all patients with spontaneous CSF leaks treated using VSS at a single center from December 2020 through June 2024. Patients underwent VSS either as primary treatment or following surgical repair. Clinical data, imaging studies, venous pressures, treatment course, and outcomes were analyzed.

Results: Fourteen patients underwent VSS of the transverse-sigmoid sinuses to manage active CSF leaks and/or prevent leak recurrence. All patients had presumed IIH, 5 had papilledema, and 12 had received acetazolamide therapy. Seven patients had undergone prior CSF leak repair surgery. VSS served as the primary treatment in 8 patients, whereas 6 underwent a staged approach, with recent skull base surgeries occurring a median of 71 days prior to stenting (range 41-157 days). The mean superior sagittal sinus pressure was 24 mm Hg (range 18-36 mm Hg), and the mean transstenotic gradient was 10 mm Hg (range 7-16 mm Hg). By the last follow-up (median 1.1 years), 13 patients had attained complete resolution of the CSF leak. Ten of the 12 patients initially taking acetazolamide were weaned off the medication, and all 5 patients with papilledema had leak resolution post-VSS.

Conclusions: VSS may serve as an effective primary or adjunctive treatment for spontaneous CSF leaks in select patients with evidence of intracranial hypertension. Further prospective studies are needed to validate these findings and clarify patient selection.

Objective: The authors previously published their experience with a multidisciplinary care pathway for the treatment of vision-threatening papilledema. Many of the patients in this series underwent optic nerve sheath fenestration (ONSF) using a medial upper eyelid approach to the optic nerve. The purpose of this study was to review the authors' experience with this surgical approach and to determine if it is a safe and effective treatment option for these patients.

Methods: The authors reviewed all patients who underwent ONSF at their institution between 2014 and 2023. All charts were reviewed for any mention of serious intraoperative or postoperative complications for which patients had to undergo a subsequent neurosurgical procedure, either ventriculoperitoneal shunt placement or transverse venous sinus stenting. The authors analyzed visual acuity and visual field mean defect prior to surgery and at the first and most recent postoperative visits.

Results: Fifty-two patients who underwent ONSF at our institution during this time were reviewed. None of these patients experienced serious complications from the surgery. Thirteen patients subsequently underwent ventriculoperitoneal shunting and 3 subsequently underwent transverse venous sinus stenting. Visual acuity did not change significantly from baseline to the first and most recent postoperative visits. Visual field mean defect significantly improved from baseline to the first and most recent postoperative visits.

Conclusions: ONSF via medial upper eyelid crease incision is a safe and effective option as part of a multidisciplinary treatment protocol for the treatment of vision-threatening papilledema.

Objective: Complex intracranial aneurysms characterized by wide necks, calcifications, intraluminal thrombus formation, irregular dome morphology, and involvement of critical branch vessels pose a formidable challenge for neurosurgeons. The "picket fence" clipping technique is an advanced clip reconstruction strategy for complex intracranial aneurysms. The technique involves stacked parallel clips (fenestrated or simple) oriented vertically such that the tip of the blade reconstructs the aneurysm neck. This study reports the largest single-surgeon series using picket fence clip reconstruction for complex intracranial aneurysm treatment.

Methods: A retrospective review of all aneurysms treated with picket fence clipping from 1998 to 2024 identified 41 patients. Demographic data, aneurysm characteristics, operative details, perioperative complications, aneurysm occlusion rates, and clinical outcomes using the modified Rankin Scale (mRS) score were recorded for descriptive analysis.

Results: Of the aneurysms, 80% (33/41) were in the anterior circulation, and 34% (14/41) were ruptured at presentation. The median admission mRS score was 0.5 (IQR 0-3), which remained stable at the most recent follow-up (median 0, IQR 0-3). Aneurysm occlusion was achieved in 88% (36/41) without branch vessel compromise from clipping. Recurrence was noted in 2 aneurysms, necessitating retreatment with bypass for flow augmentation. Good neurological outcomes (mRS score ≤ 2) occurred in 63% (26/41) of patients, whereas permanent neurological morbidity occurred in 9% (4/41). Four patients with complex aneurysms had undergone prior endovascular treatment; 3 patients had undergone prior failed attempts at coiling.

Conclusions: This study reports the largest experience of picket fence aneurysm clipping, demonstrating that the technique is safe and effective for treating complex intracranial aneurysms. The clipping procedure is associated with robust aneurysm neck reconstruction, vessel patency, and favorable clinical outcomes. The technique warrants broader neurosurgical adoption in selective aneurysms unsuitable for conventional clipping.