Neurosurgical focus最新文献

Objective: The aim of this study was to describe a bilateral occipital horn approach for ventricular lavage in treating acute pyogenic ventriculitis (APV) associated with CSF drainage and compare its efficacy with the conventional unilateral frontal horn approach.

Methods: The authors conducted a retrospective comparative study in 85 patients with APV due to CSF drainage treated by intraventricular lavage. Patients were divided into a bilateral occipital horn (bi-occipital) group (n = 41) and a unilateral frontal horn (uni-frontal) group (n = 44) based on the surgical approach used (bilateral occipital horn vs unilateral frontal horn). Primary outcomes included CSF microbiological/cytological normalization, imaging-based clearance of ventricular pus, procedure-related complications, mortality, and 90-day modified Rankin Scale (mRS) score, and these outcomes were compared between cohorts.

Results: The bi-occipital group required shorter external ventricular drainage (EVD) duration (median 22 [interquartile range (IQR) 19-29] vs 29 [IQR 25-34] days, p = 0.008), fewer external ventricular drain revisions (median 5 [IQR 4-7] vs 8 [IQR 6-10] revisions, p < 0.001), and reduced intraventricular antibiotic days (median 10 [IQR 9-12] vs 14 [IQR 11-17] days, p < 0.001). Kaplan-Meier analysis demonstrated that bi-occipital lavage significantly accelerated CSF sterilization, white blood cell normalization, and intraventricular pus clearance. The bi-occipital group showed a markedly lower incidence of complex hydrocephalus (6.7% vs 27.0%, p = 0.031) than the uni-frontal group. The mortality rate in the bi-occipital group was 7.3% (3/41), which was lower than that in the uni-frontal group (15.9%, 7/44), but this difference was not statistically significant (p = 0.219). The bi-occipital group showed a greater improvement in mRS score between day 30 and day 90 (mean ΔmRS score -0.61 [SD 0.64]) compared to the uni-frontal group (mean ΔmRS score -0.25 [SD 0.44]), with a statistically significant between-group difference (p = 0.004). On day 90, the bi-occipital group demonstrated a significantly lower proportion of patients with poor outcomes than the uni-frontal group (17.1% vs 38.6%, p = 0.032).

Conclusions: The bilateral occipital horn lavage technique demonstrated superior clinical efficacy to unilateral frontal horn lavage in APV management, as evidenced by accelerated infection control and improved neurological recovery. This technically feasible approach provided an effective alternative in resource-limited settings.

Objective: Intraventricular and subarachnoid neurocysticercosis (IVSN) represents a severe extraparenchymal manifestation of Taenia solium infection, frequently leading to obstructive hydrocephalus and increased intracranial pressure. Despite advances in medical therapy, standardized protocols for endoscopic management remain lacking. The authors aimed to establish a comprehensive diagnostic and surgical workflow for IVSN and evaluate the clinical outcomes of neuroendoscopic management in a large single-center cohort.

Methods: The medical records of 51 patients (mean age 43.4 years, 68.6% male) with IVSN treated via endoscopic surgery from 2009 to 2025 were retrospectively reviewed. Preoperative diagnostics included high-resolution T2-weighted 3D SPACE MRI and lateral view radiographic imaging of the lower legs to enhance the detection of cysts. Endoscopic procedures involved cyst excision, endoscopic third ventriculostomy, and septostomy. Postoperative management included corticosteroids, albendazole, and antiepileptics. Outcomes were assessed via radiological follow-up and clinical monitoring over a mean period of 98.3 months.

Results: Complete cyst removal was achieved in 88.2% of patients. Three-dimensional SPACE (sampling perfection with application-optimized contrast using different flip angle evolutions) MRI enabled clear visualization of cyst membranes in all cases, outperforming conventional sequences. Intramuscular calcifications were detected in 94.1% of patients via lateral leg radiographic imaging. The recurrence rate was 2.0%, and only 9.8% of patients required ventriculoperitoneal shunt placement. Postoperative complications were minimal, with intracranial infections in 2 cases (3.9%), both of which were successfully managed. No neurological deficits were observed following surgery.

Conclusions: Neuroendoscopic surgery offers a safe and effective treatment for IVSN when combined with advanced imaging and structured medical therapy. The integration of 3D SPACE MRI and standardized endoscopic protocols facilitates accurate diagnosis, complete cyst removal, and long-term disease control with low complication and recurrence rates.

Objective: Meningitis involves high mortality and morbidity, particularly when associated with elevated intracranial pressure (ICP). Lumbar and external ventricular drainage (LD/EVD) have been used as adjuncts to standard antimicrobial therapy in severe meningitis; however, there is no established standard of care for incorporating these into existing treatment paradigms. This study aimed to synthesize the existing literature and provide treatment recommendations regarding CSF diversion in meningitis, emphasizing the use of divertive treatment even in the absence of hydrocephalus.

Methods: The PubMed database was systematically reviewed according to the PRISMA guidelines and included all studies describing LD and/or EVD in meningitis.

Results: Forty-one studies on the use of LD and/or EVD in meningitis were identified, involving 715 total patients. Twenty-five (61%) of 41 studies used LD, and 24 (59%) used EVD. Study designs included a nonrandomized controlled trial (n = 1), a cohort study (n = 1), case-control studies (n = 3), case series (n = 3), and individual case reports (n = 33). There were 16 reports of fungal meningitis (39%), 11 (27%) bacterial, and 6 (15%) tuberculous. Nine reports (22%) described comorbid HIV infection. Of the 6 studies including a control group, 4 (67%) reported favorable results associated with CSF diversion. Seven (16%) of 45 patients described in case reports or case series died despite CSF diversion (5 with EVD, 2 with LD), and 17 (38%) required permanent shunt placement (9 ventriculoperitoneal shunts, 8 lumboperitoneal shunts).

Conclusions: The studies reviewed in this paper suggested CSF diversion may lead to more favorable outcomes in certain cases, particularly fungal, bacterial, and tuberculous meningitis compared to conservative treatment alone, even in the absence of radiological evidence of hydrocephalus. These more favorable outcomes may be related to improved infectious source clearance or opportunity for intrathecal drug delivery in addition to sustained ICP reduction. The authors recommend that, while it may be appropriate to initially offer a less invasive approach to CSF diversion in the form of a lumbar drain, they believe it is appropriate to escalate care to more aggressive treatment via an external ventricular drain in patients who do not respond to LD, and as initial treatment in higher risk patients with a need for continuous ICP monitoring or signs of hydrocephalus. Nevertheless, studies were heterogeneous and prone to selection bias, underscoring the need for future well-designed interventional studies in homogeneous patient populations.

Objective: In complex cranial wound closures, plastic and reconstructive surgeons provide advanced techniques to improve healing and reduce complications, including infection. Although this multidisciplinary approach shows promise, data supporting its routine use remain limited. The authors performed an evaluation of neurosurgical patients requiring plastic and reconstructive surgical interventions for complex scalp wounds to assess the reconstructive techniques used and associated outcomes.

Methods: A retrospective analysis was conducted on patients jointly treated by neurosurgery and plastic and reconstructive surgery at the University Hospital Zurich in the period from 2016 to 2023. Patients aged 16 years or older with informed consent were eligible for inclusion. Collected data encompassed demographics, primary diagnoses, wound healing risk factors, procedural details, and outcomes.

Results: Thirty-seven patients with a mean age 60.8 years were included in the study; 56.8% were female. Most cases were oncological (73.0%), and among this group, 51.3% had received prior radiotherapy. Overall, patients had a mean of 3.8 previous cranial surgeries. Preexisting wound healing impairment or infection was present in 64.9% of patients. A total of 47 procedures involved plastic and reconstructive surgeons, whose involvement was secondary (after failed primary closure) in 85.1% of cases. Free flaps (46.8%) and local flaps (38.3%) were the most common reconstructions. Postoperative local scalp wound complications occurred in 34.0% of cases (16/47), and 25.5% (12/47) required rehospitalization for revision surgery. No free flap failures occurred. The mean operating time was 266.5 minutes, and the mean hospital stay was 12.4 days.

Conclusions: Patients with complex scalp defects, especially after multiple surgeries or radiotherapy, remain at high risk for wound complications and infection despite advanced reconstruction. Early plastic and reconstructive surgeon involvement and interdisciplinary planning may be helpful in reducing infection risk and improving outcomes. Proactive identification of high-risk cases for plastic surgery consultation is recommended to enhance wound closure and prevent cranial wound infections. Prospective studies are needed to confirm these strategies.

Objective: Intracranial empyemas (IEs) are rare but severe complications of ear, nose, and throat (ENT) infections, defined as purulent collections in the normally virtual meningeal spaces. IEs can be classified as sinogenic (S-IE) or otogenic (O-IE), according to the initial infection. These life-threatening complications can entail long-term neurological disabilities. Few studies have described their characteristics, and cohorts are usually small and heterogeneous. In the Greater Paris area, all cases of pediatric IE are referred to the authors' center. The aim of this study was to describe the characteristics of IE and their treatment and risk factors for repeated surgery and neurological disabilities.

Methods: This single-center, retrospective observational cohort study included all consecutive cases of IE admitted to the authors' institution between January 2016 and January 2025.

Results: A total of 248 patients with IE were included: 115 with S-IE and 133 with O-IE. The mean age was 6.9 ± 5.2 years. An increase in the incidence of IEs was observed over the final years of the study. Two clinical presentations were distinguished. O-IEs were observed in younger children (mean 40 ± 37 months vs 133 ± 44 months for S-IE). O-IEs were almost exclusively extradural (96%), whereas around half of S-IEs had subdural involvement (51%). S-IEs were associated with more neurological symptoms. All patients underwent surgery. Overall, 95% of patients with O-IEs and 85% of those with S-IEs underwent ENT surgery. Neurosurgery was necessary for 7% (9/133) of O-IEs and 60% (69/115) of S-IEs. Bacteriological samples were obtained, and identification was achieved in 86% (culture or polymerase chain reaction techniques). For O-IE, Fusobacterium necrophorum (47%) was the most frequent, whereas in S-IE cases, the Streptococcus milleri group (52%) was predominant. Cerebral venous thrombosis (CVT) was the most frequent complication, in 55% of O-IE cases and 21% of S-IE cases (p < 0.0001). There were no deaths in this cohort. Neurological disabilities were observed in 17% of patients, with a higher rate for those with S-IEs (27%) than those with O-IEs (8%) (p < 0.0001). Subdural empyema and parietal and interhemispheric locations were identified risk factors for neurological sequelae. Repeat surgery was necessary for 30% of patients with S-IEs and 11% of patients with O-IEs (p < 0.0001). The observed risk factors were residual IE at control MRI and the association of CVT.

Conclusions: This study describes the largest pediatric IE cohort to date. An increase in incidence has been observed since 2021. The favorable results of this cohort suggest that the authors' multidisciplinary standardized treatment protocol provides successful treatment to most patients with IE.

Objective: The authors aimed to determine whether the size of a brain abscess on presentation was related to the number of surgical interventions required to manage it adequately.

Methods: Adult and pediatric patients admitted with a brain abscess who underwent surgical intervention between April 2013 and April 2023 at a single neurosurgical unit in the United Kingdom were included. Ordinal logistic regression analysis was conducted to assess whether the size of brain abscess on admission, age, or symptom duration correlated with the number of surgical interventions ultimately required. Furthermore, a Kruskal-Wallis test was conducted to examine the effect of the number of pathogens isolated and the number of predisposing risk factors on the number of surgical interventions required.

Results: Fifty-four patients with a median age of 59 (range 2-85) years were identified; 55% of patients were male. A total of 38 patients underwent 1 procedure, 13 of whom underwent craniotomy and the remainder, burr hole aspiration. Of those who required more than 1 procedure, 10 required 2 aspirations, 3 needed craniotomy following aspiration, 1 patient underwent 3 aspirations, 1 patient needed 2 craniotomies, and another patient required craniotomy followed by 2 aspirations. Abscess size was associated with the number of surgical interventions required (β = 3.056, SE = 1.124, Wald = 7.394; p = 0.007). Other risk factors assessed were not significantly associated with the number of surgical interventions required.

Conclusions: Brain abscess size on presentation is associated with the number of surgical interventions ultimately required for treatment. This observation may serve to counsel patients regarding prognosis and guide management.

Objective: Brain abscesses are severe infections with high morbidity and mortality. Surgical drainage is essential, but the optimal technique remains unclear. The aim of this multicenter study was to compare navigated/stereotactic aspiration and microsurgical resection in terms of reoperation rates, clinical outcomes, and surgery-related complications in patients with primary pyogenic brain abscess.

Methods: A multicentric retrospective analysis was conducted across 5 university centers in Germany and Austria, and included patients who underwent surgery for primary pyogenic brain abscesses from January 2008 to December 2023. Exclusion criteria were previous head surgery or trauma, lack of preoperative MRI, multiple abscesses, concomitant subdural empyema, and infratentorial or deep-seated abscesses (> 2 cm from the cortical surface). The primary endpoint was reoperation for the abscess, while secondary endpoints included unfavorable clinical outcomes (modified Rankin Scale [mRS] score ≥ 3) at discharge, 3 months, and 6 months after surgery and surgery-related complications.

Results: Of 148 patients (102 male, mean age 49.1 years) included in the analysis, 82 (55.4%) underwent microsurgical resection and 66 (44.6%) underwent aspiration. Reoperations were significantly more frequent in the aspiration group (39.4%) than in the resection group (20.7%) (p = 0.018). Surgical complication rates did not differ significantly. A significant improvement in clinical status (median mRS score of 1) was observed in both the aspiration and resection groups (p < 0.001 each) after surgery, with 26 patients (17.6%) still having an mRS score ≥ 3 at discharge. In the aspiration group, no further improvement was noted between hospital discharge and the 3-month follow-up (p = 0.34), but significant improvement occurred between the 3- and 6-month follow-up evaluations (p = 0.02). In contrast, patients in the resection group showed significant improvement between discharge and the 3-month follow-up (p < 0.001), with no additional improvement observed between 3 and 6 months (p = 0.49). Five in-hospital deaths occurred, all in the aspiration group, resulting in an overall mortality of 3.4% (p = 0.005).

Conclusions: Aspiration was linked to an increased reoperation rate and higher in-hospital mortality, although surgical complication rates were similar. Patients in both groups had comparable favorable outcomes at discharge and at 3- and 6-month follow-up evaluations. Patients who underwent open resection showed faster early recovery.

Objective: Pituitary abscess (PA) is a rare but life-threatening condition, accounting for < 1% of pituitary lesions. At a single center, 140 endoscopic transsphenoidal surgeries for pituitary lesion resection were performed since 2018, with 13 patients diagnosed with PA at an unusually high incidence rate of 9.2%. The aim of this study was to characterize the diagnostic criteria, symptoms, microbiological profile, radiological features, and endocrinological characteristics of PA, while exploring potential reasons for the increased frequency of PA in the post-COVID-19 era.

Methods: A single-center retrospective review of patients with primary and secondary PA from 2018 to 2024 was conducted. Diagnosis was confirmed through intraoperative pus detection or laboratory confirmation. A univariate analysis was performed to assess factors associated with postoperative hormonal disorders and the accuracy of MRI-based preoperative diagnosis. Univariate ANOVA was used for quantitative variables, and categorical variables were analyzed using the chi-square and Fisher's exact tests.

Results: Of 13 patients (9 female, mean age 56.5 years) included in the analysis, risk factors were present in 30.8%. The most common symptoms at presentation were visual disturbance (69%), headache (53%), and pituitary insufficiency (38%). A correct preoperative diagnosis was made via MRI, based on characteristically high signal intensity on T1-weighted images, for 69% of patients. No infectious symptoms were observed. A bacterial agent was identified in 84.6% of patients, with gram-positive bacteria more common. Treatment included pus evacuation and postoperative antibiotics. Headaches resolved for all patients and visual deficits improved in 7 of 9 patients, but endocrine abnormalities persisted or newly developed in some cases. One patient (7.7%) experienced recurrence, and no deaths were recorded. The study period was from 2018 to 2024, with a substantial increase in the frequency of PA after 2020 (post-COVID-19 era).

Conclusions: MRI features of PA can mimic other pituitary pathologies. Pus evacuation remains the primary treatment. Preoperative antibiotics might be unnecessary in stable patients without signs of infection. The incidence of PA could be higher in the post-COVID-19 era, possibly due to immune system changes and healthcare disruptions.

Objective: Multiloculated brain abscesses represent a clinical challenge due to their complex morphology and management. This study aimed to analyze the clinical features, microbiological data, radiological findings, surgical interventions, complications, and outcomes in patients diagnosed with multiloculated abscesses.

Methods: The authors conducted a retrospective review of 120 patients diagnosed with multiloculated brain abscesses. Demographic data, clinical presentation, microbiological profile, radiological findings, surgical details, and outcomes were recorded. Statistical analysis included univariate analysis for unfavorable outcomes, with regression analysis performed to identify independent predictive factors.

Results: The mean age of the cohort was 33.8 ± 19.3 years, with a male predominance (74.2%). The most common causes of abscesses were otogenic (25%), and 84.2% were supratentorial in location. Streptococcus ssp. were the most commonly isolated organisms (19.2%), although no organism could be isolated in 56.7% of samples. Surgical management included burr hole aspiration in 22.5% of patients and craniotomy and excision in 77.5%. The mortality rate of the cohort was 10%, and an unfavorable outcome at last follow-up was observed in 21.7% of patients. Univariate analysis revealed that Glasgow Coma Scale (GCS) score (p = 0.029), hydrocephalus (OR 4.88, p = 0.01), isolated organism on culture (OR 4.00, p = 0.011), and fungal abscess (OR 5.52, p = 0.021) were significant predictors of unfavorable outcomes. Regression analysis confirmed GCS score (OR 1.74, p = 0.035) and presence of hydrocephalus (OR 12.28, p = 0.003) as independent predictive factors for unfavorable outcomes. Craniotomy and excision of the abscess was protective against recurrence (OR 0.08, p < 0.005).

Conclusions: A low GCS score at presentation and hydrocephalus requiring external ventricular drainage have a significant association with poor outcomes for patients with multiloculated abscesses. Burr hole aspiration is associated with increased recurrence rates and requires reoperation. Further studies are needed to refine the surgical strategies and improve patient outcomes.