Neurosurgical focus最新文献

Objective: Cerebral infection syndromes are life-threatening diseases with high mortality and morbidity rates worldwide. They are often associated with refractory elevated intracranial pressure (ICP). The role and clinical outcomes of decompressive craniectomy (DC) in patients with intracranial infections are still a controversial topic. The authors aimed to provide the largest known retrospective analysis on the effect of DC in intracranial infections.

Methods: A retrospective cohort study was designed based on patients who underwent DC between 2010 and 2024 at the Department of Neurosurgery and Neurointervention, Semmelweis University. Seventeen cases were selected in which the indication for surgery was elevated ICP due to cerebral infection (encephalitis, meningitis, meningoencephalitis, subdural empyema, or brain abscess). Patient demographics, preoperative clinical status, timing of surgery, imaging findings, and microbiological results were analyzed. Functional outcome was assessed using the Glasgow Outcome Scale (GOS) at discharge and the 6-month follow-up.

Results: Seventeen patients (9 pediatric, 8 adults; mean age 25.9 years) were included. Subdural empyema (41.2%) and viral encephalitis (35.3%) were the most common diagnoses. A preoperative Glasgow Coma Scale score ≤ 8 was seen in 82.4%, and midline shift was detected in all cases (mean 7.49 mm). ICP monitoring was performed in 35.3% of patients, with a mean preoperative ICP of 28.3 mm Hg. DC was unilateral in 47.1% and bilateral in 52.9%. At discharge, the median GOS score was 2; at the 6-month follow-up, the median GOS score improved to 5. Excellent long-term outcome (GOS score of 5) was achieved in 41.2%, and the inpatient mortality rate was 5.9%. Cranioplasty was completed in 47.1%, and residual epilepsy occurred in 29.4%. ICP monitoring and the absence of pupillary asymmetry were associated with better outcomes.

Conclusions: DC may offer substantial survival and functional benefits in patients with cerebral infections and medically refractory elevated ICP. Invasive ICP monitoring and early surgical intervention may improve functional outcome. This study presents the largest known retrospective analysis of DC in infectious intracranial pathologies and underscores the need for larger prospective studies to establish clinical guidelines.

Objective: Microbiological analysis might not be able to identify the causative pathogen in one-third of brain abscess patients. Proteomics analysis of brain abscesses can aid in microbiological diagnosis. This could help tailor the antimicrobial therapy, give possible insights into the source of the abscess, and aid in developing targeted antimicrobial agents.

Methods: This was a single-center prospective study including patients with brain abscess recruited over a 1-year period. Proteome-based analysis was used to identify the causative pathogen, and the results were compared using conventional microbiological analysis. The involved host proteins were identified and correlated with the abscess volume.

Results: Thirty-four patients with brain abscesses were included. The mean volume of the abscess was 30.4 cm3. A pus sample was obtained by craniotomy excision (67.6% of cases), burr hole aspiration (17.6% of cases), or twist-drill craniostomy aspiration (14.7% of cases). Proteomics analysis was successful in 19 (55.9%) samples. The remaining samples were rejected during preprocessing due to technical/sampling issues. In total, 7331 proteins were identified from 19 samples, with a mean of 385 proteins (range 291-615 proteins) per sample. All patients except one were found to have polymicrobial infection based on proteomics analysis, with a median of 4 microorganisms per sample. The causative pathogen could be identified by microbiological analysis in 25 of 34 (73.5%) patients and in 15 of 19 (78.9%) patients with successful proteomics analysis. Staphylococcus aureus, Acinetobacter baumannii, and Escherichia coli were the most common microorganisms on proteomics analysis, whereas Streptococcus intermedius, Streptococcus constellatus, and S. aureus were the most common microorganisms on microbiological analysis. Microorganisms identified by microbiological analysis matched one of the results from proteomics analysis in 66.7% of patients. Of the inflammatory proteins identified, ferritin heavy chain, neutrophil collagenase isoform XI, proteasome subunit beta type-1, ferritin light chain isoform XI, proteasome subunit alpha type-6 isoform a, resistin precursor, and neutrophil defensin 1 isoform XI showed a positive correlation with abscess volume, whereas complement C3 preproprotein, serotransferrin isoform 1, and histone H2B type 1-D protein showed a negative correlation.

Conclusions: Proteomics analysis suggests that most brain abscesses contain polymicrobial colonization, which underscores the importance of broad-spectrum antibiotics in their treatment. It can aid in diagnosis when conventional tests fail to isolate the pathogen and can provide deeper insights into microorganism-host interactions.

Objective: Growing evidence suggests that dressings containing chlorhexidine-gluconate (CHX) have the potential to lower the incidence of external ventricular drain (EVD)-associated infections (EVDAIs). A previous prospective randomized trial (NCT02078830) detected significant reductions in bacterial cutaneous and catheter colonization. However, the study was underpowered to demonstrate significant clinical efficacy. The present study aimed to report infection rates within the same institution before and after the abovementioned randomized controlled trial (RCT) with consecutive introduction of CHX-containing dressings for silver-coated EVDs as the standard of care after the trial had been completed.

Methods: This study was a retrospective (2009-2013) and prospective (2014-2018) analysis of patients who underwent silver-coated EVD insertion. The control group consisted of patients treated from January 2009 to February 2016, when the CHX dressings were not in use. The study group consisted of patients treated between October 2013 and December 2018, including the RCT period when CHX dressings were introduced. The primary endpoint was the diagnosis of EVDAI. Comparisons were made by modeling the outcome with multivariable logistic regression analysis. Regression coefficients estimates (RCE) and inverse probability weighting (IPW) were implemented to adjust for confounding. Statistical significance was set at p ≤ 0.05.

Results: In total, 258 of 362 (72%) patients with overall 2373 cumulative EVD days were eligible for analysis, of whom 152 (59%) received a CHX dressing. Overall EVDAI rates (20/106 [19%] vs 12/152 [8%]), the prevalence per 100 persons (19 vs 8), and the incidence per year (2.64 vs 1.50), as well as per 10 person-days (0.20 vs 0.09), were halved after the introduction of CHX dressings, resulting in an unadjusted absolute risk reduction of 11% and a number needed to treat of 9. Fewer permanent cerebrospinal fluid diversion procedures due to postinfectious hydrocephalus were necessary (7/106 [7%] vs 6/152 [4%]). The adjusted RCE and IPW analysis confirmed the potential of CHX dressings to reduce the odds of EVDAIs with OR 0.415 (95% CI 0.186-0.927) and OR 0.429 (95% CI 0.264-0.533), respectively.

Conclusions: The occurrence of EVDAIs was significantly reduced when using additional CHX dressings (8%), compared to silver-coated EVDs alone (19%), without extending antibiotic prophylaxis or using antibiotic-impregnated catheters as a valid alternative in terms of antibiotic stewardship. This finding should encourage the neurosurgical community to generate more awareness in using and evaluating postoperative measures that prevent this impactful complication in further research.

Objective: Middle meningeal artery embolization (MMAE) has emerged as an alternative to surgical treatment of nonacute subdural hematoma (NASDH). When used in conjunction with surgery, it has been shown to reduce recurrence, but its effectiveness as a standalone therapy remains to be established. The aim of this study was to investigate the comparative effectiveness of standalone MMAE (sMMAE) versus surgical evacuation in patients with NASDH.

Methods: This retrospective propensity score-matched cohort study included consecutive patients with NASDH who underwent either sMMAE or surgical evacuation at a single institution from January 2017 to June 2024. The primary outcome was reintervention due to hematoma recurrence. Secondary outcomes included the hospital length of stay (LOS), new neurological deficits, and cardiorespiratory, neurological, and other medical adverse events.

Results: Overall, 265 patients (median age 73 years) with NASDH were included. After matching, the sMMAE and surgical evacuation groups each included 85 patients. There was no baseline difference in clinical characteristics at presentation. During a median follow-up of 72 days in the sMMAE group and 59 days in the surgical group, the incidence rate of reintervention did not differ between the two treatments (incidence rate ratio [IRR] 1.38, p = 0.41). The median hospital LOS was shorter in the sMMAE group compared with the surgical evacuation group (4 days vs 6 days, p = 0.003). No differences were observed between groups in terms of new neurological deficits at 30 days (RR 0.85, p = 0.717) or the risk of cardiorespiratory (RR 0.50, p = 0.327) or neurological (RR 0.66, p = 0.657) adverse events. Patients treated with sMMAE had a lower risk of other medical adverse events compared with those treated with surgery (1.1% vs 15.2%; RR 0.07, p = 0.013).

Conclusions: Patients who underwent sMMAE had shorter hospital stays and a lower risk of medical adverse events, without increased risk of recurrence, compared with patients who underwent open surgical treatment. Larger studies are warranted to establish the effectiveness of sMMAE in the management of NASDH.

Objective: Antithrombotic (AT) therapy is frequently prescribed to patients for stroke prevention, atrial fibrillation, or other purposes, but it is a potential risk factor for chronic subdural hematoma (cSDH) development and growth. Premorbid AT use is common among patients who present with cSDH requiring treatment. The authors assessed the prevalence of AT use outside established clinical guidelines among patients who underwent cSDH treatment at three academic hospitals.

Methods: This was a multicenter retrospective review of patients with cSDH who underwent surgical intervention and/or middle meningeal artery embolization (MMAE) between 2019 and 2024. Demographic data, presenting clinical and radiographic findings, and AT indications and types were extracted. Appropriateness of AT use was assessed according to clinical guidelines.

Results: The cohort comprised 148 patients (77% male; mean age 74.96 ± 10.37 years) who underwent evacuation surgery alone (66.9%), MMAE (18.9%), or surgery with MMAE (14.2%). At presentation, the mean maximum hematoma thickness was 18.83 ± 6.5 mm, and 87.8% of patients had a midline shift. The most common indications for AT use were atrial fibrillation (27.0%) and coronary artery disease (24.3%). Antiplatelet monotherapy had been prescribed premorbidly to 58.1% of patients, anticoagulation monotherapy to 28.4%, and both to 13.5%. AT agents included aspirin (47.3%), direct oral anticoagulants (20.9%), warfarin (18.9%), dual antiplatelet therapy (18.2%), clopidogrel (7.4%), and therapeutic low-molecular-weight heparin (3.4%). Per clinical guidelines, 31.1% of patients were found to be inappropriately on AT therapy. Specific AT agents were not found to be associated with inappropriate AT consumption. Multivariable analysis identified cardiac stents (OR 3.95, 95% CI 1.05-14.88; p = 0.042) and primary and secondary stroke prevention (OR 10.59, 95% CI 3.20-35.09; p = 0.001) as indications associated with inappropriate AT use. Conversely, atrial fibrillation was associated with a lower likelihood of inappropriate AT use (OR 0.17, 95% CI 0.03-0.85; p = 0.031).

Conclusions: In this study, nearly one-third of patients requiring treatment for cSDH were found to be inappropriately using AT medications, with primary and secondary stroke prevention and cardiac stents identified as independent predictors of such use. Greater vigilance among care teams is essential to address the burden of inappropriate AT use and potentially prevent the development of cSDH.

Objective: Chronic subdural hematoma (cSDH) is one of the most common diseases treated by neurosurgeons. While surgical evacuation has been the traditional way to address symptomatic lesions, there is expanding evidence of the beneficial use of middle meningeal artery (MMA) embolization as a treatment or as an adjunct for cSDH. With the current strain on healthcare resources, physicians must balance providing the best care for patients and making cost-conscious decisions. Therefore, the aim of this study was to compare the cost of surgery alone versus surgery plus MMA embolization for treatment of cSDH, and to calculate an institutional tipping point for cost benefit.

Methods: This is a retrospective study of patients with symptomatic cSDH requiring surgical intervention at a single institution from May 2019 to December 2022. The patients were concurrently enrolled in a prospective randomized controlled trial. To compare the cost of surgical treatment alone versus surgical treatment plus MMA embolization, all charges related to cSDH treatment from admission to the last follow-up were categorized (procedure, radiology, pharmacy, intensive care unit bed, laboratory, floor bed, and other) and assessed. The institutional tipping point (point at which it becomes financially beneficial to add MMA embolization to surgical evacuation during the same admission) was calculated to help guide decision-making.

Results: Forty-one patients (28 male, mean age 67.9 years) were included in the analysis, and were previously randomized to surgical intervention only (n = 21) or surgical intervention plus MMA embolization (n = 20). The groups were comparable in terms of demographic and cSDH characteristics. The overall mean cost for the index admission was lower in the surgery only group (US$158,320 vs $235,263; p = 0.037). This was also true for all categories of charges. Throughout the duration of the study there were 27 admissions in the surgery only group and 20 admissions in the surgery plus MMA embolization group (p = 0.0052). When analyzing costs per patient instead of per admission, no differences were observed between treatment groups for any of the categories. Likewise, the overall mean costs related to the care of patients in either treatment group showed no statistical difference ($203,554 vs $235,263; p = 0.25). Consequently, the institutional tipping point for the addition of MMA embolization was 20.8%.

Conclusions: MMA embolization can be considered as an adjunct to surgery in the treatment of symptomatic cSDH, decreasing the overall cost by lowering rates of readmission and repeat intervention. The tipping point formula used in this study is versatile and adaptable. It can be a useful guide to determine appropriate treatment options for patients with symptomatic cSDH according to institutional or national standards.

Objective: Chronic subdural hematoma (cSDH) is a frequently treated entity for neurosurgeons worldwide. Because this pathology is common in older patients and those with multiple comorbidities, the demographic shift increases pressure on healthcare systems, which already face major economic challenges. Various surgical procedures are used, although the high recurrence rate leads to the even greater importance of standardizing the medical approach. Therefore, the aim of this study was to compare bedside cSDH evacuation using hollow screws (HSs) under local anesthesia with evacuation using enlarged burr holes (BHs) under general anesthesia.

Methods: This prospective randomized study, conducted at a single center from September 2015 to August 2020, included patients with space-occupying (hematoma thicker than the skull) and/or symptomatic cSDH who underwent surgical treatment. During the study period, 140 patients were enrolled and 9 patients were excluded.

Results: A total of 131 patients (mean age 77 years) were included in the analysis. HS trephination demonstrated comparable recurrence rates to that of BH trephination (BH 31.2% vs HS 47.8%, p = 0.06) and equivalent clinical outcomes (p > 0.05). Yet, HS placement was a less invasive surgical approach associated with a significantly shorter operation duration (p < 0.05) and shorter hospital stay (median BH 4.3 days vs HS 3.0 days, p = 0.003).

Conclusions: In treating cSDH, HS trephination should be considered a reasonable alternative to BH trepanation, especially with the demographic changes occurring in modern society and the associated requirements for healthcare systems.

Objective: Chronic subdural hematoma (CSDH) is a common neurosurgical pathology, especially among older patients, with increasing incidence due to aging populations and widespread antithrombotic use. Despite the relatively straightforward nature of its surgical treatment, recurrence remains a major concern, with rates up to 30% reported. Among the factors implicated in recurrence, postoperative pneumocephalus has emerged as a significant and potentially modifiable risk factor. This study aimed to compare the efficacy and safety of a burr hole craniostomy with a closed drainage system (CDS) versus the traditional burr hole with standard irrigation (SI), with a focus on recurrence, pneumocephalus, and patient recovery.

Methods: This retrospective, single-center cohort study included 460 patients undergoing surgical evacuation of symptomatic CSDH between 2010 and 2024. Patients were divided into two groups based on surgical technique: CDS (n = 358) and SI (n = 102). Demographics, clinical status, radiological features, and surgical outcomes were analyzed. Univariate and multivariate logistic regression analyses were utilized to assess predictors of 30-day recurrence. Volumetric analysis of hematomas and pneumocephalus was performed using standardized imaging protocols.

Results: Baseline characteristics were well balanced. Postoperative pneumocephalus was significantly reduced in the CDS group (3.0 ± 1.78 cm3) compared with SI (49.3 ± 11.97 cm3) (p < 0.0001). Recurrence rates were markedly lower in the CDS group (10.1% vs 27.5%, p < 0.001), with CDS also associated with a mean shorter hospital stay (6.8 vs 11.2 days, p < 0.001), faster hematoma reabsorption (2.1 vs 3.2 months, p < 0.001), and lower 30-day mortality (1.1% vs 4.9%, p = 0.042). Multivariate analysis identified postoperative pneumocephalus volume (OR 1.0293 per cm3, p < 0.001) and residual hematoma (OR 1.00 per cm3, p = 0.046) as the only independent predictors of recurrence, while undergoing SI as opposed to the CDS was associated with a significantly increased risk of recurrence (OR 6.63, 95% CI 1.08-40.74; p = 0.041). No significant association was found between recurrence and antithrombotic therapy.

Conclusions: The CDS technique offers a cost-effective, safe, and efficient approach for the treatment of CSDH. By limiting air entry and promoting controlled drainage, it significantly reduces recurrence and improves patient outcomes. Given its simplicity and low resource requirements, the CDS method should be considered as a preferred first-line surgical strategy, particularly in the context of value-based care for an aging population.

Objective: The aim of this study was to compare outcomes in cancer patients treated with middle meningeal artery embolization (MMAE) versus surgical treatment for chronic subdural hematomas (cSDHs), with outcome measures of requirement of rescue treatment and time to resumption of previously held systemic cancer therapy.

Methods: A retrospective cohort study was conducted that included a review of medical records of cancer patients with cSDH treated with MMAE or surgical drainage. Patients without adequate follow-up including radiological follow-up and patients who underwent dual therapy (i.e., MMAE plus surgery) were excluded. The primary outcome was the requirement for rescue treatment within 180 days, defined as surgical reintervention or repeat embolization due to hematoma progression or symptom recurrence. Secondary outcomes included the time to resumption of previously held systemic cancer therapy. Inverse probability of treatment weighting using covariate balancing propensity scores was used to adjust for baseline differences.

Results: A total of 110 patients were included. Of these patients, 54 received MMAE and 56 were treated with surgical drainage. No significant differences were found regarding baseline demographic features. Although patients in the surgery group had a higher incidence of headaches and dizziness preoperatively, no difference in preoperative motor deficits was found. The MMAE group had a higher incidence of clotting disturbances and thrombocytopenia. Within 180 days, 5.6% of the patients who underwent MMAE required rescue treatment, all performed through surgical drainage. In contrast, 30.4% of the surgically treated patients required rescue treatment that included surgery, MMAE, or a combination of both. A Poisson regression analysis for rescue treatment within 180 days demonstrated that patients treated with MMAE had an 87.5% lower incidence rate of rescue treatment compared with those who underwent surgical drainage (p = 0.001). Additionally, the surgery group received significantly more postoperative platelet transfusions (median of 6 units) when compared with 0 units in the MMAE group. Time to restart previously held chemotherapy was significantly shorter in the MMAE group (p = 0.005).

Conclusions: MMAE as a primary therapy for cSDH in cancer patients was associated with lower recurrence rates, earlier resumption of cancer therapy, reduction in platelet transfusion, and shorter hospitalizations compared with surgical drainage. These findings suggest that MMAE alone is safe and effective, and facilitates earlier resumption of chemotherapy in the oncology population.