Neurosurgical focus最新文献

Objective: Preclinical studies suggest that robotic carotid artery stenting (CAS) could be superior to manual CAS. However, very limited comparative data exist for patients who have undergone robotic versus manual CAS. In addition, no data exist comparing the costs of manual and robotic CAS.

Methods: All robotic CAS cases at two academic neurosurgery centers were retrospectively reviewed and 1:1 propensity matched with manual CAS cases. Personnel costs, supply costs, and total procedure costs were collected in collaboration with hospital administration by using time-driven activity-based cost analysis.

Results: A total of 24 robotic CAS operations were performed between 2019 and 2023. Comorbidities and baseline procedural characteristics were well matched between robotic and manual cases. Unplanned manual conversion was observed in only 1 robotic case (4.2%). Robotic CAS complications and outcomes were comparable to manual. Robotic CAS was associated with a significantly increased fluoroscopy time (29.0 vs 19.2 minutes; p < 0.001). Robotic procedure time (88.9 ± 18.2 minutes) was significantly (p = 0.003) longer than manual time (68.72 ± 22.4 minutes). Health personnel costs ($1589.71 ± $176.92 vs $1375.99 ± $233.39, p = 0.005); supply costs ($3918.25 ± $421.20 vs $2152.74 ± $1030.26, p < 0.001); and total procedure costs ($5306.11 ± $608.95 vs $3437.56 ± $1165.67, p < 0.001) were greater for robotic CAS.

Conclusions: In the first multicenter study and largest sample to date, the authors show that robotic CAS, with a low rate of procedural failure and postoperative complications, is safe and feasible. In addition, robotic CAS achieves comparable clinical outcomes to manual CAS. Robotic CAS was associated with increased fluoroscopy time, but fluoroscopy time decreased as operators gained familiarity with the CorPath GRX system. Robotic CAS was associated with a greater procedural cost, which was driven by greater personnel and supply costs. Robotic CAS failed to show superiority to manual CAS. These findings set a foundation for randomized controlled trials of robotic CAS, and also highlight the need for further studies to optimize robotic CAS and reduce its associated costs.

Objective: The authors investigated the predictors of cost of admission (CoA) for robot-assisted pedicle screw placement to assess the value of robotic systems in spine operations.

Methods: Demographic, operative, and postoperative variables were retrospectively collected from 506 patients undergoing robot-assisted spine surgery utilizing the ExcelsiusGPS robot at two high-volume tertiary care centers from 2017 to 2023. Perioperative parameters were evaluated against total hospital admission cost utilizing the Kruskal-Wallis and Wilcoxon rank-sum tests followed by multivariable linear regression.

Results: The majority of patients were female (53.6%), 50-80 years of age (77.7%), and White (73.9%); had at least 1 comorbidity (58.1%); and presented with an average functional preoperative Frankel grade (57.5%). The mean CoA was $69,458 ± $47,910. On univariable analysis, demographic data including sex, age, race, and Frankel grade were not associated with CoA. The presence of a comorbidity, however, was associated with increased CoA (p < 0.001). Intraoperatively, one-third of the operations (31.8%) were revisions from prior operations and were subsequently associated with increased CoA (p = 0.021). Thoracic-level operations constituted roughly one-quarter of the cohort (24.1%) and were also associated with increased CoA (p < 0.001). Intraoperative durotomies occurred in 7.7% of patients, leading to increased CoA (p = 0.003). Extended surgical durations also demonstrated elevated CoA (p < 0.001). Postoperatively, the median length of stay (LOS) was 3 days, and an LOS of greater than 3 days was one of the primary drivers of cost (p < 0.001). Postoperative complications occurred in just 6.3% of the cohort but were also associated with increased CoA (p < 0.001). On multivariable analysis, LOS, number of screws placed, operative duration, and postoperative complications were the primary predictors of increased CoA.

Conclusions: Understanding the drivers of cost in robot-assisted pedicle screw placement is crucial to elucidate the value associated with the use of robotic systems in spine surgery. These results indicate that patient and surgical complexity influence cost and that robotic systems may augment management in spine surgery. Further investigation is warranted to determine the long-term benefits and cost-effectiveness of new technologies compared with traditional techniques in spine surgery.

Objective: Innovations in robotics continue to reshape the landscape of neurosurgery. Here, the authors evaluated the safety and efficacy of the ExcelsiusGPS robot in the treatment of neuro-oncological, intracranial lesions.

Methods: The authors conducted a retrospective analysis of 19 consecutive adult patients with a neuro-oncological diagnosis who underwent intracranial biopsy and/or laser interstitial thermal therapy (LITT) with the assistance of the ExcelsiusGPS robot and intraoperative CT. Demographic and clinical data were collected from the electronic medical record and the robot software.

Results: All 19 patients harbored lesions that were deep seated, involving the eloquent cortex, or subcentimeter. Definitive tissue diagnosis was achieved in all cases involving stereotactic biopsy (n = 16), with glioblastoma as the most common diagnosis. The mean ± SD time for setting up the robotic stereotaxis system was 57.4 ± 10.7 minutes. The mean procedural time after that was 71.6 ± 41.0 minutes for stereotactic needle biopsy and 188.4 ± 61.2 minutes for procedures involving LITT. The mean radial errors of the actual trajectory relative to the planned trajectory at the entry and target points were 0.625 ± 0.443 mm and 0.745 ± 0.472 mm, respectively. There were no procedural complications or new postoperative deficits, although routine postoperative CT showed new hyperdensity at the target site in 3/19 patients (15.7%). All patients who underwent elective procedures were discharged by postoperative day 3 (mean 1.38 ± 0.619 days). There were two 30-day readmissions (pulmonary embolus and general weakness), and neither was attributable to the surgical procedure.

Conclusions: The authors' pilot experience with the ExcelsiusGPS robot in neuro-oncology procedures indicates a favorable efficacy and safety profile.

Objective: The objective of this study was to develop a murine system for the delivery of laser interstitial thermotherapy (LITT) with probe-based thermometry as a model for human glioblastoma treatment to investigate thermal diffusion in heterogeneous brain tissue.

Methods: First, the tissue heating properties were characterized using a diode-pumped solid-state near-infrared laser in a homogeneous tissue model. The laser was adapted for use with a repurposed stereotactic surgery frame utilizing a micro laser probe and Hamilton syringe. The authors designed and manufactured a stereotactic frame attachment to work as a temperature probe stabilizer. Application of this novel design was used as a precise method for real-time thermometry at known distances from the thermal ablative center mass during murine LITT studies.

Results: Temperature measurements were achieved during LITT that verified the direct thermometry capability of the system without the need for MR-based thermal monitoring. Application of multiple stereotactic design iterations led to an accurately reproducible surgical laser ablation procedure. Histological staining confirmed precise thermal ablation and controllable lesion size based on time and temperature control. Treatment of a syngeneic intracranial glioma model highly resistant to conventional therapy resulted in a modest survival benefit.

Conclusions: The authors have successfully developed a murine model system of LITT with direct in situ thermometry for investigation into the effects of thermal ablation and combinatorial treatments in murine brain tumor models.

Objective: Laser interstitial thermal therapy (LITT) is a minimally invasive procedure used to ablate abnormal tissue in a targeted fashion. It is most commonly used to treat epileptic foci, brain tumors, and radiation necrosis. This study aimed to compare immediate postoperative outcomes between these indications.

Methods: This study analyzed clinical data from the Nationwide Readmissions Database (NRD) from 2016 to 2019 and identified 2234 patients who underwent LITT procedures using ICD-10 codes. The authors analyzed patient demographics, complications, discharge disposition, readmission rates, and mortality. Following propensity score matching, 317 patients treated for epilepsy and 323 patients treated for brain tumors were compared.

Results: The mean ages were similar (epilepsy: 45.7 vs tumor: 49.0 years, p = 0.55), as were the proportions of female patients (epilepsy: 45.4% vs tumor: 52.9%, p = 0.83), all-payer costs (p = 0.81), income quartiles (p = 0.58), insurance types (p = 0.70), frailty rates (p = 0.85), and comorbid disease burdens as assessed by ECI score (p = 0.73). No significant differences were observed in rates of hemorrhage (p = 0.1), pulmonary embolism (p = 0.32), or infection (p = 0.16). However, the tumor cohort had higher rates of deep vein thrombosis (3.4% vs < 3.15%, p = 0.045), nonroutine discharge (26.6% vs 16.4%, p = 0.04), and 1-year hospital readmission (32.5% vs 18.6%, p = 0.006). One-year mortality rates were similar (tumor: 3.4% vs epilepsy: < 3.15%, p = 0.08).

Conclusions: While postoperative complications and 1-year mortality rates were similar among patients undergoing LITT for epilepsy and brain tumors, the tumor cohort experienced higher rates of deep vein thrombosis, nonroutine discharge, and 1-year hospital readmission.

Objective: Laser interstitial thermal therapy (LITT) is an emerging tool for treating a variety of focal brain lesions, including recurrent high-grade glioma (HGG). While the efficacy and uses of LITT have been well studied, the impact of this treatment on patient functional outcomes has not been analyzed in detail. This study sought to better define the role of LITT in treating patients with recurrent HGG, examining which patients exhibit good functional outcomes after LITT, and to determine risk factors for worsening neurological function.

Methods: The medical records of patients treated with LITT for recurrent HGG at a single tertiary care center were retrospectively reviewed. Functional status was assessed using the Karnofsky Performance Scale (KPS). Demographic, clinical, and radiological data were examined for associations with change in KPS score assessed 4-6 weeks following surgery.

Results: Forty-seven patients were included in the study with histopathologically confirmed recurrent HGG. The mean age was 57 years, and 21 (45%) patients were female. The pre-LITT KPS scores were as follows: 100 in 4 (9%) patients, 90 in 15 (32%) patients, 80 in 10 (21%) patients, 70 in 13 (28%) patients, and 60 in 5 (11%) patients. Overall, 59% of patients showed a stable or improved KPS score after undergoing LITT. Tumor volume was the sole predictor of decreased KPS score after LITT. Notably, tumor location including eloquent location, preoperative KPS score, and other comorbidities were not independently associated with change in functional status.

Conclusions: The majority of patients undergoing LITT for recurrent HGG had a favorable functional outcome at the initial follow-up visit. The treated tumor volume was inversely and independently associated with post-LITT functional outcome. This information may help guide patient selection and treatment optimization in the setting of LITT-based approaches for recurrent HGG.

Objective: Maximizing safe resection in neuro-oncology has become paramount to improving patient survival and outcomes. Laser interstitial thermal therapy (LITT) offers similar survival benefits to traditional resection, alongside shorter hospital stays and faster recovery times. The extent of ablation (EOA) achieved using LITT is linked to patient outcomes, with greater EOA correlating with improved outcomes. However, the preoperative predictors for achieving supramaximal ablation (EOA ≥ 100%) are not well understood. By leveraging machine learning (ML) techniques, this study aimed to identify these predictors to enhance patient selection and therefore outcomes. The objective was to explore preoperative predictors for supramaximal EOA using ML in patients with glioblastoma.

Methods: A retrospective study was conducted on the medical records of 254 patients undergoing LITT from 2013 to 2023 at a single tertiary center. Cohort criteria included age ≥ 18 years, diagnosis of glioblastoma, single-trajectory ablation, and a complete dataset. The study assessed preoperative clinical and radiographic factors, using EOA ≥ 100% as the endpoint. Five ML models were used: logistic regression, random forest (RF), gradient boosting, Gaussian naive Bayes, and support vector machine. Training and testing cohorts were subsequently assessed across ML models with fivefold cross-validation. Models were optimized using hyperparameter tuning. Performance was primarily quantified using the area under the curve (AUC) of the receiver operating characteristic curve.

Results: The final cohort consisted of 72 patients. Among the ML models, RF achieved the highest AUC (mean ± SD 0.94 ± 0.06). The leading models identified that lower preoperative volume, history of prior radiation therapy, history of prior craniotomy, preoperative neurological deficits, history of preoperative seizures, and distance from intracranial heat sinks were predictive of successful ablations in patients. Additionally, RF had the best mean metrics: accuracy 0.88, precision 0.87, specificity 0.87, and sensitivity 0.89.

Conclusions: This is the first study to investigate the role of ML for optimizing ablation volumes in LITT. These ML models suggest that low preoperative volumes, previous craniotomy, previous radiation therapy, no previous neurological deficits, larger catheter-heat sink distance, and the presence of preoperative seizures are important prognostic factors for predicting successful supramaximal ablations with LITT.

Objective: Laser interstitial thermal therapy (LITT) has emerged as an alternative for treating glioblastoma (GBM) in patients deemed unsuitable for resection due to deep-seated or eloquent location, age, or comorbidities. However, its safety and efficacy in large-volume, deep-seated, newly diagnosed GBM (nGBM) tumors remain insufficiently studied. Therefore, the authors aimed to assess the outcomes of LITT in the treatment of deep-seated, large-volume nGBM.

Methods: A retrospective analysis of patients with nGBM who underwent LITT between February 2013 and August 2023 was conducted. Patients with deep-seated tumor volume ≥ 10 cm3 treated with LITT were compared to patients with deep-seated tumor volume < 10 cm3. Demographic, perioperative, and follow-up data were collected and compared among both groups. Kaplan-Meier survival analysis and Cox proportional hazards regression were performed to evaluate the impact of various clinical and treatment-related factors on patient survival.

Results: A total of 33 patients in the study group (mean ± SD age 65.7 ± 10.2 years, 58% male) with mean tumor volume 36.0 ± 21.6 cm3 were compared to 23 controls (mean age 67.0 ± 12.5 years, 61% male) with mean tumor volume 5.2 ± 2.7 cm3. There were no significant differences in hospital length of stay (p = 0.494), temporary neurological deficits and edema within 30 days (p = 0.705 and p > 0.999, respectively), 30-day readmissions (p = 0.139), < 30-day complications (p = 0.918), complications between 30 days and 3 months (p = 0.903), and new motor and speech deficits within 3 months (p = 0.883 and p > 0.999, respectively) between the study and control groups. Kaplan-Meier analysis did not reveal any statistically significant difference in overall survival (OS) between groups (p = 0.227). Multivariate analysis indicated that tumor volume did not significantly affect the hazard ratio for individuals undergoing LITT (HR 1.16, 95% CI 0.83-3.29, p = 0.150).

Conclusions: This pilot study suggests that LITT is safe for treating patients with large-volume, deep-seated nGBM compared to those with small-volume tumor. Although there appears to be improved OS in patients with smaller lesions with greater EOA, significance was not achieved in this cohort.