Neurosurgical focus最新文献

Objective: Middle meningeal artery (MMA) embolization for chronic subdural hematoma (cSDH) has ushered in a treatment paradigm shift. The objective of this study was to determine whether the superficial temporal artery (STA) could be used consistently and just as effectively compared to conventional femoral and radial artery access.

Methods: The authors retrospectively reviewed a series of consecutive cases from January 1, 2024, to February 28, 2025, where the STA was used to treat cSDH. The 90-day readmission, retreatment, and death rates were collected and compared against a set of internal comparison cases that underwent similar treatment, though via femoral or radial artery puncture.

Results: The study included 40 patients with STA retrograde (STAR) access and 50 patients who had traditional transfemoral or radial artery approaches. In the STA group, there was significantly reduced radiation exposure (p < 0.001) and less contrast administration (p < 0.001). There were no differences between the groups in terms of the 90-day readmission (p = 0.82), retreatment (p = 0.93), or death rates (p = 0.42). One access site complication was observed after a transfemoral intervention.

Conclusions: STAR access is an alternative for MMA embolization in cSDH. This innovative approach can potentially rival the results achieved by traditional techniques.

Objective: This study aimed to identify the hematoma volume (HV) and midline shift (MLS) grade that need to be reduced for immediate postoperative improvement in patients with surgically treated chronic subdural hematoma (CSDH). Additionally, the study investigated risk factors for recurrence and explored whether specific anatomical burr hole locations and drain directions can influence these outcomes.

Methods: This retrospective analysis included patients treated for hemispheric CSDH using burr hole trephination and subdural drain placement during a study period over 3 years. Volumetric assessment of HV and subdural air (SA) was performed with 3D reconstruction. Analysis A examined the relationship between postoperative HV and MLS reduction and immediate postoperative improvement of hematoma-associated signs and symptoms. Analysis B involved bivariate and multivariate analyses to identify risk factors for recurrence. Analysis C evaluated whether anatomical burr hole location and drain placement influenced postoperative outcomes. Patients were divided into three groups (group 1, frontal burr hole with parietal drain; group 2, frontal burr hole with frontal/temporal drain; group 3, parietal burr hole with frontal drain).

Results: Analysis A found that patients with immediate postoperative improvement had significantly lower residual HV (38.5% vs 52%, p = 0.02) and MLS (37.3% vs. 60%, p = 0.039). Analysis B identified specific items associated with recurrence, including clopidogrel use (p = 0.029), statin use (p = 0.017), lower preoperative platelet count (p = 0.035), and higher preoperative HV (p < 0.001) and MLS (p = 0.024). Additionally, postoperative SA (p = 0.029) was associated with recurrence. Clopidogrel use and postoperative SA remained significant in multivariate analysis (p = 0.022 and p = 0.009, respectively). Cutoff values for preoperative HV (≥ 122.3 ml) and SA (≥ 6.95 ml) were identified, with high negative predictive values of 96.3% and 90.5%, respectively. Analysis C did not demonstrate any superiority of any of the treatment groups regarding HV and MLS reduction nor recurrence and complications.

Conclusions: Reducing HV and MLS is crucial for immediate symptom relief in CSDH patients. Preoperative use of clopidogrel and postoperative SA are key factors associated with recurrence. The choice of burr hole and drain locations can be individualized.

Objective: To date, there is no consensus on treatment indications for chronic subdural hematoma (CSDH) in patients in their 10th decade of life. The present investigation aims to focus on and carefully evaluate the clinical course of this particularly fragile subgroup of patients.

Methods: The authors retrospectively analyzed the clinical, radiological, and surgical records from a multicentric prospectively maintained database of patients with CSDH surgically treated between June 2005 and August 2021. Patients included in the study were divided into two subgroups: group A, those whose age was < 90 years; and group B, those whose age was ≥ 90 years. The following variables were recorded for each patient: age, sex, clinical disease onset, history of traumatic brain injury, antiplatelet or anticoagulant use, and pre- and/or postoperative corticosteroid medication intake. The surgical approach and whether a surgical drain had been left in the subdural space were recorded, as was the anesthesia protocol. Clinical results were measured using the Markwalder Grading Scale. Recurrence and mortality were analyzed separately.

Results: The final cohort comprised 1312 patients who had undergone surgery for CSDH, 1240 patients whose age was < 90 years and 72 patients whose age was ≥ 90. Patients in their 10th decade of life experienced similar or even better clinical outcomes than their younger counterparts. In particular, the pre-postoperative variation in Markwalder grades was favorable in elderly patients (p = 0.006). Multivariate analyses confirmed that local anesthesia (p = 0.013), single-sided CSDH (p = 0.010), and no antiplatelet or anticoagulant intake (p = 0.004 and p = 0.037, respectively) are independent predictors of favorable outcomes.

Conclusions: Patients in their 10th decade can experience clinical and radiological outcomes similar to those in their younger counterparts. Such patients could be eligible for standard minimally invasive treatments.

Objective: Surgical evacuation is the mainstay of treatment for patients with chronic subdural hematoma (cSDH) who have symptomatic mass effect, yet it carries a recurrence risk of up to 20%. Recent randomized trials have shown that adding middle meningeal artery embolization (MMAE) can significantly reduce both reoperations and overall treatment failures. However, whether performing MMAE and surgical evacuation in a single session impacts treatment efficacy remains an open question.

Methods: The authors retrospectively identified 429 patients across 14 institutions who underwent MMAE plus surgical evacuation of cSDH. Patients were stratified into single-session (MMAE and evacuation under the same anesthesia session) or staged (separate sessions) cohorts. Baseline demographic, procedural, and imaging data were collected. Propensity score matching was performed to balance key baseline variables. Primary outcomes included hematoma recurrence, hospital length of stay (LOS), and functional independence (modified Rankin Scale score ≤ 2).

Results: Of 429 patients, 205 (47.8%) received single-session treatment. In the unmatched analysis, single-session patients showed a lower rate of cSDH reaccumulation and repeat surgery (4.7% vs 10.7%, p = 0.010) and a shorter median LOS (6 vs 7 days, p < 0.005). After matching, reaccumulation rates were not significantly different, but LOS remained significantly shorter (5 vs 7 days, p = 0.002). Functional outcomes and overall mortality were similar in both groups. Complication rates did not differ, and MMAE-related adverse events were rare.

Conclusions: Single-session MMAE plus surgical evacuation appears to be safe and shortens LOS compared with a staged approach. The rates of functional outcomes, re-evacuation, and mortality did not differ significantly from those observed in patients who underwent staged procedures.

Objective: The aim of the study was to evaluate the effect of the postoperative Trendelenburg position on the recurrence of chronic subdural hematoma (CSH) in patients after surgical drainage.

Methods: A pilot randomized, controlled clinical trial was conducted in 3 hospitals in Colombia. Patients with CSH were enrolled and assigned to a Trendelenburg position (30° leg elevation and 10° head tilt; intervention group) or to a flat position (control group) for 24 hours postoperatively. CSH recurrence was measured at 3 months, along with functional outcome (modified Rankin Scale [mRS] score), adverse events, and patient comfort.

Results: Twenty-three patients were assigned to the Trendelenburg group and 23 to the control group. Two patients from the intervention group were assigned to the control group because of minor complications. Recurrence of CSH was 4.8% in the intervention group and 28.6% in the control group (p = 0.038). A favorable outcome (mRS score 0-2) was achieved in 95.2% of the intervention group versus 66.7% in the control group (p = 0.025). Patient comfort was equal in both groups (47.6% vs 48%, p = 0.979).

Conclusions: In patients with CSH who require surgery, the postoperative Trendelenburg position is associated with lower recurrence and improved functional outcome at 3 months. Further studies are required to obtain more clinical evidence.

Objective: Chronic subdural hematoma (cSDH) is one of the most common neurosurgical pathologies. Despite the optimization of surgical approaches, outcomes such as recurrence and complication rates remain unacceptably high. Consolidated evidence-based pathways have demonstrated a clear impact on surgical outcomes. Herein, the authors aggregated literature evidence and institutional experience to design and implement an enhanced recovery pathway for cSDH.

Methods: A multicenter cohort study was conducted over two periods: prior to (July 2021 to June 2022) and after (July 2022 to June 2023) pathway implementation. All adult patients with surgically evacuated cSDH or subacute subdural hematoma (SDH) were included in the study. Patients with SDHs that were managed conservatively, acute SDH treated with craniotomy or craniectomy, or subdural empyemas were excluded. Demographic details as well as preoperative clinical and radiological data were collected. Outcome measures included hospital length of stay (LOS), complication rate, discharge location, 30-day mortality, and 3-month recurrence. An excellent outcome was defined as discharge within a week of burr hole evacuation to a location similar to or better than premorbidly and no 3-month recurrence.

Results: One hundred seventy prepathway and 169 postpathway patients were included in the final analysis and were comparable both demographically and clinically. After multivariable logistic regression analysis, the postpathway group had a shorter median LOS (9 vs 7 days, p = 0.003) and were more likely to be discharged to home or a rehabilitation facility (OR 2.77, 95% CI 1.45-5.56, p = 0.002). The 3-month recurrence rate reduced from 11.8% prepathway to 7.7% postpathway, although the difference between the two was not statistically significant (p = 0.13). Excellent outcomes were more likely postpathway, increasing from 34.7% to 49.7% (OR 1.92, 95% CI 1.19-3.13, p = 0.008).

Conclusions: The treatment of cSDH is ever evolving with newer adjuncts and treatment modalities described in the literature. However, with the simple standardization of care in patients with cSDH, a reduced LOS, an optimized patient discharge location, and an increase in the proportion of patients with excellent outcomes were noted.

Objective: Chronic subdural hematoma (CSDH) is one of the most common neurosurgical diseases. Middle meningeal artery embolization (MMAE) is a treatment option in addition or as an alternative to conservative or surgical therapy. The objective of this study was to investigate whether MMAE can be used as a primary treatment method in patients with CSDH without an acute indication for surgery, and as a therapeutic option instead of a reoperation in cases of recurrence after surgery.

Methods: Fifty-one patients with MMAE as the primary treatment method for CSDH or for cases of recurrence after surgical treatment were prospectively included. A retrospective matching with patients treated only surgically was performed using the criteria of age, gender, size and side of the CSDH, as well as anticoagulation therapy. In the follow-up, the frequency of rescue operations and complications and the resumption of anticoagulation treatment were analyzed.

Results: Eleven patients with MMAE and 14 controls underwent rescue surgery due to relevant worsening of symptoms (p = 0.638). None of the patients with MMAE experienced a complication, compared with 7 of the controls (p = 0.012). When anticoagulation treatment was resumed, there was a tendency in favor of MMAE (p = 0.058).

Conclusions: There is a tendency toward superiority of MMAE for CSDH in certain patients. However, uncertainties remain regarding the exact methodology and optimal indications, and further research will be needed.

Objective: Hemifacial spasm (HFS) is occasionally caused by neurovascular compression (NVC) from a tortuous and elongated vertebral artery (VA), often with dolichoectatic changes. The aim of this study was to determine whether patients with HFS and VA involvement as an offending vessel exhibit clinicosurgical features distinct from those patients without VA involvement.

Methods: Demographics, clinical and surgical characteristics, and treatment outcomes of consecutive patients who underwent microvascular decompression (MVD) for HFS at a single institution from October 2011 to December 2016 were retrospectively reviewed. In addition, relevant publications were reviewed for the clinicosurgical characteristics of patients with HFS and tortuous VA involvement.

Results: Of 279 included patients (192 female, mean age 53.9 years), 100 (35.8%) had involvement of a tortuous VA as the offending vessel (VA+ group) and 179 (64.2%) did not (VA- group). The VA+ group had a significantly higher proportion of males (OR 2.01, 95% CI 1.19-3.38; p = 0.01) and significantly higher left-sided preponderance (OR 0.37, 95% CI 0.22-0.62; p = 0.002) compared with the VA- group. For 3 patients (3%) in the VA+ group, the VA was the sole offending vessel responsible for HFS, while the remaining 97 patients (97%) had multiple offending vessels involved, including the anterior inferior cerebellar artery (AICA) and/or posterior inferior cerebellar artery (PICA). Compared with the VA- group, the VA+ group had a higher percentage of PICA involvement (50% vs 33%) and lower percentage of AICA involvement (61% vs 78.2%). No significant difference was observed in the surgical outcomes (p = 0.58) or incidence of complications (p = 0.90) between the two groups. Additionally, the literature review indicated that patients with HFS and tortuous VA involvement in previous studies tended to show a weaker female preponderance and a stronger left-sided predominance compared with those without VA involvement.

Conclusions: Patients with HFS involving the VA as the offending vessel had distinct clinicosurgical features compared with those without VA compression. Furthermore, during MVD for VA-involved HFS, special attention is required to avoid missing concurrent small arteries beneath the VA on the NVC site of the affected facial nerve.