Neurosurgical focus最新文献

Objective: Dolichoectasia of the intracranial arteries is a rare vascular disorder. Patients with vertebrobasilar dolichoectasia (VBD) can present with cranial nerve deficits, such as cranial rhizopathies. The aim of this study was to systematically review existing literature and to share an institutional experience in treating VBD-associated trigeminal neuralgia (TN) and hemifacial spasm (HFS), as well as to provide an overview for optimal therapeutic decision-making in these patients.

Methods: A systematic search was conducted across three major databases to identify publications on VBD in which patients presented with TN or HFS. Articles were screened based on predefined eligibility criteria. Relevant patient data were extracted from the included articles, and statistical analyses were performed to evaluate the effectiveness of different treatment modalities.

Results: A total of 155 articles were identified comprising 801 patients, plus 7 patients from the authors' institution, resulting in 808 patients (mean age 60.1 years) with VBD-associated TN and/or HFS. Among patients receiving nonsurgical treatments such as medication, symptoms did not fully resolve. Of patients who underwent radiosurgery, 63.7% experienced symptom resolution, but 47.2% had recurrence after a mean of 14.1 months. Among patients treated with microvascular decompression (MVD), symptoms resolved in 87.3%, improved in 11.7%, and recurred in 6.5% (over a mean of 17.4 months after surgery). A significant statistical difference was seen between the recurrence rates of MVD and radiosurgery (p < 0.005). Interestingly, interposition and transposition surgical techniques showed similar efficacy, with symptom resolution in 89.2% and 87.4% of patients, respectively. Moreover, endoscopic approaches significantly reduced complication rates compared to microscope-assisted approaches (5.3% vs 23.8%), although their impact on complete symptom resolution was not statistically significant.

Conclusions: Compared with the other therapeutic approaches, MVD had a higher rate of symptom resolution and a lower recurrence rate. Notably, endoscope-assisted decompression was linked to fewer complications. Additionally, the interposition and transposition surgical techniques showed similar efficacy.

Objective: Trigeminal neuralgia (TN) is a neurological disorder that typically manifests as excruciating orofacial pain along the branches of the trigeminal nerve. Percutaneous treatments for TN have been shown to provide short-term pain relief, but they are often associated with the recurrence of pain. In this study, the authors assessed the role of frailty status in postoperative pain and numbness outcomes for patients treated with primary percutaneous glycerin rhizotomy.

Methods: At the authors' institution, 231 older patients (age ≥ 60 years) who underwent primary glycerin rhizotomy between 2011 and 2022 were reviewed. These patients were dichotomized by the presence or absence of frailty using the modified 5-item Frailty Index. Demographic data, comorbidity information, clinical characteristics, intraoperative complications, and postoperative outcomes were collected. Kaplan-Meier analysis, multivariable ordinal regression, and Cox proportional hazards analysis were used to compare Barrow Neurological Institute (BNI) pain and numbness index outcomes between frail and nonfrail patients.

Results: Frail patients (n = 87) had significantly higher rates of hypertension, diabetes, history of cerebrovascular accidents, chronic kidney disease, hyperlipidemia, chronic obstructive pulmonary disease, and congestive heart failure compared to nonfrail patients (n = 144, p < 0.05). Frail patients had significantly worse pain at final follow-up compared to nonfrail patients (p < 0.01). They also experienced significantly higher rates of pain recurrence (p < 0.01) and rhizotomy failure (p < 0.01), defined as a BNI pain index score > 3 within 3 months after surgery. Multivariable ordinal regression determined that frailty was significantly associated with higher BNI pain index scores at final follow-up (p < 0.01). Cox proportional hazards models indicated that while male sex was associated with greater pain recurrence (p < 0.01), frailty was associated with a higher likelihood of rhizotomy failure (p < 0.01).

Conclusions: In this study, frail older patients who underwent primary glycerin rhizotomy experienced greater pain levels postoperatively and had a higher incidence of rhizotomy failure relative to their nonfrail counterparts. Therefore, frailty status should be considered during preoperative counseling prior to percutaneous glycerin rhizotomy to guide clinical decision-making and inform patient expectations following the procedure.

Objective: Microvascular decompression (MVD) is the definitive surgical procedure for hemifacial spasm (HFS), with reported success rates exceeding 90%. However, the complexity of neurovascular compression varies between patients, and the presence of perforating arteries at the root exit zone (REZ) may hinder optimal decompression. This study aimed to analyze anatomical patterns and characteristics of perforating arterial branches at the REZ, and to evaluate their potential impact on the MVD procedure and surgical outcomes.

Methods: The authors conducted a retrospective review of high-quality intraoperative images and videos of patients who underwent MVD for HFS between January 2017 and October 2022. Inclusion criteria were pure arterial compression and a minimum postoperative follow-up of 6 months. Patient demographics; number of perforators within a 5-mm radius of the REZ and their length, direction, and involvement in facial nerve decompression; and postoperative outcomes were assessed.

Results: One hundred five patients met the inclusion criteria. The mean patient age was 55.6 (SD 11.2) years, with a male-to-female ratio of 1:1.63 and a mean follow-up duration of 24.4 (SD 28.1) months. Favorable outcome reached 89.5% (94/105 patients), and persistent complications occurred in 3.81%. The compressing vessel was solely the anterior inferior cerebellar artery (AICA) in 28.6% of patients, the posterior inferior cerebellar artery (PICA) in 38.1%, and a combination in the remainder. The median number of perforators per patient was 2, with notable differences in length and vascular territory: AICA perforators were significantly shorter and more likely to supply the cranial nerve (CN) VII-VIII complex (p < 0.05). Furthermore, AICA perforators interfered more frequently with decompression than those from the PICA (53.3% vs 22.5%, p < 0.05). Postoperative outcomes did not differ significantly between groups.

Conclusions: The anatomical characteristics of perforating branches vary depending on the parent vessel. AICA perforators are usually shorter and more often supply the CN VII-VIII complex, thereby posing a greater challenge during MVD compared to PICA branches. Nonetheless, with appropriate surgical expertise, neuroendoscopic visualization, and adjunctive intraoperative monitoring, favorable outcomes can still be reliably achieved.

Objective: Initial medical management fails in nearly half of patients with trigeminal neuralgia (TN), and patients will seek surgical management with either rhizotomy or microvascular decompression. The impact of preoperative medical management on post-rhizotomy outcomes is unclear. The authors aimed to further evaluate this relationship.

Methods: In this single-center, retrospective cohort study, the authors recorded clinical and demographic data for patients with TN who underwent first-time rhizotomy at their institution (1995-2023). Univariate logistic regression and Cox regression analyses were used to evaluate associations between the number and duration of preoperative pain medications with postoperative outcomes, including pain improvement, medication-free remission, and time to pain recurrence.

Results: A total of 413 patients met inclusion criteria (mean age 62.6 ± 15.7 years, 63.0% female). The mean time on preoperative pain medications for TN was 57.0 ± 73.1 months. At the time of presentation, 85.5% of patients were taking ≥ 1 pain medication for TN, with anticonvulsants being the most commonly prescribed (78.7%). Postoperatively, 75.3% experienced pain improvement and 14.3% achieved remission. The median time to recurrence was 8.6 (95% CI 6.2-11.0) months among the entire cohort, 12.8 (95% CI 8.8-16.7) months for patients who had postoperative improvement in TN pain, and 36.0 (95% CI 12.7-59.3) months for patients who achieved pain remission not requiring medication. There were no significant associations between time on preoperative pain medications, number of pain medications tried, number of pain medications at presentation to neurosurgery, and postoperative outcomes.

Conclusions: While early neurosurgical referral is valuable for discussing treatment options, the authors' findings suggest that prolonged medication use does not diminish the effectiveness of rhizotomy in relieving TN symptoms.

Objective: The authors of this retrospective study evaluated the long-term surgical outcomes and complications of microvascular decompression (MVD) for glossopharyngeal neuralgia (GPN) using the combined transcondylar fossa (trans-CF) and unilateral transcerebellomedullary fissure (trans-CMF) approach.

Methods: All patients with idiopathic GPN treated via MVD at the authors' institution from 2003 to 2019 were considered for study inclusion. The combined trans-CF and unilateral trans-CMF approach was utilized with particular attention to securing the offending vessel(s) to the dura mater to prevent recurrence. Surgical outcomes were evaluated using the Barrow Neurological Institute (BNI) pain intensity scale.

Results: Of the 23 patients treated with MVD via the combined trans-CF and unilateral trans-CMF approach in the study period, 21 (14 females [66.7%] and 7 males [33.3%], mean age 60.6 years) were followed up for more than 5 years (mean 149.9 months, range 63-235 months). Twenty (95.2%) of the 21 patients reported immediate pain relief (BNI pain score I), and only one required reoperation for recurrent pain. At the final follow-up, the 20 patients without reoperation reported complete pain relief and no increase in their BNI pain score (indicating greater pain). Seven patients (33.3%) experienced transient mild dysphagia or hoarseness postsurgery, but there were no permanent complications.

Conclusions: MVD for GPN using the combined trans-CF and unilateral trans-CMF approach achieved excellent outcomes with few complications. This technique offers several advantages: 1) wider exposure of the lower cerebellopontine angle, 2) reduced cerebellar retraction, 3) improved visualization for transposition of offending vessels, particularly a high-origin posterior inferior cerebellar artery, and 4) minimal manipulation of the lower cranial nerves. The selection of a suitable approach based on careful preoperative imaging and appropriate vessel transposition techniques is essential for achieving favorable long-term outcomes.

Objective: How to manage the superior petrosal vein (SPV) obstructing the operative field during microvascular decompression (MVD) for trigeminal neuralgia (TN) remains controversial. The authors aimed to evaluate the safety profile of a specific SPV division technique used during MVD for TN.

Methods: This retrospective analysis included patients who underwent first-time MVD for medically refractory TN from 2005 to 2025 at a single center. When the SPV obstructed the operative field, it was coagulated at its main trunk near the entry site into the superior petrosal sinus, maintaining venous crossflow through its contributories. This strategy was performed in 171 patients (79%), but not in the other 46 patients (21%). Demographic and clinical data, surgical findings, and postoperative complications were assessed and compared between groups. The primary outcome was the occurrence of venous-related complications.

Results: A total of 217 patients (122 female, mean age 60 years) with TN were included, with a mean pain duration of 79 months. Operative findings revealed arterial conflict in 187 patients (86%), venous conflict in 91 patients (42%), and arachnoid adhesions in 149 patients (68%). The SPV division group had 3 possibly venous-related complications, including asymptomatic small intracerebellar hemorrhage, which was managed conservatively (n = 1); transient mild ataxia associated with a small infarct in the dorsolateral pons (n = 1); and intracerebellar hemorrhage that manifested with transient right-sided ataxia (n = 1). The overall complication rate was not statistically different between the group in which the SPV division technique was used and the group in which the SPV was preserved.

Conclusions: These findings suggest that sectioning the SPV at its main trunk while maintaining venous crossflow through its contributory veins is a safe strategy during MVD for TN. This approach can improve visualization of the operative field without significantly increasing the risk of venous-related complications.

Objective: Because of the frequent recurrence of pain for patients with trigeminal neuralgia (TN), many undergo repeat percutaneous rhizotomy. The aim of this study was to assess whether the use of radiofrequency thermocoagulation with glycerin rhizotomy (RFTC-GR) or GR alone in repeat rhizotomy procedures influences postoperative pain and numbness outcomes.

Methods: The electronic medical records of 465 patients with TN who underwent repeat rhizotomy at the authors' institution between 2011 and 2022 were reviewed. Patients were dichotomized by treatment type: RFTC-GR or GR. Baseline demographics, comorbidities, and clinical characteristics were collected. The primary outcomes measured were pain and numbness, preoperatively and postoperatively, using the modified Barrow Neurological Institute (BNI) pain intensity scale and the BNI facial numbness scale. To compare pain and numbness outcomes between the RFTC-GR and GR groups, Kaplan-Meier, multivariate ordinal regression, and Cox proportional hazards analyses were performed.

Results: Preoperatively, patients who received RFTC-GR had higher BNI pain scores and lower BNI numbness scores than those who received GR alone. Postoperatively, patients in the RFTC-GR group had higher BNI numbness scores than patients in the GR group, but the RFTC-GR group had significantly less rhizotomy failure (defined as a BNI pain score > 3 within 90 days after surgery). Multivariate ordinal regression analysis determined that RFTC-GR was associated with higher BNI numbness scores at the time of pain recurrence or the final follow-up (p = 0.04). A Cox proportional hazards model demonstrated that glycerin-only rhizotomy was associated with greater risk of failure compared with RFTC-GR (p < 0.01).

Conclusions: In this study, RFTC-GR caused greater postoperative numbness than GR alone, while reducing the risk of rhizotomy failure compared with GR. Thus, RFTC-GR could be a more appropriate repeat procedure for patients with minimal numbness preoperatively.

Objective: Long-term data on outcomes following microvascular decompression (MVD) without neurectomy for glossopharyngeal neuralgia (GPN), specifically focusing on pain location, are sparse. The aim of this study was to investigate the long-term efficacy and safety of MVD without neurectomy for GPN with particular emphasis on redo MVD and pain location.

Methods: Consecutive patients who underwent MVD for classical GPN performed by the senior author from 2013 to 2021 were included in this retrospective cohort study. Medical records were reviewed, and clinical and telemedicine follow-up were analyzed to assess outcomes.

Results: Among 29 patients (18 male, median age at surgery 65.0 years) included in the analysis, 38% had throat pain radiating to the ear and 35% had throat pain only. Eleven patients (38%) had previously undergone other unsuccessful procedures. After MVD, 83% of patients were immediately pain free and 10% experienced partial pain relief. The mean follow-up duration was 65.3 months. At the final follow-up, 86% of patients were completely pain free and 11% had partial pain relief. Three patients each (10% and 11%) experienced immediate and long-term complications, respectively. Redo MVD completely relieved pain in 3 of 4 patients.

Conclusions: These findings support the use of MVD without neurectomy in patients with classical GPN, including redo MVD in patients with persistent neurovascular compression. The direction of symptom radiation was not associated with pain outcomes.

Objective: Although MGMT promoter methylation, gross-total resection (GTR), and adjuvant chemoradiation therapy are known to independently improve clinical outcomes for patients with glioblastoma (GBM), their combined influence remains unclear. In the present study, the authors investigated the complementary role of these factors in GBM prognosis.

Methods: The 2022 National Cancer Database was queried for individuals with histologically confirmed IDH-wildtype GBM WHO grade 4 and available MGMT promoter methylation status data. Demographic, clinical, and treatment-related variables were analyzed. Kaplan-Meier survival and multivariate Cox proportional hazards analyses were conducted, stratified by MGMT promoter methylation and chemoradiation therapy status.

Results: A total of 27,858 patients were included in the analysis. Chemotherapy, radiation therapy, and MGMT promoter methylation status were independently associated with improved survival in the overall cohort (p < 0.001). In Kaplan-Meier analysis, MGMT promoter methylation was associated with improved overall survival for individuals who received standard chemoradiation therapy (p < 0.001) but not for individuals who did not receive chemoradiation therapy (p = 0.649). In the overall cohort, GTR was associated with a 40% improvement in overall survival relative to excisional biopsy (HR 0.633 [95% CI 0.52-0.77], p < 0.001) in multivariate analysis. In patients with MGMT promoter-methylated tumors, GTR was associated with a 70% (HR 0.30 [95% CI 0.12-0.71], p = 0.007) improvement in overall survival compared with excisional biopsy in those who did not receive chemoradiation therapy, but GTR did not significantly improve survival in those who received chemoradiation therapy (HR 0.97 [95% CI 0.54-1.73], p = 0.912). For patients with MGMT promoter-unmethylated tumors, GTR was associated with improved overall survival for both those who received chemoradiation therapy (HR 0.48 [95% CI 0.33-0.70], p < 0.001) and those who did not (HR 0.50 [95% CI 0.28-0.89], p = 0.018).

Conclusions: In this large registry study, the authors demonstrated that maximizing the extent of resection improves overall survival, especially for individuals with MGMT unmethylated GBM or those not receiving chemoradiation therapy. However, the impact of gross-total resection requires further investigation in patients with MGMT promoter-methylated GBM who receive adjuvant therapy. These findings support future studies exploring new diagnostic techniques for preoperative evaluation of MGMT methylation to aid surgical planning.