Neurologia medico-chirurgica最新文献

Fetal surgery for myelomeningocele is not yet standard practice in Japan. To establish baseline data for the outcomes of standard postnatal care for patients eligible for fetal surgery, we compared the results from our large, single-institution cohort with those of the Management of Myelomeningocele Study trial's postnatal group. We retrospectively reviewed 65 patients who underwent postnatal myelomeningocele repair at our center between 2002 and 2021. In our cohort, the myelomeningocele lesion level was thoracic in 18% of patients, L1-L2 in 12%, and L3 or below in 69%. Key outcomes, including the rate of cerebrospinal fluid shunt placement at 12 months and ambulation status at 30 months, were compared to the published data from the Management of Myelomeningocele Study postnatal cohort. The rate of cerebrospinal fluid shunt placement in our cohort (88%) and ambulation rates at 30 months (28%) showed no statistically significant difference from the Management of Myelomeningocele Study postnatal group (83%, p = 0.39, and 20%, p = 0.29, respectively). Our cohort had a significantly lower rate of shunt infection (0% vs. 9%, p = 0.02). However, the rates of surgery for symptomatic Chiari II malformation (18% vs. 5%, p = 0.01) and for tethered cord syndrome (9% vs. 1%, p = 0.03) were significantly higher in our cohort. The outcomes of modern postnatal myelomeningocele repair at a major Japanese center are largely consistent with the international benchmark set by the Management of Myelomeningocele Study trial. This study provides an essential baseline of data that will be indispensable for counseling families and for the objective evaluation of fetal surgery as it is introduced in Japan.

This study aimed to compare the anterior lateral ventricular index with established radiological markers, including the Evans Index, callosal angle, and disproportionately enlarged subarachnoid-space hydrocephalus, in evaluating postoperative radiological improvement in patients with idiopathic normal pressure hydrocephalus. A retrospective analysis was conducted on 46 patients who underwent ventriculoperitoneal shunt surgery between January 2019 and February 2025. Pre- and postoperative cranial computed tomography and magnetic resonance imaging scans were used to measure Evans Index, anterior lateral ventricular index, callosal angle and the presence of disproportionately enlarged subarachnoid-space hydrocephalus was assessed. Clinical parameters, including gait performance (10-meter walking and 360° turning steps) and urinary continence, were compared with radiological changes. Both Evans Index and anterior lateral ventricular index significantly decreased postoperatively (Evans Index: 0.388→0.336, p < 0.001; anterior lateral ventricular index: 0.552→0.479, p < 0.001), while callosal angle significantly increased (85.3°→99.7°, p < 0.05). Anterior lateral ventricular index reduction correlated moderately with Evans Index reduction (r = 0.37, p = 0.011) and weakly with callosal angle increase (r = 0.26, p = 0.080). Gait performance improved significantly (p < 0.001), and urinary incontinence resolved in 40.9% of affected patients. Anterior lateral ventricular index reduction showed stronger correlations with gait improvement (r = -0.45, p = 0.002) and continence recovery (r = -0.33, p = 0.024) compared with Evans Index or callosal angle. Disproportionately enlarged subarachnoid-space hydrocephalus positivity was not significantly associated with postoperative outcomes. These findings suggest that anterior lateral ventricular index may provide a more sensitive and clinically relevant linear measure than traditional indices and can serve as a complementary parameter to Evans Index and callosal angle in the postoperative evaluation of idiopathic normal pressure hydrocephalus.

High-grade gliomas, especially glioblastoma, are associated with poor prognosis. We investigated the prognostic impact of first visiting a neurosurgery department or other departments among patients with high-grade gliomas in real-world clinical practice in Japan. We analyzed health insurance claims data from the Japan Medical Data Centre Claims Database for 540 patients with records of C71 (malignant neoplasm of the brain), surgery, radiotherapy, and temozolomide, indicative of high-grade gliomas. The median age was 54 years, 70.9% of the patients were aged <60 years, and 63.0% of the patients were male. Among 375 evaluable patients who first visited a hospital different to the one where the surgery was performed, the most common department visited was general internal medicine (43.0%); 13.0% visited a neurosurgical department. The median interval from the initial visit to surgery was 35.0 days and 19.0 days for patients who first visited a general internal medicine and a neurosurgery department, respectively. The proportions of patients who underwent surgery within 21 days of the initial visit to a general internal medicine and a neurosurgery department were 37.5% and 62.2%, respectively. The 3-year overall survival rates were numerically greater in patients who first visited a neurosurgery department (72.7%) than in patients who first visited other departments (57.7%), but not significantly (log-rank p = 0.39). Our results suggest that the treatment of high-grade gliomas was delayed if patients first visited non-neurosurgery departments, leading to poor outcomes. Our findings suggest that early neurosurgery consultation and surgery may improve the outcomes of patients with high-grade gliomas.

The Woven EndoBridge device is used for endovascular treatment of wide-neck bifurcation cerebral aneurysms. Conventional sizing methods often result in oversizing and require subsequent resizing. Although recent studies demonstrated the accuracy of volumetric methods for sizing, they are often complex. We aimed to develop a simplified method for estimating the appropriate Woven EndoBridge size using two-dimensional angiographic images by inscribing rectangles in aneurysms modeled as ellipsoids, which we named the Inscribed Rectangle Method. This retrospective, single-center study included 12 patients with wide-neck bifurcation cerebral aneurysms treated with the Woven EndoBridge device between May 2023 and July 2024. Aneurysm projections were approximated as ellipses, with the horizontal and vertical axes corresponding to the aneurysm's mean width and minimum height, respectively. The largest inscribed rectangle dimensions (D_rec, H_rec) were calculated. We then developed a predictive formula for Woven EndoBridge sizing based on D_rec and H_rec and compared its performance with conventional sizing methods. Adequate perioperative occlusion was achieved in 83% of cases, and no significant procedural complications were observed. Analysis of these cases revealed that the implanted Woven EndoBridge width and height were approximately D_rec × 1.5 and H_rec, respectively. The Inscribed Rectangle Method, which uses D_rec × 1.5 and H_rec, more closely predicted the implanted Woven EndoBridge size than conventional methods (p < 0.01). The Inscribed Rectangle Method provides a simplified, two-dimensional angiography-based approach for Woven EndoBridge sizing that may reduce the need for device resizing while preserving procedural efficiency.

Anterior cervical discectomy and fusion has become established as a standard surgical method for degenerative cervical disease. Various materials have been used, and we currently usually use double titanium cylindrical cages. Many investigators have reported on the incidence of subsidence after anterior cervical discectomy and fusion. This study focused on the radiological position of the inserted cages and radiological factors influencing the surgical method and examined their relationship with subsidence. Participants in this retrospective study comprised 112 patients diagnosed with cervical myelopathy and radiculopathy caused by disc herniation and spondylosis who underwent one-level anterior cervical discectomy and fusion at a single institution between September 2012 and December 2022. Subsidence was defined as a ≥3-mm decrease in segmental disc height on lateral X-ray at the 1-year follow-up compared to that on postoperative day 1. Subsidence was identified in 53 patients (47.3%). At the view of radiological cage position, our univariate analysis demonstrated that the only deviation of the inserted cages from the anatomical center on the anterior-posterior view was significantly associated with subsidence. Inserting cages in a central position thus appears important to prevent radiological subsidence after anterior cervical discectomy and fusion. Despite high subsidence rates, no patients required additional procedures at the same level by the end of the minimum 2-year follow-up period.

We investigated how subthalamic local field potentials evolve as the microlesion effect emerges and wanes after electrode implantation in Parkinson's disease. Thirteen patients underwent repeated resting recordings that were analyzed across six predefined postoperative periods (days 0-6, 7-30, 31-90, 91-180, 181-365, and ≥366). Power spectral density (1-50 Hz) was decomposed into periodic and aperiodic components. Period-wise changes were tested with nonparametric within-subject analyses, and spatial differences across sensing-electrode pairs were evaluated with population-averaged regression under multiplicity control. Total local field potential power and aperiodic parameters (offset and exponent) followed an inverted-U trajectory, peaking at 31-90 days and declining by ≥12 months. In contrast, periodic beta power (13-30 Hz) increased from approximately 1-3 months onward and remained elevated at 6-12 months, resulting in a higher periodic-to-total beta ratio in late windows. Spatially, periodic beta was maximal over more dorsal, putative sensorimotor territories, whereas the aperiodic exponent was relatively larger ventrally, indicating distinct topographies of oscillatory versus aperiodic activity. Clinically, Movement Disorder Society-Unified Parkinson's Disease Rating Scale Part III improved at 6 months with partial attenuation by 12 months; time-matched correlations with electrophysiological metrics did not survive multiple-comparison adjustment. These findings suggest that the microlesion initially suppresses oscillatory beta more than broadband activity, with a later relative prominence of the periodic component, and that spatial dissociation between periodic and aperiodic features may inform biomarker selection and contact targeting for adaptive stimulation.

Stereoelectroencephalography electrodes are widely used to identify the epileptogenic zone. When performing resection of the epileptogenic zone identified by intracranial electroencephalography using stereoelectroencephalography electrodes, accurate delineation of the resection boundaries is critical for complete removal while preserving neurological function. However, intraoperative brain shifts often make it difficult to identify the resection boundaries. To address this challenge, we aimed to develop a novel surgical approach, the fence-post-like stereoelectroencephalography electrode-guided focus resection technique, in which implanted stereoelectroencephalography electrodes are used for epileptogenic zone localization and as intraoperative landmarks to guide precise resection. Between April 2021 and December 2024, 4 patients with drug-resistant focal epilepsy underwent stereoelectroencephalography implantation followed by epileptogenic zone resection using the fence-post-like stereoelectroencephalography electrode-guided focus resection technique. In all patients, complete epileptogenic zone resection was achieved, and postoperative seizure outcomes were classified as Engel class I. Regarding complications, one patient experienced slight weakness in the distal upper limb due to resection involving the supplementary motor area; no complications were observed in the remaining patients. The fence-post-like stereoelectroencephalography electrode-guided focus resection technique facilitates accurate and safe epileptogenic zone resection, even in the presence of brain shift, and is expected to contribute to favorable seizure outcomes.

We conducted a three-arm randomized controlled trial to assess the efficacy of upper-extremity motor recovery among post-stroke patients. Subacute post-stroke patients (n = 69) were randomly assigned into 3 groups: rehabilitation alone, rehabilitation with repetitive transcranial magnetic stimulation, and rehabilitation with both repetitive transcranial magnetic stimulation and repetitive peripheral magnetic stimulation. For daily repetitive transcranial magnetic stimulation, 1,000 pulses were delivered to the hand area of the primary motor cortex in the ipsilesional hemisphere (10 trains of 10 Hz for 10 sec with a 15-sec intertrain interval). For daily repetitive peripheral magnetic stimulation, 1,000 pulses was delivered to the paretic-side forearm (40 trains of 25 Hz for 1 sec with a 2-sec intertrain interval). We also randomly assigned the patients into 3 groups based on their Brunnstrom recovery stages to make the Brunnstrom recovery stage distribution the same in each group. After 4 weeks of treatment, motor recovery was evaluated based on the changes in the patient's scores on the Fugl-Meyer Assessment. Compared to the rehabilitation-alone group, the rehabilitation + repetitive transcranial magnetic stimulation group demonstrated significant additional improvement on the Fugl-Meyer Assessment (p < 0.05), and the rehabilitation + repetitive transcranial magnetic stimulation + repetitive peripheral magnetic stimulation group demonstrated the most evident Fugl-Meyer Assessment improvement (p < 0.01). No significant difference in Fugl-Meyer Assessment improvement was observed between the rehabilitation + repetitive transcranial magnetic stimulation group and the rehabilitation + repetitive transcranial magnetic stimulation + repetitive peripheral magnetic stimulation group. These results indicate that the implementation of repetitive transcranial magnetic stimulation and repetitive peripheral magnetic stimulation can facilitate motor recovery in subacute stroke patients, and repetitive peripheral magnetic stimulation may be useful to enhance the effect of repetitive transcranial magnetic stimulation. The optimization of the best repetitive peripheral magnetic stimulation protocols is a future task.

The combined technique (simultaneous use of a stent retriever and contact aspiration) is widely used for mechanical thrombectomy to treat acute large-vessel occlusions, but its clinical benefits remain unclear. We compared the efficacy and safety of different vessel-recanalization strategies on clinical outcomes across age groups. We analyzed 301 consecutive patients with internal carotid or middle cerebral artery occlusions. Between January 2017 and March 2021, 145 patients underwent single-device mechanical thrombectomy (stent retriever or contact aspiration) as the first-line strategy. Between April 2021 and December 2023, the combined technique was used as the first-line strategy in 96 patients. The modified first-pass effect (Thrombolysis in Cerebral Infarction grade ≥2b), final reperfusion outcomes, and functional outcomes were compared between strategy groups in patients <75 years and ≥75 years. In patients aged <75 years, the modified first-pass effect rate was significantly higher in the first-line combined-technique group than in the first-line single-device group (68.1% vs. 38.1%, p = 0.033), but favorable functional outcomes were similar. In patients ≥75 years, the first-line combined-technique group showed higher modified first-pass effect rates (61.3% vs. 42.7%, p = 0.03) and more frequent favorable functional outcomes than the first-line single-device group (31.3% vs. 13.4%, p = 0.0079). Thus, when performing mechanical thrombectomy for acute large-vessel occlusions, the combined technique should be used as a first-line strategy in older patients, as it is associated with more favorable functional outcomes than a first-line single-device strategy. In contrast, the favorable outcome rate in younger patients does not appear to differ by strategy.

C5 palsy is a significant yet poorly understood complication following cervical posterior surgery. Currently, few predictive models exist for estimating the preoperative risk of C5 palsy. This study aimed to develop and internally validate such a predictive model. We included patients aged 18 years or older who underwent cervical laminoplasty for cervical spondylosis or ossification of the posterior longitudinal ligament at a single institution. Demographic and radiographic data were collected. Key radiographic parameters included the C2-7 Cobb angle, C7 slope, presence of ossification of the posterior longitudinal ligament, anterior projection of the superior articular process of C5, and the width of the intervertebral foramen at C4/5, measured on computed tomography. Logistic regression with optimism adjustment was used to develop the model. A total of 180 patients were analyzed, with 18 cases (10.0%) of C5 palsy. Logistic regression identified width of the intervertebral foramen, C7 slope, age, and sex as significant predictors. The model demonstrated an area under the curve of 0.797 (95% confidence interval: 0.695-0.900) and a Brier score of 11.7%. After internal validation using bootstrapping, the optimism-adjusted area under the receiver operating characteristic curve was 0.736 (95% confidence interval 0.629-0.830). Final regression coefficients were 0.054 for C7 slope, -0.039 for age, -1.161 for female sex, and -0.721 for width of the intervertebral foramen. In conclusion, we developed and internally validated a preoperative prediction model for C5 palsy following double-door laminoplasty. Predictors such as width of the intervertebral foramen, C7 slope, age, and sex may aid in risk assessment and surgical planning.