Neurosurgery最新文献

Background and objectives: Meningiomas invading the superior sagittal sinus (SSS) present significant challenges for surgical management. Stereotactic radiosurgery (SRS) is increasingly used as a primary or salvage management in these difficult cases. The aims of this study were to evaluate the rate of long-term tumor control and the long-term neurological outcomes.

Methods: The authors retrospectively reviewed outcomes in 248 patients (152 females, 67.3%; median age, 61 years) with SSS invasive meningiomas who underwent primary or salvage SRS during a 22-year interval. The clinical presentation, radiographic characteristics, and neurological function of each patient were recorded. A total of 140 patients underwent resection before SRS for their SSS meningiomas. Overall, 56% of the patient had tumors involve the posterior one-third of the SSS; 51.6% of patients presented with peritumoral edema before SRS.

Results: The 1-, 2-, 5-, and 10-year local tumor control (LTC) rates were 97.7%, 94.1%, 85.7%, and 78.3%, respectively. Upfront SRS for SSS-invading meningiomas provided LTC comparable with that observed with salvage SRS for histologically confirmed WHO Grade I meningiomas (hazard ratio 0.86, CI 95% 0.33-2.24, P = .76). Tumor volumes <5.2 cc predicted better LTC (hazard ratio 5.1, CI 95% 1.9-19.3, P = .03). The median overall survival after SRS was 14.6 years. Ten patients (4%) died related to documented local intracranial tumor progression. A total of 12 patients (4.8%) developed symptomatic adverse radiation effects at median duration post-SRS of 14 months (range 2-182 months). Motor function improved in 20% patients who presented with motor weakness, after SRS.

Conclusion: SRS is safe and effective in managing small to medium sized SSS invading meningiomas, especially when the tumors involve the posterior one-third of the SSS. For larger SSS meningioma with symptomatic mass effect, adjuvant SRS for residual or recurrent tumors provides long-term tumor control.

Background and objectives: Free and open access to research data and findings promotes equity in access to healthcare knowledge and equity in patient care and treatment. To benefit the health care of the population studied, research findings must be accessible to clinicians, academics, and policymakers serving those populations. The aim of this study was to assess the extent of published Tanzanian neurosurgical data and its accessibility to those practicing within the country.

Methods: A systematic review of all published neurosurgical studies from Tanzania was conducted. Authorship, funding, and open-access status were recorded. Tanzanian neurosurgeons were surveyed by telephone or in person about their methods of accessing literature.

Results: We identified 96 Tanzanian neurosurgical studies published in 42 journals between 1982 and 2023 with an exponentially increasing number of publications per year. Fifty-nine studies (62%) are available open access at the publisher. Open access publication is associated with Tanzanian first authorship (odds ratio = 2.6, 95% CI: 1.0-6.8) or last authorship (odds ratio = 2.7, 95% CI: 1.0-7.1). However, overall only 34 of 96 studies (35%) had Tanzanian first authors and 32 of 96 (33%) had Tanzanian last authors. We contacted 26 of 27 neurosurgeons working in Tanzania. None had in-country institutional library service access. One used a research initiative login to access neurosurgical literature, and 2 used institutional logins from outside Tanzania. Ten neurosurgeons (38%) reported alternative methods of accessing literature behind a paywall such as Sci-Hub or direct contact with authors. These methods could have given access to all but 9 of 96 neurosurgical studies (9%).

Conclusion: Only 62% of Tanzanian neurosurgical literature is easily freely accessible to Tanzanian neurosurgeons, and 9% of all Tanzanian neurosurgical literature is extremely challenging to access for neurosurgeons working in Tanzania. Expanding open-access publishing, repositories, and publisher and institutional initiatives for equitable data and publication access are crucial for improving access to local data to improve patient care.

Background and objectives: This study aimed to investigate the clinical presentation, natural history, and long-term outcome of sporadic cerebral cavernous malformations (CCMs) based on initial Zabramski classification.

Methods: A prospective cohort of 285 patients with sporadic CCMs was analyzed. Patients were classified into Zabramski Types I-IV based on diagnostic MRI. Clinical presentation, lesion size, location, and developmental venous anomaly presence were recorded. Prospective symptomatic hemorrhage (SH) (censored at first hemorrhage, surgery, or last follow-up) and functional outcomes were assessed using Kaplan-Meier and Cox regression analyses. Functional outcomes were measured with the modified Rankin Scale (mRS) at baseline, annually, and at the last follow-up.

Results: The cohort included 58.9% women and 41.1% men, with a mean age at diagnosis of 44.5 years. Zabramski Types I-IV (n = 113, 125, 40, and 7, respectively) differed significantly in clinical presentation ( P < .001). Type I lesions were symptomatic in 97.3%, Types II and III in 34.4% and 22.5%, respectively, while all Type IV lesions were asymptomatic. Type I lesions had the highest annual hemorrhage rate (13.9% per year) and a 5-year cumulative risk of 50.6%. Types II and III had lower rates (2.9% and 1.8%), whereas no hemorrhages occurred in Type IV lesions. At baseline, 70.8% of Type I patients had mRS ≥2, which decreased to 35.4% at the last follow-up. Type III lesions had favorable outcomes, with 7.5% of patients having mRS ≥2 at the last follow-up. Type IV lesions remained asymptomatic throughout. Severe SH significantly increased the odds of poor outcomes (mRS ≥3; P < .001), whereas Zabramski type was not predictive of outcomes after adjustment.

Conclusion: Zabramski classification aids in stratifying hemorrhage risk and guiding management in CCMs. Severe SH is a critical determinant of functional outcomes, underscoring the need for comprehensive risk assessments and individualized patient care strategies.

The blood-brain barrier (BBB) presents a major challenge in administering pharmacological therapy for neurological disorders such as chronic pain. Focused ultrasound (FUS)-mediated BBB opening (BBBO) presents an alternative means of drug delivery. We examine potential candidate drugs and particle technology for use in FUS-mediated BBBO for treatment of pain. In this scoping review, we searched Pubmed and Embase databases for articles discussing FUS and pain. Using the Rayyan platform, we identified 705 articles and 376 were identified for abstract review, ultimately resulting in text review of 95. This scoping review was designed to address the following: (1) What are the limitations of chronic pain treatments in BBB penetration? and (2) What advancements in particles are likely to be used in FUS and BBBO for chronic pain? Despite interest in FUS-mediated BBBO for drug delivery in central nervous system disorders, no human studies have been conducted to assess its efficacy for the treatment of chronic pain. Preclinical work shows that many receptor agonists/antagonists reduce allodynia and hyperalgesia when administered directly to the brain, but not peripherally. Recent advances in particle and FUS technology allows precise targeting of specific brain regions and may hinder efflux and degradation of compounds at target. In combination with advancements in particle and FUS technology, drugs for treatment of chronic pain have been successful in preclinical models. Care must be chosen for selecting parameters, drugs, and particles for initial clinical studies to move the field forward successfully.

Background and objectives: Patients with gliomas often experience neuropsychological deficits affecting their quality of life. Awake surgery (AwS) can reduce permanent cognitive deficits compared with asleep surgery (AsS), but it does not allow intraoperative mapping of all cognitive functions, including attention. Understanding how AwS and AsS affect attention is crucial, given its pivotal role in supporting various cognitive functions.

Methods: We conducted a retrospective analysis on 64 glioma patients treated with AwS or AsS. Attention was assessed with visual search tasks and Trail Making Test Part A before and 1 week and 1 month after surgery. Volumetric T1-weighted and T2/Fluid Attenuated Inversion Recovery MRI sequences before and after surgery were used to delineate the lesion and the surgical cavity. The extent of resection was calculated to determine supramaximal resection for both contrast-enhanced and non-contrast-enhanced tumor regions.

Results: There was a significant decrease in attentional scores 1 week after surgery, followed by a complete recovery. AwS was the only significant predictor of postoperative attentional deterioration. Univariate lesion analysis revealed negative association between lesions in the default mode network and postoperative attentional scores, whereas a multivariate network approach highlighted the involvement of several large-scale functional systems in sustaining attentional processes. AwS patients exhibited more extensive supramaximal resections of non-contrast-enhanced areas, which correlated with immediate postoperative attentional deterioration. The Kaplan-Meier analysis showed significantly longer overall survival for AwS patients with isocitrate dehydrogenase wild-type glioblastomas (mean days = 887.73) compared with AsS patients (mean days = 553.71; P < .05).

Conclusion: Although AwS enables a more extensive resection and thus an improved oncological outcome with longer overall survival rate, it also leads to higher transient postoperative decline in attentional performance. These results emphasize the need for careful patient selection, especially for lesions that involve anterior anatomical regions of the left default mode network. Future developments of standardized, reliable, and quantitative intraoperative monitoring of attention may further optimize surgical outcomes.

Background and objectives: It remains unclear whether decompressive craniectomy (DC) is beneficial in patients who suffer symptomatic intracerebral hemorrhage (sICH) after acute ischemic stroke (AIS). We sought to study the effect of DC on functional outcomes in patients with sICH after AIS who underwent mechanical thrombectomy (MT).

Methods: Patients with AIS from anterior circulation large vessel occlusion who underwent MT and subsequently developed sICH were identified from the Stroke Thrombectomy and Aneurysm Registry database. The primary outcome was acceptable 90-day functional neurological outcome, defined as modified Rankin scale (mRS) 0-3. Multivariable logistic regression and propensity-score matching were used to identify and quantify risk factors.

Results: Of 464 patients identified with sICH after AIS after MT, 97 patients (20.9%) underwent DC. Patients who underwent DC were more likely to be female ( P < .001), younger ( P < .001), have a measured medical comorbidity, have higher baseline mRS ( P = .02), and have higher-grade hemorrhages ( P = .01). At 90 days, 14% of patients had the primary outcome of mRS 0-3 and 56% had died. The primary outcome was observed in 11 patients who underwent DC (11%) and 55 (15%) of those without DC (odds ratio [OR] 0.7, 95% CI 0.4-1.4, P = .40). DC did not affect mRS shift at 90 days ( P = .10) but was associated with lower mortality (OR 0.5, 95% CI 0.3-0.8, P = .01). Multivariable analysis demonstrated that DC decreased the odds of primary outcome (adjusted OR 0.2, 95% CI 0.02-0.9, P = .045), but did not affect mortality ( P = .94), mRS shift ( P = .50), or length of stay ( P = .90). Propensity-matched analysis similarly demonstrated that non-DC patients were more likely to achieve the primary outcome (24% vs 8%, P = .045).

Conclusion: In patients with sICH after AIS after MT, those selected for DC had less favorable outcomes and similar rates of mortality at 90 days.

Background and objectives: It is unknown what determines the volume of aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate the features associated to the burden of subarachnoid hemorrhage after aneurysm rupture and its impact on clinical outcomes.

Methods: Patients admitted with aSAH between 2009 and 2022 were included. Clinical data were obtained from electronic medical records. Aneurysm location and morphological measurements were assessed using digital subtraction angiography. aSAH volume was objectively quantified on admission noncontrast computed tomography using semiautomated software. Univariate and multivariate analyses were performed to identify predictors of hemorrhage volume and examine its association with delayed cerebral ischemia (DCI), clinical vasospasm, and 7-day mortality in younger (18-64 years) and elderly (≥65 years) patients.

Results: Two hundred ruptured intracranial aneurysms were analyzed. Ruptured bifurcating aneurysms exhibited larger hemorrhage volume compared with sidewall aneurysms (23.16 mL, IQR: 34.2 vs 11.95 mL, IQR: 20.9, P = .002). In multivariate analysis, age (exp β 1.02; 95% CI 1.01-1.03; P < .001), Hunt and Hess (exp β 1.46, 95% CI: 1.31-1.62, P <.001), and bifurcation aneurysms (exp β 1.76; 95% CI 1.37-2.26; P <.001) were correlated with increased aSAH volume. Among younger patients, higher aSAH volume was associated with DCI (odds ratio [OR] 1.04; 95% CI 1.02-1.06; P < .001), clinical vasospasm (OR 1.02; 95% CI 1.01-1.03; P = .02), and 7-day mortality (OR 1.05; 95% CI 1.02-1.07; P < .001). In elderly population, larger aSAH was only associated with 7-day mortality (OR 1.04; 95% CI 1.01-1.07; P = .01).

Conclusion: Older age, bifurcating aneurysms, and higher Hunt and Hess are associated with larger aSAH volumes. In younger patients, greater aSAH volume is linked to an increased risk of DCI, clinical vasospasm, and 7-day mortality. Among older patients, increased aSAH volume is only associated with 7-day mortality.

Background: Surgical intervention remains an important option in the management of vestibular schwannoma (VSs). Development of a systematic approach to choose the most appropriate route for this intervention, based on existing published evidence, is an important goal.

Objective: To review the literature published since the 2018 Congress of Neurological Surgeons Guideline on surgical intervention for patients with sporadic VSs and use this information to update that set of recommendations.

Methods: The literature in the PubMed and MEDLINE databases from January 2015 through May 20, 2022, was searched for manuscripts pertaining to surgical intervention for VSs. Those manuscripts meeting inclusion criteria were then analyzed for creation of recommendations in response to a set of updated questions.

Results: The resultant findings included a considerable amount of data that did not alter the recommendations form the 2018 publication on this topic. Thus, recommendations stating hearing preservation surgery through the middle fossa or retrosigmoid approach may be considered in individuals with good preoperative hearing as an alternative to simple observation remain. In addition, if microsurgical resection is necessary after stereotactic radiosurgery, it is recommended that patients be counseled that there is an increased likelihood of a subtotal resection and decreased facial nerve function. In some questions, insufficient data were present to create an answer and that is stated.

Conclusion: This guideline demonstrates surgical intervention for VSs and represents a range of options, and the choice of the intervention depends on the specific aspects of the lesion and the individual that harbors them. Objective refinement of those choices will require thoughtful research design by investigations that wish to address those items for which we still have insufficient information. The full guideline can be seen online athttps://www.cns.org/guidelines/treatment-adults-vestibular-schwannoma/7-surgical-resection-treatment-of-patients-with-ve-2.

Background: Imaging is a critical aspect of vestibular schwannoma (VS) management, influencing essentially every aspect of care including diagnosis, surveillance, treatment decision making, and follow-up after either resection or stereotactic radiosurgery. Despite this, treatment protocols are heterogeneous, and frequently based on historical practices, or low-quality evidence.

Objective: To update evidence-based guidelines for the use of imaging in the clinical management of patients with VS published by the Congress of Neurological Surgeons in 2018.

Methods: Systematic review of the literature published from 1/1/2015 to 5/20/2022 regarding imaging protocols for VS management. Salient questions were identified by a writing group of diverse individuals with topic-specific expertise. Questions were validated by the Congress of Neurological Surgeons Guidelines Committee. Following systematic review, literature tables and summary statements pertinent to the study questions were generated by the writing group, which underwent subsequent evaluation and revision by the task force before formalization.

Results: Seven questions were formulated; adequate literature was identified to formulate updated recommendations for 6 of these. Search strategy identified 1143 unique records, of which 109 underwent full-text review, and 57 were included in this study. Most studies provided level III evidence, with rare level II studies noted, yielding level III recommendations.

Conclusion: The current evidence base for imaging protocols in VS clinical management is broad, diverse, low certainty, and low quality. This in part reflects a heterogeneous disease, although variability in treatment philosophies may also influence local decision making. Key areas for future study include the clinical utility of advanced imaging techniques and head-to-head comparisons of imaging protocols for patients in common initial VS management pathways (eg, observation, resection, or stereotactic radiosurgery). The full guideline can be seen online athttps://www.cns.org/guidelines/treatment-adults-vestibular-schwannoma/5-role-of-imaging-in-management-of-patients-with-v.

Background: Intraoperative neuromonitoring (IONM) has become vital in the management of vestibular schwannoma (VS) with the paradigm shift from tumor eradication to functional preservation. Several facial nerve (FN) monitoring strategies have been explored over the past few decades ranging from free-running electromyography, direct nerve stimulation, continuous nerve stimulation, facial motor evoked potentials, blink reflex, and others. Hearing preservation surgery is guided primarily by far-field auditory brainstem response and real-time cochlear nerve action potentials. Given the heterogeneity in tumor and patient factors, it remains very difficult to accurately predict cranial nerve outcomes, regardless of the monitoring strategy.

Objective: To critically appraise literature regarding IONM during VS surgery and update the previous evidence-based clinical practice guideline.

Methods: This is a systematic review of the literature, incorporating articles from March 2015 to May 2022. Literature published before 2015 that would have been included in the previous Congress of Neurological Surgeons guideline was not searched again in this update.

Results: FN monitoring provides better functional outcomes compared with anatomic dissection alone and may guide the extent of tumor resection. While facial motor evoked potentials and free-running electromyography can provide continuous noninvasive FN monitoring, there are insufficient data to determine which more strongly correlates with facial function outcomes. Both electrophysiological data and tumor size correlate with facial function outcomes. The ideal hearing monitoring strategy remains unclear as there are insufficient data comparing cochlear nerve action potentials with far-field auditory brainstem response. All studies were graded as Class III evidence.

Conclusion: IONM should be used in all VS cases. While the optimal FN and hearing monitoring strategy remains elusive, available data support the use of a combination of strategies, including preoperative tumor size, to maximize sensitivity and specificity. There remains a significant need for high-quality comparative studies to determine which intraoperative monitoring scheme can provide intraoperative guidance and predict postoperative outcome. The full guideline can be seen online athttps://www.cns.org/guidelines/treatment-adults-vestibular-schwannoma/3-intraoperative-cranial-nerve-monitoring-in-manag.