Neurosurgery最新文献

Background: Given the increasing prevalence and shifting disease demographic of vestibular schwannoma toward smaller tumors in people with less advanced symptoms, increasing emphasis has been placed on functional hearing preservation.

Objective: To provide an update to the 2018 CNS Guideline on hearing preservation outcomes in patients with sporadic vestibular schwannoma.

Methods: Systematic review and clinical practice guideline summarizing data pertaining to hearing preservation outcomes within the first 10 years after contemporary stereotactic radiation, microsurgery, or observation with serial imaging. The analysis incorporates studies included in the 2018 guideline and additional literature published up to May 20, 2022, providing a comprehensive up-to-date review of published clinical outcome data over time.

Results: Pooled estimated rates of serviceable hearing preservation are presented for observation, radiosurgery, and microsurgery for adults with sporadic vestibular schwannoma who have documented serviceable hearing in the ipsilateral ear at the time of diagnosis. Overall estimated rates of maintaining serviceable hearing are 78% at 2 years, 59% at 5 years, and 47% at 10 years during observation; 71% at 2 years, 59% at 5 years, and 38% at 10 years after radiosurgery; and 48% at 2 years, 40% at 5 years, and 32% at 10 years after microsurgery. In addition, features portending hearing outcome among management modalities are reported to guide accurate patient counseling.

Conclusion: Regardless of treatment modality, fewer than half of patients with sporadic vestibular schwannoma who present with serviceable hearing will maintain useful hearing by 10 years. Across all studies, microsurgery and radiosurgery seem to accelerate this decline over the natural history, although further research is needed given limitations of available evidence. The full guideline can be seen online athttps://www.cns.org/guidelines/treatment-adults-vestibular-schwannoma/4-hearing-preservation-outcomes-in-patients-with-s.

Background and objectives: Papillary tumors of the pineal region (PTPR) are rare neuroepithelial tumors that are at high risk of local recurrence even after gross total resection. Their optimal management, including the potential role of stereotactic radiosurgery (SRS), remains a matter of debate. Only a few retrospective outcome studies have been reported. This study was designed to provide multi-institutional data to strengthen the evidence related to the use of SRS for PTPR.

Methods: Centers participating in the International Radiosurgery Research Foundation were asked to provide data for patients who had SRS and at least 6 months of follow-up for a histology-confirmed PTPR.

Results: In total, 19 patients (12 male and 7 female) underwent SRS for PTPR in 6 institutions: 7 patients had primary SRS after biopsy, 9 had adjuvant SRS, and 3 had SRS for recurrent tumor. The median margin dose used was 16 Gy, and median treatment volume was 1.73 cc. Initial local control was achieved in all patients after SRS, with a median progression-free survival of 5 years. A total of 6 patients had local recurrence, managed by repeat SRS in 4 patients, surgical resection in 1, and both interventions in the other. The cumulative actuarial local control at 20 years, considering additional SRS procedures as needed, was 69%. One patient had ventricular and leptomeningeal dissemination which led to death. The mean survival duration was 15.8 years, with an estimated survival rate of 83% at 10 years and 69% after 20 years. Adverse radiation effects were observed in 5 cases, 4 of which were symptomatic, but eventually resolved in all patients.

Conclusion: SRS for PTPR is safe and enables local tumor control in most cases. SRS can be considered as primary management after diagnosis of PTPR.

Background and importance: Craniopagus deformity is a rare congenital anomaly occurring in 1 of 1 700 000 live births and represents 2%-6% of all conjoined twins. Staged surgical separation, with a focus on disconnecting shared venous anatomy, has become the mainstay of treatment for most patients in the modern era. The aim of this report was to classify the shared venous anatomy of these twins and determine implications on surgical separation.

Clinical presentation: Cases from Dr James Goodrich's library were classified and rendered according to their venous anatomy into virtual models. Data from 16 sets of twins were studied. Two were O'Connell type I, 4 were type II, and 10 were type III twins. Two patterns of venous anatomical communication and sharing emerged with twins showing a more acute angle of rotation demonstrated a common circumferential sinus pattern, and twins with a greater rotational angle (type II) demonstrated a helical sinus orientation of their sagittal sinuses.

Conclusion: This is the largest anatomical study of craniopagus twins, focused on shared venous anatomy. A better understanding of the anatomical patterns of these patients may result in safer surgical disconnection in the future. We observed that as axial rotation approaches 90°, the organization around a circumferential sinus slowly transitions into a continuous helical sinus, connecting the anterior superior sagittal sinus of each twin. In the future, as our understanding of the vascular anatomy matures, a vessel-specific plan for separation within these two patterns, taking into account blood flow and perfusion, will be possible before ever stepping foot into the operating room.

Background and objectives: Healthcare policies have seen significant reforms, with a marked transition toward a patient-centered approach. This shift emphasizes the use of subjective patient-reported outcome measures as key metrics. However, these measures often face limitations, particularly in identifying clinically meaningful changes over time. To address this challenge, the concept of the minimal clinically important difference (MCID) was introduced. This study aims to evaluate the predictive effectiveness of relative change and its associated threshold, the minimal clinically important relative change (MCIRC), as a potential alternative to absolute differences and the MCID.

Methods: Data prospectively collected between 2006 and 2021 from the Swedish Spine Registry (Swespine) were analyzed. Patient-reported outcome measures included the Numeric Rating Scale (NRS) for neck and arm pain, the EQ5D index, EQ VAS, and the Neck Disability Index (NDI). Anchor-based methods were used to calculate the MCID and MCIRC. The predictive performance of absolute differences and relative changes was compared using the area under the receiver operating characteristic curve.

Results: 1756 patients were included. The selected MCID values were -3 for NRS neck pain intensity, -2 for arm pain intensity, 0.09 for the EQ5D index, 7 for EQ VAS, and -12 for NDI scores. For MCIRC, the chosen values were -47% for NRS neck pain intensity, -40% for arm pain intensity, 386% for the EQ5D index, 52% for EQ VAS, and -32% for NDI scores. On area under the ROC curve, relative change was superior for NRS neck and arm pain scores and NDI, while absolute difference was superior for EQ5D and EQ VAS scores.

Conclusion: Relative change, along with its associated minimal clinically important value (MCIRC), proved to be a more suitable indicator of subjective satisfaction for NRS and NDI scores. By contrast, absolute differences and the MCID were better suited for evaluating the EQ5D index and EQ VAS scores.

Background and objectives: The prevalence of pial arterial supply (PAS) to intracranial dural arteriovenous fistulas (DAVFs) and its implications for the management of these fistulas have been limited to relatively small cohort studies and remain somewhat controversial. We conducted a retrospective study to characterize PAS in DAVFs and explore its implications for treatment.

Methods: Consecutive patients evaluated over a 21-year period were retrospectively reviewed. Angiograms were examined to characterize the angioarchitecture of DAVFs and identify the presence of PAS. PAS was classified into 2 types: dilated preexisting dural branches and pure pial supply. Baseline characteristics, treatment approaches, and treatment and follow-up outcomes were compared between the DAVF cohorts with and without PAS. To minimize patient selection bias, the 2 cohorts were matched in a 1:1 ratio using propensity score matching.

Results: In this cohort, 259 out of 1101 patients (23.5%) exhibited an additional PAS. Multivariate analysis identified 7 independent predictors of PAS: younger age ( P < .001), longer disease duration ( P = .021), multiple DAVFs ( P < .001), tentorial DAVFs ( P < .001), transverse-sigmoid sinus DAVFs ( P < .001), and the presence of venous ectasia ( P = .019) and congestion ( P < .001). Complication rates were higher in the PAS group, particularly for postoperative hemorrhage ( P < .001) and ischemia-related complications ( P < .001), which remained significant even after propensity score matching ( P = .013 and P = .001).

Conclusion: The findings suggest that embolization of PAS before DAVF closure may significantly increase the risk of both intracranial hemorrhagic and ischemic complications. Therefore, routine embolization of PAS before DAVF closure is not supported by these results, particularly given the exceptionally low incidence of presumed hemorrhagic complications arising from an unobliterated "pure" pial supply before DAVF obliteration.

In 2019, the Congress of Neurological Surgeons published clinical practice guidelines for the management of myelomeningocele (MMC), which were informed by Level I evidence from the Management of Myelomeningocele Study trial and aimed to optimize clinical outcomes, particularly regarding prenatal vs postnatal repair. This study evaluates the perceived impact of these guidelines on the pediatric neurosurgical community. A cross-sectional survey was distributed to 700 members of the pediatric neurosurgery community, with 98 responses analyzed. The survey addressed practice patterns, familiarity with the guidelines, and barriers to guideline adherence. Among centers with higher volumes of MMC repairs, there was a reported increase in referrals for prenatal repair, with 25% of domestic and 5% of international respondents offering prenatal repair postguidelines. However, prenatal repair remains limited, particularly in lower-volume and international centers. Barriers such as insufficient training, lack of fetal surgery programs, and limited institutional resources were frequently cited. Regional differences in perceptions regarding ventriculomegaly and tethered cord syndrome further highlight the variability in guideline interpretation. Notably, 71% of international respondents believed persistent ventriculomegaly negatively affects neurocognition, compared with only 30% of domestic respondents. While the guidelines have influenced clinical practices, their implementation remains uneven. The findings underscore the influence of institutional capacity, volume of practice, and regional differences on guideline adoption. Although the 2019 Congress of Neurological Surgeons guidelines have made strides in improving MMC care, continued efforts are necessary to address these barriers, especially in resource-limited settings. Collaboration among academic institutions, policymakers, and healthcare providers is critical to enhancing global implementation of evidence-based practices for myelomeningocele management. Further research is needed to refine practices and standardize outcome measures.

Background and objectives: Chronic subdural hematoma (CSDH) often recurs after surgical evacuation, with rates ranging from 2% to 37%. Middle meningeal artery embolization (MMAE) has emerged as a potential adjunct to surgery to reduce recurrence. The aim of this study was to systematically review the added value of adjunctive MMAE to surgical treatment (MMAE+S) compared with surgical treatment alone (S) in managing CSDH with consideration to matching and randomization status of the 2 groups.

Methods: A systematic search identified 16 studies encompassing 1814 patients (939 MMAE+S, 1440 S). Five studies were randomized trials, 3 studies were matched studies, and the remaining were unmatched cohorts. Data on recurrence, radiological and functional outcomes, complications, and hospital stay were analyzed using a random-effects meta-analysis. The risk of bias was evaluated using Risk of Bias in Nonrandomized Studies of Interventions and Risk of Bias in Randomized Trials tools.

Results: The 2 treatment groups were comparable regarding all preoperative characteristics except for antithrombotic use which was higher in the MMAE+S group ( P = .03). Compared with surgery alone, the MMAE+S group had significantly lower recurrence rates (4.7% vs 17.7%, relative risk [RR] 0.31, P < .01) and reduced postoperative hematoma thickness (standardized mean difference [SMD] -0.17, P = .04), volume (SMD -0.25, P = .01), and midline shift (SMD -0.24, P = .01). Reduced recurrence was also observed in the subgroup of matched/randomized studies (RR 0.28, P < .01) and only randomized studies (RR 0.28, P < .01). Complication rates were comparable between the 2 groups when analyzing all (RR 0.90, P = .46), matched/randomized (RR 1.05, P = .62), and only randomized studies (RR 1.05, P = .63). The outcomes were influenced by the choice of embolic agent and timing of embolization, with liquid agents, and postoperative embolization showing slightly better outcomes compared with other embolization approaches. Functional outcomes, complications, mortality, and length of hospital stay were comparable between groups.

Conclusion: MMAE combined with surgery effectively reduces CSDH recurrence and improves radiological outcomes without increasing complications. These findings support MMAE as a valuable adjunct to surgical treatment, warranting further research to optimize its clinical application.