Neurosurgery最新文献

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.

Background and objectives: Hemangioblastomas (HGBs) are rare, benign, World Health Organization grade 1 vascular tumors, which are most commonly located in the cerebellum, and may occur sporadically or in association with von Hippel-Lindau (VHL) disease, a hereditary VHL-mutated tumor syndrome. Limited data are available regarding factors affecting outcomes after stereotactic radiosurgery (SRS). We aim to provide a contemporary evaluation of SRS for HGBs through an international, multicenter study. In this study, we assess local tumor control and SRS-related complications in patients with intracranial HGBs.

Methods: A retrospective analysis from 17 centers was performed. Data on patient characteristics, SRS parameters, and outcomes were collected. The study included 104 patients with VHL and 89 sporadic cases, with 433 and 137 tumors, respectively. The median follow-up after the initial SRS was 52 months for patients with VHL and 44 months for sporadic cases.

Results: At the last follow-up, tumor control was achieved in 85% of VHL tumors and 76% of sporadic tumors. Radiation-induced changes were identified in 13 (3.5%) VHL cases and 5 (3.8%) sporadic cases. The overall 3-year and 5-year cumulative incidences of tumor progression were 13% and 22% for all tumors, 14% and 25% for VHL, and 13% and 17% for sporadic cases. Tumor progression was more common in cystic than in solid tumors in the sporadic group. Overall survival probability and progression-free survival were better in VHL cases compared with the sporadic group. Older age at SRS, male sex, and multiple tumors were associated with reduced local tumor control in all tumors and in the VHL group, whereas a margin dose >15 Gy was associated with improved local tumor control in both groups.

Conclusion: SRS offers an effective treatment of intracranial HGBs, whether VHL-associated or sporadic, with a favorable risk profile. HGBs without a cystic component were more likely to be controlled after SRS in the sporadic group.

Background and objectives: Hydrocephalus is a rare and potentially fatal complication of methylmalonic acidemia (MMA) and is associated with a poor prognosis, requiring prompt clinical decision making. The aim of our study was to evaluate the clinical characteristics and quality of life of infants with hydrocephalus caused by MMA and to determine the optimal timing of surgery.

Methods: This is a retrospective observational study. We reviewed 77 MMA-related hydrocephalus cases from 1671 hydrocephalus patients admitted between June 2012 and March 2022. Data collected included clinical characteristics, surgical data, and health-related quality of life assessed using the Pediatric Quality of Life Inventory (PedsQL™) 4.0 generic core scales.

Results: The most common clinical manifestations were developmental retardation, poor appetite, and altered consciousness. The most frequent mutation was c.609G>A in MMACHC gene (70%). Sixty-six patients (85.7%) underwent ventriculoperitoneal shunting with higher Evans index than the non-VPS group ( P < .001). An Evans index cutoff point of 0.45 was identified. The non-VPS group scored better on all PedsQL™ domains. Of the 66 cases in the ventriculoperitoneal shunting group, 19 (24.7%) needed revision surgery. They had a shorter duration of drug treatment ( P = .002) and underwent surgery at a younger age ( P = .049) than those in the nonrevision group. Optimal cutoff points were duration of drug treatment >1 month and age of surgical treatment >4.5 months. The revision group had lower psychosocial health and school functional scores.

Conclusion: Our study provides insights into the clinical profile and health-related quality of life of patients with hydrocephalus caused by MMA. Those with severe hydrocephalus had lower PedsQL™ scores and need surgery. The optimal timing for surgery in these patients is Evans index >0.45, duration of drug treatment >1 month, and age of surgical treatment >4.5 months after birth to reduce surgical complications and improve quality of life.

Background and objectives: The Silk Vista Baby (SVB) flow diverter (FD) stent (Balt SAS) is the first device designed for treating distally located brain aneurysms. It can be delivered through a 0.017-inch ID microcatheter, enabling access to small, distal vessels. The aim of this study was to evaluate the effectiveness, safety, technical success, occlusion rate, and clinical outcomes of the SVB device.

Methods: This retrospective, multicenter study included data from 18 centers from November 2023 to September 2024. Procedures were performed by experienced neurointerventionalists following institutional standards of care. Outcomes analyzed included effectiveness, safety, and aneurysm occlusion rates. Descriptive analyses and Pearson χ 2 or Independent t -Test were used for statistical evaluation.

Results: A total of 95 patients, mean age 55.4 years, were included. A total of 31% of aneurysms were ruptured at admission. Most (58.3%) were located in the anterior circulation, and 45% had previous treatment, mainly coiling (69.4%). Complication rates were higher for ruptured aneurysms (24.1%) compared with unruptured ones (9.2%). Two deaths occurred, 1 (1.1%) related to the procedure. At discharge, 87% of patients had modified Rankin Scale ≤2. The latest follow-up showed overall complete/near-complete occlusion rates of 76.1%, with 81.14% for ruptured and 73.43% for unruptured aneurysms. Technical success was higher in unruptured cases (100% vs 93.1%).

Conclusion: Our case series demonstrated the efficacy of the SVB with a high rate of technical success. The occlusion rates for ruptured cases are comparable with those of other FDs. However, the rates are lower for unruptured cases. This discrepancy is likely due to the characteristics of the aneurysms, particularly in the presence of side branches in bifurcation lesions. The SVB safety profile is similar to other FDs in unruptured cases, while the ruptured group presented more complications.

Background: Vestibular schwannoma (VS) represents a benign tumor of the vestibulocochlear nerve that presents with otologic dysfunction. Although MRI remains the most common technique for imaging diagnosis of VS, there are no unifying guidelines to suggest when a practitioner should obtain a screening MRI for new otologic complaints to rule out VS.

Objective: We aim to assess the diagnostic yield of MRI in the detection of VS in patients presenting with asymmetric sensorineural hearing loss (SNHL), unilateral tinnitus, and sudden SNHL.

Methods: The questions from the previously published guideline were updated to patient/intervention/comparison/outcome format. A comprehensive literature search from 1/1/2015 to 5/20/2022 was performed to answer preconceived research questions drafted by the joint tumor task force. A systematic review of the existing body of evidence was conducted based on predefined inclusion criteria to determine the diagnostic yield of MRI for the diagnosis of VS in patients presenting with (1) asymmetric SNHL, (2) unilateral tinnitus, and (3) sudden SNHL.

Results: Of the 704 articles initially reviewed, 14 individual publications incorporating 13 733 patients met inclusion criteria. When considering nonredundant data sets, the diagnostic yield of MRI for VS remains low in patients presenting with SNHL (1.68%), unilateral tinnitus (1.56%), and sudden SNHL (3.66%).

Conclusion: This document serves as Congress of Neurologic Surgeon's most up to date and current recommendations on the audiometric screening of VS expanding on the previous 2018 version. Patients presenting with otologic complaints of asymmetric SNHL, tinnitus, or sudden SNHL have an estimated 1%-3% chance of a VS being the causative lesion. Current screening protocols have an approximate 15% rate of abnormal MRI leading to a diagnosis other than VS meaning that 85% of patients presenting with asymmetric SNHL, tinnitus, and sudden SNHL will have no structural cause on imaging studies. The full guideline can be seen online athttps://www.cns.org/guidelines/treatment-adults-vestibular-schwannoma/2-audiologic-screening-in-diagnosis-management-of.

Background and objectives: This study aimed to evaluate predictors of hypertrophic olivary degeneration (HOD) in patients with brainstem cerebral cavernous malformations (CCMs) and to examine its association with functional outcomes.

Methods: A cohort of 120 patients with brainstem CCM was analyzed using prospectively collected registry data and retrospective chart reviews. Demographic, clinical, radiological, and surgical data were evaluated. Predictors of HOD and poor functional outcomes were identified through univariate and multivariate analyses.

Results: The cohort included 54 females (45.0%), with a mean age at diagnosis of 43.8 years (SD = 16.5). Symptomatic hemorrhage was present in 70.8% of patients at diagnosis, and 28.3% underwent surgical intervention. Radiographic HOD was observed in 20% of patients (n = 24), with 87% of cases involving lesions within the Guillain-Mollaret triangle (GMT). Larger lesion size (odds ratio [OR] = 1.09, 95% CI: 1.01-1.19, P = .027), pontine location (OR = 19.81, P = .006), and GMT involvement (OR = 25.24, P < .001) were significantly associated with HOD. Repeated symptomatic hemorrhage and surgery, including the extent of resection, did not predict the development of HOD. Patients with HOD had worse functional outcomes at last follow-up ( P = .012), with GMT involvement remaining the sole independent predictor of mRS ≥3 (OR = 3.44, P = .040).

Conclusion: HOD reflects trans-synaptic degeneration within the GMT and is strongly associated with lesion location and size. It serves as a radiological marker of cumulative damage to the brainstem. Preoperative imaging and risk stratification focusing on GMT involvement are critical for guiding management and counseling patients with brainstem CCM.

Background and objectives: Major depressive disorder affects approximately 10% of all adults in the United States, but the condition remains underdiagnosed for patients with degenerative spine disease and radicular pain. The impact of comorbid undiagnosed depression on postoperative outcomes after lumbar fusion is not well characterized and may contribute to excessive health care utilization. This study isolates the relationship between undiagnosed depression, assessed by the Patient Health Questionnaire 2 (PHQ-2) screening tool, and short-term postoperative outcomes after single-level posterior lumbar fusion.

Methods: PHQ-2 data were prospectively collected, and retrospectively reviewed, among consecutive patients (n = 3225) undergoing single-level posterior-only lumbar spinal fusion surgery over 10 years at a multihospital academic medical center. Coarsened exact matching analysis was performed to match patients on factors known to affect outcome, isolating the impact of PHQ-2 scores. Matched characteristics included sex, race, body mass index, smoking status, median household income, and medical comorbidities determined by the Charlson Comorbidity Index. Primary outcomes were emergency department visits, readmission, and discharge disposition after surgery. Secondary outcomes included reoperation, intraoperative complications, and length of postoperative stay.

Results: Amongst all patients undergoing surgery, 306 (9.5%) patients showed risk for depression (PHQ-2 scores of 3-6). High-risk patients had significantly more 90-day postoperative emergency department visits ( P = .0348, odds ratio = 1.93 [1.04, 3.61]) when compared with otherwise matched patients with no risk factors for depression (PHQ-2 score 0). There were no differences in intraoperative complications, length of stay, discharge disposition, readmissions, or reoperations.

Conclusion: Elevated preoperative PHQ-2 depression screening scores are associated with increased postoperative resource utilization after lumbar spinal fusion. The PHQ-2, as a predictor of undiagnosed depression, may identify high-risk populations before surgery. Prospective studies to assess mitigation strategies to improve outcomes, and reduce resource utilization, are warranted.

Background: Stereotactic radiosurgery (SRS) is an established modality for treatment of adult patients with vestibular schwannomas (VS). The aim of this work was to provide an updated literature review on this topic.

Objective: To review the literature published since the last guideline on this topic.

Methods: OVID MEDLINE and Embase were searched for the period January 1, 2015, to May 20, 2022, using search terms and search strategies to identify pertinent abstracts. These were then screened using published exclusion/inclusion criteria to identify full-text review articles. Evidence tables were constructed using data derived from full-text reviews and recommendations made from the evidence derived.

Results: From the total 1035 abstracts identified, 26 full-text articles met inclusion/exclusion criteria and were included in this update. Four new level III recommendations stemmed from this work. In adult patients with sporadic intracanalicular or <2 cm VS, SRS should not be recommended as superior to observation alone for hearing preservation. In adult patients with sporadic VS treated with SRS, cochlear dose constraint should be considered because it provides better hearing preservation than no constraint. In the same population, single fraction SRS should be recommended rather than hypofractionated SRS (>1 and ≤5 fractions) because it results in decreased cranial nerve dysfunction. Finally, adult patients with sporadic VS undergoing SRS should be informed that SRS does not result in an increased number of secondary malignancies compared with the rate expected in the overall population.

Conclusion: Recent published literature provides new recommendations for the treatment of adult patients with VS with SRS. The full guideline can be seen online athttps://www.cns.org/guidelines/treatment-adults-vestibular-schwannoma/6-role-of-radiosurgery-srs-radiation-therapy-in-ma.