Neurosurgery最新文献

Background and objectives: Since the introduction of the Leksell Gamma Knife to North America in 1987, stereotactic radiosurgery (SRS) has increasingly been used for patients with intracranial meningiomas. We evaluated the evolving application and outcomes of meningioma patients managed with both primary and adjuvant SRS during a 35-year interval.

Methods: The authors reviewed the outcomes of meningioma patients (1229 female, 69.8%; 2220 tumors) who underwent single-fraction SRS from August 1987 to March 2022 and who had a minimum of 6-month follow-up. The rates of treated tumor control and overall survival up to 20 years after SRS were measured. Risk factors analyzed included age, sex, tumor volume, margin dose, Ki-67, anatomical location, and pre-SRS surgical resection.

Results: Primary SRS showed superior tumor control compared with adjuvant SRS after previous resection. Overall, 191 of 2220 patients (8.6%) had local progression at last follow-up with the 5-year, 10-year, 15-year, and 20-year tumor control rates were 92.1%, 88.3%, 84.1%, and 81.1%, respectively. The median overall survival after SRS was 17.4 years, and 2.6% of patients died related to meningioma progression. Patients treated so that ≥60% of the tumor received at least 16 Gy demonstrated significantly superior tumor control. Fifty-eight patients (3.3%) experienced symptomatic adverse radiation effects after SRS.

Conclusion: SRS provided excellent local tumor control rates that extended beyond 20 years. Primary SRS was an effective strategy for patients with unresected or known WHO grade I meningiomas. Adjuvant SRS was an important option to enhance tumor control and survival in patients with residual or progressive tumors after resection.

Background and objectives: Firearm-related penetrating traumatic brain injury (pTBI) carries a high mortality risk and grim prognosis. This study aimed to quantify interhospital variation in operative intervention for this patient population and assess whether cranial surgery tendency is associated with inpatient mortality.

Methods: We conducted a retrospective cohort study using the American College of Surgeons Trauma Quality Improvement Program (TQIP) data set to identify adult patients presenting with firearm-related pTBI. Risk-adjusted hierarchical regression evaluated associations with cranial surgery. Hospitals were stratified into quartiles based on surgical tendency (lowest, quartile 1; highest, quartile 4 [Q4]). Propensity score matching was performed across quartiles, and a multivariable regression model was constructed to investigate associations between hospital quartile and inpatient mortality. Effect modification by pupillary reactivity was tested.

Results: Cranial surgery rates for 4895 patients (median age, 31 years) varied widely across 309 hospitals (0%-71%; median, 21%; median odds ratio, 1.33). After matching, treatment at Q4 hospitals was associated with significantly reduced odds of mortality compared with treatment at quartile 1 hospitals (odds ratio, 0.61; 95% CI, 0.47-0.78). Patients presenting with one (interaction P = .03) or both (interaction P = .03) unreactive pupils experienced amplified survival benefits from treatment at Q4 hospitals.

Conclusion: Substantial interhospital variation exists in operative intervention for firearm-related pTBI. Hospitals with higher surgical tendency were associated with improved survival, and this effect was amplified for patients presenting with unreactive pupils. These findings suggest a need to standardize operative decision-making for patients with firearm-related pTBI, aligning with ongoing efforts by organizations such as the Brain Trauma Foundation.

Background and objectives: Dural arteriovenous fistula (DAVF) is a rare cerebrovascular disease, but current studies have not revealed its etiology. The aim of our study was to explore the relationship between single-nucleotide polymorphisms, DAVF formation, and angioarchitecture.

Methods: This study included 118 DAVF patients who received treatment and underwent genetic sequencing at our hospital. We sequenced the exons of 7 genes and investigated correlations between single-nucleotide polymorphisms, testing results, and clinical characteristics.

Results: Among 118 patients (70.3% male, mean age 45.6 years), transverse/sigmoid sinus was the most common shunt location (47.5%). Pial feeders were present in 43.2% of cases, and 39.8% had cerebral venous sinus thrombosis (CVST). Genetic sequencing revealed 22 nonsynonymous mutations, with the PROS1 gene accounting for 9 sites. Pial feeders were associated with lower D-dimer levels ( P = .012) and higher prothrombin time and international normalized ratio values ( P = .012 and .004). CVST cases had lower protein S and adenosine diphosphate platelet aggregation levels ( P = .016 and .042) and higher prothrombin time/international normalized ratio values ( P = .040 and .047). Risk analysis indicated that MTHFR c.665 T/T carriers had reduced risks of pial feeders and high Borden grade DAVFs, whereas PROS1 c.2097 A/G and G/G genotypes were linked to elevated CVST risk.

Conclusion: This study represents the most comprehensive study of DAVF genetic characteristics to date, featuring the broadest range of genes and the largest patient cohort. Protein S levels are significantly reduced in DAVF patients with CVST, and the PROS1 c.2097 A>G polymorphism is identified as a significant risk factor of sinus thrombosis in these patients.

Background and objectives: The growing importance of diversity in health care and medical education prompted this study to identify trends and disparities in academic neurosurgery. The goal was to provide insights for reshaping future policies and educational strategies while evaluating the evolution of gender and racial/ethnic representation over time. The aim of this study was to assess demographic trends of neurosurgical academic faculty in the United States from 2012 to 2021, within the context of the neurosurgical educational pipeline.

Methods: A retrospective analysis was conducted using data from the Association of American Medical Colleges Report on Residents and the Accreditation Council of Graduate Medical Education GME Data Resource Book(s). The study focused on race, ethnicity, and gender data of medical school and neurosurgical residents and faculty from academic years 2012 to 2021.

Results: Neurosurgery Faculty Trends (2012-2021): The data revealed that diversity of neurosurgery faculty lags behind the diversity of the US population at large. Most academic neurosurgery faculty positions are currently held by White and Asian physicians. There has been no significant increase in the proportion of neurosurgery faculty from ethnic groups viewed as underrepresented in neurosurgery over this time period. Neurosurgery faculty members and residents are predominately male, though there is a trend toward an increase in female neurosurgeons.

Conclusion: The study is the first in neurosurgical literature to examine trends in neurosurgery faculty composition by race and gender over the past 10 years. To see changes in the demographics in the future, intentional efforts at diversification of the neurosurgery pipeline are needed.

Background: Penetrating traumatic brain injury (pTBI) affects civilian and military populations resulting in significant morbidity, mortality, and health care costs. No up-to-date and evidence-based guidelines exist to assist modern medical and surgical management of these complex injuries.

Methods: A preliminary literature search informed a need for updated guidelines. Methodologists experienced in TBI guidelines supported 2 co-chairs, a diverse steering committee and three expert working groups. Over half of our panelists were active service military or military veterans and they addressed twenty-six Key Questions (KQs). We searched Ovid MEDLINE®, EMBASE, and Cochrane CENTRAL from inception to August 31, 2022, reference lists, and clinical trial registries. Penetrating, perforating and tangential penetrating brain injuries were included. Predefined criteria were used to identify studies; pre-specified methods were used to assess study quality and strength of evidence for key outcomes. Effects were analyzed qualitatively and quantitatively where appropriate.

Results: 125 studies provided evidence and another 80 studies provided contextual data for these guidelines. In general there was a paucity of literature and most of the identified evidence was judged to be high risk of bias due to study design. We did not identify any studies meeting inclusion criteria for 12 KQs. The highest quality evidence, rated moderate in strength, was identified for four KQs that covered: cerebral angiography vs computed tomography angiography, the relationship between bihemispheric injury in adult pTBI and mortality, the ability of the Surviving Penetrating Injury to the Brain (SPIN) score to predict mortality, and the relationship between infection and cerebrospinal fluid fistula. Evidence for most KQs came from case series.

Conclusions: The development of up-to-date evidence and consensus based clinical care guidelines and algorithms for pTBI provide guidance to care providers in the prehospital and emergency medicine, surgical and intensive care settings. Few moderately strong conclusions on the benefit of specific management strategies for penetrating brain injury could be made. Detailed reporting of patient outcomes in future studies could advance the field by providing greater evidence for specific treatments by patient population, mechanism of injury, severity of injury, and specific interventions employed.

Background and objectives: Recent efforts have highlighted gender disparities in neurosurgery in leadership, conference involvement, and scientific productivity. Despite efforts to improve diversity, systemic barriers persist. Given the weight publications carry in the neurosurgical match, this study analyzes gender differences in publication metrics among matched neurosurgical residency applicants, identifying opportunities to increase female representation.

Methods: Neurosurgical residents from the 2023 match were examined using PubMed, Scopus, and departmental websites for detailed publication information, program details, gender, and medical school.

Results: Of the 242 successfully matched applicants, male applicants tended to work with male senior authors (84.62% vs 76.68%, P = .044), and more female applicants worked with female senior authors (23.21% vs 15.33%, P = .045). Having a female senior author increased odds of female first authorship (odds ratio = 1.64, 95%, P < .001). Compared with female-identifying applicants, male-identifying applicants had more publications (11.80 vs 6.78, P < .001), first-authorships (3.88 vs 2.00, P < .001), higher H-indices (4.74 vs 3.27, P < .001), and more unique senior authors (5.63 vs 4.37, P = .036). Male applicants published more often in spine ( P < .001). Geographically, female applicants were more likely from the West, least likely from the South ( P = .036), and more likely to match at home programs than male applicants (32.8% vs 19.8%, P = .037).

Conclusion: For matched neurosurgical applicants, gender of the senior author influences likelihood of junior authorship. Specifically, having female senior authors correlates with increased likelihood of publication for female applicants and is associated with female first authorship. Gender disparities persist in publications: male applicants typically publish, collaborate with senior authors, and work with male senior authors at higher rates. These results highlight systemic barriers female applicants face in preparing competitive applications and ensuring equal residency acceptance. Research instruction and active mentorship of female applicants from both male and female neurosurgical mentors is critical to improving gender disparity in neurosurgery.

Background and objectives: Identifying prognostic factors and biomarkers to predict postoperative outcomes in patients surgically treated for cervical spondylotic myelopathy (CSM) is an area of ongoing research. While intraoperative spinal cord perfusion changes are believed to play a role, few imaging modalities can readily quantify spinal cord perfusion intraoperatively. Contrast-enhanced ultrasound (CEUS) shows promise in evaluating neural structure perfusion but has only been demonstrated postdecompression. Capturing predecompression and postdecompression CEUS spinal cord perfusion data is essential to understanding perfusion's role in recovery after surgical decompression for CSM. We aimed to develop a technique for acquiring CEUS spinal cord perfusion predecompression and postdecompression in patients with CSM and to correlate perfusion data with preoperative and long-term neurologic status.

Methods: Sixteen adult participants undergoing elective posterior cervical decompression for CSM were enrolled. Before and immediately after decompression, a 10 µL/kg bolus of DEFINITY contrast was administered intravenously. The spinal cord was imaged in the midline sagittal plane for 120 seconds. CEUS data were analyzed using time intensity curve analyses where wash-in-time (WIT), appearance-time, and time-to-peak were calculated. Demographics, neurologic examinations, and modified Japanese Orthopedic Association scores were collected preoperatively and postoperatively.

Results: The CEUS technique for predecompression and postdecompression spinal cord perfusion imaging was feasible and void of complications. WIT values significantly correlated with neurologic status, as measured by modified Japanese Orthopedic Association scores. Specifically, WIT values correlated with preoperative (slope = -0.20, 95% CI [-0.37, -0.02], F [1,14] = 6.00, P = .028), 1 month postoperative (slope = -0.27, 95% CI [-0.47, -0.06], F [1,14] = 7.56, P = .016), and 6 month postoperative scores (slope = -0.28, 95% CI [-0.49, -0.07], F [1,14] = 8.08, P = .013).

Conclusion: CEUS can acquire spinal cord perfusion data before and after decompression in patients with CSM. This modality shows promise in elucidating the role of perfusion in CSM recovery and may serve as a prognostic tool.