Neurosurgery最新文献

Background and objectives: Comparing microsurgery and embolization for spinal cord arteriovenous malformations (SCAVMs) is challenging because of the disease's rarity and the highly heterogeneous angioarchitecture. The aim of this study was to compare outcomes between microsurgery and embolization using a grading system for SCAVMs that effectively stratifies angioarchitectural complexities.

Methods: A total of 714 patients were included, with 308 undergoing microsurgery. The grading system was developed based on independent risk factors of incomplete resection, including anterior sulcal artery supply, metameric manifestations, the maximum diameter of lesion, and lesion depth. Each parameter was assigned one point, stratifying angioarchitectural complexities of SCAVMs into five grades.

Results: Microsurgery carried significantly higher treatment risks than embolization across all grades. For patients scoring 0 to 2 points, microsurgery achieved significantly higher complete obliteration rates than embolization. For patients scoring 3 or 4 points, the complete obliteration rates between the two methods were similar. Long-term clinical deterioration after microsurgery was significantly more frequent after embolization for patients scoring 1; for patients scoring 0, the higher long-term deterioration rate after embolization was also observed, but not statistically significant; for patients scoring 2 to 4 points, risks of long-term clinical deterioration between the two methods were comparable. At the last follow-up, the rate of poor prognosis was similar between the two methods for patients scoring 0 points. For the remaining groups, microsurgery showed a worse prognosis.

Conclusion: Embolization should be the primary treatment option for patients with SCAVMs; however, microsurgery should be considered as an alternative for patients scoring 0 or 1 point if endovascular treatment fails to achieve complete obliteration.

Background and objectives: To assess the impact of subventricular zone (SVZ) invasion on neurocognitive dysfunction in patients with diffuse glioma.

Methods: We analyzed neuropsychological assessments of 129 patients with World Health Organization grade 2-4 treatment-naive diffuse glioma (2017-2023). Univariable and multivariable regression analyses were used to identify factors associated with cognitive dysfunction. A nomogram was developed to predict cognitive impairment probabilities, and the model's predictive accuracy was assessed using area under the curve. Statistical analyses were performed using IBM SPSS 20 and R. A P -value of <.05 was considered significant.

Results: SVZ invasion (SVZ+) was present in 64 patients and was linked to more cognitive deficits compared with SVZ- (65 patients). In low-grade gliomas, SVZ+ increased risks of language and visual learning impairments, whereas in high-grade tumors, it heightened language and auditory learning vulnerabilities. In right hemispheric tumors, SVZ+ conferred worse global cognition, executive, and language function; in left hemispheric tumors, SVZ+ increased risks of language and auditory learning impairments. Frontal horn of SVZ+ was related to working memory decline, and body part of SVZ+ was related to emotional deficits. SVZ+ was an independent predictor of cognitive decline alongside age, T2 volume, and World Health Organization grade. A final model and nomogram composed of age, T2 volume, and SVZ invasion achieved moderate predictive accuracy (area under the curve 0.749) for cognitive dysfunction.

Conclusion: SVZ invasion affects preoperative neurocognitive function independent of tumor laterality and grade, with distinct SVZ subregions associated with specific cognitive impairments. These findings highlight the need for precise tumor mapping considering the SVZ to evaluate neurocognitive outcomes and consider preventive or rehabilitative interventions.

Background and objectives: Generating computed tomography (CT) angiography (CTA) 3-dimensional (3D) volume-rendered (3DVR) images can be time consuming without specialized technical staff or artificial intelligence solutions. However, their role in aneurysm detection in patients with subarachnoid hemorrhage is not known. Our aim was to assess the diagnostic utility of 64-detector row CTA with 3DVR (CTA+3DVR) vs without 3DVR (CTA-3DVR) in intracranial aneurysm detection.

Methods: A retrospective analysis of patients presenting with spontaneous subarachnoid hemorrhage (regardless of location) who underwent 64-detector row CTA and subsequent digital subtraction angiography (DSA) between 2013 and 2020 was performed. DSA was the reference standard. Almost all DSAs were performed with 3D rotational angiography. Two neuroradiologists blinded to the DSA results separately reviewed CTA source and maximum intensity projection images without 3DVR images (CTA-3DVR) and then immediately followed by the 3DVR images (CTA + 3DVR). Disagreements were resolved by consensus review. Aneurysm size was measured on DSA.

Results: In total, 200 patients were included in the study. 140 aneurysms in 114 patients were detected on DSA. CTA-3DVR detected 135 of 140 aneurysms (96.4%), and CTA+3DVR detected 136 of 140 aneurysms (97.1%). All missed aneurysms measured 2-4 mm. Three of four missed aneurysms were associated with multiple aneurysms, and 1 was a singly occurring, 2-mm M3 segment aneurysm. The 1 additional aneurysm detected by CTA + 3DVR was a 3-mm left A3 segment aneurysm. No false positives occurred with or without 3DVR.

Conclusion: CTA+3DVR detected 1 additional distal A3 aneurysm vs CTA-VR. 3DVR does not seem to substantially improve the detection of aneurysms but may be useful in the emergent setting for aneurysm morphology characterization.

Background and objective: Postoperative computed tomography (CT) scan has become a routine practice after any intracranial surgery. This study evaluates the clinical significance and utility of early postoperative CT scans after brain surgery in guiding patient management decisions.

Methods: A total of 339 patients who underwent intracranial surgery were included in the study. Postoperatively, patients were clinically examined in the intensive care unit and categorized into 3 groups: no fresh deficit, expected deficit, and unexpected deficit. All patients underwent a CT scan within 6 hours of surgery. CT findings were classified as postoperative changes only, operative site hematoma without mass effect, or operative site hematoma with mass effect. Management decisions were based on these findings, including continuation of ongoing management, modification of medical therapy, or surgical intervention if necessary.

Results: Among the 339 patients, 332 patients had either no deficit or expected deficit. 330 (97.34%) patients had postoperative changes only (eg, pneumocephalus, oedema, surgical corridor changes). Only 9 (2.65%) patients had operative site hematoma without mass effect. Of these 9, 6 patients required a change in medical management. However, no patient required surgical intervention even in unexpected deficit group. For the patients with unexpected deficit (n = 7, 2.06%), they were more likely to have an abnormal CT finding (odds ratio = 6.22, 95% CI 0.64-60.598, P = .193).

Conclusion: Early postoperative CT scans provide minimal benefit in extubated patients with no neurological deficit or expected deficits. Routine use of early CT scans does not significantly alter management and should be reserved for cases with clinical deterioration or unreliable neurological examination.

The integration of mobile health (mHealth) technologies is transforming neurosurgery. Despite its potential, many uses remain unrealized due to the unique challenges and complexity of developing mHealth technology. While neurosurgeons bring invaluable clinical expertise and an understanding of patient needs, the technical intricacies of application development often require collaboration with developers and computer scientists, a process that can feel unfamiliar and difficult to navigate. The aim of this article was to demystify mHealth development by providing a guide for neurosurgeons seeking to develop disease-specific mHealth applications. We outline this process using the development of SynapTrack, an mHealth tool designed to provide objective assessments of degenerative cervical myelopathy, a chronic condition caused by symptomatic compression of the cervical spinal cord. This article offers neurosurgeons concrete guidance on navigating key considerations such as design decisions, algorithm integration, database architecture, and data security. By grounding these insights with SynapTrack, this guide offers a transparent view into the development process and provides a practical framework that can be adapted to the development of other mHealth tools. The aim of this work was to foster interdisciplinary collaboration and enable neurosurgeons to develop mHealth applications tailored to the specific needs of their specialty.

Background and objectives: Bone metastases, affecting more than 4.8% of patients with cancer annually, and particularly spinal metastases require urgent intervention to prevent neurological complications. However, the current process of manually reviewing radiological reports leads to potential delays in specialist referrals. We hypothesized that natural language processing (NLP) review of routine radiology reports could automate the referral process for timely multidisciplinary care of spinal metastases.

Methods: We assessed 3 NLP models-a rule-based regular expression (RegEx) model, GPT-4, and a specialized Bidirectional Encoder Representations from Transformers (BERT) model (NYUTron)-for automated detection and referral of bone metastases. Study inclusion criteria targeted patients with active cancer diagnoses who underwent advanced imaging (computed tomography, MRI, or positron emission tomography) without previous specialist referral. We defined 2 separate tasks: task of identifying clinically significant bone metastatic terms (lexical detection), and identifying cases needing a specialist follow-up (clinical referral). Models were developed using 3754 hand-labeled advanced imaging studies in 2 phases: phase 1 focused on spine metastases, and phase 2 generalized to bone metastases. Standard McRae's line performance metrics were evaluated and compared across all stages and tasks.

Results: In the lexical detection, a simple RegEx achieved the highest performance (sensitivity 98.4%, specificity 97.6%, F1 = 0.965), followed by NYUTron (sensitivity 96.8%, specificity 89.9%, and F1 = 0.787). For the clinical referral task, RegEx also demonstrated superior performance (sensitivity 92.3%, specificity 87.5%, and F1 = 0.936), followed by a fine-tuned NYUTron model (sensitivity 90.0%, specificity 66.7%, and F1 = 0.750).

Conclusion: An NLP-based automated referral system can accurately identify patients with bone metastases requiring specialist evaluation. A simple RegEx model excels in syntax-based identification and expert-informed rule generation for efficient referral patient recommendation in comparison with advanced NLP models. This system could significantly reduce missed follow-ups and enhance timely intervention for patients with bone metastases.

Background and objectives: Complications are an unfortunate but ubiquitous part of neurosurgery, affecting both patient outcomes and surgeons' well-being. No study exists which has defined the impact that these complications have on neurosurgeons' emotional well-being or sought to define the various ways they choose to cope with them.

Methods: We surveyed 142 members of the Congress of Neurological Surgeons about the impact that complications have on them.

Results: Most respondents had complications that resulted in the death of a patient (58.4%) and even more had complications that resulted in short-term or long-term harm (80.3% and 79.6%, respectively). Complications had a significant (55.6%) or profound (38.0%) impact on emotional well-being. The most common defense mechanisms used were humor (64.1%) and intellectualization (68.3%). On subgroup analysis, junior neurosurgeons were more likely to use a greater number of both adaptive and maladaptive coping mechanisms than were senior neurosurgeons (parameter estimate [standard error] = -0.31 [0.14], P = .02 and parameter estimate [standard error] = -0.37 [0.14], P = .01, respectively). Academic neurosurgeons were more likely to question their clinical abilities than were private (OR 2.68, 95% CI 1.21-5.96). Neurosurgeons with maladaptive coping mechanisms were 5.84 times more likely to consider leaving the profession (95% CI 2.34-1.60) and 3.08 times more likely to limit their practice in the short term (95% CI 1.35-6.99). When assessing years of practice, type of practice, or sex, there was no difference in contemplation of leaving the field, self-doubt, propensity to admit fault, or number and type of coping mechanisms.

Conclusion: Complications have a major impact on the well-being of neurosurgeons, who use a variety of mechanisms to cope with them. Neurosurgeons with maladaptive coping mechanisms are more likely to question their career choice, consider leaving the field, and modify their practice after experiencing a complication.