Neurosurgery最新文献

Background and objectives: The optimal management strategy for pediatric patients with symptomatic moyamoya disease (MMD) is not well established. This systematic review and meta-analysis compares surgical vs conservative management and direct/combined bypass (DB/CB) vs indirect bypass (IB) for pediatric patients with symptomatic MMD.

Methods: MEDLINE and PubMed were searched from inception to March 17, 2024. For analysis of surgical vs conservative treatment, the primary and secondary outcomes were follow-up ischemic stroke and intracranial hemorrhagic events, respectively. For analysis of DB/CB vs IB, the primary outcome was follow-up ischemic stroke, and secondary outcomes included follow-up transient ischemic attack, new or worsened seizures, symptomatic improvement, modified Rankin Scale score ≤2, and Matsushima grade A at the last follow-up.

Results: Twenty-two included studies yielded 1091 patients, with a median follow-up duration of 35.7 months. Regarding surgical vs conservative management, 428 patients were analyzed. Surgical treatment was associated with lower odds of ischemic stroke (odds ratios [OR] = 0.33 [95% CI, 0.11-0.97], P = .04), and intracranial hemorrhagic events tended to be lower with surgery (OR = 0.25 [0.06-1.03], P = .05). Regarding DB/CB techniques vs IB, 875 patients were analyzed. The groups had similar rates of ischemic stroke (OR = 0.79 [0.31-1.97], P = .61), transient ischemic attack (OR = 1.27[0.46-3.55], P = .64), new or worsened seizures (OR = 1.05[0.3-3.65], P = .93), symptomatic improvement (OR = 2.45[0.71-8.45], P = .16), and follow-up modified Rankin Scale ≤2 (OR = 1.21 [0.16-8.85], P = .85). CB was associated with higher Matsushima grade A relative to IB (OR = 3.44 [1.32-9.97], P = .01).

Conclusion: Surgical revascularization yielded more favorable clinical outcomes than conservative management in this meta-analysis. Clinical outcomes were similar between DB/CB vs IB techniques. Surgical flow augmentation, either by DB/CB or IB, seems to benefit pediatric patients with symptomatic MMD.

Background and objectives: Scholarship has been critical to neurosurgery. As grades and board examinations become pass-fail, finding metrics to distinguish applicants coupled with an emphasis on research has led to growth of reported academic output among neurosurgery applicants. We aimed to evaluate applicant factors that associate with an academically productive neurosurgery resident.

Methods: Applicant characteristics were extracted from Electronic Residency Application Service archives from 2 geographically distinct neurosurgical programs for the 2014 to 2015 match cycle. Publications during residency were quantified, and residency careers were examined. Factors associated with residency publications were examined using univariate and multivariate regressions.

Results: A total of 228 United States (US) applicants to neurosurgery were assessed (89% of US neurosurgery applicants), with 173 matching across 93 programs. The average publication number of matched applicants was higher at 6.6 (median: 4, range: 0-43) that of than unmatched applicants (mean: 2.9, median: 1, range: 0-51). A total of 93.1% of publications were substantiated on PubMed review. Matched candidates published 19.3 manuscripts (median: 13, range: 0-120) on average during residency. On univariate analysis, factors associated with higher residency publications included taking a non-degree-granting extra year for research in medical school, consistently high clerkship grades, depth of preresidency research involvement, number of coresidents, program R25 status, and academic output of neurosurgery department leadership. After multivariate correction, the training environment played an outsized role in predicting resident academic output, with program R25 status significantly associated with resident academic output (odds ratio: 1.25, P = .012). Taking an extra research year in medical school approached but was not significant (odds ratio: 1.19, P = .099). Twelve matched international medical school graduates (IMGs) were also assessed (75% of matched IMG neurosurgery applicants). IMGs exhibited higher total publications and conference abstracts than US matched applicants and also published more during residency.

Conclusion: Cultivating an environment that promotes research endeavors is critical for neurosurgical resident academic growth. Preresidency publication number does not predict publication potential during residency.

Background and objectives: Bacterial brain abscesses may have long-term clinical consequences, eg, mental fatigue or epilepsy, but long-term structural consequences to the brain remain underexplored. We asked if brain abscesses damage brain activity long term, if the extent of such damage depends on the size of the abscess, and if the abscess capsule, which is often left in place during neurosurgery, remains a site of inflammation, which could explain long-lasting symptoms in patients with brain abscess.

Methods: 2-[18F]-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography (FDG-PET/CT), electroencephalography, and MRI were performed 2 days to 9 years after neurosurgery for bacterial brain abscess.

Results: FDG-PET/CT revealed hypometabolism in the neocortex or cerebellum overlying the previous bacterial abscess in 38 of 40 patients. The larger the abscess, the greater was the extent of the subsequent hypometabolism (r = 0.63; p = 3 × 10-5). In 9 patients, the extent of subsequent hypometabolism seemed to coincide with the extent of peri-abscess edema in the acute phase. Follow-up MRI after ≥1 year in 9 patients showed focal tissue loss and gliosis. In 13 patients with abnormal electroencephalography recordings, abnormalities extended beyond the cerebral lobe affected by the abscess, indicating damage to wider brain networks. The abscess capsule had an FDG signal indicating inflammation only during the first week after neurosurgical pus drainage.

Conclusion: The bigger a brain abscess is allowed to grow, the more extensive is the long-term focal reduction in brain activity. This finding emphasizes the need for rapid neurosurgical intervention. The abscess capsule does not display long-lasting inflammation and probably does not explain long-term symptoms after brain abscess.

Background and objectives: The management of World Health Organization (WHO) grade 2 meningiomas is complicated by their diverse clinical behaviors. Stereotactic radiosurgery (SRS) can be an effective management option. Literature on SRS dose selection is limited but suggests that a higher dose is better for tumor control. We characterize the predictors of post-SRS outcomes that can help guide planning and management.

Methods: We reviewed a cohort of consecutive patients with pathologically-proven WHO grade 2 meningiomas who underwent SRS at a single institution between 2011 and 2023.

Results: Ninety-nine patients (median age 62 years) underwent SRS, 11 of whom received hypofractionated SRS in 5 fractions. Twenty-two patients had received previous irradiation. The median follow-up was 49 months. The median overall survival was 119 months (95% CI 92-NA) with estimated 5- and 10-year survival of 83% and 27%, respectively. The median progression-free survival (PFS) was 40 months (95% CI 32-62), with 3- and 5-year rates at 54% and 35%, respectively. The median locomarginal PFS was 63 months (95% CI 51.8-NA) with 3- and 5-year rates at 65% and 52%. Nine (9%) patients experienced adverse events, 2 Common Terminology Criteria for Adverse Events grade 3 and 7 grade 2, consisting of worsening neurologic deficit from edema. In the single-session cohort, Ki-67 significantly predicted both overall survival and intracranial PFS. Tumors with Ki-67 >10% had 2.17 times the risk of locomarginal progression compared with Ki-67 ≤10% (P = .018) adjusting for covariates. Sex, prescription dose, tumor volume, and location also predicted tumor control. In tumors with Ki-67 >10%, margin dose ≥14 Gy was associated with significantly better tumor control but not for tumors with Ki-67 ≤10%.

Conclusion: The management of WHO grade 2 meningiomas requires a multimodality approach. This study demonstrates the value of a targeted SRS approach in patients with limited disease and further establishes predictive biomarkers that can guide planning through a personalized approach.

Background and objectives: Accredited neurosurgery fellowship training is available in 10 subspecialties and can sometimes be completed during the postgraduate year (PGY)-7 residency year. However, it is not clear whether there are sufficient residency graduates to fill the number of positions available, and residency curriculum structure to support enfolded training is evolving.

Methods: Detailed information about the 117 accredited neurosurgery residency programs and the 282 accredited neurosurgery fellowships was obtained from the Accreditation Council for Graduate Medical Education and Committee on Advanced Subspecialty Training, respectively. Information about residency chief year structure (PGY-6 vs PGY-7) was obtained electronically from each program. An analysis was performed to correlate residency and fellowship training characteristics at each program.

Results: The total number of neurosurgery fellowship positions available per year (352) is much higher than the total number of residency positions (237). Eighty-eight (75%) institutions with a neurosurgery residency offer at least 1 fellowship, and 51 of these have more fellowships than graduating residents. The resident complement at each program correlates with the number of fellowships offered (r2 = .56, P < .05), and the average institutional resident complement where fellowships are offered is greater than 2 per year. Thirty-eight residencies (32%) use a PGY-6 chief model (allowing for enfolded fellowships), and these programs offer significantly more fellowship programs on average than those using a traditional PGY-7 chief model (3.0 vs 2.1, P < .05). For most subspecialties, a minority of fellowships are offered in programs with a PGY-6 chief model.

Conclusion: The number of accredited neurosurgery subspecialty fellowship slots in the United States far exceeds the number of graduating neurosurgery residents. There is no standard for residency curriculum or enfolded fellowships, but smaller programs offer fewer opportunities for subspecialty training. There may be advantages to a uniform approach that standardizes subspecialty training across programs and matches fellowship availability to demand.

Background and objectives: Intracranial hypertension (IH) is associated with an unfavorable outcome in traumatic brain injury (TBI), and management strategies guided by intracranial pressure monitoring improve prognosis. Owing to the limitations of using invasive devices, measurement of optic nerve sheath diameter (ONSD) by ultrasonography is an alternative noninvasive method. However, its accuracy has not been validated in patients with TBI, so we aim to determine the diagnostic accuracy of measuring ONSD by ultrasonography in patients with TBI to estimate IH, compared with invasive monitoring.

Methods: Systematic review of electronic databases and manual literature review from inception to June 2023. The analysis included diagnostic accuracy studies of ultrasonographic measurement of ONSD compared with invasive monitoring published in any language and with patients of any age. A qualitative synthesis was performed describing the clinical and methodological characteristics, strengths, limitations, and quality of evidence. In addition, a bivariate random effects model meta-analysis and a hierarchical summary receiver operating characteristics model were performed for the pediatric and adult population separately.

Results: Five hundred and forty eight patients of 688 in 16 eligible studies were adults and 120 were children. Pooled sensitivity and specificity of ONSD measurement by ultrasonography were 84% (95% CI, 76%-89%) and 83% (95% CI, 73%-90%), respectively. During the sensitivity analysis, these parameters exhibited consistent values. Pooled area under the curve was 0.91 for adults and 0.76 for children. Optimal threshold for estimating IH was 5.76 mm for adults and 5.78 mm for children.

Conclusion: Measurement of ONSD by ultrasonography is a reliable, low-cost, and safe alternative for the estimation of IH with TBI in adults. More robust studies are needed to overcome the high risk of bias and heterogeneity for this analysis.

Background and objectives: Deep brain stimulation (DBS) is an effective treatment for Parkinson's disease (PD) motor symptoms. DBS is also associated with postoperative cognitive change in some patients. Previous studies found associations between medial active electrode contacts and overall cognitive decline. Our current aim is to determine the relationship between active electrode contact location and domain-specific cognitive changes.

Methods: A single-institution retrospective cohort study was conducted in patients with PD who underwent subthalamic nucleus (STN) DBS from August 05, 2010, to February 22, 2021, and received preoperative and postoperative neuropsychological testing. Standardized norm-referenced test z-scores were categorized into attention, executive function, language, verbal memory, and visuospatial domains. SD change scores were averaged to create domain-specific change scores. We identified anterior commissure/posterior commissure coordinates of active electrode contacts in atlas space. We evaluated differences in active electrode contact location between patients with a domain score decrease of at least 1 SD and less than 1 SD. We performed multiple variable linear regression controlling for age, sex, education, time from surgery to postoperative neuropsychological testing (follow-up duration), disease duration, preoperative unified Parkinson's disease rating scale off medication scores, and preoperative memory scores to determine the relationship between active electrode contact location and domain change.

Results: A total of 83 patients (male: n = 60, 72.3%) were included with a mean age of 63.6 ± 8.3 years, median disease duration of 9.0 [6.0, 11.5] years, and median follow-up duration of 8.0 [7.0, 11.0] months. More superior active electrode contact location in the left STN (P = .002) and higher preoperative memory scores (P < .0001) were associated with worsening memory. Active electrode contact location was not associated with change in other domains.

Conclusion: In patients with PD who underwent STN DBS, we found an association between superior active electrode contacts in the left STN and verbal memory decline. Our study increases understanding of factors associated with cognitive change after DBS and may help inform postoperative programming.

Background and objectives: Pineocytomas are grade 1 tumors arising from the pineal parenchyma. Gross total resection can potentially cure these benign lesions but can be associated with morbidity. This study was designed to provide multi-institutional data to evaluate the results of stereotactic radiosurgery (SRS) for pineocytomas.

Methods: Centers participating in the International Radiosurgery Research Foundation were asked to review their database and provide data for patients who had SRS for histology confirmed grade 1 pineocytomas, for whom clinical and imaging follow-up of at least 6 months was available.

Results: In total, 38 patients underwent SRS as part of the management of a pineocytoma. The median age at SRS was 39 years (range 8-76). SRS was performed as primary approach in 68%, adjuvant after partial resection 19%, and at recurrence in 13% of patients. The median margin dose was 15 Gy (range 11-25 Gy). The median treatment volume was 3.35 cc (range 0.1-17.9 cc). Local tumor control was achieved in 92% of patients, with a mean actuarial progression-free survival of 21.6 years (median not reached). At last follow-up, 82% were still controlled, 8% had local recurrence, and 10% had cerebrospinal fluid dissemination. Tumor control was significantly better when SRS was used as primary care compared with the adjuvant or recurrent setting (P = .016). Five patients (13%) died during follow-up, all from tumor progression. The actuarial mean survival duration was 24.3 years, with a 5-year survival rate of 91%, and an estimated rate of 76% at 29 years. Larger tumor volume at SRS was found to be correlated to increased risk of death (P = .045). Transient symptomatic adverse radiation effects were observed in 4 patients (11%).

Conclusion: SRS appears safe and effective for the management of pineocytomas. Long-term tumor control is achieved in most cases. SRS can be offered to selected patients as an alternative to surgical resection.

Background and objectives: Stereotactic radiosurgery (SRS) represents an effective treatment for nonfunctioning pituitary adenomas (NFPAs). However, no data have yet been published regarding results of SRS on NFPAs after multiple previous resections.

Methods: Retrospective multicentric data of patients diagnosed with NFPA and who underwent multiple resections (≥2) before SRS were reviewed and analyzed. The treatment interval spanned the period of 1992 to 2022. Cox regression and Kaplan-Meier curves were used to assess predictive factors and the probability of tumor control and hypopituitarism.

Results: Among the 311 patients (median age: 50.2 [IQR: 18.0] years), 226 (72.7%) had undergone ≥2 previous resections. The median margin dose was 14 Gy (IQR: 4.0 Gy), and the median tumor volume 3.6 cm3 (IQR: 4.8). Overall, the probability of tumor control after SRS was 93.3% (CI 95%: 89.9-96.9) and 86.7% (CI 95%: 81.1-92.6) at 5 and 10 years, respectively. A margin dose >14 Gy was associated with a decreased risk of tumor progression (hazard ratio = 0.33, CI 95% = 0.15-0.75, P = .008). At a last clinical follow-up of 4.1 (IQR 6.1) years, 10.1% (30/296) developed at least 1 new hormone deficiency after SRS. The cumulative probability of new hormone deficiency was 6.1% (95% CI: 3.0-9.1), 10.3% (95% CI: 5.8-14.6), and 18.9% (95% CI: 11.5-25.8) at 3, 5, and 10 years after SRS, respectively. The average latency between SRS and development of new hormone deficiencies was 3.3 years (IQR 4.1). A maximum point dose to the pituitary stalk >10 Gy was associated with a new deficiency (hazard ratio = 4.06, CI 95% = 1.57-10.5, P-value = .004).

Conclusion: For patients with NFPA with multiple previous resections, SRS offers effective local tumor control and a low risk of delayed hypopituitarism for managing these challenging adenomas. SRS should be strongly considered in patients with NFPA with 2 previous resections compared with considering a third resection.