Neurosurgery最新文献

Background and objectives: Vertebral hemangiomas are the most common primary spine tumors with an estimated prevalence of 10% to 12%. Approximately 1% are "aggressive", expanding and eroding osseous confines. Treatment aims at limiting their growth and symptomatology. This study evaluated the effectiveness of various treatment modalities for symptoms and recurrence control.

Methods: Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 compliant study. Medline and Scopus were searched in March 2024. Inclusion criteria were English language, published between 2000 and 2023, adults (older than 18 years), primary aggressive vertebral hemangioma (AVH) Enneking stage 3. Data included patient-level demographics, treatment, outcomes, and recurrence. Excluded were case reports, studies focusing on nonaggressive vertebral hemangioma, other primary or metastatic tumors, and studies on the treatment of recurrent AVHs. Results of descriptive studies, pooled proportions, correlation, and regression are presented in tables and forest plots.

Results: Sixteen studies with 150 AVHs in 149 patients. Mean age (SD) was 50.4 (16.8) years, and 55/149 (36.9%) were men. Mean follow-up (SD) was 49.8 (57) months. Weighted pooled proportions: gross total resection 18.2%, recurrence 7.9%, symptom resolution 43.4%, and Frankel score improvement 68.4%. Initial sensory deficit (OR: 29.1, P = .02) and performing corpectomy/spondylectomy (OR: 0.034, P < .01) were independent predictors for symptom resolution. Embolization (49.5%, P = .0151), open surgery (48.8%, P = .0019), and complete resection (82.1%, P < .0001) showed strong correlation with symptom improvement. Higher symptom resolution was observed with kyphoplasty/vertebroplasty (82.5%, P < .0001), no open surgery (78.9%, P = .0019), and no surgical tumor resection (72%, P < .0001). No independent predictors were found for recurrence.

Conclusion: Embolization, intralesional ablation, vertebroplasty, and kyphoplasty are options for AVH without cord compression and neurological deficits. For cord compression, open surgery with or without these interventions can be considered. Radiation is for persistent pain and locally advanced tumors. The extent of tumor progression is correlated with symptom control.

Background and objectives: Although magnetic resonance imaging guided focused ultrasound (MRgFUS) thalamotomy has shown a robust safety and efficacy profile for tremor treatment, gait disturbances have been reported but often lack objective measurement. The aim of this study was to evaluate gait and balance outcomes in patients with essential tremor (ET)-only and tremor-dominant Parkinson's disease with or without ET (TDPD ± ET) who have undergone MRgFUS thalamotomy for treatment of their tremors, using validated, multidimensional measures.

Methods: This retrospective review included all consecutive patients who underwent MRgFUS thalamotomy between June 14, 2021, and February 1, 2023. Patients who did not have a preprocedure or postprocedure gait and balance evaluation, and those lost to follow-up, were excluded. Primary outcomes were changes in the preprocedural and postprocedural Tinetti gait and balance scores and timed up and go time at the 3-month visit. Additional outcomes included changes in ambulation time, steps taken to walk 30 feet, and clinical improvement.

Results: Of 92 total patients (72 ET-only, 20 TDPD ± ET), the ET-only cohort had a median follow-up of 94 days (IQR 91-113), and the TDPD ± ET cohort had a follow-up of 99.5 days (IQR 92.25-119.00). In ET-only patients, significant improvements were observed in median Tinetti balance (pre 15 [IQR 12-16] vs post 15 [IQR 13-16], P = .031) and median 30-ft ambulation time (8.11 seconds [IQR 6.74-10.77] vs 8.06 seconds [IQR 6.21-10.23], P = .009), with no change in median Tinetti gait, Tinetti total scores, timed up and go time, or steps to ambulate 30-ft. In patients with TDPD ± ET, only the median Tinetti gait improved (9.00 [IQR 6.00-11.00] vs 9.50 [IQR 7.75-12.00], P = .004).

Conclusion: MRgFUS thalamotomy is associated with a low risk of gait/balance disturbances and may also improve these functions in patients with ET and TDPD ± ET. This supports MRgFUS as a viable treatment option.

Background and objectives: Endovascular treatment (EVT) is widely regarded as superior to best medical treatment (BMT) for basilar artery occlusion. However, the benefit of EVT in patients with poor collateral circulation remains uncertain.

Methods: We conducted a post hoc analysis of data from the ATTENTION study. Patients were categorized into good and poor collateral groups based on CT angiography, using the Basilar Artery on Computed Tomography Angiography scores and the posterior circulation collateral score. The efficacy of EVT vs BMT was then assessed within each group.

Results: Among 238 patients, 116 had good collaterals and 122 had poor collaterals. In the good collaterals group, EVT significantly improved functional outcomes compared with BMT (modified Rankin Scale 0-3: 65.3% vs 34.1%; P = .004). By contrast, EVT offered limited benefit in the poor collaterals group (modified Rankin Scale 0-3: 27.5% vs 14.3%; P = .388). Subgroup analyses demonstrated that EVT consistently outperformed BMT across nearly all good collateral subgroups. A significant interaction between treatment modality and the presence of atherosclerosis was observed in the good collaterals group ( P = .038), with EVT showing greater benefit in patients with nonatherosclerotic stroke (odds ratio 7.33; 95% CI, 2.47-21.74).

Conclusion: EVT is strongly recommended for basilar artery occlusion patients with good collateral circulation, especially those with nonatherosclerotic causes of stroke. For patients with poor collaterals, treatment decisions between EVT and BMT should be carefully individualized based on clinical context.

Background and objectives: Stereotactic body radiotherapy (SBRT) has emerged as an effective treatment modality for spinal metastases. However, high-powered studies evaluating clinical and radiographic outcomes, and prognostic risk factors for local tumor progression (LTP), remain underreported. The objective of this study was to evaluate local tumor control, adverse radiation effects, pain response, and overall survival after SBRT for spinal metastases and to develop an internally derived LTP prediction tool to guide personalized patient management.

Methods: A prospectively maintained database of 936 SBRT treatments (600 patients) from 2001-2024 for spinal metastases at a quaternary referral center was analyzed. Single-fraction and multifraction SBRT with median prescribed doses of 16 Gy (IQR: 15-17) and 24 Gy (IQR: 24-27), respectively, were included.

Results: The median follow-up and overall survival were 8 months (IQR: 2-22) and 11 months (IQR: 3-28), respectively. There were 129 (13.8%) LTPs. Local tumor control rates at 1 year and 3 years were 84.2% (95% CI: 81.1%-87.3%) and 75.1% (95% CI: 70.8%-79.5%). An LTP risk scoring system was developed using high-fidelity machine learning models, with scores summed on a 0-15 scale using treatment characteristics (spinal instability neoplastic score >6 [4 points], lytic lesion [4 points], radiographic spinal misalignment [3 points], no prior chemotherapy [2 points], and polymetastatic disease [2 points]). Crude LTP incidences in low-risk (LTP score: 0-5), intermediate-risk (LTP score: 6-8), and high-risk groups (LTP score: 9-15) were 2.4%, 10.2%, and 35.5%, respectively. Stratified survival analyses demonstrated significant LTP differences between all risk groups (log-rank and Gray test, P < .001). Pain response or stability at 1, 3, and 6 months after SBRT was 94.4%, 90.6%, and 84.3%, respectively. The crude risk of grade II or III adverse radiation effects was 12.6%.

Conclusion: This large clinical cohort investigation demonstrates that SBRT is safe and effective for spinal metastases. Risk stratification using clinical and radiographic variables may help inform patient selection to optimize outcomes.

Background and objectives: Severe traumatic brain injury (TBI) in children is associated with poor outcomes, but evidence surrounding the role of operative cranial surgery in this patient population is limited. Thus, we sought to evaluate associations between cranial surgery and hospital discharge outcomes among pediatric patients with severe TBI and to identify patient subgroups most likely to benefit.

Methods: This was a retrospective cohort study using data from the Trauma Quality Improvement Program database (2017-2022). Pediatric patients with severe TBI (presenting Glasgow Coma Scale ≤8) were included. Hierarchical regression and propensity score matching investigated associations between open cranial surgery (craniotomy or decompressive craniectomy) and favorable discharge disposition (home or inpatient rehabilitation). A causal forest model was constructed to identify heterogenous treatment effects of cranial surgery across strata of patient baseline and injury characteristics.

Results: Among 2705 patients (median age, 13 years), 23% underwent cranial surgery. In both full and propensity score-matched cohorts (N = 998), risk-adjusted hierarchical regression analyses revealed that cranial surgery was associated with greater odds of favorable discharge (matched cohort odds ratio, 1.53; 95% CI, 1.04-2.27; P = .03) and lower odds of inpatient mortality (matched cohort odds ratio, 0.28; 95% CI, 0.18-0.45; P < .001). Causal forest analysis identified younger age, lower presenting Glasgow Coma Scale, higher Injury Severity Score, midline shift >5 mm, and the absence of pupil reactivity as key modifiers of treatment effect, with the greatest estimated benefit observed for patients younger than 12 years and for the most severely injured patients.

Conclusions and relevance: Cranial surgery was associated with improved functional and survival outcomes in pediatric severe TBI compared with nonoperative measures, with the largest relative benefit in patients younger than 12 years and those with high-risk clinical features. These findings support operative cranial intervention for selected pediatric patients and may inform refinement of age- and injury-specific operative management guidelines for pediatric severe TBI.

Background and objectives: Health-related quality of life (HRQoL) in patients with degenerative cervical myelopathy (DCM) ranks among the lowest across chronic medical conditions. We aim to evaluate the impact of neck pain on postoperative HRQoL after surgical decompression for DCM.

Methods: We conducted a retrospective analysis of a multicenter international DCM cohort comprising 1047 patients enrolled from 2005 to 2021. Neck pain severity was assessed using the pain intensity subdomain of the Neck Disability Index. Baseline and 1-year HRQoL scores measured using the SF-36 physical component summary (PCS) and mental component summary (MCS) were compared between neck pain and no neck pain cohorts. Multivariable regression models, adjusted for key clinical covariates, were used to examine the association between neck pain severity and HRQoL.

Results: Neck pain was present preoperatively in 81.5% of patients. The neck pain group had significantly lower PCS (34.72 ± 9.02 vs 39.56 ± 10.20, P < .001) and MCS scores (40.59 ± 11.73 vs 45.64 ± 12.86, P < .001) compared with the no neck pain group. At 1 year postsurgery, 35.5% reported being pain-free. Increasing neck pain severity was associated with progressively lower PCS (exp β = -3.64, -7.45, and -10.47 for mild, moderate, and severe pain) and MCS scores (exp β = -2.96, -7.69, and -11.80). Persistent moderate and severe neck pain at 1 year independently predicted failure to achieve minimal clinically important difference for PCS [odds ratio = 0.57 (95% CI 0.39-0.83, P < .05) and 0.37 (95% CI 0.25-0.55, P < .05), respectively] and MCS [odds ratio = 0.49 (95% CI 0.34-0.71, P < .05) and 0.60 (95% CI 0.41-0.88, P < .05), respectively]. Model fit predictions for 1-year HRQoL were improved with inclusion of neck pain scores (PCS: χ2 = 37.21, MCS: χ2 = 19.18, both P < .0001).

Conclusion: Neck pain is highly prevalent among patients with DCM and is independently associated with poorer postoperative HRQoL. While surgery restores neurological function, optimizing patient-reported outcomes requires adjunctive strategies specifically targeting neck pain.

Background and objectives: Management of chronic subdural hematoma (cSDH) in elderly patients receiving antithrombotic therapy remains heterogeneous, and surgical evacuation is often delayed allowing partial pharmacological washout despite limited supporting evidence. The aim of this study was to determine whether a structured perioperative pathway permits safe evacuation of cSDH as soon as logistically feasible, without awaiting drug washout, and to evaluate differences in recurrence probability and timing across antiplatelet, anticoagulant, and nonantithrombotic cohorts.

Methods: A multicenter retrospective analysis was conducted on consecutive elderly patients treated through a shared perioperative management. Patients were stratified into antiplatelet therapy (Group A, n = 199), anticoagulant therapy (Group B, n = 254), and no antithrombotic therapy (Group C, n = 226). Early recurrence rates were compared using predefined ±10% equivalence margins. Independent predictors of recurrence probability were identified using multivariate logistic regression analysis, and determinants of recurrence timing were assessed with Cox proportional hazards model.

Results: Early recurrence occurred in 9.0% of Group A, 11.8% of Group B, and 13.7% of Group C, with no significant differences among groups. Equivalence testing confirmed that recurrence rates met predefined equivalence criteria across all pairwise comparisons. Mean time to recurrence differed significantly (P = .023), with earlier recurrence in antiplatelet-treated patients. In the multivariate logistic regression model, postoperative length of stay was the only independent predictor of recurrence probability (P < .001). In the Cox model, antiplatelet therapy (hazard ratio 3.387, P < .001) and a history of stroke (hazard ratio 2.726, P = .034) independently influenced recurrence timing, whereas pharmacological status did not increase recurrence incidence. Complication rates were comparable across groups, and no thromboembolic events were observed.

Conclusion: A shared perioperative pathway allowed cSDH evacuation as soon as logistically feasible while maintaining comparable early recurrence rates across antiplatelet, anticoagulant, and nonantithrombotic groups, despite differences in time to recurrence. Distinct predictors of recurrence probability and timing support the feasibility and clinical relevance of immediate surgical treatment within a coordinated perioperative framework.

Background and objectives: Cerebral edema (CE) is a common contributor to neurological decline after brain tumor resection. While corticosteroids are effective in managing CE perioperatively, their use is associated with significant side effects and potential interference with immunotherapeutic efficacy in patients with malignant brain tumors. This study aimed to evaluate the anti-inflammatory effects of 2 inhibitors of the receptor for advanced glycation end products (RAGE)-TTP488 and FPS-ZM1-on CE development after glioma resection in murine models.

Methods: Mice bearing orthotopic CT-2A gliomas were randomized into 4 treatment groups before undergoing fluorescence-guided microsurgical tumor resection. The groups received perioperative administration (from day -4 to day +7) of TTP488, FPS-ZM1, dexamethasone, or vehicle. Postoperative CE was assessed using serial brain MRI over a 7-day period and quantified using manual segmentation. Neurological function, wound healing, and response to anti-PD-1 immunotherapy were also evaluated. Bulk RNA sequencing was performed to analyze differential gene expression associated with RAGE inhibition.

Results: Across all groups, CE peaked on postoperative day 2 and subsided by day 7. On postoperative day 1, both TTP488 and FPS-ZM1 significantly reduced CE compared with vehicle (P = .03 for TTP488; P = .03 for FPS-ZM1). Notably, unlike dexamethasone, neither RAGE inhibitor impaired the efficacy of anti-PD-1 immunotherapy. FPS-ZM1 treatment was also associated with improved neurological recovery, enhanced wound healing, and potentiated anti-PD-1 therapy at higher doses.

Conclusion: RAGE inhibitors effectively reduced postoperative CE to a degree comparable with dexamethasone, without compromising the efficacy of immunotherapy or wound healing. These findings suggest that RAGE inhibition may offer a promising steroid-sparing strategy for perioperative management of CE in patients with brain tumor undergoing immunotherapy.

Background and objectives: Cranioplasty (CP) is a critical neurosurgical intervention typically performed after decompressive craniectomy (DC). However, the optimal timing remains uncertain due to conflicting evidence and heterogeneous study designs. This pooled comparative meta-analysis aims to address this gap.

Methods: We conducted a systematic search for studies reporting outcomes of patients who underwent primary DC followed by CP on September 2024. Ultra-early CP was defined as ≤35 days, early CP as ≤86 days, and late CP as >86 days after DC. Outcomes included functional recovery measured by various scales and procedure-related complications.

Results: Thirty-eight studies (n = 4703) were included. Early CP was associated with improved functional outcomes: Karnofsky performance scale (mean difference [MD] 15.50, 95% CI [0.80, 31.80], P < .0001), Barthel Index (MD 13.10, 95% CI [0.24, 25.96], P = .01), functional independence measure (MD 11.23, 95% CI [7.61, 14.85], P < .00001), and activities of daily living (MD 13.65, 95% CI [1.44, 25.86], P = .03), compared with late CP. Other scales showed no significant differences. Overall complication rates did not differ between early and late CP (risk ratio 1.08, 95% CI [0.83, 1.41], P = .55), except for hydrocephalus, which was more common in early CP (risk ratio 1.58, 95% CI [1.07, 2.33], P = .02). No statistically significant differences in complication rates were observed for the ultra-early subgroup.

Conclusion: Our findings suggest that early CP is associated with improved neurological function and greater daily independence, reflected by higher Karnofsky performance scale, Barthel Index, functional independence measure, and activities of daily living scores, without a significant increase in overall complication rates compared with late CP after DC. However, hydrocephalus appears more frequently after early CP. Standardized, multicenter prospective studies using consistent timing definitions are needed to refine individualized CP strategies.

Background and objectives: Glymphatic function affects brain health and could be part of the pathophysiology in idiopathic normal-pressure hydrocephalus. Elevated intracranial pressure pulsatility and increased resistance to cerebrospinal fluid (CSF) outflow (Rout) are commonly observed in idiopathic normal-pressure hydrocephalus. Whether such alterations indicate impaired glymphatic function or affect ventricle volumetrics in ordinary elderly is unknown. We investigated the associations between CSF dynamics and changes in cognitive performance, gait, and brain MRI parameters over a 10-year period in a cohort of healthy older adults.

Methods: Twenty-nine subjects (mean age 79 ± 6, range 71-92 years) were investigated with brain MRI, clinical testing, and a CSF infusion test. MRI and clinical testing were repeated after 10 years. An automated software program was used to calculate ventricle volumes, and linear ventricle radiological indices were calculated (Evan's index, callosal angle, and z-Evan's index). CSF dynamic parameters were correlated with longitudinal changes in clinical and MRI parameters.

Results: In a multivariable regression model including age, sex, baseline cognitive performance, and CSF dynamic parameters, lower CSF outflow resistance was associated with better cognitive performance after 10 years (standardized β = 0.37, P = .047, n = 29). In a bivariate analysis, outflow resistance had a negative correlation to the difference in cognitive testing score between baseline and follow-up (r = -.44, 95% CI -0.701 to -0.08, P = .017, n = 29, Spearman's rho). CSF dynamic parameters were not associated with changes in gait performance or ventricle volume. Intracranial pressure pulsatility was associated with reduced callosal angle (standardized β = -0.35, P = .02, n = 29) and intracranial pressure with increased z-Evan's index (standardized β = 0.18, P = .003, n = 29).

Conclusion: Our results provide insight into the complexity of CSF physiology and its possible role in longitudinal change in brain function and structure. Measurement of CSF outflow characteristics hold potential in furthering the understanding of glymphatic performance with regard to change in cognitive function and warrants further investigation.