Neurosurgery最新文献

Background and objectives: While cortical venous drainage (CVD) is recognized as a high-risk angiographic feature for dural arteriovenous fistulas (dAVFs), the drainage pattern itself is not well scrutinized. In this study, we sought to delineate the prevalence, clinical presentation, and untreated course of dAVFs with parenchymal venous reflux (PVR) from CVD vs those draining into cortical veins that more simply drain directly into a venous sinus.

Methods: An institutional database was queried for demographical, angiographic data and the untreated course of dAVFs with direct CVD (Cognard type III or IV). Clinical presentation and annualized risk of new intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND) were stratified by the presence or lack of PVR. Multivariate logistic regression or Cox proportional hazards regression were used to delineate the impact of PVR on presentation modality or untreated course.

Results: Of 128 dAVFs with direct CVD, 61% had angiographic PVR and 55% presented with ICH/NHND. The presence of PVR was associated with a 7-fold increased risk (95% CI 3.11-18.32, P < .001) and an 80% sensitivity for aggressive presentation (ICH/NHND). Annualized ICH/NHND rates were 31.6% in the PVR group and 2.4% in the no-PVR group (log-rank P = .008) over the untreated follow-up period.

Conclusion: Angiographic PVR is associated with a greater risk of ICH/NHND on presentation and over follow-up, suggesting it may serve as an indicator of clinically more significant venous hypertension.

Background and objectives: Microvascular decompression (MVD) is accepted as the most effective surgery for patients with trigeminal neuralgia (TN), but controversy remains regarding operative technique.

Methods: A prospective registry of 523 patients undergoing MVD for unilateral Type 1 TN from July 1999 through September 2022 was reviewed. Patients with Type 2 TN, secondary TN, bilateral TN, vertebrobasilar compression, or previous MVD were excluded. The goal at surgery was to have nothing contacting the trigeminal nerve: arteries in contact with the trigeminal nerve were mobilized away from the nerve root whenever possible and secured with Teflon whereas veins in contact with the trigeminal nerve were sacrificed. Partial sensory rhizotomy was performed if the vascular compression was insignificant or no vascular compression was noted. The primary outcome was pain-free survival without medications. The median follow-up after surgery was 8.2 years.

Results: More patients were women (n = 310, 59.3%), the median age was 63 years, the median pain duration was 5 years, and 110 patients (21.0%) had previous ablative procedures. Operative technique was arterial transposition (n = 255, 48.8%), arterial transposition and vein sacrifice (n = 182, 34.8%), vein sacrifice (n = 64, 12.2%), and partial sensory rhizotomy (n = 22, 4.2%). Initially, 485 patients (92.7%) were pain-free without medications. Pain-free survival estimates at 5, 10, and 15 years were 77.6%, 72.5%, and 69.7%, respectively. Women (hazards ratios = 1.48, P = .03) had a lower rate of pain-free survival. Eighty-three patients (15.9%) had postoperative complications; the most common was new facial numbness (n = 37, 7.1%). Three patients (0.6%) had venous infarctions, and 2 patients (0.4%) had reported Teflon granulomas.

Conclusion: A noncompressive MVD using vein sacrifice, arterial transposition whenever possible, and Teflon implantation provided long-term pain relief for most patients with Type 1 TN with a low risk of venous infarction or Teflon granuloma formation.

Background and objectives: Management options for foramen magnum meningiomas (FMM) include observation, attempts at surgical resection, and radiation therapy. The authors report the single-institution long-term experience of the use of primary or adjuvant stereotactic radiosurgery (SRS) for FMMs.

Methods: A total of 40 FMM patients (29 female) underwent SRS between 1987 and 2022. The median age at SRS was 62.0 (range: 30-82) years. Ten patients had prior surgical resection (2 gross total resections, 8 subtotal resections), whereas 4 patients had prior fractionated radiation therapy. Tumors were located at the anterior midline (5 patients), anterior lateral (25 patients), posterior midline (5 patients), and posterior lateral (5 patients) quadrants. The median prescription dose was 12.5 Gy (range: 10-16), and the median cumulative FMM tumor volume treated was 2.3 cc (range: 0.35-12.0).

Results: The median follow-up time was 88.0 months (range: 12-253). Fourteen patients had a follow-up >5 years, and 12 additional patients had >10-year follow-ups. Complete imaging response was noted in 1 patient, partial regression was noted in 13 patients, and 25 patients had no further growth. One patient had tumor progression 9 months after initial SRS and then underwent repeat surgical resection. The overall local tumor control rate was 98%. A total of 35 patients had improved or stable neurological symptoms after SRS, and 5 patients reported delayed worsening of symptoms. Ten patients were deceased at the last clinical follow-up. The median overall survival was 102 months (range: 41-164). None of the patients died related to central nervous system disease progression. No post-SRS adverse radiation effects were detected.

Conclusion: Progressive FMM presents a management challenge. In this experience, SRS effectively prevented local tumor progression and preserved neurological function. Our experience supports the role of SRS as a primary or adjuvant management strategy.

Background and objectives: Acute vestibular syndrome is highly disabling in physical and psychological stress of patients. The aim of this study was to evaluate the effects of perioperative vestibular dysfunction in patients who received unilateral vestibular schwannoma (VS) surgery as unilateral acute vestibular dysfunction model cases and to study the vestibular compensation process in these patients.

Methods: The 101 participants with unilateral VS had received a series vestibular function tests including subjective visual vertical/horizontal (SVV/SVH), caloric test, cervical vestibular-evoked myogenic potentials, ocular VEMP, and video head impulse test within 3 months before surgery. SVV, SVH, and Visual Analog Scale for vertigo were evaluated on the first day (postoperative day 1, POD 1), on the third day (POD 3), on the 7 day (POD 7), in the first month (POD 30), and in the third month (POD 90) of postoperative follow-up visit.

Results: The tilts of SVV and SVH significantly increased after surgery compared with baseline on POD 1, POD 3, and POD 7. The SVV of the participants had recovered to the preoperative level on POD 30, and the SVH of the participants had recovered to the preoperative level on POD 90. The changes of SVV/SVH were significantly correlated with changes of Visual Analog Scale for vertigo within 90 days. After surgery, the tilts of SVV and SVH within 7 days were significantly higher in patients with normal caloric tests and video head impulse test than those with abnormal results in these 2 tests.

Conclusion: Static vestibular function may recover effectively within 1 month after surgery in VS, which was positively correlated to the recovery of subjective dizziness. Patients with preoperative vestibular dysfunction may recover sooner and better in the process of vestibular compensation in the early postoperative stage compared with those with normal preoperative vestibular function.

Background: Penetrating traumatic brain injury (pTBI) is an important wounding mechanism which is seen increasingly as a result of violent crime and armed conflicts. pTBI is very challenging to manage as it is often highly complex yet requires expeditious treatment. Treatment algorithms thus can assist even experienced clinicians to avoid pitfalls while caring for these patients.

Methods: To supplement the evidence-based recommendations produced in conjunction with the Brain Trauma Foundation Guidelines for the Management of Penetrating Brain Injury, Second Edition, we developed protocols for care to help bridge limitations of published evidence with care decisions required at the bedside. Our working group of over 30 diverse expert panelists identified care, care pathways and key decisions relevant to pTBI care through discussion. A rigorous, blinded Delphi consensus process was then applied. Items achieving at least an 80% consensus vote were incorporated into the treatment algorithms. Consensus voting also approved the final versions of the care pathways.

Results: To meet the needs of diverse pTBI patients we created a Master Care Pathway relevant to all patients. We also created 'Toolkits' designed to address care issues that only some patients will have. Toolkits for surgical management, protruding foreign bodies, severe injury, skull base injury and vascular injury were developed. In addition, a futility assessment is provided to assist with delineating the small proportion of patients for whom initial non-aggressive care might be considered with the recognition that avoidance of nihilism is critical to achieving best outcomes in pTBI victims.

Conclusions: Care pathways are presented which reflect suggestions for care that aim to inspire thoughtful management. The algorithms also aim to avoids potential pitfalls in management to help achieve best possible outcomes for pTBI patients.

Background and objectives: Intraventricular chemotherapy administered through an Ommaya reservoir (OmR) constitutes an integral part of therapy for patients with leptomeningeal metastasis. Unfortunately, OmR infections remain a frequent, costly, morbid, and occasionally fatal complication, limiting the benefit of this approach. We evaluate the efficacy, cost savings, and toxicity of vancomycin coadministered with intraventricular chemotherapy for the prevention of OmR-associated bacterial meningitis.

Methods: This was a cohort study comparing a treatment group treated from May 1, 2021, to April 30, 2022, and a retrospective control group treated from 2016 to 2021. Patients were included if they had a diagnosis of leptomeningeal metastasis and subsequent placement of an OmR, followed by delivery of planned intraventricular chemotherapy. Patients in the treatment group received a 10-mg dose of intraventricular vancomycin in addition to their standard chemotherapy regimen at each treatment. We compared this group to a retrospective cohort from the preceding 5 years who did not receive intraventricular vancomycin, evaluating the rate of infection, adverse events, and associated treatment costs between groups.

Results: The infection rate was 0% (95% CI 0%-6.75%) among the 63 patients and 0% (0%-0.76%) in the 501 consecutive treatments administered over the 12-month study period, compared with 10.25% (7.39%-14.0%) among the 322 patients and 1.71% (1.22%-2.39%) in 1932 treatments over the preceding 5 years. The absolute risk reduction was 10.3% (3.83-14.04), P = .0028. The number needed to treat was 10 (7-26). Cost per vancomycin dose was $10.00 ($5010 over 12 months). The cost of nonsurgical treatment of 1 OmR-associated infection is $88 372, which translates into $618 604 for the estimated 7 patients over 12 months who developed an OmR-associated infection. No treatment-associated toxicity was observed.

Conclusion: Prophylactic intraventricular vancomycin eliminated OmR-associated infections without added toxicity and with dramatic cost savings.

Background and objectives: Unrecognized cavernous sinus (CS) invasion by adenomas is a major factor in surgical failure and recurrence of Cushing disease (CD), and pituitary adenomas. Exploration of the CS during trans-sphenoidal surgery (TSS) and resection of the involved medial wall of CS (medial wall of the CS) can achieve apparent gross total resection. However, novel strategies are needed to identify patients with occult tumor residuals and direct them to early radiotherapy. We developed the normalized early postoperative value (NEPV) of adrenocorticotropic hormone (ACTH) and cortisol as potential early predictors of remission. In this study, we integrate exploration of CS and NEPV into a clinical decision-making strategy in CD.

Methods: We analyzed data from 315 patients (2012-2023) undergoing TSS by a single surgeon for CD. Surgical approaches included sublabial TSS, CS exploration, and medial wall resection based on preoperative imaging or intraoperative findings. Postoperative cortisol and ACTH levels were assessed at extubation and every 6 hours postoperatively for 72 hours before corticosteroid replacement.

Results: CS exploration was performed in 50 patients (33 female; median age 26.5 years) because of preoperative MRI findings (n = 37) or intraoperative findings (n = 13). Adenoma adherence (n = 18, 36%) or invasion (n = 32, 64%) of the medial wall was observed. Thirteen patients with subtotal resection were recommended for radiation. Among 37 patients with gross total resection, 12 (29.7%) received radiotherapy because of elevated postoperative hormone levels, including persistent hypercortisolemia (n = 5), elevated NEPV ACTH (n = 5), or cortisol (n = 5). No recurrence occurred in these 12 patients. Transient cranial neuropathies (<90 days) were observed in 4 patients, with no arterial injuries reported.

Conclusion: Preoperative MRI often underestimates CS invasion. CS exploration and medial wall resection are safe and effective for durable remission. An integrated strategy, using intraoperative findings and postoperative biochemical monitoring, may guide effective adjuvant therapy in CD.

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.