Neurosurgery最新文献

Background and objectives: To propose a multiparametric score for discrimination of grade 2/3 from grade 1 intracranial meningiomas (IMs) based on preoperative patient and MRI data.

Methods: A retrospective cohort (n = 463) was used to test patient (age and sex) and MRI characteristics (volume, edema, necrosis, cysts, contrast patterns, edge irregularity, location) to detect a significant correlation with grade 2/3 IMs using binary logistic regression analysis with Hosmer-Lemeshow-test. All IMs were classified according to the 2021 classification. Depending on the variables' strength of correlation, points were assigned based on rounded β-coefficient from binary logistic regression and tallied together to form a total score. A cutoff score was defined by the highest Youden-index. The score was validated in a prospective (n = 211) and DNA methylation-based classification cohort (n = 18). Area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

Results: Six variables were significantly correlated with grade 2/3 IMs (edema, location at the convexity, volume >40 cm 3 , male sex, necrosis and cysts). By applying 1 point for male sex, edema, and cysts and 2 points for location at the convexity, volume ≥40 cm 3 , and necrosis, a cutoff value of 3 was identified for discrimination (91 grade 2/3; 372 grade 1 IMs [AUC = 0.791, sensitivity 76.9%, specificity 64.8%, PPV 34.8% and NPV 92%]). The cutoff value 3 was confirmed in the validation cohort (45 grade 2/3 and 166 grade 1 IMs [AUC 0.773, sensitivity 86%, specificity 60.7%, PPV 35.9%, and NPV 95.2%]) and in the DNA methylation-based classification (6 grade 2/3 and 12 grade 1 IMs [AUC 0.750, sensitivity 75%, specificity 83.3%, PPV 90%, and NPV 62.5%]).

Conclusion: The MEN-CCVol score ( M ale, E dema, N ecrosis, C onvexity, C yst, Vol ume) provides a readily applicable discrimination tool to identify grade 2/3 IMs. It may guide patients' counseling, timing of surgery, and surgical strategy. Further validation using genetic and epigenetic markers is required.

Background and objectives: Adequate understanding of health information has been shown to be a stronger determinant of health than several demographic factors, including age, income, or employment status. However, existing neurosurgical patient education materials (PEMs) may be too complex for the average American and may contribute to poor health literacy. Large language model chatbots may provide a rapid and low-cost means of rewriting existing PEMs at a lower reading level to improve patient understanding and overall health literacy.

Methods: Neurosurgical PEMs pertaining to stroke, laminectomy, pituitary tumors, epilepsy, and hydrocephalus published by the top 100 US hospitals were collected. For all PEMs, common measures of reading level and difficulty were generated, including Flesch Kincaid Grade Level, Flesch Reading Ease (FRE), Gunning Fog Index, Automated Readability Index, Coleman-Liau Index, and the Simple Measure of Gobbledygook Index readability score. ChatGPT-4 was then used to rewrite 25 randomly selected PEMs at or near the reading level of the average American (eighth-grade reading level). The rewritten PEMs were assessed for readability using the same measures of reading level and difficulty.

Results: The mean FRE for PEMs on all 5 common neurosurgical conditions were significantly greater than corresponding scores for an eighth-grade reading level ( P < .001). The mean Kincaid value, Automated Readability Index, Coleman-Liau score, Gunning Fog Index, and Simple Measure of Gobbledygook Index for PEMs on each condition were all significantly greater than an eighth-grade reading level ( P < .01). The mean FRE score for rewritten PEMs on each topic were significantly lower than nonrewritten materials ( P < .01) except spinal stenosis ( P = .104) and were validated for accuracy.

Conclusion: Existing PEMs published by the top US hospitals for common neurosurgical conditions may be too complicated for the average American that reads at an eighth-grade level. Large language model chatbots can be used to efficiently rewrite these PEMs at a lower reading level while maintaining the accuracy of the material.

Background and objectives: Gynecological cancers represent 10% to 15% of cancers in women, but brain metastases (BM) are uncommon, with limited evidence regarding their management. This study investigates the role of stereotactic radiosurgery (SRS) for BM from primary gynecological cancers.

Methods: Institutions of the International Radiosurgery Research Foundation participated in this study. Inclusion criteria required histological diagnosis of epithelial ovarian, cervical, or endometrial cancer, SRS between 2000 and 2020, and at least 1 imaging or clinical follow-up.

Results: A total of 276 patients having SRS for 977 BM were included. Median age at SRS was 62 years (IQR, 55-70). Primary cancer origin was ovarian in 128 (46%), cervical in 43 (16%), and endometrial in 105 patients (38%). Median Karnofsky Performance Scale was 80%, and systemic disease was active in 124 (45%) of patients. A median of 1 metastasis was treated (IQR, 1-3) per patient. Median individual metastasis volume was 0.27 cc (IQR, 0.05-1.59 cc). The majority (91%) received single-fraction SRS, using a median margin dose of 18 Gy (IQR, 16-20 Gy). Actuarial overall survival was 77%, 65%, and 44% at 6, 12, and 24 months, respectively. Predictors of worsened survival included older age, cervical and endometrial primary, previous whole-brain radiation therapy (WBRT), active systemic disease, worsened Karnofsky Performance Scale, absence of subsequent surgery, and increasing number of BM. Actuarial local control was 94% at 6 months, 89% at 12 months, and 78% at 24 months. Previous SRS or WBRT, tumor bed treatment, and cervical histology increased the risk of local failure. New remote BM and leptomeningeal dissemination occurred in 44% and 11% of patients, respectively. Adverse radiation effects (ARE) occurred in 13% of cases but were symptomatic in only 3%. Previous WBRT or SRS and increased tumor diameter increased the risk of ARE.

Conclusion: SRS is an effective management for BM from gynecological cancers with low risks of symptomatic ARE.

Background and objectives: Intracranial schwannomas are benign peripheral nerve sheath tumors usually identified as vestibular schwannomas (VSs). Among nonvestibular intracranial schwannomas (non-VSs), trigeminal and jugular foramen schwannomas are predominantly observed. Although the loss of NF2 function plays a significant role in sporadic VS tumorigenesis, a recent large-scale study showed the involvement of other recurrent gene mutations, in addition to the SH3PXD2A-HTRA1 gene fusion, in sporadic schwannomas. However, the genetic landscape of non-VS remains unclear.

Methods: We performed targeted panel sequencing and microsatellite analysis of 22q in 51 patients with sporadic intracranial schwannomas, including 30 patients with non-VS and 21 with VS, and explored the differences in the genetic backgrounds between non-VS and VS.

Results: NF2 somatic mutations were frequently identified in tumor samples (25 patients, 49%); non-VS showed a significantly lower frequency of NF2 mutations than VS (26.7% vs 80.9%, respectively; P = 1.8 × 10 -4 ). Despite no differences in the frequency of 22q loss of heterozygosity between non-VS and VS, that of NF2 alterations ( NF2 mutation or 22q loss of heterozygosity) was significantly different (56.7% vs 95.2%, respectively, P = 3.2 × 10 -3 ). The NF2 , LZTR1 , and SMARCB1 germline variants that predispose for NF2 or SMARCB1 - and LZTR1 -related schwannomatosis were not identified in blood samples; however, low allelic somatic mosaicism was suspected in one case of VS without a typical phenotype. In this article, we demonstrated that in intracranial schwannomas, the frequency of NF2 alterations varied depending on the tumor location, whereas that of other known mutations did not differ between non-VS and VS.

Conclusion: Our results suggested the potential involvement of factors other than NF2 inactivation in tumorigenesis, especially in non-VS. However, further comprehensive molecular analyses are warranted.

Background and objectives: Type II odontoid fractures (T2OF) are the most prevalent cervical spine injuries among the elderly. Nonetheless, there are insufficient data regarding the influence of frailty on outcomes for both nonoperative and operative treatment approaches. We sought to evaluate the influence of frailty on outcomes using 5-factor modified frailty index.

Methods: We performed a retrospective review of the American College of Surgeons Trauma Quality Improvement Program database from 2015 to 2020. We analyzed nonoperative and operative traumatic T2OF cases. Outcomes included major complications, hospital length of stay (LOS), nonhome discharge (NHD), mortality rates, and survival probabilities. We used unmatched and propensity score-matched risk-adjusted models to assess the association between frailty and all outcomes. Survival probabilities were examined using Kaplan-Meier plots, stratified by frailty strata.

Results: A total of 22 440 patients comprising 7138 (31.8%) robust, 7913 (35.2%) normal, 5158 (22.9%) frail, and 2231 (9.9%) very frail patients were included. Results from unmatched multivariable analyses revealed a dose-dependent relationship between frailty and all outcomes, in both cohorts ( P < .05). Propensity score-matched resulted in 3942 nonoperative and operative matched pairs. Preoperative characteristics were similar between cohorts, except for age: 75 years (IQR: 60-83) for nonoperative and 70 years (IQR: 56-78) for operative, and male sex: 1799 (55.8%) for nonoperative and 439 (61.1%) for operative cohorts. Significant mortality reductions (43%-77%; P < .05) were observed in the operative cohort compared with the nonoperative cohort across all frailty strata. As expected, the operative cohort had longer LOS and increased NHD risk ranging from 64% to 97%, P < .001. In Kaplan-Meier analyses, survival declined significantly across increasing frailty strata P < .001.

Conclusion: Increasing frailty was independently associated with major complications, LOS, NHD, and decreased survival. Operative patients exhibited improved survival compared with nonoperative patients across all frailty strata. These findings highlight the importance of frailty in T2OF management and care coordination.

Background and objectives: Flow-diverting stents (FDSs) have improved treatment options for intracranial aneurysms. Although FDS have proven successful in treating aneurysms that would previously have required complex microsurgical or endovascular repairs, treatment failures remain a concern. In this multicenter study, we aim to analyze the predictors of residual aneurysmal filling at early angiographic follow-up.

Methods: A retrospective analysis of a prospectively maintained neuroendovascular database at 14 high-volume US centers was conducted for all patients who underwent FDS placement for intracranial aneurysms between 2011 and 2019. Aneurysms were graded on the O'Kelly-Marotta scale (OKM).

Results: A total of 2277 patients underwent FDS embolization for intracranial aneurysms during the study period. The patient's mean age was 55 (SD ± 13.5) years, and 82% were female. The median maximal aneurysm diameter was 6.7 mm (IQR 4.10-11 mm). Complete aneurysm obliteration (OKM grade 4) occurred in 1109 patients (68%), and 146 (9%) were OKM grade 3, 188 (12%) were OKM grade 2, and 174 (11%) were OKM grade 1. In the adjusted multivariate analysis, individuals in the 65-74 years and 75+ years age groups had significantly increased risk of residual aneurysm filling at 6-month follow-up compared with the 18-44 years age group (odds ratio [OR] 1.92 (95% CI: 1.33-2.78) and 2.92 (95% CI: 1.79-4.77), respectively). Aneurysms arising from the superior cerebellar artery, the basilar artery, and the carotid terminus were more likely to have a residual filling (OR 12.6, 95% CI: 1.39-14.7; OR 4.27, 95% CI: 1.39-14.7; OR 3.16, 95% CI: 1.24-8.06, respectively).

Conclusion: As the utilization of FDS for intracranial aneurysms becomes more widespread, the efficacy of aneurysm obliteration needs to be assessed. Our results indicate that several patient-dependent factors, such as age, aneurysm location, and size, predict the likelihood of residual aneurysm filling 6 months post-treatment.