Neurosurgery最新文献

Background and objectives: Although carotid endarterectomy (CEA) and carotid artery stenting (CAS) reduce the risk of stroke, their efficacy in improving decreased vision is unclear. This study aims to evaluate the effects of CEA and CAS on ocular blood flow (OBF) and visual acuity (VA) in patients with carotid artery stenosis, while also exploring the possible relevance of postoperative microembolisms to visual recovery.

Methods: The results of 78 procedures (CEA, 39; CAS, 39) performed in 76 patients with carotid artery stenosis were prospectively analyzed. OBF was measured using laser speckle flowgraphy to assess the mean blur ratio, which reflects the absolute retinal blood flow. VA was assessed using Contrast Sensitivity Vision-1000, which measures contrast sensitivity, and the area under the log contrast sensitivity function (AULCSF) was calculated as a measure of VA. Microembolisms were evaluated using magnetic resonance imaging immediately after surgery, and their effects on retinal vessels were assessed using optical coherence tomography of the central fovea.

Results: Both treatments significantly enhanced OBF (MBR: 31.4 to 37.9 [P < .0001] for CEA; 33.9 to 37.8 [P = .007] for CAS). VA improved significantly after CEA (AULCSF: 1.03 to 1.06, P = .02), but not after CAS (1.08 vs 1.06, P = .37). In the analysis of all 78 patients, those with postoperative microembolisms showed poorer visual improvement (AULCSF change 0.01 vs -0.07, P = .01). In addition, among 39 patients assessed with optical coherence tomography, retinal vessel density decreased significantly more after CAS than CEA (-0.5 vs 1.1, P = .04).

Conclusion: Although carotid revascularization can enhance OBF, VA improved only after CEA. Microembolisms appear to impair visual recovery. These findings emphasize the importance of assessing visual function in patients with carotid artery stenosis and the need for personalized treatment approaches based on individual visual profiles and stroke risk.

Background and objectives: The publication "arms race" refers to the recent, exponential increase in publications among residency "Match" applicants. Total number of residency applicant publications is the strongest predictor of "Match" success in neurosurgery beyond licensing examination scores. This study sought to introduce an objective metric by which publications may be scored to assess residency applicant authorship effort.

Methods: A retrospective, quantitative assessment of 537 publications by 57 interviewed applicants at a neurosurgery residency program was conducted from the 2022 to 2023 "Match" cycle. A 4-point scale was used to calculate a Publication Effort Score (PES) for each publication, ranging from a letter/editorial/historical commentary (PES = 1) to a high-effort clinical/basic science/cadaveric study (PES = 4). Each PES was subsequently divided by the applicant's authorship position to assign a corresponding publication value unit (PVU), which was calculated for each applicant publication and summated for an applicant's cumulative PVU (cPVU). An Arms Race Control Score (ARCS) was calculated by eliminating all minimal effort publications (PVU ≤ 1) from the cPVU score.

Results: Mean publication number among applicants was 9.28 (±10.7), with approximately one-third (31.8%, N = 169) of publications first-authored by an applicant. Approximately one-quarter (26.1%, N = 140) of publications were minimal effort publications. A minority of publications (41.3%, N = 222) had a PVU of greater than 2. ARCS implementation resulted in a major ranking change (±≥5 positions) for 61.4% (N = 35) of applicants, ranging from an increase in 22 positions to a decrease in 26 positions. Following ARCS, four positions changed among applicants ranked 1 to 10.

Conclusion: ARCS standardizes residency applicant publication assessment by attempting to capture applicant authorship effort. ARCS implementation may drive residency applicants to focus on higher effort publications, offering a novel solution to the publication "arms race." Automated ARCS scoring for the upcoming "Match" cycle may be calculated using an applicant's last name and publications' PubMed IDs using https://arcscalculator.com.

Background and objectives: The traditional management of pregnant patients with Chiari I malformation (CM-I) heavily favors cesarean section and general anesthesia to limit the perceived risk of maternal neurological complications attributed to vaginal delivery and neuraxial anesthesia. The aim of this study was to compare reported neurological symptoms and radiographic presentations before and after childbirth performed by patients with CM-I, with and without associated syrinx.

Methods: Neurological symptoms, mode of delivery, administered anesthesia, extent of cerebellar tonsillar descent, and syrinx diameter and length were recorded before and after delivery from electronic medical records of 36 patients with CM-I who delivered between January 2008 and August 2022. Data were analyzed using paired Student t-tests.

Results: Thirty two vaginal deliveries and 44 cesarean sections performed on 36 mothers were included. 60 deliveries used neuraxial anesthesia. Average tonsillar descent prepartum and postpartum was 9.3 ± 4.28 mm and 9.4 ± 4.81 mm, respectively (P = .215). Average syrinx diameter prepartum and postpartum was 5.2 ± 2.72 mm and 5.2 ± 2.31 mm, respectively (P = .611). There was no significant difference between prepartum and postpartum average tonsillar descent measurements among cesarean sections (P = .115) or vaginal deliveries (P = .620). There was no significant difference in syrinx diameter or length between prepartum and postpartum in cesarean section patients or in vaginal deliveries. Of the 76 deliveries, 2.6% of patients had worsened Chiari symptoms postoperatively, both are cesarean deliveries. Logistic regression demonstrated no significant worsening of Chiari-related symptoms, regardless of delivery or anesthesia type.

Conclusion: Our findings suggest that patients with CM-I may deliver vaginally and receive neuraxial anesthesia with low risk of neurological complications or radiographic worsening. As these patients were not prospectively selected, limitations exist, and it remains important to consider the severity of the patient's clinical and radiographic presentation when selecting anesthetic and delivery modality.

Background and objectives: Identifying patients with basal ganglia intracranial hemorrhage (ICH) at risk of hematoma expansion (HE) may better define selection criteria for early surgical evacuation. The aim of this study was to use automated radiographic feature extraction to improve risk stratification for basal ganglia ICH expansion.

Methods: A single-center retrospective review was performed to identify patients with basal ganglia ICH between 2013 and 2024. ICH volumes were automatically segmented from the initial noncontrast computed tomography (CT) of the head using a custom-trained convolutional neural network. Features were quantified from the segmented ICH including stereotactic location, normalized volumetric CT density (nv-CTD, measured as mean ICH CT density divided by the background parenchymal CT density), volume, orientation, and border irregularity. HE was defined as an increase in hemorrhage volume of 10 mL or at a rate of 1.7 mL/h.

Results: A total of 108 patients (median age 55 years, 62% male) were included. HE occurred in 24 patients (22%) and was associated with shorter duration between symptom onset and initial CT (median 1 vs 3 hours, P = .006), a lower nv-CTD (median 2.0 vs 2.2, P = .011), and a positive spot sign (41% vs 5%, P < .001). nv-CTD was positively associated with time to presentation (R2 = 0.13, P < .001) and was negatively associated with HE in spot-sign-negative patients (median 2.0 vs 2.1, P = .016). Multivariate logistic regression modeling using nv-CTD and spot sign as inputs demonstrated improved diagnostic accuracy compared with that of the spot sign alone (area under the receiver operating characteristic curve 0.80 vs 0.68, P = .008). The area under the receiver operating characteristic curve of nv-CTD alone was 0.67 (95% CI: 0.56-0.78), which was statistically similar to that of the spot sign alone (0.68, 95% CI: 0.54-0.82) (P = .819).

Conclusion: nv-CTD is a measure of bgICH acuity and can augment spot-sign bgICH expansion risk stratification.

Background and objectives: Aggressive resection for primary tumors of the spine are associated with a high rate of adverse events (AEs), but the impact of AEs on patient-reported outcomes (PROs) remains unknown and is critical to the shared decision-making. Our primary objective was to assess the impact of surgical AEs on PROs using an international registry. Assessing the impact on clinical outcomes and identifying risk factors for AEs were our secondary objectives.

Methods: Patients who underwent surgery for a primary spinal tumor were selected through the Primary Tumor Research and Outcomes Network. Our primary outcome was the impact of AEs on PROs at 3 and 12 months after surgery (measured with Spinal Oncology Study Group Outcomes Questionnaire, Short-Form 36, and EuroQol 5 Dimension). We also assessed the impact on clinical outcomes (local control, surgical margins, readmission, reoperation, and mortality). We stratified our results according to severity of AEs, histology, and type of resection.

Results: 374 patients met inclusion criteria (219 males/155 females). The mean age of the cohort was 48.7 years. The most frequent histology was chordoma (37.3%) followed by chondrosarcoma (8.8%). Sixty-seven patients (17.9%) experienced at least 1 intraoperative AE and 117 patients (31.3%) had at least 1 postoperative AE within 3 months. Overall, 159 patients (42.5%) experienced AEs. The readmission rate was significantly higher in patients who experienced AEs (Any AE: 10.1% vs no AE: 1.9% within 3 months; P = <0.001). PROs were not significantly affected by AEs in most questionnaires. Local control, risk of reoperation, mortality, and achieving preplanned margins were similar between AE groups.

Conclusion: The rate of surgical AEs is considerable in this population. Surgical AEs seem to be associated with a higher number of readmissions, but do not seem to result in significant differences in PROs or in a higher risk of reoperation, mortality, and failure to achieve preplanned margins.

Background and objectives: Despite the high morbidity associated with glenohumeral dysplasia (GHD) in children with brachial plexus birth injuries, the progression of this condition often remains unnoticed, even after correcting for the underlying brachial plexus birth injuries. GHD, driven by a multifactorial process involving disruptions in both direct and indirect neural regulation of bony and muscular structures, can lead to intermittent or permanent shoulder mobility imbalances, significantly impacting the quality of life of those affected. Recent research efforts are increasingly directed toward identifying the root causes, managing the deformity, and determining effective treatment options for correcting GHD.

Methods: A comprehensive search strategy was used by the authors to identify relevant literature relating to the progression, pathoanatomy, clinical presentation, and management of GHD following brachial plexus birth injuries across various search engines, such as PubMed, Scopus, and Embase. Considering the topic's interdisciplinary nature, articles were retrieved from both neurosurgical and orthopaedic journals to enrich the review.

Results: Given the challenges in managing patients with brachial plexus birth injuries, a multidisciplinary care team consisting of certified occupational hand therapists, neurosurgeons, plastic surgeons, and orthopedic surgeons, specializing in brachial plexus injuries should be advocated for. The aim of this collaborative effort is to correct brachial plexus birth injuries and prevent the persistence of GHD.

Conclusion: As research continues to focus on understanding the complexities of this condition, the aim of this review article is to summarize the current literature on the course of brachial plexus birth injury and the development of GHD. By doing so, we hope to provide neurosurgeons with the necessary knowledge and essential tools needed to identify and effectively treat GHD during management of brachial plexus birth injuries.

Background and objectives: Isocitrate dehydrogenase (IDH)-mutant astrocytomas central nervous system World Health Organization grade 2 and 3 show heterogeneous appearance on MRI. In the premolecular era, the discrepancy between T1 hypointense and T2 hyperintense tumor volume in absolute values has been proposed as a marker for diffuse tumor growth. We set out to investigate if a ratio of T1 to T2 tumor volume (T1/T2 ratio) is associated with resectability and overall survival (OS) in patients with IDH-mutant astrocytomas.

Methods: Patient data from 2 centers (Sahlgrenska University Hospital, Center A; LMU University Hospital, Center B) were collected retrospectively. Inclusion criteria were as follows: pre and postoperative MRI scans available for volumetric analysis (I), diagnosis of an IDH-mutant astrocytoma between 2003 and 2021 (II), and tumor resection at initial diagnosis (III). Tumor volumes were manually segmented. The T1/T2 ratio was calculated and correlated with extent of resection, residual T2 tumor volume, and OS.

Results: The study comprised 134 patients with 65 patients included from Center A and 69 patients from Center B. The median OS was 134 months and did not differ between the cohorts ( P = .29). Overall, the median T1/T2 ratio was 0.79 (range 0.15-1.0). Tumors displaying a T1/T2 ratio of 0.33 or lower showed significantly larger residual tumor volumes postoperatively (median 17.9 cm 3 vs 4.6 cm 3 , P = .03). The median extent of resection in these patients was 65% vs 90% ( P = .03). The ratio itself did not correlate with OS. In multivariable analyses, larger postoperative tumor volumes were associated with shorter survival times (hazard ratio 1.02, 95% CI 1.01-1.03, P < .01).

Conclusion: The T1/T2 ratio might be a good indicator for diffuse tumor growth on MRI and is associated with resectability in patients with IDH-mutant astrocytoma. This ratio might aid to identify patients in which an oncologically relevant tumor volume reduction cannot be safely achieved.

Background and objectives: Appropriate correction relative to the age-adjusted sagittal alignment target reduces the proximal junctional failure (PJF) risk. Nonetheless, a considerable number of patients suffer from PJF despite optimal correction. The aim of this study was to identify the risk factors of PJF that occurs despite optimal correction relative to the sagittal age-adjusted score (SAAS) in adult spinal deformity surgery.

Methods: Patients aged 60 years or older with adult spinal deformity who underwent ≥5-level fusion to the sacrum were initially screened. Among them, only patients who achieved optimal sagittal correction relative to the SAAS were included in the study. Optimal correction was defined as the SAAS point between -1 and +1. Various clinical and radiographic factors were compared between the PJF and no PJF groups and were further evaluated using multivariate analysis.

Results: The final study cohort comprised 127 patients. The mean age was 67 years, and there were 111 women (87.4%). A mean of total fusion length was 7.2. PJF occurred in 42 patients (33.1%), while 85 patients (66.9%) did not develop PJF. Multivariate analysis showed that a high body mass index (odds ratio [OR] = 1.153, 95% CI = 1.027-1.295, P = .016), a higher lordosis distribution index (LDI) (OR = 1.024, 95% CI = 1.003-1.045, P = .022), and no use of hook fixation (OR = 9.708, 95% CI = 1.121-76.923, P = .032) were significant risk factors of PJF development. In the receiver operating characteristic curve analysis, the cutoff value for the LDI was calculated as 61.0% (area under the curve = 0.790, P < .001).

Conclusion: PJF developed in a considerable portion of patients despite optimal correction relative to the age-adjusted alignment. The risk factors of PJF in this patient group were high body mass index, high LDI exceeding 61%, and no use of hook fixation. PJF could be further decreased by properly managing these risk factors along with optimal sagittal correction.

Background and objectives: Pleomorphic xanthoastrocytoma (PXA) is a rare low-grade glial tumor primarily affecting young individuals. Surgery is the primary treatment option; however, managing residual/recurrent tumors remains uncertain. This international multi-institutional study retrospectively assessed the use of stereotactic radiosurgery (SRS) for PXA.

Methods: A total of 36 PXA patients (53 tumors) treated at 11 institutions between 1996 and 2023 were analyzed. Data included demographics, clinical variables, SRS parameters, tumor control, and clinical outcomes. Kaplan-Meier estimates summarized the local control (LC), progression-free survival, and overall survival (OS). Secondary end points addressed adverse radiation effects and the risk of malignant transformation. Cox regression analysis was used.

Results: A total of 38 tumors were grade 2, and 15 tumors were grade 3. Nine patients underwent initial gross total resection, and 10 received adjuvant therapy. The main reason for SRS was residual tumors (41.5%). The median follow-up was 34 months (range, 2-324 months). LC was achieved in 77.4% of tumors, with 6-month, 1-year, and 2-year LC estimates at 86.7%, 82.3%, and 77.8%, respectively. Younger age at SRS (hazard ratios [HR] 3.164), absence of peritumoral edema (HR 4.685), and higher marginal dose (HR 6.190) were significantly associated with better LC. OS estimates at 1, 2, and 5 years were 86%, 74%, and 49.3%, respectively, with a median OS of 44 months. Four patients died due to disease progression. Radiological adverse radiation effects included edema (n = 8) and hemorrhagic change (n = 1). One grade 3 PXA transformed into glioblastoma 13 months after SRS.

Conclusion: SRS offers promising outcomes for PXA management, providing effective LC, reasonable progression-free survival, and minimal adverse events.

The future of global neurosurgery should focus on addressing the unmet neurosurgical need from a health system approach should we hope to achieve sustainable and ethical change. In this article, we review the global building blocks, as defined by the World Health Organization, and use this framework to propose strategies to strengthen neurosurgical care on the global frontier. The targets for Universal Healthcare Coverage by 2030, as outlined by the United Nations Sustainable Development Goals, are reviewed, and the role of neurosurgeons in addressing the global targets is discussed. Surgical indicators according to the Lancet Commission on Global Surgery are also reviewed, and neurosurgical indicators are proposed according to the 6 surgical indicators of the commission. The execution of these global targets and indicators within the context of health system strengthening will be a persistent challenge, given the complexity of health system and its components. The neurosurgical community must continue to support, promote, and diversify collaborations, especially among deserts of neurosurgical care across the world. Innovative technology and education are essential to this global dilemma.