World neurosurgery最新文献

Objective: To determine whether shorter surgical delays for chronic subdural hematoma (CSDH) are associated with improved functional outcomes.

Methods: Post hoc analysis of the FINISH trial, a nationwide multicenter randomized controlled trial. The primary outcome was functional outcome at six months post-surgery assessed by the modified Rankin Scale (mRS). Secondary outcomes included dichotomized mRS (0-3 favorable, 4-6 unfavorable), mortality, adverse events, and reoperation rates within six months.

Results: This study included 589 patients (median age 78 years, interquartile range [IQR] 72-84; 28.0% females) with a median surgical delay of 21 hours (IQR 9-33). The optimal cut-off point for surgery delay in relation to favorable functional outcome was 22 hours. In the early surgery (≤22h) group, 10.0% had an unfavorable functional outcome versus 15.8% in the late surgery (>22h) group (P = 0.06). After adjusting for confounding factors, the common odds ratio for mRS for late surgery versus early surgery was 1.42 (95% CI 1.01-2.00, P = 0.046). The probability of unfavorable functional outcome increased with surgical delay, peaking between 72-96 hours. There was no association between surgical delay, mortality, and adverse events after confounding adjustment. Reoperation rates were 17.5% in the early surgery groups and 13.1% in the late surgery group (P = 0.14).

Conclusions: In this post hoc analysis, shorter surgical delays for CSDH were associated with improved functional outcome. Our findings suggest that symptomatic CSDH patients should be operated on as soon as reasonably possible.

Although most patients with low-grade epilepsy-associated neuroepithelial tumors (LEATs) achieve satisfactory long-term postoperative seizure control, optimal surgical strategies remain undefined. We employed subdural electrode implantation and extended resection, including the tumor and surrounding cortices, in patients with LEATs to assess whether this approach improved seizure outcomes over a 10-year postoperative follow-up. Forty-five patients (26 men, 19 women) who underwent LEAT removal, with ≥2 years of follow-up, were included, and 34 (75.6%) showed temporal lobe tumors. In 30 (66.7%) patients, intracranial subdural electrodes were implanted, and video electroencephalography was performed. Seizure outcomes were classified using the International League Against Epilepsy (ILAE) criteria. Clinical variables independently associated with seizure-free (ILAE class I and Ia) outcomes were determined using univariate and multivariate analyses. The median postoperative follow-up was 117.6 (range, 24-319) months. At the final follow-up, 36 (80.0%) of 45 patients were seizure-free. Although 62.2% patients were seizure-free (ILAE class I and Ia) 1 year after surgery, the 4- and 5-year seizure-free rates were significantly higher; this indicated a running-down phenomenon. Univariate analysis showed significantly higher seizure-free rates for patients with temporal lobe tumors than for those with extra-temporal lobe tumors. Multivariate analysis confirmed tumor location as the only variable significantly correlated with seizure outcomes. Extended resection of the LEAT and surrounding tissue resulted in an 80% seizure-free rate at an average of 10 years after surgery. Outcomes were more favorable for temporal than for extra-temporal lobe tumors. Patients with LEATs may experience a running-down phenomenon for several years postoperatively.

Objective: Screw loosening is one of the most frequent complications after instrumented spine surgery, which constitutes a heavy burden for patients and the healthcare system. Low-virulent colonialization with biofilm formation has been identified as a possible cause for screw loosening. The aim of this study was to investigate the rate of low virulent infections in recurrent screw loosening after revision surgery.

Methods: Seventy-nine patients from January 2015 - July 2018 undergoing revision surgery due to clinically aseptic implant loosening were included in our observational study. Sonication of the loosened implant was performed. All identified patients received clinical and radiographic follow-up. Screw loosening was evaluated in CT-scans carried out at least 12 months after revision surgery. Patients were differentiated into three groups: One group included all patients with low virulent colonialization, who received antibiotic treatment (Co+ABX), the second group involved all patients with colonialization without postoperative antibiotic treatment (Co-ABX). The third group served as reference cohort containing all patients without colonialization (noCo).

Results: Seventy-nine patients (51 female, mean age 65.12 years) were identified. Forty-two patients (51.2%) received radiological follow-up with CT-scan for implant control. These patients were assigned to three groups (Co+ABX, n=5, 12%; Co-ABX n=8, 19%; noCo, n=29, 69%). In 10 out of 13 patients with positive sonication results (Co+ABX and Co-ABX) recurrent screw loosening occurred (76.9%). Antibiotic administration had no influence on screw loosening rates (4 out of 5 patients (80%,) in Co+ABX and 6 out of 8 (75%) patients in Co-ABX (p>0.05). In the reference group noCo 11 out of 29 patients (37.9%) recurrent screw loosening was identified (p=0.043).

Conclusion: In patients with screw revision surgery incidence of low-virulent microorganism colonialization is high and may play a role in the incidence of screw loosening. New therapeutic approaches addressing low-virulent infections and biofilm formation may be helpful.

Purpose: High-grade gliomas (HGG) are aggressive tumors known for their poor prognosis. Despite research into its molecular and clinical aspects, current management minimally impacts survival. It is unclear whether combining temozolomide (TMZ) with metformin (MET) could enhance survival in this population.

Methods: A systematic search on PubMed, Embase, and Cochrane Library databases was conducted for studies comparing TMZ+MET vs. TMZ alone for HGG. The outcomes of interest were overall survival (OS), progression-free survival (PFS), and subgroup analysis with MGMT and patients with diabetes. The analysis comprised outcomes reported as hazard ratios (HRs) and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) as all the outcomes are continuous. A significance level of p < 0.05 was considered statistically significant. Heterogeneity was assessed using the I² statistic with P values inferior to 0.10, and I² > 25% were considered significant for heterogeneity. The random effects model was employed for all outcomes.

Results: Ten studies were included, comprising 3,623 patients, of which 346 (9.5%) were assigned for TMZ+MET. The TMZ+MET group was associated with a significant reduction in mortality rates when compared to the TMZ alone group (HR 0.74; 95% CI 0.59, 0.93; p < 0.01; I² 29%). There was no significant difference between groups for PFS (HR 0.87; 95% CI 0.68-1.12; p = 0.29). In a subgroup analysis restricted to patients who received TMZ+MET, the diabetic subgroup had a significantly higher mortality rate than the normoglycemic subgroup (OR 1.25; 95% CI 1.10, 1.41; p < 0.01; I² 79%).

Conclusion: Our results showed that patients who received TMZ+MET had a significantly higher OS than patients who received TMZ alone. These findings support the use of MET along with TMZ for the treatment of high-grade gliomas.

Objective: Cavernous malformations of the brainstem (BSCM) often cause severe morbidity and mortality. Literature is limited for the optimal surgical approach. Our objective is to demonstrate successful use of the posterior median sulcus to access BSCM.

Methods: We present the case of a 20-year-old woman with an exophytic cavernous malformation of the brainstem showing signs of acute bleeding. The lesion, located near the ventricle surface, was successfully excised with entry through the posterior median sulcus.

Results: The patient sustained a mild post-operative weakness but no bulbar symptoms. Complete resection was confirmed on MRI.

Conclusions: The posterior median sulcus is a safe route for exophytic lesions of the medulla.

Objective: The utility of the tubular retractor for deep-seated tumors, including intraventricular tumors, has recently been reported. However, the surgical field's depth and narrowness can lead to blind spots, and it is crucial to prevent damage to the cortex and white matter fibers in eloquent areas. Therefore, preoperative simulation is critical for tubular retractor surgery. In this study, we investigated the benefits of threedimensional (3D)-printed intraventricular tumor models for tubular retractor surgery.

Methods: Nine patients with intraventricular central neurocytoma who underwent tubular retractor surgery at our institution between March 2013 and August 2023 were retrospectively reviewed. Fusion images and 3D-printed intraventricular tumor models were developed from preoperative computed tomography (CT) and magnetic resonance imaging (MRI). The puncture points of the tubular retractor were simulated using fusion images and 3D-printed intraventricular tumor models by 11 neurosurgeons (3 experts in brain tumors, 2 experts in areas other than brain tumors, and 6 residents). The dispersion of puncture points among 8 neurosurgeons (excluding brain tumor experts) was compared in each simulation model.

Results: These cases were categorized into two groups based on the dispersion of puncture points simulated by fusion images. Puncture point dispersion was markedly smaller in all cases when using 3D-printed intraventricular tumor models compared to simulations solely based on fusion images.

Conclusions: In intraventricular tumor surgery using a tubular retractor, 3D-printed intraventricular tumor models proved more beneficial in preoperative simulation compared to fusion images.

Background: Neurosurgical procedures are associated with the highest rate of malpractice claims. We present this Questionnaire-based study to evaluate the risk factors of neurosurgical malpractice claims in Egypt.

Materials and methods: We formulated two separate online questionnaires. 950 Egyptian neurosurgeons were invited to participate in the first online questionnaire. 1100 Patients who had undergone neurosurgical operations (either spinal or cranial) were invited to participate in the second online questionnaire.

Results: Responses were received from 360 neurosurgeons, 69.4% of whom were at consultant or professor levels. 61.11% of them reported a total income of > $ 200 (American dollar) per month. 36.1% of neurosurgeons believe that malpractice claims are related mainly to spine surgeries. Death is considered the primary motivating surgical outcome for raising malpractice claims by 30.6% of our neurosurgeons. 61.1% of our neurosurgeons are practicing defensive medicine. Responses were also received from 380 neurosurgical patients, 83.3% of whom had spine surgery. 75% of patients underwent their surgery in private hospitals. 41.7% experienced complications. 83.3% of patients reported satisfactory communication during their surgeries, and 86.1% were satisfied with their surgeries.

Conclusion: Most Egyptian neurosurgeons prefer to practice defensive medicine because of the high number of malpractice claims. Very thorough measures and collaboration between the health systems, media, regulatory bodies, and neurosurgeons would be required to dismantle the complex situation and improve the practice at risk, and improve overall patient care.