World neurosurgery最新文献

Each year, thousands of individuals, particularly young adults, experience traumatic brachial plexus injuries (TBPIs), leading to significant limitations, permanent disabilities, reduced quality of life, and infrequent return to work. Current treatments and assistive devices have shown limited success, resulting in considerable social and economic challenges for patients. Given the devastating nature of this injury and the lack of literature on return to work rates among young adults, this study aims to determine the percentage of individuals reintegrating into work after a TBPI. Furthermore, it compares outcomes across different health care systems, including those in Germany, Serbia, and the United Kingdom. This dual approach has been selected to investigate the influence of various factors on the outcomes associated with returning to work after TBPI. Preliminary findings indicate that approximately 60% of patients with TBPI return to work, although most require a change in their occupational roles. Despite variations in health care systems and governmental support, the reintegration of patients with TBPI into work and society remains a critical and universal challenge. This comparative analysis highlights disparities in TBPI research and outcomes, providing valuable insights for future improvements in patient care and support mechanisms.

Background and purpose: We explored the impact of various craniotomy approaches on the outcomes and long-term cognitive function of microsurgical clipping for superiorly projecting anterior communicating artery (ACoA) aneurysms.

Methods: We retrospectively analyzed 127 superiorly projected ACoA aneurysms underwent microsurgical clipping between January 2014 and January 2022. Patients were categorized into two types: type 1 (70 patients), characterized by the posterior positioning of the ipsilateral A2 segment (open A2 plane side), and type 2 (57 patients), characterized by the anterior positioning of the ipsilateral A2 segment (closed A2 plane side). The analysis focused on clinical outcomes (modified Rankin Scale score, mRS) and long-term cognitive function (Montreal Cognitive Assessment, MoCA).

Results: No significant differences in initial attributes were observed between the two groups. No differences in mRS (P = 0.483), cognitive impairment (P = 0.190), or severe cognitive impairment (P = 0.332) between the two groups. Furthermore, no significant differences in delayed cerebral ischemia (P = 0.852), delayed bleeding (P = 0.912), or intraoperative rupture (P = 0.141) between the two groups. However, the occurrence of MoCA subcategories of postponed memory items (P < 0.05) and conceptualization items (P < 0.05) demonstrated a significant decrease on the accessible A2 plane side during a shorter operative time (P = 0.03) and reduced gyrus rectus aspiration frequency (P = 0.000).

Conclusions: The anterior position of the A2 segment can offer better visualization of the aneurysm dome, bilateral A2, and AcoA, leading to reduced operative time and gyrus rectus aspiration frequency, potentially enhancing long-term cognitive function.

Brainstem cavernous malformations are relatively rare lesions with a higher tendency of hemorrhage than supratentorial cavernous malformations. Due to the compact arrangement of fiber tracts and nuclei of the region, any hemorrhagic event can cause severe neurological deficits. This eloquent architecture of the area also makes any surgical attempt challenging. Anatomical location and dimension of the lesion, presence of hemorrhage, age, and the neurological status of the patient need to be considered before determining the appropriate course of treatment. A surgical approach is preferred for young symptomatic patients with at least 1 previous episode of bleeding. Subtemporal and supracerebellar infratentorial approaches can be used to access these lesions.^1-5 We present a 44-year-old woman with a hemorrhagic tegmental cavernous malformation presenting with imbalance and right-sided hemiparesis (Video 1). The paramedian supracerebellar infratentorial translateral mesencephalic sulcus approach is used to resect the lesion with the patient in a dynamic lateral semisitting position. The paramedian variant of the supracerebellar infratentorial approach provides a relatively bridging vein-free corridor compared with midline approaches.⁶ With the patient in the semisitting position, gravity retraction of the brain provided a natural corridor with a clear surgical field. In the dynamic lateral semisitting position, we aimed to reduce the risk of venous air embolism associated with the sitting position by keeping the patient in the lateral decubitus position during the dural and extradural phases of the surgery.⁷.

Background: Revision surgery for patients with persistent, recurrent, or progressive syringomyelia following foramen magnum decompression (FMD) for Chiari malformation I-syringomyelia (CM-SM) is not uncommon and presents both strategic and technical challenges.

Methods: We conducted a retrospective study including all patients who underwent revision Cerebellar Tonsillectomy (CTL) for CM-SM between 2003 and 2023. Additionally, we performed uni- and multivariate analyses to identify possible factors contributing to failed CTL outcomes.

Results: Sixty-three consecutive patients (13 males; average age 45.86±11.18 years) underwent surgical treatment for persistent (n=29), progressive (n=21), or recurrent (n=13) syringomyelia, with an average interval of 65.57±73.33 months (range: 3-480 months) between the two surgeries. Factors significantly associated with the effectiveness of the revision CTL included dural incision and tonsil manipulation during the first surgery, severe intradural adhesions during the revision CTL, and spinal cord atrophy before the revision CTL. Multivariate logistic regression revealed that dural incision (P=0.031, OR=6.779, 95%CI (1.187∼38.719)), tonsillar manipulation (P=0.037, OR=7.432, 95%CI (1.131∼48.835)), and severe intradural adhesions (P=0.030, OR=11.465, 95%CI (1.264∼103.967)) constituted risk factors significantly statistical associated with prognosis outcomes. Long-term follow-up (average 18.75±6.86 months, range: 12-72 months) of revision CTL demonstrated clinical stabilization in 55.6% of cases for at least 1.5 years. The complication rate for revision CTL was 14.3% (n=9).

Conclusion: Dural incision and tonsillar manipulation during the first surgery, spinal cord atrophy prior to revision CTL, and severe intradural adhesions during revision CTL are significant risk factors associated with poor prognosis in revision surgery for CM-SM.

Backgrounds: Postoperative inflammatory parameters are important markers of surgical site infection. Some authors have reported that spine surgery with instrumentation elevates CRP levels more than that without instrumentation does. However, those studies compared early postoperative inflammatory markers with or without instrumentation in different patients, although CRP levels vary widely among patients. Therefore, we investigated the impact of early postoperative inflammatory reaction with or without instrumentation in the same patients.

Methods: Data were examined for 72 patients who had undergone lumbar surgery twice, once with instrumentation and once without instrumentation. CRP level, white blood cell (WBC) count, and neutrophil count (NC) were measured before surgery and at 1, 3, 7, and 14 days after surgery. All surgery with instrumentation were PLIF and all without instrumentation were laminotomy.

Results: Comparison of peak CRP between procedures with instrumentation and those without instrumentation showed a consistent peak on day 3 for all patients across both types of surgical procedures. After PLIF, there was a significantly elevated CRP, WBC, and NC in comparison to these for laminotomy. There were significant interactions between time and PLIF in relation to CRP, WBC, and NC levels. There were significant interactions between time and number of levels (N-level) in relation to CRP and NC. Age, gender, blood loss, and duration of surgery did not influence the observed elevations of all markers.

Conclusions: Early postoperative trends were significantly higher after PLIF than after laminotomy for all three indices, with a significant interaction between time and N-level for CRP and NC.

Background: Burr holes can lead to cranial defects that result in cosmetic and functional issues. Effective reconstruction of these burr holes is crucial for improving patient outcomes, yet there is no consensus on the optimal techniques and materials. This systematic review critically evaluates the efficacy and safety of various materials used in neurosurgical practice for burr hole reconstruction.

Methods: A comprehensive literature search was performed across PubMed, Medline (via Ovid), Embase, and the Cochrane Library, targeting studies published from January 2000 onwards. The quality of the included studies was systematically assessed, and data pertaining to the types of reconstruction materials, clinical outcomes, and complication rates was extracted.

Results: Seventeen studies met the inclusion criteria. The materials employed in burr hole reconstruction were categorized into biological and synthetic groups. Biological materials, such as autologous bone grafts and bone dust, demonstrated varying degrees of integration and resorption, with cortical bone grafts showing superior results. Synthetic materials were assessed for their safety, complication profiles, and esthetic outcomes. Titanium covers were associated with the lowest rates of skin depression. However, the overall quality of evidence was constrained by the heterogeneity in study designs, the brief follow-up periods, and a reliance on subjective outcome measures.

Conclusions: Burr hole reconstruction is essential for enhancing esthetic outcomes and patient satisfaction post-trephination. Autologous bone grafts, particularly cortical grafts, demonstrate superior integration, while synthetic materials offer viable alternatives with low complication rates. Future research should focus on long-term outcomes and the implementation of standardized, objective evaluation methods.

Purpose: Failure to rescue (FTR) is defined as mortality within 30 days following a major complication. While FTR has been studied in various brain tumor resections, its predictors in malignant brain tumor resection (mBTR) remain unexplored. This study aims to identify FTR predictors in mBTR resection patients using a frailty-driven model.

Methods: Patients undergoing craniotomy for mBTR were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2012- 2020), with frailty measured by the Risk Analysis Index (RAI).

Results: Of 14,721 mBTR patients, 1,275 (8.66%) developed major postoperative complications, and 166 (13.01%) experienced FTR. The cohort's median age was 59, interquartile range (47-68). Multivariate analysis revealed non-elective surgery (OR: 1.48, 95% CI: 1.02-2.16, p<.05) as an independent risk factor for FTR. Frailty was a significant independent predictor of FTR with mBTR, with both frail (N=110) and very frail (N=22) patients having a 5.34-fold and 8.10-fold higher odds of FTR, respectively (p<.001). Expectedly, major postoperative complications were predictive of FTR, including unplanned intubation (OR: 2.56, CI: 1.66-3.95, p<.001), prolonged ventilation (OR: 2.00, CI: 1.37-3.14, p<.01), cardiac arrest (OR: 16.64, CI: 8.20-33.74, p<.001), and septic shock (OR: 2.08, CI: 1.10-3.91, p<.05). The RAI-driven frailty model demonstrated excellent discriminatory accuracy for predicting FTR patients undergoing mBTR (c-statistic: 0.82, 95% CI: 0.79-0.85).

Conclusion: Preoperative RAI-measured frailty, alongside non-elective surgery and major postoperative complications were significant predictors of FTR in mBTR patients. Identifying mBTR patients at risk for FTR using frailty strata may aid in preoperative neurosurgical risk stratification to optimize patients prior to surgery.

This study explores the integration of chimeric antigen receptor T-cell (CAR-T) therapy with convection-enhanced delivery (CED) as a novel approach for treating diffuse intrinsic pontine glioma, a highly aggressive pediatric brain tumor with limited treatment options. Preliminary clinical results indicate that CED improves CAR-T cell distribution within the tumor microenvironment, leading to promising antitumor responses. However, challenges such as catheter-related complications and potential on-target/off-tumor toxicity remain. Ongoing research is essential to optimize these strategies and address ethical considerations surrounding patient safety and equitable access to innovative therapies. The aim is to assess the safety, efficacy, and distribution of CAR T cells delivered directly to the tumor site via CED, thereby enhancing therapeutic outcomes while minimizing systemic side effects.

Objective: Alcohol use disorder carries major effects shown to limit social support, increase recovery times, and lead to a higher incidence of surgical complications. This retrospective cohort study investigated the influence of AUD on perioperative outcomes and adverse events after spinal fusions in the largest sample size to date and spanning 11 years.

Methods: Data for adult (>18 years old) patients who underwent a spinal fusion as their primary surgery were identified from the Nationwide Inpatient Sample (NIS) database for the years 2009-2020. Patients were separated into an AUD cohort and a no AUD (control) cohort. Univariable and multivariable linear and logistic regression analyses were utilized to highlight statistically significant differences in their perioperative complications and adverse events.

Results: A total of 4,896,757 patients who underwent spinal fusion were identified. AUD was present in 97,565 (2.0%) patients, with the remaining patients serving as a control group. On multivariable analysis, patients with AUD had significantly increased odds of longer length of stay (odds ratio [OR]=3.40; 95% confidence interval [CI][3.24-3.57]p<0.001, and of the following perioperative complications and adverse events: neurologic injury (OR=3.24; 95% CI[3.05-3.44]p<0.001), respiratory-related (OR=3.06; 95% CI[2.91-3.21]p<0.001), systemic infectious (OR=2.79; 95% CI[2.48-3.13]p<0.001), neurologic (stroke) (OR=2.73; 95% CI[2.22-3.35])p<0.001, urinary-related (OR=2.23; 95% CI[2.11-2.36]p<0.001), venous thrombotic-related (OR=2.12; 95%[1.87-2.40]p<0.001), gastrointestinal-related (OR:1.91; 95% CI[1.79-2.03]p<0.001), wound-related (OR=2.32; 95% CI[2.10-2.56]p<0.001), cardiac-related (OR=1.44; 95% CI[1.34-1.55]p<0.001), and fusion disorders (OR=1.22; 95% CI[1.15-1.2]p<0.001).

Conclusion: We found that AUD carries a significantly negative influence over perioperative outcomes and adverse events after spinal fusion in a large database population.