Neurochirurgie最新文献

Background

The microscope has been the gold standard in neurosurgical practice due to its ability to magnify anatomical structures. However, it has limitations, including restricted visual fields and ergonomic challenges that can lead to surgeon fatigue and musculoskeletal issues. The exoscope is an emerging technology that may address these limitations by offering comparable magnification with improved ergonomics.

Methods

This study compares the traditional microscope (KINEVO 900) with a 3D digital exoscope (Aeos Digital Microscope) in visual field width, image sharpness, and ergonomic impact. Visual field assessments were conducted using millimeter paper at a fixed distance, while image sharpness was evaluated using graph paper with pins at different depths. Ergonomic evaluation involved simulating surgical positions using a spine anatomical model. The practical applicability was tested during Selective Dorsal Rhizotomy (SDR) procedures, comparing the surgeon's experience with both devices over 20 consecutive cases.

Results

The exoscope provided a larger visual field (81.18 cm²) compared to the microscope's (54.10 cm²). Image sharpness was similar for both devices across various depths and zoom levels. Ergonomically, the exoscope allowed the surgeon to maintain a neutral posture while visualizing extreme angles, unlike the microscope, which required significant upper body movement. In SDR procedures, the exoscope improved surgeon comfort and interaction with the operating team, despite an initial learning curve.

Conclusions

The exoscope presents notable advantages in terms of visual field and ergonomics. The exoscope’s ability to facilitate better posture and team communication without compromising image quality makes it an addition to neurosurgical practice, as in SDR.

Background

Despite multiple calls for more inclusive studies, most clinical trial eligibility criteria remain too restrictive. Thrombectomy trials have been no exception.

Methods

We review the landmark trials that have shown the benefits of thrombectomy, their eligibility criteria, and consequences on clinical practice. We discuss the rationale behind various reasons for exclusions. We also examine the logical problem involved in using eligibility criteria as indications for treatment.

Results

Most thrombectomy trials have been too restrictive. This has been shown by a plethora of follow-up studies that have refuted most of the previously recommended trial eligibility restrictions. Meanwhile, the effect of clinical recommendations based on restrictive eligibility criteria is that treatment has been denied to the majority of patients who could have benefitted. Trial eligibility criteria cannot be used to make clinical decisions or recommendations unless, like any other medical diagnosis, they have been shown capable of reliably differentiating patients into those that will, and those that will not benefit from treatment. This goal can only be achieved with all-inclusive pragmatic trials.

Conclusion

Restrictive eligibility criteria render clinical trials incapable of guiding medical decisions or recommendations.

Purpose

Methods

Results

Conclusion

Introduction

The aim of this study was to assess the capability of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) to discriminate unruptured intracranial aneurysms (UIAs) at high risk for subarachnoid hemorrhage (aSAH).

Material and method

During the period from January 2012 to December 2022, we included all consecutive adult patients admitted to our institution for an aSAH caused by the rupture of a saccular IA. The patient-related, aneurysm-related and treatment-related risk factors considered by UIATS were retrieved from medical records. After UIATS calculation for all ruptured IAs in the cohort, patients were categorized as “true positives (TP)” if UIATS would have (appropriately) oriented the management toward treatment, whereas patients for whom the UIATS would have (inappropriately) recommended observation were categorized as “false negatives (FN)”. Patients for whom UIATS was inconclusive were categorized as “undetermined (UND)”. Sensitivity of the UIATS (Se _UIATS) was calculated by using the following formula: TP/(TP + FN).

Results

A total of 346 patients (253 women, 73%; mean age = 56 ± 1.45 years) were incorporated into the final analysis. There were 140 T P (40%), 79 F N (23%) and 127 UND (37%), leading to a Se _UIATS of 63.9% (CI 58.3–69.5). Cumulatively, the UIATS failed to provide an appropriate recommendation in 60% of the entire cohort.

Conclusion

By retrospectively applying the UIATS in a cohort of ruptured IAs, our study emphasizes how vulnerable the UIATS can be. Even if the UIATS suggests conservative management, clinicians should inform patients that there is still a small risk of rupture.

Background

An important difference between explanatory and pragmatic clinical trials concerns eligibility criteria. Eligibility criteria are restrictive in explanatory trials, while pragmatic trials are more inclusive or even all-inclusive.

Methods

To better understand the diverging views regarding eligibility criteria, we examine the contrast between theoretical and clinical medicine, and 3 different research contexts: laboratory research, population studies and clinical trials. In each context we review the purpose for selecting study subjects or research material, as well as the type of inductive inference or generalization that is sought by such selection.

Results

In each context, selection concerns different things and serves different purposes: In the laboratory, selection concerns the homogenous research material that will help isolate a causal signal. In the epidemiological context selection concerns the (random) sampling method, designed to produce a representative sample of the population. In the clinical trial setting, selection concerns patients in need of care. Restrictive eligibility criteria become inappropriate in the care setting because the aim of the trial is not to represent a population nor to isolate a causal signal, but to find out which patients benefit from treatment.

Conclusion

The idea of selecting patients comes from methods that belong to theoretical medicine. In the care setting, most clinical trials should be pragmatic and as inclusive as possible.

Background

Hemorrhage management is crucial for surgical resection of pediatric posterior-fossa tumors (PPFTs). Tumor volume and vascularity on preoperative magnetic resonance imaging (MRI) can help predict and control intraoperative blood loss (IBL). The present study aimed to assess the correlation between MRI features and IBL in PPFTs.

Methods

Eleven patients treated for PPFTs at our hospital using the transcerebellomedullary fissure approach were enrolled, including five (45.5%) males and six (54.5%) females, with a median age of 10 (range, 4–16) years. Nine patients with medulloblastoma, one with ependymoma, and one with atypical teratoid/rhabdoid tumor were included. Using susceptibility-weighted imaging-based intratumoral susceptibility signal (ITSS) grade as an index of tumor vascularity, we performed univariate analysis of the association of degree of vascularity (ITSS grade 0–2 vs. 3) and multivariate analysis of IBL.

Results

Univariate analysis showed that the high vascularity group (ITSS grade 3) had significantly larger tumor volume (p = 0.009) and higher IBL (p = 0.004). In multivariate analysis of age, tumor volume, ITSS grade, cerebral blood volume, and extent of resection, tumor volume was the only significant factor (p = 0.001); however, ITSS grade was also positively associated with IBL (p = 0.074).

Conclusion

In this study, tumor volume and vascularity of PPFTs were strongly correlated, and tumor volume was the sole factor significantly associated with IBL. This study suggests that ITSS grade and tumor volume collaboratively influence IBL in surgical resection of PPFTs. IBL should be assessed based on MRI features, and suitable treatment strategies should be established.

Study design

Retrospective literature review analysis

Objective

Analyze the risk factors, characteristics, outcome, and follow up of surgical management of disc herniation in children ≤15 years old (y.o) through a review of the literature.

Background

Disc herniation is a rare disease in the pediatric population. While conservative treatment if very often tried, some cases require surgical treatment.

Methods

A literature search was conducted using PubMed data base using the terms ‘pediatric/children/adolescent disc herniation’ and ‘surgical management’ as key words. Significant manuscripts i.e: case reports, case series, reviews were identified and analyzed. The exclusion criteria were: series and cases with patients >15 y.o, results non-individualizable and medical management.

Results

49 studies were identified, 28 were retained. 69 children <15 y.o were identified with a median age of 13 y.o (SD 1–15). The mean FU was 3.3 years. Trauma and repeated micro traumatism were identified as the main causes of disc herniation in this population. It is mostly a lumbar disease, with very anecdotic cases of thoracic or cervical herniation described.

In the absence of neurological deficit, conservative treatment should be tried. Different types of surgery exist (open, endoscopic, tubular), with no difference in outcome or complications. The post-operative outcome was very satisfactory, with no neurological sequalae described with excellent recovery.

Conclusions

Pediatric disc herniation is often caused by precipitating factors such as trauma. In the absence of resolution with conservative treatment, surgical options yield favorable short term clinical outcomes with minimal complications and no neurological sequalae.

Chiari malformation type III is a rare congenital anomaly. It consists of the posterior fossa contents herniation through an occipital or high cervical encephalocele sac. Although it has traditionally been associated with a high mortality rate, the absence of certain poor prognostic factors and appropriate medical and surgical treatment allow these children to survive and have a remarkable initial functional improvement. Surgical goals are defect repair, preservation of viable brain tissue, adequate skin coverage and hydrocephalus management. Despite all of this, the tendency of these newborns is to maintain a significant disability and if they present poor prognostic criteria, they usually demise within a short period of time.

We report the case of a newborn with Chiari malformation type III diagnosed during pregnancy. After characterizing the anomaly with a postnatal MRI, the encephalocele was excised and multi-layer closure was performed. The patient progressively developed hydrocephalus during the postoperative period and required ventriculoperitoneal shunt placement. After an initial uneventful course, our patient suffered several episodes of respiratory disturbances. The child became ventilator dependent and palliative care was established in agreement with the parents after ruling out shunt malfunction.