Operative Neurosurgery最新文献

Background and objectives: Using confocal endomicroscopy (CLE) in neurosurgery holds the potential for intraoperative diagnosis and correct identification of tumor margins. Still, the correct employment of such a promising technique requires either an external dedicated person to interact with the neurosurgeon during the operation to check the quality of the acquired images or the operator to look directly and frequently outside of the operative field while maintaining the confocal microscopy probe in the surgical cave, thus interrupting the surgical flow, potentially disturbing the correct execution of surgical maneuvers and hindering a correct image acquisition.

Methods: To overcome this problem, we integrated the confocal microscopy interface (Zeiss CONVIVO®) into the surgical view through the operative microscope (Heads-up display). We enrolled patients undergoing surgery with the use of CLE for different pathologies, and we randomly allocated them to be operated with the heads-up display integration or without it. The mean CLE employment time and the number of usable and nonusable captures were annotated.

Results: Twenty-two patients were enrolled of which 12 patients underwent the procedure without the heads-up integration (54.5%) and 10 (45.5%) with it. The mean usage time of the CONVIVO® was 137 (±134) seconds, 61.1 (±38) seconds for the heads-up display group, and 201.6 (±154.1) seconds for the non-heads-up display group (P = .01). The heads-up display group showed a higher proportion of usable images (11 [±4] vs 50 [±37], 21.7%) than the non-heads-up display group (30 [±21] vs 163 [±33], 18.4%), although nonsignificant (P = .06). A significant influence of the intraoperative visualization on overall employment of CLE and a reduced number of images collected (611 vs 2139; P = .007).

Conclusion: By allowing the operator to check the quality of the images directly while still looking inside the operating field, better-quality images and a reduced number of unemployable captures are obtained, resulting in more efficient and less time-consuming use of intraoperative confocal microscopy, ultimately leading to reduced operative length.

Background and objectives: Patient frailty has been shown to be a powerful predictor of poor surgical outcome across specialties and may guide patient selection. In awake craniotomy, patient selection is particularly important for completion of intraoperative mapping and to reduce conversion to general anesthesia. We evaluated whether frailty is associated with unsuccessful awake craniotomy or poor outcome.

Methods: We performed a single-center retrospective study of adult patients with tumor, epilepsy, and vascular pathologies that underwent first-time awake craniotomy between 2018 and 2024. The Modified Frailty Index-11 (mFI-11) was calculated for each patient, and frailty was defined as a mFI-11 ≥2. We evaluated the association of frailty with unsuccessful awake craniotomy and postoperative complications.

Results: In total, 143 patients met inclusion criteria. There were 39 (27%) frail patients (mFI-11 ≥2) and 104 (73%) nonfrail patients (mFI-11 <2). Frail patients were significantly older (P < .001), had a higher American Society of Anesthesia classification (P = .015), higher rates of obstructive sleep apnea (P = .001), higher body mass index (P = .035), and glioblastoma (P < .001) compared with the nonfrail group. Frail patients had longer length of stay (P = .008) and had more than 2 times increased odds of discharge to skilled nursing facility or inpatient rehab facility (P = .01). Frail patients had no significant increased risk of conversion to general anesthesia or incomplete mapping, intraoperative deficit, 24-hour postoperative deficit, 30-day readmission, or residual neurologic deficit at follow-up.

Conclusion: In our cohort, frailty was associated with higher anesthetic risk and longer length of stay but was not significantly associated with unsuccessful awake craniotomy, postoperative complications, or neurologic outcome.

Background and objectives: Flow diversion (FD) of intracranial aneurysms (IAs) is an increasingly used and efficacious treatment modality. Transcirculation approaches, or approaches that cross the contralateral or anteroposterior arterial supply before reaching a target vessel, have been used to treat cerebrovascular pathologies when traditional approaches are unsuitable or require intraoperative complication management. This study sought to review IAs treated with FD using a transcirculation approach to determine the technique's safety and efficacy.

Methods: A systematic review of the PubMed, Scopus, Web of Science, and Embase databases was completed per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were included if they described transcirculation approaches in adult patients with IAs undergoing FD. Outcomes of interest included intraoperative complications and aneurysm occlusion rates.

Results: Twelve studies with 19 patients (N = 19, mean age = 54.1 y, 89.5% female) were identified. Wide-necked (N = 5, 26.3%) and saccular (N = 5, 26.3%) aneurysms were most represented, while 57.9% (N = 11) of aneurysms were unruptured and 15.8% (N = 3) of aneurysms were ruptured. The mean aneurysm sac and neck size were 16.9 mm and 11.9 mm, respectively. The most commonly deployed flow diverter was the Pipeline Embolization Device (N = 14, 73.9%). Successful FD (complete occlusion and/or good wall apposition) was recorded in 84.6% of qualifying patients with follow-up data, while 2 patients (15.4%) developed an intraoperative carotid-cavernous fistula.

Conclusion: Transcirculation approaches to FD offer neurointerventionalists a safe and efficacious method for device deployment, rescue scenarios, and challenging anatomy. Prospective studies may determine the most appropriate indications for transcirculation approaches to FD, while novel, lower profile devices may improve its technical feasibility and safety.