Operative Neurosurgery最新文献

Background and objectives: Endoscopic skull base surgery aims to reduce surgical morbidity by minimizing tissue manipulation and exposure. However, the anatomic constraints posed by the narrow surgical corridors and constrained operative workspace present technical challenges due to reduced dexterity. This study evaluates the applicability of a novel dexterity-enhancing handheld robot for endoscopic skull base approaches.

Methods: The robotic system is comprised of interchangeable articulated end-effectors coupled to a handheld controller. Two attending skull base neurosurgeons and 2 neurosurgery residents performed 8 skull base approaches on cadaveric specimens, spanning anterior, anterolateral, lateral, posterolateral, and posterior approaches. Conventional instruments were used to expose anatomic landmarks, followed by intraoperative tasks using the handheld robot. Participants were interviewed during the procedures to assess the robot's feasibility (ability to safely reach and perform its objective of manipulating tissue at the operative site) and usefulness (ability to perform desired objectives well).

Results: The handheld robotic system was tested across 8 endoscopic skull base approaches, achieving feasibility in all cases. Superior workspace reach compared with standard instruments was demonstrated in 6 of 8 approaches. Tissue manipulation was satisfactory in all approaches. All surgeons reported that the current or a future device prototype could be useful across all 8 approaches. The most frequently cited advantage was the expanded dextrous workspace reach provided by the articulated end-effectors, particularly in approaches with long working channels, such as the endonasal approach. However, the robot encountered difficulties in transcranial approaches (trans-sylvian and subtemporal) due to the lack of shorter, curved shafts, which impaired visualization.

Conclusion: The handheld robotic system demonstrated applicability across various endoscopic skull base approaches, offering increased dextrous workspace and effective tissue manipulation capabilities. Overall, this study supports the potential of handheld robots in endoscopic skull base surgery while highlighting the need for iterative development to optimize instrument design and functionality.

Background and objectives: The temporalis muscle flap has historically been used for repairing defects from orbital procedures and is commonly used in cranial, oral, and facial reconstructions. However, its application for reconstructing the skull base after a transorbital approach has not been explored. Reconstruction after a transorbital intradural approach is still object of preclinical and clinical investigation, with various techniques emerging recently. This study introduces a novel method suitable for extensive resections of the skull base, including intradural resections of the anterior, middle, and posterior cranial fossae.The study aimed to investigate the feasibility of rotating a vascularized myofascial flap from the anterior third of the temporalis muscle onto the skull base, exploring its extension into the middle cranial fossa after drilling the greater wing of the sphenoid.

Methods: Six endoscopic dissections were performed on formalin-fixed heads to illustrate the feasibility of preparing a deep fascia flap from the temporalis muscle. Red silicone latex was injected into the external carotid artery to confirm the vascular integrity of the deep temporal branches of the maxillary artery.

Results: The deep temporalis myofascial flap offers a large, well-vascularized tissue that can be easily rotated to cover skull base defects after transorbital approaches. Its coverage extends from the middle and anterior cranial fossae to the infratemporal fossa and the lateral wall of the cavernous sinus. It also effectively covers dural defects at the temporal pole.

Conclusion: With an appropriate temporal bony window and sufficient exposure, it is feasible to endoscopically prepare a rotation flap from the anterior third of the temporalis muscle, minimizing the need for resecting the lateral orbital margin. This approach is a favorable alternative to traditional reconstruction techniques, offering quick setup in a single operative procedure. Future studies are needed to confirm minimal donor site morbidity regarding masticatory function.

Background and objectives: Mechanical thrombectomy (MT) is the standard of care in patients with large vessel occlusion (LVO). Despite successful recanalization, about 5% of patients are at risk for developing recurrent LVO. Our study identifies predictors of recurrent LVO and outcomes after repeat MT.

Methods: This was a retrospective multicenter study of patients who underwent MT for LVO. Cases were patients who developed recurrent LVO after successful recanalization (thrombolysis in cerebral infarction ≥2b) and controls were patients who did not develop recurrent LVO. Descriptive statistics and univariate analyses were used to compare both cohorts.

Results: Six hundred twenty nine patients achieved successful recanalization after MT. A total of 13 patients developed recurrent LVO. On univariate analysis, age (odds ratio [OR]: 0.96, 95% CI: 0.93-0.99), initiation of antithrombotics (OR: 0.09, 95% CI: 0.03-0.30), number of attempts (OR: 0.97, 95% CI: 0.96-0.99; P < .05), and postoperative statin use (OR: 0.21, 95% CI: 0.06-0.70) were significantly associated with decreased odds of recurrent LVO. Presence of underlying disease in target vessel (OR: 3.23, 95% CI: 1.03-10.06) and thrombolysis in cerebral infarction 3 revascularization (OR: 5.08, 95% CI: 1.54-16.71) were associated with increased odds of recurrent LVO. Ten patients (76.9%) who developed recurrent LVO had a thrombus in the same vessel as the initial occlusion. Most patients developed reocclusion within 24 hours of the initial MT (n = 8, 61.5%). Five patients (38.5%) were functionally independent on discharge (modified Rankin Score 0-2).

Conclusion: Our study identified predictors of recurrent LVO after successful recanalization from MT. Further validation of risk factors of recurrent LVO could help cater antithrombotic regimen in this cohort.

Background and objectives: The study aims to investigate the significance of using synchronous video monitoring for lateral spread response (LSR) during microvascular decompression (MVD) surgery for hemifacial spasm.

Methods: A retrospective analysis was conducted on data from 75 patients with primary hemifacial spasm who underwent MVD treatment at our hospital between September 2018 and June 2019. Traditional intraoperative LSR monitoring and synchronous video LSR monitoring were compared to predict postoperative spasm relief outcomes at 1 week, 1 month, 6 months, 1 year, and 5 years, alongside actual clinical observations. Traditional LSR monitoring showed moderate agreement with actual clinical observations at 1 week postoperatively (K1w = 0.433;, fair agreement at 1 month, 6 months, and 1 year (K1m = 0.386, K6m = 0.295, K1y = 0.225); and poor agreement at 3 years and 5 years (K3y = 0.182, K5y = 0.138).

Results: In comparison, synchronous video LSR monitoring demonstrated moderate agreement at 1 week, 1 month, 6 months, and 1 year (K1w = 0.533, K1m = 0.535, K6m = 0.574, K1y = 0.182) and fair agreement at 3 years and 5 years (K3y = 0.321, K5y = 0.217). Patients with intraoperative LSR changes experienced earlier symptom relief within 6 months compared with those without LSR changes. The overall relief rates at 1 year, 3 years, and 5 years were 93.33%, 94.67%, and 96.00%, respectively. The delayed resolution rates were 70.59%, 76.47%, and 82.35% at 1 year, 3 years, and 5 years, respectively.

Conclusion: The application of synchronous video LSR monitoring facilitates the assessment of patients' clinical prognosis within 6 months postoperatively, thereby guiding surgical interventions. In predicting the consistency of post-MVD spasm relief, synchronous video LSR monitoring outperforms traditional LSR monitoring methods.

Background and objectives: Decompressive craniectomy (DC) is a critical surgical intervention for reducing elevated intracranial pressure. However, subsequent cranioplasty (CP) can be complicated by adhesions between anatomic layers, particularly the temporalis muscle (TM), dura mater, and brain surface. A dual-layer dural substitute during DC can help prevent these adhesions, improving CP outcomes.

Methods: In this three-year prospective multicenter study, 59 patients underwent DC followed by CP. A dual-layer dural substitute was placed between the TM and dura mater (and sometimes the subcutaneous layer) during DC. Outcomes evaluated included adhesion formation, ease of dissection during CP, and overall functional results.

Results: No infections or wound complications were reported. The dual-layer technique significantly reduced adhesions in the muscle-cutaneous flap layers, facilitating TM elevation during CP. This resulted in minimal fibrotic adhesions, no change in TM thickness postoperatively, significantly shorter operative times, negligible blood loss, and a 0% rate of postoperative CP-related epilepsy.

Conclusion: Using a dual-layer dural substitute during DC effectively prevents adhesion formation, reducing wound healing complications. This technique improves subsequent CP success by facilitating TM elevation, preserving its function, and protecting underlying brain structures. It also shortens surgical time, minimizes blood loss, reduces hospital stays, and lowers postoperative epilepsy rates.