Operative Neurosurgery最新文献

Open microsurgical and endovascular techniques are the 2 primary strategies for treating intracranial aneurysms. Microsurgical clipping and adjuvant technical maneuvers are well-established techniques with a track record for high occlusion rates and durable repairs. Endovascular, endosaccular, and extrasaccular therapies are associated with lower peri-procedural morbidity but with generally higher rates of retreatment. We discuss key clinical and anatomic considerations in treatment decision-making and compare the risks and benefits of microsurgical vs endovascular treatment within each context.

Background and objectives: Endovascular therapy (EVT) has recently become the most widely used treatment method for intracranial aneurysms (IAs). However, the literature on this topic is heterogeneous, with studies assessing and reporting surgical and clinical outcomes in different ways, lacking standardization. We aimed to evaluate the quality of these studies and propose a reporting guideline focusing on essential elements to ensure reproducibility and comparability.

Methods: After Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, we searched Medline, Embase, Cochrane Library, and Web of Science databases. Eligible studies were observational or randomized, reported clinical and/or surgical outcomes of EVTs for IAs, included over 200 patients, and were published in English between January 1, 2022, and January 1, 2024. Studies were assessed focusing on key domains: (1) reporting on the baseline characteristics of the patient sample, (2) assessment and reporting on imaging methods and aneurysm characteristics, (3) reporting on pivotal concepts definitions, (4) reporting on operator(s) and staff characteristics, (5) reporting on anesthetic protocol, (6) reporting on antiaggregant and anticoagulation therapy, (7) reporting on surgical details, (8) assessing and reporting clinical and surgical outcomes, and (9) reporting retreatment details.

Results: Thirty-nine studies comprising 79 604 patients were included. Our assessment revealed substantial gaps in the literature on EVTs for IAs, including deficiencies across all domains. An EndoIAs Reporting Guideline was developed, consisting of 74 items distributed across 10 domains, focusing on key surgical and clinical outcomes.

Conclusion: Substantial deficiencies were identified in data collection and outcomes reporting in the available literature on EVT for IAs, thereby impeding comparability and reproducibility and hindering the building of cumulative evidence. The aim of the proposed EndoIAs Reporting Guideline was to address these fundamental aspects and has the potential to enhance the reproducibility and comparability of future studies, thereby fostering the building of cumulative and reliable evidence of EVT for IAs.

Background and objectives: Polymeric clamp-like devices present potential advantages regarding plates and screws to close craniotomies; however, no clinical research has provided enough evidence to compare them. This randomized controlled trial compares the clinical safety and performance of clamp-like devices with the standard of care for craniotomy closure: titanium plates and screws (P&S).

Methods: A prospective, double-arm, multicenter randomized controlled trial was performed at 3 sites, recruiting 60 patients undergoing neurosurgical interventions requiring craniotomy. Patients were randomly allocated to 2 groups depending on the bone flap fixation system to be used: plates and screws (any brand) and clamp-like devices (Cranial LOOP, NEOS Surgery S.L.). The primary end point of the study (bone flap alignment) was assessed 6 months after surgery through neuroimaging. Secondary end points included adverse events and device deficiency assessment, closure method usability assessed by the surgeon, and patient-reported device-related inconveniences.

Results: It was necessary to use a median of 3 Cranial LOOP and 4 plates and 8 screws to close craniotomies. All patients from both groups had equally good bone flap alignment. Most implantations were reported as easy or very easy for both groups, and surgeons were generally satisfied or very satisfied with both treatments. No related adverse events have been reported for any of the treatment groups. Two patients reported discomfort or protuberances caused by P&S; no inconveniences were reported for Cranial LOOP.

Conclusion: Cranial LOOP performance is equal to P&S for fixation of the cranial bone flap. In addition, it presents some advantages, such as the use of a lower number of devices, potentially making this system more affordable, and the lack of discomfort previously linked with the use of P&S.

Background and objective: Iatrogenic spinal durotomies occur at a rate of 1% to 17%. Surgical simulation for durotomy repair is needed to provide affordable, accessible, and validated practice. This study sought to design and validate a simple 3-dimensional printed model for spinal cerebrospinal fluid (CSF) leak repair and to introduce the Rochester original objective structured assessment of technical skills (OSATS) CSF leak (ROCL) repair criteria for assessment.

Methods: A spinal model was designed to mimic a lumbar laminectomy with the L3-5 lamina removed and 3-dimensional printed using Vero polymers. The model was paired with a porcine collagen "dura" that was pressurized using IV saline and overlayed with gel-molded fascial, muscle, and skin layers with an opening. Participants were provided a training model with a 1.5-cm midline durotomy, surgical microinstrument set, microscope, and 6-0 prolene suture. The 25-point ROCL repair criteria were adapted from the original OSATS principles to assess proficiency in surgical repair by 2 blinded neurosurgeons not participating in the trials. Postsimulation survey data regarding model realism were collected.

Results: Six residents and 4 attendings participated. Median operative time in minutes was 13 minutes among residents and 7 minutes among attendings. Moreover, the ROCL score was a median of 19/25 for attendings and 15/25 for residents. The suture angle was statistically more consistent among senior residents and attendings compared with junior residents. Participants agreed that the model was realistic (median 4/5), useful for improving the operative technique (median 5/5), and would increase comfort in spinal CSF leak repair procedures (median 5/5). Each reusable model had a cost of $19.99 if printed with polylactic acid and each replacement dura cost <3¢.

Conclusion: This study presents an affordable, realistic, and educational spinal CSF leak repair model and introduces ROCL for assessment.

Background and objectives: In the past, microscopic transcranial approach was the mainstay of treatment of trigeminal schwannomas. In recent years, several endoscopic procedures have been reported for trigeminal schwannomas. For trigeminal schwannomas arising around the Meckel cave, we introduced a fully endoscopic procedure with a small temporal craniotomy in June 2020 and have performed radical tumor removal as in the conventional approach. This article describes the details of the purely endoscopic subtemporal keyhole approach (PESKA) surgical procedure and reports the initial surgical results.

Methods: Between June 2020 and November 2023, 8 cases of trigeminal schwannoma were treated with PESKA. The mean tumor diameter was 33.1 mm. The surgical procedure for PESKA consists of a 7-cm linear skin incision made upward from the anterior to the auricle on the side of the lesion, followed by a 4-cm temporal craniotomy and then endoscopic manipulation. The intradural part of the middle cranial fossa is observed, and the Meckel cave is identified and opened. The tumor is removed with preserving most normal trigeminal nerve fibers. The site of the lesion, the extent of resection, complications, operative time, Karnofsky Performance Status, and intraoperative blood loss were evaluated.

Results: All 8 patients underwent gross total resection. Only one patient had new temporal edema on the side of the lesion, which was asymptomatic. The mean operative time was 4 hours and 21 minutes.

Conclusion: We report on PESKA, a fully endoscopic procedure with a small temporal craniotomy for a trigeminal schwannoma arising around the Meckel cave. The use of an endoscope allowed for a wide field of view, even in a narrow operative field, reducing brain traction and allowing radical resection of the tumor while preserving normal trigeminal nerve fibers. This method may represent an effective surgical alternative for trigeminal schwannomas.