Operative Neurosurgery最新文献

Background and objectives: Realistic 3-dimensional (3D) anatomical models may enhance three-dimensional comprehension of the complex anatomy of the skull base. Such models may be generated by photogrammetry, a technical algorithm for photorealistic surface scanning. This study presents a 360° visualization of key neuroanatomical landmarks of the central skull base.

Methods: One formaldehyde-fixed head specimen with polymer-injected vessels underwent extensive exocranial and endocranial dissections on the right side after a sagittal cut. Initially, the dissection of the orbital region, cavernous sinus, and paranasal sinuses identified cranial nerves II, III, IV, and VI; their branches; extraocular muscles; and major vessels. Subsequently, the 5 terminal branches of the VII were exposed, along with cranial nerves IX, X, XI, and XII. A retrolabyrinthine approach and neck dissection revealed the entire course of cranial nerve VII, sigmoid sinus, the jugular bulb, and the intracranial and extracranial segments of nerves IX, X, XI, and XII. In addition, the infratemporal fossa, pterygopalatine fossa, and middle ear structures were presented. Finally, the vertebral artery segments (v2-v4) and the internal carotid artery, including the petrosal and cavernous segments, were dissected and documented. The specimen was 3D scanned by photogrammetry 3D, refined with 3D modeling software, and uploaded to virtual reality and web visualization.

Results: Seven photorealistic models were created and virtual reality videos demonstrating the relevant anatomy in an immersive environment. The courses of intracranial nerves and the associated vascular and soft tissue anatomy were systematically captured from both intracranial and exocranial viewpoints, creating an accurate 360° virtual depiction of the pertinent anatomy.

Conclusion: The 3D 360° photogrammetric models developed in this study may allow a better understanding of essential intracranial and extracranial structures of the skull base. These models facilitate customizable views and represent a valuable, freely accessible resource that complements traditional dissections, photographic atlases, and conventional 3D models.

Background and objectives: Deep brain stimulation (DBS) is a highly effective therapeutic intervention for managing neurological disorders, including Parkinson disease. However, conventional lead fixation methods, such as covering devices, often lead to complications, including cranial deformities and electrode migration. The aim of our study was to present a novel technique that integrates n-butyl-2-cyanoacrylate adhesive with a titanium "dog-bone" plate for DBS lead fixation, to enhance both esthetic and functional outcomes.

Methods: A retrospective analysis was conducted on 32 patients with medication-refractory Parkinson disease or parkinsonism who had previously undergone DBS surgery using this fixation technique. The method involved applying n-butyl-2-cyanoacrylate around the lead at the burr-hole site, followed by secondary stabilization with a titanium plate. Intraoperative imaging confirmed lead positioning, and patients were monitored for up to 21.6 months (±10.2) for migration, infection, and esthetic satisfaction.

Results: All 32 patients showed successful lead fixation without cases of migration, displacement, or mechanical failure over the follow-up. No postoperative infections, seizures, or meningitis were reported, indicating a favorable safety profile. The method provided a smooth cranial contour, with high patient satisfaction, especially among those with alopecia or thin skin. In addition, the technique potentially reduced operative time because of the rapid polymerization of the adhesive, thereby minimizing risks associated with prolonged surgeries.

Conclusion: The combination of n-butyl-2-cyanoacrylate and a titanium "dog-bone" plate for DBS lead fixation offers an effective, aesthetically superior, and cost-efficient alternative to conventional methods. The reduced complication rates and enhanced patient satisfaction suggest that this technique may represent a viable future standard for DBS procedures. Further multicenter studies are recommended to validate these findings.

Background and objective: The efficacy of middle meningeal artery (MMA) embolization for chronic subdural hematomas (cSDH) has been widely demonstrated in the literature. However, the role of distal embolic penetration on incidence of cSDH resolution remains controversial. In this study, we examined the effect of number of branches embolized and volume of embolic material used on the incidence of radiographic clearance of cSDH.

Methods: This is a retrospective review of all MMA embolizations performed at our institution for the treatment of cSDH. Baseline characteristics and technical parameters, including branches embolized and volume of embolic material used, were compared between patients with and without radiographic cSDH resolution at last follow-up. Further comparisons in outcomes were made between patients with multiple distal MMA branches embolized and those with a single branch embolized. Univariate statistical analysis was performed.

Results: A total of 131 MMA embolizations in 104 patients performed at our institution were included. Of the 131 cSDH, 70 (53.4%) showed complete radiographic resolution at last follow-up. Persistent cSDH was associated with older age ( P = .01), kidney disease ( P = .001), and larger subdural size ( P = .03). There was no difference in proportion of cSDH resolution between those with both anterior and posterior MMA branches embolized and those with a single branch embolized. However, the volume of embolic material used was significantly associated with subdural resolution ( P = .04).

Conclusion: The volume of embolic material used during MMA embolization was significantly associated with radiographic cSDH resolution at last follow-up, while the number of MMA branches embolized did not affect cSDH resolution. Selection of MMA branches for better penetration of areas supplying the cSDH while minimizing the risk of reflux into nontarget branches can be considered in future optimization of this procedure.

Background and objectives: Endosaccular flow disruption with the Woven EndoBridge (WEB) embolization device emerged as an alternative treatment for wide-necked bifurcation aneurysms (WNBAs). Previous studies used pooled aneurysm locations to conclude the efficacy of the WEB device, failing to account for locational differences in outcomes, most notably at the middle cerebral artery (MCA). Thus, we analyzed characteristics and outcomes among a cohort of WEB-eligible MCA bifurcation aneurysms treated surgically.

Methods: We retrospectively reviewed a prospectively maintained aneurysm database at UT Southwestern between 2002 and 2022. WEB-eligible aneurysms met the criteria of a dome-to-neck ratio ≥1, a neck diameter >4.0 mm or a dome-to-neck ratio of ≤2, and an aneurysm diameter of 3.0-11.0 mm. Both unruptured and ruptured aneurysms were included. The end points assessed were functional status changes (modified Rankin scale [mRS]), complication rates, aneurysm recurrence, residual, morbidity, and mortality.

Results: One hundred two patients met radiographic inclusion criteria as WEB-eligible WNBA who underwent microsurgical clipping. Eighty-five (83.3%) aneurysms were unruptured. Patients with ruptured aneurysms presented with a worse mRS and experienced more significant improvements in functional status at the final follow-up. Regardless of rupture status, outcomes with open surgery were excellent, with a 99% treatment success rate, 4.9% morbidity rate, and 0% mortality rate. Among unruptured MCA WNBAs, functional outcomes showed a final mRS ≤2 in 94.1% of patients and an improved or stable functional status in 91.8%. Microsurgical treatment of unruptured MCA WNBA carried a 5.9% thromboembolic complication rate.

Conclusion: Outcomes of WEB-eligible MCA WNBAs are comparable with the high success rates in large, heterogeneous series of MCA aneurysms and superior to those in WEB cohorts. Functional outcomes remain excellent regardless of treatment strategy; however, surgical treatment may offer higher complete occlusion rates, lower retreatment rates, and lower complication rates than endovascular treatment with WEB.

Background and objectives: The choice of the optimal surgical position in the treatment of posterior fossa lesions still remains a controversial and debated issue. Morphometric data on the different perspective of vision offered by different surgical position are scarce. This article investigated the differences due to the vision perspectives provided by the sitting and park bench positions.

Methods: The study was conducted using 4 fixed cadaver heads. A standardized retrosigmoid approach was performed on each side of each head. Three operators collected anatomic observation and 2 separate measurements each, for all the sides and diagonals of the projections of 2 areas delimited by the cranial nerves in the cerebellopontine angle (defined as working windows ABCD and ABEF). The collection of the measurements was repeated for each side of each head, both in the sitting and in the park bench positions. The average areas of the working windows were calculated for each position and then compared by statistical analysis.

Results: The park bench position is associated to larger areas for both working windows ( P = .0013 for ABCD; P < .001 for ABEF) compared with the sitting position. These measures allow to quantify the differences of the working windows that are an indirect expression of the different angle of vision of each position.

Conclusion: Our cadaveric study shows that there is a better vision perspective offered by the park bench position for lesions that do not modify the course of the cranial nerves in the cerebellopontine angle. However, different positioning of patients presents different advantages and limitations for surgeon based on size of the tumor and lesion location. In our opinion, choice of patient positioning could be tailored to lesion's peculiarities more than on surgical habits.

Background and objectives: Spondylodiscitis (SD) is an infection of the intervertebral disk. In the nonseptic, MRI-positive patient without focal deficits, current guidelines recommend computed tomography-guided biopsy (CTGB) for pathogen identification. Yet, pathogen positivity from CTGB is low (37%). Percutaneous endoscopic debridement and drainage (PEDD) may improve pathogen identification and reduce pain. We aimed to evaluate the utility of PEDD as the first-line intervention for the diagnosis and management of SD.

Methods: Demographic characteristics, perioperative outcomes, intraoperative data, and microbiological data were collected through retrospective chart review from 9 consecutive adult patients with suspected SD managed with PEDD between 2021 and 2024. Patients were followed postoperatively until no longer seen in clinic. Paired t -tests were used to compare Visual Analog Pain Scale and morphine milligram equivalents change after intervention.

Results: The mean age was 56.4 years (SD: 10.0) with 7 male patients (77.8%). The mean follow-up was 7.1 months (SD: 9.6). On presentation, back pain was reported in 100% and lower extremity weakness and paresthesia in 33.3%; 77.8% of patients were treated with antibiotics preoperatively. The mean operative duration was 87.7 minutes (SD: 21.2). The mean estimated blood loss was 16.9 mL (SD: 20.7). The mean length of stay was 9.6 days (SD: 9.9). There were no intraoperative or postoperative complications associated with PEDD. Successful pathogen identification was achieved in 88.9%. The mean time to pathogen identification was 5.5 days (SD: 5.2). All patients had postoperative pain relief. There was a significant reduction in Visual Analog Pain Score postoperatively from 9.2 to 3.2 ( P < .001). This pain reduction was also associated with a significant reduction in morphine milligram equivalents from 32.7 to 29.5 ( P < .001).

Conclusion: We demonstrate that PEDD is a safe and effective procedure for the management of SD. PEDD may improve pathogen identification compared with CTGB while simultaneously reducing pain and opioid requirements. These data suggest that PEDD may be considered as a first-line intervention for SD. Further prospective studies are required to inform guidelines.