Operative Neurosurgery最新文献

Background and objectives: Intracranial and craniocervical junction dural arteriovenous fistulas (DAVFs) with spinal perimedullary drainage are rare, and large cohort studies are lacking. The aim of this study was to describe clinical characteristics and angioarchitecture of these DAVFs, share our treatment experience, and identify risk factors associated with subarachnoid hemorrhage and poor outcomes.

Methods: A total of 158 consecutive patients treated at our neurosurgical center were retrospectively reviewed. The patients were grouped according to lesion location, and their baseline clinical characteristics, angioarchitecture, treatment strategies, and outcomes were summarized.

Results: The patients' mean age was 53.4 years. Most patients were male with 141 patients (89.2%). The most common clinical manifestation was nonhemorrhagic neurological deficits (71.5%), followed by subarachnoid hemorrhage (28.5%). Microsurgery was the most common treatment strategy applied for 112 patients (70.9%), 34 patients (21.5%) were treated with interventional embolization only, and 12 (7.6%) received both interventional embolization and microsurgery. At the last follow-up, there were 122 patients (77.2%) with favorable outcomes (modified Rankin Scale <3). Clinical manifestation of numbness (odds ratio [OR] 4.098, 95% CI 1.491-11.263, P = .006), clinical manifestation of urinary dysfunction (OR 3.991, 95% CI 1.378-11.558, P = .011), and pretreatment modified Rankin Scale ≥3 (OR 19.523, 95% CI 5.066-75.242, P < .001) were significantly associated with poor outcomes.

Conclusion: Intracranial and craniocervical junction DAVFs with spinal perimedullary drainage are indeed rare. Specific sign on magnetic resonance imaging is beneficial for accurate diagnosis. The choice between microsurgery or interventional embolization is primarily based on lesion location and angioarchitecture. Early diagnosis, prevention of misdiagnosis, and appropriate treatment are crucial for improved outcomes.

Background and objectives: Sarcopenia has recently been shown to increase risk of early adjacent segment disease (ASD) development after transforaminal lumbar interbody fusion. We sought to evaluate whether sarcopenia increases risk of ASD after retroperitoneal approaches for lumbar interbody fusion (eg, anterior lumbar interbody fusion or oblique lateral lumbar interbody fusion).

Methods: Retrospective data were collected from 104 adult patients aged older than 18 years who underwent short-segment fusion through anterior lumbar interbody fusion or oblique lateral lumbar interbody fusion approach from 2013 to 2023. The primary outcome was development of ASD within 3 years of surgery. Patients who had prior surgery for ASD, underwent long-construct deformity correction, had an ongoing oncological process, or lacked sufficient follow-up were excluded. Psoas and vertebral body volumetric measurements were calculated at the L4 pedicle level using preoperative MRI. Spinopelvic parameters of pelvic tilt, pelvic incidence (PI), lumbar lordosis (LL), and PI-LL mismatch were recorded from standing upright radiographs. Odds ratios were calculated with logistic regression analyses.

Results: Of 104 patients undergoing fusion through retroperitoneal approaches, 25 (24.04%) developed ASD within 3 years. Patient demographics and medical comorbidities did not predict early ASD. Left and right psoas area (cm 2 ) and psoas:vertebral body ratio strongly predicted ASD development ( P < .0001). Nineteen patients were categorized as sarcopenic, defined as bilateral psoas:vertebral body ratios >1 SD below the study population gender mean. 16 of the 19 sarcopenic patients developed ASD within 3 years, compared with 9 of the 85 nonsarcopenic patients (84.21% vs 10.59%, P < .0001). Postoperative pelvic tilt and PI-LL mismatch were predictive of ASD on univariate but not multivariate analysis.

Conclusion: Sarcopenia significantly predicts ASD development within 3 years after lumbar fusion through retroperitoneal approaches. Irrespective of approach, sarcopenia is a risk factor of ASD formation and should be evaluated preoperatively. Morphometric analysis provides a simple screening tool and can be used to tailor preoperative and postoperative therapies to improve outcomes.

Background and importance: Surgery for jugular paragangliomas (JPs) is known to be a formidable challenge because of the tumor's intimate involvement of neurovascular structures. Although radiosurgery is commonly the first-line treatment, recent advances in neuroimaging, surgical techniques, and intraoperative monitoring have positioned surgery as a feasible alternative for aggressive tumors with substantial intradural extension not amenable to upfront radiosurgery, provided the surgeon has an in-depth knowledge of lateral skull-base anatomy and access to safe and effective preoperative embolization.

Clinical presentation: A patient with a Fisch Type D JP with extensive intradural tumor and brainstem compression underwent a combined petrosal approach with transcochlear extension at our institution. The transcochlear extension allowed additional anteromedial access to the petrous apex and internal carotid artery, whereas the combined craniotomy granted access to the supratentorial space for the tumor with transtentorial extension. The surgery's critical steps, along with key neurovascular structures, were documented and reviewed in a surgical video.

Conclusion: The combined petrosal approach with transcochlear extension is a complex but effective surgical approach for large JPs invading the petrous apex and involving the internal carotid artery not amenable to upfront radiosurgical treatment. This procedure relies on a thorough understanding of temporal bone anatomy and should be reserved for experienced multidisciplinary teams in specialized centers.

Background and objectives: Tegmen tympani and tegmen mastoideum defects can be accompanied either with or without encephaloceles and can result in cerebrospinal fluid (CSF) leaks. The tegmen region is a very thin segment of a dependent area of the temporal bone, making it susceptible to dehiscence with CSF pulsations over time. Approaches for repair generally consist of middle fossa (MF), transmastoid (TM), or a combination of the two (MF + TM). Surgical repair of tegmen defects commonly consists of meningocele removal when present, followed by dural repair. This is often followed by reconstruction of the bony defect. There are a number of repair methods that have been described in series of smaller size without long-term follow-up. Our series includes the current largest number of patients undergoing a combined approach (MF + TM), with up to 16-year follow-up. We provide clinical and illustrative demonstration of our repair technique.

Methods: A retrospective review was performed of patients with tegmen defects who underwent a combined mastoidectomy with MF craniotomy for surgical repair by a multidisciplinary team between September 2006 and December 2023.

Results: A total of 103 tegmen repair operations were performed in 97 patients with tegmen defects, with 6 (6.2%) of these patients having bilateral defects requiring staged bilateral operations. Sixty-seven (65.0%) were spontaneous etiology. The second most common etiology was history of infection (19.4%). No patients required return to operating room for CSF leak at the site of repair. Average length of stay was 2.5 days. Follow-up for this series was as long as 16 years.

Conclusion: A multidisciplinary combined mastoidectomy and MF craniotomy with dural onlay and titanium mesh repair, with or without lumbar drain, can serve as an effective long-term method for surgical repair of tegmen defects.

Background and objectives: MRI-based neuronavigation may suffer from inaccuracies that can be compensated by navigated 3D intraoperative ultrasound (iUS) and applying MRI-iUS rigid image fusion (RIF). In this work, such an automated application is evaluated.

Methods: Twenty-five adult patients with gliomas were enrolled and underwent resection using navigated iUS. Intraoperative evaluation and postoperative quantification [ie, measurement of the target registration error (TRE)] were conducted to assess the accuracy of registration-based fusion and automated RIF at various stages of surgery [before dura opening (BDO), after dura opening (ADO), after partial resection (APR), after completion of resection (ACR)]. Linear mixed models were used to assess and analyze TRE and the effect of patient- and tumor-related factors on the performance of the RIF. Furthermore, the TRE was measured after applying different prealignments.

Results: In total, 79 MRI-iUS data sets derived from 24 patients and enriched with 600 anatomic landmark pairs were evaluated. Overall, RIF resulted in a significantly reduced mean TRE compared with registration-based fusion (from 4.7 mm to 3.5 mm, P < .002). This difference in TRE was dependent on the stage of surgery, being significant for BDO, ADO, and APR stages, but not ACR. It was independent of any tumor-related factors. Simulation tests showed that RIF can significantly improve TRE for a range of ±15 mm prealignment accuracy with highest effect for BDO and ADO.

Conclusions: RIF using intraoperative navigated ultrasound improves registration accuracy for intra-axial tumor surgeries. It shows reliable results not only for preresection stages but also partially for later surgical stages.

Background and objectives: Cerebral bypass can provide flow augmentation for select patients with moyamoya disease (MMD) and steno-occlusive cerebrovascular disease (SOCD). Earlier work has suggested that sacrificing the nondonor branch of the superficial temporal artery (STA) can optimize direct flow, which we assessed in real time.

Methods: This was a single-institution observational study of consecutive patients undergoing direct STA-middle cerebral artery (MCA) bypass with indirect encephalo-duro-myo-synangiosis for MMD and SOCD over 1 year. Excluding patients with significant STA-intracranial collateralization, the intraoperative effect of nondonor STA branch temporary occlusion on direct STA-MCA bypass flow was assessed using a Charbel flow probe. Patient characteristics and perioperative and postoperative data were reviewed.

Results: Eleven patients (5 MMD, 6 SOCD; mean age 53.5 ± 15.3 years) underwent combined revascularization (4 left, 7 right). The mean donor STA branch flow increased from 4.91 ± 2.79 (baseline) to 16.63 ± 11.92 mL/min after anastomosis (95% CI 1.25-17.50; P = .015), and to 20.94 ± 10.63 mL/min after nondonor STA branch test occlusion (95% CI 1.71-6.90; P = .002). The parietal STA branch was used as the donor in 8 cases (72%). In 9 patients, the nondonor STA branch was sacrificed. Perioperatively, 1 patient experienced transient dysarthria/paresthesias (9.1%); there were no strokes or other major complications. The median hospital stay was 5.0 (IQR 4.0, 7.0) days, with 81% of patients discharged home. Over a mean follow-up of 6.2 ± 3.0 months, no patients had significant wound-healing issues, and the median modified Rankin Scale score improved from 2 (IQR 1.0, 2.5) preoperatively to 0 (IQR 0.0, 0.0) (95% CI 0.11-1.69; P < .015). Six-month angiography (available in 9 patients) demonstrated 100% direct bypass patency and a median direct bypass flow grade of 2.0 (IQR 2.0, 3.0).

Conclusion: In patients without STA-intracranial anastomoses, STA-MCA direct bypass flow may be optimized safely by nondonor STA branch sacrifice.