Operative Neurosurgery最新文献

Background and importance: The usefulness of intraoperative real-time fluorescence navigation using indocyanine green (ICG) for metastatic brain tumors, schwannomas, and meningiomas is well established. However, its application in cases of radiation-induced brain necrosis remains unexplored. Surgical intervention is performed in symptomatic and medically refractory cases; however, radiation-necrotic lesions often exhibit a diffuse pattern with unclear surgical boundaries, making it challenging for surgeons to identify the lesion during the surgery.

Methods: Four patients with intracranial necrotic tissues received 1.5 mg/kg ICG 1 hour before observation during the surgery. We used near-infrared fluorescence to identify the necrotic location.

Clinical presentation: Case 1: A 61-year-old man with lung cancer and metastatic brain tumor history exhibited left-sided weakness a year after craniotomy and radiotherapy. A new lesion required surgery, where ICG fluorescence imaging highlighted a significant contrast in the resection cavity, aiding in successful lesion removal without complications. Case 2: A 51-year-old man with resected glioblastoma developed paralysis. ICG fluorescence during surgery confirmed necrosis and enabled the lesion's removal despite potential inaccuracies due to brain shift, without ICG-related complications. Near-infrared fluorescence could visualize necrotic tissues in all 4 cases. The mean signal-to-background ratio of the necrotic tissues in delayed window ICG was 3.5 ± 0.7. The ratio of the gadolinium-enhanced T1 tumor signal to the brain (T1-weighted background ratio) was 2.3 ± 0.4.

Conclusion: This report is the first to demonstrate the efficacy of ICG intraoperative fluorescence imaging in identifying radiation-induced necrotic brain tissues.

Background and objectives: External ventricular drain (EVD) is a common neurosurgical procedure with potential complications, including catheter misplacement, infection, mechanical obstruction, and inadvertent catheter pull-out. A less discussed but critical complication is the misadministration of medications into EVD. This project aimed to review the literature on EVD misadministration and discuss preventative measures, emphasizing the new International Organization for Standardization (ISO) standard for neuraxial connectors.

Methods: A systematic review of PubMed, Embase, and SCOPUS databases was conducted to identify studies reporting misadministration in EVD systems. We also present a case of misadministration of a blood product into an EVD. Factors contributing to these events were researched, relevant guidelines from professional organizations were reviewed, and preventive strategies, including the novel NRFit® connector designed to prevent such errors, were discussed.

Results: The literature review identified 7 reports of 8 cases of misadministration involving substances such as gadolinium-based contrast agents, anesthetic agents, and antiepileptic drugs. In addition, we report a case of an 87-year-old man with multiple traumatic brain injuries, where a blood transfusion line was mistakenly connected to the EVD. This incident is the first reported case of blood misadministration through EVD. Despite immediate drainage and flushing of the EVD system with saline, the patient's condition did not improve, and he eventually died. Contributing factors included unfamiliarity with the EVD system, similarity to IV connectors, and poor visibility during procedures. Importantly, the novel ISO 80369 standard for all neuraxial connectors, including NRFit® connectors that have a 20% smaller nozzle outside diameter than traditional Luer connectors, has been recommended to prevent misconnection errors and mitigate associated risks.

Conclusion: Misadministration to EVD connectors is a preventable event that highlights the need for enhanced safety solutions. Adoption of ISO standard neuraxial connectors, thorough training, and the use of distinctly marked equipment are critical steps in minimizing risks.

Background and objectives: Stereotactic procedures are used to manage a diverse set of patients across a variety of clinical contexts. The stereotactic devices and software used in these procedures vary between surgeons, but the fundamental principles that constitute safe and accurate execution do not. The aim of this work is to describe these principles to equip readers with a generalizable knowledge base to execute and understand stereotactic procedures.

Methods: A combination of a review of the literature and empirical experience from several experienced surgeons led to the creation of this work. Thus, this work is descriptive and qualitative by nature, and the literature is used to support instead of generate the ideas of this framework.

Results: The principles detailed in this work are categorized based on 5 clinical domains: imaging, registration, mechanical accuracy, target planning and adjustment, and trajectory planning and adjustment. Illustrations and tables are used throughout to convey the concepts in an efficient manner.

Conclusion: Stereotactic procedures are complex, requiring a thorough understanding of each step of the workflow. The concepts described in this work enable functional neurosurgeons with the fundamental knowledge necessary to provide optimal patient care.

Background and objectives: Identifying and characterizing sources of targeting error in stereotactic procedures is essential to maximizing accuracy, potentially improving surgical outcomes. We aim to describe a generic framework which characterizes sources of stereotactic inaccuracy.

Methods: We assembled a list of stereotactic systems: ROSA, Neuromate, Mazor Renaissance, ExcelsiusGPS, Cirq, STarFix (FHC), Nexframe, ClearPoint, CRW, and Leksell. We searched the literature for qualitative and quantitative work identifying and quantifying potential sources of inaccuracy and describing each system's implementation using Standards for Reporting Qualitative Research guidelines. Our literature search spanned 1969 to 2024, and various studies were included, with formats ranging from phantom studies to systematic reviews. Keyword searches were conducted, and the details about each system were used to create a framework for identifying and describing the unique targeting error profile of each system.

Results: We describe and illustrate the details of various sources of stereotactic inaccuracies and generate a framework to unify these sources into a single framework. This framework entails 5 domains: imaging, registration, mechanical accuracy, target planning and adjustment, and trajectory planning and adjustment. This framework was applied to 10 stereotactic systems.

Conclusion: This framework provides a rubric to analyze the sources of error for any stereotactic system. Illustrations allow the reader to understand sources of error conceptually so that they may apply them to their practice.

Background and objectives: In conventional freehand frontal ventriculostomy, the Kocher point is the entry point, the external auditory canal is the sagittal target, and the coronal targets include the ipsilateral medial canthus (IMC), the midpoint between the bilateral external auditory meatus (MAM), the contralateral medial canthus (CMC), and the region perpendicular to the skull (P). The aim of this study was to calculate puncture accuracy of the 4 conventional methods to guide clinical selection.

Methods: Patient data from thin-slice computed tomography scans were imported, and a 3-dimensional model was reconstructed using software to simulate puncture. The accuracy and puncture depth of the 4 freehand frontal ventriculostomy methods were analyzed.

Results: From January 1, 2022, to December 30, 2023, 520 patients were screened and 206 were enrolled; 137 (66.5%) participants were males, and 69 (33.5%) were females. The median age of the patients was 64 years (IQR 53-73). The maximal frontal horn width was 21.7-53.7 mm (IQR 34.4-40.0), and the intercanthal distance was 26.0-43.2 mm (IQR 30.7-34.9). Simulating bilateral ventricular puncture, for the IMC trajectory, the puncture accuracy was 13.3% (55/412) [95% CI 10.4-17.0] and the puncture depth was 41.8 ± 4.6 mm. For the MAM trajectory, the puncture accuracy was 74.5% (307/412) [95% CI 70.1-78.5] and the puncture depth was 43.6 ± 4.3 mm. For the P trajectory, the puncture accuracy was 90.5% (373/412) [95% CI 87.3-93.0] and the puncture depth was 49.4 ± 5.9 mm. For the CMC trajectory, the puncture accuracy was 100.0% (412/412) [95% CI 99.1-100.0] and the puncture depth was 47.2 ± 5.2 mm.

Conclusion: Compared with the MAM trajectory, the CMC and P trajectories were more reliable in frontal ventriculostomy, but the P trajectory may enter the contralateral ventricle. The IMC trajectory is not recommended unless the frontal horn is wider than 45 mm or the Kocher point is moved inward.