Operative Neurosurgery最新文献

Background and objectives: With advancements in endovascular techniques, an increasing number of tentorial dural arteriovenous fistulas (TDAVFs) can now be successfully treated with endovascular intervention alone. In this study, we present a summary of one single-center experience in the treatment of TDAVFs, along with a subgroup analysis based on the Lawton classification.

Methods: We conducted a retrospective review of patients with TDAVF treated at a single center over a 21-year period. Patients with TDAVFs were included and categorized into 6 types. Patient demographics and angiographic data were recorded. Postprocedural and follow-up angiographic and clinical outcomes were assessed.

Results: A total of 275 cases of TDAVFs involving the Galenic, straight sinus, torcular, tentorial sinus, petrosal, or incisural regions were recorded in the database. Of the total cases, 236 of DAVFs (85.8%) occurred in male patients, with a mean age of 51.1 ± 11.6 years. In 245 cases (92.8%), fistulas were complete occluded immediately using various modalities, with a treatment-related complication rate of 12.5%. Galenic, straight sinus, and torcular DAVFs had higher incidence of internal cerebral vein drainage ( P < .001). Superior petrosal sinus DAVF shows a higher incidence of perimedullary venous drainage ( P < .001) and a relatively higher proportion of microsurgical treatments compared with other types ( P < .001). Galenic DAVFs had a lower immediate complete occlusion rate compared with other types of TDAVFs ( P = .013). Both Galenic and superior petrosal sinus DAVFs exhibited a higher complication rate compared with other types of TDAVFs ( P = .008). Torcular DAVFs had a tendency to develop new fistulas after treatment ( P = .008).

Conclusion: We present the characteristics of 275 patients with TDAVFs, predominantly middle-aged men. Most TDAVFs can be effectively treated with an endovascular approach, superior petrosal sinus DAVFs more often require microsurgical intervention.

Background and objectives: In endoscopic endonasal surgery, the Doppler probe has proven useful for localizing the paraclival and cavernous internal carotid arteries (ICA) and avoiding ICA injury. Similarly, during transcranial brain tumor removal, the Doppler probe may help avoid major vascular injury, particularly for tumors encasing or adherent to Circle of Willis branches. In this study, we describe the technique, outcomes, and potential neurovascular benefits of real-time navigation using the Doppler probe during craniotomy for brain tumor removal.

Methods: Patients from 2015 to 2022 who underwent craniotomy for brain tumor resection and the Doppler probe was used were retrospectively analyzed. Data collection included demographics, tumor pathology, incidence of major/minor vascular injury, MRI-confirmed stroke/infarction, and extent of tumor resection.

Results: In total, 695 patients underwent 840 craniotomies for brain tumor resection; in 501 craniotomies (59.6%), the Doppler was used. One major vascular injury (0.2%) of a supraclinoid ICA was directly attributed to non-Doppler probe use immediately before vessel injury, leading to stroke and severe neurological decline. There were 7 strokes (1.4%) leading to permanent neurological deficit attributable to vasospasm or small vessel injury and 26 asymptomatic infarctions/strokes (5.2%) attributable to unrecognized vascular injury or spasm at the time of surgery.

Conclusion: In this series of 501 craniotomies for brain tumor removal where the Doppler probe was used, the rate of direct large vessel injury was under 1%. Although our data show that smaller vessel injuries can still occur and may lead to permanent neurological deficits, routine Doppler probe use may help guide tumor dissection and aggressiveness of removal, avoiding inadvertent major arterial injury. Our experience suggests that it is most useful as tumor dissection progresses as the resulting brain shift makes stereotactic neuronavigation less reliable. We recommend routine Doppler probe use during transcranial brain tumor removal, particularly for tumors encasing or adherent to major arteries.

Far-lateral craniotomy is a versatile skull base approach that combines a suboccipital craniotomy with a C1 hemilaminectomy. The approach was initially described to manage vascular pathologies of the vertebrobasilar junction; however, the corridor provided by this approach can be applied to various pathologies in the ventral and ventrolateral craniovertebral region. Safe and successful execution of the approach requires an extensive understanding of the anatomy and technique. In this article, we discuss the advantages and disadvantages of the approach, as well as important technical nuances and common pitfalls. The goal of this article is to provide an up-to-date technical report of this approach supplemented by original high-quality dissections and a 4K 2-dimensional video as an educational resource for trainees and junior neurosurgeons.

Background and objectives: Neuromodulation for the treatment of epilepsy is a growing field, and several thalamic nuclei (including the anterior nucleus, centromedian nucleus [CM], and pulvinar) have been implicated and targeted. Although an anterior trajectory approach to the CM is conventionally used, we report on a novel posterior trajectory which can be useful when the conventional anterior approach is surgically challenging, or where dual CM and pulvinar coverage is desired.

Methods: Clinical and imaging data were retrospectively collected from 7 patients with at least 1 posterior trajectory CM lead and 4 patients with at least 1 anterior trajectory CM lead.

Results: Patients in the anterior and posterior trajectory groups had a mean of 48.1% and 65.2% seizure reduction, respectively, and were not significantly different ( P = .53). Patients in the posterior trajectory group had contacts within the CM and/or pulvinar. There were no pulvinar contacts in the anterior trajectory group. Analysis of structural connectivity in 1 patient from each group revealed temporal- and occipital-projecting tracts for electrodes within the anterior and medial pulvinar nuclei. Stimulated thalamic nuclei from the anterior trajectory lead did not show any temporal- or occipital-projecting tracts.

Conclusion: We demonstrate that a posterior trajectory approach to the CM is feasible, safe, and effective in drug-resistant epilepsy. This provides an alternative option when the conventional anterior approach is surgically infeasible or when dual CM/pulvinar coverage is desired.

Background and objectives: Patients treated with permissive hypertension during cerebral vasospasm, particularly those on antiplatelets, may have an increased risk of femoral access site complications after endovascular therapy. This study aimed to identify potential risks associated with endovascular access approach and the impact of dual antiplatelet therapy (DAPT) on complications in intra-arterial therapy for vasospasm.

Methods: A prospectively maintained database was queried for patients undergoing endovascular treatment of aneurysmal subarachnoid hemorrhage-related cerebral vasospasm to compare access-site complications between femoral and radial access. Subgroup and multivariate analyses were performed to parse out effect sizes of access and the use of periprocedural DAPT.

Results: A total of 422 endovascular procedures were included: 30% transradial (TRA), 69% transfemoral (TFA), and 1% crossover from radial to femoral access. The access-site complication rate was 4% overall, including a 3.8% access-related hemorrhagic complication rate and a 0.2% rate of femoral artery occlusion. TRA had a lower complication rate of 0.8% as compared with 5.4% in the TFA group (95% CI of difference-in-proportions 0.7%-7.5%, P = .03), remaining significant in a multivariate analysis (adjusted odds ratio 0.05 [95% CI 0.004-0.78]; P = .03). Among the subgroup of patients taking DAPT, the hemorrhagic complication rate of TFA was 13.5% as compared with 3.8% in TRA. A multivariate analysis demonstrated a 7-fold higher access site hemorrhagic complication risk when using TFA in patients on DAPT (adjusted odds ratio 7.2 [1.9-27.0]; P = .003).

Conclusion: Radial access was associated with a significantly lower rate of access-site complications when treating postaneurysmal subarachnoid hemorrhage cerebral vasospasm, particularly in patients on DAPT.

Background and objectives: Peripheral nerve decompression (PND), including carpal tunnel release and ulnar nerve decompression, is a common procedure performed by neurosurgeons, orthopedic surgeons, and plastic surgeons. Because of the lack of established assessment parameters and performance standards for Entrustable Professional Activities in PND in the current literature, we conducted this study to define these assessment parameters and identify the expected standards of performance for graduating residents across the fields of neurosurgery, plastic surgery, and orthopedic surgery.

Methods: Electronic survey was sent to neurosurgery, plastic surgery, and orthopedic surgery faculty to obtain their perspectives on parameters of assessment and the expected standard competence performance regarding PND.

Results: Sixty-one participants returned fully completed questionnaires giving a completion rate of 53%. The overall recommended number of assessments was 5, and the recommended number of assessors was 2. Regarding each specialty, there was no significant difference in the recommended number of assessments; however, neurosurgeons and orthopedic surgeons recommended a significantly fewer median number of assessors (n = 2) than plastic surgeons (n = 3) ( P = .01). Based on total responses, 77% believed that PND was appropriate for the general practice of their specialties. The majority of respondents expected graduating residents to achieve level E (50.8%) or level D (42.6%) for PND. There was no significant difference in the belief that PND was appropriate for general practice of their specialty or considering entrustment level E as a graduation target across the specialties.

Conclusion: Our study found significant agreement across specialties in the parameters of assessment expected of residents and the expected levels of mastery for independent practice. These results are relevant to residency programs and certification bodies like the American Accreditation Council for Graduate Medical Education in designing the assessment of milestones related to peripheral nerve surgery. This study has important implications for the design of residency and fellowship education in peripheral nerve surgery internationally.

Background and objectives: Cochlear safety is paramount during middle fossa surgery because of the proximity of the cochlea to adjacent potential surgical targets such as the internal auditory canal (IAC). Several proposed methods are based on general anatomical relationships and distance averages between the cochlea and adjacent structures or reconstruction of lines drawn between other structures around the cochlea. We assessed the feasibility and safety of using the cochlear dimple as a direct cochlear localization landmark during a middle fossa approach to the IAC.

Methods: The middle fossa approach was simulated in 13 fresh cadaveric temporal bone specimens and 2 intact heads (4 sides). The middle fossa rhomboid was drilled to expose the anterior and superior aspects of the IAC and the cochlear dimple.

Results: The cochlear dimple was identified as a triangular depression in the distal dura of the anterior IAC with a mean distance of 3.2 mm from the laterally located cochlea. In no specimen did exposure of the cochlear dimple violate the cochlea. The cochlear dimple was identifiable in all specimens, and it was created by the divergence of the distal intracanalicular course of the facial and cochlear nerves near the IAC fundus.

Conclusion: The cochlear dimple is a direct anatomical landmark that can be used to localize the cochlea. It is the only landmark whose establishment is not contingent on the identification of any other structure. It may be used as an additional measure to protect the cochlea during middle fossa surgery.