Brain & spine最新文献

•The combination subgaleal drainage with one burr-hole instead of one burr-hole with subdural drainage is non-inferior.•Subgaleal drainage in cSDH with one burr-hole seemed to be equally efficient and safe compared to two burr-holes.•The use of subgaleal drain leads to a significant lower risk for seizures.

Introduction and research question: Augmented reality (AR) is increasingly being used to improve surgical planning and assist in real time surgical procedures. A retrospective investigation was conducted to study its feasibility in pediatric epilepsy surgery at a single institution.

Methods: Functional neuronavigation using multimodal imaging data (fMRI, DTI-tractography, PET, SPECT, sEEG) were used to augment the surgical navigation by transferring MRI imaging reconstructions as AR maps into the surgical microscope overlaying the surgical field.

Results: Altogether, 43 patients (17 female, 0-18 yrs, mean 9 yrs) were operated between 10/2020 and 10/2023 and fulfilled the inclusion criteria. 26 patients (60.5%) had an extra-temporal and 17 (39.5%) a temporal seizure origin. The 3 top histological diagnoses encountered were: FCD (32.6%), ganglioglioma (23.3%) and DNET (11.6%). Preoperative MRI studies showed no epileptogenic lesion in 11 patients (25.6%, MRI negativ group), which necessitated implantation of depth electrodes before resection. There were no adverse events while using AR enhanced neuronavigation. Altogether, of 24 patients with a follow up of more than one year, 83.3% displayed a favorable ILAE grade 1 seizure outcome (75% ILAE 1a), 14 % experienced a transient hemiparesis, 4.3% a permanent quadrantanopia and one needed a subdural-peritoneal shunt.

Discussion and conclusion: AR supported navigated microscope resection allowed targeting and removal of lesional as well as non-lesional (sEEG defined) epileptogenic zones in pediatric epilepsy surgery with low morbidity and an expected seizure outcome.

Introduction: Colloid cysts are challenging regarding their location. Surgical resection remains the therapeutic option of choice for symptomatic cysts. However, choosing the optimal surgical approach is still a subject of debate.

Research question: The aim of the study is to compare three surgical approaches; Pure endoscopic (PE), pure microscopic (PM) and endoscope assisted microsurgical (EA).

Material and methods: Retrospective data extraction from our database was done and we included patients who underwent surgical resection for colloid cysts since 2008. Patients were categorized into three groups based on the forementioned surgical techniques. Outcome measures assessed included extent of resection (EOR), morbidity using modified Rankin Scale (mRS), hospital stay duration (HSD), and complications.

Results: 41 patients met our inclusion criteria and were divided as follows; PM 13 patients (31.7%), PE 19 patients (46.3%) and EA with 9 patients (22.0%). Mean age (SD) was 37.4 ± 12.2. Male: Female is 1:1.05 and average follow-up was 3.9 ± 2.8 years. Gross total resection(GTR) reached 92.3% (12/13) using PM, 78.9% (15/19) with PE and 100% (9/9) under EA. Morbidity was 15.4%, 10.5% and 0% respectively (mRS >2). Hospital stay duration was significantly shorter in PE and EA (p = 0.012).

Discussion and conclusion: EA excision of colloid cysts is safe and effective. When compared to PE and PM approaches, it can combine the advantages of both tools utilizing the microscope and endoscope to achieve a safe, gross total resection while minimizing hospitalization duration. The choice of surgical approach, however, should be individualized based on the cyst's location, size, and the surgeon's expertise and preference.

Introduction: The management of de novo non-specific spinal infections (spondylodiscitis - SD) remains inconsistent due to varying clinical practices and a lack of high-level evidence, particularly regarding the indications for surgery.

Research question: This study aims to develop consensus recommendations for the diagnosis and management of SD, addressing diagnostic modalities, surgical indications, and treatment strategies.

Material and methods: A Delphi process was conducted with 26 experts from the European Association of Neurosurgical Societies (EANS). Sixtytwo statements were developed on diagnostic workup, management decisions, surgical techniques, non-surgical treatment, and follow-up and submitted to the panel of experts.

Results: Consensus was reached on 38 of 62 statements. MRI was confirmed as the gold standard for diagnosis. Regarding surgical indications, the panel agreed that any new neurological deficit, even subtle, warrants surgical consideration. Motor deficits with a motor score (MRC) below 4 and bladder or bowel dysfunction were unanimously considered clear indications for surgery. For spinal deformity and instability, thresholds such as kyphosis >20°, scoliosis >10°, and vertebral body collapse >50% were established to guide surgical decision-making. Minimally invasive surgery (MIS) was endorsed whenever feasible, and a 12 week antibiotic treatment regimen was favored in cases of complicated infections.

Discussion and conclusion: This EANS consensus provides updated recommendations for SD management, incorporating recent evidence on improved outcomes with surgical therapy. While these guidelines offer a more structured approach to clinical decision-making, further research is required to optimize surgical timing and validate the long-term impact of these treatment strategies.

Research question: The goal of this study was to assess the diagnostic accuracy of spinal time-resolved contrast-enhanced MR angiography (4D-MRA) for the detection and localization of spinal dural arteriovenous fistulas (SDAVF) in our institution.

Material and methods: Single center retrospective cohort study of patients with the clinical suspicion of a SDAVF. Patients were included who had undergone spinal 4D-MRA in the period January 2010-February 2021. A subgroup was identified, who had subsequent digital subtraction angiography (DSA), or clinical/radiological follow-up. Diagnostic performance measures of 4D-MRA were calculated (sensitivity, positive predictive value, specificity, and negative predictive value) with DSA serving as the reference standard.

Results: Overall, 120 patients with the clinical suspicion of having a SDAVF and who underwent spinal 4D-MRA were identified. A subgroup of 30 patients had both 4D-MRA and DSA, or follow-up. In this group, the sensitivity of 4D-MRA for the detection of a SDAVF was 100% and specificity was 91% (positive predictive value of 95% and a negative predictive value of 100%). Sidedness was correctly identified on 4D-MRA in 74% of the cases and the level of the SDAVF in 68%.

Discussion and conclusion: The results indicate that 4D-MRA has a high sensitivity and specificity for the detection and localization of a SDAVF, which is in line with previous studies published in literature. Furthermore, 4D-MRA can serve to guide DSA and shorten the procedural time, which reduces the risk of angiography related complications, and decreases patient discomfort.

Introduction: Thoracolumbar kyphosis (TLK) is a frequently reported spinal deformity in achondroplasia, which in combination with the characteristic narrow spinal canal in achondroplasia predisposes for symptomatic spinal stenosis. There is however no consensus on the optimal treatment, due to limited data on diagnostic criteria, the natural development and the prevalence of TLK.

Research question: This study aims to assess the prevalence, natural development, and diagnostic criteria for pathological TLK in individuals with achondroplasia.

Material and methods: A systematic review and meta-analysis were conducted. Studies involving achondroplasia patients, which reported TLK measurement methods were included. The primary outcome was the pooled prevalence of TLK, stratified by age.

Results: Eight studies, encompassing 852 patients, met the inclusion criteria. Pathological TLK was most frequently defined as a Cobb angle of 20° or greater, between T10 and L2. TLK was present in 87% (95% CI 80%-91%) of patients under two years old, decreasing to 33% (24%-43%) at age three, 26% (19%-35%) between five and ten years, and 23% (16%-31%) in patients aged 10-20 years.

Discussion and conclusion: Pathological TLK in achondroplasia, defined as a Cobb angle of 20° or greater, appears primarily in early childhood and often resolves by walking age. However, approximately one-fourth of cases persist into adulthood, with factors such as developmental motor delay and vertebral wedging contributing to this persistence. Routine clinical and radiological evaluations during childhood, along with conservative management, are recommended to mitigate the need for surgery during adulthood.

Research question: to describe and investigate the case of an 11-year-old boy with the concomitant pneumocephalus, subcutaneous- and orbitopalpebral emphysema after the removal of a giant meningioma. Furthermore, our aim is to discuss the findings and the pathophysiology in relation to cases found in literature.

Material and methods: We performed a search in PubMed, Cochrane, MEDLINE and Google Scholar by the usage of the words orbital or periorbital, combined with emphysema and neurosurgery. In addition, a manual search was performed from reference lists.

Results: In the absence of a trauma and fracture in the orbit, it is considered extremely rare with the simultaneous presentation of an orbital emphysema and pneumocephalus. The literature search revealed 1101 results, with four cases of the simultaneous presentation of orbital emphysema and pneumocephalus after a neurosurgical procedure. Our case of an orbitopalpebral emphysema and pneumocephalus following the removal of a giant meningioma is unique.

Discussion and conclusion: Orbital emphysema might give rise to orbital compartment syndrome, an ophthalmologic emergency, that untreated can result in blindness. Differentiating orbitopalpebral emphysema from postoperative swelling can be accomplished through palpation, which might reveal crepitations, and via an acute CT scan that highlights the presence of air.Following a neurosurgical procedure, orbital emphysema is an extremely rare phenomenon. Given the rarity of this case, we present informed assumptions and propose a bidirectional migration of air: from intracranial space, to the orbit and subcutaneously to the palpebrae.

•Defining the concept of "onco-functional" balance.•Detailing the clinical implications in brain tumor surgery.•Discussing the future of this philosophy.

Introduction: and research question: Prognostic factors to predict the behavior of pituitary neuroendocrine tumors (PitNET) are scarce. PD-L1 expression was associated with prognosis in other neuroendocrine neoplasms and we analyzed PD-L1 expression in PitNET, according to the 2022 WHO classification.

Material and methods: A retrospective analysis was performed. Immunohistochemistry was used to define PD-L1 expression, which was quantified as TPS (tumor proportion score). The primary outcome was to assess the correlation between PD-L1 expression and transcription factors (TF), namely T-pit, Pit-1, SF-1 and GATA-3. As secondary outcomes, we evaluated the association between PD-L1 expression and proliferation indexes.

Results: Eighty-eight patients were included. The largest group belonged to the SF-1-lineage (48%), followed by tumors of the Pit-1 lineage (32%) and T-pit lineage (17%). PD-L1 expression was associated with Pit-1 expression (p < 0.001) and with the somatotroph, lactotroph and mammosomatotroph subgroups. A TPS ⩾35% showed a 100% sensitivity for the mammosomatotroph subtype, while the optimal cut-off point was 20% for somatotroph and 15% for lactotroph tumors. PD-L1 expression was negatively associated with SF-1 and GATA3 expression(p < 0.001), with an optimal cut-point ≤5%. No association was found between PD-L1 expression and immunohistochemical proliferative factors but PD-L1 expression was associated with female sex and a younger age at diagnosis.

Conclusion: PD-L1 expression was associated with PIT-1 lineage, while it was downregulated in SF-1-lineage tumors. No correlation was found with proliferative factors. The role of PD-L1 expression in determining the biological behavior of PitNET remains debated and larger studies are necessary to further confirm these findings.