Acta Neurochirurgica最新文献

Purpose

Cerebral bypasses are technically challenging procedures essential in the neurosurgeon’s armamentarium. Decreasing surgical indications leading to reduced caseload has resulted in less than ideal clinical outcomes, particularly in low to medium volume centres. We describe the neuroplastics approach to cerebral bypasses in the largest retrospective series to date and demonstrate how this approach has been able to smoothen the learning curve and achieve consistent outcomes approximating that of high-volume centres.

Methods

A retrospective study was conducted. All patients who received a bypass were classified into those with bypasses performed using the neuroplastics approach (NP group) and those performed by solo neurosurgeons (Solo group). Technical outcomes and clinical outcomes were compared.

Results

There were 19 patients in the NP group and 50 patients in the Solo group. There were 17 patients in the NP group with double-barrel bypasses and 2 with single-barrel bypasses (total of 36 direct anastomoses) and 45 patients of the Solo group with single-barrel bypasses and 5 patients with conversion to indirect bypasses. Patients in the Solo group were more likely to experience a postoperative stroke in the bypassed territory (Solo, 17.8%; NP, 0%; p = 0.008). Although not statistically significant, there was a difference in the proportion of patients with conversion to indirect bypass (Solo, 10.0%; NP, 0%), postoperative anastomotic bleed (Solo, 8.9%; NP, 0%), and long-term patency (Solo, 93.9%; NP, 100%). Patients in the NP group had a shorter median length of stay (NP, 3 [2 – 7] days; Solo, 6 [5 – 9] days; p = 0.005) and 1-year modified Rankin scale approached significance (NP, 0 [0 – 0]; Solo, 0 [0 – 2]).

Conclusion

Our experience supports the adoption of a neuroplastics approach to the training and execution of cerebrovascular bypasses in small to medium volume centres. This collaboration allowed us to deliver cerebral bypasses to indicated patients with excellent outcomes.

Background

Although the use of vasopressors is recommended after aneurysmal subarachnoid hemorrhage (aSAH) to maintain adequate cerebral perfusion pressure, data on potential adverse effects on delayed cerebral ischemia (DCI) are lacking. The aim of this study was to evaluate the effects of early high-dose vasopressor therapy with norepinephrine alone or additional vasopressin on the subsequent occurrence of DCI, DCI-related infarction and functional outcomes.

Methods

Retrospective evaluation of aSAH patients admitted between January 2010 and December 2022. Demographic, clinical and outcome data as well as daily norepinephrine equivalent (NEE) scores were collected. Potential risk factors for DCI, DCI-related infarction and functional outcome 3 months after discharge were assessed by logistic regression analyses.

Results

A total of 288 patients were included. 208 patients (72%) received vasopressor therapy during the first 14 postictal days with a mean NEE score of 3.8 µg/kgBW/h. The highest NEE scores were observed in the acute phase after hemorrhage and mainly in poor-grade patients. The mean NEE score during the postictal days 1–4 was significantly higher in patients who developed DCI or DCI-related infarction and who had an unfavorable functional outcome. Multivariable logistic regression analysis identified a high NEE score on postictal days 1–4 as an independent predictor of DCI and unfavorable functional outcome.

Conclusions

Vasopressor use is common in aSAH patients in the acute phase after hemorrhage. Our results suggest that high NEE scores during the first 4 days after ictus represent an independent prognostic factor and might aggravate the complex cerebral sequelae associated with the disease.

Purpose

Stereoelectroencephalography (SEEG) is the standard for invasive investigations in epilepsy surgery. Our aim was to investigate if similar precision and low complication rate can be achieved with optimized frameless navigation as with frame-based or dedicated stereotactic SEEG robot.

Methods

We compared five different implantation techniques assessing entry, target errors and complications in 53 SEEGs from 50 patients: Group 1 – surface registration and Vertek probe, Group 2 – rigid registration with conventional CT and Vertek probe, Group 3 – rigid registration and Vertek probe, Group 4 – rigid registration and Autoguide, Group 5 – rigid, sterile registration and Autoguide. Analysis was done using random effects linear modelling to calculate improvement in percent using Group 1 as a reference, p < 0.001 was considered significant.

Results

Mean patient age at implantation was 23 years (range 4–46 years) and mean number of implanted electrodes per patient were 11 (range 3–15). Accuracy data was available for 36 SEEG implantations (419 electrodes). The median entry/target errors were (mm): Group 1:4.6/4.3; Group 2:1.8/2.3; Group 3:0.9/1.5; Group 4:1.1/1.2; Group 5:0/0.7. Improvement of accuracy for entry error was 38% for Group 2 (p = 0.004), 47% for Group 3 (p < 0.001), 50% for Group 4 (p < 0.001), and 72% for Group 5 (p < 0.001). Improvement of accuracy for target error was 17% for Group 2 (p = 0.17), 22% for Group 3 (p < 0.001), 35% for Group 4 (p < 0.001), and 51% for Group 5 (p < 0.001). Complications (hemorrhage, edema, headache) occurred in 7/53 SEEGs, none of these led to permanent deficit. 40/53 investigations resulted in an epilepsy surgery procedure.

Conclusion

High precision and low complication rate in SEEG implantation can be achieved with frameless navigation using rigid, sterile registration.

Purpose

Glioblastoma is one of the most common malignant brain tumors. To ensure a treatment that does not only lengthen survival, but also improves preservation of neurocognitive functions, reliable methods to measure changes in neurocognitive abilities at an early stage are necessary. The most direct way to objectify neurocognitive properties is neuropsychological testing. Neurocognitive decline is often based on lesions of the connectome. We take the corpus callosum (CC) as a reliable structure to identify decline of white matter (WM) integrity. We hypothesized a relation between compromised structural integrity in specific regions of the CC and neurocognitive deficits in glioma patients.

Methods

We included 28 patients with high-grade glioma who underwent a neuropsychological test battery and MRI with Diffusion tensor imaging (DTI) preoperatively. MRI data was processed using the software fsl, Oxford. Neuropsychological parameters were correlated with the fractional anisotropy (FA) in three parts of the CC.

Results

Preoperatively, most of the neuropsychological parameters correlated significantly with FA of at least one of the CC volumes. Higher FA-values were associated with better focus, memory, speed and speech fluency. Different tests examined the same neuropsychological parameter and then correlated with the same region of the CC.

Conclusions

We consider the FA of the CC for an adequate parameter to examine the influence of distant lesions on neurocognitive abilities.

Background

Leukoencephalopathy is the most prevalent and delayed adverse radiation effect (ARE) after intracranial radiotherapy (RT). Patients with leukoencephalopathy experience some levels of cognitive and neurological dysfunction. This investigation assessed the frequency and clinical outcomes of leukoencephalopathy following stereotactic radiosurgery (SRS) alone or SRS following whole-brain radiation therapy (WBRT) in breast cancer brain metastasis.

Methods

We retrospectively evaluated the data of brain metastases from breast cancer individuals who underwent SRS between 2007 and 2022. MRI sequences were examined to assess white matter changes and tumor control.

Results

Among 125 patients with 1,077 brain metastases, 58 (46.4%) patients received WBRT prior to SRS. By year 3, 23.4% of WBRT + SRS patients developed high-grade leukoencephalopathy (grades 2–3) compared to 5.7% in the SRS-only group (p < 0.001). In univariate analyses, significant predictors of high-grade leukoencephalopathy included prior WBRT (HR: 18.4, p = 0.005), cumulative integral dose > 3 J (HR: 4.17, p = 0.029), and the total number of lesions (HR: 1.22, p < 0.001). In multivariate analyses, prior WBRT (HR: 11.1, p = 0.022) and total lesions (HR: 1.14, p = 0.037) remained significant predictors.

Conclusion

Our findings demonstrated that WBRT plus SRS is associated with higher leukoencephalopathy rates than SRS alone. This underscores the importance of carefully weighing the benefits and risks of different ionizing radiation approaches in the management of brain metastasis from breast cancer.

Background

Acute postoperative seizures (APOS) are common phenomena following resective epilepsy surgery and can be categorized as running-down (RDS) or running-up seizures (RUS). This differentiation is made retrospectively, considering their classification is based on seizure recurrence. However, early differentiation of RDS from RUS may prevent unnecessary escalation of anti-seizure medication or reoperation. This review provides an overview of the available literature on variables influencing the evolution to RDS/RUS in patients exhibiting acute or early postoperative seizures.

Methods

A database search was performed addressing studies related to the running-down phenomenon and postoperative seizures in PubMed and Embase. Eligibility required a clear definition of acute or early postoperative seizures. Studies concerning any type of epilepsy surgery or pathology were accepted, excluding those related to high-grade malignancies.

Results

The search yielded a total of n = 1,690 records. We included n = 21 studies with a total of n = 1,496 patients, which examined variables associated with long-term seizure outcome. Interictal epileptiform discharge presence/laterality, epileptogenic zone size, APOS frequency, and history of generalized tonic–clonic seizures, head trauma, or encephalitis were associated with seizure outcome. Ictal expression and timing of seizure recurrence appeared less relevant. However, these associations are uncertain due to conflicting results between studies, likely due to small sample sizes, a limited reporting of secondary variables, and heterogeneity in study population and methodology.

Conclusions

The variability in clinical outcome following APOS highlights the need for a refined classification of postoperative seizures. Future research should focus on constructing and validating a multifactorial model integrating EEG-derived variables, APOS frequency, and medical history to more accurately predict long-term seizure outcome following resective epilepsy surgery.

Background

Inferior Fronto-Occipital Fascicle (IFOF) is a multitasking connection bundle essential for communication and high level mentalization. The aim of the present study was to quantitatively assess its radiological-anatomical-morphometric modifications according to different brain tumor histotype.

Methods

A retrospective multicentric Italian study was conducted. IFOF reconstructions were calculated for both hemispheres for each patient diagnosed with Glioblastoma (GBM), Low Grade Glioma (LGG), Brain Metastasis and Meningioma using Elements Fibertracking software (Brainlab AG). A 3D object of each fascicle was evaluated for volume, average fractional anisotropy (FA) and length. The cerebral healthy hemisphere was compared to the pathological contralateral in different tumor histotype.

Results

1294 patients were evaluated. 156 met the inclusion criteria. We found a significant difference between healthy hemisphere and the contralateral for IFOF mean length and volume (p-value < 0.001). Considering GBM subgroup, Student’s t-test confirmed the results. In LGG subgroup, there was significant difference between the 2 hemispheres for IFOF mean length, mean FA and volume (respectively p-value 0.011; p-value 0.021, p-value < 0.001). In patients affected by brain metastasis (18) Student’s t-test showed a significant difference for FA and volume (p-value 0.003 and 0.02 respectively). No differences were found in patients affected by meningiomas.

Conclusions

The careful preoperative neuroradiological evaluation of the brain-tumor interface is indispensable to plan a tailored surgical strategy and perform a safe and effective surgical technique. It depends on the tumor histology and pattern of growth. GBM have a mixed component, with the solid enhancing nodule which accounts for IFOF displacement and the peritumoral area which accounts for an infiltrative/destructive effect on the fascicle. LGG determine a prevalent infiltrative pattern. Metastases determine an IFOF dislocation due to peritumoral oedema. Meningiomas do not impact on WM anatomy.

Background

Atypical Hangman’s fractures may involve bilateral C2 pedicle fractures. Surgical fixation is often required to prevent instability and neurological impairment. The Judet technique, involving transpedicular screw fixation, offers a targeted approach to stabilize C2 pedicle fractures while preserving cervical motion.

Method

This article presents a neuronavigation-guided modification of the Judet technique for C2 pedicle screw placement. Advanced intraoperative computed tomography (CT) imaging, virtual trajectory planning and intraoperative navigation guidance provide surgical precision and patient safety.

Conclusion

Neuronavigation can improve the classical Judet technique, enhancing clinical safety and accuracy in fixation of C2 pedicle fractures. This minimally invasive/mini-open approach preserves C1-C2 mobility and reduces complications.

Background

Multimodal neuromonitoring (MMM) aids early detection of secondary brain injury in neurointensive care and facilitates research in pathophysiologic mechanisms of the injured brain. Invasive ICP monitoring has been the gold standard for decades, however additional methods exist (aMMM). It was hypothesized that local practices regarding aMMM vary considerably and that inter-and intracenter consensus is low. The survey aimed to investigate this hypothesis including the knowledge, attitudes towards, and use of aMMM in the neurointensive care setting in the Nordic countries.

Method

The survey was distributed amongst 54 neurosurgical trainees at a Nordic neurosurgery training course and supplemented with 16 center-appointed neuromonitoring experts representing 16 of the 19 neurosurgical centers in the Nordic countries (Norway, Sweden, Denmark, and Finland).

Results

The response rate was 100% amongst the training course attendents, as well as the center-appointed experts with a total of 70 respondents. The experts covered 16/19 Nordic centers. In-center disagreement was high concerning the use of aMMM methods. In patients with traumatic brain injury, subarachnoid hemorrhage, or other acute brain injuries 50% of the appointed experts stated transcranial Doppler ultrasound (TCD) to be used in most cases in their ICU, and an additional 25% for selected cases. Most appointed experts agreed on electroencephalography (EEG) for selected cases 63%, but only 19% for most cases. Routine use of Invasive brain tissue oxygenation (PbtO₂) was stated by 25–63% and cerebral microdialysis (CMD) by 19–38%. The main perceived concerns with aMMM methods were the usefulness for outcome-changing interventions (43%) and financial issues (19%). Most respondents (67%) believed automated combined analysis of aMMM to be a likely future scenario.

Conclusion

There was a remarkable variation in the reported use of aMMM among Nordic neurosurgical centers, indicating an extensive lack of consensus on need and utility. Surprisingly routine use of TCD was stated by 75%, presumably for routine monitoring of SAH patients, whereas CMD was mostly considered a research tool. Interestingly, junior staff and appointed experts disagreed on intended local routines, indicating that application of aMMM was more governed organically and by case than on explicit guidelines or that uniform management was not prioritized.

Background

Decompressive craniectomy (DC) is a last-tier treatment for managing refractory intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage (aSAH), though concerns persist about whether it primarily prolongs survival in a state of severe disability. This study investigated patient characteristics, surgical indications, complications, and outcomes following DC in aSAH.

Methods

In this Swedish, retrospective multi-center study, 123 aSAH patients treated with DC between 2008–2022 were included. Data collection included demographic details, aSAH characteristics, injury severity, DC indication, complications, and outcome at roughly six months post-DC (modified Rankin scale [mRS]) dichotomized as survival vs. mortality (0–5 vs. 6) and favorable vs. unfavorable (0–3 vs. 4–6).

Results

The median age was 53 years and 66% were females. Two thirds presented with a WFNS grade 4–5 and 83% with a Fisher grade 4 hemorrhage. Most aneurysms were located at the middle cerebral artery (65%) and treated with clip ligation (59%). DC significantly reduced midline shift from 9 to 2 mm and obliteration rates of basal cisterns from 95 to 22% (p < 0.05). Reoperation for hematomas or extension of the DC were rare (< 5%). At follow-up, 20% were deceased, while 33% had recovered favorably. In univariate logistic regressions, younger age was associated with favorable outcome and reduced mortality. Other patient demographics, injury severity, and factors related to the DC surgery lacked association with outcome.

Conclusions

aSAH patients treated with DC presented with severe primary brain injuries and signs of intracranial hypertension. DC resulted in radiological improvements regarding mass effect and a low rate of postoperative complications. Although the results were based on a selected population of aSAH patients, an encouraging rate of favorable outcome was found, particularly among younger patients. However, the absence of additional outcome predictors underscores the ongoing challenges in improving patient selection for DC in aSAH.