Acta Neurochirurgica最新文献

Background

The fully endoscopic combined endonasal and supraorbital keyhole approach, which integrates the endoscopic endonasal approach (EEA) and the endoscopic supraorbital keyhole approach (eSKA), is effective for complex suprasellar tumors extending beyond the internal carotid artery (ICA). We detail its application for tuberculum sellae meningiomas with lateral extension.

Method

Tumor resection is performed via the EEA, with support from the eSKA. This allows for careful management of the optic nerve under direct visualization and enables sufficient tumor resection.

Conclusion

This combined approach facilitates extensive tumor resection, effective skull base reconstruction, and preservation of surrounding structures.

Background

Postoperative delirium is a frequent complication with negative consequences for neurosurgical patients. Recorded music has been shown to reduce the incidence of delirium, however its economic benefit remains unclear. This study aimed to investigate the cost-effectiveness of perioperative music in preventing postoperative delirium.

Methods

This study used data from a randomized controlled trial (Clinical Trials.gov; NCT04649450) that compared the effect of perioperative music with standard of clinical care on the occurrence of postoperative delirium in patients undergoing craniotomy at the Erasmus Medical Centre. The primary outcome of this study is the cost-effectiveness of the music intervention. A trial-based cost-effectiveness analysis (CEA) was conducted from a societal perspective. Mean costs were calculated using bootstrapping with 95% confidence intervals. Secondary outcomes included postoperative complications, mortality, cognitive functioning, and quality of life. Costs and patient outcomes were assessed separately for the initial hospital admission and long-term follow-up until 6 months after discharge.

Results

This study included 91 patients in the intervention group and 93 in the control group. On average, medical costs during initial admission were lower, albeit not statistically significant, in the music group compared to the control group (€ 11,819 vs. € 13,106), mostly due to a shorter length of stay. Total costs over the 6-month period were nearly identical between the groups, at € 18,587 and € 18,571 in the music and control group, respectively.

Conclusions

Pre-recorded perioperative music may be a cost-effective intervention for reducing postoperative delirium in neurosurgical patients, possibly by decreasing healthcare utilization and costs during primary admission. Further studies are needed to confirm its potential as a cost-effective intervention.

Background

Treatment of unruptured intracranial aneurysms (UIA) less than 7 mm is controversial. We created a scoring system to guide decision making and validated the system utilizing over 700 cases treated with microsurgery or endovascular procedures.

Methods

The scoring system SMALLSS included Size, (4–7 mm: 1 point, < 3.9 mm: 0 point), Multiple aneurysms (yes: 1, no: 0), Anatomic location (posterior: 1, anterior: 0), Lineage- family history of aneurysm (yes:1, no: 0), Lifetime risk (age < 65: 1, age > 65: 0), Smoking history (yes: 1, no: 0 ), Shape (irregular:1, smooth:0 ). Validation of this system was performed through retrospective review of prospectively maintained data for UIA patients treated between 2014 and 2021. We then performed an external validation of a cohort of 200 small aneurysms < 7 mm treated at a high volume cerebrovascular center.

Results

A total of 1152 cases with unruptured intracranial aneurysms were treated over the study interval, of which 771 aneurysms (66.9%) were under 7 mm, with the majority (64.3%) having SMALLSS score more than 2. Serious neurologic complications occurred in 18 out of 771 aneurysms (2.33%) of which 4 were hemorrhagic and 14 were ischemic. The obliteration rate was 98% in microsurgery group, 89.7% in endovascular group. During this same interval, 1126 patients with aneurysms < 7 mm were evaluated and not offered treatment, with 74.7% SMALLSS scores of 2 and under. External validation data showed no significant deviations from our cohort with 150 out of 200 aneurysms (75%) with a SMALLSS score of 2 or greater.

Conclusion

The SMALLSS scoring system can be a good tool to guide treatment decision making for patients with small UIA. The risk of treatment did not increase with the projected increased risk of rupture and overall high obliteration rates were achieved with endovascular and surgical techniques.

Background

Micro-arteriovenous malformations (AVMs) are a subgroup of AVMs with a nidus smaller than 1- cm. As such, intraoperative localization of micro-AVMs can be challenging. Once identified intraoperatively, however, treatment of the micro-AVM is often straightforward.

Method

We discuss and illustrate the fundamental imaging and intraoperative steps to localize micro-AVMs with the aid of an illustrative clinical case.

Conclusion

Micro-AVMs can be challenging to localize intraoperatively. With the aid of anatomical, clinical, and intraoperative findings, the micro-AVMs small draining vein can be localized and traced in a retrograde fashion to identify and remove the micro-AVM.

Background

Deep-seated brain tumors pose a distinctive neurosurgical challenge, as frequently surrounded by eloquent structures. 3D exoscope represents a potential new paradigm for mini-invasive neurosurgery, which shows advantage during the neurosurgical procedure for this kind of challenging cases.

Methods

Utilizing a combination of 3D exoscopes and endoscopes, we successfully removed a left tentorial meningioma in a patient via a subtemporal keyhole approach.

Conclusion

Combination of 3D exoscope and endoscope has the advantages of precise tissue identification, minimized brain traction and enhanced visibility in hidden areas by integrating the strengths of both.

Background:

Establishing a causation relationship between treatments and patient outcomes is of essential importance for researchers to guide clinical decision-making with rigorous scientific evidence. Despite the fact that randomized controlled trials are widely regarded as the gold standard for identifying causal relationships, they are not without its generalizability and ethical constraints. Observational studies employing causal inference methods have emerged as a valuable alternative to exploring causal relationships.

Methods:

In this tutorial, we provide a succinct yet insightful guide about identifying causal relationships using observational studies, with a specific emphasis on research in the field of neurosurgery.

Results:

We first emphasize the importance of clearly defining causal questions and conceptualizing target trial emulation. The limitations of the classic causation framework proposed by Bradford Hill are then discussed. Following this, we introduce one of the modern frameworks of causal inference, which centers around the potential outcome framework and directed acyclic graphs. We present the obstacles presented by confounding and selection bias when attempting to establish causal relationships with observational data within this framework.

Conclusion:

To provide a comprehensive overview, we present a summary of efficient causal inference methods that can address these challenges, along with a simulation example to illustrate these techniques.

Background

The management of extensive craniofacial fibrous dysplasia requires balancing the extent of resection with the perioperative morbidity and complications.

Method

The authors describe a case involving the resection of extensive craniofacial fibrous dysplasia performed in two stages. The first surgery aims on removing most of the lesion and planning for bony reconstruction, while the second stage focuses to complete disease removal and implant a custom-made prosthesis.

Conclusion

This case highlights the benefits of a two-stage surgical approach in reducing morbidity compared to a single extensive surgery while achieving excellent disease resection and functional outcomes.

Craniopharyngiomas (CPs) are surgically challenging tumors. The prevalence of BRAF mutation in papillary craniopharyngioma (PCP) and the positive response with BRAF-MEK inhibitors have shifted the treatment paradigm towards targeted therapy. However, maximal safe resection remains the goal, particularly for adamantinomatous craniopharyngioma (ACP). In this report, we describe two cases of CP where intraoperative ultrasonography (IOUS) was helpful in differentiating the subtype of CP, thus enabling intraoperative decision-making regarding the extent of resection. Additionally, IOUS images of three more (two PCP and one ACP) patients who underwent endoscopic endonasal resection for CPs were retrospectively evaluated. Each of these entities showed characteristic appearances on IOUS.

Background

Magnetic Resonance Imaging guided Laser Interstitial Thermal Therapy (MRIgLITT) is a promising treatment for drug-resistant epilepsy (DRE) and an alternative to open surgery. However, the relationship between clinical and radiological factors and postoperative outcomes is unclear. This study explores the indications, technical challenges, and outcomes of MRIgLITT in terms of seizure control and cognitive changes across various pathologies.

Methods

A retrospective single-center analysis included 32 MRIgLITT procedures performed between January 2019 and December 2023. Procedures used the Visualase^® system for laser ablation, with stereotactic robotic guidance for fiber placement. Data included demographics, clinical and surgical details (ablated volume, timing, power and accuracy), and postoperative follow-up assessed seizure outcomes and complications. Cognitive changes were analyzed using a Reliable Change Index (RCI) before and one year after the procedure.

Results

The 32 procedures involved 28 patients with MRI-diagnosed pathologies: 14 hippocampal sclerosis (HS), 7 hypothalamic hamartoma (HH), 3 focal cortical dysplasia (FCD), 2 periventricular heterotopia (PVH), 1 tuberous sclerosis complex (TSC), and 1 low-grade glioma. Some cases required multiple approaches.

Postoperative follow-up averaged 33 months. Among HS patients, 71.42% achieved Engel I, and 21.43% Engel II. In HH, 85.7% initially became gelastic seizure-free, with complete freedom after additional treatment. Engel I outcomes were 28.6%, while 57.2% showed significant improvement (Engel I + II). FCD patients had a 66.6% Engel I success rate. One PVH patient became seizure-free, while the TSC patient was Engel III at last follow-up. RCI analysis showed that 71.44% of patients experienced cognitive stability (RCI > −1.64) or improvement (RCI > 1.64) at one-year post-procedure.

Conclusions

MRIgLITT is a safe, minimally invasive alternative for epilepsy surgery, offering quicker recovery and showing better performance preserving cognitive function. It is particularly effective for deep or complex epileptic foci and patients who might refuse open surgery.