Acta Neurochirurgica最新文献

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.

Purpose

Methylprednisolone (MP) is a synthetic glucocorticoid known for its anti-inflammatory and immunosuppressive effects, yet its application in global spinal cord injury (SCI) research has not been thoroughly summarized. This study aims to assess the current status and trends of methylprednisolone research in SCI, providing insights for future scholarly work.

Methods

Articles on methylprednisolone in SCI published from 1975 to 2023 were retrieved from the Web of Science database. Metrics such as publication counts, H-index values, and data on countries, institutions, authors, and journals were analyzed. Co-citation, collaboration, and co-occurrence analyses of keywords were performed using CiteSpace.

Results

A total of 1,651 articles were identified, and publication numbers showed a consistent annual increase. The United States and Canada led in publication counts, H-index values, and citations, with the University of Toronto and the Veterans Health Administration being significant contributors. Bracken M.B. was the leading author. The most frequent keywords included ‘trauma,’ ‘lipid peroxidation,’ ‘dose response,’ ‘ischemia,’ and ‘methylprednisolone.’ A co-occurrence analysis classified 225 keywords into three clusters, highlighting key research areas in SCI.

Conclusions

These findings offer valuable insights into authors, countries, institutions, keywords, and research hotspots in SCI over the past 50 years, guiding future research directions in this field.

Introduction

Management for elderly patients (> 65yo) with incidental meningiomas remains unclear. This study aims to characterize the functional and tumor outcomes of expectant and stereotactic radiosurgery (SRS) management of asymptomatic meningioma elderly patients.

Methods

Using retrospectively collected data from 14 centers, SRS outcomes were compared to radiographic and clinical observation of asymptomatic meningiomas in elderly patients following propensity score matching.

Results

Following propensity score matching, 114 patients were in each cohort. Tumor control was achieved at 97.37% in the SRS cohort, and no meningioma growth was seen 71.93% of the observation cohorts (p < 0.01; OR 14.44 [95% CI 4.27–48.78]). New neurological deficits developed in 1.39% of the SRS cohort but in none of the patients managed conservatively. 3.5% of patients underwent resection in the active surveillance matched cohort compared to 0.9% of patients in the SRS cohort (p = 0.063; OR 0.135 [95% CI 0.163–1.117]). The all-cause mortality rate was almost half in the SRS group (9.65%) compared to the observation group (18.42%) (p = 0.06; OR 0.47 [95% CI .22–1.03]).

Conclusion

SRS achieves superior radiological tumor control compared to surveillance but with a slightly increased the risk of new SRS-related neurological deficits in elderly patients with asymptomatic meningiomas. Although SRS reduces meningioma progression, the need for of an open neurosurgical procedure and mortality were not significantly reduced. Furthermore, mortality in the observation group was not directly related to the meningioma in any of the patients.

Background

Neurofibromatosis type 2 (NF2)-related schwannomatosis is a rare genetic disorder associated with meningiomas. Stereotactic radiosurgery (SRS) has emerged as a potential non-invasive method. This study aims to synthesize the available evidence on using SRS to treat these tumors.

Methods

PubMed/Medline, Embase, Scopus, and Web of Science were searched until March 21, 2024. This study was prepared by adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA).

Results

Four studies were included comprising 101 patients with NF2-associated meningiomas treated with SRS. All included studies used gamma knife stereotactic radiosurgery (GKRS) as treatment modality. Overall survival rates remained high (100%) up to 3 years post-treatment, with slight declines at five years of 98% (95% CI: 0.95–1.01) and ten years of 68% (95% CI: 0.48–0.87). Progression-free survival rates were similarly favorable, with 95% (95% CI: 89-101%) at three years, 93% (95% CI: 86-99%) at five years, and 81% (95% CI: 51-111%) at ten years. The pooled radiation necrosis rate was 5% (95% CI: 3-7%), while the overall radiation toxicity rate was 16% (95% CI: 11-21%). Local tumor control rates were high at six months, and at 12 months, they were 100% (95% CI: 1.00–1.00).

Conclusion

GKRS demonstrates high efficacy and a favorable safety profile for NF2-associated meningiomas, offering a valuable treatment option for this challenging patient population.

Background

We aimed to determine the diagnostic accuracy of intraoperative muscle motor evoked potentials (mMEPs) in predicting postoperative motor deficits in individual muscles of patients with benign intramedullary spinal cord tumors (IMSCTs), and to correlate them with long-term functional outcome.

Methods

A retrospective study of patients operated for benign IMSCTs from 2009 to 2021 was performed. Sixty-nine patients in whom baseline mMEP recordings were obtained from at least one muscle were included for analysis. A persistent drop of the baseline mMEP by ≥ 50% from baseline was considered significant.

Results

The mean age of the patients was 33.2 ± 15.8 years and 47 (68.1%) of them were male. The most common tumor was ependymoma (56.5%). Baseline mMEPs were obtained in 400/1011 muscles that were monitored. Postoperative worsening of motor power was noted in 109/400 (27.3%) muscles with baseline mMEP recordings compared to 213/611 (34.9%) muscles with no baseline recordings (p = 0.01). Patients who had deterioration of mMEPs had a significantly higher rate of worsening of muscle power postoperatively compared to those who had no deterioration of mMEPs (100% vs. 30.2%, p < 0.001). The sensitivity of mMEPs in predicting postoperative motor function in monitored muscles was 53.1% (95% CI 43.5–62.6), specificity was 97.9% (95% CI 95.5–99.2), PPV was 90.9% (95% CI 81.6–95.7) and NPV was 84.1% (95% CI 81.3–86.6). At median follow-up of 18.5 (IQR 13–40) months, there was no significant difference in Nurick grade between patients who had intraoperative deterioration of mMEPs and those who did not.

Conclusions

Intraoperative mMEP reduction had high specificity and low sensitivity for predicting immediate postoperative neurological deficits following IMSCT resection. However, the majority of patients who had worsening of mMEPs, recovered to their preoperative functional status or a better status at follow-up and there was no significant difference in long-term functional outcome between patients with and without intraoperative mMEP changes.

Background

Deep brain stimulation (DBS) has been successfully used for the treatment of circuitopathies including movement, anxiety, and behavioral disorders. The hypothalamus is a crucial integration center for many peripheral and central pathways relating to cardiovascular, metabolic, and behavioral functions and constitutes a potential target for neuromodulation in treatment-refractory conditions. To conduct a systematic review, investigating hypothalamic targets in DBS, their indications, and the primary clinical findings.

Methods

PubMed, Scopus, and Web of Science databases were searched in accordance with the PRISMA guideline to identify papers published in English studying DBS of the hypothalamus in humans.

Results

After screening 3,148 papers, 34 studies consisting of 412 patients published over two decades were included in the final review. Hypothalamic DBS was indicated in refractory headaches (n = 238, 57.8%), aggressive behavior (n = 100, 24.3%), mild Alzheimer’s disease (n = 58, 14.1%), trigeminal neuralgia in multiple sclerosis (n = 5, 1.2%), Prader-Willi syndrome (n = 4, 0.97%), and atypical facial pain (n = 3, 0.73%). The posterior hypothalamus was the most common DBS target site across 30 studies (88.2%). 262 (63.6%) participants were males, and 110 (26.7%) were females. 303 (73.5%) patients were adults whereas 33 (8.0%) were pediatrics. The lowest mean age of participants was 15.25 ± 4.6 years for chronic refractory aggressiveness, and the highest was 68.5 ± 7.9 years in Alzheimer’s disease patients. The mean duration of the disease ranged from 2.2 ± 1.7 (mild Alzheimer’s disease) to 19.8 ± 10.1 years (refractory headaches). 213 (51.7%) patients across 29 studies (85.3%) reported symptom improvements which ranged from 23.1% to 100%. 25 (73.5%) studies reported complications, most of which were associated with higher voltage stimulations.

Conclusions

DBS of the hypothalamus is feasible in selected patients with various refractory conditions ranging from headaches to aggression in both pediatric and adult populations. Future large-scale studies with long-term follow-up are required to validate the safety and efficacy data and extend these findings.

Purpose

Spinal schwannomas are benign tumours that can compress the spinal cord or nerve roots, causing neurological symptoms. Despite successful surgical resection, some patients experience suboptimal functional recovery. Several risk factors for poor prognosis have been identified, but limited research has explored the influence of tumour distribution and characteristics. In this study, we aimed to identify prognostic variables associated with residual neurological deficit in patients undergoing surgical resection for sporadic spinal schwannomas.

Methods

Clinical and radiological data of consecutive patients who underwent surgery for spinal schwannomas at Saitama Medical Centre between January 2010 and March 2024 were retrospectively reviewed. Patients with neurofibromatosis type 2 or foraminal and paravertebral schwannomas were excluded. Data collected included patient demographics, radiological features, and surgical complications. Residual neurological deficit was defined as a Modified McCormick scale grade of II–V, persistent neurogenic pain, or bladder/bowel dysfunction.

Results

Gross total resection was achieved in 55 cases (76.4%). Postoperative complications occurred in 6 cases (8.3%), including cerebrospinal fluid fistula and vascular injury. At a median follow-up of 26.4 months, 20 patients (27.8%) had residual neurological deficits. Univariable and multivariable logistic regression identified thoracic spine involvement (odds ratio [OR], 5.03; 95% confidence interval [CI], 1.47–18.6; p = 0.01) and dumbbell-shaped tumours (OR, 0.15; 95% CI, 0.02–1.28; p = 0.04) as significantly associated with residual neurological deficits. Moreover, thoracic spinal schwannomas were associated with a significantly higher incidence of persistent postoperative neurogenic pain than that associated with cervical or lumbosacral tumours (p = 0.001).

Conclusions

Thoracic spine involvement and tumours that are not dumbbell-shaped were identified as significant risk factors for residual neurological deficits in patients undergoing surgical treatment for spinal schwannomas. Awareness of tumour distribution and characteristics may assist in refining preoperative assessments, guiding strategic decisions, and potentially improving surgical management for better patient care. 

Background

Several studies have attributed decreasing case fatality rates (CFRs) of aneurysmal subarachnoid hemorrhage (aSAH) to the gradually increasing use of endovascular treatment without considering improvements in other outcome-affecting factors. To assess the independent effect of a treatment modality on CFRs, we investigated CFR changes in a high-volume center rapidly transitioning from surgical to endovascular operations as the first-line treatment for all aSAH patients except those with middle cerebral artery (MCA) aneurysms.

Methods

We identified all surgically/endovascularly treated aSAH patients in Helsinki University Hospital (HUH) during 2012–2017. As the treatment shift occurred in 2015, we defined two treatment eras: surgical (2012–2014) and endovascular (2015–2017). We compared time-dependent changes in 1-year CFRs between non-MCA and MCA patients using a Poisson regression model. To analyze consistency in operation rates, we also identified sudden-death and conservatively treated aSAHs in the HUH catchment area via two externally validated registers.

Results

Of all 665 hospitalized aSAH cases in the HUH catchment area, 557 (84%) received operative treatment; 367 (66%) underwent surgical and 190 (34%) endovascular operations. Between the treatment eras, endovascular treatment for non-MCA cases increased from 21 to 79%, whereas 99% of the MCA cases were treated surgically during the whole study-period. Among the operatively treated patients, the 1-year CFRs decreased similarly in patients with non-MCA (42%; from 14 to 8%; adjusted risk ratio (aRR) = 0.66 (95% CI 0.37–1.19)) and MCA aneurysms (42%; from 15 to 9%; aRR = 0.66 (0.16–1.60)). The proportion of operatively treated patients, their clinical condition on admission, and amount of bleeding on the first CT-scan remained unchanged over time.

Conclusions

We found similar CFR decreases in aSAH groups with and without undergoing a fast transition from surgery to endovascular operations, providing real-world evidence on the small independent effect of endovascular treatment on the decreasing CFRs in high-volume centers.

Purpose

Gamma Knife radiosurgery (GKRS) is a precise and efficacious treatment modality for vestibular schwannoma (VS) with favorable cranial nerve preservation rates. This study aims to better characterize facial nerve (FN) outcomes in VS after GKRS.

Methods

A query of six medical databases was conducted following PRISMA guidelines. Eligible studies exclusively reported VS managed with single-fraction GKRS and included House-Brackmann (HB) scale assessments prior to and following GKRS. Data was analyzed using random-effects modeling, and FN preservation was defined as HB I or II at last follow-up.

Results

Data was analyzed from 15 articles with 3,155 patients at an mean age of 55.0 years. Mean tumor volume, radiation dose, follow-up, tumor control, and hearing preservation were 4.28 cm³, 13.3 Gy, 59.4 months, 92.7%, and 62.6%, respectively. The pooled FN preservation rate was 92.9%. Mean preoperative tumor volume > 2.5 cm³ and age > 60 years were significantly associated with worse preoperative FN function (p = 0.019, p = 0.023, respectively). Normal FN function (HB = 1) at last follow up was 95.8% for VS volume < 2.5 cm³ and 89.4% with larger volumes (p < 0.001). Doses ≤ 13 Gy were significantly associated with superior FN preservation (96.5%) compared to higher doses (p < 0.001). Tumor control and hearing preservation were not significantly associated with FN preservation.

Conclusion

This meta-analysis identifies tumor volume and radiation dose as prognostic factors for FN preservation. A FN preservation rate of 93% may be expected at five years after GKRS. This study provides a unique characterization of FN outcome that should be considered in the management of VS.

Objective

There is a lack of available data regarding the incidence and characteristics of optic canal invasion (OCI) in large midline non-tuberculum sellae anterior skull base meningiomas (NTSAM), specifically those originating predominantly from the olfactory groove and planum sphenoidale. This study aims to describe the incidence and characteristics of OCI as well as clinical and visual outcomes following extensive tumor resection with optic canal exploration in intra-optic canal tumor removal. In addition, the predictive performance of OCI by preoperative magnetic resonance imaging (MRI) is investigated.

Materials and methods

From 2016 to 2024, we retrospectively reviewed 24 patients with large midline NTSAM who underwent extensive tumor resection in our institution. The OCI was evaluated and compared between preoperative MRI and intraoperative findings. The OCI was classified as follows. Type 1 represented no invasion, type 2 represented secondary invasion, type 3 represented partial wall invasion (two subtypes), and type 4 represented invasion into the superior-medial-inferior walls of the optic canal. Visual functions were assessed before and after surgery.

Results

Among 24 patients, a mean tumor size of 57.2 mm (range 39.0–79.0). The OCI was observed intraoperatively in 22 cases (91.7%), with 19 cases exhibiting bilateral OCI. Among the 48 optic canals in the 24 patients, 18 (37.5%) were type 4, 12 (25.0%) were type 3-inferomedial, 9 (18.8%) were type 3-superomedial, and 2 (4.2%) were type 2, where 7 (14.6%) optic canals were without OCI. A significant correlation was observed between intraoperative OCI and the tumors that exhibited involvement of the tuberculum sellae (TS) on MRI (p < 0.001). For patients with visual impairment, the vision in 27 of 38 (71.1%) eye sides showed improvement following the surgery. There was 1 (4.2%) case of tumor recurrence at the mean follow-up time of 27.3 months (range 4–73 months).

Conclusions

A high incidence of OCI was observed in the large midline NTSAM. The identification of TS involvement on MRI can serve as a strong predictor of OCI. Therefore, optic canal exploration to remove the optic canal invasion during the surgical removal of these particular tumors should be contemplated to attain radical tumor resection to enhance the possibility of improving visual function and reduce the risk of recurrence.