Acta Neurochirurgica最新文献

Background

Chronic subdural hematoma (cSDH) is a common neurosurgical pathology causing significant morbidity and mortality, yet optimal management and intervention remains controversial.

Methods

We describe embolization of the middle meningeal artery (MMA) and placement of subdural evacuating port systems (SEPS) by a dual trained open and endovascular neurosurgeon. Both procedures are done in sequence in the interventional radiology suite, and real time radiographic results are demonstrable with Xper-CT.

Conclusions

MMA Embolization followed by evacuation of cSDH with a SEPS is a valuable strategy to mitigate perioperative risk factors and patient comorbidities, through a minimally invasive evacuation with subsequent embolization minimizing recurrence.

Purpose

Glioblastoma (GBM) is an aggressive brain tumor often accompanied by a vasogenic peritumoral edema, which contributes to symptoms both at diagnosis and during later stages of the disease. Previous studies have suggested effectiveness of the endogenous protein, Antisecretory Factor (AF), in reducing the intracranial pressure in cytotoxic brain edema after trauma. Interestingly, AF also seems to carry antineoplastic effects in experimental GBM models. This study investigated whether AF reduces peritumoral edema in GBM patients. As a secondary aim, we assessed potential effects on tumor progression by AF.

Methods

Fifteen newly diagnosed GBM patients were treated for 7 days preoperatively with AF in addition to standard of care (SOC) treatment with corticosteroids. The change in edema volume was assessed volumetrically using T2/FLAIR weighted MRI and compared to a control group of 10 GBM patients receiving SOC only.

Results

At baseline the mean tumor volume for the entire cohort was 35.7 cm3 with a mean edema of 62.2 cm3. There was no significant difference in edema volume change between the AF treated patients, who demonstrated a mean edema reduction of 7.1cm3 (95%CI -5.4–19.6), and the controls, 11.3cm3 (95%CI -0.8–23.5), p = 0.61. No difference was observed in tumor volume change between the two groups, p = 0.79. No adverse treatment effects were noted.

Conclusion

Treatment with AF in addition to SOC does not seem to reduce the peritumoral edema in GBM patients. The treatment was well tolerated. The lack of edema-reducing effect may be related to the different pathophysiological properties of vasogenic and cytotoxic edema.

Background

Intracerebral microdialysis is an advanced method to guide clinicians during intensive care of patients with severe acute brain injury. Using intracerebral microdialysis, markers of brain metabolism and homeostasis can be analysed. Currently, trends are considered more important in clinical decision-making than absolute values. Establishing absolute reference values in healthy brain tissue may facilitate an earlier detection of abnormal brain tissue metabolism and provide better decision support for clinicians. However, the current evidence on normal values in the uninjured human brain has not previously been summarized. The aim of this study was to summarise the literature regarding microdialysate concentrations of common markers of brain energy metabolism (glucose, lactate, pyruvate, glutamate, and glycerol) in vivo in healthy brain tissue of humans and gyrencephalic animals.

Method

MEDLINE, Embase, CENTRAL, CINAHL, and Web of Science were searched for published studies that report values of microdialysis in healthy brain tissue. In order to identify unpublished studies, we searched ClinicalTrials.gov, WHO International Clinical Trials Registry Platform (ICTRP), and EU Clinical Trials Register. Study quality was evaluated using a pre-specified protocol.

Result

Out of 3257 studies identified, 39 studies were included. Six of these studies were in humans (total n = 54), 26 in pigs/swine (n = 432), two on monkeys (n = 10), one in sheep (n = 15), and one in dogs (n = 10). We found a high degree of clinical and methodological heterogeneity in both human and gyrencephalic animal studies.

Conclusion

This scoping review identified studies that applied microdialysis to measure common biomarkers in healthy brain tissue. The clinical and methodological heterogeneity between the measured values was substantial, limiting any conclusions. Furthermore, the quality of several human studies was moderate at best. Methodologically comparable studies are warranted to establish reference values for markers of brain energy metabolism using intracerebral microdialysate.

Purpose

Chronic subdural hematoma (cSDH) is a highly prevalent condition that frequently requires surgical evacuation. This is typically achieved through burr hole evacuation, which can be performed under either local anesthesia (LA) or general anesthesia (GA). In the present study, we provide a systematic review and meta-analysis to study and compare the safety and efficacy of cSDH evacuation in LA and GA.

Methods

Following the PRISMA guidelines, we screened four databases for studies that compared postoperative outcomes after burr hole evacuation of cSDH in LA versus GA. Baseline characteristics and postoperative outcome data were collected, and risk ratios were calculated for each study as well as pooled across records. Random effect models were applied to continuous data points. Bias was assessed using the MINORS tool.

Results

We identified 22 eligible studies covering 3917 patients in total. LA was associated with decreased risk for complications (p < 0.001), shorter surgery duration (p < 0.001) and hospital stay (p < 0.001). There was no statistically significant association with recurrence rates, postoperative seizure or occurrence of pneumocephalus. In a subanalysis including only data from studies utilizing subdural drainage, results remained largely similar with LA proving advantageous in terms of shorter surgery duration (p < 0.001) and hospital stay (p < 0.001).

Conclusion

LA may serve as a safe alternative to GA for cSDH surgery, associated with fewer postoperative complications and providing benefits regarding shorter hospital stay and surgery duration.

Purpose

Patients with diffuse lower-grade gliomas (LGG) often suffer from mental fatigue. In healthy subjects, mental fatigue has a negative impact on cognitive functioning. This relation may be more complex in LGG, where tumor localization and growth rate also impact brain function. Our aim was to investigate how self- and observer-reported variables of mental fatigue and cognitive functioning were connected before tumor treatment.

Methods

Consecutive patients scheduled for surgery due to presumed LGG were screened (n = 157). LGG was presumed if the mass was suggestive of diffuse glioma, but without significant contrast enhancement. Isocitrate dehydrogenase (IDH)-mutated WHO grade 2 or 3 gliomas (the LGG group) were analyzed separately. We included 101 patients in the entire cohort, whereas 71 patients constituted the LGG group. Patient data included: (1) self-reported assessments of mental fatigue and cognitive functioning, (2) neuropsychological test performances, and (3) clinical/demographic characteristics. Spearman's partial correlations were calculated between the variables and visualized in a correlation network.

Results

Cognitive impairment was self-reported by 50% of the entire cohort and 45% of the LGG group, while observer-evaluated testing showed cognitive impairment in 40% and 34% of the cases respectively. Self-reported assessments showed no correlations (≥ 0.3 or ≤-0.3) with neuropsychological test performances. A consistent correlation was seen between self-reported mental fatigue and self-reported cognitive functioning (entire cohort: rho=-0.66, LGG group: -0.64).

Conclusion

Our results highlight the complexity of evaluating symptoms of mental fatigue and cognitive functioning even prior to surgery. Self-reports and neuropsychological testing were weakly correlated, hence these should be handled complimentary.

Purpose

This study evaluates surgical outcomes for acromegaly at King’s College Hospital(2012–2022), focusing on predictive factors for surgical cure. A novel radiological metric, the MI Ratio, is introduced to enhance the prediction of clinical remission post-surgery, providing a more accurate prognosis and informing treatment planning.

Methods

This single-centre cohort study involved a retrospective analysis of prospectively collected data from a UK tertiary referral centre. Included were patients with histologically proven somatotroph tumours who underwent endoscopic trans-sphenoidal surgery (TSS) between 2012 and 2022. Exclusions were made for incomplete data or lost follow-up. Patient demographics, tumour characteristics, radiological parameters, and biochemical markers were analysed. The MI Ratio was defined as the distance from the midline to the lateral maximum of a tumour, divided by the distance between the two cavernous carotid arteries on coronal MRI.

Results

Out of 157 patients, 150 met the inclusion criteria. Using the 2018 consensus OGTT nadir < 0.40 ng/mL, microadenomas had a higher surgical cure rate (72%) compared to macroadenomas (48%), with an overall cure rate of 53%. Significant predictors of surgical cure included the MI Ratio (p < 0.001), microadenomas (p = 0.022), Knosp score < 2 (p = 0.012), immediate post-operative GH level (p = 0.016), and patient gender (p = 0.005). Pre-operative medical management did not significantly impact surgical remission (p = 0.19), while pre-operative GH level approached significance (p = 0.06). CV between operators for MI was < 5% indicating minimal Interoperator variability.

Conclusions

This study is the first to describe the MI Ratio, demonstrating its utility in predicting surgical remission in acromegaly patients. A combination of radiological features, demographics, and hormone profiles can more accurately identify patients less likely to achieve surgical cure.

Bone wax alternatives, such as Ostene®, are marketed as substitutes for traditional bone wax, offering the benefits of resorbability, improved bone osteogenesis, and reduced inflammatory reactions, granulomas, and infection risks. However, the limitations of these agents in cranial neurosurgery, particularly for sealing exposed air cells during skull base repair, are underreported. We present an early post-operative case of subcutaneous emphysema, pneumocephalus, and bone flap infection following the failure of Ostene® to provide a durable seal of air cells after temporal craniotomy and tumour resection. This highlights a limitation of Ostene® and other water-soluble bone haemostasis agents in cranial neurosurgery.

Background

Analysis of B-waves in overnight intracranial pressure (ICP) recordings used to be an important element in the diagnosis of normal pressure hydrocephalus (NPH). Here, we tested the hypothesis that equivalents to B-waves can be detected and quantified in a noninvasively measured electric capacitance signal termed W.

Methods

We measured ICP and W in a cohort of 15 patients with suspected diagnosis of NPH or spontaneous intracranial hypotension during infusion testing, identifying B-waves in both signals by wave-template matching in the time domain.

Results

We found very strong correlation between the duration of B-waves in ICP and W (R² = 0.86, p < 10^–6), and weak correlation between the average B-wave amplitudes in ICP and W (R = 0.34, p = 0.02).

Conclusions

The concurrent presence of B-waves in the signals suggests that vasogenic activity of cerebral autoregulation is reflected in W. The weaker correlation of amplitudes may be attributed to W being an indirect measure of cranial volume composition, whereas ICP is a measure of pressure, with the two linked by the non-linear craniospinal pressure-volume relation that varies between patients. Analysis of the noninvasively acquired W signal should be evaluated as a triage tool for patients with NPH and other disorders characterized by reduced compliance.

Background

Tuberculum sellae meningiomas pose a surgical challenge due to the tumor adhesion to vital structures. In many cases, tumor residue and dural tail sign may contribute to an opportunity for future recurrence.

Methods

In this study, we introduced endoscopic technique in supraorbital keyhole approach to further resected residual tumor and dural attachments that are traditionally difficult to detect under microscopic surgery, and finally achieved Simpson Grade II resection.

Conclusion

The use of endoscopy offers enhanced visualization and ensures more reliable Simpson Grade II resection outcomes for tuberculum sellae meningiomas.

Background

We present a surgical technique for retrograde stenting of ostial stenosis of the common carotid artery (CCA) in a 74-year-old male patient.

Method

The carotid bifurcation was widely exposed. A 9-French (Fr) balloon guide catheter (BGC) was inserted via a small arteriotomy of the CCA and fixed using balloon inflation. The BGC was curved and placed toward the leg side. Transluminal angioplasty followed by stent deployment was then performed. The contrast medium injected via a diagnostic 4-Fr catheter was aspirated through the BGC.

Conclusion

Our modified transcarotid retrograde stenting technique appears to be a feasible approach for managing ostial stenosis of the CCA.