Acta Neurochirurgica最新文献

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.

Background

Cranioplasty is performed to restore cranial integrity following decompressive hemicraniectomy, with both autologous bone grafts (ABGs) and synthetic grafts (SGs) serving as reconstructive options. While previous studies have examined clinical outcomes, there is a lack of robust data comparing aesthetic outcomes and complication rates between ABGs and SGs. This study evaluates these parameters to guide optimal graft selection.

Method

A single-center retrospective review was conducted on patients who underwent cranioplasty with either ABGs or SGs between January 2017 and November 2023. Patient demographics, perioperative variables, and postoperative complications were collected. Aesthetic outcomes were assessed using axial CT scans to measure frontal and parietal asymmetry. Statistical analyses included univariate and multivariate comparisons, adjusting for potential confounders such as age, cerebrovascular accident (CVA) history, hypertension (HTN), atrial fibrillation (AFib), ventriculoperitoneal (VP) shunt status, and insurance type.

Results

Among 200 patients, 82 (41.0%) received ABGs, and 118 (59.0%) received SGs. Frontal and parietal asymmetry scores did not significantly differ between groups (p = 0.321, p = 0.348). Median time to cranioplasty was shorter for ABGs than SGs (106.5 vs. 117 days; p = 0.038). Postoperative complications were significantly higher in the SG group compared to ABGs (30.5% vs. 9.8%; p = 0.001), with infections being more frequent in SGs (p = 0.048). SGs were also associated with a higher rate of revision surgeries.

Conclusions

ABGs and SGs provide comparable aesthetic outcomes, but SGs carry a significantly higher risk of complications and revisions. Given its lower complication rates and cost-effectiveness, ABGs should be prioritized when feasible. However, SGs remain a viable option in cases where autologous bone is unavailable or contraindicated. Future studies should focus on long-term follow-up and patient-reported outcomes to further refine cranioplasty decision-making.

Background

A widely accepted tool to assess hemodynamics, one of the most important factors in aneurysm pathophysiology, is Computational Fluid Dynamics (CFD). As current workflows are still time consuming and difficult to operate, CFD is not yet a standard tool in the clinical setting. There it could provide valuable information on aneurysm treatment, especially regarding local risks of rupture, which might help to optimize the individualized strategy of neurosurgical dissection during microsurgical aneurysm clipping.

Method

We established and validated a semi-automated workflow using 3D rotational angiographies of 24 intracranial aneurysms from patients having received aneurysm treatment at our centre. Reconstruction of vessel geometry and generation of volume meshes was performed using AMIRA 6.2.0 and ICEM 17.1. For solving ANSYS CFX was used. For validational checks, tests regarding the volumetric impact of smoothing operations, the impact of mesh sizes on the results (grid convergence), geometric mesh quality and time tests for the time needed to perform the workflow were conducted in subgroups.

Results

Most of the steps of the workflow were performed directly on the 3D images requiring no programming experience. The workflow led to final CFD results in a mean time of 22 min 51.4 s (95%-CI 20 min 51.562 s–24 min 51.238 s, n = 5). Volume of the geometries after pre-processing was in mean 4.46% higher than before in the analysed subgroup (95%-CI 3.43–5.50%). Regarding mesh sizes, mean relative aberrations of 2.30% (95%-CI 1.51–3.09%) were found for surface meshes and between 1.40% (95%-CI 1.07–1.72%) and 2.61% (95%-CI 1.93–3.29%) for volume meshes. Acceptable geometric mesh quality of volume meshes was found.

Conclusions

We developed a semi-automated workflow for aneurysm CFD to benefit from hemodynamic data in the clinical setting. The ease of handling opens the workflow to clinicians untrained in programming. As previous studies have found that the distribution of hemodynamic parameters correlates with thin-walled aneurysm areas susceptible to rupture, these data might be beneficial for the operating neurosurgeon during aneurysm surgery, even in acute cases.

Background

Although older traumatic brain injury (TBI) patients often exhibit cerebral autoregulatory impairment with high pressure reactivity index (PRx), the role of autoregulatory-guided management in these patients remains elusive. In this study, we aimed to explore if age affected the prognostic role of the autoregulatory variables, PRx and the PRx-derived optimal cerebral perfusion pressure (CPPopt), in a large TBI cohort.

Methods

In this observational study, 550 TBI patients who had been treated in the neurocritical care unit, Addenbrooke’s Hospital, Cambridge, UK, between 2002 and 2022 with available data on age, intracranial pressure monitoring, and outcome (Glasgow Outcome Scale [GOS]) were included. The patients were classified into three age groups; youth and early adulthood (16–39 years), middle adulthood (40–59 years), and senior adulthood (60 years and above). Autoregulatory variables were studied in relation to outcome using heatmaps. Multivariate logistic regressions of mortality and favourable outcome (GOS 4 to 5) were performed with PRx and ΔCPPopt (CPP-CPPopt) in addition to baseline variables.

Results

TBI patients in the senior adulthood group exhibited higher PRx and lower ICP than younger patients. There was a transition towards worse outcome with higher PRx in heatmaps for all age groups. The combination of high PRx together with low CPP or negative ΔCPPopt was particularly associated with lower GOS. In multivariate logistic regressions, higher PRx remained independently associated with higher mortality and lower rate of favourable outcome in the senior adulthood cohort. There was a transition towards worse outcome for negative ΔCPPopt for all age groups, but it did not reach statistical significance for the senior adulthood group.

Conclusions

PRx was found to be an independent outcome predictor and influenced the safe and dangerous CPP and ΔCPPopt interval for all age groups. Thus, TBI patients older than 60 years may also benefit from autoregulatory-guided management and should not necessarily be excluded from future trials on such therapeutic strategies.

Background

The optimal timing for rescue stenting (RS) following failed thrombectomy in patients with underlying intracranial atherosclerosis (ICAS)-related large vessel occlusion (LVO) remains unknown. We aimed to determine this by comparing the angiographic and clinical outcomes of early and late RS.

Methods

We retrospectively enrolled patients with acute ischemic stroke who underwent stent-retriever thrombectomy for ICAS-related LVO. Per-pass analysis was performed to assess recanalization rates after each retrieval in all patients. Patients were classified into early and late groups based on the number of stent retrievals before RS (early: 1 or 2 attempts; late: ≥ 3 attempts). Angiographic and clinical outcomes were compared between these two groups.

Results

Among 126 patients with ICAS-related LVO, 257 retrievals were evaluated. Successful and complete recanalization rates were highest on the first attempt and significantly decreased between the second and third passes. Overall, 56 patients underwent RS, of which 27 and 29 were classified into the early and late RS groups, respectively. The early RS group had shorter procedure times (45 min vs. 70 min, p < 0.001) and higher rates of favorable outcomes (85.2% vs. 55.2%, p = 0.014) than the late RS group. Intact stent patency rates were also higher in the early RS group than in the late RS group (88.0% vs. 65.4%, p = 0.059). Multivariate analysis identified early RS (OR, 7.187; 95% CI, 1.385–37.306; p = 0.019) and stent patency (OR, 7.291; 95% CI, 1.288–41.277; p = 0.025) as significant factors influencing favorable outcomes.

Conclusion

RS should be performed at an early stage after failed thrombectomy for ICAS-related LVO.

Background

Burnout is a condition of mental, emotional, and physical enervation affecting personnel working in human services and has been reported high among neurosurgical doctors. However, previous burnout reports are based on low response rates and measured by the Maslach Burnout inventory, which for several reasons has proven problematic. Burnout has not previously been investigated among neurosurgical doctors in Denmark. With this study we measure the prevalence of burnout among neurosurgical doctors in Denmark with sustainable methodology and a clinically relevant burnout interpretation.

Methods

Burnout was measured among neurosurgical doctors in Denmark using the Copenhagen Burnout Inventory (CBI) consisting of three subscales measuring personal burnout, work-related burnout and patient-related burnout. To gain better understanding of factors contributing to burnout, the psychosocial working conditions and moral distress was measured using the Danish Psychosocial Work Environment Questionnaire (DPQ) and a questionnaire of eight items previously used to assess moral distress.

Results

With 73 responders and a response rate of 90.1%, clinically relevant burnout was reported in 27.4% in personal burnout, 16.5% in work-related burnout and 5.5% in patient-related burnout. Cohort members with children living at home experienced a significant higher degree of burnout regarding work-related burnout and patient-related burnout.

Within the DPQ domains of ‘Demands at work’ and ‘Work organization and job content’, several moderate to strong correlations were observed between specific sub-dimensions and both personal and work-related burnout. Higher levels of the domain ‘Interpersonal relations’ was moderately correlated with lower levels of both personal and work-related burnout. In the testing of moral distress, only 2 responders (2.7%) scored as ‘somewhat injured’.

Conclusion

Neurosurgical doctors in Denmark report relatively low prevalence of clinically relevant burnout. However, doctors with children living at home exhibited higher levels of work- and patient-related burnout. Our findings highlight the psychosocial work environment as a significant factor contributing to burnout, while moral distress appears to have a limited impact on the development of burnout in the study population.