Acta Neurochirurgica最新文献

Purpose

In resective epilepsy surgery for drug-resistant focal epilepsy (DRE), good seizure outcome is strongly associated with visualization of an epileptogenic lesion on MRI. Standard clinical MRI (≤ 3 Tesla (T)) may fail to detect subtle lesions. 7T MRI enhances detection and delineation, the potential benefits of increasing field strength to 9.4T are explored.

Methods

A 36 years old male patient with DRE evaluated for resective surgery, in which 3T and 7T MRI failed to detect any epileptogenic lesions, was submitted to a dedicated epilepsy scan protocol using T1 and T2* weighted imaging at 9.4T. Images were evaluated independently by two neuroradiologists and one neurosurgeon.

Results

9.4T MRI offered increased spatial resolution and enhanced depiction of anatomical structures vital for epilepsy imaging, exemplified by regions mesio-temporal (hippocampus, amygdala), latero-temporal, insula, frontal and temporal operculum, and gray-white matter junction (precentral gyrus/frontal lobe) compared to 3T and 7T, albeit with challenges in mesial-temporal and antero-inferior temporal lobe imaging. No epileptogenic lesion was identified.

Conclusion

9.4T demonstrates promise in the identification and delineation of anatomical structures and small epileptogenic lesions in patients with DRE eligible for resective surgery. Whether clinical 9.4T MRI in DRE has clinical advantages over 7T or leads to a more complete resection of the epileptogenic zone and improved seizure outcome after epilepsy surgery needs to be established.

Purpose

A substantial proportion of patients undergoing surgery for chronic subdural hematoma (CSDH) use anticoagulation medication due to atrial fibrillation (AF). We assessed the risk of postoperative thromboembolic and hemorrhagic complications in CSDH surgery patients with a history of anticoagulation for AF and their association with outcome.

Methods

This posthoc analysis of a nationwide multicenter randomized controlled trial conducted during 2020–2022 included CSDH patients undergoing surgery with a history of preoperative anticoagulation use for AF. We assessed the incidence of thromboembolic and hemorrhagic complications and their associations with functional outcomes and mortality.

Results

Of 589 patients, 128 patients (median age 83 years, 24% females) were on anticoagulation medication due to AF. The incidences of postoperative thromboembolic and hemorrhagic complications were 8% and 6%, respectively. A significantly higher proportion of patients with a thromboembolic complication had unfavorable functional outcome (70% vs. 21%, p < 0.001) and higher mortality (50% vs. 14%) than those without. After adjusting for risk factors, a thromboembolic complication was independently associated with a higher risk for unfavorable outcome (OR 16.8, 95% CI 3.0–94.2) and death (OR 11.1, 95% CI 2.4–52.0). Similarly, hemorrhagic complications associated independently with unfavorable outcome, although the effect size was smaller than for thromboembolic complications.

Conclusion

The risk for thromboembolic complications seemed to be slightly higher than the risk for postoperative hemorrhagic complications after CSDH surgery in patients with a history of preoperative anticoagulation medication use due to AF. The occurrence of a thromboembolic complication was detrimental for patient prognosis, underscoring the importance of strategies to prevent thromboembolic events. There is an urgent need for a trial assessing the optimal timing of restarting anticoagulation medication after CSDH surgery.

Trial registration

ClinicalTrials.gov identifier NCT04203550.

Objective

Communicating hydrocephalus (CH) is an uncommon complication that can affect patients with glioblastoma (GBM). Due to its clinical and radiological findings, it presents as a chronic hydrocephalus. The mechanisms underlying its occurrence and impact on the prognosis of the disease are poorly known, but some studies have suggested that shunting can have a positive impact on the quality of life of these patients.

Methods

The authors performed a systematic literature review and meta-analysis to identify the possible risk factors that could help to identify CH cases in glioblastoma, using the MEDLINE/PubMed and Cochrane Database of Systematic Reviews databases. The Joanna Briggs Institute critical appraisal tool was used to assess the risk of bias.

Results

Our search yielded 273 studies, but only 9 records were included in the final quantitative analysis. CH in glioblastoma patients was found to be very uncommon (proportion 0.04 out of 1; range 0.03–0.05, p < 0.01, CI:95%) and its occurrence was associated with a previous ventricular opening (0.85 out of 1; range 0.66–0.94, p < 0.01, CI:95%).

Conclusion

CH in glioblastoma should be suspected in patients with GBM who have undergone accidental ventricular opening during tumor resection and presenting with chronic hydrocephalus symptoms.

Background

Superficial temporal artery (STA)-middle cerebral artery (MCA) side-to-side microvascular anastomosis can achieve the same clinical effects as traditional STA-MCA end-to-side anastomosis in extracranial-intracranial revascularization surgery, furthermore, STA-MCA side-to-side anastomosis has the lower risk of postoperative cerebral hyperperfusion syndrome (CHS) and the potential to recruit all scalp arteries as the donor sources via self-regulation. Therefore, STA-MCA side-to-side microvascular anastomosis seems to be a revascularization strategy superior to traditional STA-MCA end-to-side anastomosis. In this study, we presented seven cases in which a STA-MCA side-to-side microvascular anastomosis was performed with a 4–5 mm long arteriotomy using the in-situ intraluminal suturing technique.

Methods

Superficial temporal artery (STA)-middle cerebral artery (MCA) side-to-side anastomosis was performed in seven patients using the in-situ intraluminal suturing technique.

Results

The diameters of the recipient MCA and the donor STA were approximately 0.94 mm (range 0.8–1.4 mm) and 1.65 mm (range 1.4–2.0 mm), respectively, and the length of the arteriotomy was approximately 4.71 mm (range 4–5 mm). The MCA was temporarily occluded in approximately 25.00 min (range 20–29 min). 100% patency rates of the STA-MCA microvascular anastomosis were achieved in all patients. No obvious CHS was recorded. Intraoperative Indocyanine green videoangiography (ICG-VA) and postoperative digital subtraction angiography (DSA) demonstrated three different blood flow distribution patterns after the STA-MCA side-to-side anastomosis, the donor MCA received not only antegrade blood flow from the proximal preanastomotic STA but also retrograde blood flow from the distal postanastomotic STA in one case; the donor MCA received all the antegrade blood from the proximal STA without retrograde blood flow from the distal STA in two case; whereas, the recipient MCA territories received only partial antegrade blood flow from the proximal preanastomotic STA.

Conclusions

STA-MCA side-to-side microvascular anastomosis with a 4–5 mm long arteriotomy using the in situ intraluminal suturing technique is a safe and effective revascularization surgery, and the anastomosis can serve as a shunt for blood flow self-regulation.

Background

Wall shear stress (WSS) plays a crucial role in the natural history of intracranial aneurysms (IA). However, spatial variations among WSS have rarely been utilized to correlate with IAs’ natural history. This study aims to establish the feasibility of using spatial patterns of WSS data to predict IAs’ rupture status (i.e., ruptured versus unruptured).

Methods

“Patient-specific” computational fluid dynamics (CFD) simulations were performed for 112 IAs; each IA’s rupture status was known from medical records. Recall that CFD-simulated hemodynamics data (wall shear stress and its derivatives) are located on unstructured meshes. Hence, we mapped WSS data from an unstructured grid onto a unit disk (i.e., a uniformly sampled polar coordinate system); data in a uniformly sampled polar system is equivalent to image data. Mapped WSS data (onto the unit disk) were readily available for Radiomics analysis to extract spatial patterns of WSS data. We named this innovative technology “WSS-informatics” (i.e., using informatics techniques to analyze WSS data); the usefulness of WSS-informatics was demonstrated during the predictive modeling of IAs’ rupture status.

Results

None of the conventional WSS parameters correlated to IAs’ rupture status. However, WSS-informatics metrics were discriminative (p-value < 0.05) to IAs’ rupture status. Furthermore, predictive models with WSS-informatics features could significantly improve the prediction performance (area under the receiver operating characteristic curve [AUROC]: 0.78 vs. 0.85; p-value < 0.01).

Conclusion

The proposed innovations enabled the first study to use spatial patterns of WSS data to improve the predictive modeling of IAs’ rupture status.

Objective

To explore the correlation between posterior fossa crowding and the occurrence of classical trigeminal neuralgia (TN).

Methods

A total of 60 patients diagnosed with classical TN and 60 age- and sex-matched healthy volunteers were included as a control group for a case-control study. All subjects underwent high-resolution 3D magnetic resonance imaging (MRI) examinations (including 3D-FIESTA and 3D-TOF MRA sequences). The original data were subjected to 3D reconstruction and measurement of posterior fossa volume (PFV) and hindbrain volume (HBV) using 3D-slicer software. The posterior fossa crowding index (PFCI) was calculated as HBV/PFV × 100%. Finally, data were analyzed using SPSS 22.0 statistical software.

Results

The average PFCI in patients with TN was 85.0% ± 3.9%, compared to 82.7% ± 3.9% in the control group, with a significant statistical difference (P = 0.025). Female patients with TN had a more crowded posterior fossa than male patients (86.4% ± 3.8% vs. 83.4% ± 3.4%, P = 0.033). Multiple linear regression analysis showed that a higher PFCI was associated with being female (P = 0.022), younger age (P = − 0.003), and being a patient with TN (P = − 0.023).

Conclusion

Patients with PTN have a more crowded posterior fossa compared to the healthy control group. A higher PFCI is associated with being female, younger age, and being a patient with TN. Posterior fossa crowding may be a risk factor for neurovascular conflict (NVC), making it more likely to lead to the occurrence of TN.

Background

Intraoperative ultrasound is becoming a common tool in neurosurgery. However, effective simulation methods are limited. Current, commercial, and homemade phantoms lack replication of anatomical correctness and texture complexity of brain and tumour tissue in ultrasound images.

Methods

We utilise ex-vivo brain tissue, as opposed to synthetic materials, to achieve realistic echogenic complexity and anatomical correctness. Agar, at 10–20% concentrate, is injected into brain tissue to simulate the tumour mass. A commercially available phantom was purchased for benchmarking.

Results

Qualitative analysis is performed by experienced professionals, measuring the impact of the addition of agar and comparing it to the commercial phantom. Overall, the use of ex vivo tissue was deemed more accurate and representative, compared to the synthetic materials-based phantom, as it provided good visualisation of real brain anatomy and good contrast within tissue. The agar tumour correctly produced a region of higher echogenicity with slight diffusion along the margin and expected interaction with the neighbouring anatomy.

Conclusion

The proposed method for creating tumour-mimicking tissue in brain tissue is inexpensive, accurate, and simple. Beneficial for both the trainee clinician and the researcher. A total of 576 annotated images are made publicly available upon request.

Purpose

It was noticed that anterior choroidal artery (AChoA) aneurysms appear to rupture at relatively smaller sizes compared with aneurysms in other intracranial locations, based on anecdotal clinical experience. We therefore aimed to compare ruptured AChoA aneurysms with other ruptured aneurysms in other intracranial locations, pertaining to aneurysm dimensions. This may help in finding out if the rupture risk stratification, based on the amalgamation of aneurysms of multiple locations in one group, precisely estimates aneurysm rupture risk.

Methods

255 ruptured intracranial aneurysms, which underwent assessment with catheter angiography with 3D reconstruction, in a single tertiary center between January 2000 and December 2023, were included. 6 aneurysm dimensions were compared.

Results

Statistically significant larger aneurysm maximum diameter, height, width and size ratio (SR) of the ruptured posterior communicating artery (PCOMM) aneurysms were identified when compared with ruptured AChoA aneurysms.

No statistically significant difference in the aneurysm maximum diameter, height and width between the ruptured AChoA and ruptured anterior cerebral artery (ACA), anterior communicating artery (Acom), pericallosal artery and basilar tip aneurysms was found.

AChoA aneurysms appear to rupture at a relatively small size, which is comparable to other aneurysm locations that are often grouped into different categories in rupture risk stratification.

Conclusion

More detailed location-specific rupture risk estimation may be needed. The combination of multiple intracranial aneurysm locations into a single category for risk stratification may not reflect the true aneurysm size at rupture for some aneurysms.

Background

Reaching parenchymal segments of the lateral lenticulostriate artery (LSA) perforators, which represent the medial resection limit in insular gliomas (IG), remains a challenge. The currently described methods are indirect and sometimes, imprecise.

Methods

We report an antegrade direct skeletonization technique to identify these tiny arteries at the medial end of IGs with an illustrative case of grade 2 astrocytoma. The patient recovered uneventfully following a near total tumor resection without any postoperative radiological ischemia in the LSA territory.

Conclusions

Our microsurgical technique of antegrade LSA skeletonization may be useful in insular gliomas with a sharp medial border.

A 54-year-old man presented with gait disturbances, urinary incontinence, and headache for 6 months. Head computed tomography indicated several high-density mass lesions in the quadrigeminal cistern, causing occlusive hydrocephalus. Digital subtraction angiography confirmed tentorial dural arteriovenous fistulae (AVF). Transarterial embolization (TAE) achieved complete angiographic resolution. However, acute occlusive hydrocephalus worsened, necessitating endoscopic third ventriculostomy (ETV). The patient was discharged without new symptoms and no hydrocephalus recurrence at six-month follow-up. Hydrocephalus is rare in patients with dural AVF and mostly resolves spontaneously after treatment; however, if thrombosis and enlargement of the varix occur after treatment, acute occlusive hydrocephalus can develop.