Acta Neurochirurgica最新文献

Purpose

This study introduces a retrospective analysis of the surgical management of 213 consecutive cases of cervical spine metastases and Multiple Myeloma Cases.

Materials and methods

Retrospective analysis of prospectively collected data in a single surgical center of patients who underwent surgery for tumors of the cervical spine between 1994 and 2017. Exclusion criteria were intradural tumors and primary tumors. We analyzed epidemiological data, clinical presentation, radiological findings, and treatment methods.

Results

From a total of 213 patients, 125 (59%) were male and 88 (41%) were female. The mean age was 61 years (range: 5 to 88 years). The most common entity was lung cancer (19.5%). In 5% of the cases, staging detected no primary (CUP). In most patients, a combined approach (96 patients; anterior-posterior in 80 cases, posterior-anterior in 16 cases) was needed for surgery. From an anterior approach, only 49 patients were treated, while in 68 cases, a posterior approach alone was sufficient. In the atlantoaxial group, in the majority of patients, a transoral approach was performed (30 cases), mostly combined with posterior stabilization (27 patients). The average number of stabilized segments was 2.8 (range: 0–10). The mean postoperative follow-up was 14.2 ± 9.44 months.

Conclusions

Most cervical spine metastases and multiple myeloma cases can be treated with long-term control or cure of the lesion and preservation of neurological function. Anterior approaches provide adequate exposure to safely remove most of these lesions. Nevertheless, combined surgery with varying degrees of complexity is often required.

Objectives

To report the results of an international patient-reported survey that adds to the growing body of evidence surrounding the role of surgery in the management of a subset of patients with non-hydrocephalic symptomatic pineal cyst.

Design

An international web-based survey of health outcomes in patients with nhSPC.

Subjects

All survey participants who self-reported a diagnosis of symptomatic pineal cyst without hydrocephalus after radiological imaging.

Methods

The survey was developed in collaboration with the patient group Pineal Cyst UK. It was publicised and distributed via several online platforms and social media. Data collected included demographics, cyst size, symptom frequency and severity, number of appointments with healthcare professionals, treatment options trialled, and whether patients underwent surgery.

Results

543 participants (mean age 38.6 years, range 1–83) were included in the analysis, of which 82 (mean age 38.9 years, range 16–72) had undergone cyst resection. After a median period of 18.3 months between date of surgery and date of questionnaire completion, 72 (90%) of the surgical cohort reported overall improvement, and all symptoms improved overall, whereas no symptoms improved overall in the non-surgical cohort. Of the non-surgical cohort (n = 461), 269 participants received some form of conservative treatment, of whom 194 (72.1%) did not experience symptom improvement on any treatment offered.

Conclusions

A cohort of patients with nhSPC who participated in this international survey reports substantial and durable improvement in symptom severity and quality of life after pineal cyst resection.

Purpose

Familial cerebral cavernous malformation syndrome (FCCM) is characterized by multiple hemorrhagic lesions and is sometimes mistaken for cerebral amyloid angiopathy (CAA).

Methods

We compared clinical and radiologic characteristics in patients with definite (N = 32) and presumed FCCM (n = 76) to patients with definite (N = 29) and probable CAA (N = 21).

Results

Patients with CAA were older (78.6 years CAA vs. 43.4 FCCM; p < 0.0001), had cognitive complaints (66.0% CAA vs. 8.3% FCCM; p < 0.0001), and less likely to have a family history (4.0% CAA vs. 50.9% FCCM; p < 0.0001). FCCM patients were more likely to have at least 1 Zabramski type 2 lesion (0 CAA vs. 79.6% FCCM; p < 0.0001). Presence of any subcortical white matter hemorrhagic lesion (23.0% CAA vs. 99.1% FCCM; p < 0.0001), a lesion in either the basal ganglia, internal capsule or cerebellum (28.0% CAA vs 79.6% FCCM; p < 0.0001) and a subcortical white matter to cortical ribbon distribution of hemorrhagic lesions ≥ 1.0 was predictive of FCCM (6.0% CAA vs 83.9% FCCM; p < 0.0001). CAA patients more commonly had white matter disease, sulcal subarachnoid hemorrhage, and severely enlarged perivascular spaces in the centrum. However, none of the latter features were unique to CAA. FCCM patients meeting Boston 2.0 criteria for CAA (n = 14) had additional factors that helped distinguish them from CAA.

Conclusions

Patients with FCCM can be reliably distinguished from CAA by accurately applying the Boston 2.0 criteria, assessing hemorrhagic lesion distribution and types, and assessing for clinical features unique to FCCM. FCCM criteria are proposed. The frequent finding of leukoaraiosis and enlarged perivascular spaces in the centrum semiovale in FCCM patients deserves further investigation.

Objective

To provide an explanation for the intraoperative onset of severe naming deficits in the course of awake resection of left insular glioma.

Methods

We retrospectively reviewed a series of 14 patients operated on in awake conditions for a left insular IDH-mutated glioma. Preoperative MRI included high-resolution diffusion sequences, to which constrained spherical deconvolution pipeline was applied, to obtain a whole brain tractogram. Whole brain T1 parcellation was obtained by Freesurfer, allowing to dissect the tractogram and identify the connections between the caudate nucleus and Broca’s area. Postoperative MRI standard diffusion the day after surgery was performed, allowing to delineate and register to the preoperative MRI any area of hyperintense diffusion with low apparent diffusion coefficient. The pathway between pars triangularis (resp. opercularis) and Broca’s area were considered as damaged whenever more than 50% of streamlines were passing through the mini-strokes. Patients’ language abilities (including a picture naming task) were assessed and reported before, during and after surgery by certified speech therapists. Severe postoperative naming deficits were defined as a score lower than 40/80 items. Contingency tables were analyzed with Fisher exact test (statistical significance set at 0.05).

Results

Out the 14 patients, 8 patients had a mini-stroke on the immediate postoperative MRI. None of the 6 patients without any stroke had postoperative naming severe deficits. Five out the 8 patients with a mini-stroke had a severe postoperative naming deficit, characterized by strong verbal perseverations. This difference was statistically significant (exact Fisher test, p = 0.03). For the five patients with a deficit, the mini-stroke damaged either the pars triangularis – caudate pathway or the pars opercularis – caudate pathway, whenever the pars triangularis was resected after negative cortical mapping. For the three patients without severe postoperative naming deficit, the mini-stroke spared the Broca-caudate pathway. All patients recovered quasi-normal naming abilities at the 4-month postoperative evaluation.

Conclusions

The occurrence of mini-strokes within the connections between Broca’s area and the caudate nucleus explains the sudden naming deficits observed intraoperatively in some patients during awake resection of IDH-mutated insular glioma. Further studies are needed to better predict such event and to assess its impact on other cognitive functions.

Aim

Flow diverters (FDs) are being increasingly used off-label for treatment of intracranial vertebral artery dissection aneurysms (IVADAs). However, the safety and efficacy of FDs for unruptured IVADAs remain unclear. This study was performed to investigate whether FDs-alone are safer and more effective than conventional stent-asisted coiling.

Methods

We retrospectively analyzed 152 patients who underwent endovascular stenting from December 2011 to December 2022. The baseline data, aneurysm characteristics, surgical details, perioperative complications, follow-up angiography, and clinical outcomes were collected and compared between patients who underwent stenting with FD-alone versus conventional stent-asisted coiling. Propensity score matching was also conducted.

Results

All 152 patients underwent successful endovascular therapy. Forty patients were treated with FDs-alone, and 112 were treated with conventional stent-asisted coiling (including 62 with double stents). The complete occlusion rate was 93.75% in the FD group and 93.61% in the conventional stent group (p = 0.979). The complication rate was 5.00% in the FD group and 8.93% in the conventional stent group (p = 0.653). The in-stent restenosis rate was 3.13% in the FD group and 5.32% in the conventional stent group (p = 0.615). The procedure duration was significantly shorter in the FD than conventional stent group (p = 0.034). After propensity score matching, 37 patients with FDs were successfully matched, and the procedure duration was still significantly shorter in the FD group (p = 0.042).

Conclusion

FD placement is a safe and effective treatment for IVADAs. It is also a simpler procedure with a shorter operation time than conventional stent placement.

Trial registration number: ChiCTR2300074171

ClinicalTrials.gov ID:NCT06134557

Purpose

Meningiomas are the most common primary brain tumour and account for over one-third of cases. Traditionally, estimations of morbidity and mortality following surgical resection have depended on subjective assessments of various factors, including tumour volume, location, WHO grade, extent of resection (Simpson grade) and pre-existing co-morbidities, an approach fraught with subjective variability. This systematic review and meta-analysis seeks to evaluate the efficacy with which machine learning (ML) algorithms predict post-operative outcomes in meningioma patients.

Methods

A literature search was conducted in December 2023 by two independent reviewers through PubMed, DARE, Cochrane Library and SCOPUS electronic databases. Random-effects meta-analysis was conducted.

Results

Systematic searches yielded 32 studies, comprising 142,459 patients and 139,043 meningiomas. Random-effects meta-analysis sought to generate restricted maximum-likelihood estimates for the accuracy of alternate ML algorithms in predicting several postoperative outcomes. ML models incorporating both clinical and radiomic data significantly outperformed models utilizing either data type alone as well as traditional methods. Pooled estimates for the AUCs achieved by different ML algorithms ranged from 0.74–0.81 in the prediction of overall survival and progression-/recurrence-free survival, with ensemble classifiers demonstrating particular promise for future clinical application. Additionally, current ML models may exhibit a bias in predictive accuracy towards female patients, presumably due to the higher prevalence of meningiomas in females.

Conclusion

This review underscores the potential of ML to improve the accuracy of prognoses for meningioma patients and provides insight into which model classes offer the greatest potential for predicting survival outcomes. However, future research will have to directly compare standardized ML methodologies to traditional approaches in large-scale, prospective studies, before their clinical utility can be confidently validated.

Purpose

There is scant data on the relationship between skeletal maturity and pelvic parameters such as the pelvic incidence (PI). The aim of this study was to report on the relationship between PI and the modified Oxford Hip Score (mOHS) as a measure of skeletal maturity. We hypothesised a significant correlation would be determined between the mOHS and PI.

Methods

CT performed for major trauma or abdominal pathology was assessed. The PI and segmental vertebral body angles, L1-L5, were obtained. The mOHS was used to assess maturity with total scores ranging from 16 to 25 (least-most mature). 193 scans were analysed. The mean age 9.7 years (range 4.0 - 15.7); 62 female (32%).

Results

There were significant positive correlations between age and all components of the mOHS: FH (r = 0.765; p < 0.001), GT (r = 0.749; p < 0.001), LT (r = 0.704; p < 0.001), TC (r = 0.775; p < 0.001), IL (r = 0.642; p < 0.001) and mOHS (r = 0.811; p < 0.001). Mean PI for the cohort was 40.8 (s.d. 9.1; range 19.3–69.4). There were significant albeit weak correlations with FH (r = 0.213; p = 0.003), GT (r = 0.209; p = 0.004), LT (r = 0.247; p < 0.001), TC (r = 0.263; p = < 0.001), IL (r = 0.221; p = 0.002) and total mOHS (r = 0.255; p < 0.001). Multivariable linear regression indicated TC and LT the best predictors of PI. Significant correlations noted between L1 segmental lordosis and all components of the mOHS, strongest with triradiate (r=-0.406; p < 0.001).

Conclusions

In this CT-based study, the mOHS correlated weakly with PI and proximal vertebral body lordosis. Of the mOHS components, triradiate and lesser trochanter cartilage status appeared to be best correlated with PI and may be anatomic variables to focus on in future research.

Background

Traumatic brain injury (TBI) can significantly disrupt autonomic nervous system (ANS) regulation, increasing the risk for secondary complications, hemodynamic instability, and adverse outcome. This retrospective study evaluated windowed time-lagged cross-correlation (WTLCC) matrices for describing cerebral hemodynamics–ANS interactions to predict outcome, enabling identifying high-risk patients who may benefit from enhanced monitoring to prevent complications.

Methods

The first experiment aimed to predict short-term outcome using WTLCC-based convolution neural network models on the Wroclaw University Hospital (WUH) database (P_training = 31 with 1,079 matrices, P_val = 16 with 573 matrices). The second experiment predicted long-term outcome, training on the CENTER-TBI database (P_training = 100 with 17,062 matrices) and validating on WUH (P_val = 47 with 6,220 matrices). Cerebral hemodynamics was characterized using intracranial pressure (ICP), cerebral perfusion pressure (CPP), pressure reactivity index (PRx), while ANS metrics included low-to-high-frequency heart rate variability (LF/HF) and baroreflex sensitivity (BRS) over 72 h. Short-term outcome at WUH was assessed using the Glasgow Outcome Scale (GOS) at discharge. Long-term outcome was evaluated at 3 months at WUH and 6 months at CENTER-TBI using GOS and GOS-Extended, respectively. The XGBoost model was used to compare performance of WTLCC-based model and averaged neuromonitoring parameters, adjusted for age, Glasgow Coma Scale, major extracranial injury, and pupil reactivity in outcome prediction.

Results

For short-term outcome prediction, the best-performing WTLCC-based model used ICP-LF/HF matrices. It had an area under the curve (AUC) of 0.80, vs. 0.71 for averages of ANS and cerebral hemodynamics metrics, adjusted for clinical metadata. For long-term outcome prediction, the best-score WTLCC-based model used ICP-LF/HF matrices. It had an AUC of 0.63, vs. 0.66 for adjusted neuromonitoring parameters.

Conclusions

Among all neuromonitoring parameters, ICP and LF/HF signals were the most effective in generating the WTLCC matrices. WTLCC-based model outperformed adjusted neuromonitoring parameters in short-term but had moderate utility in long-term outcome prediction.

Background

Craniocervical junction (CCJ) dural arteriovenous fistulas (DAVFs) represent a rare yet critical vascular anomaly that may result in significant neurological impairments.

Method

We report the case of a 52-year-old male with a history of medullary hemorrhage who underwent surgical intervention for a left CCJ DAVF. Through comprehensive surgical planning and meticulous intraoperative monitoring, multiple feeders of the DAVF were safely coagulated and transected, with successful DAVF obliteration confirmed by intraoperative angiography.

Conclusion

The patient demonstrated full recovery, underscoring the efficacy of surgical management in complex cases facilitated by advanced techniques in a hybrid operating theatre.