Acta Neurochirurgica最新文献

Background

Surgeries performed at night may carry higher risk due to provider fatigue and reduced staffing, but data from neurosurgical populations are limited. We evaluated whether nighttime evacuation of chronic subdural hematoma (CSDH) was associated with increased complications or recurrence.

Methods

We conducted a retrospective cohort study of adults undergoing CSDH surgery at a tertiary neurosurgical center between 2006 and 2023. The primary exposure was nighttime surgery, defined by procedure start time. Primary outcomes were moderate-to-severe complications (Landriel-Ibáñez grade II–IV within 30 days) and CSDH recurrence (reoperation within 6 months). Multivariable logistic regression was used to adjust for confounders.

Results

Of 2860 patients, 709 (25%) underwent nighttime surgery. Nighttime surgery was independently associated with an increased risk of moderate-to-severe complications (OR 1.58, 95% CI 1.04–2.37; p = 0.028). This risk peaked during the final hours of the night shift. Although CSDH recurrence was more common after nighttime surgery in unadjusted analysis (13% vs. 10%), this difference was not significant after confounder adjustment.

Conclusion

Nighttime surgery for CSDH was associated with an increased risk of moderate-to-severe complications. When feasible, surgery should be performed during daytime hours.

Background

Anterior inferior cerebellar artery (AICA) compression is a common cause of hemifacial spasm (HFS). Endoscopic-assisted microvascular decompression (eMVD) offers several advantages, including minimal invasiveness, wide viewing angles, and clear visualization.

Methods

The surgical procedure was performed under a four-step endoscopic technique. Step 1: A 0° endoscope was used to dissect the cerebellopontine cistern and release cerebrospinal fluid for decompression. Step 2: A 30° endoscope was employed to dissect the arachnoid around the facial nerve and expose the root exit zone (REZ). Step 3: The AICA was identified, carefully dissected, and transposed away from the REZ. Step 4: Adequate decompression and hemostasis were confirmed.

Conclusion

The four-step endoscopic approach can achieve effective decompression in cases of HFS caused by AICA compression, providing favorable surgical outcomes.

Background

Intracranial meningiomas(IM) are often associated with peritumoral brain edema(PTBE), visible as hyperintensities on T2/FLAIR MRI. Postoperative persisting PTBE-like changes likely represent gliosis that, in turn, contributes to surgical morbidity. Since the human eye is unable to distinguish between PTBE and gliosis on MR images, we hypothesized that radiomic analysis of preoperative peritumoral T2/FLAIR hyperintensities could distinguish preoperatively established gliosis from reversible edema.

Methods

MRI of patients with gross totally resected IM were retrospectively analyzed. Preoperative and 1-year postoperative PTBE were segmented on MRI. One-year MRI were classified into two categories based on whether PTBE resolution exceeded 80% of the initial volume. RF were extracted from meningioma and PTBE regions on T1-contrast-enhanced, T2, and FLAIR MRI sequences. The dataset was split into training, validation, and test cohorts(70–10-20%). Feature reduction used correlation-based exclusion and recursive feature elimination with cross-validation. Nine ML algorithms were trained and evaluated, and best model’s interpretability assessed using Shapley Additive Explanations(SHAP).

Results

644 RF were extracted per individual from the pre and postoperative MRI of 123 operated patients. The Random Forest model utilizing 10 RF achieved the best performance (accuracy:0.91;precision:0.92;F1-score:0.92;ROC-AUC:0.94), demonstrating radiomics’ utility in predicting PTBE resolution at 1-year post-surgery. SHAP analysis provided interpretability, highlighting key RF, differences between patient groups, and potential sources of algorithmic error.

Conclusions

These results underscore the potential of radiomics and ML to accurately predict postoperative PTBE resolution, differentiating transient PTBE from persistent PTBE-like changes (gliosis). This study provides initial insights into the potential of advanced imaging and computational techniques for non-invasive preoperative assessment, which may contribute to more personalized surgical strategies.

Background

Laser Interstitial Thermal Therapy (LITT) is a minimally invasive option for treating epilepsy and neuro-oncologic lesions, including those deemed inoperable. However, it does not allow for histomolecular diagnosis.

Methods

We describe our technique for combining stereotactic brain biopsy and LITT, focusing on biopsy sample quantity and its effects on MRI thermometry and ablation quality.

Conclusion

Stereotactic biopsy can be safely integrated with LITT. Limiting sampling to two specimens minimizes air diffusion and hemorrhagic risk, reducing thermometric artifacts and preserving the accuracy of ablation.

Background

Cerebral vasospasm remains a leading cause of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage (aSAH). Despite advances in critical care, current monitoring strategies are reactive and non-personalized. Machine learning (ML) has emerged as a promising tool to anticipate vasospasm risk.

Methods

A systematic review and meta-analysis were performed following PRISMA 2020 guidelines. PubMed and Embase databases were searched for studies applying ML algorithms to predict clinical or radiological vasospasm. Data were pooled using bivariate and proportional meta-analyses and their quality was assessed with the PROBAST tool.

Results

Twelve studies (2011–2025) encompassing 25 ML models were included. Deep learning achieved the highest sensitivity (mean: 97.6%) and AUC-ROC (0.97), outperforming regression, ensemble, and SVM methods in sensitivity (p = 0.003) but not in specificity or AUC. SVM models showed the highest NPV (85%), while ensemble and regression methods had superior PPV. Across cohort types, deep learning consistently delivered high accuracy and generalizability, although with greater PPV variability. Bivariate analysis confirmed that artificial neural networks and random forest models achieved favorable sensitivity–specificity trade-offs. Risk of bias was low to moderate, with most concerns related to patient selection and lack of external validation.

Conclusion

ML models, particularly deep learning and ensemble methods, demonstrate promising accuracy in predicting vasospasm after aSAH. These tools may enable earlier, personalized interventions; however, methodological heterogeneity, limited external validation, and lack of prospective trials currently hinder clinical adoption.

Background

Extracranial-intracranial (EC-IC) bypass surgery is performed to reduce the risk of ipsilateral cerebral infarction in selected patients with chronic intracranial atherosclerotic steno-occlusive disease (ICAD) with reduced cerebral blood flow (CBF). However, postoperative watershed shift induced ischemic stroke (WSIS) may occasionally occur despite maintained bypass patency and improved CBF. We report the incidence and characteristic features of WSIS after superficial temporal artery-middle cerebral artery (STA-MCA) bypass for chronic WSIS.

Methods

We retrospectively analyzed 158 patients with symptomatic chronic ICAD and impaired CBF and cerebrovascular reactivity who underwent STA-MCA bypass between 2013 and 2023. Clinical data and pre- and postoperative imaging findings were analyzed to identify WSIS.

Results

Postoperative bypass patency was 100%. Ischemic complications occurred in 3 of 158 patients (1.9%), all of which were WSIS. Notably, 3 WSIS cases occurred in patients with severe internal carotid artery stenosis. These infarctions occurred on postoperative day 3, despite good bypass patency. Angiography confirmed bypass flow supplied the entire MCA, but anterograde ICA flow was consequently reduced, leading to a hemodynamic shift.

Conclusions

WSIS is a rare (1.9%), but important complication after STA-MCA bypass, occurring in patients who have preserved anterograde flow preoperatively.

Introduction

Cervical disc herniation (CDH) in working-age adults may cause substantial functional impairment. But knowledge is sparse on their transition from primary care to specialist evaluation, and whether regional differences in referral pathways influence management and outcome.

Aim

To examine regional variation in CDH referral pathways, surgical rates, and work capacity outcomes in Denmark’s five healthcare regions.

Methods

Using national registry data, we identified 4,322 individuals aged 18–65 with incident CDH in 2017, defined as the first presentation to specialist health care with no CDH record in the preceding year. Patients were stratified by region and by department type at the first contact (medical, surgical, or emergency) in the specialized health care sector. Work capacity one year prior to diagnosis was categorized as low (< 20%), intermediate (20–80%), or high (≥ 80%) of a standard 37-h work week and followed for two years after the initial contact in the specialized health care sector.

Results

Regional rates of specialized health care contacts for incident CDH were comparable, at 12–13 per 10,000 residents in Denmark aged 18–65 years. Nationally, 1,296 per 10,000 patients seen in specialized health care underwent surgery. However, surgical rates varied markedly between regions, from 793 per 10,000 patients in the Capital Region to 2,320 per 10,000 patients in the North Denmark Region. Nationally, 60.5% of patients were referred to medical departments, 30.7% to surgical departments, and 8.8% to emergency departments, but the pathways differed substantially across the regions of Denmark. The highest surgical rate was observed among those referred through emergency departments, where 95 of 379 referred patients underwent surgery (2,507 per 10,000 patients). In contrast, medical departments evaluated 2,615 patients, of whom 182 received surgery (696 per 10,000 patients), while surgical departments evaluated 1,328 patients, with 283 undergoing surgery (2,132 per 10,000 patients). A total of 87% of patients with high and 83% with intermediate baseline work capacity regained pre-diagnosis work capacity within six months, whereas only 5% of those with low capacity achieved a work capacity of 20% or above within two years.

Conclusion

Although national referral rates for incident CDH with specialized healthcare sector contact are comparable, substantial regional disparities were observed in entry pathways and surgical intervention rates. These findings underscore the need to identify the optimal specialized clinical pathway for CDH patients who are refractory to initial conservative treatment in primary care.

Purpose

Chronic subdural hematoma (CSDH) is a common neurosurgical disease, especially prevalent among the elderly and is associated with reduced life expectancy. This study investigated mortality and causes of death after burr-hole drainage surgery for CSDH.

Methods

We included patients from the FINISH trial, a national, multicenter, randomized study conducted in Finland during 2020–2022. We obtained mortality data from Statistics Finland. For the classification of causes of death, we used the European shortlist of 86 causes, which is derived from the 10th revision of the International Classification of Diseases and Related Health Problems (ICD-10).

Results

Overall, the FINISH trial population included 589 patients (median age 78 years, 28% women). After a median follow-up of 16.4 months (IQR 9.7–23.1), 82 patients (14%) died. The median age at death was 85 years (IQR 81–89), and the median time from surgery to death was 6.5 months (IQR 2.4–15.3). The leading causes of death were circulatory diseases (34%), accidents (16%), and dementia (15%). A higher number of pre-existing comorbidities was significantly associated with increased mortality. In particular, dementia, cardiac arrhythmia, prior cerebrovascular events, and hypertension emerged as significant risk factors for death.

Conclusion

This study provides valuable insights into mortality rates and causes of death among patients undergoing CSDH surgery. The findings underscore the critical role of pre-existing comorbidities in influencing patient outcomes.

Trial Registration

The FINISH trial was registered with ClinicalTrials.gov (NCT04203550) on Dec 16, 2019. The trial is completed.

Purpose

This study aims to investigate the outcome of shunt surgery in patients with idiopathic normal pressure hydrocephalus (iNPH) in relation to age at surgery, using data from the Swedish Hydrocephalus Quality Registry (SHQR). The disease affects older patients, with a mean age at diagnosis of 74 years. Since shunt surgery, which introduces a risk of serious complications, is the only available treatment, appropriate selection of patients eligible for surgery is essential. It has been suggested that higher age negatively affects outcome after shunt surgery.

Methods

Patients operated upon during January 2004–February 2022 were included. The inclusion criteria were: age ≥ 60 years and data available from ≥ 3 domains by the iNPH scale. Clinical outcomes were assessed at 3 and 12 months using the modified version of the iNPH scale (miNPH), the Timed Up-and-Go (TUG) test and the modified Rankin scale (mRS). These were related to 5-year-interval age groups.

Results

Improvement was seen in all age groups, with no statistically significant differences in outcome between age groups in miNPH score, TUG or mRS. The oldest group (> 85 years) showed significant improvements, as illustrated by miNPH scale score changes at 3 and 12 months of 4.3 (–8.1 to 21.5) and 10.1 (–6.5 to 36.8), respectively.

Conclusions

This population-based study shows similarly favourable outcomes across ages, suggesting that there should be no upper age limit for shunt surgery in patients with iNPH.

Background

Navigated transcranial magnetic stimulation (nTMS) is increasingly used in neurosurgical practice for preoperative motor mapping. The resting motor threshold (RMT), a measure of cortical excitability, has been linked to postoperative motor outcomes. However, RMT is influenced by many inter-individual factors, potentially limiting its interpretability. This study aimed to assess the influence of clinical and anatomical variables on RMT variability in neurosurgical patients.

Methods

A total of 642 patients with motor-eloquent brain lesions underwent preoperative nTMS, yielding 1,193 bilateral RMT observations. Variables included age, sex, tumor volume, peritumoral edema, tumor side, skull-to-cortex distance (SCD), recurrence, motor deficits, tumor dominance, handedness, histology, anatomical location, and use of anticonvulsants, benzodiazepines, corticosteroids, or antidepressants. Linear mixed models were applied.

Results

RMT showed substantial inter-individual variability (mean 34 ± 8%, range 15–86%). Higher RMT included smaller peritumoral edema (estimate: -0.01; 95% CI: -0.03, -0.001; p = 0.032), greater SCD (estimate: 0.85; 95% CI: 0.63, 1.09; p < 0.001) and presence of motor deficits (estimate: 2.26; 95% CI: 0.89, 3.64; p = 0.001). Tumors outside the central region were associated with lower RMT (estimate: -1.87; 95% CI: -3.26, -0.47; p = 0.010). Medication analysis revealed that carbamazepine (estimate: 3.82; 95% CI: 0.81, 6.87; p = 0.014), benzodiazepines (estimate: 3.45; 95% CI: 1.11, 5.78; p = 0.004), and corticosteroids increased RMT (estimate: 1.56; 95% CI: 0.03, 3.09; p = 0.049), whereas antidepressants decreased it (estimate: -3.24; 95% CI: -5.90, -0.58; p = 0.019). Other factors showed no statistically significant effect.

Conclusion

This study modeled the influence of clinical and anatomical factors on corticospinal excitability. This highlights the need for consideration of these variables when interpreting intervention-related changes in RMT or for risk stratification. Notably, the detailed analysis of common neurosurgical medications on RMT is unprecedented, emphasizing the importance of considering these factors.