Acta Neurochirurgica最新文献

Background

The far-lateral approach, frequently employed by skull base surgeons, targets lesions in the ventrolateral region of the craniovertebral junction (CVJ). Although various incisions can be utilized, the linear incision is notably less invasive and more efficient. Despite its advantages, the literature lacks a comprehensive description of the technical steps involved in this approach.

Methods

We discuss the pertinent surgical anatomy and provide a step-by-step intraoperative description of performing the linear incision far-lateral approach, accompanied by clear intraoperative photographs.

Conclusion

The linear incision for the far-lateral approach reduces the extent of soft tissue dissection while having a negligible impact on surgical exposure. Key factors for ensuring the procedure safe and effective include: (1) a comprehensive understanding of the surgical anatomy in the suboccipital region and accurate identification of the midline from this specific position and incision; and (2) employing the “interfascial-subperiosteal-interdural dissection” technique to manage the soft tissues around the CVJ, thereby minimizing the risk of vertebral artery injury.

Background

Perineural tumor spread (PNTS) to the brachial plexus (BP) is a rare and challenging condition. This study aimed to elucidate the clinical presentations, diagnostic challenges, and outcomes of patients with PNTS to the BP.

Methods

We retrospectively reviewed patients diagnosed with PNTS to the BP at our institution between January 2009 and June 2024. Clinical characteristics, magnetic resonance imaging (MRI), ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) findings, and treatment outcomes were analyzed.

Results

Seven patients (mean age, 50.3 years) were identified. The primary cancer diagnoses included invasive ductal carcinoma of the breast (n = 3), metaplastic carcinoma of the breast (n = 1), lung adenocarcinoma (n = 2), and papillary thyroid carcinoma (n = 1). The median time from the initial cancer diagnosis to PNTS symptom onset was 71.0 months. All patients initially presented with progressive unilateral pain or paresthesia, followed by motor weakness. Lower trunk plexopathy was the most common electrodiagnostic finding (n = 5). In most patients, BP MRI showed diffuse tubular enlargement and T2 hyperintensity throughout the BP (n = 6), with gadolinium enhancement primarily in the proximal regions (n = 7). ¹⁸F-FDG PET/CT demonstrated increased uptake in the BP, most prominently at the cervical spinal root or trunk levels (n = 6). Despite treatment, neurological outcomes were generally poor. Six of the seven patients died after a median follow-up of 19 months post-PNTS diagnosis.

Conclusions

PNTS to the BP can occur years after initial cancer diagnosis and may signify cancer progression. A high index of suspicion is crucial for timely diagnosis, particularly in patients with cancer and progressive upper extremity symptoms. Comprehensive imaging, including BP MRI and PET/CT, is essential for diagnosis. Despite treatment, prognosis remains poor, highlighting the need for improved diagnostic and therapeutic strategies.

Background

Pituitary adenomas (PAs) often require adjuvant Gamma Knife radiosurgery (GKRS) due to partial resection or postoperative recurrence. The purpose of this study was to evaluate the long-term efficacy of GKRS for such cases.

Methods

Population-based, observational cohort study of patients who underwent GKRS for postoperative residual or recurrent PAs between 1999 and 2020. We assessed long-term progression-free survival (PFS), identified predictors of tumor growth, and documented adverse radiation events (AREs).

Results

147 patients were included, with a median follow-up time of 8.1 years. Following GKRS, the 5-year and 10-year PFS was 86% and 68%, respectively, with a median PFS of 18.7 years. Somatotrophic adenomas showed a significantly lower risk of tumor progression in the regression analysis (OR 0.11, p = 0.003). Hypopituitarism was the most common ARE, affecting 32% of patients.

Conclusion

GKRS is an effective treatment option for recurrent or residual PAs, offering substantial long-term control. However, the risk for AREs, particularly hypopituitarism, is not negligeable.

In recent years, knowledge about cerebrospinal cavernomas has grown considerably, leading to the development of initial guidelines and treatment recommendations. However, due to the rarity and heterogeneity of the disease, the level of evidence remains limited, leaving many questions unanswered and subject to ongoing debate. Therefore, an up-to-date review of this field's latest developments and controversies is reasonable.

Objective

Before commonly used targets such as the Retrogasserian Zone (RGZ) and the Root Entry Zone (REZ) were adopted for the radiosurgical treatment of trigeminal neuralgia (TN), a more anterior target involving the Gasserian ganglion was used. Thanks to advancements in imaging technology, it is now possible to identify and target separate nerve divisions in Meckel’s Cave as desired. Although this approach has been mentioned previously, no clinical study has investigated it until now. This study aims to fill this gap in the literature.

Methods

Trigeminal neuralgia patients who received radiosurgical treatment between February 2019 and June 2022 in a single centre were included in the study. Pain relief, medication dependency and side effect profiles of the investigated anterior selective target (AST) were compared to those of the classical targets at 1 week, 1–3-6 months, and 1 year.

Results

A total of 66 patients were included in the study. Effectiveness, safety and application convenience parameters were compared between; the REZ (n = 21), RGZ (n = 20) and AST (n = 25) groups. All groups showed significant improvement in pain with similar results to each other. AST treatments were performed in significantly shorter beam-on-times and with significantly lower brainstem doses.

Conclusions

The investigated AST showed comparable results to the classical targets without any indication of superiority or inferiority in terms of efficacy and safety in this preliminary investigation. As no blocks were needed to protect the brainstem with this method, it can be used for select patients as needed and could even be investigated in larger studies as an alternative approach.

Purpose

Grade 3 meningiomas, although rare, are associated with high morbidity and mortality. The respective impacts of extent of surgical resection and adjuvant radiotherapy are still debated. Moreover, anaplastic meningiomas are studied in heterogenous cohort of de novo and progressive anaplastic tumors.

Methods

We conducted a retrospective multicentric study on patients operated from a de novo anaplastic meningioma between 1999 and 2021. A centralized pathological review using 2016 WHO criteria was performed for all cases. Patients with history of radiotherapy or NF2-related Schwannomatosis were excluded.

Results

Sixty-five patients were included in the study. Median progression free survival was 23 months and median overall survival was 2 years. Neither quality of resection nor adjuvant radiotherapy alone were predictive of better overall survival. Progression free survival were impacted by combination of gross-total resection and adjuvant radiotherapy (HR = 0.47 CI95% = [0.24–0.92], p = 0.027) and age at diagnosis (HR = 2.92 CI95% = [1.38–6.21], p = 0.005) in univariate analyses. Within anaplastic tumors, those graded on mitosis number had a poorer prognosis than those graded on overt anaplasia. Among anaplastic tumors with high mitotic score (> 20/10HPF), progression free survival were impacted by postoperative radiotherapy (HR = 0.44 CI95% = [0.22–0.88], p = 0.020) and gross total resection and adjuvant radiotherapy association (HR = 0.44 CI95% = [0.21–0.90], p = 0.024) in univariate analyses.

Conclusion

Simpson grade didn’t show any impact on overall survival. Gross total resection + adjuvant radiotherapy favorably impacted progression free survival in our cohort of de novo anaplastic meningiomas.

Background

This study compares Selective Amygdalohippocampectomy (SAHE) and Anterior Temporal Lobectomy (ATL) for temporal lobe epilepsy (TLE), focusing on seizure control and visual field deficits (VFD). While previous research suggests potential benefits of SAHE, this meta-analysis aims to clarify the comparative effectiveness of bothprocedures.

Methods

This study adhered to PRISMA guidelines, comparing seizure outcomes and VFDs between SAHE and ATL for temporal lobe epilepsy. Comprehensive data extraction and meta-analysis revealed comparable efficacy, with SAHE potentially offering advantages in VFD risk reduction. Quality assessment ensured methodological rigor.

Results

29 studies comparing SAHE and ATL for TLE. Seizure freedom analysis encompassed 23 studies (n = 3238), showing no significant difference between SAHE and ATL (RR = 0.96, 95% CI = 0.89–1.03, P = 0.26). SAHE exhibited significantly lower visual field deficits (RR = 0.87, 95% CI = 0.78–0.97, P = 0.01). Subgroup analyses highlighted differences between transsylvian SAHE and ATL but not transcortical SAHE. No significant difference was found in seizure freedom between SAHE and ATL in patients with hippocampal sclerosis.

Conclusions

ATL is more effective than transsylvian SAHE in achieving seizure freedom. However, no significant difference in seizure freedom was observed between transcortical SAHE and ATL. There were no notable differences in seizure outcomes between the two techniques in patients with hippocampal sclerosis. In contrast, SAHE carries a lower risk of postoperative visual field deficits compared to ATL.

Background

Idiopathic normal pressure hydrocephalus (iNPH) is characterized by cerebrospinal fluid circulation disorders, and presents as gait and balance disturbances similar to those observed in other incurable neurological diseases. Although previous studies have reported deficits in bimanual coordination among patients with iNPH, these potential pathological characteristics have not received much attention to date. This study investigated the temporal characteristics of a bimanual finger-tapping task in patients with iNPH, focusing on within- and between-hand coordination.

Methods

Study participants comprised three groups: patients with iNPH (N = 19, mean age = 76.9 ± 5.6 years), older adults (N = 19, 76.4 ± 5.3 years), and younger adults (N = 13, 32.2 ± 8.5 years). Participants performed a bimanual finger-tapping task under five conditions that manipulated the temporal differences between the two taps.

Results

The iNPH group exhibited significantly greater errors in both within- and between-hand coordination tasks compared to the other two groups.

Conclusion

These results suggest that assessing temporal errors in bimanual coordination tasks, particularly within-hand coordination, may be useful for uncovering pathological characteristics specific to iNPH.

Laser interstitial thermal therapy (LITT) is a minimally invasive surgical treatment for drug-resistant, focal epilepsies. With MRI guidance, LITT can also be used to treat hypothalamic hamartoma. Here, we report on the first European case of LITT for hypothalamic hamartoma. No complication occurred except a transitory peripheral facial paralysis. The short- and long term outcomes (for both epilepsy and cognitive development) were excellent.

Objective

This study aimed to identify predictive factors for cerebral infarction after bypass surgery in adult patients with moyamoya disease (MMD) using quantitative parameters in 4D-CT perfusion software.

Methods

A total of 108 patients who underwent combined revascularization, including superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and encephalo-duro-myo-synangiosis (EDMS), in our hospital between September 2019 and August 2023 were analyzed retrospectively. Preoperative relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), relative mean transit time (rMTT), and relative time to maximum residual function (rTmax) perfusion parameters were obtained using 4D-CT perfusion software. These quantitative parameters, combined with related clinical and angiographic factors, were statistically analyzed using univariate and multivariate regression analyses to determine the significant predictors of cerebral infarction after bypass surgery.

Results

Acute cerebral infarction occurred in 12 patients postoperatively. Univariate analysis showed that a history of previous ischemic events (P = 0.024), higher Suzuki stage (P = 0.006), higher modified Rankin score (mRS) (P = 0.013), rCBV (P = 0.026), rMTT (P = 0.001), and rTmax (P < 0.001) were associated with postoperative cerebral infarction. Further multivariate regression analysis showed that a history of previous ischemic events (OR = 12.830, 95%CI = 1.854–875.672, P = 0.031) and higher rTmax (OR = 16.968, 95%CI = 2.035–141.451, P = 0.009) were independently associated with new postoperative cerebral infarction. The cutoff value for rTmax was 2.025 (AUC = 0.935).

Conclusions

Previous ischemic event history and rTmax greater than 2.025 are independent risk factors for predicting cerebral infarction after combined revascularization with high sensitivity in adult patients with MMD. These patients should be more cautious when deciding on combined revascularization.