Neurocirugia (English Edition)最新文献

Purpose of the study

A prospective, randomized, double-blind study was designed to assess differences in brain relaxation between 20% mannitol and 3% hypertonic saline (HS) during elective supratentorial brain tumour surgery in patients with midline shift.

Material and methods

Sixty patients undergoing supratentorial craniotomy for tumour resection were enrolled to receive either 5 mL/kg of 20% mannitol (n = 30) or 3% HS (n = 30) administered at skin incision. P_CO2 in arterial blood was maintained within 35–40 mmHg and arterial blood pressure was controlled within baseline values ±20%. The primary outcome was the proportion of satisfactory brain relaxation. The surgeon assessed brain relaxation on a four-point scale (1 = excellent with no swelling, 2 = minimal swelling, 3 = serious swelling not requiring treatment, 4 = severe swelling requiring treatment). Postsurgical intracranial changes determined by imaging techniques, postoperative complications, PACU and hospital stay, and mortality at 30 days were also recorded. Appropriate statistical tests were used for comparison; P < 0.05 was considered as significant. This trial was registered in Eudract.ema.europa.eu (#2021-006290-40).

Results

There was no difference in brain relaxation: 2.00 [1.00–2.00] and 2.00 [1.75–3.00] for patients in mannitol and HS groups, respectively (P = 0.804). Tumour size (OR: 0.99, 95% CI: 0.99–1.01; P = 0.371), peritumoral oedema classification (OR: 0.57, 95% CI: 0.11–2.84; P = 0.493), mass effect (OR: 0.86, 95% CI: 0.16–4.87; P = 0.864), anaesthesia (OR: 4.88, 95% CI: 0.82–28.96; P = 0.081) and midline shift (OR: 5.00, 95% CI: 0.84–29.70; P = 0.077) did not have a significant influence on brain swelling in patients treated with either mannitol or HS. No significant differences in perioperative outcomes, mortality and length of PACU and hospital stay were observed.

Conclusions

5 mL/kg of 20% mannitol or 3% HS result in similar brain relaxation scores in patients undergoing craniotomy for supratentorial brain tumour with midline shift.

Brain metastases are tumors that arise from a tumor cell originated in another organ reaching the brain through the blood. In the brain this tumor cell is capable of growing and invading neighboring tissues, such as the meninges and bone.

In most patients a known tumor is present when the brain lesion is diagnosed, although it is possible that the first diagnose is the brain tumor before there is evidence of cancer elsewhere in the body.

For this reason, the neurosurgeon must know the management that has shown the greatest benefit for brain metastasis patients, so treatments can be streamlined and optimized.

Specifically, in this document, the following topics will be developed: selection of the cancer patient candidate for surgical resection and the role of the neurosurgeon in the multidisciplinary team, the importance of immunohistological and molecular diagnosis, surgical techniques, radiotherapy techniques, treatment updates of chemotherapy and immunotherapy and management algorithms in brain metastases.

With this consensus manuscript, the tumor group of the Spanish Society of Neurosurgery (GT-SENEC) exposes the most relevant neurosurgical issues and the fundamental aspects to harmonize multidisciplinary treatment, especially with the medical specialties that are treating or will treat these patients.

Cerebrospinal fluid (CSF) shunt placement is a commonly performed procedure for patients with hydrocephalus of various etiologies.

We present the case of a 68-year-old male patient treated with a ventriculoperitoneal shunt for obstructive hydrocephalus management. Eight years later, a computed tomography (CT) scan detected migration of distal catheter into the pulmonary artery. We conducted a systematic review in Medline database using PubMed search engine to identify previous cases and their management. Our literature review identified eighteen single case reports describing this complication and different strategies to attempt catheter retrieval. To the best authors’ knowledge, this is the first case where conservative management was chosen.

Objectives

To evaluate the efficacy of treatment with linear accelerator-based stereotactic radiosurgery (LINAC) in cerebellopontine angle meningiomas.

Methods

We analyzed 80 patients diagnosed with cerebellopontine angle meningiomas between 2001 and 2014, treated with stereotactic radiosurgery (SRS), of whom 81.9% (n = 68) were women, with an average age of 59.1 years (32–79). SRS was applied as primary treatment in 83.7% (n = 67) and in 16.3% (n = 13) as an adjuvant treatment to surgery. SRS treatment was provided using LINAC (Varian 600, 6 MeV) with M3 micromultilamines (brainLab) and stereotactic frame. The average tumor volume was 3.12 cm³ (0.34–10.36 cm³) and the coverage dose was 14 Gy (12–16 Gy). We performed a retrospective descriptive analysis and survival analysis was performed with the Kaplan–Meier method and multivariate analysis to determine those factors predictive of tumor progression or clinical improvement.

Results

After an average follow-up period of 86.9 months (12–184), the tumor control rate was 92.8% (n = 77). At the end of the study, there was an overall reduction in tumor volume of 32.8%, with an average final volume of 2.11 cm³ (0–10.35 cm³). The progression-free survival rate at 5, 10 and 12 years was 98%, 95% and 83.3% respectively. The higher tumor volume (p = 0.047) was associated with progression. There was clinical improvement in 26.5% (n = 21) of cases and clinical worsening in 16.2% (n = 13). Worsening is related to the radiation dose received by the brainstem (p = 0.02). Complications were 8.7% (7 cases) of hearing loss, 5% (4 cases) of brain radionecrosis, and 3.7% (3 cases) of cranial nerve V neuropathy. Hearing loss was related to initial tumor size (p = 0.033) and maximum dose (p = 0.037). The occurrence of radionecrosis with the maximum dose (p = 0.037).

Conclusions

Treatment of cerebellopontine angle meningiomas with single-dose SRS using LINAC is effective in the long term. Better tumor control rates were obtained in patients with small lesions.

Pituitary tumors (PT) account for 15% of intracranial tumors affect 10.7–14.4% of the population although the incidence of clinically relevant PT is 5.1 cases/100,000 inhabitants. Surgical treatment is indicated in PTs with hormone hypersecretion (except for prolactin-producing PTs) and those with local compressive or global neurological symptoms. Multidisciplinary care, is essential for patients with PTs, preferably delivered in a center of excellence and based on a well-defined care protocol. In order to facilitate and standardize the clinical procedures for this type of tumor, this document gathers the positioning of the Neuroendocrinology Knowledge Area of the Spanish Society of Endocrinology and Nutrition (SEEN) and the Spanish Society of Neurosurgery (SENEC) on the management of patients with PTs and their preoperative, surgical and postoperative follow-up.

Objective

The purpose of this study is to analyze a series of patients with intradural extramedullary tumors (IDEM) and assess factors that may modify or determine the final long term outcome and management.

Materials and methods

Single Center, retrospective study of a series of surgical patients with IDEM lesions from our Institution operated between 2010 and 2021. Patients with less than 6 months of follow up were excluded. Several preoperative demographics, clinical, imaging and surgical features, as well as histopathology, recurrence and adjuvancy were assessed. Patients’ final clinical outcome was categorized using the McCormick scale.

Results

A total of 203 patients with a mean follow-up of 30.50 months (range 6–130) were included. 57.64% of the analyzed population was female and the mean age was 50.51 years.

The most frequent location of the tumors was dorsal (34.98%) followed by the lumbar region (32.02%). Total resection was achieved in 84.24% of cases, and the most frequent histopathology was Schwannoma (36.45%), followed by Meningioma (30.05%). Pain was the most usual initial symptom (63.05%).

In our analysis, functional outcome after surgery was associated with statistical significance with preoperative McCormick grade, tumor type, EOR and postoperative complications such as hematoma and sphincter involvement.

Conclusion

The management of these lesions depends on many factors. It is worthy of mention that clinical presentation, EOR, histopathology and postoperative complications have shown significant prognostic value for the final outcome. Early treatment with the intention of achieving GTR when possible, using carefully tailored approaches, should be considered before the onset of significant symptoms.

Background and objective

Intraoperative neurophysiological monitoring allows us to predict the functional status of the facial nerve after vestibular schwannoma surgery. Due to the great variability of the neurophysiological protocols used for it, the goal of this study is to determine the prognostic ability of our neurophysiological protocol.

Material and methods

We have performed a statistical analysis of the neurophysiological monitoring data collected from patients operated between March 2009 and July 2021 at the Neurosurgery Service of Salamanca according to their functional status, both in the immediate post-surgical period and one year after surgery.

Results

A number of 51 patients between 46 and 63 years old (median: 54) were analyzed. We have found significant differences studying the threshold value of the stimulation intensity of the facial nerve and the variation of the Cortico-bulbar Evoked Motor Potentials (P = 0.043 and P  = 0.011, respectively) between the patients with good and bad clinical situation after surgery. The most discriminating intensity threshold value was 0.35 mA (Sensitivity: 85%; Specificity: 48%). No statistical relationship was found in the study group one year after surgery.

Conclusions

Our intraoperative monitoring protocol allows us to predict the clinical situation of patients in the immediate postoperative period and improve information for the patient and her relatives after surgery. We cannot, however, use these parameters to predict the functional situation one year after surgery and make clinical decisions in this regard.

Background

Traditionally, most centers would use microelectrode recording (MER) to refine targeting in deep brain stimulation (DBS) surgery. In recent years, intraoperative imaging (IMG) guided DBS has become an alternative way to verify lead placement. Currently, there is still controversy surrounding the necessity of MER or IMG for DBS. This meta-analysis aims to explore lead accuracy, clinical efficacy and safety between IMG and MER guided DBS for Parkinson's disease (PD).

Methods

PubMed, Embase, Web of Science, Cochrane Library were searched up to Mar, 2021 for studies reporting comparisons between IMG and MER guided DBS for PD. Subgroup analysis was conducted to assess effects of different IMG technology and DBS targeting site.

Results

Six studies, comprising of 478 patients were included in our analysis. The mean difference between the two implantation techniques in stereotactic accuracy, lead passes per trajectory, improvement% of Unified Parkinson's Disease Rating Scale part III and levodopa equivalent daily dose were −0.45 (95% confidence interval, CI = −1.11 to 0.20), −0.18 (95% CI = −0.41 to 0.06), 3.40 (95% CI = −5.36 to 12.16), and 5.00 (95% CI = −1.40 to 11.39), respectively. No significant differences were observed in each adverse event and operation/procedure time between the two implantation techniques.

Conclusions

Both IMG and MER guided DBS offered effective control of motor symptoms for PD. Besides, IMG guided is comparable to MER guided DBS, in terms of safety, accuracy and efficiency. It is recommended for each hospital to select DBS guidance technology based on available resources and equipment.

Objective

Although the putamen is the most common area of spontaneous intracerebral hemorrhage, previous reports about the effects of surgery are limited. We sometimes experience a poor prognosis in patients in whom there is no damage to the internal capsule, but with injury in the long insular artery (LIA) region. The purpose of this study was to confirm the relationship between LIA damage and patient prognosis following surgery for putaminal hemorrhage.

Methods

We retrospectively collected data of 287 surgical cases who presented with putaminal hemorrhage between January 2004 and March 2022. Among them, we chose patients without initial damage to the posterior limb of the internal capsule, and divided these patients into two groups, those without (Group A) and with (Group B) final damage in the LIA region. We compared positivity rates of final manual muscle test (MMT) scores ≥ 3 and related factors.

Results

Sixty-three of the 287 patients were included in this study. Of them, 11 cases in Group A were positive for MMT scores ≥ 3 (68.8%) and 9 cases (19.1%) in Group B had MMT scores ≥ 3 seven days after surgery. Group A thus had a significantly higher rate of MMT scores ≥ 3 than group B (p = 0.00).

Conclusion

In patients without initial damage to the internal capsule, LIA injury might be a key sign for predicting the functional prognosis of putaminal hemorrhage.