Neurosurgery practice最新文献

Background and importance: This case highlights the effectiveness of endovascular balloon dilatation (percutaneous transluminal angioplasty (PTA)) for treating vasospasm in a radial artery (RA) bypass graft from the internal carotid artery to the M2 branch of the middle cerebral artery in a patient with severe subarachnoid hemorrhage.

Clinical presentation: A 69-year-old woman with severe subarachnoid hemorrhage due to a ruptured giant aneurysm in the ophthalmic segment of the right internal carotid artery underwent an extracranial-intracranial high-flow bypass with a RA graft, followed by trapping of the aneurysm. During her intensive care unit stay, vasospasms developed primarily in the intracranial radial graft and M2 branches. These spasms showed only minimal improvement after standard care and intra-arterial vasospasmolysis with nimodipine. Thus, after systemic anticoagulation, balloon PTA was performed, treating both the intracranial and extracranial sections of the graft, including areas near the anastomosis. The procedure was complication-free, with immediate morphological success and significant improvement in perfusion to the middle cerebral artery territory.

Conclusion: Endovascular balloon PTA should be considered a rescue measure for vasospasm in extracranial-intracranial bypasses, particularly with RA grafts post-SAH. Owing to its muscular structure, the RA graft is especially prone to spasm, potentially compromising graft patency. When pharmacological treatments fail, balloon PTA offers a targeted intervention to restore vessel caliber, stabilizing blood flow and preventing ischemic complications, thus supporting the bypass's long-term success.

Background and objectives: Craniostomies performed at bedside are one of the most important procedures in neurosurgery allowing for cranial access for monitoring of intracranial pressure, evacuation of subdural or epidural hematomas, or the placement of external ventricular drains. Although neurosurgery as a whole has seen rapid advances in its technology, craniostomies continue to be performed with hand crank drill technology similar to what was used in the 1600s. The purpose of this study was to compare the efficacy and safety profile of a novel electrical cranial access drill with autostop technology (ECAD) to that of traditional hand crank drills.

Methods: Using both drills, holes were drilled into the cranial vault of human cadavers by a veteran cranial surgeon and by a medical student without prior experience in the procedure. Time to drill each hole and the number of dural violations was compared between drills.

Results: Overall, 30 craniostomies were created with the hand crank drill and 61 were created with the ECAD. The average time to hole competition was significantly longer with the hand crank drill than with the ECAD (24.1 vs 16.5 seconds, P < .001). There were significantly more dural violations with the hand crank drill than with the ECAD (13 vs 2, P = .002), which engaged autostop in 100% of procedures.

Conclusion: The electric drill with autostop technology demonstrated faster time to hole completion and significantly fewer dural violations than the traditional hand crank drill.

Background and objectives: Cranial trepanation is a fundamental neurosurgical procedure that has evolved significantly with the development of disposable cranial perforators designed to enhance safety and efficiency. The aim of this study was to evaluate and compare the safety, efficiency, and cost-effectiveness of disposable cranial perforators used in neurosurgical procedures.

Methods: A retrospective analysis was conducted on 129 trepanations performed by a single surgeon between May and December 2024, using 3 disposable cranial perforators: Codman (Integra LifeSciences Production Corporation), MERIDIAN (adeor medical AG), and ACRA-CUT (ACRA-CUT Inc.). Clinical parameters assessed included trepanation success rates, operative times, and complication rates. In addition, a cadaveric study examined the impact of varying drilling angles on dural integrity. Structural distinctions among perforators were investigated using digital microscopy.

Results: ACRA-CUT was approximately twice as expensive as Codman and MERIDIAN. Clinically, Codman demonstrated the lowest success rate (69%) compared with MERIDIAN (97.7%) and ACRA-CUT (100%). ACRA-CUT also achieved the shortest median trepanation time (11.8 seconds) compared with Codman (74.6 seconds) and MERIDIAN (26.4 seconds). However, the cadaveric analysis revealed a higher incidence of dural injury with ACRA-CUT at oblique angles. Structural analysis highlighted ACRA-CUT's distinctive acute tip and tri-curved blade design, correlating with its superior performance but an increased risk profile.

Conclusion: ACRA-CUT offers unparalleled efficiency and speed, but its high cost and greater propensity for dural injury at nonperpendicular angles necessitate cautious application. MERIDIAN emerges as a safer choice for routine procedures, whereas Codman, despite being cost-effective, is hindered by its lower success rate and potential for prolonged operative times. Further randomized studies are warranted to validate these findings and optimize perforator selection.

Background and importance: Hemifacial spasm (HFS) is known to be caused by certain activities and, in rare cases, has been shown to be position-dependent. This is the first case of HFS caused in a patient when lying in a prone position that completely resolved after surgical decompression.

Clinical presentation: A 29-year-old female presented with HFS when lying in the prone position. In this case, the trigeminal, facial, and vestibulocochlear nerves were abutted by the anterior inferior cerebellar artery, posterior inferior cerebellar artery, and 2 small vessels. Microvascular decompression resulted in relief from the HFS.

Conclusion: In cases where vessels abut but do not compress the facial nerve, there can still be position-dependent HFS because of position-dependent compression of the facial nerve, which can be relieved by surgical decompression.

Background and importance: A 51-year-old woman with multiple sclerosis (MS) presented for MS management and follow-up, including repeat MRIs. On imaging, a slowly growing enhancing lesion was noted in the left posterior insula. Histopathology reported this tumor as a low-grade mesenchymal neoplasm, not elsewhere classified. The case reported here will add to the library of central nervous system tumors, which may help identify other previously unclassifiable tumors.

Clinical presentation: The lesion was inconsistent with MS plaques, and MRI and computed tomography angiography showed no signs of aneurysm. After evaluation, we recommended surgery to remove the lesion. Surgical excision posed a challenge as the dominant hemisphere posterior insula can be difficult to access. We used a trans-sylvian approach, sparing vasculature within the sylvian fissure with clean excisional margins. The trans-sylvian approach enabled minimal manipulation of brain tissue surrounding the lesion, including the receptive speech center. The patient recovered without complications. Postsurgical follow-up revealed no new neurological symptoms or deficits and no sign of tumor recurrence.

Conclusion: The trans-sylvian approach we used to excise the tumor resulted in a favorable outcome for the patient. This case supports that the trans-sylvian approach, while technically more demanding, is feasible and potentially beneficial.

Background and objectives: We aimed to clarify the association between neurological deterioration pre-endovascular therapy (EVT) and outcome in patients with large-vessel occlusion due to intracranial atherosclerotic disease (ICAD-LVO) undergoing EVT.

Methods: Consecutive patients with acute ischemic stroke due to ICAD-LVO within 24 h of onset who underwent EVT were enrolled in the Japanese multicenter registry from 2017 to 2019. Patients were grouped according to neurological severity transition as follows: mild symptoms (baseline National Institutes of Health Stroke Scale [NIHSS] score <6 and NIHSS score pre-EVT <6), symptom deterioration (baseline NIHSS score <6 and NIHSS score pre-EVT ≥6), and severe symptoms (baseline NIHSS score ≥6 and NIHSS score pre-EVT ≥6). Outcomes included favorable outcomes (modified Rankin Scale [mRS] score of 0-2 at 90 days), ordinal mRS shift, and symptomatic intracranial hemorrhage. Multivariable logistic regression assessed the association of outcomes with the transition of neurological severity by calculating odds ratios and 95% CIs, with mild symptoms as reference.

Results: In total, 480 patients with acute ICAD-LVO who underwent EVT (150 women [31.2%]; median age, 72 years IQR, 66-80) and had median baseline NIHSS score 12 (IQR, 6-20) were analyzed. Patients with symptom deterioration (n = 34) and severe symptoms (n = 375) had lower favorable outcomes (deterioration 38.2% vs mild 62.9%; adjusted odds ratio 0.30, 95% CI 0.09-0.97, severe 35.3%; 0.47, 0.33-0.65) and a significant mRS shift (deterioration vs mild; 3.63, 1.46-9.03, severe; 2.27, 1.74-2.96) than those with mild symptoms (n = 71). Symptomatic intracranial hemorrhage rates did not differ (mild 0%; deterioration 0%; severe 1.9%).

Conclusion: Patients with ICAD-LVO who experienced worsening symptoms were less likely to achieve favorable outcomes after EVT than those with mild symptoms. Early identification of neurological deterioration and EVT intervention may improve outcomes in these patients.

Background and objectives: Subdural hemorrhage (SDH) is a common and potentially devastating intracranial injury routinely treated in neurosurgical practice. There are limited data regarding the mortality rates associated with SDH in older adults. Quantifying SDH-related mortality is crucial, especially considering the potential financial burden from ongoing medical and rehabilitative care associated with SDH morbidity and mortality in the elderly.

Methods: Adults aged 65 years or older in the United States whose deaths attributed to SDH occurred between 1999 and 2020 were extracted from the Centers for Disease Control and Prevention's Wide-ranging Online Data for Epidemiological Research database. Ethnicity and race were divided into exclusive categories as Hispanic or Latino, non-Hispanic Black or African American, or non-Hispanic White. SDH-related age-adjusted mortality rate (AAMR) per 100 000 persons was determined by standardizing the crude mortality rate to the 2000 US population. Overall population and subgroup segmented regression analyses were performed using Joinpoint Regression Program.

Results: Total of 203 295 SDH-related deaths occurred in older adults between 1999 and 2020 (AAMR 22.1 per 100 000 individuals). Of the total deaths, 110 684 (54.4%) were men, 92 611 (45.6%) women, 170 953 (84.1%) non-Hispanic White, 14 654 (7.2%) non-Hispanic Black or African American, and 9656 (4.7%) Hispanic or Latino. Overall AAMR increased from 17.4 in 1999 to 24.6 in 2020 with an average annual percent change of 1.3%; 95% CI (0.9, 1.8). The AAMR had an increase from 1999 to 2005 (annual percent change, 3.4%; 95% CI [2.0, 4.9]) followed by a slower increase from 2005 to 2020 (annual percent change, 0.5%; 95% CI [2.0, 4.9]).

Conclusion: There is an alarming rise in overall SDH-related mortality among the elderly population in the United States, and notable disparities in SDH outcomes across various demographic and geographic sectors continue to exist. Future health interventions aimed at SDH need to address the disparities as highlighted in this study.

Background and importance: Parsonage-Turner syndrome is a rare disorder characterized by sudden onset of severe pain in the upper limb, followed by muscle weakness or atrophy, and remains a challenge for clinicians. Although the etiology remains unknown, surgical identification of nerve torsions and recent advances in diagnostic imaging, particularly high-resolution ultrasound and MRI, have introduced a distinct entity known as hourglass-like constriction (HLC), which may be a manifestation of Parsonage-Turner syndrome. This case report presents the first-known case of HLC involving the brachial plexus in an adult patient.

Clinical presentation: A 66-year-old man developed brachial plexus palsy after arthroscopic rotator cuff surgery, initially manifesting as severe pain and later, after pain relief, progression to paralysis of the deltoid, biceps, and muscles innervated by the radial nerve. Despite initial conservative treatment, minimal recovery was observed at 6 months, which warranted surgery. Exploration showed a severe fibrous thickening of the anterior division was found, revealing an HLC. The unsalvageable nerve portion was resected, and direct suture was performed. Complete recovery of the deltoid nerve (M5) and almost complete recovery of the radial and musculocutaneous nerves (M4+ and M4, respectively) were noted at 30 months.

Conclusion: The case highlights the importance of considering HLC in cases of idiopathic brachial plexus palsy, even when imaging does not exhibit clear torsions. Surgery should be considered especially if there is no spontaneous recovery after 6 months. The choice of surgical technique should depend on the severity of the constriction and the expertise of the surgeon.

Background and objectives: Currently, there are no standardized clinical mapping protocols for monitoring of executive functions during awake glioma surgery, primarily due to a lack of evidence-based data for cognitive mapping. By aligning procedures and documentation practices across institutions, clinicians can overcome the current fragmentation in the field and iteratively work toward generating reproducible, high-quality Data sets that will better clarify the clinical relevance of white matter pathways involved in executive functions. A previously conducted pilot study led to the development of a standardized monitoring protocol and demonstrated that pooling of data is feasible when surgical teams commit to the study requirements. The primary goal of this multicenter study protocol is to investigate whether using this standardized protocol can identify white matter tracts involved in executive functions.

Methods: In this prospective, clinical observational study, we will continue data collection in 4 neurosurgical departments from the previously conducted pilot study and expand to other hospitals providing neurosurgical care. We aim to include adult patients that will undergo awake primary glioma surgery and undergo monitoring of executive functions with a uniform set of tasks for the following white matter tracts: frontal aslant tract, superior longitudinal fasciculus II and II, arcuate fasciculus, inferior fronto-occipital fasciculus. Data will be collected in a standardized manner for each patient before, during, and after surgery.

Expected outcomes: The primary objective of this study was to determine if executive functions can be effectively monitored using a standardized protocol during awake glioma surgery in multiple neurosurgical centers.

Discussion: Despite limitations inherent to multicenter and observational studies, this study represents a necessary step toward developing a validated uniform way of collecting intraoperative findings on mapping of executive functions. The generation of high-quality Data sets is highly needed to extend the scientific basis for monitoring of white matter pathways involved in executive functions.

Background and objectives: Traumatic brain injury (TBI) affects over 69 million people worldwide, most of whom suffer a so-called "mild" injury. Patients with mild TBI, defined as a Glasgow Coma Scale (GCS) of 13-15 on presentation, often have a significant symptom burden as detected by the Rivermead Post-Concussion Questionnaire (RPQ). In this study, we aimed to determine whether social determinants of health (SDOH) may influence patient self-report of symptoms within a month of injury.

Methods: Patients presenting to an academic Level I trauma center with GCS 13-15 were included in the study with data collected as part of a prospectively maintained neurotrauma registry. Overall, 451 individuals completed the RPQ at a follow-up clinic visit. Demographic variables, injury characteristics, comorbidities, and geocoded SDOH information were captured from the electronic medical record. Multivariable regression analysis was performed.

Results: Variables contributing to increased symptom burden on the RPQ included sex, living in an area with a high fraction of poverty, history of depression or anxiety, initial GCS score, history of illicit drug use, obesity, and positive head CT.

Conclusion: In addition to the expected patient and injury characteristics, fraction living in poverty was a significant variable contributing to scores on the RPQ-3 and RPQ-13. Efforts to incorporate screening for SDOH factors should be considered to identify patients at risk of poor recovery after mild TBI.