Neurosurgery practice最新文献

Background and objectives: Although the characteristics of osseous shunted pouches of cavernous sinus (CS) arteriovenous fistula (AVF) have recently been a focus of investigation, few studies have reported details of CS AVF possessing nonosseous shunted pouches. We therefore compared detailed characteristics between osseous and nonosseous AVFs in the CS.

Methods: A total of 31 patients who underwent rotational angiography in our department between 2012 and 2023 were reviewed. We divided anatomical shunted pouches into 3 types: extraosseous, intraosseous, and mixed. We analyzed and compared characteristics and treatment results between types.

Results: Of the 31 CS AVF patients, 14 showed extraosseous type, 10 showed mixed type, and 7 showed intraosseous type. The mean ages of patients with these types were 70.0 ± 7.9 years, 73.6 ± 8.5 years, and 76.9 ± 5.3 years, respectively, showing no significant differences. However, when limited to female patients, the mean ages were 68.3 ± 6.0 years, 75.1 ± 3.4 years, and 76.9 ± 5.3 years, respectively, showing significant differences among types. The number of single shunts was significantly lower with mixed type, and the incidence of cortical venous reflux was significantly lower with extraosseous type. Ten cases of extraosseous type (71%), 7 cases of mixed type (70%), and 5 cases of intraosseous type (71%) were treated with selective transvenous embolization of the shunted pouch. Ten extraosseous-type cases (71%), 5 mixed-type cases (50%), and 6 intraosseous-type cases (86%) were completely occluded by embolization.

Conclusion: Restricted to women, high age was significantly associated with intraosseous-type CS AVF. Although significant differences were evident in the number of shunted pouches and incidence of cortical venous reflux among groups, treatment method did not depend on the type of CS AVF.

Background and objective: Birth defects occur more often in low-income and middle-income countries. This study delineates the epidemiology of myelomeningocele (MMC) patients presenting to the Bernard Mevs Hospital (HBM) in Haiti.

Methods: Pediatric patients with MMC at HBM between 2018 and 2022 were reviewed, and statistical analyses were performed.

Results: The study included 54 spina bifida patients with a mean age of 1.2 ± 2.4 months, predominantly male (64.8%, n = 35). The prevalence from 2018 to 2022 was approximately 0.4 cases per 10 000 live births. Half of the patients (50.0%, n = 27) had a birth weight of 2500 to 4000 g. Hydrocephalus was commonly associated, present in 55.6% (n = 30) of patients. Lumbar defects were most frequent, found in 63% (n = 34) of cases. The average hospital stay was 31.3 ± 43.5 days, with 94.4% (n = 51) showing clinical improvement; there were 3 deaths (5.6%). Regarding timing of intervention, 25.9% (14/54) underwent early repair and 74.1% (40/54) late repair. Hydrocephalus was present in 64.3% of the early group and 52.5% of the late group (P = .652). Favorable postoperative results were slightly lower in the early group (85.7% vs 97.5%, P = .328). Folate supplementation was reported in 44.4% (n = 24) of mothers, and unemployment was common among parents, with 42.6% of mothers and 31.5% of fathers being unemployed.

Conclusion: The study highlights the epidemiology of MMC at HBM, with a high prevalence of hydrocephalus and lumbar defects. Shorter postoperative stays were linked to better outcomes. The findings highlight the need for improved prenatal care, folate supplementation, and addressing socioeconomic challenges to improve outcomes.

Background and objectives: Diversity, equity, and inclusion (DEI) are increasingly relevant in academic neurosurgery and workforce recruitment. This study assessed DEI statements and initiatives available on US neurosurgery residency program (NRP) websites, recognizing this as one objective measure of DEI efforts.

Methods: NRP websites were identified and selected based on defined inclusion and exclusion criteria. Websites were examined for DEI statements, dedicated DEI language, information about current residents and faculty, disability assistance, and subinternships and residency interviews financial support.

Results: Among 110 eligible websites, 35 NRPs (32%) mentioned DEI on their home page or mission statement. Of these, 24 programs (22%) had a specific diversity statement. Gender, race, and ethnicity were mentioned in 13 (54%), 11 (46%), and 8 statements (33%), respectively. Disability, sexual orientation, LGBTQ+, and minority statuses were noted in 5 (21%), 8 (33%), 2 (8%), and 2 statements (8%). Among the 86 programs without a diversity statement, 11 (13%) mentioned DEI, 2 (2%) discussed gender, 2 (2%) mentioned disability and gender, and 1 (1%) covered race, ethnicity, LGBTQ+, and minority statuses. Eight programs (7.2%) offered scholarships for visiting fourth-year students, but none provided financial support for residency interviews.

Conclusions: Dedicated DEI statements and initiatives available on NRP websites represent a tangible metric of DEI representation in neurosurgery. Our study showed substantial variation in the depth and specificity of DEI representation on NRP websites and provides a benchmark on this topic. Strategies aimed at enhancing DEI representation might enhance the future success of diversification of the neurosurgery workforce.

Neurosurgery has experienced significant growth over the past century, but much of that development has been centralized in Europe and North America. Despite their high burden of neurosurgical conditions, African countries like The Gambia continue to face barriers in accessing neurosurgical care. We intend to accentuate the barriers to neurosurgical care in The Gambia, elucidate pragmatic ways of improving this issue, and highlight models of sustainable neurosurgical development that have been used in similar lower- and middle-income countries. Our study analyzed the limited literature available on The Gambia's neurosurgical capabilities, disease burden, and outcomes. The keywords "Gambia" and "Neurosurgery" were searched on PubMed, from inception to July 1, 2024. Then, a complementary search was performed on Google using the keywords "The Gambia," "Healthcare," "Neurosurgery," and "Africa." The pertinent data from our search were collected and composed into a review. Neurosurgery in The Gambia is still in its infancy. Although several domestic general surgeons and a few visiting neurosurgeons have performed neurosurgical procedures in the past, the country did not have a designated neurosurgical department until 2018. Although neurosurgical activity has ramped up in The Gambia recently, the country continues to trail behind both regionally and internationally in neurosurgical care capacity. While the shortage of a neurosurgical workforce is the core of this issue, paucity of neurosurgical research and training and the limited availability of neuroimaging also amplify this problem. Neurosurgery in The Gambia is plodding because of workforce shortage, paucity of research, and inadequate neuroimaging. Eradicating these barriers would be salient in attaining sustainable neurosurgical development. With the devotion of the local team and the philanthropic efforts of international partners, The Gambia can experience similar advances seen in other lower- and middle-income countries.

Background and objectives: The purpose of this systematic review was to provide a comprehensive overview of the available literature on 5-aminolevulinic acid (5-ALA)-induced protoporphyrin IX (PpIX) fluorescence-guided surgery (FGS) for the resection of brain metastases (BMs).

Methods: A comprehensive search of the PubMed database for literature on 5-ALA use in BMs surgery was performed. For inclusion, BMs studies had to have data on the observed intraoperative fluorescence available. Additional data categories included the number of metastatic tumors, 5-ALA dosage and timing, the imaging system (eg, microscope) used, imaging wavelength(s), fluorescence grading ("simple" and "detailed"), fluorescence consistency (heterogeneous vs homogeneous), intracranial tumor location, metastatic primary tumor location, and extent of resection, among others.

Results: Twenty-three articles published between 2007 and 2022 met the inclusion criteria. These studies comprised 1709 total patients; 870 metastatic samples were collected from 855 patients with 377 (43.3%) fluorescence-negative and 493 (56.7%) fluorescence-positive samples. The pooled overall prevalence of fluorescence-positive metastatic lesions was 66% (95% CI 55%-75%; I² = 85%, P < .01). The fluorescence grading was as follows: (a) simple fluorescence (n = 599): 295 (49.3%) fluorescence-negative and 304 (50.8%) fluorescence-positive samples and (b) detailed fluorescence (n = 271): 82 (30.3%) no fluorescence, 107 (39.5%) weak fluorescence, and 82 (30.3%) strong fluorescence. A total of 764 lesions had primary tumor site data available: 702 lesions had fluorescence data with 384 (54.7%) fluorescence-positive samples.

Conclusion: FGS using 5-ALA/PpIX in BMs demonstrates varying benefits as an adjunct for maximizing the extent of resection. Thus, preoperative knowledge of the primary tumors' origin may inform surgeons regarding the potential utility of 5-ALA/PpIX for FGS management of BMs.

Background and objectives: Spontaneous intracerebral hemorrhage (sICH) carries a high mortality and morbidity burden, with multiple factors influencing outcomes. The aim of this study was to identify the predictors of in-hospital outcomes for patients with sICH at a tertiary hospital in Ghana.

Methods: In this retrospective study, approved by the Institutional Review Board, adult patients with sICH at the University of Ghana Medical Centre between 2021 and 2023 were reviewed to characterize the association between sociodemographics, clinical features, and management strategies to in-hospital outcomes. Based on in-hospital outcomes, patients were categorized into "mortality" and "survival" groups. Statistical analyses were performed using Wilcoxon rank sum, χ², and logistic and Cox regression to identify predictors of mortality and time to mortality.

Results: Among the 168 patients, 71 (42.3%) died, with a male predominance in both groups (60.6% and 70.1%, respectively). Altered level of consciousness was more common in mortality cases (70.4% vs 45.4%, P = .002). The average Glasgow Coma Scale (GCS) score at presentation was lower in the mortality group (8.19 vs 12.5, P < .001). Patients who died had a higher initial systolic blood pressure (SBP) (179 vs 163 mm Hg, P = .004). Imaging showed a mean hematoma volume of (35.2 mL vs 22.7 mL, P = .112). Intraventricular extension was present in (69.7% vs 50.5%, P = .024). Predictors of in-hospital mortality were intraventricular extension (odds ratio: 2.18, 95% CI: 1.13-4.19, P = .019), management complications (OR: 10.76, 95% CI: 3.99-29.06, P < .001), and increasing mean SBP (OR: 1.02, 95% CI: 1.00-1.03, P = .023). Independent predictors of earlier time to mortality were a drop in GCS (hazard ratio: 3.28, 95% CI: 1.86-5.80, P < .001) and increasing ICH score (hazard ratio: 1.51, 95% CI: 1.24-1.85, P < .001).

Conclusion: Predictors of in-hospital mortality included intraventricular extension, management complications, changes in GCS, and increasing SBP. Identifying and mitigating these factors, along with implementing rapid intervention protocols, are essential for improving outcomes in patients with sICH.

Background and importance: Basilar artery fenestration aneurysms (BAFAs) present significant clinical challenges because of their high rupture risk and complex anatomy. Comprehensive management strategies are required, including thorough vascular assessment and post-treatment surveillance. Integration of complementary analyses such as computational fluid dynamics (CFD) holds promise in facilitating preoperative planning for these intricate lesions.

Clinical presentation: A 60-year-old female was diagnosed with a BAFA during evaluation for headaches. Digital subtraction angiography revealed the aneurysm projecting posteriorly with a neck predominantly based on the right limb of the fenestration. After initial treatment with a pipeline embolization device, the aneurysm remained patent, requiring further treatment. A secondary approach with stent-assisted loose-packing coil embolization was then performed, resulting in complete occlusion of the aneurysm. Analysis of pretreatment 3-dimensional rotational angiogram images with CFD provided critical hemodynamic insights. It identified that 38.89% of the aneurysm area was exposed to low wall shear stress (WSS) and 11.5% was exposed to high WSS, indicating a high rupture risk profile with significant areas of both low and high WSS. In addition, low WSS was observed in regions corresponding to daughter sacs, suggesting a higher rupture risk. Streamline analysis indicated increased inflow through the right vertebral artery and the right limb of the fenestration, supporting the initial angiographic impression and guiding the choice of therapeutic strategy.

Conclusion: This is the first study to analyze the morphology and pretreatment hemodynamics of a BAFA using CFD, illustrating the potential for future development of individualized therapeutic approach-based CFD in complex aneurysms.

Background and objectives: In patients treated with stereotactic radiosurgery (SRS) for brain metastases, follow-up imaging demonstrating progression may result from treatment effect/radionecrosis (RN) or tumor progression. We report long-term outcomes for a cohort of patients who demonstrated radiological progression on serial imaging after initial radiation and who underwent resection, at which point histology informed further management.

Methods: A retrospective chart review identified 76 patients with an associated 82 brain lesions between 2009 and 2022, that were initially treated with SRS, and then demonstrated suspicious imaging developing through at least 2 scan time points with either pathologic confirmation of tumor or RN.

Results: Of the 82 lesions, 55 lesions (67.1%) were found to be tumor and were treated with repeat radiation and 27 (32.9%) were found to have pathologically confirmed RN and conservatively managed. 14/27 lesions ultimately found to be radionecrotic required steroids preoperatively due to neurological symptoms. None of these lesions required further intervention with median postsurgery follow-up of 24.4 months (range 1-104 months). There were 55 instances (in 51 patients) of confirmed recurrent/progressive tumor who we treated with repeat aggressive radiation with either Cs-131 brachytherapy (12 [21.8%]) or SRS (43 [78.2%]). Among patients treated with reirradiation, the median follow-up to local failure was 15.2 months (95% CI 7.3-26.6 months). The 2-year local control rate was 79.5% (95% CI 68.3%-92.5%).

Conclusion: These results support resection of radiosurgery-treated lesions with progression continuing through serial imaging, and this pathology-informed management results in excellent control of both RN and tumor progression after radiosurgery.

Background and importance: The case describes the management of a giant and recurrent aneurysm in a patient. The treatment involved a combination of microsurgical protective low-flow, followed by high-flow revascularization and parent artery occlusion.

Clinical presentation: The patient presented with severe headaches and progressive visual impairment. Brain magnetic resonance imaging revealed a giant saccular intracranial aneurysm in the left internal carotid artery. The examination also revealed hypoplasia of the right anterior cerebral artery and a fetal-type left posterior cerebral artery originating from the neck of the aneurysm. Considering the location and size of the aneurysm, a combination of endovascular and microsurgical approaches was applied. A protective low-flow procedure was followed by high-flow revascularization and occlusion of the parent artery. After 12 months, the aneurysm recanalized through the graft. To address the recurrence of giant complex aneurysms, endovascular embolization was performed through the radial artery grafts. These interventions showed positive midterm outcomes for the patient's giant aneurysm.

Conclusion: In the treatment of complex giant aneurysms, it is important to consider both endovascular and microsurgical approaches as complementary, rather than mutually exclusive. Endovascular embolization using radial artery grafts may be used when dealing with retrograde recanalization and the challenges associated with accessing the aneurysm.

Background and objectives: Neurosurgical management of idiopathic intracranial hypertension (IIH) can be challenging given high rates of revision associated with cerebrospinal fluid shunting. In this study, we present a technical report and early outcomes for lumbocaval shunt (LCS) placement in difficult-to-manage cases.

Methods: A literature search was performed for previous reports of LCS or lumboatrial shunt. Electronic medical records of patients who underwent placement of LCS for the treatment of IIH at a single institution were reviewed. Based on early experience and outcomes, our modified technique for LCS is described.

Results: Six patients (4 females, median age 36 years [IQR 31-43]) underwent placement of LCS between October 2023 and April 2024. LCS was completed in all cases without intraoperative complications. The median operative time was 88.5 minutes [IQR 79.5-158.8]. One patient developed low-pressure headaches that resolved after the addition of a shunt-assist device. Five of 6 patients reported improved headache at the last follow-up visit, with 4 of 5 patients reporting that their high-pressure headaches completely resolved (median time to the last follow-up of one month [IQR 1-2 months]). During the study period, one shunt revision was performed because of migration of the lumbar shunt into a suprafascial pocket. This led to modification of the surgical technique, specifically the inclusion of anchoring dips.

Conclusion: LCS may represent an alternative shunting technique in difficult-to-manage patients with IIH. Further assessment of long-term outcomes is needed.