Neurosurgery practice最新文献

Background and objective: Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common complication in craniotomy patients. The duration of surgery has been identified as a risk factor for the development of VTE. In a pilot study, the use of intermittent pneumatic venous compression (IPC) dramatically reduced the incidence of VTE. Despite randomization, a significant difference in the duration of surgery between the groups limited the validity of this result. The study was underpowered to compensate for this problem. We now present the protocol of a multicenter trial.

Methods: All patients receive medical compression stockings and low-molecular-weight heparin from the first postoperative day. The therapy group receives IPC stockings intraoperatively. Postoperatively, all patients receive lower-extremity duplex sonography to detect/exclude DVT within the first 7 postoperative days. Contrast-enhanced chest CT is the gold standard for the detection of PE and is performed in cases of clinical suspicion of PE.

Expected outcomes: The incidence of VTE is the primary end point. The distinction between symptomatic and asymptomatic, etiologies, influence of lesion type, duration of surgery, and mortality will be evaluated as secondary end points. The pilot study showed a VTE incidence of 26% in the control group vs 7% in the treatment group. To avoid overly optimistic treatment effect assumptions, we assume VTE rates of 9% and 24% in the treatment and control groups, respectively, and thus calculated a number of 127 patients per treatment group.

Discussion: If this trial shows that intraoperative IPC reduces the risk of VTE to the extent observed in our pilot study (number needed to treat: 5.24), the potential benefit to neurosurgical patients would be significant. The results would potentially influence treatment guidelines by providing the high-quality evidence needed to make robust recommendations.

Background and objectives: Although half of patients with vestibular schwannoma (VS) experience some form of vestibular dysfunction, it is rarely the most prominent symptom. The effect of VS resection on preexisting vestibulopathy remains poorly understood. Our objective was to perform a scoping review to elucidate the incidence and role of postoperative vestibulopathy after microsurgery (MS) as it relates to long-term quality of life (QOL) and predictors of recovery and to identify optimal management of vestibulopathy as a presenting symptom.

Methods: Studies were identified using the PubMed database published in the English language peer-reviewed recent literature (2000-2023) using MeSH and tiab terms, and additional studies identified from a secondary review of reference lists.

Results: Thirty-one articles were selected and reviewed. The literature quotes a wide range for the incidence of postoperative vestibulopathy after MS (4%-100%). Persistent vertigo universally demonstrates a strong negative effect on long-term QOL. Potential predictors of poor vestibular compensation include sex, advanced age, and tumor size. Few studies examine postoperative vertigo compared with preoperative baseline. Studies are inconsistent and variable in their use of measurement tools to assess vestibulopathy and QOL. Improvement in baseline vestibulopathy can be seen in long-term post-MS, particularly in patients with severe or disabling vertigo, although outcomes relative to other treatment modalities are otherwise similar.

Conclusion: Further understanding of predictors and comparative management strategies for vestibulopathy would be valuable in addressing an important negative influence on QOL in patients with VS. Prospective studies factoring preoperative baseline and using standardized measurement tools are needed.

Care for the patient with traumatic brain injury (TBI) in austere or combat environments is challenging because resources are substantially limited as compared with care for these patients in a tertiary medical facility. Significant research has been and will continue to be performed on TBI care in these settings. This includes high-quality, evidence-based guidelines that are routinely updated to help guide the treating team as to best practices for a wide range of TBI presentations, complications, and outcomes. Much less is known regarding best practices for TBI care in a resource-limited environment, such as a facility in an austere environment without advanced imaging, dedicated neurointensive care, or definitive neurosurgical capabilities. The aim of this study was to identify the methodology that will be used for an upcoming in-person guideline conference, focusing on the care of patients with TBI in resource-limited austere and/or combat zones.

Background and importance: Enterogenic cysts often occur along the spinal axis and are frequently associated with congenital spinal malformations. The special location of the lesion can limit the surgical resection to achieve complete removal. In this report, the authors describe a successful case of complete resection of a ventral enterogenic cyst in the cervical spinal cord using a posterior midline approach in the lateral position.

Clinical presentation: This report discusses a case of a 36-year-old young female patient who presented with relatively short-term discomfort and pain in the left shoulder and neck area. MRI examination revealed a cystic mass located ventrally in the C3 cervical spinal cord. We performed a posterior surgical approach and, under the lateral position, the lesion was completely resected. The surgical treatment alleviated the neurological dysfunction. During the follow-up periods of 3 and 6 months, the patient recovered well, and magnetic resonance imaging scans showed no residual lesion.

Conclusion: Complete surgical resection of the cyst wall is the only effective treatment for enterogenic cysts because partial resection or subtotal resection may lead to recurrence. For patients with concomitant spinal malformations, a posterior midline approach in the lateral position is a viable surgical option.

Background and objectives: Low-quality data on image-guided external ventricular drain (EVD) accuracy are in large part due to a lack of widespread usage of this system for EVD placement. The potential disconnect between user preferences and existing technologies should be explored to guide future developments. The goal of this study was to survey neurosurgical residents regarding their EVD practices and determine the acceptable amount of setup time for an ideal neuronavigation system.

Methods: A 4-question survey was sent to approximately 1512 residents at 108 Acreditation Council for Graduate Medical Education-approved medical doctor neurosurgical training programs in the United States. The responses were received electronically, tabulated, and analyzed using descriptive statistics.

Results: A total of 130 respondents (9%) completed the survey, reflecting the highest number of neurosurgical resident respondents in an electronic qualitative survey of EVD practices thus far. Residents were willing to accept 6.39 min (SD = 3.73 min) on average for the setup of a bedside EVD image guidance system. The majority chose to use image guidance during EVD placement for cases of narrow slit-like ventricles (86.92%) over intraventricular hemorrhage (13.08%) and hydrocephalus (0%). A total of 90% of all resident respondents misplaced at least 1 EVD with 74% of post-graduate year-7 respondents misplacing more than 3 EVDs in their career. A total of 88.46% of respondents deemed more than a single pass as acceptable.

Conclusion: Future EVD neuronavigation technologies should focus on achieving rapid registration times. These systems may be prioritized for patients with anatomic distortions. Current resident attitudes are accepting multiple EVD passes, likely because of the inherent limitations of the traditional freehand approach. Efforts should be made to encourage the best course for the patient.

Background and importance: Approximately 25% to 55% of patients with essential tremor will eventually develop medication-refractory tremor. Currently, the standard surgical treatment for this condition is deep brain stimulation (DBS) of the ventralis intermedius nucleus of the thalamus and, more recently, the posterior subthalamic area. However, MRI-guided focused ultrasound (FUS) thalamotomy has shown promising results in improving tremor in patients with refractory essential tremor.

Clinical presentation: We present 2 cases of patients with a disabling action tremor, recurring after DBS. A 55-year-old right-handed male and a 52-year-old woman presented with bilateral medically refractory action tremor, which began in their second decade of life. Both underwent bilateral DBS-ventralis intermedius, with the first patient showing a good initial response but the second patient showing a suboptimal response within the first year after DBS. In both cases, the DBS system was removed and the patients subsequently underwent left-sided FUS thalamotomy with a dramatic improvement of their tremor.

Conclusion: These cases demonstrate the feasibility of performing FUS thalamotomy as a rescue treatment for disabling tremor after DBS.

Background and objectives: Intracranial aneurysms affect 3% to 4% of the population, with 20% to 25% having multiple aneurysms. Aggressive treatment is warranted for multiple unruptured aneurysms because of their higher risk of rupture and enlargement compared with single aneurysms. However, the risks and appropriate timing of secondary clipping surgeries are underreported. We assessed the prognosis and risks of treating multiple cerebral aneurysms with a second surgery and determined the differences in prognosis based on the timing of these surgeries.

Methods: We retrospectively reviewed patients who underwent secondary clipping surgery for multiple unruptured cerebral aneurysms at our hospital and affiliated institutions. The number, size, and location of aneurysms, patient demographics, and antithrombotic drug history were compared between the first and second surgeries. The modified Rankin Scale score and postoperative complications, including ischemia, hemorrhage, seizures, chronic subdural hematoma requiring surgery, infection, and postoperative hospital days, were investigated.

Results: A total of 38 patients (mean age, 65 years) were included. No significant differences were observed in modified Rankin Scale score worsening, postoperative hospital stay, or complication rates between the 2 surgeries. Older patients tended to undergo the second surgery within 6 months, with no significant difference in complication rates. The first surgery targeted larger aneurysms.

Conclusion: The absence of complications between surgeries and the absence of rupture or re-treatment during follow-up emphasize the importance of choosing the most appropriate approach for each aneurysm. The first and second surgeries for multiple cerebral aneurysms did not significantly affect postoperative complications. Performing 2 craniotomies may facilitate the curative and safe treatment of aneurysms.

Background and objectives: Directional deep brain stimulation (DBS) enables treatment optimization by current steering using segmented leads. Identification of the lead's rotational orientation is critical to guide programming decisions. Orientation is often assessed during or immediately after implant, but the degree of lead rotation in the following weeks is not well appreciated. Our objective was to measure the degree of DBS lead rotational orientation changes within the first few weeks after surgery.

Methods: We retrospectively reviewed the clinical records of patients who were implanted with segmented DBS leads at our institution. All included patients had at least 1 immediate postoperative computed tomography (CT) (CT1) and another CT at least 1 week later (CT2). We assessed lead rotational orientation angles on CT1 and CT2 and calculated the degrees of rotation change between the scans. We also assessed for any effect of the time interval between scans by calculating the correlation between CT1-CT2 latency and degrees of lead rotation.

Results: We assessed a total of 75 DBS lead orientations for 38 patients. The average change in lead orientation between CT1 and CT2 was 8.6° (median = 2.9°, range = 0.11-168.2°). Only 8 percent of patients (3/38) were found to have a significant change in orientation (>30°); however, when it occurred, it occurred bilaterally. There was no correlation between CT1-CT2 latency and lead rotation (r(74) = 0.04, P = .73).

Conclusion: Our study finds that changes in lead orientation occurring over the first few weeks after surgery are rare. Thus, for most patients, the immediate postoperative CT is adequate for determining the orientation angles for clinical programming. However, if programming is found to be difficult, a repeat CT scan could be beneficial for a minority of patients.

Background and importance: The human motor homunculus is a well-known topographical map of the functional-anatomical relationships of the precentral gyrus. Within this homunculus, the primary hand motor area is considered one of the least plastic functional-anatomical relationships. Only a few cases in the literature describe relocation of functional hand representation away from the classical anatomical location. These cases have been reported in the context of children, primary gliomas, or arteriovenous malformations.

Clinical presentation: Here, we describe a unique case where the area of lowest hand motor stimulation threshold (ie, hand motor representation) was found in the postcentral gyrus in an older adult with a metastasis in the premotor area of the brain. This localization was based on intraoperative cortical stimulation-evoked motor potentials and confirmed with electrophysiological phase reversal and MRI-based neuronavigation. This mapping was repeated and consistent 2 months later during a reoperation for recurrence. In addition, the remapped anatomical location was found in an area that was active during finger tapping on preoperative functional MRI.

Conclusion: These findings suggest that neuroplastic remapping of hand motor cortex to the postcentral gyrus can occur in brain metastases even in adults. This has implications for planning tumor resections and interventional neurorehabilitation strategies, and it suggests that the motor homunculus may have more plastic potential in adulthood than previously recognized.

Background and objectives: Postoperative cerebrospinal fluid (CSF) leaks and meningitis are well-known risks of retromastoid craniotomy. Use of abdominal fat grafts, collagen allografts, and rigid or semirigid buttresses have demonstrated efficacy in preventing CSF leaks and meningitis in endoscopic endonasal surgery. This study aims to determine the utility of a similar multilayered reconstruction technique for retromastoid craniotomy.

Methods: We retrospectively reviewed 212 consecutive patients who underwent retromastoid craniotomy for tumor removal or microvascular decompression from 2007 to 2022. Scalp incisions were linear or slightly curved, muscle and facia opening was performed sharply avoiding monopolar cautery; craniotomies had a maximum dimension of 3 cm. A primary water-tight dural closure was rarely achieved favoring collagen sponge overlay often augmented with autologous fat. Clinical factors including pathology, mastoid air cell entry, and reconstruction material were analyzed. Outcomes including postoperative CSF leakage and meningitis were assessed.

Results: Of 212 patients (mean age 56 ± 16 years; 60% female; 10% with prior surgery), 148 (70%) had tumor resection and 64 (30%) had microvascular decompression. Mastoid air cells were breached in 67%. Collagen sponge dural overlay was used in 201/212 (95%). A fat graft was placed in 116 (55%) cases: 69% with air cell entry, 27% without air cell entry; 158 (75%) patients had their bone flap replaced, 46 (21%) had titanium mesh cranioplasty, 8 (4%) had no bone flap or titanium mesh. There were no CSF leaks or meningitis. One patient had a lumbar drain placement preoperatively, none postoperatively. Median length of stay was 2 days.

Conclusion: Retromastoid craniotomy multilayered reconstruction with liberal use of collagen sponge and abdominal fat grafts seems to reliably avoid postoperative CSF leaks and meningitis including in the setting of nonwatertight dural closure and mastoid cell entry. Use of shorter incisions, avoidance of monopolar cautery, and a relatively small craniotomy may contribute to the absence of CSF leaks in this series.