British Journal of Neurosurgery最新文献

Background: Resection of insular tumours utilising modern neurosurgical techniques has become commonplace since its safety and reduced morbidity was first established. Interest has grown in the cognitive consequences of insula neurosurgery and studies have largely shown postoperative stability or minor decline. Major or widespread improvements in cognitive functioning following resection of insular tumours have not previously been reported.Case description: A 34-year-old, left-handed man with a right insular low-grade glioma (LGG) presented with seizures, nausea, altered sensation, poor balance and extensive cognitive decline. Comprehensive neuropsychological assessment highlighted a striking left hemispatial neglect and impairments in attention, working memory, verbal learning and fluency. During an awake craniotomy with functional cortical mapping, he reported intraoperative improvements in hand function and processing speed. Resolution of the neglect and significant improvements in cognition, mood and functioning were observed at follow-up and sustained over several years.Conclusions: This case highlights that right insular LGGs can cause significant cognitive and functional deficits and that neurosurgery has the potential to alleviate these difficulties to an extent beyond those documented in the extant literature.

Objective: The aim of this study was to identify independent anatomic, morphologic and hemodynamic features of the ACoA (anterior communicating artery) complex that serve as risk factors for the occurrence of ACoA aneurysms.

Methods: Fifteen consecutive patients with 15 ACoA aneurysms were included. Computational fluid dynamics (CFD) simulations based on patient-specific models were carried out using 3D time-of-flight magnetic resonance angiography (3D-TOF-MRA) images. A reverse reconstruction technique was used to generate a pre-aneurysm vessel anatomy. Geometric parameters and hemodynamic changes were compared and evaluated.

Results: The overall prevalence of symmetric, dysplastic, and absent A1 segments were 53.3%, 26.7%, and 20%. The mean wall shear stress (WSS) of the absent group (AG) was significantly higher than that of the symmetric group (SG) and dysplastic group (DG). The absolute mean A1 artery flow rate (410.2 ± 88 versus 439.4 ± 101 mL/min; p = .45) of the aneurysm side was similar between the SG and DG but significantly higher in the AG (528.1 ± 77 mL/min; p < .05). The A1-A2 angles of the aneurysm side showed no significant differences among the 3 groups (p = .32). However, the mean A1-A2 angle on the aneurysm side was smaller than the contralateral A1-A2 angle (101.9 ± 9.1˚ versus 120.3 ± 7.7˚; p <.05). A regression analysis demonstrated that high WSS was significantly associated with a large A1-A2 ratio (R²=0.52; p <.05).

Conclusions: ACoA aneurysms are a high-WSS pathology. Severe flow impingement and the anatomic vasculature structures play a role in triggering the occurrence of ACoA aneurysms.

Background and importance: Corticosteroid pre-treatment in patients with primary central nervous system lymphoma (PCNSL) can lead to the phenomenon of ghost tumours (GhT). This affects the diagnostic yield of biopsies and potentially causes misdiagnosis of the condition. The usual strategy of neuronavigation using preoperative magnetic resonance imaging (MRI) or localisation using intraoperative MRI (iMRI) can be rendered ineffective in this situation.

Clinical presentation: A middle-aged Chinese male with newly diagnosed human immunodeficiency virus infection was found to have an intracranial lesion suggestive of PCNSL. Preoperatively corticosteroid led to an attenuation of the contrast enhancing lesion on iMRI. However, intraoperative use of FS allowed the successful identification, biopsy and diagnosis of the condition.

Conclusion: FS is useful in the biopsy of PCNSL GhT even when the lesion is not seen in subsequent MRI imaging.

Purpose: Akt/mTOR/p70S6K signaling pathway promotes motor function recovery after spinal cord injury (SCI) in both neurons and astrocytes. But the role and mechanism of this pathway in oligodendrocytes during nerve repair following SCI has not been researched. This study aimed to investigate the effect and mechanism of this signaling pathway in oligodendrocytes on nerve myelin regeneration and motor function recovery in rats with SCI.

Methods: After inhibiting or activating this signaling pathway, Western blotting and double immunofluorescence labeling were used to determine the levels of the signaling molecules in this pathway and myelin formation-related proteins in the plane of the thoracic segment of the injured spinal cord. The level of motor function recovery was evaluated and the oligodendrocytes involved in nerve myelin regeneration were studied. Primary oligodendrocytes were isolated and cultured in vitro, then MBP, PLP, and MOG were measured with reverse transcription-quantitative polymerase chain reaction (RT-qPCR).

Results: Akt/mTOR/p70S6K signaling pathway was activated after SCI compared with the sham-operated rats, prominently elevated levels of the pathway components were observed in the SC79-treated group. The activation of the signaling pathway significantly increased the expression levels of myelin formation-related proteins, including MBP, PLP, and MOG, and improved the Basso, Beattie, and Bresnahan (BBB) scores in the injured spinal cord. Conversely, rapamycin suppressed the expression of these signaling molecules and reduced the levels of myelin formation-related proteins.

Conclusion: Akt/mTOR/p70S6K signaling pathway activation can contribute to nerve myelin regeneration and has the potential to improve the regenerative environment and motor function, as well as the potential to promote repair of SCI.

Objective: Cavernous carotid aneurysms (CCA) comprehend around 5% of all intracranial aneurysms. The main risk factors for an intracranial aneurysm seem not to influence the incidence of CCAs. The aim of this study was to investigate the association of CCAs and the presence of upstream aneurysms.

Methods: 1403 patients, admitted in Hospital das Clinicas de São Paulo, Brazil, from September 2009 to August 2018, enrolled this study. Diagnosis was performed with Digital Subtraction Angiography (DSA). Upstream aneurysm was defined as an intracranial aneurysm on anterior cerebral circulation, ipsilateral to the CCA (if present) or crossing the midline (e.g. anterior communicating artery).

Results: 177 individuals were diagnosed with CCA (12.6% of the population), totalizing 225 aneurysms (10% of the total number of aneurysms, 2253). No association was found between CCA and UA (p= .090, OR: 1.323, 95% CI: 0.957-1.828). Studying only patients with CCA, multivariable analysis showed smoking as the only factor associated with UA (p= .010, OR: 0.436, 95% CI: 0.232-0.821).

Conclusions: Cavernous carotid aneurysms were present in 12% of our population, mostly in female. They seem to be independent of the modifiable risk factors already associated with intracranial aneurysms. A higher frequency of mirror aneurysms was seen in this location. CCA did not influence the presence of ipsilateral and anterior circulation aneurysms.

Background: Cortical bone trajectory (CBT) technique has a theoretical benefit for patients with osteoporosis, and leads to reduce screw loosening. However, there are no reports of complications and outcomes of CBT.

Methods: Consecutive patients (n = 34) with degenerative lumbar spines who underwent PLIF between December 2013 and December 2015 and were followed up for at least six months were analyzed in this study. Bone mineral density, fusion rate, cage subsidence, C-arm, screw loosening, screw violation, trajectory angle of the screw, Hounsfield unit and extent of facetectomy were examined. Outcome assessments were obtained in all patients preoperatively and postoperatively.

Results: There were 34 patients and 73 screw levels. After the surgery with cortical screw fixation and PLIF, patients had good clinical outcomes. However, ten of the 34 patients had problems with cortical screw fixation such as screw loosening or cage migration. In the patients with screw loosening, two underwent revision surgery due to cage migration, and one had an infection. Incorrect trajectory angles of the screw were significantly related with screw loosening. Low BMD and HU at screw fixation level were associated with screw loosening. Cage subsidence was statistically related with clinical outcomes.

Conclusion: The cortical screw offers improved clinical outcomes since it requires minimal muscle dissection. However, we have experienced some early complications using this technique. To reduce complications such as screw loosening, an exact insertion angle of the screw and osteoporotic bone quality should be considered carefully.

Purpose: In this study, we investigated the effect of local injection of ropivacaine and bupivacaine with magnesium sulfate on postoperative pain in vertebral laminectomy surgery.

Design: This randomized double-blind prospective study was conducted among 60 patients aged 18-65 years old with ASA class I and II.

Methods: Group RM: (30 people) received 70 mg ropivacaine (14 ml) plus 1 ml magnesium sulfate (500 mg) volume up to 20 ml with normal saline. Group BM: (30 people) received 70 mg bupivacaine (14 ml) plus 1 ml magnesium sulfate (500 mg) volume up to 20 ml with normal saline. The results were analyzed by SPSS 23 software, and statistical analysis consisted of χ² test and t-test, and a p value less than .05 was considered significant.

Findings: Mean pain score based on VAS in 6 and 12 h after surgery in the RM group was lower in the BM group (p < 0.05). The analgesic request frequency in the RM group was lower than the BM group (p = 0.01). The mean morphine consumption in the RM group was 185 mg and in the BM group was 220 mg. According to the T-test, there was a significant difference between the two groups (p = 0.03). there was no significant difference between the mean arterial blood pressure and mean heart rate between the two groups at 6, 12, 24 and 24 h after surgery (p > 0.05).

Conclusion: This study showed that wound infiltration with ropivacaine and magnesium sulfate compared to bupivacaine and magnesium sulfate provided better postoperative analgesia and significantly reduced postoperative opioid consumption in patients undergoing lumbar laminectomy.

Purpose: Both phenotypic and genotypic variations now underpin glioma classification, thus helping to more accurately guide their clinical management. However, WHO Grade III anaplastic astrocytoma (AA) remains an unpredictable, heterogeneous entity; displaying a variable prognosis, clinical course and treatment response. This study aims to examine whether additional tumour characteristics influence either overall survival (OS) or 3-year survival in AA.

Materials and methods: Data were collected on all newly diagnosed cases of AA between 2003 and 2014, followed up for a minimum of 3 years. Molecular information was obtained from case records and if missing, was re-analysed. Histological slides were independently examined for Ki-67 proliferation index, cellularity and number of mitotic figures. Kaplan-Meier and Cox regression analyses were used to assess OS.

Results: In total, 50 cases were included with a median OS of 14.5 months (range: 1-150 months). Cumulative 3-year survival was 31.5%. Median age was 50 years (range: 24 - 77). Age, IDH1 mutation status, lobar location, oncological therapy and surgical resection were significant independent prognostic indicators for OS. In cases demonstrating an OS ≥ 3 years (n = 15), Ki-67 index, number of mitotic figures and percentage areas of 'high cellularity' were significantly reduced, i.e. more characteristic of lower-grade/WHO Grade II glioma.

Conclusions: IDH1 status, age, treatment and location remain the most significant prognostic indicators for patients with AA. However, Ki-67 index, mitotic figures and cellularity may help identify AA cases more likely to survive < 3 years, i.e. AA cases more similar to glioblastoma and those cases more likely to survive > 3 years, i.e. more similar to a low-grade glioma.

Objective: Hyperselective neurectomy is used to treat spastic arm paralysis. The aim of the study was to analyze the nerve branching patterns of elbow and wrist flexors/pronator to inform hyperselective neurectomy approached.

Methods: Eighteen upper extremities of fresh cadaver specimen were dissected. The number of motor branches from the musculocutaneous nerve to biceps brachii and brachialis, median nerve to pronator teres, flexor carpi radialis and ulnar nerve to flexor carpi ulnaris were counted. The origin site of each primary motor branch was documented.

Results: Either biceps or brachialis was innervated by one or two primary motor branches. Pronator teres was innervated by one to three motor trunks and the pattern for flexor carpi radialis was a common trunk with other branches. The origin of the biceps and brachialis nerve trunk was located approximately 30% to 60% of the length of the arm. The median nerve branched to pronator teres and flexor carpi radialis at the region about 34mm (SD 18.8mm) above and 50mm (SD 14.9mm) below the medial epicondyle. Flexor carpi ulnaris was innervated by one to three motor trunks and the mean distance from the medial epicondyle to the origin of flexor carpi ulnaris nerve on ulnar nerve was 18.7 mm (SD 6.5mm).

Conclusion: Primary motor branches to elbow flexors, wrist flexors and pronators were various, while the regions of their origins were relatively settled. It was recommended the incisions be designed according to the location of the primary motor trunks.

Objective: To explore the changes of a series of cytokines before and after percutaneous balloon kyphoplasty (PKP) and prognostic markers for response to PKP.Methods: From 1 January 2019 to 31 May 2019, all single-level lumbar osteoporotic vertebral compression fracture (OVCF) patients diagnosed by MRI who matched the inclusion and exclusion criteria were enrolled in this study. They were classified into the effective group and the ineffective group based on the outcome after PKP. The levels of a series of inflammatory factors and indices of spinal functions were obtained before and after PKP.Results: A total of 72 patients were included in this study, 59 in the effective group and 13 in the ineffective group. The anterior height (AH) and posterior height (PH) were 77.3 ± 11.2% and 91.2 ± 9.3%, respectively, in the effective group after PKP, which were higher than that in the ineffective group (p<.001). While, the Kyphotic angle, visual analog scale (VAS), and Oswestry Disability Index (ODI) score were 9.1 ± 4.3°, 3.1 ± 1.9, and 19.2 ± 4.1 in the effective group, which was lower than that in ineffective group (p<.001). The serum levels of IL-1β, IL-6, and TNF-α were found significantly decreased after treatment in the effective group (p<.05). The logistic regression showed that the levels of IL-6 TNF-α and AH were significant predictor of outcome.Conclusions: Our results demonstrated that PKP can reduce the serum levels of IL-6, IL-1β, and TNF-α, moreover, the IL-6, TNF-α, and AH were significant predictors of outcome.