Surgical neurology international最新文献

Background: The management choice for the middle cerebral artery aneurysms (MCAAs) is still controversial. This review aims to describe a single-center "clipping first" policy for MCAA over 40 years of experience and compare the short- and long-term clinical outcomes by aneurysm's location.

Methods: This retrospective cohort study reviews the whole series of a single-center intracranial aneurysm mainly based on the micro-neurosurgical experience of the senior authors (EOA and EKA). More than 968 aneurysm patients were treated at the University Hospital "Hôpital des Spécialités" Ibn Sina of Rabat in Morocco since 1983. We have included aneurysmal subarachnoid hemorrhage patients with the World Federation of Neurosurgical Societies (WFNS) Grade ≤III (64.7% clipped; 6.9% coiled) and those with WFNS Grade ≥IV (27.5% clipped; 0.9% coiled).

Results: From the database of 1069 IAs in 968 patients, we depicted 218 (22.5%) patients carrying 279 (26.1%) MCAA. About 92.1% (n = 257) of the MCAAs were microsurgically clipped, and 96.3% (n = 210) were discharged with good outcomes (modified Rankin Scale [mRS] ≤2). In the post hoc test, the mean of intracerebral hemorrhage (ICH) (4.178) among the group of poor outcome patients (mRS >2) was significantly (P = 0.001) high compared to that of 0.827 good outcome patients (mRS ≤2). The negative correlation found between the dome/neck ratio and the mRS (Pearson's r = -0.023, 95%confidence interval [CI] 0.110--0.156) at admission (Pearson's r = -0.073, 95%CI 0.061--0.204) and at discharge confirmed that the wider the MCAA neck is, the more susceptible it is to have a poor prognosis.

Conclusion: The good clinical outcome from the microsurgically clipped patients is overwhelming and allows us to conclude that microsurgical treatment should be mostly considered for MCAA management. The patient's poor outcome with MCAA at discharge was significantly associated with ICH at admission in the frequency of 68.9%.

Background: Stroke is high in both mortality and disability; this makes stroke the world's second leading cause of death and the number one cause of long-term impairment. Surprisingly, intracerebral hemorrhage (ICH), the second largest type of stroke, is deadlier than ischemic strokes , with a high mortality rate and lack of effective treatment for ICH. This case report aims to identify and collect the various factors that increase the mortality rate of patients with ICH.

Methods: A retrospective review was done on 115 patients who experienced ICH at neurosurgical unit care between 2021 and 2024. Data were collected from medical record post admission reports. The study concentrated on factors such as the initial Glasgow coma scale (GCS) score, the volume of intracerebral bleeding, the ratio of neutrophils to lymphocytes, leukocyte count, and the administration of neuroprotective medications. We first ran univariate tests. Next, to evaluate the relationship between each component and patient mortality, we performed bivariate analyses with Spearman's correlation test. To determine the predictor factor from all the various variables that have been evaluated, we use multivariate analysis with logistic regression.

Results: Univariate analysis results show that ICH often occurs at the age of 41-50 years in males. Meanwhile, most of the patients who died were men aged 51-60 years. The results of the bivariate analysis showed that each predictor had a significant relationship with mortality. GCS has a negative relationship with mortality (-0.633 with P < 0.001). The neutrophil-to-lymphocyte ratio (NLR) (0.418), leukocyte count (0.527), and ICH blood volume (0.671) had a positive effect on ICH mortality. Multivariate analysis with logistic regression demonstrated that all predictor factors had a significant impact (P < 0.05) on mortality patients with hemorrhagic stroke. The most common neuroprotective therapy used in hemorrhagic stroke is the combination of citicoline and mecobalamin. The co-administration of citicoline and mecobalamin showed the highest number of survivors and deaths, indicating that no effective therapy for ICH has been found among all the neuroprotectants administered.

Conclusion: This study showed that GCS, ICH volume, leukocyte count, and NLR are predictors of mortality in ICH patients. At present, no ICH therapy can reduce complications and improve the physical and mental condition of ICH patients. Therefore, further research is needed to find an effective therapy for ICH.

Background: Omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex is a rare, life-threatening congenital malformation primarily treated with abdominogenital repair. The optimal indication and timing of neurosurgical interventions for the associated spinal cord lesions remains insufficiently studied. We reviewed spinal dysraphism in OEIS to evaluate the best timing for neurosurgical intervention.

Methods: We retrospectively reviewed 10 patients with OEIS, analyzing their clinical and imaging data, as well as surgical and pathological findings.

Results: Terminal myelocystocele (TMCC) and spinal lipomas were observed in 5 patients each. Of the spinal lipomas, one had a single filar lipoma, while four had double lipomas (3 caudal and dorsal; 1 filar and dorsal). TMCC manifested with severe lower limb motor dysfunction in addition to abdominogenital disorder at birth, with the cyst-induced lumbosacral mass increasing over time. Spinal lipomas were less symptomatic except for abdominogenital issues and demonstrated minimal growth of the intraspinal lipoma over time. Untethering surgery was performed in 8 patients (5 TMCC; 3 spinal lipomas) at a median age of 3 (range, 2-10) months for TMCC and 6 (range, 2-14) months for spinal lipomas. One TMCC patient (surgery at 10 months) experienced postoperative cerebrospinal fluid leakage, necessitating three reoperations.

Conclusion: Magnetic resonance imaging is essential to diagnose spinal cord malformations accurately. The necessity and timing of surgical intervention differ between TMCC and spinal lipomas. Since TMCC lesions tend to enlarge, surgery should be performed as soon as the patient's abdominogenital condition stabilizes. For spinal lipomas, surgery should be considered carefully based on the patient's neurological condition.

Neurosurgical operations treat involuntary movement disorders (MvDs), spasticity, cranial neuralgias, cancer pain, and other selected disorders, and implantable neurostimulation or drug delivery devices relieve MvDs, epilepsy, cancer pain, and spasticity. In contrast, studies of surgery or device implantations to treat chronic noncancer pain or mental conditions have not shown consistent evidence of efficacy and safety in formal, randomized, controlled trials. The success of particular operations in a finite set of disorders remains at odds with disconfirming results in others. Despite expectations that surgery or device implants would benefit particular patients, the normalization of unproven procedures could jeopardize the perceived legitimacy of functional neurosurgery in general. An unacknowledged challenge in functional neurosurgery is the limitation of biological determinism, wherein network activity is presumed to exclusively or predominantly mediate nociception, affect, and behavior. That notion regards certain pain states and mental conditions as disorders or dysregulation of networks, which, by implication, make them amenable to surgery. Moreover, implantable devices can now detect and analyze neural activity for observation outside the body, described as the extrinsic or micro perspective. This fosters a belief that automated analyses of physiological and imaging data can unburden the treatment of selected mental conditions and pain states from psychological subjectivity and complexity and the inherent sematic ambiguity of self-reporting. That idea is appealing; however, it discounts all other influences. Attempts to sway public opinion and regulators to approve deep brain stimulation for unproven indications could, if successful, harm the public interest, making demands for regulatory approval beside the point.

Background: Petroclival meningiomas are still a neurosurgical challenge due to their proximity to cranial nerves and cerebral vasculature along the surgical corridor. The usual extension of large petroclival meningiomas is along the posterior fossa, frequently compromising and displacing adjunct cranial nerves such as the sixth and seventh-eight cranial nerve complex with brainstem compression, causing progressive neurological deficit and severe headache. The goal of sizeable petroclival meningioma surgery treatment is a maximal resection with preservation of neurological function. Several surgical approaches to the petroclival region have been described, and decisions depend on the valuable hearing, tumor origin, and lesion extension. Alongside, the semi-sitting position is a simple and feasible adaptation for several posterior fossa interventions, reducing venous hemorrhage and preventing venous air embolism.

Case description: Hereby, we present the case of a 39-year-old female patient with progressive intermittent headache and right-sided hemiparesis secondary to a large petroclival meningioma. After a careful case study, surgical treatment was performed employing a retrosigmoid approach, aiming for the safest and maximal resection possible.

Conclusion: The retrosigmoid is an auditory sparing procedure that, with a semi-sitting position, provides direct visualization of the posterior fossa lateral triangles and the tumor and its dural implantation site with no blood and surgical view comprised of debris. This surgical video illustrates anatomical nuances and critical aspects of the retrosigmoid approach and semi-sitting position as safe and adequate access to complete resection and a favorable long-term clinical outcome. The patient consented to the procedure and the publication of his/her image.

Background: Intradural extramedullary tuberculoma of the spinal cord (IETSC) is an exceedingly rare manifestation of tuberculosis (TB) affecting the central nervous system.

Case description: A 33-year-old immunocompetent female with disseminated TB, including pulmonary involvement and leptomeningeal tuberculomas, developed progressive paraplegia and urinary incontinence over 2 months. Magnetic resonance imaging revealed diffuse intradural extramedullary soft tissue from C7 to L2 vertebral levels, indicative of abscess formation and severe spinal cord compression. The surgical intervention involved posterior decompression and abscess removal from D7 to L2 vertebral levels, resulting in partial resolution of granulomatous lesions.

Conclusion: This case emphasizes the importance of considering IETSC in the differential diagnosis of spinal cord compression in TB-endemic regions. Further research is warranted to elucidate optimal management strategies, including the role of surgical intervention, in improving long-term neurological outcomes for patients with this rare but debilitating form of spinal TB.

Background: Recent studies have suggested that high-dose tranexamic acid (TXA) may be an effective method for reducing blood loss during adolescent idiopathic scoliosis (AIS) surgery. This study aims to perform a systematic review and meta-analysis to compare the outcomes of high-dose versus low-dose TXA for AIS surgery.

Methods: Searches were conducted in major databases such as PubMed, Scopus, Google Scholar, and Cochrane Library for relevant studies comparing high-dose and low-dose TXA outcomes in terms of blood loss, red blood cell transfusions, and hemoglobin changes. This systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and registered with PROSPERO (CRD42024547735).

Results: Four studies were included, published between 2009 and 2022, encompassing a total of 531 patients. High-dose TXA showed less blood loss compared to low-dose TXA, with a pooled mean difference of -0.40 (95% CI, -0.79--0.01). Neither the volume of blood products used nor the decrease in hemoglobin levels showed significant differences between the groups.

Conclusion: High-dose TXA appears to be more effective in reducing blood loss during AIS surgery compared to low-dose TXA. Further robust clinical trials with larger sample sizes are necessary to confirm these results and establish optimal dosing regimens for maximizing efficacy while ensuring safety.

Background: Carpal tunnel syndrome (CTS) is a common nerve entrapment condition, and there is ongoing debate regarding the superiority of traditional open versus minimally invasive carpal tunnel surgery.

Methods: This meta-analysis reviewed six studies involving 478 patients to compare recovery and functional outcomes between the traditional longitudinal technique and the minimally invasive mini-transverse technique. The primary outcomes included the functional status scale (FSS), symptoms severity scale (SSS), pain scores, time to return to work, duration of operation, and incidence of complications.

Results: The mini-transverse technique was associated with lower FSS and SSS scores compared to the longitudinal technique, with mean differences (MD) of -0.32 (95% confidence level [CI]: -0.52, -0.12, P = 0.002) and -0.43 (95%CI: -0.6, -0.25, P < 0.00001), respectively. Pain scores were also lower with the mini-transverse technique (MD) of -0.5 (95%:CI: -0.71, -0.3, P < 0.00001). The mini-transverse group had a statistically significant shorter time to return to work (MD) of -8.34 (95%CI: -13.55, -3.13, P = 0.002). No significant differences were found in the duration of surgery (MD) of -6.96 (95%CI: -16.66, 2.74, P = 0.16) or incidence of complications (MD) of 0.46 (95%CI: 0.15, 1.4, P = 0.17).

Conclusion: The mini-transverse approach for CTS resulted in better outcomes, including less pain, faster recovery, and improved hand function. There was no significant difference in surgery time or complications compared to the traditional technique, suggesting it may be the preferable option.

Background: The delayed-window indocyanine green (DWICG) technique is useful for the removal of brain and spinal tumors.

Case description: A 41-year-old female presented with lower left back and radicular pain. An magnetic resonance imaging (MRI) revealed an extramedullary L3 lesion located ventrally in the spinal canal that appeared to be a schwannoma. Intravenous indocyanine green (dose, 0.25 mg/kg) was administered 1 h before the L2-L4 laminectomy and L3/L4 posterior lumbar fusion. At surgery utilizing a strong near-infrared (NIR) signal, the tumor was clearly visualized through the dura. Complete tumor excision was confirmed when the NIR signal could no longer be detected. Pathologically, the lesion proved to be a schwannoma. A postoperative MRI scan further confirmed complete tumor excision.

Conclusion: In a 41-year-old female, the DWICG technique intraoperatively facilitated localization of a L3 schwannoma through the dura and expedited gross total tumor removal.