Surgical neurology international最新文献

Background: Mechanical thrombectomy has improved the outcome of patients with acute ischemic stroke, but complications such as subarachnoid hemorrhage (SAH) can worsen the prognosis. This study investigates the frictional forces exerted by stent retrievers (SRs) on vessel walls, hypothesizing that these forces contribute to vascular stress and a risk of hemorrhage. We aimed to understand how vessel diameter, curvature, and stent deployment position influence these forces.

Methods: Using a silicone vascular model simulating the middle cerebral artery, we created virtual vessels with diameters of 2.0 mm and 2.5 mm, each with branching angles of 60° and 120°. A Trevo NXT (4 × 28 mm) SR was deployed and retracted through these models, measuring the maximum static frictional force at the moment the SR began to move. The stent deployment position relative to the curvature (straight, distal 1/4, center, and proximal 1/4) was also varied to assess its impact on frictional forces. Each condition was tested 15 times, and the results were statistically analyzed.

Results: The highest frictional force was observed in the 2.0 mm/120° model, followed by the 2.0 mm/60°, 2.5 mm/120°, and 2.5 mm/60° models. Narrower and more sharply curved vessels exhibited significantly higher frictional forces. Friction also increased with more distal stent deployment, particularly in the narrower vessels.

Conclusion: Smaller vessel diameters, greater curvature, and more distal stent deployment positions increase frictional forces during thrombectomy, potentially leading to SAH. These findings highlight the importance of selecting appropriately sized SRs and considering stent deployment positions to minimize vascular stress.

Background: Endoscopic transsphenoidal surgery has become a mainstay surgical approach for sellar pathologies and can effectively decompress mass effects on the optic nerves. Visual-evoked potentials (VEPs) have been utilized as an intraoperative adjunct during endoscopic transsphenoidal surgery to monitor the integrity of the optic pathways, but the data surrounding its reliability and efficacy remain heterogeneous.

Case description: An 80-year-old male underwent endoscopic transsphenoidal resection of a pituitary macroadenoma with preoperative visual deficits related to optic nerve compression. During fat packing of the resection cavity, a decrease in VEPs was noted, which seemingly improved after partial fat removal, although with paradoxically reduced VEP latencies. Despite this, the patient developed a visual field deficit postoperatively, requiring re-operation for further removal of the fat packing.

Conclusion: This was a case of initially poorly formed VEPs that deteriorated and apparently improved following surgical intervention. The finding of shortened latencies of the VEPs was likely from noise contamination, creating the illusion of improved signal amplitudes. We recommend careful assessment of VEP data for baseline reproducibility, particularly in patients with pre-existing visual field deficits. Appropriate anesthetic selection is also important to reduce noise interference from the electroencephalogram.

Background: Otitis media (OM) can uncommonly lead to intracranial complications. Epidural abscesses represent a large proportion of cases; however, literature regarding the optimal surgical management of otogenic epidural abscesses is sparse. Favorably located epidural abscesses may be amenable to drainage through a transmastoid approach because the tegmen mastoideum lies immediately inferior to the middle cranial fossa (MCF).

Case description: We report 3 pediatric patients with OM complicated by epidural abscesses of the MCF. The ages ranged from 3 to 6 years old, with 2 females and 1 male. All 3 patients had acute mastoiditis with an abscess of the MCF ranging from 1.6 cm to 6.3 cm at the largest dimension. All patients underwent canal wall-up mastoidectomy with the evacuation of the MCF abscess through a small window, 0.7 × 0.7 cm or less, created in the tegmen mastoideum. All patients were successfully treated through this approach and had complete resolution of their infection on follow-up imaging. There were no postoperative temporal lobe encephaloceles.

Conclusion: This is one of the few descriptions of the treatment of an otogenic epidural abscess of the MCF through a transmastoid approach. Collaboration with neurosurgery is vital because their familiarity with the intracranial space helped to guide the accurate direction of dissection. This highlights the importance of a multidisciplinary approach in the treatment of epidural intracranial abscess of the MCF through this approach. The risk of postoperative temporal lobe encephalocele was minimized due to the small tegmen defect size.

Background: Lumbar spine surgery for discectomy or laminectomy is mostly performed under general anesthesia (GA). Here, we explored whether, in a series of 84 patients, better peri-operative outcomes and lower complication rates could be achieved for those undergoing diskectomy/laminectomy under spinal anesthesia (SA) versus GA.

Methods: From 2022 to 2023, 84 patients were randomly assigned to undergo lumbar discectomy/laminectomy for stenosis under SA: 42 patients versus GAGA: 42 patients. For these two populations, we analyzed and compared multiple variables, including duration of anesthesia, estimated blood loss (EBL), and outcomes (i.e., including pre/post-operative Visual Analogue Scale, Oswestry disability index, and short-form 36 questionnaires).

Results: Major advantages of SA versus GA included a reduced mean EBL, shorter mean operative time, reduced mean hospital length of stay, and fewer post-operative side effects. Notably, baseline heart rate or mean arterial blood pressure showed no significant differences between SA and GA groups.

Conclusion: Based on this small preliminary sample of patients undergoing lumbar disc/stenosis surgery, it appeared that SA reduced the mean EBL, offered shorter mean operative times, mean hospital lengths of stay, and fewer post-operative side effects versus GA.

Background: Dural arteriovenous fistula (DAVF) in the anterior cranial fossa (ACF) is known to show a high risk of intracranial hemorrhage. Recently, multi-modal fusion imaging with computed tomography angiography, computed tomography venography, and three-dimensional (3D) rotation angiography have been used preoperatively to ensure anatomical safety. We report on endovascular treatment as a first-line approach for ACFDAVF based on the understanding of vascular anatomy obtained from multi-modal fusion imaging.

Methods: All patients with ACF-DAVF treated endovascularly as a first-line approach were included in this study. Analyses took into account complications (particularly visual function), immediate angiographic outcomes, and follow-up findings in consecutive patients with ACF-DAVF treated with interventional treatment based on multi-modal fusion imaging.

Results: Five patients with ACF-DAVF underwent six sessions of transarterial embolization (TAE) in our institution. The five male patients (mean age, 74.5 years; range, 60-84 years) were treated with liquid embolic agents (Onyx, four procedures; n-butyl 2-cyanoacrylate, two procedures). No difference was seen between preoperative image evaluation and image evaluation during the endovascular procedure, and in all cases, a microcatheter was navigated into a target artery assumed from preoperative multi-modal imaging, allowing treatment completion in a single procedure. In all cases, the shunt disappeared completely and visual function after procedure was maintained. At the last follow-up, all patients showed a modified Rankin scale score of 0 or 1 with no recurrences.

Conclusion: Multi-modal fusion imaging facilitates a 3D understanding of the vascular anatomy, allowing TAE as the first-line treatment for ACF-DAVF.

Background: Fat is commonly used for preventing cerebrospinal fluid (CSF) leakage during endoscopic transsphenoidal surgery (ETSS). However, fat is soft, slippery, and sometimes not easy to handle. The present study aimed to examine the efficacy of our Surgicel^® wrapping method, which allows for better fat handling, in preventing the occurrence of CSF leakage among patients undergoing ETSS.

Methods: We used fat tissues removed from the abdomen. The fat was cut with scissors into pieces that were approximately 5 mm in size. Surgicel^® was also cut into 2.5 cm². The fat tissues were encased with these Surgicel^® squares and slightly moistened with a saline solution.

Results: Between January 2023 and August 2024, 34 patients aged 18-86 years (average 54.9 years) underwent ETSS. Among these patients, 20 had pituitary tumors, 6 had Rathke's cysts, and 8 had other conditions. None of the patients had CSF leakage postoperatively. The use of Surgicel^®-wrapped fat during ETSS is better than the use of fat alone.

Conclusion: The Surgicel^® wrapping method allows for better fat handling during ETSS.

Background: Spinal arteriovenous fistulae (AVF) located at the craniocervical junction (CCJ) are rare and usually present with hemorrhage. Bleeding is usually attributed to arterial feeders arising from the anterior spinal artery (ASA) and aneurysms located on such feeders. Perimedullary AVFs are typically found on the ventral surface of the spinal cord, which makes them difficult to treat through traditional microsurgical methods. In addition, their unique vessel angioarchitecture frequently precludes safe embolization. We present the first case of a CCJ perimedullary AVF successfully treated using flow diversion.

Case description: A 76-year-old man was brought to the emergency department after suddenly losing consciousness. On further evaluation, infratentorial subarachnoid hemorrhage and a perimedullary AVF at the ventral surface of the spinal cord were identified. The ASA originated from the left V4 segment, providing a single feeder to the lesion associated with a 2 mm aneurysm. After initial antiplatelet loading, 8 hydrophilic polymer-coated flow diverters were deployed to cover the ASA's origin in two sessions, achieving the complete occlusion of the lesion and the aneurysm 5 months later, without evidence of ischemic lesions.

Conclusion: CCJ perimedullary AVFs can bleed with devastating consequences. These lesions can be challenging to treat through traditional microsurgical or endovascular techniques. Progressive occlusion with flow diversion is feasible in single-feeder AVFs, theoretically allowing blood flow reorganization to the cervical spinal cord.

Background: Undergraduate conferences may improve exposure to neurosurgery among medical students. Hence, this study aimed to evaluate the effect of a neurosurgical skills conference on medical students' comprehension and perceptions of the specialty.

Methods: A before-and-after (BA) study design was employed to assess the effects of a conference that integrated presentations with hands-on sessions. Practical workshops covered craniotomy, spinal fixation, surface anatomy, intracranial pressure (ICP) monitoring, basic surgical skills, and microsurgical simulation. Pre-conference and post-conference surveys, utilizing Likert scales, gauged participants' attitudes, prior neurosurgical exposure, and understanding of neurosurgical skills. Statistical analysis was conducted on dichotomized responses.

Results: Thirty-one participants completed both surveys, with the majority being 1^st and 2^nd-year medical students. Among the participants, 58.1% were female, and 77.4% identified with BAME ethnicities. Following the conference, there was a notable increase in comprehension regarding neurosurgical careers (from 58.1% to 96.8%, P < 0.001) and training criteria (from 22.6% to 93.5%, P < 0.001). The conference enhanced knowledge of indications for craniotomy (P < 0.001), ICP monitoring (P < 0.001), and spinal fixation (P < 0.001). Participants reported improved understanding of the steps involved in craniotomy (P < 0.001), familiarity with basic cranial surgical surface anatomy (P < 0.001), and confidence in performing basic surgical instrument ties (P < 0.001). Although interest in pursuing a career in neurosurgery remained high (from 87.1% to 90.3%, P = 1.000), a majority of participants, both BA the conference, expressed concerns about the impact on personal life (from 58.1% to 64.5%, P = 0.774).

Conclusion: This study underscores the role of undergraduate mixed-method conferences in augmenting understanding of neurosurgery and nurturing early interest.

Background: Chordomas are primary bone tumors derived from the embryonic notochord. They represent 1-4% of all malignant bone tumors. They have a predominantly extra-axial location, arising in the clival region in 35% of reported cases. The prognosis is generally poor, and radical resection remains the first-line treatment. This study aims to describe a case of a clival chordoma that was resected through a combined microscopic transoral and endoscopic endonasal approach, with excellent clinical outcomes.

Case description: A 24-year-old woman with low cranial nerve symptomatology was admitted for a two-stage surgical approach. An occipital-cervical fixation was performed in the first stage, while a combined endonasaltransoral resection was performed later for tumor resection.

Conclusion: Microscopic transoral and endoscopic endonasal approaches offer advantages for treating clival chordomas, with careful consideration of anatomical constraints and potential for postoperative recurrence being essential in approach selection.