Surgical neurology international最新文献

Background: Vagus nerve stimulation (VNS) is currently approved for conditions such as drug-resistant epilepsy and stroke with promising results. In addition, it is also being investigated for many other conditions. The goal of this study is to review the scope of VNS clinical trials.

Methods: We conducted a retrospective review of active and completed clinical trials using ClinicalTrials.gov, with "Vagus Nerve Stimulation" as the search term. The number of studies taking place over time was assessed using Pearson correlation coefficient.

Results: An examination of ClinicalTrials.gov revealed 440 clinical trials, with 346 meeting our inclusion criteria. The number of VNS clinical trials increased annually from 2000 to 2024, demonstrating exponential growth after 2015 (P < 0.001, R² = 0.924). Of these, 42.5% were completed, with published results being available for 9.8% of the completed trials. Completed trials were predominantly from the United States, spanning various conditions including a wide variety of disorders such as cardiovascular diseases (n = 38), chronic pain disorders (n = 31), gastrointestinal disorders (n = 24), autoimmune disorders (n = 23), neurodegenerative diseases (n = 19), COVID-19 (n = 13) and diabetes (n = 11). Among the included trials, 86% were non-invasive with 91% of trials with results reporting improvements in symptoms.

Conclusion: This increasing number of trials assessing a wide breadth of clinical disorders suggests the promising future of VNS as from the currently approved treatments. Physicians should familiarize themselves with these results and potentially upcoming indications for VNS.

Background: Diffusion-weighted imaging (DWI) detects ischemic injury after microsurgical clipping of unruptured intracranial aneurysms (UIAs), yet non-ischemic parenchymal effects remain poorly characterized. This study evaluated early postoperative T2-weighted imaging (T2WI) abnormalities to characterize corridor-related tissue impact and identify anatomical determinants of non-ischemic parenchymal changes.

Methods: This retrospective study analyzed 797 anterior circulation UIA clipping procedures performed by a single surgeon under uniform protocol. Early postoperative magnetic resonance imaging (day 4-5) and 12-month follow-up were obtained. T2WI hyperintensities without restricted diffusion were classified as non-ischemic parenchymal changes. Stratified analyses isolated the effects of aneurysm depth within trans-sylvian (TS) approaches and rectal gyrus separation within interhemispheric (IH) approaches. Multivariate regression identified independent predictors.

Results: Non-ischemic T2WI changes occurred in 20.1% (160/797) of procedures. IH approaches showed significantly higher incidence (50.7%) than TS approaches (13.8%, P < 0.001). Within IH approaches, anterior communicating artery aneurysms demonstrated a higher incidence (68.8%) than distal anterior cerebral artery aneurysms (11.6%, P < 0.001). Independent predictors included IH approach (odds ratio [OR] = 3.34, P < 0.001), deep location (OR = 2.28, P < 0.001), and aneurysm size ≥7 mm (OR = 1.71, P = 0.015). At 12-month follow-up, 97.2% of lesions resolved or decreased. DWI-detected ischemia occurred in 7.0% of procedures. No permanent neurological deficits occurred.

Conclusion: Early postoperative T2WI abnormalities represent a distinct imaging signature of corridor-related tissue impact, strongly associated with approach depth and anatomy. Their reversibility indicates transient mechanical stress rather than permanent injury. T2WI serves as an objective biomarker complementing DWI-based assessment and may inform surgical quality monitoring and patient counseling.

Background: Middle meningeal artery embolization (MMAE) has emerged as a promising adjunct or alternative to surgical evacuation in the management of recurrent chronic subdural hematoma (CSDH). By targeting the vascular supply to the neomembrane, MMAE disrupts the pathological cycle of angiogenesis and microhemorrhage that underlies recurrence. However, direct angiographic evidence of active MMA bleeding into the subdural space remains exceedingly rare, and optimal embolization strategies in such settings are not well established.

Case description: We report a case of a 57-year-old man with recurrent postsurgical CSDH and new neurological deficits. Digital subtraction angiography revealed active contrast extravasation from a distal MMA branch into the subdural drain, suggesting ongoing arterial bleeding. A hybrid embolization approach was performed using a coil to scaffold the site of leakage, followed by Onyx injection to achieve definitive devascularization. Additional embolization of the contralateral MMA was also performed. The patient recovered without complications, and follow-up imaging confirmed near-complete resolution without recurrence.

Conclusion: This case illustrates a rare angiographic finding of active MMA bleeding and supports the use of coil-assisted liquid embolization in technically complex or high-flow situations. A review of current embolization strategies and their pathophysiologic rationale is presented to guide management in similar cases.

Background: Spinal tumors are neoplasms occurring in or around the spinal cord and can be classified based on tissue type and location within the spine. These lesions can lead to spinal cord compression and neurologic deficit. Low- and middle-income countries (LMICs) often face a significant burden of disease due to limited access to healthcare and advanced treatments. We investigate surgical and adjunctive therapies for spinal column tumors in LMICs.

Methods: A systematic search was completed to identify articles related to spinal tumors in LMICs. Data were extracted for study parameters and patient outcomes. Country-specific variables were collected for each country. A pooled meta-analysis was completed with this data.

Results: Of 99 included articles, 67 provided data on gross total resection (GTR), while 39 articles reported use of adjunctive therapies. Since 1990, there has been an increase in the use of both treatments in LMICs; however, there were significant correlations between the use of adjunctive therapy, life expectancy, and access to healthcare.

Conclusion: While treatment and outcomes of spinal column tumors vary within the United States based on socioeconomic factors, including income and gender, this has not been studied on a global scale and in relation to accessibility of specific treatments in LMICs. In this study, we found that specific diagnoses and country income levels were significant drivers of GTR or adjunctive therapy rates. The poor accessibility of these treatments may be overcome with targeted investment, and this should be explored in future research.

Background: Gliomas frequently arise in eloquent cortical regions, where achieving maximal resection while preserving neurological function poses a major challenge. Awake craniotomy (AC) with intraoperative mapping is increasingly employed for this purpose, but its comparative effectiveness against general anesthesia (GA) remains unclear.

Methods: This systematic review conducted under Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in PROSPERO, searched PubMed, Embase, Cochrane Library, and Scopus for English-language studies published from 2015 to 2025. Eligible studies compared AC and GA in adults with supratentorial gliomas and reported outcomes on extent of resection, neurological preservation, survival, safety, quality of life, or cost-effectiveness. Data extraction was performed independently by three reviewers, and study quality was assessed with Risk of Bias 2, Newcastle-Ottawa Scale, or AMSTAR 2. Due to heterogeneity, findings were synthesized narratively.

Results: Six studies were included (4 primary, 2 reviews); only two directly compared approaches. Extent of resection (P = 0.657, P = 0.17), overall survival (adjusted hazard ratio [HR] 0.84, P = 0.48), and progression-free survival (adjusted HR 0.9, P = 0.66) showed no significant differences. AC cost $2,175 more per case (P < 0.001). Neurocognitive function was generally preserved; psychomotor speed declined most.

Conclusion: Neither approach demonstrated superiority. AC enables functional monitoring but offers no survival benefit and increases costs. Surgical decisions should be individualized. High-quality randomized trials are needed.

Background: Giant cavernous internal carotid artery (ICA) aneurysms present with therapeutic challenges, especially if associated with a persistent primitive trigeminal artery (PPTA). Although flow diverters (FDs) are commonly used, the PPTA can maintain collateral inflow to the aneurysm sac, preventing complete thrombosis.

Case description: A 74-year-old woman presented with progressive oculomotor nerve palsy and visual decline. High-flow external carotid-middle cerebral artery bypass with distal ICA occlusion beyond the aneurysm was performed. The bypass remained patent without infarction, and partial aneurysm thrombosis occurred, whereas PPTA flow was preserved.

Conclusion: This case emphasizes the importance of individual microsurgical strategies if FD treatment may be ineffective due to complex embryonic vascular anatomy.

Background: Large conus-region tumors may be difficult to remove when the tumor-conus interface is indistinct and dense adhesion to the conus/rootlets is present.

Case description: A 47-year-old male with 4 years of leg pain and bladder dysfunction rapidly deteriorated to wheelchair dependence over 1 week. Magnetic resonance imaging showed a large thoracolumbar intradural extramedullary mass with an unclear interface with the conus. Emergency T12-L2 laminectomy was performed. After internal decompression, meticulous sharp dissection along the tumor-neural interface with preservation of surface microvasculature enabled identification of the root of origin and gross-total resection. Pathology confirmed schwannoma. Motor function recovered and he returned to work within 1 month, but sphincter dysfunction persisted. No recurrence was noted at 11 years.

Conclusion: A stepwise strategy - sharp interface dissection with vascular preservation - can facilitate safe gross-total resection of large conus-region tumors despite dense adhesion or an ill-defined interface.

Background: Pediatric tumors of the posterior fossa represent a significant challenge in neurosurgery. Various dural substitutes have been used to repair dural defects, with a wide range of success rates and associated complications. This study aims to evaluate the feasibility of autologous cervical fascia duraplasty, describe surgical technique, and report incidence rates of postoperative complications.

Methods: A retrospective observational study included 24 pediatric patients (1-16 years) with posterior fossa tumors who underwent tumor resection with autologous cervical fascia dural closure at a tertiary hospital in Mexico between 2019 and 2024. Postoperative complications were assessed over 12 months. Tumor resection and watertight dural closure used a 5 × 5 cm fascia graft harvested from the superficial layer of the cervical fascia, with careful preservation of the underlying musculature and occipital nerve. Medical records were reviewed to collect demographic data and postoperative outcomes.

Results: 13 of 24 patients were male (54.2%), and 13 of 24 patients (54.2%) had preoperative hydrocephalus. No procedure-related mortality was observed. Postoperative complications included aseptic meningitis in 2 cases (8.3%) and hydrocephalus requiring VP shunt in 3 cases (12.5%). No cerebrospinal fluid (CSF) fistulas, pseudomeningoceles, or wound dehiscence were observed.

Conclusion: Autologous cervical fascia duraplasty is a safe and effective technique for pediatric posterior fossa tumor surgery, providing reliable watertight closure with low rate of CSF leak, pseudomeningocele, hydrocephalus, and aseptic meningitis. Its accessibility and lower cost make it a practical option in low-resource settings.

Background: Spinal extradural arachnoid cysts (SEACs) represent <1% of all spinal epidural lesions. They mostly occur in the thoracic region and occasionally are thoracolumbar in location. Typically, patients may be asymptomatic or exhibit pain with/without a neurological deficit.

Case description: A 44-year-old female presented with a 5-year history of chronic low back pain and intermittent dysesthesia but had no neurological deficits. The magnetic resonance revealed an extradural cyst at D12-L1, isointense to cerebrospinal fluid (CSF) and displacing the dural sac ventrally. The patient underwent a D12-L1 hemilaminectomy for excision of a thin-walled cyst; there were adhesions to the conus, and we encountered no CSF leakage. Postoperatively, pain rapidly improved, and the patient remains asymptomatic.

Conclusion: A 44-year-old female presented with pain attributed to a T12-L1 dorsal extradural cyst that was successfully removed through a hemilaminectomy, resulting in full resolution of her pain complaints.

Background: Retro-orbital pain occurring during burr-hole irrigation surgery for chronic subdural hematoma (CSDH) is extremely rare.

Case description: A 65-year-old man had undergone burr-hole irrigation surgery for organized CSDH 2 months previously. The patient was referred to our hospital for thick residual hematoma and persistent motor weakness after surgery. Endoscopic removal of the hematoma and the inner membrane was performed under local anesthesia. After half of the inner membrane had been resected, the patient complained of pulsatile pain behind his left eyeball. As the removal of the inner membrane progressed, the patient became agitated reporting the pain to be excruciating. He was sedated in an attempt to resume the surgery; however, this was impossible because the brain had expanded to just beneath the dura mater. Postoperative studies revealed subarachnoid and intracerebral hemorrhages in addition to good brain expansion, while the left internal cerebral artery was dilated compared to preoperative studies. The patient recovered and was able to walk but remained disoriented.

Conclusion: Surgery for organized CSDH with long-term brain compression requires inner membranectomy. However, rapid decompression by aggressive membranectomy increases the risk of intracranial hemorrhage and mortality, and it is often difficult to determine how much of the membrane should be excised. In the present case, the abrupt increase in cerebral blood flow (CBF) may have resulted in hemorrhage, and this could have been avoided if the surgery had been performed in two stages. Retro-orbital pain suggests excessive CBF increase and could be a warning sign to stop surgery immediately.