Author: cba

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Ventriculosinus shunt: a pilot study to investigate new technology to treat hydrocephalus and mimic physiological principles of cerebrospinal fluid drainage

J Neurosurg 139:1412–1419, 2023

Devices draining CSF to the intracranial venous sinus for the treatment of hydrocephalus have been tested in the past, and while clinically effective, have not shown efficacy in the long term. The majority of these devices become obstructed within 3 months due to endothelial overgrowth. In this study, the authors investigated a newly developed ventriculosinus (VS) shunt outlet device with the objective of showing it would remain patent for at least 6 months.

METHODS Twelve patients in need of shunting for hydrocephalus underwent an operation using the investigational device and were followed for 6 months to record patency of the shunt.

RESULTS In 10 patients, the shunt was patent at 6 months, with the outlet device remaining unobstructed. In the remaining 2 patients, one died just before reaching the 6-month endpoint, and in the other the outlet was misplaced during surgery and therefore ceased to function after 3 months. No occlusion of the internal jugular vein or thrombus formation was noted in any of the 12 cases.

CONCLUSIONS These findings indicate that the outlet device can remain patent and has the capability to mimic physiological drainage by diverting CSF to the intracranial sinus. Additional confirmation of its potential as part of a new VS shunt system and ultimately as a viable alternative for ventriculoperitoneal and ventriculoatrial shunting to reduce complication rates requires further clinical trials.

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Preoperative Microsoft HoloLens 2 planning‑assisted surgical clipping of a fetal posterior cerebral artery aneurysm

Acta Neurochirurgica (2023) 165:3371–3374

The treatment of intracranial aneurysms has predominantly shifted towards endovascular strategies, but complex cases still necessitate microsurgery. Preoperative stimulation can be beneficial for inexperienced young neurosurgeons in preparing for safe microsurgery.

Method A 72-year-old female with a left irregular fetal posterior cerebral artery (PCA) aneurysm underwent clipping repair. Microsoft HoloLens 2, utilizing mixed reality technology, was employed for preoperative stimulation and anatomical study. During the operation, we successfully identified the planned relationship between the aneurysm and the fetal PCA. The patient was cured without any complications.

Conclusion We hope that this report will highlight the significance of Microsoft HoloLens 2 in microsurgical planning and education.

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Trends in the size of treated unruptured intracranial aneurysms over 35 years

J Neurosurg 139:1328–1338, 2023

In the absence of clear guidelines and consistent natural history data, the decision to treat unruptured intracranial aneurysms (UIAs) is a matter of some controversy. Currently, decisions are often guided by a consensus of cerebrovascular specialist teams and patient preferences. It is unclear how paradigm-shifting developments in the detection and treatment of UIAs have affected the size of the UIAs that are selected for treatment. Herein, the authors aimed to study potential changes in the average size of the UIAs that were treated over time. They hypothesized that the average size of UIAs that are treated is decreasing over time.

METHODS A systematic search of the literature was performed to identify all studies describing the size of UIAs that were treated using any modality. Scatter diagrams with trend lines were used to plot the size of the aneurysms treated over time and assess for the presence of a potentially significant trend via statistical correlation tests. Subgroup analyses based on type of treatment, country of study, and specialty of the authors were performed.

RESULTS A total of 240 studies including 35,150 UIAs treated between 1987 and 2021 met all eligibility criteria and were entered in the analysis. The mean age of patients was 55.5 years, and 70.7% of the patients were females. There was a significant decrease in the size of treated UIAs over time (Spearman’s r = −0.186, p < 0.001), with a 0.71-mm decrease in the average size of treated UIAs every 5 years since 1987 and an annual mean dropping below 7 mm in 2012. This decreasing trend was present in surgically and endovascularly treated UIAs (p < 0.001 for both), in more developed and developing countries (p < 0.001 for both), within neurosurgical and non-neurosurgical specialties (p < 0.001 for both), most prominently in the US (Spearman’s r = −0.482, p < 0.001), and less prominently in Europe (Spearman’s r = −0.221, p < 0.001) and was not detected in East Asia.

CONCLUSIONS The present study indicates that based on the treated UIA size data published in the literature over the past 35 years, smaller UIAs are being treated over time. This trend is likely driven by safer treatments. However, future studies should elucidate the cost-effectiveness of treating smaller UIAs as well as the possible real-world contribution of this trend in preventing aneurysmal subarachnoid hemorrhage.

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Middle Meningeal Artery Embolization in Adjunction to Surgical Evacuation for Treatment of Subdural Hematomas

Neurosurgery 93:1082–1089, 2023

Surgical evacuation is the standard treatment for chronic subdural hematomas (CSDHs) but is associated with a high risk of recurrence and readmission. Middle meningeal artery embolization (MMAE) is a novel treatment approach which could be performed upfront or in adjunction to surgical evacuation. MMAE studies are limited by small sample sizes. This study aimed to describe and compare outcomes of MMAE in adjunction to surgery with those of surgery alone on a national level.

METHODS: The national Vizient Clinical Database was queried by use of a specific validated set of International Classification of Diseases, Tenth Revision codes (October 2018-June 2022). Patients with the diagnosis of nontraumatic CSDH who received MMAE and surgical drainage in the same hospitalization were identified, and their outcomes were compared with isolated surgical drainage.

RESULTS: A total of 606 subjects from 156 institutes and 6340 subjects from 369 institutes were included in the MMAE plus surgery (M&S) and surgery groups, respectively. Average length of stay was significantly longer in the M&S group (9.87 vs 7.53 days; P < .01). There was no significant difference in the in-hospital mortality rate (2.8% vs 2.9%), but the complication rate was significantly higher in the M&S group (8.7% vs 5.5%; P < .01). Complications that were significantly more common in the M&S group included aspiration pneumonia, postoperative sepsis, and anesthesia-related. Mean direct costs were significantly higher in the M&S group (28 834 vs 16 292 US dollars; P < .01). The 30-day readmission rate was significantly lower in the M&S group compared with the surgery group (4.2% vs 8.0%; P < .01).

CONCLUSION: This analysis of large-scale national data indicates that MMAE performed in adjunction to surgery for treatment of CSDH is associated with higher direct costs, higher complication rates, and longer length of stay but lower readmission rates compared with surgical evacuation alone.

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Predictors of Progression-Free Survival in Patients With Spinal Intramedullary Ependymoma: A Multicenter Retrospective Study by the Neurospinal Society of Japan

Neurosurgery 93:1046–1056, 2023

Ependymoma is the most common spinal intramedullary tumor. Although clinical outcomes have been described in the literature, most of the reports were based on limited numbers of cases or been confined to institutional experience. The objective of this study was to analyze more detailed characteristics of spinal intramedullary ependymoma (SIE) and provide clinical factors associated with progression-free survival (PFS).

METHODS: This retrospective observational multicenter study included consecutive patients with SIE in the cervical or thoracic spine treated surgically at a total of 58 institutions between 2009 and 2020. The results of pathological diagnosis at each institute were confirmed, and patients with myxopapillary ependymoma, subependymoma, or unverified histopathology were strictly excluded from this study. Outcome measures included surgical data, surgery-related complications, postoperative systemic adverse events, postoperative adjuvant treatment, postoperative functional condition, and presence of recurrence.

RESULTS: This study included 324 cases of World Health Organization grade II (96.4%) and 12 cases of World Health Organization grade III (3.6%). Gross total resection (GTR) was achieved in 76.5% of cases. Radiation therapy (RT) was applied after surgery in 16 cases (4.8%), all of which received local RT and 5 of which underwent chemotherapy in combination. Functional outcomes were significantly affected by preoperative neurological symptoms, tumor location, extent of tumor resection, and recurrence. Multivariate regression analysis suggested that limited extent of tumor resection or recurrence resulted in poor functional outcomes. Multiple comparisons among the groups undergoing GTR, subtotal resection and biopsy, or partial resection of the tumor showed that the probability of PFS differed significantly between GTR and other extents of resection.

CONCLUSION: When GTR can be safely obtained in the surgery for SIE, functional maintenance and longer PFScan be expected.

 

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Complications of the Prone Transpsoas Lateral Lumbar Interbody Fusion for Degenerative Lumbar Spine Disease: A Multicenter Study

Neurosurgery 93:1106–1111, 2023

The prone transpsoas (PTP) approach for lateral lumbar interbody fusion (LLIF) is a novel technique for degenerative lumbar spine disease. However, there is a paucity of information in the literature on the complications of this procedure, with all published data consisting of small samples. We aimed to report the intraoperative and postoperative complications of PTP in the largest study to date.

METHODS: A retrospective electronic medical record review was conducted at 11 centers to identify consecutive patients who underwent LLIF through the PTP approach between January 1, 2021, and December 31, 2021. The following data were collected: intraoperative characteristics (operative time, estimated blood loss [EBL], intraoperative complications [anterior longitudinal ligament (ALL) rupture, cage subsidence, vascular and visceral injuries]), postoperative complications, and hospital stay.

RESULTS: A total of 365 patients were included in the study. Among these patients, 2.2% had ALL rupture, 0.3% had cage subsidence, 0.3% had a vascular injury, 0.3% had a ureteric injury, and no other visceral injuries were reported. Mean operative time was 226.2 ± 147.9 minutes. Mean EBL was 138.4 ± 215.6 mL. Mean hospital stay was 2.7 ± 2.2 days. Postoperative complications included new sensory symptoms—8.2%, new lower extremity weakness—5.8%, wound infection—1.4%, cage subsidence—0.8%, psoas hematoma—0.5%, small bowel obstruction and ischemia—0.3%, and 90-day readmission—1.9%.

CONCLUSION: In this multicenter case series, the PTP approach was well tolerated and associated with a satisfactory safety profile.

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Combined subtarsal contralateral transmaxillary retroeustachian and endoscopic endonasal approaches to the infrapetrous region

J Neurosurg 139:992–1001, 2023

The eustachian tube (ET) limits endoscopic endonasal access to the infrapetrous region. Transecting or mobilizing the ET may result in morbidities. This study presents a novel approach in which a subtarsal contralateral transmaxillary (ST-CTM) corridor is coupled with the standard endonasal approach to facilitate access behind the intact ET.

METHODS Eight cadaveric head specimens were dissected. Endoscopic endonasal approaches (EEAs) (i.e., transpterygoid and inferior transclival) were performed on one side, followed by ST-CTM and sublabial contralateral transmaxillary (SL-CTM) approaches on the opposite side, along with different ET mobilization techniques on the original side. Seven comparative groups were generated. The length of the cranial nerves, areas of exposure, and volume of surgical freedom (VSF) in the infrapetrous regions were measured and compared.

RESULTS Without ET mobilization, the combined ST-CTM/EEA approach provided greater exposure than EEA alone (mean ± SD 288.9 ± 40.66 mm 2 vs 91.7 ± 49.9 mm 2 ; p = 0.001). The VSFs at the ventral jugular foramen (JF), entrance to the petrous internal carotid artery (ICA), and lateral to the parapharyngeal ICA were also greater in ST-CTM/EEA than in EEA alone (p = 0.002, p = 0.002, and p < 0.001, respectively). EEA alone, however, provided greater VSF at the hypoglossal canal (HGC) than did ST-CTM/EEA (p = 0.01). The SL-CTM approach did not increase the EEA exposure (p = 0.48). The ST-CTM/EEA approach provided greater exposure than EEA with extended inferolateral (EIL) or anterolateral (AL) ET mobilization (p = 0.001 and p = 0.02, respectively). The ST-CTM/EEA also increased the VSF lateral to the parapharyngeal ICA in comparison with EEA/EIL ET mobilization (p < 0.001) but not with EEA/AL ET mobilization (p = 0.36). Finally, the VSFs at the HGC and JF were greater in EEA/AL ET mobilization than in ST-CTM/EEA without ET mobilization (p = 0.002 and p = 0.004, respectively).

CONCLUSIONS Combining the EEA with the more laterally and superiorly originating ST-CTM approach allows greater exposure of the infrapetrous and ventral JF regions while obviating the need for mobilizing the ET. The surgical freedom afforded by the combined approaches is greater than that obtained by EEA alone.

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Endoscopic odontoidectomy for brainstem compression in association with posterior fossa decompression and occipitocervical fusion

J Neurosurg 139:1152–1159, 2023

Endonasal endoscopic odontoidectomy (EEO) is an alternative to transoral surgery for symptomatic ventral compression of the anterior cervicomedullary junction (CMJ), allowing for earlier extubation and feeding. Because the procedure destabilizes the C1–2 ligamentous complex, posterior cervical fusion is often performed concomitantly. The authors’ institutional experience was reviewed to describe the indications, outcomes, and complications in a large series of EEO surgical procedures in which EEO was combined with posterior decompression and fusion.

METHODS A consecutive, prospective series of patients who underwent EEO between 2011 and 2021 was studied. Demographic and outcome metrics, radiographic parameters, extent of ventral compression, extent of dens removal, and increase in CSF space ventral to the brainstem were measured on the preoperative and postoperative scans (first and most recent scans).

RESULTS Forty-two patients (26.2% pediatric) underwent EEO: 78.6% had basilar invagination, and 76.2% had Chiari type I malformation. The mean ± SD age was 33.6 ± 3.0 years, with a mean follow-up of 32.3 ± 4.0 months. The majority of patients (95.2%) underwent posterior decompression and fusion immediately before EEO. Two patients underwent prior fusion. There were 7 intraoperative CSF leaks but no postoperative CSF leaks. The inferior limit of decompression fell between the nasoaxial and rhinopalatine lines. The mean ± SD vertical height of dens resection was 11.98 ± 0.45 mm, equivalent to a mean ± SD resection of 74.18% ± 2.56%. The mean increase in ventral CSF space immediately postoperatively was 1.68 ± 0.17 mm (p < 0.0001), which increased to 2.75 ± 0.23 mm (p < 0.0001) at the most recent follow-up (p < 0.0001). The median (range) length of stay was 5 (2–33) days. The median time to extubation was 0 (0–3) days. The median time to oral feeding (defined as, at minimum, toleration of a clear liquid diet) was 1 (0–3) day. Symptoms improved in 97.6% of patients. Complications were rare and mostly associated with the cervical fusion portion of the combined surgical procedures.

CONCLUSIONS EEO is safe and effective for achieving anterior CMJ decompression and is often accompanied by posterior cervical stabilization. Ventral decompression improves over time. EEO should be considered for patients with appropriate indications.

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Midline lumbar interbody fusion: a review of the surgical technique and outcomes

J Neurosurg Spine 39:462–470, 2023

Midline lumbar interbody fusion (MidLIF) is a mini-open posterior interbody fusion technique defined by a cortical screw trajectory wherein screws are placed from a more medial to lateral trajectory compared with traditional pedicle screws. This enables the surgeon to perform a smaller muscle dissection with the benefits of improved blood loss, less muscle retraction, decreased operative time, shorter length of stay, and improved back pain outcomes compared with the traditional posterior lumbar interbody fusion techniques utilizing pedicle screw fixation.

Importantly, MidLIF offers comparable clinical outcomes and radiographic outcomes to other posterior lumbar interbody fusion techniques.

In the current review, the authors aimed to educate readers about the MidLIF surgical technique, as well as surgical, clinical, radiographic, cost effectiveness, and biomechanical outcomes, when compared with both open and minimally invasive posterior lumbar interbody fusion techniques with pedicle screw fixation.

Readers will be able to utilize this information to determine how the MidLIF procedure compares as an alternative to traditional techniques.

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Robot-assisted percutaneous pedicle screw placement accuracy compared with alternative guidance in lateral single-position surgery

J Neurosurg Spine 39:443–451, 2023

While single-position surgery (SPS) eliminates the need for patient repositioning, the placement of screws in the unconventional lateral position poses unique challenges related to asymmetry relative to the surgical table. Use of robotic guidance or intraoperative navigation can help to overcome this. The aim of this study was to compare the relative accuracies offered by these various navigation modalities for pedicle screws placed in lateral SPS.

METHODS According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the PubMed/Medline, Embase, and Cochrane Library databases were queried for studies reporting pedicle screw placement accuracy using fluoroscopic, CT-navigated, O-arm, or robotic guidance in lateral SPS, and a systematic review and meta-analysis was performed. Included studies all compared evaluated screw placement accuracy in lateral SPS using a single navigation method. Quality assessment was performed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system; risk of bias was assessed using the Newcastle-Ottawa Scale and the Joanna Briggs Institute checklist. The primary outcome, rate of pedicle screw breach, was analyzed using random-effects meta-analysis.

RESULTS Eleven studies were included comprising 548 patients who underwent the placement of instrumentation with 2488 screws. For the fluoroscopic, CT-navigated, O-arm, and robotic guidance cohorts, there were 3, 2, 3, and 3 studies, respectively. Breach rates by modality were as follows: fluoroscopic guidance (6.6%), CT navigation (4.7%), O-arm (3.9%), and robotic guidance (3.9%). Random-effects meta-analysis showed a significant difference between studies, with an overall breach rate of 4.9% (95% CI 3.1%–7.5%; p < 0.001); however, testing for subgroup differences failed to show a significant difference between guidance modalities (Q M = 0.69, df = 3; p = 0.88). Heterogeneity between studies was significant (I 2 = 79.0%, τ 2 = 0.41, χ 2 = 47.65, df = 10; p < 0.001).

CONCLUSIONS Robotic guidance of screws is noninferior to alternative guidance modalities in lateral SPS; however, additional prospective studies directly comparing different guidance types are merited.

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Surgical, functional, and oncological considerations regarding awake resection for giant diffuse lower-grade glioma of more than 100 cm3

J Neurosurg 139:934–943, 2023

Surgery for giant diffuse lower-grade gliomas (LGGs) is challenging, and very few data have been reported on this topic in the literature. In this article, the authors investigated surgical, functional, and oncological aspects in patients who underwent awake resection for large LGGs with a volume > 100 cm3.

METHODS The authors retrospectively reviewed a consecutive cohort of patients who underwent surgery in an awake condition for an LGG (WHO grade 2 with possible foci of grade 3 transformation) with a volume > 100 cm3.

RESULTS A total of 108 patients were included, with a mean age of 36.1 ± 8.5 years. The mean presurgical LGG volume was 136.7 ± 34.5 cm3. In all but 2 patients a disconnection resective surgery up to functional boundaries was possible thanks to active patient collaboration during the awake period. At 3 months of follow-up, all but 1 patient had a normal neurological examination, with a mean Karnofsky Performance Status (KPS) score of 89.8 ± 10.36. In all patients with preoperative epilepsy, there was postoperative control or significant reduction of seizure events. Moreover, 85.1% of patients returned to work. The mean extent of resection (EOR) was 88.9% ± 7.0%, with a mean residual tumor volume (RTV) of 16.3 ± 12.0 cm3 (median RTV 15 cm3). Pathological examination revealed 73 grade 2 gliomas (67.6%; 26 oligodendrogliomas and 47 astrocytomas) and 35 gliomas with foci of grade 3 (32.4%; 19 oligodendrogliomas and 16 astrocytomas). During the postoperative period, 93.6% of patients underwent adjuvant chemotherapy with a median interval between surgery and first chemotherapy of 14 months (IQR 2–26 months), and 55% of patients had radiotherapy with a median interval of 38.5 months (IQR 18–59.8 months). At the last follow-up, 69.7% of patients were still alive with a median follow-up of 62 months (IQR 36–99 months). Overall survival (OS) rates at 1, 5, and 10 years were 100% (95% CI 0.99–1), 80% (95% CI 0.72–0.9), and 58% (95% CI 0.45–0.73), respectively. The median OS was 138 months. In multivariable Cox regression analysis, RTV was established as the only independent prognostic factor for survival.

CONCLUSIONS With the application of rigorous surgical methodology based on functional-guided resection, resection of giant LGGs (volume > 100 cm3) can be reproducibly achieved during surgery with patients under awake mapping with both favorable functional results (< 1% permanent neurological worsening) and favorable long-term oncological outcomes (median OS > 11 years, with a more significant benefit when the RTV is < 15 cm3).

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Patient-Reported Outcomes After Focused Ultrasound Thalamotomy for Tremor-Predominant Parkinson’s Disease

Neurosurgery 93:884–891, 2023

Magnetic resonance–guided focused ultrasound (MRgFUS) has emerged as a precise, incisionless approach to cerebral lesioning and an alternative to neuromodulation in movement disorders. Despite rigorous clinical trials, long-term patient-centered outcome data after MRgFUS for tremor-predominant Parkinson’s Disease (TPPD) are relatively lacking.

OBJECTIVE: To report long-term data on patient satisfaction and quality of life after MRgFUS thalamotomy for TPPD.

METHODS: In a retrospective study of patients who underwent MRgFUS thalamotomy for TPPD at our institution between 2015 and 2022, a patient survey was administered to collect self-reported measures of tremor improvement, recurrence, Patients’ Global Impression of Change (PGIC), and side effects. Patient demographics, FUS parameters, and lesion characteristics were analyzed.

RESULTS: A total of 29 patients were included with a median follow-up of 16 months. Immediate tremor improvement was achieved in 96% of patients. Sustained improvement was achieved in 63% of patients at last follow-up. Complete tremor recurrence to baseline occurred for 17% of patients. Life quality improvement denoted by a PGIC of 1 to 2 was reported by 69% of patients. Long-term side effects were reported by 38% of patients and were mostly mild. Performing a secondary anteromedial lesion to target the ventralis oralis anterior/posterior nucleus was associated with higher rates of speech-related side effects (56% vs 12%), without significant improvement in tremor outcomes.

CONCLUSION: Patient satisfaction with FUS thalamotomy for tremor-predominant PD was very high, even at longer term. Extended lesioning to target the motor thalamus did not improve tremor control and may contribute to greater frequency of postoperative motor- and speech-related side effects.

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Outcome of 107 conservatively managed unruptured brain arteriovenous malformations

J Neurosurg 139:1025–1035, 2023

Since the publication of A Randomized Trial of Unruptured Brain AVMs (ARUBA), the management of unruptured brain arteriovenous malformations (bAVMs) has been controversially discussed. Long-term follow-up data on the exclusively conservative management of unruptured bAVMs are scarce. The authors evaluated the long-term outcomes of patients with unruptured untreated bAVMs in a real-life cohort.

METHODS A retrospective observational cohort of 107 patients (of 897 bAVM patients referred to the authors’ institution) with a diagnosis of unruptured and conservatively managed bAVMs is presented. AVMs of all Spetzler-Martin grades were observed. The mean follow-up period was 84 months. In 44% of patients, a follow-up period of 5 years or longer was observed. A national death register comparison completed the outcome analysis.

RESULTS The median age at diagnosis, sex distribution, neurological presentation, and modified Rankin Scale score were comparable to the patients in the medical management arm of the ARUBA study. Patients were mainly young, predominantly male, and in good clinical condition. Similar to the ARUBA cohort, 77% of this study’s cohort presented in an excellent clinical status at the time of last follow-up. However, 17% of patients had at least one hemorrhage, resulting in an overall annual hemorrhage risk of 2.7% in the observation period. Moreover, the cumulative 1-, 5-, and 10-year overall hemorrhage rates were 3.0%, 11.3%, and 15.3%, respectively. Consequently, the long-term follow-up AVM-related mortality rate amounted to 8%. The estimated median overall survival after AVM diagnosis was 19.3 years (95% CI 14.024.6 years). A multivariate Cox regression model revealed temporal and deep-seated localization as an independent risk factor for AVM hemorrhage, while the presence of seizures reached borderline significance as a risk factor.

CONCLUSIONS The authors’ results represent the long-term course of unruptured untreated bAVMs. Their data support the conclusion that even in the post-ARUBA era, tailored active treatment options may be offered to patients with unruptured bAVMs. For patient counseling, individual risk factors should be weighed against the center’s treatmentspecific risks.

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Modification to the Hartel Route Radiofrequency Technique for the Treatment of Trigeminal Neuralgia: A Technical Note

World Neurosurg. (2023) 178:14-19

OBJECTIVE: To evaluate a modification to the classical Hartel technique for the treatment of trigeminal neuralgia.

METHODS: Intraoperative radiographs of 30 patients with trigeminal neuralgia treated with radiofrequency were retrospectively reviewed. The distance between the needle and the anterior edge of the temporomandibular joint (TMJ) was measured on strict lateral skull radiographs. Surgical time was reviewed, and clinical outcomes were evaluated.

RESULTS: All patients showed clinical improvement in pain (Visual Analog Scale). In all radiographs, the measurement between the needle and the anterior edge of the TMJ ranged from 10 mm to 22 mm. None of the measurements were below 10 mm or above 22 mm. In most cases, this distance was 18 mm (9 patients), followed by 16 mm in 5 patients.

CONCLUSIONS: Considering the inclusion of the oval foramen in a Cartesian coordinate system with axes X, Y, and Z is useful. Directing the needle to a point located 1 cm from the anterior edge of the TMJ, avoiding the medial aspect of the upper jaw ridge, allows for a safer and faster procedure.

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Endoscopic endonasal transclival approach for clipping of the ruptured vertebral artery aneurysm

Acta Neurochirurgica (2023) 165:2825–2830

Vertebral artery aneurysms account for less than 5% of all cerebral aneurysms. They have a high risk of rupture and are associated with threatening clinical outcomes compared with anterior circulation aneurysms.

Method The endoscopic endonasal transclival approach (EETA) was used. During the temporary clipping, the neck of the aneurysm was dissected, and a permanent clip was applied. The repair of the skull base defect was carried out with the nasoseptal mucoperiosteal flap on the vascular pedicle.

Conclusion The EETA is a feasible alternative for the clipping of the medially located ruptured vertebral artery aneurysm. EETA can be recommended for centers with a large volume of cerebrovascular and endoscopic neurosurgical procedures.

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Biomechanical Comparison of Facet Versus Laminar C2 Screws

Neurosurgery 93:910–917, 2023

Transpedicular or transisthmic screws for C2 instrumentation represent the gold standard; however, the anatomy is not always compatible (hypoplastic pedicles, procidentia of the vertebral artery). Laminar screws (LS) have been proposed as a rescue technique and recently, bicortical facet screws (FS). To date, the biomechanical property of FS remains unknown.

OBJECTIVE: To compare the pull-out resistance of bicortical facet (FS) vs laminar (LS) C2 screws.

METHODS: Thirty-two human cadaveric C2 vertebrae were screened by CT scan imaging and dual x-ray absorptiometry before receiving both techniques and were randomized according to side and sequence (FS or LS first). Screw positioning was validated using 2-dimensional x-rays. Sixty-four mechanical tests were performed using pure tensile loading along the axis of the screws until pull-out. Mean pull-out strengths were compared using paired tests, multivariate and survival analysis (Kaplan-Meier curves).

RESULTS: The morphometric data were consistent with previous studies. Over 64 tests, the mean pull-out strength of LS (707 ± 467 N) was significantly higher than that of FS (390 ± 230 N) (P = .0004). Bone mineral density was weakly correlated with pull-out strength (r = 0.42 for FS and r = 0.3 for LS). Both techniques were mechanically equivalent for vertebrae in which intralaminar cortical grip was not achievable for LS. The mean pull-out strength for LS with laminar cortical grip (1071 ± 395 N) was significantly higher than that of LS without (423 ± 291 N) (P < .0001).

CONCLUSION: Our results suggest that bicortical FS of C2 offer less mechanical resistance than LS.

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HummingFlow: novel single twist-drill access for ventricular drainage, irrigation, monitoring, and automated local drug delivery in subarachnoid hemorrhage

J Neurosurg 139:1036–1041, 2023

The management of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage (aSAH) remains one of the most important targets for neurocritical care. Advances in monitoring technology have facilitated a more thorough understanding of the pathophysiology and therapeutic approaches, but interventions are generally limited to either systemic therapies or passive CSF drainage. The authors present a novel approach that combines a multimodal monitoring bolt-based system with an irrigating ventricular drain capable of delivering intrathecal medications and describe their early experience in patients with aSAH.

METHODS The authors performed a retrospective review of cases treated with the combined Hummingbird multimodal bolt system and the IRRAflow irrigating ventriculostomy.

RESULTS Nine patients were treated with the combined multimodal bolt system with irrigating ventriculostomy approach. The median number of days to clearance of the third and fourth ventricles was 3 days in patients with obstructive intraventricular hemorrhage. Two patients received intrathecal alteplase for intraventricular hemorrhage clearance, and 2 patients received intrathecal nicardipine as rescue therapy for severe symptomatic angiographic vasospasm.

CONCLUSIONS Combined CSF drainage, irrigation, multimodality monitoring, and automated local drug delivery are feasible using a single twist-drill hole device. Further investigation of irrigation settings and treatment approaches in high-risk cases is warranted.

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Endoscopic far‑lateral supracerebellar infratentorial approach for resection of dumbbell‑shaped trigeminal schwannoma

Acta Neurochirurgica (2023) 165:2913–2921

Trigeminal schwannomas (TSs) are mostly benign tumors. However, dumbbell-shaped TSs are most challenging for surgeons and pose a high surgical risk.

Objective We describe the technique of the purely endoscopic far-lateral supracerebellar infratentorial approach (EFLSCITA) for removing dumbbell-shaped TSs and further discuss the feasibility of this approach and our experience. Methods EFL-SCITA was performed for resection of 5 TSs between January 2020 and March 2023. The entire procedure was performed endoscopically with the goal of total tumor resection. During the operation, the tumor was exposed in close proximity and multiple angles under the endoscope, and the peri-tumor nerves were carefully identified and protected, especially the normal trigeminal fiber bundles around the tumor.

Results All the tumors of 5 patients involved the middle and posterior cranial fossa, of which total removal was achieved in 2 patients and near-total removal in 3 patients. The most common preoperative symptoms were relieved after surgery. Two patients had postoperative mild facial paralysis (House-Brackmann grade II), and 1 patient had abducens palsy; both recovered during the follow-up period. Two patients experienced new postoperative facial hypesthesia, and 1 experienced mastication weakness, which did not recover. There was no tumor recurrence or residual tumor growth during the follow-up period in any of the patients.

Conclusion EFL-SCITA is a new and effective alternative for the surgical treatment of TSs. For dumbbell-shaped TSs, this approach provides sufficient surgical field exposure and freedom of operation.

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Minimally Invasive Transforaminal Lumbar Interbody Fusion in the Ambulatory Surgery Center Versus Inpatient Setting: A 1-Year Comparative Effectiveness Analysis

Neurosurgery 93:867–874, 2023

Ambulatory surgery centers (ASCs) have emerged as an alternative setting for surgical care as part of the national effort to lower health care costs. The literature regarding the safety of minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) in the ASC setting is limited to few small case series.

OBJECTIVE: To assess the safety and efficacy of MIS TLIF performed in the ASC vs inpatient hospital setting.

METHODS: A total of 775 patients prospectively enrolled in the Quality Outcomes Database undergoing single-level MIS TLIF at a single ASC (100) or the inpatient hospital setting (675) were compared. Propensity matching generated 200 patients for analysis (100 per cohort). Demographic data, resource utilization, patient-reported outcome measures (PROMs), and patient satisfaction were assessed.

RESULTS: There were no significant differences regarding baseline demographic data, clinical history, or comorbidities after propensity matching. Only 1 patient required inpatient transfer from the ASC because of intractable pain. All other patients were discharged home within 23 hours of surgery. The rates of 90-day readmission (2.0%) and reoperation (0%) were equivalent between groups. Both groups experienced significant improvements in all PROMs (Oswestry Disability Index, EuroQol-5D, back pain, and leg pain) at 3 months that were maintained at 1 year. PROMs did not differ between groups at any time point. Patient satisfaction was similar between groups at 3 and 12 months after surgery.

CONCLUSION: In carefully selected patients, MIS TLIF may be performed safely in the ASC setting with no statistically significant difference in safety or efficacy in comparison with the inpatient setting.

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Convergence of the arcuate fasciculus and third branch of the superior longitudinal fasciculus with direct cortical stimulation–induced speech arrest area in the anterior ventral precentral gyrus

J Neurosurg 139:1140–1151, 2023

The objective was to identify the correspondence between the anterior terminations of the arcuate fasciculus (AF) and third branch of the superior longitudinal fasciculus (SLF-III) and the intraoperative direct cortical electrical stimulation (DCS)–induced speech arrest area.

METHODS The authors retrospectively screened 75 glioma patients (group 1) who received intraoperative DCS mapping in the left dominant frontal cortex. To minimize the influence of tumors or edema, we subsequently selected 26 patients (group 2) with glioma or edema not affecting Broca’s area, the ventral precentral gyrus (vPCG), and the subcortical pathways to generate DCS functional maps and to construct the anterior terminations of AF and SLF-III with tractography. Next, a grid-by-grid pairwise comparison was performed between the fiber terminations and the DCS-induced speech arrest sites to calculate Cohen’s kappa coefficient (κ) in both groups 1 and 2. Finally, the authors also demonstrated the distribution of the AF/SLF-III anterior projection maps obtained in 192 healthy participants (group 3) and subsequently correlated these with the speech arrest sites in group 2 to examine their validity in predicting speech output area.

RESULTS The authors found that speech arrest sites were substantially consistent with SLF-III anterior terminations (group 1, κ = 0.64 ± 0.03; group 2, κ = 0.73 ± 0.05) and moderately consistent with AF (group 1, κ = 0.51 ± 0.03; group 2, κ = 0.49 ± 0.05) and AF/SLF-III complex (group 1, κ = 0.54 ± 0.03; group 2, κ = 0.56 ± 0.05) terminations (all p < 0.0001). The DCS speech arrest sites of the group 2 patients mainly (85.1%) emerged at the anterior bank of the vPCG (vPCGa). In group 3, both terminations of AF and SLF-III converged onto the vPCGa, and their terminations well predicted the DCS speech output area of group 2 (AF, area under the curve [AUC] 86.5%; SLF-III, AUC 79.0%; AF/SLF-III complex, AUC 86.7%).

CONCLUSIONS This study supports the key role of the left vPCGa as the speech output node by showing convergence between speech output mapping and anterior AF/SLF-III connectivity in the vPCGa. These findings may contribute to the understanding of speech networks and could have clinical implications in preoperative surgical planning.

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