Tag: Neurosurgery

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Ethical aspects of waiting lists in neurosurgery

Acta Neurochirurgica (2026) 168:135

This narrative review examines the ethical implications of prolonged waiting lists for elective neurosurgery worldwide, using a four-principles bioethics framework (beneficence, nonmaleficence, autonomy, justice). It synthesizes literature, global examples, and case illustrations to show how extended delays can worsen outcomes, increase psychosocial burden, and mask hidden rationing.

The paper identifies systemic drivers of waiting lists—including resource limits, poor management, and policy choices—and argues for multifaceted solutions: transparent prioritization, improved referral and patient-flow systems, strengthened accountability across government, institutions, and clinicians, and better data collection to guide ethically grounded reforms.

Scope Long waiting times and large waiting lists for elective neurosurgery are a persistent global problem, intensified when outpatient and diagnostic delays are included.

Evidence gap Most available waiting-time evidence comes from high-volume non-neurosurgical procedures (e.g., cataract, hip/knee), with limited neurosurgery-specific research and few comprehensive multicenter/multinational datasets.

Clinical & psychosocial harm Delayed neurosurgical care is associated with uncertainty, dissatisfaction, pain/anxiety, severe depression risk, worse outcomes, higher costs, reduced quality of life, inequalities, and erosion of patient trust.

Bioethics—beneficence & nonmaleficence Extended waiting generally conflicts with doing good and avoiding harm by prolonging suffering and enabling deterioration, though limited exceptions exist where delaying surgery can prevent unnecessary procedures (e.g., some disc herniations with potential spontaneous recovery).

Bioethics—autonomy Long waits can undermine patient autonomy by preventing timely treatment aligned with patient wishes, limiting options as conditions evolve, and weakening informed consent when circumstances change between consent and surgery; lack of transparent queue/wait-time information is a key problem.

Bioethics—justice tension Under constrained access, distributive justice principles can conflict; long waiting lists can function as hidden rationing, with risks of unequal access tied to socioeconomic status, age, ethnicity, communication skills, gender, or geography.

Accountability Ethical responsibility for waiting lists spans government (macro resource commitments), hospital management (meso organization/capacity), and physicians (micro-level indications, prioritization, patient information/advocacy), though not equally.

Conclusion & direction Long waiting lists potentially violate three core biomedical principles (beneficence, nonmaleficence, autonomy) and challenge justice; addressing them requires better documentation plus multifaceted reforms beyond simply adding resources, emphasizing transparent prioritization and fair, ethical governance.

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Nighttime surgery increases complication risk in chronic subdural hematoma: a population‑based cohort study

Acta Neurochirurgica (2025) 167:311

This population-based retrospective cohort study of 2,860 adults undergoing chronic subdural hematoma (CSDH) evacuation at a tertiary neurosurgical center (2006–2023) examines whether nighttime procedures increase postoperative risk. Nighttime surgery—defined by local shift boundaries—was independently associated with higher moderate-to-severe complications (OR 1.58), with risk peaking during final night-shift hours, while adjusted recurrence differences were not statistically significant.

The paper details standardized surgical protocols, staffing patterns, sensitivity analyses using alternative nighttime definitions, and multivariable models adjusting for comorbidity and neurological status. Authors conclude that when clinical stability permits, deferring CSDH evacuation to daytime hours may reduce significant complications, while acknowledging retrospective limitations and potential residual confounding.

Nighttime surgery: Undergoing chronic subdural hematoma (CSDH) surgery at night is independently associated with a higher risk of moderate-to-severe postoperative complications compared to daytime surgery (OR 1.58; 95% CI 1.04–2.37; p = 0.028).

Complication risk timing: The risk of complications increases gradually overnight and peaks during the final hours of the night shift, suggesting a circadian or fatigue-related effect.

Absolute risk increase: Nighttime surgery results in a 1.6% absolute increase in moderate-to-severe complications, with a number needed to harm (NNH) of 63, indicating a modest but clinically meaningful risk.

CSDH recurrence: Although recurrence rates were higher after nighttime surgery in unadjusted analysis, this difference was not statistically significant after adjusting for confounders (adjusted OR 1.28; 95% CI 0.98–1.65; p = 0.067).

Complication types: The most common moderate-to-severe complications include subdural empyema (1.4%), surgical site infection requiring revision (0.3%), and cerebral herniation (0.3%).

Clinical recommendation: When feasible and the patient is stable, deferring CSDH surgery to daytime hours is advised to minimize complication risk.

Prior research limitations: Previous studies were often underpowered, used inconsistent nighttime definitions, and found mixed results regarding the safety of nighttime CSDH surgery.

Study limitations: Retrospective design, possible unmeasured confounding, small differences in baseline severity, and limited generalizability to other healthcare settings with different resources or scheduling practices.

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AtlasGPT: a language model grounded in neurosurgery with domain-specific data and document retrieval

J Neurosurg 143:560–567, 2025

AtlasGPT, a neurosurgery-specific large language model grounded in expert-verified sources and retrieval-augmented generation, outperformed GPT-4 and Gemini Advanced on a neurosurgery board exam, showed greater resistance to medical misinformation, and generated more comprehensive, relevant, and well-referenced answer explanations than standard preparation materials.

• AtlasGPT is a neurosurgery-specific large language model (LLM) built on GPT-4 with retrieval-augmented generation (RAG) from trusted neurosurgical sources.

• AtlasGPT outperformed GPT-4 and Gemini Advanced on a 149-question neurosurgery board exam (accuracy: 90.6% vs 80.5%).

• AtlasGPT showed the highest accuracy on spine and imaging-based questions, even without access to image data.

• In adversarial testing, AtlasGPT was more robust to misinformation, being fooled only 14% of the time, compared to 44% for GPT-4 and 68% for Gemini Advanced.

• Expert neurosurgeons rated AtlasGPT’s explanations as more comprehensive, relevant, and better referenced than official board prep materials.

• AtlasGPT did not produce hallucinations or harmful content in its responses.

• The study suggests domain-specific LLMs like AtlasGPT can enhance medical education, decision-making, and exam preparation in complex fields.

• Limitations include use of a single question bank and need for broader source material in future work.

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A novel robot-assisted method for implanting intracortical sensorimotor devices for brain-computer interface studies

J Neurosurg 142:1280–1288, 2025

A novel robot-assisted method for implanting intracortical microelectrode arrays in brain-computer interface studies was successfully demonstrated in a tetraplegic participant. The technique ensured precise placement, facilitating high-quality signal communication for motor control and sensory feedback, with promising implications for restoring upper-limb function.

• A novel robot-assisted method for implanting intracortical microelectrode arrays in brain-computer interface (BCI) studies is presented, focusing on surgical techniques and challenges.

• The technique was applied in a 31-year-old male with tetraplegia, enabling 2D control of a virtual arm with high success rates and maintaining recording quality over time.

• The robotic neurosurgery technique provides high accuracy and time efficiency, reducing human error and surgeon burden in repetitive procedures.

• Preoperative imaging and robotic systems were used for precise planning and execution of array implantations, ensuring minimal cortical damage and high signal quality.

• The study demonstrated that robotic neurosurgery could be successfully translated into BCI device implantation, aiming to restore upper-limb function.

• Future challenges include refining insertion methods, increasing automation, and addressing intraoperative adjustments for microvessels.

• The study was conducted under an investigational device exemption from the US Food and Drug Administration and received institutional review board approval.

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Artificial intelligence as a modality to enhance the readability of neurosurgical literature for patients

J Neurosurg 142:1189–1195, 2025

The study evaluates ChatGPT 3.5 and GPT4’s ability to generate readable, accurate summaries of neurosurgical literature, enhancing patient comprehension. GPT4 showed higher readability and accuracy, suggesting its potential in improving patient education and bridging the gap between medical findings and public understanding.

Study Overview

• Objective: Assess ChatGPT’s ability to generate readable, accurate neurosurgical summaries.

• Methods: Analyzed 150 abstracts from top neurosurgical journals.

• Models Used: GPT3.5 and GPT4.

Findings

• Readability Improvement: GPT4 summaries more readable than original abstracts.

• Scientific Accuracy: 84.2% of GPT4 summaries maintained moderate accuracy.

• Readability Metrics: GPT4 outperformed GPT3.5 in multiple readability scores.

Implications

• Patient Education: GPT4 can enhance neurosurgical literature comprehension for patients.

• Health Literacy: Potential to improve health literacy nationwide.

Limitations and Future Research

• Accessibility: GPT4’s restricted access limits broader application.

• Future Studies: Explore GPT4’s use in other medical specialties.

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Digital 3D exoscope is an effective tool for the surgery of falx and parasagittal meningiomas

Acta Neurochirurgica (2025) 167:5

Digital 3D exoscopes are promising tools for microneurosurgery. The results of exoscope-assisted resection of intracranial meningiomas have only been addressed in few case reports. We retrospectively compared the results of exoscope and microscope-assisted surgery of falx and parasagittal meningiomas.

Methods We included all consecutive adult patients (n = 36) with falx or parasagittal meningioma who were operated with curative intention during an 8-year period by one senior neurosurgeon. The operations were performed either with a surgical microscope (n = 16; Zeiss Kinevo or Pentero 900) or a digital 3D exoscope (n = 20, Aesculap Aeos). We reviewed the pre- and postoperative radiological images, clinical examinations and surgical reports to assess clinical outcomes and complications. We also analyzed surgical videos.

Results Gross-total resection (Simpson grade I-II) was achieved in approximately 90% of the patients in both groups (89% in exoscope and 92% in microscope group). The duration of the operation was slightly longer (117 vs. 88 min) in the exoscope group. Surgical outcomes were comparable, despite there being larger tumors (median diameter 53 vs. 38 mm) with higher grades (WHO Grade 2–3: 45% vs. 19%) in the exoscope group. Transient postoperative complications were more frequent in the exoscope group (40 vs. 25%) mainly related to the larger tumor size.

Conclusion The digital 3D exoscope is an effective tool for performing surgery on falx and parasagittal meningiomas. The extent of removal, clinical results and complications seem to be comparable to surgical microscope even in large tumors. Larger prospective studies are required to confirm this result.

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A Quantitative Assessment of ChatGPT as a Neurosurgical Triaging Tool

Neurosurgery 95:487–495, 2024

ChatGPT is a natural language processing chatbot with increasing applicability to the medical workflow. Although ChatGPT has been shown to be capable of passing the American Board of Neurological Surgery board examination, there has never been an evaluation of the chatbot in triaging and diagnosing novel neurosurgical scenarios without defined answer choices. In this study, we assess ChatGPT’s capability to determine the emergent nature of neurosurgical scenarios and make diagnoses based on information one would find in a neurosurgical consult.

METHODS: Thirty clinical scenarios were given to 3 attendings, 4 residents, 2 physician assistants, and 2 subinterns. Participants were asked to determine if the scenario constituted an urgent neurosurgical consultation and what the most likely diagnosis was. Attending responses provided a consensus to use as the answer key. Generative pretraining transformer (GPT) 3.5 and GPT 4 were given the same questions, and their responses were compared with the other participants.

RESULTS: GPT 4 was 100% accurate in both diagnosis and triage of the scenarios. GPT 3.5 had an accuracy of 92.59%, slightly below that of a PGY1 (96.3%), an 88.24% sensitivity, 100% specificity, 100% positive predictive value, and 83.3% negative predicative value in triaging each situation. When making a diagnosis, GPT 3.5 had an accuracy of 92.59%, which was higher than the subinterns and similar to resident responders.

CONCLUSION: GPT 4 is able to diagnose and triage neurosurgical scenarios at the level of a senior neurosurgical resident. There has been a clear improvement between GPT 3.5 and 4. It is likely that the recent updates in internet access and directing the functionality of ChatGPT will further improve its utility in neurosurgical triage.

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Presentation and Management of Cerebral Venous Sinus Thrombosis After Supratentorial Craniotomy

Neurosurgery 95:34–45, 2024

Cerebral venous sinus thrombosis (CVST) after supratentorial craniotomy is a poorly studied complication, for which there are no management guidelines. This study assessed the incidence, associated risk factors, and management of postoperative CVST after awake craniotomy.

METHODS: This is an observational, retrospective, monocentric analysis of patients who underwent a supratentorial awake craniotomy. Postoperative CVST was defined as a flow defect on the postoperative contrast-enhanced 3D T1weighted sequence and/or as a T2* hypointensity within the sinus.

RESULTS: In 401 supratentorial awake craniotomies (87.3% of diffuse glioma), the incidence of postoperative CVST was 4.0% (95% CI 2.5-6.4): 14/16 thromboses located in the superior sagittal sinus and 12/16 located in the transverse sinus. A venous sinus was exposed during craniotomy in 45.4% of cases, and no intraoperative injury to a cerebral venous sinus was reported. All thromboses were asymptomatic, and only two cases were diagnosed at the time of the first postoperative imaging (0.5%). Postoperative complications, early postoperative Karnofsky Performance Status score, and duration of hospital stay did not significantly differ between patients with and without postoperative CVST. Adjusted independent risk factors of postoperative CVST were female sex (adjusted Odds Ratio 4.00, 95% CI 1.24-12.91, P = .021) and a lesion ≤1 cm to a venous sinus (adjusted Odds Ratio 10.58, 95% CI 2.93-38.20, P < .001). All patients received standard prophylactic-dose anticoagulant therapy, and none received treatment-dose anticoagulant therapy. No thrombosis-related adverse event was reported. All thromboses presented spontaneous sinus recanalization radiologically at a mean of 89 ± 41 days (range, 7-171).

CONCLUSION: CVST after supratentorial awake craniotomy is a rare event with satisfactory clinical outcomes and spontaneous sinus recanalization under conservative management without treatment-dose anticoagulant therapy. These findings are comforting to neurosurgeons confronted with postoperative MRI reports suggesting CVST.

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Efficacy and Safety of Carmustine Wafer Implantation After Ventricular Opening in Glioblastomas, Isocitrate Dehydrogenase-Wildtype, in Adults

Neurosurgery 94:1227–1236, 2024

We assessed the impact of ventricular opening on postoperative complications and survival of carmustine wafer implantation during surgery of newly diagnosed supratentorial glioblastomas, isocitrate dehydrogenase (IDH)-wildtype in adults.

METHODS: We performed an observational, retrospective, single-center cohort study at a tertiary surgical neurooncological center between January 2006 and December 2021.

RESULTS: One hundred ninety-four patients who benefited from a first-line surgical resection with carmustine wafer implantation were included. Seventy patients (36.1%) had a ventricular opening. We showed that ventricular opening (1) did not increase overall postoperative complication rates (P = .201); (2) did not worsen the early postoperative Karnofsky Performance Status score (P = .068); (3) did not increase the time interval from surgery to adjuvant oncological treatment (P = .458); (4) did not affect the completion of the standard radiochemotherapy protocol (P = .164); (5) did not affect progression-free survival (P = .059); and (6) did not affect overall survival (P = .142).

CONCLUSION: In this study, ventricular opening during first-line surgical resection did not affect the survival and postoperative complications after use of carmustine wafer implantation in adult patients with a newly diagnosed supratentorial glioblastoma, IDH-wildtype. This warrants a prospective and multicentric study to clearly assess the impact of the ventricular opening after carmustine wafer implantation in glioblastoma, IDH-wildtype.

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Intermittend pneumatic venous thrombembolism (VTE) prophylaxis during neurosurgical procedures

Acta Neurochirurgica (2024) 166:264

The management of perioperative venous thrombembolism (VTE) prophylaxis is highly variable between neurosurgical departments and general guidelines are missing. The main issue in debate are the dose and initiation time of pharmacologic VTE prevention to balance the risk of VTE-based morbidity and potentially life-threatening bleeding. Mechanical VTE prophylaxis with intermittend pneumatic compression (IPC), however, is established in only a few neurosurgical hospitals, and its efficacy has not yet been demonstrated. The objective of the present study was to analyze the risk of VTE before and after the implementation of IPC devices during elective neurosurgical procedures.

Methods All elective surgeries performed at our neurosurgical department between 01/2018–08/2022 were investigated regarding the occurrence of VTE. The VTE risk and associated mortality were compared between groups: (1) only chemoprophylaxis (CHEMO; surgeries 01/2018–04/2020) and (2) IPC and chemoprophylaxis (IPC; surgeries 04/2020–08/2022). Furthermore, general patient and disease characteristics as well as duration of hospitalization were evaluated and compared to the VTE risk.

Results VTE occurred after 38 elective procedures among > 12.000 surgeries. The number of VTEs significantly differed between groups with an incidence of 31/6663 (0.47%) in the CHEMO group and 7/6688 (0.1%) events in the IPC group. In both groups, patients with malignant brain tumors represented the largest proportion of patients, while VTEs in benign tumors occurred only in the CHEMO group.

Conclusion The use of combined mechanical and pharmacologic VTE prophylaxis can significantly reduce the risk of postoperative thromboembolism after neurosurgical procedures and, therefore, reduce mortality and morbidity.

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Mixed Reality for Cranial Neurosurgical Planning

Operative Neurosurgery 26:551–558, 2024

Mixed reality (MxR) benefits neurosurgery by improving anatomic visualization, surgical planning and training. We aim to validate the usability of a dedicated certified system for this purpose.

METHODS: All cases prepared with MxR in our center in 2022 were prospectively collected. Holographic rendering was achieved using an incorporated fully automatic algorithm in the MxR application, combined with contrast-based semiautomatic rendering and/or manual segmentation where necessary. Hologram segmentation times were documented. Visualization during surgical preparation (defined as the interval between finalized anesthesiological induction and sterile draping) was performed using MxR glasses and direct streaming to a side screen. Surgical preparation times were compared with a matched historical cohort of 2021. Modifications of the surgical approach after 3-dimensional (3D) visualization were noted. Usability was assessed by evaluating 7 neurosurgeons with more than 3 months of experience with the system using a Usefulness, Satisfaction and Ease of use (USE) questionnaire.

RESULTS: One hundred-seven neurosurgical cases prepared with a 3D hologram were collected. Surgical indications were oncologic (63/107, 59%), cerebrovascular (27/107, 25%), and carotid endarterectomy (17/107, 16%). Mean hologram segmentation time was 39.4 ± 20.4 minutes. Average surgical preparation time was 48.0 ± 17.3 minutes for MxR cases vs 52 ± 17 minutes in the matched 2021 cohort without MxR (mean difference 4, 95% CI 1.7527-9.7527). Based on the 3D hologram, the surgical approach was modified in 3 cases. Good usability was found by 57% of the users.

CONCLUSION: The perioperative use of 3D holograms improved direct anatomic visualization while not significantly increasing intraoperative surgical preparation time. Usability of the system was adequate. Further technological development is necessary to improve the automatic algorithms and reduce the preparation time by circumventing manual and semiautomatic segmentation. Future studies should focus on quantifying the potential benefits in teaching, training, and the impact on surgical and functional outcomes.

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Targeted Epidural Blood Patch Injection Through a Mini-Open Approach for Treatment of Spontaneous Intracranial Hypotension

Operative Neurosurgery 26:398–405, 2024

Spontaneous intracranial hypotension is recognized as a cause for refractory headache. Treatment can range from blind blood patch injection to microsurgical repair of the cerebrospinal fluid (CSF) leak. The objective of the study was to investigate the safety and efficacy of the targeted blood patch injection (TBPI) technique through a mini-open approach in treatment of refractory intracranial hypotension.

METHODS: We retrospectively reviewed cases of 20 patients who were treated for spontaneous intracranial hypotension at our institute between 2011 and 2022. Head and spine MRI and whole-spine myelography were performed in an attempt to localize the CSF leak. All patients underwent implantation of two epidural drains above and beneath the index level through a minimally invasive interlaminar microsurgical approach under general anesthesia. Then, blood patch was injected under clinical surveillance. Treatment success and surgical complications were evaluated postoperatively and at follow-up.

RESULTS: Patients presented with orthostatic headache, vertigo, sensory deficits, and hypacusis (95%, 15%, 15%, and 10%, respectively). Subdural effusions were present in 65% of the cases. A CSF leak was identified in all patients. The exact site of the CSF leak could be identified in 80% of cases. TBPI was performed with an average blood amount of 37.5 mL. A significant improvement of symptoms was reported in 90% of the cases. A total of 15% of the patients showed recurrent symptoms and underwent a second TBPI, resulting in symptom relief. No therapy-related complications were reported.

CONCLUSION: TBPI is a safe and efficient treatment for spontaneous intracranial hypotension. It is performed in a minimally invasive procedure and can be repeated, if necessary, with a very low-risk profile.

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Lateral‑PLIF for spinal arthrodesis

Acta Neurochirurgica (2024) 166:123

Posterior lumbar interbody fusion (PLIF) surgery represents an effective option to treat degenerative conditions in the lumbar spine. To reduce the drawbacks of the classical technique, we developed a variant, so-called Lateral-PLIF, which we then evaluated through a prospective consecutive series of patients.

Methods All adult patients treated at our institute with single or double level Lateral-PLIF for lumbar degenerative disease from January to December 2017 were prospectively collected. Exclusion criteria were patients < 18 years of age, traumatic patients, active infection, or malignancy, as well as unavailability of clinical and/or radiological follow-up data. The technique consists of insert the cages bilaterally through the transition zone between the central canal and the intervertebral foramen, just above the lateral recess. Pre- and postoperative (2 years) questionnaires and phone interviews (4 years) assessed pain and functional outcomes. Data related to the surgical procedure, postoperative complications, and radiological findings (1 year) were collected.

Results One hundred four patients were selected for the final analysis. The median age was 58 years and primary symptoms were mechanical back pain (100, 96.1%) and/or radicular pain (73, 70.2%). We found a high fusion rate (95%). A statistically significant improvement in functional outcome was also noted (ODI p < 0.001, Roland-Morris score p < 0.001). Walking distance increased from 812 m ± 543 m to 3443 m ± 712 m (p < 0.001). Complications included dural tear (6.7%), infection/ wound dehiscence (4.8%), and instrument failure (1.9%) but no neurological deterioration.

Conclusions Lateral-PLIF is a safe and effective technique for lumbar interbody fusion and may be considered for further comparative study validation with other techniques before extensive use to treat lumbar degenerative disease.

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Circulating Brain Injury Biomarkers: A Novel Method for Quantification of the Impact on the Brain After Tumor Surgery

Neurosurgery 93:847–856, 2023

Clinical methods to quantify brain injury related to neurosurgery are scarce. Circulating brain injury biomarkers have recently gained increased interest as new ultrasensitive measurement techniques have enabled quantification of brain injury through blood sampling.

OBJECTIVE: To establish the time profile of the increase in the circulating brain injury biomarkers glial fibrillary acidic protein (GFAP), tau, and neurofilament light (NfL) after glioma surgery and to explore possible relationships between these biomarkers and outcome regarding volume of ischemic injury identified with postoperative MRI and new neurological deficits.

METHODS: In this prospective study, 34 adult patients scheduled for glioma surgery were included. Plasma concentrations of brain injury biomarkers were measured the day before surgery, immediately after surgery, and on postoperative days 1, 3, 5, and 10.

RESULTS: Circulating brain injury biomarkers displayed a postoperative increase in the levels of GFAP (P < .001), tau (P < .001), and NfL (P < .001) on Day 1 and a later, even higher, peak of NFL at Day 10 (P = .028). We found a correlation between the increased levels of GFAP, tau, and NfL on Day 1 after surgery and the volume of ischemic brain tissue on postoperative MRI. Patients with new neurological deficits after surgery had higher levels of GFAP and NfL on Day 1 compared with those without new neurological deficits.

CONCLUSION: Measuring circulating brain injury biomarkers could be a useful method for quantification of the impact on the brain after tumor surgery or neurosurgery in general.

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Minimally invasive image‑guided endoscopic evacuation of intracerebral haemorrhage

Acta Neurochirurgica (2023) 165:1597–1602

Minimally invasive endoscopic hematoma evacuation (MEHE) is an emerging surgical technique for treating spontaneous supratentorial intracerebral haemorrhage (SSICH). Multiple studies, analysing whether the outcome after such a procedure is improved, are still ongoing.

Method We herein present the indications, advantages, and perioperative considerations for the surgical technique of MEHE applied at our institution.

Conclusion MEHE with a view through a transparent brain access device is a valid and safe approach for the surgical evacuation of SSICH.

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Safety and technical efficacy of early minimally invasive endoscopy‑guided surgery for intracerebral haemorrhage: the Dutch Intracerebral haemorrhage Surgery Trial pilot study

Acta Neurochirurgica (2023) 165:1585–1596

Previous randomised controlled trials could not demonstrate that surgical evacuation of intracerebral haemorrhage (ICH) improves functional outcome. Increasing evidence suggests that minimally invasive surgery may be beneficial, in particular when performed early after symptom onset. The aim of this study was to investigate safety and technical efficacy of early minimally invasive endoscopy-guided surgery in patients with spontaneous supratentorial ICH.

Methods The Dutch Intracerebral Haemorrhage Surgery Trial pilot study was a prospective intervention study with blinded outcome assessment in three neurosurgical centres in the Netherlands. We included adult patients with spontaneous supratentorial ICH ≥10mL and National Institute of Health Stroke Scale (NIHSS) score ≥2 for minimally invasive endoscopy-guided surgery within 8 h after symptom onset in addition to medical management. Primary safety outcome was death or increase in NIHSS ≥4 points at 24 h. Secondary safety outcomes were procedure-related serious adverse events (SAEs) within 7 days and death within 30 days. Primary technical efficacy outcome was ICH volume reduction (%) at 24 h.

Results We included 40 patients (median age 61 years; IQR 51–67; 28 men). Median baseline NIHSS was 19.5 (IQR 13.3–22.0) and median ICH volume 47.7mL (IQR 29.4–72.0). Six patients had a primary safety outcome, of whom two already deteriorated before surgery and one died within 24 h. Sixteen other SAEs were reported within 7 days in 11 patients (of whom two patients that already had a primary safety outcome), none device related. In total, four (10%) patients died within 30 days. Median ICH volume reduction at 24 h was 78% (IQR 50–89) and median postoperative ICH volume 10.5mL (IQR 5.1–23.8).

Conclusions Minimally invasive endoscopy-guided surgery within 8 h after symptom onset for supratentorial ICH appears to be safe and can effectively reduce ICH volume. Randomised controlled trials are needed to determine whether this intervention also improves functional outcome.

Trial registration Clinicaltrials. gov: NCT03608423, August 1st, 2018.

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A Sensorised Surgical Glove to Analyze Forces During Neurosurgery

Neurosurgery 92:639–646, 2023

Measuring intraoperative forces in real time can provide feedback mechanisms to improve patient safety and surgical training. Previous force monitoring has been achieved through the development of specialized and adapted instruments or use designs that are incompatible with neurosurgical workflow.

OBJECTIVE: To design a universal sensorised surgical glove to detect intraoperative forces, applicable to any surgical procedure, and any surgical instrument in either hand.

METHODS: We created a sensorised surgical glove that was calibrated across 0 to 10 N. A laboratory experiment demonstrated that the sensorised glove was able to determine instrument-tissue forces. Six expert and 6 novice neurosurgeons completed a validated grape dissection task 20 times consecutively wearing the sensorised glove. The primary outcome was median and maximum force (N).

RESULTS: The sensorised glove was able to determine instrument-tissue forces reliably. The average force applied by experts (2.14 N) was significantly lower than the average force exerted by novices (7.15 N) (P = .002). The maximum force applied by experts (6.32 N) was also significantly lower than the maximum force exerted by novices (9.80 N) (P = .004). The sensorised surgical glove’s introduction to operative workflow was feasible and did not impede on task performance.

CONCLUSION: We demonstrate a novel and scalable technique to detect forces during neurosurgery. Force analysis can provide real-time data to optimize intraoperative tissue forces, reduce the risk of tissue injury, and provide objective metrics for training and assessment.

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Novel Merging of CT and MRI to Allow for Safe Navigation into Kambin’s Triangle for Percutaneous Lumbar Interbody Fusion

Operative Neurosurgery 24:331–340, 2023

For percutaneous lumbar fusion (percLIF), magnetic resonance imaging and computed tomography are critical to defining surgical corridors. Currently, these scans are performed separately, and surgeons then use fluoroscopy or neuromonitoring to guide instruments through Kambin’s triangle. However, anatomic variations and intraoperative positional changes are possible, meaning that safely accessing Kambin’s triangle remains a challenge because nerveroot visualization without endoscopes has not been thoroughly described.

OBJECTIVE: To overcome the known challenges of percLIF and reduce the likelihood of iatrogenic injuries by showing real-time locations of neural and bony anatomy.

METHODS: The authors demonstrate an intraoperative navigational platform that applies nerve root segmentation and image fusion to assist with percLIF. Five patients from a single institution were included.

RESULTS: Of the 5 patients, the mean age was 71 ± 8 years and 3 patients (60%) were female. One patient had general anesthesia while the remaining 4 patients underwent awake surgery with spinal anesthesia. The mean area for the L4-L5 Kambin’s triangle was 76.1 ± 14.5 mm2. A case example is shown where the side of approach was based on the fact that Kambin’s triangle was larger on one side compared with the other. The mean operative time was 170 ± 17 minutes, the mean blood loss was 32 ± 16 mL, and the mean hospital length of stay was 19.6 ± 8.3 hours. No patients developed postoperative complications.

CONCLUSION: This case series demonstrates the successful and safe application of nerve segmentation using magnetic resonance imaging/computed tomography fusion to perform percLIF and provide positive patient outcomes.

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Dissociation of Broca’s area from Broca’s aphasia in patients undergoing neurosurgical resections

J Neurosurg 138:847–857, 2023

Broca’s aphasia is a syndrome of impaired fluency with retained comprehension. The authors used an unbiased algorithm to examine which neuroanatomical areas are most likely to result in Broca’s aphasia following surgical lesions.

METHODS Patients were prospectively evaluated with standardized language batteries before and after surgery. Broca’s area was defined anatomically as the pars opercularis and triangularis of the inferior frontal gyrus. Broca’s aphasia was defined by the Western Aphasia Battery language assessment. Resections were outlined from MRI scans to construct 3D volumes of interest. These were aligned using a nonlinear transformation to Montreal Neurological Institute brain space. A voxel-based lesion-symptom mapping (VLSM) algorithm was used to test for areas statistically associated with Broca’s aphasia when incorporated into a resection, as well as areas associated with deficits in fluency independent of Western Aphasia Battery classification. Postoperative MRI scans were reviewed in blinded fashion to estimate the percentage resection of Broca’s area compared to areas identified using the VLSM algorithm.

RESULTS A total of 289 patients had early language evaluations, of whom 19 had postoperative Broca’s aphasia. VLSM analysis revealed an area that was highly correlated (p < 0.001) with Broca’s aphasia, spanning ventral sensorimotor cortex and supramarginal gyri, as well as extending into subcortical white matter tracts. Reduced fluency scores were significantly associated with an overlapping region of interest. The fluency score was negatively correlated with fraction of resected precentral, postcentral, and supramarginal components of the VLSM area.

CONCLUSIONS Broca’s aphasia does not typically arise from neurosurgical resections in Broca’s area. When Broca’s aphasia does occur after surgery, it is typically in the early postoperative period, improves by 1 month, and is associated with resections of ventral sensorimotor cortex and supramarginal gyri.

 

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Intraoperative confocal laser endomicroscopy: prospective in vivo feasibility study of a clinical-grade system for brain tumors

J Neurosurg 138:587–597, 2023

The authors evaluated the feasibility of using the first clinical-grade confocal laser endomicroscopy (CLE) system using fluorescein sodium for intraoperative in vivo imaging of brain tumors.

METHODS A CLE system cleared by the FDA was used in 30 prospectively enrolled patients with 31 brain tumors (13 gliomas, 5 meningiomas, 6 other primary tumors, 3 metastases, and 4 reactive brain tissue). A neuropathologist classified CLE images as interpretable or noninterpretable. Images were compared with corresponding frozen and permanent histology sections, with image correlation to biopsy location using neuronavigation. The specificities and sensitivities of CLE images and frozen sections were calculated using permanent histological sections as the standard for comparison. A recently developed surgical telepathology software platform was used in 11 cases to provide real-time intraoperative consultation with a neuropathologist.

RESULTS Overall, 10,713 CLE images from 335 regions of interest were acquired. The mean duration of the use of the CLE system was 7 minutes (range 3–18 minutes). Interpretable CLE images were obtained in all cases. The first interpretable image was acquired within a mean of 6 (SD 10) images and within the first 5 (SD 13) seconds of imaging; 4896 images (46%) were interpretable. Interpretable image acquisition was positively correlated with study progression, number of cases per surgeon, cumulative length of CLE time, and CLE time per case (p ≤ 0.01). The diagnostic accuracy, sensitivity, and specificity of CLE compared with frozen sections were 94%, 94%, and 100%, respectively, and the diagnostic accuracy, sensitivity, and specificity of CLE compared with permanent histological sections were 92%, 90%, and 94%, respectively. No difference was observed between lesion types for the time to first interpretable image (p = 0.35). Deeply located lesions were associated with a higher percentage of interpretable images than superficial lesions (p = 0.02). The study met the primary end points, confirming the safety and feasibility and acquisition of noninvasive digital biopsies in all cases. The study met the secondary end points for the duration of CLE use necessary to obtain interpretable images. A neuropathologist could interpret the CLE images in 29 (97%) of 30 cases.

CONCLUSIONS The clinical-grade CLE system allows in vivo, intraoperative, high-resolution cellular visualization of tissue microstructure and identification of lesional tissue patterns in real time, without the need for tissue preparation.

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