Tag: Outcomes

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A 7-Year Experience in Microsurgical Treatment of Unruptured Intracranial Aneurysms in Older Patients

Neurosurgery 98:1325–1338, 2026

This article reports a 7-year single-center retrospective analysis comparing one-year neurological outcomes after microsurgical clipping of unruptured intracranial aneurysms in patients >65 years versus younger adults. It details patient selection, aneurysm characteristics, statistical methods, and primary endpoint assessment using the modified Rankin Scale.

Findings indicate similar favorable 1-year outcomes between older and younger cohorts, with diabetes and de novo aneurysm formation/growth identified as independent predictors of poor outcome in the older group. The discussion contextualizes results against endovascular options, comorbidity considerations, and limitations of retrospective single-center data.

Question addressed Whether to treat unruptured intracranial aneurysms (UIAs) in patients >65 remains controversial because of frailty/comorbidities and procedural risk vs rupture risk under conservative management.

Study design Retrospective review of UIA patients treated with microsurgical clipping (single quaternary center, 2014–2020), including only those with admission mRS ≤2; primary endpoint was 1-year mRS, with poor outcome defined as mRS >2.

Cohort 390 total surgically treated patients; 132 (34%) were >65 with mean age 71±4 years.

Main outcome No significant difference in poor neurological outcome at 1 year between older vs younger patients (11% vs 9.3%, P=.82), indicating comparable functional outcomes after microsurgery in selected older adults.

Aneurysm differences with age Older patients had larger aneurysm dimensions and more calcification (e.g., calcification 15% vs 2.8%) and higher PHASES/ELAPSS scores than younger patients.

Univariate risk factors (older group) Factors associated with poor 1-year outcome included diabetes, higher Charlson Comorbidity Index, calcification, treating multiple aneurysms, de novo formation/growth, and higher aspect ratio.

Independent predictors On multivariable analysis in older patients, only diabetes (OR 19.1, P=.02) and de novo formation or growth (OR 12.7, P=.02) predicted poor neurological outcome.

Clinical implication Chronological age alone is not a stand-alone contraindication to microsurgical treatment; individualized selection and comorbidity/risk stratification (notably diabetes and aneurysm growth patterns) are key.

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Shifts in epilepsy treatment: a 12-year review of surgical approaches and outcomes in lesional and nonlesional epilepsy

J Neurosurg 144:259–272, 2026

This study analyzes national inpatient trends from 2009–2020 comparing lesional and nonlesional epilepsy patients who underwent surgical or neuromodulation treatments. Using NIS data with propensity score matching, it reports demographic differences, socioeconomic disparities, and shifting utilization patterns across VNS, RNS, DBS, resection, radiosurgery, and LITT.

The findings reveal increasing adoption of RNS and LITT, declining VNS and radiosurgery, higher costs for most interventions, and shorter length of stay with LITT. Persistent racial and income-based inequities in access and differing outcomes by lesion status prompt calls for tailored care and further cost-effectiveness and long-term outcome studies.

Distinct Patient Profiles: Lesional epilepsy patients are older, more likely male, have higher comorbidity burdens, and higher income/Medicare coverage compared to nonlesional epilepsy patients, who are more prevalent in lower income quartiles and rely more on Medicaid or private insurance.

Surgical Treatment Trends: Use of responsive neurostimulation (RNS) and laser interstitial thermal therapy (LITT) increased significantly for both lesional and nonlesional epilepsy from 2009–2020, while vagus nerve stimulation (VNS) declined for nonlesional epilepsy; deep brain stimulation (DBS) and radiosurgery declined for both groups.

Resective Surgery Patterns: Resective surgery utilization increased significantly for nonlesional epilepsy, but not for lesional epilepsy, indicating a growing acceptance of surgery in nonlesional cases despite the absence of overt lesions.

Healthcare Disparities: White patients, and those in higher income quartiles, have higher probabilities of receiving advanced treatments (VNS, RNS, DBS, resective surgery, radiosurgery); Black patients have persistently lower access regardless of income, and Hispanic patients show variable, income-dependent access.

Outcomes by Modality: RNS and LITT are associated with shorter or unchanged length of stay (LOS) and higher likelihood of routine discharge, while DBS and resective surgery increase LOS and costs; all surgical interventions increase hospital charges.

LITT Advantages: LITT is linked to decreased LOS and improved routine discharge rates, especially for lesional epilepsy, but incurs higher total charges compared to other modalities.

Mortality Impact: None of the interventions (VNS, RNS, DBS, resective surgery, radiosurgery, LITT) significantly affected mortality in either lesional or nonlesional epilepsy groups.

Need for Tailored Approaches: Persistent demographic, socioeconomic, and clinical differences between lesional and nonlesional epilepsy patients highlight the importance of individualized treatment strategies and further research on long-term and cost-effectiveness outcomes.

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Natural History of Sporadic Cerebral Cavernous Malformations by Zabramski Classification: Hemorrhage Risk and Functional Outcomes Over 5 Years

Neurosurgery 98:376–383, 2026

This prospective cohort study examines sporadic cerebral cavernous malformations (CCMs) categorized by Zabramski MRI types I–IV, reporting lesion features, presentation, hemorrhage rates, and mRS outcomes over a mean follow-up of 4.7 years. Type I lesions had the highest symptomatic presentation, largest size, brainstem predominance, and elevated hemorrhage risks.

Functional outcomes improved for some patients, but Type I had the poorest outcomes. Severe symptomatic hemorrhage was the strongest predictor of sustained disability (mRS ≥3). Types III and IV had low hemorrhage rates and favorable prognoses, supporting conservative management and tailored follow-up imaging.

Zabramski Classification: Stratifies cerebral cavernous malformations (CCMs) into Types I–IV based on MRI features, which correlate with clinical presentation, hemorrhage risk, and functional outcomes.

Type I Lesions: Show the highest annual symptomatic hemorrhage (SH) rate (13.9%), a 5-year cumulative risk of 50.6%, are mostly symptomatic at presentation, often located in the brainstem, and have the poorest long-term functional outcomes (mRS ≥2 in 35.4% at last follow-up).

Type II and III Lesions: Exhibit lower annual hemorrhage rates (2.9% and 1.8%, respectively), more frequently present with seizures or focal neurological deficits rather than hemorrhage, and have better long-term functional outcomes (Type II: mRS ≥2 in 11.2%; Type III: mRS ≥2 in 7.5% at last follow-up).

Type IV Lesions: Are exclusively asymptomatic, detected incidentally, have no observed hemorrhagic events during follow-up, and show no functional impairment (no cases of mRS ≥2).

Severe Symptomatic Hemorrhage: Is the strongest independent predictor of poor functional outcome (mRS ≥3), outweighing lesion type, age, location, or surgical intervention in multivariate analysis (HR 10.88, P < .001).

Dynamic Lesion Evolution: Zabramski type can change over time, particularly for Type I lesions, highlighting the need for longitudinal imaging and dynamic risk assessment rather than reliance on a single timepoint classification.

Clinical Management Implications: Conservative management is appropriate for most Type III and IV lesions due to their benign natural history, while Type I lesions require closer monitoring and individualized intervention strategies due to higher risk.

Study Limitations: Small sample sizes for Types III and IV, potential MRI protocol variability, and single-center design may limit generalizability; multicenter studies are needed for broader validation.

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Single-Fraction Stereotactic Radiosurgery as Primary Management of Sporadic Meningiomas: A 25-Year Cohort Study

Neurosurgery 97:1267–1274, 2025

This study reports long-term outcomes of single‑fraction Gamma Knife stereotactic radiosurgery (SRS) as primary treatment for 653 sporadic intracranial meningiomas in 616 patients over a 25‑year period. With median margin dose 15 Gy and median imaging follow-up 6.3 years, progression‑free survival was excellent (99.8% at 5 years, 99.0% at 10 years), and raw tumor control reached 98.6%.

Treatment‑related neurological sequelae were uncommon (1.8% permanent/intervention), though larger tumor volume, higher V12, and greater number of isocenters increased complication risk. The authors conclude single‑fraction SRS at studied doses offers high long‑term control for small‑to‑medium sporadic meningiomas, emphasizing careful patient selection.

Stereotactic Radiosurgery (SRS) Effectiveness: Single-fraction SRS is highly effective as a primary treatment for sporadic, small- to medium-volume intracranial meningiomas, achieving a 99% tumor control rate at 10 years and 93% at 15 years progression-free survival (PFS).

Low Permanent Morbidity: The risk of permanent treatment-related neurological complications is low (1.8%), with most side effects being temporary or minor.

Key Predictors of Outcome: Larger tumor volume is the main predictor of both tumor progression and treatment-related complications, emphasizing the importance of patient selection for SRS.

Radiosurgical Parameters: Increased number of isocenters, higher 12-Gy volume (V12), larger tumor volume, and lower maximal dose are associated with higher risk of treatment-related complications.

Comparison to Observation: SRS provides superior tumor control compared to observation in patients with incidentally discovered, asymptomatic meningiomas, with similar rates of new neurological deficits.

Radiation Dose Recommendations: A median margin dose of 13–15 Gy balances long-term tumor control and risk of complications; doses below 12 Gy may increase recurrence risk, while higher doses increase morbidity.

Biological Effective Dose (BED): In this cohort, higher BED was not predictive of improved PFS, likely due to the already high dosing protocol; however, other studies suggest BED can be a useful predictor when a wider dose range is used.

Limitations: The study is retrospective and single-institution, with potential selection bias and incomplete follow-up; findings may not generalize to syndromic or radiation-induced meningiomas.

 

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Recurrence of initial angiographic occlusion in intracranial dural arteriovenous fistulas

J Neurosurg 143:1530–1538, 2025

This clinical study analyzes recurrence after angiographic cure of intracranial dural arteriovenous fistulas (DAVFs) using a single-center DREAM-INI cohort of 510 patients. It reports an overall recurrence rate of 8.0%, estimated cumulative recurrence of 13.9% at 36 months and 24.1% at 105 months, and an annual recurrence risk of 6.2%, with most recurrences occurring within 15 months but some delayed beyond 10 years.

The paper identifies independent risk factors including age <45 years, transverse–sigmoid sinus location, multiple fistulae, pial arterial supply, and venous congestion, distinguishes in situ versus remote-site recurrence, explores pathophysiologic mechanisms (venous hypertension, incomplete embolization, angiogenesis), and recommends angiographic follow-up beyond one year for high-risk cured patients.

Recurrence Rate: The overall recurrence rate of intracranial dural arteriovenous fistulas (DAVFs) after initial angiographic cure was 8.0%, with estimated recurrence rates of 13.9% at 36 months and 24.1% at 105 months; the annual recurrence risk was 6.2%.

Types of Recurrence: DAVF recurrence can be classified as in situ recurrence (at the original site) or remote site recurrence (at a different location); both are closely linked to unresolved venous hypertension and previously masked portions of the fistula.

Timing of Recurrence: Most recurrence events (76.6%) occurred within 15 months after initial cure, but delayed recurrences were observed, including cases more than 3 years and up to 10 years later.

Risk Factors: Key risk factors for recurrence included age younger than 45 years, transverse–sigmoid sinus location, multiple fistulae, pial arterial supply, and venous congestion.

Borden Classification: Recurrence was more frequently observed in Borden type II DAVFs, whereas Borden type III DAVFs had a lower recurrence rate when complete occlusion of the proximal draining vein was achieved.

Treatment Implications: Almost all recurrences occurred after endovascular therapy, highlighting the importance of ensuring complete occlusion of the draining vein to minimize recurrence risk.

Clinical Symptoms: There was no clear correlation between clinical symptoms and DAVF recurrence; many recurrences were asymptomatic, emphasizing the need for routine angiographic follow-up.

Follow-Up Recommendation: All patients with cured DAVFs, especially those with identified risk factors, should undergo angiographic follow-up beyond 1 year to detect and manage possible recurrences.

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The Association of Area Deprivation Index and Spine Surgery Outcomes: A Systematic and Narrative Review

Operative Neurosurgery 29:775–784, 2025

This systematic review examines the relationship between neighborhood-level socioeconomic disadvantage, measured by the Area Deprivation Index (ADI), and outcomes after various spine surgeries. Ten North American observational studies (56,925 patients) indicate higher ADI is associated with increased readmissions, emergency visits, longer lengths of stay, higher costs, and worse patient-reported outcomes for cervical and lumbar procedures.

The review outlines potential mechanisms—limited health literacy, barriers to follow-up, comorbidity control, and access deficits—and proposes targeted interventions across education, income/employment, housing, and household support to mitigate disparities and improve perioperative optimization and outcomes.

Area Deprivation Index (ADI): ADI is a validated, neighborhood-level measure of socioeconomic disadvantage, incorporating 17 variables across education, income/employment, housing, and household characteristics, with scores ranked from 0 (least disadvantaged) to 100 (most disadvantaged).

Association with Spine Surgery Outcomes: High ADI is linked to worse outcomes after spine surgery, including higher rates of postoperative readmissions, complications, emergency room visits, longer hospital stays, and poorer patient-reported outcomes (PROs).

Cervical Spine Surgery: Increased ADI is associated with higher costs of care, increased surgical utilization, and longer hospital length of stay after anterior cervical discectomy and fusion (ACDF); some studies also report increased likelihood of 30-day readmission, though not always statistically significant.

Lumbar Spine Surgery: High ADI predicts worse preoperative pain, function, depression, and anxiety scores; patients with high ADI experience greater rates of complications (e.g., respiratory failure), longer hospital stays, increased emergency visits, higher costs, and are less likely to achieve clinically meaningful improvements postoperatively.

Mechanisms of Disparity: Poor health literacy, reduced access to primary and follow-up care, barriers to transportation, and poor control of comorbidities are key mechanisms by which high ADI leads to worse surgical outcomes.

Potential Interventions: Targeted interventions addressing education (health literacy outreach, transitional care), income/employment (public assistance, nutrition programs), housing (medical-legal partnerships, transitional housing), and household resources (home health, internet access, transportation assistance) may help mitigate disparities for high ADI patients.

Limitations: Evidence is limited by heterogeneity of included studies, moderate risk of bias, small sample sizes for some subgroups, and lack of generalizability across all spine surgery types.

Future Directions: ADI can serve as a prognostic tool for identifying at-risk patients; further research should validate these associations and evaluate the effectiveness of targeted interventions to improve spine surgery outcomes in disadvantaged populations.

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Tentorial Dural Arteriovenous Fistulas: A Retrospective Cohort Study

Operative Neurosurgery 29:678–685, 2025

This single-center retrospective cohort study analyzes 275 patients with tentorial dural arteriovenous fistulas (TDAVFs) treated between 2001 and 2022, detailing demographic, angiographic, and treatment data across six Lawton-classified subtypes. Results highlight a predominance of middle-aged male patients, high immediate occlusion rates with endovascular techniques, and subtype-specific differences in venous drainage patterns and complication rates.

The manuscript compares treatment modalities and outcomes, noting superior petrosal sinus TDAVFs more often require microsurgery, while Galenic and torcular subtypes showed lower immediate cure rates and higher complications or new fistula formation. Follow-up angiographic and clinical data emphasize favorable functional recovery for most patients despite treatment-related risks.

• Patient Demographics: Tentorial dural arteriovenous fistulas (TDAVFs) predominantly affect middle-aged men, with 85.8% of cases occurring in males and a mean age of 51.1 years.

• Subtype Distribution: The most common TDAVF subtype is superior petrosal sinus (34.9%), followed by tentorial sinus (31.6%), Galenic (15.6%), torcular (7.3%), incisural (5.5%), and straight sinus (5.1%).

• Aggressiveness and Presentation: TDAVFs are less common than other DAVFs but are the most aggressive, frequently presenting with hemorrhage or progressive neurological deficits; more than half of patients present with intracranial hemorrhage or nonhemorrhagic neurological deficits (NHNDs).

• Treatment Approach: Most TDAVFs (83.0%) can be effectively treated with endovascular embolization, but superior petrosal sinus TDAVFs more often require microsurgical intervention (31.6% in this group).

• Immediate Occlusion and Complications: Immediate complete occlusion was achieved in 92.8% of treated cases, with Galenic TDAVFs showing a lower occlusion rate and both Galenic and superior petrosal sinus TDAVFs exhibiting higher complication rates (12.5% overall).

• Outcomes: Favorable clinical outcomes (mRS <3) were achieved in 82.6% of patients, with torcular and tentorial sinus TDAVFs associated with better outcomes compared to other subtypes.

• Recurrence and New Fistulas: Recurrence after complete occlusion was rare (0.9%), but torcular TDAVFs had a higher tendency to develop new fistulas post-treatment (2.6% of cases).

• Key Technical Considerations: Endovascular treatment is preferred when feasible, but surgical approaches are indicated for lesions with unfavorable arterial access or higher risk of complications, particularly in superior petrosal sinus TDAVFs.

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Outcomes After Standardized Burr-Hole Surgery for Chronic Subdural Hematomas: A Population-Based Consecutive Cohort Study of 2655 Patients

Neurosurgery 97:298–309, 2025

This large population-based study of 2655 chronic subdural hematoma patients treated with mostly single burr-hole craniotomy found an 11% recurrence and complication rate, 12% 1-year mortality, and identified male sex, diabetes, antithrombotic use, midline shift, and bilateral surgery as independent recurrence predictors.

• Large cohort study (n=2655) analyzed outcomes after standardized burr-hole craniotomy (BHC) for chronic subdural hematoma (CSDH) at a single center (2006–2022).

• Reoperation for hematoma recurrence occurred in 11% of patients, with most recurrences happening within 23 days.

• Independent predictors of recurrence included male sex, diabetes, preoperative antithrombotic therapy, midline shift, and bilateral hematomas.

• Postoperative complications occurred in 11% (3.9% moderate-to-severe); urinary tract infections, subdural empyema, and seizures were most common.

• 1-year postoperative mortality was 12%.

• Higher Charlson Comorbidity Index and lower Glasgow Coma Scale score were independent predictors of moderate-to-severe complications.

• Minicraniotomy was used in 9.3% of cases, with similar recurrence but slightly higher complication rates compared to BHC.

• Predictive models for recurrence and complications had low performance, suggesting other unmeasured factors are important.

 

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Feasibility, Safety, and Impact of Awake Resection for Recurrent Insular Diffuse Gliomas in Adults

Neurosurgery 97:399–409, 2025

Function-based transopercular awake resection for recurrent insular diffuse gliomas in adults is feasible and safe, with similar resection rates, complications, and outcomes as first-time surgery, though prior combined treatments may increase intraoperative cooperation difficulties and sick leave, especially in high-grade gliomas.

• Transopercular awake resection for recurrent insular diffuse gliomas is feasible and safe, showing similar resection rates and outcomes to first-time surgery.

• No significant increase in intraoperative adverse events or surgery-related complications was observed for recurrent cases compared to first-line surgeries.

• Patients with previous combined oncological treatments had a higher risk of insufficient intraoperative cooperation, but this did not lead to mapping failure.

• Extent of resection and 6-month postoperative outcomes (Karnofsky Performance Status, seizure control, sick leave) were similar between recurrent and first-line groups.

• Longer sick leave was associated with high-grade gliomas and adjuvant treatments, not with surgery type.

• Shorter awake phase duration was observed in recurrent cases, likely due to easier access from prior surgeries and smaller tumor volumes.

• Study supports careful preoperative counseling and patient selection, especially for those with previous combined treatments.

• Results are specific to adult insular glioma patients treated with transopercular awake surgery and may not generalize to other populations or techniques.

 

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Cerebellopontine Angle Meningiomas: A Multi-Institutional Cohort Study

Neurosurgery 97:105–111, 2025

This multi-institutional study of 95 cerebellopontine angle meningioma cases found that gross total resection, especially with internal auditory canal drilling for intracanalicular invasion, improves symptom control and reduces recurrence. Most patients experienced stable or improved hearing, with postoperative complications and recurrence rates detailed.

• Cerebellopontine angle (CPA) meningiomas are challenging due to their proximity to neurovascular structures and present commonly with hearing loss, ataxia, and headaches.

• Gross total resection (GTR) was achieved in 62.1% of 95 patients; smaller tumor size and drilling the internal auditory canal (IAC) for tumors with intracanalicular invasion were associated with higher GTR rates.

• Most patients had stable or improved hearing postoperatively; only a minority experienced worsening.

• Postoperative complications included cranial nerve dysfunction, CSF leak, and hydrocephalus, but there were no perioperative deaths.

• Tumor progression or recurrence occurred in 25.3% of patients, with higher rates in WHO grade 2 tumors; Simpson grade I/II resection and older age reduced recurrence risk.

• Extent of resection (EOR) is not reliably predicted by tumor size alone; other anatomical factors are important.

• Adjuvant radiation was mainly used for higher-grade tumors with subtotal resection, but most progression cases were managed with observation or salvage therapy.

• Surgical resection is effective for symptom control and reducing recurrence, especially with GTR and appropriate IAC management.

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Impact of patient positioning on bleeding rate in stereotactic brain biopsies: semi‑sitting versus supine position

Acta Neurochirurgica (2025) 167:159

The study found that using a semi-sitting position (30° head elevation) during stereotactic brain biopsies significantly reduced the rate of hemorrhagic complications compared to the supine position, suggesting patient positioning is a key, modifiable factor for improving safety and outcomes in these neurosurgical procedures.

• Study compared bleeding rates in stereotactic brain biopsies between semi-sitting and supine positions.

• Retrospective analysis of 78 patients: 39 semi-sitting, 39 supine.

• Hemorrhagic complications were significantly lower in the semi-sitting group (7.7%) vs supine (33.3%).

• Semi-sitting position is a potential protective factor against bleeding (OR 0.17, p=0.009).

• Groups were similar in age, sex, tumor type, and biopsy site; more samples were taken in semi-sitting group.

• No symptomatic bleedings occurred in either group.

• Semi-sitting position may reduce intracranial venous pressure, lowering bleeding risk.

• Authors recommend further prospective, multicenter studies to validate findings.

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The Rate and Risk Factors of Deep Brain Stimulation–Associated Complications

Operative Neurosurgery 28:519–527, 2025

The study investigates complications associated with deep brain stimulation (DBS) surgery, analyzing patient demographics, surgical techniques, and outcomes. It identifies factors influencing complications such as pneumocephalus, infection, and hemorrhage, aiming to improve patient selection and surgical strategies for better outcomes.

• Deep Brain Stimulation (DBS) is a recognized neurosurgical procedure for various neurological disorders, considered safe but not without complications. The study investigates these complications and their association with patient characteristics and surgical techniques.

• The study analyzed 481 patients who underwent DBS lead implantation between January 2012 and January 2020, with a total of 859 leads implanted.

• Common complications included pneumocephalus, edema, altered mental state, and infection. General anesthesia, hypertension, heart disease, and depression were linked to longer postoperative stays.

• High BMI was associated with increased rates of surgery-related infections and lead revision/explantation.

• Intraoperative mean arterial pressure and anesthesia type were significant predictors of postoperative pneumocephalus.

• The study found that certain comorbidities, such as hypertension, heart disease, and depression, were associated with longer hospital stays.

• Older patients were less likely to require lead revision/explantation, while those with high BMI were at higher risk.

• Infection prevention techniques, like vancomycin powder, were effective, with infection rates at the lower end of the reported range.

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Outcomes After Definitive Surgery for Spinal and Sacral Chordoma in 101 Patients Over 20 Years

Neurosurgery 96:494–504, 2025

• Study Objective: Investigate postoperative outcomes of spinal chordoma surgery over 20 years.

• Patient Cohort: 101 patients, average follow-up of 6.0 ± 4.2 years.

• Recurrence and Mortality: 24.8% recurrence, 9.9% mortality.

• Risk Factors: Tumors ≥100 cm³ and mobile spine chordomas linked to worse outcomes.

• Neoadjuvant Radiotherapy: Associated with improved local recurrence-free survival (LRFS).

• Age Impact: Patients ≥65 years at surgery have a higher mortality risk.

• Surgical Outcomes: Pain decreased post-surgery, sensory deficits and weakness remained static.

• Functional Outcomes: 39% of patients pain-free long-term, no significant change in sensory deficits.

• Surgical Complications: 65.3% experienced complications; 32.7% required reoperation.

• Radiotherapy Advances: Newer modalities like stereotactic photon therapy show promising LRFS rates.

• Study Design: Retrospective review from 2003-2023 at a quaternary spinal oncology center.

• Data Analysis: Multivariable Cox regression used to identify predictors of LRFS and OS.

• Surgical Approach: Enneking Appropriate surgery preferred for better outcomes.

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External assessment of preoperative scores for predicting outcome after microvascular decompression for trigeminal neuralgia

J Neurosurg 141:1056–1062, 2024

Recently, two scoring systems have been developed for predicting pain-free outcomes after microvascular decompression (MVD). Evaluation of these scores on large external datasets has been limited. In this study, the authors aimed to evaluate the performance of published MVD scoring systems in predicting pain-free outcome.

METHODS A total of 458 patients who underwent MVD for trigeminal neuralgia (TN) between 2007 and 2020 and had at least 6 months of follow-up were included in this study. Hardaway and Panczykowski scores were retrospectively computed for each patient and compared with postoperative pain recurrence and pain-free duration.

RESULTS The mean ± SD area under the receiver operating characteristic curve for predicting any pain recurrence after MVD was 0.567 ± 0.081 using the Hardaway score and 0.546 ± 0.085 using the Panczykowski score. On log-rank tests and Kaplan-Meier analysis, the patients with Hardaway scores of 0–2 had significantly shorter pain-free survival times after MVD than did those with a score of 3. Patients with a Panczykowski score of 1 had a significantly shorter pain-free duration after surgery compared with both patients with scores of 2–3 and patients with scores of 4–5. Patients with Panczykowski scores of 2–3 also had significantly shorter pain-free duration compared with patients with scores of 4–5.

CONCLUSIONS Both the Hardaway and Panczykowski scores may be useful for predicting postoperative pain-free duration in TN patients, and their utility may be greatest when scores are clustered. Continued refinement of both scoring systems will help to improve our ability to predict patient outcomes after MVD.

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Stent-assisted Woven EndoBridge device for the treatment of intracranial aneurysms: an international multicenter study

J Neurosurg 140:1071–1079, 2024

The Woven EndoBridge (WEB) device is an intrasaccular flow disruptor designed for wide-necked bifurcation aneurysms. These aneurysms may require the use of a concomitant stent. The objective of this study was to determine the clinical and radiological outcomes of patients undergoing stent-assisted WEB treatment. In addition, the authors also sought to determine the predictors of a concomitant stent in aneurysms treated with the WEB device.

METHODS The data for this study were taken from the WorldWideWEB Consortium, an international multicenter cohort including patients treated with the WEB device. Aneurysms were classified into two groups based on treatment: stent-assisted WEB and WEB device alone. The authors compared clinical and radiological outcomes of both groups. Univariable and multivariable binary logistic regression analyses were performed to determine factors that predispose to stent use.

RESULTS The study included 691 intracranial aneurysms (31 with stents and 660 without stents) treated with the WEB device. The adequate occlusion status did not differ between the two groups at the latest follow-up (83.3% vs 85.6%, p =0.915). Patients who underwent stenting had more thromboembolic (32.3% vs 6.5%, p < 0.001) and procedural (16.1% vs 3.0%, p < 0.001) complications. Aneurysms treated with a concomitant stent had wider necks, greater heights, and lower dome-to-neck ratios. Increasing neck size was the only significant predictor for stent use.

CONCLUSIONS This study demonstrates that there is no difference in the degree of aneurysm occlusion between the two groups; however, complications were more frequent in the stent group. In addition, a wider aneurysm neck predisposes to stent assistance in WEB-treated aneurysms.

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Does waiting for surgery matter? How time from diagnostic MRI to resection affects outcomes in newly diagnosed glioblastoma

J Neurosurg 140:80–93, 2024

Maximal safe resection is the standard of care for patients presenting with lesions concerning for glioblastoma (GBM) on magnetic resonance imaging (MRI). Currently, there is no consensus on surgical urgency for patients with an excellent performance status, which complicates patient counseling and may increase patient anxiety. This study aims to assess the impact of time to surgery (TTS) on clinical and survival outcomes in patients with GBM.

METHODS This is a retrospective study of 145 consecutive patients with newly diagnosed IDH–wild-type GBM who underwent initial resection at the University of California, San Francisco, between 2014 and 2016. Patients were grouped according to the time from diagnostic MRI to surgery (i.e., TTS): ≤ 7, > 7–21, and > 21 days. Contrast-enhancing tumor volumes (CETVs) were measured using software. Initial CETV (CETV1) and preoperative CETV (CETV2) were used to evaluate tumor growth represented as percent change (ΔCETV) and specific growth rate (SPGR; % growth/day). Overall survival (OS) and progression-free survival (PFS) were measured from the date of resection and were analyzed using the Kaplan-Meier method and Cox regression analyses.

RESULTS Of the 145 patients (median TTS 10 days), 56 (39%), 53 (37%), and 36 (25%) underwent surgery ≤ 7, > 7–21, and > 21 days from initial imaging, respectively. Median OS and PFS among the study cohort were 15.5 and 10.3 months, respectively, and did not differ among the TTS groups (p = 0.81 and 0.17, respectively). Median CETV1 was 35.9, 15.7, and 10.2 cm 3 across the TTS groups, respectively (p < 0.001). Preoperative biopsy and presenting to an outside hospital emergency department were associated with an average 12.79-day increase and 9.09-day decrease in TTS, respectively. Distance from the treating facility (median 57.19 miles) did not affect TTS. In the growth cohort, TTS was associated with an average 2.21% increase in ΔCETV per day; however, there was no effect of TTS on SPGR, Karnofsky Performance Status (KPS), postoperative deficits, survival, discharge location, or hospital length of stay. Subgroup analyses did not identify any high-risk groups for which a shorter TTS may be beneficial.

CONCLUSIONS An increased TTS for patients with imaging concerning for GBM did not impact clinical outcomes, and while there was a significant association with ΔCETV, SPGR remained unaffected. However, SPGR was associated with a worse preoperative KPS, which highlights the importance of tumor growth speed over TTS. Therefore, while it is ill advised to wait an unnecessarily long time after initial imaging studies, these patients do not require urgent/emergency surgery and can seek tertiary care opinions and/or arrange for additional preoperative support/resources. Future studies are needed to explore subgroups for whom TTS may impact clinical outcomes.

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Optimizing surgical management of facet cysts of the lumbar spine: systematic review, meta-analysis, and local case series of 1251 patients

J Neurosurg Spine 39:793–806, 2023

Lumbar facet cysts (LFCs) can cause neurological dysfunction and intractable pain. Surgery is the current standard of care for patients in whom conservative therapy fails, those with neurological deficits, and those with evidence of spinal instability. No study to date has comprehensively examined surgical outcomes comparing the multiple surgical treatment options for LFCs. Therefore, the authors aimed to perform a combined analysis of cases both in the literature and of patients at a single institution to compare the outcomes of various surgical treatment options for LFC.

METHODS The authors performed a literature review in accordance with PRISMA guidelines and meta-analysis of the PubMed, Embase, and Cochrane Library databases and reviewed all studies from database inception published until February 3, 2023. Studies that did not contain 3 or more cases, clearly specify follow-up durations longer than 6 months, or present new cases were excluded. Bias was evaluated using Cochrane Collaboration’s Risk of Bias in Nonrandomised Studies–of Interventions (ROBINS-I). The authors also reviewed their own local institutional case series from 2015 to 2020. Primary outcomes were same-level cyst recurrence, same-level revision surgery, and perioperative complications. ANOVA, common and random-effects modeling, and Wald testing were used to compare treatment groups.

RESULTS A total of 1251 patients were identified from both the published literature (29 articles, n = 1143) and the authors’ institution (n = 108). Patients were sorted into 5 treatment groups: open cyst resection (OCR; n = 720), tubular cyst resection (TCR; n = 166), cyst resection with arthrodesis (CRA; n = 165), endoscopic cyst resection (ECR; n = 113), and percutaneous cyst rupture (PCR; n = 87), with OCR being the analysis reference group. The PCR group had significantly lower complication rates (p = 0.004), higher recurrence rates (p < 0.001), and higher revision surgery rates (p = 0.001) compared with the OCR group. Patients receiving TCR (3.01%, p = 0.021) and CRA (0.0%, p < 0.001) had significantly lower recurrence rates compared with those undergoing OCR (6.36%). The CRA group (6.67%) also had significantly lower rates of revision surgery compared with the OCR group (11.3%, p = 0.037).

CONCLUSIONS While PCR is less invasive, it may have high rates of same-level recurrence and revision surgery. Recurrence and revision rates for modalities such as ECR were not significantly different from those of OCR. While concomitant arthrodesis is more invasive, it might lead to lower recurrence rates and lower rates of subsequent revision surgery. Given the limitations of our case series and literature review, prospective, randomized studies are needed.

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Effect of Lumbar Discectomy or Lumbar Decompression on Axial Back Pain: Results of a Meta-Analysis

World Neurosurg. (2023) 177:109-121

This meta-analysis evaluated the impact of lumbar disk herniation and lumbar spinal stenosis (LSS) on axial back pain and the extent of improvement of axial and radicular pain following lumbar decompression and discectomy surgery in patients with low back pain (LBP).

METHODS: A systematic search for published literature between January 2012 and January 2023 was made on PubMed, Google Scholar, and Cochrane library database on 31 st January 2023.

Original articles that included patients with lumbar disc herniation or LSS who underwent lumbar discectomy or lumbar decompression respectively were included in the study.

RESULTS: A total of 71 studies including 16,770 patients with LBP undergoing lumbar discectomy or decompression surgery were included in the metaanalysis. The pooled standard mean difference between postoperative and preoperative: Visual Analog Scale scores for leg pain was L5.14 with 95% confidence interval (CI): L6.59 to L3.69 (P-value [ 0) and for back pain was L2.90 with 95% CI: L3.79 to L2.01 (P value [ 0), Numerical pain Rating Scale for leg pain was L1.64 with 95% CI: L1.97 to L1.30 (P-value<0.01) and for back pain was L1.58 with 95% CI: L1.84 to L1.32 (P-value <0.01), Oswerty Disability Index score was L4.76 with 95% CI: L6.22 to L3.29 (P-value [ 0) and the Japanese Orthopaedic Association score was 3.45 with 95% CI: 0.02 to 6.88 (P value 0) at follow-up.

CONCLUSIONS: This meta-analysis provides evidence that lumbar discectomy and decompression are effective in improving axial LBP in patients with lumbar disk herniation and LSS.

 

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Pediatric Vagus Nerve Stimulation: Case Series Outcomes and Future Directions

Neurosurgery 92:1043–1051, 2023

Vagus nerve stimulation (VNS) is a neuromodulatory procedure most extensively studied as an adjunct to medically refractory epilepsy. Despite widespread adoption and decades of clinical experience, clinical predictors of response to VNS remain unclear. OBJECTIVE: To evaluate a retrospective cohort of pediatric patients undergoing VNS at our institution to better understand who may benefit from VNS and identify factors which may predict response to VNS.

METHODS: We conducted a retrospective cohort study examining pediatric patients undergoing VNS over nearly a 20-year span at a single institution. Presurgical evaluation, including demographics, clinical history, and diagnostic electroencephalogram, and imaging findings were examined. Primary outcomes included VNS response.

RESULTS: Two hundred ninety-seven subjects were studied. The mean age at surgery was 10.1 (SD = 4.9, range = 0.8-25.3) years; length of follow-up was a mean of 4.6 years (SD = 3.5, median = 3.9 years, range 1 day-16.1 years). There was no association between demographic factors, epilepsy etiology, or genetic basis and VNS outcomes. There was an association between reduction in main seizure type with positive MRI finding. Of all MRI findings analyzed, brain atrophy was significantly associated with worse VNS outcomes, whereas dysplastic hippocampus and chronic periventricular leukomalacia findings were found to be associated with improved outcomes. Increased seizure semiology variability and seizure type were also associated with improved seizure outcomes.

CONCLUSION: Predicting response to VNS remains difficult, leading to incompletely realized benefits and suboptimal resource utilization. Specific MRI findings and increased seizure semiology variability and type can help guide clinical decision making and patient counseling.

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“July Effect” in Spinal Fusions: A Coarsened Exact-Matched Analysis

Neurosurgery 92:623–631, 2023

Few neurosurgical studies examine the July Effect within elective spinal procedures, and none uses an exact-matched protocol to rigorously account for confounders.

OBJECTIVE: To evaluate the July Effect in single-level spinal fusions, after coarsened exact matching of the patient cohort on key patient characteristics (including race and comorbid status) known to independently affect neurosurgical outcomes.

METHODS: Two thousand three hundred thirty-eight adult patients who underwent single-level, posterior-only lumbar fusion at a single, multicenter university hospital system were retrospectively enrolled. Primary outcomes included readmissions, emergency department visits, reoperation, surgical complications, and mortality within 30 days of surgery. Logistic regression was used to analyze month as an ordinal variable. Subsequently, outcomes were compared between patients with surgery at the beginning vs end of the academic year (ie, July vs April–June), before and after coarsened exact matching on key characteristics. After exact matching, 99 exactly matched pairs of patients (total n = 198) were included for analysis.

RESULTS: Among all patients, operative month was not associated with adverse postoperative events within 30 days of the index operation. Furthermore, patients with surgeries in July had no significant difference in adverse outcomes. Similarly, between exact-matched cohorts, patients in July were observed to have noninferior adverse postoperative events.

CONCLUSION: There was no evidence suggestive of a July Effect after single-level, posterior approach spinal fusions in our cohort. These findings align with the previous literature to imply that teaching hospitals provide adequate patient care throughout the academic year, regardless of how long individual resident physician assistants have been in their particular role.

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