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Fiber Density and Structural Brain Connectome in Glioblastoma Are Correlated With Glioma Cell Infiltration

Neurosurgery 92:1234–1242, 2023

Glioblastoma (GBM) preferred to infiltrate into white matter (WM) beyond the recognizable tumor margin.

OBJECTIVE: To investigate whether fiber density (FD) and structural brain connectome can provide meaningful information about WM destruction and glioma cell infiltration.

METHODS: GBM cases were collected based on inclusion criteria, and baseline information and preoperative MRI results were obtained. GBM lesions were automatically segmented into necrosis, contrast-enhanced tumor, and edema areas. We obtained the FD map to compute the FD and lnFD values in each subarea and reconstructed the structural brain connectome to obtain the topological metrics in each subarea. We also divided the edema area into a nonenhanced tumor (NET) area and a normal WM area based on the contralesional lnFD value in the edema area, and computed the NET ratio.

RESULTS: Twenty-five GBM cases were included in this retrospective study. The FD/lnFD value and topological metrics (aCp, aLp, aEg, aEloc, and ar) were significantly correlated with GBM subareas, which represented the extent of WM destruction and glioma cell infiltration. The FD/lnFD values and topological parameters were correlated with the NET ratio. In particular, the lnFD value in the edema area was correlated with the NET ratio (coefficient, 0.92). Therefore, a larger lnFD value indicates more severe glioma infiltration in the edema area and suggests an extended resection for better clinical outcomes.

CONCLUSION: The FD and structural brain connectome in this study provide a new insight into glioma infiltration and a different consideration of their clinical application in neurooncology.

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Asymptomatic Postoperative Cerebral Venous Sinus Thrombosis After Posterior Fossa Tumor Surgery: Incidence, Risk Factors, and Therapeutic Options

Neurosurgery 92:1171–1176, 2023

Cerebral venous sinus thrombosis (CVST) is a known complication of posterior fossa surgery near the sigmoid and transverse sinus. The incidence and treatment of postoperative asymptomatic CVST are controversial.

OBJECTIVE: To analyze incidence, risk factors, and management of asymptomatic postoperative CVST after posterior fossa tumor surgery.

METHODS: In this retrospective, single-center study, we included all patients who underwent posterior fossa tumor surgery in the semisitting position between January 2013 and December 2020. All patients underwent preoperative and postoperative imaging using MRI with/without additional computed tomography angiography. We analyzed the effect of demographic and surgical data on the incidence of postoperative CVST. Furthermore, therapeutic anticoagulation or conservative treatment for postoperative CVST and the incidence of intracranial hemorrhage were investigated.

RESULTS: In total, 266 patients were included. Thirty-three of 266 (12.4%) patients developed postoperative CVST. All patients were asymptomatic. Thirteen of 33 patients received therapeutic anticoagulation, and 20 patients did not. Univariate analysis showed that age (P= .56), sex (P = .20), American Society of Anesthesiology status (P = .13), body mass index (P = .60), and length of surgery (P= .176) were not statistically correlated with postoperative CVST. Multivariate analysis revealed that meningioma (P < .001, odds ratio 11.3, CI 95% 4.1-31.2) and vestibular schwannoma (P = .013, odds ratio 4.4, CI 95% 1.3-16.3) are risk factors for the development of new postoperative CVST. The use of therapeutic anticoagulation to treat postoperative CVST was associated with a higher rate of intracranial hemorrhage (n = 4, P = .017).

CONCLUSION: Tumor entity influences the incidence of postoperative CVST. In clinically asymptomatic patients, careful decision making is necessary whether to initiate therapeutic anticoagulation or not.

 

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Management strategies in clival and craniovertebral junction chordomas: a 29-year experience

J Neurosurg 138:1640–1652, 2023

Chordomas represent one of the most challenging subsets of skull base and craniovertebral junction (CVJ) tumors to treat. Despite extensive resection followed by proton-beam radiation therapy, the recurrence rate remains high, highlighting the importance of developing efficient treatment strategies. In this study, the authors present their experience in treating clival and CVJ chordomas over a 29-year period.

METHODS The authors conducted a retrospective study of clival and CVJ chordomas that were surgically treated at their institution from 1991 to 2020. This study focuses on three aspects of the management of these tumors: the factors influencing the extent of resection (EOR), the predictors of survival, and the outcomes of the endoscopic endonasal approaches (EEAs) compared with open approaches (OAs).

RESULTS A total of 265 surgical procedures were performed in 210 patients, including 123 OAs (46.4%) and 142 EEAs (53.6%). Tumors that had an intradural extension (p = 0.03), brainstem contact (p = 0.005), cavernous sinus extension (p = 0.004), major artery encasement (p = 0.01), petrous apex extension (p = 0.003), or high volume (p = 0.0003) were significantly associated with a lower EOR. The 5-year progression-free survival (PFS) and overall survival (OS) rates were 52.1% and 75.1%, respectively. Gross-total resection and Ki-67 labeling index < 6% were considered to be independent prognostic factors of longer PFS (p = 0.0005 and p = 0.003, respectively) and OS (p = 0.02 and p = 0.03, respectively). Postoperative radiation therapy correlated independently with a longer PFS (p = 0.006). Previous surgical treatment was associated with a lower EOR (p = 0.01) and a higher rate of CSF leakage after EEAs (p = 0.02) but did not have significantly lower PFS and OS compared with primary surgery. Previously radiation therapy correlated with a worse outcome, with lower PFS and OS (p = 0.001 and p = 0.007, respectively). EEAs were more frequently used in patients with upper and middle clival tumors (p = 0.002 and p < 0.0001, respectively), had a better rate of EOR (p = 0.003), and had a lower risk of de novo neurological deficit (p < 0.0001) compared with OAs. The overall rate of postoperative CSF leakage after EEAs was 14.8%.

CONCLUSIONS This large study showed that gross-total resection should be attempted in a multidisciplinary skull base center before providing radiation therapy. EEAs should be considered as the gold-standard approach for upper/middle clival lesions based on the satisfactory surgical outcome, but OAs remain important tools for large complex chordomas.

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Indications and outcomes of endoscopic transorbital surgery for trigeminal schwannoma based on tumor classification: a multicenter study with 50 cases

J Neurosurg 138:1653–1661, 2023

Trigeminal schwannoma is a rare CNS tumor and involves the multicompartmental skull base. Recently, the endoscopic transorbital approach (ETOA) has emerged as a technique for minimally invasive surgery. The objective of this study was to evaluate the optimal indications and clinical outcomes of the ETOA for trigeminal schwannomas based on their tumor classification.

METHODS Between September 2016 and February 2022, the ETOA was performed in 50 patients with trigeminal schwannoma at four tertiary hospitals. There were 15 men and 35 women in the study, with a mean age of 46.9 years. All tumors were classified as type A (predominantly involving the middle cranial fossa), type B (predominantly involving the posterior cranial fossa), type C (dumbbell-shaped tumors involving the middle and posterior fossa), or type D (involvement of the extracranial compartment). Type D tumors were also subclassified by ophthalmic division (D1), maxillary division (D2), and mandibular division (D3). Clinical outcome was analyzed, including extent of resection and surgical morbidities.

RESULTS In this study, overall gross-total resection (GTR) was performed in 35 (70.0%) of 50 patients and near-total resection (NTR) in 9 patients (18.0%). The mean follow-up period was 21.9 (range 1–61.7) months. There was no tumor regrowth or recurrence during the follow-up period. Based on the classification, there were 17 type A tumors, 20 type C, and 13 type D. There were no type B tumors. Of the 13 type D tumors, 7 were D1, 1 D2, and 5 D3. For type A tumors, GTR or NTR was achieved using an ETOA in 16 (94.1%) of 17 patients. Eighteen (90.0%) of 20 patients with type C tumors attained GTR or NTR. Ten (76.9%) of 13 patients with type D tumors underwent GTR. Statistical analysis showed that there was no significant difference in the extent of resection among the tumor subtypes. Surgical complications included transient partial ptosis (n = 4), permanent ptosis (n = 1), transient diplopia (n = 7), permanent diplopia (n = 1), corneal keratopathy (n = 7), difficulties in mastication (n = 5), and neuralgic pain or paresthesia (n = 14). There were no postoperative CSF leaks or enophthalmos during follow-up.

CONCLUSIONS This study showed that trigeminal schwannomas can be effectively treated with a minimally invasive ETOA in all tumor types, except those predominantly involving the posterior fossa (type B). For the extracranial compartments, D2 or D3 tumor types often require an ETOA combined with the endoscopic endonasal approach, while D1 tumor types can be treated using an ETOA alone.

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The benefits of automated CSF drainage in normal pressure hydrocephalus

Acta Neurochirurgica (2023) 165:1505–1509

The commonly used cerebrospinal fluid (CSF) drainage system remains the manual drip-chamber drain. The LiquoGuard (Möller Medical GmbH, Germany) is an automated CSF management device with dual functionality, measuring intracranial pressure and automatic pressure- or volume-led CSF drainage. There is limited research for comparison of devices, particularly in the neurosurgical field, where it has potential to reshape care.

Objective This study aims to compare manual drip-chamber drain versus LiquoGuard system, by assessing accuracy of drainage, associated morbidity and impact on length of stay.

Method Inclusion criteria consisted of suspected normal pressure hydrocephalus (NPH) patients undergoing extended lumbar drainage. Patients were divided into manual drain group versus automated group.

Results Data was analysed from 42 patients: 31 in the manual group versus 11 in the LiquoGuard group. Volumetric overdrainage was seen in 90.3% (n = 28) versus 0% (p < 0.05), and under-drainage in 38.7% (n = 12) versus 0% (p < 0.05), in the manual and automatic group, respectively. Symptoms of over-drainage were noted in 54.8% (n = 17) of the manual group, all of which had episodes of volumetric over-drainage, versus 18.2% (n = 2) in automated group, of which neither had actual over-drainage (p < 0.05). Higher over-drainage symptoms of manual drain is likely due to increased fluctuation of CSF drainage, instead of smooth CSF drainage seen with LiquoGuard system. An increased length of stay was seen in 38.7% (n = 12) versus 9% (n = 1) (p < 0.05) in the manual and LiquoGuard group, respectively.

Conclusion The LiquoGuard device is a more superior way of CSF drainage in suspected NPH patients, with reduced morbidity and length of stay.

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Surgical management of large cerebellopontine angle meningiomas: long-term results of a less aggressive resection strategy

J Neurosurg 138:1630–1639, 2023

Cerebellopontine angle (CPA) meningiomas present many surgical challenges depending on their volume, site of dural attachment, and connection to surrounding neurovascular structures. Assuming that systematic radical resection of large CPA meningiomas carries a high risk of permanent morbidity, the authors adopted an alternative strategy of optimal resection followed by radiosurgery or careful observation of the residual tumor and assessed the efficiency and safety of this approach to meningioma treatment management.

METHODS This single-center retrospective cohort study included 50 consecutive patients who underwent surgery for meningioma between January 2003 and February 2020.

RESULTS The most common main dural attachments of the meningiomas were posterior (42%) and superior (26%) to the internal auditory meatus. The suboccipital retrosigmoid route was the most routinely used (92%). At the last follow-up examination, 93% of the patients with normal preoperative facial nerve (FN) function retained good House-Brackmann (HB) grades of I and II, whereas 3 patients (7%) displayed intermediate HB grade III FN function. Hearing preservation was achieved in 86% of the patients who presented with preoperative serviceable hearing, and recovery after surgery was achieved in 19% of the patients experiencing preoperative hearing loss. In order to preserve all cranial nerve function, gross-total resection was obtained in 26% of patients. Of the 35 patients who had undergone subtotal resection, 20 (57%) had been allocated into a wait-and-rescan treatment approach and 15 (43%) underwent upfront Gamma Knife surgery (GKS). The mean postoperative tumor volume was 1.20 cm 3 in the upfront GKS group and 0.73 cm 3 in the waitand-rescan group (p = 0.08). Tumor control was achieved in 87% and 55% of cases (p < 0.001), with a mean follow-up of 85 and 69 months in the GKS and wait-and-rescan groups, respectively. The 1-, 5-, and 7-year tumor progression-free survival rates were 100%, 100%, and 89% in the GKS group and 95%, 59%, and 47% in the wait-and-rescan group, respectively (p < 0.001).

CONCLUSIONS Optimal nonradical resection of large CPA meningiomas provides favorable long-term tumor control and functional preservation. Adjuvant GKS does not carry additional morbidity and appears to be an efficient adjuvant treatment.

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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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Surgical removal of a corpus callosum arteriovenous malformation using a robotic digital microscope

Acta Neurochirurgica (2023) 165:1609–1613

This report described the surgical nuance of a challenging deep-seated corpus callosum arteriovenous malformation (AVM) using a novel robotic digital microscope.

Method A 64-year-old male was admitted to treat a ruptured corpus callosum AVM. In order to facilitate surgical manipulation under the robotic digital microscope, a gravity-assisted supine position was utilized. Intraoperatively, identifying and preserving the transit and bystander artery is important while skeletonizing the anterior cerebral artery. The nidus was totally resected and the patient was discharged without sequella.

Conclusion It is feasible to perform complicated AVM resection under the robotic digital microscope with a rigorous surgical plan.

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Comparison of Clinical Outcomes of Cervical Laminoplasty for Cervical Spondylotic Myelopathy: Double-Door With Lamina Staple, Single-Door With Miniplate, and Double-Door With Spacer—A 2-Year Follow-Up Study

Neurosurgery 92:1259–1268, 2023

There were few studies to compare the outcomes of different types of cervical laminoplasties.

OBJECTIVE: To compare the clinical outcomes of double-door cervical laminoplasty with lamina staple (double-door staple), single-door cervical laminoplasty with miniplate (singledoor miniplate), and double-door cervical laminoplasty with spacer (double-door spacer).

METHODS: The study involved 166 patients with cervical spondylotic myelopathy (CSM). Fifty-two patients underwent double-door staple, 63 patients underwent single-door miniplate, and 51 patients underwent double-door spacer. The clinical outcomes were measured.

RESULTS: There was no significant difference in Japanese Orthopedic Association score among the 3 groups (P > .05). The operation time was significantly shorter in double-door staple and single-door miniplate groups than in the double-door spacer group (P < .005). The estimated blood loss was significantly more in the single-door miniplate group than in double-door staple and double-door spacer groups (P < .005). The expansion ratio of cervical intraspinal cross-sectional area decreased in the order of double-door staple > double-door spacer > single-door miniplate. There were no significant differences in the expansion ratio of dural sac cross-sectional area among the 3 groups.

CONCLUSION: Double-door staple, double-door spacer, and single-door miniplate can achieve favorable clinical outcomes for CSM. The blood loss of double-door staple is less than that of single-door miniplate, and the operation time of double-door staple is shorter than that of double-door spacer. The mean expansion ratio of cervical intraspinal cross-sectional area decreased in the order of double-door staple > double-door spacer > single-door miniplate. Overall, double-door staple is a safe and innovative alternative choice for treatment of CSM.

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Factors associated with readmission after minimally invasive transforaminal lumbar interbody fusion

J Neurosurg Spine 38:681–687, 2023

The objective of this study was to identify factors that lead to a prolonged hospital stay or 30-day readmission after minimally invasive surgery (MIS) for transforaminal lumbar interbody fusion (TLIF) at a single institution.

METHODS Consecutive patients who underwent MIS TLIF from January 1, 2016, to March 31, 2018, were retrospectively analyzed. Demographic data, including age, sex, ethnicity, smoking status, and body mass index, were collected along with operative details, indications, affected spinal levels, estimated blood loss, and operative duration. The effects of these data were evaluated relative to the hospital length of stay (LOS) and 30-day readmission.

RESULTS The authors identified 174 consecutive patients who underwent MIS TLIF at 1 or 2 levels from a prospectively collected database. The mean (range) patient age was 64.1 (31–81) years, 97 were women (56%), and 77 were men (44%). Of 182 levels fused, 127 were done at L4–5 (70%), 32 at L3–4 (18%), 13 at L5–S1 (7%), and 10 at L2–3 (5%). Patients underwent 166 (95%) single-level procedures and 8 (5%) 2-level procedures. The mean (range) procedural duration, defined as the time from incision to closure, was 164.6 (90–529) minutes. The mean (range) LOS was 1.8 (0–8) days. Eleven patients (6%) were readmitted within 30 days; the most frequent causes were urinary retention, constipation, and persistent or contralateral symptoms. Seventeen patients had LOS greater than 3 days. Six of those patients (35%) were identified as widows, widowers, or divorced, and 5 of them lived alone. Six patients with prolonged LOS (35%) required placement in either skilled nursing or acute inpatient rehabilitation. Regression analyses showed living alone (p = 0.04) and diabetes (p = 0.04) as predictors of readmission. Regression analyses revealed female sex (p = 0.03), diabetes (p = 0.03), and multilevel surgery (p = 0.006) as predictors of LOS > 3 days.

CONCLUSIONS Urinary retention, constipation, and persistent radicular symptoms were the leading causes of readmission within 30 days of surgery in this series, which is distinct from data from the American College of Surgeons National Surgical Quality Improvement Program. The inability to discharge a patient home for social reasons led to prolonged inpatient hospital stays. Identifying these risk factors and proactively addressing them could lower readmission rates and decrease LOS among patients undergoing MIS TLIF.

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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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Asymptomatic Postoperative Cerebral Venous Sinus Thrombosis After Posterior Fossa Tumor Surgery: Incidence, Risk Factors, and Therapeutic Options

Neurosurgery 92:1171–1176, 2023

Cerebral venous sinus thrombosis (CVST) is a known complication of posterior fossa surgery near the sigmoid and transverse sinus. The incidence and treatment of postoperative asymptomatic CVST are controversial.

OBJECTIVE: To analyze incidence, risk factors, and management of asymptomatic postoperative CVST after posterior fossa tumor surgery.

METHODS: In this retrospective, single-center study, we included all patients who underwent posterior fossa tumor surgery in the semisitting position between January 2013 and December 2020. All patients underwent preoperative and postoperative imaging using MRI with/without additional computed tomography angiography. We analyzed the effect of demographic and surgical data on the incidence of postoperative CVST. Furthermore, therapeutic anticoagulation or conservative treatment for postoperative CVST and the incidence of intracranial hemorrhage were investigated.

RESULTS: In total, 266 patients were included. Thirty-three of 266 (12.4%) patients developed postoperative CVST. All patients were asymptomatic. Thirteen of 33 patients received therapeutic anticoagulation, and 20 patients did not. Univariate analysis showed that age (P= .56), sex (P = .20), American Society of Anesthesiology status (P = .13), body mass index (P = .60), and length of surgery (P= .176) were not statistically correlated with postoperative CVST. Multivariate analysis revealed that meningioma (P < .001, odds ratio 11.3, CI 95% 4.1-31.2) and vestibular schwannoma (P = .013, odds ratio 4.4, CI 95% 1.3-16.3) are risk factors for the development of new postoperative CVST. The use of therapeutic anticoagulation to treat postoperative CVST was associated with a higher rate of intracranial hemorrhage (n = 4, P = .017).

CONCLUSION: Tumor entity influences the incidence of postoperative CVST. In clinically asymptomatic patients, careful decision making is necessary whether to initiate therapeutic anticoagulation or not.

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The value of ventricular measurements in the prediction of shunt dependency after aneurysmal subarachnoid hemorrhage

Acta Neurochirurgica (2023) 165:1545–1555

Chronic hydrocephalus requiring shunt placement is a common complication of aneurysmal subarachnoid hemorrhage (SAH). Different risk factors and prediction scores for post-SAH shunt dependency have been evaluated so far. We analyzed the value of ventricle measurements for prediction of the need for shunt placement in SAH patients.

Methods Eligible SAH cases treated between 01/2003 and 06/2016 were included. Initial computed tomography scans were reviewed to measure ventricle indices (bifrontal, bicaudate, Evans’, ventricular, Huckman’s, and third ventricle ratio). Previously introduced CHESS and SDASH scores for shunt dependency were calculated. Receiver operating characteristic analyses were performed for diagnostic accuracy of the ventricle indices and to identify the clinically relevant cut-offs.

Results Shunt placement followed in 221 (36.5%) of 606 patients. In univariate analyses, all ventricular indices were associated with shunting (all: p<0.0001). The area under the curve (AUC) ranged between 0.622 and 0.662. In multivariate analyses, only Huckman’s index was associated with shunt dependency (cut-off at ≥6.0cm, p<0.0001) independent of the CHESS score as baseline prediction model. A combined score (0–10 points) containing the CHESS score components (0–8 points) and Huckman’s index (+2 points) showed better diagnostic accuracy (AUC=0.751) than the CHESS (AUC=0.713) and SDASH (AUC=0.693) scores and the highest overall model quality (0.71 vs. 0.65 and 0.67), respectively.

Conclusions Ventricle measurements are feasible for early prediction of shunt placement after SAH. The combined prediction model containing the CHESS score and Huckman’s index showed remarkable diagnostic accuracy regarding identification of SAH individuals requiring shunt placement. External validation of the presented combined CHESS-Huckman score is mandatory.

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Precuneal gliomas promote behaviorally relevant remodeling of the functional connectome

J Neurosurg 138:1531–1541, 2023

The precuneus hosts one of the most complex patterns of functional connectivity in the human brain. However, due to the extreme rarity of neurological lesions specifically targeting this structure, it remains unknown how focal damage to the precuneus may impact resting-state functional connectivity (rsFC) at the brainwide level. The aim of this study was to investigate glioma-induced rsFC modulations and to identify patterns of rsFC remodeling that accounted for the maintenance of cognitive performance after awake-guided surgical excision.

METHODS In a unique series of patients with IDH1-mutated low-grade gliomas (LGGs) infiltrating the precuneus who were treated at a single neurosurgical center (Montpellier University Medical Center, 2014–2021), the authors gauged the dynamic modulations induced by tumors on rsFC in comparison with healthy participants. All patients received a preoperative resting-state functional MRI and underwent operation guided by awake cognitive mapping. Connectome multivariate pattern analysis (MVPA), seed-network analysis, and graph theoretical analysis were conducted and correlated to executive neurocognitive scores (i.e., phonological and semantic fluencies, Trail-Making Test [TMT] parts A and B) obtained 3 months after surgery.

RESULTS Seventeen patients with focal precuneal infiltration were selected (mean age 38.1 ± 11.2 years) and matched to 17 healthy participants (mean age 40.5 ± 10.4 years) for rsFC analyses. All patients underwent awake cognitive mapping, allowing total resection (n = 3) or subtotal resection (n = 14), with a mean extent of resection of 90.6% ± 7.3%. Using MVPA (cluster threshold: p–false discovery rate corrected < 0.05, voxel threshold: p-uncorrected < 0.001), remote hotspots with significant rsFC changes were identified, including both insulas, the anterior cingulate cortex, superior sensorimotor cortices, and both frontal eye fields. Further seed-network analyses captured 2 patterns of between-network redistribution especially involving hyperconnectivity between the salience, visual, and dorsal attentional networks. Finally, the global efficiency of the salience-visual-dorsal attentional networks was strongly and positively correlated to 3-month postsurgical scores (n = 15) for phonological fluency (r 15 = 0.74, p = 0.0027); TMT-A (r 15 = 0.65, p = 0.012); TMTB (r 15 = 0.70, p = 0.005); and TMT-B-A (r 15 = 0.62, p = 0.018).

CONCLUSIONS In patients with LGGs infiltrating the precuneus, remote and distributed functional connectivity modulations in the preoperative setting are associated with better maintenance of cognitive performance after surgery. These findings provide a new vision of the mechanistic principles underlying neural plasticity and cognitive compensation in patients with LGGs.

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Middle Meningeal Artery Embolization Versus Conventional Management for Patients With Chronic Subdural Hematoma: A Systematic Review and Meta-Analysis

Neurosurgery 92:1142–1154, 2023

The results from studies that compare middle meningeal artery (MMA) embolization vs conventional management for patients with chronic subdural hematoma are varied.

OBJECTIVE: To conduct a systematic review and meta-analysis on studies that compared MMA embolization vs conventional management.

METHODS: Medline, PubMed, and Embase databases were searched. Primary outcomes were treatment failure and surgical rescue; secondary outcomes were complications, follow-up modified Rankin scale > 2, mortality, complete hematoma resolution, and length of hospital stay (day). The certainty of the evidence was determined using the GRADE approach.

RESULTS: Nine studies yielding 1523 patients were enrolled, of which 337 (22.2%) and 1186 (77.8%) patients received MMA embolization and conventionalmanagement, respectively.MMA embolization was superior to conventional management for treatment failure (relative risk [RR] = 0.34 [0.14-0.82], P = .02), surgical rescue (RR = 0.33 [0.14-0.77], P = .01), and complete hematoma resolution (RR = 2.01 [1.10-3.68], P = .02). There was no difference between the 2 groups for complications (RR= 0.93 [0.63-1.37], P = .72), follow-up modified Rankin scale >2 (RR= 0.78 [0.449-1.25], P= .31), mortality (RR= 1.05 [0.51-2.14], P = .89), and length of hospital stay (mean difference = 0.57 [ 2.55, 1.41], P = .57). ForMMAembolization, the number needed to treat for treatment failure, surgical rescue, and complete hematoma resolution was 7, 9, and 3, respectively. The certainty of the evidence was moderate to high for primary outcomes and low to moderate for secondary outcomes.

CONCLUSION: MMA embolization decreases treatment failure and the need for surgical rescue without furthering the risk of morbidity and mortality. The authors recommend considering MMA embolization in the chronic subdural hematoma management.

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Surgical complications and recurrence factors for asymptomatic meningiomas: a single‑center retrospective study

Acta Neurochirurgica (2023) 165:1345–1353

Observation is the first management option in asymptomatic meningiomas, but when an enlargement or mass effect is observed, surgery is indicated. This study is aimed at exploring risk factors for complications and recurrence after surgery for asymptomatic meningioma. We also examined the impact of preoperative tumor embolization, which is considered controversial.

Methods We retrospectively reviewed 109 patients with primary asymptomatic meningiomas surgically treated at our institute between April 2007 and March 2021. Patients who only had headaches as a nonspecific complaint were included in the asymptomatic group. Complications, time to recurrence, and Glasgow Outcome Scale (GOS) score were the endpoints of the study. Risk factors for complications and recurrence were explored. Moreover, the effect of the resection on nonspecific headaches was also explored.

Results The permanent postoperative complication rate related to the surgical procedure was 1.8%. Of the total, 107 patients (98.2%) with asymptomatic meningiomas who were surgically treated achieved a GOS score of 5 1 year after the operation. Preoperative headache was present in 31 patients and improved postoperatively in 21 patients. Multivariate analysis using the Cox proportional hazard model showed that preoperative tumor embolization with > 80% resolution of tumor staining (p < 0.001) was negatively related to recurrence, whereas age (p = 0.046) and Simpson grade IV resection (p = 0.041) were positively related to recurrence.

Conclusion Although surgery for asymptomatic meningiomas can, in many cases, be safe, it is not free of complications Thus, surgical intervention for asymptomatic meningiomas should be considered cautiously. However, more than half the patients with headaches showed improvement. Simpson grade IV resection cases should be assessed for recurrence, and preoperative tumor embolization might be effective in controlling recurrence.

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Laser interstitial thermal therapy in the treatment of brain metastases: the relationship between changes in postoperative magnetic resonance imaging characteristics and tumor recurrence

Acta Neurochirurgica (2023) 165:1379–1387

Laser interstitial thermal therapy (LITT) has been used to treat brain metastases (BMs) in several countries, and its safety and effectiveness have been confirmed. In most cases, magnetic resonance imaging (MRI) reveals an increase in tumor volume with an enhanced margin after LITT. However, little is known about the relationship between this MRI change and tumor recurrence.

Objective We report the first case series of BMs treated by LITT in China to evaluate the clinical characteristics and predictive factors of tumor recurrence.

Material and methods Patients with less than four brain metastatic lesions and a Karnofsky performance status (KPS) > 70 were eligible for study inclusion. Standard LITT procedures were performed, and a follow-up MRI was performed to analyze the radiographic changes, especially the volume ratio of the enhanced margin and the whole lesion on MRI at 30 days postoperatively. All the volume-related data were delineated and calculated using 3D Slicer software. Related predictors were also collected to evaluate the correlation with local tumor control.

Results Eighteen patients with nineteen lesions were enrolled for treatment and follow-up. Primary tumor histology included pulmonary carcinoma (n = 11) and breast cancer (n = 4). On average, the tumor size measured 3.01 cm3 (range, 0.40–7.40 cm3), the total ablation time was 13.58 min (range, 2.88–37.15 min), and the complete ablation rate was 92.4% (range, 29.2–100%). Comparing 3s0-day follow-up MRI results with preoperative MRI findings, 18 lesions showed a 2.28-fold (range, 1.21–4.88) volume increase; all the lesions displayed an enhanced component with a volume ratio of 42.35% (range, 10.14–100%). Five patients experienced tumor recurrence, and the local tumor control rates at 90 days and 180 days of followup were 68.4% and 66.7%, respectively. Univariate analysis indicated that the primary tumor, ablation rate, and enhanced volume ratio (EVR) > 40% in the 30-day MRI were associated with tumor recurrence, whereas multivariate analysis showed that only EVR > 40% was a predictive factor of local control.

Conclusion LITT is a minimally invasive method used to ablate brain metastases which can be used as the first-line treatment for BM patients under certain indications. After LITT, most tumors showed volume enlargement on the 30-day MRI scan, and EVR > 40% on the 30-day MRI may indicate late tumor recurrence.

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Transforaminal lumbar interbody fusion (TLIF) versus posterolateral instrumented fusion (PLF) in degenerative lumbar disorders

Eur Spine J (2013) 22:2022–2029

The aim of the present study was to analyze outcome, with respect to functional disability, pain, fusion rate, and complications of patients treated with transforaminal lumbar interbody fusion (TLIF) in compared to instrumented poserolateral fusion (PLF) alone, in low back pain. Spinal fusion has become a major procedure worldwide. However, conflicting results exist. Theoretical circumferential fusion could improve functional outcome. However, the theoretical advantages lack scientific documentation.

Methods Prospective randomized clinical study with a 2-year follow-up period. From November 2003 to November 2008, 100 patients with severe low back pain and radicular pain were randomly selected for either posterolateral lumbar fusion [titanium TSRH (Medtronic)] or transforaminal lumbar interbody fusion [titanium TSRH (Medtronic)] with anterior intervertebral support by tantalum cage (Implex/Zimmer). The primary outcome scores were obtained using Dallas Pain Questionnaire (DPQ), Oswestry disability Index, SF-36, and low back pain Rating Scale. All measures assessed the endpoints at 2-year follow-up after surgery.

Results The overall follow-up rate was 94 %. Sex ratio was 40/58. 51 patients had TLIF, 47 PLF. Mean age 49(TLIF)/45(PLF). No statistic difference in outcome between groups could be detected concerning daily activity, work leisure, anxiety/depression or social interest. We found no statistic difference concerning back pain or leg  pain. In both the TLIF and the PLF groups the patients had significant improvement in functional outcome, back pain, and leg pain compared to preoperatively. Operation time and blood loss in the TLIF group were significantly higher than in the PLF group (p \ 0.001). No statistic difference in fusion rates was detected.

Conclusions Transforaminal interbody fusion did not improve functional outcome in patients compared to posterolateral fusion. Both groups improved significantly in all categories compared to preoperatively. Operation time and blood loss were significantly higher in the TLIF group.

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Predicting the growth of middle cerebral artery bifurcation aneurysms using differences in the bifurcation angle and inflow coefficient

J Neurosurg 138:1357–1365, 2023

Growing intracranial aneurysms (IAs) are prone to rupture. Previous cross-sectional studies using postrupture morphology have shown the morphological or hemodynamic features related to IA rupture. Yet, which morphological or hemodynamic differences of the prerupture status can predict the growth and rupture of smaller IAs remains unknown. The purpose of this longitudinal study was to investigate the effects of morphological features and the hemodynamic environment on the growth of IAs at middle cerebral artery (MCA) bifurcations during the follow-up period.

METHODS One hundred two patients with MCA M1–2 bifurcation saccular IAs who underwent follow-up for more than 2 years at the authors’ institutions between 2011 and 2019 were retrospectively identified. During the follow-up period, cases involving growth of MCA IAs were assigned to the event group, and those with MCA IAs unchanged in size were assigned to the control group. The morphological parameters examined were aneurysmal neck length, dome height, aspect ratio and volume, M1 and M2 diameters and their ratio, and angle configurations among M1, M2, and the aneurysm. Hemodynamic parameters were flow rate and wall shear stress in M1, M2, and the aneurysm, including the aneurysmal inflow rate coefficient (AIRC), defined as the ratio of the aneurysmal inflow rate to the M1 flow rate. Those parameters were compared statistically between the two groups. Correlations between morphological and hemodynamic parameters were also examined.

RESULTS Eighty-three of 102 patients were included: 25 with growing MCA IAs (event group) and 58 with stable MCA IAs (control group). The median patient age at initial diagnosis was 66.9 (IQR 59.8–72.3) years. The median follow-up period was 48.5 (IQR 36.5–65.6) months. Both patient age and the AIRC were significant independent predictors of the growth of MCA IAs. Moreover, the AIRC was strongly correlated with sharper bifurcation and inflow angles, as well as wider inclination angles between the M1 and M2 arteries.

CONCLUSIONS The AIRC was a significant independent predictor of the growth of MCA IAs. Sharper bifurcation and inflow angles and wider inclination angles between the M1 and M2 arteries were correlated with the AIRC. MCA IAs with such a bifurcation configuration are more prone to grow and rupture.

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Evaluating syntactic comprehension during awake intraoperative cortical stimulation mapping

J Neurosurg 138:1403–1410, 2023

Electrocortical stimulation mapping (ECS) is widely used to identify essential language areas, but sentence-level processing has rarely been investigated.

METHODS While undergoing awake surgery in the dominant left hemisphere, 6 subjects were asked to comprehend sentences varying in their demands on syntactic processing.

RESULTS In all 6 subjects, stimulation of the inferior frontal gyrus disrupted comprehension of passive sentences, which critically depend on syntactic processing to correctly assign grammatical roles, without disrupting comprehension of simpler tasks. In 4 of the 6 subjects, these sites were localized to the pars opercularis. Sentence comprehension was also disrupted by stimulation of other perisylvian sites, but in a more variable manner.

CONCLUSIONS These findings suggest that there may be language regions that differentially contribute to sentence processing and which therefore are best identified using sentence-level tasks. The functional consequences of resecting these sites remain to be investigated.

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