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The Danish chronic subdural hematoma study—predicting recurrence of chronic subdural hematoma

Acta Neurochirurgica (2019) 161:885–894

An increasing incidence of chronic subdural hematoma (CSDH) and an unchanging high recurrence rate of 10–20% call for individualized treatment. The aim of this study was to establish individualized prediction models for the risk of recurrence treating death as a competing risk.

Methods A retrospective national cohort of unilateral CSDH was included for analysis. Using competing risk survival analysis, we tested whether available covariates were associated with the risk of recurrence. We further established a preand a postoperative prediction model, where predictors were chosen using a LASSO approach. The models were visualized in nomograms. Predictive performance was evaluated by c index and calibrations plots.

Results A total of 763 patients with surgically evacuated unilateral CSDH were included for analysis. The recurrence rate was 14% while 12% of patients died during follow-up (1 year). In our association model, hematoma size, drain type, drainage time, presence of complications, and Glasgow Coma Score were significantly associated to recurrence. Subdural drain was associated with a lower recurrence risk than subgaleal drain. The preoperative model included hematoma size, hematoma density, and history of hypertension. The postoperative model included further drain type, drainage time, and surgical complications.

Conclusion The nomograms allow easy assessment of the recurrence risk for the individual patient, providing a better possibility for individual adjustment of treatment and follow-up. The predictive performance indicates that significant unaccounted or unknown factors still remain. The association test found passive subdural drain superior to passive subgaleal drain in minimizing the risk of CSDH recurrence

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Clipping aneurysms improves outcomes for patients undergoing coiling

J Neurosurg 130:1491–1497, 2019

Most intracranial aneurysms are now treated by endovascular rather than by microsurgical procedures. There is evidence to demonstrate superior outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) treated by endovascular techniques. However, some cases continue to require microsurgery. The authors have examined the relationship between the number of aneurysms treated by microsurgery and outcome for patients undergoing treatment for aSAH at neurosurgical centers in England.

METHODS The Neurosurgical National Audit Programme (NNAP) database was used to identify aSAH cases and to provide associated 30-day mortality rates for each of the 24 neurosurgical centers in England. Data were compared for association by regression analysis using the Pearson product-moment correlation coefficient and any associations were tested for statistical significance using the one-way ANOVA test. The NNAP data were validated utilizing a second, independent registry: the British Neurovascular Group’s (BNVG) National Subarachnoid Haemorrhage Database.

RESULTS Increasing numbers of microsurgical cases in a center are associated with lower 30-day mortality rates for all patients treated for aSAH, irrespective of treatment modality (Pearson r = 0.42, p = 0.04), and for patients treated for aSAH by endovascular procedures (Pearson r = 0.42, p = 0.04). The correlations are stronger if all (elective and acute) microsurgical cases are compared with outcome. The BNVG data validated the NNAP data set for patients with aSAH.

CONCLUSIONS There is a statistically significant association between local microsurgical activity and center outcomes for patients with aSAH, even for patients treated endovascularly. The authors postulate that the number of microsurgical cases performed may be a surrogate indicator of closer neurosurgical involvement in the overall management of neurovascular patients and of optimal case selection.

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Outcome After Clipping and Coiling for Aneurysmal Subarachnoid Hemorrhage in Clinical Practice in Europe, USA, and Australia

Neurosurgery 84:1019–1027, 2019

Within randomized clinical trials (RCTs), coiling of the ruptured aneurysm to prevent rebleeding results in better outcomes than clipping in patients with aneurysmal subarachnoid hemorrhage (aSAH).

OBJECTIVE: To study the association of coiling and clipping with outcome after aSAH in daily clinical practice.

METHODS: In this controlled, nonrandomized study, we compared outcomes after endovascular coiling and neurosurgical clipping of ruptured intracranial aneurysms in an administrative dataset of 7658 aSAH patients (22 tertiary care hospitals from Europe, USA, Australia; 2007-2013). Because the results contradicted those of the randomized trials, findings were further explored in a large clinical dataset from 2 European centers (2006- 2016) of 1501 patients.

RESULTS: In the administrative dataset, the crude 14-d case-fatality rate was 6.4% (95% confidence interval [CI] 5.6%-7.2%) after clipping and 8.2% (95% CI 7.4%-9.1%) after coiling. After adjustment for age, sex, and comorbidity/severity, the odds ratio (OR) for 14-d casefatality after coiling compared to clipping was 1.32 (95% CI 1.10-1.58). In the clinical dataset crude 14-d case fatality ratewas 5.7% (95% CI 4.2%-7.8%) for clipping and 9.0% (95% CI 7.3%- 11.2%) for coiling. In multivariable logistic regression analysis, the OR for 14-d case-fatality after coiling compared to clipping was 1.7 (95% CI 1.1–2.7), for 90-d case-fatality 1.28 (95% CI 0.91–1.82) and for 90-d poor functional outcome 0.78 (95% CI 0.6–1.01).

CONCLUSION: In clinical practice, coiling after aSAH is associated with higher 14-d case-fatality than clipping and nonsuperior outcomes at 90 d. Both options need to be considered in aSAH patients. Further studies should address the reasons for the discrepancy between current data and those from the RCTs.

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Three-dimensional neuronavigation in SEEG-guided epilepsy surgery

Acta Neurochirurgica (2019) 161:917–923

Epilepsy surgery is mainly cortical surgery and the precise definition of the epileptogenic zone on the complex cortical surface is of paramount importance. Stereoelectroencephalography (SEEG) may delineate the epileptogenic zone even in cases of non-lesional epilepsy. The aim of our study was to present a technique of 3D neuronavigation based on the brain surface and SEEG electrodes reconstructions using FSL and 3DSlicer software.
Patients and methods Our study included 26 consecutive patients operated on for drug-resistant epilepsy after SEEG exploration between January 2015 and December 2017. All patients underwent 1.5 T pre-SEEG MRI, post-SEEG CT, DICOM data post- processing using FSL and 3DSlicer, preoperative planning on 3DSlicer, and intraoperative 3D neuronavigation. Accuracy and precision of 3D SEEG reconstruction and 3D neuronavigation was assessed.
Results We identified 125 entry points of SEEG electrodes during 26 operations. The accuracy of 3D reconstruction was 0.8 mm (range, 0–2 mm) with a precision of 1.5 mm. The accuracy of 3D SEEG neuronavigation was 2.68 mm (range, 0–6 mm). The precision of 3D neuronavigation was 1.48 mm.
Conclusion 3D neuronavigation for SEEG-guided epilepsy surgery using free software for post-processing of common MRI sequences is possible and a reliable method even with navigation systems without a brain extraction tool.

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The Promise of Proton Therapy for Central Nervous System Malignancies

Neurosurgery, Volume 84, Issue 5, May 2019, Pages 1000–1010

Radiation therapy plays a significant role in management of benign and malignant diseases of the central nervous system. Patients may be at risk of acute and late toxicity from radiation therapy due to dose deposition in critical normal structures.

In contrast to conventional photon delivery techniques, proton therapy is characterized by Bragg peak dose deposition which results in decreased exit dose beyond the target and greater sparing of normal structure which may reduce the rate of late toxicities from treatment. Dosimetric studies have demonstrated reduced dose to normal structures using proton therapy as compared to photon therapy. In addition, clinical studies are being reported demonstrating safety, feasibility, and low rates of acute toxicity.

Technical challenges in proton therapy remain, including full understanding of depth of proton penetration and the biological activity in the distal Bragg peak. In addition, longer clinical followup is required to demonstrate reduction in late toxicities as compared to conventional photon-based radiation techniques.

In this review, we summarize the current clinical literature and areas of active investigation in proton therapy for adult central nervous system malignancies.

 

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Computer-aided analysis of middle cerebral artery tortuosity: association with aneurysm development

J Neurosurg 130:1478–1484, 2019

Blood vessel tortuosity may play an important role in the development of vessel abnormalities such as aneurysms. Currently, however, there are no studies analyzing the impact of brain blood vessel tortuosity on the risk of aneurysm formation. Therefore, the authors performed a computer-aided analysis of middle cerebral artery (MCA) tortuosity, especially among patients diagnosed with MCA aneurysms.

METHODS Anatomy of the MCAs of 54 patients with unruptured MCA aneurysms was retrospectively analyzed, as was that of 54 sex-, age-, and vessel side–matched control patients without MCA aneurysms. From medical records, the authors obtained each patient’s medical history including previous and current diseases and medications. For each patient, they calculated the following tortuosity descriptors: relative length (RL), sum of angle metrics (SOAM), triangular index (TI), product of angle distance (PAD), and inflection count metric (ICM).

RESULTS Patients with an MCA aneurysm had significantly lower RLs (0.75 ± 0.09 vs 0.83 ± 0.08, p < 0.01), SOAMs (0.45 ± 0.10 vs 0.60 ± 0.17, p < 0.01), and PADs (0.34 ± 0.09 vs 0.50 ± 0.17, p < 0.01). They also had significantly higher TIs (0.87 ± 0.04 vs 0.81 ± 0.07, p < 0.01) and ICMs (3.07 ± 1.58 vs 2.26 ± 1.12, p < 0.01). Female patients had significantly higher RLs (0.76 ± 0.11 vs 0.80 ± 0.09, p = 0.03) than male patients.

CONCLUSIONS Middle cerebral artery aneurysm formation is strongly associated with blood vessel tortuosity parameters, which can potentially be used to screen for patients at risk for MCA aneurysm formation.

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The future of open vascular neurosurgery: perspectives on cavernous malformations, AVMs, and bypasses for complex aneurysms

Despite the erosion of microsurgical case volume because of advances in endovascular and radiosurgical therapies, indications remain for open resection of pathology and highly technical vascular repairs. Treatment risk, efficacy, and durability make open microsurgery a preferred option for cerebral cavernous malformations, arteriovenous malformations (AVMs), and many aneurysms.

In this paper, a 21-year experience with 7348 cases was reviewed to identify trends in microsurgical management. Brainstem cavernous malformations (227 cases), once considered inoperable and managed conservatively, are now resected in increasing numbers through elegant skull base approaches and newly defined safe entry zones, demonstrating that microsurgical techniques can be applied in ways that generate entirely new areas of practice.

Despite excellent results with microsurgery for low-grade AVMs, brain AVM management (836 cases) is being challenged by endovascular embolization and radiosurgery, as well as by randomized trials that show superior results with medical management. Reviews of ARUBA-eligible AVM patients treated at high-volume centers have demonstrated that open microsurgery with AVM resection is still better than many new techniques and less invasive approaches that are occlusive or obliterative. Although the volume of open aneurysm surgery is declining (4479 cases), complex aneurysms still require open microsurgery, often with bypass techniques. Intracranial arterial reconstructions with reimplantations, reanastomoses, in situ bypasses, and intracranial interpositional bypasses (third-generation bypasses) augment conventional extracranial-intracranial techniques (first- and second-generation bypasses) and generate innovative bypasses in deep locations, such as for anterior inferior cerebellar artery aneurysms. When conventional combinations of anastomoses and suturing techniques are reshuffled, a fourth generation of bypasses results, with eight new types of bypasses. Type 4A bypasses use in situ suturing techniques within the conventional anastomosis, whereas type 4B bypasses maintain the basic construct of reimplantations or reanastomoses but use an unconventional anastomosis. Bypass surgery (605 cases) demonstrates that open microsurgery will continue to evolve. The best neurosurgeons will be needed to tackle the complex lesions that cannot be managed with other modalities. Becoming an open vascular neurosurgeon will be intensely competitive. The microvascular practice of the future will require subspecialization, collaborative team effort, an academic medical center, regional prominence, and a large catchment population, as well as a health system that funnels patients from hospital networks outside the region. Dexterity and meticulous application of microsurgical technique will remain the fundamental skills of the open vascular neurosurgeon.

 

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Long-Term Outcome of Spinal Cord Stimulation in Failed Back Surgery Syndrome: 20 Years of ExperienceWith 224 Consecutive Patients

Neurosurgery (84) 5-1011–1018

Failed back surgery syndrome (FBSS) is a challenging condition that lacks a curative treatment. In selected patients, spinal cord stimulation (SCS) has provided a satisfactory outcome.

OBJECTIVE: To evaluate the long-term outcome of SCS in FBSS, as measured by (1) the explantation rate, (2) complications, and (3) patient satisfaction with the global perceived effect (GPE).

METHODS: We studied 224 consecutive FBSS patients who underwent an SCS trial with surgically implanted leads at our hospital between January 1996 and December 2014. The patients’ satisfaction with the GPE of treatment was measured through a postal questionnaire at the end of follow-up.

RESULTS: Based on a 1-wk trial, permanent SCS was implanted in 175 (78%) patients. Out of these patients, 153 (87%) reported satisfactory outcomes after 2 mo. During the mean follow-up of 6 yr, 34 (19%) of SCS devices were permanently explanted due to inadequate pain relief, and 11 (6%) were explanted for other reasons. Electrode revision due to inadequate pain relief was done for 22 patients. In total, 26 complications were reported due to: 7 deep infections, 11 hardwaremalfunctions, 1 subcutaneous hematoma, 4 instances of discomfort due to the pulse generator, and 3 electrode migrations. One hundred thirty patients (74%) continued with SCS until the end of follow-up. Of them, 61 (47%) returned the questionnaire, and 42 (69%) reported substantially improved or better GPE.

CONCLUSION: SCS can provide a good outcome in the treatment of FBSS. Patient selection could be further improved by developing novel predictive biomarkers.

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Contemporary concepts of pain surgery

J Neurosurg 130:1039–1049, 2019

Pain surgery is one of the historic foundations of neurological surgery. The authors present a review of contemporary concepts in surgical pain management, with reference to past successes and failures, what has been learned as a subspecialty over the past 50 years, as well as a vision for current and future practice.

This subspecialty confronts problems of cancer pain, nociceptive pain, and neuropathic pain. For noncancer pain, ablative procedures such as dorsal root entry zone lesions and rhizolysis for trigeminal neuralgia (TN) should continue to be practiced. Other procedures, such as medial thalamotomy, have not been proven effective and require continued study. Dorsal rhizotomy, dorsal root ganglionectomy, and neurotomy should probably be abandoned.

For cancer pain, cordotomy is an important and underutilized method for pain control. Intrathecal opiate administration via an implantable system remains an important option for cancer pain management.

While there are encouraging results in small case series, cingulotomy, hypophysectomy, and mesencephalotomy deserve further detailed analysis.

Electrical neuromodulation is a rapidly changing discipline, and new methods such as high-frequency spinal cord stimulation (SCS), burst SCS, and dorsal root ganglion stimulation may or may not prove to be more effective than conventional SCS. Despite a history of failure, deep brain stimulation for pain may yet prove to be an effective therapy for specific pain conditions. Peripheral nerve stimulation for conditions such as occipital neuralgia and trigeminal neuropathic pain remains an option, although the quality of outcomes data is a challenge to these applications. Based on the evidence, motor cortex stimulation should be abandoned. TN is a mainstay of the surgical treatment of pain, particularly as new evidence and insights into TN emerge.

Pain surgery will continue to build on this heritage, and restorative procedures will likely find a role in the armamentarium. The challenge for the future will be to acquire higher-level evidence to support the practice of surgical pain management.

 

 

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Utility of Cervical Collars Following Cervical Fusion Surgery. Does It Improve Fusion Rates or Outcomes?

World Neurosurg. (2019) https://doi.org/10.1016/j.wneu.2018.12.066

The use of postoperative cervical collars following cervical fusions is common practice. Its use has been purported to improve fusion rates and outcomes. There is a paucity in the strength of evidence to support its clinical benefit. Our objective is to critically evaluate the published literature to determine the strength of evidence supporting the use of postoperative cervical collar use following cervical fusions.

METHODS: A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (also known as PRISMA) was performed. An online search using Medline and Cochrane Central Register of Controlled Trials databases was used to query prospective and retrospective clinical trials evaluating cervical fusions with or without postoperative collar.

RESULTS: The search identified 894 articles in Medline and 65 articles in the Cochrane database. From these articles, 130 were selected based on procedure and collar use. Only 3 studies directly compared between collar use and no collar use. Our analysis of the mean improvement in neck disability index scores and improvement over time intervals did not show a statistically significant difference between collar versus no collar (P [ 0.86).

CONCLUSIONS: We found no strong evidence to support the use of cervical collars after 1- and 2-level anterior cervical discectomy and fusion procedures, and no studies comparing collar use and no collar use after posterior cervical fusions. Given the cost and likely impact of collar use on driving and the return to work, our study shows that currently there is no proven benefit to routine use of postoperative cervical collar in patients undergoing 1- and 2-level anterior cervical discectomy and fusion for degenerative cervical pathologies.

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Caroticoclinoid Bar: A Systematic Review and Meta-Analysis of Its Prevalence and Potential Implications in Cerebrovascular and Skull Base Surgery

World Neurosurg. (2019) 124:267-276

The presence of a caroticoclinoid bar (CCB) has been implicated in both transcranial and endonasal surgery. Its morphology reflects differences in the microsurgical anatomy of the parasellar area and its manipulation during anterior or middle clinoidectomy can result in internal carotid artery injury. Although adjustment of the surgical technique according to the CCB anatomic variants is required for safe surgical access to the paraclinoid region, a review indicated the lack of a systematic assortment of reported data regarding the prevalence of the CCB. Thus, our objective was to systematically review and document the prevalence of the CCB and its anatomic variations.

METHODS: Three databases were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement through August 2018 to identify relevant studies.

RESULTS: A total of 27 reports (7521 subjects or specimens, 14,449 sides) were included in the present meta-analysis. The overall pooled prevalence of the CCB was 32.6% (95% confidence interval [CI], 26.6%e38.8%) when measured in the subjects or specimens and 23.6% (95% CI, 19.7%e27.6%) when measured in each side. The overall prevalence of the CCB reported from imaging studies was 23.1% (95% CI, 8.9%e41.4%) for the subjects/specimens and 18.7% (95% CI, 12.6%e25.7%) for each side. The presence of the CCB was slightly more prevalent (P [ 0.050) on the right side.

CONCLUSIONS: Our results showed a considerable prevalence of the CCB, with lower prevalence rates found among imaging studies. Although meticulous preoperative investigation is mandatory, surgeons treating patients with parasellar pathologic entities should always be vigilant regarding the CCB.

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Tentorial sling for microvascular decompression in patients with trigeminal neuralgia

J Neurosurg 130:1315–1320, 2019

Trigeminal neuralgia is a debilitating pain disorder most often caused by arterial compression of the trigeminal nerve, although there are other etiologies. Microvascular decompression (MVD) remains the most definitive treatment for this disorder, with cure rates reported between 60% and 80%. Traditional MVD techniques involve a retrosigmoid craniotomy with placement of an inert foreign material, such as Teflon, between the nerve and compressive vessel. Recurrence of trigeminal neuralgia after MVD has been associated with vessel migration, adhesion formation, and arterial pulsation against the Teflon abutting the nerve. Additionally, foreign materials such as Teflon have been reported to trigger inflammatory responses, resulting in recurrence of trigeminal pain. An alternative method for decompression involves the use of a sling to transpose the compressive vessel away from the nerve. Results of various sling techniques as a decompressive strategy are limited to small series and case reports. In this study, the authors present their experience utilizing a tentorial sling for MVD in patients with trigeminal neuralgia.

METHODS Institutional review board approval was obtained in order to contact patients who underwent MVD for trigeminal neuralgia via the tentorial sling technique. Clinical outcomes were assessed utilizing the Barrow Neurological Institute (BNI) pain intensity score immediately after surgery and at the time of the study.

RESULTS The tentorial sling technique was performed in 45 patients undergoing MVD for trigeminal neuralgia. In 41 of these patients, this procedure was their first decompressive surgery. Immediate postoperative relief of pain (BNI score I) was achieved in 80% of patients undergoing their first decompressive procedure. At last follow-up, 73% of these patients remained pain free. Three patients experienced recurrent trigeminal pain, with surgical exploration demonstrating an intact tentorial sling. The complication rate was 6.6%.

CONCLUSIONS Transposition techniques for MVD have been described previously in small series and case reports. This study represents the largest experience in which the utilization of a tentorial sling for MVD in patients with trigeminal neuralgia is described. The technique represents a novel method for decompression of the trigeminal nerve by transposition of the offending vessel without the use of foreign material. Although the authors’ preliminary results parallel the historical cure rate, further outcome data are required to assess long-term durability of this method.

 

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Image guidance and improved accuracy of external ventricular drain tip position particularly in patients with small ventricles

J Neurosurg 130:1268–1273, 2019

External ventricular drain (EVD) insertion is one of the most common emergency neurosurgical procedures. EVDs are traditionally inserted freehand (FH) in an emergency setting, but often result in suboptimal positioning. Image-guided surgery (IGS) is selectively used to assist placement. However, the accuracy and practicality of IGS use is yet to be reported. In this study, the authors set out to assess if IGS is practical and improves the accuracy of EVD placement.

METHODS Case notes and images obtained in patients who underwent frontal EVD placement were retrospectively reviewed. Ventriculomegaly was determined by the measurement of the Evans index. EVD location was classified as optimal (ipsilateral frontal horn) or suboptimal (any other location). Propensity score matching of the two groups (IGS vs FH) for the Evans index was performed. Data were analyzed for patient age, diagnosis, number of EVDs, and complications. Those without postoperative CT scans were excluded.

RESULTS A total of 607 patients with 760 EVDs placed were identified; 331 met inclusion criteria. Of these, 287 were inserted FH, and 44 were placed with IGS; 60.6% of all unmatched FH EVDs were optimal compared with 75% of the IGS group (p = 0.067). The IGS group had a significantly smaller Evans index (p < 0.0001). Propensity score matching demonstrated improved optimal position in the IGS group when compared with the matched FH group (75% vs 43.2%, OR 4.6 [1.5–14.6]; p = 0.002). Patients with an Evans index of ≥ 0.36 derived less benefit (75% in IGS vs 66% in FH, p = 0.5), and those with an Evans index < 0.36 derived more benefit (75% in IGS vs 53% in FH, p = 0.024). The overall EVD complication rate was 36% in the FH group versus 18% in the IGS group (p = 0.056). Revision rates were higher in the FH group (p = 0.035), and the operative times were similar (p = 0.69). Long intracranial EVD catheters were associated with tip malposition irrespective of the group.

CONCLUSIONS Image guidance is practical and improves the accuracy of EVD placement in patients with small ventricles; thus, it should be considered for these patients.

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Hemorrhagic burden in poor-grade aneurysmal subarachnoid hemorrhage

Acta Neurochirurgica (2019) 161:791–797

Volumetric assessment of aneurysmal bleeding has been evaluated in few studies and emerged as a promising outcome predictor. There is a lack of studies evaluating its impact in the poor-grade population.

Methods Retrospective review of 63 consecutive poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients, defined as grade IV and V according to theWorld Federation of Neurological Surgeons (WFNS) classifications. Global intracranial bleeding volume was calculated with its subarachnoid, intracerebral (ICH), and intraventricular (IVH) portions by means of analytical software. Univariate and multivariate analyses were performed in order to identify independent predictors of outcome. Good outcome was defined as modified Rankin Scale (mRS) 0–2 and mortality as mRS 6. The cutoff values of bleeding volumes were derived by receiver operating curve (ROC) analysis.

Results Mean follow-up was of 12.5 (± 1.5) months. Thirty (47.7%) patients achieved good outcome, whereas 19 (30.2) patients out of 63 died. Global intracranial bleeding resulted as an independent predictor of good outcome (cutoff 24 mL). Furthermore, ICH relative percentage of global volume (10% of total) and pure SAH (64% of total) emerged respectively as independent predictors of worsened and improved outcome. Global bleeding volume (cutoff 51 mL) along with global cerebral edema showed to independently predict mortality in the examined poor-grade aSAH population.

Conclusions Volumetric assessment of aneurysmal bleeding has the potential for identifying cutoff values that independently predict outcome. Further insights into the relative importance of different bleeding volumes may be implicated in better tailoring the management of this dismal aSAH population.

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Keyhole strategy aiming at minimizing hospital stay for surgical clipping of unruptured middle cerebral artery aneurysms

J Neurosurg 130:1359–1366, 2019

Aneurysms of the middle cerebral artery (MCA) are still most often treated by clipping through standard craniotomy, but a longer hospital stay is one of the main drawbacks of this treatment. The authors developed a pterional keyhole clipping strategy for unruptured MCA aneurysms with the intention of minimizing hospital stay. In this paper, they report on their experience with this approach and analyze the long-term neurological and radiological outcomes.

METHODS A total of 160 relatively small unruptured MCA aneurysms (mean 6.4 mm) were clipped through the pterional keyhole approach (19–30 mm, mean 24.6 mm) in 149 patients (aged 34–79 years, mean 62 years). Neurological and cognitive function were examined by several scales, including the modified Rankin Scale (mRS) and Mini–Mental State Examination (MMSE). Patients’ level of depression was assessed using the Beck Depression Inventory and Hamilton Depression Scale. The state of clipping was assessed at 1 year and then every few years after the operation.

RESULTS The mean duration of postoperative hospitalization was 2.3 ± 3.4 days; in 31.3% of the cases, the patients were discharged on the day after the operation (overnight hospital stay) and in 93.2% within 3 days. Of the patients younger than 60 years, 40.4% required only an overnight stay. Complete aneurysm neck clipping was confirmed in 157 cases (98.1%). None of the completely clipped aneurysms showed any recurrence during the mean follow-up period of 5.0 years. The mean length of clinical follow-up was 5.4 years. After 2 (1.3%) of the surgical procedures, the patients showed persistent neurological deficits, defined as mRS score 1, but the overall operative morbidity based on the International Study of Unruptured Intracranial Aneurysms (ISUIA) definition (mRS score ≥ 2 or MMSE score < 24) was 0% at the last examination. Depression scores were significantly improved after surgery, and in 85.6% of the cases the patients were satisfied with their cosmetic results.

CONCLUSIONS Pterional keyhole clipping is less invasive than clipping via standard craniotomy, minimizes hospital stay, and achieves durable treatment for relatively small unruptured MCA aneurysms.

 

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Global hydrocephalus epidemiology and incidence: systematic review and meta-analysis

J Neurosurg 130:1065–1079, 2019

Hydrocephalus is one of the most common brain disorders, yet a reliable assessment of the global burden of disease is lacking. The authors sought a reliable estimate of the prevalence and annual incidence of hydrocephalus worldwide.

METHODS The authors performed a systematic literature review and meta-analysis to estimate the incidence of congenital hydrocephalus by WHO region and World Bank income level using the MEDLINE/PubMed and Cochrane Database of Systematic Reviews databases. A global estimate of pediatric hydrocephalus was obtained by adding acquired forms of childhood hydrocephalus to the baseline congenital figures using neural tube defect (NTD) registry data and known proportions of posthemorrhagic and postinfectious cases. Adult forms of hydrocephalus were also examined qualitatively.

RESULTS Seventy-eight articles were included from the systematic review, representative of all WHO regions and each income level. The pooled incidence of congenital hydrocephalus was highest in Africa and Latin America (145 and 316 per 100,000 births, respectively) and lowest in the United States/Canada (68 per 100,000 births) (p for interaction < 0.1). The incidence was higher in low- and middle-income countries (123 per 100,000 births; 95% CI 98–152 births) than in high-income countries (79 per 100,000 births; 95% CI 68–90 births) (p for interaction < 0.01). While likely representing an underestimate, this model predicts that each year, nearly 400,000 new cases of pediatric hydrocephalus will develop worldwide. The greatest burden of disease falls on the African, Latin American, and Southeast Asian regions, accounting for three-quarters of the total volume of new cases. The high crude birth rate, greater proportion of patients with postinfectious etiology, and higher incidence of NTDs all contribute to a case volume in low- and middle-income countries that outweighs that in high-income countries by more than 20-fold. Global estimates of adult and other forms of acquired hydrocephalus are lacking.

CONCLUSIONS For the first time in a global model, the annual incidence of pediatric hydrocephalus is estimated. Low and middle-income countries incur the greatest burden of disease, particularly those within the African and Latin American regions. Reliable incidence and burden figures for adult forms of hydrocephalus are absent in the literature and warrant specific investigation. A global effort to address hydrocephalus in regions with the greatest demand is imperative to reduce disease incidence, morbidity, mortality, and disparities of access to treatment.

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Endoscopic endonasal transoculomotor triangle approach for adenomas invading the parapeduncular space

J Neurosurg 130:1304–1314, 2019

Pituitary adenomas may extend into the parapeduncular space by invading through the roof of the cavernous sinus. Currently, a transcranial approach is the preferred choice, with or without the combination of an endonasal approach. In this paper the authors present a novel surgical approach that takes advantage of the natural corridor provided by the tumor to further open the oculomotor triangle and resect tumor extension into the parapeduncular space.

METHODS Six injected specimens were used to demonstrate in detail the surgical anatomy related to the approach. Four cases in which the proposed approach was used were retrospectively reviewed.

RESULTS From a technical perspective, the first step involves accessing the superior compartment of the cavernous sinus. The interclinoid ligament should be identified and the dura forming the oculomotor triangle exposed. The oculomotor dural opening may be then extended posteriorly toward the posterior petroclinoidal ligament and inferolaterally toward the anterior petroclinoidal ligament. The oculomotor nerve should then be identified; in this series it was displaced superomedially in all 4 cases. The posterior communicating artery should also be identified to avoid its injury. In all 4 cases, the tumor invading the parapeduncular space was completely removed. There were no vascular injuries and only 1 patient had a partial oculomotor nerve palsy that completely resolved in 2 weeks.

CONCLUSIONS The endoscopic endonasal transoculomotor approach is an original alternative for removal of tumor extension into the parapeduncular space in a single procedure. The surgical corridor is increased by opening the dura of the oculomotor triangle and by working below and lateral to the cisternal segment of the oculomotor nerve.

 

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Neurosurgical Coverage for Emergency and Trauma Call

Neurosurgery, Volume 84, Issue 4, April 2019, Pages 977–984

Traditionally, neurosurgeons have responded to calls to treat new patients or address emergent, acute neurosurgical pathology in the hospitals they staff as part of their duty to the medical profession and community. Due to increasing financial pressures placed upon neurosurgical practice from hospitals and regulatory mandates, remuneration for neurosurgeon availability to serve on trauma call has become more frequent and is increasingly seen as essential.

In this study, we present the first peer-review published survey of neurosurgical emergency and trauma call coverage patterns, scope, schedules, compensation, liability exposure, and call cessation. We surveyed all practicing neurosurgeon members of the American Association of Neurological Surgeons and Congress of Neurological Surgeons with a 24% response rate. The vast majority of respondents (86%), through their practice, provide 24/7/365 trauma coverage at their primary hospital site. About a third (29%) of respondents have been sued by a patient seen in the emergency department. Twenty percent of respondents anticipate retiring within the next 2 yr.

Understanding trauma call coverage, remuneration, and the barriers to taking call provide needed transparency to neurosurgeons who are providing emergency, life-saving services for patients across the country. An understanding of supply and demand forces governing call coverage also assists the field in necessary workforce planning and innovation in providing access to needed, timely acute neurosurgical care.

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Predictors of postoperative motor function in rolandic meningiomas

J Neurosurg 130:1283–1288, 2019

Resection of supratentorial meningiomas is generally considered a low-risk procedure, but tumors involving the rolandic cortex present a unique challenge. The rate of motor function deterioration associated with resecting such tumors is not well described in the literature. Thus, the authors sought to report the rates and predictors of postoperative motor deficit following the resection of rolandic meningiomas to assist with patient counseling and surgical decision-making.

METHODS An institution’s pathology database was screened for meningiomas removed between 2000 and 2017, and patients with neuroradiological evidence of rolandic involvement were identified. Parameters screened as potential predictors included patient age, sex, preoperative motor severity, tumor location, tumor origin (falx vs convexity), histological grade, FLAIR signal (T2-weighted MRI), venous involvement (T1-weighted MRI with contrast), intratumoral hemorrhage, embolization, and degree of resection (Simpson grade). Variables of interest included preoperative weakness and postoperative motor decline (novel or worsened permanent deficit). The SPSS univariate and bivariate analysis functions were used, and statistical significance was determined with alpha < 0.05.

RESULTS In 89 patients who had undergone resection of convexity (80.9%) or parasagittal (19.1%) rolandic meningiomas, a postoperative motor decline occurred in 24.7%. Of 53 patients (59.6%) with preoperative motor deficits, 60.3% improved, 13.2% were unchanged, and 26.4% worsened following surgery. Among the 36 patients without preoperative deficits, 22.2% developed new weakness. Predictors of preoperative motor deficit included tumor size (41.6 vs 33.2 cm3, p = 0.040) and presence of FLAIR signal (69.8% vs 50.0%, p = 0.046). Predictors of postoperative motor decline were preoperative motor deficit (47.2% vs 22.2%, p = 0.017), minor (compared with severe) preoperative weakness (25.6% vs 21.4%, p < 0.001), and preoperative embolization (54.5% vs 20.5%, p = 0.014). Factors that trended toward significance included parafalcine tumor origin (41.2% vs 20.8% convexity, p = 0.08), significant venous involvement (44.4% vs 23.5% none, p = 0.09), and Simpson grade II+ (34.2% vs 17.6% grade I, p = 0.07).

CONCLUSIONS Resection of rolandic area meningiomas carries a high rate of postoperative morbidity and deserves special preoperative planning. Large tumor size, peritumoral edema, preoperative embolization, parafalcine origin, and venous involvement may further increase the risk. Alternative surgical strategies, such as aggressive internal debulking, may prevent motor decline in a subset of high-risk patients.

 

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Pedicle Screw Placement Using Augmented Reality Surgical Navigation With Intraoperative 3D Imaging

Spine 2019;44:517–525

The aim of this study was to evaluate the accuracy of pedicle screw placement using augmented reality surgical navigation (ARSN) in a clinical trial.

Summary of Background Data. Recent cadaveric studies have shown improved accuracy for pedicle screw placement in the thoracic spine using ARSN with intraoperative 3D imaging, without the need for periprocedural x-ray. In this clinical study, we used the same system to place pedicle screws in the thoracic and lumbosacral spine of 20 patients.

Methods. The study was performed in a hybrid operating room with an integrated ARSN system encompassing a surgical table, a motorized flat detector C-arm with intraoperative 2D/3D capabilities, integrated optical cameras for augmented reality navigation, and noninvasive patient motion tracking. Three independent reviewers assessed screw placement accuracy using the Gertzbein grading on 3D scans obtained before wound closure. In addition, the navigation time per screw placement was measured.

Results. One orthopedic spinal surgeon placed 253 lumbosacral and thoracic pedicle screws on 20 consenting patients scheduled for spinal fixation surgery. An overall accuracy of 94.1% of primarily thoracic pedicle screws was achieved. No screws were deemed severely misplaced (Gertzbein grade 3). Fifteen (5.9%) screws had 2 to 4mm breach (Gertzbein grade 2), occurring in scoliosis patients only. Thirteen of those 15 screws were larger than the pedicle in which they were placed. Two medial breaches were observed and 13 were lateral. Thirteen of the grade 2 breaches were in the thoracic spine. The average screw placement time was 5.24.1 minutes. During the study, no device-related adverse event occurred. Conclusion. ARSN can be clinically used to place thoracic and lumbosacral pedicle screws with high accuracy and with acceptable navigation time. Consequently, the risk for revision surgery and complications could be minimized. Key words: augmented reality, image-guided surgery, intraoperative 3D cone beam computed tomography imaging, pedicle screw accuracy, scoliosis.

Level of Evidence: 3

 

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