A 7-year retrospective single-center study on treatment strategy and clinical outcome of giant intracranial aneurysm

BACKGROUND

A giant intracranial aneurysm (GIA) measures ≥ 25 mm and is a rare, challenging condition to treat with a poor prognosis. Selecting the appropriate treatment approach, whether surgical, endovascular, or a combination of both, is crucial for achieving favorable outcomes. However, the unique characteristics of each GIA imply that no single treatment option can be considered optimal universally. This study aimed to evaluate the treatment strategies and clinical outcomes at our center.

METHODS

This retrospective, single-center study conducted between 2012 and 2018, included 20 patients with GIA. We comprehensively reviewed demography, aneurysm characteristics, clinical and radiography data, treatment strategies, and angiography and clinical outcomes.

RESULTS

The average maximum GIA was 29.4 mm (excluding serpentine). Twelve aneurysms were located in the internal carotid artery (ICA); three, anterior cerebral artery; and five, middle cerebral artery. Morphologically, 18 saccular and 2 serpentine aneurysms were observed. Among them, 14 were symptomatic, with 8 presenting with subarachnoid hemorrhage, of which, 5 (62.5 %) were accompanied by intracerebral hemorrhage. Cranial nerve-related symptoms were observed in five ICA aneurysms, and two involved a carotid cavernous fistula. Five patients had multiple aneurysms accompanied by GIA. The treatment modalities varied; eight patients initially underwent surgical treatment. Regarding the number of treatment steps, 14 patients required one step, 4 required two steps, and 2 required three steps. In eight patients, parent artery occlusion (with or without bypass surgery) was the final treatment approach. After 1 year, 70 % of patients achieved a favorable outcome, as indicated by a modified Rankin Scale score ≤ 2.

CONCLUSIONS

Patient-specific treatments are crucial for improving clinical outcomes. Advancements in endovascular treatment have been made owing to the development of new devices. Parent artery occlusion with vascular bypass was a reliable treatment option.

Functional outcomes following treatment of unruptured middle cerebral artery aneurysms: a single-centre comparison of microsurgical vs. endovascular management

PURPOSE

Optimal management of unruptured, middle cerebral artery (MCA) aneurysms, remains undetermined between microsurgical clipping and endovascular intervention. This study aims to compare post-operative functional outcomes between microsurgically and endovascularly treated, unruptured MCA aneurysms.

MATERIALS AND METHODS

All cases of unruptured MCA aneurysms undergoing treatment during a 10-year time period were identified and included. Functional status (FS) was measured using the Modified Rankin Scale. FS was assessed pre-treatment and at 1-month, 6-months and 12-months post-treatment. Median FS was compared between groups and relative risk ratios (RR) calculated to compare the risk of post-operative deterioration between the microsurgical and endovascular cohort at each time point. Occlusion and retreatment rates were also compared.

RESULTS

In total, 119 cases of treated, unruptured MCA aneurysms were identified, of which 40 (34%) were managed microsurgically and 79 (66%) endovascularly. Mean age was 55 years (SD ± 11). No significant difference was seen in any demographic domain pre-operatively. 30-day survival in both cohorts was 100%. No significant difference in median FS was seen between the cohorts at any time point post-treatment. There was a significantly increased risk of deterioration in FS amongst the microsurgical cohort at 1-month post-treatment (RR 1.98, 95% CI 1.08 - 3.62, p = 0.03). There was no significant risk of deterioration in FS at either the 6-month nor 12-month time point post-treatment. Complete occlusion in the microsurgical cohort was greater than the endovascular cohort (91% vs. 66%), demonstrating a significantly reduced RR of incomplete occlusion (RR 0.25, 95% CI: 0.08 - 0.77, p = 0.02).

CONCLUSIONS

At 1-month post-treatment, the risk of a decline in FS from baseline was almost twice as great in the microsurgical cohort. However, there was no significant difference in the risk of deterioration in FS at 6-months nor 12-months post-treatment.

The Low-Income and Middle-Income Countries' Perspective on Global Neurosurgery Collaborations

BACKGROUND AND OBJECTIVES

Access to neurosurgical care is limited in low-income and middle-income countries (LMICs) and in marginalized communities in high-income countries (HICs). International partnerships represent one possible means of addressing this issue. Insights from surgeons in HICs have been explored, but data from LMICs' counterparts are scarce. We aimed to study the perspectives of neurosurgeons and trainees from LMICs regarding global neurosurgery (GN) collaborations and interests, motivators, and challenges in participating.

METHODS

An online survey was conducted targeting neurosurgeons and trainees from LMICs. The survey explored demographics, previous experiences, ongoing activities, interests, and barriers related to GN activities. Data were collected between July 2022 and December 2022 and analyzed.

RESULTS

Responses involved 436 individuals. The most represented region (25%) was sub-Saharan Africa, and most respondents were male (87.8%) aged 35-49 years. Interest in GN was high, with 91% after its developments. Most respondents (96.1%) expressed interest in training, professional, or research experience in HICs, but only 18.1% could cover the expenses. A majority (73.2%) strongly agreed to return to their home country for work after HIC training. Ongoing HIC-LMIC partnerships were reported by 27.8% of respondents. Clinical exposure emerged as the most relevant motivating factor (87%), while financial concerns, lack of opportunities, and lack of program support were identified as important barriers. Funding and dedicated time were highlighted as the most crucial facilitators.

CONCLUSION

Understanding the perspectives of neurosurgeons and trainees from LMICs is essential to expanding HICs-LMICs collaborations and improving access to neurosurgical care worldwide. Financial support and targeted interventions are needed to address barriers and promote equitable partnerships in GN.

Dynamic Craniotomy With Khanna NuCrani Plates as an Alternative to Craniotomy With Fixed Plates in Traumatic Brain Injury

BACKGROUND AND OBJECTIVES

Dynamic craniotomy as opposed to a fixed plate craniotomy provides cranial decompression with a controlled outward bone flap movement to accommodate postoperative cerebral swelling and/or hemorrhage. The objective of this study was to evaluate if fixation of the bone flap following a trauma craniotomy with dynamic plates provides any advantage over fixed plates.

METHODS

A review of our clinical series of 25 consecutive adult patients undergoing dynamic craniotomy with the Khanna NuCrani reversibly expandable bone flap fixation plates for the treatment of traumatic brain injury associated with mass lesions including subdural, epidural, and cerebral hematomas was conducted.

RESULTS

Postoperative cerebral swelling was encountered in 21 of 25 patients (84%), which was compensated for with outward bone flap movement in all these patients and associated decreased midline shift. Severe brain swelling with outward bone flap movement of 8 mm or more was noted in 40% of the patients. All patients had a normal intracranial pressure after surgery. None of the patients required any reoperations for hematoma evacuation, rescue decompressive craniectomies, cranioplasty, or complications related to wound healing. The bone flap retracted after the resolution of the brain swelling, and none of the patients reported cosmetic symptoms related to bone flap or wound healing. Overall, 84% (21 of 25) of the patients achieved a good outcome.

CONCLUSION

Craniotomy bone flap fixation with dynamic plates is an alternative to craniotomy with fixed plates. The main advantage of dynamic craniotomy over a craniotomy with fixed plates is that it allows for immediate intracranial volume expansion with reversible outward bone flap migration in patients who may develop postoperative worsening brain swelling and/or hemorrhage, with decreased need for repeat surgeries and associated complications.

Nitric oxide synthases: A delicate dance between bone regeneration and neuronal birth

Spinal cord injury (SCI) is a devastating condition resulting from traumatic or nontraumatic injury/chronic disorder. The pathogenesis of SCI necessitates a comprehensive approach, as it involves therapeutic strategies addressing both bone (spine) and neural (spinal cord) damage. This review centers on the pivotal role of nitric oxide (NO) and its synthesizing enzymes, nitric oxide synthases (NOS), in mediating the crosstalk between osteogenesis and neurogenesis. NO's effects are context-dependent, exhibiting a delicate balance between beneficial and detrimental actions. Reduced levels of nitric oxide (NO), primarily derived from endothelial NOS (eNOS), tipically stimulate osteoblast activity and promote neurogenesis by influencing neural stem cell (NSC) migration and differentiation. Conversely, elevated NO levels, predominantly from inducible NOS (iNOS), tipically triggered by inflammation, inhibit both processes through pro-apoptotic mechanisms. Nevertheless, these phenomena are not merely simplistic; they can be influenced by a variety of other factors. We explore the intricate interplay of NO/NOS with key signaling pathways crucial in neurogenesis and osteogenesis, including mechanical stimuli, Wnt, interleukins, BMPs, NF-κB, etc., revealing their influence on neuroinflammation, neurogenesis, and osteoblast differentiation. The temporal and spatial dynamics of NO/NOS activity and the implications for therapeutic intervention have been discussed. Precise modulation of NO levels and NOS isoforms, potentially through targeted therapies manipulating these interacting signaling pathways, emerges as a promising strategy for promoting bone and neural regeneration. This review highlights the critical need for a balanced approach in therapeutic strategies to harness the beneficial effects of NO/NOS while mitigating its detrimental consequences.

Prognostic factors of selective nerve root block under fluoroscopic guidance for the treatment of young patients with lumbar disc herniation and its role in preventing surgery

BACKGROUND

As a transitional treatment between conservative treatment and surgical treatment for lumbar disc herniation (LDH), selec tive nerve root block (SNRB) has attracted increasing attention recently. The objective of this study was to evaluate the efficacy and prognostic factors of SNRB in young patients with LDH.

METHODS

A prospective observational cohort study was employed. A total of 134 patients with LDH who received SNRB treatment in our hospital from January 2023 to August 2023 were selected and divided into a recurrence group and a nonrecurrence group according to whether they experienced recurrence after SNRB. The demographic characteristics, clinical and imaging data and SNRB-related information were compared between the two groups. Multivariate logistic regression was used to analyze the factors influencing symptom recurrence after SNRB surgery.

RESULTS

Surgery was avoided in 95.522%, 86.567%, 78.358% and 64.925% of the patients at 2 weeks, 3 months, 6 months and 12 months after SNRB treatment, respectively. Multivariate logistic regression analysis revealed that a disease course of ≥ 3 months (OR = 6.031, 95% CI: 2.592-14.035, P = 0.001) was an independent risk factor for postoperative recurrence of SNRB, and extreme lateral protrusion (OR = 0.273, 95% CI: 0.078-0.956, P = 0.042) and the HIZ sign (OR = 0.200, 95% CI: 0.057-0.702, P = 0.012) were protective factors against postoperative recurrence of SNRB.

CONCLUSIONS

The curative effect of SNRB in the treatment of young patients with LDH is significant. A disease course of ≤ 3 months, far-lateral protrusion and the HIZ sign are predictors of good outcomes. In addition, SNRB combined with medication and physical therapy is recommended as an alternative to surgery for patients who do not have acute surgical indications.

Comparison of percutaneous endoscopic lumbar discectomy (PELD) and unilateral biportal endoscopic (UBE) discectomy in the treatment of far lateral lumbar disc herniation (FLLDH): a retrospective study

PURPOSE

This study aimed to compare the clinical efficacy of percutaneous endoscopic lumbar discectomy (PELD) and unilateral biportal endoscopic (UBE) discectomy in treating patients with far lateral lumbar disc herniation (FLLDH).

METHODS

From January 2020 to January 2022, 65 patients with FLLDH underwent either PELD or UBE discectomy. Among them, 35 were treated with PELD (25 males and 10 females, average age 35.3 ± 12.7), and 30 were treated with UBE (21 males and 9 females, average age 43.5 ± 9.2). Factors such as operation time, fluoroscopy frequency, length of hospitalization, in-bed time after operation, hospitalization cost, complications, visual analogue scale (VAS, 0-10), Oswestry Disability Index (ODI, 0-100%), and modified MacNab criteria were assessed and compared between the two groups.

RESULTS

The demographic data were well matched between the PELD group and UBE group, without significant differences (P > 0.05). After surgery, both surgical procedures achieved significant improvement in VAS and ODI scores (P < 0.05). Compared to the UBE group, the PELD group had lower VAS scores for low back pain on the first postoperative day (P < 0.05), but no significant differences were found in alleviating leg pain in patients postoperatively between these two surgical procedures (P > 0.05). The PELD group was superior to the UBE group, showing shorter hospital stay (P < 0.05). Conversely, the UBE group exhibited significantly longer operation time and higher hospitalization cost than the PELD group (P < 0.05).

CONCLUSIONS

Both PELD and UBE discectomy are safe and effective surgical procedures which can achieve satisfactory results in treating FLLDH. PELD causes less back pain in the immediate postoperative period. PELD offers advantages in rapid recovery, while UBE discectomy is a suitable option for patients with conditions such as high iliac crest, hypertrophy of the transverse process, or intolerance to pain under local anesthesia.

Unilateral Biportal Endoscopic Discectomy via the Contralateral Approach in Upward Migrated Foraminal Disc Herniations

OBJECTIVE

Lumbar upward migrated foraminal disc herniations are extremely rare and technically challenging to operate. In this study, a contralateral approach using unilateral biportal endoscopy, which has the advantages of structural protection, efficacy, and safety is presented.

METHODS

Between 2019 and December 2022, five patients with lumbar upward migrated foraminal disc herniations underwent unilateral biportal endoscopic discectomy via the contralateral approach. The patients were 4 males and 1 female patient. All patients had severe radicular pain. Neurological examination revealed sensory impairment and motor weakness in 2 patients but no deficits in the others. Magnetic resonance images confirmed lumbar upward migrated foraminal disc herniations in all patients.

RESULTS

The study shows a significant reduction in Oswestry Disability Index. Symptoms improved immediately after surgery in all patients, and satisfactory results were achieved at the last follow-up. No surgical complications or recurrent herniations were observed. The mean preoperative Oswestry Disability Index decreased from 44.6 to 11.4. In addition, mean preoperative Visual Analog Scale declined from 8.4 to 1.6. The patients were assessed after a follow-up period of at least 22 months, and their level of pain level was documented.

CONCLUSIONS

Although unilateral biportal endoscopic discectomy via the contralateral approach is not a common surgical procedure, it can offer a viable alternative for patients with lumbar upward migrated foraminal disc herniations.

Total resection of sacral giant cell tumor with en bloc resection, sacral nerve reconstruction, and custom 3D-printed implant: a case report with long-term follow-up

INTRODUCTION

Giant cell tumor (GCT) of the sacrum is a rare, locally aggressive bone tumor. Surgical resection is the primary treatment, but preserving sacral nerve function remains challenging. We present a case of sacral GCT treated with a novel nerve-preserving en bloc resection technique, resulting in long-term tumor control and functional recovery.

CASE PRESENTATION

A 33-year-old male presented with progressive sacral pain and neurological symptoms. Imaging revealed a sacral GCT involving the S1 vertebral body and nerve root canal. The patient underwent en bloc resection with sacral nerve preservation and reconstruction, along with custom 3D-printed prosthesis implantation. Postoperative recovery was uncomplicated, with preserved bowel, bladder, and lower limb function. There was no evidence of recurrence during the 8-year follow-up period.

CLINICAL DISCUSSION

Sacral GCTs present substantial surgical challenges due to their proximity to critical neurovascular structures. While en bloc resection effectively reduces recurrence rates, it often compromises sacral nerve function. Our technique successfully preserved key sacral nerve roots, leading to superior postoperative functional outcomes compared to conventional approaches. A review of relevant literature supports the advantages of nerve-sparing strategies in sacral tumor surgery.

CONCLUSION

This case highlights the feasibility and benefits of sacral nerve-preserving en bloc resection for GCT. The long-term follow-up confirms durable tumor control and robust functional recovery, suggesting its potential as a preferred surgical approach for carefully select cases.

Differences in neuroradiological impacts of hematoma volume and midline shift on clinical symptoms and recurrence rate in patients with unilateral chronic subdural hematoma

OBJECTIVE

Chronic subdural hematoma (CSDH) is a prevalent neurosurgical condition, particularly among the elderly. Hematoma volume (HV) and midline shift (MLS) on CT imaging are critical for assessing CSDH severity and recurrence risk. Brain atrophy has also been linked to recurrence. This study investigates the impact of HV and MLS on clinical symptoms and recurrence, considering brain atrophy.

METHODS

A retrospective analysis was conducted on patients with unilateral CSDH who underwent burr hole surgery for symptoms such as headache, disturbances of consciousness, hemiparesis, and gait disturbance. HV, MLS, and relative cortical atrophy index (RCAI) were measured using preoperative (pre-) and postoperative (post-) CT images. The rate of change in RCAI (RCAI-CR) between pre- and post-CT images was calculated to assess contralateral brain compression. Associations between HV, MLS, RCAI, RCAI-CR, symptoms, and recurrence were analyzed.

RESULTS

The study included 293 patients (mean age 79.4 ± 12.1 years), with a recurrence rate of 15.0 % (44/293). Pre-HV (per 10 mL) was significantly associated with hemiparesis and gait disturbance (odds ratio [OR] 1.12, 95 % confidence interval [CI] 1.03-1.21, p = 0.011; OR 1.14, 95 % CI 1.05-1.24, p = 0.003). Pre-MLS was significantly correlated with disturbances of consciousness (OR 1.26, 95 % CI 1.14-1.39, p < 0.001) and was elevated in patients with high RCAI-CR. Significant predictors of recurrence included Pre-HV (per 10 mL) (OR 1.16, 95 % CI 1.03-1.31, p = 0.014), postoperative subdural cavity volume (per 10 mL) (OR 1.18, 95 % CI 1.02-1.36, p = 0.026), antiplatelet drug use (OR 0.23, 95 % CI 0.06-0.89, p = 0.032), and CT classification (OR 2.35, 95 % CI 1.15-4.82, p = 0.020).

CONCLUSIONS

HV and MLS have distinct clinical implications in CSDH. Pre-HV is linked to motor disturbances, while Pre-MLS correlates with disturbances of consciousness, with high RCAI-CR indicating significant brain compression. HV is a key predictor of recurrence, while MLS and RCAI are not. These findings may improve outcome prediction and management strategies.

Different in vivo administration routes of essential oil for various therapies: A review

Essential oils derived from aromatic and non-aromatic plant sources, are recognized for their in vivo potential therapeutic benefits, including anti-oxidant, anti-inflammatory, anti-cancer, immunomodulatory and other regulatory roles by the scientific community. However, translation of such in vivo therapeutic application in clinical field is not yet available. This study examines the pre-clinical scientific studies on varied administration methods of essential oils for therapeutic purposes. The focus of this study is to explore the different administration routes, which are crucial for optimizing the delivery of these bioactive compounds for internal administration and improving their therapeutic effectiveness. Traditional and innovative methods, such as inhalation, dermal application, oral ingestion, intraperitoneal injection, and intravenous infusion are investigated. Each route has its advantages and challenges, which may impact the bioavailability, systemic distribution and toxicity of essential oils. However, such comparative pharmacokinetic and toxicity studies are lacking for the essential oils. The available basic information regarding in vivo bioavailability and toxic reactions of essential oils are discussed briefly in this review. The research findings have significant implications for developing targeted and personalized essential oil treatments, advancing integrative medicine and complementary therapy approaches. The analysis of various in vivo therapeutic study findings implies that a promising therapeutic efficiency can be achieved with essential oils at different dose ranges for different routes of administrations. The comparative analysis on therapeutic effects of different routes of administration and methods essential oil extraction are lacking. The bioavailability and toxicity studies are also limited for these therapeutic studies. Furthermore, the detailed molecular mechanism of in vivo therapeutic actions is not yet established in the studies. Ultimately, this investigation adds to the expanding knowledge base on essential oil administration routes, providing valuable guidance for healthcare professionals and researchers in the field of natural medicine. However, extensive in vivo pre-clinical studies are warranted for translation of essential oil therapy to clinical usage. Also all the traditional uses of essential oil for therapy must be validated via scientific studies.

Rates of achieving meaningful outcomes after undergoing minimally-invasive far lateral tubular decompression

PURPOSE

To evaluate rates of achieving meaningful outcomes among patients undergoing far lateral tubular decompression (FLTD) for neuroforaminal stenosis. Traditional midline approaches are ineffective in treating isolated neuroforaminal stenosis. Direct decompression via a far lateral approach offers a minimally invasive, facet-sparing surgery with minimal surgical dissection.

METHODS

Patients who underwent FLTD between January 2014 and January 2019 for isolated foraminal stenosis were included. The study collected patient demographics, perioperative data, and pre- and postoperative patient-reported outcomes (PROs). The study calculated thresholds for achieving minimal clinically important difference (MCID) on each PRO and performed logistic regression analysis to identify predictors of achieving meaningful clinical outcomes and clinical failure.

RESULTS

64 patients were included with a 2-year follow-up. The analysis showed improvement in each PRO over the 2-year period (p < 0.001 for all). 90.2% of patients achieved MCID for at least one PRO, with the VAS leg pain having the highest achievement rate at 79.7%. During the follow-up period, 17.2% required additional surgery. Increased severity of preoperative symptoms was associated with a greater likelihood of achieving MCID in all three PROs (p < 0.05, each). The presence of spondylolisthesis was associated with decreased odds of achieving MCID by ODI (p = 0.04). Increased operative time was associated with increased odds of achieving MCID by ODI (p = 0.03). No variables were associated with revision surgery.

CONCLUSIONS

FLTD is an effective treatment option for direct decompression of foraminal and extra foraminal stenosis in well-indicated patients. Most patients achieved MCID two years from surgery, with more severe symptoms having a greater likelihood of improvement, particularly with radicular pain. Further research should be performed on patients with spondylolisthesis to prescribe treatment resulting in maximal benefit.

LEVEL OF EVIDENCE: 4

Functional network reorganization and memory impairment in unruptured brain arteriovenous malformations

Background

Brain arteriovenous malformations (AVMs) are congenital vascular anomalies that can affect cognitive, particularly memory functions. However, the underlying mechanisms of neurocognitive abnormalities in unruptured AVMs remain unclear. This study aimed to explore spontaneous functional network reorganization associated with memory impairment in unruptured AVM patients using resting-state functional MRI (rsfMRI).

Methods

Using rsfMRI data, we compared functional activity and connectivity patterns between 25 AVM patients and healthy controls, including regional homogeneity (ReHo), fractional amplitude of low-frequency fluctuations (fALFF), seed-based functional connectivity (FC), and lesion network mapping. Correlation analysis was performed to clarify the relationship between these parameters and memory performance in AVM patients.

Results

We identified memory-related spontaneous functional network reorganization in AVM patients, particularly involving the somatomotor network (SMN), frontoparietal control network (FPN), and default mode network (DMN). Subgroup analyses based on lesion location (frontal vs. non-frontal) and laterality (left vs. right) revealed location-dependent differences in connectivity reorganization. In particular, left-sided AVMs showed disrupted FC within the SMN, correlated with working memory and executive function, while right-sided and frontal AVMs exhibited more complex patterns involving multiple networks. Moreover, functional disconnection maps indicated that AVM lesions did not directly impair resting-state memory networks.

Conclusion

Patients with unruptured AVMs exhibit resting-state memory network reorganization, which is closely related to the lesion location. These findings highlight the functional network alterations in AVM patients and suggest the potential neural mechanisms underlying memory deficits.

Time to Recurrence of Ameloblastoma and Associated Factors in a Multi-institutional Black Patient Cohort

Ameloblastoma is a highly recurrent odontogenic neoplasm with variable global distribution. However, impact of race and ethnicity on ameloblastoma recurrence are still unclear. The primary aim of this study was to assess duration of time between primary and recurrent ameloblastomas in a predominantly Black multi-institutional patient cohort and secondarily to determine whether recurrent ameloblastomas are more readily discovered when clinically-symptomatic rather than by radiographic surveillance. A retrospective cross-sectional design was used to evaluate demographic, clinical, and pathological information on recurrent ameloblastomas patients. Outcome variable was time to recurrence, determined as period between the diagnosis of primary and recurrent ameloblastomas. We assessed associations between outcome variable and race, time lapse between primary and recurrent ameloblastomas and clinical symptoms of recurrent ameloblastomas at time of diagnosis. Among 115 recurrent ameloblastomas identified, 90.5% occurred in adults, 91.3% in Blacks, and similarly, 91.3% were conventional ameloblastomas. About 41% affected the posterior mandible. 93.9% were clinically symptomatic at time of presentation while 6.1% non-symptomatic lesions were discovered by routine diagnostic radiology. Median time to presentation of recurrent tumor was significantly longer in females (90 months, p = 0.016) and clinically symptomatic group of ameloblastoma patients (75 months, p = 0.023). Ameloblastoma recurrence was distinctively high in Black patients, occurred faster in males than females and was located mostly in the posterior mandible. Concomitant with delayed access to healthcare of Black individuals, routine post-surgical follow-up is essential because time lag between primary and recurrence tumors was longer in clinically symptomatic ameloblastomas at the time of diagnosis.

Current State of the Neurotrauma Registry Implementation in Africa (NEUTRIA STUDY) and Challenges

BACKGROUND

Traumatic brain injury (TBI) data in Africa remain limited, underscoring the need for a robust neurotrauma registry. This study evaluates the availability, implementation, and challenges of the Neurotrauma Registry in Africa (NEUTRIA) and provides recommendations for developing a continent-wide TBI registry.

METHODS

An e-survey was distributed via Google Forms to neurosurgeons and neurosurgical trainees across Africa from November 1 to December 10, 2024. From the 54 African countries, 81.5% (n = 44) responded. Ninety-seven responses were recorded for 91 (93.8%) inclusion from 39 (72.2%) African countries. Statistical analysis was performed using JAMOVI 3.2.0.

RESULTS

Neurosurgical centers were unevenly distributed, with 47.3% of respondents reporting 3-5 centers across 21 countries. Most centers (75.8%) served public and private systems, while 22.0% were exclusively public. Paper-based registries for TBI and traumatic spinal cord injury were used in 79.1% of centers, while 46.2% employed electronic systems, with Excel being the most common platform. Seven countries (Tanzania, Mozambique, Egypt, Rwanda, Cameroon, Zambia, and Uganda) had national registries, each with variable patient volumes. Key challenges included administrative burdens, material and staffing shortages, time constraints, and limited awareness about the registry's importance. Financial support from governments and nongovernment organizations was crucial for implementing national registries and improving data collection and neurotrauma care across the continent.

CONCLUSIONS

This study highlights the uneven distribution of neurotrauma care and African registries. Although progress is evident, significant barriers hinder widespread implementation. Expanding financial support and addressing systemic challenges is critical for advancing data collection and improving neurotrauma care continent-wide.

Oral toxicity assessment and the mitigation of lung carcinogenesis by phytol and α-bisabolol combination treatment in swiss albino mice: insights into redox enzyme modulation and caspase-dependent cell death mechanisms

This study examined the safety and potential anti-lung cancer effects of combinations of phytol and α-bisabolol in Swiss albino mice. Both acute and subacute toxicity assessments showed that the combination of phytol and α-bisabolol is safe, with no adverse effects observed at higher concentrations. Hematological, biochemical, and histopathological tests showed no signs of toxicity in the heart, lungs, liver, spleen, and kidneys. The LD50 was greater than 2000 mg/kg, indicating a large safety margin. Histopathological analysis confirmed cancer induction in the B(a)P-induced group, which had significantly altered relative lung weights. Lung weight increased slightly pre and post-treatment, but histopathology showed normal alveolar epithelium. GSH and SOD levels increased significantly in B(a)P-exposed groups, indicating an adaptive antioxidant response. CAT levels increased significantly in the post-treatment group, demonstrating the role of combination of phytol and α-bisabolol in protecting against B(a)P-induced oxidative damage. Upregulation of Bax and downregulation of Bcl-2 caused a pro-apoptotic environment, suggesting a way to inhibit malignant cell survival. Modulation of caspase-3 and caspase-9 showed the complexity of carcinogen-induced apoptotic signaling. In conclusion, phytol and α-bisabolol were found to be safe and organ-protective, and demonstrated no acute or subacute toxicity. They modulate antioxidant defenses and apoptotic pathways, which may help prevent and treat lung cancer.

Timing of neurosurgical interventions for intracranial hypertension: the intensivists' and neurosurgeons' view

PURPOSE OF REVIEW

The aim of this study was to highlight clinical considerations regarding medical versus surgical management of elevated intracranial pressure (ICP), describe limitations of medical management, and summarize evidence regarding timing of neurosurgical interventions.

RECENT FINDINGS

The optimal ICP management strategy remains elusive, and substantial practice variations exist. Common risks of medical treatments include hypotension/shock, cardiac arrhythmias and heart failure, acute renal failure, volume overload, hypoxemia, and prolonged mechanical ventilation.In traumatic brain injury (TBI), recent randomized controlled trials (RCT) did not demonstrate outcome benefits for early, prophylactic decompressive craniectomy, but indicate a role for secondary decompressive craniectomy in patients with refractory elevated ICP. A recent meta-analysis suggested that when an extraventricular drain is required, insertion 24 h or less post-TBI may result in better outcomes.In large ischemic middle cerebral artery strokes, pooled analyses of three RCTs showed functional outcome benefits in patients less than 60 years who underwent prophylactic DC within less than 48 h. In intracranial hemorrhage, a recent RCT suggested outcome benefits for minimally invasive hematoma evacuation within less than 24 h.

SUMMARY

More data are needed to guide ICP targets, treatment modalities, predictors of herniation, and surgical triggers; clinical decisions should consider individual patient characteristics, and account for risks of medical and surgical treatments.

Comparative analysis of mini-open trans-thoracic transpleural and posterior approaches in thoracic disc herniation surgery: A 10-year retrospective review

Introduction

Thoracic disc herniations (TDHs) are rare, and surgery is typically reserved for patients with radiculopathy, myelopathy, or intractable back pain. Despite established algorithms, the optimal surgical strategy remains debated.

Research question

What are the clinical, surgical, and radiological outcomes of anterior and posterior surgical approaches for TDHs over a 10-year period?

Material and methods

A retrospective analysis of 54 patients who underwent surgery for TDHs (2013-2022) was performed. Patients were grouped by surgical approach: anterior (34 patients) and posterior (20 patients). Data included preoperative and postoperative outcomes such as operative times, hospital stays, complications, reoperations, and assessments using the Frankel scale, Nurick score, and Visual Analog Scale (VAS) for pain.

Results

Both approaches improved clinical outcomes. No significant differences in postoperative Nurick or VAS pain scores were observed. However, the anterior approach showed better Frankel score improvements but was associated with longer operative times and hospital stays. Complications were more frequent in the anterior group.

Discussion and conclusion

Both approaches effectively alleviate symptoms in symptomatic TDHs. The anterior approach offers greater neurological improvement but carries higher complication risks. Surgical strategy should be tailored based on herniation characteristics and surgeon expertise. Anterior approaches are ideal for central, large, or calcified herniations, while posterior approaches are preferable for lateral ones.

A novel, easy-to-use scoring system for the diagnosis of extraforaminal stenosis of lumbosacral transition using X-ray and CT scan

BACKGROUND

The diagnosis of extraforaminal stenosis of the lumbosacral transition (ESLT) using conventional two-dimensional (2D) magnetic resonance imaging (MRI) (2D-MRI) is challenging, with some overlooking of ESLT. It is desirable to have criteria for determining whether patients require additional three-dimensional MRI (3D-MRI). In this study, we created a simple scoring system to screen for ESLT using X-rays and computed tomography (CT).

METHODS

Ninety-two cases with unilateral L5 radiculopathy were recruited. We used 3D-MRI to determine the presence of ESLT. X-rays and CT were assessed by two examiners. X-rays were assessed for "vertebral inclination", "lumbosacral overlap sign", "lordosis angle", "disc height", and "vacuum phenomenon". Axial CT slices were assessed for "transverse process drooping," "nearthrosis" between transverse process and sacral ala, "osteosclerosis" of L5 endplate, and "osteophyte". Correlation between ESLT and each radiological variable was assessed. Reproducible variables were defined as >0.6 for both intra- and interobserver agreement. Multivariate logistic regression analysis was performed using the radiological variables that were correlated with ESLT and judged to be reproducible. Finally, a score was assigned to each selected variable considering the odds ratio (OR), and a radiological index for screening the extraforaminal stenosis (RISE) score was established. The receiver operating characteristic (ROC) curve analysis was performed for external validation.

RESULTS

Vertebral inclination (>3°) (OR: 4.8, p = 0.003), nearthrosis (OR: 10.2, p < 0.001), and osteophyte (OR: 5.2, p = 0.002) were selected. Considering the OR, 1 point was assigned to vertebral inclination and osteophyte, and 2 points were assigned to nearthrosis, obtaining RISE score (0-4 points). The area under the ROC curve was 0.91.

CONCLUSIONS

The RISE score accurately predicted the presence of ESLT, allowing aids in the selection of cases that require 3D-MRI.

Comparison of brain volume increase in patients with intracranial hypertension after decompressive craniectomy and expansion craniotomy

Intracranial hypertension is a critical condition often resulting from traumatic brain injury or malignant middle cerebral artery ischemia, necessitating surgical intervention when conservative treatments fail. This study compares the efficacy of decompressive craniectomy (DC) and expansion craniotomy (EC) in managing cerebral edema. Sixty-three patients, 52 undergoing DC and 11 undergoing EC, were evaluated for changes in brain volume, midline shift, and other key parameters using pre- and post-operative CT scans. Results indicated that brain volume increased significantly more in the EC group (100 ± 51 cm³) compared to the DC group (72 ± 51 cm³, p < 0.05). Both techniques effectively reduced midline displacement, but EC showed a superior capacity for brain expansion. The findings suggest that EC, which raises the cranial operculum to reduce soft tissue tension and provide hemostatic effects, may offer advantages over DC by allowing greater decompression and reducing the risk of complications such as epidural hematomas. These results support the potential of EC as a promising alternative to DC for treating intracranial hypertension. Future research should investigate long-term outcomes to further validate these findings.

Clinical Anatomy of the Sacral Nerve Roots and Its Relevance to Their Reconstruction After Sacrectomy

BACKGROUND AND OBJECTIVES

En bloc sacrectomy is associated with sacral root transection causing loss of urinary bladder, rectum, and sexual function. The aim of the study was to determine the position of the pudendal branches (sensorimotor) and pelvic splanchnic nerves (parasympathetic) on the sacral roots relative to the sacrum, and the minimal and maximal defects in the sacral roots that can be reconstructed by grafting after various types of sacrectomy.

METHODS

Five cadaveric pelves were dissected bilaterally. The lengths and widths of the S1-S4 roots and their branches were measured. Then, the minimal and maximal defects between the proximal and distal stumps of the sacrificed roots were measured following 3 models of sacrectomy (below S2, below S1, and total sacrectomy).

RESULTS

The mean distance of the splanchnic nerves from the S2 and S3 anterior sacral foramina was 17.7 ± 7.3 and 23.6 ± 11.1 mm, respectively, and the mean distance of the pudendal S2 and S3 branches was 36.8 ± 13.7 and 30.2 ± 10.8 mm, respectively. The mean widths of the S2 and S3 roots were 9.3 ± 1.9 and 5.4 ± 1.2 mm, respectively. The mean maximal defects in S2 and S3 roots after various types of sacrectomies were between 61.8 ± 16.3 and 100.7 ± 14.3 mm and between 62.7 ± 20.2 and 84.7 ± 25.1 mm, respectively. There were no statistically significant differences between sides or sexes for all obtained measurements.

CONCLUSION

The reconstruction of the S2-S3 roots is anatomically feasible after partial or total sacrectomies in which the resection of the soft tissue does not extend further than approximately 1.5 to 2 cm ventrally from the sacrum.

Awake Craniotomy for Eloquent Brain Arteriovenous Malformations: A Systematic Review and Individual Patient Data Meta-Analysis

BACKGROUND

Arteriovenous malformations (AVMs) pose a risk of neurologic deterioration, particularly when located in eloquent areas. While awake surgery is well-established for treating low-grade gliomas near eloquent areas, its efficacy for AVMs is less conclusively reported.

METHODS

This study conducted a systematic review and individual patient data meta-analysis following Cochrane Collaboration and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Literature searches were performed in PubMed, Embase, and Web of Science. Eligible studies included case reports, case series, retrospective or prospective cohorts, and randomized trials evaluating awake craniotomy (AC) for AVMs. Single proportion analysis with 95% confidence intervals (CIs) was utilized to pool the data. Case series and case reports were put together as a unique cohort.

RESULTS

An analysis of 20 studies encompassing 287 patients was performed. The individual patient data cohort had 53 patients. The primary outcome pooled analysis indicated an 88% (95% CI: 81%-95%; I2=63%) rate of total resection. Moreover, a rate of nearly 12% (95% CI: 5%-19%; I2=63%) of subtotal resection was observed. Furthermore, the analysis unveiled a 20% (95% CI: 13%-28%; I2=58%) rate of postoperative neurological deficits, alongside a 6% (95% CI: 3%-9%; I2=29%) rate of follow-up neurological deficits. The mean hospital stay was 4.13 (95% CI: 3.61-4.66; I2=73%) days.

CONCLUSIONS

AC for eloquent AVMs showed promising results. A significant rate of postoperative neurological deficits was found, which was reduced at follow-up. A small mean length of hospitalization was also found. These results suggest that AC for AVMs should be considered in eloquent lesion cases.

Clinical Characteristics and Outcomes of Traumatic Brain Injury in a High-Volume Tertiary Care Center in India: A Prospective Observational Cohort Study

BACKGROUND AND OBJECTIVES

Traumatic brain injury (TBI) is a major public health challenge in India but there is a lack of high-quality data on its clinical characteristics and outcomes. We aimed to describe the TBI population of a tertiary care center in India, identify predictors of inpatient mortality, and assess the performance of existing prognostic tools.

METHODS

We conducted a prospective observational cohort study of patients admitted to a high-volume tertiary care center in Vellore, India, after a TBI between 2013 and 2019.

RESULTS

We identified 3172 patients (2667 males, 84%) admitted after a TBI (median age = 34 years [IQR 23-48]). Two-wheeler road traffic accidents caused 2259 (71%) injuries, in which 13 (0.6%) patients were wearing a helmet. There were 174 (5%) inpatient deaths (median length of stay = 6 days [IQR 4-10]) and overall mortality (median follow-up = 6 months [IQR 3-9]) was 17% (n = 540). Age, Glasgow Coma Scale motor score, systolic blood pressure ≤90 mm Hg, and key computed tomography imaging features were independently associated with inpatient mortality. Existing prognostic models predicted inpatient mortality with good performance (International Mission for Prognosis and Analysis of Clinical Trials in TBI: Brier = 0.0876, area under the curve (AUC) = 83% [95% CI 79%-87%]; Rotterdam CT: Brier = 0.0890, AUC 79% [95% CI 75%-83%]), but showed poorer performance for post-discharge mortality (International Mission for Prognosis and Analysis of Clinical Trials in TBI: Brier = 0.134, AUC = 75% [95% CI 72%-78%]; Rotterdam CT: Brier = 0.145, AUC 66% [95% CI 63%-69%]).

CONCLUSION

In a tertiary care center in India, we described a predominantly young male TBI population with a high contribution of 2-wheeler road traffic accidents and significant post-discharge mortality. Existing prognostic models showed poor performance when predicting which patients died after discharge. These findings should inform public health interventions to reduce the significant burden of TBI in India.

Optimizing resources: financial evaluation of flow diverters versus stent assisted coiling in large and giant cerebral aneurysm management in Brazil public health system

BACKGROUND

Cerebral aneurysms, especially large and giant aneurysms, pose challenges in neurointerventional surgery. Treatment choices involve clinical presentation, aneurysm details, and global resource variations. Neurointerventional methods, while innovative, may be cost restrictive in certain regions. In public healthcare, cost is crucial, notably in countries like Brazil. This study examines the device specific cost estimation of flow diverters (FD) and traditional stent assisted coiling (SAC) for large and giant cerebral aneurysms, providing insights into optimizing neurosurgical interventions within the Brazilian public health system's unique challenges.

METHODS

A comprehensive retrospective analysis was conducted at our medical center of cases of large and giant aneurysms treated between 2013 and 2023. Determination of the estimated number of coils for aneurysms previously treated with FDs at our center was made, with the cost of each case, and the difference between both treatments was calculated.

RESULTS

We investigated the profiles of 77 patients: 40 had large aneurysms (51.9%) and 37 had giant aneurysms (48.1%). Large aneurysms had a mean cost difference of US$274 (standard deviation (SD) $2071), underscoring the device specific cost estimation of FDs over SAC in their treatment. For giant aneurysms, the mean cost difference increased to $6396 (SD $2694), indicating FDs as the more economically sound choice.

CONCLUSION

Our study indicated that, for the treatment of giant aneurysms and some large aneurysms, the FD intervention was more economical than SAC.

Unique considerations in the assessment and management of traumatic brain injury in older adults

The age-specific incidence of traumatic brain injury in older adults is rising in high-income countries, mainly due to an increase in the incidence of falls. The severity of traumatic brain injury in older adults can be underestimated because of a delay in the development of mass effect and symptoms of intracranial haemorrhage. Management and rehabilitation in older adults must consider comorbidities and frailty, the treatment of pre-existing disorders, the reduced potential for recovery, the likelihood of cognitive decline, and the avoidance of future falls. Older age is associated with worse outcomes after traumatic brain injury, but premorbid health is an important predictor and good outcomes are achievable. Although prognostication is uncertain, unsubstantiated nihilism (eg, early withdrawal decisions from the assumption that old age necessarily leads to poor outcomes) should be avoided. The absence of management recommendations for older adults highlights the need for stronger evidence to enhance prognostication. In the meantime, decision making should be multidisciplinary, transparent, personalised, and inclusive of patients and relatives.

Development and Validation of a Novel Classification System and Prognostic Model for Open Traumatic Brain Injury: A Multicenter Retrospective Study

INTRODUCTION

Open traumatic brain injury (OTBI) is associated with high mortality and morbidity; however, the classification of these injuries and the determination of patient prognosis remain uncertain, hindering the selection of optimal treatment strategies. This study aimed to develop and validate a novel OTBI classification system and a prognostic model for poor prognosis.

METHODS

This retrospective study included patients with isolated OTBI who received treatment at three large medical centers in China between January 2020 and June 2022 as the training set. Data on patients with OTBI collected at the Fuzong Clinical Medical College of Fujian Medical University between July 2022 and June 2023 were used as the validation set. Clinical parameters, including clinical data at admission, radiological and laboratory findings, details of surgical methods, and prognosis were collected. Prognosis was assessed through a dichotomized Glasgow Outcome Scale (GOS). A novel OTBI classification was proposed, categorizing patients based on a combination of intracranial hematoma and midline shift observed on imaging, and logistic regression analyses were performed to identify risk factors associated with poor prognosis and to investigate the association between the novel OTBI classification and prognosis. Finally, a nomogram suitable for clinical application was established and validated.

RESULTS

Multivariable logistic regression analysis identified OTBI classification type C (p < 0.001), a Glasgow Coma Scale score (GCS) ≤ 8 (p < 0.001), subarachnoid hemorrhage (SAH) (p = 0.004), subdural hematoma (SDH) (p = 0.011), and coagulopathy (p = 0.020) as independent risk factors for poor prognosis. The addition of the OTBI classification to a model containing all the other identified prognostic factors improved the predictive ability of the model (Z = 1.983; p = 0.047). In the validation set, the model achieved an area under the curve (AUC) of 0.917 [95% confidence interval (CI) = 0.864-0.970]. The calibration curve closely approximated the ideal curve, indicating strong predictive performance of the model.

CONCLUSIONS

The implementation of our proposed OTBI classification system and its use alongside the other prognostic factors identified here may improve the prediction of patient prognosis and aid in the selection of the most suitable treatment strategies.

Primary Diffuse Large B-Cell Lymphoma of the Clivus: Systematic Review and Illustrative Case Example

BACKGROUND

Primary non-Hodgkin's lymphoma arising from the skull base is a rare entity most commonly subclassified as diffuse large B-cell lymphoma (DLBCL). This lesion often arises from the clivus and demonstrates a cranial nerve (CN) VI palsy. In this case report and literature review, we document the clinical presentation and management of a case of clival DLBCL, along with a review of current literature pertaining to DLBCL of the skull base.

METHODS

A retrospective chart review and systematic literature search using the PubMed and Ovid MEDLINE databases were conducted. Presenting symptomatology, neoplasm location, immunohistochemistry, and follow-up data were extracted from each work.

RESULTS

A 71-year-old man presented with a month-long history of headache, fatigue, night sweats, and left lateral rectus palsy, with magnetic resonance imaging revealing a lesion of the clivus. He underwent biopsy and subtotal resection, in which histopathologic and immunohistochemical characteristics were consistent with DLBCL. He received rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone therapy with subsequent improvement of his symptoms. Systematic review identified 25 publications (58 patients) with a mean age of 65 years. The most common primary location for DLBCL was the clivus (26%) with resultant CN VI palsy (33%). Immunohistochemical markers were predominantly CD20 and CD45 positivity; treatment generally involves biopsy followed by adjuvant chemo and/or radiotherapy.

CONCLUSIONS

DLBCL arising from the skull base often originates from the clivus and results in CN VI palsy. Current publications indicate a unique clinical presentation and immunohistochemical profile. Treatment generally involves biopsy, followed by chemo and/or radiotherapy.

Parasellar region meningiomas with optic canal (OC) invasion: Correlation between the degree of decompression of the OC and the improvement of visual acuity

PURPOSE

To evaluate the correlation between the degrees of circumferential decompression of the optic canal (OC) and the improvement of visual acuity in patients with parasellar meningiomas (PMs) with optic canal invasion.

METHODS

This is a monocentric retrospective study conducted at author's institution. The visual acuity was evaluated preoperative and at 3-months after surgery with Snellen acuity test. The degree of decompression of the OC was calculated through postoperative multiplanar CT-scan reconstructions in coronal plane at intraorbital opening (IOO), intracranial opening (ICO) and middle point between them (MP). OC was then divided in two segments (anterior and posterior).

RESULTS

29 consecutive patients were identified. Improvement of visual acuity was observed in 18 patients (62 %). Mean decompression achieved at ICO, MP and IOO was 226.2°± 43.6° (range: 68.7°-297.1°), 217.5°± 37.2° (range: 75.3°-268.7°) and 204.6°± 41.2° (range: 67.3°-252.6°) respectively. A decompression > 90° of the anterior segment of the OC, a decompression > 180° of the posterior segment and a full-length decompression > 90° were associated visual acuity improvement at univariate analysis (p = 0.010, p = 0.002 and p < 0.001, respectively). A decompression > 180° of the posterior segment and a full-length decompression > 90° of the OC maintained statistical significance at multivariate analysis (p = 0.030 and p = 0.035, respectively).

CONCLUSION

Anterior segment decompression > 90° and posterior segment decompression > 180° were associated with improvement of visual acuity at 3 months after surgery. A full-length decompression of the optic canal > 90° showed better visual outcome, while a full-length decompression > 180° did not seem to be related to significative improvements in visual acuity.

Global Neurosurgery: A Path Forward Through Health System Strengthening

The future of global neurosurgery should focus on addressing the unmet neurosurgical need from a health system approach should we hope to achieve sustainable and ethical change. In this article, we review the global building blocks, as defined by the World Health Organization, and use this framework to propose strategies to strengthen neurosurgical care on the global frontier. The targets for Universal Healthcare Coverage by 2030, as outlined by the United Nations Sustainable Development Goals, are reviewed, and the role of neurosurgeons in addressing the global targets is discussed. Surgical indicators according to the Lancet Commission on Global Surgery are also reviewed, and neurosurgical indicators are proposed according to the 6 surgical indicators of the commission. The execution of these global targets and indicators within the context of health system strengthening will be a persistent challenge, given the complexity of health system and its components. The neurosurgical community must continue to support, promote, and diversify collaborations, especially among deserts of neurosurgical care across the world. Innovative technology and education are essential to this global dilemma.

Recurrence rate of intracranial aneurysms: a systematic review and a meta-analysis comparing craniotomy and endovascular coiling

Patients with intracranial aneurysm (IA) are at high risk of cerebral hemorrhage, which is associated with high mortality. Craniotomy or interventional endovascular coiling are common treatment methods in clinical practice, depending on the patient's condition. However, the recurrence rate of IA after either method remains unclear. This meta-analysis was conducted to study the relationship between different treatment regimens and IA recurrence. PubMed, CNKI, Web of Science, Wan Fang, and VIP databases were used to identify studies on "intracranial aneurysm," "craniotomy," "endovascular coiling," and "recurrence rate." Included studies adhered to rigorous screening and diagnostic criteria, and statistical models were applied based on homogeneity testing. This study encompassed 28 articles, including five on craniotomy and 23 on endovascular coiling, published between 2007 and 2022; among 1,448 cases treated with craniotomy, 20 experienced recurrences (recurrence rate: 1.4%, 95% CI: 0.2%), while among 5,975 cases treated with endovascular coiling, 872 cases experienced recurrence (recurrence rate: 14.6%, 95% CI: 14%, 20%). High heterogeneity (87%) was observed in the endovascular coiling, likely due to differences in patient demographics and aneurysm characteristics. For IAs, although endovascular coiling has advantages in terms of lower trauma and faster recovery, its high recurrence rate warrants closer post-treatment monitoring. Despite being more invasive, Craniotomy may be preferable in specific cases, such as when treating aneurysms with complex shapes or challenging locations. Treatment choice should be individualized, and future advancements in endovascular coiling technologies may help reduce recurrence rates.

Role of Sulcal Hyperintensity and Web/Net Appearance on MRI in Patients With Chronic Subdural Hematoma Presenting With Transient Neurological Deficits

BACKGROUND AND OBJECTIVES

Transient neurological deficits (TNDs) in patients with chronic subdural hematoma (CSDH), such as fluctuating aphasia, hemiparesis, or sensory disturbances, present diagnostic and treatment challenges as their pathophysiology remains unclear. The aim of this study was to investigate the association between specific MRI findings and TNDs in patients with CSDH and explored their relationship through intraoperative observation.

METHODS

We retrospectively evaluated 72 patients with CSDH who underwent preoperative MRI among 251 CSDH patients treated from January 2020 to December 2023. Sulcal hyperintensity (SHI) on fluid-attenuated inversion recovery images and web/net appearance (W/N) on T2*-weighted images were assessed and their association with TNDs was analyzed. Flexible neuroendoscopic surgery (FNS) was performed on 8 patients with TNDs exhibiting these MRI findings, allowing intraoperative observation of intrahematoma conditions. Histopathological examination was performed on hematoma samples.

RESULTS

Thirteen patients (5.2%) presented with preoperative TNDs. Diffuse SHI and W/N were strongly associated with preoperative TNDs (odds ratio = 150.0, P < .001). FNS revealed organized hematomas with inflammatory changes corresponding to the SHI and W/N seen on MRI. Patients who underwent FNS experienced complete resolution of TNDs postprocedure, with diffuse SHI disappearing by one month. No recurrence was observed at a mean follow-up of 5.9 months.

CONCLUSION

This study provided the first evidence that the combination of diffuse SHI and W/N on MRI strongly correlates with TNDs in patients with CSDH, serving as valuable diagnostic indicators. These findings will aid in guiding surgical approach selection and facilitate more personalized treatment strategies for patients with CSDH presenting with TNDs.

Unraveling the Mysteries of Ameloblastoma in African Population: A Comprehensive Analysis of 371 Cases from Clinical, Radiological, and Histopathological Perspectives

OBJECTIVE

To analyze the frequency, clinical, histopathological, and radiological characteristics of ameloblastoma in Nigeria over the course of two decades.

STUDY DESIGN

A retrospective analysis was conducted on 371 cases at a Nigerian university hospital between 2000 and 2023. Age, gender, site, histological variants, tumor size and duration were analyzed. Statistical analyses included the Shapiro-Wilk test, Mann-Whitney U test, Chi-square test, and Spearman rank correlation analysis.

RESULTS

The median patient age was 30 years (mean age 32.2), with a male-to-female ratio of 1.12:1. 54.7% of cases occurred in young adults (age range 20-39 years). Among the lesions, 11.3% were in the maxilla and 88.7% in the mandible. Patients with mandibular lesions had a median age of 29 years, while those with maxillary lesions had a statistically significantly higher median age of 37.5 years p-value = 0.001. Median tumor size was 36 cm2 for the mandible and 24 cm2 for the maxilla (significant p-value of 0.002). There was no correlation between tumor size, age, or gender. However, there was a significant correlation between tumor size and the duration of the condition.

CONCLUSION

The study concludes that ameloblastoma is more frequent among younger individuals in Nigeria and often presents with larger tumor sizes, emphasizing the need for early detection and intervention.

TILTomorrow today: dynamic factors predicting changes in intracranial pressure treatment intensity after traumatic brain injury

Practices for controlling intracranial pressure (ICP) in traumatic brain injury (TBI) patients admitted to the intensive care unit (ICU) vary considerably between centres. To help understand the rational basis for such variance in care, this study aims to identify the patient-level predictors of changes in ICP management. We extracted all heterogeneous data (2008 pre-ICU and ICU variables) collected from a prospective cohort (n = 844, 51 ICUs) of ICP-monitored TBI patients in the Collaborative European NeuroTrauma Effectiveness Research in TBI study. We developed the TILTomorrow modelling strategy, which leverages recurrent neural networks to map a token-embedded time series representation of all variables (including missing values) to an ordinal, dynamic prediction of the following day's five-category therapy intensity level (TIL(Basic)) score. With 20 repeats of fivefold cross-validation, we trained TILTomorrow on different variable sets and applied the TimeSHAP (temporal extension of SHapley Additive exPlanations) algorithm to estimate variable contributions towards predictions of next-day changes in TIL(Basic). Based on Somers' Dxy, the full range of variables explained 68% (95% CI 65-72%) of the ordinal variation in next-day changes in TIL(Basic) on day one and up to 51% (95% CI 45-56%) thereafter, when changes in TIL(Basic) became less frequent. Up to 81% (95% CI 78-85%) of this explanation could be derived from non-treatment variables (i.e., markers of pathophysiology and injury severity), but the prior trajectory of ICU management significantly improved prediction of future de-escalations in ICP-targeted treatment. Whilst there was no significant difference in the predictive discriminability (i.e., area under receiver operating characteristic curve) between next-day escalations (0.80 [95% CI 0.77-0.84]) and de-escalations (0.79 [95% CI 0.76-0.82]) in TIL(Basic) after day two, we found specific predictor effects to be more robust with de-escalations. The most important predictors of day-to-day changes in ICP management included preceding treatments, age, space-occupying lesions, ICP, metabolic derangements, and neurological function. Serial protein biomarkers were also important and may serve a useful role in the clinical armamentarium for assessing therapeutic needs. Approximately half of the ordinal variation in day-to-day changes in TIL(Basic) after day two remained unexplained, underscoring the significant contribution of unmeasured factors or clinicians' personal preferences in ICP treatment. At the same time, specific dynamic markers of pathophysiology associated strongly with changes in treatment intensity and, upon mechanistic investigation, may improve the timing and personalised targeting of future care.

DTI fiber-tracking parameters adjacent to gliomas: the role of tract irregularity value in operative planning, resection, and outcome

PURPOSE

The goal of glioma surgery is maximal tumor resection associated with minimal post-operative morbidity. Diffusion tensor imaging-tractography/fiber tracking (DTI-FT) is a valuable white-matter (WM) visualization tool for diagnosis and surgical planning. Still, it assumes a descriptive role since the main DTI metrics and parameters showed several limitations in clinical use. New applications and quantitative measurements were recently applied to describe WM architecture that surround the tumor area. The brain adjacent tumor area (BAT) is defined as the region adjacent to the gross tumor volume, which contains signal abnormalities on T2-weighted or FLAIR sequences. The DTI-FT analysis of the BAT can be adopted as predictive values and a guide for safe tumor resection.

METHODS

This is an observational prospective study on an extensive series of glioma patients who performed magnetic resonance imaging (MRI) with pre-operative DTI-FT analyzed on the BAT by two different software. We examined DTI parameters of Fractional anisotropy (FA mean, min-max), Mean diffusivity (MD), and the shape-metric "tract irregularity" (TI) grade, comparing it with the surgical series' clinical, radiological, and outcome data.

RESULTS

The population consisted of 118 patients, with a mean age of 60.6 years. 82 patients suffering from high-grade gliomas (69.5%), and 36 from low-grade gliomas (30.5%). A significant inverse relationship exists between the FA mean value and grading (p = 0.001). The relationship appears directly proportional regarding MD values (p = 0.003) and TI values (p = 0.005). FA mean and MD values are susceptible to significant variations with tumor and edema volume (p = 0.05). TI showed an independent relationship with grading regardless of tumor radiological features and dimensions, with a direct relationship with grading, ki67% (p = 0,05), PFS (p < 0.001), and EOR (p < 0.01).

CONCLUSION

FA, MD, and TI are useful predictive measures of the clinical behavior of glioma, and TI could be helpful for tumor grading identification and surgical planning.

Post-injury treatment with 7,8-dihydroxyflavone attenuates white matter pathology in aged mice following focal traumatic brain injury

Traumatic brain injury (TBI) is a major cause of morbidity and mortality, not least in the elderly. The incidence of aged TBI patients has increased dramatically during the last decades. High age is a highly negative prognostic factor in TBI, and pharmacological treatment options are lacking. We used the controlled cortical impact (CCI) TBI model in 23-month-old male and female mice and analyzed the effect of post-injury treatment with 7,8 dihydroxyflavone (7,8-DHF), a brain-derived neurotrophic factor (BDNF)-mimetic compound, on white matter pathology. Following CCI or sham injury, mice received subcutaneous 7,8-DHF injections (5 ​mg/kg) 30 ​min post-injury and were sacrificed on 2, 7 or 14 days post-injury (dpi) for histological and immunofluorescence analyses. Histological assessment with Luxol Fast Blue (LFB)/Cresyl Violet stain showed that administration of 7,8-DHF resulted in preserved white matter tissue at 2 and 7 dpi with no difference in cortical tissue loss at all investigated time points. Treatment with 7,8-DHF led to reduced axonal swellings at 2 and 7 dpi, as visualized by SMI-31 (Neurofilament Heavy Chain) immunofluorescence, and reduced number of TUNEL (Terminal deoxynucleotidyl transferase dUTP nick end labelling)/CC1-positive mature oligodendrocytes at 2 dpi in the perilesional white matter. Post-injury proliferation of Platelet-derived Growth Factor Receptor (PDGFRα)-positive oligodendodrocyte progenitor cells was not altered by 7,8-DHF. Our results suggest that 7,8-DHF can attenuate white matter pathology by mitigating axonal injury and oligodendrocyte death in the aged mouse brain following TBI. These data argue that further exploration of 7,8-DHF towards clinical use is warranted.

Relative Cortical Atrophy Index as a Strong Predictor of Recurrence After Surgery for Chronic Subdural Hematoma

BACKGROUND AND OBJECTIVES

Chronic subdural hematoma (CSDH) presents significant management challenges in neurosurgical practice, with recurrence being a notable postoperative consideration. This study aimed to evaluate the Relative Cortical Atrophy (RCA) Index as a predictor of recurrence after CSDH surgery.

METHODS

A retrospective analysis was conducted on 98 patients who underwent surgical evacuation for unilateral CSDH. The RCA Index was calculated using pre- and postoperative cranial imaging, correlating it with patient demographics, hematoma characteristics, and recurrence. Inter-rater reliability among measurements by 4 independent physicians was assessed using the intraclass correlation coefficient (ICC). Correlation and regression analyses were performed to identify the correlation of the RCA Index with other factors and their potential predicting power of CSDH recurrence, respectively.

RESULTS

The study population had a mean age of 74.1 (11.9) years, with a 23.5% (23 patients) recurrence rate of CSDH. The ICC analysis showed excellent inter-rater reliability for RCA Index measurements (ICC: 0.998, 95% CI: 0.997-0.998, P < .001). A higher preoperative RCA Index was significantly associated with recurrence (0.215 [0.031] in the recurrent group vs 0.125 [0.034] in the nonrecurrent group, P < .001). The preoperative RCA Index highly correlated with the postoperative RCA Index (Pearson's correlation: 0.918, P < .001), and there was only a small (average: 0.005) but significant increase in the RCA Index of the unaffected hemisphere after surgery ( P = .01).The preoperative RCA Index positively correlated with age, preoperative SDH thickness and volume, and recurrence. A RCA Index cutoff value of 0.165 predicted CSDH recurrence with high sensitivity (95.6%) and specificity (93.3%) (area under the curve = 0.97, 95% CI: 0.93-1).

CONCLUSION

The RCA Index is a simple yet robust predictor of CSDH recurrence. Incorporating this measure into the preoperative assessment may enhance surgical planning and postoperative management, potentially reducing recurrence rates.

Deferoxamine alleviates ferroptosis in seawater immersion combined with traumatic brain injury

Traumatic brain injury (TBI) is a major cause of death and disability worldwide, with its severity potentially exacerbated by seawater immersion. Ferroptosis, a form of regulated cell death driven by iron-dependent lipid peroxidation, has been implicated in TBI pathogenesis. However, the specific occurrence and underlying mechanisms of ferroptosis in the context of TBI compounded by seawater immersion remain unclear. Subsequently, we investigated the effects of seawater immersion on ferroptosis after the application of deferoxamine (DFO), an iron chelator and ferroptosis inhibitor, to explore its potential therapeutic value. We conducted RNA sequencing, protein expression analysis, oxidative stress assessment, histopathological examination, and behavioral testing to comprehensively evaluate the impact of DFO on ferroptosis and neurological outcomes. Our results demonstrated that seawater immersion significantly exacerbated ferroptosis in TBI. DFO treatment, however, attenuated ferroptosis, alleviated oxidative stress, reduced brain tissue damage, improved neuronal survival, and promoted motor function recovery. Despite these benefits, DFO exhibited limited effects on anxiety, novel object recognition, and spatial learning and memory. These findings suggest that ferroptosis represents a novel pathological mechanism in TBI under seawater immersion, and that DFO is a promising neuroprotective agent capable of modulating ferroptosis and enhancing neurological function. This study offers new insights into the complex injury conditions associated with TBI and seawater immersion, highlighting the potential of targeting ferroptosis for therapeutic intervention.

Clinical Use of Hematoma Volume Based On Automated Segmentation of Chronic Subdural Hematoma Using 3D U-Net

PURPOSE

To propose a method for calculating hematoma volume based on automatic segmentation of chronic subdural hematoma (CSDH) using 3D U‑net and investigate whether it can be used clinically to predict recurrence.

METHODS

Hematoma volumes manually measured from pre- and postoperative computed tomography (CT) images were used as ground truth data to train 3D U‑net in 200 patients (400 CT scans). A total of 215 patients (430 CT scans) were used as test data to output segmentation results from the trained 3D U‑net model. The similarity with the ground truth data was evaluated using Dice scores for pre and postoperative separately. The recurrence prediction accuracy was evaluated by obtaining receiver operating characteristic (ROC) curves for the segmentation results. Using a typical mobile PC, the computation time per case was measured and the average time was calculated.

RESULTS

The median Dice score of the test data were preoperative hematoma volume (Pre-HV): 0.764 and postoperative subdural cavity volume (Post-SCV): 0.741. In ROC analyses assessing recurrence prediction, the area under the curve (AUC) of the manual was 0.755 in Pre-HV, whereas the 3D U‑net was 0.735. In Post-SCV, the manual AUC was 0.779; the 3D U‑net was 0.736. No significant differences were found between manual and 3D U‑net for all results. Using a mobile PC, the average time taken to output the test data results was 30 s per case.

CONCLUSION

The proposed method is a simple, accurate, and clinically applicable; it can contribute to the widespread use of recurrence prediction scoring systems for CSDH.

Paramedian Unilateral 'Bitubular' Endoscopic Access for a Far Lateral Disc Herniation: A Novel Approach for Far Lateral Lumbar Pathologies

We present a novel technique to approach far lateral lumbar pathologies using a bitubular, biportal endoscopic system and a paramedian approach. Background: Conventional approaches for lumbar far lateral discectomy range from open approaches to newer minimally invasive approaches such as tubular discectomy and single portal endoscopic discectomy. We present a case of a patient suffering with a left L3-4 and left L4-5 extraforaminal disc herniation who was treated successfully with a left sided bitubular, biportal endoscopic 2 level far lateral discectomy. A paramedian 'bitubular' biportal endoscopic approach is safe and effective for far lateral lumbar pathologies with excellent visualisation due to good outflow of irrigation fluid.

Polymorphic low-grade neuroepithelial tumors of the young: disease characteristics and treatment decisions from the epilepsy surgery perspective

Background

The Polymorphic Low-Grade Neuroepithelial Tumor of the Young (PLNTY) is a rare, epilepsy-associated brain tumor that has been increasingly recognized but is not well understood due to the scarcity of clinical reports. Our study reviews the clinical characteristics and treatment outcomes of 14 patients with PLNTY to enhance the understanding of this condition from an epilepsy surgery perspective.

Methods

We performed a retrospective analysis of 14 PLNTY cases at our hospital. A literature review on prior studies was also conducted.

Results

Our study included 8 males and 6 females, all presenting with epilepsy. Despite anti-seizure medication, 92.3% of patients continued to have seizures, with 58.3% diagnosed as having drug-resistant epilepsy. Neuroimaging revealed that 64.3% of the lesions were in the temporal lobe, with 75.0% showing calcification on CT, 71.4% exhibiting mixed signals on T2-weighted images, and 92.7% showing tumor enhancement. The transmantle sign was noted in 57.1% of T2 FLAIR sequences. EEGs indicated abnormal activity in 69.2% of patients, with 30.7% showing bilateral discharges. SEEG in two patients confirmed the tumor's epileptogenicity. A 78.6% total resection rate was achieved, with a 90.0% postoperative seizure-free rate and an 85.7% excellent Engel grade 1 rate. No instances co-occurring with focal cortical dysplasia (FCD) were observed.

Conclusion

PLNTY is characterized by unique neuroimaging features and a strong association with epilepsy. SEEG is pivotal for cases with unclear lateralization, aiding in identifying the link between the tumor and seizures. Following established epilepsy surgery protocols for brain tumor management, early intervention and extended resection can improve the rate of postoperative seizure freedom.

Disparities in casemix, acute interventions, discharge destinations and mortality of patients with traumatic brain injury between Europe and India

Background

Traumatic brain injury (TBI) is a major global health problem that disproportionally affects low- and middle-income countries. The needs for patients with TBI therefore may differ between levels of national development. We aimed to describe differences in epidemiology and acute care provision of TBI between India and Europe.

Methods

We used data from two prospective observational registry studies - the Collaborative Indian NeuroTrauma Effectiveness Research in TBI (CINTER-TBI) and the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI), which included TBI patients with an indication for brain CT-scan presenting to 65 centres across Europe and Israel and two trauma centres in India. We performed descriptive analyses of demographic, injury, and treatment characteristics and used random-effects logistic regression with covariate adjustment to examine the likelihood of acute neurosurgical interventions and in-hospital mortality.

Results

We included 22 849 patients from CENTER-TBI and 3904 from CINTER-TBI. The median age in Europe was 55 years (IQR = 32-76) compared to 27 years (IQR = 18-40) in India. The most common cause of TBI in Europe were falls (n = 12150 (53%), while traffic incidents predominated in India (n = 2130 (55%)). The proportion of patients with severe TBI was higher in India (n = 867 (22%)) than in Europe (n = 1661 (7%). Professional pre-hospital care involving ambulance service was utilised by three-fourths (n = 17203 (75%)) of European and less than a one-tenth (n = 224 (6%)) of Indian patients in our sample. Patients with severe TBI were more likely to undergo surgical contusion/haematoma evacuation in India compared to Europe (OR = 2.0; 95% CI = 1.7-2.5) and Indian patients had higher odds of undergoing intracranial pressure monitor placement (OR = 2.3; 95% CI = 2.0-2.7). A primary decompressive craniectomy was likewise more often performed in the Indian cohort (OR = 5.1; 95% CI = 3.5-7.5). Discharge destinations in Europe included rehabilitation centres (n = 1261 (6%)) or nursing homes (n = 1208 (5%)), which was rarely the case in India (n = 13 (0%) and n = 9 (0%), respectively).

Conclusions

Substantial disparities between India and Europe exist along the neurotrauma care chain, with both systems being likely to face unique features and challenges in the future.

Achieving Equity Through Global Neurosurgery Research

Since the release of the Lancet Commission on Global Surgery report in 2015, there has been an increase in the number of published papers on global neurosurgery, gaining widespread support from major neurosurgery journals. However, there remains no consensus on what may be considered part of global neurosurgery literature. Here, we propose that global neurosurgery research encompasses all scholarly work that measure, explore, or address inequity in the care of neurosurgical disease. We describe the growth of global neurosurgery research, cite landmark papers, and discuss barriers to participation, particularly among neurosurgeons in low- and middle-income countries. We introduce the 3Rs framework, advocating for global neurosurgery research that is rigorous, responsive, and responsible. This narrative review aims to guide young neurosurgeons and other researchers interested in the field, and to provide a framework through which global neurosurgery practitioners and advocates can evaluate previously accomplished work, paving the way toward neurosurgery that is timely, safe, and affordable to all.

Clinical profile of patients with acute traumatic brain injury undergoing cranial surgery in the United States: report from the 18-centre TRACK-TBI cohort study

Background

Contemporary surgical practices for traumatic brain injury (TBI) remain unclear. We describe the clinical profile of an 18-centre US TBI cohort with cranial surgery.

Methods

The prospective, observational Transforming Research and Clinical Knowledge in Traumatic Brain Injury Study (2014-2018; ClinicalTrials.gov #NCT02119182) enrolled subjects who presented to trauma centre and received head computed tomography within 24-h (h) post-TBI. We performed a secondary data analysis in subjects aged ≥17-years with hospitalisation. Clinical characteristics, surgery type/timing, hospital and six-month outcomes were reported.

Findings

Of 2032 subjects (age: mean = 41.4-years, range = 17-89-years; male = 71% female = 29%), 260 underwent cranial surgery, comprising 65% decompressive craniectomy, 23% craniotomy, 12% other surgery. Subjects with surgery (vs. without surgery) presented with worse neurological injury (median Glasgow Coma Scale = 6 vs. 15; midline shift ≥5 mm: 48% vs. 2%; cisternal effacement: 61% vs. 4%; p < 0.0001). Median time-to-craniectomy/craniotomy was 1.8 h (interquartile range = 1.1-5.0 h), and 67% underwent intracranial pressure monitoring. Seventy-three percent of subjects with decompressive craniectomy and 58% of subjects with craniotomy had ≥3 intracranial lesion types. Decompressive craniectomy (vs. craniotomy) was associated with intracranial injury severity (median Rotterdam Score = 4 vs. 3, p < 0.0001), intensive care length of stay (median = 13 vs. 4-days, p = 0.0002), and six-month unfavourable outcome (62% vs. 30%; p = 0.0001). Earlier time-to-craniectomy was associated with intracranial injury severity.

Interpretation

In a large representative cohort of patients hospitalised with TBI, surgical decision-making and time-to-surgery aligned with intracranial injury severity. Multifocal TBIs predominated in patients with cranial surgery. These findings summarise current TBI surgical practice across US trauma centres and provide the foundation for analyses in targeted subpopulations.

Funding

National Institute of Neurological Disorders and Stroke; US Department of Defense; Neurosurgery Research and Education Foundation.

Enhancing Precision and Esthetics: Endoscopy-Assisted Total Maxillectomy for Locally Invasive Maxillary Ameloblastoma Using Contralateral Transmaxillary Approach Without Subciliary Incision

This report presents a notable approach to treating a locally invasive maxillary ameloblastoma in a 46-year-old woman using an endoscopy-assisted total maxillectomy via a contralateral transmaxillary approach without a subciliary incision. Ameloblastomas, though benign, require radical surgical management due to their aggressive nature and high recurrence rates, especially in the maxilla. Traditional techniques often involve extensive facial incisions, leading to significant scarring and potential complications. In this case, the notable approach allowed for precise osteotomy of the pterygoid process and accurate delineation of the mucosal margins during ethmoidectomy while preserving facial esthetics. The surgery achieved complete tumor resection with successful reconstruction, avoiding the esthetic drawbacks associated with conventional methods. Postoperative recovery was uneventful, with no residual tumor observed at the six-month follow-up. This technique demonstrates the potential for reducing surgical morbidity and improving cosmetic outcomes in the management of complex maxillary tumors.

Global neurotrauma: A systematic review and summary of the current state of registries around the world

Neurotrauma registries (NTR) collect data on traumatic brain injuries (TBI) to advance knowledge, shape policies, and improve outcomes. This study reviews global NTRs from High-Income (HICs) and Low- and Middle-Income countries (LMICs). A systematic review was conducted using PubMed, Google Scholar, Embase, and Web of Science following PRISMA guidelines to identify relevant NTRs. Twenty-six articles were included, revealing ten different NTRs from Europe, North America, Latin America, the Middle East, and Asia. North America had the most registries at four, followed by Europe and Asia with two each, and Latin America and the Middle East with one each. The median database size was 1,734 patients (Range: 65-25,000), with the largest registry from the United States (FITBIR DB) and the smallest from Iran (NSCIR-IR). The longest data collection period was 32 years, with a mean age of 43.1 years (Range: 9.07-60.0). Males comprised 70 % of patients. Sixty-six percent of articles emphasized outcomes such as functionality, length of stay, and mortality. Key challenges identified included issues with missing data and incomplete records (n = 4), lack of standardization in data collection procedures (n = 3), staffing shortages (n = 5), lack of IT infrastructure (n = 3), and problems with reproducibility, particularly in high-income countries (n = 4). Our review highlights the need for a large-scale global NTR, addressing LMIC barriers through private-public partnerships with organized neurosurgery members.

Minimally invasive far lateral tubular microdiscectomy: surgical technique and case series of 176 patients

BACKGROUND

Far lateral (extraforaminal) disc herniations comprise approximately 10% of symptomatic lumbar disc herniations. They represent operative challenges due to accessibility and surgical unfamiliarity. Surgical strategies in the past have included open discectomy and posterior lumbar interbody fusion. Tubular microdiscectomies have gained traction due to their minimally invasive advantages, including reduced morbidity, pain and length of hospital stay.

METHODS

We report our retrospective single institution consecutive case series of tubular far lateral microdiscectomies. One hundred and seventy-six patients were operated on over an eight-year period. Clinical outcomes were assessed after institutional ethics approval. We additionally describe our surgical technique with an illustrative video case.

RESULTS

Over a mean follow-up of 21 weeks, 77% of patients had good or excellent clinical outcomes according to the MacNab criteria. 12% of patients underwent reoperation at the index level for symptom recurrence or persistence. Mean length of hospital stay was 1.3 days. There was a 1% rate of both postoperative haematoma and infection. Mean operation duration was 86 minutes.

CONCLUSION

This case series represents the largest currently reported in the literature. Minimally invasive microdiscectomies performed through tubes allow for precise localisation, reduced tissue disruption and favourable clinical outcomes. Our results appear consistent with a review of the literature, demonstrating the safety and efficacy of this approach.

Evolution of Thoracic Disc Herniation Surgery: Future Perspectives from a Systematic Review and Meta-Analysis

BACKGROUND

The neurosurgical treatment of thoracic disc herniation (TDH) has undergone dramatic changes over the years in terms of surgical approaches and intraoperative technological tools. There is still no unanimous consent on the criteria for approach selection, and the choice varies among Institutions. The aim of this study is to compare anterior and posterolateral approaches for TDH in terms of functional and surgical outcomes.

METHODS

A systematic literature review and meta-analysis according to PRISMA guidelines from EMBASE, PubMed, Cochrane Library, Web of Science, and Google Scholar online databases up to May 2024 incorporated studies that reported outcomes of thoracic disc herniation surgeries. Analyzed factors included major peri- and postoperative complications, intraoperative blood loss, hospital stay, neurological improvement, and complete hernia resection. Random-effect models were used to calculate pooled odds ratios and mean differences.

RESULTS

The posterolateral approach was associated with significantly lower rates of major medical (OR 0.14, 95% CI: 0.07 to 0.27) and surgical complications (OR 0.61, 95% CI: 0.38 to 0.99) compared to the anterior approach. Additionally, posterolateral approaches reduced intraoperative blood loss and shorter hospital stays. Posterolateral techniques were linked to higher odds of neurological improvement (OR 0.65, 95% CI: 0.43 to 0.99) and higher rates of complete hernia resection (OR 0.38, 95% CI: 0.21 to 0.71).

CONCLUSIONS

Posterolateral approaches offer advantages in terms of safety, recovery, neurological improvement, and complete hernia resection. More extensive prospective studies are needed to confirm these findings and refine surgical strategies. Emerging technologies, such as the exoscope and 45° endoscopy, may further enhance surgical outcomes.

Pipeline Embolization device for the treatment of unruptured intracranial saccular aneurysms: a systematic review and meta-analysis of long-term outcomes

INTRODUCTION

The pipeline embolization device (PED) is commonly used for intracranial aneurysm treatment. While its effectiveness for certain types of aneurysms is well-established, its efficacy for saccular aneurysms remains controversial. We aimed to assess the long-term outcomes of PED treatment for unruptured intracranial saccular aneurysms.

METHODS

Systematic review and meta-analysis were conducted following PRISMA guidelines. Studies with at least one year of follow-up after PED treatment for saccular aneurysms were included. The primary endpoint was angiographic aneurysm occlusion at long-term follow-up (≥ 12 months), and the secondary outcome was long-term complications. We conducted a meta-regression analysis to explore potential sources of heterogeneity across studies.

RESULTS

Eleven studies of 797 patients with 963 aneurysms were included. Long-term angiographic occlusion rate was 85% (95% CI, 77-91%; p < 0.01), symptomatic ischemic stroke rate was 1% (95% CI, 0-3%; p < 0.01), rupture rate was 1% (95% CI, 0-2%; p = 0.02), and intracranial hemorrhage (ICH) rate was 0.2% (95% CI, 0-1%; p = 0.11). Meta-regression analysis revealed a non-significant decreasing trend per year for aneurysmal occlusion, ischemic stroke rate, delayed aneurysmal rupture, and ICH.

CONCLUSION

PED demonstrates high long-term occlusion and low complication rates, suggesting it is a safe and effective treatment option for saccular aneurysms. Additionally, newer devices exhibit reduced thrombogenic profiles and safety with decreasing trends in ICH, ischemic stroke, and delayed aneurysmal rupture.

Collaborative Initiatives in Neurosurgery Research and Publications Between High-Income and Low/Middle-Income Countries: A Bibliometric Analysis

Despite the globalization of health information, collaborations between high-income countries (HICs) and low/middle-income countries (LMICs), while present, could still increase. This study builds on previous research highlighting LMIC underrepresentation in neurosurgery literature. We conducted a comprehensive bibliometric analysis using the Scopus database to investigate collaborative neurosurgical research between HIC institutions and those in low-income country (LIC)/LMICs. Articles published between 2018 and 2020 were examined. Articles were categorized into 3 groups: guidelines, conferences, and consensus statements; articles related to training and collaborations; and other articles. We categorized articles and authors by country, role, and specific subtopic. We included 238 reports from 34 neurosurgical journals for analysis. Geographic distribution indicated that India led LIC/LMIC contributions (25.21%). Among HICs, the United States had the highest contribution (47.76%). In collaborative studies, Uganda, Cameroon, Tanzania, Indonesia, and Nigeria made significant contributions. LICs and LMICs accounted for 446 authors, while HICs contributed with 592. India has presented the highest number of authors in significant positions. In HICs, significant positions are recognized in USA articles. When scoring authors' position in collaborative papers, still HICs had a clear prevalence. The highest number of collaborations between HICs and LICs/LMICs has been observed in articles related to training and collaborations. Kenya matched India's contributions in training and collaborations. Global guidelines and consensus papers can enhance patient care, but LMICs' involvement remains limited. Further attention to training and collaboration initiatives is needed. This study emphasizes the importance of promoting collaboration and training between countries with varying resources to advance neurosurgical care globally.