TN-RS: a novel scoring system predicts Gamma Knife Radiosurgery outcome for trigeminal neuralgia patients.

BACKGROUND: Gamma Knife Radiosurgery (GKRS) is an effective treatment option for medically refractory trigeminal neuralgia (TN). This study examines GKRS outcome in a large cohort of TN patients and highlights pretreatment factors associated with pain relief. METHODS: This is a single-center retrospective analysis of patients treated with GKRS for TN between 2011 and 2019. Pain relief was assessed at 1 year, and 2-3 years following GKRS. Multivariable analysis identified several factors that predicted pain relief. These predicting factors were applied to establish a pain relief scoring system. RESULTS: A total of 162 patients met inclusion criteria. At 1 year post-GKRS, the breakdown of Barrow Neurological Institute (BNI) score for pain relief was as follows: 77 (48%) score of I, 13 (8%) score of II, 37 (23%) score of III, 22 (14%) score of IV, and 13 (8%) score of V. Factors that were significantly associated with pain-free outcome at 1 year were: Typical form of TN (OR = 2.2 [1.1, 4.9], p = 0.049), No previous microvascular decompression (OR = 4.4 [1.6, 12.5], p = 0.005), Response to medical therapy (OR = 2.7 [1.1, 6.1], p = 0.018), and Seniority > 60 years (OR = 2.8 [1.4, 5.5], p = 0.003). The term "Trigeminal Neuralgia-RadioSurgery" was used to create the TN-RS acronym representing the significant factors. A stepwise increase in the median predicted probability of pain-free outcome at 1 year from 3% for patients with a score of 0 to 69% for patients with a maximum score of 4. CONCLUSION: The TN-RS scoring system can assist clinicians in identifying patients that may benefit from GNRS for TN by predicting 1-year pain-free outcomes.

Prevalence and Characteristics of Cervical Ossified Posterior Longitudinal Ligament in the Jewish Population.

BACKGROUND: Numerous studies have demonstrated an association between ethnic identity and the prevalence rate of cervical ossified posterior longitudinal ligament (C-OPLL). To date, its prevalence rate in the Jewish population has not been determined. The aim of this historical prospective study is to evaluate the prevalence and characteristics of C-OPLL in the Jewish population. METHODS: We performed a retrospective evaluation of imaging studies of all adult patients who underwent both cervical computed tomography and magnetic resonance imaging for all clinical indications within a span of 36 months between January 2017 and July 2020 at a single tertiary referral hospital located in central Israel. Identified C-OPLL carriers were interviewed by telephone. All the patients provided informed consent and then were questioned for current symptoms and demographics, including religion, Jewish ethnic identity, birthplace, parental birthplace and ethnic identity, and family history of spinal disorders. RESULTS: Overall, 440 participants were radiographically evaluated. The prevalence of C-OPLL in the Jewish population was 7.5% (33 of 440). The mean age of the C-OPLL carriers was 65.8 years. All the C-OPLL carriers were symptomatic at analysis. The carriers had an increased proportion with a Sephardic Jewish ethnic identity (65.4%), with a significantly high rate of homogeneous parental Jewish identity (92.4%), suggesting a prominent genetic contribution to the development of this condition. CONCLUSIONS: The prevalence of C-OPLL in the Jewish population in central Israel was 7.5%. This rate is significantly higher than that in other previously studied populations. To the best of our knowledge, this is the first study to identify the Jewish population as experiencing an increased prevalence of C-OPLL.

Elongated, finger-like ophthalmic segment aneurysms: Implications for selection of treatment modality.

BACKGROUND: Microsurgical treatment of ophthalmic segment aneurysms often requires anterior clinoidectomy and optic nerve mobilization prior to successful clipping. OBJECTIVE: We hypothesize that ophthalmic segment aneurysms that are elongated and finger-like grow unconstrained, lateral to the optic nerve. We note that this avoids the need for clinoid resection and optic nerve mobilization. METHODS: Three cases with up-pointing aneurysms were reviewed. Patient and aneurysm characteristics were collected. RESULTS: The first two patients with elongated ophthalmic segment aneurysms were found to have aneurysms growing lateral to the optic nerve. This allowed for straightforward treatment via microsurgical clipping without anterior clinoidectomy or division of the falciform ligament. The third patient presented with distortion of the optic chiasm superiorly and medially by a giant ventral ICA aneurysm. A concomitant ophthalmic aneurysm in this patient exhibited elongated morphology, with a high-resolution MRI demonstrating the patient's optic nerve was located inferior and medial to the ophthalmic artery aneurysm dome. This supports our hypothesis that an overriding optic nerve normally impedes vertical growth of ophthalmic segment aneurysms. CONCLUSIONS: Ophthalmic segment aneurysms may acquire a round morphology when their growth is constrained superiorly by the optic nerve. Elongated ophthalmic segment aneurysms may be the result of growth lateral to the optic nerve. For these aneurysms, an anterior clinoidectomy is not required, and microsurgical clipping represents a straightforward treatment option.

Neurological event prediction for patients with symptomatic cerebral cavernous malformation: the BLED2 score.

OBJECTIVE: Retrospective patient cohort studies have identified risk factors associated with recurrent focal neurological events in patients with symptomatic cerebral cavernous malformations (CCMs). Using a prospectively maintained database of patients with CCMs, this study identified key risk factors for recurrent neurological events in patients with symptomatic CCM. A simple scoring system and risk stratification calculator was then created to predict future neurological events in patients with symptomatic CCMs. METHODS: This was a dual-center, prospectively acquired, retrospectively analyzed cohort study. Adult patients who presented with symptomatic CCMs causing focal neurological deficits or seizures were uniformly treated and clinically followed from the time of diagnosis onward. Baseline variables included age, sex, history of intracerebral hemorrhage, lesion multiplicity, location, eloquence, size, number of past neurological events, and duration since last event. Stepwise multivariable Cox regression was used to derive independent predictors of recurrent neurological events, and predictive accuracy was assessed. A scoring system based on the relative magnitude of each risk factor was devised, and Kaplan-Meier curve analysis was used to compare event-free survival among patients with different score values. Subsequently, 1-, 2-, and 5-year neurological event rates were calculated for every score value on the basis of the final model. RESULTS: In total, 126 (47%) of 270 patients met the inclusion criteria. During the mean (interquartile range) follow-up of 54.4 (12-66) months, 55 patients (44%) experienced recurrent neurological events. Multivariable analysis yielded 4 risk factors: bleeding at presentation (HR 1.92, p = 0.048), large size ≥ 12 mm (HR 2.06, p = 0.016), eloquent location (HR 3.01, p = 0.013), and duration ≤ 1 year since last event (HR 9.28, p = 0.002). The model achieved an optimism-corrected c-statistic of 0.7209. All factors were assigned 1 point, except duration from last event which was assigned 2 points. The acronym BLED2 summarizes the scoring system. The 1-, 2-, and 5-year risks of a recurrent neurological event ranged from 0.6%, 1.2%, and 2.3%, respectively, for patients with a BLED2 score of 0, to 48%, 74%, and 93%, respectively, for patients with a BLED2 score of 5. CONCLUSIONS: The BLED2 risk score predicts prospective neurological events in symptomatic CCM patients.

Minimally Invasive Intracerebral Hematoma Evacuation Using a Novel Cost-Effective Tubular Retractor: Single-Center Experience.

BACKGROUND: Spontaneous intracerebral hematoma (ICH) is a common disease with a dismal overall prognosis. Recent development of minimally invasive ICH evacuation techniques has shown promising results. Commercially available tubular retractors are commonly used for minimally invasive ICH evacuation yet are globally unavailable. METHODS: A novel U.S. $7 cost-effective, off-the-shelf, atraumatic tubular retractor for minimally invasive intracranial surgery is described. Patients with acute spontaneous ICH underwent microsurgical tubular retractor-assisted minimally invasive ICH evacuation using the novel retractor. Patient outcome was retrospectively analyzed and compared with open surgery and with commercial tubular retractors. RESULTS: Ten adult patients with spontaneous supratentorial ICH and median preoperative Glasgow Coma Scale score of 10 were included. ICH involved the frontal lobe, parietal lobe, occipitotemporal region, and solely basal ganglia in 3, 3, 2, and 2 patients, respectively. Mean preoperative ICH volume was 80 mL. Mean residual hematoma volume was 8.7 mL and mean volumetric hematoma reduction was 91% (median, 94%). Seven patients (70%) underwent >90% volumetric hematoma reduction. The total median length of hospitalization was 26 days. On discharge, the median Glasgow Coma Scale score was 12.5 (mean, 11.7). Thirty to 90 days' follow-up data were available for 9 patients (90%). The mean follow-up modified Rankin Scale score was 3.7 and 5 patients (56%) had a modified Rankin Scale score of 3. CONCLUSIONS: The novel cost-effective tubular retractor and microsurgical technique offer a safe and effective method for minimally invasive ICH evacuation. Cost-effective tubular retractors may continue to present a valid alternative to commercial tubular retractors.

Minimally Invasive Spine Surgery: The Learning Curve of a Single Surgeon.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The learning curve associated with the implementation of minimally invasive spinal surgery (MIS) has been the center of attention in numerous publications. So far, these studies referred to a single MIS procedure. In our view, minimally invasive surgical skills are acquired simultaneously through a variety of procedures that share common features. The aim of this study was to analyze the skills progression of a single surgeon implementing diverse minimally invasive techniques. METHODS: We retrospectively collected all patients who underwent spinal surgery for thoracic or lumbar pathology by a single surgeon between 2012 and 2015 at a single institute. Both minimally invasive as well as open surgical techniques were analyzed; these groups were compared on the basis of surgical indications and outcomes. Skills progression analysis in reference to minimally invasive technique was performed. RESULTS: A total of 230 patients met the inclusion criteria for this study. MIS group included higher percentage of lumbar discectomy and the open-surgery group included higher percentage of tumor resection surgery. Learning curve evaluation demonstrated increased surgical complexity, evaluated by number of levels treated, over the 4-year period, which corresponded with decreased complication rates. DISCUSSION: A gradual increase in surgical complexity over 4 years, together with careful patient selection, enables the surgeon to maintain the rate of complication within acceptable limits. The main challenge facing the MIS community is constructing an education program for MIS surgeons in order to reduce the learning curve-induced complications. CONCLUSION: Advancement of educational aids for MIS surgical skill improvement, including spine models, virtual and augmented reality aids and surgical simulators may reduce the learning curve of spine surgeons.

The Utility of Early Postoperative Neuroimaging in Elective/Semielective Craniotomy Patients: A Single-Arm Prospective Trial.

BACKGROUND: The necessity and timing of early postoperative imaging (POI) are debated in many studies. Despite the consensus that early POI does not change patient management, these examinations are routinely performed. This is the first prospective study related to POI. Our aims were to assess the necessity of early POI in asymptomatic patients and to verify accuracy of the presented algorithm. METHODS: This was an algorithm-based prospective single-center study. The algorithm addressed preoperative, perioperative, and postoperative considerations, including estimated pathology type, device placement, and postoperative neurologic change. Early computed tomography scans were obtained in all patients, but if postoperative algorithm indications did not recommend a scan, the treating team was blinded to them, and patient management was conducted based on clinical examinations alone. A neuroradiologist and study-independent neurosurgeon reviewed all the scans. RESULTS: Of 103 enrolled patients, 88 remained asymptomatic, and 15 experienced symptoms postoperatively. Pathology was present on POI in 1% of the asymptomatic patients and 53% of the symptomatic patients (P < 0.001). In the asymptomatic group, no treatment modifications were made postoperatively. Blinding of the surgical team was not removed, and 20% of the symptomatic patients returned to the operating room because of imaging and neurologic findings. The goal of <5% algorithm failure was reached with statistical significance. CONCLUSIONS: In asymptomatic postoperative patients in whom early imaging is not performed for oncologic indications, device placement verification, or similar reasons, POI is unnecessary and does not change the management of these patients.

Natural History of Untreated Transverse/Sigmoid Sinus Thrombosis Following Posterior Fossa Surgery: Case Series and Literature Review.

BACKGROUND: Transverse or sigmoid sinus thrombosis occurs in 4% to 11% of patients following posterior fossa surgery. Anticoagulation has been the mainstay treatment, mostly based on extrapolation from the literature on spontaneous sinus thrombosis. OBJECTIVE: To analyze the rate and associated complications of postoperative transverse/sigmoid sinus thrombosis for patients undergoing posterior fossa tumor resection. In this series, no antithrombotic therapy was initiated, and no postoperative treatment alterations were made following thrombosis diagnosis. METHODS: Prospectively accrued cases from a single surgeon operating at a single academic center were retrospectively reviewed to determine the natural history of untreated transverse/sigmoid sinus thrombosis following posterior fossa surgery. Inclusion criteria were patients 18 yr or older undergoing resection of a posterior fossa tumor. A total of 538 patients were analyzed. RESULTS: In all 26 out of 538 (4.8%) patients were diagnosed with transverse/sigmoid sinus thrombosis on routine postoperative imaging. Early postoperative complication rate was 38% in the sinus thrombosis group, as compared to 15% in the no-thrombosis group (P = .02). A significantly higher rate of pseudomeningocele, dysphagia requiring gastrostomy, and cerebellar stroke signs were noted in patients with postoperative sinus thrombosis. However, only 3 of the 26 patients (12%) with postoperative sinus occlusion suffered prolonged central nervous system complications. CONCLUSION: Transverse/sigmoid sinus thrombosis following suboccipital craniectomy results in a higher rate of early complications; however, most of these complications resolve without anticoagulation. It may be reasonable, therefore, to manage these patients conservatively in order to avoid the risks associated with anticoagulation in the perioperative period.