Anatomoradiological comparison between the minipterional and supraorbital eyebrow approaches to the interpeduncular region.

OBJECTIVE: Advances in surgical technology and microneurosurgery have led to increased utilization of so-called minimally invasive approaches, including the supraorbital eyebrow (SE) and minipterional (MPT) approaches for lesions involving the interpeduncular region. This study aimed to describe and compare anatomical landmarks, along with highlighting the advantages and disadvantages of the SE and MPT approaches to the interpeduncular region. METHODS: Ten formalin-fixed, latex-injected cadaveric specimens were used to perform bilateral SE and MPT approaches to the interpeduncular region. The operative depth of each approach to key anatomical landmarks was measured. Forty-five axial thin-slice computed tomography studies were reviewed to calculate the operative angles, with consideration of the midline as a reference. A 3D interactive anatomical model generated through the photogrammetry scanning technique was described. RESULTS: The depths of the operative corridors of the SE and MPT approaches to the interpeduncular fossa were 83.4 ± 1.8 mm and 67.7 ± 3.2 mm, respectively (p < 0.001). The mean angle of the MPT approach to the interpeduncular fossa was significantly wider than the one provided by the SE approach (39.9° ± 5.1° vs 28.4° ± 3.6°, p < 0.001). The interpeduncular region can consistently be accessed through the carotid-oculomotor triangle with the SE approach, as well as with the MPT approach. Furthermore, the SE route offered adequate access to the interpeduncular fossa through the opticocarotid triangle. The MPT route provided direct access to the upper prepontine cistern and anterior mesencephalic zone (AMZ). CONCLUSIONS: The MPT approach provides a wider and shorter operative corridor and can be employed for lesions in the interpeduncular region with extension to the prepontine cistern and ventrolateral midbrain lesions requiring access through the AMZ. The SE approach is better suited for ventromedial midbrain lesions requiring access via the interpeduncular fossa safe entry zone. Additional studies analyzing these approaches in a clinical setting will help to delineate their reliability and efficacy.

Pilot Trial on Awake Surgery for Low-Grade Arteriovenous Malformations in Speech Area and Systematic Review of the Literature.

OBJECTIVE: One of the pressing constraints in the treatment of arteriovenous malformations (AVM) is the potential development of new neurologic deficits, mainly when the AVM is in an eloquent area. The risk of ischemia when an en passage arterial supply is present is not negligible. In this regard, awake surgery holds promise in increasing the safety of low-grade AVM resection. METHODS: We conducted a pilot trial on 3 patients with low-grade AVMs affecting speech areas to evaluate the safety of awake craniotomy using Conscious Sedation. Each feeder was temporarily clipped before the section. Also, we performed a systematic review to analyze the existing data about the impact of awake surgery in eloquent AVM resection. RESULTS: None of the 3 patients presented with neurologic deficits after the procedure. Awake craniotomy was useful in 1 case, as it allowed the detection of speech arrest during the temporal clipping of 1 of the feeders. This vessel was identified as an en passage vessel, closer to the nidus. The second attempt revealed the feeder of the AVM, which was sectioned. Systematic review yielded 7 studies meeting our inclusion criteria. Twenty-six of 33 patients included in these studies presented with AVM affecting speech area. Only 2 studies included the motor evoked potentials. Six studies used direct cortical and subcortical stimulation. In all studies the asleep-awake-asleep technique was used. CONCLUSIONS: Awake craniotomies are safe procedures and may be helpful in avoiding ischemic complications in low-grade AVMs, either affecting eloquent areas and/or when en passage feeders are present.

A Comparison of Clinical Outcomes Between Anterior Cervical Discectomy and Fusion Versus Posterior Cervical Laminoplasty for Multilevel Cervical Myelopathy.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: To compare patient-reported outcomes and surgical outcomes after anterior cervical discectomy and fusion (ACDF) versus cervical laminoplasty for multilevel cervical spondylotic myelopathy. BACKGROUND: Treatment options for multilevel cervical spondylotic myelopathy include ACDF and cervical laminoplasty. Given that the literature has been mixed regarding the optimal approach, especially in patients without kyphosis, there is a need for additional studies investigating outcomes between ACDF and cervical laminoplasty. METHODS: A retrospective review was conducted of adult patients undergoing 3 or 4-level surgery. Patients with preoperative kyphosis based on C2-C7 Cobb angles were excluded. The electronic medical record and institutional databases were reviewed for baseline characteristics, surgical outcomes, and patient-reported outcomes. RESULTS: A total of 101 patients who underwent ACDF and 52 patients who underwent laminoplasty were included in the study. The laminoplasty cohort had a higher overall Charlson Comorbidity Index (3.10 ± 1.43 vs 2.39 ± 1.57, P = 0.011). Both groups had a comparable number of levels decompressed, C2-C7 lordosis, and diagnosis of myelopathy versus myeloradiculopathy. Patients who underwent laminoplasty had a longer length of stay (2.04 ± 1.15 vs 1.48 ± 0.70, P = 0.003) but readmission, complication, and revision rates were similar. Both groups had similar improvement in myelopathy scores (∆modified Japanese Orthopedic Association: 1.11 ± 3.09 vs 1.06 ± 3.37, P = 0.639). ACDF had greater improvement in Neck Disability Index (∆Neck Disability Index: -11.66 ± 19.2 vs -1.13 ± 11.2, P < 0.001), neck pain (∆Visual Analog Scale-neck: -2.69 ± 2.78 vs -0.83 ± 2.55, P = 0.003), and arm pain (∆Visual Analog Scale-arm: -2.47 ± 3.15 vs -0.48 ± 3.19, P = 0.010). These findings persisted in multivariate analysis except for Neck Disability Index. CONCLUSION: ACDF and cervical laminoplasty appear equally efficacious at halting myelopathic progression. However, patients who underwent ACDF had greater improvements in arm pain at 1 year postoperatively. Longitudinal studies evaluating the efficacy of laminoplasty to mitigate adjacent segment disease are indicated to establish a robust risk-benefit assessment for these 2 procedures. LEVEL OF EVIDENCE: III.

Enhanced Recovery after Cranial Surgery in Elderly: A Review.

BACKGROUND: Enhanced recovery after surgery (ERAS) is a multidisciplinary approach aimed at reducing the length of hospital stay, improving patient outcomes, and reducing the overall cost of care. Although ERAS protocols have been widely adopted in various surgical fields, their application in cranial surgery remains relatively limited. METHODS: Considering that the aging of the population presents significant challenges to healthcare systems, and there is currently no ERAS protocol available for geriatric patients over the age of 65 requiring cranial surgery, this article proposes a new ERAS protocol for this population by analyzing successful ERAS protocols and optimal perioperative care for geriatric patients described in the literature. RESULTS: Our aim is to develop a feasible, safe, and effective protocol for geriatric patients undergoing elective craniotomy, which includes preoperative, intraoperative, and postoperative assessments and management, as well as outcome measures. CONCLUSIONS: This multidisciplinary and evidence-based ERAS protocol has the potential to reduce perioperative morbidity, improve functional recovery, and enhance postoperative outcomes after cranial surgery in elderly. Further research will be necessary to establish strict guidelines.

Infratentorial Relapsing Neuroglial Tumors in Adults: Management and Unsolved Issues-A Systematic Review.

(1) Background: Gangliogliomas are rare tumors accounting for about 0.4% of all central nervous system tumors. They are usually located in the temporal lobes of children and young adults, though such tumors in the infratentorial region and adult-age patients rarely reported. (2) Methods: A systematic review on ganglioglioma with infratentorial location in the adult population was conducted in accordance with the PRISMA guidelines. A total of 275 articles were found, and 23 were included. Demographic data, the location and histology of the lesion, pre-operative neurological status, the type of surgery, recurrence, radiotherapy/chemotherapy adjuvant treatments, neurological outcomes and follow-up information were collected. We also presented an illustrative case. (3) Results: A total of 27 patients were included. In 51%, the location was the cerebellum; in 40%, it was the fourth ventricle; in 11%, it was brainstem; and in 4%, it was the cerebellopontine angle. STR was performed in 44%, GTR in 26% and biopsy in 15% of the cases. Adjuvant radiotherapy was found in 22% of cases. Disease recurrence occurred in 15% of patients between 1 and 12 months after surgery with a diagnosis of high-grade ganglioglioma, while in six cases, no disease recurrence was documented. (4) Conclusions: Infratentorial glioneuronal tumors are rare findings in the adult population. Histopathological characterization does not seem to fully reflect their true behavior. Future studies are warranted for better characterizing histopathological findings and treatment.

Invasive Preoperative Investigations in Idiopathic Normal Pressure Hydrocephalus: A Comprehensive Review.

Idiopathic normal pressure hydrocephalus (iNPH) is a neurological disorder characterized by the triad of gait disturbance, cognitive impairment, and urinary incontinence. The condition is diagnosed mainly in older adults and is associated with ventricular enlargement without an increase in cerebrospinal fluid pressure. The clinical assessment involves a detailed medical history, physical examination, and cognitive testing. Neuroimaging is an essential part of the diagnostic workup for iNPH. However, to determine the suitability of patients for shunt surgery, a range of invasive preoperative investigations are employed. This narrative review aims to provide a comprehensive analysis of the current literature on invasive preoperative investigations in iNPH, focusing primarily on the lumbar infusion test, cerebrospinal fluid drainage tests, and continuous intracranial pressure monitoring. The strengths and limitations of each method, as well as their potential impact on treatment outcomes, are discussed.

Health-Related Quality of Life and Role of Surgical Treatment in Idiopathic Normal Pressure Hydrocephalus: A Systematic Review.

OBJECTIVE: Although shunting has been shown to ameliorate symptoms in idiopathic normal pressure hydrocephalus (iNPH), its impact on health-related quality of life (HRQoL) has yet to be fully elucidated. Patient and caregiver subjective life satisfaction and HRQoL represent crucial indicators for assessing the well-being of individuals facing chronic illnesses, including iNPH. This study aimed to systematically analyze the existing data about HRQoL in iNPH-treated patients to evaluate the role of surgical treatment in such a scenario. METHODS: Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, the literature in the PubMed/Medline, Web of Science, and Scopus databases was searched. Fourteen studies met our inclusion criteria. The Joanna Briggs Institute critical appraisal tool was used to assess the risk of bias. RESULTS: Overall, HRQoL improved significantly within 1 year after shunt placement although patients with iNPH reported worse HRQoL values compared with healthy-matched individuals. Up to 5 years after shunting, a sustained heterogeneity exists on published data showing improved scores across all domains for at least 21 months after shunting. Further, although surgical treatment can improve HRQoL, long-term follow-up showed that it remained lower than that of healthy controls. These data suggest a significant decrease of HRQoL in patients with iNPH over time after shunting, probably due to aging, comorbidities, and disease progression. CONCLUSIONS: Despite that iNPH has been recognized as a potentially reversible neurological disorder, the available data about the impact of shunting on the HRQoL are unsatisfactory. To improve the well-informed clinical decision-making, it is essential to reach additional high-quality evidence regarding the effect of shunting on HRQoL. New prospective studies, using validated instruments specifically tailored for assessing HRQoL in patients with iNPH, and improved reporting standards are needed. Current evidence suggests that although shunting can provide initial benefits, affected patients may experience long-term impairment in HRQoL.

MR-guided focused ultrasound-induced blood-brain barrier opening for brain metastasis: a review.

Although the therapeutic armamentarium for brain metastases (BMs) has been expanded from innovative surgical techniques and radiotherapy to include targeted therapies and immunotherapy, the prognosis of BMs remains poor. Despite the proven efficacy of numerous compounds in preclinical studies, the limited penetration of promising therapeutic agents across the blood-brain barrier (BBB) remains an unaddressed issue. Recently, low-intensity magnetic resonance-guided focused ultrasound (MRgFUS) in combination with microbubbles has been shown to overcome vascular and cellular transport barriers in the brain and tumor microenvironment, resulting in increased drug diffusion and preliminary effective results. Preclinical studies have investigated the increased penetration of many therapeutic agents including doxorubicin, trastuzumab, and ipilimumab into the CNS with promising results. Furthermore, anticancer drugs combined with MRgFUS-induced BBB opening have been demonstrated to improve animal survival and slow tumor progression. Accordingly, the first clinical trial has recently been launched and hopefully the results will provide evidence for the safety and efficacy of drug delivery enhanced by MRgFUS-induced BBB opening in BMs. This review aims to provide an overview of transcranial low-intensity MRgFUS application for BBB disruption and a comprehensive overview of the most relevant evidence in the treatment of BMs.

Perioperative Dexamethasone Does Not Reduce Postoperative Opioid Use Following Anterior Cervical Discectomy and Fusion.

OBJECTIVE: To determine if dexamethasone administration reduced narcotic consumption during hospitalization and to evaluate if patients who received dexamethasone refilled fewer opioid prescriptions postoperatively. METHODS: All adult patients who underwent primary elective 1- to 4-level anterior cervical discectomy and fusion at a single center were retrospectively identified. Prescription opioid use was collected from governmental online prescription drug monitoring programs, and in-hospital opioid use was collected from each patient's medication administration record and recorded as morphine milligram equivalents (MMEs). Patients were categorized by whether or not intravenous dexamethasone was administered perioperatively. Dexamethasone protocols were considered high dose if weight-based dosing was >0.20 mg/kg and low dose if <0.20 mg/kg. Multivariable linear regression was conducted to assess the relationship between dexamethasone administration and MMEs prescribed at each time point while accounting for confounders. RESULTS: Of 249 included patients, 167 (67%) were administered dexamethasone. Patients in both groups used a similar quantity of opioids while hospitalized (no dexamethasone: 56.7 MMEs/day vs. dexamethasone: 39.4 MMEs/day, P = 0.350). Patients in both groups refilled a similar quantity of opioids in all postoperative time periods: 0-3 weeks (3.38 vs. 4.07 MMEs/day, P = 0.528), 3-6 weeks (0.36 vs. 0.75 MMEs/day, P = 0.198), 6-12 weeks (0.53 vs. 0.75 MMEs/day, P = 0.900), and 3 months to 1 year (0.28 vs. 0.43 MMEs/day, P = 0.531). On multivariable linear regression, dexamethasone was not associated with a reduction in opioid volume at any time point (all P > 0.05). CONCLUSIONS: Administration of perioperative dexamethasone does not reduce in-hospital or home opioid usage regardless of weight-based dose. Analgesia should not be the primary driver of dexamethasone administration for anterior cervical discectomy and fusion.

The impact of cerebrospinal fluid shunting on quality of life in idiopathic normal pressure hydrocephalus: a long-term analysis.

OBJECTIVE: Idiopathic normal pressure hydrocephalus (iNPH) represents an insidious type of dementia considered reversible after shunt placement. Although the clinical outcome has been widely studied, few studies have reported on quality of life (QOL) after surgery. This study evaluated the long-term clinical and QOL outcomes of iNPH patients after ventriculoperitoneal shunt (VPS) implantation. Factors influencing QOL in iNPH were also investigated. METHODS: From 2009 to 2020, a single-institution retrospective study was conducted to compare shunted iNPH patients with a homogeneous control group. QOL was analyzed using the SF-36 questionnaire with yearly follow-up for as long as 11 years. Severity of symptoms, comorbidities, and clinical data were also recorded. RESULTS: Among 187 treated patients, 15 had died at the time of the authors' evaluation, and 45 did not match the inclusion criteria. The mean ± SD (range) follow-up was 118.5 ± 4.2 (18-132) months. QOL improved in 103/130 (79%) patients through 5 years after shunt surgery, although it remained lower than that of the control group (p < 0.0001). The SF-36 score reduced progressively, reaching baseline at 5-7 years of follow-up and decreased to below baseline at 7-11 years of follow-up (p < 0.0001). Predictors of improved QOL were younger age (p < 0.001), lower body mass index (BMI) (p < 0.001), and better Mini-Mental State Examination (MMSE) performance (p < 0.001) before surgery. Decreased postoperative QOL was associated with cerebrovascular disease, diabetes, and severity of symptoms (gait and cognition) at presentation (p < 0.001). CONCLUSIONS: VPS implantation, along with a strict and comprehensive follow-up, has been shown to improve QOL in iNPH patients for as long as 5 years after surgery. Younger age, lower BMI, and better MMSE score are positive predictors of improved QOL after shunt placement.

Spinal Canal Remodeling and Indirect Decompression of Contralateral Foraminal Stenosis After Endoscopic Posterolateral Transforaminal Lumbar Interbody Fusion.

OBJECTIVE: There is a lack of literature on indirect decompression in uniportal endoscopic posterolateral transforaminal lumbar interbody fusion (EPTLIF). Our aim is to evaluate the dimensions of the spinal canal and contralateral foramen before and after EPTLIF. METHODS: This is a retrospective study of patients who underwent EPTLIF in a tertiary spine centre over a 2-year period. The cross-sectional area of the spinal canal and the contralateral foramen at the level of fusion were measured on magnetic resonance imaging scan at 1-day postoperation and at the final follow-up. Patients were grouped according to the decompression performed as per the clinician's judgement. RESULTS: One hundred fifty-two levels of fusion were performed in 120 patients. There was a statistically significant clinical improvement in visual analogue scale and Oswestry Disability Index scores postoperation. The measurements of the spinal canal area were 106.0 mm2, 138.8 mm2, and 195.5 mm2; while contralateral foraminal area were 73.2 mm2, 104.4 mm2, and 120.7 mm2 at preoperation, 1-day postoperation, and at the final follow-up, respectively (p < 0.001). For the subgroup analyses, spinal canal area measurements for the bilateral decompression cohort (n = 35) were 57.0 mm2, 123.9 mm2, and 191.8 mm2; for the ipsilateral decompression cohort (n = 42) were 89.3 mm2, 128.9 mm2, 183.3 mm2; and for the cohort without any decompression and only cage inserted (n = 75) were 138.3 mm2, 151.2 mm2, and 204.1 mm2 (p < 0.001). Contralateral foraminal area measurements were 73.3 mm2, 106.4 mm2 and 120.4 mm2 in the bilateral decompression cohort; 69.5 mm2, 99.0 mm2, 116.9 mm2 in the ipsilateral decompression cohort; and 75.1 mm2, 106.5 mm2, 122.9 mm2 in the cohort without any decompression (p < 0.001). CONCLUSION: Indirect decompression of both the spinal canal and the contralateral foramen can be achieved via EPTLIF. Decompression on an asymptomatic contralateral side is not necessary.