Congenital Brain Tumors: Surgical Outcomes and Long-Term Prognostic Factors.

OBJECTIVE: To evaluate long-term outcomes of surgical resection for congenital brain tumors (CBTs) in infants under one year of age and to identify factors related to survival. METHODS: Our retrospective study analyzed infants who underwent gross total (GTR) or subtotal resection (STR) for CBTs between 2001 and 2019. Data were obtained from medical records, including demographics, clinical presentation, diagnosis, tumor characteristics, and presence of hydrocephalus. Additional factors such as pre- and/or postoperative ventriculoperitoneal shunt (VPS) placement and adjuvant chemotherapy or radiotherapy were also reviewed. Cox regression analysis was used to identify factors associated with survival. RESULTS: The study included 70 patients, with median age at surgery of 198.5 days, and 28 (40%) were girls. Seizures (31.4%) and vomiting (24.3%) were the most common presenting symptoms. High-grade tumors were present in 29 (41.4%) patients. GTR was achieved in 64.3% of cases, with surgical mortality rate of 7.1%. Overall survival rates at 5 and 10 years were 78% and 63%, respectively. Long-term follow-up data were available for 61 patients (87%), with median follow-up of 74.2 months. Among 45 long-term survivors, 55.5% had neurological sequelae. Factors associated with reduced survival included high-grade, preoperative hydrocephalus, larger tumor size, and VPS placement. The extent of resection improved survival only in low-grade tumor cases. Multivariable Cox regression analysis identified tumor grade and size as independent predictors of poor prognosis. CONCLUSIONS: Surgical resection remains crucial for treating CBTs in infants under one year, yet the aggressive nature of malignant tumors results in suboptimal outcomes regarding prognosis.

Clinical Characteristics and Rehabilitation Results of Traumatic Brain Injury Patients Who Have Early Rehabilitation.

AIM: To examine the clinical characteristics and early rehabilitation results and to investigate the relationship between rehabilitation initiation time and rehabilitation-related outcome measurements in traumatic brain injury (TBI) patients who have early rehabilitation. MATERIAL AND METHODS: Forty-seven TBI patients who were referred for rehabilitation in the neurosurgery department were enrolled in the study retrospectively. Clinical characteristics and rehabilitation-related outcome measurements including consciousness, functional outcome, daily living activities, functional mobility, and ambulation of all patients were recorded. The paired samples t-test was used to compare data before and after rehabilitation. The relationship between rehabilitation initiation time and the other outcomes was analyzed with Pearson's correlation test. RESULTS: Most of the TBI patients were male (83%) and the severities of the trauma were mostly mild (42%). The causes of trauma were mostly falls (53%). Twenty-three (49%) of the patients underwent surgical intervention. The lengths of time between admission and consultation and between surgery and consultation were 19.82±17.9 and 14.24±15.4 days, respectively. The lengths of stay in intensive care and hospital were respectively 27.32±34.93 and 41.35±32.83 days. The rehabilitation time was 21.50±24.32 days. The before and after rehabilitation results showed that all rehabilitation-related outcome measurements improved significantly (p < 0.001). The relationship between rehabilitation initiation time and the other outcomes was statistically significant (p < 0.05). CONCLUSION: This was a descriptive study in terms of demonstrating the demographic and clinical characteristics of TBI patients who need rehabilitation in the neurosurgery department. Early rehabilitation can enhance the rehabilitation-related outcome including consciousness, functional outcome, daily living activities, functional mobility, and ambulation in TBI patients as soon as their medical condition is stable. Early rehabilitation initiation time is important for improving the rehabilitation-related outcomes.

Narrative review of patient-specific 3D visualization and reality technologies in skull base neurosurgery: enhancements in surgical training, planning, and navigation.

Recent advances in medical imaging, computer vision, 3-dimensional (3D) modeling, and artificial intelligence (AI) integrated technologies paved the way for generating patient-specific, realistic 3D visualization of pathological anatomy in neurosurgical conditions. Immersive surgical simulations through augmented reality (AR), virtual reality (VR), mixed reality (MxR), extended reality (XR), and 3D printing applications further increased their utilization in current surgical practice and training. This narrative review investigates state-of-the-art studies, the limitations of these technologies, and future directions for them in the field of skull base surgery. We begin with a methodology summary to create accurate 3D models customized for each patient by combining several imaging modalities. Then, we explore how these models are employed in surgical planning simulations and real-time navigation systems in surgical procedures involving the anterior, middle, and posterior cranial skull bases, including endoscopic and open microsurgical operations. We also evaluate their influence on surgical decision-making, performance, and education. Accumulating evidence demonstrates that these technologies can enhance the visibility of the neuroanatomical structures situated at the cranial base and assist surgeons in preoperative planning and intraoperative navigation, thus showing great potential to improve surgical results and reduce complications. Maximum effectiveness can be achieved in approach selection, patient positioning, craniotomy placement, anti-target avoidance, and comprehension of spatial interrelationships of neurovascular structures. Finally, we present the obstacles and possible future paths for the broader implementation of these groundbreaking methods in neurosurgery, highlighting the importance of ongoing technological advancements and interdisciplinary collaboration to improve the accuracy and usefulness of 3D visualization and reality technologies in skull base surgeries.

Repeat endoscopic endonasal transsphenoidal surgery for residual or recurrent Cushing's disease: safety, feasibility, and success.

PURPOSE: The success and outcomes of repeat endoscopic transsphenoidal surgery (ETS) for residual or recurrent Cushing's disease (CD) are underreported in the literature. This study aims to address this gap by assessing the safety, feasibility, and efficacy of repeat ETS in these patients. METHODS: A retrospective analysis was conducted on 56 patients who underwent a total of 65 repeat ETS performed by a single neurosurgeon between January 2006 and December 2020. Data including demographic, clinical, laboratory, radiological, and operative details were collected from electronic medical records. Logistic regression was utilized to identify potential predictors associated with sustained remission. RESULTS: Among the cases, 40 (61.5%) had previously undergone microscopic surgery, while 25 (38.5%) had prior endoscopic procedures. Remission was achieved in 47 (83.9%) patients after the first repeat ETS, with an additional 9 (16.1%) achieving remission after the second repeat procedure. During an average follow-up period of 97.25 months, the recurrence rate post repeat surgery was 6.38%. Sustained remission was achieved in 48 patients (85.7%), with 44 after the first repeat ETS and 4 following the second repeat ETS. Complications included transient diabetes insipidus (DI) in 5 (7.6%) patients, permanent (DI) in 2 (3%) patients, and one case (1.5%) of panhypopituitarism. Three patients (4.6%) experienced rhinorrhea necessitating reoperation. A serum cortisol level > 5 µg/dL on postoperative day 1 was associated with a reduced likelihood of sustained remission. CONCLUSION: Repeat ETS is a safe and effective treatment option for residual or recurrent CD with satisfactory remission rates and low rates of complications.

Quantitative assessment and objective improvement of the accuracy of neurosurgical planning through digital patient-specific 3D models.

Objective: Neurosurgical patient-specific 3D models have been shown to facilitate learning, enhance planning skills and improve surgical results. However, there is limited data on the objective validation of these models. Here, we aim to investigate their potential for improving the accuracy of surgical planning process of the neurosurgery residents and their usage as a surgical planning skill assessment tool. Methods: A patient-specific 3D digital model of parasagittal meningioma case was constructed. Participants were invited to plan the incision and craniotomy first after the conventional planning session with MRI, and then with 3D model. A feedback survey was performed at the end of the session. Quantitative metrics were used to assess the performance of the participants in a double-blind fashion. Results: A total of 38 neurosurgical residents and interns participated in this study. For estimated tumor projection on scalp, percent tumor coverage increased (66.4 ± 26.2%-77.2 ± 17.4%, p = 0.026), excess coverage decreased (2,232 ± 1,322 mm2-1,662 ± 956 mm2, p = 0.019); and craniotomy margin deviation from acceptable the standard was reduced (57.3 ± 24.0 mm-47.2 ± 19.8 mm, p = 0.024) after training with 3D model. For linear skin incision, deviation from tumor epicenter significantly reduced from 16.3 ± 9.6 mm-8.3 ± 7.9 mm after training with 3D model only in residents (p = 0.02). The participants scored realism, performance, usefulness, and practicality of the digital 3D models very highly. Conclusion: This study provides evidence that patient-specific digital 3D models can be used as educational materials to objectively improve the surgical planning accuracy of neurosurgical residents and to quantitatively assess their surgical planning skills through various surgical scenarios.

Axial Sections of Brainstem Safe Entry Zones and Clinical Importance of Intrinsic Structures: A Review.

Brainstem surgery is more difficult and riskier than surgeries in other parts of the brain due to the high density of critical tracts and cranial nerves nuclei in this region. For this reason, some safe entry zones into the brainstem have been described. The main purpose of this article is to bring on the agenda the significance of the intrinsic structures of the safe entry zones to the brainstem. Having detailed information about anatomic localization of these sensitive structures is important to predict and avoid possible surgical complications. In order to better understand this complex anatomy, we schematically drew the axial sections of the brainstem showing the intrinsic structures at the level of 9 safe entry zones that we used, taking into account basic neuroanatomy books and atlases. Some illustrations are also supported with intraoperative pictures to provide better surgical orientation. The second purpose is to remind surgeons of clinical syndromes that may occur in case of surgical injury to these delicate structures. Advanced techniques such as tractography, neuronavigation, and neuromonitorization should be used in brainstem surgery, but detailed neuroanatomic knowledge about safe entry zones and a meticulous surgery are more important. The axial brainstem sections we have drawn can help young neurosurgeons better understand this complex anatomy.