Journal of Neurosurgery Publishing Group

From the November Journal of Neurosurgery Publishing Group Pediatrics Issue Saarinen et al: https://lnkd.in/gTgAw2UT Summary: 65-80% of patients with myelomeningocele ultimately required CSF diversion for hydrocephalus and there has been some evidence suggesting early VP shunt placement is associated with higher rates of shunt infection and revision. The authors performed a meta-analysis of 12 nonrandomized studies including 4894 neonates who underwent postnatal myelomeningocele closure before postnatal day 29 and either simultaneous or delayed ventriculoperitoneal shunt placement. Surgeries were simultaneous if they were done within 24 hours of each other. Comparison of patients who underwent simultaneous VPS placement to those who underwent delayed placement showed no difference in the relative risk of shunt infection (0.77, 95% CI [0.41, 1.42]) or revision (0.49; [0.19, 1.30]), mortality (0.87; [0.09, 8.57]), CSF leak from the VPS or myelomeningocele wound (0.20; [0.03, 1.23]) or myelomeningocele wound dehiscence (0.52; [0.07, 3.71]). When subanalyzing the studies by country-of-origin income level, studies from high-income countries suggested lower rates of shunt infection (0.49; [0.31, 0.78]) and revision (0.30; [0.09, 0.95]) in neonates undergoing simultaneous shunting. Main Findings: In most settings current evidence does not support simultaneous VPS shunting as superior to delayed shunting for neonates undergoing myelomeningocele repair. #Myelomeningocele #SpinaBifida #VentriculoperitonealShunt #NeuralTubeDefect #Hydrocephalus Okko Saarinen Tytti Pokka willy Serlo Salokorpi Niina University of Oulu Oulu University Hospital

From the November JNS Peds Issue Habibzadeh et al: https://lnkd.in/g7XRZC7w Summary: ETV is a commonly employed strategy for CSF diversion in patients with obstructive hydrocephalus, notably aqueductal stenosis, and may help avoid VP shunt placement. The ETV Success Score is a previously described stratification tool with reasonable predictive power, though is imperfect. Here the authors examined a cohort of 98 children (mean age 16.4±19.1mo) who underwent ETV for hydrocephalus over a 7-year period at a single center and evaluated the predictive power of the cortical subarachnoid space (CSAS) maximal diameter and pulsatility index (PI). CSAS was measured on preoperative axial brain CT through the foramen of Monro and PI was defined as 3rd ventricular pulsatility in beats/min based upon intraoperative video recording. Using ETV failure at 6- and 12mo, the authors found that greater max CSAS was independently predictive of lower odds of shunt failure (OR 0.46 [0.26, 0.84]) at 6mo and greater median PI was predictive of decreased failure at 1yr (OR 0.44; [0.24, 0.81]). ETV success score was not considered in the analysis though. Main Findings: Pulsatility index and cortical subarachnoid space maximal diameter are two straightforward, objective measures that may help predict the odds of ETV success in the pediatric patient population. However, further investigation and comparison to the conventional ETV success score is necessary. #Hydrocephalus #EndoscopicThirdVentriculostomy #VentriculoperitonealShunt #ETVSuccessScore #CSFPulsatility Adrina Habibzadeh Sina Zoghi Mohammad Sadegh Masoudi Omid Yousefi Reza Taheri Fasa University of Medical Sciences Shiraz University of Medical Sciences

From the November Neurosurgical Focus Issue Wilhelmy et al: https://lnkd.in/g8eEHRkj Summary: Laser interstitial thermal therapy (LITT) is seen as an increasingly attractive, minimally invasive option for the treatment of some cases of epilepsy and intraaxial neoplasm. Here the authors retrospectively reviewed the records of patients treated over a four-year period at a single center to examined functional outcomes (Karnofsky Performance Scale in first 8 weeks of follow-up) among patients treated with LITT for recurrent high-grade glioma. Ablation was monitored w real-time MR thermometry to estimate regions receiving doses of ≥2 cumulative minutes of heating to 43°C and ≥10 minutes overall, aimed at ablating the entire enhancing region. Ablation volume estimated by postprocedure MR. Of 47 included patients, 59% had stable to improved KPS following LITT. All patients underwent resection prior to LITT. Odds of KPS remaining stable or improving were negatively correlated with tumor volume. Approximately half of patients required either a new corticosteroid regimen post-LITT, or an increase in their existing regimen. Main Findings: For patients with recurrent high-grade glioma, LITT may allow for preservation of function in better than half of patients at 8-weeks post-procedure. However, further research in expanded cohorts is necessary along with evaluation of progression-free survival. #HighGradeGlioma #Glioblastoma #LaserInterstitialThermalTherapy #LITT #FunctionalOutcomes #KPS Bradley Wilhelmy Jr. Riccardo Serra Mark V. Mishra Dario Rodrigues, PhD Neeraj Badjatia Alexander Ksendzovsky University of Maryland School of Medicine

From Nov 2024 Neurosurgical Focus on “Contemporary Applications of Laser Interstitial Therapy” Chen et al: https://lnkd.in/gF5i7xgz Summary: Radiation necrosis occurs in 25-46% of patients treated with radiotherapy for intraaxial lesions. Magnetic-resonance-guided laser interstitial thermal therapy (MRgLITT), which has seen increased attention as a minimally invasive alternative to craniotomy for intraaxial neoplasms and epilepsy, may be an alternative option for radiation necrosis management, offering 1-year survival similar to craniotomy (71.1-77.1%). The authors analyzed 2869 patients from the National Inpatient Sample and propensity score matched those treated with MRgLITT to those treated with craniotomy; matching was 2:1 and created groups similar regarding treating hospital size and patient income quartile. Lesion size and shape could not be included because of data granularity. The matched group was 447 patients with craniotomy and 224 w MRgLITT. The latter was associated with shorter hospitalizations (β -1.18d 95%CI [-2.90, -0.71]; p=0.002), fewer complications (OR 0.18 [0.04, 0.86]; p=0.033), and greater odds of home discharge (OR 3.05; [1.05, 8.82]; p=0.041) with similar mortality risk (22.8% vs 22.3%; p=0.429) and admission costs (β $6229, p=0.081). However, 4-year total costs were significantly lower for patients treated with MRgLITT versus craniotomy (-$25,685) or -$183,464 per quality-adjusted life-year – significantly lower than the societal willingness to pay. O Main Findings: For patients with radiation necrosis and circumscribed lesions <3cm in diameter, MRgLITT can reduce complication rates and increase the odds of home discharge without significantly impacting the index costs of admission. Interestingly, long-term costs may be lower for MRgLITT, to a point where they surpass the $100,000/QALY threshold held to be the societal willingness to pay. #LaserInterstitialThermalTherapy #BrainTumor #MinimallyInvasiveSurgery #RadiationNecrosis #Glioblastoma Joseph (Jia-Shu) Chen Alexander Haddad Oliver Tang, MD Winson Ho Shawn Hervey-Jumper Manish Aghi University of California, San Francisco

Check out the upcoming Neurosurgical Focus Journal Club! December 2024 FOCUS Journal Club Information Form Date and time:?December 12@ 9am ET Issue topic name:?Robotics in the neurosurgical operating room Selections listed below: Manuscript Number: FOCUS-DEC 2024-24-479R1 Author: Pascal Jabbour Title: Robotic Carotid Artery Stenting: A Multi-Center, Propensity-Score Matched Analysis of Clinical Outcomes and Cost-Effectiveness DOI link:?https://lnkd.in/gdkmDyJF City/State: Philadelphia, Pennsylvania Institution: Thomas Jefferson University Hospital Manuscript Number: FOCUS-DEC 2024-24-540R1 Author: Ezequiel Goldschmidt Title: Design, fabrication and testing of a new soft robot with 6 degrees of freedom to expand the reach of open and endonasal skull base approaches. DOI link:?https://lnkd.in/gXUbgM-s City/State: San Francisco, California Institution: University of California, San Francisco Topic Moderator:?Peter Vajkoczy? Reference Manuscript Number: FOCUS-DEC 2024-24-598 City/State: Berlin, Germany Institution: Charite - Univeritaetsmedizin Berlin Co-moderated with Drs. William Couldwell (Editor-in-Chief) and Aaron Cohen-Gadol (Associate Editor) ? Dr. Cohen-Gadol: President, The Neurosurgical Atlas Department of Neurosurgery, Keck School of Medicine at University of Southern California, Los Angeles, California Neurosurgical Atlas attendee link: https://lnkd.in/gXK5iyDq Pascal Jabbour MD FAANS, FACS, FAHA Peter Vajkoczy William Couldwell Aaron Cohen-Gadol, MD University of Utah School of Medicine Keck School of Medicine of the University of Southern California Charité - University Medicine Berlin Thomas Jefferson University

From November Journal of Neurosurgery Publishing Group Spine Zhang et al: https://lnkd.in/gYt3NKqB Summary: The authors prospectively enrolled 47 patients with cervical spondylotic myelopathy (CSM) undergoing surgical evaluation wo concurrent thoracolumbar stenosis and 21 controls. Patient underwent conventional T1/T2 MR and diffusion imaging – diffusion tensor imaging/DTI and diffusion basis spectrum imaging/DBSI to evaluate axonal/white matter integrity and the presence of vasogenic edema consistent with cord compression. Machine learning models with extreme gradient boosting were then applied to 1) parse patients into healthy controls, mild CSM, and moderate/severe CSM, and 2) CSM patients who did and did not experience clinically meaningful improvement at 2 years following decompression. Using 5-fold cross-validation the authors found DBSI was able to classify patients and predict clinical improvement better than traditional MR: classification = (0.81 95% CI [0.808-0.814] vs 0.647; [0.64-0.65]); prognostication = (0.72 [0.718-0.73] vs 0.575 [0.57-0.58]). Main findings: The use of advanced MR protocols, specifically DBSI may help to improve both the diagnosis of CSM severity and the prognostication for improvement following surgical decompression versus conventional MR imaging. #CervicalSpondyloticMyelopathy #MRI #Prognostication #DiffusionTensorImaging #MachineLearning WashU Medicine Neuroscience Saad Javeed Jacob GreenbergKathleen Botterbush Braeden Benedict Natasha Hongsermeier-Graves, MD, MPH Brandon Sherrod, MD Mark Mahan Andrew Dailey Erica Bisson Sheng-Kwei Song Wilson Ray

From November Journal of Neurosurgery Publishing Group Spine Issue Yee et al (https://lnkd.in/gUW64y-A): Summary: Given increased focus on healthcare costs, the authors examined the cost-effectiveness of single-level PLIF/TLIF for grade 1 degenerative spondylolisthesis using a prospective cohort of patients treated at 12 academic centers. The authors used Medicare reimbursement-based cost estimates using diagnosis-related group (DRG) 460 and Centers for Medicare/Medicaid Services charge-to-cost ratios with a defined society willingness-to-pay threshold of $100,000. Costs and quality-adjusted life year (QALY) gains were calculated at 5-year follow-up and used to estimate cost per QALY. Across the 385 included patients (mean age 60.2), average cost was $31,634/patient with 7% of patients having a cost per QALY <$100,000. Costs/QALY were significantly higher for those experiencing complications ($26,077 vs $13,522), especially when revision surgery was required ($59,156 vs $12,192). Only in patients who suffered complications requiring operative revision was the cost/QALY found to not be cost effective. Limitations were the inability to control for out-of-pockets costs, medications, radiology-related costs, and indirect costs, but nevertheless, even using conservative estimates, single-stage PLIF/TLIF was found to be a cost-effective intervention. Main findings: Single-stage PLIF/TLIF was found to be a cost-effective means of treating grade 1 degenerative lumbar spondylolisthesis. #spondylolisthesis #TLIF #SpinalFusion #QualityOfLife #CostEffectiveness #TransforaminalLumbarInterbodyFusion Timothy Yee Anthony DiGiorgio, DO, MHA Dom Coric Eric Potts Erica Bisson John Knightly Kai-Ming Fu Kevin Foley, M.D. Mark Shaffrey Mohamad Bydon Dean Chou, MD Andrew Chan, MD Scott A. Meyer, MD, FAANS Anthony (Tony) Asher Chris SHAFFREY , MD, FACS, FAANS Michael Wang Dr. Regis Haid Steven Glassman Michael Virk Praveen Mummaneni, MD, MBA Paul Park University of California, San Francisco Mayo Clinic Neuro Vanderbilt University School of Medicine Goodman Campbell Brain and Spine Norton Leatherman Spine Center Semmes Murphey Clinic Weill Cornell Medicine Columbia University Vagelos College of Physicians and Surgeons University of Virginia School of Medicine University of Utah School of Medicine University of Miami Miller School of Medicine Duke University School of Medicine Carolina NeuroSurgery & Spine Associates

From the November Issue: Sloane et al (https://lnkd.in/gwCnVuVh) Summary: Hearing preservation and preservation of facial nerve function are two key outcomes in vestibular schwannoma surgery. The authors examined outcomes in 100 adults with AAO-HNS class A/B hearing (serviceable hearing) who underwent microsurgical resection of vestibular schwannoma using auditory brainstem responses with direct CN8 monitoring (n=28) or ABRs alone (n=72). Tumor size, ABR wave I, III, and V morphology, baseline hearing function, and porus acusticus drilling were considered in the multivariable model, which found only baseline AOO-HNS class to be predictive of postoperative serviceable hearing preservation among all comers. However, increasing tumor size in the direct CN8 monitoring group was also a significant negative predictor of serviceable hearing preservation. There was no significant difference in postoperative facial nerve function between the two groups. Of note, direct CN8 monitoring appeared most useful for serviceable hearing preservation in small (≤1.5cm) tumors. Main Findings: The addition of direct CN8 monitoring to ABRs during vestibular schwannoma resection may increase the odds of serviceable hearing preservation, but the present result was not statistically significant. Preoperative hearing was the strongest predictor of postoperative serviceable hearing retention. #HearingPreservation #Microsurgery #VestibularSchwannoma #AcousticNeuroma #DirectCranialNerveMonitoring #AuditoryBrainstemResponse Mohammed Nuru, MD MS Nathan Pecoraro, M.D. Oleksandr Strelko Rebecca Rajasekhar Ignacio Jusue-Torres, MD, FCNS, FEBNS Mayo Clinic Neuro Loyola University Chicago Stritch School of Medicine SUNY Downstate Health Sciences University UPMC

From the November Issue Chintapalli et al: https://lnkd.in/gj6PWAmN Summary: Flow-diversion is an increasingly popular technique for the management of unruptured carotid circulation aneurysms. Twenty-three cerebrovascular experts (17 neurosurgeons) participated in a Delphi consensus process aimed at identifying points of consensus regarding the management of aneurysms demonstrating persistent filling 6-24 months after flow diversion. There was near consensus that filling at 6-month did not define treatment failure and that retreatment at that point was unwarranted in the absence of growth or clinical symptoms. Most (78%) defined persistent filling at 12-months as treatment failure only in the presence of growth or symptoms, and 74% defined persistent filling with/without symptoms at 24-months to defined treatment failure. For those with persistent filling at 12-months, observation was favored for aneurysm with reduced size and treatment was favored for those with growth. Almost all (96%) favored retreatment if there was persistent filling at 24-months and the aneurysm had previously rupture, was causing symptoms, or imaging demonstrated stent malposition. Most (87%) preferred retreatment with a secondary flow diverter. Main Findings: A panel of 23 experts defined treatment after flow diversion as persistent filling at 24-months, or the presence of growth on 6- or 12-month follow-up. Repeat flow diversion was the favored retreatment with most basing the decision to treat on aneurysm growth or the present of symptoms. #aneursym #flowdiversion #DelphiConsensus #cerebrovascularneurosurgery #endovascular ADIB ADNAN ABLA Karol Budohoski CRAIG J KILBURG Daniel Raper Guilherme Dabus, MD, MHL, FACR, FAHA Alan Coulthard Peter Kang, MD, MSCI, FANA Pascal Jabbour MD FAANS, FACS, FAHA Jan-Karl Burkhardt, MD Robert Starke Riitta Rautio Guiseppe Lanzino W. Chris Fox, MD, FAANS Christopher S. Ogilvy Kunal Raygor University of Utah School of Medicine Mayo Clinic Neuro University of Miami Miller School of Medicine UPMC Beth Israel Deaconess Medical Center Barrow Neurological Institute University of California, San Francisco Turku University Hospital University of Washington - School of Medicine University of Pennsylvania School of Medicine Thomas Jefferson University

As a last highlight for the October issues, we highlight the following article from Ravindra et al and the Hydrocephalus Clinical Research Network (doi: https://lnkd.in/gYPTKV-j) ? Summary: In this multicenter prospective cohort of 14 centers, 416 patients ≤18 years old were enrolled who underwent ventriculoatrial or ventriculopleural (VPL) shunting with a primary outcome of shunt failure. The authors included patients with VA or VPL as a first shunt or revision of prior VP shunt, and included patients who had hydrocephalus secondary to one of multiple etiologies, including aqueductal stenosis and IVH of prematurity. Patients who underwent VPL and VA shunting had similar rates of complications (9.2 vs 6.0%), including similar rates of pseudomeningocele, wound complications, meningitis, and CSF leak. Time-to-event analysis showed a nonsignificanlty longer survival than VA shunts. Patients <6years old (HR 1.60; 95% CI [1.24=2.07]) and those undergoing shunting for hydrocephalus following IVH of prematurity had significantly higher risk of shunt failure. In multivariate cox proportional hazard model, there were no signficant predictors of survival, though young age (<6 vs ≥6yo; p=0.072) and post-IVH of immaturity hydrocephalus (p=0.058) trended towards significance). When comparing to VP shunt, VA but not VA shunts were significantly more likely to fail. ? Main Findings: Ventriculoatrial and ventriculopleural shunts appear to offer similar survival times in children undergoing shunting. VA shunts in patients <6yo may have shorter shunt survival relative to other groups. Vijay Ravindra Richard Holubkov Jennifer Strahle Tamara Simon Eric Jackson Jonathan Pindrik Patrick McDonald Children's Hospital Los Angeles (CHLA) The Johns Hopkins University School of Medicine Nationwide Children's Hospital The University of British Columbia Vanderbilt University School of Medicine Texas Children's Hospital University of Utah School of Medicine Naval Medical Center San Diego UNIVERSITY OF CALIFORNIA, SAN DIEGO MEDICAL CENTER University of Alabama at Birmingham Keck School of Medicine of the University of Southern California Seattle Children's #hydrocephalus #pediatricneurosurgery #shuntfailure #multicentercollaboration #ventriculoatrialshunt