Journal of neurosurgery
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Journal of neurosurgery · Sep 2023
Randomized Controlled Trial Multicenter StudyCost-effectiveness of thrombectomy alone versus alteplase before thrombectomy in acute ischemic stroke: results from the DIRECT-MT.
The use of thrombectomy alone (endovascular thrombectomy [EVT]) was found to be noninferior to combination therapy (EVT plus intravenous thrombolysis [IVT] with alteplase before thrombectomy [EVT+IVT]) in the DIRECT-MT (Direct Intra-Arterial Thrombectomy in Order to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals: A Multicenter Randomized Clinical Trial), yet the economic value of omitting alteplase was unclear. Thus, in this paper the authors assessed the cost-effectiveness of EVT alone versus EVT+IVT in the DIRECT-MT. ⋯ In this economic analysis based on a trial conducted in China, the authors found that EVT alone was not associated with economic dominance over EVT+IVT in patients with anterior circulation large-vessel occlusion.
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Journal of neurosurgery · Sep 2023
Effect of lesion temperature on the durability of percutaneous radiofrequency rhizotomies to treat trigeminal neuralgia.
Percutaneous radiofrequency rhizotomy is a common procedure for trigeminal neuralgia (TN) that creates thermocoagulative lesions in the trigeminal ganglion. Lesioning parameters for the procedure are left to the individual surgeon's discretion, and published guidance is primarily anecdotal. The purpose of this work was to assess the role of lesioning temperature on long-term surgical outcomes. ⋯ The study findings suggest that lower lesion temperatures and, separately, postoperative numbness result in improved long-term outcomes for patients with TN who undergo percutaneous radiofrequency rhizotomies. Given the limitations of retrospective analysis, the authors suggest that a prospective multisite clinical trial testing lesion temperatures would provide definitive guidance on this issue with specific recommendations about the number needed to treat and trial design.
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Journal of neurosurgery · Sep 2023
ReviewNovel approaches to targeting gliomas at the leading/cutting edge.
Despite decades of clinical trials and surgical advances, the most common high-grade glioma, glioblastoma (GBM), remains an incurable disease with a dismal prognosis. Because of its infiltrative nature, GBM almost always recurs at the margin, or leading edge, where tumor cells invade the surrounding brain parenchyma. This region of GBMs is unique, or heterogeneous, with its own microenvironment that is different from the tumor bulk or core. ⋯ The current paradigm of resection of GBM tumors mainly focuses on resection of the contrast-enhancing component of tumors, while GBMs extend well beyond the contrast enhancement. The infiltrative margin represents a unique challenge and opportunity for solutions that may overcome current limitations in tumor treatments. In this review of the current literature, the authors discuss the current and developing advances focused on the detection and treatment of GBM at the infiltrative margin and how this could impact patient outcomes.
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Journal of neurosurgery · Sep 2023
Glucose-6-phosphate dehydrogenase and 8-iso-prostaglandin F2α as potential predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.
Delayed cerebral ischemia (DCI) is a serious complication of aneurysmal subarachnoid hemorrhage (aSAH), which is responsible for significant death and disability. The dynamic balance between the production and elimination of reactive oxygen species (ROS) in patients with DCI is suspected be shifted to favor ROS formation. The authors assessed the relationship between F2-isoprostanes (F2-IsoPs), oxidative stress biomarkers, and glucose-6-phosphate dehydrogenase (G6PD), which are responsible for nicotinamide adenine dinucleotide phosphate (NADPH) production for glutathione system function, with post-aSAH DCI. ⋯ Decreased G6PD indirectly informs the reduced antioxidant response, especially for the glutathione system. G6PD concentration was lower in patients with DCI than those without, which may explain the increased F2-IsoP concentrations. mFisher grade, plasma F2-IsoP concentration, and G6PD concentration on day 2 after aSAH, in combination, may serve as predictors of DCI. Further research is necessary to investigate the therapeutic utility of F2-IsoPs and antioxidants in clinical practice.
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A reluctance to monitor extraocular cranial nerve (EOCN) function has restricted skull base surgery worldwide. Spontaneous and triggered electromyography (EMG) monitoring can be recorded intraoperatively to identify and assess potential cranial nerve injury. Determining the conductive function of EOCNs requires the collection of clear, reliable, and repeatable compound muscle action potentials (CMAPs) secondary to stimulation. EOCN EMG needle electrodes can, although infrequently, cause ocular morbidity including hematoma, edema, and scleral laceration. The aim of this study was to ascertain if minimally invasive 7-mm superficial needle electrodes would record CMAPs as well as standard 13-mm intraorbital electrodes. ⋯ Because of artifact contamination, 106 false-positive responses (25%), and 17 false-negative responses (4%), the minimally invasive EMG technique cannot reliably record CMAP responses intraoperatively as well as the intraorbital technique. Less-invasive techniques can lead to an inaccurate EOCN assessment and potential postoperative morbidity. EOCN palsies can be debilitating and lifelong; therefore, the benefits of preserving EOCN function outweigh the potential risks of morbidity from electrode placement. EMG monitoring with intraorbital electrodes remains the most reliable method of intraoperative EOCN assessment.