Pakistan journal of pharmaceutical sciencesJinshan Xie, Xiaoli Li, Feng Jian
BACKGROUND: Selecting appropriate anesthetic agents and techniques that ensure hemodynamic stability and attenuate perioperative stress responses is crucial for ovarian cancer surgery. OBJECTIVES: This study aimed to evaluate the effects of etomidate combined with transversus abdominis plane block (TAPB) on perioperative hemodynamics, inflammatory and oxidative stress responses and immune function in patients undergoing radical resection of ovarian cancer. METHODS: A total of 80 patients were randomly assigned to receive total intravenous anesthesia (TIVA) alone or TIVA combined with TAPB. Hemodynamic parameters, serum inflammatory markers, oxidative stress indicators, pain mediators, immune cell subsets and adverse reactions were compared between the two groups. RESULTS: Perioperative hemodynamic parameters changed dynamically in both groups, with heart rate and mean arterial pressure increasing intraoperatively and decreasing postoperatively. However, the research group had significantly lower heart rate and mean arterial pressure than the control group during the peak intraoperative period (P<0.001), indicating improved hemodynamic stability. Preoperative levels of inflammatory, oxidative stress, pain-related and immune indexes were comparable between groups (P>0.05). At 24 h postoperatively, the research group showed significantly reduced serum levels of high-sensitivity C-reactive protein, tumor necrosis factor-α, malondialdehyde, cortisol, prostaglandin E2 and substance P compared with the control group (all P<0.05), reflecting attenuation of systemic inflammation, oxidative stress and nociceptive activation. Postoperative immune function was better preserved in the research group, as evidenced by higher CD3+ and CD4+ cell counts and CD4+/CD8+ ratio, along with a lower CD8+ level (P<0.05). The overall incidence of adverse reactions was low and did not differ significantly between groups (4.4% vs 8.9%, P>0.05). CONCLUSION: Etomidate combined with transversus abdominis plane block provides stable anesthesia and modulates perioperative inflammatory and immune responses while reducing postoperative biochemical pain mediator levels, thereby supporting a safer and more physiologically balanced recovery following ovarian cancer surgery.
Radiographics : a review publication of the Radiological Society of North America, IncEvgeny Pavlushkov, Jay Starkey, Ramon F Barajas, Jinhee Jang, Daniel R Cleary, Ahmed M Raslan
Neurosurgical reviewLina Raffaella Barzaghi, Antonella Castellano, Matteo Scalise, Maria Antonietta Volonté, Luigi Albano, Edoardo Pompeo, Roberta Balestrino, Federica Agosta, And…
We report our experience adopting high angular resolution diffusion imaging (HARDI) tractography to define the target in the Ventralis Intermedius (Vim) nucleus in patients with essential tremor (ET). Retrospective observational cohort study on 18 consecutive Gamma Knife Stereotactic (GKRS)-thalamotomies. Dento-Rubro-Thalamo-Cortical-tract (DRTT), Cortico-spinal tract (CST) and Medial Lemniscus (ML) were reconstructed and used to adjust the coordinates-based target. The DRTT received a median maximum dose of 116 Gy (IQR 92.8-124.2 Gy) and the median volume receiving > 20 Gy (V20) was 154 mm3 (IQR 63.5-190.2 mm3). The maximum dose to the Vim was 126 Gy (IQR 126.2-127 Gy) and the median volume covered by 100 Gy was 25 mm3 (IQR 23-28-2 mm3), corresponding to the 14.5% of the whole volume (IQR 10.7-18.0%). The median Euclidean distance between the indirect (in-Vim) and adjusted Vim (ad-Vim) was 1 mm (IQR 0.7-1.9) and the final position of the ad-Vim was 1 mm cranial compared to the in-Vim (p < 0.001). Tremor improved in 15 of 18 thalamotomies (83.3%) and in all 11 cases with follow-up longer than 12 months, with a median ΔT% of 63.7% (IQR 57.4-72.3). The only prognostic factor was higher dose rate (p = 0.007), associated with faster response. No patients presented adverse radio-induced events during the follow-up. GKRS thalamotomy adopting DRTT projection, as landmark for the Vim in addition to standard coordinates, and maintaining the CST outside the 20 Gy isodose line, is effective and safe in ET.
Journal of robotic surgeryLanfang Liu, Chenglou Zhu
This study systematically assessed the current state of research on robot-assisted stereotactic neurosurgery, identified major research focuses, and investigated evolving trends in this field, with the intention of providing useful guidance for future scientific studies and clinical practice. In this study, publications related to robot-assisted stereotactic neurosurgery published between 2005 and 2025 were retrieved from the Science Citation Index Expanded database within the Web of Science Core Collection. Descriptive and visual bibliometric analyses were conducted to evaluate publication characteristics, including research topics, journals, countries or regions, institutions, authors, and citation performance. A total of 194 publications were ultimately included in the analysis. The yearly publication output demonstrated a general upward trend over time, with a particularly noticeable increase observed after 2018. These studies were published in 88 journals, among which Operative Neurosurgery (16 publications), Acta Neurochirurgica (11 publications), and World Neurosurgery (8 publications) were the most productive journals. The most productive countries were the United States (50 publications, 25.8%), China (35 publications, 18.0%), and Germany (23 publications, 11.9%). Keyword analysis showed that recent research hotspots mainly focused on "safety," "efficacy," and "radiosurgery". Robot-assisted stereotactic neurosurgery has shown a steady increase in research activity over the past two decades and has gradually evolved toward more clinically oriented applications. However, bibliometric indicators primarily reflect publication and citation patterns rather than clinical effectiveness. Further studies based on high-quality clinical evidence are required to better evaluate its practical value and long-term outcomes.
Current neurology and neuroscience reportsNitish Seenarine, Samuel Latzman, Laura Mittelman, Vadim Zhigin, Emily Hirowski, Shoaib Syed, Heustein Sy, Randy S D'Amico
PURPOSE OF REVIEW: Postoperative seizures occur in up to 20% of seizure-naïve adult patients undergoing craniotomy for tumor resection, contributing to morbidity and readmissions. Yet, routine prophylactic use of anti-seizure medications (ASMs) in this population remains unsupported by current evidence-based guidelines. In this review, we synthesize current evidence on seizure incidence, timing, risk factors, and practical perioperative management strategies. RECENT FINDINGS: Postoperative seizure risk varies by tumor type, cortical involvement, peritumoral edema, hemorrhage, and tumor grade. Across randomized trials and meta-analyses, prophylactic ASM administration has not been shown to consistently reduce postoperative seizure incidence, and older agents can increase toxicity and interaction risk. Some studies suggest a modest reduction of early seizures within the first postoperative week, though this benefit is not sustained long-term. When prophylaxis is employed, second-generation ASMs such as levetiracetam are often favored for their higher tolerability and fewer drug-drug interactions compared to older agents. Emerging evidence has described alternative agents to levetiracetam with greater blood-brain-barrier permeability, but further investigation is required. Routine ASM prophylaxis in seizure-naïve patients undergoing intracranial tumor resection is not supported by current evidence or clinical guidelines. A selective, risk-based approach with short-term prophylaxis may be considered in patients with high-risk features. Future prospective, risk-stratified trials are needed to better define subgroups that may benefit from targeted prophylactic strategies.
Child's nervous system : ChNS : official journal of the International Society for Pediatric NeurosurgeryMario G Siqueira, Roberto S Martins, Bruno S A G Freitas, Carlos O Heise
This historical vignette highlights key aspects of the professional life of the Scottish surgeon Robert Kennedy and details the first reported surgical repair cases of brachial plexus birth palsy, which achieved remarkably favorable outcomes. These cases represent the first documented attempt at surgical reconstruction of neonatal brachial plexus palsy and predate the modern era of nerve surgery by several decades.
Journal of investigative surgery : the official journal of the Academy of Surgical ResearchXinyang Heng, Aina Xu, Yajing Xiong, Rumei Ding, Jiangfeng Zhao
BACKGROUND: As a typical complication, postoperative nausea and vomiting (PONV) usually occurs among patients undergoing general anesthesia surgery, diminishing postoperative satisfaction and recovery. OBJECTIVE: Herein, we applied a new G-protein-biased μ-opioid receptor agonist, oliceridine, to compare its management with fentanyl on PONV among high-risk patients receiving general anesthesia with transversus abdominis plane block (TAP). METHODS: In this prospective, double-blind, randomized controlled study, a total of 280 patients were enrolled for general anesthesia surgery, including laparoscopic cholecystectomy and laparoscopic gynecological surgery. Participants were randomly divided into either the oliceridine group or the fentanyl group at a 1: 1 ratio. Afterwards, the primary outcome was the rate of nausea and vomiting on postoperative day 2. The secondary outcomes comprised the visual analogue scale (VAS) score of PONV, intraoperative analgesic effect, rescue antiemetic treatment, hemodynamic parameters during T1-T5, postoperative pain assessment, hospitalization period, gut function, time of drink and food intake, drainage tube removal, hospitalizations, and perioperative complications. RESULTS: Among the enrolled 279 patients, oliceridine effectively reduced the occurrence of nausea (26.4% versus 12.9%, p = 0.005) and vomiting (24.3% versus 6.5%, p < 0.001). In addition, the postoperative nausea VAS score showed significantly lower in the oliceridine group compared with the fentanyl group (1.40 ± 1.31 versus 2.01 ± 1.79, p = 0.013), accompanied by reduced rescue antiemetic rate (17.1% versus 7.2%, p = 0.011), with stable hemodynamic condition and comparable postoperative recovery. DISCUSSION: According to our study, oliceridine may be a viable substitute for general anesthesia to ameliorate postoperative incidence of PONV, along with its impressive pain control during anesthesia induction and maintenance. CLINICAL TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2400089121).
Life science allianceOmar Flores-Sandoval, Skarleth Cárdenas-Romero, Adrián Báez-Ruiz, Roberto C Salgado-Delgado, Nadia Saderi
Increased sympathetic tone and hypertension are hallmarks of metabolic syndrome and contribute to chronic kidney disease. Although renal sympathetic denervation transiently lowers blood pressure, its role in the development of metabolic and renal alterations remains unclear. Here, we evaluated the contribution of renal sympathetic input to the onset and progression of high-fat diet-induced alterations. Male Wistar rats underwent bilateral renal denervation before metabolic challenge and were fed a standard or high-fat diet for 8 or 12 wk. High-fat feeding induced hypertension, proteinuria, increased angiotensin II, and reduced creatinine clearance, urinary flow, and potassium excretion, independently of denervation. Renal norepinephrine content confirmed effective denervation and was not affected by diet. Denervation attenuated ketonuria in high-fat diet-fed rats. The phosphorylation of AKT, PI3K, and ERK1/2 in the kidney was modulated by interactions among diet, renal sympathetic input, and time. These findings indicate that renal sympathetic nerves contribute to early stages of metabolic dysregulation, whereas prolonged hypercaloric exposure overrides autonomic control and promotes cardiovascular and renal complications.
Annals of medicineJun Yang, Xiaocui Yang, Jiajia Liu, Ke Li, Jiawei Shi, Yingzhun Liang, Shuangshuang Liang, Hanjie Liu, Hui Qiao, Xing Fan
BACKGROUND: Microvascular decompression (MVD) is the current definitive treatment for achieving a radical cure of primary hemifacial spasm (pHFS). The current study aimed to integrate blink reflex (BR) monitoring into MVD for pHFS to assess surgical efficacy and explore its predictive value for postoperative spasm when combining with lateral spread response (LSR) monitoring. METHODS: A prospective cohort study included 105 patients with pHFS undergoing MVD. Intraoperative zygomatic LSR (ZYG-LSR), mandibular LSR (MAN-LSR), and BR were monitored. Multivariate logistic regression was used to assess independent predictors of postoperative spasm at 3 months after surgery. Two predictive models (Model 1: LSR; Model 2: LSR plus BR) for postoperative spasm were compared using Receiver Operating Characteristic (ROC) curve analysis at four postoperative time points: 1 day, 1 week, 1 month, and 3 months, with the area under the curve (AUC) quantifying overall accuracy and the DeLong test for comparison. RESULTS: BR showed a higher elicitation rate (99.0%) than ZYG-LSR (97.1%) and MAN-LSR (91.4%). Persistent ZYG-LSR (odds ratio 28.99), MAN-LSR (odds ratio 12.06), and BR (odds ratio 10.38) were identified as independent predictors for postoperative spasm at 3 months after surgery (all p < 0.05). Regarding the two predictive models, their performance improved over time. At 3 months, Model 2 showed a numerically higher AUC than Model 1 (0.955 versus 0.901), while the DeLong test still did not reach statistical significance (p = 0.083). CONCLUSION: In conclusion, intraoperative BR monitoring appears to be a feasible and potentially useful adjunct to conventional LSR monitoring in MVD for pHFS, and warrants further evaluation in larger studies.
International journal of pediatric otorhinolaryngologyEric Cunningham, Alireza Zonnour, Krish Suresh, Michael G Brandel, Michael L Levy, Marc S Schwartz, Rick A Friedman
OBJECTIVE: Middle fossa craniotomy (MFC) with exposure of the internal auditory canal and/or petrous apex (anterior petrosectomy) is an uncommon operation in the pediatric population. We report our institution's experience and surgical outcomes with pediatric MFC. METHODS: Retrospective case series including all MFC with exposure of the internal auditory canal and/or petrous apex, performed between May 2018 and September 2024, in patients aged 18 years and younger. Primary outcome measures were pre-operative and postoperative facial nerve function and hearing status. RESULTS: Sixteen patients met inclusion criteria. Median age was 12 years (range 1-18), 10 (63%) were male and six (37%) were female. On preoperative MRI, median tumor size was 12.5 mm (range 3-63). Gross total resection was achieved in 11 (69%) cases, near total in 1 (6%), and subtotal in 4 (25%). Facial nerve outcomes were favorable: of 11 patients with preoperative House-Brackmann (HB) I, 10 (91%) maintained HBI postoperatively. All 9 patients with vestibular schwannoma (VS) had class A hearing preoperatively. At first postoperative follow-up (median 8 days), five (56%) maintained class A hearing and four (44%) were class D. CONCLUSIONS: MFC can be safely performed in children for appropriately selected skull base lesions. VS in NF2 is the most common indication, and MFC offers a valuable hearing-preserving option in these cases. Early intervention for small, growing tumors with associated hearing loss, coupled with modern intraoperative monitoring and multidisciplinary expertise, allow for facial nerve and hearing outcomes similar to the adult population.
Journal of investigative surgery : the official journal of the Academy of Surgical ResearchHao-Chien Yang
PURPOSE: Atypical meningiomas have higher recurrence and mortality than benign variants, and age may influence treatment decisions and outcomes. We evaluated associations between age, treatment modality, and survival in patients with atypical meningioma. METHODS: Adults with histologically confirmed intracranial atypical meningioma were identified from the 2000-2021 Surveillance, Epidemiology, and End Results database. Multivariable Cox regression assessed overall survival (OS) and cancer-specific survival (CSS), and logistic regression evaluated predictors of gross total resection (GTR) versus subtotal resection (STR). RESULTS: Among 3,882 patients, advanced age was associated with worse OS and CSS. Compared with patients aged <40 years, those aged ≥60 years had higher overall mortality (aHR 5.29, 95% CI 3.78-7.39) and cancer-specific mortality (aHR 3.15, 95% CI 1.99-4.99; both p < 0.001). Patients aged 40-59 years showed intermediate OS risk but no significant difference in CSS. Older patients received radiotherapy less often, whereas age was not an independent predictor of GTR. STR, male sex, unmarried status, tumor ≥5 cm, and Black race were associated with poorer survival. CONCLUSION: Advanced age independently predicted inferior OS and CSS but not a lower likelihood of GTR, supporting individualized, age-sensitive management.
Annals of medicineDavide De Santo, Roberta Marie Gentile, Giuseppe Mirenda, Giovanni Di Lorenzo, Maria Sole Scalia, Chiara Dal Pozzolo, Elena Magni, Federica Scrimin, Alessandro…
BACKGROUND: Pain perception is a major limitation of office hysteroscopy and may lead to premature suspension of the procedure. Current guidelines do not routinely recommend local analgesia, and the effectiveness of paracervical block during office hysteroscopy performed with a vaginoscopic approach remains insufficiently investigated. OBJECTIVES: The primary objective was to assess whether paracervical block is associated with reduced pain perception during office hysteroscopy with a vaginoscopic approach. The secondary objective was to evaluate its impact on procedure suspension. MATERIALS AND METHODS: his retrospective observational cohort study included patients undergoing diagnostic and/or operative office hysteroscopy between January 2018 and January 2022. Paracervical block was administered without speculum or tenaculum. Confounders were addressed using multivariable regression and propensity score matching. RESULTS: A total of 2,028 patients were analyzed. In patients who did not receive PB, nulliparity was associated with severe pain (aOR 2.87, 95% CI 1.20-6.85) and procedure suspension (aOR 3.07, 95% CI 1.27-7.39), and cervical canal stenosis with markedly increased odds of both severe pain (aOR 23.17, 95% CI 10.44-51.40) and suspension (aOR 25.10, 95% CI 11.19-56.30). In patients receiving PB, nulliparity was no longer significantly associated with either outcome, and the effect of cervical canal stenosis was substantially attenuated (aOR 2.68, 95% CI 1.57-4.58 for severe pain; aOR 3.70, 95% CI 2.07-6.62 for suspension). CONCLUSION: Overall, in this large retrospective cohort, paracervical block performed through a vaginoscopic approach was associated with reduced pain perception and procedure suspension in selected patients.
Annals of medicineLiyuan Ren, Zhenhua Nan, Yanshuang Li, Yanping Wang
OBJECTIVE: To evaluate the analgesic efficacy of thoracic paravertebral block (TPVB) with different doses of liposomal bupivacaine (LB) or ropivacaine in patients undergoing single-port thoracoscopic lung surgery. METHODS: A total of 105 patients scheduled for video-assisted single-port thoracoscopic lung surgery were randomized in a 1:1:1 ratio into three groups: low-dose LB group (group LL), high-dose LB group (group HL), or ropivacaine group (group R). All received ultrasound-guided TPVB at the T5/6 level preoperatively. The primary outcome was the area under the curve (AUC) of NRS of pain at activity (AUC-aNRS) from 1 to 72 h postoperatively. Secondary outcomes included the AUC of NRS of pain at rest (AUC-rNRS) from 1 to 72 h postoperatively, NRS of pain at rest and at activity at 1, 6, 24, 48, and 72 h postoperatively, and the cumulative opioid consumption at 24, 48, and 72 h postoperatively. Additionally, postoperative recovery and adverse events were assessed. RESULTS: AUC-aNRS differed significantly among groups (p = 0.0092), with high-dose LB lower than low-dose LB (p = 0.0071), but not versus ropivacaine. No significant difference was found in AUC-rNRS (p > 0.05). The group-by-time interactions for NRS of pain at rest and at activity were not significant (p > 0.05). Cumulative opioid consumption at 24, 48, and 72 h was lower in group HL versus group LL (all p < 0.017), but not versus ropivacaine. Postoperative recovery and adverse events showed no differences (p > 0.05). CONCLUSION: LB combined with TPVB is not superior to ropivacaine for postoperative analgesia in single-port thoracoscopic lung resection.
Annals of medicineYu Zhou, Hong-Zhang Ding, Xiao-Qian Li, Teng Zheng, Mao-Lin Ran, Ai-Ling Song, Yi-Min Qiu, Jin-Bao Li, Feng Chen
BACKGROUND: Shoulder arthroscopy frequently causes severe postoperative pain that may impede recovery. Liposomal bupivacaine provides prolonged analgesia, and ultrasound-guided superior trunk block (STB) offers comparable analgesia to interscalene block with a lower risk of hemidiaphragmatic paralysis. However, the optimal concentration of liposomal bupivacaine for STB remains unknown. METHODS: This randomized, double-blind, controlled trial will enrol 282 adult patients scheduled for elective arthroscopic rotator cuff repair. Patients will be randomly allocated (1:1:1) to receive ultrasound-guided STB with liposomal bupivacaine 66 mg (Group A), 44 mg (Group B) or 33 mg (Group C), each diluted to 10 mL. The co-primary outcomes are (1) rest pain Numeric Rating Scale (NRS) score at 48 h post-surgery and (2) cumulative oral morphine milligram equivalents (MME) consumption within 0-48 h after surgery. Secondary outcomes include rest pain NRS scores at 6, 24 and 72 h; motor function assessed by Muscle Balance Scale, Bromage score and American Shoulder and Elbow Surgeons (ASES) score at 6, 24, 48 and 72 h; and Quality of Recovery-15 (QoR-15) score at 24 and 48 h. DISCUSSION: This study will provide evidence on the optimal concentration of liposomal bupivacaine for STB in arthroscopic shoulder surgery, aiming to achieve effective and prolonged analgesia without compromising shoulder mobility.
The involvement of necroptosis and the underlying mechanism in retinal ganglion cell (RGC) death is not fully understood. We aim to determine whether the NR_045396/miRNA761/Fas-associated protein with death domain (FADD) axis participates in the regulation of necroptosis in RGCs. A mouse model of optic nerve crush was employed for in vivo experiments. Apoptosis and necrosis were assessed by TUNEL and Propidium iodide (PI) exclusion. We found that the necrotic rate increased in a time-dependent manner in RGCs following optic nerve injury, whereas apoptosis peaked at 7 days following nerve damage. Immunohistochemistry revealed that the expression levels of key markers of necroptosis, pRIP3 and pMLKL, were upregulated, whereas FADD expression was reduced in RGCs at 14 days after optic nerve injury. Enforced expression of FADD in RGCs by an AAV vector attenuated necrotic response and promoted RGC survival. A dual-luciferase reporter gene assay showed that miR761 directly regulated FADD expression. Intraocular application of AAV2 expressing sequences complementary to miR761 binding site (AAV2-miR761 sponge) enhanced FADD expression and regulated RGC necrosis and survival. Moreover, the long non-coding RNA (lncRNA) NR_045396 binds directly to miR761 and modulates the necrotic program of RGCs. Thus, we demonstrate the anti-necroptosis and neuroprotective effects of the NR_045396/miR761/FADD axis.
InjuryNishant Merchant, Douglas J MacLean, Sarah R Vincze, Jyoti Chhabra, Aseel Walker, Kevin Finkel
PURPOSE: Despite long-standing use of thoracic epidural block (TEB) for multiple rib fracture trauma, emerging research suggests that the erector spinae plane block (ESPB) offers similar analgesia and increased safety benefits. This study compared the analgesic effectiveness and safety of TEB versus ESPB for multiple rib fracture trauma. METHODS: A historical cohort analysis was conducted, including 324 adult patients who received continuous TEB (n = 188) or ESPB (n = 136) plus multimodal analgesia following multiple rib fracture trauma. The primary objective compared average numeric pain scale (NPS) scores at rest and with activity over the first five days of local anesthetic infusion. Other outcomes included opioid consumption, length of stay data, venous thromboembolism (VTE) prophylaxis time measures, as well as vasoactive support, complication, and mortality rates. RESULTS: Average pre- and post-block NPS scores at rest were greater in the TEB group [5.6 (2.1) vs. 4.8 (2.2), p = 0.002; 48-72 h: 3.7 (2.2) vs. 2.9 (2.2), p = 0.002, respectively). However, the daily changes in NPS scores throughout anesthetic infusion were similar between groups, without significant difference in opioid consumption. First VTE prophylaxis was given prior to block placement more frequently in the ESPB group (66.9 vs. 31.4%, p < 0.001), and median time between pre and post block VTE prophylactic doses was shorter [12.6 (13.7) vs. 23.9 (12.3) hours, p < 0.001]. CONCLUSION: Continuous TEB and ESPB demonstrated similar analgesic efficacy for multiple rib fracture trauma. The ESPB group received earlier VTE prophylaxis without disruption in dose administration for block placement, supporting enhanced safety of ESPB.
Physical medicine and rehabilitation clinics of North AmericaD Scott Kreiner, Tyler Woodworth, Imran Qureshi
When caring for spine patients, accurate diagnosis is essential, as interventional treatments are only effective when the true pain generator is correctly identified. Diagnostic procedures generally fall into provocative tests, which reproduce pain, and analgesic blocks, which relieve pain through anesthetic injections. However, both approaches are limited by false positives, particularly with uncontrolled medial branch or sacroiliac blocks. Controlled comparative blocks improve accuracy, but predictive value remains modest unless combined with history, examination findings, and imaging. This principle underlies the broader theme of interventional spine care: technical skill alone is insufficient; outcomes depend on diagnostic precision and careful patient selection.
NeurosurgeryShabbar F Danish, Joshua M Rosenow, Jason M Schwalb, Ellen L Air, Jennifer Sweet, Jon T Willie, John D Rolston, Dario J Englot, Nir Lipsman, Ajmal Zemmar, Jose…
Since its US Food and Drug Administration approval in 2016, magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy has grown into one of the procedures of choice among patients with essential tremor (ET). Approved applications for the procedure have expanded over time from unilateral thalamotomy to treat ET and Parkinson disease tremor to bilateral staged thalamotomy for ET. As the procedure expands to healthcare environments beyond large academic centers, guidance is required to ensure that the responsible clinicians are appropriately trained to undertake this operative procedure. Although multidisciplinary movement disorder teams are important for the optimal management of patients, MRgFUS lesions are inherently surgical interventions. Neurosurgeons are trained to evaluate these patients, consider surgical alternatives and conduct these operations, particularly after completing a fellowship in the subspecialty of stereotactic and functional neurosurgery. At present, all high-level evidence regarding the safety and efficacy of MRgFUS lesions to treat movement disorders derives from procedures performed by neurosurgeons, so those results may not be generalizable to other physicians. Based on these considerations and potential liability issues, the American Society for Stereotactic and Functional Neurosurgery, which acts as the joint section representing the field of stereotactic and functional neurosurgery on behalf of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, puts forth this position statement that only neurosurgeons appropriately trained to conduct functional neurosurgery procedures should conduct MRgFUS surgical lesions.
BACKGROUND AND OBJECTIVES: MRgFUS Vim thalamotomy has recently been developed as a novel treatment for various movement disorders. An automated atlas segmentation application (BRAINLAB® Elements) enables individualized planning by registering atlas-based Vim segmentation to each patient's MRI. We investigated whether automated atlas segmentation application-based preoperative planning affects the treatment outcomes of MRgFUS Vim thalamotomy. METHODS: Between January 2019 and May 2022, patients with refractory essential tremor or tremor-dominant Parkinson disease underwent MRgFUS Vim thalamotomy at Ohnishi Neurological Center group, planning was performed according to anatomical landmarks and atlas, and in the segmentation-based group, planning was conducted using automated atlas segmentation application. We compared distributions of the center of the target at preoperative planning and coordinate deviation between preoperative planning and final lesion. Treatment outcome was also evaluated. RESULTS: A total of 80 consecutive patients were included, with 40 patients in the conventional group and 40 patients in the segmentation-based group. The clinical improvement ratio of the Clinical Rating Scale for Tremor A + B subscore did not differ significantly between the 2 groups. The number of intraoperative target adjustments was significantly lower in the segmentation-based group (1.3 ± 0.9 vs 0.9 ± 0.7, 95% CI -0.8 to -0.1; P = .011). The number of sonications was significantly lower in the segmentation-based group (9.0 ± 2.5 vs 6.7 ± 1.8 times, 95% CI -3.3 to -1.3; P < .001). CONCLUSION: Although it is difficult to eliminate the influence of the learning curve, our retrospective analysis revealed that automated atlas segmentation application-based preoperative planning and visualization requires fewer intraoperative target adjustments and sonications than anatomical landmarks and atlas-based preoperative planning in MRgFUS Vim thalamotomy.
Operative neurosurgery (Hagerstown, Md.)Christina A Faraj, Merve Hasanov, Denái R Milton, Kalman A Katlowitz, Subhiksha Srinivasan, Dima Suki, Eric A Goethe, Sujit S Prabhu, Chibawanye I Ene, Jeffrey…
BACKGROUND AND OBJECTIVES: Surgical decision making in patients with brain metastasis is complex, particularly for patients with melanoma brain metastasis (MBM). Few studies specifically address neurosurgical outcomes based on histology. This study aims to identify clinical factors associated with early mortality and overall survival (OS) after tumor resection in patients with MBM. METHODS: Patients diagnosed with MBM from 2009 to 2018 at our institution who underwent surgical resection as their first-line therapy were included in the study. The primary outcomes were postoperative OS, 90-day mortality, and leptomeningeal disease (LMD) incidence. Associations between OS and postoperative 90-day mortality with demographic/clinical factors were assessed using Cox proportional hazards regression models and logistic regression models, respectively. The cumulative incidence of LMD was determined using competing risks, and associations with demographic/clinical factors were assessed using proportional subdistribution hazards regression models. RESULTS: A total of 103 patients with MBM were included. Ninety-day mortality occurred in 18% (n = 19). Elevated lactate dehydrogenase at MBM diagnosis (odds ratio [OR] [95% CI]: OR = 7.17 [1.50-34.25]; P = .013) was associated increased odds of early mortality in multivariable analysis. Postoperative Karnofsky Performance Scale ≥80 (OR = 0.13 [0.03-0.62]; P = .010) and MBM at stage 4 diagnosis (OR = 0.11 [0.02-0.67]; P = .016) were associated with reduced odds of early mortality. Factors associated with better postoperative OS (hazard ratio [HR] [95% CI]) included synchronous diagnosis of MBM and stage 4 disease (HR = 0.59 [0.36-0.95]; P = .032), preoperative Karnofsky Performance Scale ≥80 (HR = 0.46 [0.27-0.80]; P = .006), adjuvant stereotactic radiosurgery (HR = 0.55 [0.32-0.93]; P = .026), and surgical reduction of volumetric intracranial tumor burden ≥95.6% (HR = 0.47 [0.28-0.80]; P = .005). No factors were significantly associated with cumulative incidence of LMD. CONCLUSION: This is the largest analysis of patients with MBM who underwent surgery as first-line therapy. We identified clinical factors associated with early postoperative mortality and survival including surgical reduction of intracranial tumor burden.