Outcomes of retreatment for intracranial aneurysms - a meta-analysis

Long term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with coiling compared to clipping, but do not report the outcome of retreatment. The aim of this meta-analysis was to evaluate retreatment related outcomes.A meta-analysis in accordance with PRISMA guidelines was conducted using Medline search engines PubMed and EMBASE to identify articles describing outcomes after retreatment for intracranial aneurysms. Pooled prevalence rates for complete occlusion rate and mortality were calculated. Outcomes of different treatment and retreatment combinations were not compared because of indication bias. Twenty-five articles that met the inclusion criteria were included in the meta-analysis. Surgery after coiling had a pooled complete occlusion rate of 91.2% (95%-CI: 87.0-94.1) and a pooled mortality rate of 5.6% (95%-CI: 3.7-8.3). Coiling after coiling had a pooled complete occlusion rate of 51.3% (95%-CI: 22.1-78.0) and a pooled mortality rate of 0.8% (95%-CI: 0.15-3.7). Surgery after surgery did not provide a pooled estimate for complete occlusion as only one study was identified but had a pooled mortality rate of 5.9% (95%-CI: 3.1-11.2). Coiling after surgery had a pooled complete occlusion rate of 56.1% (95%-CI: 11.4- 92.7) and a pooled mortality rate of 9.3% (95%-CI: 4.1-19.9). All pooled incidence rates were produced using random-effect models.Conclusion:Surgical retreatment was associated with a high complete occlusion rate but considerable mortality. Conversely, endovascular retreatment was associated with low mortality but also a low complete occlusion rate. Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

When Time Is Critical, Is Informed Consent Less So? A Discussion of Patient Autonomy in Emergency Neurosurgery

Neurosurgical interventions frequently occur in an emergency setting. In this setting, patients often have impaired consciousness and are unable to directly express their values and wishes regarding their treatment. The limited time available for clinical decision making has great ethical implications, as the informed consent procedure may become compromised. The ethical situation may be further challenged by different views between the patient, family members, and the neurosurgeon; the presence of advance directives; the use of an innovative procedure; or if the procedure is part of a research project. This moral opinion piece presents the implications of time constraints and a lack of patient capacity for autonomous decision making in emergency neurosurgical situations. Potential solutions to these challenges are presented that may help to improve ethical patient management in emergency settings. Emergency neurosurgery challenges the respect of autonomy of the patient. The outcome in most scenarios will rely on the neurosurgeon acting in a professional way to manage each unique situation in an ethically sound manner.Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

Fibrinolytics and intraventricular hemorrhage: a systematic review and meta-analysis

Intraventricular hemorrhage (IVH) is an independent poor prognostic factor in subarachnoid and intra-parenchymal hemorrhage. The use of intraventricular fibrinolytics (IVF) has long been debated, and its exact effects on outcomes are unknown. A systematic review and meta-analysis were performed in accordance with the PRISMA guidelines to assess the impact of IVF after non-traumatic IVH on mortality, functional outcome, intracranial bleeding, ventriculitis, time until clearance of third and fourth ventricles, obstruction of external ventricular drains (EVD), and shunt dependency. Nineteen studies were included in the meta-analysis, totaling 1020 patients. IVF was associated with lower mortality (relative risk [RR] 0.58; 95% confidence interval [CI] 0.47-0.72), fewer EVD obstructions (RR 0.41; 95% CI 0.22-0.74), and a shorter time until clearance of the ventricles (median difference [MD] - 4.05 days; 95% CI - 5.52 to - 2.57). There was no difference in good functional outcome, RR 1.41 (95% CI 0.98-2.03), or shunt dependency, RR 0.93 (95% CI 0.70-1.22). Correction for publication bias predicted an increased risk of intracranial bleeding, RR 1.67 (95% CI 1.01-2.74) and a lower risk of ventriculitis, RR 0.68 (95% CI 0.45-1.03) in IVH patients treated with IVF. IVF was associated with improved survival, faster clearance of blood from the ventricles and fewer drain obstructions, but further research is warranted to elucidate the effects on ventriculitis, long-term functional outcomes, and re-hemorrhage.Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

The endoscope-assisted supraorbital "keyhole" approach for anterior skull base meningiomas: an updated meta-analysis

Introduction The gold-standard treatment for symptomatic anterior skull base meningiomas is surgical resection. The endoscope-assisted supraorbital "keyhole" approach (eSKA) is a promising technique for surgical resection of olfactory groove (OGM) and tuberculum sellae meningioma (TSM) but has yet to be compared with the microscopic transcranial (mTCA) and the expanded endoscopic endonasal approach (EEA) in the context of existing literature. Methods An updated study-level meta-analysis on surgical outcomes and complications of OGM and TSM operated with the eSKA, mTCA, and EEA was conducted using random-effect models. Results A total of 2285 articles were screened, yielding 96 studies (2191 TSM and 1510 OGM patients). In terms of effectiveness, gross total resection incidence was highest in mTCA (89.6% TSM, 91.1% OGM), followed by eSKA (85.2% TSM, 84.9% OGM) and EEA (83.9% TSM, 82.8% OGM). Additionally, the EEA group had the highest incidence of visual improvement (81.9% TSM, 54.6% OGM), followed by eSKA (65.9% TSM, 52.9% OGM) and mTCA (63.9% TSM, 45.7% OGM). However, in terms of safety, the EEA possessed the highest cerebrospinal fluid leak incidence (9.2% TSM, 14.5% OGM), compared with eSKA (2.1% TSM, 1.6% OGM) and mTCA (1.6% TSM, 6.5% OGM). Finally, mortality and intraoperative arterial injury were 1% or lower across all subgroups. Conclusions In the context of diverse study populations, the eSKA appeared not to be associated with increased adverse outcomes when compared with mTCA and EEA and offered comparable effectiveness. Case-selection is paramount in establishing a role for the eSKA in anterior skull base tumours.Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

The endoscopic endonasal approach is not superior to the microscopic transcranial approach for anterior skull base meningiomas-a meta-analysis

Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

Innovation in neurosurgery: Evaluation of neurosurgical innovation, related ethics, and solutions

Patient outcomes have been tremendously improved through neurosurgical innovation for which there are countless examples. However, how neurosurgical innovation occurs generally lacks structure. This lack results in several ethical and practical problems related to patient safety. In this thesis, a new framework for neurosurgical innovation is proposed. This framework aims to provide an adequate valuation of structured and careful innovation. In recent neurosurgical innovations, related ethical dillema’s and excisiting frameworks for innovation were evaluated to come to this framework.Based on an extensive review of the literature, several recent neurosurgical innovations were not introduced in a structured fashion. This unstructured introduction holds potentially far-reaching consequences for informed consent, patient safety, and knowledge regarding long-term outcomes.Neurosurgical innovation holds several ethical dilemmas. These dilemmas range from the need to innovate in an emergency setting to the learning curve that every novel procedure brings. This thesis describes these dilemmas in detail and discusses potential solutions.Existing frameworks for innovation in medicine, such as the IDEAL Framework and learning health systems, have limited application to neurosurgery because of its unique patient population. Nevertheless, these frameworks form the inspiration for the beforementioned newly suggested framework for neurosurgical innovation. LUMC / Geneeskund

The endoscopic endonasal approach or microscopic transcranial approach for anterior skull base meningiomas-it is all about right indication rather than superiority

Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

Letter: Laser Ablation of Abnormal Neurological Tissue using Robotic Neuroblate System (LAANTERN): Procedural Safety and Hospitalization

Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

Treatment and survival differences across tumor sites in malignant peripheral nerve sheath tumors: a SEER database analysis and review of the literature

Scientific Assessment and Innovation in Neurosurgical Treatment Strategie

Outcomes of retreatment for intracranial aneurysms - a meta-analysis

Long term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with coiling compared to clipping, but do not report the outcome of retreatment. The aim of this meta-analysis was to evaluate retreatment related outcomes.A meta-analysis in accordance with PRISMA guidelines was conducted using Medline search engines PubMed and EMBASE to identify articles describing outcomes after retreatment for intracranial aneurysms. Pooled prevalence rates for complete occlusion rate and mortality were calculated. Outcomes of different treatment and retreatment combinations were not compared because of indication bias. Twenty-five articles that met the inclusion criteria were included in the meta-analysis. Surgery after coiling had a pooled complete occlusion rate of 91.2% (95%-CI: 87.0-94.1) and a pooled mortality rate of 5.6% (95%-CI: 3.7-8.3). Coiling after coiling had a pooled complete occlusion rate of 51.3% (95%-CI: 22.1-78.0) and a pooled mortality rate of 0.8% (95%-CI: 0.15-3.7). Surgery after surgery did not provide a pooled estimate for complete occlusion as only one study was identified but had a pooled mortality rate of 5.9% (95%-CI: 3.1-11.2). Coiling after surgery had a pooled complete occlusion rate of 56.1% (95%-CI: 11.4- 92.7) and a pooled mortality rate of 9.3% (95%-CI: 4.1-19.9). All pooled incidence rates were produced using random-effect models.Conclusion:Surgical retreatment was associated with a high complete occlusion rate but considerable mortality. Conversely, endovascular retreatment was associated with low mortality but also a low complete occlusion rate. </p