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Minimally invasive surgery for spinal cerebrospinal fluid leaks in spontaneous intracranial hypotension

Jürgen Beck, Ulrich Hubbe, Jan-Helge Klingler, Roland Roelz, Luisa Mona Kraus, Florian Volz, Niklas Lützen, Horst Urbach, Kristin Kieselbach, and Christian Fung


Spinal CSF leaks cause spontaneous intracranial hypotension (SIH). Surgical closure of spinal CSF leaks is the treatment of choice for persisting leaks. Surgical approaches vary, and there are no studies in which minimally invasive techniques were used. In this study, the authors aimed to detail the safety and feasibility of minimally invasive microsurgical sealing of spinal CSF leaks using nonexpandable tubular retractors.


Consecutive patients with SIH and a confirmed spinal CSF leak treated at a single institution between April 2019 and December 2020 were included in the study. Surgery was performed via a dorsal 2.5-cm skin incision using nonexpandable tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach. The primary outcome was successful sealing of the dura, and the secondary outcome was the occurrence of complications.


Fifty-eight patients, 65.5% of whom were female (median age 46 years [IQR 36–55 years]), with 38 ventral leaks, 17 lateral leaks, and 2 CSF venous fistulas were included. In 56 (96.6%) patients, the leak could be closed, and in 2 (3.4%) patients the leak was missed because of misinterpretation of the imaging studies. One of these patients underwent successful reoperation, and the other patient decided to undergo surgery at another institution. Two other patients had to undergo reoperation because of insufficient closure and a persisting leak. The rate of permanent neurological deficit was 1.7%, the revision rate for a persisting or recurring leak was 3.4%, and the overall revision rate was 10.3%. The rate of successful sealing during the primary closure attempt was 96.6% and 3.4% patients needed a secondary attempt. Clinical short-term outcome at discharge was unchanged in 14 patients and improved in 25 patients, and 19 patients had signs of rebound intracranial hypertension.


Minimally invasive surgery with tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach is safe and effective for the treatment of spinal CSF leaks. The authors suggest performing a minimally invasive closure of spinal CSF leaks in specialized centers.

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Unilateral contrast-enhancing pontomedullary lesion due to an intracranial dural arteriovenous fistula with perimedullary spinal venous drainage: the exception that proves the rule

Roland Roelz, Vera Van Velthoven, Peter Reinacher, Volker Arnd Coenen, Irina Mader, Horst Urbach, and Stephan Meckel

A large spectrum of possible diagnoses must be taken into consideration when a contrast-enhancing lesion of the pontomedullary region is found on MRI. Among these diagnoses are neoplastic, inflammatory, and infectious, as well as vascular pathologies. The authors report a rare case of an intracranial dural arteriovenous fistula (DAVF) with perimedullary spinal venous drainage (Cognard Type V) that initially presented as a unilateral contrast-enhancing pontomedullary lesion mimicking a brainstem neoplasm in a 76-year-old man. Following occlusion of the DAVF by transarterial embolization that resulted in clinical and radiological improvement, the fistula recurred 10 months later and was finally cured by a combined endovascularand surgical approach that resulted in complete occlusion. Clinical symptoms and MRI findings gradually improved following this treatment. A literature review on the MRI findings of Cognard Type V DAVF was performed. Centrally located medullary or pontomedullary edema represents the typical imaging finding, while unilateral edema as seen in the authors’ patient is exceptionally rare. The hallmark imaging finding suggestive of DAVF consisting of perimedullary engorged vessels may not always be present or may only be very subtly visible. Therefore, the authors suggest performing contrast-enhanced MR angiography or even digital subtraction angiography in the presence of an unclear edematous brainstem lesion before scheduling stereotactic biopsy.

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Dural arteriovenous fistulas of the hypoglossal canal: systematic review on imaging anatomy, clinical findings, and endovascular management

Björn Spittau, Diego San Millán, Saad El-Sherifi, Claudia Hader, Tejinder Pal Singh, Edith Motschall, Werner Vach, Horst Urbach, and Stephan Meckel

Dural arteriovenous fistulas (DAVFs) of the hypoglossal canal (HCDAVFs) are rare and display a complex angiographic anatomy. Hitherto, they have been referred to as various entities (for example, “marginal sinus DAVFs”) solely described in case reports or small series. In this in-depth review of HCDAVF, the authors describe clinical and imaging findings, as well as treatment strategies and subsequent outcomes, based on a systematic literature review supplemented by their own cases (120 cases total). Further, the involved craniocervical venous anatomy with variable venous anastomoses is summarized. Hypoglossal canal DAVFs consist of a fistulous pouch involving the anterior condylar confluence and/or anterior condylar vein with a variable intraosseous component. Three major types of venous drainage are associated with distinct clinical patterns: Type 1, with anterograde drainage (62.5%), mostly presents with pulsatile tinnitus; Type 2, with retrograde drainage to the cavernous sinus and/or orbital veins (23.3%), is associated with ocular symptoms and may mimic cavernous sinus DAVF; and Type 3, with cortical and/or perimedullary drainage (14.2%), presents with either hemorrhage or cervical myelopathy. For Types 1 and 2 HCDAVF, transvenous embolization demonstrates high safety and efficacy (2.9% morbidity, 92.7% total occlusion). Understanding the complex venous anatomy is crucial for planning alternative approaches if standard transjugular access is impossible. Transarterial embolization or surgical disconnection (morbidity 13.3%–16.7%) should be reserved for Type 3 HCDAVFs or lesions with poor venous access. A conservative strategy could be appropriate in Type 1 HCDAVF for which spontaneous regression (5.8%) may be observed.

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Surgical treatment of parietal lobe epilepsy

Clinical article

Devin K. Binder, Martin Podlogar, Hans Clusmann, Christian Bien, Horst Urbach, Johannes Schramm, and Thomas Kral


Parietal lobe epilepsy (PLE) accounts for a small percentage of extratemporal epilepsies, and only a few and mostly smaller series have been reported. Preoperative findings, surgical strategies, pathological bases, and postoperative outcomes for PLE remain to be elucidated.


Patients with PLE were identified by screening a prospective epilepsy surgery database established in 1989 at the University of Bonn. Charts, preoperative imaging studies, surgical reports, and neuropathological findings were reviewed. Seizure outcome was classified according to Engel class (I–IV).


Forty patients (23 females and 17 males) with PLE were identified and had a mean age of 25.0 years and a mean preoperative epilepsy duration of 13.7 years. Nine patients had a significant medical history (for example, trauma, meningitis/encephalitis, or perinatal hypoxia). Preoperative MR imaging abnormalities were identified in 38 (95%) of 40 patients; 26 patients (65%) underwent invasive electroencephalography evaluation. After lesionectomy of the dominant (in 20 patients) or nondominant (in 20 patients) parietal lobe and additional multiple subpial transections (in 11 patients), 2 patients suffered from surgical and 12 from neurological complications, including temporary partial Gerstmann syndrome. There were no deaths. Histopathological analysis revealed 16 low-grade tumors, 11 cortical dysplasias, 9 gliotic scars, 2 cavernous vascular malformations, and 1 granulomatous inflammation. In 1 case, no histopathological diagnosis could be made. After a mean follow-up of 45 months, 27 patients (67.5%) became seizure free or had rare seizures (57.5% Engel Class I; 10% Engel Class II; 27.5% Engel Class III; and 5% Engel Class IV).


Parietal lobe epilepsy is an infrequent cause of extratemporal epilepsy. Satisfactory results (Engel Classes I and II) were obtained in 67.5% of patients in our series. A temporary partial hemisensory or Gerstmann syndrome occurs in a significant number of patients.

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Surgical treatment of occipital lobe epilepsy

Devin K. Binder, Marec Von Lehe, Thomas Kral, Christian G. Bien, Horst Urbach, Johannes Schramm, and Hans Clusmann


Occipital lobe epilepsy (OLE) accounts for a small percentage of extratemporal epilepsies and only few and mostly small patient series have been reported. Preoperative findings, surgical strategies, histopathological bases, and postoperative outcomes for OLE remain to be elucidated.


A group of 54 patients with occipital lobe involvement were identified from a prospective epilepsy surgery database established in 1989. Medical charts, surgical reports, MR imaging, and histopathology data were reviewed, and patients with additional temporal and/or parietal involvement were categorized separately. Seizure outcome was classified according to the Engel classification scheme (Classes I–IV). Two patients were excluded due to incomplete data sets. Fifty-two patients with intractable epilepsy involving predominantly the occipital lobe were included in the study, comprising 17.8% of 292 patients undergoing operations for extratemporal epilepsies.


In nearly all cases (50 [96.2%] of 52), a structural lesion was visible on preoperative MR imaging. Of these cases, 29 (55.8%) had “pure” OLE with no temporal or parietal lobe involvement. Most patients (83%) had complex partial seizures, and 60% also had generalized seizures. All patients underwent occipital lesionectomies or topectomies; 9 patients (17.3%) underwent additional multiple subpial transections. Histopathology results revealed 9 cortical dysplasias (17.3%), 9 gangliogliomas (17.3%), 6 other tumors (11.5%), 13 vascular malformations (25%), and 15 glial scars (28.8%). Visual field deficits were present in 36.4% of patients preoperatively, and 42.4% had new or aggravated visual field deficits after surgery. After a mean follow-up of 80 months, 36 patients were seizure free (69.2% Engel Class I), 4 rarely had seizures (7.7% Engel Class II), 8 improved more than 75% (15.4% Engel Class III), and 4 had no significant improvement (7.7% Engel Class IV). Multifactorial logistic regression analysis revealed that early age at epilepsy manifestation (p = 0.031) and shorter epilepsy duration (p = 0.004) were predictive of better seizure control. All other clinical and surgical factors were not significant in predicting outcome.


Occipital lobe epilepsy is an infrequent but significant cause of extratemporal epilepsy. Satisfactory results (Engel Class I or II) were obtained in 77% of patients in our series. Postoperative visual field deficits occurred in a significant proportion of patients. In the modern MR imaging era, lesions should be investigated in patients with OLE and lesionectomies should be performed early for a better outcome.

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Treatment of painful osteoporotic compression and burst fractures using kyphoplasty: a prospective observational design

Michael Stoffel, Iris Wolf, Florian Ringel, Carsten Stüer, Horst Urbach, and Bernhard Meyer


The aim of this study was to test the hypothesis that kyphoplasty is an effective treatment in painful osteoporotic vertebral fractures, even with involvement of the posterior cortical wall.


Between December 2001 and May 2004, 74 consecutive patients were treated with kyphoplasty for 118 painful osteoporotic compression (38%) or burst (62%) fractures. Additional decompression of the spinal canal was performed in six patients, internal fixation in three. Data were collected in a prospective observational design until May 2005. The preoperative workup included neuroimaging (plain x-ray films, densitometry, short tau inversion recovery magnetic resonance imaging, and computed tomography scanning) and clinical parameters (general and neurological examinations, visual analog scale [VAS], Karnofsky Performance Scale [KPS], and 36-Item Short Form Health Survey [SF]–36). At predefined time intervals (at discharge and 6 weeks and 3, 6, 12, and 24 months post-therapy) the patients were evaluated (x-ray films, neurological status, VAS, KPS, and SF-36).

Kyphoplasty led to a significant reduction in kyphotic deformity (mean ± standard error of the mean, sagittal index: preoperative 10 ± 1°, postoperative 5 ± 1°), and an improvement in pain (VAS: preoperative 70 ± 3, postoperative 23 ± 2), activity (KPS score: preoperative 51 ± 3, postoperative 71 ± 2), and mental and physical health (SF-36, mental status: preoperative 43, postoperative 58; SF-36, physical status: preoperative 24, postoperative 35). No secondary narrowing of the spinal canal by the retropulsed posterior wall was observed after the procedure. Clinical improvement was durable (mean follow up 15 ± 1.1 months), although the VAS score secondarily increased slightly. All patients, who suffered from a compression-induced motor deficit, recovered completely during the follow-up interval. The main procedural complications consisted of one symptomatic extravertebral cement leakage (permanent monoparesis) requiring open revision, two nerve root contusions (transient radiculopathy), and one wound infection.


Kyphoplasty is effective in the treatment of painful osteoporotic vertebral compression and burst fractures, at least under medium-term conditions. The potential complication of procedure-related secondary narrowing of the spinal canal by the retropulsed posterior wall in burst fractures appears to be more of a theoretical than an actual risk.

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Degenerative lumbar spondylolisthesis—induced radicular compression: nonfusion-related decompression in selected patients without hypermobility on flexion—extension radiographs

Rudolf A. Kristof, Ales F. Aliashkevich, Michael Schuster, Bernhard Meyer, Horst Urbach, and Johannes Schramm

Object. The authors conducted a study to determine the results of decompressive surgery without fusion in selected patients who presented with radicular compression syndromes caused by degenerative lumbar spondylolisthesis and in whom there was no evidence of hypermobility on flexion—extension radiographs.

Methods. The medical records and radiographs obtained in 49 patients were reviewed retrospectively. Clinical status was quantified by summing self-assessed Prolo Scale scores. All 49 patients (55% female, mean age 68.7 years) presented with leg pain accompanied by lumbalgia in 85.7% of the cases. Preoperatively the median sum of Prolo Scale scores was 4. The mean preoperative degree of forward vertebral displacement was 13.5% and was located at L-4 in 67% of the cases. Osseous decompression alone was performed in 53%, and an additional discectomy at the level of displacement was undertaken in the remaining patients because of herniated discs. Major complications (deep wound infection) occurred in 2%. During a mean follow-up period of 3.73 years, 10.2% of the patients underwent instrumentation-assisted lumbar fusion when decompression alone failed to resolve symptoms. At last follow up the median overall Prolo Scale score was 8. Excellent and good results were demonstrated in 73.5% of the patients. Prolonged back pain (r = 0.381) as well as the preoperative degree of displacement (r = 0.81) and disc space height (r = 0.424) influenced outcome (p ≤ 0.05); additional discectomy for simultaneous disc herniation at the displaced level did not influence outcome (p > 0.05).

Conclusions. These results appear to support a less invasive approach in this subgroup of elderly patients with degenerative lumbar spondylolisthesis—induced radicular compression syndromes and without radiographically documented hypermobility. Additional discectomy for simultaneous disc herniation of the spondylolisthetic level did not adversely influence the outcome. Complication rates are minimized and fusion can eventually be performed should decompression alone fail. A prospective controlled study is required to confirm these results.

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Is stagnating flow in former feeding arteries an indication of cerebral hypoperfusion after resection of arteriovenous malformations?

Bernhard Meyer, Horst Urbach, Carlo Schaller, and Johannes Schramm

Object. The authors' goal in this study was to challenge the proposed mechanism of the occlusive hyperemia theory, in which it is asserted that stagnating flow in the former feeding arteries of cerebral arteriovenous malformations (AVMs) leads to parenchymal hypoperfusion or ischemia, from which postoperative edema and hemorrhage originate.

Methods. Cortical oxygen saturation (SaO2) was measured in 52 patients by using microspectrophotometry in areas adjacent to AVMs before and after resection. The appearance of the former feeding arteries was categorized as normal (Group A); moderately stagnating (Group B); and excessively stagnating (Group C) on postoperative angiographic fast-film series. Patients and SaO2 values were pooled accordingly and compared using analysis of variance and Duncan tests (p < 0.05). Angiographic stagnation times in former feeding arteries were correlated in a linear regression/correlation analysis with SaO2 data (p < 0.05). All values are given as the mean ± standard deviation.

The average median postoperative SaO2 in Group C (15 patients) was significantly higher than in Groups B (17 patients) and A (20 patients) (Group C, 75.2 ± 8.5; Group B, 67.5 ± 10.8; Group A, 67.1 ± 12 %SaO2), as was the average postoperative increase in SaO2 (Group C, 25.9 ± 14.9; Group B, 14.6 ± 14; Group A, 11.1 ± 14 %SaO2). Angiographically confirmed stagnation times were also significantly longer in Group C than in Group B (Group C, 5.6 ± 2.5; Group B, 1.3 ± 0.6 seconds). A significant correlation/regression analysis showed a clear trend toward higher postoperative SaO2 levels with increasing stagnation time.

Conclusions. Stagnating flow in former feeding arteries does not cause cortical ischemia, but its presence on angiographic studies is usually indicative of hyperperfusion in the surrounding brain tissue after AVM resection. In the context of the pathophysiology of AVMs extrapolations made from angiographically visible shunt flow to blood flow in the surrounding brain tissue must be regarded with caution.

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Occlusive Hyperemia