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Florian Gessler, Markus Bruder, Stephan Duetzmann, Stephanie Tritt, Joshua D. Bernstock, Volker Seifert, and Christian Senft

OBJECTIVE

Neurosurgical intervention may increase the risk of developing cerebral vein and dural sinus thrombosis (CVT). The clinical management of CVT in postoperative patients remains unclear. This retrospective study explores the disease occurrence, associated risk factors, and outcomes in patients with tumors who developed CVT after craniotomy.

METHODS

A retrospective analysis and review of patient records in those who had undergone cranial tumor removal within the authors' neurosurgical department was performed. In so doing, the authors identified a cohort of patients who developed CVT postoperatively. The study included patients who presented to the department between January 2004 and December 2013.

RESULTS

Of 2286 patients with intracranial lesions who underwent craniotomy, 35 (1.5%) went on to develop CVT. The authors identified the semisitting position (OR 7.55, 95% CI 3.73–15.31, p < 0.001); intraoperative sinus injury (OR 1.5, 95% CI 3.57–15.76, p < 0.001); and known CVT risk factors (OR 7.77, 95% CI 2.28–21.39, p < 0.001) as predictors of CVT development. Of note, 19 patients (54.3%) had good outcomes (modified Rankin Scale Score 0–1), whereas 9 patients (25.7%) had suffered dependency or death (modified Rankin Scale Score 4–6) at last follow-up. Intracerebral hemorrhage (OR 21.27, 95% CI 1.59–285.01, p = 0.02) and delayed delivery of an intermediate dose of low-molecular-weight heparin anticoagulation (OR 24.12, 95% CI 2.08–280.13, p = 0.01) were associated with unfavorable outcomes.

CONCLUSIONS

Only a minority of patients undergoing craniotomy for tumor removal develop CVT, and the majority of those who do develop CVT recover well. Early administration of an intermediate dose of low-molecular-weight heparin anticoagulation might be considered once CVT is diagnosed.

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Johannes Platz, Erdem Güresir, Marlies Wagner, Volker Seifert, and Juergen Konczalla

OBJECTIVE

Delayed cerebral ischemia (DCI) has a major impact on the outcome of patients suffering from aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to assess the influence of an additional intracerebral hematoma (ICH) on the occurrence of DCI.

METHODS

The authors conducted a single-center retrospective analysis of cases of SAH involving patients treated between 2006 and 2011. Patients who died or were transferred to another institution within 10 days after SAH without the occurrence of DCI were excluded from the analysis.

RESULTS

Additional ICH was present in 123 (24.4%) of 504 included patients (66.7% female). ICH was classified as frontal in 72 patients, temporal in 24, and perisylvian in 27. DCI occurred in 183 patients (36.3%). A total of 59 (32.2%) of these 183 patients presented with additional ICH, compared with 64 (19.9%) of the 321 without DCI (p = 0.002). In addition, DCI was detected significantly more frequently in patients with higher World Federation of Neurosurgical Societies (WFNS) grades.

The authors compared the original and modified Fisher Scales with respect to the occurrence of DCI. The modified Fisher Scale (mFS) was superior to the original Fisher Scale (oFS) in predicting DCI. Furthermore, they suggest a new classification based on the mFS, which demonstrates the impact of additional ICH on the occurrence of DCI.

After the different scales were corrected for age, sex, WFNS score, and aneurysm site, the oFS no longer was predictive for the occurrence of DCI, while the new scale demonstrated a superior capacity for prediction as compared with the mFS.

CONCLUSIONS

Additional ICH was associated with an increased risk of DCI in this study. Furthermore, adding the presence or absence of ICH to the mFS improved the identification of patients at the highest risk for the development of DCI. Thus, a simple adjustment of the mFS might help to identify patients at high risk for DCI.

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Philipp J. Slotty, Amr Abdulazim, Kunihiko Kodama, Mani Javadi, Daniel Hänggi, Volker Seifert, and Andrea Szelényi

OBJECTIVE

Methods of choice for neurophysiological intraoperative monitoring (IOM) within the infratentorial compartment mostly include early brainstem auditory evoked potentials, free-running electromyography, and direct cranial nerve (CN) stimulation. Long-tract monitoring with somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) is rarely used. This study investigated the incidence of IOM alterations during posterior fossa surgery stratified for lesion location.

METHODS

Standardized CN and SEP/MEP IOM was performed in 305 patients being treated for various posterior fossa pathologies. The IOM data were correlated with lesion locations and histopathological types as well as other possible confounding factors.

RESULTS

Alterations in IOM were observed in 158 of 305 cases (51.8%) (CN IOM alterations in 130 of 305 [42.6%], SEP/MEP IOM alterations in 43 of 305 [14.0%]). In 15 cases (4.9%), simultaneous changes in long tracts and CNs were observed. The IOM alterations were followed by neurological sequelae in 98 of 305 cases (32.1%); 62% of IOM alterations resulted in neurological deficits. Sensitivity and specificity for detection of CN deficits were 98% and 77%, respectively, and 95% and 85%, respectively, for long-tract deficits. Regarding location, brainstem and petroclival lesions were closely associated with concurrent CN IOM and SEP/MEP alterations.

CONCLUSIONS

The incidence of IOM alterations during surgery in the posterior fossa varied widely between different lesion locations and histopathological types. This analysis provides crucial information on the necessity of IOM in different surgical settings. Because MEP/SEP and CN IOM alterations were commonly observed during posterior fossa surgery, the authors recommend the simultaneous use of both modalities based on lesion location.

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Juergen Konczalla, Sepide Kashefiolasl, Nina Brawanski, Christian Senft, Volker Seifert, and Johannes Platz

OBJECT

Subarachnoid hemorrhage (SAH) is usually caused by a ruptured intracranial aneurysm, but in some patients no source of hemorrhage can be detected. More recent data showed increasing numbers of cases of spontaneous nonaneurysmal SAH (NASAH). The aim of this study was to analyze factors, especially the use of antithrombotic medications such as systemic anticoagulation or antiplatelet agents (aCPs), influencing the increasing numbers of cases of NASAH and the clinical outcome.

METHODS

Between 1999 and 2013, 214 patients who were admitted to the authors’ institution suffered from NASAH, 14% of all patients with SAH. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months. Risk factors were identified based on the outcome.

RESULTS

The number of patients with NASAH increased significantly in the last 15 years of the study period. There was a statistically significant increase in the rate of nonperimesencephalic (NPM)-SAH occurrence and aCP use, while the proportion of elderly patients remained stable. Favorable outcome (mRS 0–2) was achieved in 85% of cases, but patients treated with aCPs had a significantly higher risk for an unfavorable outcome. Further analysis showed that elderly patients, and especially the subgroup with a Fisher Grade 3 bleeding pattern, had a high risk for an unfavorable outcome, whereas the subgroup of NPM-SAH without a Fisher Grade 3 bleeding pattern had a favorable outcome, similar to perimesencephalic (PM)-SAH.

CONCLUSIONS

Over the years, a significant increase in the number of patients with NASAH has been observed. Also, the rate of aCP use has increased significantly. Risk factors for an unfavorable outcome were age > 65 years, Fisher Grade 3 bleeding pattern, and aCP use. Both “PM-SAH” and “NPM-SAH without a Fisher Grade 3 bleeding pattern” had excellent outcomes. Patients with NASAH and a Fisher Grade 3 bleeding pattern had a significantly higher risk for an unfavorable outcome and death. Therefore, for further investigations, NPM-SAH should be stratified into patients with or without a Fisher Grade 3 bleeding pattern. Also, cases of spontaneous SAH should be stratified into NASAH and aneurysmal SAH.

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Patrick Schuss, Jürgen Konczalla, Johannes Platz, Hartmut Vatter, Volker Seifert, and Erdem Güresir

Object

Subarachnoid hemorrhage (SAH) with simultaneous acute subdural hematoma (SDH) is a severe disease. The authors' objective was to analyze the incidence, prognosis, and clinical outcome of patients suffering from aneurysm-related SAH and space-occupying acute SDH.

Methods

Between June 1999 and June 2011, data from 989 patients with aneurysm-related SAH were prospectively entered into a database. Eighteen patients (1.8%) presented with aneurysm-related SAH and space-occupying acute SDH. The treatment decision (clip or coil) was based on an interdisciplinary approach. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months and was dichotomized into favorable outcome (mRS Score 0–2) versus unfavorable outcome (mRS Score 3–6). PubMed was searched for published studies of aneurysm-related SAH and acute SDH to gain a larger population. A multivariate regression analysis was performed on the pooled data.

Results

Literature data, including the current series, revealed a total of 111 patients. Overall, 38 (34%) of 111 patients with aneurysm-related SAH and acute SDH achieved favorable outcome. Favorable outcome was achieved in 68% of patients with good-grade clinical presentation on admission (Hunt and Hess Grades I–III) versus 23% of the patients with poor-grade presentation (Hunt and Hess Grades IV and V, p < 0.0001). In the multivariate analysis, poor clinical condition at admission was the only predictor for unfavorable outcome (p = 0.02).

Conclusions

The present data confirm that patients with aneurysm-related SAH and acute SDH, even when presenting in poor clinical condition, might achieve favorable outcome. Therefore, treatment of patients with SAH and acute SDH should not be discontinued, but careful individual decision making is necessary for each patient.

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Giuseppe Lanzino

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Erdem Güresir, Patrick Schuss, Volker Seifert, and Hartmut Vatter

Object

Resolution of oculomotor nerve palsy (ONP) after clipping of posterior communicating artery (PCoA) aneurysms has been well documented. However, whether additional decompression of the oculomotor nerve via aneurysm sac dissection or resection is superior to pure aneurysm clipping is the subject of much debate. Therefore, the objective in the present investigation was to analyze the influence of surgical strategy—specifically, clipping with or without aneurysm dissection—on ONP resolution.

Methods

Between June 1999 and December 2010, 18 consecutive patients with ruptured and unruptured PCoA aneurysms causing ONP were treated at the authors' institution. Oculomotor nerve palsy was evaluated on admission and at follow-up. The electronic database MEDLINE was searched for additional data in published studies of PCoA aneurysms causing ONP. Two reviewers independently extracted data.

Results

Overall, 8 studies from the literature review and 6 patients in the current series (121 PCoA aneurysms) met the study inclusion criteria. Ninety-four aneurysms were treated with simple aneurysm neck clipping and 27 with clipping plus aneurysm sac decompression. The surgical strategy, simple aneurysm neck clipping versus clipping plus oculomotor nerve decompression, had no effect on full ONP resolution on univariate (p = 0.5) and multivariate analyses. On multivariate analysis, patients with incomplete ONP at admission were more likely to have full resolution of the palsy than were those with complete ONP at admission (p = 0.03, OR = 4.2, 95% CI 1.1–16).

Conclusions

Data in the present study indicated that ONP caused by PCoA aneurysms improves after clipping without and with oculomotor nerve decompression. The resolution of ONP is inversely associated with the initial severity of ONP.

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Andrew E. Sloan

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Ági Oszvald, Erdem Güresir, Matthias Setzer, Hartmut Vatter, Christian Senft, Volker Seifert, and Kea Franz

Object

The objective of this study was to analyze whether age influences the outcome of patients with glioblastoma and whether elderly patients with glioblastoma can tolerate the same aggressive treatment as younger patients.

Methods

Data from 361 consecutive patients with newly diagnosed cerebral glioblastoma (2000–2006) who underwent regular follow-up evaluation from initial diagnosis until death were prospectively entered into a database. Patients underwent resection (complete, subtotal, or partial) or biopsy, depending on tumor size, location, and Karnofsky Performance Scale score. Following surgery, all patients underwent adjuvant treatment consisting of radiotherapy, chemotherapy, or combined treatment. Patients older than 65 years of age were defined as elderly (146 total).

Results

Two hundred thirty-four patients underwent tumor resection (complete 26%, subtotal 29%, and partial 45%). One hundred twenty-seven underwent biopsy. Mean patient age was 61 years, and overall survival was 11.6 ± 12.1 months. The overall survival of elderly patients (9.1 ± 11.6 months) was significantly lower than that of younger patients (14.9 ± 16.7 months; p = 0.0001). Stratifying between resection or biopsy, age was a negative prognostic factor in patients undergoing biopsy (4.0 ± 7.1 vs 7.9 ± 8.7 months; p = 0.007), but not in patients undergoing tumor resection (13.0 ± 8.5 vs 13.3 ± 14.5 months; p = 0.86). Survival of elderly patients undergoing complete tumor resection was 17.7 ± 8.1 months.

Conclusions

In this series of patients with glioblastoma, age was a prognostic factor in patients undergoing biopsy, but not in patients undergoing resection. Tumor location and patient clinical status may prohibit extensive resection, but resection should not be withheld from patients only on the basis of age. In elderly patients with glioblastoma, undergoing resection to the extent feasible, followed by adjuvant therapies, is warranted.

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Patrick Schuss, Erdem Güresir, Joachim Berkefeld, Volker Seifert, and Hartmut Vatter

Object

Intracranial aneurysms of the anterior circulation might become symptomatic by causing visual deficits. The influence of treatment modality on improvement is still unclear. The objective of this study was to analyze the recovery of visual deficits caused by the mass effect of intracranial aneurysms after surgical clipping or endovascular treatment.

Methods

Between June 1999 and December 2009, 20 patients with unruptured intracranial aneurysms causing visual dysfunction due to compression of the optical nerve were treated at the authors' institution. Visual deficits were recorded at admission and at follow-up. To evaluate a larger number of patients, MEDLINE was searched for published studies involving visual disturbance caused by an aneurysm. A multivariate analysis was performed to find independent predictors for favorable visual outcome.

Results

Nine (75%) of 12 patients treated surgically achieved improvement of visual symptoms, compared with 3 (38%) of 8 patients treated endovascularly. A literature review, including the current series, revealed a total of 165 patients with UIAs causing visual dysfunction. Surgical treatment was associated with a significantly higher rate of visual improvement (p = 0.002) compared with endovascular treatment. According to the multivariate analysis, surgical clipping was the only variable significantly associated with improvement of visual outcome (p = 0.02).

Conclusions

Aneurysm-related visual dysfunction developed from direct mechanical compression may improve after surgical clipping and endovascular coiling. However, based on the present series combined with pooled analysis of data from the literature, the only factor significantly associated with improvement of visual dysfunction was surgical clipping.