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  • Author or Editor: Volker Seifert x
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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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Ági Oszvald, Hartmut Vatter, Christian Byhahn, Volker Seifert and Erdem Güresir

Object

Quality and safety are basic concerns in any medical practice. Especially in daily surgical practice, with increasing turnover and shortened procedure times, attention to these topics needs to be assured. Starting in 2007, the authors used a perioperative checklist in all elective procedures and extended the checklist in January 2011 according to the so-called team time-out principles, with additional assessment of patient identity and the planned surgical procedure performed immediately before skin incision, including the emergency cases.

Methods

The advanced perioperative checklist includes parts for patient identification, preoperative assessments, team time-out, postoperative treatment, and imaging controls. All parts are signed by the responsible physician except for the team time-out, which is performed and signed by the theater nurse on behalf of the surgeon immediately before skin incision.

Results

Between January 2007 and December 2010, 1 wrong-sided bur hole in an emergency case and 1 wrong-sided lumbar approach in an elective case (of 8795 surgical procedures) occurred in the authors' department. Using the advanced perioperative checklist including the team time-out principles, no error occurred in 3595 surgical procedures (January 2011–June 2012). In the authors' department all team members appreciate the chance to focus on the patient, the surgical procedure, and expected difficulties. The number of incomplete checklists and of patients not being transferred into the operating room was lowered significantly (p = 0.002) after implementing the advanced perioperative checklist.

Conclusions

In the authors' daily experience, the advanced perioperative checklist developed according to the team time-out principles improves preoperative workup and the focus of the entire team. The focus is drawn to the procedure, expected difficulties of the surgery, and special needs in the treatment of the particular patient. Especially in emergency situations, the team time-out synchronizes the involved team members and helps to improve patient safety.

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Giuseppe Lanzino

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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.

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Matthias Setzer, Hartmut Vatter, Gerhard Marquardt, Volker Seifert and Frank D. Vrionis

Object

In this report, the authors describe their experience in the surgical management of spinal meningiomas at two neurosurgical centers. The results of a literature review are also presented.

Methods

Eighty consecutive patients (22 men and 58 women) with spinal meningiomas who had undergone an operation at two specific neurosurgical centers were included in this study. Functional outcomes were evaluated using univariate and multivariate analyses. A review of the literature yielded an additional 651 patients with spinal meningiomas from 9 large studies.

Results

On multivariate analysis, the variable of a poor preoperative neurological state (p < 0.02, odds ratio [OR] 13.6, 95% confidence interval [CI] 2.6–71.4) and invasion of the arachnoid/pia mater (p < 0.03, OR 15.2, 95% CI 2.5–90.4) were independent predictors of a poor outcome, whereas invasion of the arachnoid/pia (p < 0.02, OR 8.9, 95% CI 2.2–35) and duration of symptoms (p < 0.001, OR 1.12/month, 95% CI 1.05–1.2) predicted no improvement (stable or deteriorated condition). The Cox proportional hazards regression analysis showed three significant predictor variables for recurrence: invasion of the arachnoid/pia (p < 0.05; hazard ratio [HR] 1.8, 95% CI 1.2–3.6), Simpson resection grade (p < 0.012, HR 6.8, 95% CI 1.5–3.0), and histological tumor grade (Grade I; p < 0.001, HR 0.001–0.17).

Conclusions

Because of the excellent outcome of surgery for benign spinal meningiomas and the association between duration of symptoms and neurological compromise with a poor functional outcome, early operation is the treatment of choice. In cases of malignant transformation, adjuvant therapies must be considered.

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Juergen Konczalla, Volker Seifert, Juergen Beck, Erdem Güresir, Hartmut Vatter, Andreas Raabe and Gerhard Marquardt

OBJECTIVE

Outcome analysis of comatose patients (Hunt and Hess Grade V) after subarachnoid hemorrhage (SAH) is still lacking. The aims of this study were to analyze the outcome of Hunt and Hess Grade V SAH and to compare outcomes in the current period with those of the pre–International Subarachnoid Aneurysm Trial (ISAT) era as well as with published data from trials of decompressive craniectomy (DC) for middle cerebral artery (MCA) infarction.

METHODS

The authors analyzed cases of Hunt and Hess Grade V SAH from 1980–1995 (referred to in this study as the earlier period) and 2005–2014 (current period) and compared the results for the 2 periods. The outcomes of 257 cases were analyzed and stratified on the basis of modified Rankin Scale (mRS) scores obtained 6 months after SAH. Outcomes were dichotomized as favorable (mRS score of 0–2) or unfavorable (mRS score of 3–6). Data and number needed to treat (NNT) were also compared with the results of decompressive craniectomy (DC) trials for middle cerebral artery (MCA) infarctions.

RESULTS

Early aneurysm treatment within 72 hours occurred significantly more often in the current period (in 67% of cases vs 22% in earlier period). In the earlier period, patients had a significantly higher 30-day mortality rate (83% vs 39% in the current period) and 6-month mortality rate (94% vs 49%), and no patient (0%) had a favorable outcome, compared with 23% overall in the current period (p < 0.01, OR 32), or 29.5% of patients whose aneurysms were treated (p < 0.01, OR 219). Cerebral infarctions occurred in up to 65% of the treated patients in the current period.

Comparison with data from DC MCA trials showed that the NNTs were significantly lower in the current period with 2 for survival and 3 for mRS score of 0–3 (vs 3 and 7, respectively, for the DC MCA trials).

CONCLUSIONS

Early and aggressive treatment resulted in a significant improvement in survival rate (NNT = 2) and favorable outcome (NNT = 3 for mRS score of 0–3) for comatose patients with Hunt and Hess Grade V SAH compared with the earlier period. Independent predictors for favorable outcome were younger age and bilateral intact corneal reflexes. Despite a high rate of cerebral infarction (65%) in the current period, 29.5% of the patients who received treatment for their aneurysms during the current era (2005–2014) had a favorable outcome. However, careful individual decision making is essential in these cases.

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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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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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Erdem Güresir, Hartmut Vatter, Patrick Schuss, Ági Oszvald, Andreas Raabe, Volker Seifert and Jürgen Beck

Object

The object of this study was to describe the rapid closure technique in decompressive craniectomy without duraplasty and its use in a large cohort of consecutive patients.

Methods

Between 1999 and 2008, supratentorial rapid closure decompressive craniectomy (RCDC) was performed 341 times in 318 patients at the authors' institution. Cases were stratified as 1) traumatic brain injury, 2) subarachnoid hemorrhage, 3) intracerebral hemorrhage, 4) cerebral infarction, and 5) other. A large bone flap was removed and the dura mater was opened in a stellate fashion. Duraplasty was not performed—that is, the dura was not sutured, and a dural substitute was neither sutured in nor layed on. The dura and exposed brain tissue were covered with hemostyptic material (Surgicel). Surgical time and complications of this procedure including follow-up (> 6 months) were recorded. After 3–6 months cranioplasty was performed, and, again, surgical time and any complications were recorded.

Results

Rapid closure decompressive craniectomy was feasible in all cases. Complications included superficial wound healing disturbance (3.5% of procedures), abscess (2.6%) and CSF fistula (0.6%); the mean surgical time (± SD) was 69 ± 20 minutes. Cranioplasty was performed in 196 cases; the mean interval (± SD) from craniectomy to cranioplasty was 118 ± 40 days. Complications of cranioplasty included epidural hematoma (4.1%), abscess (2.6%), wound healing disturbance (6.1%), and CSF fistula (1%).

Compared with the results reported in the literature for decompressive craniectomy with duraplasty followed by cranioplasty, there were no significant differences in the frequency of complications. However, surgical time for RCDC was significantly shorter (69 ± 20 vs 129 ± 43 minutes, p < 0.0001).

Conclusions

The present analysis of the largest series reported to date reveals that the rapid closure technique is feasible and safe in decompressive craniectomy. The surgical time is significantly shorter without increased complication rates or additional complications. Cranioplasty after a RCDC procedure was also feasible, fast, safe and not impaired by the RCDC technique.

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Erdem Güresir, Patrick Schuss, Hartmut Vatter, Andreas Raabe, Volker Seifert and Jürgen Beck

Object

The aim of this study was to analyze decompressive craniectomy (DC) in the setting of subarachnoid hemorrhage (SAH) with bleeding, infarction, or brain swelling as the underlying pathology in a large cohort of consecutive patients.

Methods

Decompressive craniectomy was performed in 79 of 939 patients with SAH. Patients were stratified according to the indication for DC: 1) primary brain swelling without or 2) with additional intracerebral hematoma, 3) secondary brain swelling without rebleeding or infarcts, and 4) secondary brain swelling with infarcts or 5) with rebleeding. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months (mRS Score 0–3 favorable vs 4–6 unfavorable).

Results

Overall, 61 (77.2%) of 79 patients who did and 292 (34%) of the 860 patients who did not undergo DC had a poor clinical grade on admission (World Federation of Neurosurgical Societies Grade IV–V, p < 0.0001). A favorable outcome was attained in 21 (26.6%) of 79 patients who had undergone DC. In a comparison of favorable outcomes in patients with primary (28.0%) or secondary DC (25.5%), no difference could be found (p = 0.8). Subgroup analysis with respect to the underlying indication for DC (brain swelling vs bleeding vs infarction) revealed no difference in the rate of favorable outcomes. On multivariate analysis, acute hydrocephalus (p = 0.009) and clinical signs of herniation (p = 0.02) were significantly associated with an unfavorable outcome.

Conclusions

Based on the data in this study the authors concluded that primary as well as secondary craniectomy might be warranted, regardless of the underlying etiology (hemorrhage, infarction, or brain swelling) and admission clinical grade of the patient. The time from the onset of intractable intracranial pressure to DC seems to be crucial for a favorable outcome, even when a DC is performed late in the disease course after SAH.