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Physiological Salt Solutions for Brain Surgery

Studies of Local pH and Pial Vessel Reactions to Buffered and Unbuffered Isotonic Solutions

K. A. C. Elliott and H. H. Jasper

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Kim Rijkers, Jasper van Aalst, Erkan Kurt, Marc A. Daemen, Emile A. M. Beuls and Geert H. Spincemaille

The authors present the case of a 49-year-old female patient with complex regional pain syndrome–Type I (CRPSI) who was suffering from nonhealing wounds and giant bullae, which dramatically improved after spinal cord stimulation (SCS). The scientific literature concerning severe cutaneous manifestations of CRPS-I and their treatment is reviewed. Nonhealing wounds and bullae are rare manifestations of CRPS-I that are extremely difficult to treat. Immediate improvement of both wounds and bullae after SCS, such as in this case, has not been reported previously in literature. Considering the rapidly progressive nature of these severe skin manifestations, immediate treatment, possibly with SCS, is mandatory.

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Jasper van Aalst, Toon F. M. Boselie, Emile A. M. Beuls, Johan S. H. Vles and Henny W. M. van Straaten


The origin of spinal congenital dermal sinuses is not known. A local nondisjunction of the closing neural tube and the epidermal ectoderm is thought to be the cause of this malformation. In this experimental study, a nondisjunction was mimicked in chick embryos to create an animal model for the dermal sinus.


A piece of amniotic tissue was implanted in the closing neural tube in ovo in chick embryos at 2 days of incubation. A total of 50 embryos were manipulated. After a further incubation time of 2–7 days, the embryos were macroscopically and histologically evaluated.


Dermal sinus–like anomalies were induced in 24 embryos. The induced abnormalities varied from superficial, epidermal lesions to epidermal dimples continuing as a strand of tissue toward the neural tube. This strand invariably was of nonneuronal origin. Additionally, in 3 embryos a split cord malformation was noted, most likely caused by damage to the neural tube during implantation.


Implantation of donor amniotic tissue in the closing chick neural tube does result in a dimple, from which a strand of tissue continues to the neural tube in various cases, indicating that formation of a dermal sinus–like anomaly can be successfully induced by experimental continuation of the connection between neural tube and surface ectoderm. This finding strengthens the hypothesis that a human dermal sinus arises after nondisjunction of neural tube and surface ectoderm.

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Jasper van Aalst, Emile A. M. Beuls, Ferenc A. van Nie, Johan S. H. Vles and Erwin M. J. Cornips

✓ The authors report on four third ventriculostomy procedures in which upward ballooning of the third ventricular floor occurred immediately after perforation of the floor and withdrawal of a Fogarty catheter. The floor herniated into the third ventricle, hindering the endoscopic view.

Preoperative magnetic resonance imaging demonstrated a similar anatomy in all four cases, consisting of hydrocephalus, extreme dilation of the third ventricle, and disappearance of the interpeduncular cistern due to a very thin, membranous floor of the third ventricle, which herniated downward, draping over the basilar artery. The authors suggest that excessive rinsing in combination with this anatomical configuration provoked the phenomenon of upward ballooning of the third ventricular floor, which is described in this report.

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Jasper H. van Lieshout, Ina Pumplün, Igor Fischer, Marcel A. Kamp, Jan F. Cornelius, Hans J. Steiger, Hieronymus D. Boogaarts, Athanasios K. Petridis and Kerim Beseoglu


Initiation of external CSF drainage has been associated with a significant increase in rebleeding probability after aneurysmal subarachnoid hemorrhage (aSAH). However, the implications for acute management are uncertain. The purpose of this study was to evaluate the role of the amount of drained CSF on aneurysmal rebleeding.


Consecutive patients with aSAH were analyzed retrospectively. Radiologically confirmed cases of aneurysmal in-hospital rebleeding were identified and predictor variables for rebleeding were retrieved from hospital records. Clinical predictors were identified through multivariate analysis, and logistic regression analysis was performed to ascertain the cutoff value for the rebleeding probability.


The study included 194 patients. Eighteen cases (9.3%) of in-hospital rebleeding could be identified. Using multivariate analysis, in-hospital rebleeding was significantly associated with initiation of CSF drainage (p = 0.001) and CSF drainage volume (63 ml [interquartile range (IQR) 55–69 ml] vs 25 ml [IQR 10–35 ml], p < 0.001). Logistic regression showed that 58 ml of CSF drainage within 6 hours results in a 50% rebleeding probability. The relative risk (RR) for rebleeding after drainage of more than 60 ml in 6 hours was 5.4 times greater compared with patients with less CSF drainage (RR 5.403, 95% CI 2.481–11.767; p < 0.001, number needed to harm = 1.687).


Volume of CSF drainage was highly correlated with the probability of in-hospital aneurysmal rebleeding. These findings suggest that the rebleeding probability can be affected in acute management should the placement of an external ventricular catheter be necessary. This finding necessitates meticulous control of the amount of drained CSF and the development of a definitive treatment protocol for this group of patients.

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Hieronymus D. Boogaarts, Jasper H. van Lieshout, Martinus J. van Amerongen, Joost de Vries, André L. M. Verbeek, J. André Grotenhuis, Gert P. Westert and Ronald H. M. A. Bartels


Aneurysmal rerupture prior to treatment is a major cause of death and morbidity in aneurysmal subarachnoid hemorrhage. Recognizing risk factors for aneurysmal rebleeding is particularly relevant and might help to identify the aneurysms that benefit from acute treatment. It is uncertain if the size of the aneurysm is related to rebleeding. This meta-analysis was performed to evaluate whether an association could be determined between aneurysm diameter and the rebleeding rate before treatment. Potentially confounding factors such age, aneurysm location, and the presence of hypertension were also evaluated.


The authors systematically searched the PubMed, Embase, and Cochrane databases up to April 3, 2013, for studies of patients with aneurysmal subarachnoid hemorrhage that reported the association between aneurysm diameter and pretreatment aneurysmal rebleeding. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were used to evaluate study quality.


Seven studies, representing 2121 patients, were included in the quantitative analysis. The quality of the studies was low in 2 and very low in 5. Almost all of the studies used 10 mm as the cutoff point for size among other classes, and only one used 7 mm. An analysis was performed with this best unifiable cutoff point. Overall rebleeding occurred in 360 (17.0%) of 2121 patients (incidence range, from study to study, 8.7%–28.4%). The rate of rebleeding in small and large aneurysms was 14.0% and 23.6%, respectively. The meta-analysis of the 7 studies revealed that larger size aneurysms were at a higher risk for rebleeding (OR 2.56 [95% CI 1.62–4.06]; p = 0.00; I2 = 60%). The sensitivity analysis did not alter the results. Five of the 7 studies reported data regarding age; 4 studies provided age-adjusted results and identified a persistent relationship between lesion size and the risk of rebleeding. The presence of hypertension was reported in two studies and was more prevalent in patients with rebleeding in one of these. Location (anterior vs posterior circulation) was reported in 5 studies, while in 4 there was no difference in the rebleeding rate. One study identified a lower risk of rebleeding associated with posterior location aneurysms.


This meta-analysis showed that aneurysm size is an important risk factor for aneurysmal rebleeding and should be used in the clinical risk assessment of individual patients. The authors' results confirmed the current guidelines and underscored the importance of acute treatment for large ruptured aneurysms.