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Thomas Sauvigny, Jennifer Göttsche, Patrick Czorlich, Eik Vettorazzi, Manfred Westphal and Jan Regelsberger

OBJECTIVE

Decompressive craniectomy (DC) is an established part of treatment in patients suffering from malignant infarction of the middle cerebral artery (MCA) or traumatic brain injury (TBI). However, no clear evidence for intracranial pressure (ICP)-guided therapy after DC exists. The lack of this evidence might be due to the frequently used, but simplified threshold for ICP of 20 mm Hg, which determines further therapy. Therefore, the objective of this study was to evaluate this threshold's accuracy and to investigate the course of ICP values with respect to neurological outcome.

METHODS

Data on clinical characteristics and parameters of the ICP course on the intensive care unit were collected retrospectively in 102 patients who underwent DC between December 2007 and April 2014 at the authors' institution. The postoperative ICP course in the first 168 hours was recorded and analyzed. From these findings, ICP thresholds discriminating favorable from unfavorable outcome were calculated using conditional inference tree analysis. Additionally, survival analysis was performed using the Kaplan-Meier method. Prognostic factors were assessed via univariate analysis and multivariate logistic regression. Favorable outcome was defined as a score of 0–4 on the modified Rankin Scale.

RESULTS

Multivariate logistic regression revealed that anisocoria, diagnosis, and ICP values differed significantly between the outcome groups. ICP values in the favorable and unfavorable outcome groups differed significantly (p < 0.001), while the mean ICP of both groups lay below the limit of 20 mm Hg (17.5 and 11.5 mm Hg, respectively). These findings were reproduced when analyzing the underlying pathologies of TBI and MCA infarction separately. Based on these findings, optimized time-dependent threshold values were calculated and found to be between 10 and 17 mm Hg. These values significantly distinguished favorable from unfavorable outcome and predicted 30-day mortality (p < 0.001).

CONCLUSIONS

This study systematically evaluated ICP levels in a long-term analysis after DC and provides new, surprisingly low, time-dependent ICP thresholds for these patients. Future trials investigating the benefit of ICP-guided therapy should take these thresholds into consideration and validate them in further patient cohorts.

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Stefan Kluge, Hans Jörg Baumann, Jan Regelsberger, Uwe Kehler, Jan Gliemroth, Barbara Koziej, Hans Klose and Andreas Meyer

Object

Ventriculoatrial (VA) shunts inserted for the treatment of hydrocephalus are known to be a risk factor for pulmonary hypertension. The aim of this study was to evaluate the incidence of pulmonary hypertension among adult patients with VA shunts.

Methods

All patients who had received a VA shunt at one of two institutions between 1985 and 2000 were invited for a cardiopulmonary evaluation. The investigation included a thorough history taking, clinical examination, echocardiography, and pulmonary function testing including diffusing capacity of the lung for carbon monoxide (DLCO). Pulmonary hypertension was defined as systolic pulmonary artery pressure > 35 mm Hg at rest.

Results

The study group consisted of 86 patients, of whom 38 (44%) could be examined. The patients' mean age was 47.1 ± 18.4 years; the median interval between shunt insertion and cardiopulmonary evaluation was 15 years (range 5–20 years). Of the 38 patients, 20 (53%) had Doppler velocity profiles of tricuspid regurgitation that were adequate for the estimation of pulmonary artery systolic pressure. Doppler-defined pulmonary hypertension was observed in 3 patients (8%), 2 of whom underwent right heart catheterization. Chronic thromboembolic pulmonary hypertension was confirmed in both patients, and medical therapy, including anticoagulation, was started. The VA shunt was removed in both cases and replaced with a different type of device. Pulmonary function tests revealed a restrictive pattern in 15% and typical obstructive findings in 9% of patients. In 30% of patients the DLCO was less than 80% of predicted, and blood gas analysis showed hypoxemia in 6% of patients. No significant differences in pulmonary function tests were noted between the patients with and without echocardiographic evidence of pulmonary hypertension. However, patients with pulmonary hypertension had significantly lower DLCO values.

Conclusions

The authors detected pulmonary hypertension by using Doppler echocardiography in a significant proportion of patients with VA shunts. It is therefore recommended that practitioners perform regular echocardiography and pulmonary function tests, including single-breath DLCO in these patients to screen for pulmonary hypertension to prevent hazardous late cardiopulmonary complications.

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Matthias Reitz, Till Burkhardt, Eik Vettorazzi, Frank Raimund, Erik Fritzsche, Nils Ole Schmidt, Jan Regelsberger, Manfred Westphal and Sven Oliver Eicker

OBJECT

Intramedullary spinal cavernoma (ISC) is a rare entity and accounts for approximately 5%−12% of all spinal vascular pathologies. The purpose of the present study was to examine the influence of clinical presentation, localization, and different surgical approaches on long-term outcome in patients treated for ISC.

METHODS

The authors performed a retrospective single-center study of 48 cases of ISC treated microsurgically over the past 28 years. Analyzed factors included preoperative clinical history, microsurgical strategies, neurological outcome (American Spinal Injury Association [ASIA] grade, Epstein and Cooper grade), and the occurrence of postoperative spinal ataxia. Univariate analysis was performed to identify factors influencing long-term outcome.

RESULTS

Preoperatively, 18.8% of all patients experienced a slow, progressive decline in neurological function and 33.3% suffered repetitive episodes of acute neurological deterioration over a time frame of months to years. Moreover, 16.7% noted the sudden onset of a severe neurological deficit, whereas 25% experienced the sudden onset of symptoms with a subsequent gradually progressive decline in neurological function. On long-term follow-up after treatment (mean ± SD, 79.3 ± 35.2 months), 70.8% of patients showed no change in neurological function, 6.3% suffered from a decline, and 22.9% improved neurologically. Thoracolumbar localization (p = 0.043), low preoperative Epstein and Cooper grade for the lower extremities (p < 0.001), and a low preoperative ASIA grade (p < 0.001) were identified as factors associated with an unfavorable outcome (ASIA Grade A-C). The rate of spinal ataxia related to surgical approach was 16.7%.

CONCLUSION

Postoperative neurological function in ISC patients is determined by the preoperative neurological status. On long-term follow-up after microsurgical treatment, 93.7% of patients presented with a stable or improved condition (ASIA grade); thus, definite microsurgical treatment should be considered as long as patients present with only mild symptoms after the diagnosis of symptomatic ISC.

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Jan Regelsberger, Günter Delling, Michael Tsokos, Knuth Helmke, Gertrude Kammler, Heidi Kränzlein and Manfred Westphal

Object

Positional plagiocephaly has become an increasing problem for pediatricians and craniofacial specialists. Diagnosis is commonly based on history and clinical features, but may be difficult in some cases when characteristic features are missing and radiographic studies seem to be necessary. Near-field high-frequency ultrasound has been used to evaluate the sonographic findings of suture anatomy and confirm the diagnosis of positional plagiocephaly as well as provide information of prognostic value.

Methods

The authors report on 100 pediatric patients between the ages of 2 and 13 months, who were admitted to their department since 2004 with an abnormal head shape suggesting nonsynostotic plagiocephaly (NSP). Suture anatomy was examined using a 7.5-MHz linear transducer and a Siemens Elegra ultrasound scanner by two independent investigators. Measurements of suture width and bone thickness were obtained, and the findings were correlated with clinical data as well as sonographic and histopathological findings in both normal and fused cranial sutures. Interobserver variability was assessed by means of paired t-tests. Linear regression analyses were used for correlating patient age with suture width and bone thickness.

Patency of lambdoid sutures was confirmed in 99 cases in which the clinical findings suggested NSP. Morphological characteristics of the sutures—interosseous hypoechoic areas between hyperechoic bone plates—were comparable to those of normal cranial sutures. In one patient, partial synostosis was diagnosed. Overlapping hyperechoic bone plates were found in 51 patients on the affected side of the skull and in 36 patients on the unaffected side. Suture width decreased over time from 6.5 to 2 mm, and thickness of bone in the affected area increased from 0.6 to 1.2 mm until the age of 13 months. The method was found to be limited by age (upper limit 13 months) and anatomical variations but did not show any interobserver variability (p < 0.05).

Conclusions

High-frequency ultrasound is a relatively inexpensive, safe, and easy-to-use tool for confirming the diagnosis of positional plagiocephaly and excluding true synostosis. Overlapping bone plates may be seen on the affected side of the skull in a majority of plagiocephalic patients, but this finding seems to have no prognostic value regarding early fusion of sutures and therefore should not affect treatment decisions. With its lack of interobserver variability and the advantage of not involving ionizing radiation, sonography has the potential to be a standard modality for investigating plagiocephaly in infants and should be offered in craniofacial outpatient clinics.

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Jan Regelsberger, Tobias Schmidt, Björn Busse, Julia Herzen, Michael Tsokos, Michael Amling and Felix Beckmann

Object

Both CT and high-frequency ultrasound have been shown to be reliable diagnostic tools used to differentiate normal cranial sutures from suture synostosis. In nonsynostotic plagiocephaly, overlapping of the bony plates and the so-called “sticky suture” is still controversial and is believed to represent a pathological fusion process. Synchrotron–microcomputed tomography (SRmCT) studies were undertaken to determine whether positional head deformities can be assumed to be true suture pathologies.

Methods

Morphological features and growth development of 6 normal cranial sutures between the ages of 3 and 12 months were analyzed histologically. Additionally 6 pathological sutures, including sagittal synostosis and nonsynostotic plagiocephaly (NSP), were compared with the group of normal sutures by histological and SRmCT studies. Synchrotron-microcomputed tomography is a special synchrotron radiation source with a high photon flux providing a monochromatic x-ray beam with a very high spatial resolution. Morphological characteristics of the different suture types were evaluated and bone density alongside the sutures was measured to compare the osseous structure of the adjacent bony plates of normal and pathological sutures.

Results

Histologically jointlike osseous edges of the normal sutures were seen in the 1st month of life and interlocking at the age of approximately 12 months. During this 1st year, bone thickness increases and suture width decreases. The SRmCT studies showed that: 1) sutures and adjacent bones in NSP are comparable to normal sutures in terms of their morphological aspects; 2) bone densities in the adjacent bony plates of NSP and normal sutures are not different; 3) thickening of the diploe with ridging of the bone in sagittal synostosis is associated with significantly higher bone density; 4) synostotic sutures are only partially fused but vary in their extent; and 5) nonfused sections in sagittal synostosis behave like normal sutures without any signs of pathological bone formation.

Conclusions

Sutures in patients with NSP were found without any morphological irregularities or different osseous structures alongside those compared with normal sutures. Thus, a true suture pathology or osseous change of the adjacent bony plates is highly unlikely in NSP. Even though the number of specimens is limited in this series, cranial suture fusion seems to start at one undetermined point and spread along the suture, whereas other parts of the same suture are not involved according to morphological aspects and bone density measurements of the adjacent bones. This theory may represent a dynamic fusion process completed over time but just starting too early.

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Klaus Christian Mende, Mathias Gelderblom, Cindy Schwarz, Patrick Czorlich, Nils Ole Schmidt, Eik Vettorazzi, Jan Regelsberger, Manfred Westphal and Tammam Abboud

OBJECTIVE

The aim of this prospective study was to investigate the value of somatosensory evoked potentials (SEPs) in predicting outcome in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH).

METHODS

Between January 2013 and January 2015, 48 patients with high-grade SAH (Hunt and Hess Grade III, IV, or V) who were admitted within 3 days after hemorrhage were enrolled in the study. Right and left median and tibial nerve SEPs were recorded on Day 3 after hemorrhage and recorded again 2 weeks later. Glasgow Outcome Scale (GOS) scores were determined 6 months after hemorrhage and dichotomized as poor (Scores 1–3) or good (Scores 4–5). Results of SEP measurements were dichotomized (present or missing cortical responses or normal or prolonged latencies) for each nerve and side. These variables were summed and tested using logistic regression and a receiver operating characteristic curve to assess the value of SEPs in predicting long-term outcome.

RESULTS

At the 6-month follow-up visit, 29 (60.4%) patients had a good outcome, and 19 (39.6%) had a poor outcome. The first SEP measurement did not correlate with clinical outcome (area under the curve [AUC] 0.69, p = 0.52). At the second measurement of median nerve SEPs, all patients with a good outcome had cortical responses present bilaterally, and none of them had bilateral prolonged latencies (p = 0.014 and 0.003, respectively). In tibial nerve SEPs, 7.7% of the patients with a good GOS score had one or more missing cortical responses, and bilateral prolonged latencies were found in 23% (p = 0.001 and 0.034, respectively). The second measurement correlated with the outcome regarding each of the median and tibial nerve SEPs and the combination of both (AUC 0.75 [p = 0.010], 0.793 [p = 0.003], and 0.81 [p = 0.001], respectively).

CONCLUSIONS

Early SEP measurement after SAH did not correlate with clinical outcome, but measurement of median and tibial nerve SEPs 2 weeks after a hemorrhage did predict long-term outcome in patients with high-grade SAH.