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Johannes Goldberg, Peter Vajkoczy and Nils Hecht

OBJECTIVE

In superficial temporal artery–middle cerebral artery (STA-MCA) bypass surgery, recipient vessel properties are likely one of the main reasons for bypass failure. In daily practice, most surgeons select the recipient with the largest diameter. However, selection of the ideal recipient remains debatable because there are no objective selection criteria if multiple potential recipients exist. Here, the authors assessed the benefit of using indocyanine green videoangiography (ICG-VA) to optimize recipient vessel selection in patients undergoing STA-MCA bypass surgery for hemodynamic compromise.

METHODS

All patients who had undergone STA-MCA bypass procedures with pre- and postanastomosis ICG-VA between 2010 and 2019 were eligible for inclusion in this study. The primary bypass surgeon was blinded to the preanastomosis ICG-VA. Preanastomosis white-light and ICG-VA images were compared to determine the identifiability of potential recipient vessels and pathological flow patterns. After completion of the anastomosis, a second (postanastomosis) ICG-VA image was used to analyze the flow increase within the chosen recipient based on the vessel diameter, initial recipient blood flow, initial sequence of appearance on ICG-VA, initial blood flow direction within the recipient, and orientation of the bypass graft. ICG-VA, FLOW 800, and intraoperative white-light images, as well as demographic, clinical, and radiographic patient data, were retrospectively analyzed by a clinician who was not directly involved in the patients’ care.

RESULTS

Sixty patients underwent 65 STA-MCA bypass procedures with pre- and postanastomosis ICG-VA. The ICG-VA permitted identification of a significantly higher number of potential recipient vessels (median 4, range 1–9) than the white-light images (median 2, range 1–5; p < 0.001), with detection of pathological flow patterns in 20% of all procedures. No association was found between the diameter and blood flow within potential recipients (Spearman r = 0.07, p = 0.69). After bypass grafting, the highest flow increase was noted in recipients with an initially low flow (p < 0.01), a late appearance (p < 0.01), and an initially retrograde flow direction (p = 0.02). Interestingly, flow increase was not significantly influenced by the recipient diameter (p = 0.09) or graft orientation (p = 0.44).

CONCLUSIONS

ICG-VA facilitates identification of potential recipient vessels and detection of pathological flow patterns. Recipients with an initially low flow, a late appearance, and a retrograde flow seem to bear the highest potential for flow increase, possibly due to a higher hemodynamic need for revascularization.

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Johannes Goldberg, Christian Jaeggi, Daniel Schoeni, Pasquale Mordasini, Andreas Raabe and David Bervini

OBJECTIVE

Cerebral cavernous malformations (CCMs) are frequently diagnosed vascular malformations of the brain. Although most CCMs are asymptomatic, some can be responsible for intracerebral hemorrhage or seizures. In selected cases, microsurgical resection is the preferred treatment option. Treatment with the unselective β-blocker propranolol has been presumed to stabilize and eventually lead to CCM size regression in a limited number of published case series; however, the underlying mechanism and evidence for this effect remain unclear. The aim of this study was to investigate the risk for CCM-related hemorrhage in patients on long-term β-blocker medication.

METHODS

A single-center database containing data on patients harboring CCMs was retrospectively interrogated for a time period of 35 years. The database included information about hemorrhage and antihypertensive medication. Descriptive and survival analyses were performed, focusing on the risk of hemorrhage at presentation and during follow-up (first or subsequent hemorrhage) in patients on long-term β-blocker medication versus those who were not. Follow-up was censored at the first occurrence of new hemorrhage, surgery, or the last clinical review. For purposes of this analysis, the β-blocker group was divided into the following main subgroups: any β-blocker, β1-selective β-blocker, and any unselective β-blocker.

RESULTS

Of 542 CCMs among 408 patients, 81 (14.9%) were under treatment with any β-blocker; 65 (12%) received β1-selective β-blocker, and 16 (3%) received any unselective β-blocker. One hundred thirty-six (25.1%) CCMs presented with hemorrhage at diagnosis. None of the β-blocker groups was associated with a lower risk of hemorrhage at the time of diagnosis in a univariate descriptive analysis (any β-blocker: p = 0.64, β1-selective: p = 0.93, any unselective β-blocker: p = 0.25). Four hundred ninety-six CCMs were followed up after diagnosis and included in the survival analysis, for a total of 1800 lesion-years. Follow-up hemorrhage occurred in 36 (7.3%) CCMs. Neither univariate descriptive nor univariate Cox proportional-hazards regression analysis showed a decreased risk for follow-up hemorrhage under treatment with β-blocker medication (any β-blocker: p = 0.70, HR 1.19, 95% CI 0.49–2.90; β1-selective: p = 0.78, HR 1.15, 95% CI 0.44–3.00; any unselective β-blocker: p = 0.76, HR 1.37, 95% CI 0.19–10.08). Multivariate Cox proportional-hazards regression analysis including brainstem location, hemorrhage at diagnosis, age, and any β-blocker treatment showed no reduced risk for follow-up hemorrhage under any β-blocker treatment (p = 0.53, HR 1.36, 95% CI 0.52–3.56).

CONCLUSIONS

In this retrospective cohort study, β-blocker medication does not seem to be associated with a decreased risk of CCM-related hemorrhage at presentation or during follow-up.

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Nicolai Maldaner, Valentin K. Steinsiepe, Johannes Goldberg, Christian Fung, David Bervini, Adrien May, Philippe Bijlenga, Karl Schaller, Michel Roethlisberger, Daniel W. Zumofen, Donato D’Alonzo, Serge Marbacher, Javier Fandino, Rodolfo Maduri, Roy Thomas Daniel, Jan-Karl Burkhardt, Alessio Chiappini, Thomas Robert, Bawarjan Schatlo, Martin A. Seule, Astrid Weyerbrock, Luca Regli, Martin Nikolaus Stienen and for the Swiss SOS Study Group

OBJECTIVE

The objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort.

METHODS

The authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009–2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined.

RESULTS

Among 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74–1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89–12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23–2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30–0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676).

CONCLUSIONS

Microsurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.