Publications by authors named "Annika Herten"

14 Publications

  • Page 1 of 1

Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) as a radiographic marker of clinically relevant intracranial hypertension and unfavorable outcome after subarachnoid hemorrhage.

Eur J Neurol 2021 Jul 22. Epub 2021 Jul 22.

Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany.

Background And Purpose: The severity of early brain edema (EBE) after aneurysm rupture was reported to be strongly associated with the risk of poor outcome after aneurysmal subarachnoid hemorrhage (SAH). Using the recently developed Subarachnoid Hemorrhage Early Brain Edema Score (SEBES), we analyzed the predictors of EBE and its impact on complications related to intracranial pressure (ICP) increase after SAH and on poor outcome.

Methods: All consecutive SAH cases treated between January 2003 and June 2016 with assessable SEBES were included (n = 745). Data on demographic characteristics, medical history, initial severity of SAH, need for conservative ICP treatment and decompressive craniectomy, occurrence of cerebral infarctions and unfavorable outcome at 6 months (modified Rankin scale score > 2) were collected. Univariable and multivariable analyses were performed.

Results: Younger age (<55 years; adjusted odds ratio [aOR] 3.16, 95% confidence interval [CI] 2.28-4.38), female sex (aOR 1.64, 95% CI 1.16-2.31), poor initial clinical condition (World Federation of Neurosurgical Societies score 4-5; aOR 1.74, 95% CI 1.23-2.46), presence of intracerebral hemorrhage (aOR 1.63, 95% CI 1.12-2.36), hypothyroidism (aOR 0.60, 95% CI 0.37-0.98) and renal comorbidity (aOR 0.29, 95% CI 0.11-0.78) were independently associated with SEBES (scores 3-4). There was an independent association between SEBES 3-4 and the need for conservative ICP treatment (aOR 2.43, 95% CI 1.73-3.42), decompressive craniectomy (aOR 2.68, 95% CI 1.84-3.89), development of cerebral infarcts (aOR 2.24, 95% CI 1.53-3.29) and unfavorable outcome (aOR 1.48, 95% CI 1.0-2.17).

Conclusions: SEBES is a reliable predictor of ICP-related complications and poor outcome of SAH. Our findings highlight the need for further research of the impact of patients' demographic characteristics and comorbidities on the severity of EBE after SAH.
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http://dx.doi.org/10.1111/ene.15033DOI Listing
July 2021

The Subarachnoid Hemorrhage-Weather Myth: A Long-Term Big Data and Deep Learning Analysis.

Front Neurol 2021 5;12:653483. Epub 2021 May 5.

Department of Neurosurgery and Spine Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany.

The frequency of aneurysmal subarachnoid hemorrhage (aSAH) presents complex fluctuations that have been attributed to weather and climate changes in the past. In the present long-term big data and deep learning analysis, we have addressed this long-held myth. Bleeding dates and basic demographic data for all consecutive patients ( = 1,271) admitted to our vascular center for treatment of aSAH between January 2003 and May 2020 (6,334 days) were collected from our continuously maintained database. The meteorological data of the local weather station, including 13 different weather and climate parameters, were retrieved from Germany's National Meteorological Service for the same period. Six different deep learning models were programmed using the Keras framework and were trained for aSAH event prediction with meteorological data from January 2003 to June 2017, with 10% of this dataset applied for data validation and model improvement. The dataset from July 2017 to May 2020 was tested for aSAH event prediction accuracy for all six models using the area under the receiver operating characteristic curve (AUROC) as the metric. The study group comprised of 422 (33.2%) male and 849 (66.8%) female patients with an average age of 55 ± 14 years. None of the models showed an AUROC larger than 60.2. From the presented data, the influence of weather and climate on the occurrence of aSAH events is extremely unlikely. The myth of special weather conditions influencing the frequency of aSAH is disenchanted by this long-term big data and deep learning analysis.
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http://dx.doi.org/10.3389/fneur.2021.653483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8131675PMC
May 2021

Size does matter: The role of decompressive craniectomy extent for outcome after aneurysmal subarachnoid hemorrhage.

Eur J Neurol 2021 07 3;28(7):2200-2207. Epub 2021 May 3.

Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany.

Background And Purpose: In previous studies in patients with traumatic brain injury and ischemic stroke, the size of decompressive craniectomy (DC) was reported to be paramount with regard to patient outcomes. We aimed to identify the impact of DC size on treatment results in individuals with aneurysmal subarachnoid hemorrhage (SAH).

Methods: The extent of DC in 232 patients with SAH who underwent bifrontal or hemicraniectomy between January 2003 and December 2015 was analyzed using semi-automated surface measurements. The study endpoints were course of intracranial pressure (ICP) treatment after DC, occurrence of cerebral infarcts, in-hospital mortality, and unfavorable outcome at 6 months (defined as modified Rankin scale score >3). The associations of DC size with the study endpoints were adjusted for DC timing, patient age, clinical and radiographic severity of SAH, aneurysm location, and treatment modality.

Results: The mean DC surface area was 100.9 (±45.8) cm . In multivariate analysis, a large DC (>105 cm ) was independently associated with a lower risk of cerebral infarcts (adjusted odds ratio [aOR] 0.30, 95% confidence interval [CI] 0.16-0.56), in-hospital mortality (aOR 0.28, 95% CI 0.14-0.56) and unfavorable outcome (aOR 0.51, 95% CI 0.27-0.98). Moreover, SAH patients with a small DC size (<75 cm ) were more likely to require prolonged (>3 days, aOR 3.60, 95% CI 1.37-9.42) and enhanced (aOR 2.31, 95% CI 1.12-4.74) postoperative ICP treatment.

Conclusion: This is the first study showing the impact of DC size on postoperative ICP control and patient outcome in the context of SAH; specifically, a large craniectomy flap (>105 cm ) might lead to better outcomes in SAH patients requiring decompressive surgery.
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http://dx.doi.org/10.1111/ene.14835DOI Listing
July 2021

Cerebral cavernous malformations: Prevalence of cardiovascular comorbidities and allergic diseases compared to the normal population.

Eur J Neurol 2021 06 3;28(6):2000-2005. Epub 2021 Apr 3.

Department of Neurosurgery and Spine Surgery, University Hospital Essen, Essen, Germany.

Background: To determine the prevalence of cardiovascular comorbidities and allergic diseases in patients with cavernous malformations of the central nervous system compared to the normal population.

Methods: Clinical and magnetic resonance imaging data of 1352 patients with cerebral cavernous malformations (CCM) from an observational, cross-sectional, single-institutional study were analyzed and compared to an age-and-gender stratified and matched sample from a population-based, epidemiological study assessing cardiovascular risk factors in the local normal population of the same area (RECALL study).

Results: Of 1352 patients, 810 (60%) were female. Mean age was 40.4 ± 16 years. 221 patients (16%) suffered from familial disease. Presence of cardiovascular risk factors and intake of certain drugs in the overall cohort was mostly equal to the normal population reference sample (n = 786). The prevalence of allergic diseases was found to be significantly higher in all CCM patients compared to the normal population (30% vs. 20%, odds ratio [OR] 1.35 [1.12-1.63]) and in sporadic CCM cases compared to the normal population and familial cases (32% vs. 20% (OR 1.46 [1.19-1.78], p = 0.0001) and 22% vs. 20%, respectively).

Conclusions: We present novel data on CCM using a large single-institution and population-based setup. The study elaborates disease characteristics of CCM patients in detail. For the first time, evidence for an unexplained high prevalence of allergic diseases in this patient population is described (differing between sporadic and familial cases), supporting the hypothesis that immune response is involved in the pathogenesis of CCM.
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http://dx.doi.org/10.1111/ene.14833DOI Listing
June 2021

Modifiable Cardiovascular Risk Factors in Patients With Sporadic Cerebral Cavernous Malformations: Obesity Matters.

Stroke 2021 Apr 16;52(4):1259-1264. Epub 2021 Feb 16.

Department of Neurosurgery and Spine Surgery (B.C., D.S., S.R., A.H., L.R., A.S., Y.Z., R.J., K.H.W., U.S., P.D.), University Hospital Essen, University of Duisburg-Essen, Germany.

Background And Purpose: This study aims to assess the influence of modifiable cardiovascular risk factors on hemorrhage risk of sporadic cerebral cavernous malformations (CCMs).

Methods: From 1219 consecutive CCM patients (2003-2018), adult subjects with sporadic CCM and complete magnetic resonance imaging were included. We evaluated presence of intracerebral hemorrhage (ICH) as mode of presentation, occurrence of ICH during follow-up and risk factors arterial hypertension, diabetes, hyperlipidemia, nicotine abuse, and obesity (body mass index >30 kg/m). Impact of risk factors on ICH at presentation was calculated using univariate and multivariate logistic regression with age and sex adjustment. We performed Kaplan-Meier and Cox regression to analyze cumulative 5-year risk for (re)bleeding.

Results: We included 682 patients with CCM. The univariate logistic regression showed a significant relationship (odds ratio=1.938 [95% CI, 1.120-3.353], =0.018) between obesity and ICH as mode of presentation. Multivariate adjusted logistic regression confirmed significant correlation with odds ratio=1.902 (95% CI, 1.024-3.532, =0.042). Cox regression did not identify predictors for occurrence of (re)hemorrhage (>0.05; hazard ratios: arterial hypertension 1.112 [95% CI, 0.622-1.990], diabetes 0.850 [95% CI, 0.208-3.482], hyperlipidemia 0.719 [95% CI, 0.261-1.981], nicotine abuse 1.123 [95% CI, 0.591-2.134], and obesity 0.928 [95% CI, 0.416-2.070]).

Conclusions: This study provides evidence that obesity may be a risk factor for CCM hemorrhage. It was significantly associated with ICH as mode of presentation. Other risk factors (arterial hypertension, diabetes, hyperlipidemia, and current nicotine abuse) showed no such effect. None of the factors showed to be independent predictors for cumulative 5-year risk of (re)bleeding.
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http://dx.doi.org/10.1161/STROKEAHA.120.031569DOI Listing
April 2021

Assessment and validation of proposed classification tools for brainstem cavernous malformations.

J Neurosurg 2020 Oct 16:1-7. Epub 2020 Oct 16.

1Department of Neurosurgery and Spine Surgery, University Hospital Essen; and.

Objective: Treatment indications for patients with brainstem cavernous malformations (BSCMs) remain difficult and controversial. Some authors have tried to establish classification tools to identify eligible candidates for surgery. Authors of this study aimed to validate the performance and replicability of two proposed BSCM grading systems, the Lawton-Garcia (LG) and the Dammann-Sure (DS) systems.

Methods: For this cross-sectional study, a database was screened for patients with BSCM treated surgically between 2003 and 2019 in the authors' department. Complete clinical records, preoperative contrast-enhanced MRI, and a postoperative follow-up ≥ 6 months were mandatory for study inclusion. The modified Rankin Scale (mRS) score was determined to quantify neurological function and outcome. Three observers independently determined the LG and the DS score for each patient.

Results: A total of 67 patients met selection criteria. Univariate and multivariate analyses identified multiple bleedings (p = 0.02, OR 5.59), lesion diameter (> 20 mm, p = 0.007, OR 5.43), and patient age (> 50 years, p = 0.019, OR 4.26) as predictors of an unfavorable postoperative functional outcome. Both the LG (AUC = 0.72, p = 0.01) and the DS (AUC = 0.78, p < 0.01) scores were robust tools to estimate patient outcome. Subgroup analyses confirmed this observation for both grading systems (LG: p = 0.005, OR 6; DS: p = 0.026, OR 4.5), but the combined use of the two scales enhanced the test performance significantly (p = 0.001, OR 22.5).

Conclusions: Currently available classification systems are appropriate tools to estimate the neurological outcome after BSCM surgery. Future studies are needed to design an advanced scoring system, incorporating items from the LG and the DS score systems.
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http://dx.doi.org/10.3171/2020.6.JNS201585DOI Listing
October 2020

Multimodal outcome assessment after surgery for brainstem cavernous malformations.

J Neurosurg 2020 Oct 16:1-9. Epub 2020 Oct 16.

1Department of Neurosurgery, University Hospital Essen.

Objective: The object of this study was to assess outcome after surgery for brainstem cavernous malformations (BSCMs) using functional, health-related quality of life (HRQOL), and psychological surveys to analyze the interrelation of these measurements, and to compare HRQOL and anxiety and depression scores with those in a healthy population.

Methods: The authors performed a cross-sectional outcome study of all patients surgically treated for BSCM in their department between January 1, 2003, and December 31, 2019. They assessed functional outcome via the modified Rankin Scale (mRS), health-related quality of life (HRQOL) via the SF-36 and 9-item Life Satisfaction Questionnaire (LISAT-9), cranial nerve and brainstem function using a questionnaire, symptom-based psychological outcome via the Hospital Anxiety and Depression Scale (HADS), and timepoint of a return to previous employment. They analyzed the correlation between absolute (mRS score ≤ 2) and relative (postoperative deterioration in initial mRS score) outcome endpoints and the interrelation of the outcome measures and performed a comparison of HRQOL and HADS scores with findings in a healthy population.

Results: Seventy-four patients were eligible for inclusion in the study. HRQOL was impaired after surgery for BSCM compared to that in a healthy population. This impairment was substantial in patients with an unfavorable functional outcome (mRS > 2) but was also present in those with a favorable outcome (mRS ≤ 2) in selected domains. Psychological impairment was negligible in patients with a favorable outcome and grave in those with an unfavorable outcome. LISAT-9 results revealed that brainstem and cranial nerve symptoms reduce satisfaction mainly in self-care abilities for both unfavorable and favorable outcome patients. Among the brainstem and cranial nerve symptoms, balance impairment showed the most significant impact on HRQOL. Absolute outcome endpoints were superior to relative outcome endpoints in reflecting impairment in HRQOL after surgery.

Conclusions: The study data can improve patient counseling and decision-making in BSCM treatment and may function as a benchmark. The authors report outcomes after BSCM surgery in high detail, emphasizing the specific impact of cranial nerve and brainstem symptoms on HRQOL. When reporting BSCM surgery outcome, absolute outcome endpoints should be applied.
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http://dx.doi.org/10.3171/2020.6.JNS201823DOI Listing
October 2020

Adjustable pressure valves for chronic hydrocephalus following subarachnoid hemorrhage: Is it worthwhile?

Clin Neurol Neurosurg 2020 11 5;198:106133. Epub 2020 Aug 5.

Department of Neurosurgery and Spine Surgery, University Hospital, University of Duisburg-Essen, Essen, Germany.

Objective: Compared to fixed pressure valves (FPV), adjustable pressure valves (APV) might reduce the rates of over/underdrainage necessitating revision surgery after shunt placement. But due to higher implant costs and valve vulnerability, the use APV in neurosurgery is still limited. The aim of this study was to evaluate the clinical utility of APV in patients with aneurysmal subarachnoid hemorrhage (aSAH).

Material And Methods: All consecutive aSAH patients undergoing ventriculoperitoneal shunt (VPS) placement at our institution between 2003 and 2016 were eligible. Rates and the risk factors for shunt valve dysfunction and over/underdrainage were evaluated.

Results: A total of 189 patients were included in the final analysis. FPV were implanted in the majority of patients (173/91.5 %). Revision surgery due to over/underdrainage was performed in 8 (4.6 %) cases with FPV and in no case with APV. Higher patients' age (>65 years, p = 0.011; aOR 10.36) and bone flap reimplantation following decompressive craniectomy (p = 0.044; aOR 6.53) independently predicted the need for revision surgery for over/underdrainage. There was no difference in the occurrence of valve dysfunction between the two valve types (1 [6.3 %] APV, 12 [6.9 %] FPV), p > 0.99). Patients requiring revision surgery for over/underdrainage had a higher risk for unfavorable outcome at 6 months follow-up (mRS>3, p = 0.009; aOR = 8.0).

Conclusion: APV is a valuable option for aSAH individuals undergoing VPS implantation to reduce the need for revision surgery for over/underdrainage. Particularly, elderly patients and those requiring bone flap reimplantation might benefit from APV.
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http://dx.doi.org/10.1016/j.clineuro.2020.106133DOI Listing
November 2020

Hemorrhage from cerebral cavernous malformations: The role of associated developmental venous anomalies.

Neurology 2020 07 8;95(1):e89-e96. Epub 2020 Jun 8.

From the Department of Neurosurgery (B.C., A.H., D.S., S.R., Y.Z., R.J., K.H.W., U.S., P.D.), Institute of Diagnostic and Interventional Radiology and Neuroradiology (A.R.), Institute for Medical Informatics, Biometry and Epidemiology (B.S.), and Department of Neurology (C.K.), University Hospital Essen, University of Duisburg-Essen, Essen, Germany.

Objective: To determine the role of associated developmental venous anomalies (DVAs) in intracranial hemorrhage (ICH) caused by cerebral cavernous malformations (CCMs).

Methods: We analyzed patient registry data of 1,219 patients with cavernous malformations treated in our institution between 2003 and 2018. Patients with spinal and familial CCM and patients without complete MRI data were excluded. The impact of various variables on ICH as a mode of presentation was assessed with multivariate binary logistic regression analysis. Kaplan Meier/Cox regression analysis was performed to analyze cumulative 5-year-risk for (re)hemorrhage and to identify baseline predictors of this outcome.

Results: Seven hundred thirty-one patients with CCM were included. Multivariate logistic regression confirmed a statistically significant negative correlation with DVA (odds ratio [OR] 0.635 [95% confidence interval (CI) 0.459-0.878]) and positive correlation with brainstem localization (OR 6.277 [95% CI 4.287-9.191]) with ICH as the mode of presentation. Among 731 patients, 76 experienced (re)hemorrhage during 2,338 person-years of follow-up. Overall cumulative 5-year risk was 24.1% (95% CI 21.1%-27.5%). Cox regression analysis revealed initial presentation with ICH (hazard ratio [HR] 8.0 [95% CI 3.549-18.122]) and brainstem localization (HR 2.9 [95% CI 1.756-4.765]) as independent baseline predictors of (re)hemorrhage. Presence of DVA added no independent prognostic information (HR 1.1 [95% CI 0.717-1.885]).

Conclusion: Patients with CCM with associated DVA are at lower risk to present with ICH. During untreated 5-year follow-up, they showed equal (re)hemorrhage risk compared to patients with CCM without DVA.
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http://dx.doi.org/10.1212/WNL.0000000000009730DOI Listing
July 2020

Secondary hemorrhagic complications in aneurysmal subarachnoid hemorrhage: when the impact hits hard.

J Neurosurg 2019 Jan 25:1-8. Epub 2019 Jan 25.

1Department of Neurosurgery, University Hospital, University of Duisburg-Essen; and.

Objective: Clinical data on secondary hemorrhagic complications (SHCs) in patients with aneurysmal subarachnoid hemorrhage (SAH) are sparse and mostly limited to ventriculostomy-associated SHCs. This study aimed to elucidate the incidence, risk factors, and impact on outcome of SHCs in a large cohort of SAH patients.

Methods: All consecutive patients with ruptured aneurysms treated between January 2003 and June 2016 were eligible for this study. Patients' charts were reviewed for clinical data, and imaging studies were reviewed for radiographic data. SHCs were divided into those associated with ventriculostomy and those not associated with ventriculostomy, as well as into major and minor bleeding forms, depending on clinical impact.

Results: Sixty-two (6.6%) of the 939 patients included in the final analysis developed SHCs. Ventriculostomy-associated bleedings (n = 16) were independently predicted by mono- or dual-antiplatelet therapy after aneurysm treatment (p = 0.028, adjusted odds ratio [aOR] = 10.28; and p = 0.026, aOR = 14.25, respectively) but showed no impact on functional outcome after SAH. Periinterventional use of thrombolytic agents for early effective anticoagulation was the only independent predictor (p = 0.010, aOR = 4.27) of major SHCs (n = 38, 61.3%) in endovascularly treated patients. In turn, a major SHC was independently associated with poor outcome at the 6-month follow-up (modified Rankin Scale score > 3). Blood thinning drug therapy prior to SAH was not associated with SHC risk.

Conclusions: SHCs present a rare sequela of SAH. Antiplatelet therapy during (but not before) SAH increases the risk of ventriculostomy-associated bleedings, but without further impact on the course and outcome of SAH. The use of thrombolytic agents for early effective anticoagulation carries relevant risk for major SHCs and poor outcome.
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http://dx.doi.org/10.3171/2018.9.JNS182105DOI Listing
January 2019

Aneurysm rebleeding before therapy: a predictable disaster?

J Neurosurg 2018 Nov 1:1-8. Epub 2018 Nov 1.

1Department of Neurosurgery and.

OBJECTIVECurrent guidelines for subarachnoid hemorrhage (SAH) include early aneurysm treatment within 72 hours after ictus. However, aneurysm rebleeding remains a crucial complication of SAH. The aim of this study was to identify independent predictors allowing early stratification of SAH patients for rebleeding risk.METHODSAll patients admitted to the authors' institution with ruptured aneurysms during a 14-year period were eligible for this retrospective study. Demographic and radiographic parameters, aneurysm characteristics, medical history, and medications as well as baseline parameters at admission (blood pressure and laboratory parameters) were evaluated in univariate and multivariate analyses. A novel risk score was created using independent risk factors.RESULTSData from 984 cases could be included into the final analysis. Aneurysm rebleeding occurred in 58 cases (5.9%), and in 48 of these cases (82.8%) rerupture occurred within 24 hours after SAH. Of over 30 tested associations, preexisting arterial hypertension (p = 0.02; adjusted odds ratio [aOR] 2.56, 1 score point), aneurysm location at the basilar artery (p = 0.001, aOR 4.5, 2 score points), sac size ≥ 9 mm (p = 0.04, aOR 1.9, 1 score point), presence of intracerebral hemorrhage (p = 0.001, aOR 4.29, 2 score points), and acute hydrocephalus (p < 0.001, aOR 6.27, 3 score points) independently predicted aneurysm rebleeding. A score built upon these parameters (0-9 points) showed a good diagnostic accuracy (p < 0.001, area under the curve 0.780) for rebleeding prediction.CONCLUSIONSCertain patient-, aneurysm-, and SAH-specific parameters can reliably predict aneurysm rerupture. A score developed according to these parameters might help to identify individuals that would profit from immediate aneurysm occlusion.
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http://dx.doi.org/10.3171/2018.7.JNS181119DOI Listing
November 2018

Accuracy and bias of automatic hippocampal segmentation in children and adolescents.

Brain Struct Funct 2019 Mar 3;224(2):795-810. Epub 2018 Dec 3.

Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Clinic Rheinisch-Westfälische Technische Hochschule Aachen, Neuenhofer Weg 21, 52074, Aachen, Germany.

The hippocampus (Hc) is of great importance in various psychiatric diseases in adults, children and adolescents. Automated Hc segmentation has been widely used in adults, implying sufficient overlap with manual segmentation. However, estimation biases related to the Hc volume have been pointed out. This may particularly apply to children who show age-related Hc volume changes, thus, questioning the accuracy of automated Hc segmentation in this age group. The aim of this study was to compare manual segmentation with automated segmentation using the widely adopted FreeSurfer (FS) and MAGeT-Brain software. In 70 children and adolescents (5-16 years, mean age 10.6 years), T1-weighted images were acquired on one of two identical 3T scanners. Automated segmentation was performed using the FS subcortical segmentation, the FS hippocampal subfields segmentation and the MAGeT-Brain software. In comparison with manual segmentation, volume differences, Dice similarity coefficient (DSC), Bland-Altman plot, intraclass correlation coefficient (ICC) and left-right consistency of automated segmentation were calculated. The average percentage of volume differences (PVD) with manual segmentation was 56.8% for FS standard segmentation, 32.2% for FS subfield segmentation and - 15.6% for MAGeT-Brain. The FS Hc subfields segmentation (left/right DSC = 0.86/0.87) and MAGeT-Brain (both hemispheres DSC = 0.91) resulted in a higher volume overlap with manual segmentation compared with the FS subcortical segmentation (DSC = 0.79/0.78). In children aged 5-10.5 years, MAGeT-Brain yielded the highest overlap (DSC = 0.92/0.93). Contrary volume estimation biases were detected in FS and MAGeT-Brain: FS showed larger volume overestimation in smaller Hc volumes, while MAGeT-Brain showed more pronounced volume underestimation in larger Hc volumes. While automated Hc segmentation using FS hippocampal subfields or MAGeT-Brain resulted in adequate volume overlap with manual segmentation, estimation biases compromised the reliability of automated procedures in children and adolescents.
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http://dx.doi.org/10.1007/s00429-018-1802-2DOI Listing
March 2019

Aneurysmal intracerebral hematoma: Risk factors and surgical treatment decisions.

Clin Neurol Neurosurg 2018 10 19;173:1-7. Epub 2018 Jul 19.

Department of Neurosurgery, University Hospital, University of Duisburg-Essen, Essen, Germany.

Objectives: Intracerebral hematoma (ICH) complicates the course of aneurysmal subarachnoid hemorrhage (SAH). To date, there are no unique guidelines for management of aneurysmal ICH. The aim of this study was to identify risk factors for and impact of aneurysmal ICH with special attention on treatment decisions derived from ICH volume.

Patients And Methods: All patients admitted with aneurysmal SAH between 2003 and 2016 were eligible for this study. Various demographic, clinical and radiographic characteristics of patients were correlated with the occurrence and volume of ICH in univariate and multivariate manner. The associations between ICH volume and the need for surgical procedures and functional outcome were also analyzed.

Results: 991 patients were included into final analysis. ICH occurred in 301 (30.4%) cases. Location in the middle cerebral artery (MCA, p < 0.001, aOR = 7.04), WFNS grade 4-5 (p < 0.001, aOR = 4.43), rebleeding before therapy (p = 0.004, aOR = 2.45), intracranial pressure over 20 mmHg upon admission (p = 0.008, aOR = 1.60) and intraventricular bleeding (p = 0.008, aOR = 1.62) were independently associated with ICH presence. In turn, WFNS grade 4-5 (p < 0.001) and MCA aneurysms (p < 0.001) were the only independent predictors of ICH volume. According to the receiver operating characteristic curves, the clinically relevant cutoff for additional surgical interventions (decompression/hematoma evacuation) was 17 mL. ICH occurrence and ICH volume ≥17 mL independently predicted poor outcome at 6 months after SAH (defined as modified Rankin Scale>3).

Conclusion: Of over 30 tested variables, the location of the ruptured aneurysm in the MCA remains the major risk factor for occurrence and volume of ICH. Given the presence of brain swelling and other bleeding components of SAH, surgical intervention on aneurysmal ICH is indicated at lower volume values, than it is generally accepted for spontaneous ICH.
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http://dx.doi.org/10.1016/j.clineuro.2018.07.014DOI Listing
October 2018

Intraventricular Hemorrhage Caused by Subarachnoid Hemorrhage: Does the Severity Matter?

World Neurosurg 2018 Mar 3;111:e693-e702. Epub 2018 Jan 3.

Department of Neurosurgery, University Hospital Essen, Essen, Germany.

Objective: Aneurysm rupture might be accompanied by intraventricular hemorrhage (IVH), which is associated with poor outcome of subarachnoid hemorrhage (SAH). The aim of this study was to analyze risk factors and clinical impact of IVH severity.

Methods: A total of 995 consecutive patients with SAH treated at our institution between January 2003 and June 2016 were eligible for this study. Clinical and radiologic findings were correlated with the presence and severity of IVH assessed with the original Graeb score.

Results: A total of 487 patients with SAH (48.9%) presented with IVH (mean IVH severity, 5.48 points [±3.5]). IVH severity correlated with poorer initial clinical condition (World Federation of Neurosurgical Societies grade >3; P < 0.001), acute hydrocephalus (P = 0.001), and poor outcome at 6 months (modified Rankin Scale score >2; P < 0.001). The location of the ruptured aneurysm in the anterior cerebral artery independently predicted the occurrence (P = 0.007) and severity of IVH (P < 0.001). In turn, aneurysm size affected only the severity of IVH (P = 0.001) but not its occurrence (P = 0.153). Early complications of SAH occurring within 72 hours after the bleeding event (cerebral infarction [P = 0.043], early mortality [P = 0.001], and primary craniectomy [P = 0.043]) were independently associated with the severity of IVH.

Conclusions: Severity of aneurysmal IVH is a strong contributor to initial severity and early complications of SAH. Patients with larger aneurysms, especially located in the anterior cerebral artery, are at particular risk of severe IVH in cases of aneurysm rupture.
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http://dx.doi.org/10.1016/j.wneu.2017.12.148DOI Listing
March 2018
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