Publications by authors named "Christian Scheiwe"

41 Publications

Pterional Orbit Decompression in Grave Disease with Dysthyroid Optic Neuropathy.

World Neurosurg 2021 Jan 19. Epub 2021 Jan 19.

Department of Neurosurgery, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg, Germany. Electronic address:

Objective: The choice of surgical technique in sight-threatening Grave orbitopathy remains controversial. Available data are mostly derived from mixed cohorts with multiple surgical indications and techniques. The authors assessed predictors for visual outcome after standardized pterional orbital decompression for dysthyroid optic neuropathy.

Methods: Retrospective analysis of 62 pterional orbital decompressions performed on 40 patients with dysthyroid optic neuropathy.

Results: Visual acuity improved by an average of 3.8 lines in eyes with preoperative visual impairment (95% confidence interval [CI]: 1.8-5.8 lines, P < 0.001) and remained stable in eyes without prior visual impairment (95% CI -1.3 to 1 line, P = 0.81). Proptosis was reduced by an average of 3.1 mm (95% CI 1.8-4.3 mm, P < 0.001). Higher degrees of proptosis were predictive of worse visual outcomes (P = 0.017). New-onset diplopia developed in 2 patients, while previous diplopia resolved after surgery in 6 patients.

Conclusions: This cohort is the largest series of pterional orbit decompressions and the first to focus exclusively on dysthyroid neuropathy. Complication rates were low. Decompression surgery was highly effective at restoring and maintaining visual acuity in patients with dysthyroid optic neuropathy.
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http://dx.doi.org/10.1016/j.wneu.2021.01.040DOI Listing
January 2021

Long-Term Results after Multilevel Fusion of the Cervical Spine and the Cervicothoracic Junction: To Bridge or Not To Bridge?

World Neurosurg 2021 Jan 19. Epub 2021 Jan 19.

Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Objective: For patients with multilevel degenerative cervical myelopathy, laminectomy and fusion are widely accepted techniques for ameliorating the disorder. However, the idea of whether one should bridge the cervicothoracic junction to prevent instrument failure or adjacent segment disease has been a subject of controversial discussion. In the present study, we compared the incidence of these complications and the revision rates in multilevel fusions extending to C7 or T1-T3.

Methods: In the present single-center, retrospective cohort study, patients with multilevel degenerative cervical myelopathy treated with laminectomy and fusion to C7 or T1-T3 from 2004 to 2016 were included for evaluation. The primary outcome measure was radiologically proven complications at the most caudal level or the adjacent spinal fusion level.

Results: Laminectomy and multilevel fusion were performed in 84 patients. After applying the exclusion criteria, 20 patients with fusion to C7 (treated from 2004 to 2012; follow-up, 124.6 ± 10.6 months) and 38 patients with fusion to T1-T3 (treated from 2008 to 2016; follow-up, 58.2 ± 15.7 months) were evaluated. The incidence of complications at the most caudal or adjacent level of fusion was twice as high (P = 0.087; NS) in the C7 group (11 of 20; 55.0%) compared with the T1-T3 group (11 of 38; 28.9%). In the C7 group, 9 of the 20 patients (45.0%) had required revision surgery compared with 2 of 38 patients (5.3%) in the T1-T3 group (P = 0.001).

Conclusions: We found that fewer revisions were necessary if the fusion had extended to the thoracic spine. Thus, we recommend bridging the cervicothoracic junction when fusion starts at C0-C3.
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http://dx.doi.org/10.1016/j.wneu.2021.01.025DOI Listing
January 2021

The PRESSURE score to predict decompressive craniectomy after aneurysmal subarachnoid haemorrhage.

Brain Commun 2020 17;2(2):fcaa134. Epub 2020 Sep 17.

Department of Neurosurgery, University Hospital of Essen, D-45147 Essen, Germany.

The prognosis of patients with aneurysmal subarachnoid haemorrhage requiring decompressive craniectomy is usually poor. Proper selection and early performing of decompressive craniectomy might improve the patients' outcome. We aimed at developing a risk score for prediction of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. All consecutive aneurysmal subarachnoid haemorrhage cases treated at the University Hospital of Essen between January 2003 and June 2016 (test cohort) and the University Medical Center Freiburg between January 2005 and December 2012 (validation cohort) were eligible for this study. Various parameters collected within 72 h after aneurysmal subarachnoid haemorrhage were evaluated through univariate and multivariate analyses to predict separately primary (PrimDC) and secondary decompressive craniectomy (SecDC). The final analysis included 1376 patients. The constructed risk score included the following parameters: intracerebral ('arenchymal') haemorrhage (1 point), 'apid' vasospasm on angiography (1 point), arly cerebral infarction (1 point), aneurysm ac > 5 mm (1 point), clipping (' urgery', 1 point), age nder 55 years (2 points), Hunt and Hess grade ≥ 4 ('educed consciousness', 1 point) and xternal ventricular drain (1 point). The score (0-9 points) showed high diagnostic accuracy for the prediction of PrimDC and SecDC in the test (area under the curve = 0.842/0.818) and validation cohorts (area under the curve = 0.903/0.823), respectively. 63.7% of the patients scoring ≥6 points required decompressive craniectomy (versus 12% for the PRESSURE < 6 points,  < 0.0001). In the subgroup of the patients with the PRESSURE ≥6 points and absence of dilated/fixed pupils, PrimDC within 24 h after aneurysmal subarachnoid haemorrhage was independently associated with lower risk of unfavourable outcome (modified Rankin Scale >3 at 6 months) than in individuals with later or no decompressive craniectomy ( < 0.0001). Our risk score was successfully validated as reliable predictor of decompressive craniectomy after aneurysmal subarachnoid haemorrhage. The PRESSURE score might present a background for a prospective randomized clinical trial addressing the utility of early prophylactic decompressive craniectomy in aneurysmal subarachnoid haemorrhage.
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http://dx.doi.org/10.1093/braincomms/fcaa134DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7660044PMC
September 2020

Distinct ictal hippocampal sharp transients in scalp EEG.

Clin Neurophysiol 2020 Aug 29;131(8):1925-1927. Epub 2020 May 29.

Epilepsy Center, Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany. Electronic address:

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http://dx.doi.org/10.1016/j.clinph.2020.05.012DOI Listing
August 2020

Oligodendrocyte lineage and myelination are compromised in the gray matter of focal cortical dysplasia type IIa.

Epilepsia 2020 01 24;61(1):171-184. Epub 2019 Dec 24.

Experimental Epilepsy Research, Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Objectives: Focal cortical dysplasias (FCDs) are local malformations of the human neocortex and a leading cause of medically intractable epilepsy. FCDs are characterized by local architectural disturbances of the neocortex and often by a blurred gray-white matter boundary indicating abnormal white matter myelination. We have recently shown that myelination is also compromised in the gray matter of dysplastic areas, since transcripts encoding factors for oligodendrocyte differentiation and myelination are downregulated and myelin fibers appear fractured and disorganized.

Methods: Here, we characterized the gray matter-associated myelination pathology in detail by in situ hybridization, immunohistochemistry, and electron microscopy with markers for myelin, mature oligodendrocytes, and oligodendrocyte precursor cells in tissue sections of FCD IIa and control cortices. In addition, we isolated oligodendrocyte precursor cells from resected dysplastic tissue and performed proliferation assays.

Results: We show that the proportion of myelinated gray matter is similar in the dysplastic cortex to that in controls and myelinated fibers extend up to layer III. On the ultrastructural level, however, we found that the myelin sheaths of layer V axons are thinner in dysplastic specimens than in controls. In addition, the density of oligodendrocyte precursor cells and of mature oligodendrocytes was reduced. Finally, we show for the first time that oligodendrocyte precursor cells isolated from resected dysplastic cortex have a reduced proliferation capacity in comparison to controls.

Significance: These results indicate that proliferation and differentiation of oligodendrocyte precursor cells and the formation of myelin sheaths are compromised in FCD and might contribute to the epileptogenicity of this cortical malformation.
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http://dx.doi.org/10.1111/epi.16415DOI Listing
January 2020

Cross-Species Single-Cell Analysis Reveals Divergence of the Primate Microglia Program.

Cell 2019 12;179(7):1609-1622.e16

Institute of Neuropathology, Faculty of Medicine, University of Freiburg, Freiburg, Germany; Signaling Research Centres BIOSS and CIBSS, University of Freiburg, Freiburg, Germany; Center for NeuroModulation, Faculty of Medicine, University of Freiburg, Freiburg, Germany. Electronic address:

Microglia, the brain-resident immune cells, are critically involved in many physiological and pathological brain processes, including neurodegeneration. Here we characterize microglia morphology and transcriptional programs across ten species spanning more than 450 million years of evolution. We find that microglia express a conserved core gene program of orthologous genes from rodents to humans, including ligands and receptors associated with interactions between glia and neurons. In most species, microglia show a single dominant transcriptional state, whereas human microglia display significant heterogeneity. In addition, we observed notable differences in several gene modules of rodents compared with primate microglia, including complement, phagocytic, and susceptibility genes to neurodegeneration, such as Alzheimer's and Parkinson's disease. Our study provides an essential resource of conserved and divergent microglia pathways across evolution, with important implications for future development of microglia-based therapies in humans.
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http://dx.doi.org/10.1016/j.cell.2019.11.010DOI Listing
December 2019

Impact of Stereotactic Ventriculocisternostomy on Delayed Cerebral Infarction and Outcome After Subarachnoid Hemorrhage.

Stroke 2020 02 4;51(2):431-439. Epub 2019 Dec 4.

Department of Stereotactic and Functional Neurosurgery (B.S., V.A.C., P.C.R.), University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany.

Background and Purpose- Delayed cerebral infarction (DCI) is an important cause of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Stereotactic catheter ventriculocisternostomy (STX-VCS) and fibrinolytic/spasmolytic lavage is a new method for DCI prevention. Here, we assess the effects of implementing STX-VCS in an unselected aSAH patient population of a tertiary referral center. Methods- Retrospective cohort study of all consecutive aSAH patients admitted to a neurosurgical referral center during a 7-year period (April 2012 to April 2019). Midterm STX-VCS was introduced and offered to patients at high risk for DCI. We compared the incidence and burden of DCI, neurological outcome, and the use of induced hypertension and endovascular rescue therapy in this consecutive aSAH population 3.5 years before versus 3.5 years after STX-VCS became available. Results- Four hundred thirty-six consecutive patients were included: 222 BEFORE and 214 AFTER. Fifty-seven of 214 (27%) patients received STX-VCS. Stereotactic procedures resulted in one (2%) subdural hematoma. Favorable neurological outcome at 6 months occurred in 118 (53%) patients BEFORE and 139 (65%) patients AFTER (relative risk, 0.79 [95% CI, 0.66-0.95]). DCI occurred in 40 (18.0%) patients BEFORE and 17 (7.9%) patients AFTER (relative risk, 0.68 [95% CI, 0.57-0.86]), and total DCI volumes were 8933 (100%) and 3329 mL (36%), respectively. Induced hypertension was used in 97 (44%) and 30 (15%) patients, respectively (relative risk, 0.55 [95% CI, 0.46-0.65]). Thirty (13.5%) patients BEFORE versus 5 (2.3%) patients AFTER underwent endovascular rescue therapies (relative risk, 0.17 [95% CI, 0.07-0.42]). Conclusions- Selecting high-risk patients for STX-VCS reduced the DCI incidence, burden, and related mortality in a consecutive aSAH patient population. This was associated with an improved neurological outcome.
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http://dx.doi.org/10.1161/STROKEAHA.119.027424DOI Listing
February 2020

Mapping microglia states in the human brain through the integration of high-dimensional techniques.

Nat Neurosci 2019 12 18;22(12):2098-2110. Epub 2019 Nov 18.

Institute of Neuropathology, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Microglia are tissue-resident macrophages of the CNS that orchestrate local immune responses and contribute to several neurological and psychiatric diseases. Little is known about human microglia and how they orchestrate their highly plastic, context-specific adaptive responses during pathology. Here we combined two high-dimensional technologies, single-cell RNA-sequencing and time-of-flight mass cytometry, to identify microglia states in the human brain during homeostasis and disease. This approach enabled us to identify and characterize a previously unappreciated spectrum of transcriptional states in human microglia. These transcriptional states are determined by their spatial distribution, and they further change with aging and brain tumor pathology. This description of multiple microglia phenotypes in the human CNS may open promising new avenues for subset-specific therapeutic interventions.
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http://dx.doi.org/10.1038/s41593-019-0532-yDOI Listing
December 2019

Survival and Prognostic Predictors of Anaplastic Meningiomas.

World Neurosurg 2019 Nov 26;131:e321-e328. Epub 2019 Jul 26.

Department of Neurosurgery, Medical Center-University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Background: Anaplastic meningiomas are rare tumors with a poor prognosis, even after complete surgical resection and radiotherapy. There has been limited evidence with respect to the clinical factors and their effects on the course of the disease. Various retrospective studies have not been able to provide clear evidence of standardized treatment, usually presenting contradictory results. The aim of this study was to evaluate the prognostic factors influencing the progression-free survival (PFS) and overall survival (OS) of anaplastic meningiomas, with a particular focus on the roles of the extent of resection and postoperative adjuvant radiotherapy.

Methods: Between October 2001 and March 2016, 36 patients with anaplastic meningiomas were treated in our Department of Neurosurgery, of whom 11 underwent gross total resection (GTR) and 18 subtotal resection. Twenty-one patients received postoperative adjuvant radiotherapy, and 8 were treated with surgery alone. GTR (Simpson grades I and II) was associated with significantly improved PFS (P = 0.01) and OS (P = 0.004). Furthermore, adjuvant radiotherapy showed an improvement in PFS (P = 0.01) but not in OS (P = 0.16).

Conclusions: The extent of resection in anaplastic meningiomas is correlated with a better outcome. However, resection alone is not sufficient for the long-term control of anaplastic meningiomas. Adjuvant radiotherapy is an essential component in the adjuvant treatment of anaplastic meningiomas, including for patients undergoing GTR. Further investigations through which to improve adjuvant therapy options are necessary to improve meningioma therapy.
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http://dx.doi.org/10.1016/j.wneu.2019.07.148DOI Listing
November 2019

Cisternal lavage via third ventriculostomy through the fenestrated lamina terminalis after aneurysm clipping: Technical note.

J Clin Neurosci 2019 Jun 25;64:283-286. Epub 2019 Mar 25.

Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg Germany.

Delayed cerebral infarction (DCI) contributes to the burden of morbidity and mortality acquired by patients with aneurysmal subarachnoid hemorrhage (SAH). Cisternal lavage may prevent DCI. Delivery of lavage therapy to the basal cisterns, however, is challenging. Here, we report a novel method for the delivery of cisternal lavage using a cisterno-ventricular catheter (CVC) inserted via the fenestrated lamina terminalis during aneurysm clipping. In two high-risk aSAH patients a CVC was inserted into the third ventricle through the fenestrated lamina terminalis during aneurysm clipping. Post-operatively, continuous cisternal lavage using Urokinase or Nimodipine was applied using an external ventricular drain (EVD) as inflow tract and the CVC as outflow tract. Neurological outcome at 6 months was assessed by modified Rankin scale. Catheter placement into the third ventricle through the fenestrated lamina terminalis was performed without complications. Application of a free-running electrolyte solution containing Urokinase or Nimodipine via the EVD and drainage via the CVC was feasible. Cisternal Nimodipine application normalized sonographic vasospasm in both cases. DCI did not occur. CVC placement for ventriculo-cisternal lavage may represent a useful method for DCI prevention. It can be considered in aSAH patients at risk for DCI if the chiasmatic region is accessed during aneurysm clipping.
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http://dx.doi.org/10.1016/j.jocn.2019.03.026DOI Listing
June 2019

Author Correction: Spatial and temporal heterogeneity of mouse and human microglia at single-cell resolution.

Nature 2019 Apr;568(7751):E4

Institute of Neuropathology, Medical Faculty, University of Freiburg, Freiburg, Germany.

In this Letter, Dominic Grün and Sagar have been added to the author list (affiliated with Max-Planck-Institute of Immunology and Epigenetics (MPI-IE), Freiburg, Germany). The author list, 'Author contribution' and 'Acknowledgements' sections have been corrected online. See accompanying Amendment.
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http://dx.doi.org/10.1038/s41586-019-1045-2DOI Listing
April 2019

Spatial and temporal heterogeneity of mouse and human microglia at single-cell resolution.

Nature 2019 02 13;566(7744):388-392. Epub 2019 Feb 13.

Institute of Neuropathology, Medical Faculty, University of Freiburg, Freiburg, Germany.

Microglia have critical roles not only in neural development and homeostasis, but also in neurodegenerative and neuroinflammatory diseases of the central nervous system. These highly diverse and specialized functions may be executed by subsets of microglia that already exist in situ, or by specific subsets of microglia that develop from a homogeneous pool of cells on demand. However, little is known about the presence of spatially and temporally restricted subclasses of microglia in the central nervous system during development or disease. Here we combine massively parallel single-cell analysis, single-molecule fluorescence in situ hybridization, advanced immunohistochemistry and computational modelling to comprehensively characterize subclasses of microglia in multiple regions of the central nervous system during development and disease. Single-cell analysis of tissues of the central nervous system during homeostasis in mice revealed specific time- and region-dependent subtypes of microglia. Demyelinating and neurodegenerative diseases evoked context-dependent subtypes of microglia with distinct molecular hallmarks and diverse cellular kinetics. Corresponding clusters of microglia were also identified in healthy human brains, and the brains of patients with multiple sclerosis. Our data provide insights into the endogenous immune system of the central nervous system during development, homeostasis and disease, and may also provide new targets for the treatment of neurodegenerative and neuroinflammatory pathologies.
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http://dx.doi.org/10.1038/s41586-019-0924-xDOI Listing
February 2019

A novel rescue therapy for cerebral vasospasm: Cisternal Nimodipine application via stereotactic catheter ventriculocisternostomy.

J Clin Neurosci 2019 May 5;63:244-248. Epub 2019 Feb 5.

Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany.

Delayed Cerebral Infarction (DCI) due to Cerebral Vasospasm (CVS) is an important contributor to poor outcome after aneurysmal subarachnoid haemorrhage (aSAH). Despite established risk factors CVS and DCI are unpredictable at the individual patient level. Efficient treatments are lacking. We report a novel rescue therapy for DCI: Access to the basal cisterns by stereotactic catheter ventriculocisternostomy (STX-VCS) and direct cisternal application of the spasmolytic agent Nimodipine. On the basis of individual treatment decisions three aSAH patients who developed CVS underwent STX-VCS. Continuous lavage with Nimodipine was performed. CVS was assessed by daily transcranial doppler ultrasonography. Neurological outcome at 3 months was assessed by modified Rankin scale. STX-VCS was performed without complications in all patients. CVS rapidly resolved upon cisternal application of Nimodipine. CVS recurred in two patients upon interruption of Nimodpine application and resolved upon restart of Nimodipine. DCI did not occur in all three cases. STX-VCS and cisternal Nimodipine application is a novel rescue therapy for CVS treatment and DCI-prevention in patients with aSAH.
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http://dx.doi.org/10.1016/j.jocn.2019.01.039DOI Listing
May 2019

A Case of Large Meningeal Epithelioid Hemangioendothelioma With WWTR1-CAMTA1 Gene Rearrangement and Slow Growth Over 15 Years.

J Neuropathol Exp Neurol 2018 10;77(10):871-876

Institute of Neuropathology, Faculty of Medicine.

Epithelioid hemangioendothelioma (EHE) is a rare vascular neoplasm predominantly occurring in the soft tissue. A majority of EHE cases is driven by a WW domain containing transcription regulator protein 1 (WWTR1)-calmodulin-binding transcription activator 1 (CAMTA1) gene fusion. The clinical course of EHE ranges from long-term favorable to rapidly aggressive. Few cases of intracranial EHE have been reported, none of which has been molecularly proven. We report a case of left parietal meningeal EHE, which was resected 15 years after initial radiological detection. Four years prior to surgery, a second atlantooccipital lesion and pulmonary nodules were detected, which remained constant in subsequent radiological controls. The tumor infiltrated the cranial bone. Histology showed an isomorphic tumor with epithelioid cells forming vacuoles that contained erythrocytes. Necrosis was absent and anaplasia and proliferative activity were scant. Immunohistochemistry showed expression of the endothelial markers CD34, CD31, vascular endothelial growth factor, and factor VIII and predominantly nuclear overexpression of CAMTA1. Fluorescence in situ hybridization showed WWTR1-CAMTA1 gene fusion. Our report provides the first case of intracranial EHE with molecular proof of WWTR1-CAMTA1 gene fusion. The slowly progressive clinical course of 15 years is the longest so far reported for intracranial EHE.
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http://dx.doi.org/10.1093/jnen/nly066DOI Listing
October 2018

Atlantoaxial Instability in Patients Older Than 70 Years: What Is the Outcome When Further Conservative Treatment Is Not an Option?

J Neurol Surg A Cent Eur Neurosurg 2018 Sep 4;79(5):372-379. Epub 2018 Jul 4.

Department of Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Objective:  We report on our experiences of navigated posterior C1-C2 spondylodesis in the elderly (≥ 70 years of age).

Patients:  This retrospective cohort study evaluated all patients ≥ 70 years of age treated with navigated posterior spondylodesis C1-C2 (at the most to C3) from 2008 to 2015 with a minimum follow-up of 1 year. Minor and major complications within 30 days after surgery, patient outcome, and the rate of solid fusion in computed tomography were recorded. The follow-up over 1 year was conducted by outpatient examinations and via telephone interviews.

Results:  Twenty-two patients with a mean age of 79.9 years (range: 71-91 years) were treated. Minor complications were mild pneumonia (18.2%), postoperative confusion (9.1%), and urinary tract infection (4.5%). Major complications were severe pneumonia (4.5%) and clinically asymptomatic vertebral artery injury (4.5%). The mortality rate was 13.6% ( = 3) within the first 30 days after surgery and 22.7% ( = 5) within 1 year. All deceased patients were > 85 years of age.

Conclusion:  In our patient population, posterior spondylodesis was shown to be beneficial for patients > 70 years up to age ∼ 85 years. The mortality rate increased sharply in patients > 85 years. In these patients the indication for surgery should be critically evaluated.
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http://dx.doi.org/10.1055/s-0038-1646958DOI Listing
September 2018

Surgical Treatment of Extratemporal Epilepsy: Results and Prognostic Factors.

Neurosurgery 2019 01;84(1):242-252

Department of Neurosurgery, Medical Center-University of Freiburg, Frieburg, Germany.

Background: Surgery is a widely accepted option for the treatment of pharmacoresistant epilepsies of extratemporal origin.

Objective: To analyze clinical and epileptological results and to provide prognostic factors influencing seizure outcome.

Methods: This retrospective single-center study comprises a consecutive series of 383 patients, most of whom had an identifiable lesion on MRI, who underwent resective surgery for extratemporal epilepsy. Data including diagnostic modalities, surgical treatment, histopathology, prognostic factors, and epileptological outcome were analyzed.

Results: Resective procedures were located as follows: frontal (n = 183), parietal (n = 44), occipital (n = 24), and insular (n = 24). In 108 cases resection included more than 1 lobe. Histopatholological evaluation revealed focal cortical dysplasias (n = 178), tumors (n = 110), cavernomas (n = 27), gliosis (n = 42), and nonspecific findings (n = 36). A distinct epileptogenic lesion was detected in 338 (88.7%) patients. After a mean follow-up of 54 mo, 227 (62.5%) patients remained free from disabling seizures (Engel class I), and 178 (49%) were completely seizure free (Engel class Ia). There was no perioperative mortality. Permanent morbidity was encountered in 46 cases (11.8%). The following predictors were significantly associated with excellent seizure outcome (Engel I): lesion visible on magnetic resonance imaging (MRI; P = .02), noneloquent location (P = .01), complete resection of the lesion (P = .001), absence of epileptic activity postoperatively (P = .001), circumscribed histological findings (P = .001), lower age at surgery (P = .008), and shorter duration of epilepsy (P = .02).

Conclusion: Surgical treatment of extratemporal epilepsy provides satisfying epileptological results with an acceptable morbidity. Best results can be achieved in younger patients with circumscribed MRI lesions, which can be resected completely.
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http://dx.doi.org/10.1093/neuros/nyy099DOI Listing
January 2019

Gradual External Ventricular Drainage Weaning Reduces The Risk of Shunt Dependency After Aneurysmal Subarachnoid Hemorrhage: A Pooled Analysis.

Oper Neurosurg (Hagerstown) 2018 11;15(5):498-504

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

Background: Chronic posthemorrhagic hydrocephalus necessitating shunt placement is a common complication of subarachnoid hemorrhage (SAH).

Objective: To evaluate the role of external ventricular drainage (EVD) weaning on risk of shunt dependency after SAH.

Methods: Two German university hospitals with different EVD management regimes (rapid weaning [RW] vs gradual weaning [GW]) pooled the data of their observational cohorts containing altogether 1171 consecutive SAH patients treated between January 2005 and December 2012. Development and timing of shunt dependency in SAH survivals were the endpoints of the study.

Results: The final cohort consisted of 455 and 510 SAH survivors treated in the centers with RW and GW, respectively. Mortality rates, as well as baseline demographic, clinical, and radiographic parameters, showed no differences between the centers. Patients with GW were less likely to develop shunt dependency (27.5% vs 34.7%, P = .018), Multivariate analysis confirmed independent association between RW regime and shunt dependency (P = .026). Shunt-dependent SAH patients undergoing GW required significantly longer time until shunting (mean 29.8 vs 21.7 d, P < .001) and hospital stay (mean 39 vs 34.4 d, P = .03). In addition, patients with GW were at higher risk for secondary shunt placement after successful initial weaning (P = .001). The risk of cerebrospinal fluid infection was not associated with the weaning regime (15.3% vs 12.9%, P = .307).

Conclusion: At the expense of longer treatment, GW may decrease the risk of shunt dependency after SAH without an additional risk for infections. Due to the risk of secondary shunt dependency, SAH patients with GW require proper posthospital neurological care.
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http://dx.doi.org/10.1093/ons/opy009DOI Listing
November 2018

Piezosurgery-A Safe Technique to Perform Lateral Suboccipital Craniotomy?

Oper Neurosurg (Hagerstown) 2018 12;15(6):664-671

Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.

Background: Piezosurgery (PS) is a relatively new technique based on microvibrations generated by the piezoelectric effect. It selectively cuts bone tissue and preserves the surrounding soft tissue.

Objective: To evaluate the use of PS for performing lateral suboccipital craniotomy.

Methods: PS was used to perform a lateral suboccipital craniotomy in 22 patients who underwent surgery for different cerebellopontine angle (CPA) pathologies in the neurosurgical department. The applicability of PS for lateral suboccipital craniotomy was evaluated with respect to safety, preciseness of bone cutting, and in particular the preservation of the adjacent dura and sigmoid and transverse sinuses.

Results: Lateral suboccipital craniotomy in 22 patients who underwent surgery for different CPA pathologies (13 vestibular schwannoma, 5 petrous bone meningioma, 1 petroclival meningioma, 2 epidermoid cysts, and 1 petrous bone cholesterol granuloma) was performed with PS without any complications. A burr hole was set before piezosurgical craniotomy in 6 patients, with no prior burr hole in 16 patients. Incidental durotomy during piezosurgical craniotomy occurred in 6 patients, and small lacerations of the sigmoid sinus caused by the piezosurgical device were observed in 3 patients.

Conclusion: Although PS is a safe and selective bone cutting technique that preserves the surrounding soft tissue, it can still lead to unintended dural tears during lateral suboccipital craniotomy. This must be kept in mind when using PS for craniotomies and relying on the selective bone cutting properties of PS.
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http://dx.doi.org/10.1093/ons/opx272DOI Listing
December 2018

Piezosurgery-, neuroendoscopy-, and neuronavigation-assisted intracranial approach for removal of a recurrent petrous apex cholesteatoma: technical note.

J Neurosurg Pediatr 2018 03 22;21(3):322-328. Epub 2017 Dec 22.

Departments of1Neurosurgery and.

Current approaches for resection of petrous bone cholesteatomas (PBCs), such as canal wall up (closed) and canal wall down (open) mastoidectomies, in the pediatric population present recurrence rates ranging between 17% and 70% with a high rate of postoperative complications involving hearing loss and facial nerve weakness. This technical note illustrates an alternative intracranial approach that was used in combination with the techniques of piezoelectric surgery, neuroendoscopy, and neuronavigation for safe and effective removal in a difficult pediatric case of recurrent PBC. The third recurrence of a PBC in a 14-year-old girl was diagnosed by CT and MRI. A retrosigmoid approach gave access to the petrous apex, allowing for the safe and complete removal of the lesion and decompression of the facial nerve and internal carotid artery. The intraoperative implementation of piezoelectric surgery, neuronavigation, neuroendoscopy, and neuromonitoring ensured better intraoperative visualization, safer bone removal, and preservation of nerve function, facilitating a macroscopically total resection of the pathology without additional neurological damage of the adjacent tissues. Cholesteatoma extension could be clearly verified by intraoperative neuronavigation. Neuroendoscopy and piezoelectric surgery provided good support in the safe bone removal in close vicinity to neurovascular structures and in full vision inside the cholesteatoma cavity beyond the line of sight of the microscope. Hearing and facial nerve function could be preserved. The presented intracranial retrosigmoid approach combined with multiple intraoperative assisting techniques proved to be effective for the safe and complete removal of recurrent PBC, providing excellent intraoperative visualization and the possibility of preserving cranial nerve function.
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http://dx.doi.org/10.3171/2017.8.PEDS17327DOI Listing
March 2018

3 Tesla MRI-negative focal epilepsies: Presurgical evaluation, postoperative outcome and predictive factors.

Clin Neurol Neurosurg 2017 Dec 31;163:116-120. Epub 2017 Oct 31.

Epilepsy Center, Department of Neurosurgery, Medical Center-University of Freiburg, Germany.

Objective: To investigate presurgical diagnostic modalities, clinical and seizure outcome as well as predictive factors after resective epilepsy surgery in 3 Tesla MRI-negative focal epilepsies.

Patients And Methods: This retrospective study comprises 26 patients (11 males/15 females, mean age 34±12years, range 13-50 years) with 3 Tesla MRI-negative focal epilepsies who underwent resective epilepsy surgery. Non-invasive and invasive presurgical diagnostic modalities, type and localization of resection, clinical and epileptological outcome with a minimum follow-up of 1year (range 1-11 years, mean 2.5±2.3years) after surgery as well as outcome predictors were evaluated.

Results: All patients underwent invasive video-EEG monitoring after implantation of intracerebral depth and/or subdural electrodes. Ten patients received temporal and 16 extratemporal or multilobar (n=4) resections. There was no perioperative death or permanent morbidity. Overall, 12 of 26 patients (46%) were completely seizure-free (Engel IA) and 65% had a favorable outcome (Engel I-II). In particular, seizure-free ratio was 40% in the temporal and 50% in the extratemporal group. In the temporal group, long duration of epilepsy correlated with poor seizure outcome, whereas congruent unilateral FDG-PET hypometabolism correlated with a favorable outcome.

Conclusions: In almost two thirds of temporal and extratemporal epilepsies defined as "non-lesional" by 3 Tesla MRI criteria, a favorable postoperative seizure outcome (Engel I-II) can be achieved with accurate multimodal presurgical evaluation including intracranial EEG recordings. In the temporal group, most favorable results were obtained when FDG-PET displayed congruent unilateral hypometabolism.
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http://dx.doi.org/10.1016/j.clineuro.2017.10.038DOI Listing
December 2017

Feasibility of stereotactic catheter ventriculocisternostomy for cisternal lavage therapy in patients with subarachnoid hemorrhage.

Clin Neurol Neurosurg 2017 Dec 16;163:94-102. Epub 2017 Oct 16.

Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106 Freiburg, Germany. Electronic address:

Objective: Delayed cerebral infarction (DCI) confers considerable morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Available prevention strategies are insufficient. Cisternal blood clearance by stereotactic catheter ventriculocisternostomy (STX-VCS) and cisternal lavage therapy is a novel concept for DCI prevention. Here, we assess the general feasibility, pitfalls and imaging requirements of STX-VCS after aSAH.

Patients And Methods: 73 aSAH patients admitted between 2008 and 2015 with appropriate imaging for simulation of stereotactic procedures were included. Surgical feasibility of a transventricular trajectory to the basal cisterns was assessed.

Results: Transventricular catheter access to the basal cisterns was feasible in 94% of cases. In 6% vascular obstacles precluded a transventricular approach and access to the basal cisterns could be simulated via a transparenchymal trajectory. CT-artifacts that interfered with stereotactic planning were observed in 58% after coiling and 5% after clipping. In these cases stereotactic planning was enabled by MRI. Logistic regression of aneurysm size and distance-to-target allowed for precise prediction whether MRI was required for stereotactic planning of STX-VCS after coiling.

Conclusions: Stereotactic catheter access to the basal cisterns after aSAH appears to be generally feasible. Coil artifacts compromising CT-based planning can be precisely anticipated and planning enabled by MRI.
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http://dx.doi.org/10.1016/j.clineuro.2017.10.012DOI Listing
December 2017

Atypical meningioma: progression-free survival in 161 cases treated at our institution with surgery versus surgery and radiotherapy.

J Neurooncol 2018 Jan 28;136(1):147-154. Epub 2017 Oct 28.

Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.

Although atypical meningioma recurs frequently in spite of total resection and/or radiotherapy, no consensus on optimal adjuvant management was found. However, several retrospective studies analysed the additional effect of adjuvant radiotherapy in atypical meningioma with inconsistent results. Therefrom, the purpose of this study was to evaluate prognostic factors influencing the recurrence/progression and progression-free survival (PFS) rates of atypical meningioma, particularly focused on the role of postoperative adjuvant radiotherapy. Between February 2001 and March 2015, 161 atypical meningioma resections were performed in our Department of Neurosurgery, of which, 128 cases underwent surgical treatment alone and 33 cases underwent surgery and radiotherapy. Kaplan-Meier analysis was used to provide median point estimates and PFS rates. The Cox-regression model was used in the univariate and multivariate analysis to identify significant factors associated with treatment. The extent of resection (Simpson grade I and II) significantly influenced the risk of recurrence (hazard ratio = 1.8, CI (95%) 1.3-2.6, p-value = 0.0004). There was no significant benefit for progression-free survival after adjuvant radiotherapy (hazard ratio = 1.48, CI (95%) 0.76-2.86, p-value = 0.22). Additionally, meningioma located at the anterior and posterior fossa showed a significantly longer PFS compared to other locations (p-value = 0.03). Adjuvant postoperative radiotherapy had no significant impact on recurrence/progression rate or PFS. The extent of resection according to Simpson grade remains the most important prognostic factor associated with lower recurrence/progression rates and longer PFS in patients with atypical meningioma. The location of the tumours at the anterior or posterior fossa was an independent factor associated with improved PFS.
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http://dx.doi.org/10.1007/s11060-017-2634-2DOI Listing
January 2018

Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage: A Matched Cohort Study.

Stroke 2017 10 13;48(10):2704-2709. Epub 2017 Sep 13.

From the Department of Neurosurgery (R.R., C.S., I.C.), Department of Stereotactic and Functional Neurosurgery (V.A.C., P.C.R.), Department of Neurology (W.-D.N.), Department of Neuroradiology (K.E., H.U.), and Department of Nursing-IT (R.K.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; and Department of Neurosurgery, University Hospital Essen, Germany (R.J.).

Background And Purpose: Delayed cerebral infarction (DCI) is a major source of morbidity and mortality after aneurysmal subarachnoid hemorrhage. We report a novel intervention-stereotactic catheter ventriculocisternostomy (STX-VCS) and fibrinolytic/spasmolytic lavage therapy-for DCI prevention. Outcomes of 20 consecutive patients are compared with 60 matched controls.

Methods: On the basis of individual treatment decisions, STX-VCS was performed in 20 high-risk aneurysmal subarachnoid hemorrhage patients admitted to our department between September 2015 and October 2016. Three controls matched for age, sex, aneurysm treatment method, and admission Hunt and Hess grade were assigned to each case treated by STX-VCS. DCI was the primary outcome. Mortality and mRS at rehabilitation discharge were secondary outcome parameters. The association between STX-VCS and DCI, mortality, and mRS was assessed by conditional logistic regression.

Results: Stereotactic procedures were performed without surgical complications. Continuous cisternal lavage was feasible in 17 of 20 patients (85%). One adverse event because of cisternal lavage was without sequelae. DCI occurred in 25 of 60 (42%) controls and 3 of 20 (15%) patients with STX-VCS (odds ratio, 0.15; 95% confidence interval, 0.04-0.64). Mortality occurred in 20 of 60 (33%) controls and 1 of 20 (5%) patients with STX-VCS, respectively (odds ratio, 0.08; 95% confidence interval, 0.01 - 0.66). Favorable outcome (mRS≤3) at rehabilitation discharge was observed in 12 of 20 patients with STX-VCS (60%) versus 21 of 60 (35%) matched controls (odds ratio, 0.26; 95% confidence interval, 0.8-0.86).

Conclusions: STX-VCS was feasible and safe in patients with severe aneurysmal subarachnoid hemorrhage. Initial results indicate that DCI and mortality can be reduced, and neurological outcome may be improved with this method.
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http://dx.doi.org/10.1161/STROKEAHA.117.018397DOI Listing
October 2017

Piezosurgery in Modified Pterional Orbital Decompression Surgery in Graves Disease.

World Neurosurg 2017 Oct 11;106:422-429. Epub 2017 Jul 11.

Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Objective: Piezosurgery uses microvibrations to selectively cut bone, preserving the adjacent soft tissue. The present study evaluated the use of piezosurgery for bone removal in orbital decompression surgery in Graves disease via a modified pterional approach.

Methods: A piezosurgical device (Piezosurgery medical) was used in 14 patients (20 orbits) with Graves disease who underwent orbital decompression surgery in additional to drills and rongeurs for bone removal of the lateral orbital wall and orbital roof. The practicability, benefits, and drawbacks of this technique in orbital decompression surgery were recorded. Piezosurgery was evaluated with respect to safety, preciseness of bone cutting, and preservation of the adjacent dura and periorbita. Preoperative and postoperative clinical outcome data were assessed.

Results: The orbital decompression surgery was successful in all 20 orbits, with good clinical outcomes and no postoperative complications. Piezosurgery proved to be a safe tool, allowing selective bone cutting with no damage to the surrounding soft tissue structures. However, there were disadvantages concerning the intraoperative handling in the narrow space and the efficiency of bone removal was limited in the orbital decompression surgery compared with drills.

Conclusions: Piezosurgery proved to be a useful tool in bone removal for orbital decompression in Graves disease. It is safe and easy to perform, without any danger of damage to adjacent tissue because of its selective bone-cutting properties. Nonetheless, further development of the device is necessary to overcome the disadvantages in intraoperative handling and the reduced bone removal rate.
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http://dx.doi.org/10.1016/j.wneu.2017.06.180DOI Listing
October 2017

Comparative Study of C-Arms for Intraoperative 3-dimensional Imaging and Navigation in Minimally Invasive Spine Surgery Part II: Radiation Exposure.

Clin Spine Surg 2017 Jul;30(6):E669-E676

Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany.

Study Design: A radiation exposure study in vitro.

Objective: This study aimed to compare the radiation exposure of 2 different 3-dimensional (3D) C-arm devices on an anthropomorphic phantom.

Summary Of Background Data: Minimally invasive pedicle screw placement requires intraoperative imaging techniques for visualization of the unexposed spine. Mobile 3D C-arms compose a 3D image data set out of multiple successive fluoroscopic images.

Methods: We compared the 3D C-arm devices Siremobil Iso-C 3D (Siemens Sector Healthcare, Erlangen, Germany) and Vision FD Vario 3D (Ziehm Imaging, Nuremberg, Germany) regarding their radiation exposure. For this purpose, dosimeters were attached on an anthropomorphic phantom at various sites (eye lenses, thyroid gland, female, and male gonads). With each C-arm, 10 automated 3D scans as well as 400 fluoroscopic images were performed on the cervical and lumbar spine, respectively.

Results: The Vision FD Vario 3D generally causes higher radiation exposures than the Siremobil Iso-C 3D. Significantly higher radiation exposures were assessed at the eye lenses performing cervical (294.1 vs. 84.6 μSv) and lumbar 3D scans (22.5 vs. 11.2 μSv) as well as at the thyroid gland performing cervical 3D scans (4405.2 vs. 2761.9 μSv). Moreover, the Vision FD Vario 3D caused significantly higher radiation exposure at the eye lenses for standard cervical fluoroscopic images (3.2 vs. 0.4 μSv).

Conclusions: 3D C-arms facilitate minimally invasive and accurate pedicle screw placement by providing 3D image datasets for intraoperative 3D imaging and navigation. However, the hereby potentially increased radiation exposure has to be considered. In particular, the Vision FD Vario 3D appears to generally evoke higher radiation exposures than the Siremobil Iso-C 3D. Well-indicated application of ionizing radiation and compliance with radiation protection principles remain mandatory to keep radiation exposure to patient and staff as low as reasonably achievable.
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http://dx.doi.org/10.1097/BSD.0000000000000187DOI Listing
July 2017

Comparative Study of C-arms for Intraoperative 3-dimensional Imaging and Navigation in Minimally Invasive Spine Surgery Part I: Applicability and Image Quality.

Clin Spine Surg 2017 Jul;30(6):276-284

Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany.

Study Design: This was a retrospective analysis.

Objective: This study compares 2 different 3-dimensional (3D) C-arm devices for intraoperative imaging and navigation with regard to clinical applicability and image quality.

Summary Of Background Data: Minimally invasive spine surgery requires intraoperative imaging techniques to adequately visualize the unexposed spine. For this purpose, mobile 3D C-arms became available along with the evolution of intraoperative navigation techniques.

Methods: The C-arm devices Siremobil Iso-C 3D (Siemens) and Vision FD Vario 3D (Ziehm) perform an automated orbital rotation around the patient acquiring a 3D image set out of multiple successive fluoroscopic images. We report on technical specifications of the C-arms and our daily experience regarding clinical applicability. Furthermore, 5 spine surgeons evaluated blinded triplanar planes of 40 cervical, thoracic, and lumbar 3D scans that were obtained during routine surgery regarding usability for navigation. We assessed the delineation of cortical bone, artifacts, and overall image quality using a 0-10 numeric rating scale.

Results: The Siremobil Iso-C 3D requires 128 seconds for its 190-degree scanning arc with equidistant isocenter. The Vision FD Vario 3D performs an elliptical scanning arc and completes its 135-degree scan in 64 seconds; furthermore, it features a flat panel detector and fully digital imaging. The smaller dimensions of the Vision FD Vario 3D made it easier to maneuver in the operating room compared with the more bulky Siremobil Iso-C 3D. With respect to image quality in cervical 3D scans, the Siremobil Iso-C 3D reached significantly higher scores in all categories. The Vision FD Vario 3D revealed less artifacts in lumbar 3D scans.

Conclusions: The Siremobil Iso-C 3D provides high-quality 3D scans in slender spine regions (eg, cervical spine), whereas the Vision FD Vario 3D appears to have advantages in the lumbar spine. Further evolution and novel devices are needed to optimize image quality and handling.
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http://dx.doi.org/10.1097/BSD.0000000000000186DOI Listing
July 2017

Surgical Treatment of Mesiotemporal Lobe Epilepsy: Which Approach is Favorable?

Neurosurgery 2017 Dec;81(6):992-1004

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

Background: Mesiotemporal lobe epilepsy is one of the most frequent causes for pharmacoresistant epilepsy. Different surgical approaches to the mesiotemporal area are used.

Objective: To analyze epileptological and neuropsychological results as well as complications of different surgical strategies.

Methods: This retrospective study is based on a consecutive series of 458 patients all harboring pharmacoresistant mesiotemporal lobe epilepsy. Following procedures were performed: standard anterior temporal lobectomy, anterior temporal or key-hole resection, extended lesionectomy, and transsylvian and subtemporal selective amygdalohippocampectomy. Postoperative outcome was evaluated according to different surgical procedures.

Results: Overall, 1 yr after surgery 315 of 432 patients (72.9%) were classified Engel I; in particular, 72.8% were seizure-free after anterior temporal lobectomy, 76.9% after key-hole resection, 84.4% after extended lesionectomy, 70.3% after transylvian selective amygdalohippocampectomy, and 59.1% after subtemporal selective amygdalohippocampectomy. No significant differences in seizure outcome were found between different resective procedures, neither in short-term nor long-term follow-up. There was no perioperative mortality. Permanent morbidity was encountered in 4.4%. There were no significant differences in complications between different resection types. In the majority of patients, selective attention improved following surgery. Patients after left-sided operations performed significantly worse regarding verbal memory as compared to right-sided procedures. However, surgical approach had no significant effect on memory outcome.

Conclusion: Different surgical approaches for mesiotemporal epilepsy analyzed resulted in similar epileptological, neuropsychological results, and complication rates. Therefore, the approach for the individual patient does not only depend on the specific localization of the epileptogenic area, but also on the experience of the surgeon.
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http://dx.doi.org/10.1093/neuros/nyx138DOI Listing
December 2017

Stereotactic Catheter Ventriculocisternostomy for Clearance of Subarachnoid Hemorrhage in Patients with Coiled Aneurysms.

Oper Neurosurg (Hagerstown) 2018 03;14(3):231-235

Department of Stereotactic and Functional Neurosurg-ery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.

Background: Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Current treatments of cerebral vasospasm are insufficient. Cisternal blood clearance is a promising treatment option. However, a generally applicable, safe, and effective method to access the cisterns of the brain is lacking.

Objective: To report on stereotactic catheter ventriculocisternostomy (STX-VCS) as a method to access the cisterns of the brain for clearance of subarachnoid hemorrhage in patients with aSAH and coiled aneurysms.

Methods: In 9 aSAH patients at high risk for DCI (Hunt and Hess grade ≥3, modified Fisher grade ≥3), access to the basal cisterns of the brain was created by STX-VCS. Fibrinolytic and/or spasmolytic lavage therapy was administered.

Results: STX-VCS was feasible and safe in all patients. Subarachnoid blood was rapidly cleared by irrigation with urokinase. Vasospasm occurred in 2 patients and was interrupted by irrigation with nimodipine. There was 1 fatality due to pneumogenic sepsis. Minor DCI occurred in 1 patient. Eight survived without DCI and are independent (modified Rankin score [mRS] ≤ 3) at 6 mo after aSAH.

Conclusion: STX-VCS allows for rapid clearance of subarachnoid hemorrhage in patients with coiled aneurysms.
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http://dx.doi.org/10.1093/ons/opx129DOI Listing
March 2018

Transsylvian Selective Amygdalohippocampectomy for Mesiotemporal Epilepsy: Experience with 162 Procedures.

Neurosurgery 2017 03;80(3):454-464

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

Background: Mesial temporal lobe epilepsy (MTLE) is one of the most common forms of epilepsy refractory to medical therapy. Among different surgical approaches, selective amygdalohippocampectomy has gained increasing interest for its rationale of isolated removal of the epileptogenic mesiotemporal area.

Objective: To summarize our experience with surgical treatment of MTLE in 162 patients using the transsylvian approach and to analyze possible effects of length of hippocampal resection and postoperative gliosis on seizure and cognitive outcome.

Methods: Clinical, radiological, histopathological and neuropsychological findings of 162 patients with MTLE who were operated by the senior author between 1993 and 2012 were retrospectively evaluated. Postoperative follow-up mounted up to 240 months (59 ± 56 months). Seizure outcome was available in 156 patients with minimum follow-up of 3 months. Extent of hippocampal resection was evaluated in 70 and postoperative gliosis in 62 of the 92 patients. Results were then correlated with seizure and cognitive outcome.

Results: Of 134 patients with a follow-up of at least 1 year, 85 (63.4%) remained completely seizure free (Engel Ia) and 118 (88.0%) had a worthwhile improvement after surgery (Engel I+II). There was no perioperative death. Permanent morbidity was encountered in 4 patients (2.5%). Neither the extent of hippocampal resection nor postoperative gliosis correlated with seizure outcome or postoperative memory performance.

Conclusion: Transsylvian selective amygdalohippocampectomy can be recommended as an adequate procedure for the surgical treatment of mesiotemporal epilepsy with favorable epileptological results and acceptable morbidity.
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http://dx.doi.org/10.1093/neuros/nyw089DOI Listing
March 2017