Publications by authors named "Fee Keil"

20 Publications

  • Page 1 of 1

The Added Value of Cerebral Imaging in Patients With Pyogenic Spinal Infection.

Front Neurol 2021 4;12:628256. Epub 2021 May 4.

Department of Neurosurgery, Goethe University Hospital, Frankfurt am Main, Germany.

The incidence of pyogenic spinal infection has increased in recent years. In addition to treatment of the spinal infection, early diagnosis and therapy of coexisting infections, especially of secondary brain infection, are important. The aim of this study is to elucidate the added value of routine cerebral imaging in the management of these patients. This was a retrospective single-center study. Cerebral imaging consisting of cerebral magnetic resonance imaging (cMRI) was performed to detect brain infection in patients with a primary pyogenic spinal infection. We analyzed a cohort of 61 patients undergoing cerebral imaging after diagnosis of primary pyogenic spinal infection. The mean age in this cohort was 68.7 years and the gender distribution consisted of 44 males and 17 females. Spinal epidural abscess was proven in 32 (52.4%) patients. Overall positive blood culture was obtained in 29 (47.5%) patients, infective endocarditis was detected in 23 (37.7%) patients and septic condition at admission was present in 12 (19.7%) Patients. Coexisting brain infection was detected in 2 (3.3%) patients. Both patients revealed clinical signs of severe sepsis, reduced level of consciousness (GCS score 3), were intubated, and died due to multi-organ failure. Brain infection in patients with spinal infection is very rare. Of 61 patients with pyogenic spinal infection, two patients had signs of cerebral infection shown by imaging, both of whom were in a coma (GCS 3), and sepsis.
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http://dx.doi.org/10.3389/fneur.2021.628256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8129560PMC
May 2021

Association of Lesion Pattern and Dysphagia in Acute Intracerebral Hemorrhage.

Stroke 2021 May 18:STROKEAHA120032615. Epub 2021 May 18.

Department of Neurology, Goethe University, Frankfurt am Main, Germany. (F.H., C.F., A.S., S.L.).

Background And Purpose: Dysphagia is a common and severe symptom of acute stroke. Although intracerebral hemorrhages (ICHs) account for 10% to 15% of all strokes, the occurrence of dysphagia in this subtype of stroke has not been widely investigated. The aim of this study was to evaluate the overall frequency and associated lesion locations and clinical predictors of dysphagia in patients with acute ICH.

Methods: Our analysis included 132 patients with acute ICH. Clinical swallowing assessment was performed within 48 hours after admission. All patients underwent computed tomography imaging. Voxel-based lesion-symptom mapping was performed to determine lesion sites associated with dysphagia.

Results: Eighty-four patients (63.6%) were classified as dysphagic. Higher scores on the National Institutes of Health Stroke Scale, larger ICH volumes, and higher degree of disability were associated with dysphagia. Voxels showing a statistically significant association with dysphagia were mainly located in the right insular cortex, the right central operculum, as well as the basal ganglia, corona radiata, and the left thalamus and left internal capsule. In contrast to lobar regions, in subcortical deep brain areas also small lesion volumes (<10 mL) were associated with a substantial risk of dysphagia. Intraventricular ICH extension and midline shift as imaging findings indicating a space-occupying effect were not associated with dysphagia in multivariate analysis.

Conclusions: Dysphagia is a frequent symptom in acute ICH. Distinct cortical and subcortical lesion sites are related to swallowing dysfunction and predictive for the development of dysphagia. Therefore, patients with ICH should be carefully evaluated for dysphagia independently from lesion size, in particular if deep brain regions are affected.
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http://dx.doi.org/10.1161/STROKEAHA.120.032615DOI Listing
May 2021

Functional outcome and morbidity after microsurgical resection of spinal meningiomas.

Neurosurg Focus 2021 05;50(5):E20

Departments of1Neurosurgery and.

Objective: The aim of this study was to evaluate functional outcome, surgical morbidity, and factors that affect outcomes of surgically treated patients.

Methods: The authors retrospectively analyzed patients who underwent microsurgical resection for spinal meningiomas between 2009 and 2020. Patient data and potential variables were collected and evaluated consecutively. Functional outcomes were evaluated using univariate and multivariate analyses.

Results: A total of 119 patients underwent microsurgical resection of spinal meningioma within the study period. After a mean follow-up of 25.4 ± 37.1 months, the rates of overall complication, tumor recurrence, and poor functional outcome were 9.2%, 7.6%, and 5%, respectively. Age, sex, revision surgery, and tumor recurrence were identified as independent predictors of poor functional outcome. Obesity and surgeon's experience had an impact on the complication rate, whereas extent of resection and tumor calcification affected the rate of tumor recurrence.

Conclusions: Microsurgical resection of spinal meningiomas remains safe. Nevertheless, some aspects, such as obesity and experience of the surgeons that result in a higher complication rate and ultimately affect clinical outcome, should be considered when performing surgery.
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http://dx.doi.org/10.3171/2021.2.FOCUS201116DOI Listing
May 2021

Meningioma Surgery in Patients ≥70 Years of Age: Clinical Outcome and Validation of the SKALE Score.

J Clin Med 2021 Apr 22;10(9). Epub 2021 Apr 22.

Department of Neurosurgery, University Hospital Frankfurt, Goethe University, 60528 Frankfurt, Germany.

Along with increasing average life expectancy, the number of elderly meningioma patients has grown proportionally. Our aim was to evaluate whether these specific patients benefit from surgery and to investigate a previously published score for decision-making in meningioma patients (SKALE). Of 421 patients who underwent primary intracranial meningioma resection between 2009 and 2015, 71 patients were ≥70 years of age. We compared clinical data including World Health Organization (WHO) grade, MIB-1 proliferation index, Karnofsky Performance Status Scale (KPS), progression free survival (PFS) and mortality rate between elderly and all other meningioma patients. Preoperative SKALE scores (Sex, KPS, ASA score, location and edema) were determined for elderly patients. SKALE ≥8 was set for dichotomization to determine any association with outcome parameters. In 71 elderly patients (male/female 37/34) all data were available. Postoperative KPS was significantly lower in elderly patients ( < 0.0001). Pulmonary complications including pneumonia (10% vs. 3.2%; = 0.0202) and pulmonary embolism (12.7% vs. 6%; = 0.0209) occurred more frequently in our elderly cohort. Analyses of the Kaplan Meier curves revealed differences in three-month (5.6% vs. 0.3%; = 0.0033), six-month (7% vs. 0.3%; = 0.0006) and one-year mortality (8.5% vs. 0.3%; < 0.0001) for elderly patients. Statistical analysis showed significant survival benefit in terms of one-year mortality for elderly patients with SKALE scores ≥8 (5.1 vs. 25%; = 0.0479). According to our data, elderly meningioma patients face higher postoperative morbidity and mortality than younger patients. However, resection is reasonable for selected patients, particularly when reaching a SKALE score ≥ 8.
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http://dx.doi.org/10.3390/jcm10091820DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8122404PMC
April 2021

Direct oral anticoagulants vs. low-molecular-weight heparin for pulmonary embolism in patients with glioblastoma.

Neurosurg Rev 2021 Apr 26. Epub 2021 Apr 26.

Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60598, Frankfurt, Germany.

Glioblastoma (GBM) is a cancer type with high thrombogenic potential and GBM patients are therefore at a particularly high risk for thrombotic events. To date, only limited data on anticoagulation management after pulmonary embolism (PE) in GBM is available and the sporadic use of DOACs remains off-label. A retrospective cohort analysis of patients with GBM and postoperative, thoracic CT scan confirmed PE was performed. Clinical course, follow-up at 6 and 12 months and the overall survival (OS) were evaluated using medical charts and neuroradiological data. Out of 584 GBM patients, 8% suffered from postoperative PE. Out of these, 30% received direct oral anticoagulants (DOACs) and 70% low-molecular-weight heparin (LMWH) for therapeutic anticoagulation. There was no significant difference in major intracranial hemorrhage (ICH), re-thrombosis, or re-embolism between the two cohorts. Although statistically non-significant, a tendency to reduced mRS at 6 and 12 months was observed in the LMWH cohort. Furthermore, patients receiving DOACs had a statistical benefit in OS. In our analysis, DOACs showed a satisfactory safety profile in terms of major ICH, re-thrombosis, and re-embolism compared to LMWH in GBM patients with postoperative PE. Prospective, randomized trials are urgent to evaluate DOACs for therapeutic anticoagulation in GBM patients with PE.
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http://dx.doi.org/10.1007/s10143-021-01539-9DOI Listing
April 2021

Advantages of methohexital over amobarbital in determining hemispheric language and memory lateralization in the Wada test - A retrospective study.

Epilepsy Behav 2020 12 24;113:107551. Epub 2020 Nov 24.

Epilepsy Center Frankfurt Rhine-Main, Department of Neurology, University Hospital Frankfurt and Goethe University, Frankfurt am Main, Germany; LOEWE Center for Personalized Translational Epilepsy Research (CePTER), Goethe University, Frankfurt am Main, Germany.

Objective: Due to supply shortage, amobarbital, the traditional anesthetic agent in Wada testing, was replaced by methohexital in many epilepsy centers. This study aimed to compare the two barbiturates to identify possible advantages or disadvantages of methohexital as compared to amobarbital with regard to the adequacy of language and memory testing during the Wada test.

Methods: Data from 75 patients with temporal lobe epilepsy who underwent bilateral Wada tests using either amobarbital (n = 53) or methohexital (n = 22) as part of presurgical work-up were analyzed retrospectively. The two subgroups were compared regarding hemispheric language and memory lateralization results and Wada testing characteristics, and the adequacy of language and memory testing was assessed.

Results: We observed shorter durations of motor-, speech-, and EEG recovery after each injection in patients receiving methohexital compared to amobarbital. In addition, significantly more items could be presented during effective hemispheric inactivation in the methohexital group. Moreover, significant correlations of Wada memory scores with standard neuropsychological memory test scores could be found in the methohexital group.

Significance: Our findings confirm that methohexital is not only equally suitable for Wada testing but has several advantages over amobarbital. Wada testing can be performed more efficiently and under more constant hemispheric inactivation using methohexital. Furthermore, the adequacy of language and memory testing during the Wada test might be affected by the anesthetic agent used.
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http://dx.doi.org/10.1016/j.yebeh.2020.107551DOI Listing
December 2020

Sequential implementation of DSC-MR perfusion and dynamic [F]FET PET allows efficient differentiation of glioma progression from treatment-related changes.

Eur J Nucl Med Mol Imaging 2021 06 26;48(6):1956-1965. Epub 2020 Nov 26.

University Cancer Center Frankfurt (UCT), University Hospital, Goethe University Frankfurt am Main, Frankfurt am Main, Germany.

Purpose: Perfusion-weighted MRI (PWI) and O-(2-[F]fluoroethyl-)-l-tyrosine ([F]FET) PET are both applied to discriminate tumor progression (TP) from treatment-related changes (TRC) in patients with suspected recurrent glioma. While the combination of both methods has been reported to improve the diagnostic accuracy, the performance of a sequential implementation has not been further investigated. Therefore, we retrospectively analyzed the diagnostic value of consecutive PWI and [F]FET PET.

Methods: We evaluated 104 patients with WHO grade II-IV glioma and suspected TP on conventional MRI using PWI and dynamic [F]FET PET. Leakage corrected maximum relative cerebral blood volumes (rCBV) were obtained from dynamic susceptibility contrast PWI. Furthermore, we calculated static (i.e., maximum tumor to brain ratios; TBR) and dynamic [F]FET PET parameters (i.e., Slope). Definitive diagnoses were based on histopathology (n = 42) or clinico-radiological follow-up (n = 62). The diagnostic performance of PWI and [F]FET PET parameters to differentiate TP from TRC was evaluated by analyzing receiver operating characteristic and area under the curve (AUC).

Results: Across all patients, the differentiation of TP from TRC using rCBV or [F]FET PET parameters was moderate (AUC = 0.69-0.75; p < 0.01). A rCBV cutoff > 2.85 had a positive predictive value for TP of 100%, enabling a correct TP diagnosis in 44 patients. In the remaining 60 patients, combined static and dynamic [F]FET PET parameters (TBR, Slope) correctly discriminated TP and TRC in a significant 78% of patients, increasing the overall accuracy to 87%. A subgroup analysis of isocitrate dehydrogenase (IDH) mutant tumors indicated a superior performance of PWI to [F]FET PET (AUC = 0.8/< 0.62, p < 0.01/≥ 0.3).

Conclusion: While marked hyperperfusion on PWI indicated TP, [F]FET PET proved beneficial to discriminate TP from TRC when PWI remained inconclusive. Thus, our results highlight the clinical value of sequential use of PWI and [F]FET PET, allowing an economical use of diagnostic methods. The impact of an IDH mutation needs further investigation.
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http://dx.doi.org/10.1007/s00259-020-05114-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113145PMC
June 2021

Direct oral anticoagulants for therapeutic anticoagulation in postoperative pulmonary embolism after meningioma resection.

J Clin Neurosci 2020 Nov 16;81:265-269. Epub 2020 Oct 16.

Department of Neurosurgery, University Medicine of Rostock, Rostock, Germany.

Background: Acute postoperative pulmonary embolism (PE) is a dreaded complication with severe mortality rates. Brain tumor patients are at the highest risk for postoperative PE. The juxtaposition of low-molecular-weight heparin (LMWH), vitamin K antagonists (VKA) and direct oral anticoagulation (DOAC) in the treatment of postoperative PE in meningioma patients is largely unexplored.

Patients/methods: This is a single center observational analysis of meningioma patients who underwent neurosurgical resection with a thoracic CT scan confirmation of postoperative PE. The treatment modality, clinical course and outcome were investigated.

Results: Of 538 meningioma patients operated, 30 (6%) developed acute postoperative PE. After diagnosis, these patients received different long-term anticoagulation regimes. No significant difference in postoperative hemorrhage (p < 0.56), re-operation rate (p < 0.70) or Karnofsky performance scale (KPS) at 3 (p < 0.34) and 12 months (p = 1) were identified, when compared according to the different anticoagulation regimes.

Conclusion: DOACs were not associated with elevated risk for hemorrhage, recurrent thrombosis or poor outcome when compared with traditional anticoagulation regimes. Prospective randomized trials are necessary to verify the non-inferiority of DOACs for long-term anticoagulation in postoperative pulmonary embolism after meningioma resection.
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http://dx.doi.org/10.1016/j.jocn.2020.09.059DOI Listing
November 2020

Supervised Valsalva Maneuver after Burr Hole Evacuation of Chronic Subdural Hematomas: A Prospective Cohort Study.

J Neurotrauma 2021 Apr 14;38(7):911-917. Epub 2020 Dec 14.

Department of Neurosurgery, University Hospital, and Goethe University, Frankfurt, Germany.

Research on chronic subdural hematoma (cSDH) management has primarily focused on potential recurrence after surgical evacuation. Herein, we present a novel postoperative/non-invasive treatment that includes a supervised Valsalva maneuver (SVM), which may serve to reduce SDH recurrence. Accordingly, the aims of the study were to investigate the effects of SVM on SDH recurrence rates and functional outcomes. A prospective study was conducted from December 2016 until December 2019 at the Goethe University Hospital Frankfurt. Of the 204 adult patients with surgically treated cSDH who had subdural drains placed, 94 patients were assigned to the SVM group and 82 patients were assigned to the control group. The SVM was performed by having patients blow into a self-made SVM device at least two times/h for 12 h/day. The primary end-point was SDH recurrence rate, while secondary outcomes were morbidity and functional outcomes at 3 months of follow-up. SDH recurrence was observed in 16 of 94 patients (17%) in the SVM group, which was a significant reduction as compared with the control group, which had 24 of 82 patients (29.3%;  = 0.05) develop recurrent SDHs. Further, the infection rate (e.g., pneumonia) was significantly lower in the SVM group (1.1%) than in the control group (13.4%;  < 0.001; odds ratio [OR] 0.1). At the 3-month follow-up, 85 of 94 patients (90.4%) achieved favorable outcomes in the SVM group compared with 62 of 82 patients (75.6%) in the control group ( = 0.008; OR 3.0). Independent predictors for favorable outcome at follow-up were age (OR 0.9) and infection (OR 0.2). SVM appears to be safe and effective in the post-operative management of cSDHs, reducing both recurrence rates and infections after surgical evacuation, thereby resulting in favorable outcomes at follow-up.
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http://dx.doi.org/10.1089/neu.2020.7391DOI Listing
April 2021

Risk incidence of fractures and injuries: a multicenter video-EEG study of 626 generalized convulsive seizures.

J Neurol 2020 Dec 10;267(12):3632-3642. Epub 2020 Jul 10.

Center of Neurology and Neurosurgery, Epilepsy Center Frankfurt Rhine-Main, Goethe-University Frankfurt, Schleusenweg 2-16 (Haus 95), 60528, Frankfurt am Main, Germany.

Objective: To evaluate the incidence and risk factors of generalized convulsive seizure (GCS)-related fractures and injuries during video-EEG monitoring.

Methods: We analyzed all GCSs in patients undergoing video-EEG-monitoring between 2007 and 2019 at epilepsy centers in Frankfurt and Marburg in relation to injuries, falls and accidents associated with GCSs. Data were gathered using video material, EEG material, and a standardized reporting form.

Results: A total of 626 GCSs from 411 patients (mean age: 33.6 years; range 3-74 years; 45.0% female) were analyzed. Severe adverse events (SAEs) such as fractures, joint luxation, corneal erosion, and teeth loosening were observed in 13 patients resulting in a risk of 2.1% per GCS (95% CI 1.2-3.4%) and 3.2% per patient (95% CI 1.8-5.2%). Except for a nasal fracture due to a fall onto the face, no SAEs were caused by falls, and all occurred in patients lying in bed without evidence of external trauma. In seven patients, vertebral body compression fractures were confirmed by imaging. This resulted in a risk of 1.1% per GCS (95% CI 0.5-2.2%) and 1.7% per patient (95% CI 0.8-3.3%). These fractures occurred within the tonic phase of a GCS and were accompanied by a characteristic cracking noise. All affected patients reported back pain spontaneously, and an increase in pain on percussion of the affected spine section.

Conclusions: GCSs are associated with a substantial risk of fractures and shoulder dislocations that are not associated with falls. GCSs accompanied by audible cracking, and resulting in back pain, should prompt clinical and imaging evaluations.
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http://dx.doi.org/10.1007/s00415-020-10065-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7674387PMC
December 2020

Pulmonary embolism in neurocritical care-introduction of a novel grading system for risk stratification: the Frankfurt AMBOS score.

Neurosurg Rev 2021 Apr 12;44(2):1165-1171. Epub 2020 May 12.

Department of Neurosurgery, University Hospital, Goethe University, Frankfurt, Germany.

Pulmonary embolism (PE) due to deep vein thrombosis is a complication with severe morbidity and mortality rates. Neurocritical care patients constitute an inhomogeneous cohort with often strict contraindications to conventional embolism treatment. The aim of the present study is to identify risk factors for pulmonary embolism for intensified risk stratification in this demanding cohort. In this retrospective analysis, 387 neurocritical care patients received computed tomography for clinical suspicion of PE (304 neurosurgical and 83 neurological patients). Analysed parameters included age, gender, disease pattern, the presence of deep vein thrombosis, resuscitation, in-hospital mortality, present anticoagulation, coronary artery disease, diabetes mellitus, smoking status, hypertension and ABO blood type. Computed tomography confirmed 165 cases of pulmonary embolism among 387 patients with clinical suspicion of pulmonary embolism (42%). Younger age (p < 0.0001), female gender (p < 0.006), neurooncological disease (p < 0.002), non-O blood type (p < 0.002) and the absence of Marcumar therapy (p < 0.003) were identified as significant risk factors for pulmonary embolism. On the basis of the identified risk factors, the AMBOS score system is introduced. Neurocritical care patients with high AMBOS score are at elevated risk for PE and should therefore be put under intensified monitoring for cardiovascular events in neurocritical care units.
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http://dx.doi.org/10.1007/s10143-020-01310-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8035103PMC
April 2021

Age dependency and modification of the Subarachnoid Hemorrhage Early Brain Edema Score.

J Neurosurg 2020 Mar 20;134(3):946-952. Epub 2020 Mar 20.

1Department of Neurosurgery, University Hospital Frankfurt, Goethe-University.

Objective: The Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) system measures cerebral edema on CT and can be used to predict outcome after subarachnoid hemorrhage (SAH). The authors developed a modified SEBES (SEBES 6c) and assessed whether it could predict outcome after SAH better than the SEBES. Furthermore, they verified the age dependency of these scores.

Methods: In this retrospective study, all patients with aneurysmal SAH in the period from January 2011 to February 2017 at a single institution were analyzed. The SEBES, which is based on the absence of visible sulci at two defined CT levels (0-4 points), and the SEBES 6c were determined from the initial CT. The SEBES 6c system includes the two levels from the original SEBES and one level located 2 cm below the vertex (0-6 points). The authors investigated whether the various SEBESs are age dependent and if they can predict delayed infarction (DI) and outcome.

Results: Two hundred sixty-one patients met the study inclusion criteria. The SEBES was an independent predictor for DI (OR 1.6 per 1-point increase) and unfavorable outcome (OR 1.36 per 1-point increase), in accordance with findings in the first publication on SEBES. However, here the authors found that the SEBES was age dependent. In the age group younger than 60 years, the patients with high-grade SEBESs (3-4 points) had DIs and unfavorable outcomes significantly more often than the patients with low-grade scores (0-2 points). In the age groups 60-69 years and ≥ 70 years, no significant differences in DI and outcome were identified between high-grade and low-grade scores, although trends toward DI and unfavorable outcomes among the 60-69 age group were noted in patients with high-grade SEBESs.Receiver operating characteristic curve analysis showed that SEBES 6c had a higher prognostic value in predicting outcome than SEBES (p < 0.001). Furthermore, SEBES 6c predicted an unfavorable outcome (OR 1.31 per 1-point increase) and DI (OR 1.36 per 1-point increase) independent of vasospasms. SEBES 6c showed an age dependency similar to that of SEBES.

Conclusions: SEBES 6c is more suitable for predicting outcome after SAH than SEBES. Furthermore, it predicts outcome and DI independently of vasospasm, so it can be used to differentiate between early brain injury- and vasospasm-dependent infarctions and outcome. However, SEBES and SEBES 6c are both age dependent and can be used for patients aged < 60 years and may have limited suitability for patients aged 60-69 years and no suitability for patients aged ≥ 70 years.
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http://dx.doi.org/10.3171/2019.12.JNS192744DOI Listing
March 2020

External validation and modification of the Oslo grading system for prediction of postoperative recurrence of chronic subdural hematoma.

Neurosurg Rev 2021 Apr 28;44(2):961-970. Epub 2020 Feb 28.

Department of Neurosurgery, University Hospital, Goethe-University, Frankfurt am Main, Germany.

Recently, Oslo grading system (OGS) for prediction of recurrence in chronic subdural hematoma (cSDH) was introduced. The aim of the study was to validate and if applicable to modify the grading system. Data of all patients admitted to the Goethe University Hospital between 2016 and 2018 with chronic subdural hematoma were prospectively entered into a database. Dataset of patients with uni- (n = 272) and bilateral cSDH (n = 177) were used for the validation of OGS via logistic regression analysis. Additional predictors were identified and integrated to build a modified OGS (mOGS). Internal validation of the modified OGS was performed using same dataset of patients. The OGS showed a significant good predictive value with correlating increase of recurrence rate depending on the level of score in unilateral cSDH (p = 0.002). Regarding bilateral cSDH, there was no significant predictive value found (p = 0.921). By performing uni- and multivariate analysis, additional predictors for recurrence in uni- and bilateral cSDH were identified and integrated into the score system. Accordingly, the mOGS for unilateral cSDH inherited 4 components: previous OGS with 3 components (OR1.6) and seizure (OR2.5) (0 point, 0% recurrence rate; 1-2 points, 17.4%; 3-4 points, 30.6%; ≥ 5 points, 80%). Regarding bilateral cSDH, the mOGS consisted of 4 components as well: hypodense/gradation subtypes (OR3.3), postoperative unilateral volume > 80 mL (OR7.4), postoperative unilateral air trapping > 80 mL (OR15.3), and seizure (OR5.5) (0 point, 3.6% recurrence rate; 1 point, 30.6%; 2 points, 53.5%; 3 points, 58.3%; ≥ 4 points, 100%). Furthermore, the mOGS was internally verified showing high significant predictive power for recurrent hematoma in uni- (p = 0.004) and bilateral cSDH (p < 0.001). External validation of OGS showed accurate risk stratification of recurrence in unilateral cSDH; however, the validation failed for bilateral cSDH. Thus, mOGS was developed to strengthen its clinical utility and applicability.
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http://dx.doi.org/10.1007/s10143-020-01271-wDOI Listing
April 2021

Vitamin K Antagonist (Phenprocoumon) and Subarachnoid Hemorrhage: A Single-Center, Matched-Pair Analysis.

Neurocrit Care 2020 08;33(1):105-114

Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.

Background: Demographic changes are leading to an aging society with a growing number of patients relying on anticoagulation, and vitamin K antagonists (VKA) are still widely used. As mortality and functional outcomes are worse in case of VKA-associated hemorrhagic stroke, phenprocoumon treatment seems to be a negative prognostic factor in case of subarachnoid hemorrhage (SAH). The purpose of this study was to analyze whether phenprocoumon treatment does worsen the outcome after non-traumatic SAH.

Methods: All patients treated for non-traumatic SAH between January 2007 and December 2016 in our institution were retrospectively analyzed. After exclusion of patients with anticoagulant or antiplatelet treatment other than phenprocoumon, we analyzed 1040 patients. Thirty-three patients (3%) of those were treated with continuous phenprocoumon. In total, 132 out of all 1007 patients without anticoagulant treatment of the remaining patients were matched as control group (ratio = 1:4).

Results: Patients with phenprocoumon treatment were significantly older (66.5 years vs. 53.9 years; p < .0001), and admission status was significantly more often poor (66.7% vs. 41.8%, p = .007) compared to all patients without anticoagulant treatment. Further, bleeding pattern and rates of early hydrocephalus did not differ. Matched-pair analysis revealed a significant higher rate of angio-negative SAH in the study group (p = .001). Overall rates of hemorrhagic or thromboembolic complications did not differ (21.4% vs. 18.8%; NS) but were more often fatal, and 30-day mortality rate was significantly higher in the phenprocoumon group than in patients of the matched-pair control group (33% vs. 24%; p < .001). 30% of the phenprocoumon group and 37% of the matched-pair control group reached favorable outcome. However, poor outcome was strong associated with the reason for phenprocoumon treatment.

Conclusion: Patients with phenprocoumon treatment at the time of SAH are significantly older, admission status is worse, and 30-day mortality rates are significantly higher compared to patients without anticoagulant treatment. However, outcome at 6 months did not differ to the matched-pair control group but seems to be strongly associated with the underlying cardiovascular disease. Treatment of these patients is challenging and should be performed on an interdisciplinary base in each individual case. Careful decision-making regarding discontinuation and bridging of anticoagulation and close observation is mandatory.
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http://dx.doi.org/10.1007/s12028-019-00868-4DOI Listing
August 2020

Thrombosis of the straight sinus and microbleedings due to deep seated arteriovenous fistula - Hemodynamic changes, cognitive impairment and improvement after microsurgery. A technical report.

J Clin Neurosci 2019 Oct 16;68:317-321. Epub 2019 Jul 16.

Department of Neurosurgery, Goethe University Hospital, Frankfurt, Germany.

Dural arteriovenous fistulas (dAVF) are rare vascular malformations accounting for only 10-15% that may lead to life threatening deficits due to hemodynamic changes in blood supply and pressure conditions. We present a 64-year old patient who was admitted with disorientation and aphasia. Following images confirmed an infratentorial dural fistula draining into the straight sinus. Additional findings were progressive thrombosis of the straight sinus, microbleedings and bithalamic edema due changes in hemodynamic conditions and venous congestion. Microsurgery was performed. After treatment improvement in clinical condition was observed and the venous congestion was regressive. Hemodynamic changes due to infratentorial dAVFs may lead to bleedings in deep regions and worsening of clinical condition fastly. Treatment requires carefully planning and visualization of angioarchitecture. Symptoms and hemodynamic changes are reversible after treatment, which are essential for treatment decisions.
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http://dx.doi.org/10.1016/j.jocn.2019.07.012DOI Listing
October 2019

Prognostic risk factors for postoperative hemorrhage in stereotactic biopsies of lesions in the basal ganglia.

Clin Neurol Neurosurg 2018 11 18;174:180-184. Epub 2018 Sep 18.

Department of Neurosurgery, Goethe University, Frankfurt, Germany. Electronic address:

Objective: The risk of hemorrhages after stereotactic biopsy is known to be low. Nevertheless hemorrhages in eloquent areas result in neurological deficit for the patients. Since the basal ganglia resemble a particularily high vascularized and eloquent location, which is often the source of hypertensive hemorrhages, we aimed to analyse possible risk factors for hemorrhage after stereotactic biopsy in this region.

Patients And Methods: We performed a retrospective analysis including patients who underwent stereotactic biopsies of lesions in the basal ganglia between January 2012 and January 2017. 63 patients were included in this study. We accessed age, gender, histopathological diagnosis, hypertension, blood pressure intraoperative, anticoagulative medication and postoperative hemorrhage.

Results: Fishers exact test revealed no significant p-values concerning anticoagulative therapy, gender, smoking and hypertension concerning postoperative hemorrhage. Wilcoxon-Mann-Whitney-Test showed no significant correlation for systolic blood pressure intraoperative, number of tissue samples and age with hemorrhage. A trend for lymphoma in correlation with postoperative hemorrhage was in patients with Lymphoma (Wilcoxon-Mann-Whitney Test).

Conclusion: Stereotactic biopsies even in eloquent areas as the basal ganglia are a safe procedure even if patients suffer under hypertension or are smoker. None of the here examined risk factors showed a significant correlation with postoperative hemorrhage. Accessing tumor tissue for histopathological diagnosis is mandatory for adequate therapy.
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http://dx.doi.org/10.1016/j.clineuro.2018.09.008DOI Listing
November 2018

The Value of Computed Tomography Imaging of the Head After Ventriculoperitoneal Shunt Surgery in Adults.

World Neurosurg 2019 Jan 20;121:e159-e164. Epub 2018 Sep 20.

Department of Neurosurgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt, Germany.

Background: Patients with a ventriculoperitoneal shunt for hydrocephalus often undergo multiple follow-up computed tomography (CT) scans of the head, increasing the risk for long-term effects of ionizing radiation. The purpose of our study was to evaluate the necessity as a routine diagnostic procedure and cost analysis of routine postoperative CT scan of the head after ventriculoperitoneal shunt surgery.

Methods: In this study, we comprised adults with ventriculoperitoneal shunt operations who underwent early CT scans within 48 hours postoperatively. We reviewed the correlation between revision surgery rate and the experience of surgeons who performed surgery and provided a cost analysis.

Results: In total, 479 surgeries were performed in 439 patients. Early revision surgery was performed in 11 (2.3%) patients. Reason for revision surgery was malposition in 9 cases and intracerebral hemorrhage in 2 patients. There was no significant correlation between the surgeon's experience and the rate of revision surgery. Placement of the ventricular catheter via an approach other than a standard right or left frontal burr hole resulted in risk of need for surgical shunt revision (P ≥ 0.002, odds ratio 54, confidence interval 13.5-223). A total of 468 CT scans of the head revealed a normal finding; thus, ∼$562,000 could be saved by omitting postoperative head CT scans.

Conclusions: Routine postoperative head CT scans after fentriculoperitoneal shunting are not necessary in all cases. The reduction of exposure to ionization radiation and the beneficial economic factor are main advantages.
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http://dx.doi.org/10.1016/j.wneu.2018.09.063DOI Listing
January 2019

Pain medication at ictus of subarachnoid hemorrhage-the influence of one-time acetylsalicylic acid usage on bleeding pattern, treatment course, and outcome: a matched pair analysis.

Neurosurg Rev 2019 Jun 22;42(2):531-537. Epub 2018 Jun 22.

Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.

Acetylsalicylic acid (ASA) is a well-known and widely used analgesic for acute pain. Patients with acute headache due to subarachnoid hemorrhage (SAH) are inclined to take ASA in this situation. Due to the antithrombotic effects, ASA intake is related to higher bleeding rates in case of hemorrhage or surgical treatment. Between January 2006 and December 2016, 941 patients without continuous antithrombotic or anticoagulant medication were treated due to SAH in our institution. Fourteen of them (1.5%) had taken ASA as a single dose because of headache within 24 h before hospital admission. A matched pair analysis was performed. Admission status was good in 93% of patients with one-time use of ASA (OTA), but only in 59% of all other patients (p < 0.01). Bleeding pattern did not differ, but half of the patients with OTA had no identifiable bleeding source; this rate was significantly lower in the rest of the patients (p < 0.005). Aneurysm treatment and related complications did not differ between both groups. Cerebral vasospasm was more often only mild and rates of cerebral infarctions were lower in the OTA group but not on a significant level. Eighty-six percent of the OTA group and 84% (p = 0.8) of the matched pair control group reached favorable outcome according to mRS 6 months after SAH. Patients with OTA in case of SAH are usually in good clinical condition and bleeding pattern does not differ. In half of the patients with OTA, no bleeding source was detectable. In the case of aneurysm treatment, related complications did not differ and most of the patients reached favorable outcome. In the case of aneurysm treatment procedure, OTA does not influence treatment course and should not influence treatment decisions.
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http://dx.doi.org/10.1007/s10143-018-1000-yDOI Listing
June 2019

Directional diffusion of corticospinal tract supports therapy decisions in idiopathic normal-pressure hydrocephalus.

Neuroradiology 2014 Jan 25;56(1):5-13. Epub 2013 Oct 25.

Department of Neuroradiology, Goethe University Frankfurt, Frankfurt, Germany.

Introduction: Gait disturbance in patients with idiopathic normal pressure hydrocephalus (iNPH) may be caused by alterations of the corticospinal tract that we aimed to measure with diffusion tensor imaging (DTI). The directional diffusion parameters axial diffusivity and fractional anisotropy (FA) reflect axon integrity, whereas mean diffusivity, radial diffusivity and magnetization transfer ratio (MTR) reflect myelin content.

Methods: Twenty-six patients with probable iNPH were grouped into drainage responders (n = 12) and drainage non-responders (n = 14) according to their improvement on gait assessment tests after a 3-day lumbar CSF drainage. We measured DTI and MTR of the corticospinal tract and, as reference, of the superior longitudinal fascicle before and after CSF withdrawal in iNPH and in ten age-matched controls. Drainage responders were re-examined after ventricoperitoneal shunting. Differences before any intervention and changes upon CSF withdrawal were evaluated.

Results: Axial diffusivity in corticospinal tract and superior longitudinal fascicle was higher in both patient groups compared to controls (p < 0.001). Only in the corticospinal tract of drainage responders was FA higher compared to controls, and both FA and axial diffusivity decreased after shunting. For axial diffusivity upon CSF drainage, a decrease of >0.7 % discriminated drainage responders from drainage non-responders with 82 % sensitivity, and a decrease of >1 % predicted overall improvement after shunting with 87.5 % sensitivity and 75 % specificity. The specificity to discriminate responders/non-responders was low for all DTI values (max. 69 % for FA values).

Conclusion: High values of directional diffusion parameters in the corticospinal tract are found in iNPH patients indicating affection of its axons. Increased values and their decrease upon CSF drainage may facilitate treatment decisions in clinically uncertain cases.
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http://dx.doi.org/10.1007/s00234-013-1289-8DOI Listing
January 2014

MR volumetric changes after diagnostic CSF removal in normal pressure hydrocephalus.

J Neurol 2012 Nov 17;259(11):2440-6. Epub 2012 May 17.

Department of Neurology, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt/Main, Germany.

Although diagnostic CSF removal in patients with suspected normal pressure hydrocephalus (NPH) is performed frequently, its impact on changes of the global brain volume and volume of the ventricles has not been studied in detail. We examined 20 patients with clinical and radiological signs of NPH. These received MRI prior to and immediately after diagnostic CSF removal, either via lumbar puncture (TAP, n = 10) or via external lumbar drainage (ELD, n = 10). Changes in global brain volume were assessed using SIENA, a tool from the FSL software library. Additionally, we determined the change of the lateral ventricles' volume by manual segmentation. Furthermore, we recorded systematic clinical assessments of the key features of NPH. The median volume of CSF removed was 35 ml in TAP patients and 406 ml in ELD patients. Changes in global brain volume were found in both patient groups. Brain volume change was significantly larger in ELD patients than in TAP patients (p = 0.022), and correlated with the volume of CSF removal (r = 0.628, p = 0.004). Brain volume expansion was most pronounced adjacent to the lateral ventricles, but also detectable in the temporal and frontal regions. The median ventricular volume decreased after CSF removal. Ventricular volume reduction was more pronounced in ELD patients than in TAP patients. This study quantifies for the first time immediate volumetric changes of global brain tissue and of ventricles after diagnostic CSF removal in NPH patients. In particular, we report evidence that CSF removal results in a change of the brain volume rather than only a change of the brain's shape.
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http://dx.doi.org/10.1007/s00415-012-6525-3DOI Listing
November 2012
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