Publications by authors named "Florian Gessler"

81 Publications

Neurosurgical Considerations Regarding Decompressive Craniectomy for Intracerebral Hemorrhage after SARS-CoV-2-Vaccination in Vaccine Induced Thrombotic Thrombocytopenia-VITT.

J Clin Med 2021 Jun 24;10(13). Epub 2021 Jun 24.

Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany.

Given the ongoing global SARS-CoV-2-vaccination efforts, clinical awareness needs to be raised regarding the possibility of an increased incidence of SARS-CoV-2-vaccine-related immune-mediated thrombocytopenia in patients with intracerebral hemorrhage (ICH) secondary to cerebral sinus and vein thrombosis (CVT) requiring (emergency) neurosurgical treatment in the context of vaccine-induced immune thrombotic thrombocytopenia (VITT). Only recently, an association of vaccinations and cerebral sinus and vein thrombosis has been described. In a number of cases, neurosurgical treatment is warranted for these patients and special considerations are warranted when addressing the perioperative coagulation. We, herein, describe the past management of patients with VITT and established a literature-guided algorithm for the treatment of patients when addressing the impaired coagulation in these patients. Increasing insights addressing the pathophysiology of SARS-CoV-2-vaccine-related immune-mediated thrombocytopenia guide physicians in developing an interdisciplinary algorithm taking into account the special considerations of this disease.
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http://dx.doi.org/10.3390/jcm10132777DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8269113PMC
June 2021

Implementation, relevance, and virtual adaptation of neuro-oncological tumor boards during the COVID-19 pandemic: a nationwide provider survey.

J Neurooncol 2021 Jul 11;153(3):479-485. Epub 2021 Jun 11.

Neuro-Oncology Center, Center of Integrated Oncology (CIO) Bonn, University Hospital Bonn, Bonn, Germany.

Purpose: Neuro-oncology tumor boards (NTBs) hold an established function in cancer care as multidisciplinary tumor boards. However, NTBs predominantly exist at academic and/or specialized centers. In addition to increasing centralization throughout the healthcare system, changes due to the COVID-19 pandemic have arguably resulted in advantages by conducting clinical meetings virtually. We therefore asked about the experience and acceptance of (virtualized) NTBs and their potential benefits.

Methods: A survey questionnaire was developed and distributed via a web-based platform. Specialized neuro-oncological centers in Germany were identified based on the number of brain tumor cases treated in the respective institution per year. Only one representative per center was invited to participate in the survey. Questions targeted the structure/organization of NTBs as well as changes due to the COVID-19 pandemic.

Results: A total of 65/97 institutions participated in the survey (response rate 67%). In the context of the COVID-19 pandemic, regular conventions of NTBs were maintained by the respective centers and multi-specialty participation remained high. NTBs were considered valuable by respondents in achieving the most optimal therapy for the affected patient and in maintaining/encouraging interdisciplinary debate/exchange. The settings of NTBs have been adapted during the pandemic with the increased use of virtual technology. Virtual NTBs were found to be beneficial, yet administrative support is lacking in some places.

Conclusions: Virtual implementation of NTBs was feasible and accepted in the centers surveyed. Therefore, successful implementation offers new avenues and may be pursued for networking between centers, thereby increasing coverage of neuro-oncology care.
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http://dx.doi.org/10.1007/s11060-021-03784-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192684PMC
July 2021

Predictive Relevance of Baseline Lactate and Glucose Levels in Patients with Spontaneous Deep-Seated Intracerebral Hemorrhage.

Brain Sci 2021 May 14;11(5). Epub 2021 May 14.

Department of Neurosurgery, University Hospital Bonn, 53127 Bonn, Germany.

(1) Background: As elements of the standard admission blood panel, lactate and glucose represent potential biomarkers for outcome prediction. In patients with intracranial hemorrhage (ICH), data on the predictive value of these blood values is exceedingly sparse. (2) Methods: Between 2014 and August 2020, all patients with deep-seated ICH referred to the neurovascular center at the authors' institution were included in the subsequent study. Serum levels of lactate and glucose at the time of admission were compared with mortality at 90 days. In addition, a multivariate analysis was performed in order to identify independent admission predictors for 90-day mortality. (3) Results: Among the 102 patients with deep-seated ICH, elevated lactate and glucose levels on admission were significantly associated with increased mortality at 90 days. Multivariate logistic regression analysis identified "ICH score ≥3" ( = 0.004) along with "admission hyperlactatemia" ( = 0.025) and "admission hyperglycemia" ( = 0.029) as independent and significant predictors of 90-day mortality in patients with deep-seated ICH. (4) Conclusions: Initially elevated lactate and glucose levels after spontaneous intracerebral hemorrhage are associated with poor outcome, suggesting a potential application for future prognostic models when considered in conjunction with other parameters.
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http://dx.doi.org/10.3390/brainsci11050633DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156008PMC
May 2021

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

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

Association of Isocitrate Dehydrogenase (IDH) Status With Edema to Tumor Ratio and Its Correlation With Immune Infiltration in Glioblastoma.

Front Immunol 2021 25;12:627650. Epub 2021 Mar 25.

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

Purpose: The extent of preoperative peritumoral edema in glioblastoma (GBM) has been negatively correlated with patient outcome. As several ongoing studies are investigating T-cell based immunotherapy in GBM, we conducted this study to assess whether peritumoral edema with potentially increased intracranial pressure, disrupted tissue homeostasis and reduced local blood flow has influence on immune infiltration and affects survival.

Methods: A volumetric analysis of preoperative imaging (gadolinium enhanced T1 weighted MRI sequences for tumor size and T2 weighted sequences for extent of edema (including the infiltrative zone, gliosis etc.) was conducted in 144 patients using the Brainlab® software. Immunohistochemical staining was analyzed for lymphocytic- (CD 3+) and myelocytic (CD15+) tumor infiltration. A retrospective analysis of patient-, surgical-, and molecular characteristics was performed using medical records.

Results: The edema to tumor ratio was neither associated with progression-free nor overall survival (p=0.90, p=0.74). However, GBM patients displaying IDH-1 wildtype had significantly higher edema to tumor ratio than patients displaying an IDH-1 mutation (p=0.01). Immunohistopathological analysis did not show significant differences in lymphocytic or myelocytic tumor infiltration (p=0.78, p=0.74) between these groups.

Conclusion: In our cohort, edema to tumor ratio had no significant correlation with immune infiltration and outcome. However, patients with an IDH-1wildtype GBM had a significantly higher edema to tumor ratio compared to their IDH-1 mutated peer group. Further studies are necessary to elucidate the underlying mechanisms.
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http://dx.doi.org/10.3389/fimmu.2021.627650DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044904PMC
March 2021

Quality of Life Following Surgical and Conservative Therapy of Pyogenic Spinal Infection: A Study of Long-term Outcome in 210 Patients.

J Neurol Surg A Cent Eur Neurosurg 2021 Mar 9. Epub 2021 Mar 9.

Department of Neurosurgery, Goethe-Universitat Frankfurt am Main Fachbereich 16 Medizin, Schleusenweg, Frankfurt, Germany.

Object:  The management and recommendations for treatment strategies of pyogenic spinal infection are still a highly controversial issue. The purpose of this study was to evaluate patient's quality of life (QoL) after surgical and conservative treatment of spinal infection.

Materials And Methods:  We conducted a retrospective, single-center study. All patients treated between 2009 and 2016 were included in this study. For evaluation of QoL, we recorded each patient's satisfaction according to the 36-Item Short Form Health Survey (SF-36) questionnaire. Scores were compared with a U.S. standard population.

Results:  Two hundred and ten adult patients with spondylodiskitis were identified. Of these, 155 (74%) underwent surgery and 55 (26%) were treated conservatively. The mean overall age was 68.6 (23-98) years. Seventy-two patients were females and 138 patients were males. The mean outcome values in the surgical group did not reach the level of the normative sample in one of eight items, whereas the conservative group revealed a reduced QoL in all items. Intergroup comparison revealed significant differences in all items (< 0.05).

Conclusion:  In the patient population we investigated, QoL in surgically treated patients was better than that in conservatively managed patients.
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http://dx.doi.org/10.1055/s-0041-1722965DOI Listing
March 2021

Triage and Allocation of Neurocritical Care Resources During the COVID 19 Pandemic - A National Survey.

Front Neurol 2020 6;11:609227. Epub 2021 Jan 6.

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

In light of the ongoing COVID-19 pandemic and the associated hospitalization of an overwhelming number of ventilator-dependent patients, medical and/or ethical patient triage paradigms have become essential. While guidelines on the allocation of scarce resources do exist, such work within the subdisciplines of intensive care (e.g., neurocritical care) remains limited. A 16-item questionnaire was developed that sought to explore/quantify the expert opinions of German neurointensivists with regard to triage decisions. The anonymous survey was conducted via a web-based platform and in total, 96 members of the Initiative of German Neurointensive Trial Engagement (IGNITE)-study group were contacted via e-mail. The IGNITE consortium consists of an interdisciplinary panel of specialists with expertise in neuro-critical care (i.e., anesthetists, neurologists and neurosurgeons). Fifty members of the IGNITE consortium responded to the questionnaire; in total the respondents were in charge of more than 500 Neuro ICU beds throughout Germany. Common determinants reported which affected triage decisions included known patient wishes (98%), the state of health before admission (96%), SOFA-score (85%) and patient age (69%). Interestingly, other principles of allocation, such as a treatment of "youngest first" (61%) and members of the healthcare sector (50%) were also noted. While these were the most accepted parameters affecting the triage of patients, a "first-come, first-served" principle appeared to be more accepted than a lottery for the allocation of ICU beds which contradicts much of what has been reported within the literature. The respondents also felt that at least one neurointensivist should serve on any interdisciplinary triage team. The data gathered in the context of this survey reveal the estimation/perception of triage algorithms among neurointensive care specialists facing COVID-19. Further, it is apparent that German neurointensivists strongly feel that they should be involved in any triage decisions at an institutional level given the unique resources needed to treat patients within the Neuro ICU.
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http://dx.doi.org/10.3389/fneur.2020.609227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874200PMC
January 2021

Influence of VEGF-A, VEGFR-1-3, and neuropilin 1-2 on progression-free: and overall survival in WHO grade II and III meningioma patients.

J Mol Histol 2021 Apr 2;52(2):233-243. Epub 2021 Feb 2.

Department of Neurosurgery, University Hospital Frankfurt, Goethe University, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.

Higher grade meningiomas tend to recur. We aimed to evaluate protein levels of vascular endothelial growth factor (VEGF)-A with the VEGF-receptors 1-3 and the co-receptors Neuropilin (NRP)-1 and -2 in WHO grade II and III meningiomas to elucidate the rationale for targeted treatments. We investigated 232 specimens of 147 patients suffering from cranial meningioma, including recurrent tumors. Immunohistochemistry for VEGF-A, VEGFR-1-3, and NRP-1/-2 was performed on tissue micro arrays. We applied a semiquantitative score (staining intensity x frequency). VEGF-A, VEGFR-1-3, and NRP-1 were heterogeneously expressed. NRP-2 was mainly absent. We demonstrated a significant increase of VEGF-A levels on tumor cells in WHO grade III meningiomas (p = 0.0098). We found a positive correlation between expression levels of VEGF-A and VEGFR-1 on tumor cells and vessels (p < 0.0001). In addition, there was a positive correlation of VEGF-A and VEGFR-3 expression on tumor vessels (p = 0.0034). VEGFR-2 expression was positively associated with progression-free survival (p = 0.0340). VEGF-A on tumor cells was negatively correlated with overall survival (p = 0.0084). The VEGF-A-driven system of tumor angiogenesis might still present a suitable target for adjuvant therapy in malignant meningioma disease. However, its role in malignant tumor progression may not be as crucial as expected. The value of comprehensive testing of the ligand and all receptors prior to administration of anti-angiogenic therapy needs to be evaluated in clinical trials.
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http://dx.doi.org/10.1007/s10735-020-09940-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8012320PMC
April 2021

Early and Late Postoperative Seizures in Meningioma Patients and Prediction by a Recent Scoring System.

Cancers (Basel) 2021 Jan 25;13(3). Epub 2021 Jan 25.

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

Seizures are among the most common symptoms of meningioma. This retrospective study sought to identify risk factors for early and late seizures in meningioma patients and to evaluate a modified STAMPE2 score. In 556 patients who underwent meningioma surgery, we correlated different risk factors with the occurrence of postoperative seizures. A modified STAMPE2 score was applied. Risk factors for preoperative seizures were edema ( = 0.039) and temporal location ( = 0.038). For postoperative seizures preoperative tumor size ( < 0.001), sensomotory deficit ( = 0.004) and sphenoid wing location ( = 0.032) were independent risk factors. In terms of postoperative status epilepticus; sphenoid wing location ( = 0.022), tumor volume ( = 0.045) and preoperative seizures ( < 0.001) were independent risk factors. Postoperative seizures lead to a KPS deterioration and thus an impaired quality of life ( < 0.001). Late seizures occurred in 43% of patients with postoperative seizures. The small sub-cohort of patients (2.7%) with a STAMPE2 score of more than six points had a significantly increased risk for seizures ( < 0.001, total risk 70%). We concluded that besides distinct risk factors, high scores of the modified STAMPE2 score could estimate the risk of postoperative seizures. However, it seems not transferable to our cohort.
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http://dx.doi.org/10.3390/cancers13030450DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7865990PMC
January 2021

Impact of Comorbidities and Frailty on Early Shunt Failure in Geriatric Patients With Normal Pressure Hydrocephalus.

Front Med (Lausanne) 2020 30;7:596270. Epub 2020 Nov 30.

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

Older patients are considered to bear a higher perioperative risk. Since idiopathic normal pressure hydrocephalus (NPH) predominantly concerns older patients, identifying risk factors for early shunt failure for preoperative risk/benefit assessment is indispensable for indication and/or consultation of patients for ventriculoperitoneal shunting (VPS). We performed a retrospective study design, including data acquired from two university hospital neurosurgical institutions between 2012 and 2019. Overall, 211 consecutive patients with clinical/radiological signs for NPH who additionally showed alleviation of symptoms after lumbar cerebrospinal fluid (CSF) drainage, received VPS and were included for further analysis. Frailty was measured using the Clinical Frailty Scale (CFS). Main outcome was early shunt failure or post-operative complications within 30 days after initial VPS surgery. The overall complication rate was 14%. Patient-related complications were observed in 13 patients (6%) and procedure-related complications in 16 patients (8%). Early post-operative complications resulted in a significantly prolonged length of hospital stay 6.9 ± 6.8 vs. 10.8 ± 11.8 days ( = 0.03). Diabetes mellitus with end-organ damage (OR 35.4, 95% CI 6.6 - 189.4, < 0.0001) as well as preexisting Parkinson's disease were associated with early patient-related post-surgical complications after VPS for NPH. Patients comorbidities but not frailty were associated with early post-operative patient-related complications in patients suffering NPH. While frailty may deter patients from other (neurosurgical) procedures, VPS surgery might contribute to treating NPH in these patients at a tolerable risk.
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http://dx.doi.org/10.3389/fmed.2020.596270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7734184PMC
November 2020

Microsurgical Treatment and Follow-Up of KOOS Grade IV Vestibular Schwannoma: Therapeutic Concept and Future Perspective.

Front Oncol 2020 20;10:605137. Epub 2020 Nov 20.

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

Purpose: Surgery of KOOS IV vestibular schwannoma remains challenging regarding the balance of extent of tumor resection (EoR) and functional outcome. Our aim was to evaluate the outcome of surgical resection and define a cut-off value for safe resection with low risk for tumor regrowth of KOOS IV vestibular schwannoma.

Methods: All patients presenting at the authors' institution between 2000 and 2019 with surgically treated KOOS IV vestibular schwannoma were included. Outcome measures included EoR, facial/hearing nerve function, surgical complications and progression of residual tumor during the median follow-up period of 28 months.

Results: In 58 patients, mean tumor volume was 17.1 ± 9.2 cm, and mean EoR of 81.6 ± 16.8% could be achieved. Fifty-one patients were available for the follow-up analysis. Growth of residual tumor was observed in 11 patients (21.6%) followed by adjuvant treatment with stereotactic radiosurgery or repeat surgery in 15 patients (29.4%). Overall serviceable hearing preservation was achieved in 38 patients (74.5%) and good facial outcome at discharge was observed in 66.7% of patients, significantly increasing to 82.4% at follow-up. Independent predictors for residual tumor growth was EoR ≤ 87% (OR11.1) with a higher EoR being associated with a very low number of residual tumor progression amounting to 7.1% at follow-up (p=0.008).

Conclusions: Subtotal tumor resection is a good therapeutic concept in patients with KOOS IV vestibular schwannoma resulting in a high rate of good hearing and facial nerve function and a very low rate of subsequent tumor progression. The goal of surgery should be to achieve more than 87% of tumor resection to keep residual tumor progression low.
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http://dx.doi.org/10.3389/fonc.2020.605137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7714957PMC
November 2020

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

Acute-on-chronic subdural hematoma: a new entity for prophylactic anti-epileptic treatment?

Eur J Trauma Emerg Surg 2020 Sep 28. Epub 2020 Sep 28.

Department of Neurosurgery, University Hospital, Goethe University, Schleusenweg 2-16, 60528, Frankfurt, Germany.

Purpose: Acute-on-chronic subdural hematoma (acSDH) describes acute bleeding into a chronic subdural hematoma (SDH), after surgery or second trauma. Because seizures are a well-known complication of SDH, associated with substantial morbidity and mortality, we aimed to analyze the incidence of acute symptomatic seizures (ASz), including status epilepticus, and determine the functional outcomes in this specific cohort of patients.

Methods: A retrospective analysis was performed, including patients with acSDH who were admitted to our department between 2010 and 2019. The incidence and timely onset of ASz and status epilepticus were evaluated. Functional outcomes at discharge and at 3-6 month follow-up were analyzed based on the modified Rankin scale.

Results: Of 506 patients with chronic SDH, 29 patients (5.7%) were diagnosed with acSDH. The overall incidence of ASz and status epilepticus were 72.4% and 10.3%, respectively. Favorable outcomes were identified in 11 patients (52.4%) in the ASz group compared with 6 patients (75%) in the non-ASz group. The mortality rate was higher in the ASz group compared with that in the control group (29% vs 0%). At follow-up, favorable outcomes were similar to those observed at discharge (52.4% in the ASz group and 71.4% in the control group). The mortality rate was still higher in the ASz group, at 32% compared with 14% for the control group.

Conclusion: AcSDH has a high risk for ASz, including status epilepticus, and is associated with unfavorable outcomes and high mortality. Thus, prophylactic treatment with antiepileptic drugs should be considered among this specific cohort of patients.
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http://dx.doi.org/10.1007/s00068-020-01508-9DOI Listing
September 2020

Pre- and Post-Surgical Dysphagia in Adults with Tumors of the Posterior Fossa: A Prospective Blinded Study.

Cancers (Basel) 2020 Sep 9;12(9). Epub 2020 Sep 9.

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

Background: While swallowing disorders are frequent sequela following posterior fossa tumor (PFT) surgery in children, data on dysphagia frequency, severity, and outcome in adults are lacking. The aim of this study was to investigate dysphagia before and after surgical removal of PFT. Additionally, we tried to identify clinical predictors for postsurgical swallowing disorders. Furthermore, this study explored the three-month outcome of dysphagic patients.

Methods: In a cohort of patients undergoing PFT surgery, dysphagia was prospectively assessed pre- and postoperatively using fiberoptic endoscopic evaluation of swallowing. Patients with severe dysphagia at discharge were re-evaluated after three months. Additionally, clinical and imaging data were collected to identify predictors for post-surgical dysphagia.

Results: We included 26 patients of whom 15 had pre-operative swallowing disorders. After surgery, worsening of pre-existing dysphagia could be noticed in 7 patients whereas improvement was observed in 2 and full recovery in 3 subjects. New-onset dysphagia after surgery occurred in a minority of 3 cases. Postoperatively, 47% of dysphagic patients required nasogastric tube feeding. Re-evaluation after three months of follow-up revealed that all dysphagic patients had returned to full oral intake.

Conclusion: Dysphagia is a frequent finding in patients with PFT already before surgery. Surgical intervention can infer a deterioration of impaired swallowing function placing affected patients at temporary risk for aspiration. In contrast, surgery can also accomplish beneficial results resulting in both improvement and full recovery. Overall, our findings show the need of early dysphagia assessment to define the safest feeding route for the patient.
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http://dx.doi.org/10.3390/cancers12092561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564918PMC
September 2020

Early versus Delayed Surgery for Spinal Epidural Abscess : Clinical Outcome and Health-Related Quality of Life.

J Korean Neurosurg Soc 2020 Nov 7;63(6):757-766. Epub 2020 Aug 7.

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

Objective: Spinal epidural abscess (SEA) is a severe and life-threatening disease. Although commonly performed, the effect of timing in surgical treatment on patient outcome is still unclear. With this study, we aim to provide evidence for early surgical treatment in patients with SEA.

Methods: Patients treated for SEA in the authors' department between 2007 and 2016 were included for analysis and retrospectively analyzed for basic clinical parameters and outcome. Pre- and postoperative neurological status were assessed using the American Spinal Injury Association Impairment Scale (AIS). The self-reported quality of life (QOL) based on the Short-Form Health Survey 36 (SF-36) was assessed prospectively. Surgery was defined as "early", when performed within 12 hours after admission and "late" when performed thereafter. Conservative therapy was preferred and recommend in patients without neurological deficits and in patients denying surgical intervention.

Results: One hundred and twenty-three patients were included in this study. Forty-nine patients (39.8%) underwent early, 47 patients (38.2%) delayed surgery and 27 (21.9%) conservative therapy. No significant differences were observed regarding mean age, sex, diabetes, prior history of spinal infection, and bony destruction. Patients undergoing early surgery revealed a significant better clinical outcome before discharge than patients undergoing late surgery (p=0.001) and conservative therapy. QOL based on SF-36 were significantly better in the early surgery cohort in two of four physical items (physical functioning and bodily pain) and in one of four psychological items (role limitation) after a mean follow-up period of 58 months. Readmission to the hospital and failure of conservative therapy were observed more often in patients undergoing conservative therapy.

Conclusion: Our data on both clinical outcome and QOL provide evidence for early surgery within 12 hours after admission in patients with SEA.
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http://dx.doi.org/10.3340/jkns.2019.0230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671776PMC
November 2020

Design and Rationale for First-in-Human Phase 1 Immunovirotherapy Clinical Trial of Oncolytic HSV G207 to Treat Malignant Pediatric Cerebellar Brain Tumors.

Hum Gene Ther 2020 10 17;31(19-20):1132-1139. Epub 2020 Aug 17.

Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Brain tumors represent the most common pediatric solid neoplasms and leading cause of childhood cancer-related morbidity and mortality. Although most adult brain tumors are supratentorial and arise in the cerebrum, the majority of pediatric brain tumors are infratentorial and arise in the posterior fossa, specifically the cerebellum. Outcomes from malignant cerebellar tumors are unacceptable despite aggressive treatments (surgery, radiation, and/or chemotherapy) that are harmful to the developing brain. Novel treatments/approaches such as oncolytic virotherapy are urgently needed. Preclinical and prior clinical studies suggest that genetically engineered oncolytic herpes simplex virus (HSV-1) G207 can safely target cerebellar malignancies and has potential to induce an antitumor immune response at local and distant sites of disease, including spinal metastases and leptomeningeal disease. Herein, we outline the rationale, design, and significance of a first-in-human immunotherapy Phase 1 clinical trial targeting recurrent cerebellar malignancies with HSV G207 combined with a single low-dose of radiation (5 Gy), designed to enhance virus replication and innate and adaptive immune responses. We discuss the unique challenges of inoculating virus through intratumoral catheters into cerebellar tumors. The trial utilizes a single arm open-label traditional 3 + 3 design with four dose cohorts. The primary objective is to assess safety and tolerability of G207 with radiation in recurrent/progressive malignant pediatric cerebellar tumors. After biopsy to prove recurrence/progression, one to four intratumoral catheters will be placed followed by a controlled-rate infusion of G207 for 6 h followed by the removal of catheters at the bedside. Radiation will be given within 24 h of virus inoculation. Patients will be monitored closely for toxicity and virus shedding. Efficacy will be assessed by measuring radiographic response, performance score, progression-free and overall survival, and quality of life. The data obtained will be invaluable in our efforts to produce more effective and less toxic therapies for children with high-grade brain tumors.
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http://dx.doi.org/10.1089/hum.2020.101DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7585605PMC
October 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

Return to work and clinical outcome after surgical treatment and conservative management of patients with intramedullary spinal cord ependymoma.

Sci Rep 2020 02 11;10(1):2335. Epub 2020 Feb 11.

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

The ability to return to work after treatment of diseases is an important issue. Aim of this study is to compare surgery and conservative management focusing on clinical outcome and ability to return to work in patients with intramedullary spinal cord ependymoma. Retrospective, single center study. The neurological status at first presentation, as well as in long-term follow-up, were assessed using the modified McCormick Disability Scale and modified Rankin Scale. The study population consisted of 56 patients, 23 (41%) were managed conservatively and 33 (59%) underwent microsurgical resection. The median age was 47.5 years in the conservative group and 44.5 in the surgical group. At first admission 18 of conservatively treated and 28 of surgically treated patients were employed, p = 0.7. At the last follow-up 15 (83%) of conservatively and 10 (36%) of surgically treated patients returned to work, p = 0.002. The median modified McCormick score in both groups (conservative vs. surgical) was at admission 1 vs. 1, p = 1.0 and at last follow up 1 vs. 2.5, p = 0.001. Patients clinical outcome in the surgical group was significantly reduced at last follow up as assessed by the modified Rankin Scale (mRs score of 0-2) at admission 100% vs. 100% and last follow-up 94% vs. 57%, p = 0.007. In our investigated study population, conservatively managed patients revealed a significantly better outcome and were more often able to return to work.
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http://dx.doi.org/10.1038/s41598-020-59328-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012826PMC
February 2020

A novel in situ multiplex immunofluorescence panel for the assessment of tumor immunopathology and response to virotherapy in pediatric glioblastoma reveals a role for checkpoint protein inhibition.

Oncoimmunology 2019;8(12):e1678921. Epub 2019 Oct 21.

Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA.

Immunotherapy with oncolytic herpes simplex virus-1 therapy offers an innovative, targeted, less-toxic approach for treating brain tumors. However, a major obstacle in maximizing oncolytic virotherapy is a lack of comprehensive understanding of the underlying mechanisms that unfold in CNS tumors/associated microenvironments after infusion of virus. We demonstrate that our multiplex biomarker screening platform comprehensively informs changes in both topographical location and functional states of resident/infiltrating immune cells that play a role in neuropathology after treatment with HSV G207 in a pediatric Phase 1 patient. Using this approach, we identified robust infiltration of CD8 T cells suggesting activation of the immune response following virotherapy; however there was a corresponding upregulation of checkpoint proteins PD-1, PD-L1, CTLA-4, and IDO revealing a potential role for checkpoint inhibitors. Such work may ultimately lead to an understanding of the governing pathobiology of tumors, thereby fostering development of novel therapeutics tailored to produce optimal responses.
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http://dx.doi.org/10.1080/2162402X.2019.1678921DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6844311PMC
October 2019

Surgery for Diffuse WHO Grade II Gliomas: Volumetric Analysis of a Multicenter Retrospective Cohort From the German Study Group for Intraoperative Magnetic Resonance Imaging.

Neurosurgery 2020 01;86(1):E64-E74

Department of Neurosurgery, University of Ulm, Günzburg, Germany.

Background: In diffuse WHO grade II gliomas (LGG), the extent of resection (EOR) required to achieve significant survival benefits remains elusive.

Objective: To evaluate the association of residual volume (RV) and EOR with progression-free survival (PFS) or overall survival (OS) in LGG in a retrospective, multicenter series by the German study group of intraoperative MRI (GeSGIM).

Methods: Consecutive cases were retrospectively assessed from 5 centers. Tumors were volumetrically quantified before and after surgery, and clinical data were analyzed, including IDH mutations and neurologic deficits. Kaplan-Meier estimates, accelerated failure time models (AFT), and multivariate Cox regression models were calculated to identify determinants of survival.

Results: A total of 140 cases were analyzed. Gross total resection (GTR) was associated with significantly longer PFS compared to any incomplete resection (P = .009). A significant survival disadvantage was evident even for small (>0-5 ml) residuals and increased for moderate (>5-20 ml) and large remnants (>20 ml) P = .001). Accordingly, PFS increased continuously for 20% incremental steps of EOR (P < .001). AFT models supported the notion of a continuous association of RV and EOR with PFS. Multivariate Cox regression models confirmed RV (P = .01) and EOR (P = .005) as continuous prognosticators of PFS. Univariate analysis showed significant associations of RV and EOR with OS.

Conclusion: Our data support the hypothesis of a continuous relationship of RV and EOR with survival for LGG with superiority seen for GTR. Hence, GTR should be achieved whenever safely feasible, and resections should be maximized whenever tumor has to be left behind to spare function.
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http://dx.doi.org/10.1093/neuros/nyz397DOI Listing
January 2020

Artificial Intelligence in the Management of Glioma: Era of Personalized Medicine.

Front Oncol 2019 14;9:768. Epub 2019 Aug 14.

Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama, Birmingham, AL, United States.

Artificial intelligence (AI) has accelerated novel discoveries across multiple disciplines including medicine. Clinical medicine suffers from a lack of AI-based applications, potentially due to lack of awareness of AI methodology. Future collaboration between computer scientists and clinicians is critical to maximize the benefits of transformative technology in this field for patients. To illustrate, we describe AI-based advances in the diagnosis and management of gliomas, the most common primary central nervous system (CNS) malignancy. Presented is a succinct description of foundational concepts of AI approaches and their relevance to clinical medicine, geared toward clinicians without computer science backgrounds. We also review novel AI approaches in the diagnosis and management of glioma. Novel AI approaches in gliomas have been developed to predict the grading and genomics from imaging, automate the diagnosis from histopathology, and provide insight into prognosis. Novel AI approaches offer acceptable performance in gliomas. Further investigation is necessary to improve the methodology and determine the full clinical utility of these novel approaches.
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http://dx.doi.org/10.3389/fonc.2019.00768DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6702305PMC
August 2019

The Role of SUMOylation and Ubiquitination in Brain Ischaemia: Critical Concepts and Clinical Implications.

Curr Issues Mol Biol 2020 18;35:127-144. Epub 2019 Aug 18.

Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA. 6Department of Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany.

Brain ischaemia is a severe form of metabolic stress that activates a cascade of pathological events involving many signalling pathways. Modulation of these pathways is largely mediated by post-translational modifications (PTMs). Indeed, PTMs can rapidly modify pre-existing proteins by attaching chemical or polypeptide moieties to selected amino acid residues, altering their functions, stability, subcellular localizations, or interactions with other proteins. Subsequently, related signalling pathways can be substantially affected. Thus, PTMs are widely deployed by cells as an adaptive strategy at the front line to efficiently cope with internal and external stresses. Many types of PTMs have been identified, including phosphorylation, O-GlcNAcylation, small ubiquitin-like modifier (SUMO) modification (SUMOylation), and ubiquitination. All these PTMs have been studied in brain ischaemia to some extent. In particular, a large body of evidence has demonstrated that both global SUMOylation and ubiquitination are massively activated after brain ischaemia, and this activation may play a critical role in defining the fate and function of cells in the post-ischaemic brain. The goal of this review will be to summarize the current findings on SUMOylation and ubiquitination in brain ischaemia and discuss their clinical implications.
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http://dx.doi.org/10.21775/cimb.035.127DOI Listing
October 2020

Angiosarcoma of the Temporal Bone: Case Report and Review of the Literature.

World Neurosurg 2019 Oct 19;130:351-357. Epub 2019 Jul 19.

Department of Neuroradiology, University of Alabama at Birmingham, Birmingham, Alabama, USA. Electronic address:

Background: Angiosarcomas are rare malignant tumors of endothelial origin. Nearly one half of all angiosarcomas occur in the head and neck. Temporal bone angiosarcomas are extremely uncommon. We present a case of temporal bone angiosarcoma and a review of the relevant data.

Case Description: We present the case of a 20-year-old man with a painful right postauricular mass after a closed head injury. Radiologic studies demonstrated a large right osteolytic and heterogeneously enhancing mass. The patient underwent right transpetrosal craniectomy for resection. Histologic studies confirmed high-grade sarcoma. Immunohistochemical staining demonstrated a uniformly positive ERG endothelial marker, CD31 staining with cytoplasmic and membranous patterns of immunopositivity, positive nuclear staining for FLI-1, positive cytoplasmic and membranous staining for CD99 and STAT6, and negative smooth muscle actin stains in the neoplastic cells. Ki-67 staining showed ∼94% positivity in the neoplastic cell nuclei. Postoperative follow-up imaging studies demonstrated evidence of metastatic right cervical lymphadenopathy.

Conclusions: Angiosarcoma of the temporal bone is extremely uncommon. In the present case report, we explored a relationship between trauma and angiosarcoma of the temporal bone. We reviewed the reported data regarding the pathogenesis, diagnosis, treatment, radiologic findings, and histologic characteristics of angiosarcoma of the temporal bone.
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http://dx.doi.org/10.1016/j.wneu.2019.07.107DOI Listing
October 2019

To treat or not to treat? A retrospective multicenter assessment of survival in patients with IDH-mutant low-grade glioma based on adjuvant treatment.

J Neurosurg 2019 Jul 19:1-8. Epub 2019 Jul 19.

2Department of Neurosurgery, University of Heidelberg.

Objective: The level of evidence for adjuvant treatment of diffuse WHO grade II glioma (low-grade glioma, LGG) is low. In so-called "high-risk" patients most centers currently apply an early aggressive adjuvant treatment after surgery. The aim of this assessment was to compare progression-free survival (PFS) and overall survival (OS) in patients receiving radiation therapy (RT) alone, chemotherapy (CT) alone, or a combined/consecutive RT+CT, with patients receiving no primary adjuvant treatment after surgery.

Methods: Based on a retrospective multicenter cohort of 288 patients (≥ 18 years old) with diffuse WHO grade II gliomas, a subgroup analysis of patients with a confirmed isocitrate dehydrogenase (IDH) mutation was performed. The influence of primary adjuvant treatment after surgery on PFS and OS was assessed using Kaplan-Meier estimates and multivariate Cox regression models, including age (≥ 40 years), complete tumor resection (CTR), recurrent surgery, and astrocytoma versus oligodendroglioma.

Results: One hundred forty-four patients matched the inclusion criteria. Forty patients (27.8%) received adjuvant treatment. The median follow-up duration was 6 years (95% confidence interval 4.8-6.3 years). The median overall PFS was 3.9 years and OS 16.1 years. PFS and OS were significantly longer without adjuvant treatment (p = 0.003). A significant difference in favor of no adjuvant therapy was observed even in high-risk patients (age ≥ 40 years or residual tumor, 3.9 vs 3.1 years, p = 0.025). In the multivariate model (controlled for age, CTR, oligodendroglial diagnosis, and recurrent surgery), patients who received no adjuvant therapy showed a significantly positive influence on PFS (p = 0.030) and OS (p = 0.009) compared to any other adjuvant treatment regimen. This effect was most pronounced if RT+CT was applied (p = 0.004, hazard ratio [HR] 2.7 for PFS, and p = 0.001, HR 20.2 for OS). CTR was independently associated with longer PFS (p = 0.019). Age ≥ 40 years, histopathological diagnosis, and recurrence did not achieve statistical significance.

Conclusions: In this series of IDH-mutated LGGs, adjuvant treatment with RT, CT with temozolomide (TMZ), or the combination of both showed no significant advantage in terms of PFS and OS. Even in high-risk patients, the authors observed a similar significantly negative impact of adjuvant treatment on PFS and OS. These results underscore the importance of a CTR in LGG. Whether patients ≥ 40 years old should receive adjuvant treatment despite a CTR should be a matter of debate. A potential tumor dedifferentiation by administration of early TMZ, RT, or RT+CT in IDH-mutated LGG should be considered. However, these data are limited by the retrospective study design and the potentially heterogeneous indication for adjuvant treatment.
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http://dx.doi.org/10.3171/2019.4.JNS183395DOI Listing
July 2019

Academic output of German neurosurgical residents in 35 academic neurosurgery residency programs.

Acta Neurochir (Wien) 2019 10 18;161(10):1969-1974. Epub 2019 Jul 18.

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

Background: The scientific activity of neurosurgeons and neurosurgery residents as measured by bibliometric parameters is of increased interest. While data about academic output for neurosurgeons in the USA, the UK, and Canada have been published, no similar results for German neurosurgical residents exist. Within this study, we aim to evaluate the academic output of German neurosurgery residents in 35 academic residency programs.

Methods: Data for each resident were collected from the departmental websites, Pubmed, and Scopus. Further analyses evaluated the relationship between publication productivity, sex, and academic degree (Dr. med.).

Results: Data from 424 neurosurgery residents were analyzed. A total of 1222 publications were considered. A total of 355 (29%) of the 1222 publications were first-author publications. The average number of publications per resident was 2.9; the average h-index and m-quotient was 1.1 and 0.4, respectively. There was a statistically significant difference in academic output and h-index among neurosurgical residents with a doctoral degree compared with residents without such degree (5.3 vs. 1.3, p < 0.0001 and 2.0 vs. 0.5, p < 0.0001).

Conclusion: This is the very first study evaluating the academic output of neurosurgical residents in academic neurosurgical departments in Germany.
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http://dx.doi.org/10.1007/s00701-019-04011-2DOI Listing
October 2019

Management of hydrocephalus after resection of posterior fossa lesions in pediatric and adult patients-predictors for development of hydrocephalus.

Neurosurg Rev 2020 Aug 9;43(4):1143-1150. Epub 2019 Jul 9.

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

The surgical management of hydrocephalus in patients with posterior fossa lesions (PFL) is critical for optimal patient outcome(s). Accordingly, it is prudent to identify patients in need of aggressive surgical intervention (i.e., ventriculoperitoneal [VP] shunting). To analyze prevalence of, and risk factors associated with, the development of post-operative hydrocephalus in both pediatrics and adults. A retrospective institutional analysis and review of patient records in those who had undergone PFL surgery was performed. In so doing, the authors identified patients that went on to develop post-operative hydrocephalus. The study included pediatric and adult patients treated between 2009 and 2017. Fifteen of 40 pediatric (37.5%) and 18 of 262 adult (6.9%) patients developed hydrocephalus after PFL surgery. The most common tumor entity in pediatrics was medulloblastoma (34%), astrocytoma (24.4%), and pilocytic astrocytoma (22%), whereas in adults, metastasis (29.5%), meningioma (22%), and acoustic neuroma (17.8%) were most common. Young age ≤ 2 years, medulloblastoma (OR 13.9), and brain stem compression (OR 5.4) were confirmed as independent predictors for hydrocephalus in pediatrics and pilocytic astrocytoma (OR 15.4) and pre-operative hydrocephalus (OR 3.6) in adults, respectively. All patients received VP shunts for hydrocephalus management and the mean follow-up was 29.5 months in pediatrics vs 19.2 months in adults. Overall complication rates related to VP shunts were 33.3% in pediatrics and 16.7% in adults, respectively. Shunt dependency and associated complications in pediatrics were noted to be higher than in adults. Given the identification of predictors for hydrocephalus, it is authors' contention that certain patients with those predictors may ultimately benefit from an alternative treatment regimen (e.g., pre-operative interventions) prior to PFT surgery.
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http://dx.doi.org/10.1007/s10143-019-01139-8DOI Listing
August 2020

Magnetic Resonance Imaging Safety of Retained Tip and Protective Coils after Faulty Deployment of an Intracranial Pipeline Embolization Device: A Case Report.

World Neurosurg 2019 Sep 13;129:221-224. Epub 2019 Jun 13.

Department of Radiology, Florida Hospital, Orlando, Florida, USA.

Background: The development of flow-diverters such as the Pipeline embolization device (PED) have allowed for safe and effective treatment of challenging and/or previously untreatable intracranial aneurysms. A rare but serious complication during PED deployment involves fracture of single or multiple components, which can lead to retained hardware. To date, there are little data regarding the safety of performing magnetic resonance imaging (MRI) when tip or capture coils remain intracranially.

Case Description: To the best of our knowledge, we present the first case demonstrating the safe completion of MRI after treatment of 2 posterior circulation aneurysms in a woman aged 69 years presenting with subarachnoid hemorrhage whose treatment was complicated by fracture and subsequent retention of the PED tip and capture coils.

Conclusions: MRI (1.5T) appears safe and effective in patients who have retained PED tips and/or capture coils.
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http://dx.doi.org/10.1016/j.wneu.2019.06.007DOI Listing
September 2019
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