Publications by authors named "Hans Clusmann"

119 Publications

Current state of social media utilization in neurosurgery amongst European Association of Neurosurgical Societies (EANS) member countries.

Acta Neurochir (Wien) 2021 Jul 27. Epub 2021 Jul 27.

Department of Neurosurgery, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.

Background: Social Media (SoMe) is becoming increasingly used in the medical community, and its use has been related with academic productivity. However, utilization of SoMe in the European neurosurgical community has not been assessed systematically.

Methods: An online search was undertaken to discover SoMe accounts of (1) national and related neurosurgical societies listed on the EANS website, (2) neurosurgical journals present on EANS website, (3) neurosurgery centers within EANS member countries, as listed on their website. SoMe accounts of Facebook, Twitter, YouTube, and Instagram were searched for journals and societies, and Twitter, Instagram, and Facebook for neurosurgery departments. The number of likes/followers/subscribers was recorded.

Results: Five (31%) neurosurgery journals had a SoMe presence. The highest number of followers, likes, and tweets was found for JNNP, and Journal of Neurological Surgery Part B had the most subscribers and video views. SoMe usage was identified for 11 national (28.2%) and 2 multi-national neurosurgical societies. From these, the French Society of Neurosurgery had the largest number of Facebook followers (> 2800) and Likes (> 2700), the Society of British Neurological Surgeons had the largest number of Twitter followers (> 2850), whereas EANS overall had the most followers on Twitter > 5100 and Facebook > 5450. A total of 87 SoMe neurosurgery center accounts were found on either Facebook, Instagram or Twitter, for 64 of 1000 centers (6.4%) in 22 of 40 different countries (55%). Of these 67% (n = 43/64) arose from 6 countries (England, Germany, Italy, Romania, Turkey, Ukraine). There were more Facebook accounts (n = 42) than Instagram accounts (n = 23) or Twitter accounts (n = 22).

Conclusion: SoMe use amongst neurosurgical societies and departments in Europe is very limited. From our perspective, explanations are lacking for the correlated numbers to the market shares of SoMe in the respective countries. Further research, including a survey, to follow up on this important topic should be undertaken among EANS members.
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http://dx.doi.org/10.1007/s00701-021-04939-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8313658PMC
July 2021

Invasive Multimodal Neuromonitoring in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review.

Stroke 2021 Jul 26:STROKEAHA121034633. Epub 2021 Jul 26.

Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany (M.A., W.A., M.W., A.H., H.C., G.A.S.).

Background And Purpose: Aneurysmal subarachnoid hemorrhage is a devastating disease leaving surviving patients often severely disabled. Delayed cerebral ischemia (DCI) has been identified as one of the main contributors to poor clinical outcome after subarachnoid hemorrhage. The objective of this review is to summarize existing clinical evidence assessing the diagnostic value of invasive neuromonitoring (INM) in detecting DCI and provide an update of evidence since the 2014 consensus statement on multimodality monitoring in neurocritical care.

Methods: Three invasive monitoring techniques were targeted in the data collection process: brain tissue oxygen tension (pO), cerebral microdialysis, and electrocorticography. Prospective and retrospective studies as well as case series (≥10 patients) were included as long as monitoring was used to detect DCI or guide DCI treatment.

Results: Forty-seven studies reporting INM in the context of DCI were included (pO: N=21; cerebral microdialysis: N=22; electrocorticography: N=4). Changes in brain oxygen tension are associated with angiographic vasospasm or reduction in regional cerebral blood flow. Metabolic monitoring with trend analysis of the lactate to pyruvate ratio using cerebral microdialysis, identifies patients at risk for DCI. Clusters of cortical spreading depolarizations are associated with clinical neurological worsening and cerebral infarction in selected patients receiving electrocorticography monitoring.

Conclusions: Data supports the use of INM for the detection of DCI in selected patients. Generalizability to all subarachnoid hemorrhage patients is limited by design bias of available studies and lack of randomized trials. Continuous data recording with trend analysis and the combination of INM modalities can provide tailored treatment support in patients at high risk for DCI. Future trials should test interventions triggered by INM in relation to cerebral infarctions.
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http://dx.doi.org/10.1161/STROKEAHA.121.034633DOI Listing
July 2021

Female Participation in Academic European Neurosurgery-A Cross-Sectional Analysis.

Brain Sci 2021 Jun 23;11(7). Epub 2021 Jun 23.

Department of Neurosurgery, University Hospital RWTH Aachen, 52074 Aachen, Germany.

The study aims to provide data on authors' gender distribution with special attention on publications from Europe. Articles (October 2019-March 2020) published in three representative neurosurgical journals () were analyzed with regard to female participation. Out of 648 publications, 503 original articles were analyzed: 17.5% ( = 670) of the 3.821 authors were female, with 15.7% ( = 79) females as first and 9.5% ( = 48) as last authors. The lowest ratio of female first and last authors was seen in original articles published in the (12.3%/7.7% vs. 14.9%/10.6% and 23.0/11.5%). Articles originated in Europe made up 29.8% (female author ratio 21.1% ( = 226)). Female first authorship was seen in 20.7% and last authorship in 10.7% (15.3% and 7.3% were affiliated to a neurosurgical department). The percentages of female authorship were lower if non-original articles ( = 145) were analyzed (11.7% first/4.8% last authorships). Female participation in editorial boards was 8.0%. Considering the percentages of European female neurosurgeons, the current data are proportional. However, the lack of female last authors, the discrepancy regarding non-original articles and the composition of the editorial boards indicate that there still is a structural underrepresentation and that females are limited in achieving powerful positions.
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http://dx.doi.org/10.3390/brainsci11070834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8301744PMC
June 2021

Non-invasive Assessment of Neurovascular Coupling After Aneurysmal Subarachnoid Hemorrhage: A Prospective Observational Trial Using Retinal Vessel Analysis.

Front Neurol 2021 14;12:690183. Epub 2021 Jun 14.

Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.

Delayed cerebral ischemia (DCI) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH) and can lead to infarction and poor clinical outcome. The underlying mechanisms are still incompletely understood, but animal models indicate that vasoactive metabolites and inflammatory cytokines produced within the subarachnoid space may progressively impair and partially invert neurovascular coupling (NVC) in the brain. Because cerebral and retinal microvasculature are governed by comparable regulatory mechanisms and may be connected by perivascular pathways, retinal vascular changes are increasingly recognized as a potential surrogate for altered NVC in the brain. Here, we used non-invasive retinal vessel analysis (RVA) to assess microvascular function in aSAH patients at different times after the ictus. Static and dynamic RVA were performed using a Retinal Vessel Analyzer (IMEDOS Systems GmbH, Jena) in 70 aSAH patients during the early (d), critical (d), late (d) phase, and at follow-up (f/u > 6 weeks) after the ictus. For comparison, an age-matched cohort of 42 healthy subjects was also included in the study. Vessel diameters were quantified in terms of the central retinal arterial and venous equivalent (CRAE, CRVE) and the retinal arterio-venous-ratio (AVR). Vessel responses to flicker light excitation (FLE) were quantified by recording the maximum arterial and venous dilation (MAD, MVD), the time to 30% and 100% of maximum dilation (tMAD, tMVD; tMAD, tMVD, resp.), and the arterial and venous area under the curve (AUC, AUC) during the FLE. For subgroup analyses, patients were stratified according to the development of DCI and clinical outcomes after 12 months. Vessel diameter (CRAE, CRVE) was significantly smaller in aSAH patients and showed little change throughout the whole observation period ( < 0.0001 vs. control for all time periods examined). In addition, aSAH patients exhibited impaired arterial but not venous responses to FLE, as reflected in a significantly lower MAD [2.2 (1.0-3.2)% vs. 3.6 (2.6-5.6)% in control subjects, = 0.0016] and AUC [21.5 (9.4-35.8)%s vs. 51.4 (32.5-69.7)%s in control subjects, = 0.0001] on d. However, gradual recovery was observed during the first 3 weeks, with close to normal levels at follow-up, when MAD and AUC amounted to 3.0 [2.0-5.0]% ( = 0.141 vs. control, = 0.0321 vs. d) and 44.5 [23.2-61.1]%s ( = 0.138 . control, < 0.01 vs. d & d). Finally, patients with clinical deterioration (DCI) showed opposite changes in the kinetics of arterial responses during early and late phase, as reflected in a significantly lower tMAD on d [4.0 (3.0-6.8) s vs. 7.0 (5.0-8.0) s in patients without DCI, = 0.022) and a significantly higher tMAD on d (24.0 (21.0-29.3) s . 18.0 (14.0-21.0) s in patients without DCI, = 0.017]. Our findings confirm and extend previous observations that aSAH results in sustained impairments of NVC in the retina. DCI may be associated with characteristic changes in the kinetics of retinal arterial responses. However, further studies will be required to determine their clinical implications and to assess if they can be used to identify patients at risk of developing DCI. ClinicalTrials.gov Identifier: NCT04094155.
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http://dx.doi.org/10.3389/fneur.2021.690183DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8236540PMC
June 2021

Levels of bioactive adrenomedullin in plasma and cerebrospinal fluid in relation to delayed cerebral ischemia in patients after aneurysmal subarachnoid hemorrhage: A prospective observational study.

J Neurol Sci 2021 Aug 5;427:117533. Epub 2021 Jun 5.

Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany. Electronic address:

Objectives: Adrenomedullin (ADM) has been identified as a promising biomarker of mortality and outcome in sepsis, heart failure and after major surgery. A recently developed assay specific for bioactive adrenomedullin (bio-ADM) has not yet been assessed in aneurysmal subarachnoid hemorrhage (aSAH). The objective of this prospective trial was to assess the time course of bio-ADM after aSAH in relation to the development of delayed cerebral ischemia (DCI) and its association with clinical outcome.

Methods: Bio-ADM levels in plasma and cerebrospinal fluid (CSF) were measured during five predefined epochs, for up to 21 days in 30 aSAH patients: early, (day 0 to day 3); acute, (day 4 to day 8); early critical, (day 9 to day 12); late critical, (day 13 to day 15), and late (day 16 to day 21). DCI was diagnosed clinically or based on multimodal monitoring and imaging, and the occurrence of DCI-related cerebral infarction, and outcome after 12 months (extended Glasgow outcome scale), was noted.

Results: Higher median bio-ADM levels in plasma during the acute phase were predictive of long-term unfavorable outcome (AUC = 0.97; 95% CI 0.91 to 1.00; p < 0.001). Early critical bio-ADM levels during DCI were lower in CSF and confirmed DCI occurrence (AUC = 0.80; 95% CI 0.59 to 1.00; p = 0.044).

Conclusion: The dynamics of bio-ADM levels in CSF present a fairly different course compared to plasma with observed higher bio-ADM concentrations in patients spared from DCI and/or developing favorable outcome.
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http://dx.doi.org/10.1016/j.jns.2021.117533DOI Listing
August 2021

Ocular Trauma with Ophthalmic Artery Injury as a Rare Cause of Subarachnoid Hemorrhage: a Case Report and Review of the Literature.

J Neurol Surg A Cent Eur Neurosurg 2021 Jun 7. Epub 2021 Jun 7.

Department of Neurosurgery, Universitätsklinikum Aachen, RWTH Aachen University, Aachen, Germany.

Background And Importance:  Traumatic avulsion of the ophthalmic artery is a rare cause of subarachnoid hemorrhage (SAH). In this case, a relative minor fall with isolated ocular trauma caused bulbar dislocation and rupture of the ophthalmic artery in its intracranial segment resulting in subarachnoid bleeding.

Clinical Presentation:  In a female patient in her 70s, a direct penetrating trauma to the orbit by a door handle resulted in basal SAH with blood dispersion into both Sylvian fissures. Cerebral angiography revealed a blunt-ending stump at the origin of the ophthalmic artery. To provide protection against further bleeding, a flow diverter stent was placed in the internal carotid artery to cover the origin of the ophthalmic artery. After a longer intensive care stay complicated by pneumonia and respiratory insufficiency, the patient made a full recovery. Of all four reported cases (including ours), delayed cerebral ischemia was seen in one patient and hydrocephalus in two patients. These potential complications necessitate close observation and fitting treatment similar to aneurysmal SAH.

Conclusion:  Due to similar physiologic aspects, this type of bleed mimics many aspects of aneurysmal SAH. In this case, we observed no hydrocephalus or the development of delayed cerebral ischemia. This represents, however, the first reported case treated by placement of a flow diverter stent to prevent rebleeding and pseudoaneurysm formation.
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http://dx.doi.org/10.1055/s-0041-1725956DOI Listing
June 2021

Urea-Creatinine Ratio (UCR) After Aneurysmal Subarachnoid Hemorrhage: Association of Protein Catabolism with Complication Rate and Outcome.

World Neurosurg 2021 Jul 18;151:e961-e971. Epub 2021 May 18.

Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.

Objective: The urea-creatinine ratio (UCR) has been proposed as potential biomarker for critical illness-associated catabolism. Its role in the context of aneurysmal subarachnoid hemorrhage (aSAH) remains to be elucidated, which was the aim of the present study.

Methods: We enrolled 66 patients with aSAH with normal renal function and 36 patients undergoing elective cardiac surgery as a control group for the effects of surgery. In patients with aSAH, the predictive or diagnostic value of early (day 0-2) and critical (day 5-7) UCRs was assessed with regard to delayed cerebral ischemia (DCI), DCI-related infarction, and clinical outcome after 12 months.

Results: Preoperatively, UCR was similar both groups. Within 2 days postoperatively, UCRs increased significantly in patients in the elective cardiac surgery group (P < 0.001) but decreased back to baseline on day 5-7 (P = 0.245), whereas UCRs in patients with aSAH increased to significantly greater levels on day 5-7 (P = 0.028). Greater early or critical UCRs were associated with poor clinical outcomes (P = 0.015) or DCI (P = 0.011), DCI-related infarction (P = 0.006), and poor clinical outcomes (P < 0.001) respectively. In multivariate analysis, there was an independent association between greater early UCRs and poor clinical outcomes (P = 0.026).

Conclusions: In this exploratory study of UCR in the context of aSAH, greater early values were predictive for a poor clinical outcome after 12 months, whereas greater critical values were associated with DCI, DCI-related infarctions, and poor clinical outcomes. The clinical implications as well as the pathophysiologic relevance of protein catabolism should be explored further in the context of aSAH.
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http://dx.doi.org/10.1016/j.wneu.2021.05.025DOI Listing
July 2021

Retinal Vessel Responses to Flicker Stimulation Are Impaired in Ca 2.3-Deficient Mice-An Evaluation Using Retinal Vessel Analysis (RVA).

Front Neurol 2021 13;12:659890. Epub 2021 Apr 13.

Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.

Metabolic demand increases with neuronal activity and adequate energy supply is ensured by neurovascular coupling (NVC). Impairments of NVC have been reported in the context of several diseases and may correlate with disease severity and outcome. Voltage-gated Ca-channels (VGCCs) are involved in the regulation of vasomotor tone. In the present study, we compared arterial and venous responses to flicker stimulation in Ca2.3-competent (Ca2.3) and -deficient (Ca2.3) mice using retinal vessel analysis. The mice were anesthetized and the pupil of one eye was dilated by application of a mydriaticum. An adapted prototype of retinal vessel analyzer was used to perform dynamic retinal vessel analysis. Arterial and venous responses were quantified in terms of the area under the curve (AUC/AUC) during flicker application, mean maximum dilation (mMD/mMD) and time to maximum dilation (tMD/tMD) during the flicker, dilation at flicker cessation (DFC/DFC), mean maximum constriction (mMC/mMC), time to maximum constriction (tMC/tMC) after the flicker and reactive magnitude (RM/RM). A total of 33 retinal scans were conducted in 22 Ca2.3 and 11 Ca2.3 mice. Ca2.3 mice were characterized by attenuated and partially reversed arterial and venous responses, as reflected in significantly lower AUC ( = 0.031) and AUC ( = 0.047), a trend toward reduced DFC ( = 0.100), DFC ( = 0.100), mMD ( = 0.075), and RM ( = 0.090) and a trend toward increased tMD ( = 0.096). To our knowledge, this is the first study using a novel, non-invasive analysis technique to document impairment of retinal vessel responses in VGCC-deficient mice. We propose that Ca2.3 channels could be involved in NVC and may contribute to the impairment of vasomotor responses under pathophysiological conditions.
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http://dx.doi.org/10.3389/fneur.2021.659890DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8076560PMC
April 2021

Body mass index and leptin levels in serum and cerebrospinal fluid in relation to delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage.

Neurosurg Rev 2021 Apr 17. Epub 2021 Apr 17.

Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.

Aneurysmal subarachnoid hemorrhage (SAH) is associated with a high mortality rate and may leave surviving patients severely disabled. After the initial hemorrhage, clinical outcome is further compromised by the occurrence of delayed cerebral ischemia (DCI). Overweight and obesity have previously been associated with protective effects in the post-bleeding phase. The aim of this study was to assess the effects of a patient's body mass index (BMI) and leptin levels on the occurrence of DCI, DCI-related cerebral infarction, and clinical outcome. In total, 263 SAH patients were included of which leptin levels were assessed in 24 cases. BMI was recorded along disease severity documented by the Hunt and Hess and modified Fisher scales. The occurrence of clinical or functional DCI (neuromonitoring, CT Perfusion) was assessed. Long-term clinical outcome was documented after 12 months (extended Glasgow outcome scale). A total of 136 (51.7%) patients developed DCI of which 72 (27.4%) developed DCI-related cerebral infarctions. No association between BMI and DCI occurrence (P = .410) or better clinical outcome (P = .643) was identified. Early leptin concentration in serum (P = .258) and CSF (P = .159) showed no predictive value in identifying patients at risk of unfavorable outcomes. However, a significant increase of leptin levels in CSF occurred from 326.0 pg/ml IQR 171.9 prior to DCI development to 579.2 pg/ml IQR 211.9 during ongoing DCI (P = .049). In our data, no association between obesity and clinical outcome was detected. After DCI development, leptin levels in CSF increased either by an upsurge of active transport or disruption of the blood-CSF barrier. This trial has been registered at ClinicalTrials.gov (NCT02142166) as part of a larger-scale prospective data collection. BioSAB: https://clinicaltrials.gov/ct2/show/NCT02142166.
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http://dx.doi.org/10.1007/s10143-021-01541-1DOI Listing
April 2021

How I do it-the posterior question mark incision for decompressive hemicraniectomy.

Acta Neurochir (Wien) 2021 05 31;163(5):1447-1450. Epub 2021 Mar 31.

Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.

Background: Decompressive hemicraniectomy (DHC) is a lifesaving procedure which every neurosurgeon should master early on. As indications for the procedure are growing, the number of patients eventually requiring skull reconstruction via cranioplasty also increases. The posterior question mark incision is a straightforward alternative to the classic trauma-flap and can easily be adopted. Some particularities exist one should consider beforehand and are discussed here in detail.

Methods: Surgical steps, aids, and pitfalls are comprehensively discussed to prepare surgeons who wish to gain experience with this type of incision.

Conclusion: Due to the lower complication rate after cranioplasty, the posterior question mark incision has superseded the traditional pre-auricular starting anterior question mark incisions, in our department for the performance of decompressive hemicraniectomies.
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http://dx.doi.org/10.1007/s00701-021-04812-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053663PMC
May 2021

Cortical volume reductions as a sign of secondary cerebral and cerebellar impairment in patients with degenerative cervical myelopathy.

Neuroimage Clin 2021 13;30:102624. Epub 2021 Mar 13.

Department of Neurosurgery, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany. Electronic address:

This study investigated supra- and infratentorial structural gray and white matter (GM, WM) alterations in patients with degenerative cervical myelopathy (DCM) as an indicator of secondary harm due to chronic cervical cord compression and micro trauma. With MRI-based anatomical assessment and subsequent voxel-based morphometry analyses, pre- and postoperative volume alterations in the primary motor cortex (MI), the primary somatosensory cortex (SI), the supplementary motor area (SMA), and the cerebellum were analyzed in 43 DCM patients and 20 controls. We assessed disease-related symptom severity by the modified Japanese Orthopaedic Association scale (mJOA). The study also explored symptom severity-based brain volume alterations as well as their association with clinical status. Patients had lower mJOA scores (p = .000) and lower GM volume than controls in SI (p = .016) and cerebellar regions (p = .001). Symptom severity-based subgroup analyses revealed volume reductions in almost all investigated GM ROIs (MI: p = .001; CB: p = .040; SMA: p = .007) in patients with severe clinical symptoms as well as atrophy already present in patients with moderate symptom severity. Clinical symptoms in DCM were associated with cortical and cerebellar volume reduction. GM volume alterations may serve as an indicator of both disease severity and ongoing disease progression in DCM, and should be considered in further patient care and treatment monitoring.
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http://dx.doi.org/10.1016/j.nicl.2021.102624DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8025145PMC
July 2021

Coarctation of the Aorta as a Rare Indirect Cause of Aneurysmal Subarachnoid Hemorrhage in the Adolescent: A Case Report and Review of the Literature.

J Neurol Surg A Cent Eur Neurosurg 2021 Feb 14. Epub 2021 Feb 14.

Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.

Aneurysmal subarachnoid hemorrhage (SAH) is rare in teenagers. We present the case of a 19-year-old woman with an aneurysmal SAH and four anterior circulation aneurysms. Due to the urgency of operative treatment, no initial conventional cerebral angiography was performed. The CT angiography depicted the aortic arch incompletely. The coarctation was discovered on day 5 after ictus in a cerebral angiography for vasospasm surveillance. We believe that in young SAH patients without an explainable predilection for aneurysm formation, imaging of the aortic arch during the initial CT angiography, not to miss a coarctation of the aorta, is highly recommended.
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http://dx.doi.org/10.1055/s-0040-1721000DOI Listing
February 2021

Intraoperative Computed Tomography-Assisted Spinal Navigation in Dorsal Cervical Instrumentation: A Prospective Study on Accuracy Regarding Different Pathologies and Screw Types.

World Neurosurg 2021 May 9;149:e378-e385. Epub 2021 Feb 9.

Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.

Background: Intraoperative computed tomography (iCT) navigated dorsal instrumentation has been successfully introduced as a new clinical standard. The proximity of vital anatomic structures makes cervical spine instrumentation an especially delicate task. Therefore, navigated approaches might prove to be beneficial. In this study, the accuracy of conventional instrumentation was compared with iCT navigated dorsal cervical spine instrumentation with focus on cervical pedicle screws (CPSs) versus lateral mass screws (LMSs) and pathologies.

Methods: We analyzed a prospective consecutive series of patients undergoing cervical dorsal instrumentation with iCT and spinal navigation and retrospectively analyzed a cohort that received conventional cervical instrumentation with C-arm fluoroscopy (control group). Accuracy was assessed with a modified Gertzbein-Robbins classification. Underlying pathologies were taken into account regarding accuracy in different entities.

Results: Fifty-nine patients were treated using iCT (357 screws: 238 CPSs, 119 LMSs), and 98 patients underwent conventional instrumentation (632 screws: 69 CPSs, 563 LMSs). We achieved an initial accuracy of 93.28% (n = 220 screws) in the iCT group and 80.9% (n = 511 screws) in the control group (P < 0.001). Significant differences were found regarding the accuracy of CPS placement in cases of degenerative disorders (iCT vs. control; 94% vs. 63%; P < 0.001) and trauma (iCT vs. control; 88% vs. 72%; P < 0.05). iCT yielded favorable precision rates in regard to LMS placement (iCT vs. control; 94.2% vs. 82%; P < 0.05).

Conclusions: Accuracy of iCT navigated instrumentation was significantly higher than conventional instrumentation. An overall tendency toward the use of CPSs with iCT navigation is evident, increasing the mechanical properties of the construct. iCT appears to be especially beneficial in elective surgery cases of degenerative spinal disorders.
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http://dx.doi.org/10.1016/j.wneu.2021.02.014DOI Listing
May 2021

Circulatory dipeptidyl peptidase 3 (cDPP3) is a potential biomarker for early detection of secondary brain injury after aneurysmal subarachnoid hemorrhage.

J Neurol Sci 2021 Mar 30;422:117333. Epub 2021 Jan 30.

Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany. Electronic address:

Introduction: Delayed cerebral ischemia (DCI) is a common complication after aneurysmal subarachnoid hemorrhage (aSAH) that can culminate in secondary brain damage. Although it remains one of the main preventable causes of aSAH-related morbidity, there is still a lack of prognostic criteria for identification of patients at risk of developing DCI. Because elevated circulatory levels of the enzyme dipeptidyl peptidase 3 (cDPP3) were recently identified as a potential biomarker for outcome prediction in critically ill patients, we evaluated the time-course of changes in cDPP3 levels after aSAH.

Materials And Methods: cDPP3 levels were quantified in serum obtained from 96 confirmed aSAH patients during the early (EP: d), critical (CP: d, d, d) and late (LP: d) phase after aSAH onset. Associations between cDPP3 levels and demographic or clinical parameters were evaluated. The relations between cDPP3 levels and DCI, DCI-related infarctions and long-term clinical outcomes were examined by receiver operating characteristics (ROC) curve analysis and multivariate logistic regression.

Results: Significantly higher cDPP3 levels during CP (d, d, d) were observed in patients with poor clinical (p < 0.001 to p = 0.033) or radiological (p = 0.012 to p = 0.039) status on admission, DCI (p < 0.001 to p = 0.001), DCI-related infarctions (p = 0.002 to p = 0.007), and poorer long-term outcome (p = 0.007 to p = 0.019). ROC curve analysis indicated that higher cDPP3 levels on d are predictive for a poor clinical outcome (area under the curve = 0.677, p = 0.007). In multivariate analysis, there was an independent association between cDPP3 levels on d and development of DCI-related infarctions (p = 0.038).

Conclusion: Our results provide first evidence that cDPP3 could serve as a promising biomarker for early diagnosis of DCI-related infarctions in poor grade aSAH patients.
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http://dx.doi.org/10.1016/j.jns.2021.117333DOI Listing
March 2021

Accuracy of Intraoperative Computed Tomography Assisted Dorsal Instrumentation in Spinal Revision Surgery.

J Neurol Surg A Cent Eur Neurosurg 2021 May 1;82(3):191-196. Epub 2021 Jan 1.

Klinik für Neurochirurgie, Uniklinik RWTH Aachen, Aachen, Germany.

Purpose:  Instrumentation in spinal revision surgery is considered challenging. Altered or missing anatomical landmarks hinder the surgeons' intraoperative orientation. In recent history, the importance of navigated approaches to spinal screw placement is constantly increasing. A growing number of medical centers have introduced intraoperative CT (iCT) navigation as a new clinical standard. In this study, we compare the accuracy of dorsal iCT-navigated instrumentation in revision surgery versus primary interventions.

Methods:  Between September 2017 and January 2019, we prospectively analyzed a consecutive series of dorsal instrumentation using iCT. Patients with previous operative interventions in the relevant spinal segments were included in the revision group and compared with a previously assessed group of primary interventions (nonrevision group). Each screw was assessed individually by an independent observer, making use of a modified Gertzbein and Robbins classification.

Results:  In this period, 39 patients were treated in the revision group with a total amount of 269 implanted screws. We achieved an overall accuracy of 95.91% compared with 95.12% in the nonrevision group (46 patients, 287 screws). We found no significant difference in accuracy between the two groups or any anatomical region of the spine.

Conclusion:  In summary, iCT-navigated screw placement yields a good accuracy in spinal revision surgery, without significant difference to primary interventions.
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http://dx.doi.org/10.1055/s-0040-1721016DOI Listing
May 2021

Risk profile of decompressive hemicraniectomy for malignant stroke after revascularization treatment.

J Neurol Sci 2021 01 16;420:117275. Epub 2020 Dec 16.

Department of Neurosurgery, RWTH Aachen University, Aachen, Germany. Electronic address:

Objective: Revascularization by pharmacological and/or endovascular treatment is an effective therapy for acute ischemic stroke caused by artery occlusion. In the context of malignant middle cerebral artery infarction (MMI), decompressive hemicraniectomy (DHC) can be life-saving. However, its effectiveness and safety after revascularization have not been thoroughly assessed. This retrospective study aimed to determine the risk profile of pre-surgical revascularization treatment (RT) for subsequent DHC.

Methods: A total of 152 consecutive patients treated by DHC after MMI were identified between 2012 and 2015. After elimination of cases with previous stroke and cases pre-treated with antiplatelets or anticoagulants (increased postoperative bleeding), twenty-four out of fifty patients (n = 24/50, 48%) received pre-surgical revascularization treatment by intravenous thrombolysis (TL), mechanical thrombectomy (MT) or a combination of both. Demographic data was compared alongside perioperative, postoperative complications (intra-/extracerebral hemorrhage, revision surgery due to hemorrhage or infection, and overall mortality) and economic parameters.

Results: Comparing patients with and without prior RT, there was no statistically significant difference in duration of surgery (RT: 83 [57-116] min vs. no-RT: 96 [69-119] min, p = 0.308), intraoperative blood loss (RT: 300 [225-375] ml vs. no-RT: 300 [250-400] ml, p = 0.763), intraoperative transfusion requirement (RT: 12.5% vs. no-RT: 26.9%, p = 0.294), or need for volume substitution (RT: 1300 [1200-1400] ml vs. no-RT: 1200 [1100-1400] ml, p = 0.359). The rate of postoperative complications was also comparable in both groups, including intra-/extracerebral hemorrhage, revision due to hemorrhage or infections, and mortality (p = 0.814, p = 0.520, p = 0.697, and p = 0.769). Health economic parameters were not affected (ventilation time: RT: 309 [12-527] hrs. vs. no-RT: 444 [171-605] hrs., p = 0.120, length of stay: RT: 23 [13-32] days vs. no-RT: 28 [19-41], p = 0.156, and stay costs: RT: 27768 [13044-60,248] € vs. no-RT: 35422 [21225-49,585] €, p = 0.312).

Conclusion: DHC for patients with MMI who previously received revascularization therapy appears to be safe and not associated with a higher complication rate or increased health economic burden.
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http://dx.doi.org/10.1016/j.jns.2020.117275DOI Listing
January 2021

Treatment of Delayed Cerebral Ischemia in Good-Grade Subarachnoid Hemorrhage: Any Role for Invasive Neuromonitoring?

Neurocrit Care 2021 Aug 10;35(1):172-183. Epub 2020 Dec 10.

Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.

Background: Good-grade aneurysmal subarachnoid hemorrhage (Hunt and Hess 1-2) is generally associated with a favorable prognosis. Nonetheless, patients may still experience secondary deterioration due to delayed cerebral ischemia (DCI), contributing to poor outcome. In those patients, neurological assessment is challenging and invasive neuromonitoring (INM) may help guide DCI treatment.

Methods: An observational analysis of 135 good-grade SAH patients referred to a single tertiary care center between 2010 and 2018 was performed. In total, 54 good-grade SAH patients with secondary deterioration evading further neurological assessment, were prospectively enrolled for this analysis. The cohort was separated into two groups: before and after introduction of INM in 2014 (pre-INM: n = 28; post-INM: n = 26). INM included either parenchymal oxygen saturation measurement (pO), cerebral microdialysis or both. Episodes of DCI (pO < 10 mmHg or lactate/pyruvate > 40) were treated via induced hypertension or in refractory cases by endovascular means. The primary outcome was defined as the extended Glasgow outcome scale after 12 months. In addition, we recorded the amount of imaging studies performed and the occurrence of silent and overall DCI-related infarction.

Results: Secondary deterioration, impeding neurological assessment, occurred in 54 (40.0%) of all good-grade SAH patients. In those patients, a comparable rate of favorable outcome at 12 months was observed before and after the introduction of INM (pre-INM 14 (50.0%) vs. post-INM 16, (61.6%); p = 0.253). A significant increase in good recovery (pre-INM 6 (50.0%) vs. post-INM 14, (61.6%); p = 0.014) was observed alongside a reduction in the incidence of silent infarctions (pre-INM 8 (28.6%) vs. post-INM 2 (7.7%); p = 0.048) and of overall DCI-related infarction (pre-INM 12 (42.8%) vs. post-INM 4 (23.1%); p = 0.027). The number of CT investigations performed during the DCI time frame decreased from 9.8 ± 5.2 scans in the pre-INM group to 6.1 ± 4.0 (p = 0.003) in the post-INM group.

Conclusions: A considerable number of patients with good-grade SAH experiences secondary deterioration rendering them neurologically not assessable. In our cohort, the introduction of INM to guide DCI treatment in patients with secondary deterioration increased the rate of good recovery after 12 months. Additionally, a significant reduction of CT scans and infarction load was recorded, which may have an underestimated impact on quality of life and more subtle neuropsychological deficits common after SAH.
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http://dx.doi.org/10.1007/s12028-020-01169-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8285339PMC
August 2021

Failed Neuroprotection of Combined Inhibition of L-Type and ASIC1a Calcium Channels with Nimodipine and Amiloride.

Int J Mol Sci 2020 Nov 24;21(23). Epub 2020 Nov 24.

Department of Neurosurgery, Medical Faculty, RWTH Aachen University, 52074 Aachen, Germany.

Effective pharmacological neuroprotection is one of the most desired aims in modern medicine. We postulated that a combination of two clinically used drugs-nimodipine (L-Type voltage-gated calcium channel blocker) and amiloride (acid-sensing ion channel inhibitor)-might act synergistically in an experimental model of ischaemia, targeting the intracellular rise in calcium as a pathway in neuronal cell death. We used organotypic hippocampal slices of mice pups and a well-established regimen of oxygen-glucose deprivation (OGD) to assess a possible neuroprotective effect. Neither nimodipine (at 10 or 20 µM) alone or in combination with amiloride (at 100 µM) showed any amelioration. Dissolved at 2.0 Vol.% dimethyl-sulfoxide (DMSO), the combination of both components even increased cell damage ( = 0.0001), an effect not observed with amiloride alone. We conclude that neither amiloride nor nimodipine do offer neuroprotection in an in vitro ischaemia model. On a technical note, the use of DMSO should be carefully evaluated in neuroprotective experiments, since it possibly alters cell damage.
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http://dx.doi.org/10.3390/ijms21238921DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7727815PMC
November 2020

Risk of postprocedural intracerebral hemorrhage in patients with ruptured cerebral aneurysms after treatment with antiplatelet agents.

J Neurol Sci 2021 01 4;420:117219. Epub 2020 Nov 4.

Department of Neurosurgery, RWTH Aachen University, Germany.

Objective: Endovascular treatment of ruptured cerebral aneurysms frequently requires antiplatelet medication to prevent thromboembolism. This might raise concern regarding the risk of postprocedural hemorrhage (pH), e.g. from placement of intracranial probes. We explored the risk of PH associated with standard antiplatelet therapy (sAP: acetylsalicylic acid, and/or clopidogrel) in the context of aneurysmal subarachnoid hemorrhage (aSAH).

Methods: We retrospectively reviewed a total of 146 consecutive cases with cerebral aneurysms treated between 1/2011-12/2015, and distinguished between minor (0.5 cm) - 4 cm) or major (> 4 cm) PH occurring within four weeks after intervention. A separate analysis included hemorrhages related to placement of intracranial probes and drainages in the subgroup of 99 cases with such surgical interventions (pPH). Clinical outcome was assessed via Glasgow Outcome Scale (GOS) twelve months after aSAH.

Results: A total of 49 cases (33.6%) in the overall sample sustained PH, there were 19 cases of pPH. Multifactorial analyses yielded sAP as an independent predictor for minor, but not major PH (p < 0.001 vs. p = 0.829), with comparable results for pPH (p = 0.001 vs. p = 0.184). sAP did not influence the clinical outcome in either group.

Conclusions: sAP was associated with a higher rate of minor PH and, more specifically, of minor pPH. However, it was neither accompanied by the occurrence of major hemorrhages nor by unfavorable clinical outcome. Future prospective studies should confirm these observations and hemorrhage risks associated with extended anticoagulation regimes after complex interventions and intra-arterial vasospasm therapy should be explored in order to facilitate interdisciplinary decision-making in aSAH.
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http://dx.doi.org/10.1016/j.jns.2020.117219DOI Listing
January 2021

Argon treatment after experimental subarachnoid hemorrhage: evaluation of microglial activation and neuronal survival as a subanalysis of a randomized controlled animal trial.

Med Gas Res 2020 Jul-Sep;10(3):103-109

Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany.

Hereinafter, we evaluate argon's neuroprotective and immunomodulatory properties after experimental subarachnoid hemorrhage (SAH) examining various localizations (hippocampal and cortical regions) with respect to neuronal damage and microglial activation 6, 24 and 72 hours after SAH. One hour after SAH (endovascular perforation rat model) or sham surgery, a mixture of gas containing 50% argon (argon group) or 50% nitrogen (control group) was applied for 1 hour. At 6 hours after SAH, argon reduced neuronal damage in the hippocampal regions in the argon group compared to the control group (P < 0.034). Hippocampal microglial activation did not differ between the treatment groups over time. The basal cortical regions did not show a different lesion pattern, but microglial activation was significantly reduced in the argon group 72 hours after SAH (P = 0.034 vs. control group). Whereas callosal microglial activation was significantly reduced at 24 hours in the argon-treated group (P = 0.018). Argon treatment ameliorated only early hippocampal neuronal damage after SAH. Inhibition of microglial activation was seen in some areas later on. Thus, argon may influence the microglial inflammatory response and neuronal survival after SAH; however, due to low sample sizes the interpretation of our results is limited. The study protocol was approved by the Government Agency for Animal Use and Protection (Protocol number: TVA 10416G1; initially approved by the "Landesamt für Natur, Umwelt und Verbraucherschutz NRW," Recklinghausen, Germany, on April 28, 2009).
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http://dx.doi.org/10.4103/2045-9912.296039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086619PMC
July 2021

Quality of life in elderly patients after surgery for drug-resistant epilepsy - The impact of seizure outcome, neurological deficits and anxiety.

Epilepsy Behav 2020 11 18;112:107410. Epub 2020 Sep 18.

Department of Neurosurgery, Ruppiner Kliniken, Brandenburg Medical School, Neuruppin, Germany; Medical Faculty, University of Bonn Medical Center, Bonn, Germany.

Introduction: Health related quality of life (HRQoL) has become a pivotal outcome parameter after surgery for drug-resistant epilepsy. The aim of the study was to investigate HRQoL and its relationship to seizure outcome, neurological deficits and anxiety after epilepsy surgery in a specific subpopulation of elderly patients.

Methods: A total of 85 elderly patients (older than 50 years) answered a standardized HRQoL questionnaire one year after epilepsy surgery. The questionnaire addressed the present self-assessed HRQoL in four subdomains (physical function, cognitive function, mood, social interaction). The questionnaire was based on the "Epilepsy Surgery Inventory-55", adapted for use in German speaking patients and validated by the QOLIE -10 and Beck Depression Inventory.

Results: A total of 51 patients (60%) were completely seizure free (ILAE1) at last available outcome (LAO). Permanent neurological deficits were observed in 8 patients (7%). Correlation analysis confirmed significant association between seizure outcome and overall HRQoL (r = -0.368, p < .001). New permanent neurological deficits showed impact on both HRQoL and the "cognitive function" subdomain. Anxiety and subjective assessment of postoperative status were strongly correlated with overall HRQoL (r = 0.692, p < .001 and r = 0.591, p < .001 respectively) and remained as independent prognostic factors in a multivariate regression analysis.

Conclusion: Surgery for drug-resistant epilepsy in elderly improves patients' HRQoL. Both seizure freedom and new neurological deficits influence overall HRQoL. Interestingly, anxiety and patients' subjective assessment of postoperative status showed the highest impact on HRQoL in this subpopulation of epilepsy patients.
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http://dx.doi.org/10.1016/j.yebeh.2020.107410DOI Listing
November 2020

Current Practice of Neurosurgical Teleconsultation in Germany.

J Neurol Surg A Cent Eur Neurosurg 2020 Nov 10;81(6):521-528. Epub 2020 Sep 10.

Department of Neurosurgery, Medical Center University of Aachen, RWTH University, Aachen, Germany.

Objective:  As neurosurgery is a demanding specialty with services in larger medical centers only, consultation over larger distances plays an important role in health care. In times of digitalization, teleconsultation for medical images and cases plays an increasing role in neurosurgical services. However, no standards and demands have been established for its execution in the subfield of neurosurgery, so far. Therefore, as a first step, we performed a survey about the current state of teleconsultation in neurosurgery in Germany.

Methods:  A standardized questionnaire consisting of 20 items was used to investigate the frequency of use and the operating conditions of teleconsultation in the field of neurosurgery. The survey was performed during the annual national German Society of Neurosurgery conference in 2017. Participation in the written survey was on voluntary and anonymous basis.

Results:  In total, 296 individuals took part in the survey (140 specialists in neurosurgery, 77 residents). Among them, 71% were male and 121 worked at a university medical center. In total, 87.5% of all participants indicated that teleconsultation was used in their institutions ( = 113 in university medical centers and  = 76 in hospitals), and a vast majority stated to have had personal experience with it (88.6% of specialists, 85.5% of residents). The most frequent initial request for a consultation was done by phone call (80.3%). Images or data were then primarily transmitted via an electronic system (77.3%), followed by transmissions via CD or by post. The reply to a consultation was also mainly done by phone call (91.3%), followed by fax, or by e-mail. No standard protocol was followed by 78.6% of the respondents, and they stated not to know about the statutory and legal rules. However, it was stated that the protection of patient data was not endangered by using teleconsultation. The usefulness of teleconsultation and its future relevance were rated highly by the participants. The risk of misinterpretation of image data, especially without having direct access to other patient data, seemed to be a critical and unequivocal challenge.

Conclusion:  The results of the survey demonstrate that teleconsultation for medical images and cases is a frequently used and well-accepted tool in neurosurgical health care. However, a standardized neurosurgical procedure is still lacking and the statutory rules for this field of digital medicine are generally not known in our community. Potential misinterpretation and resulting misjudgment seem to be realistic drawbacks. Thus, we see a necessity for elaboration of guidelines for teleconsultation in neurosurgery on national and European basis.
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http://dx.doi.org/10.1055/s-0040-1710505DOI Listing
November 2020

Procalcitonin in the context of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

J Neurosurg 2020 Sep 4:1-9. Epub 2020 Sep 4.

Departments of1Neurosurgery and.

Objective: Aneurysmal subarachnoid hemorrhage (aSAH) initiates a deleterious cascade activating multiple inflammatory processes, which can contribute to delayed cerebral ischemia (DCI). Procalcitonin (PCT) is an established marker for sepsis treatment monitoring, and its time course in the context of DCI after aSAH remains unclear. The aim of this trial was to assess the predictive and confirmative value of PCT levels in the context of DCI.

Methods: All patients admitted to the authors' institution with aSAH between 2014 and 2018 were prospectively screened for eligibility. Daily PCT levels were recorded alongside relevant aSAH characteristics. The predictive and confirmative values of PCT levels were assessed using a receiver operating characteristic and area under the curve (AUC) analysis. The course of PCT levels around the DCI event was evaluated in an infection-free subgroup of patients.

Results: A total of 132 patients with aSAH were included. Early PCT levels (first 3 days post-aSAH) had a low predictive value for the development of DCI (AUC 0.661, standard error [SE] 0.050; p = 0.003) and unfavorable long-term outcome (i.e., Glasgow Outcome Scale-Extended scores 1-4; AUC 0.674, SE 0.054; p = 0.003). In a subgroup analysis of infection-free patients (n = 72), PCT levels were higher in patients developing DCI (p = 0.001) and DCI-related cerebral infarction (p = 0.002). PCT concentrations increased gradually after DCI and decreased with successful intervention. In refractory cases progressing to cerebral infarction, PCT levels showed a secondary increase.

Conclusions: Early higher PCT levels were associated with the later development of DCI and unfavorable outcome. Analysis of PCT beyond the first couple of days after hemorrhage is hampered by nosocomial infections. In infection-free patients, however, PCT levels rise during DCI and an additional increase develops in patients developing cerebral infarction.Clinical trial registration no.: NCT02142166 (clinicaltrials.gov).
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http://dx.doi.org/10.3171/2020.5.JNS201337DOI Listing
September 2020

Asymmetric tumor-related alterations of network-specific intrinsic functional connectivity in glioma patients.

Hum Brain Mapp 2020 11 27;41(16):4549-4561. Epub 2020 Jul 27.

Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.

Resting-state functional MRI (rs-fMRI) allows mapping temporally coherent brain networks, and intra- and inter-network alterations have been described in different diseases. This prospective study investigated hemispheric resting-state functional connectivity (RSFC) differences in the default-mode network (DMN) and fronto-parietal network (FPN) between patients with left- and right-hemispheric gliomas (LH PAT, RH PAT), addressing asymmetry effects the tumor might have on network-specific intrinsic functional connectivity under consideration of the prognostically relevant isocitrate-dehydrogenase (IDH) mutation status. Twenty-seven patients (16 LH PAT, 12 IDH-wildtype) and 27 healthy controls underwent anatomical and rs-fMRI as well as neuropsychological assessment. Independent component analyses were performed to identify the DMN and FPN. Hemispheric DMN- and FPN-RSFC were computed, compared across groups, and correlated with cognitive performance. Patient groups did not differ in tumor volume, grade or location. RH PAT showed higher contra-tumoral DMN-RSFC than controls and LH PAT. With regard to the FPN, contra-tumoral RSFC was increased in both patient groups as compared to controls. Higher contra-tumoral RSFC was associated with worse cognitive performance in patients, which, however, seemed to apply mainly to IDH-wildtype patients. The benefit of RSFC alterations for cognitive performance varied depending on the affected hemisphere, cognitive demand, and seemed to be altered by IDH-mutation status. At the time of study initiation, a clinical trial registration was not mandatory at our faculty, but it can be applied for if requested.
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http://dx.doi.org/10.1002/hbm.25140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7555062PMC
November 2020

Surgery for temporal lobe epilepsy in the elderly: Improving quality of life despite cognitive impairment.

Seizure 2020 Jul 11;79:112-119. Epub 2020 May 11.

Department of Neurosurgery, Ruppiner Kliniken, Brandenburg Medical School, Neuruppin, Germany; Medical Faculty, University of Bonn Medical Center, Bonn, Germany.

Introduction: Temporal lobe epilepsy (TLE) surgery is still underutilized, especially in the elderly population because of concerns related to postoperative complication rate and cognitive deterioration. The aim of the study was to evaluate surgical data, quality of life and neuropsychological outcome in elderly patients, who underwent resective surgery for drug resistant TLE.

Methods And Materials: All patients underwent standardized presurgical assessment including clinical, neuroradiological, neuropsychological, and EEG examination. Elderly were considered all patients being 50 years or above (mean 56 yr., range 50-71 yr.). Neuropsychology was assessed before and after surgery, health-related quality of life (HRQOL) only after surgery.

Results: A total of 94 consecutive elderly patients were analyzed. Temporo-mesial resections were performed in 85 patients (90 %). Seizure outcome was available in all patients with a mean follow-up of 5.2 years (1.2-19 ± 3.75 years). 57 patients (60.6 %) were completely seizure free (ILAE 1). The overall morbidity was 10 % including 5 surgical complications and 5 permanent neurological deficits. Neuropsychological assessments in 60 patients showed considerable preoperative impairment, losses in different domains in 25-45 % and gains in about 25 % of the patients. Postoperative HRQOL data was available in 75 patients, revealing significant increase of HRQOL in all domains. Complete seizure freedom was the strongest predictor for postoperative HRQOL (p < 0.001).

Conclusion: Surgery for drug resistant temporal lobe epilepsy is a feasible option for elderly patients as seizure control rates are comparable to the younger population. The acceptable rate of permanent neurological deficits and relevant improvements in quality of life, despite considerable postoperative cognitive impairment, justify surgical resection in properly selected elderly patients.
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http://dx.doi.org/10.1016/j.seizure.2020.05.003DOI Listing
July 2020

Invasive neuromonitoring with an extended definition of delayed cerebral ischemia is associated with improved outcome after poor-grade subarachnoid hemorrhage.

J Neurosurg 2020 May 15;134(5):1527-1534. Epub 2020 May 15.

Departments of1Neurosurgery.

Objective: The current definition of delayed cerebral ischemia (DCI) is based on clinical characteristics precluding its use in patients with poor-grade subarachnoid hemorrhage (SAH). Additional concepts to evaluate the unconscious patient are required. Invasive neuromonitoring (INM) may allow timely detection of metabolic and oxygenation crises before irreversible damage has occurred.

Methods: The authors present a cohort analysis of all consecutive SAH patients referred to a single tertiary care center between 2010 and 2018. The cohort (n = 190) was split into two groups: one before (n = 96) and one after (n = 94) the introduction of INM in 2014. A total of 55 poor-grade SAH patients were prospectively monitored using parenchymal oxygen saturation measurement and cerebral microdialysis. The primary outcome was the Glasgow Outcome Scale-Extended (GOSE) score after 12 months.

Results: With neuromonitoring, the first DCI event was detected earlier (mean 2.2 days, p = 0.002). The overall rate of DCI-related infarctions decreased significantly (from 44.8% to 22.3%; p = 0.001) after the introduction of invasive monitoring. After 12 months, a higher rate of favorable outcome was observed in the post-INM group, compared to the pre-INM group (53.8% vs 39.8%), with a significant difference in the GOSE score distribution (OR 4.86, 95% CI -1.17 to -0.07, p = 0.028).

Conclusions: In this cohort analysis of poor-grade SAH patients, the introduction of INM and the extension of the classic DCI definition toward a functional dimension resulted in an earlier detection and treatment of DCI events. This led to an overall decrease in DCI-related infarctions and an improvement in outcome.
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http://dx.doi.org/10.3171/2020.3.JNS20375DOI Listing
May 2020

An altered posterior question-mark incision is associated with a reduced infection rate of cranioplasty after decompressive hemicraniectomy.

J Neurosurg 2020 Apr 24;134(3):1262-1270. Epub 2020 Apr 24.

1Department of Neurosurgery, RWTH Aachen University Hospital, Aachen; and.

Objective: Performing a cranioplasty (CP) after decompressive craniotomy is a straightforward neurosurgical procedure, but it remains associated with a high complication rate. Surgical site infection (SSI), aseptic bone resorption (aBR), and need for a secondary CP are the most common complications. This observational study aimed to identify modifiable risk factors to prevent CP failure.

Methods: A retrospective analysis was performed of all patients who underwent CP following decompressive hemicraniectomy (DHC) between 2010 and 2018 at a single institution. Predictors of SSI, aBR, and need for allograft CP were evaluated in a univariate analysis and multivariate logistic regression model.

Results: One hundred eighty-six patients treated with CP after DHC were included. The diagnoses leading to a DHC were as follows: stroke (83 patients, 44.6%), traumatic brain injury (55 patients, 29.6%), subarachnoid hemorrhage (33 patients, 17.7%), and intracerebral hemorrhage (15 patients, 8.1%). Post-CP SSI occurred in 25 patients (13.4%), whereas aBR occurred in 32 cases (17.2%). An altered posterior question-mark incision, ending behind the ear, was associated with a significantly lower infection rate and CP failure, compared to the classic question-mark incision (6.3% vs 18.4%; p = 0.021). The only significant predictor of aBR was patient age, in which those developing resorption were on average 16 years younger than those without aBR (p < 0.001).

Conclusions: The primary goal of this retrospective cohort analysis was to identify adjustable risk factors to prevent post-CP complications. In this analysis, a posterior question-mark incision proved beneficial regarding infection and CP failure. The authors believe that these findings are caused by the better vascularized skin flap due to preservation of the superficial temporal artery and partial preservation of the occipital artery. In this trial, the posterior question-mark incision was identified as an easily and costless adaptable technique to reduce CP failure rates.
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http://dx.doi.org/10.3171/2020.2.JNS193335DOI Listing
April 2020

Hemispheric Dominance for Language and Side Effects in Mapping the Inferior Frontal Junction Area with Transcranial Magnetic Stimulation.

J Neurol Surg A Cent Eur Neurosurg 2020 Mar 11;81(2):130-137. Epub 2020 Feb 11.

Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany.

Background And Study Aims:  Language mapping by navigated transcranial magnetic stimulation (TMS) is commonly applied over the left language-dominant hemisphere to indicate the language-related cortex. Detailed language mapping of Broca's region including stimulation targets in the immediate vicinity to the premotor cortex may raise concern about confounding unspecific motor effects. We performed interhemispheric comparisons to delineate such possible unspecific effects from true TMS-induced language inhibition.

Material And Methods:  Fifteen healthy German speakers named object pictures during navigated TMS over a left- and right-hemispheric target array covering the left inferior frontal junction area. Six mapping repetitions were conducted per hemisphere. Order of stimulation side was randomized between participants. Self-rating of discomfort was assessed after each stimulation; language errors and motor side effects were evaluated offline.

Results:  Naming errors were observed significantly more frequently during left- than right-hemispheric stimulation. The same pattern was found for the most frequent error category of performance errors. Hierarchical cluster analyses of normalized ratings of error severity revealed a clear focus of TMS susceptibility for language inhibition in object naming at the dorsoposterior target sites only in the left hemisphere. We found no statistical difference in discomfort ratings between both hemispheres and also no interhemispheric difference in motor side effects, but we observed significantly stronger muscle contractions of the eyes as compared with the mouth.

Conclusion:  Our results of (1) unspecific pre-/motor effects similarly induced in both hemispheres, and (2) a specific focus of TMS susceptibility in the language-dominant hemisphere render any substantial contribution of nonlanguage-specific effects in TMS language mapping of the inferior frontal junction area highly unlikely.
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http://dx.doi.org/10.1055/s-0040-1701236DOI Listing
March 2020

Patients with degenerative cervical myelopathy have signs of blood spinal cord barrier disruption, and its magnitude correlates with myelopathy severity: a prospective comparative cohort study.

Eur Spine J 2020 05 25;29(5):986-993. Epub 2020 Jan 25.

Department of Neurosurgery, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.

Purpose: The aim of this study is to detect the presence of blood spinal cord barrier (BSCB) disruption in patients with degenerative cervical myelopathy (DCM).

Methods: In this prospective non-randomized controlled cohort study, 28 patients with DCM were prospectively included. All patients had indication for neurosurgical decompression. Furthermore, 38 controls with thoracic abdominal aortic aneurysm (TAAA) and indication for surgery were included. All patients underwent neurological examination. Regarding BSCB disruption and intrathecal immunoglobulin (Ig) concentrations, cerebrospinal fluid (CSF) and blood serum were examined for albumin, IgG, IgA and IgM. Quotients (Q) (CSF/serum) were standardized and calculated according to Reibers' diagnostic criteria.

Results: Patients and controls distinguished significantly in their clinical status. AlbuminQ, as expression of BSCB disruption, was significantly increased in the DCM patients compared to the controls. Quotients of IgG and IgA differed significantly between the groups as an expression of intrathecal diffusion. In the subgroup analysis of patients with mild/moderate clinical status of myelopathy and patients with severe clinical status, the disruption of the BSCB was significantly increased with clinical severity. Likewise, IgAQ and IgGQ presented increased quotients related to the clinical severity of myelopathy.

Conclusion: In this study, we detected an increased permeability and disruption of the BSCB in DCM patients. The severity of BSCB disruption and the diffusion of Ig are related to the clinical status in our patient cohort. Having documented this particular pathomechanism in patients with DCM, we suggest that this diagnostic tool cloud be an important addition to surgical decision making in the future. These slides can be retrieved under Electronic Supplementary Material.
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http://dx.doi.org/10.1007/s00586-020-06298-7DOI Listing
May 2020
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