Publications by authors named "Markus Bruder"

29 Publications

  • Page 1 of 1

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

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

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

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

Functional outcome and morbidity after microsurgical resection of spinal meningiomas.

Neurosurg Focus 2021 05;50(5):E20

Departments of1Neurosurgery and.

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

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

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

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

Short- and midterm outcome of ruptured and unruptured intracerebral wide-necked aneurysms with microsurgical treatment.

Sci Rep 2021 Mar 2;11(1):4982. Epub 2021 Mar 2.

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

To clip or coil has been matter of debates for several years and is the domain of interdisciplinary decision making. However, the microsurgical outcome has still been elusive concerning wide neck aneurysms (WNA). A retrospective single center study was performed with all patients with ruptured WNA (rWNA) and unruptured WNA (uWNA) admitted to author´s institute between 2007-2017. Microsurgical outcome was evaluated according to Raymond-Roy occlusion grade and follow-up angiography was performed to analyze the stability of neck/aneurysm remnants and retreatment poverty. Of 805 aneurysms, 139 were rWNA (17.3%) and 148 uWNA (18.4%). Complete occlusion was achieved in 102 of 139 rWNA (73.4%) and 112 of 148 uWNA (75.6%). Neck remnants were observed in 36 patients with rWNA (25.9%) and 30 patients with uWNA (20.3%), 1 (0.7%) and 6 (4.1%) patients had aneurysmal remnant, respectively. Overall complication rate was 11.5%. At follow-up (939/1504 months), all remnants were stable except for one, which was further conservatively treated with marginal retreatment rate under 1%. Even the risk of de-novo aneurysm was higher than the risk for remnant growth (2.6% vs 0% in rWNA; 8.7% vs 5.3% in uWNA) without significant difference. Microsurgical clipping is effective for complete occlusion of r/uWNA with low complication. Furthermore, the risk of remnant growth is marginal even lower than the risk of de-novo rate low retreatment rate.
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http://dx.doi.org/10.1038/s41598-021-84339-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7925666PMC
March 2021

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A benchmark approach to hemorrhage risk management of cavernous malformations.

Neurology 2018 03 2;90(10):e856-e863. Epub 2018 Feb 2.

From the Department of Neurosurgery (S.K., M.B., N.B., V.S., J.K.), and Institute of Neuroradiology (S.T.), University Hospital Frankfurt; and Institute of Biostatistics and Mathematical Modelling (E.H.), Goethe University Frankfurt, Germany.

Objective: Despite the low annual risk of hemorrhage associated with a cavernous malformation (CM) (0.6%-1.1% per year), the risk of rehemorrhage rate and severity of neurologic deficits is significantly higher; therefore, we aimed to evaluate the rupture risk of CMs depending on various factors.

Methods: We retrospectively analyzed medical records of all patients with CM admitted to our institution between 1999 and April 2016. Cavernoma volume, location of the lesion, existence of a developmental venous anomaly (DVA), number of cavernomas, and patient characteristics (sex, age, hypertension, and antithrombotic therapy) were assessed.

Results: One hundred fifty-four patients with CM were included; 89 (58%) ruptured CMs were identified. In statistical univariable analysis, the existence of a DVA was significantly higher in the ruptured cavernoma group ( < 0.001; odds ratio [OR] 4.6). A multivariable analysis of all included independent risk factors designated young age (<45 years) ( < 0.05; OR 2.2), infratentorial location ( < 0.01; OR 2.9), and existence of a DVA ( < 0.0001; OR 4.7) with significantly higher risk of rupture in our patient cohort. A separate analysis of these anatomical locations, supratentorial vs infratentorial, indicated that the existence of a DVA ( < 0.01; OR 4.16) in ruptured supratentorial cases and CM volume (≥1 cm) ( < 0.0001; OR 3.5) in ruptured infratentorial cases were significant independent predictors for hemorrhage.

Conclusions: Young age (<45 years), infratentorial location, and the presence of a DVA are associated with a higher hemorrhage risk. CM volume (≥1 cm) and the existence of a DVA were independently in accordance with the anatomical location high risk factors for CM rupture.
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http://dx.doi.org/10.1212/WNL.0000000000005066DOI Listing
March 2018

Continuous Acetylsalicylic Acid Treatment Does Not Influence Bleeding Pattern or Outcome of Aneurysmal Subarachnoid Hemorrhage: A Matched-Pair Analysis.

World Neurosurg 2018 May 3;113:e122-e128. Epub 2018 Feb 3.

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

Objective: Demographic changes are leading to an aging society with a growing number of patients with cardiovascular diseases, relying on antiplatelet drugs like acetylsalicylic acid (ASA). Although antiplatelet agents are suspected to be protective not only in the cardiologic but in the neurovascular field, the alteration of the coagulating process could have a major impact on the course and outcome after rupture of intracranial aneurysms.

Methods: Between June 1999 and December 2014, 1422 patients were treated for aneurysmal SAH in our institution, 144 (10.1%) with continuous ASA at the time of aneurysm rupture. A matched-pair analysis was performed.

Results: The rate of patients with continuous ASA treatment while rupture of the aneurysm is rising significantly (P < 0.01). Those patients were significantly older than patients without ASA (60 vs. 53 years, P < 0.001). ASA-treated patients more often had aneurysmal rebleeding (4.7% vs. 2.3%, P = 0.3) and treatment-related hemorrhagic complications (13.9% vs. 6.2%, P = 0.06). However, rates were not different in microsurgical or endovascular procedures (16.4% vs. 12.2%, P = 0.6). Favorable outcome (Modified Rankin Scale 0-2) was achieved in 49.3% of the ASA group and 52.1% of the control group (P = 0.7).

Conclusion: Patients with continuous ASA treatment were significantly older than patients without ASA, but there was no difference in admission status or bleeding pattern. Outcome was not different in the matched-pair analysis. There was no statistical difference in treatment related-complication rates of microsurgical and endovascular procedures. Therefore, ASA use should not influence treatment decision of the ruptured aneurysm.
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http://dx.doi.org/10.1016/j.wneu.2018.01.188DOI Listing
May 2018

Surgical Treatment of Spinal Synovial Cysts in Elderly Patients: Symptoms, Treatment Course, and Outcome in Patients >75 Years of Age.

World Neurosurg 2018 Feb 16;110:e520-e525. Epub 2017 Nov 16.

Department of Neurosurgery, Goethe University, Frankfurt, Germany.

Background: With the aging of our society comes a rising number of elderly patients with progressive degeneration of the spine associated with synovial cysts. Surgical treatment may be particularly challenging in elderly patients because of comorbidities.

Methods: Patients treated in our department between 1999 and 2014 for spinal synovial cysts were screened. The 28 patients ≥75 years old were classified as elderly and were compared with 96 patients 50-74 years old. No patient underwent fusion as part of cyst resection.

Results: Despite a significantly higher frequency of muscle reflex changes in elderly patients at presentation, symptoms, cyst levels, rate of complications, and surgical method were not different between groups. Cyst adherence to the dura and subtotal resection were observed significantly more often in the elderly group (18% vs. 3%; P < 0.05). Outcome according to the Oswestry Disability Index was classified as no disability or minimal disability in 85% of the elderly group and in 82% of the control group. Recurrent cyst and delayed fusion rates were lower in the elderly group (4% and 4%) compared with the control group (7% and 8%).

Conclusions: The clinical course of elderly patients with surgical treatment of spinal synovial cysts did not differ compared with younger patients. Good or excellent results could be achieved and persisted for a long time in most cases. Fusion should be performed only in cases of severe instability. Nonaggressive cyst removal in cases of dural attachment enables low cerebrospinal fluid fistula rates without increasing cyst recurrence rates.
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http://dx.doi.org/10.1016/j.wneu.2017.11.031DOI Listing
February 2018

Acute subdural hematoma in patients on oral anticoagulant therapy: management and outcome.

Neurosurg Focus 2017 Nov;43(5):E12

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

OBJECTIVE Isolated acute subdural hematoma (aSDH) is increasing in older populations and so is the use of oral anticoagulant therapy (OAT). The dramatic increase of OAT-with direct oral anticoagulants (DOACs) as well as with conventional anticoagulants-is leading to changes in the care of patients who present with aSDH while receiving OAT. The purpose of this study was to determine the management and outcome of patients being treated with OAT at the time of aSDH presentation. METHODS In this single-center, retrospective study, the authors analyzed 116 consecutive cases involving patients with aSDH treated from January 2007 to June 2016. The following parameters were assessed: patient characteristics, admission status, anticoagulation status, perioperative management, comorbidities, clinical course, and outcome as determined at discharge and through 6 months of follow-up. Oral anticoagulants were classified as thrombocyte inhibitors, vitamin K antagonists, and DOACs. Patients were stratified based on which type of medication they were taking, and subgroup analyses were performed. Predictors of unfavorable outcome at discharge and follow-up were identified. RESULTS Of 116 patients, 74 (64%) had been following an OAT regimen at presentation with aSDH. The patients who were taking oral anticoagulants (OAT group) were significantly older (OR 12.5), more often comatose 24 hours postoperatively (OR 2.4), and more often had ≥ 4 comorbidities (OR 3.2) than patients who were not taking oral anticoagulants (no-OAT group). Accordingly, the rate of unfavorable outcome was significantly higher in patients in the OAT group, both at discharge (OR 2.3) and at follow-up (OR 2.2). Of the patients in the OAT group, 37.8% were taking a thrombocyte inhibitor, 54.1% a vitamin K antagonist, and 8.1% DOACs. In all cases, OAT was stopped on discovery of aSDH. For reversal of anticoagulation, patients who were taking a thrombocyte inhibitor received desmopressin 0.4 μg/kg, 1-2 g tranexamic acid, and preoperative transfusion with 2 units of platelets. Patients following other oral anticoagulant regimens received 50 IU/kg of prothrombin complex concentrates and 10 mg of vitamin K. There was no significant difference in the rebleeding rate between the OAT and no-OAT groups. The in-hospital mortality rate was significantly higher for patients who were taking a thrombocyte inhibitor (OR 3.3), whereas patients who were taking a vitamin K antagonist had a significantly higher 6-month mortality rate (OR 2.7). Patients taking DOACs showed a tendency toward unfavorable outcome, with higher mortality rates than patients on conventional OAT or patients in the vitamin K antagonist subgroup. Independent predictors for unfavorable outcome at discharge were comatose status 24 hours after surgery (OR 93.2), rebleeding (OR 9.8), respiratory disease (OR 4.1), and infection (OR 11.1) (Nagelkerke R = 0.684). Independent predictors for unfavorable outcome at follow-up were comatose status 24 hours after surgery (OR 12.7), rebleeding (OR 3.1), age ≥ 70 years (OR 3.1), and 6 or more comorbidities (OR 3.1, Nagelkerke R = 0.466). OAT itself was not an independent predictor for worse outcome. CONCLUSIONS An OAT regimen at the time of presentation with aSDH is associated with increased mortality rates and unfavorable outcome at discharge and follow-up. Thrombocyte inhibitor treatment was associated with increased short-term mortality, whereas vitamin K antagonist treatment was associated with increased long-term mortality. In particular, patients on DOACs were seriously affected, showing more unfavorable outcomes at discharge as well as at follow-up. The suggested medical treatment for aSDH in both OAT and no-OAT patients seems to be effective and reasonable, with comparable rebleeding and favorable outcome rates in the 2 groups. In addition, prior OAT is not a predictor for aSDH outcome.
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http://dx.doi.org/10.3171/2017.8.FOCUS17421DOI Listing
November 2017

Cerebral Vasospasm-Dependent and Cerebral Vasospasm-Independent Cerebral Infarctions Predict Outcome After Nonaneurysmal Subarachnoid Hemorrhage: A Single-Center Series with 250 Patients.

World Neurosurg 2017 Oct 12;106:861-869.e4. Epub 2017 Jul 12.

Institute of Neuroradiology, Goethe-University Hospital, Frankfurt am Main, Germany.

Objective: The number of patients with nonaneurysmal subarachnoid hemorrhage (naSAH) has increased during the last decade. Data regarding infarctions in naSAH are still limited. The aim of this study was to identify the rate of cerebral vasospasm (CVS)-dependent and CVS-independent infarctions and their influence on clinical outcomes.

Methods: Between 1999 and 2015, 250 patients suffering from naSAH were analyzed retrospectively. A delayed infarction was analyzed whether it was associated with CVS (CVS-dependent infarction) or not (CVS-independent).

Results: A total of 36 patients (14%) had cerebral infarctions. CVS was detected in 54 patients (22%), and 15 (6%) of them developed infarctions (CVS-dependent). Infarctions without signs of CVS (CVS-independent) occurred in 21 patients (8%). Overall, 86% of the patients had favorable outcome. Patients without cerebral infarctions had the best outcome (91% favorable outcome, 5% mortality rate). Patients with CVS-independent infarctions (57%) as well as patients with CVS-dependent infarctions (53%) had a favorable outcome less often. The mortality rate was also significantly greater in patients with CVS-independent (19%) and CVS-dependent infarctions (33%). A further independent predictor was anticoagulative therapy, which increased during study period and was associated with nonperimesencephalic blood distribution.

Conclusions: CVS-dependent and independent infarctions occur in naSAH and contribute to unfavorable outcomes. Whereas CVS-independent infarctions occur in any subgroup, CVS-dependent infarctions seem to be associated with blood pattern (Fisher 3). Anticoagulative therapy seems to be not only a predictor for worse outcome but also for nonperimesencephalic SAH. Accordingly, the proportion of perimesencephalic and nonperimesencephalic SAH changed during the study period (from 2.2:1 to 1:1.7).
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http://dx.doi.org/10.1016/j.wneu.2017.07.017DOI Listing
October 2017

Synovial cysts of the spine: long-term follow-up after surgical treatment of 141 cases in a single-center series and comprehensive literature review of 2900 degenerative spinal cysts.

J Neurosurg Spine 2017 Sep 7;27(3):256-267. Epub 2017 Jul 7.

Department of Neurosurgery, Goethe University, Frankfurt, Germany.

OBJECTIVE Synovial cysts of the spine are rare lesions, predominantly arising in the lumbar region. Despite their generally benign behavior, they can cause severe symptoms due to compression of neural structures in the spinal canal. Treatment strategies are still a matter of discussion. The authors performed a single-center survey and literature search focusing on long-term results after minimally invasive surgery. METHODS A total of 141 consecutive patients treated for synovial cysts of the lumbar spine between 1997 and 2014 in the authors' department were analyzed. Medical reports with regard to signs and symptoms, operative findings, complications, and short-term outcome were reviewed. Assessment of long-term outcome was performed with a standardized telephone questionnaire based on the Oswestry Disability Index (ODI). Furthermore, patients were questioned about persisting pain, symptoms, and further operative procedures, if any. Subjective satisfaction was classified as excellent, good, fair, or poor based on the Macnab classification. RESULTS The approach most often used for synovial cyst treatment was partial hemilaminectomy in 70%; hemilaminectomy was necessary in 27%. At short-term follow-up, the presence of severe and moderate leg pain had decreased from 93% to 5%. The presence of low-back pain decreased from 90% to 5%. Rates of motor and sensory deficits were reduced from 40% to 14% and from 45% to 6%, respectively. The follow-up rate was 58%, and the mean follow-up period was 9.3 years. Both leg pain and low-back pain were still absent in 78%. Outcome based on the Macnab classification was excellent in 80%, good in 14%, fair in 1%, and poor in 5%. According to the ODI, 78% of patients had no or only minimal disability, 16% had moderate disability, and 6% had severe disability at the time of follow-up. In this cohort, 7% needed surgery due to cyst recurrence, and 9% required a delayed stabilization procedure after the initial operation. CONCLUSIONS Surgical treatment with resection of the cyst provides favorable results in outcome. Excellent or good outcome persisting for a long-term follow-up period can be achieved in the vast majority of cases. Complication rates are low despite an increased risk of dural injury. With facet-sparing techniques, the stability of the segment can be preserved, and resection of spinal synovial cysts does not necessarily require segmental fusion.
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http://dx.doi.org/10.3171/2016.12.SPINE16756DOI Listing
September 2017

Outcome After Subarachnoid Hemorrhage from Blood Blister-Like Aneurysm Rupture Depends on Age and Aneurysm Morphology.

World Neurosurg 2017 Sep 27;105:944-951.e1. Epub 2017 Jun 27.

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

Background: Blood blister-like aneurysms (BBLA) are rare, challenging to treat, and prone to rerupture. We analyzed our results in relationship to type of BBLA and other prognostic factors.

Methods: Data on patient and aneurysm characteristics, clinical course, and treatment results, including data from patient records and review of imaging findings, were collected prospectively and analyzed retrospectively.

Results: There were 27 patients (mean age 56 years) with subarachnoid hemorrhage from BBLA. Of patients, 13 (48%) had BBLA of the internal carotid artery, 6 had BBLA of the anterior cerebral artery (22%), 5 had BBLA of the middle cerebral artery (19%), and 3 had BBLA of the basilar artery (11%). Most patients (n = 12) had a circumferential type IV BBLA (44%). BBLAs were treated by clip-reinforced wrapping in 13 patients (48%) and by clipping alone in 8 patients (30%); 3 (11%) patients received no treatment. The 3 remaining patients were treated endovascularly, by combined treatment, or by fenestration tube technique. Rerupture after treatment occurred in 4 patients (15%), all of whom had type IV BBLAs. Outcome was unfavorable (modified Rankin scale score 3-6) in 52% (n = 14). The highest rates of rerupture (33%), delayed infarctions (67%), unfavorable outcome (75%), and death (50%) were identified in type IV BBLAs; type I-III BBLAs had a better course.

Conclusions: Treatment of BBLA is challenging. Patients with type IV BBLAs were especially prone to rerupture, delayed infarctions, unfavorable outcomes, and death. Independent risk factors for unfavorable outcome were advanced age (≥60 years) and type IV BBLA.
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http://dx.doi.org/10.1016/j.wneu.2017.06.129DOI Listing
September 2017

Subarachnoid Hemorrhage in Advanced Age: Comparison of Patients Aged 70-79 Years and 80 Years and Older.

World Neurosurg 2017 Oct 17;106:139-144. Epub 2017 Jun 17.

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

Background: Clinical routine shows an increasing admission rate of elderly patients suffering from subarachnoid hemorrhage (SAH).

Objective: Aim of the study was to identify differences in outcome and prognostic factors to better anticipate clinical course and therefore treat this special subgroup better.

Methods: We retrospectively compared patients aged 70-79 and older than 80 years (80+). Patients were entered into a prospectively collected database. Between 1999 and June 2014, 191 patients aged ≥70 years suffered from SAH. We stratified between patients aged from 70 to 79 years (n = 138) and 80+ years (n = 53). Outcome was assessed by modified Rankin Scale 6 months after SAH.

Results: During the observation period, the rate of elderly patients increased from 9% to 24%. Patients aged 80+ years less often showed significant early hydrocephalus, cerebral vasospasm, and shunt dependence. A total of 51% of all patients were treated by coiling, whereupon also treatment modality had no influence on outcome. By comparing clinical outcomes, no significant differences could be detected. However, mortality rate was not significantly greater in patients 80+ years. Clinical status at time of admission statistically was a prognostic factor in elderly patients as well as the extent of blood clots and an early hydrocephalus. Patients aged 80+ years suffered less from severe cerebral vasospasm, which statistically was no prognostic factor for a favorable outcome in this group.

Conclusions: Patients aged 80+ years with SAH also can achieve a favorable outcome. There was no difference in clinical outcome comparing both groups, but several pathophysiological mechanisms in elderly patients (especially 80+ years) seem to have a positive influence on typical complications after SAH, such as cerebral vasospasm, early hydrocephalus, and shunt dependence.
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http://dx.doi.org/10.1016/j.wneu.2017.06.056DOI Listing
October 2017

Risk factors governing the development of cerebral vein and dural sinus thrombosis after craniotomy in patients with intracranial tumors.

J Neurosurg 2018 02 7;128(2):373-379. Epub 2017 Apr 7.

1Department of Neurosurgery and.

OBJECTIVE Neurosurgical intervention may increase the risk of developing cerebral vein and dural sinus thrombosis (CVT). The clinical management of CVT in postoperative patients remains unclear. This retrospective study explores the disease occurrence, associated risk factors, and outcomes in patients with tumors who developed CVT after craniotomy. METHODS A retrospective analysis and review of patient records in those who had undergone cranial tumor removal within the authors' neurosurgical department was performed. In so doing, the authors identified a cohort of patients who developed CVT postoperatively. The study included patients who presented to the department between January 2004 and December 2013. RESULTS Of 2286 patients with intracranial lesions who underwent craniotomy, 35 (1.5%) went on to develop CVT. The authors identified the semisitting position (OR 7.55, 95% CI 3.73-15.31, p < 0.001); intraoperative sinus injury (OR 1.5, 95% CI 3.57-15.76, p < 0.001); and known CVT risk factors (OR 7.77, 95% CI 2.28-21.39, p < 0.001) as predictors of CVT development. Of note, 19 patients (54.3%) had good outcomes (modified Rankin Scale Score 0-1), whereas 9 patients (25.7%) had suffered dependency or death (modified Rankin Scale Score 4-6) at last follow-up. Intracerebral hemorrhage (OR 21.27, 95% CI 1.59-285.01, p = 0.02) and delayed delivery of an intermediate dose of low-molecular-weight heparin anticoagulation (OR 24.12, 95% CI 2.08-280.13, p = 0.01) were associated with unfavorable outcomes. CONCLUSIONS Only a minority of patients undergoing craniotomy for tumor removal develop CVT, and the majority of those who do develop CVT recover well. Early administration of an intermediate dose of low-molecular-weight heparin anticoagulation might be considered once CVT is diagnosed.
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http://dx.doi.org/10.3171/2016.11.JNS161871DOI Listing
February 2018

MRI-detection rate and incidence of lumbar bleeding sources in 190 patients with non-aneurysmal SAH.

PLoS One 2017 3;12(4):e0174734. Epub 2017 Apr 3.

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

Background: Up to 15% of all spontaneous subarachnoid hemorrhages (SAH) have a non-aneurysmal SAH (NASAH). The evaluation of SAH patients with negative digital subtraction angiography (DSA) is sometimes a diagnostic challenge. Our goal in this study was to reassess the yield of standard MR-imaging of the complete spinal axis to rule out spinal bleeding sources in patients with NASAH.

Methods: We retrospectively analyzed the spinal MRI findings in 190 patients with spontaneous NASAH, containing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH, diagnosed by computer tomography (CT) and/or lumbar puncture (LP), and negative 2nd DSA.

Results: 190 NASAH patients were included in the study, divided into PM-SAH (n = 87; 46%) and NPM-SAH (n = 103; 54%). Overall, 23 (22%) patients had a CT negative SAH, diagnosed by positive LP. MR-imaging of the spinal axis detected two patients with lumbar ependymoma (n = 2; 1,05%). Both patients complained of radicular sciatic pain. The detection rate raised up to 25%, if only patients with radicular sciatic pain received an MRI.

Conclusion: Routine radiological investigation of the complete spinal axis in NASAH patients is expensive and can not be recommended for standard procedure. However, patients with clinical signs of low-back/sciatic pain should be worked up for a spinal pathology.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0174734PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5378360PMC
September 2017

Benefit and Complications of Frame-Based Stereotactic Biopsy in Old and Very Old Patients.

World Neurosurg 2017 Jun 23;102:442-448. Epub 2017 Mar 23.

Neurosurgical Clinic, Goethe-University Frankfurt, Frankfurt, Germany.

Objective: Stereotactic biopsy is an everyday procedure implemented in numerous neurosurgical departments. The procedure is performed to obtain tumor tissue of unclear diagnosis. Going in hand with low complication rates and high diagnostic yield, stereotactic biopsies can be performed in adults and children likewise for histopathologic evaluation of lesions in eloquent localizations. However, little is known about whether aged patients do benefit from stereotactic biopsy or rather the therapy that is derived from histopathologic results. In this study, we therefore focused on old (80-84 years) and very old patients (85 years and older) to evaluate whether stereotactic biopsy should be performed leading to further therapy. We also assessed the complication rates of the procedure in this aged population.

Methods: We performed a retrospective analysis of our database and included all patients older than 80 years who underwent stereotactic biopsy at our department from October 2005 until May 2016. Forty-seven patients were included in this study. These patients were divided into 2 subgroups: group 1 consisted of patients from 80 to 84 years old and group 2 of patients aged 85 years and older. All patients underwent stereotactic biopsy to establish histopathologic diagnosis. We excluded patients who underwent cyst puncture or puncture of a hemorrhage because the procedure was not performed for diagnostic purposes. We assessed gender, neuroradiologic diagnosis, Karnofsky Performance Score (KPS), number of tissue samples taken, histopathologic diagnosis, localization, postoperative hemorrhage, modality of anesthesia anticoagulation, and further therapy.

Results: Group 1 consisted of 34 patients and group 2 of 13 patients. KPS was 80 and 70, respectively. A histopathologic diagnosis was possible in all but 1 patient. In group 1, 61.8% of the patients agreed to further postoperative therapy (radiation, 35.3%; chemotherapy, 11.8%; combined radiochemotherapy, 11.8%; complication that prevented therapy, 2.9%), as did 53.8% of the patients in group 2 (resection, 7.7%; radiation, 15.4%; combined radiochemotherapy, 30.7%). In group 1, 38.2% declined further therapy, as did 64.1% in group 2.

Conclusions: Also in old and very old patients, a final histopathologic diagnosis should be established to provide adequate therapy. Our data show that most of these aged patients want to be treated.
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http://dx.doi.org/10.1016/j.wneu.2017.03.059DOI Listing
June 2017

Effect of heparin on secondary brain injury in patients with subarachnoid hemorrhage: an additional 'H' therapy in vasospasm treatment.

J Neurointerv Surg 2017 Jul 2;9(7):659-663. Epub 2017 Feb 2.

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

Objective: Secondary brain injury leads to high morbidity and mortality rates in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, evidence-based treatment strategies are sparse. Since heparin has various effects on neuroinflammation, microthromboembolism and vasomotor function, our objective was to determine whether heparin can be used as a multitarget prophylactic agent to ameliorate morbidity in SAH.

Methods: Between June 1999 and December 2014, 718 patients received endovascular treatment after rupture of an intracranial aneurysm at our institution; 197 of them were treated with continuous unfractionated heparin in therapeutic dosages after the endovascular procedure. We performed a matched pair analysis to evaluate the effect of heparin on cerebral vasospasm (CVS), cerebral infarction (CI), and outcome.

Results: The rate of severe CVS was significantly reduced in the heparin group compared with the control group (14.2% vs 25.4%; p=0.005). CI and multiple ischemic lesions were less often present in patients with heparin treatment. These effects were enhanced if patients were treated with heparin for >48 hours, but the difference was not significant. Favorable outcome at 6-month follow-up was achieved in 69% in the heparin group and in 65% in the control group.

Conclusions: Patients receiving unfractionated continuous heparin after endovascular aneurysm occlusion have a significant reduction in the rate of severe CVS, have CI less often, and tend to have a favorable outcome more often. Our findings support the potential beneficial effects of heparin as a multitarget therapy in patients with SAH, resulting in an additional 'H' therapy in vasospasm treatment.
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http://dx.doi.org/10.1136/neurintsurg-2016-012925DOI Listing
July 2017

Muscular atrophy in severe cases of cubital tunnel syndrome: prognostic factors and outcome after surgical treatment.

Acta Neurochir (Wien) 2017 03 21;159(3):537-542. Epub 2017 Jan 21.

Department of Neurosurgery, Goethe University, Frankfurt, Germany.

Background: Cubital tunnel syndrome (CuTS) is a frequent neuropathy, leading to sensor-motoric dysfunction. Many patients even present with muscular atrophy as a sign for severe and long-lasting nerve impairment, usually suggesting unfavourable outcome. We analysed if those patients benefit from surgical treatment on a long-term basis.

Methods: Between January 2010 and March 2015, 42 consecutive cases of CuTS with atrophy of the intrinsic hand muscles were surgically treated in our department. Clinical data of the treatment course and postoperative results were collected. Follow-up was prospectively assessed according to McGowen grading and Bishop outcome score. Mean follow-up time was 39.8 (±17.0) months.

Results: All patients were treated with in situ decompression; in 33%, submuscular transposition was performed. Forty-five percent showed improvement of sensory deficits and 57% showed improvement of motor deficits 6 months after the operation. Atrophy improved in 76%. At the time of follow-up, 79% were satisfied with the postoperative result and 77% of patients reached good or excellent outcome according to modified Bishop rating scale. Patients with improvement of atrophy had significantly shorter symptom duration period (7 ± 10 months vs 26 ± 33 months; p < 0.05). In the case of intraoperative pseudoneuroma observation, atrophy improvement was less likely (p < 0.05).

Conclusions: In severe cases of CuTS with atrophy of the intrinsic hand muscles, surgical treatment enables improvement of sensory function, motor function and atrophy even in cases with muscular atrophy. Atrophy improvement was more likely in cases of short symptom duration and less likely in cases with pseudoneuroma.
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http://dx.doi.org/10.1007/s00701-017-3086-3DOI Listing
March 2017

Outcome and prognostic factors after delayed second subarachnoid haemorrhage.

Acta Neurochir (Wien) 2017 02 10;159(2):307-315. Epub 2016 Dec 10.

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

Background: Data of patients suffering from delayed second subarachnoid haemorrhage (SAH) after aneurysm treatment are still missing. Patients become clearly older than before. Thus, the risk suffering from a second delayed SAH rises. The aim of this study was to analyse clinical outcome and prognostic factors in patients after delayed second SAH.

Method: From 1999 to 2013, 18 of 1,493 patients (1.2%) suffered from a second SAH. Clinical and radiological characteristics were entered into a prospective conducted database. Outcome was assessed according to modified Rankin Scale 6 months after second SAH. P < 0.05 was considered statistically significant.

Results: Eighteen patients were admitted to our department with a second SAH. The second SAH occurred at a mean interval of 144 months after surgical treatment and 78 months after endovascular treatment (P < 0.05), with an overall mean interval of 125 months. The earliest event of second SAH was after 35 months. In 11 (61%) patients, a de novo aneurysm was detected; in one patient (6%), no cause of second SAH was detected. In six (33%) cases, re-rupture of the formerly secured aneurysm was found. Half of the rebleedings occurred from a basilar aneurysm, 33% from an aneurysm of anterior communicating artery and in one patient from a median cerebral artery aneurysm. At second SAH, 8 of 18 patients presented WFNS grade I-III at time of admission (44%). Overall, favourable outcome was achieved in seven patients (39%). Four patients died (22%), one of them before treatment. Favourable outcome seems to be associated with younger age. In our patients, 39% achieved a favourable outcome after second SAH.

Conclusions: A delayed second SAH is a rare entity. After delayed second SAH, age seems to be a prognostic factor for patients' outcome and patients seem to have a worse prognosis. Nonetheless, up to 40% of patients can achieve a favourable outcome.
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http://dx.doi.org/10.1007/s00701-016-3045-4DOI Listing
February 2017

Stereotactic biopsy of brainstem lesions: 21 years experiences of a single center.

J Neurooncol 2016 09 13;129(2):243-50. Epub 2016 Jun 13.

Neurosurgical Clinic, Goethe-University Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany.

Stereotactic biopsies are procedures performed to obtain tumor tissue for diagnostic examinations. Cerebral lesions of unknown entities can safely be accessed and tissue can be examined, resulting in correct diagnosis and according treatment. Stereotactic procedures of lesions in highly eloquent regions such as the brainstem have been performed for more than two decades in our department. In this retrospective study we focus on results, approaches, modalities of anesthesia, and complications. We performed a retrospective analysis of our prospective database, including 26 patients who underwent stereotactic biopsy of the brainstem between April 1994 and June 2015. All of the patients underwent preoperative MRI. Riechert-Mundinger-frame was used before 2000, thereafter the Leksell stereotactic frame was used. After 2000 entry and target points were calculated by using BrainLab stereotactic system. We evaluated histopathological results as well as further treatment; additionally we compared complications of local versus general anesthesia and complications of a frontal versus a trans-cerebellar approach. Median age of all patients was 33 years, and median number of tissue samples taken was 12. In all patients a final histopathological diagnosis could be established. 5 patients underwent the procedure under local anesthesia, 21 patients in general anesthesia. In 19 patients a frontal approach was performed, while in 7 patients a trans-cerebellar approach was used. Complications occurred in five patients. Thereby no significant difference was found with regard to approach (frontal versus trans-cerebellar) or anesthesia (local versus general). Stereotactic biopsies even of lesions in the brainstem are a save way to obtain tumor tissue for final diagnosis, resulting in adequate treatment. Approach can be trans-cerebellar or frontal and procedure can be performed either under local or general anesthesia without significant differences concerning complication rate.
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http://dx.doi.org/10.1007/s11060-016-2166-1DOI Listing
September 2016

Stereotactic Biopsy of Pineal Lesions.

World Neurosurg 2016 Dec 7;96:124-128. Epub 2016 Jun 7.

Neurosurgical Clinic, Goethe-University Frankfurt, Frankfurt, Germany.

Background: Stereotactic biopsies are carried out to obtain tumor tissue of unknown entity from cerebral lesions. Thus, tumor tissue can be examined, resulting in correct diagnosis and treatment. These procedures go in hand with high accuracy, high diagnostic yield, and low complication rates.

Objectives: The aim of this study is to evaluate the results and complications of stereotactic biopsies carried out for lesions of the pineal region.

Methods: We performed a retrospective analysis of our prospective database and included 14 patients who underwent stereotactic biopsy of a pineal lesion between 2006 and February 2016. The Leksell stereotactic frame was used in all patients, and entry and target points were calculated using the BrainLab stereotactic system. We evaluated histopathologic results and postoperative complications such as hydrocephalus and hemorrhage.

Results: Histopathologic diagnosis was established in all patients. On postoperative computed tomography, 7 patients (50%) showed a circumscribed blood collection at the site of biopsy. Six patients (42.8%) required a cerebrospinal fluid drain preoperatively. Two patients needed external ventricular drain postoperatively (14.2%). One of these patients showed a small hemorrhage area that caused the hydrocephalus. The other patient showed only postoperative swelling. Preoperatively, 2 patients (14.2%) already had a ventriculoperitoneal (VP) shunt, whereas postoperatively, another 4 patients (28.5%) needed a VP shunt. Thus, of the 14 patients, 6 (42.8%) required a VP shunt.

Conclusions: Because of their localization, pineal lesions may result in emergence of a hydrocephalus. Stereotactic biopsies in this area may increase this effect and, thus, even VP shunts are necessary in some patients.
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http://dx.doi.org/10.1016/j.wneu.2016.04.130DOI Listing
December 2016

Dislocated Pacemaker Electrode Simulating Focal Epileptic State in a Patient with Subdural Hematoma-Case Report and Review of the Literature.

World Neurosurg 2016 Apr 22;88:696.e1-696.e4. Epub 2016 Jan 22.

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

Background: Due to demographic changes, the number of patients with traumatic brain injury carrying a cardiac resynchronization therapy device is increasing. One of the common complications of subdural hematoma (SDH) is epilepsy, whereas one of the most frequent early complications after cardiac resynchronization therapy device implantation is lead dislocation. The latter might then cause unintended skeletal muscle stimulation that might be misinterpreted in seizure-prone patients.

Case Description: An 86-year-old female patient with an initially conservatively treated SDH on the right side presented with a tonic muscle contraction in her left arm 2 weeks after the trauma not responding to antiepileptic therapy. A computed tomography scan revealed residual hematoma on the right side with regular, time-dependent resorption. The muscle contraction was misdiagnosed as a focal epileptic state leading to evacuation of the chronic SDH. Additionally, routine postoperative chest radiographs were performed. Postoperatively, the tonic muscle contraction in her arm persisted. Chest radiographs revealed a dislocation of the left ventricular electrode, which appeared retracted into the left subclavian vein, next to the plexus brachialis. After deactivating the electrode, the alleged focal state ceased.

Conclusions: In case of refractory treatment of epilepsy, dislocation of pacemaker electrodes is a, most certainly, rare but possible differential diagnosis. Confirmation of electrode position and function is easily and quickly feasible and will help prevent futile seizure-directed therapy.
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http://dx.doi.org/10.1016/j.wneu.2015.12.099DOI Listing
April 2016

Outcome of Patients with Long-Lasting Cerebral Vasospasm After Subarachnoid Hemorrhage: Is Prolonged Treatment for Cerebral Vasospasm Worthwhile? A Matched-Pair Analysis.

World Neurosurg 2016 Apr 20;88:488-496. Epub 2015 Oct 20.

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

Objective: Cerebral vasospasm (CVS) occurs regularly between days 3 and 12 after subarachnoid hemorrhage (SAH). Yet, some patients suffering from SAH have long-lasting cerebral vasospasm (LL-CVS, i.e., longer than 14 days). The outcome of these patients with a very long treatment is unknown.

Methods: Patients with SAH were entered into a prospectively collected database. In unconscious patients, CVS was treated until a reversal of CVS was confirmed by imaging. Outcome was assessed with the modified Rankin Scale (mRS; favorable [mRS 0-2] and unfavorable [mRS 3-6]) 6 months after SAH. Data were compared by matched pair analysis.

Results: Of 1126 patients, 106 had LL-CVS (9.4%). The mean of treatment was until day 20 (range, 15-42). Of these patients, more than 30% needed treatment longer than 21 days after SAH; 29% had a small intracerebral hematoma (ICH; <50 mL). Hydrocephalus that required external ventricular drainage was present in 81%. Outcomes were favorable in 60%, and 8% died. In the multivariate logistic regression analysis, risk factors for an unfavorable outcome were elderly patients, poor admission status, and the presence of small ICH. Compared with the matched control group, who had "regular-lasting" CVS, patients with LL-CVS had a significant better outcome (60% vs. 49%) and a significant lower mortality rate (8% vs. 27%).

Conclusion: Patients with LL-CVS had a significant better outcome than patients with "regular-lasting" CVS. Risk factors for worse outcome of patients with LL-CVS were a worse admission status, elderly age, and the presence of small ICH. We recommend using an objective method to validate the reversal of CVS in unconscious patients.
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http://dx.doi.org/10.1016/j.wneu.2015.10.033DOI Listing
April 2016

Ventriculostomy-Related Hemorrhage After Treatment of Acutely Ruptured Aneurysms: The Influence of Anticoagulation and Antiplatelet Treatment.

World Neurosurg 2015 Dec 13;84(6):1653-9. Epub 2015 Jul 13.

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

Background: Endovascular techniques have gained importance in recent years in the treatment of acutely ruptured aneurysms. Sometimes artificial anticoagulation or antiplatelet agents are indicated after endovascular aneurysm occlusion to prevent thromboembolic complications. Because many patients require ventriculostomy secondary to hydrocephalus, we analyzed ventriculostomy-related hemorrhage in patients with and without anticoagulant therapy.

Methods: Between January 2007 and December 2013, 444 patients with aneurysmal subarachnoid hemorrhage and acute hydrocephalus received treatment requiring ventriculostomy. Treatment-related complications were entered in a prospectively conducted database and analyzed retrospectively. All patients received low-molecular-weight heparin in prophylactic dosage starting 24 hours after aneurysm treatment. Heparin (dosage depending on patient weight) was administered during all endovascular procedures.

Results: In 117 of 444 patients (26%), additional anticoagulation or antiplatelet agents were administered after treatment of the ruptured aneurysm. Heparin was used in 70 of 117 patients (60%), acetylsalicylic acid was used in 61 (52%), clopidogrel was used in 25 (21%), and tirofiban was used in 23 (20%). In 42 patients (36%), anticoagulants and antiplatelet drugs were combined. Ventriculostomy-related hemorrhage was observed in 55 patients (12%). A ventriculostomy-related hemorrhage occurred in 28 of 117 patients (24%) with anticoagulation therapy and in 27 of 327 patients (8%) without anticoagulation therapy (P < 0.001). The hemorrhage rate in all patients receiving endovascular treatment was significantly higher than in patients receiving microsurgical treatment (P < 0.05). Hemorrhage was more likely to be observed when ventriculostomy was performed before the additional anticoagulation was started, although this was not statistically significant. No surgical intervention was necessary to treat ventriculostomy-related bleeding.

Conclusions: Patients receiving endovascular treatment were at higher risk for ventriculostomy-related hemorrhage, especially when anticoagulation was administered after aneurysm occlusion. Although no clinically relevant external ventricular drain-related hemorrhage occurred, ventriculostomy should be performed before anticoagulation whenever possible.
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http://dx.doi.org/10.1016/j.wneu.2015.07.003DOI Listing
December 2015

Intramedullary Solitary Fibrous Tumor--A Benign Form of Hemangiopericytoma? Case Report and Review of the Literature.

World Neurosurg 2015 Jul 6;84(1):189.e7-189.e12. Epub 2015 Mar 6.

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

Background: Solitary fibrous tumors (SFTs) are benign tumors of the soft tissue occurring anywhere in the human body but arise predominantly in the visceral pleura. SFTs of the central nervous system are rare, especially when they occur within the spinal cord.

Case Description: We present a case of an 83-year-old female patient presenting with acute spastic paralysis of the lower extremities after a history of progressive weakness and incontinence. Magnetic resonance imaging (MRI) findings were typical for meningioma, but an intradural, mainly intramedullary tumor was found at the first operation. A second operation was performed under neurophysiological monitoring, and complete removal of the tumor was achieved. Neurological conditions improved after the procedure, but the patient remained paraparetic. Histological and immunohistochemical findings revealed an SFT.

Conclusions: There is evidence that SFTs and hemangiopericytomas (HPCs) are not different entities but should be considered as different graduations of a common spectrum. The extent of resection is a prognostic factor for recurrence-free survival in SFT; therefore we recommend surgery with complete resection whenever possible depending on the results of mandatory intraoperative neurophysiological monitoring in these cases.
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http://dx.doi.org/10.1016/j.wneu.2015.02.036DOI Listing
July 2015

Subarachnoid hemorrhage and intracerebral hematoma caused by aneurysms of the anterior circulation: influence of hematoma localization on outcome.

Neurosurg Rev 2014 Oct 12;37(4):653-9. Epub 2014 Jul 12.

Department of Neurosurgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany,

Additional space-occupying intracerebral hematoma (ICH) in patients suffering from subarachnoid hemorrhage (SAH) is a known predictor for poor outcome. Emergent clot evacuation might be mandatory. However, data concerning the influence of ICH location on outcome is scarce. Therefore, we analyzed the influence of ICH location on clinical course and outcome in patients with SAH and additional ICH. One hundred seventy-four patients were treated with aneurysmal SAH and additional ICH between September 1999 and May 2012. Information including patient characteristics, treatment, and radiological findings were prospectively entered into a database. Patients were stratified according to ICH location and neurological outcome. Neurological outcome was assessed according to modified Rankin Scale (mRS). ICH location was temporal (58.6 %), frontal (28.7 %), and perisylvian ICH (12.6 %); 63.8 % presented in poor admission status and favorable outcome was achieved in 35.6 %. In the multivariate analysis, favorable outcome was associated with young age, ICH <50 ml, and good admission status. The location of ICH was not associated with outcome. The current data confirms that a significant number of patients with ICH after aneurysm rupture achieve favorable outcome. Prognostic factor for favorable outcome are "age," "size of the hematoma," and "admission status." The location of the ICH seems not to be associated with outcome.
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http://dx.doi.org/10.1007/s10143-014-0560-8DOI Listing
October 2014

Efficacy and safety of local versus general anesthesia in stereotactic biopsies: a matched-pairs cohort study.

J Neurosurg Anesthesiol 2013 Apr;25(2):148-53

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

Background: Frame-based stereotactic biopsies remain the gold standard for the diagnosis of intracerebral lesions. A major advantage is the ability to perform these procedures under local anesthesia (LA). However, there is no consensus on whether or when to use LA or general anesthesia (GA). It has been postulated that the use of LA may reduce the risk of complications. This study aims to objectify the efficacy and safety of stereotactic biopsies under LA versus GA by analyzing a prospective registry for stereotactic biopsies.

Methods: A prospective registry for stereotactic procedures was analyzed for the activities performed between May 2009 and August 2011. Inclusion criteria were patients undergoing a stereotactic biopsy. Patients with functional stereotactic procedures, cyst or abscess evacuation, and children were excluded. Of the remaining 274 patients, 204 could be randomly matched considering sex, age, American Society of Anesthesiologists (ASA) classification, and type of hospitalization. The primary endpoint was the diagnostic yield. Secondary endpoints were safety and procedural time intervals.

Results: Ninety-six percent of diagnosis was achieved in the LA group and 94% within the GA group. There was no significant difference in the overall complication rate. However, the rate of pulmonary complications was higher in the GA group (P=0.059). The rate of bleeding was significantly higher in the LA group (P=0.003) intraoperatively. However, no significant difference was found clinically or on routine postoperative computed tomography scan reports. There was a significant reduction in the time spent in the operating room within the LA group (P<0.001).

Conclusions: The type of anesthesia may not interfere with the diagnostic yield in stereotactic biopsies. Patients operated under LA are less likely to suffer pulmonary complications. Furthermore, LA could spare hospital resources in this setting.
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http://dx.doi.org/10.1097/ANA.0b013e318274ce41DOI Listing
April 2013

Ultra-long-term outcome of surgically treated far-lateral, extraforaminal lumbar disc herniations: a single-center series.

Eur Spine J 2012 Apr 17;21(4):660-5. Epub 2011 Dec 17.

Neurosurgical Clinic, Johann Wolfgang Goethe-University, Schleusenweg 2-16, 60528, Frankfurt am Main, Germany.

Purpose: Far-lateral extraforaminal lumbar disc herniation is an uncommon cause of nerve root entrapment, and studies addressing the long-term outcome of surgically treated patients are few. The purpose of this study was to analyze the ultra-long-term outcome of patients who were treated via a lateral approach.

Methods: The medical reports of 138 consecutive patients were analyzed with regard to signs and symptoms, operative findings, complications, and short-term outcome (6 weeks). To assess long-term results, standardized telephone interviews were performed using a structured questionnaire. The patients were questioned about pain using the verbal rating scale and persisting symptoms, if any. Other queries were related to the Oswestry Disability Index. Subjective satisfaction with the result of surgery was classified as excellent (no pain), good (some pain), fair (moderate pain), and poor (unchanged or worse) based on MacNab classification.

Results: At short-term follow-up, major and moderate leg pain had decreased from 99.3 to 5.1% and low back pain from 97.8 to 2.8%. Sensory and motor deficits, however, were still present in the majority of patients. A total of 87 telephone interviews were conducted, and the mean follow-up was 146 months. As many as 49 patients (56.3%) reported complete relief of symptoms, 14 patients (16.1%) had minor ailments under physical stress, and 24 patients (27.6%) had permanent residual symptoms. The most common complaint was remaining sensory disturbance. Despite residual symptoms, the vast majority of patients expressed satisfaction with the result of surgery. The outcome was subjectively rated as follows: 75.9% excellent (66 patients), 18.4% good (16 patients), 4.6% fair (4 patients), and 1.1% poor (1 patient).

Conclusions: The lateral approach is a minimally invasive and safe procedure with low complication rates. The profit from surgery is maintained beyond the usual postoperative observation periods. Thus, ultimate outcome at ultra-long-term follow-up is very gratifying in the vast majority of patients.
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http://dx.doi.org/10.1007/s00586-011-2123-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326130PMC
April 2012
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