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Abstract Background After ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus (iNPH) with adjustable gravitational valves, a certain proportion of patients develop secondary clinical worsening after initial improvement of clinical symptoms. The aim of this study was to analyze this group of patients with secondary deterioration and to evaluate the performed shunt management. Methods For this investigation, we retrospectively reviewed our NPH registry for patients included between 1999 and 2013 with a decrease by a minimum of two points in the Kiefer score in the first year of follow up and an increase of two points in the Kiefer score between the second and the fifth year after shunt surgery (secondary deterioration). Then, we analyzed the patient’s shunt management (adapting the valve pressure setting, shuntography, valve replacement, catheter replacement, implant an adjustable gravitational unit). Additionally, we searched for risk factors for secondary deterioration. Results Out of 259 iNPH patients, 53 (20%) patients showed secondary deterioration on an average of 2.7 (2–4 years) years after shunt surgery. Fourteen (26%) patients with secondary deterioration improved after shunt or valve management and 58% remained without clinical benefit after management. We had a drop-out rate of 15% due to incomplete datasets. Our shunt management reduced the rate of secondary deterioration from 20 to 15%. On the basis of our findings, we developed an algorithm for shunt management. Risk factors for secondary deterioration are the age of the patient at the time of shunting, newly diagnosed neurodegenerative diseases, and overdrainage requiring adjusting the valve to higher-pressure levels. Conclusion Twenty percent of patients with iNPH were at risk for secondary clinical worsening about 3 years after shunt surgery. About one-fourth of these patients benefited for additional years from pressure level management and/or shunt valve revision. Our findings underline the need for long-term follow-ups and intensive shunt management to achieve a favorable long-term outcome for patients with iNPH and VPS.

Objectives Since 2000/2001, no large-scale prospective studies addressing traumatic brain injury (TBI) epidemiology in Germany have been published. Our aim was to look for a possible shift in TBI epidemiology described in other European countries, to look for possible changes in TBI management and to identify predictors of 1-year outcome especially in patients with mild TBI.Design Observational cohort study.Setting All patients suffering from a TBI of any degree between 1 October 2014 and 30 September 2015, and who arrived in one of the seven participating BG hospitals within 24 hours after trauma, were included.Participants In total, 3514 patients were included.Outcome measures Initial care, acute hospital care and rehabilitation were documented using standardised documentation forms. A standardised telephone interview was conducted 3 and 12 months after TBI in order to obtain information on outcome.Results Peaks were identified in males in the early 20s and mid-50s, and in both sexes in the late 70s, with 25% of all patients aged 75 or older. A fall was the most frequent cause of TBI, followed by traffic accidents (especially bicyclists). The number of head CT scans increased, and the number of conventional X-rays of the skull decreased compared with 2000/2001. Besides, more patients were offered rehabilitation than before. Though most TBI were classified as mild, one-third of the patients participating in the telephone interview after 12 months still reported troubles attributed to TBI. Negative predictors in mild TBI were female gender, intracranial bleeding and Glasgow Coma Scale (GCS) 13/14.Conclusion The observed epidemiologic shift in TBI (ie, elderly patients, more falls, more bicyclists) calls for targeted preventive measures. The heterogeneity behind the diagnosis ‘mild TBI’ emphasises the need for defining subgroups not only based on GCS.

Abstract Background Idiopathic normal-pressure hydrocephalus (iNPH) is a distinct form of dementia, characterized by gait ataxia, cognitive impairment and urinary incontinence. In contrast to all other causes of dementia (e.g., Alzheimer-type and others), ventriculoperitoneal (VP) shunt surgery may offer a curative treatment option to patients. While being a rather low-risk type of surgery, it may cause significant over- or underdrainage complications (e.g., headaches, dizziness, vomiting, intracerebral bleeding, etc.) during posture change. Anti-siphon devices (ASDs) are a group of technically different additional valves used in shunt surgery. They are designed to maintain intraventricular pressure within a normal physiological range regardless of patient position. Fixed ASDs proved to substantially lower the rate of overdrainage complications. No significant differences, however, were noted regarding underdrainage complications. Technical successors of fixed ASDs are programmable ASDs. The aim of this study is to evaluate whether programmable ASDs compared to fixed ASDs are able to avoid both over- and underdrainage complications. Methods/design In this investigator-initiated, multicenter randomized trial, 306 patients are planned to be recruited. Male and female patients aged ≥18 years with iNPH who are eligible for VP shunt surgery and meet all other entry criteria can participate. Patients will be randomized in a balanced 1: 1 fashion to a VP shunt with a programmable valve either supplemented with a fixed ASD, or a programmable ASD. Patients will be followed-up 3, 6 and, on an optional basis, 12 months after surgery. The primary outcome measure is the cumulative incidence of over- or underdrainage 6 months post surgery, as defined by clinical and imaging parameters. Discussion SYGRAVA is the first randomized trial to determine whether programmable ASDs reduce complications of drainage compared to fixed ASDs in patients with iNPH. The results of this study may contribute to health-technology assessment of different valve systems used for VP-shunt surgery, and determination of the future standard of care. Trial registration International Standard Randomised Controlled Trial Number: ISRCTN13838310. Registered on 10 November 2016.

OBJECTIVES: To compare the clinical course of patients with subarachnoidal hemorrhage owing to ruptured cerebral aneurysms treated with endovascular coil embolization, with another group treated with microsurgical clipping. Additionally, the identification of the predictors in the clinical course of primary subarachnoidal hemorrhage.PATIENTS AND METHOD: Between September 1997 and December 2004, 71 patients with primary subarachnoidal hemorrhage and a clinical stage III-V (Hunt and Hess grading) were managed in the Unfallkrankenhaus Berlin. Thirty-two patients underwent microsurgical clipping and 39 patients underwent endovascular embolization. The outcome according to the Glasgow outcome scale, the clinical staging according to Hunt and Hess, and the computer tomography morphologic findings of the subarachnoidal hemorrhage according to Fischer Grading system were all compared on admission in hospital.RESULTS: There was no statistical significant difference of the outcome between patients treated by surgical clipping and those by endovascular coil embolization. The endovascular therapy (2.92 d) was significantly done earlier in comparison to the microsurgical clipping (5.35 d). The distribution and the configuration of the subarachnoidal hemorrhage in the computer tomography according to the Fischer grading system is a predictor for the clinical course of the disease independently of the treatment method.CONCLUSIONS: According to the clinical point of view, the coil embolization method secures an early begin of treatment, reduces therefore the risk of rebleeding, and allows the early induction of the conservative therapy. Consecutively, the coil embolization is, according to our experience, the therapy of choice for ruptured cerebral aneurysms with primary subarachnoidal hemorrhage with Hunt and Hess stage III-V. Finally, the indication for coiling or clipping must be decided individually according to the patient and the aneurismal criteria. [ABSTRACT FROM AUTHOR]

ABSTRACT:: Does the opening pressure of hydrostatic shunts influence the clinical outcome for patients suffering from idiopathic normal-pressure hydrocephalus (iNPH)? Between September 1997 and January 2003, 122 patients with iNPH were surgically treated by implanting a hydrostatic shunt at the Departments of Neurosurgery of the Unfallkrankenhaus Berlin and the University of Homburg/Saar. The results of the clinical examination, the intrathecal infusion test, and the cerebrospinal fluid tap test served as decision aids regarding shunt implantation. As part of a prospective randomized study, all patients were examined before surgery, after surgery, and 1 year after the intervention. Forty-three percent of the patients had a very good outcome, 25% had a good outcome, 20% had a fair outcome, and 12% had a poor outcome 1 year after shunt implantation. Patients treated with an opening pressure rating of 50 mm H2O in the low-pressure stage of the gravitational valve showed a statistically significant better outcome than those with an opening pressure rating of 100 or 130 mm H2O. Of the valve-independent complications observed after the intervention (11% shunt-related complications), 8 (7%) were dislocations of ventricular or abdominal catheters, 3 (2%) were catheter tear-offs, and 3 (2%) were shunt infections. Of the valve-related complications (10%), 4 patients (3%) suffered underdrainage, 8 patients (7%) showed radiologic signs of overdrainage, and 4 patients (3%) showed symptomatic overdrainage. According to present knowledge, hydrostatic shunts with an opening pressure of 50 mm H2O for the low-pressure stage are the optimal therapy option for patients with iNPH. Because of the prompt switching function as soon as the patient changes his or her posture (eg, lying down, standing, sitting), the Miethke Gravity Assisted valve (Aesculap) is more suitable for such cases than the Miethke DualSwitch valve (Aesculap). Can programmable gravitational valves contribute to further optimization of the outcome while minimizing the valve-related complications? [ABSTRACT FROM AUTHOR]

SUMMARY: In contrast to shunt implantation, the indication for endoscopic ventriculostomy in patients diagnosed for normal-pressure hydrocephalus (NPH) is not scientifically established. Between September 1997 and May 2002, NPH was diagnosed in 91 patients. The diagnosis was established by means of the clinical signs, the intrathecal lumbar or ventricular infusion test, the cerebrospinal fluid tap test, and magnetic resonance imaging (MRI) cerebrospinal fluid (CSF) flow studies preoperatively and postoperatively. In 70 of these patients (77%), a ventriculoperitoneal shunt with a Miethke dual-switch valve (MDSV) was implanted, and in 17 patients (19%), endoscopic-assisted ventriculostomy was performed. Four patients refused an operation and were excluded from this study. With our own created NPH recovery rate and use of the clinical grading system for NPH created by Kiefer and his colleagues, the operative results in an average time interval of 12 and 27 months were compared in both groups of patients. In the group of patients with a shunt operation, 10 surgical revisions (14%) were necessary because of 4 shunt infections (6%), 2 shunt obstructions (3%), 2 cases of overdrainage (3%), and 2 catheter dislocations (3%). In the ventriculostomy group, the complications were pneumatocephalus in 1 patient (6%) and a partial ischemic thalamus lesion with temporary clinical signs in another patient. Underdrainage was seen after both surgical procedures: after shunt operation in 3 patients (4%) and after ventriculostomy in 3 patients (18%). In these patients, we changed the valve and inserted one with a lower opening pressure or implanted an MDSV in 2 patients after the ventriculostomy. In another patient, we performed an additional ventriculostomy. In patients with a pathologically increased resistance to CSF outflow in the lumbar infusion test caused by NPH, shunt implantation is indicated. Patients whose outflow resistance is increased in the ventricular infusion test but who are suspected of having functional aqueduct stenosis as the result of a physiologic lumbar infusion test should be treated by means of endoscopic ventriculostomy, and they should be monitored with clinical and neuroradiologic long-term follow-up. In case of inadequate experience with ventriculostomy or in cases with an uncertain result of the intrathecal infusion test, the shunt operation with implantation of a hydrostatic valve is the method of first choice. [ABSTRACT FROM AUTHOR]

Neurosurgical therapy aims to minimize the secondary brain damage that occurs after severe head injury. This includes the evacuation of intracranial space-occupying bleeding, reduction of intracranial volumes, external ventricular drainage in hematocephalus, and conservative therapy to influence increased intracranial pressure (ICP) and a decreased oxygen partial pressure [p(ti)o2]. When conservative treatment fails, a decompressive craniectomy might be successful in lowering ICP. From September 1997 until September 2002, 559 patients with severe head injuries were operated on. Eighty patients (14%) were treated by means of a decompressive craniectomy. The prognosis after decompression depends on the clinical signs and symptoms on admission, the patient's age, and the existence of major extracranial injuries. The guidelines used at this institution for decompressive craniectomy after failure of conservative intervention and evacuation of space-occupying hematomas include patient age less than 50 years without multiple trauma, patient age less than 30 years in the presence of major extracranial injuries, severe brain swelling on a computed tomography scan, the exclusion of a primary brainstem lesion or injury, and intervention before irreversible brainstem damage. Secondarily, intervention is undertaken after monitoring ICP and p(ti)o2 for an interval up to 48 hours after the accident before irreversible brainstem damage or generalized brain damage has occurred. [ABSTRACT FROM AUTHOR]

Ventral spondylodesis by autologous bone grafting in cases of degenerative disease of the cervical spine bears the disadvantage of the complication of pain at the iliac crest. The question is if these problems can be avoided by implanting intervertebral disc spacers. Between September 1997 and December 2000, we operated on 145 patients suffering from degenerative diseases, including osteochondrosis and/or disc prolapse, of the cervical spine. Without any patient diagnosis selection, we implanted various randomly chosen disc spacer types, including 52 titanium disc spacers (Cespace) by Aesculap, 40 titanium spacers by Weber, 36 titanium spacers by Intromed, and 17 carbonium spacers by AcroMed, through anterior access and after microsurgical discectomy and removal of the dorsal osteophytes by a high-speed drill. We evaluated the handling, radiographic contrast, and costs of implantation as well as the clinical outcome after 3 months and 1 year, respectively. All four disc spacer models are suitable for the anterior spondylodesis of the cervical spine. The titanium spacer by Weber features good handling characteristics and a moderate purchase price. Cost efficiency and easy handling characterize the Intromed cage. The radiographic contrast of the carbonium spacer by AcroMed is insufficient for a controlled implantation in some cases, especially in the lower cervical spine. The handling is good, but the price is high. The AcroMed and Intromed spacers show a tendency to penetrate the base and/or cartilaginous plate of the adjacent vertebrae. Results lead us to favor the Aesculap Cespace, which impresses us by its handling and moderate price. The final assessment depends on the long-term clinical outcome for the cases studied. [ABSTRACT FROM AUTHOR]

SUMMARY: Especially in patients with normal pressure hydrocephalus (NPH), conventional differential pressure valves are known to create unphysiologic negative intraventricular pressure values when the patient moves to an upright position, with the consequence of numerous and sometimes severe complications. The recently presented gravitational devices promise improvement primarily with respect to this disadvantage. In a prospective multicenter study, the new Miethke Dual-Switch Valve (DSV) was implanted in 128 patients with NPH. The patients were assessed before surgery and at discharge, and they were re-evaluated 6 to 9 months after surgery. The technical principle of the new device is presented. The clinical follow-up showed excellent results in 63% of the patients, satisfactory results in 16%, and a poor outcome in 21%. The outcome correlated with the preoperative severity of NPH. Despite the clinical outcome, the computed tomography scans showed nearly no or only a minimal reduction of the ventricular size in most cases. We found a valve-related rate of overdrainage of 2.5%, which is clearly lower than the results of comparable series in the literature. The clinical course of patients suffering from NPH is mainly influenced by the stage of the disease, the time of beginning the therapy, and the gravitational function of the implanted device. Based on our clinical experiences with the Miethke DSV, we underline the advantages of this valve for the treatment of hydrocephalus, especially for patients with NPH. [ABSTRACT FROM AUTHOR]