Search

Purpose: Mutations in the Isocitrate Dehydrogenase (IDH) genes, IDH1 or IDH2, define a group of adult diffuse gliomas associated with a younger age at diagnosis and better prognosis than IDH wild-type glioblastoma. Within IDH mutant gliomas, a small fraction of astrocytic tumors present with grade 4 histologic features and poor prognosis. In molecular studies, homozygous deletion of CDKN2A/B is independently predictive of poor prognosis and short survival. As a consequence, 2021 WHO classification now also recognizes this molecular feature, CDKN2A/B deletion, as sufficient for classifying an astrocytoma as IDH-mutant, WHO Grade 4, regardless of histological grading. Here, we investigate outcomes of patients with WHO Grade 4 IDH-mutant astrocytoma both with and without CDKN2A/B deletion, to compare these groups and evaluate clinical and radiographic factors that contribute to survival., Methods: We retrospectively identified 79 patients with IDH-mutant astrocytoma with CDKN2A/B deletion detected at initial diagnosis across five international institutions as well as a comparison group of 51 patients with IDH-mutant, astrocytoma, histologically Grade 4 without detectable CDKN2A/B deletion. We assembled clinical and radiographic features for all patients., Results: We find that CDKN2A/B deletion was associated with significantly worse overall survival (OS; p = 0.0004) and progression-free survival (PFS; p = 0.0026), with median OS of 5.0 years and PFS of 3.0 years, compared to 10.1 and 5.0 years for tumors with a grade 4 designation based only on histologic criteria. Multivariate analysis confirmed CDKN2A/B deletion as a strong negative prognosticator for both OS (HR = 3.51, p < 0.0001) and PFS (HR = 2.35, p = 0.00095). In addition, in tumors with CDKN2A/B deletion, preoperative contrast enhancement is a significant predictor of worse OS (HR 2.19, 95% CI 1.22-3.93, p = 0.0090) and PFS (HR = 1.74, 95% CI = 1.02-2.97, p = 0.0420)., Conclusions: These findings underscore the severe prognostic impact of CDKN2A/B deletion in IDH-mutant astrocytomas and highlight the need for further refinement of tumor prognostic categorization. Our results provide a key benchmark of baseline patient outcomes for therapeutic trials, underscoring the importance of CDKN2A/B status assessment, in addition to histologic grading, in clinical trial design and therapeutic decision-making for IDH-mutant astrocytoma patients., Competing Interests: Declarations. Competing interests: D. P. C reports grants from NIH and Tawingo Fund during the conduct ofthe study; financial compensation from Servier, Boston Scientific and Pyramid Biosciences for advisory input. PYW reports research support from Astra Zeneca, Black Diamond, Bristol Meyers Squibb, Celgene, Chimerix, Eli Lily, Erasca, Genentech/ Roche, Kazia, MediciNova, Merck, Novartis, Nuvation Bio, Servier, Vascular Biogenics, VBI Vaccines; personal fees from Astra Zeneca, Black Diamond, Celularity, Chimerix, Day One Bio, Genenta, Glaxo Smith Kline, Merck, Mundipharma, Novartis, Novocure, Nuvation Bio, Prelude Therapeutics, Sapience, Servier, Sagimet, Vascular Biogenics, VBI Vaccines. T.A.J. received honoraria from CSL Behring. J.J.M. reports grants from the National Institute of Neurological Diseases and Stroke, American Cancer Society, Seeman Family Funds, National Cancer Institute, and MGH Transformative Scholar Award during the conduct of the study; personal fees from Servier., (© 2024. The Author(s).)

Introduction: The management of spinal sarcomas is complex, given their widespread involvement and high recurrence rates. Despite consensus on the need for a multidisciplinary approach with surgery at its core, there is a lack of definitive guidelines for clinical decision-making. This study examines a case series of primary spinal sarcomas, focusing on the surgical strategies, clinical results, and survival data to inform and guide therapeutic practices., Methods: We conducted a retrospective analysis of patients who underwent surgical resection for primary spinal sarcomas between 2005 and 2022. The study focused on gathering data on patient demographics, surgical details, postoperative complications, overall hospital stay, and mortality within 90 days post-surgery., Results: The study included 14 patients with a primary diagnosis of spinal sarcoma, with an average age of 48.6 ± 12.6 years. Chondrosarcoma emerged as the most common tumor type, representing 57.1% of cases, followed by Ewing sarcoma at 35.7%, and synovial sarcoma at 7.1%. Patients with chondrosarcoma were treated with en-bloc resection, while the patient with synovial sarcoma underwent intra-lesional excision and those with Ewing sarcoma received decompression and tumor debulking. Postoperative assessments revealed significant improvements in neurological conditions. Notably, functional status as measured by the Karnofski Performance Index (KPI), improved substantially post-surgery (from 61.4 to 80.0%) The mean follow-up was 34.9 ± 9.2 months. During this time period one patient experienced fatal bleeding after en-bloc resection complications involving the vena cava. None of the patient needed further surgery., Conclusions: Our 16-year study offers vital insights into managing primary spinal sarcomas, showcasing the effectiveness of surgical intervention, particularly en-bloc resection. Despite their rarity and complexity, our multidisciplinary treatment approach yields improved outcomes and highlights the potential for refined surgical strategies to become standardized care in this challenging domain., (© 2024. The Author(s).)

Purpose: Surgery for recurrent glioma provides cytoreduction and tissue for molecularly informed treatment. With mostly heavily pretreated patients involved, it is unclear whether the benefits of repeat surgery outweigh its potential risks., Methods: Patients receiving surgery for recurrent glioma WHO grade 2-4 with the goal of tissue sampling for targeted therapies were analyzed retrospectively. Complication rates (surgical, neurological) were compared to our institutional glioma surgery cohort. Tissue molecular diagnostic yield, targeted therapies and post-surgical survival rates were analyzed., Results: Between 2017 and 2022, tumor board recommendation for targeted therapy through molecular diagnostics was made for 180 patients. Of these, 70 patients (38%) underwent repeat surgery. IDH-wildtype glioblastoma was diagnosed in 48 patients (69%), followed by IDH-mutant astrocytoma (n = 13; 19%) and oligodendroglioma (n = 9; 13%). Gross total resection (GTR) was achieved in 50 patients (71%). Tissue was processed for next-generation sequencing in 64 cases (91%), and for DNA methylation analysis in 58 cases (83%), while immunohistochemistry for mTOR phosphorylation was performed in 24 cases (34%). Targeted therapy was recommended in 35 (50%) and commenced in 21 (30%) cases. Postoperatively, 7 patients (11%) required revision surgery, compared to 7% (p = 0.519) and 6% (p = 0.359) of our reference cohorts of patients undergoing first and second craniotomy, respectively. Non-resolving neurological deterioration was documented in 6 cases (10% vs. 8%, p = 0.612, after first and 4%, p = 0.519, after second craniotomy). Median survival after repeat surgery was 399 days in all patients and 348 days in GBM patients after repeat GTR., Conclusion: Surgery for recurrent glioma provides relevant molecular diagnostic information with a direct consequence for targeted therapy under a reasonable risk of postoperative complications. With satisfactory postoperative survival it can therefore complement a multi-modal glioma therapy approach., (© 2024. The Author(s).)

Purpose: In pediatric hydrocephalus (HC) treatment, programmable gravitational valves offer greater flexibility to manage overdrainage during children's growth. However, it remains unclear whether these devices provide better outcomes rather than their precursors. The study assessed the benefit from programmability of gravitational valve, i.e., programmable-SHUNTASSISTANT (proSA®) vs. SHUNTASSISTANT® (SA®)., Methods: Clinical records and imaging of pediatric patients with hydrocephalus of non-tumoral etiology treated with fixed (SA®) or programmable (proSA®) gravitational valves between January 2006 and January 2022 were analyzed in a retrospective single-center study. Valve survival was compared in relation to age and etiology. Lately explanted valves received biomechanical analysis., Results: A total of 391 gravitational valves (254 SA® and 137 proSA®) were inserted in 244 patients (n = 134 males). One hundred thirty-three SA® (52.4%) and 67 proSA® (48.9%) were explanted during a follow-up of 81.1 ± 46.3 months. Valve survival rate at 1 and 5 years with proSA® was 87.6% and 60.6% compared to 81.9% and 58.7% with SA®, with mean survival time 56.4 ± 35.01 and 51.4 ± 43.0 months, respectively (P = 0.245). Age < 2 years at implantation correlated with significantly lower valve survival rates (P < 0.001), while HC etiology showed no significant impact. Overdrainage alone accounted for more SA® revisions (39.8% vs. 3.1%, P < 0.001), while dysfunctions of the adjustment system represented the first cause of valve replacement in proSA® cohort (45.3%). The biomechanical analysis performed on 41 proSA® and 31 SA® showed deposits on the valve's internal surface in 97.6% and 90.3% of cases., Conclusion: Our comparative study between proSA® and SA® valves in pediatric HC demonstrated that both valves showed similar survival rates, regardless of etiology but only with young age at implantation. The programmability may be beneficial in preventing sequelae of chronic overdrainage but does not reduce need for valve revision and proSA® valve should be considered in selected cases in growing children older than 2 years., (© 2023. The Author(s).)

Objective: The prevalence of degenerative disorders of the spine, such as cervical spinal stenosis with cervical spine myelopathy (CSM) in the geriatric population, has rapidly increased worldwide. To date, there has been no systematic analysis comparing outcomes in older patients suffering from progressive CSM and undergoing surgery depending on their health insurance status. We sought to compare the clinical outcomes and complications after anterior cervical discectomy and fusion (ACDF) or posterior decompression with fusion in patients aged ≥ 65 years with multilevel cervical spinal canal stenosis and concomitant CSM with special focus on their insurance status., Methods: Clinical and imaging data were retrieved from patients' electronic medical records at a single institution between September 2005 and December 2021. Patients were allocated into two groups with respect to their health insurance status: statutory health insurance (SHI) vs. private insurance (PI)., Results: A total of 236 patients were included in the SHI group and 100 patients in the privately insured group (PI) group. The overall mean age was 71.7 ± 5.2 years. Regarding comorbidities, as defined with the age-adjusted CCI, SHI patients presented with higher rates of comorbidities as defined by a CCI of 6.7 ± 2.3 and higher prevalence of previous malignancies (9.3%) when compared to the PI group (CCI 5.4 ± 2.5, p = 0.051; 7.0%, p = 0.048). Both groups underwent ACDF (SHI: 58.5% vs. PI: 61.4%; p = 0.618), and the surgical duration was similar between both groups. Concerning the intraoperative blood transfusion rates, no significant differences were observed. The hospital stay (12.5 ± 1.1 days vs. 8.6 ± 6.3 days; p = 0.042) and intenisve care unit stay (1.5 ± 0.2 days vs. 0.4 ± 0.1 days; p = 0.049) were significantly longer in the PI group than in the SHI group. Similar in-hospital and 90-day mortality rates were noted across the groups. The presence of comorbidities, as defined with the age-adjusted CCI, poor neurological status at baseline, and SHI status, was significant predictor for the presence of adverse events, while the type of surgical technique, operated levels, duration of surgery, or blood loss was not., Conclusions: Herein, we found that surgeons make decisions independent of health insurance status and aim to provide the most optimal therapeutic option for each individual; hence, outcomes were similar between the groups. However, longer hospitalization stays were present in privately insured patients, while SHI patients presented on admission with poorer baseline status., (© 2023. The Author(s).)

Purpose: With the increasing role of molecular genetics in the diagnostics of intracranial tumors, delivering sufficient representative tissue for such analyses is of paramount importance. This study explored the rate of successful diagnosis after frame-based stereotactic biopsies of intracranial lesions., Methods: Consecutive patients undergoing frame-based stereotactic biopsies in 2020 and 2021 were included in this retrospective analysis. Cases were classified into three groups: conclusive, diagnosis with missing molecular genetics (MG) data, and inconclusive neuropathological diagnosis., Results: Of 145 patients, a conclusive diagnosis was possible in n = 137 cases (94.5%). For 3 cases (2.0%), diagnosis was established with missing MG data. In 5 cases (3.5%), an inconclusive (tumor) diagnosis was met. Diagnoses comprised mainly WHO 4 glioblastomas (n = 73, 56%), CNS lymphomas (n = 23, 16%), inflammatory diseases (n = 14, 10%), and metastases (n = 5, 3%). Methylomics were applied in 49% (n = 44) of tumor cases (panel sequencing in n = 28, 30% of tumors). The average number of specimens used for MG diagnostics was 5, while the average number of specimens provided was 15. In a univariate analysis, insufficient DNA was associated with an inconclusive diagnosis or a diagnosis with missing MG data (p < 0.001). Analyses of planned and implemented trajectories of cases with diagnosis with missing MG data or inconclusive diagnosis (n = 8) revealed that regions of interest were reached in almost all cases (n = 7)., Conclusion: Although stereotactic frame-based biopsies deliver a limited amount of tissue, they bear high histopathological and molecular genetic diagnostic yields. Given the proven surgical precision of the planned biopsy trajectories, optimizing surveyed lesion regions could help improve the rate of conclusive diagnoses., (© 2023. The Author(s).)

Study Design: Prospective study OBJECTIVES: The occurrence of adverse events (AEs) during surgery is a major cause of increased economic costs, disability, or even death. This study aimed to prospectively identify and quantify AEs in patients undergoing spinal surgery at a neurosurgical tertiary care hospital., Methods: Patients who underwent spinal surgery and were discharged between January 2019 and December 2022 were enrolled prospectively. Each patient underwent a peer-reviewed AE evaluation at discharge. An AE was defined as any event that occurred up to 30 days postoperatively and resulted in an undesirable outcome. Patients were allocated to four groups according to spinal pathology (degenerative, oncologic, traumatic, and infectious)., Results: During the study period, 1778 patients with a mean age of 55.4 ± 10.5 years underwent surgery. Elective surgery was performed in 90.8% (1615/1778) of patients, while emergency surgery was performed in 9.2% (163/1778). The overall rate of surgery-related AEs was relatively low (8.7%). Degenerative pathologies were the most frequent reasons for surgery (78.5%, 1396/1778). Wound infection was the most prevalent AE in patients with degenerative diseases (1.4%), of which 1.1% required revision surgery. Wound infection, dural leakage, and new neurological deficits had the same prevalence (2.1%) in patients with spinal tumors. Among patients with spinal trauma, two presented with postoperative epidural bleeding and underwent emergency surgery. Postoperative wound infection was the most prevalent AE in this group (9.5%), with 7.0% of affected patients requiring revision surgery. The overall rate of non-surgery-related AEs was 4.3%, and the overall mortality rate was low (0.4%)., Conclusion: AEs in spinal surgery remained low, with a prevalence of 8.7%. Documentation of AEs as part of clinical routine may be a key tool for identifying the occurrence of surgery-related and non-surgery-related AEs., (© 2023. The Author(s).)

Purpose: This study aimed to guide the more efficient management of type 4 and 5 thoracolumbar or lumbar osteoporotic fractures (OF) in patients aged 80 years and older with an acute onset of neurological decline. This aim was achieved by assessing the clinical course and morbidity and mortality rates and identifying potential risk factors for patient mortality METHODS: Electronic medical records were retrieved from a single institution pertaining to the period between September 2005 and December 2020. Data on patient demographics, neurological conditions, surgical characteristics, complications, hospital course, and 90-day mortality were also collected., Results: Over a 16-year period, 35 patients aged ≥80 years diagnosed with thoracolumbar and lumbar OF were enrolled in the study. The mean Charlson comorbidity index (CCI) was >6, indicating a poor baseline reserve (9.4 ± 1.9), while cardiovascular diseases were the most prevalent among comorbidities. The mean surgical duration was 231.6 ± 89.3 min, with a mean blood loss of 694.4± 200.3 mL. The in-hospital was 8.6% and 90-day mortality rates at 11.4%. Two patients underwent revision surgery for deep wound infection. Intraoperative and postoperative radiography and computed tomography (CT) imaging revealed correct screw placement. Proper alignment of the thoracolumbar spine was achieved in all the patients. Unique risk factors for mortality included the presence of comorbidities and the occurrence of postoperative complications., Conclusions: Emergent instrumentation in patients with acute onset of neurological decline and potentially unstable spines due to thoracolumbar and lumbar OF improved functional outcomes at discharge. Age should not be a determinant of whether to perform surgery., (© 2023. The Author(s).)

Introduction: Surgical intervention for management of spinal instability after traumatic subaxial fractures in octogenarians requires a clear consensus on optimal treatments. This study aimed to provide a guide for more efficient management through comparison and assessment of clinical outcomes and complications of anterior cervical discectomy and fusion with plate (pACDF) and posterior decompression fusion (PDF) instrumentation alone in patients aged 80 years., Methods: A single institution retrospective review of electronic medical records was undertaken between September 2005 and December 2021. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Logistic regression was used to identify potential risk factors for ACDF complications., Results: The rate of comorbidities were similarly high between the pACDF (n=13) and PDF (n=15) groups (pACDF: 8.7 ± 2.4 points vs. 8.5 ± 2.3 points; p=0.555). Patients in the PDF group had significantly longer surgical duration (235 ± 58.4 min vs. 182.5 ± 32.1 min; p<0.001) and significantly higher volumes of intraoperative blood loss (661.5 ± 100.1 mL vs. 487.5 ± 92.1 mL; p<0.001). The in-hospital mortality was 7.7% for the pACDF group and 6.7% for the PDF group. On day 90, the mortality rate increased in both groups from baseline (pACDF: 15.4% vs. PDF: 13.3; p>0.05). Motor scores (MS) improved significantly after surgery in both groups (pACDF: preOP MS: 75.3 ± 11.1 vs. postOP MS: 82.4 ± 10.1; p<0.05; PDF: preOP MS: 80.7 ± 16.7 vs. postOP MS: 89.5 ± 12.1; p<0.05). Statistically significant predictors for postoperative complications included longer operative times (odds ratio 1.2, 95% confidence interval 1.1-2.1; p=0.005) and larger volume of blood loss (odds ratio 1.5, 95% confidence interval 1.2-2.2; p=0.003)., Conclusions: Both pACDF and PDF can be considered safe treatment strategies for octogenarians with a poor baseline profile and subaxial fractures as they lead to patients substantial neurological improvements, and they are accompanied with low morbidity and mortality rates. Operation duration and intraoperative blood loss should be minimized to increase the degree of neurological recovery in octogenarian patients., (© 2023. The Author(s).)

Purpose: Cervical spinal epidural abscess (CSEA) is a rare condition, manifesting as rapid neurological deterioration and leading to early neurological deficits. Its management remains challenging, especially in patients older than 80 years. Therefore, we aimed to compare the clinical course and determine morbidity and mortality rates after anterior cervical discectomy and fusion (ACDF) versus corpectomy in octogenarians with ventrally located CSEA at two levels., Methods: In this single-center retrospective review, we obtained the following from electronic medical records between September 2005 and December 2021: patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality rate. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI)., Results: Over 16 years, 15 patients underwent ACDF, and 16 patients underwent corpectomy with plate fixation. Between the two groups, patients who underwent corpectomy had a significantly poorer baseline reserve (9.0 ± 2.6 vs. 10.8 ± 2.7; p = 0.004) and had a longer hospitalization period (16.4 ± 13.1 vs. 10.0 ± 5.3 days; p = 0.004) since corpectomy lasted significantly longer (229.6 ± 74.9 min vs. 123.9 ± 47.5 min; p < 0.001). Higher in-hospital and 90-day mortality and readmission rates were observed in the corpectomy group, but the difference was not statistically significant. Both surgeries significantly improved blood infection parameters and neurological status at discharge. Revision surgery due to pseudoarthrosis was required in two patients after corpectomy., Conclusions: We showed that both ACDF and corpectomy for ventrally located CSEA can be considered as safe treatment strategies for patients aged 80 years and above. However, the surgical approach should be carefully weighed and discussed with the patients and their relatives., (© 2023. The Author(s).)

Purpose: Fiber tracking (FT) is used in neurosurgical planning for the resection of lesions in proximity to fiber pathways, as it contributes to a substantial amelioration of postoperative neurological impairments. Currently, diffusion-tensor imaging (DTI)-based FT is the most frequently used technique; however, sophisticated techniques such as Q-ball (QBI) for high-resolution FT (HRFT) have suggested favorable results. Little is known about the reproducibility of both techniques in the clinical setting. Therefore, this study aimed to examine the intra- and interrater agreement for the depiction of white matter pathways such as the corticospinal tract (CST) and the optic radiation (OR)., Methods: Nineteen patients with eloquent lesions in the proximity of the OR or CST were prospectively enrolled. Two different raters independently reconstructed the fiber bundles by applying probabilistic DTI- and QBI-FT. Interrater agreement was evaluated from the comparison between results obtained by the two raters on the same data set acquired in two independent iterations at different timepoints using the Dice Similarity Coefficient (DSC) and the Jaccard Coefficient (JC). Likewise, intrarater agreement was determined for each rater comparing individual results., Results: DSC values showed substantial intrarater agreement based on DTI-FT (rater 1: mean 0.77 (0.68-0.85); rater 2: mean 0.75 (0.64-0.81); p = 0.673); while an excellent agreement was observed after the deployment of QBI-based FT (rater 1: mean 0.86 (0.78-0.98); rater 2: mean 0.80 (0.72-0.91); p = 0.693). In contrast, fair agreement was observed between both measures for the repeatability of the OR of each rater based on DTI-FT (rater 1: mean 0.36 (0.26-0.77); rater 2: mean 0.40 (0.27-0.79), p = 0.546). A substantial agreement between the measures was noted by applying QBI-FT (rater 1: mean 0.67 (0.44-0.78); rater 2: mean 0.62 (0.32-0.70), 0.665). The interrater agreement was moderate for the reproducibility of the CST and OR for both DSC and JC based on DTI-FT (DSC and JC ≥ 0.40); while a substantial interrater agreement was noted for DSC after applying QBI-based FT for the delineation of both fiber tracts (DSC > 0.6)., Conclusions: Our findings suggest that QBI-based FT might be a more robust tool for the visualization of the OR and CST adjacent to intracerebral lesions compared with the common standard DTI-FT. For neurosurgical planning during the daily workflow, QBI appears to be feasible and less operator-dependent., (© 2023. The Author(s).)

Purpose: Spontaneous spinal epidural hematoma (SSEH) is a rare but disabling disease. Although several cases have been reported in the literature, their treatment remains unclear, especially in patients with advanced age. We, therefore, aimed to describe the clinical outcomes of cervical SSEH in octogenarians with an acute onset of neurological illness undergoing laminectomy., Methods: Electronic medical records from a single institution between September 2005 and December 2020 were retrieved. Data on patient demographics, neurological conditions, functional status, surgical characteristics, complications, hospital course, and 90-day mortality were also collected., Results: Twenty-two patients aged ≥ 80 years with SSEH undergoing laminectomy were enrolled in this study. The mean Charlson comorbidity index was 9.1 ± 2.0, indicating a poor baseline reserve. Ten individuals (45.5%) were taking anticoagulant agents with a pathologic partial thromboplastin time (PTT) of 46.5 ± 3.4 s. Progressive neurological decline, as defined by the motor score (MS), was observed on admission (63.8 ± 14.0). The in-hospital and 90-day mortality were 4.5% and 9.1%, respectively. Notably, the MS (93.6 ± 8.3) improved significantly after surgery (p < 0.05). Revision surgery was necessary in 5 cases due to recurrent hematoma. Anticoagulant agents and pathological PTT are significant risk factors for its occurrence. Motor weakness and comorbidities were unique risk factors for loss of ambulation., Conclusions: Laminectomy and evacuation of the hematoma in octogenarians with progressive neurological decline induce clinical benefits. Emergent surgery seems to be the "state of the art" treatment for SSEH. However, potential complications associated with adverse prognostic factors, such as the use of anticoagulants, should be considered., (© 2022. The Author(s).)

Background: Pituitary tumors may cause compression of the optic chiasm, resulting in decreased visual acuity. Therefore, decompression of the optic chiasm is a major goal of surgical treatment in such patients. Quantitative pupillometry has been used in various clinical settings for assessing the optic system but has not been applied in patients with pituitary tumors. This study aimed to evaluate the potential of this technique to improve treatment modalities in patients undergoing surgical resection of pituitary tumors., Method: Pupillometry using the automated NPi 200® Pupillometer was performed in seven patients who underwent surgical resection of large pituitary tumors at the University of Heidelberg in 2018. The neurological pupil index (NPi) was assessed preoperatively and postoperatively, and correlations with visual acuity and magnetic resonance imaging (MRI) findings regarding optic chiasm compression were determined., Results: All patients experienced visual disturbance due to a large pituitary tumor. The NPi was < 4.0 in all patients in at least one pupil. Intraoperative MRI demonstrated successful decompression of the optic chiasm in all cases. Postoperatively, the NPi values increased, and this increase was correlated with improved visual acuity., Conclusions: We found that quantitative pupillometry can detect optic chiasm compression in patients with pituitary tumors. Furthermore, postoperative improvement of NPi values may indicate sufficient decompression of the optic chiasm. Further studies are warranted to substantiate the granularity of this technique to gain valuable information for patients with pituitary tumors who are indicated for surgery., (© 2022. The Author(s).)

Background: To examine published data and assess evidence relating to safety and efficacy of surgical management of symptomatic pineal cysts without hydrocephalus (nhSPC), we performed a systematic review of the literature and meta-analysis., Methods: Following the PRISMA guidelines, we searched Pubmed and SCOPUS for all reports with the query 'Pineal Cyst' AND 'Surgery' as of March 2021, without constraints on study design, publication year or status (PROSPERO&#95;CRD:42,021,242,517). Assessment of 1537 hits identified 26 reports that met inclusion and exclusion criteria., Results: All 26 input studies were either case reports or single-centre retrospective cohorts. The majority of outcome data were derived from routine physician-recorded notes. A total of 294 patients with surgically managed nhSPC were identified. Demographics: Mean age was 29 (range: 4-63) with 77% females. Mean cyst size was 15 mm (5-35). Supracerebellar-infratentorial approach was adopted in 90% of cases, occipital-transtentorial in 9%, and was not reported in 1%. Most patients were managed by cyst resection (96%), and the remainder by fenestration. Mean post-operative follow-up was 35 months (0-228)., Presentation: Headache was the commonest symptom (87%), followed by visual (54%), nausea/vomit (34%) and vertigo/dizziness (31%). Other symptoms included focal neurology (25%), sleep disturbance (17%), cognitive impairment (16%), loss of consciousness (11%), gait disturbance (11%), fatigue (10%), 'psychiatric' (2%) and seizures (1%). Mean number of symptoms reported at presentation was 3 (0-9)., Outcomes: Improvement rate was 93% (to minimise reporting bias only consecutive cases from cohort studies were considered, N = 280) and was independent of presentation. Predictors of better outcomes were large cyst size (OR = 5.76; 95% CI: 1.74-19.02) and resection over fenestration (OR = 12.64; 3.07-52.01). Age predicted worse outcomes (OR = 0.95; 0.91-0.99). Overall complication rate was 17% and this was independent of any patient characteristics. Complications with long-term consequences occurred in 10 cases (3.6%): visual disturbance (3), chronic incisional pain (2), sensory disturbance (1), fatigue (1), cervicalgia (1), cerebellar stroke (1) and mortality due to myocardial infarction (1)., Conclusions: Although the results support the role of surgery in the management of nhSPCs, they have to be interpreted with a great deal of caution as the current evidence is limited, consisting only of case reports and retrospective surgical series. Inherent to such studies are inhomogeneity and incompleteness of data, selection bias and bias related to assessment of outcome carried out by the treating surgeon in the majority of cases. Prospective studies with patient-reported and objective outcome assessment are needed to provide higher level of evidence., (© 2021. Crown.)

Background: The main objective of this study was to generate a hemodynamically stable swine model to detect spreading depolarizations (SDs) using electrocorticography (ECoG) and intrinsic optical signal (IOS) imaging and laser speckle flowmetry (LSF) after a 30-h middle cerebral artery (MCA) occlusion (MCAo) in German Landrace Swine., Methods: A total of 21 swine were used. The study comprised a training group (group 1, n = 7), a group that underwent bilateral craniectomy and MCAo (group 2, n = 10) and a group used for 2,3,5-triphenyltetrazolium (TTC) staining (group 3, n = 5)., Results: In group 2, nine animals that underwent MCAo survived for 30 h, and one animal survived for 12 h. We detected MCA variants with 2 to 4 vessels. In all cases, all of the MCAs were occluded. The intensity changes exhibited by IOS and LSF after clipping were closely correlated and indicated a lower blood volume and reduced blood flow in the middle cerebral artery territory. Using IOS, we detected a mean of 2.37 ± (STD) 2.35 SDs/h. Using ECoG, we detected a mean of 0.29 ± (STD) 0.53 SDs/h. Infarctions were diagnosed using histological analysis. TTC staining in group 3 confirmed that the MCA territory was compromised and that the anterior and posterior cerebral arteries were preserved., Conclusions: We confirm the reliability of performing live monitoring of cerebral infarctions using our MCAo protocol to detect SDs.

Background: Oral anticoagulants are commonly used in the ageing population and therefore, spine surgeons are increasingly confronted with anticoagulated patients requiring surgical therapy. 'Bridging therapies' with heparins are established in elective settings, but the time frame for haemostasis restoration may be too long for patients presenting with acute spinal pathology and impending disability. The goal of this study was to analyse the feasibility of prothrombin complex concentrate (PCC) administration to facilitate emergency spinal surgery in anticoagulated patients., Method: A retrospective analysis of the institutional database of neurosurgical patients receiving PCC from February 2007 to December 2013 (n = 485) identified 18 patients who received PCC prior to emergency spinal surgery. Clinical characteristics, as well as modalities of PCC administration and parameters of haemostasis were analysed. Furthermore, haemorrhagic complications and thromboembolic events in the further course were evaluated., Results: Spinal pathologies requiring urgent neurosurgical decompression were spinal haematoma (n = 9), spinal metastasis (n = 5), vertebral body fracture (n = 2), and disc herniation (n = 2). The mean international normalized ratio (INR) on admission was 2.27 ± 1.20 and after administration of PCC (mean: 1,944 ± 953 I.U.), INR significantly decreased to 1.12 ± 0.10 (p < 0.001). Emergency surgery was initiated within 4.4 h after PCC administration (range: 0-16.6 h). Postoperatively, symptoms improved in 12 patients (66.7 %). There were two deaths (11 %), one caused by acute myocardial infarction on the fourth postoperative day. Bleeding complications occurred in two patients (epidural haemorrhage n = 1, rectal tumour haemorrhage n = 1)., Conclusions: The administration of PCC facilitates emergency spinal surgery in anticoagulated patients who present with acute spinal pathology requiring urgent neurosurgical decompression. The risk of PCC-associated thromboembolic events seems to be low and justifies the use of PCC in order to avoid permanent disablement resulting from delayed surgery or non-operation.

Background: Cerebral autoregulation and, consequently, cerebrovascular pressure reactivity, can be disturbed after traumatic brain injury (TBI). Continuous monitoring of autoregulation has shown its clinical importance as an independent predictor of neurological outcome. The cerebral pressure reactivity index (PRx) reflects that changes in seconds of cerebrovascular reactivity have prognostic significance. Using an alternative algorithm similar to PRx, we investigate whether the utilization of lower-frequency changes of the order of minutes of mean arterial blood pressure (MAP) and intracranial pressure (ICP) could have a prognostic value in TBI patients., Materials and Methods: Head-injured patients requiring continued advanced multimodal monitoring, including hemodynamic, ICP and microdialysis (MD) monitoring, were analyzed retrospectively. A low-frequency sample pressure reactivity index (L-PRx) was calculated, using 20-min averages of MAP and ICP data as a linear Pearson's correlation. The mean values per patient were correlated to outcome at 6 months after injury. Differences of monitoring parameters between non-survivors and survivors were compared., Results: A total of 29 patients (mean age 37.2 years, 26 males) suffering from TBI were monitored for a mean of 109.6 h (16-236 h, SD ± 60.4). Mean L-PRx was found to be of 0.1 (-0.2 to 0.6, SD ± 0.20), six patients presented impaired (>0.2) values. The averaged L-PRx correlated significantly with ICP (r = 0.467, p = 0.011) and 6-month outcome (r = -0.556, p = 0.002). Significant statistical differences were found in L-PRx, cerebral perfusion pressure (CPP), lactate, and lactate-pyruvate ratio when comparing patients who died (n = 5) and patients who survived., Conclusions: L-PRx correlates with the 6-month outcome in TBI patients. Very slow changes of MAP and ICP may contain important autoregulation information. L-PRx may be an alternative algorithm for the estimation of cerebral autoregulation and clinical prognosis.

Background: Hemangiopericytomas (HPs) of the central nervous system are rare tumors and afflicted with a high propensity of recurrences and metastases. Histopathologically, HPs correspond to differentiated (WHO grade II) and anaplastic (WHO grade III) tumors. With respect to the available literature and our own experiences, the aggressiveness, especially of differentiated grade II HPs, seems to be underestimated., Methods: Thus, in this retrospective study, we describe tumor behavior and examined the effect of radio- and chemotherapy on tumor control with respect to the WHO classification of grade II and III neoplasms. This study consists of 15 patients with cerebral (n = 10) and spinal (n = 5) HPs., Results: Seven HPs were histopathologically classified as grade II and eight as anaplastic grade III tumors. Complete surgical resection could be achieved in 60% of cerebral and in 25% of spinal HPs. In total, local recurrences occurred in 20% of patients within 17.3 months after the primary operation. Recurrences occurred both from differentiated (n = 1) and anaplastic (n = 2) neoplasms. Treatment comprised re-operation followed by radio- and chemotherapy. Pointing out the importance of the extent of surgical resection, in this study, we could not detect a single patient showing any recurrences or systemic metastases after complete surgical resection of grade II HPs. During primary diagnostics, four patients showed systemic metastases. Although these tumors could be controlled via surgery, systemic metastases appeared in further four patients within 60.4 months. Interestingly, two of them were classified as differentiated tumors (WHO grade II). To control tumor progress, radiotherapy seemed to be partially effective. On the other hand, however, chemotherapy did not show any effect on tumor control. With respect to these results, screening investigations seem to be indispensable and are highly recommended during primary diagnostics and after the appearance of recurrences or metastases, independent of the histopathological staging of the tumor., Conclusion: With respect to our results, radical surgical resection offers the best treatment option to control tumor progress. In case of subtotal resection or histopathologically diagnosed anaplasia (WHO III), radiotherapy seems to be indicated; however, chemotherapy did not show effectiveness to control tumor progress.

Purpose: During the last winter season, some fatal sport injuries with severe traumatic brain injury (TBI) prompted major discussions about protective helmet use. Although ski helmets reportedly lead to a 60% decrease of risk to incur TBI, little is known about the distribution of helmet users and which factors are crucial for the decision to wear a helmet. Especially, it is unknown whether knowledge or experience concerning TBI in winter sports influences the use of helmets, as well as the attitude and opinion of people., Methods: Since treatment of TBI is a major field in neurosurgery, 55 neurosurgical departments (NS) in Germany, Switzerland and Austria were addressed and asked to answer anonymous questionnaires. A "non-trauma-educated" control cohort (NTP) was interviewed in ski resorts in Austria as well as sports equipment stores in Germany., Results: Questionnaires were returned by 465 NS and 546 NTP. Half of NS and NTP wore helmets in winter sports. Although some interviewees showed cognitive dissonant behaviour, experience in TBI after ski or snowboard accidents significantly affected the decision to wear helmets. After the fatal ski accidents, and increased media coverage 15.4% NS and 13.2% NTP bought their helmet. Furthermore, incidence of helmet use in children was correlated with the actual use and disposition of their parents to make the use of helmet compulsory., Conclusions: This study indicates that brain-trauma education affects ones attitude and opinion concerning protective helmet use in winter sports. However, without neglecting educational measures, emotional arguments should be added in the promotion of helmets to make them a popular integral part of winter sport outfits.

Background: Transorbital penetrating brain injuries are rare lesions without defined therapy standards., Clinical Presentation and Intervention: A male patient presented at our institution with a toilet brush handle in the right cerebral hemisphere. CT imaging identified the object entering the right orbit and having crossed the right hemisphere in the ventricular plane. After performing a medium-sized craniotomy, the object was removed step-by-step under monitoring with an intraoperative CT scan to ensure no involving major hemorrhage., Conclusion: Transorbital penetrating brain injuries are treated best by utilizing all up-to-date technical developments such as intraoperative CT-scanning to increase the safety in the management of such exceptional lesions with increased risk of immediate life-threatening intracranial bleeding.

Background: Volatile anesthetics reduce neuronal excitation and cerebral metabolism but can also increase intracellular water accumulation in normal and injured brains. While attenuation of neuronal excitation and glutamate release are beneficial under pathological conditions, any increase in edema formation should be avoided. In the present study we investigated duration-dependent effects of the commonly used isoflurane/nitrous oxide (N2O) anesthesia on EEG activity, specific NMDA receptor binding, extracellular, CSF, and plasma glutamate, and cerebral water content in brain-injured rats subjected to short (30 minutes) or prolonged (4 hours) anesthesia., Methods: Before controlled cortical impact injury (CCI), during prolonged (4-8 hours) or short anesthesia (7.5-8 hours after CCI), and before brain removal, changes in neuronal activity were determined by quantitative EEG analysis and glutamate was measured in arterial plasma. Brains were processed to determine acute and persisting changes in cerebral water content and 125I-Mk801 NMDA receptor binding at 8 and 32 hours after CCI, i.e., immediately or 24 hours after short or prolonged anesthesia. During prolonged anesthesia glutamate was measured via microdialysis within the cortical contusion. CSF was sampled before brain removal., Findings: Prolonged isoflurane (1.8 vol%) anesthesia significantly increased EEG activity, plasma, cortical extracellular, and CSF glutamate, cortical and hippocampal 125I-Mk801 NMDA receptor binding, and cerebral water content in brain-injured rats. These changes were partially reversible within 24 hours after prolonged anesthesia. At 24 hours, CSF glutamate was significantly reduced following long isoflurane anesthesia compared to rats previously subjected to short anesthesia despite an earlier significant increase. Conclusions. The partially reversible increases in EEG activity, 125I-Mk801 NMDA receptor binding, cerebral water content, plasma and CSF glutamate appear important for physiological, pathophysiological, and pharmacological studies requiring prolonged anesthesia with isoflurane. Increases in extracellular cortical and plasma glutamate could contribute to acute aggravation of underlying tissue damage.

The pineal hormone melatonin is a highly efficient physiological scavenger of free radicals involved in secondary brain damage. A variety of experimental studies have demonstrated a neuroprotective effect for melatonin, based on its antioxidant activity. The purpose of the present study was to investigate the time-dependency and a possible protective effect of exogenous melatonin in the cortical impact model in rats. The protective effect was quantified determining contusion volume, brain edema and brain water content. 45 anesthetized male Sprague-Dawley rats (250-350 mg) were subjected to cortical impact injury of moderate severity (7 m/s, deformation 2 mm). Melatonin (100 mg/kg bw i.p.), or a vehicle was injected 20 min before trauma, immediately after, and 1 and 2 hours after trauma during daytime and nighttime. Posttraumatic lesion volume using hematoxylin-eosin staining, hemispheric swelling, brain water content, cerebral perfusion pressure and intracranial pressure 24 hours after injury were investigated. Melatonin, given during nighttime, significantly reduced contusion volume corresponding to a mean reduction of contusion volume of 27% (placebo, n = 7: 41.9 +/- 5.2 mm3, melatonin, n = 8: 30.5 +/- 4.2 mm3, p < 0.05). Given during daytime, the reduction in contusion volume was not significant (placebo, n = 8: 42.1 +/- 5.1 mm3, melatonin, n = 8: 35.9 +/- 2.2 mm3, reduction of 15%, p = 0.08, n.s.). Hemispheric swelling was unchanged by melatonin treatment. Mean arterial blood pressure and rectal temperature remained stable before and after the cortical impact injury and injection of melatonin. This study shows that melatonin significantly reduces contusion volume with major effects during night.

Monitoring of comatose patients in the neurosurgical intensive care unit (NICU) is constantly extended by the development of new methods for monitoring of cerebral function, metabolism and oxygenation. To simplify the interpretation of the rising number of parameters, and to avoid data overflow, a multimodal cerebral monitoring (MCM) system has been developed for the acquisition, display, on-line analysis and recording of physiological parameters from multiple bedside data sources. This article describes the technical details and the design of this computerized data acquisition system for variable applications in clinical patient monitoring and research. A Windows (Microsoft Corporation, Redmont, Washington) platform was equipped with an analog/digital converter board. Software for multimodal cerebral monitoring was developed using LabVIEW for Windows (National Instruments, Austin, Texas), a graphical programming system. Two software modules were created: One for the automatic acquisition of data, display of time dependent trend graphs, processing of on-line histograms, special functions for research, and storage of data in compatible format. The other module serves as an off-line monitor to display recorded data in various modalities. The MCM system has been used in 30 comatose patients with severe head injury. Mean time of MCM is 5.3 days (+/- 2.8 days), resulting in a total running time of the system of about 3800 hrs. Hardware and software proved to run stable and safe. The MCM system has become a valuable tool for monitoring of comatose patients. The simultaneous display of trend graphs of various monitoring parameters and the online processing of histograms improved the survey of the patient's condition in the ICU. Recorded data were analysed offline and contribute to a consecutively increasing data bank.