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Contains fulltext : 231716.pdf (Publisher’s version ) (Closed access) BACKGROUND: Scientific research can offer the joy of discovery. For many graduating neurosurgeons, often, a seminar, class, or instructional module is their first and only formal exposure to the world of conducting research responsibly, to write down and report the results of such research. The pressure to publish scientific research is high, but any young neurosurgeon who is unaware of how predatory publishers operate can get duped by it and can lose their valuable and hard-fought research. Hence, we have attempted to provide an overview of all potentially predatory neurosurgery publications and provide some "red flags" to recognize them. METHODS: A suspected list of predatory publications was collected via a thorough review of the Neurosurgery journals listed in 4 major so-called blacklists, i.e., Beall's list, Manca's list, Cabell's blacklist, and Strinzel blacklist and then cross-referenced with UGC CARE whitelist to remove any potential legitimate journals. All journals with a scope of the Neurosurgery publication were searched using terms in the search bar: "Neurosurgery", "Neuroanatomy", "Neuropathology", and "Neurological disorder/disease". Since all predatory journals claim to be open access, all possible types of open access journals on Scimago were also searched, and thus a comparison was possible in terms of publication cost and number of legitimate open access journals when compared with predatory ones. In addition, methodologies by which these journals penetrate legitimate indexes like PubMed was investigated. RESULTS: A total of 46 predatory journals were found and were enlisted along with their publishers and web addresses. Sixty of the 360 Neurosurgery journals listed on Scimago were open access and the fee for the predatory journals was substantially lower (

OBJECTIVE Colloid cysts (CCs) are rare at all ages, and particularly among children. The current literature on pediatric CC is limited, and often included in mixed adult/pediatric series. The goal of this multinational, multicenter study was to combine forces among centers and investigate the clinical course of pediatric CCs. METHODS A multinational, multicenter retrospective study was performed to attain a large sample size, focusing on CC diagnosis in patients younger than 18 years of age. Collected data included clinical presentation, radiological characteristics, treatment, and outcome. RESULTS One hundred thirty-four children with CCs were included. Patient age at diagnosis ranged from 2.4 to 18 years (mean 12.8 ± 3.4 years, median 13.2 years, interquartile range 10.3–15.4 years; 22% were < 10 years of age). Twenty-two cases (16%) were diagnosed incidentally, including 48% of those younger than 10 years of age. Most of the other patients had symptoms related to increased intracranial pressure and hydrocephalus. The average follow-up duration for the entire group was 49.5 ± 45.8 months. Fifty-nine patients were initially followed, of whom 28 were eventually operated on at a mean of 19 ± 32 months later due to cyst growth, increasing hydrocephalus, and/or new symptoms. There was a clear correlation between larger cysts and symptomatology, acuteness of symptoms, hydrocephalus, and need for surgery. Older age was also associated with the need for surgery. One hundred three children (77%) underwent cyst resection, 60% using a purely endoscopic approach. There was 1 death related to acute hydrocephalus at presentation. Ten percent of operated patients had some form of complication, and 7.7% of operated cases required a shunt at some point during follow-up. Functional outcome was good; however, the need for immediate surgery was associated with educational limitations. Twenty operated cases (20%) experienced a recurrence of their CC at a mean of 38 ± 46 months after the primary surgery. The CC recurrence rate was 24% following endoscopic resection and 15% following open resections (p = 0.28). CONCLUSIONS CCs may present in all pediatric age groups, although most that are symptomatic present after the age of 10 years. Incidentally discovered cysts should be closely followed, as many may grow, leading to hydrocephalus and other new symptoms. Presentation of CC may be acute and may cause life-threatening conditions related to hydrocephalus, necessitating urgent treatment. The outcome of treated children with CCs is favorable.

Purpose: The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis. Methods: We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24 months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex. Results: Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12 months and 3 years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12 months (0.52 vs 0.44; p = 0.002) and 3 years (0.46 vs 0.38; p = 0.03) of follow-up. Conclusion: ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3 years following treatment.

BACKGROUND Acta Neurochirurgica, (ANCH) and World Neurosurgery (WN), are two journals of significant importance in the neurosurgical community and have been associated with international federations. Of note is that these journals carry a similar impact factor. The difference is the years they have been active (ANCH starting publications in 1973 and WN in 2010). This allows for a unique opportunity to delve deep into comparative, scientometric parameters, to understand the evolution of neurosurgical research. METHODS A title specific search of the Web of Science database using the keywords ‘ACTA NEUROCHIRURGICA’, ‘Acta’ and ‘Neurochirurgica’; ‘World Neurosurgery’; ‘World’ and ‘Neurosurgery’ was done and arranged according to number of citations. Title of the articles, authors, corresponding authors, country of origin, journal of publication, year of publication, citation count and the journal impact factor were assessed. RESULTS The average citation for ANCH was 170.1 citations, majority being original articles (83/100). The articles of WN, garnered nearly 70.48 citations, averaging 8.3 citations per publication. Most corresponding authors in Acta originated from Germany with Neuro-oncology, followed by Neurotrauma and Vascular as subjects. In contrast the United States of America followed by China were the most common countries of origin for WN with ‘Endoscopy’ and ‘Skull-base’ being the topics achieving high impact. CONCLUSIONS Neurotrauma and consensus guidelines have been shown to have maximal citations for ANCH while Endoscopy and Skull-base lesions garnered the most for WN. Author subspecialisation and increased collaboration across specialities with more articles on refinement of technique and outcome have emerged as recent trends.

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Background Predicting outcome after aneurysmal subarachnoid hemorrhage (aSAH) is known to be challenging and complex. Machine learning approaches, of which feedforward artificial neural networks (ffANNs) are the most widely used, could contribute to the patient-specific outcome prediction. Objective To investigate the prediction capacity of an ffANN for the patient-specific clinical outcome and the occurrence of delayed cerebral ischemia (DCI) and compare those results with the predictions of 2 internationally used scoring systems. Methods A prospective database was used to predict (1) death during hospitalization (ie, mortality) (n = 451), (2) unfavorable modified Rankin Scale (mRS) at 6 mo (n = 413), and (3) the occurrence of DCI (n = 362). Additionally, the predictive capacities of the ffANN were compared to those of Subarachnoid Haemorrhage International Trialists (SAHIT) and VASOGRADE to predict clinical outcome and occurrence of DCI. Results The area under the curve (AUC) of the ffANN showed to be 88%, 85%, and 72% for predicting mortality, an unfavorable mRS, and the occurrence of DCI, respectively. Sensitivity/specificity rates of the ffANN for mortality, unfavorable mRS, and the occurrence of DCI were 82%/80%, 94%/80%, and 74%/68%. The ffANN and SAHIT calculator showed similar AUCs for predicting personalized outcome. The presented ffANN and VASOGRADE were found to perform equally with regard to personalized prediction of occurrence of DCI. Conclusion The presented ffANN showed equal performance when compared with VASOGRADE and SAHIT scoring systems while using less individual cases. The web interface launched simultaneously with the publication of this manuscript allows for usage of the ffANN-based prediction tool for individual data (https://nutshell-tool.com/).

Background Spinal dysraphism with a hamartomatous growth (appendix) of the spinal cord is better known as herniated spinal cord. There are many arguments in favour of considering it a developmental defect. From this point of view, it is a type of neural tube disorder. Neural tube disorders can be caused by multiple factors, including a genetic factor. A common genetic defect in patients with a spinal dysraphism with a hamartomatous growth of the spinal cord is sought for. Case presentation In two patients with a symptomatic lesion and referred to an academic hospital a genetic analysis was performed after informed consent. Whole-exome analysis was performed. : Whole-exome analysis did not result in identification of a clinically relevant genetic variant. Conclusions This the first study to investigate the genetic contribution to spinal dysraphism with a hamartomatous growth (appendix) of the spinal cord. We could not establish a genetic cause for this entity. This conclusion cannot be definitive due to the small sample size. However, the incidental occurrence, the lack of reports of inheritance of this disorder and the absence of contribution to syndromal disorders favours a defect of normal development of the spinal cord.

Item does not contain fulltext BACKGROUND: Stent-assisted coiling (SAC) is increasingly being performed as intervention for wide-neck intracranial aneurysms. The NeuroForm Atlas Stent (CE-marked; Stryker, Kalamazoo, Michigan) is relatively new. OBJECTIVE: To evaluate the effectiveness and safety of NeuroForm Atlas SAC for intracranial aneurysms in the first such study. METHODS: We retrospectively analyzed data from all patients treated with the NeuroForm Atlas SAC of an intracranial aneurysm, both ruptured and unruptured, between June 2015 and December 2016. Primary end-points were favorable clinical outcomes (modified Rankin scale score 0-2) and successful aneurysm occlusion (Raymond-Roy class I/II), both at 6-mo follow-up. Secondary end-points were the occurrence of intervention-related complications leading to permanent neurological deficit, the occurrence of intervention-related stroke and neurological death, immediate aneurysm occlusion, rupture (or rerupture) of the aneurysm, and recanalization. RESULTS: Twenty-seven consecutive patients, 10 with ruptured saccular wide-neck aneurysms, were treated with NeuroForm Atlas SAC. At 6-mo follow-up, 18/26 (69.2%) survivors had successful aneurysm occlusion and 22/26 (84.6%) had favorable clinical outcome. One patient had died of a cause unrelated to treatment. No intervention-related complications leading to permanent neurological deficit occurred. However, intraprocedural thromboembolic complications occurred in 4/27 patients (14.8%), and ischemic stroke related to treatment occurred in 4/26 (15.4%). No hemorrhagic complications were observed. CONCLUSION: NeuroForm Atlas SAC is a feasible way to treat ruptured and unruptured wide-neck aneurysms that are not amenable to conventional coiling or clipping. Aneurysm occlusion and favorable clinical outcome are consistent with previously reported rates for SAC of wide-neck aneurysms with other devices.

Contains fulltext : 190805.pdf (Publisher’s version ) (Open Access) BACKGROUND: It is unclear which patients have the greatest risk of developing complications in the first days after endoscopic transsphenoidal pituitary surgery (ETS) and how long patients should stay hospitalized after surgery. The objective of this study is to identify which patients are at risk for early postoperative medical and surgical reinterventions to optimize the length of hospitalization. METHODS: The medical records of 146 patients who underwent ETS for a pituitary adenoma between January 2013 and July 2016 were reviewed retrospectively. Data were collected on baseline patient-related characteristics, characteristics of the pituitary adenoma, perioperative complications and interventions, and postoperative outcomes. Patients who underwent additional interventions on days 2, 3, and 4 after ETS were identified as cases, and patients who did not have any interventions after day 1 postoperatively were identified as controls. RESULTS: Diabetes mellitus (odds ratio [OR], 4.279; 95% confidence interval [CI], 1.149-15.933; P = 0.03), incomplete adenoma resection (OR, 2.840; 95% CI, 1.228-6.568; P = 0.02) and increased morning sodium concentration on day 2 after surgery (OR, 5.211; 95% CI, 2.158-12.579; P

Contains fulltext : 237739.pdf (Publisher’s version ) (Open Access) BACKGROUND: Detection of multiple intracranial aneurysms (MIAs) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is common and the optimal management of the additional unruptured intracranial aneurysms (UIA) is often a matter of debate. We calculate the incidence and the factors associated with subsequent aSAHs from untreated additional aneurysms in a single-center group of patients with aSAH and MIAs. METHODS: Charts of patients with MIAs admitted to our neurosurgery department for aSAH between January 2000 and March 2020 were retrospectively reviewed. Incidence rate and factors associated with subsequent aSAHs were calculated with univariable and multivariable analyses. RESULTS: Of the unruptured aneurysms, 50% were preventively treated. During a median follow-up of 3 years, 20 of 174 patients (11.5%) presented with a second aSAH. Incidence of rupture of an additional untreated aneurysm was 18.05 per 1000 person/years (confidence interval, 10.69-30.47). Rupture incidence of an additional aneurysm located in the anterior circulation was 32.70 per 1000 person/years and 40.73 per 1000 person/years in the posterior circulation. Presence of untreated mirror and de novo aneurysms increased the risk of overall subsequent aSAHs by 16.9-fold and 7.6-fold, respectively. Most untreated additional aneurysms causing a subsequent aSAH were smaller than 7 mm (73.3%), with middle cerebral artery being the most frequent location (40.0%). CONCLUSIONS: Incidence of subsequent aSAHs is high in patients with aSAH-MIA. Untreated mirror and de novo aneurysms are associated with higher rupture risk. Longer follow-up and prophylactic treatment of asymptomatic aneurysms at higher rupture risk are recommended to prevent the significant poor outcome of subsequent aSAHs.

Background and purposeFlow diverters are sometimes used in the setting of acutely ruptured aneurysms. However, thromboembolic and hemorrhagic complications are feared and evidence regarding safety is limited. Therefore, in this multicenter study we evaluated complications, clinical, and angiographic outcomes of patients treated with a flow diverter for acutely ruptured aneurysms.MethodsWe conducted a retrospective observational study of 44 consecutive patients who underwent flow diverter treatment within 15 days after rupture of an intracranial aneurysm at six centers. The primary end point was good clinical outcome, defined as modified Rankin Scale score (mRS) 0–2. Secondary endpoints were procedure-related complications and complete aneurysm occlusion at follow-up.ResultsAt follow-up (median 3.4 months) 20 patients (45%) had a good clinical outcome. In 20 patients (45%), 25 procedure-related complications occurred. These resulted in permanent neurologic deficits in 12 patients (27%). In 5 patients (11%) aneurysm re-rupture occurred. Eight patients died resulting in an all-cause mortality rate of 18%. Procedure-related complications were associated with a poor clinical outcome (mRS 3–6; OR 5.1(95% CI 1.0 to 24.9), p=0.04). Large aneurysms were prone to re-rupture with rebleed rates of 60% (3/5) vs 5% (2/39) (p=0.01) for aneurysms with a size ≥20 mm and ConclusionFlow diverter treatment of ruptured intracranial aneurysms was associated with high rates of procedure-related complications including aneurysm re-ruptures. Complications were associated with poor clinical outcome. In patients with available angiographic follow-up, a high occlusion rate was observed.

Contains fulltext : 193435.pdf (Publisher’s version ) (Open Access) BACKGROUND: Idiopathic ventral herniation of the spinal cord is rarely seen as a cause of gradually increasing neurologic deficit. Its cause has never been clarified. It could be the result of a developmental disorder at 30- to 60-day gestational age. Neuropathologic analysis of herniated spinal cord tissue could probably support this hypothesis. CASE DESCRIPTION: In a patient suffering from idiopathic ventral herniation of the spinal cord, a biopsy was performed in order to reduce the space-occupying effect. The biopsy was taken while intraoperative neuromonitoring was used. The patient recovered uneventfully without any additional deficit. Tissue analysis included histopathologic, immunohistochemical, and molecular examination (methylation profiling). The tissue did not appear as a normally functioning spinal cord; instead, a non-neoplastic glio-(neuronal) proliferation was found. CONCLUSION: These findings support a developmental disorder as a cause for idiopathic ventral spinal cord herniation.

Item does not contain fulltext BACKGROUND: Patients with complaints of carpal tunnel syndrome (CTS) with signs and symptoms not exclusively confined to the median nerve territory, but otherwise fulfilling the clinical criteria may erroneously be withheld from therapy. METHODS: One hundred and twenty one patients who fulfilled the clinical criteria for the diagnosis of CTS with signs and symptoms restricted to the median nerve territory (group A) and 91 patients without this restriction (group B) were included in a prospective cohort study. All patients fulfilled electrodiagnostic criteria of CTS. Outcome was determined after 7 to 9 months by means of Symptom Severity Score (SSS) and Functional Status Score (FSS) according to Levine and a patient satisfaction questionnaire. RESULTS: Response rates were 81.8% (group A) and 82.4% (group B). All patients in group B had sensory symptoms involving digit 5. There were no significant differences in improvement of SSS, FSS and patient satisfaction scores between groups after treatment. CONCLUSION: CTS patients with characteristic sensory signs and symptoms not exclusively restricted to the median nerve innervated area should be treated in the same manner as patients with CTS symptoms restricted to the median nerve innervated area and should therefore not be withheld from surgical treatment.

Object Increasing evidence exists that treatment of complex medical conditions in high-volume centers is found to improve outcome. Patients with subarachnoid hemorrhage (SAH), a complex disease, probably also benefit from treatment at a high-volume center. The authors aimed to determine, based on published literature, whether a higher hospital caseload is associated with improved outcomes of patients undergoing treatment after aneurysmal subarachnoid hemorrhage. Methods The authors identified studies from MEDLINE, Embase, and the Cochrane Library up to September 28, 2012, that evaluated outcome in high-volume versus low-volume centers in patients with SAH who were treated by either clipping or endovascular coiling. No language restrictions were set. The compared outcome measure was in-hospital mortality. Mortality in studies was pooled in a random effects meta-analysis. Study quality was reported according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria. Results Four articles were included in this analysis, representing 36,600 patients. The quality of studies was graded low in 3 and very low in 1. Meta-analysis using a random effects model showed a decrease in hospital mortality (OR 0.77 [95% CI 0.60–0.97]; p = 0.00; I2 = 91%) in high-volume hospitals treating SAH patients. Sensitivity analysis revealed the relative weight of the 1 low-quality study. Removal of the study with very low quality increased the effect size of the meta-analysis to an OR of 0.68 (95% CI 0.56–0.84; p = 0.00; I2 = 86%). The definition of hospital volume differed among studies. Cutoffs and dichotomizations were used as well as division in quartiles. In 1 study, low volume was defined as 9 or fewer patients yearly, whereas in another it was defined as fewer than 30 patients yearly. Similarly, 1 study defined high volume as more than 20 patients annually, and another defined it as more than 50 patients a year. For comparability between studies, recalculation was done with dichotomized data if available. Cross et al., 2003 (low volume ≤ 18, high volume ≥ 19) and Johnston, 2000 (low volume ≤ 31, high volume ≥ 32) provided core data for recalculation. The overall results of this analysis revealed an OR of 0.85 (95% CI 0.72–0.99; p = 0.00; I2 = 87%). Conclusions Despite the shortcomings of this study, the mortality rate was lower in hospitals with a larger caseload. Limitations of the meta-analysis are the not uniform cutoff values and uncertainty about case mix.

Contains fulltext : 137088.pdf (Publisher’s version ) (Closed access) BACKGROUND: Several studies have included different co-morbid conditions in prediction models for stroke patients. For subarachnoid haemorrhage (SAH), it is not known whether the Charlson Co-morbidity Index (CCI) is associated with outcome. We evaluated if this index was associated with outcome in patients with ruptured intracerebral aneurysms. METHODS: The data of all consecutive aneurysmal SAH (aSAH) patients treated at the Radboudumc, Nijmegen, The Netherlands and entered in the database were retrospectively analysed. Clinical condition at admission was recorded using the WFNS (World Federation of Neurological Surgeons Grading System) grade was collected, as were the age and treatment modality. The burden of co-morbidity was retrospectively registered using the CCI. Outcome was dichotomised on the modified Rankin Scale (mRS; 0-2, favourable outcome; 3-6, unfavourable outcome). A binary logistic regression analysis was performed. RESULTS: Between 6th May 2008 and 31st July 2013, 457 patients were admitted because of non-traumatic SAH (aSAH). Seventy-seven (16.8 %) patients had no aneurysm. Of the 380 patients with aSAH, information on co-morbid conditions was available for 371 patients. Thirty-six of those 371 had no treatment because of: bad clinical condition in 34 (9.2 %), a non-treatable dissecting aneurysm in 1 (0.3 %) and the explicit wishes of another. Co-morbidity was present in 113 (31.5 %) patients. Binary logistic regression analysis revealed no added value of using the CCI in predicting the outcome (p = 0.91). CONCLUSIONS: This study reports that the CCI is not associated with the outcome classified on the mRS at 6 months in patients after aSAH. The CCI has no added value in case-mix correction.

The surgical treatment of spinal metastases is evolving. The major problem is the selection of patients who may benefit from surgical treatment. One of the criteria is an expected survival of at least 3 months. A prediction model has been previously developed. The present study has been performed in order to validate externally the model and to demonstrate that this model can be generalized to other institutions and other countries than the Netherlands. Data of 356 patients from five centers in Germany, Spain, Sweden, and the Netherlands who were treated for metastatic epidural spinal cord compression were collected. Hazard ratios in the test population corresponded with those of the developmental population. However, the observed and the expected survival were different. Analysis revealed that the baseline hazard function was significantly different. This tempted us to combine the data and develop a new prediction model. Estimating iteratively, a baseline hazard was composed. An adapted prediction model is presented. External validation of a prediction model revealed a difference in expected survival, although the relative contribution of the specific hazard ratios was the same as in the developmental population. This study emphasized the need to check the baseline hazard function in external validation. A new model has been developed using an estimated baseline hazard

Item does not contain fulltext We present a case of a growing skull fracture in adult male, with an interval of 43 years after initial trauma. This finding is extremely rare, especially because growing skull fractures are mostly seen as an uncommon complication of pediatric head trauma with calvarial fracture. In our patient, this finding was incidental, existed for many years, and had no clinical consequences. Therefore, we advised a conservative treatment for our patient.

Contains fulltext : 52398.pdf (Publisher’s version ) (Closed access) BACKGROUND: The surgical treatment of spinal epidural metastasis is evolving. To be a surgical candidate, a patient should have a life expectancy of at least 3 months. Estimation of survival by experienced specialists has proven to be unreliable. METHODS: The Cox proportional hazards model was used to make a prediction model. To validate the model, Efron optimism correction by bootstrapping was performed. Retrospective data of patients treated for a spinal metastasis were used. Possible predictive factors were defined based on clinical experience and the literature. Statistical methods and clinical knowledge were also used to reveal an optimal set of predictors of survival. Data from patients treated at the Department of Radiation Oncology for spinal metastasis between 1998 and 2005 were evaluated. RESULTS: The case notes of 219 patients form the base of this study. In the final model, only 5 variables were required to predict the survival of a patient with spinal metastasis: sex, location of the primary lesion, intentional curative treatment of the primary tumor, cervical location of the spinal metastasis, and Karnofsky performance score. Examples with different predictors are given. The R(2) (N) index of Nagelkerke was 0.36 (95% confidence interval [95% CI], 0.28-0.48) and the c-index 0.72 (95% CI, 0.68-0.77). CONCLUSIONS: A reliable and simple model with which to predict the survival of a patient with spinal epidural metastasis is presented. Without the need for extensive investigations, survival can be predicted and only 5 easily obtainable parameters are required.

Contains fulltext : 49790.pdf (Publisher’s version ) (Closed access) OBJECTIVE: To describe the different imaging modalities used for the diagnosis and classification of hydrocephalus, their role in defining the optimal treatment of hydrocephalus and to define the optimal preoperative diagnostics for endoscopic third ventriculocisternostomy (ETV). METHODS: An overview on available imaging modalities for hydrocephalus will be given and their pros and cons discussed. In addition, different aspects of the treatment of hydrocephalus by shunts and by ETV will be highlighted. DISCUSSION: The role of the technical aspects of performing an ETV, the role of the surgeon's philosophy, the role of the urgency of the procedure, and the role of informed consent on the requirements for the imaging of the hydrocephalus will be discussed. CONCLUSION: The authors conclude that MRI is a conditio sine qua non for ETV in elective surgical cases.

OBJECTIVE: To describe a new endoscope shaft developed for suction-aspiration during endoscopic transsphenoidal pituitary surgery. METHODS: A custom-made shaft for a Wolf endoscope (Richard Wolf GmbH, Knittlingen, Germany) was developed with a height of 10 mm and a width of 5 mm, allowing an additional working channel for the endoscope for flexible suction tubes with a diameter of up to 10-French. RESULTS: The new shaft was used in 30 consecutive endoscopic transsphenoidal procedures for pituitary adenomas. It allowed true bimanual manipulation without having to fixate the endoscope. Tumor removal was facilitated, technical problems were not encountered, and operation time was reduced. There were no instrumentation-related complications. CONCLUSION: The new shaft improves the ergonomics of endoscopic transsphenoidal pituitary surgery in cases in which the endoscope is handheld.

Contains fulltext : 48133.pdf (Publisher’s version ) (Closed access) OBJECTIVE: A randomized controlled trial was reported recently, in which simple decompression and anterior subcutaneous transposition were compared for treatment of ulnaropathy at the elbow. Clinically, both surgical options seem to be equally effective. The objective of this study is to compare the costs, from a societal standpoint, of simple decompression versus anterior subcutaneous transposition in Euros. METHODS: Published and unpublished data from a randomized controlled trial that compared simple decompression and anterior subcutaneous transposition were used. The investigators tabulated the actual costs incurred for professional fees, use of the operating room, duration of sick leave, reintervention, and treatment of complications directly related to the surgical treatment. RESULTS: The total costs per group and per patient were statistically significantly less for those treated with simple decompression. The total median costs per patient were 1124 Euros for simple decompression and 2730 Euros for anterior subcutaneous transposition. The main difference was in the costs related to sick leave, which is significantly shorter for simple decompression. There also was a statistically significant difference in operation time in favor of simple decompression. A remarkable finding was that paid workers in both treatment groups returned to work much later than unpaid workers. CONCLUSION: Although clinically equally effective, simple decompression was associated with lower cost than anterior subcutaneous transposition for the treatment of ulnar neuropathy at the elbow. Compared with anterior subcutaneous transposition, we recommend simple decompression for the treatment of idiopathic ulnar neuropathy at the elbow.

OBJECT Aneurysmal rerupture prior to treatment is a major cause of death and morbidity in aneurysmal subarachnoid hemorrhage. Recognizing risk factors for aneurysmal rebleeding is particularly relevant and might help to identify the aneurysms that benefit from acute treatment. It is uncertain if the size of the aneurysm is related to rebleeding. This meta-analysis was performed to evaluate whether an association could be determined between aneurysm diameter and the rebleeding rate before treatment. Potentially confounding factors such age, aneurysm location, and the presence of hypertension were also evaluated. METHODS The authors systematically searched the PubMed, Embase, and Cochrane databases up to April 3, 2013, for studies of patients with aneurysmal subarachnoid hemorrhage that reported the association between aneurysm diameter and pretreatment aneurysmal rebleeding. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria were used to evaluate study quality. RESULTS Seven studies, representing 2121 patients, were included in the quantitative analysis. The quality of the studies was low in 2 and very low in 5. Almost all of the studies used 10 mm as the cutoff point for size among other classes, and only one used 7 mm. An analysis was performed with this best unifiable cutoff point. Overall rebleeding occurred in 360 (17.0%) of 2121 patients (incidence range, from study to study, 8.7%–28.4%). The rate of rebleeding in small and large aneurysms was 14.0% and 23.6%, respectively. The meta-analysis of the 7 studies revealed that larger size aneurysms were at a higher risk for rebleeding (OR 2.56 [95% CI 1.62–4.06]; p = 0.00; I2 = 60%). The sensitivity analysis did not alter the results. Five of the 7 studies reported data regarding age; 4 studies provided age-adjusted results and identified a persistent relationship between lesion size and the risk of rebleeding. The presence of hypertension was reported in two studies and was more prevalent in patients with rebleeding in one of these. Location (anterior vs posterior circulation) was reported in 5 studies, while in 4 there was no difference in the rebleeding rate. One study identified a lower risk of rebleeding associated with posterior location aneurysms. CONCLUSIONS This meta-analysis showed that aneurysm size is an important risk factor for aneurysmal rebleeding and should be used in the clinical risk assessment of individual patients. The authors' results confirmed the current guidelines and underscored the importance of acute treatment for large ruptured aneurysms.

Objective and importance: Although aneurysms of the anterior inferior cerebellar artery (AICA) are rare lesions, their occurrence in combination with high-flow lesions in the same arterial territory is even more striking. Two cases of an AICA aneurysm in combination with a high-flow lesion are described. Clinical presentation: In one case, a 52-year-old female presented with cerebellar syndrome as the result of a left-sided cerebellar tumor. Angiography revealed a highly vascularized tumor and a broad-based aneurysm at the offspring of the left AICA. In the second case, a 17-year-old female presented with a right-sided cerebellar hemorrhage. Angiography revealed a large peripheral AICA aneurysm and a distal arteriovenous malformation (AVM) fed by the AICA. Intervention: In the first case, a left lateral suboccipital craniotomy was performed and a highly vascularized tumor was removed. The AICA aneurysm could not be adequately clipped and was subsequently wrapped with muscle and reinforced with fibrin glue. Pathological examination of the tumor revealed a hemangioblastoma. Five years after surgery, the patient experienced a subarachnoid hemorrhage. Subsequent vertebral angiography revealed local enlargement of the known AICA aneurysm just at the superior aspect, but the patient refused further treatment. In the second case, the patient sustained a novel cerebellar rebleed while awaiting surgery, A right-sided lateral retromastoid suboccipital craniotomy was performed and the AICA aneurysm could be successfully clipped. More peripherally, the AVM with two draining veins could be totally removed. Postoperative angiography revealed no residual aneurysm or AVM. Conclusion: Several aspects of these cases are discussed, such as the rare occurrence of AICA aneurysm and the contribution of high-flow lesions to the genesis of the AICA aneurysms. (C) 2002, Elsevier Science Ltd. All rights reserved.

In the 1980s and 1990s, several authors suggested an endoscopic approach to the cerebellopotine angle, but it is only more recently that the technical and operative conditions for successful endoscopy could be met. The retrosigmoid approach provides simple and direct access to the cerebellopontine zone. The endoscope, owing to distal light and panoramic view, provides excellent illumination of a wide visual field within this anatomic site particularly rich in neurovascular structures. The endoscope expands the view inside the cerebellopontine angle without touching the cerebellum or the brainstem and allows clear identification of the vascular and nervous components crossing the cerebellopontine angle. The addition of endoscopic techniques during microvascular decompression surgery is a key point to ensure a safe way to recognize the offending vessels.

Contains fulltext : 88462.pdf (Publisher’s version ) (Closed access) 01 juni 2010

Increasing evidence exists that treatment of complex medical conditions in high-volume centers is found to improve outcome. Patients with subarachnoid hemorrhage (SAH), a complex disease, probably also benefit from treatment at a high-volume center. The authors aimed to determine, based on published literature, whether a higher hospital caseload is associated with improved outcomes of patients undergoing treatment after aneurysmal subarachnoid hemorrhage.The authors identified studies from MEDLINE, Embase, and the Cochrane Library up to September 28, 2012, that evaluated outcome in high-volume versus low-volume centers in patients with SAH who were treated by either clipping or endovascular coiling. No language restrictions were set. The compared outcome measure was in-hospital mortality. Mortality in studies was pooled in a random effects meta-analysis. Study quality was reported according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.Four articles were included in this analysis, representing 36,600 patients. The quality of studies was graded low in 3 and very low in 1. Meta-analysis using a random effects model showed a decrease in hospital mortality (OR 0.77 [95% CI 0.60-0.97]; p = 0.00; I(2) = 91%) in high-volume hospitals treating SAH patients. Sensitivity analysis revealed the relative weight of the 1 low-quality study. Removal of the study with very low quality increased the effect size of the meta-analysis to an OR of 0.68 (95% CI 0.56-0.84; p = 0.00; I(2) = 86%). The definition of hospital volume differed among studies. Cutoffs and dichotomizations were used as well as division in quartiles. In 1 study, low volume was defined as 9 or fewer patients yearly, whereas in another it was defined as fewer than 30 patients yearly. Similarly, 1 study defined high volume as more than 20 patients annually, and another defined it as more than 50 patients a year. For comparability between studies, recalculation was done with dichotomized data if available. Cross et al., 2003 (low volume ≤ 18, high volume ≥ 19) and Johnston, 2000 (low volume ≤ 31, high volume ≥ 32) provided core data for recalculation. The overall results of this analysis revealed an OR of 0.85 (95% CI 0.72-0.99; p = 0.00; I(2) = 87%).Despite the shortcomings of this study, the mortality rate was lower in hospitals with a larger caseload. Limitations of the meta-analysis are the not uniform cutoff values and uncertainty about case mix.

Item does not contain fulltext 3'-deoxy-3'-(18)F-fluorothymidine ((18)F-FLT) is a radiopharmaceutical depicting tumor cell proliferation with PET. In malignancies of the lung, breast, head and neck, digestive tract, brain, and other organs, quantitative assessment of (18)F-FLT targeting has been shown to correlate with the proliferation marker Ki-67 and with clinical outcome measures such as time to progression and overall survival (OS). The aim of this study was to assess various PET segmentation methods to estimate the proliferative volume (PV) and their prognostic value for OS in patients with suspected high-grade glioma. METHODS: Twenty-six consecutive patients underwent preoperative (18)F-FLT PET/CT and T1-weighted MRI of the brain after contrast application. The maximum standardized uptake value (SUV(max)) of all tumors was calculated, and 3 different segmentation methods for estimating the PV were used: the 50% isocontour of the SUV(max) signal for the PV(50%), the signal-to-background ratio (SBR) for an adaptive threshold delineation (PV(SBR)) method, and the iterative background-subtracted relative threshold level (RTL) method to estimate the PV(RTL). The prognostic value of the SUV(max) and the different PVs for OS were assessed. RESULTS: Twenty-two patients had glioblastoma multiforme, 2 had anaplastic oligodendroglioma, 1 had anaplastic ependymoma, and 1 had anaplastic astrocytoma. The median OS was 397 d (95% confidence interval, 204-577); 19 patients died during the follow-up period. The PV(SBR) showed a significantly (P = 0.002) better association with OS than did SUV(max), PV(RTL), and PV(50%). Receiver-operating-characteristic analysis resulted in a threshold volume for the PV(SBR) of 11.4 cm(3), with a sensitivity and specificity of 70% and 83%, respectively, for the prediction of OS. Kaplan-Meier analyses showed a significant discrimination between short and long OS (P = 0.024, log rank) for this threshold. CONCLUSION: The PV as determined by (18)F-FLT PET is associated with OS in high-grade malignant gliomas. The SBR method yielded the best results to predict short and long OS.

Object Several studies have suggested that neurovascular compression (NVC) of the brainstem might be a cause of hypertension. Because this compression syndrome might be demonstrated by MR imaging studies, several authors have tried to assess its prevalence in small series of patients with hypertension. This article presents a meta-analysis of these studies. Methods The studies reviewed by the authors were based on MR imaging and included the presence of left-sided NVC of the left rostral ventrolateral medulla oblongata (RVLM) and/or the cranial nerves IX and X root entry zone in patients with apparent primary hypertension compared with normotensive patients. Several studies also included patients with secondary hypertension as an additional control group, which is analyzed separately. Results Meta-analysis included data from 14 studies (597 patients with primary hypertension and 609 controls). The effect size was OR 2.68 (95% CI 1.51–4.75, p = 0.001) (random effect), which is consistent with the hypothesis that NVC of the left RVLM is more frequent in patients with apparent primary hypertension compared with normotensive individuals. Stratification for the study design revealed an effect size for prospective studies of OR 1.97 (95% CI 0.74–5.30, p = 0.178) and for retrospective studies of OR 3.36 (95% CI 1.66–6.79, p = 0.001). Conclusions This meta-analysis indicates a statistically significant effect size for left-sided NVC in apparent primary hypertension. However, this effect is absent if subanalysis is confined to prospective studies.

Contains fulltext : 98061.pdf (Publisher’s version ) (Closed access) BACKGROUND: The endoscopic removal of third ventricular colloid cysts has been developed as an alternative to microsurgical transcortical-transventricular and transcallosal approaches. OBJECTIVE: To examine the value of endoscopic technique by reviewing the large number of endoscopically treated patients with long-term follow-up in 2 neurosurgical centers. METHODS: A retrospective chart review was conducted for all patients admitted for resection of a third ventricular colloid cyst to the Radboud University Nijmegen Medical Centre (Nijmegen, The Netherlands) and the Hopital Henri Mondor (Paris, France) between 1994 and 2007. Both clinical and radiological symptoms and operative results were evaluated. RESULTS: Postdischarge clinical follow-up was available for 85 patients over a mean period of 4 years 3 months. Permanent morbidity occurred in 1 patient (persisting preoperative memory deficit). Follow-up imaging of 80 evaluable patients showed that total or nearly total cyst removal was possible in 46 individuals (57.5%). Residual cyst was present in 34 patients (42.5%), and 6 required repeated endoscopic surgery for symptomatic regrowth. Recurrent cysts were mainly seen within the first 2 years after surgery. CONCLUSION: It is debatable whether the higher numbers of recurrent or residual cysts can be justified by the slightly lower complication rates achieved with endoscopic removal. However, results have been improving over the years. Moreover, the modifications observed on control magnetic resonance images justify the need for regular control imaging for at least the first 2 years postoperatively.

Contains fulltext : 89439.pdf (Publisher’s version ) (Closed access) Spinal cord injury (SCI) results in loss of nervous tissue in the spinal cord and consequently loss of motor and sensory function. The impairments are permanent because endogenous repair events fail to restore the damaged axonal circuits that are involved in function. There is no treatment available that restores the injury-induced loss of function. The consequences of SCI are devastating physically and socially. The assessment of functional loss after SCI has been standardized in the larger part of the world. For medical care however there are no standards available. During the early phase, treatments that stabilize the patient's health and attempt to limit further neurological deterioration need to be implemented. During the later phase of SCI, the focus needs to be on prevention and/or treatment of secondary complications such as pain, pressure ulcers, and infections. Neuroprotective, axon growth-promoting and rehabilitative repair approaches are currently being tested but, so far, none of these has emerged as an effective treatment that reverses the consequences of SCI. Promising new repair approaches have emerged from the laboratory during the last years and entered the clinical arena including stem cell transplantation and functional electrical stimulation.

Contains fulltext : 89613.pdf (Publisher’s version ) (Open Access) Regulatory T cells (Tregs) accumulate in tumors and can contribute to the dismal immune responses observed in these tumors. We reported that the percentage of tumor infiltrating Tregs is strongly correlated with the WHO grade of the brain tumor. We now report on the clinical follow-up of this patient cohort (n=83). Subgroup analyses in patients with glioblastomas (n=29) showed a moderate, not significant, inverted association between Tregs and survival. We further show that Tregs in glioblastomas, in contrast to other tumor infiltrating effector lymphocytes, highly express the CCR4 chemokine receptor. Moreover, the CCR4 ligand CCL22 is secreted by glioblastomas and may explain the specific Treg accumulation seen in these tumors.

Item does not contain fulltext We investigated whether small-animal positron emission tomography (PET) could be used in combination with computed tomography (CT) imaging techniques for longitudinal monitoring of the injured spinal cord. In adult female Sprague-Dawley rats (n = 6), the ninth thoracic (T9) spinal cord segment was exposed by laminectomy and subsequently contused using the Infinite Horizon impactor (Precision System and Instrumentation, Lexington, KY) at 225 kDyn. In control rats (n = 4), the T9 spinal cord was exposed by laminectomy but not contused. At 0.5 hours and 3, 7, and 21 days postinjury, 2-[(18)F]fluoro-2-deoxy-d-glucose ([(18)F]FDG) was given intravenously followed 1 hour later by sequential PET and CT. Regions of interest (ROIs) at T9 (contused) and T6 (uninjured) spinal cord segments were manually defined on CT images and aided by fiduciary markers superimposed onto the coregistered PET images. Monte Carlo simulation revealed that about 33% of the activity in the ROIs was due to spillover from adjacent hot areas. A simulation-based partial-volume compensation (PVC) method was developed and used to correct for this spillover effect. With PET-CT, combined with PVC, we were able to serially measure standardized uptake values of the T9 and T6 spinal cord segments and reveal small, but significant, differences. This approach may become a tool to assess the efficacy of spinal cord repair strategies. 01 april 2010

Contains fulltext : 81728.pdf (Publisher’s version ) (Open Access) The brain is a specialized immune site representing a unique tumor microenvironment. The availability of fresh brain tumor material for ex vivo analysis is often limited because large parts of many brain tumors are resected using ultrasonic aspiration. We analyzed ultrasonic tumor aspirates as a biosource to study immune suppressive mechanisms in 83 human brain tumors. Lymphocyte infiltrates in brain tumor tissues and ultrasonic aspirates were comparable with respect to lymphocyte content and viability. Applying ultrasonic aspirates, we detected massive infiltration of CD4+FoxP3+CD25(high) CD127(low) regulatory T cells (Tregs) in glioblastomas (n = 29) and metastatic brain tumors (n = 20). No Treg accumulation was observed in benign tumors such as meningiomas (n = 10) and pituitary adenomas (n = 5). A significant Treg increase in blood was seen only in patients with metastatic brain tumors. Tregs in high-grade tumors exhibited an activated phenotype as indicated by decreased proliferation and elevated CTLA-4 and FoxP3 expression relative to blood Tregs. Functional analysis showed that the tumor-derived Tregs efficiently suppressed cytokine secretion and proliferation of autologous intratumoral lymphocytes. Most tumor-infiltrating Tregs were localized in close proximity to effector T cells, as visualized by immunohistochemistry. Furthermore, 61% of the malignant brain tumors expressed programmed death ligand-1 (PD-L1), while the inhibitory PD-1 receptor was expressed on CD4+ effector cells present in 26% of tumors. In conclusion, using ultrasonic tumor aspirates as a biosource we identified Tregs and the PD-L1/PD-1 pathway as immune suppressive mechanisms in malignant but not benign human brain tumors.

Contains fulltext : 80699.pdf (Publisher’s version ) (Open Access) Bone marrow stromal cells (BMSC) transplanted into the contused spinal cord may support repair by improving tissue sparing. We injected allogeneic BMSC into the moderately contused adult rat thoracic spinal cord at 15 min (acute) and at 3, 7, and 21 days (delayed) post-injury and quantified tissue sparing and BMSC survival up to 4 weeks post-transplantation. BMSC survival within the contusion at 7 days post-transplantation was significantly higher with an acute injection (32%) and 3-day delayed injection (52%) than with a 7- or 21-day delayed injection (9% both; p < 0.01). BMSC survival at 28 days post-transplantation was close to 0 in all paradigms, indicating rejection. In contused rats without a BMSC transplant (controls), the volume of spared tissue gradually decreased until 46% (p < 0.001) of the volume of a comparable uninjured spinal cord segment at 49 days post-injury. In rats with BMSC, injected at 15 min, 3, or 7 days post-injury, spared tissue volume was significantly higher in grafted rats than in control rats at the respective endpoints (i.e., 28, 31, and 35 days post-injury). Acute and 3-day delayed but not 7- and 21-day delayed injection of BMSC significantly improved tissue sparing, which was strongly correlated (r = 0.79-1.0) to BMSC survival in the first week after injection into the contusion. Our data showed that neuroprotective effects of BMSC transplanted into a moderate rat spinal cord contusion depend strongly on their survival during the first week post-injection. Acutely injected BMSC elicit more tissue sparing than delayed injected BMSC.

Object The authors prospectively evaluated the safety and efficacy of a novel polyethylene glycol (PEG) hydrogel sealant in patients undergoing elective cranial surgery with documented cerebrospinal fluid (CSF) leakage after sutured dural repair. Methods The PEG hydrogel sealant was used at 11 different study sites in 111 patients with documented intraoperative CSF leakage after neurosurgical dural repair for a variety of conditions. Intraoperative CSF leakage was either spontaneous or induced by a Valsalva maneuver. Patients were monitored for 3 months postoperatively with physical examinations, clinical laboratory analyses, and diagnostic imaging. The PEG hydrogel sealant was 100% effective in stopping CSF leakage in all patients. There were no sealant-related adverse events and all clinical outcomes were consistent with expectations for seriously ill patients undergoing prolonged neurosurgical procedures. Conclusions The PEG hydrogel sealant provides a safe and effective watertight closure when used as an adjunct to sutured dural repair during cranial surgery.

Contains fulltext : 52342.pdf ( ) (Open Access) BACKGROUND: laminectomy is a valuable surgical treatment for some patients with a cervical radiculomyelopathy due to cervical spinal stenosis. More recently attention has been given to motion of the spinal cord over spondylotic spurs as a cause of myelopathic changes. Immobilisation by fusion could have a positive effect on the recovery of myelopathic signs or changes. This has never been investigated in a prospective, randomised trial. Lamifuse is an acronyme for laminectomy and fusion. METHODS/DESIGN: Lamifuse is a multicentre, randomised controlled trial comparing laminectomy with and without fusion in patients with a symptomatic cervical canal stenosis. The study population will be enrolled from patients that are 60 years or older with myelopathic signs and/or symptoms due to a cervical canal stenosis. A kyphotis shape of the cervical spine is an exclusion criterium. Each treatment arm needs 30 patients. DISCUSSION: This study will contribute to the discussion whether additional fusion after a cervical laminectomy results in a better clinical outcome. ISRCT NUMBER: ISRCTN72800446.

Background PROCON was designed to assess the clinical outcome, development of adjacent disc disease and costs of cervical anterior discectomy without fusion, with fusion using a stand alone cage and implantation of a Bryan's disc prosthesis. Description of rationale and design of PROCON trial and discussion of its strengths and limitations. Methods/Design Since proof justifying the use of implants or arthroplasty after cervical anterior discectomy is lacking, PROCON was designed. PROCON is a multicenter, randomized controlled trial comparing cervical anterior discectomy without fusion, with fusion with a stand alone cage or with implantation of a disc. The study population will be enrolled from patients with a single level cervical disc disease without myelopathic signs. Each treatment arm will need 90 patients. The patients will be followed for a minimum of five years, with visits scheduled at 6 weeks, 3 months, 12 months, and then yearly. At one year postoperatively, clinical outcome and self reported outcomes will be evaluated. At five years, the development of adjacent disc disease will be investigated. Discussion The results of this study will contribute to the discussion whether additional fusion or arthroplasty is needed and cost effective. Trial registration Current Controlled Trials ISRCTN41681847

Contains fulltext : 48336.pdf (Publisher’s version ) (Closed access) BACKGROUND: Cerebrospinal fluid (CSF) leaks are widely recognized as commonly occurring postoperative complications of neurosurgical procedures. We will focus on the direct costs associated with CSF leaks in a single center across multiple neurosurgical procedures, based on a retrospective analysis. We will also compare the costs of using a synthetic agent to prevent such leaks with these costs from a more recent study. METHODS: The single-center retrospective study was carried out at the Neurosurgical Center Nijmegen (University Medical Center St Radboud and Canisius Wilhelmina Hospital, Nijmegen, Netherlands) from January 01, 1999, until December 31, 1999. Four hundred twelve consecutive, nontrauma, elective procedures were examined. RESULTS: By applying strict criteria for CSF leakage (including those self-limiting subcutaneous minor CSF collection), we found an overall leak rate of 10.7% with a lower number for supratentorial and transsphenoidal procedures and much higher numbers for infratentorial procedures and extensive skull base procedures (6 [12.8%] of 47 and 18 [34.6%] of 52, respectively). The CSF leak in these 44 patients was associated with high additional costs which accounted for 21.7% of the total costs of all 412 procedures or on average 1508 per patient and procedure. If DuraSeal (Confluent Surgical, Inc, Waltham, MA) were to be used prophylactically for every procedure, and assuming a 4% leak rate postprocedure (which was achieved in a more recent study of 46 patients using DuraSeal), there would be a saving of 550 for every procedure (reduction in additional costs of CSF leak minus the cost of the sealant), or a total saving of 226600 in the series of 412 patients. CONCLUSION: Our analysis establishes that CSF leaks occur with high frequency and incur significant costs across all types of surgical procedures. A direct correlation of this complication (and ensuring costs) is observed with more extensive procedures, and reduction of these significant costs can be achieved by using augmentation of the dural closure with DuraSeal.

Contains fulltext : 47371.pdf (Publisher’s version ) (Closed access) OBJECTIVE: The main objective of this study was to compare the clinical outcome of participants treated by simple decompression (SD) of the ulnar nerve versus anterior subcutaneous transposition (AST). METHODS: A prospective randomized controlled study was performed. Three hundred forty participants were referred to our institution between March 1999 and July 2002. One hundred fifty-two patients met the inclusion criteria and were randomized into two surgical groups: 75 were assigned to SD, and 77 were assigned to AST. Participants were followed for 1 year after surgery. The main outcome measure was clinical outcome 1 year after surgery. RESULTS: An excellent or good result was obtained in 49 of 75 participants who underwent SD and in 54 of 77 participants undergoing AST. The difference was not statistically significant. However, the complication rate was statistically lower in the SD group (9.6%) compared with the AST group (31.1%) (risk ratio, 0.32; 95% confidence interval, 0.14-0.69). Duration of symptoms, (sub)luxation of the ulnar nerve, and severity of the complaints did not influence outcome. CONCLUSION: Surgery for ulnar neuropathy at the elbow is effective. The outcomes of SD and AST are equivalent, except for the complication rate. Because the intervention is simpler and associated with fewer complications, SD is advised, even in the presence of (sub)luxation.

Contains fulltext : 57538.pdf (Publisher’s version ) (Closed access) OBJECTS: A lot has been published about neuroendoscopic procedures over the last decade. Most of these publications are about the effectiveness of endoscopic third ventriculostomy, the most frequently performed neuroendoscopic procedure. Little is published about the effectiveness of other, less frequently performed neuroendoscopic procedures. Over the years more reports about the complications of endoscopic procedures are published, but again most of these publications are about endoscopic third ventriculostomy and only a little is presented about the complications of all other neuroendoscopic procedures. Furthermore, most reports are about intraoperative and immediate postoperative complications; only a few reports evaluated the long-term complications of neuroendoscopic procedures. There are also a few publications that analyse the failures of neuroendoscopic procedures but a good definition of failure is not given. The reports mention, again, mainly endoscopic third ventriculostomy procedures, and are mostly directed at the short-term failure rates, defined as the need for a shunt to be placed. Less attention is paid to the effects of the endoscopic procedures in the longer term. Looking at longer terms emphasises the need for a better definition of failure. METHODS: To get more insight into the long-term complications and failures of neuroendoscopic procedures, we reviewed the literature and evaluated our own series of 485 different cranial endoscopic procedures. With the information gathered we tried to answer the questions mentioned above. CONCLUSIONS: Most of the complications of neuroendoscopic procedures are transient, either spontaneously or by medical intervention. Only a few permanent complications are known, in our series 1.6%, and most of them are not typically related to the endoscopic procedure itself but are due to the ventricular approach necessary for and the management of the endoscopy. Mortality rates are less than 1%. A uniform definition of failure cannot be given for all neuroendoscopic procedures, because the procedures are too heterogeneous and the indications are widespread. Failures are mainly diagnosed within a few months of the procedure but neurosurgeons must be aware of failure in the longer term, because if not diagnosed they can give rise to increased morbidity and probably mortality.

Objective: To compare the cosmetic outcome, pain and tenderness around the operation scar of carpal tunnel syndrome surgery using either nylon, polyglactin 910 or stainless steel sutures for skin closure. Methods: A randomised clinical trial comparing nylon, polyglactin 910 or stainless steel sutures for skin closure in 61 patients undergoing carpal tunnel syndrome surgery was performed. Pain, tenderness, scar hypertrophy, redness and the presence of granulomas were assessed in all patients at ten days and six weeks after surgery and compared by non-parametric statistical tests. Results: Adequate surgical decompression of the median nerve could be achieved in all patients. All but two patients experienced significant relief of tingling of the fingers. Nearly all patients reported some degree of discomfort around the scar. At ten days, the mean pain score was 1.7 (±2.2), 3.1 (±2.3) and 1.9 (±2.3) for the nylon, vicryl and steel groups, respectively. At six weeks, the pain score was 3.6 (±3.1), 3.4 (±2.6) and 2.7 (±2.1) for the nylon, vicryl and steel groups, respectively. The infection rate was 0%, 8% and 0% for the nylon, vicryl and steel groups, respectively. Suture granulomas were significantly more present in the vicryl group (p Conclusions: Nylon and stainless steel sutures are both suitable for skin closure after carpal tunnel surgery. Based on this study, absorbable vicryl sutures should not be used, since the incidence of infections and the presence of suture granulomas was much higher than in the nylon and steel suture groups.

Item does not contain fulltext OBJECTIVE: The in vitro stability of fibrin sealant in cerebrospinal fluid (CSF) was investigated to verify the efficacy of intracranial application of fibrin sealant. METHODS: Human CSF was collected from 11 patients. Fibrin glue spheres (diameter, 5 mm) were incubated in CSF specimens at 37 degrees C. At 2, 4, 8, 24, and 48 hours, the diameter of the spheres was measured and the ultrastructure was evaluated by transmission electron microscopy. A control group consisted of sealant spheres in physiological saline (n = 2). RESULTS: In all CSF samples, the fibrin sealant did not degrade with time. The size, consistency, color, and shape of the sealant remained unchanged, even 48 hours after placement in the CSF. Transmission electron microscopic analysis of the fibrin sealant revealed an amorphous, fibrinous meshwork. No morphological differences existed between fibrin sealant complex placed in the CSF for different time periods and sealant placed in physiological saline. CONCLUSION: Within the limitations of this in vitro study, human CSF has no adverse effects on fibrin sealant in terms of alteration of structure and morphology. Fibrin sealant is stable in a CSF environment and can be effectively used in the cisternal or subarachnoidal space.

A kindred is reported on with suspected autosomal dominant congenital hydrocephalus and aqueduct stenosis. In contrast to patients with X-linked congenital hydrocephalus with stenosis of the aqueduct of Sylvius (HSAS) our patients were not mentally retarded and they did not show any pyramidal tract dysfunction or clasped thumbs; the pyramids were not affected either, as was confirmed by autopsy, CT or MRI. Molecular genetic studies in our patients have not revealed abnormalities of eight exons of the L1 neural adhesion molecule gene that is related to HSAS.

✓ The authors determined the landmarks and coordinates for intraoperative ventricular puncture directly from the supraorbital craniotomy opening via an eyebrow incision. Fifty magnetic resonance (MR) imaging studies were obtained from patients with no pathological cerebral characteristics or ventricular distortion. The cerebral entry point of the ventriculostomy was located directly under the key bur hole (just behind the zygomatic process of the frontal bone) at the base of the frontal lobe because it represents a stable, reliable point that can be used as the bur hole during supraorbital craniotomy via an eyebrow incision. From this point, the coordinates for lateral ventricular puncture were determined using MR imaging studies and neuronavigational software. The cerebral entry point of the ventriculostomy was situated directly under the key bur hole at the base of the frontal lobe. The catheter was directed at a 45° angle to the midline and a 20° angle up from an imaginary line parallel to the orbitomeatal line. The catheter will usually be inserted into the ventricle at a point 5 cm deep to the cortex and may be inserted as deep as 6.5 cm. Using this technique, the frontal horn of the lateral ventricle can be easily tapped. The landmark required for this technique is readily available in all patients.

Sixty-one patients with SAH due to rupture of a cerebral aneurysm, classified in Grades I to IV according to Hunt and Hess, received a constant venous infusion of Nimodipine in a dose of 2mg/h for at least 14 days, followed by an oral administration of 60 mg/6 h for at least 4 days. Patients admitted after the 6th day of SAH, patients with SAH but without aneurysm on the angiogram and patients in Grade V were excluded. Mortality in 30 patients of Grades I-II was 3.3%, in 31 patients of Grades III-IV 42%. In the latter group 1 patient died due to cerebral vasospasm. Transient vasospasm occurred in 2 patients of Grades I-II. Recovery was complete in both cases. Thus, incidence of cerebral vasospasm was 4.9%, the incidence of poor-outcome-vasospasm even only 1.6%. The syndrome of cerebral vasospasm seems to be more than only constriction of cerebral vessels. The deleterious effects of Ca2+ shift into vascular cells and into neural cells which causes irreversible damage are discussed. Early administration of a specific 'cerebral' calcium antagonist like Nimodipine after SAH will prevent the intracellular Ca2+ overloading, thus protecting the neural cells and preventing Ca2+-induced smooth-muscle contraction of cerebral vessels, which encourages ischaemic deficits after SAH. The preventive use of Nimodipine has markedly reduced the incidence of symptomatic vasospasm in our clinic.