Regional Spinal Cord Atrophy Is Associated with Poor Outcome After Surgery on Intramedullary Spinal Cord Ependymoma: A New Aspect of Delayed Neurological Deterioration.

BACKGROUND: A considerable number of patients suffer delayed neurologic deficits, even after a successful removal of intramedullary spinal cord ependymoma. The underlying pathology remains unknown. Radiologic findings could provide an explanation for poor outcome after surgery. METHODS: We conducted a retrospective study of all cases treated from 1980 to 2016 in our department. The cohort included all patients with intramedullary spinal cord ependymoma treated with microsurgical excision. The cross-sectional area of the spinal cord at the level of the former performed surgery was compared using magnetic resonance imaging (MRI), follow-up MRI, adjacent unaffected levels, and the control group. RESULTS: Fifty-four patients with an intramedullary spinal cord lesion were treated in this period. Ependymoma was the predominant tumor (n = 28) followed by intramedullary gliomas and vascular lesions. Mean age (±SD) was 48.2 ± 10.5 years with a female predominance (16 women, 12 men). An unfavorable outcome was observed in 53% of the patients after an initially uneventful postoperative course. The follow-up cross-sectional area of the spinal cord was significantly reduced in these patients compared to adjacent unoperated levels and the control group. Sagittal and axial spinal MRI showed spinal cord narrowing owing to atrophic changes in the area of the performed surgery in 53% of patients with resected ependymoma after a mean follow-up time of 9 years. Functional outcome in ependymoma was significantly associated with spinal cord atrophy (P < 0.05). CONCLUSIONS: Spinal cord atrophy seems to be a predicting factor in long-term outcome after surgical removal of intramedullary spinal cord ependymoma.

Impact of Stereotactic Biopsy in HIV Patients.

OBJECTIVE: During their disease a significant number of human immunodeficiency virus (HIV)-infected patients develop neurologic symptoms due to intracerebral pathologies. Entities commonly found are toxoplasmosis, lymphomas, or progressive multifocal leukoencephalopathy. In some patients, diagnosis is not feasible with imaging alone, requiring biopsy. The objective of this study was to evaluate the impact of stereotactic biopsy in HIV patients on adjustment of therapy. METHODS: Between January 2004 and May 2015 at our clinic, 26 HIV-infected patients underwent stereotactic biopsy. Thin-layer magnetic resonance images were obtained and fused with computed tomography scans, taken with the stereotactic frame (Leksell) mounted. Biopsy material was evaluated pathologically and microbiologically. RESULTS: Histologic analysis revealed B-cell lymphoma in 6 patients (23.1%) and progressive multifocal leukoencephalopathy in 2 patients (7.7%). Abscess and toxoplasmosis were found in 3 patients each (11.5% and 11.5%), and encephalitis occurred in 4 patients (15.4%). In 2 patients each (7.7%), vasculitis, metastasis, and glioblastoma were diagnosed. Further findings comprised non-Hodgkin lymphoma and Burkitt lymphoma in 1 patient each. After biopsy, treatment was significantly changed in 18 (69.2%) patients (P < 0.01). Antibiotic therapy was adjusted in 6 patients (23.1%), and chemotherapy in 3 patients (16.7%). Other changes included antibiotic/antiviral therapy to chemotherapy in 3 patients (16.7%), chemotherapy to radiation, cortisone to chemotherapy, and aciclovir to cortisone in 1 patient each. One patient with glioblastoma underwent resection, and another patient received radiation. One patient underwent palliative care. CONCLUSION: Stereotactic biopsy in HIV-infected patients results in significant changes of therapy in more than two thirds of the patients.

Bone flap resorption: risk factors for the development of a long-term complication following cranioplasty after decompressive craniectomy.

Aseptic bone flap resorption (BFR) is a known long-term complication after cranioplasty (CP). We analyzed our institutional data in order to identify risk factors for BFR. From October 1999 to April 2012, 254 patients underwent CP after decompressive craniectomy (DC) at our institution, and had a long-term follow-up period of >1 year after CP (range 12-146 months). Overall, BFR occurred in 10 of 254 patients as a long-term complication after CP (4%). BFR developed more often in patients aged ≤18 years (p=0.008), in patients who previously underwent DC for traumatic brain injury (p=0.04), and in patients with multiple fractures within the reinserted bone flap (p=0.002). Furthermore, BFR developed significantly more often in patients who underwent cranioplasty ≤2 months after DC (p=0.008), as well as in patients with wound healing disturbance or abscess as an early complication after the CP procedure (p=0.01). The multivariate analysis of the present data identified the presence of multiple fractures within the bone flap (p=0.002, OR 10.3, 95% CI 2.4-43.8), wound infection after CP (p=0.003, OR 12.3, 95% CI 2.3-65.3), and cranioplasty performed ≤2 months after DC (p=0.01, OR 6.3, 95% CI 1.5-26.3) as independent risk factors for the development of BFR after CP in a large series with long-term follow-up. This might influence future surgical decision making, especially in patients fulfilling high risk criteria for developing BFR.

Cranioplasty after decompressive craniectomy: the effect of timing on postoperative complications.

Decompressive craniectomy (DC) due to intractably elevated intracranial pressure mandates later cranioplasty (CP). However, the optimal timing of CP remains controversial. We therefore analyzed our prospectively conducted database concerning the timing of CP and associated post-operative complications. From October 1999 to August 2011, 280 cranioplasty procedures were performed at the authors' institution. Patients were stratified into two groups according to the time from DC to cranioplasty (early, ≤2 months, and late, >2 months). Patient characteristics, timing of CP, and CP-related complications were analyzed. Overall CP was performed early in 19% and late in 81%. The overall complication rate was 16.4%. Complications after CP included epidural or subdural hematoma (6%), wound healing disturbance (5.7%), abscess (1.4%), hygroma (1.1%), cerebrospinal fluid fistula (1.1%), and other (1.1%). Patients who underwent early CP suffered significantly more often from complications compared to patients who underwent late CP (25.9% versus 14.2%; p=0.04). Patients with ventriculoperitoneal (VP) shunt had a significantly higher rate of complications after CP compared to patients without VP shunt (p=0.007). On multivariate analysis, early CP, the presence of a VP shunt, and intracerebral hemorrhage as underlying pathology for DC, were significant predictors of post-operative complications after CP. We provide detailed data on surgical timing and complications for cranioplasty after DC. The present data suggest that patients who undergo late CP might benefit from a lower complication rate. This might influence future surgical decision making regarding optimal timing of cranioplasty.