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.

"Team time-out" and surgical safety-experiences in 12,390 neurosurgical patients.

OBJECT: Quality and safety are basic concerns in any medical practice. Especially in daily surgical practice, with increasing turnover and shortened procedure times, attention to these topics needs to be assured. Starting in 2007, the authors used a perioperative checklist in all elective procedures and extended the checklist in January 2011 according to the so-called team time-out principles, with additional assessment of patient identity and the planned surgical procedure performed immediately before skin incision, including the emergency cases. METHODS: The advanced perioperative checklist includes parts for patient identification, preoperative assessments, team time-out, postoperative treatment, and imaging controls. All parts are signed by the responsible physician except for the team time-out, which is performed and signed by the theater nurse on behalf of the surgeon immediately before skin incision. RESULTS: Between January 2007 and December 2010, 1 wrong-sided bur hole in an emergency case and 1 wrong-sided lumbar approach in an elective case (of 8795 surgical procedures) occurred in the authors' department. Using the advanced perioperative checklist including the team time-out principles, no error occurred in 3595 surgical procedures (January 2011-June 2012). In the authors' department all team members appreciate the chance to focus on the patient, the surgical procedure, and expected difficulties. The number of incomplete checklists and of patients not being transferred into the operating room was lowered significantly (p = 0.002) after implementing the advanced perioperative checklist. CONCLUSIONS: In the authors' daily experience, the advanced perioperative checklist developed according to the team time-out principles improves preoperative workup and the focus of the entire team. The focus is drawn to the procedure, expected difficulties of the surgery, and special needs in the treatment of the particular patient. Especially in emergency situations, the team time-out synchronizes the involved team members and helps to improve patient safety.

Chronic subdural haematoma in elderly patients: a retrospective analysis of 322 patients between the ages of 65-94 years.

BACKGROUND: Chronic subdural haematoma (cSDH) is a common disease in neurosurgical practise, especially in elderly patients. This is of growing importance as the number of elderly people in the population is increasing steadily. There are scarce data focussing especially on elderly patients with cSDH. This study intended to evaluate the outcome and peri-operative risks in elderly patients with cSDH. METHODS: We retrospectively reviewed medical records of 322 consecutive patients aged ≥65 years treated at our department between 2002 and 2009 focussing on outcome, aetiology, peri-operative risks, recurrence rate, and co-factors such as concomitant diseases and therapy with anticoagulants. The surgical procedure included burr-hole craniostomy followed by insertion of a subdural drain in each case. The outcome was classified according to the Karnofsky performance status (KPS) and modified Rankin Scale (mRS) score. Patients were divided into three groups according to age (group I: age 65-74 years, group II: 75-84 years, group III: 85-94 years). RESULTS: Three hundred twenty-two patients underwent burr-hole craniostomy for cSDH in 399 surgical procedures. The mean age was 76 ± 7.9 years. After surgery, the mean neurological status improved in all three groups. Overall favourable outcome (mRS 0-2) was achieved in 83 % in group I, 68 % in group II and 51 % in group III, respectively. The rate of recurrence was lower in group III (7.5 %) compared to groups I (21.5 %) and II (27.37 %, p = 0.004). Overall, complication rates and peri-operative mortality (2.75 %) did not differ significantly between the age groups. CONCLUSION: The data of the current study suggest that treatment of cSDH is safe in elderly patients. Patients aged above 85 years carry a greater risk for peri-operative complications, i.e. aSDH, and therefore have to be examined and monitored meticulously in order to prevent complications.

Resection of gliomas in the cingulate gyrus: functional outcome and survival.

Functional outcome after resection of tumors arising from the gyrus cinguli (GC), part of the limbic system, is not well analyzed. The purpose of this study was to evaluate the feasibility and functional outcome of surgical treatment for a series of 65 patients with gliomas involving the GC. Preoperative data, extent of resection, functional outcome (Karnofsky performance index, KPI, and the National Institute of Health Stroke Scale, NIHSS), and survival of 65 patients with gliomas arising from the GC were analyzed on the basis of a prospectively conducted database of gliomas between 06/1999 and 07/2010. Extent of resection (complete, subtotal, or partial) was based on early postoperative MRI. Eighty-six percent of the gliomas were located in the anterior part of the GC and 14 % in the posterior part. Fifty-five percent of the patients presented with seizures and 17 % with hemiparesis (mean preoperative KPI = 86 ± 17, NIHSS = 1.4 ± 1.7). Histologically, the tumors were WHO Grade II in 25 %, Grade III in 26 %, and Grade IV in 49 %. Complete resection was achieved for 59 %, subtotal resection for 32%, and partial resection for 9 %. Postoperative transient deficits included SMA lesion (14 %) and new or worsened hemiparesis (8 %), which resolved within 30 days (NIHSS early postoperatively 1.7 ± 1.4, late postoperatively 0.8 ± 1.4, and after 6 months 0.6 ± 1.4). According to histopathological grading, median survival was 67 months (WHO°II), 87 months (WHO°III), and 16.5 months (WHO°IV), and overall survival was 34 months. Microsurgical resection of gliomas arising from the GC is feasible; gross total resection can be achieved for 90 % of gliomas arising from the GC with 5 % long-term morbidity.

Glioblastoma therapy in the elderly and the importance of the extent of resection regardless of age.

OBJECT: The objective of this study was to analyze whether age influences the outcome of patients with glioblastoma and whether elderly patients with glioblastoma can tolerate the same aggressive treatment as younger patients. METHODS: Data from 361 consecutive patients with newly diagnosed cerebral glioblastoma (2000-2006) who underwent regular follow-up evaluation from initial diagnosis until death were prospectively entered into a database. Patients underwent resection (complete, subtotal, or partial) or biopsy, depending on tumor size, location, and Karnofsky Performance Scale score. Following surgery, all patients underwent adjuvant treatment consisting of radiotherapy, chemotherapy, or combined treatment. Patients older than 65 years of age were defined as elderly (146 total). RESULTS: Two hundred thirty-four patients underwent tumor resection (complete 26%, subtotal 29%, and partial 45%). One hundred twenty-seven underwent biopsy. Mean patient age was 61 years, and overall survival was 11.6 ± 12.1 months. The overall survival of elderly patients (9.1 ± 11.6 months) was significantly lower than that of younger patients (14.9 ± 16.7 months; p = 0.0001). Stratifying between resection or biopsy, age was a negative prognostic factor in patients undergoing biopsy (4.0 ± 7.1 vs 7.9 ± 8.7 months; p = 0.007), but not in patients undergoing tumor resection (13.0 ± 8.5 vs 13.3 ± 14.5 months; p = 0.86). Survival of elderly patients undergoing complete tumor resection was 17.7 ± 8.1 months. CONCLUSIONS: In this series of patients with glioblastoma, age was a prognostic factor in patients undergoing biopsy, but not in patients undergoing resection. Tumor location and patient clinical status may prohibit extensive resection, but resection should not be withheld from patients only on the basis of age. In elderly patients with glioblastoma, undergoing resection to the extent feasible, followed by adjuvant therapies, is warranted.

Rapid closure technique in decompressive craniectomy.

OBJECT: The object of this study was to describe the rapid closure technique in decompressive craniectomy without duraplasty and its use in a large cohort of consecutive patients. METHODS: Between 1999 and 2008, supratentorial rapid closure decompressive craniectomy (RCDC) was performed 341 times in 318 patients at the authors' institution. Cases were stratified as 1) traumatic brain injury, 2) subarachnoid hemorrhage, 3) intracerebral hemorrhage, 4) cerebral infarction, and 5) other. A large bone flap was removed and the dura mater was opened in a stellate fashion. Duraplasty was not performed-that is, the dura was not sutured, and a dural substitute was neither sutured in nor layed on. The dura and exposed brain tissue were covered with hemostyptic material (Surgicel). Surgical time and complications of this procedure including follow-up (> 6 months) were recorded. After 3-6 months cranioplasty was performed, and, again, surgical time and any complications were recorded. RESULTS: Rapid closure decompressive craniectomy was feasible in all cases. Complications included superficial wound healing disturbance (3.5% of procedures), abscess (2.6%) and CSF fistula (0.6%); the mean surgical time (± SD) was 69 ± 20 minutes. Cranioplasty was performed in 196 cases; the mean interval (± SD) from craniectomy to cranioplasty was 118 ± 40 days. Complications of cranioplasty included epidural hematoma (4.1%), abscess (2.6%), wound healing disturbance (6.1%), and CSF fistula (1%). Compared with the results reported in the literature for decompressive craniectomy with duraplasty followed by cranioplasty, there were no significant differences in the frequency of complications. However, surgical time for RCDC was significantly shorter (69 ± 20 vs 129 ± 43 minutes, p < 0.0001). CONCLUSIONS: The present analysis of the largest series reported to date reveals that the rapid closure technique is feasible and safe in decompressive craniectomy. The surgical time is significantly shorter without increased complication rates or additional complications. Cranioplasty after a RCDC procedure was also feasible, fast, safe and not impaired by the RCDC technique.

Is the surgical repair of unruptured atherosclerotic aneurysms at a higher risk of intraoperative ischemia?

BACKGROUND: The incidence of ischemia might be increased in the surgical repair of atherosclerotic unruptured aneurysms compared to non-atherosclerotic aneurysms. The atherosclerotic wall might increase the occurrence of thrombembolic events or its rigidity might endanger the occlusion of perforators within the aneurysm vicinity. METHODS: 87 patients (53 patients without and 34 patients with atherosclerotic unruptured aneurysms, 50.5 ± 9.7 years) were analyzed for severity of atherosclerosis within the aneurysm and the aneurysm bearing vessel, surgical maneuvers, intraoperative alterations in evoked potentials and clinical and neuroradiological results. RESULTS: Temporary vessel occlusion (25% vs. 50%, p = 0.021), repositioning of a permanent clip (21% vs. 56%, p = 0.001) and aneurysm remnants (2% vs. 18%, p = 0.012) occurred more often in patients with atherosclerotic aneurysms. At 6 months, 3/34 patients with atherosclerosis (8.8%) had an unfavorable outcome, all patients without atherosclerosis had a favorable outcome (p = 0.056). CONCLUSION: The surgical repair of unruptured aneurysms is safe but patients with atherosclerotic altered vessels and aneurysms accounted to a minor increase in unfavorable outcome and an increased risk of morbidity at 6 months postoperatively. This factor should be taken into consideration when performing surgery of atherosclerotic, unruptured aneurysms.

Influence of iMRI-guidance on the extent of resection and survival of patients with glioblastoma multiforme.

Intraoperative MRI (iMRI) is used in glioma surgery mainly to determine the extent of resection, allowing surgeons to immediately continue resection in case of residual tumor tissue. The aim of this study is to report on the influence of the use of iMRI on the extent of resection and survival of patients with glioblastoma multiforme (GBM). We analyzed our prospectively collected database of patients with GBM operated upon during the initial period after installation of an iMRI; between July 2004 and December 2005, all patients with GBM undergoing intended complete tumor resection were included in this study, while patients undergoing mere tumor biopsy or intended incomplete resection were not. In total, 43 Patients met the inclusion criteria. Of these, 10 patients (23.3%) were operated upon with the help of iMRI while 33 underwent conventional tumor resection. All patients underwent postoperative high-field MR imaging at 1.5 Tesla to determine the extent of resection. Subsequently, all patients received adjuvant treatment. Median patient age was 60.0 years; median overall survival was 70.7 weeks. Radiologically complete tumor resection (P < 0.001) and the administration of temozolomide chemotherapy (P < 0.01) were statistically significant prognostic factors in a multivariate analysis. The rate of complete tumor resections was significantly higher in the iMRI group than in the conventional surgery group (P < 0.05). Patient age was not a prognostic factor in our series of patients (P = 0.22). Intraoperative MRI is a helpful tool to increase the extent of resection in GBM surgery and thereby improve patient survival.

Genome-wide association study of intracranial aneurysm identifies three new risk loci.

Saccular intracranial aneurysms are balloon-like dilations of the intracranial arterial wall; their hemorrhage commonly results in severe neurologic impairment and death. We report a second genome-wide association study with discovery and replication cohorts from Europe and Japan comprising 5,891 cases and 14,181 controls with approximately 832,000 genotyped and imputed SNPs across discovery cohorts. We identified three new loci showing strong evidence for association with intracranial aneurysms in the combined dataset, including intervals near RBBP8 on 18q11.2 (odds ratio (OR) = 1.22, P = 1.1 x 10(-12)), STARD13-KL on 13q13.1 (OR = 1.20, P = 2.5 x 10(-9)) and a gene-rich region on 10q24.32 (OR = 1.29, P = 1.2 x 10(-9)). We also confirmed prior associations near SOX17 (8q11.23-q12.1; OR = 1.28, P = 1.3 x 10(-12)) and CDKN2A-CDKN2B (9p21.3; OR = 1.31, P = 1.5 x 10(-22)). It is noteworthy that several putative risk genes play a role in cell-cycle progression, potentially affecting the proliferation and senescence of progenitor-cell populations that are responsible for vascular formation and repair.

[Combined radiotherapy and gemcitabine. Evaluation of clinical data based on experimental knowledge]. / Kombination von Radiotherapie und Gemcitabine. Bewertung der klinischen Daten auf der Basis experimenteller Erkenntnisse.

BACKGROUND: In experimental studies the nucleoside analog Gemcitabine (2',2' difluorodesoxycytidine) clearly demonstrates radiation enhancing properties. After describing the pharmacological Gemcitabine-related data and the clinical studies regarding combined radiochemotherapy and taking under consideration the in-vitro data and the results provided by animal models, this overview is aimed to draw clinically relevant conclusions, resulting in the improvement of treatment approaches. MATERIALS AND METHODS: The available literature data regarding the metabolism and the mechanism of action, the evaluation of possible schedules of administration, and combined radiochemotherapy including Gemcitabine has been reviewed. Publications reporting experimental data in vitro and in vivo as well as our own experimental results have been incorporated. RESULTS: In clinical phase I and II studies, the favorable tumor response is accompanied by a high incidence of grade III-IV toxicities whereby the maximum-tolerated dose (MTD) of the various schedules of administration used is always lower compared to the MTD of single-agent treatment. In in-vitro and in-vivo data addressing the description and the evaluation of the radiation enhancing mechanism (especially influence on cell cycle, depletion of the dATP pool, induction of apoptosis, inhibition of DNA synthesis, reduction of DNA repair) this effect is already observed with non and moderately toxic Gemcitabine concentrations and depends on drug concentration and exposure time. Independent of the fractionation effect of radiotherapy, the radiation enhancement is persistent for at most 72 hours after the end of drug exposure. Taking under consideration the single dose per day and the target volume, a prolonged infusion and/or a twice-weekly administration of Gemcitabine at low concentration each and simultaneous radiotherapy are presumably considered to resemble the experimental data. CONCLUSION: It is without doubt that data provided by clinical studies are of highest relevance for the evaluation of an optimized radiochemotherapy with Gemcitabine. However, although it is often difficult to transfer experimental data into the clinical situation, these data offer the possibility to develop an improved schedule of administration in patient treatment based on rational evidence in tumor biology.