Management of perimesencephalic nonaneurysmal subarachnoid hemorrhage: a national survey.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (NASAH) is a rare type of subarachnoid hemorrhage (SAH), usually associated with minor complications compared to aneurysmal SAH. Up to date, data is scarce and consensus on therapeutic management and follow-up diagnostics of NASAH is often missing. This survey aims to evaluate the clinical management among neurosurgical departments in Germany. 135 neurosurgical departments in Germany received a hardcopy questionnaire. Encompassing three case vignettes with minor, moderate and severe NASAH on CT-scans and questions including the in-hospital treatment with initial observation, blood pressure (BP) management, cerebral vasospasm (CV) prophylaxis and the need for digital subtraction angiography (DSA). 80 departments (59.2%) answered the questionnaire. Whereof, centers with a higher caseload state an elevated complication rate (Chi2 < 0.001). Initial observation on the intensive care unit is performed in 51.3%; 47.5%, 70.0% in minor, moderate and severe NASAH, respectively. Invasive BP monitoring is performed more often in severe NASAH (52.5%, 55.0%, 71.3% minor, moderate, severe). CV prophylaxis and transcranial doppler ultrasound (TCD) are performed in 41.3%, 45.0%, 63.8% in minor, moderate and severe NASAH, respectively. Indication for a second DSA is set in the majority of centers, whereas after two negative ones, a third DSA is less often indicated (2nd: 66.2%, 72.5%, 86.2%; 3rd: 3.8%, 3.8%, 13.8% minor, moderate, severe). This study confirms the influence of bleeding severity on treatment and follow-up of NASAH patients. Additionally, the existing inconsistency of treatment pathways throughout Germany is highlighted. Therefore, we suggest to conceive new treatment guidelines including this finding.

Hydrocephalus, cerebral vasospasm, and delayed cerebral ischemia following non-aneurysmatic spontaneous subarachnoid hemorrhages: an underestimated problem.

Non-aneurysmal subarachnoid hemorrhage (NASAH) is rare and mostly benign. However, complications such as cerebral vasospasm (CV), delayed cerebral ischemia (DCI), or post-hemorrhagic hydrocephalus (HC) may worsen the prognosis. The aim of this study was to evaluate the rate of these complications comparing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH. Monocentric, retrospective analysis of patients diagnosed with NASAH from 01/2010 to 01/2021. Diagnosis was set only if vascular pathologies were excluded in at least one digital subtraction angiography, and NASAH was confirmed by cranial computed tomography (cCT) or lumbar puncture (LP). One hundred patients (62 female) with a mean age of 54.9 years (27-84) were identified. Seventy-three percent had a World Federation of Neurological Surgeons (WFNS) grading scale score I, while 9% were WFNS score IV or V at the time of admission. SAH was diagnosed by cCT in 86%, in 14% by lumbar puncture. Twenty-five percent necessitated short-term CSF diversion by extraventricular drainage or lumbar drainage, whereof 7 suffered from long-term HC treated with ventriculoperitoneal shunting (VPS). One patient without a short-term CSF drainage developed long-term HC. Ten percent developed CV, four of whom received intraarterial spasmolysis. Radiological DCI was diagnosed in 2%; none of these correlated with CV. Despite a mortality of 3% occurring solely in NPM SAH, the analyzed complication rate was comparable in both groups. We observed post-hemorrhagic complications in 35% of cases during the first 3 weeks after bleeding, predominantly in patients with NPM SAH. For this reason, close observation and cranial imaging within this time may be indicated not to overlook these complications.

Implementation of a three-dimensional (3D) robotic digital microscope (AEOS) in spinal procedures.

Three-dimensional exoscopes have been designed to overcome certain insufficiencies of operative microscopes. We aimed to explore the clinical use in various spinal surgeries. We performed surgery on patients with different spine entities in a neurosurgical department according to the current standard operating procedures over a 4-week period of time. The microsurgical part has been performed with Aesculap AEOS 3D microscope. Three neurosurgeons with different degree of surgical expertise completed a questionnaire with 43 items based on intraoperative handling and feasibility after the procedures. We collected and analyzed data from seventeen patients (35% male/65% female) with a median age of 70 years [CI 47-86] and median BMI of 25.8 kg/m2 [range 21-33]. We included a variety of spinal pathologies (10 degenerative, 4 tumor and 3 infectious cases) with different level of complexity. Regarding setup conflicts we observed issues with adjustment of the monitor position or while using additional equipment (e.g. fluoroscopy in fusion surgery) (p = 0.007/p = 0.001). However image resolution and sharpness as well as 3D-depth perception were completely satisfactory for all surgeons in all procedures. The utilization of the exoscopic arm was easy for 76.5% of the surgeons, and all of them declared a significant improvement of the surgical corridor. The 3D-exoscope implementation appears to achieve very satisfactory results in spinal procedures especially with minimally invasive approaches.

Resection of supratentorial brain metastases with intraoperative radiotherapy. Is it safe? Analysis and experiences of a single center cohort.

Introduction: Intraoperative Radiotherapy (ioRT) is an emerging treatment option in oncologic surgery for various diseases including intraaxial brain lesions to improve surgical outcome and accelerate the adjuvant oncologic therapy. Despite its use in glioma surgery, the application and data regarding ioRT in the treatment of brain metastases (BMs) is sparse. Here were report the largest series of supratentorial BMs treated with resection and ioRT according to functional outcome and adverse events. Methods: We performed a retrospective chart review analysis of patients undergoing surgery for BMs following an interdisciplinary tumor board decision in every case with ioRT at our institution. Patient properties, functional status (Karnofsky Performance Score/KPS) before and after surgery as well as oncologic (disease, recursive partitioning analysis, lesion size) and operative parameters were analyzed until hospital discharge. Adverse events (AE) were recorded until 30 days after surgery and rated according to the Clavien Dindo Grading (CDG) scale. Results: 70 patients (40 female) with various oncologic diseases were identified and analyzed. Six underwent prior RT. Mean age was 66 ± 11 years. Preoperative median KPS was 80% with a mean BM volume of 3.2 ± 1.2 cm3. Nine patients (13%) experienced in total 14 AEs, including 2 cases (3%) of postoperative death (CDG5) and 2 with new postoperative epilepsy necessitating additional pharmacotreatment (CDG2). Five patients suffered from new neurologic deficit (CDG1) not needing further surgical or medical treatment. After surgery, the neurological status in 7 patients (10%) deteriorated while it improved in 21 cases (30%). Patients experiencing AEs had longer hospitalization and poorer postoperative KPS mdn. 90 vs. 80%. There was no statistically significant deterioration of the functional status during the immediate postoperative course in the whole patient cohort. Conclusion: Surgery for supratentorial BMs with ioRT seems safe and feasible. Further studies on the benefit regarding oncologic outcome need to be performed.

The use of strain, strain rate, and displacement by 2D speckle tracking for assessment of systolic left ventricular function in goats: applicability and influence of general anesthesia.

BACKGROUND: Assessment of left ventricular (LV) systolic function can be achieved by conventional echocardiographic methods, but quantification of contractility, regional myocardial function, and ventricular synchrony is challenging. The goal of this study was to investigate the applicability of two-dimensional speckle tracking (2DST) to characterize segmental and global wall motion for assessment of LV function and LV synchrony in healthy goats. We aimed to describe the techniques, report normal values of a variety of 2DST indices, and determine the influence of general anesthesia. METHODS: Prospective study on 22 healthy female Saanen goats (3.7 ± 1.1 y, 60.2 ± 10.5 kg [mean ± SD]). All goats underwent two transthoracic echocardiographic examinations, the first standing and unsedated and the second 7.4 ± 3.5 days later during isoflurane anesthesia and positioned in sternal recumbency. Data analyses were performed offline, blinded, and in random order. Left ventricular longitudinal, radial and circumferential strain and strain rate as well as longitudinal and radial displacement were measured using 2DST methods. Summary statistics were generated and differences of 2DST variables between myocardial segments and treatments (i.e., awake vs. anesthetized) were assessed statistically (alpha level=0.05). RESULTS: Echocardiographic analyses by 2DST were feasible in all goats and at both time points. Longitudinal systolic strain, strain rate and displacement followed a gradient from apex to base. Absolute systolic strain was generally lower and strain rate was higher in awake goats compared to anesthetized goats. Circumferential and radial indices did not consistently follow a segmental pattern. Generally, peak strain occurred later in anesthetized goats compared to awake goats. General anesthesia did not significantly influence LV synchrony. CONCLUSIONS: 2SDT is a valid method for non-invasive characterization of LV wall motion in awake and anesthetized goats. The results of this study add to the understanding of LV mechanical function, aid in the diagnosis of global and segmental LV systolic dysfunction, and will be useful for future cardiovascular studies in this species. However, effects of anesthesia and species-specific characteristics should be considered when goats are used as animal models for human disease.

Ultrasonographic characterization of the liver, caudal vena cava, portal vein, and gallbladder in goats.

OBJECTIVE: To characterize the localization, visible extent (ie, measurement of selected dimensions), and appearance of the liver, caudal vena cava, portal vein, and gallbladder during ultrasonography in healthy goats. ANIMALS: 27 female Saanen goats. PROCEDURES: A 5.0-MHz linear transducer was used to ultrasonographically examine the localization, visible extent of various dimensions, and appearance of the liver, caudal vena cava, portal vein, and gallbladder from the right side of each goat. RESULTS: Images of the liver were obtained in all goats. The dorsal margin of the liver extended in a cranioventral to caudodorsal direction parallel to the caudal margin of the lungs. The greatest visible extent of the liver was evident at the seventh and eighth intercostal spaces (mean value, 15.9 cm), and width was evident at the 10th intercostal space (mean value, 5.2 cm). The caudal vena cava had a triangular shape on cross section; the maximum width in cross section, circumference, and surface area ranged from 1.2 to 1.8 cm, 4.8 to 5.2 cm, and 0.8 to 1.1 cm², respectively. The portal vein was round on cross section (diameter, 0.8 to 1.7 cm) with stellate ramifications into the liver parenchyma. The gallbladder was pear-shaped and variable in size; it extended beyond the ventral margin of the liver to a variable degree depending on the amount of bile. CONCLUSIONS AND CLINICAL RELEVANCE: Results provided information regarding the ultrasonographic appearance of the liver, caudal vena cava, portal vein, and gallbladder in healthy goats; these data may be useful during examination of goats with suspected liver disease.

Comparison of racemic ketamine and S-ketamine as agents for the induction of anaesthesia in goats.

OBJECTIVE: To compare racemic ketamine and S-ketamine as induction agents prior to isoflurane anaesthesia. STUDY DESIGN: Prospective, blinded, randomized experimental study. ANIMALS: Thirty-one healthy adult goats weighing 39-86 kg. METHODS: Goats were premedicated with xylazine (0.1 mg kg(-1)) intravenously (IV) given over 5 minutes. Each goat was assigned randomly to one of two treatments for IV anaesthetic induction: group RK (15 goats) racemic ketamine (3 mg kg(-1)) and group SK (16 goats) S-ketamine (1.5 mg kg(-1)). Time from end-injection to recumbency was measured and quality of anaesthetic induction and condition for endotracheal intubation were scored. Anaesthesia was maintained with isoflurane in oxygen for 90 minutes. Heart rate, invasive arterial blood pressure, oxygen saturation, temperature, end-tidal carbon dioxide and isoflurane were recorded every 5 minutes. Arterial blood samples were taken for analysis every 30 minutes. Recovery time to recurrence of swallowing reflex, to first head movement and to standing were recorded and recovery quality was scored. Two-way repeated measures anova, Mann-Whitney and a Mantel-Cox tests were used for statistical analysis as relevant with a significance level set at p<0.05. RESULTS: Induction of anaesthesia was smooth and uneventful in all goats. There was no statistical difference between groups in any measured parameter. Side effects following anaesthetic induction included slight head or limb twitching, moving forward and backward, salivation and nystagmus but were minimal. Endotracheal intubation was achieved in all goats at first or second attempt. Recovery was uneventful on all occasions. All goats were quiet and needed only one or two attempts to stand. CONCLUSIONS AND CLINICAL RELEVANCE: S-ketamine at half the dose rate of racemic ketamine in goats sedated with xylazine and thereafter anaesthetised with isoflurane induces the same clinically measurable effects.