The Usefulness of Intraoperative Cerebral C-Arm CT Angiogram for Implantation of Intracranial Depth Electrodes in Stereotactic Electroencephalography Procedure.

BACKGROUND: Stereotactic electroencephalography (SEEG) is an invasive diagnostic tool for localizing the epileptic zone in patients with medically refractory focal epilepsy. Despite technical and imaging advances in guiding the electrode placement, vascular injury is still one of its most serious complications. OBJECT: To investigate the usefulness of intraoperative cerebral C-arm CT angiogram (CCTA) in avoiding intracranial hemorrhagic complications during SEEG electrode implantation. METHODS: Trajectory data from 12 patients who underwent SEEG electrode implantation were studied in detail. This included an analysis of the implantation of 146 SEEG electrodes, which were guided by intraoperative CCTA, as well as the standard planning based on preoperative contrast-enhanced MRI. In addition, a prospective analysis of SEEG hemorrhagic complications using the studied methodology was performed in a total of 87 patients receiving 1,310 electrodes. RESULTS: There was no complication related to the CCTA itself. Intraoperative CCTA entailed modification of the original trajectory based on the preoperative MRI in 27 of 146 electrode implantations (18.5%). In 10 of them, a severe vascular complication was adverted by intraoperative CCTA. The safety of this new approach was also confirmed by the analysis of postinterventional CT, which revealed a symptomatic hematoma caused by 1 single electrode out of the 1,310 implanted. CONCLUSIONS: This study showed that intraoperative CCTA in addition to preoperative MRI is useful in guiding a safer SEEG electrode implantation. The combination of both imaging modalities essentially minimizes the risk of serious hemorrhagic complications.

Subdural Hematoma and Oral Anticoagulation: A Therapeutic Dilemma from the Neurosurgical Point of View.

BACKGROUND: Oral anticoagulation is a common prophylactic therapy for several diseases with a high thromboembolic risk. Such medication harbors a possible hemorrhage risk, with a special risk for subdural hematoma (SDH). The safety and efficacy of resumption of oral anticoagulation versus long-term discontinuation has not been fully clarified in patients who experienced SDH while under treatment with oral anticoagulation. MATERIAL AND METHODS: We investigated the outcome of 49 patients who were identified retrospectively to have a SDH while receiving oral anticoagulation. RESULTS: Most bleeding occurred while patients were within the recommended therapeutic window for oral anticoagulation. Mortality was 15%. The event-free survival probability was higher in the group of patients with reinstitution of phenprocoumon therapy than in the group without. Over a median follow-up of 32 months, thromboembolic events occurred in 4 of 23 patients without oral anticoagulation versus in none of 15 patients with phenprocoumon; hemorrhagic complications occurred in 1 in 23 versus 3 in 15 patients. CONCLUSIONS: Reinstitution of oral anticoagulation with phenprocoumon after previous SDH appears to have an acceptable risk for hemorrhagic complications. Decision making might consider case-by-case differences. To establish specific guidelines, prospective large cohort studies are needed.

PROSAIKA: a prospective multicenter registry with the first programmable gravitational device for hydrocephalus shunting.

OBJECTIVE: Cerebrospinal fluid (CSF) overdrainage is a major problem in shunt therapy for hydrocephalus. The adjustable gravitational valve proSA allows for the first time a targeted compensation for overdrainage in the upright position without interfering with the differential pressure valve. To evaluate benefit, safety and reliability, the multicenter prospective registry PROSAIKA was conducted in 10 German neurosurgical centers. METHODS: Between March 2009 and July 2010, 120 hydrocephalic patients undergoing first time shunt implantation or shunt revision using proSA entered the study. 93 patients completed the 12 months follow-up. RESULTS: Hydrocephalus symptoms were improved in 86%, unchanged in 9% and deteriorated in 3%. In 51%, the proSA opening pressure was readjusted one or several times to treat suspected suboptimal shunt function, this resulted in clinical improvement in 55%, no change in 25%, and deterioration in 20% of these patients. The 1 year censored proSA shunt survival rate was 89%. Device related shunt failure was seen in two cases. CONCLUSIONS: This is the first clinical report on the implantation of the adjustable gravitational valve proSA with a follow-up of 12 months in a substantial number of patients. Irrespective of different hydrocephalus etiologies and indications for shunt surgery, the overall results after 12 months were very satisfying. The high frequency of valve readjustments underlines the fact that preoperative selection of the appropriate valve opening pressure is difficult. The low number of revisions and complications compared to other valves proves that proSA implantation adds no further risk; this valve is reliable, helpful and safe.

Subacute steroid-induced paraparesis: surgical treatment of a devastating "invisible" side effect.

PURPOSE: To emphasize an underestimated side effect following long-term use of steroids. METHODS: We report on surgical treatment of two patients with serious neurologic deficits caused by epidural spinal lipoma following long-term intake of cortisone. RESULTS: Early decompression of the spinal cord by removal of epidural lipoma was the most effective treatment in these patients with progressive symptoms. CONCLUSION: Diagnostic work-up of such patients should include early spinal MRI resulting in surgical intervention, if indicated. Decompression of the spinal cord eventually combined with fusion is necessary.

MRI safety of a programmable shunt assistant at 3 and 7 Tesla.

OBJECTIVE: Several new shunt technologies have been developed to optimize hydrocephalus treatment within the past few years. Overdrainage, however, still remains an unresolved problem. One new technology which may reduce the frequency of this complication is the use of a programmable shunt assistant (proSA). Inactive in a horizontal position, it impedes CSF flow in a vertical position according to a prescribed pressure level ranging from 0 to 40 cm H(2)O. METHODS: We exposed the proSA valve in an ex vivo protocol to MR systems operating at 3 and 7 Tesla to investigate its MRI safety. RESULTS: Following 3 Tesla exposure, no changes in valve settings were noted. Adjustment to any pressure level was possible thereafter. The mean deflection angle was 23 ± 3°. After exposure to 7 Tesla, however, there were unintended pressure changes, and the mechanism for further adjustment of the valves even disintegrated. CONCLUSION: According to the results of this study, proSA is safe with heteropolar vertical magnet alignment at 3 Tesla. Following 7 Tesla exposure, the valves lost their functional capability.

Stereotactic versus endoscopic surgery in periventricular lesions.

OBJECT: Endoscopic and stereotactic surgery have gained widespread acceptance as minimally invasive tools for the diagnosis of intracerebral pathologies. We investigated the specific advantages and disadvantages of each technique in the assessment of periventricular lesions. METHOD: This study included a retrospective series of 70 patients with periventricular lesions. Endoscopic surgery was performed in 17 patients (mean age, 37 years; range, 4 months-78 years) and stereotactic biopsy in 55 patients (mean age, 63 years; range, 23-80 years), including two patients who underwent both procedures. RESULTS: Hydrocephalus was present in 13/17 patients in the endoscopic group (77%) and in 11/55 patients in the stereotactic group (20%). Diagnosis was achieved in all patients in the endoscopic group and in all but one patient in the stereotactic group, in whom histological diagnosis was obtained by endoscopic biopsy during a second operation. In the endoscopic group, additional procedures performed included ventriculostomy (2/17), cyst fenestration (3/17), endoscopic shunt revision (3/17) and placement of Rickham reservoirs or external cerebrospinal fluid drains (6/17). Adverse events occurred in one patient after endoscopy (chronic subdural hematoma) and in two patients after stereotactic surgery (one mild hemiparesis and one transitory paresis of the contralateral leg). CONCLUSIONS: Endoscopic and stereotactic surgery have distinct advantages and disadvantages in approaching periventricular lesions. The advantages of endoscopy encompass the possibility to perform additional surgical procedures during the same session (e.g. tumour reduction, third ventriculostomy, fenestration of a cyst). The visual control reduces the hazard of injury to anatomical structures and allows for a better control of bleeding although there is a considerable blind-out in such situations. The advantages of stereotactic surgery include a smaller approach and precise planning of the trajectory. It is usually performed under local anaesthesia. Both methods provide a safe and efficient therapeutic option in periventricular lesions with low surgical-related morbidity.

The adjustable proGAV shunt: a prospective safety and reliability multicenter study.

OBJECTIVE: To evaluate the reliability of the gravitation-assisted adjustable proGAV shunt system with a prospective multicenter study conducted in 10 German hospitals. METHODS: Enrollment for this observational study began in April 2005 and concluded in February 2006. The protocol required re-examinations 3 and 6 months postoperatively and fixed the endpoint of follow-up at 12 months after implantation. Patients with different types of adult, juvenile, and pediatric hydrocephalus were included and 165 patients were enrolled; 9 died and 12 had incomplete follow-up. RESULTS: Of the assessable 144 patients, 130 completed the protocol after 12 months, whereas 14 failed because of the need to explant the device, mainly because of infection. In 12 patients, components of the shunt, not the valve, were revised. In 65 of the 144 patients, there were 102 readjustments of the valve in 67 incidences because of underdrainage and in 35 because of overdrainage. In 1 case, readjustment was not possible. Determination of pressure level with the verification instrument was safe and corresponded to the required x-ray controls after adjustments. No unintended readjustments were noted. CONCLUSION: The proGAV is a safe and reliable device.

The diagnostic value of erythrocyte sedimentation rate in management of brain tumors.

OBJECTIVE: Erythrocyte sedimentation rate (ESR) is considered as an indicator of inflammatory processes, and it has a prognostic value in the management of specific neoplastic diseases. It also responds to surgical intervention. There is very little data about the alteration of ESR in patients with brain tumors and information on its course after intracranial tumor surgery is completely lacking. METHODS: ESR was measured for 10 days in 46 patients (19 women and 27 men; mean age: 49.7 years; range: 13-70 years) who underwent elective craniotomy for tumor microsurgery (70-425 minutes with a mean of 230 minutes) under general anaesthesia. Blood samples were taken on the day before surgery and on each consecutive day after surgery for 10 days. The standard method of measuring ESR was based on the technique first described by Westergren. RESULTS: The mean ESR level on the day before surgery was 8.26 +/- 7.27 mm/h after 1 hour and 14.80 +/- 10.36 mm/h after 2 hours. After tumor surgery, ESR increased stepwise. The mean peak value of 22.89 +/- 13.41 mm/h after the first hour was reached on the third post-operative day. Whereas mean values varied over time, ESR remained increased and did not decline to normal values until the tenth post-operative day. The mean ESR peak value was higher in patients having undergone surgery for intra-axial lesions (31.36 +/- 30.43 mm/h on the post-operative day 6) as compared to patients with extra-axial lesions (21.31 +/- 12.20 mm/h on the post-operative day 3). CONCLUSION: ESR is not relevantly increased in patients harboring brain tumors. Because it remains elevated until the tenth post-operative day after uneventful craniotomy and generally responds more slowly than other indicators like C-reactive protein, it is also not suitable for the detection of post-operative infective complications.

Exophytic giant cell glioblastoma of the medulla oblongata.

Giant cell glioblastoma is a rare variant within the spectrum of glioblastoma multiforme (GBM) tumors. A giant cell glioblastoma may be associated with a better prognosis than the common type of GBM after combined treatment involving tumor resection and radiochemotherapy. A giant cell glioblastoma may occur at various sites in the brain and spinal cord. To the authors' knowledge, this type of tumor has not been previously reported as arising as an exophytic tumor from the medulla oblongata. The authors report on a 40-year-old man who presented with a large tumor located in the caudal fourth ventricle. The tumor was removed completely and the patient underwent percutaneous radiotherapy with 60 Gy and concomitant chemotherapy with temozolomide. Histopathological examination of the tumor revealed the typical features of a giant cell glioblastoma. At the 2-year follow-up the patient was doing well and showed no signs of tumor recurrence. It is important to identify variants of GBM because they may predict favorable long-term outcome, even when they arise from the caudal brainstem.

Modified calcium accumulation after controlled cortical impact under cyclosporin A treatment: a 45Ca autoradiographic study.

OBJECTIVE: As a neuroprotective drug, cyclosporin A (CsA) has been subject of multiple experimental works in traumatic brain injury (TBI) research. It is well known that CsA inhibits calcium (Ca2+) induced mitochondrial permeability transition (mPT). The aim of this study was to investigate the influence of CsA on the alteration of Ca2+ homeostasis after experimental brain injury. METHODS: Sprague-Dawley male rats (n = 36) with a mean weight of 330 g (280-350 g) were general anesthetized with isofluran through gas mask. The anesthetized animals (n = 24) were subjected to a controlled cortical impact (CCI) over the left parietotemporal cortex using round-tip impounder with a 5 mm diameter at a velocity of approximately 3.7 m/s and a penetration depth of 2 mm. The sham group (n = 12) underwent anesthesia and craniotomy without CCI. In the CCI groups, CsA (n = 12) or vehicle (n = 12) was administered 15 minutes post-injury with a subsequent i.p. injection after 24 hours. Thirty-three hours after injury or sham craniotomy, 45calcium (45Ca) suspended in physiologic saline solution was injected in the left femoral vein. Five hours after isotope administration, animals were killed and the brain was quickly removed and placed in powdered dry ice. Coronal plane sections (20 microm thick) taken every 400 microm from the frontal cortex through the occipital cortex, were exposed to cyclotron films for 14 days at -18 degrees C. Relative optical density was utilized to provide a relative measure of 45Ca accumulation within seven different structures. RESULTS: The difference of 45Ca accumulation (measured by relative optical density) in the CsA group was greater by 30-70% in the following structures compared to vehicle treated traumatized animals: temporal cortex, CA1, anteromedial and posteromedial thalamus (p < 0.05). CONCLUSION: Post-traumatic 45Ca accumulation is modified under CsA. The crucial neuroprotective effect of CsA might be unrelated to a reduction of post-traumatic Ca2+ accumulation, especially with regard to the importance of Ca2+ as an intracellular messenger governing a large number of cellular functions.

Chordomas of the skull base: surgical management and outcome.

OBJECT: The goal of this study was to report on the surgical management of skull base chordomas and to evaluate both the short- and long-term treatment outcomes. METHODS: The authors retrospectively studied data from 49 patients who had undergone consecutive surgeries at a single institution. They also analyzed patterns of chordoma extension. Complications and surgery-related morbidity were recorded. A Kaplan-Meier analysis was performed to determine survival rates in patients 5 and 10 years after their first surgery. Operative approaches were selected on the basis of the predominant tumor extension. RESULTS: The approach used most frequently was the transethmoidal in 36.3%, followed by the pterional in 23.4% and the retrosigmoid in 23.4%. The tumor was totally removed in 49.4% and subtotally in 50.6%. The rate of total removal was highest at initial surgery (78%) and progressively declined thereafter. In 11.8% of cases a new neurological deficit developed, while the preoperative deficit remained unchanged. In 20% of cases the preoperative deficits improved, but new deficits also appeared. The 5- and 10-year survival rates are 65 and 39%, respectively. CONCLUSIONS: With an individually tailored surgical approach, total tumor removal in 78% of the cases was achieved at the initial surgery. Radical surgery appears to increase slightly the surgical morbidity, but at the same time prolongs the recurrence-free interval. Chordomas cannot be regarded as surgically curable tumors given the 5- and 10-year survival rates in patients harboring such lesions.

Ventriculoperitoneal shunt dysfunction in a patient presenting with neurogenic pulmonary edema. Case report.

The authors report on a patient with dysfunction of a ventriculoperitoneal shunt who presented with two episodes of neurogenic pulmonary edema within the space of a few months. The edema resolved on correction of the shunt dysfunction. Because neurogenic pulmonary edema may be a rare consequence of shunt dysfunction, it is important to recognize this unusual association and provide appropriate diagnostic measures and treatment.

Response of C-reactive protein after craniotomy for microsurgery of intracranial tumors.

OBJECTIVE: C-reactive protein (CRP) is used as an indicator of inflammatory processes. However, its expression is unspecific and will increase after surgery. Without normative data on its regular course after craniotomy, postoperative infection can barely be detected or excluded. METHODS: CRP was measured for 10 days in 46 patients who underwent elective craniotomy for microsurgery of intracranial tumors. RESULTS: After craniotomy, CRP rapidly increased to reach a peak mean value of 32.43 +/- 38.02 mg/l (P < 0.001) on the second postoperative day. In 39 patients (85%), CRP reached its maximum level within the first 2 days. From Days 3 to 5 after surgery, mean CRP values constantly and significantly declined (P < 0.001) to arrive at a mean of 6.67 +/- 10.80 mg/l) on the fifth postoperative day. On Day 4, the mean CRP level returned to below one-third of the peak value (10.63 +/- 17.08 mg/l). On an individual basis, this was true for 34 patients (74%). During the period of initial increase of CRP until the second postoperative day, there was no significant correlation between CRP and erythrocyte sedimentation rate, body temperature, hemoglobin, hematocrit, red cell count, platelet count, and white cell count. CRP increase was more pronounced with intrinsic brain tumors and was not correlated to the degree of malignancy. CONCLUSION: Because CRP can be considerably increased in patients for 4 days after regular intracranial surgery, its diagnostic value during this period is limited. Only prolonged elevation or a secondary increase may indicate an ongoing infection.

Cavernous hemangioma of the cavernous sinus, skin, and retina: hemodynamic changes after treatment: case report.

OBJECTIVE: There are several reports concerning cavernous hemangiomas of the skin and central nervous system. Additional retinal involvement has also been reported. CLINICAL PRESENTATION: The authors report a 69-year-old woman with a giant extra-axial cavernous hemangioma of the right cavernous sinus involving the supra- and parasellar region, retina, and skin. INTERVENTION: Shrinkage of its cutaneous part lead to subsequent increase of the volume of the intracranial part. Owing to compression of the optic and the oculomotor nerves, oculomotor disturbances, ptosis, and visual impairment to 0.2 occurred. Via a pterional approach microsurgical removal of the tumor except for a remnant of the intracavernous part was performed. CONCLUSION: Hemodynamic connection between cutaneous, retinal, and intracranial hemangiomas should be considered.

Management of vestibular schwannomas in young patients-comparison of clinical features and outcome with adult patients.

OBJECTS: Vestibular schwannomas (VS) in young patients are rare. They are regarded to have different biological characteristics. Our objective is to analyze a series of such patients, with respect to their clinical presentation, treatment, and outcome and to compare the results to a matched series of adult patients. MATERIALS AND METHODS: Retrospective analysis of 20 patients under 21 years of age. All patients underwent surgery via the retrosigmoid approach. The analysis included: age, gender, tumor size, clinical, and neurological pre- and postoperative status including cochlear and facial nerve function, and complications. Statistical comparison of the young patient's data with a series of 200 adult patients previously published by the authors. CONCLUSIONS: The current study demonstrates that the outcome after surgical management in patients harboring VS does not show any significant difference between young and adult patients.