Efficacy of Surgery and Further Treatment of Progressive Glioblastoma.

BACKGROUND: Treatment options for patients with glioblastoma at progression have remained controversial, and selection criteria for the appropriate type of intervention remain poorly defined. The objectives were to determine which factors favor the decision for second surgery and which factors are associated with overall survival (OS) and to evaluate the National Institutes of Health (NIH) recurrent glioblastoma scale. The scale includes tumor involvement of eloquent brain regions, functional status, and tumor volume. METHODS: A retrospective single-center analysis of patients with newly diagnosed glioblastoma undergoing initial surgery between January 2007 and December 2011 was performed. Patients were separated into two groups: those with versus those without second resection surgery at disease progression. OS was compared using the multiple logistic regression model, Cox proportional hazard regression, and Kaplan-Meier survival analysis. RESULTS: The data of 98 patients were statistically analyzed. Among the patients, 58 had initial surgery only (age 61.27 years; median OS [mOS] 14.81 months) and 40 underwent second surgery at disease progression (age 55 years; mOS 18.86 months). Age was the only predictor for repeated surgery (P = 0.012; odds ratio 0.94). At the time of tumor progression, administration of alkylating chemotherapy (P = 0.004; hazard ratio [HR] 0.24) or bevacizumab (P = 0.001; HR 0.23) was associated with longer OS. Reoperation was associated with a lower HR (P = 0.134; HR 0.66). The NIH recurrent glioblastoma scale showed statistically significant improvement of prognosis prediction with the addition of age. CONCLUSIONS: Surgery of progressive glioblastoma and postoperative treatment at the time of progression is associated with improved OS in some patients. The addition of age may improve survival prediction of the NIH recurrent glioblastoma scale.

Third-generation cephalosporins as antibiotic prophylaxis in neurosurgery: what's the evidence?

To analyze the role of third-generation cephalosporins as prophylactic antibiotics in neurosurgery. We reviewed the literature for data from randomized controlled trials (RCTs) on third-generation cephalosporins compared to other antibiotic regimen in neurosurgery. End point of the RCTs was the occurrence of surgical site infections (SSIs)--data were pooled in a fixed-effects meta-analysis. Five randomized controlled trials enrolling a total of 2209 patients were identified. The pooled odds ratio for SSIs (overall) with third-generation cephalosporins prophylaxis in the five RCTs was 0.94 (95% CI, 0.59-1.52; P=0.81). No significant difference between third-generation cephalosporins and alternative regimen was identified. When analyzing organ SSIs (osteomyelitis, meningitis, and others intracranial infections) in data derived from four RCTs (1596 patients), third-generation cephalosporins failed to show superiority (pooled odds ratio 0.88; 95% CI 0.45-1.74; P=0.72). Third-generation cephalosporin antibiotic prophylaxis fails to show superiority over conventional regimens regarding both incisional and organ related SSIs in neurosurgery.

Meteorological influences on the incidence of aneurysmal subarachnoid hemorrhage - a single center study of 511 patients.

OBJECTIVE: To assess the potential meteorological influence on the incidence of aneurysmal subarachnoid hemorrhage (SAH). Previous studies used inhomogeneous patient groups, insufficient study periods or inappropriate statistics. PATIENTS AND METHODS: We analyzed 511 SAH admissions between 2004 and 2012 for which aneurysmal rupture occurred within the Zurich region. The hourly meteorological parameters considered are: surface pressure, 2-m temperature, relative humidity and wind gusts, sunshine, and precipitation. For all parameters we investigate three complementary statistical measures: i) the time evolution from 5 days before to 5 days after the SAH occurrence; ii) the deviation from the 10-year monthly mean; and iii) the change relative to the parameter's value two days before SAH occurrence. The statistical significance of the results is determined using a Monte Carlo simulation combined with a re-sampling technique (1000×). RESULTS: Regarding the meteorological parameters considered, no statistically significant signal could be found. The distributions of deviations relative to the climatology and of the changes during the two days prior to SAH events agree with the distributions for the randomly chosen days. The analysis was repeated separately for winter and summer to exclude compensating effects between the seasons. CONCLUSION: By using high-quality meteorological data analyzed with a sophisticated and robust statistical method no clearly identifiable meteorological influence for the SAH events considered can be found. Further studies on the influence of the investigated parameters on SAH incidence seem redundant.

Ruptured Rathke cleft cyst mimicking pituitary apoplexy.

Rathke cleft cysts (RCCs) are benign cystic lesions of the sellar and suprasellar region that are asymptomatic in most cases. Occasionally, compression of the optic pathway and hypothalamo-pituitary structures may cause clinical symptoms, such as headaches, visual deficits and endocrinopathies. Acute presentation caused by hemorrhage into an RCC have been described in the literature, and the term "Rathke cleft cyst apoplexy" has been coined. We present the case of a 32-year-old man with acute onset of meningitis-type symptoms and imaging findings resembling hemorrhagic pituitary tumor apoplexy. In retrospect, clinical symptoms, intraoperative appearance, and histologic examination were compatible with the diagnosis of nonhemorrhagic rupture of an RCC. Thus, the clinical presentation of "Rathke cleft cyst apoplexy" is not necessarily caused by hemorrhage.

Case report: Trabecular juvenile ossifying fibroma presenting as a sellar mass.

A 15-year-old girl presented with left occulomotor nerve palsy and was found to have a space occupying lesion of the sellar region with invasion of the left cavernous sinus. A transsphenoidal approach lead to subtotal removal of a solid tumor with some remnants in the cavernous sinus and revealed the diagnosis of trabecular juvenile ossifying fibroma (JOF). A repeat magnetic resonance imaging was obtained within 1 month that showed intrasellar recurrence and growing tumor in the cavernous sinus. Therefore, a combined transsphenoidal and transcranial approach was performed to more aggressively remove the tumor. Subsequently, adjuvant proton radiotherapy was performed. JOF of the trabecular type is a rare fibro-osseous lesion of the craniofacial skeleton almost exclusively occurring in the maxilla or the mandible. To our knowledge, this is the first case of this tumor entity presenting as a sellar mass.

Subdural drainage versus subperiosteal drainage in burr-hole trepanation for symptomatic chronic subdural hematomas.

BACKGROUND: Symptomatic chronic subdural hematoma (scSDH) is one of the most frequent diseases in neurosurgical practice, and its incidence is increasing. However, treatment modalities are still controversial. OBJECT: The aim of this retrospective single-center study is to compare for the first time two surgical methods in the treatment of subdural hematoma that have been proven to be efficient in previous studies in a direct comparison. METHODS: We analyzed the data of 143 scSDHs in 113 patients undergoing surgery for subdural hematoma with placement of subperiosteal or subdural drainage after double burr-hole trepanation for hematoma evacuation. RESULTS: Overall, there were no statistically significant differences regarding general patient characteristics, preoperative and postoperative symptoms, postoperative hematoma remnant, rates of recurrences, mortality, complications, and outcome at discharge and at 3-month follow up between the groups. There was a close to significant tendency of lower mortality after placement of subperiosteal drainage system and a tendency towards lower rate of recurrent hematoma after placement of subdural drainage system. CONCLUSIONS: Our study shows for the first time a direct comparison of two mainly used surgical techniques in the treatment of scSDH. Both methods proved to be highly effective, and general patient data, complications, outcome and mortality of both groups are equal or superior compared with previously published series. Because there is a clear tendency to less mortality and fewer serious complications, treatment with double burr-hole trepanation, irrigation, and placement of subperiosteal drainage is our treatment of choice in patients with predictable high risk of complications.

Decreasing expression of the interleukin-13 receptor IL-13Ralpha2 in treated recurrent malignant gliomas.

The IL-13Ralpha2 gene encodes for a 65 kDa protein that forms one of the subunits of the interleukin-13 (IL-13) receptor. This gene is highly expressed in various types of human tumors including malignant gliomas. The expression level of IL-13Ralpha2 was examined in a total of 45 tissue samples of anaplastic astrocytomas (AAs) World Health Organization (WHO) grade III, glioblastomas (GBMs) WHO grade IV, and first-recurrent glioblastomas (frGBMs) after treatment with radiation and chemotherapy. IL-13Ralpha2 expression was detected by semiquantitative reverse transcription real-time polymerase chain reaction (PCR) using ABI PRISM 7700 and Qiagen QuantiTect SYBR Green PCR kits. The expression level of IL-13Ralpha2 (15 fold) was significantly reduced in frGBMs compared to the primary GBMs (p = 0.014), and significantly reduced by more than 15 fold (p = 0.003) in all untreated malignant astrocytomas (AAs and GBMs) compared with treated frGBMs. Expression of IL-13Ralpha2 seems to be lower in frGBMs compared to GBMs. The promising antitumor effect of IL-13 cytotoxin could be greatly reduced in frGBM or only achievable with higher amounts of cytotoxin, due to the significantly lower expression of the cytotoxin's target structure.