One-step CAD/CAM titanium cranioplasty after drilling template-assisted resection of intraosseous skull base meningioma: technical note.

INTRODUCTION: Cranial defects following intra-osseous tumor removal may be large and require adequate reconstruction. CAD/CAM implants have been used for years to achieve an optimal cosmetic result. The disadvantage is that such implants require a second surgery. A preoperative virtual planning of resection margins and the simultaneously fabrication of the cranioplasty could be a possibility to subsume the steps tumor resection and cosmetic restoration to a single procedure. METHODS: We present two cases of patients with complex intra-osseous spheno-orbital meningioma. Tumor resection was performed with the help of a drilling template in form of a frame. The template also served as a negative for the computer-designed cranioplasty. The devices were manufactured by DMD GmbH - Digital Medical Design/DDI-Group, Dortmund, Germany. DISCUSSION: The usage of the template was highly practicable. Small adjustments in bone removal were necessary to achieve an optimal fitting of the implant. The 6-month follow-up showed for one patient a good and for one a satisfactory cosmetic result. No second surgery was necessary. CONCLUSIONS: Drilling template application could contribute to challenging cases of large fronto-basal meningiomas with the aim of minimizing operation time and achieving a good esthetic outcome.

The pre-interventional psychiatric history - an underestimated confounder in benign intracranial lesions studies.

OBJECTIVES: The current study was designed to analyze the influence of a positive pre-interventional psychiatric history on the quality of life (QOL) after successful treatment of benign intracranial extra-cerebral lesions. METHODS: Patients treated due to meningioma WHO I or unruptured intracranial aneurysms in two German neurosurgical centers between 2007 and 2013 were screened for exclusion criteria including malignant/chronic diseases, recurrence of the tumor/aneurysm and neurological deficits among others. 131 patients who met the criteria of an objectively unaffected health status were included. The pre-interventional psychiatric histories and the rates of post-interventional headaches, sleeping disorders, symptoms of chronic fatigue syndrome (CFS), post-traumatic stress disorder (PTSD) and QOL were determined by questionnaires which were mailed to the patients. RESULTS: 103 patients returned the questionnaires. Despite the objectively unaffected health status, the patients with a positive pre-interventional psychiatric history demonstrated a post-interventionally significantly lower QOL (p=0.002), a significantly higher Pittsburgh Sleep Quality Index sum score (p=0.009), as well as significantly higher rates of symptoms of a chronic fatigue syndrome (p=0.003) and PTSD (p=0.024), compared to the patient collective with a negative pre-interventional psychiatric status. CONCLUSION: The results of the current study demonstrate the importance of taking the pre-interventional psychiatric history as a significant and independent confounder into consideration when evaluating the outcome after treatment of benign intracranial extra-cerebral lesions. A pre-interventional psychiatric screening and an early psychological intervention might help to improve the overall outcome after successful treatment of such lesions.

Patient characteristics support unfavorable psychiatric outcome after treatment of unruptured intracranial aneurysms.

INTRODUCTION: Previous studies demonstrated an unfavorable psychological outcome after treatment of unruptured intracranial aneurysms despite an objectively favorable clinical and radiological outcome. The current study was therefore designed to analyze the psychiatric vulnerability of this specific patient collective. MATERIALS AND METHODS: Patients treated for a WHO grade I meningioma and incidental intracranial aneurysms in two German neurosurgical centers between 2007 and 2013 were screened for exclusion criteria including malignant/chronic diseases, recurrence of the tumor/aneurysm after more than 12 months and focal neurological deficits, among others. Seventy-five meningioma patients (M) and 56 incidental aneurysm patients (iA) met the inclusion criteria. The past medical psychiatric history, post-morbid personality characters and coping strategies were determined by questionnaires mailed to the patients in a printed version (Brief COPE, Big Five Personality Test). RESULTS: Fifty-eight M and 45 iA patients returned the questionnaires. Patients with iA demonstrated significantly higher pre-interventional rates of depressive episodes (p = 0.002) and psychological supervision (p = 0.038). These findings were especially aggravated in iA patients who received their cranial imaging for unspecific symptoms such as dizziness, headaches or tinnitus (n = 33, history of depressions: 39.4%; previous psychological supervision: 33.3%). Furthermore, the analysis of the Big Five personality traits revealed remarkably elevated neuroticism scores in the iA collective. CONCLUSION: The current study demonstrates an increased rate of positive pre-interventional psychiatric histories in the iA collective. Although those patients represent only a small subgroup, they still may play an important role concerning the overall outcome after iA treatment. Early detection and psychological support in this subgroup might help to improve the overall outcome. Further studies are needed to evaluate the influence of this new aspect on the multifactorial etiology of unfavorable psychiatric outcome after treatment of iA.

Charlson comorbidity index: an additional prognostic parameter for preoperative glioblastoma patient stratification.

PURPOSE: Dismal glioblastoma (GB) patient outcome calls for the elucidation of further reliable predictors of prognosis. Established "biomarkers," age and functional status, employed in today's patient stratification have limits in fingerprinting this heterogeneous tumor entity. We aimed at ascertaining additional prognostic factors that may facilitate patient stratification for surgery. METHODS: A retrospective review of 233 consecutive adult patients operated on for newly diagnosed GB at a single tertiary institution over a 5-year period (2006-2011) was conducted. Modern defined outcome associating factors recorded included demographics (preoperative age, gender, signs, symptoms, comorbidity status quantified by the Charlson comorbidity index (CCI), functional status computed by the Karnofsky performance scale (KPS)), tumor characteristics (size, location, isocitrate dehydrogenase mutation, and O-6-methylguanine-DNA methyltransferase promoter methylation status), and treatment parameters (volumetrically quantified extent of resection and adjuvant therapy). Survival analysis was performed by the Kaplan-Maier method. Influence of variables was evaluated using log-rank test. RESULTS: Median neuroradiographic evidence of tumor progression was 6 months after surgery (range 0-72). The median overall survival was 9.5 months (range 0-72). Age > 65 years, KPS ≤ 70, and CCI > 3 were significantly associated with both poor OS (each p < 0.0001) and PFS (p < 0.0001, p < 0.001 and p < 0.002), respectively. Also, patients older than 65 years significantly had a CCI > 3 (p < 0.0001). CONCLUSIONS: Our data evidence that aside established prognostic parameters (age and KPS) for GB patient outcome, the CCI additionally significantly impacts outcome and may be employed for preoperative patient stratification.

High rates of prasugrel and ticagrelor non-responder in patients treated with therapeutic hypothermia after cardiac arrest.

INTRODUCTION: After cardiac arrest due to acute coronary syndromes (ACS) therapeutic hypothermia (HT) is the standard care to reduce neurologic damage. Additionally, the concomitant medical treatment with aspirin and a P2Y12 receptor inhibitor like clopidogrel (Cl), prasugrel (Pr) or ticagrelor (Ti) is mandatory. The platelet inhibitory effect of these drugs under hypothermia remains unclear. METHODS: 164 patients with ACS were prospectively enrolled in this study. 84 patients were treated with HT, 80 patients were under normothermia (NT). All patients were treated with aspirin and one of the P2Y12 receptor inhibitors Cl, Pr or Ti. 24h after the initial loading dose the platelet reactivity index (PRI/VASP-index) was determined to achieve the platelet inhibitory effect. RESULTS: In the HT-group the PRI/VASP-index was significantly higher compared to the NT-group (54.86%±25.1 vs. 28.98%±22.8; p<0.001). In patients under HT receiving Cl, the platelet inhibition was most markedly reduced (HT vs. NT: 66.39%±19.1 vs. 33.36%±22.1; p<0.001) compared to Pr (HT vs. NT: 37.6%±25.0 vs. 27.04%±25.5; p=0.143) and Ti (HT vs. NT: 41.5%±21.0 vs. 17.83%±14.5; p=0.009). The rate of non-responder defined as PRI/VASP-index>50% was increased in HT compared to NT (60.7% vs. 22.5%; p<0.001) with the highest rates in the group receiving Cl (CL: 82% vs. 26%, p<0.001; Pr: 32% vs. 23%; n.s.; Ti: 30% vs. 8%, n.s.). CONCLUSION: The platelet inhibitory effect in patients treated with HT after cardiac arrest is significantly reduced. This effect was most marked with the use of Cl. The new P2Y12-inhibitors Pr and Ti improved platelet inhibition in HT, but could not completely prevent non-responsiveness.

Evidence level in the treatment of meningioma with focus on the comparison between surgery versus radiotherapy. A review.

In the majority of cases surgery of intracranial meningioma is the primary treatment option. If tumor regrowth occurs or a tumor remnant is left, radiotherapy or radiosurgery are performed. Purpose of this review is to clarify the question, if evidence based data exists regarding the treatment of meningiomas with special focus on the efficacy of stereotactic radiosurgery/ radiotherapy (SRS/ SRT) compared to surgery. A systematic literature search in the most relevant medical databases was done. Primary studies and systematic review with focus on epidemiologic problems and different therapeutic approaches for the treatment of meningioma were included. Standardized data extraction was performed. A total of 31 publications were included. Information and results in the data published with a surgical focus vary strongly regarding the localization of the meningiomas. No randomized clinical trials or prospective cohort studies could be identified. Comparison between surgical and radiotherapeutic success rates was not clearly possible due to different outcome scales (Simpson grading versus tumor volume reduction) used. Progression free survival was ranging from 77% to 97% (complete surgical resection) and 82% to 97% (surgical resection and additional radiotherapeutical treatment) in publications not differentiating between the location of the meningioma. Although no clear evidence exists that one treatment is better than the other, in symptomatic meningioma surgery is considered to be the primary treatment, if the surgical risk is acceptable. Stereotactic radiosurgery and radiotherapy are reserved to locations (optic sheet, cavernous sinus), where surgical risk is expected to be higher.

Prolonged administration of temozolomide in adult patients with anaplastic glioma.

PURPOSE: Prolonged administration of temozolomide is widely used in patients with glioblastoma; whereas the treatment of anaplastic glioma differs between neurooncological centres. The safety, feasibility and efficacy of prolonged temozolomide administration in patients with anaplastic gliomas was evaluated. PATIENTS AND METHODS: Forty-two patients with primary, recurrent or secondary anaplastic glioma were retrospectively analysed for the course of their disease. Treatment mostly consisted of surgery, followed by radiotherapy with concomitant and adjuvant temozolomide. In five patients with recurrence of primary anaplastic glioma, chemotherapy was initiated without previous surgery. Temozolomide was administered until evidence of tumour recurrence, appearance of serious side-effects or patients' wish to finish chemotherapy. RESULTS: The median overall survival (OS) was 39 months with a median cycle number of 7.5 (1-42). Treatment with temozolomide was stopped in 12 patients due to side-effects in general, whereas in only three patients (7.1%) treatment had to be discontinued due to haematological side-effects. There was no evidence of treatment related infections or grade IV toxicity. Extent of surgery had a significant influence on OS in anaplastic gliomas, the number of adjuvant temozolomide cycles showed a positive influence as well on time to progression (TTP) and OS. CONCLUSION: Prolonged administration of adjuvant temozolomide is safe and can be favorable for patients with anaplastic gliomas.

Management of patients with low-grade gliomas - a survey among German neurosurgical departments.

BACKGROUND AND AIMS OF THE STUDY: The diagnosis and treatment of low-grade gliomas (LGG) are multimodal. Today, there is no defined standard in diagnosis and treatment. Controversies are, in general, about a "wait-and-see" strategy, diagnostic workup, surgical intervention, postoperative imaging, adjuvant treatment, and follow-up. The aim of this study is to gain an overview about management strategies of high-volume German neurosurgical departments treating these patients. MATERIAL AND METHODS: A questionnaire including diagnostic, preoperative, perioperative, and postoperative parameters and 5 cases with magnetic resonance imaging data with questions to various treatment options in these patients was sent to all 34 German neurosurgical departments at university hospitals. RESULTS: In total, 24 questionnaires were returned and analysed. Centres were divided into those who generally practice a "wait-and-see" strategy vs. those who do not or only in highly selected cases. Statistical analyses were performed with Fisher test and Chi (2)-test. Interestingly, 50% of all centres routinely follow a "wait-and-see" strategy. CONCLUSION: Although the management of patients with LGG is complex and a simple questionnaire will not be able to define a standard in diagnosis and treatment, this study offers an overview on strategies at high-volume academic centres dealing with these patients. There is consensus to resect superficially located lobar and circumscribed low-grade lesions. However, the differences between centres become apparent with increasing complexity of the lesions.

Response to temozolomide in supratentorial multifocal recurrence of malignant ependymoma.

Intracranial anaplastic ependymomas are a very rare entity within the group of adult CNS neoplasms. Thus, no standard adjuvant therapy after surgical resection has been defined so far. External radiotherapy is commonly administered, but the role of chemotherapy is still unclear in malignant ependymomas. The case of a 25-year-old female patient with multifocal recurrence of a supratentorial malignant ependymoma administered temozolomide as second-line therapy is reported. Currently, 5 months after initiation of temozolomide treatment, there is no evidence of radiographic progression. Temozolomide could constitute a promising approach to supratentorial recurrent and multifocal anaplastic ependymoma of adults.

Robot- and computer-assisted craniotomy (CRANIO): from active systems to synergistic man-machine interaction.

Computer and robot assistance in craniotomy/craniectomy procedures is intended to increase precision and efficiency of the removal of calvarial tumours, enabling the preoperative design and manufacturing of the corresponding implant. In the framework of the CRANIO project, an active robotic system was developed to automate the milling processes based on a predefined resection planning. This approach allows for a very efficient milling process, but lacks feedback of the intra-operative process to the surgeon. To better integrate the surgeon into the process, a new teleoperated synergistic architecture was designed. This enables the surgeon to realize changes during the procedure and use their human cognitive capabilities. The preoperative planning information is used as guidance for the user interacting with the system through a master-slave architecture. In this article, the CRANIO system is presented together with this new synergistic approach. Experiments have been performed to evaluate the accuracy of the system in active and synergistic modes for the bone milling procedure. The laboratory studies showed the general feasibility of the new concept for the selected medical procedure and determined the accuracy of the system. Although the integration of the surgeon partially reduces the efficiency of the milling process compared with a purely active (automatic) milling, it provides more feedback and flexibility to the user during the intra-operative procedure.

[Translaminar fenestration for caudally herniated lumbar discs--a technical note]. / Translaminäre Fensterung bei nach kaudal sequestriertem lumbalem Bandscheibenvorfall--Technische Mitteilung.

Translaminar approaches have been described for lumbar disc herniations which are displaced cranially or laterally into the neuroforamen. This technique provides the advantages of a minimally invasive approach with regard to postoperative instability or partial facet joint resection and avoids a medial arthrectomy. We describe this technique for the first time as an option for a caudally sequestrated disc herniation via a transaxillar sequesterotomy.

Anterior cervical discectomy and titanium cage fusion - 7-year follow-up.

BACKGROUND AND STUDY AIMS: The purpose of this study was to prospectively evaluate long-term results after anterior cervical discectomy and titanium cage fusion (ACDF) and titanium cage fusion. Special focus was on the adjacent levels. METHODS: 54 patients (age: 48+/-10 years; one level operation in 44 patients and two level operation in 10 patients) entered the study. Re-evaluation consisted of a clinical out patient investigation and was possible in 33 patients. VAS, PROLO and Oswestry scores were used. Lateral radiographs were taken and changes in the operated and adjacent segments were measured and compared to radiographs directly after surgery. Clinical patient data was compared with the data prior to surgery. RESULTS: The mean follow-up time of the 33 patients was 7.26 +/- 0.22 years. One patient needed re-surgery of the cervical spine above the fused segment. PROLO results showed a significant improvement (PROLO F 1.52+/-0.67 to 3.79+/-1.17 p<0.01; PROLO E 1.52+/-0.5 to 3.55+/-1.42 p<0.01). Mean VAS at the time of investigation was 3.2+/-2.5. Oswestry score was 16.4+/-9.5. The alignment of the whole cervical spine was stable lordotic (Katsuura 10.9+/-9.0 degrees to 11.5+/-7.8 degrees ; p=0.76). Total segmental height had reduced from 36.6+/-4.6 mm to 34.6+/-3.9 mm (p=0.04). No significant reduction of disc space height of adjacent levels was detectable (superior: 5.8+/-1.6 mm to 5.2+/-1.6 mm; inferior: 6.0+/-1.7 mm to 5.3+/-1.9 mm). One adjacent superior level showed spontaneous fusion. Ventral and dorsal osteophytes in the superior and inferior adjacent levels increased in number and increased significantly in degree. Patients with bi-segmental fusion (n=7) showed similar results. CONCLUSION: ACDF with titanium cages has good clinical long-term results. A significant progression of degenerative changes can be observed on radiographs without clinical consequences for the patients. A comparison with patients without surgery and conservative therapy is needed to allow a better interpretation of the radiological results.

Computed tomographic angiography: diagnostic procedure of choice in the management of subarachnoid hemorrhage in the elderly patient?

BACKGROUND: The objective of this study was to establish whether 3D computed tomographic angiography (CTA) can be used to determine further management in patients older than 70 years admitted with acute subarachnoid hemorrhage (SAH). PATIENTS AND METHODS: CTA evaluation included analysis of the source images, image-slice-based multiplanar reconstruction, multi-intensity projection (MIP) and finally 3-dimensional rendering. The location and size of the aneurysm, its precise anatomical morphology and the configuration of the circle of Willis were evaluated. Based on these findings, surgery, endovascular coiling or conservative management was selected. RESULTS: Between October 2001 and June 2005, 44 patients over 70 years of age (38 females, 6 males) were admitted to our neurosurgical department with acute SAH. All patients underwent CTA, and additional 2D digital subtraction angiography (2D-DSA) was performed in 14 patients. Forty-five aneurysms (38 ruptured and 7 unruptured) were diagnosed. Six patients were found to have SAH of unknown origin (no aneurysm on CTA nor 2D-DSA). In 20 patients surgery was performed, in 10 patients endovascular coiling of the aneurysm was carried out, and 12 patients were treated conservatively. The findings on CTA and 2D-DSA could be compared for 26 patients (59%). Correlation between CTA and 2D-DSA was good in 25 of these cases (96%). Glasgow Outcome Scale scores of 4 or 5 were calculated for 37% of the operated patients, 27% of those treated with coils, and 36% of the patients treated conservatively. CONCLUSION: In older patients with degenerative vascular diseases, CTA can replace 2D-DSA in most cases if the image quality is excellent and analysis is performed carefully.

Perioperative complication rate of lumbar disc microsurgery depending on the surgeon's level of training.

AIM: Lumbar disc surgery is one of the procedures performed early in neurosurgical training. Agreement exists concerning the use of microsurgical techniques. With increasing surgical experience the clinical outcome should improve, partly because of a reduction in the complication rate. The aim of this study was to evaluate the correlation between patients' immediate clinical outcome, the perioperative complication rate and the surgeons' level of experience. METHODS: Patients undergoing surgery for lumbar disc herniation between January 1998 and December 2000 were investigated. Exclusion criteria were recurrent disc herniations and spinal stenosis. The surgeons were divided into four groups depending on their neurosurgical experience (group A: < or =2 years, group B >2 to < or =6 years, group C: >6 to < or =10 years, group D: >10 years). Anthropometric data, duration of surgery, early and late surgery-related complications and outcome at discharge were analysed. RESULTS: A total of 1 205 patients (556 females, 649 males) were entered in the study. Six hundred and six of the 1 205 patients were treated by surgeons with < or =6 years of training. Seventy-five patients (6.2%) required re-operation. The re-operation rate was lowest (2.91%) in group A and higher (5.25-9.5%) in the other groups. The intraoperative complication rate was highest (4.75%) in group B and significantly lower (1.1-2.5%) in the other groups. On the other hand, fewer patients in group B had persistent postoperative radicular pain. CONCLUSIONS: The clinical outcome after surgery for lumbar disc herniation does not improve linearly with the surgeon's experience. The intraoperative complication rate is highest between the 3rd and the 6th year of training.

[Pigmented villonodular synovitis involving the thoracic spine: a case report]. / Pigmentierte villonoduläre Synovitis der thorakalen Wirbelsäule - operatives Langzeitergebnis: ein Fallbericht.

Spinal diffuse-type giant cell tumours (also known as pigmented villonodular synovitis [PVNS]) are benign. Their occurrence in the thoracic spine is a very rare entity, nevertheless it should be considered in the differential diagnosis. We report about the case of a 35-year-old male presenting with an osteolytic and expansive mass compressing the spinal cord from C7 to Th2. Surgical resection was performed. Histopathological diagnosis was PVNS. 2 years postoperatively the patient was without pain and fully reintegrated in his previous job as a physician.

[Asynchronous lumbar synovial cysts after surgical resection: a case report]. / Asynchrone Facettgelenks-Zyste nach Facettgelenks-Punktion: eine Falldemonstration.

Lumbar synovial cysts represent a rare condition, they are believed to arise from defects of the joint capsule due to degeneration, trauma, rheumatoid arthritis or spondylosis. The symptom spectrum ranges from neural claudication to neurological deficits. We report the case of a contralateral asynchronous facet joint cyst after surgical resection and review the literature.

[Occult sacral meningocele--a diagnostic challenge]. / Okkulte sakrale Meningozele--eine diagnostische Herausforderung.

Occult sacral meningoceles are a rare causative factor for neural claudication or radiculopathy. Facet joint cysts in the lumbar spine causing similar symptoms are much more frequent. We report the case of a patient with the radiological diagnosis of a facet joint cyst causing neural claudication. During surgery an occult sacral meningocele was diagnosed. In the literature there are only few cases reported. Hence, the findings and important differential diagnoses of cystic epidural lesions in the lumbar spine are discussed.

Treatment of degenerative cervical disc disease with uncoforaminotomy--intermediate clinical outcome.

BACKGROUND: Anterior cervical uncoforaminotomy (uncoforaminotomy) is an operative method intended to preserve the functional motion segment of the cervical spine while removing the underlying pathology. Controversy exists concerning the patients best suited for this treatment modality. Furthermore, no long-term outcome analyses have been published. METHODS: Between November 2002 and June 2004, 96 patients underwent single-level uncoforaminotomy in our neurosurgical department for the treatment of cervical radiculopathy. The patients were divided into three groups: A, soft disc; B, hard disc; C, hard and soft disc. Follow-up was performed 2 years after surgery. Clinical outcome was classified according to Odom et al. and to the cervical Oswestry and 11-point box scales for arm and neck pain. RESULTS: Ninety patients (92%) underwent intermediate follow-up examinations at an average of 33 months after surgery. Forty-nine patients were in group A, 24 in group B, and 17 in group C. At discharge, 98% of those in group A, 96% in group B, and 94% in group C showed excellent or good results. In two patients revision surgery was performed within 4 weeks due to recurrent disc herniation. In one patient revision was carried out due to a subcutaneous hematoma. In group B one case of vertebral artery injury occurred. Additionally in one patient of this group revision surgery was performed due to inadequate decompression of the neural foramen. At follow-up 94% of the patients in group A, 89% in group B, and 87% in group C had excellent or good results. The scores on the cervical Oswestry scale and the 11-point-box scale showed no significant differences among the groups. CONCLUSION: Uncoforaminotomy, especially in patients with soft-disc pathologies, is a good operative method for the treatment of radicular pain.

Computed tomographic angiography in the evaluation of clip placement for intracranial aneurysm.

BACKGROUND: Computed tomographic angiography (CTA) has been shown to reliably detect aneurysms pre-operatively. The aim of this study was to compare the ability of post-operative CTA to detect aneurysmal remnants in connection with clip placement compared with digital subtraction angiography (DSA). Furthermore, special attention was paid to identifying factors influencing the image quality of CTA. METHOD: Between January 2005 and January 2006 a total of 76 patients with intracranial aneurysms were treated in our department. Thirty-two patients with a total of 33 clipped aneurysm were included in this study. All patients underwent CTA and DSA after surgery. Two investigators, each blinded to the classifications of the other, assessed image quality and clip placement. FINDINGS: In three patients aneurysmal remnants could be detected with CTA and DSA. One 2-mm aneurysmal remnant was not clearly identified on CTA; two small (<2-mm) aneurysmal remnants were definitely not seen on CTA. A single titanium clip was used for aneurysmal clipping in 26 patients, two clips were needed in six patients and one aneurysm required three clips being used. Overall, use of one titanium clip tended to result in better image quality. In addition, clip-gantry angles between 30 degrees and 60 degrees tended to yield better image quality. CONCLUSION: Post-operatively, CTA can be recommended as a reliable non-invasive diagnostic tool only with optimal image quality and with this criterion up to 66% of the aneurysms can be evaluated. Titanium artefacts, especially in the important zone (<2 mm) around the clip in which small aneurysmal remnants can occur, can render adequate evaluation impossible. CTA image quality depends on the number of titanium clips used, but clip-gantry-angle does not significantly influence the image quality.