Expertise in surgical neuro-oncology. Results of a survey by the EANS neuro-oncology section.

Introduction: Technical advances and the increasing role of interdisciplinary decision-making may warrant formal definitions of expertise in surgical neuro-oncology. Research question: The EANS Neuro-oncology Section felt that a survey detailing the European neurosurgical perspective on the concept of expertise in surgical neuro-oncology might be helpful. Material and methods: The EANS Neuro-oncology Section panel developed an online survey asking questions regarding criteria for expertise in neuro-oncological surgery and sent it to all individual EANS members. Results: Our questionnaire was completed by 251 respondents (consultants: 80.1%) from 42 countries. 67.7% would accept a lifetime caseload of >200 cases and 86.7% an annual caseload of >50 as evidence of neuro-oncological surgical expertise. A majority felt that surgeons who do not treat children (56.2%), do not have experience with spinal fusion (78.1%) or peripheral nerve tumors (71.7%) may still be considered experts. Majorities believed that expertise requires the use of skull-base approaches (85.8%), intraoperative monitoring (83.4%), awake craniotomies (77.3%), and neuro-endoscopy (75.5%) as well as continuing education of at least 1/year (100.0%), a research background (80.0%) and teaching activities (78.7%), and formal interdisciplinary collaborations (e.g., tumor board: 93.0%). Academic vs. non-academic affiliation, career position, years of neurosurgical experience, country of practice, and primary clinical interest had a minor influence on the respondents' opinions. Discussion and conclusion: Opinions among neurosurgeons regarding the characteristics and features of expertise in neuro-oncology vary surprisingly little. Large majorities favoring certain thresholds and qualitative criteria suggest a consensus definition might be possible.

Vasospasm of the basilar artery following spontaneous SAH-clinical observations and implications for vascular research.

The basilar artery (BA), as a reference vessel for laboratory investigations of cerebral vasospasm (CVS) in many experimental models, warrants a sufficient blood supply despite hemodynamic changes during CVS. In a prospective evaluation study, we analyzed  patients who were admitted to our department with subarachnoid hemorrhage (SAH) for the occurrence and sequelae of CVS. Specifically, we sought to identify patients with CVS of the BA. As per institutional protocol, all patients with CVS detected in the posterior circulation had magnetic resonance imaging (MRI) examinations instead of CTA. Between January and December 2016, 74 patients were treated for spontaneous SAH. CVS occurred in 45 (61%) patients, and 31 (42%) patients developed associated cerebral infarctions (CI). CVS was significantly associated with CI (p < 0.0001; OR 44). In 18 (24.3%) patients, CVS significantly affected the basilar artery. Poor admission clinical state, younger age, and treatment modalities were significantly associated with BACVS. BACVS was more often detected in patients with severe CVS (p < 0.046; OR 4.4). Patients with BACVS developed cerebral infarction in a frequency comparable to other patients with CVS (61% vs. 70%, p = 0.7), but none of these infarctions occurred in the brain stem or pons even though vessel diameter was dramatically reduced according to CT- and/or MR-angiography. BACVS does not appear to be followed by cerebral infarction in the BA territory, presumably due to a vascular privilege of this vessel and its perforating branches. In contrast, brain ischemia can frequently be observed in the territories of other major arteries affected by CVS.

Comparison of carotid and basilar bifurcation aneurysms versus non-T-angled bifurcations: the geometry is associated with the outcome.

Patients with ruptured aneurysms of carotid bifurcation artery seem to suffer less often from cerebral vasospasm and early brain injury and have a better clinical outcome. Aim of our study was to identify differences in clinical course and outcome in aneurysms of terminus segments (carotid bifurcation artery and basilar tip) compared to aneurysms of other aneurysm locations except carotid bifurcation artery and basilar tip. Patients with SAH were entered into a prospectively collected database (1999 to June 2014). A total of 471 patients ('T-shaped' aneurysms n = 63, 'non-T-shaped' aneurysms n = 408) were selected. Outcome was assessed by modified Rankin Scale (mRS) 6 months after SAH. Mean age was 53.75 years. Statistically, analysis showed a significant better outcome in 'T-shaped' aneurysms (p = 0.0001) and a significant lower mortality rate (p = 0.02) despite higher rates of Fisher 3 bleeding pattern and CVS. In 'T-shaped' aneurysms, no prognostic factors for outcome could be detected. In 'non-T-shaped' aneurysms admission status (p < 0.0001), early hydrocephalus (p < 0.0001), shunt-dependence (p = 0.001), and the occurrence of severe CVS (p = 0.01) statistically were factors influencing patients' outcome. Multivariate analysis showed 'non-T-shaped' aneurysms itself as independent prognostic factor for patients' outcome. Despite same rate of poor admission status, early hydrocephalus and shunt dependence 'T-shaped' aneurysms have a highly significantly better. Pathophysiological mechanism actually is not understood. Further studies are necessary to identify, which factors lead to the decreased outcome in "non-T-shaped"- aneurysms.

Decision-making in a patient with cardiac arrest due to venous thromboembolism within 24 h after glioblastoma resection.

In the fulminant VTE form with cardiac arrest, systemic thrombolysis remains the most effective therapy. However, several contraindications restrict the use such as intracranial neoplasm or a recent history of intracranial surgery. Here, we report the case of a 59-year-old man who underwent glioblastoma resection and suffered from a fulminant pulmonary embolism with cardiac arrest. After CPR, continuous tPA infusion via an endovascularly placed pulmonary catheter was maintained over a period of 8 h. In this case, we report on our decision-making process and the use of local thrombolysis as a successful therapy in a patient with multiple contraindications.

Non-aneurysmal subarachnoid hemorrhage in 173 patients: a prospective study of long-term outcome.

BACKGROUND AND PURPOSE: In some patients with subarachnoid hemorrhage (SAH) a bleeding source cannot be identified. Perimesencephalic (PM) SAH is assumed to have an excellent outcome. Our objective was to analyze the long-term physical and psychological outcome of patients after non-aneurysmal SAH. METHODS: One hundred and seventy-three patients met the inclusion criteria. Short-term follow-up 6 months after SAH was assessed according to the modified Rankin Scale (0-2 favorable). A short-form health survey with 36 questions (SF-36) and eight scales was used as questionnaire for long-term follow-up. RESULTS: Thirty-seven answers were received from the two groups, PM and non-perimesencephalic (NPM) SAH, on average 76 months after ictus (range 1.5-14 years). PM- and NPM-SAH without Fisher grade 3 blood pattern have excellent short-term outcomes. The quality of life (QoL) is significantly reduced after non-aneurysmal SAH, especially in NPM-SAH. In particular, patients with a Fisher 3 blood pattern had significantly higher risks for cerebral vasospasm, delayed cerebral ischaemia, unfavorable outcome, reduced QoL and mortality in short- and long-term follow-up. CONCLUSIONS: Excluding rolph, only patients with a PM-SAH have a similar QoL at long-term follow-up compared to the standard population. Patients with NPM-SAH have a significantly decreased QoL in long-term follow-up. Furthermore, the Fisher 3 blood pattern group in particular had a significantly worse outcome - at short-term and long-term follow-up. Therefore the NPM-SAH group was stratified into patients with Fisher 3 blood pattern and patients without Fisher 3 in further investigations.

Activation of executioner caspases is a predictor of progression-free survival in glioblastoma patients: a systems medicine approach.

Glioblastoma (GBM) is the most common and aggressive primary brain tumor in adults. GBM cells are highly resistant to apoptosis induced by antitumor drugs and radiotherapy resulting in cancer progression. We assessed whether a systems medicine approach, analysing the ability of tumor cells to execute apoptosis could be utilized to predict the response of GBM patients to treatment. Concentrations of the key proapoptotic proteins procaspase-3, procaspase-9, Smac and Apaf-1 and the antiapopotic protein XIAP were determined in a panel of GBM cell lines and GBM patient tumor resections. These values were used as input for APOPTO-CELL, a systems biological based mathematical model built to predict cellular susceptibility to undergo caspase activation. The modeling was capable of accurately distinguishing between GBM cells that die or survive in response to treatment with temozolomide in 10 of the 11 lines analysed. Importantly the results obtained using GBM patient samples show that APOPTO-CELL was capable of stratifying patients according to their progression-free survival times and predicted the ability of tumor cells to support caspase activation in 16 of the 21 GBM patients analysed. Calculating the susceptibility to apoptosis execution may be a potent tool in predicting GBM patient therapy responsiveness and may allow for the use of APOPTO-CELL in a clinical setting.

Plasmon-enhanced photocathode for high brightness and high repetition rate x-ray sources.

In this Letter, we report on the efficient generation of electrons from metals using multiphoton photoemission by use of nanostructured plasmonic surfaces to trap, localize, and enhance optical fields. The plasmonic surface increases absorption over normal metals by more than an order of magnitude, and due to the localization of fields, this results in over 6 orders of magnitude increase in effective nonlinear quantum yield. We demonstrate that the achieved quantum yield is high enough for use in rf photoinjectors operating as electron sources for MHz repetition rate x-ray free electron lasers.

Intra-operative subcortical electrical stimulation: a comparison of two methods.

OBJECTIVE: For intra-operative subcortical electrical stimulation of the corticospinal tract, two techniques - originally described for cortical stimulation - have evolved: the 50-Hz-stimulation first described by Penfield in 1937 and the high-frequency multipulse train stimulation technique first described by Taniguchi in 1993. Motor thresholds of both methods in combination with a bipolar and monopolar stimulation technique and their reliability for eliciting motor evoked potentials (MEPs) were studied. METHODS: Data were obtained in 20 patients (50±17 years; 10 females) undergoing tumour resection under general anaesthesia. Both 50-Hz-stimulation of 1-s duration and a multipulse stimulation (5 pulses interstimulus interval 4 ms, 0.5-Hz repetition rate) were applied with a bipolar probe (1.5-mm ball tip, 8-mm interelectrode distance) and a monopolar probe (1.5-mm-diameter tip). MEPs were recorded in muscles contralateral to the stimulated hemisphere. Comparison of different stimulation modalities was performed at the site where monopolar multipulse stimulation technique elicited MEPs with the lowest stimulation intensity (constant current monophasic cathodal stimulation, individual pulse width 0.5 ms, max. 25 mA). RESULTS: MEPs were elicited by monopolar multipulse stimulation with an intensity of 8±3.9 mA (21/21 stimulation sites); monopolar 50-Hz stimulation with 12±5.4 mA (18/21 stimulation sites); bipolar multipulse stimulation with 14±8.1 mA (12/21 stimulation sites) and bipolar 50-Hz stimulation with 15±6.3 mA (11/21 stimulation sites). CONCLUSIONS: Stimulation intensities for eliciting MEPs are significantly lowest for the monopolar multipulse stimulation (p<0.025). Monopolar compared to bipolar stimulation resulted in eliciting MEPs in a higher number of tested patients (Fisher's p<0.0001). SIGNIFICANCE: Subcortical stimulation with a monopolar probe and a multipulse stimulation is most efficient for the purpose of identifying the corticospinal tract. This is explained by the more radiant electric field properties of the monopolar probe compared to the bipolar probe.

The influence of preoperative anticoagulation on outcome and quality of life after surgical treatment of chronic subdural hematoma.

The main aim of this study was to investigate the influence of perioperative anticoagulation on the clinical course and outcome of 144 patients who underwent surgery for chronic subdural hematoma (CSDH). The outcome was categorized according to the modified Rankin Scale (mRS), Barthel Index and postoperative quality of life (QoL) scale. There was a significant correlation between preoperative aspirin medication and reoperation (Mann-Whitney U-test, p<0.05). Moreover, dosage and duration of postoperative low-molecular-weight heparin (LMWH) administration were associated with a higher risk of reoperation (Mann-Whitney U-test, p<0.01) and a worse outcome on the mRS (Mann-Whitney U-test, p<0.05). Intraoperative treatment with prothrombin complex concentrate led to a poor outcome on the mRS (Craddock-Flood test, p<0.05). Reoperation is the strongest predictive factor of a poor QoL after surgical treatment of CSDH. Both preoperative and postoperative anticoagulation treatment may affect reoperation rate and, thus, postoperative QoL.

Family history of coronary artery disease and cholesterol: screening children in a disadvantaged inner-city population.

BACKGROUND AND PURPOSE: Little information relating to cholesterol levels and screening for hypercholesterolemia in inner-city children exists. For this study, given the disrupted family backgrounds of many of our patients and the unreliability of family histories, our hypothesis was that in comparison with other samples, family history of coronary heart disease would be a poor screening tool for the identification of children with elevations in total serum cholesterol (TSC). SUBJECTS AND METHODS: During 15 months, more than 400 pediatric outpatients, 2 through 14 years old, were screened for a family history of atherosclerotic disease. These children were attending a clinic serving a disadvantaged black and Hispanic population at Kings County Hospital Center. Nonfasting TSC levels were measured in 300 children. Positive risk for coronary heart disease was determined by the presence of a family history of coronary heart disease (defined as angina, stroke, or myocardial infarction in any parent or grandparent) at less than 55 years age. RESULTS: The mean TSC level was 4.27 mmol/L SD +/- 0.85) (165.0 mg/dL [SD +/- 32.8]). The 29.4% of this population with a history suggestive of high risk for hypercholesterolemia had a mean TSC of 4.48 mmol/L (SD +/- 0.971) (173.2 mg/dL [SD +/- 37.5]), and those with no risk history had a mean TSC of 4.18 mmol/L (SD +/- 0.750) (161.4 mg/dL [SD +/- 29.9]) (P < .005). Use of family history of coronary artery disease as a screening tool had a sensitivity of 39.3%, a specificity of 74.5%, and a positive predictive value of 39.8% for detection of moderate hypercholesterolemia (TSC > or = 4.66 mmol/L [180 mg/dL]). CONCLUSIONS: This population's mean TSC level did not differ (P > .10) from those obtained in multiple large studies of average North American populations, and the predictive value and sensitivity of family history as a screening tool was comparable, although the prevalence of a positive family history was greater. The findings may be due to a greater prevalence of coronary artery disease at a young age in these families. In this population, a positive risk history is an important indicator for further evaluation of these children.

Detection of acute avascular necrosis of the femoral head in dogs: dynamic contrast-enhanced MR imaging vs spin-echo and STIR sequences.

OBJECTIVE: Spin-echo MR imaging has been shown to be highly sensitive in the detection of avascular necrosis. Very early avascular necrosis can, however, appear normal on MR images. We compared dynamic contrast-enhanced MR imaging with conventional spin-echo and short Tl inversion-recovery (STIR) sequences for detecting acute osteonecrosis in an animal model. MATERIALS AND METHODS: Avascular necrosis was induced unilaterally in the femoral heads of five dogs that were imaged with a 1.5-T system within 3 hr of devascularization. After standard T1-weighted, T2-weighted, and STIR images, gradient-recalled echo images, 28/5 (TR/TE) with a 45 degrees flip angle, were obtained at 6-sec intervals for 90 sec synchronous with the IV administration of 0.2 mmol of gadoteridol per kilogram of body weight at a rate of 2 ml/sec via an automated injector. Two animals were reimaged after 7 days. RESULTS: Spin-echo and STIR images did not show any acute changes in the ischemic femoral heads. In contrast, significant differences were present in the enhancement profiles of the marrow spaces in the normal and ischemic femoral heads (p = .005). Normal marrow was characterized by rapid enhancement, with an average signal intensity increase of 83% peaking at 36 sec; no measurable enhancement was seen in the marrow of the ischemic femoral head. Spin-echo images, obtained 7 days after devascularization (n = 2), showed changes characteristic of avascular necrosis. Dynamic contrast-enhanced MR images showed persistent lack of enhancement in the avascular marrow of the ischemic femoral head. A junctional zone, characterized by rapid contrast enhancement in excess of 120% without early washout, was identified at the interface between normal and avascular marrow. CONCLUSION: In this experimental model, dynamic contrast-enhanced MR imaging proved significantly more sensitive than conventional spin-echo and STIR imaging in the detection of acute avascular necrosis.