Use of a p64 MW Flow Diverter with Hydrophilic Polymer Coating (HPC) and Prasugrel Single Antiplatelet Therapy for the Treatment of Unruptured Anterior Circulation Aneurysms: Safety Data and Short-term Occlusion Rates.

PURPOSE: To assess the safety and short-term occlusion rates in procedures using the p64 MW hydrophilic polymer-coated (HPC) flow diverter (FD) with prasugrel single antiplatelet therapy (SAPT) for the treatment of anterior circulation saccular aneurysms. METHODS: We retrospectively identified patients who underwent treatment of one or more intracranial anterior circulation saccular aneurysms between March 2020 and December 2021 with a p64 MW HPC FD and prasugrel SAPT with verified P2Y12 platelet receptor inhibition. Patients diagnosed with fusiform, dissecting, or recently ruptured aneurysms were excluded. Periprocedural and postprocedural complications, clinical outcomes, and angiographic follow-up results were evaluated. RESULTS: One hundred and two patients with 132 intracranial aneurysms met the inclusion criteria. Previous or concomitant treatments (e.g., coil occlusion) had been performed on 18 of these aneurysms. The technical success rate (i.e., implantation of the intended FD) was 100% with an average of 1.1 devices implanted per patient. Periprocedural and postprocedural complications occurred in 13.6% and 6.8% of these patients, respectively. No mortality or permanent clinical deterioration (i.e., modified Rankin scale score ≥ 3) were reported. Early follow-up digital subtraction angiography revealed aneurysmal occlusion rates of 72.6% and 83.8% at four and nine months, respectively. CONCLUSIONS: The implantation of a p64 MW HPC FD with prasugrel SAPT is safe and results in rapid, reliable and effective aneurysmal occlusion.

[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]. / Prolongiertes Weaning in der neurologisch-neurochirurgischen Frührehabilitation : S2k-Leitlinie herausgegeben von der Weaning-Kommission der Deutschen Gesellschaft für Neurorehabilitation e. V. (DGNR).

Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".

[Dysphagia after ventral spondylodesis]. / Dysphagie nach HWS-Operation.

BACKGROUND: Complications caused by osteosynthetic material after cervical spine surgery are rare. PATIENT AND METHOD: The case of a 36-year-old patient is reported, who suffered the extrusion of a screw and migration through the hypopharynx after ventral spondylodesis of a cervical spine fracture. RESULT: Dysphagia occurred shortly after spinal surgery. The lack of one osteosynthesis screw in the spine was detected by X-ray and the material was located in the rectum. The screw had passed through the intestinal tract and was excreted spontaneously. An ENT medical control was carried out because of persisting dysphagia. Endoscopy revealed a cherry-sized granuloma of the posterior hypopharynx wall which was removed surgically. The healing process of the mucosa continued without further complications. CONCLUSION: X-ray control and endoscopy are required immediately when dysphagia occurs after osteosynthesis of the cervical spine due to possible complications caused by the implanted material. Further therapeutic measures depend on the case-specific constellation.

Prospective comparative study of the effectiveness of epidural morphine and ropivacaine for management of pain after spinal operations.

OBJECTIVE: Evaluation of the effectiveness of local application of morphine or ropivacaine for treatment of local and radicular pain after lumbar disc operations. Critical review of the literature about the possibilities of management of postoperative pain after spinal operations. METHODS: A total of 113 patients were randomly given 5 mg morphine sulfate (N=42), 10 ml 0,25% ropivacaine (N=42) or physiological NaCl solution (N=21) locally after lumbar disc operation before wound closure. Postoperative lumbar and radicular pain was scored by the patients from 0 to 10 and registered on the evening of the day of operation and on the 1., 2., 3., and 5. days. Mean pain numbers of the 3 groups have been compared, subdivided into local lumbar and in radicular pain. Our own results have been compared with the results of reports in the literature. RESULTS: In our own study the morphine group had less lumbar and less radicular pain on all 5 days than both of the two other groups. This difference was statistically significant on days 0, 1, 2, and 3. The ropivacaine group was on all days less effective than the morphine group, better than the placebo group on the operation and first day, but the difference against the placebo group was statistically not significant. CONCLUSION: Local application of 5 mg morphine sulfate is effective in prevention or reduction of postoperative lumbar and radicular pain after lumbar disc operations. Ropivacain is less effective. The routine application of epidural morphine at the end of spinal operations can be recommended. It also can be justified to try to prolong the morphine effect by mixing it into a paste as described by Needham and by Hurlbert, and to irrigate the operative field with ropivacaine at the end of the operation.

[Symptomatic Langerhans-cell-histiocytosis of the cervical spine in a child: case report]. / Die symptomatische Langerhanszell-Histiozytose der kindlichen HWS: Eine Falldarstellung.

We report on a six year old female presented with a painful torticollis and a hemidysaesthesia caused by destruction of the third cervical vertebra and a paravertebral soft-tissue mass. At diagnostic routine finally a biopsy gives the diagnosis of Langerhans cell histiocytosis. In a second open approach the destructed vertebral body was replaced by a precisely adjusted autologous bone interponate and the patient was maintained in halo vest immobilisation. The outcome is described and an overview of the current literature is given.

[Subarachnoid hemorrhage from the anterior communication artery in a sex offender. Considerations regarding liability]. / Subarachnoidalblutung aus Aneurysma der A. communicans anterior bei einem Sexualstraftäter. Uberlegungen zur Schuldfähigkeit.

A 32-year-old man was accused of attempted rape. While urinating at the side of the road he felt an erection. He approached a 9-year-old girl who happened to be coming along and pressed his penis between her legs until ejaculation. Shortly afterwards he was arrested. He confessed, but claimed partial amnesia and had no explanation for the offence, which he normally would never have thought of. Shortly before the event a witness had seen him nearby in a poor state of orientation. Three months later in prison he suffered massive subarachnoidal hemorrhage from an aneurysm of the anterior communicating artery. The evaluation of his legal responsibility must take account of a putative psychomotor seizure at the time of the offence. With regard to the aneurysm diagnosed later, a pathogenetic connection, in terms of a preceding warning leak, might be assumed.

Microsurgery of cerebral lesions under stereotactic conditions.

Microsurgical excision of cerebral lesions was carried out under CT-guided stereotactic conditions. For lesions located in critical cortical areas, cerebral teleangiography under stereotactic conditions provided the coordinates of the vascular elements related to the structures and adjacent to the lesion without X-ray distortion. Small size cortical and subcortical lesions were targeted using the stereotactic biopsy probe as a guide. In twenty-four patients stereotactic microsurgery was used for following lesions: 8 cavernomas, 8 metastases, 7 gliomas, and 1 tuberculoma. Unpredictable permanent neurological complications did not occur, but predicted transient impairment after surgery in functional territories was tolerated with the complete removal of the lesion. The advantages of microsurgery using stereotactic coordinates are: precise knowledge of the location of brain structures and exact targeting of intracerebral lesions, better evaluation of surgical risks, easy spatial orientation, and minimization of the surgical damage to the healthy brain tissue.

[Effect of recombinant human erythropoietin on autologous blood donation for heart surgery]. / A rekombináns humán erythropoetin hatása a preoperatív autológ vérgyüjtésre szívmütétek kapcsán.

Pharmacological stimulation of erythropoiesis was studied in patients selected for open heart surgery, and undergoing a programme of autologous blood predonation prior to surgery. Sixteen patients (group I: ery) received 4000 I. U. of recombinant human erythropoietin (r-huepo) subcutaneously weekly three times during a 3-week period preoperatively, another group of 21 patients (group II: control) were not given r-huepo. Patients in both groups received orally 2 x 80 mg iron daily. Predonation of five units of blood was planned in each patients, beginning on the 21. preoperative day; no blood was taken from patients if the hematocrit dropped below 0.34, or if any other complications occurred. The average amount of blood taken from patients in the ery group was 4.8 +/- 0.4 Units, and in the control group: 3.7 +/- 1.1 Units. In the ery group the planned 5 Units of blood could be taken from 13/16 patients, while in the controls only from 7/21. The differences are statistically significant. Reticulocyte counts were significantly higher consecutively during the preoperative period in the ery group than in the controls. In the postoperative period erythropoiesis was less pronounced in the ery group than in the controls. It is concluded that 1. r-huepo is an effective drug in preventing (or reducing) the anaemia due to repeated preoperative blood withdrawals, and thus larger amounts of autologous blood will be available for predonation. 2. More pronounced decrease of circulating reticulocytes observed in the postoperative period points to a possible suppression of endogenous erythropoietin production in the ery group.(ABSTRACT TRUNCATED AT 250 WORDS)

[Neuroradiologic diagnosis of intracranial epidermoid tumors]. / Zur neuroradiologischen Diagnostik der intrakraniellen Epidermoide.

Intracranial epidermoids are primarily extracerebral congenital cysts. Intra- and extradural types are differentiated: intradural lesions originate in the intracranial CSF spaces, and extradural lesions in the bony skull. Epidermoids increase in size passively as the result of an increase in the cyst volume and not because of active growth. Clinically epidermoids behave like benign, slow-growing cerebral tumours. Differential diagnosis includes other cysts and cystic tumours. Neuroradiologically epidermoids present as polycystic lesions showing extensive growth in the extracerebral CSF spaces and secondary invagination of the brain. On CT and MR, despite the high cholesterol content, epidermoids show the characteristics of liquor and not those of fat. It can be shown that the typical CT and MR appearance of an epidermoid is due to the different proportions of CSF in the cyst content, which results from diffusion or dehiscence of the cyst capsule. The present study was based on analysis of 6 cases selected from a total of 29 patients with CNS epidermoids.

Premature craniosynostosis. A retrospective analysis of a series of 52 cases.

A retrospective analysis of a consecutive series of 52 cases with premature craniosynostosis is presented. Excellent functional, cosmetic, and social results could be achieved by resection of prematurely fused sutures and the creation of artificial growth sutures. Pronounced skull deformities have been corrected using the "basket handle", the "visor plasty", and the "T- bone" techniques or a combination of several of these skull form correction techniques. The surgical correction of the skull base by the "frontal advancement" technique in combination with orbitotomy was only necessary in 2 of our cases and could have been considered in 2 additional cases viewed retrospectively. Our results support the hypothesis that the primary cause of skull deformity is the premature closure of vault sutures and not a primary deformity of the skull base.

Prognostic factors in the treatment of cerebellar haemorrhage.

A prospective study for the treatment of cerebellar haemorrhage was conducted in a non-selected group of 33 patients. All patients with cerebellar haemorrhage arriving at the Department of Neurosurgery at Homburg/Saar have been included in this study, also those in bad condition, with high risk factors, and the aged. All of them required intensive care respectively intensive supervision. The following management protocol has been established. I. Cases with small haemorrhage, in good clinical condition, without hydrocephalus and/or occlusion of the basal cisterns: intensive supervision, operative intervention only if they deteriorate into one of the following groups. II. Cases with hydrocephalus-even if not yet pronounced-but without occluded basal cisterns and without major tonsillar herniation: pressure monitored ventricular drainage, which opens at 15 mm Hg and thus prevents higher CSF pressure developing. III. a): Cases with large haematoma, occluded basal cisterns and/or tonsillar herniation, but without severe general risk factors, as a first step: pressure monitored ventricular drainage; as a second step, if they do not improve soon after the normalization of the ventricular pressure: open surgical evacuation of the haematoma, which also decompresses the posterior fossa. If present and possible, causative vascular malformations may be dealt with at the same session. III. b): Same intracranial situation, but patients with severe general risk factors: pressure monitored ventricular drainage only. IV. Cases with causative aneurysm or angioma, who initially had been treated conservatively or by ventricular drainage: secondary operation of the vascular malformation after stabilization of the general conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraventricular haemorrhage caused by aneurysms and angiomas.

More than 200 intraventricular haematomas (IVH) have been treated in the Homburg Neurosurgical University Clinic since computed tomography was available and facilitated the diagnosis. Among 200 consecutive cases, which are analysed and presented in this publication, there were 71 patients with subarachnoid haemorrhage (SAH)--58 of whom with angiographically and/or pathologically verified aneurysms--, and 21 cases with intraventricular angiomas. IVH without concomitant intracerebral haematoma (ICH) and without evidence of SAH is highly suggestive of intraventricular angioma. In our experience panangiography [if available digital subtraction angiography (DAS)] should be done as soon as possible in all cases of IVH. It is a precondition for early diagnosis and operative elimination of the source of bleeding, because the retrospective analysis of our material shows that rebleeding is by far the highest single risk factor in cases with IVH caused by aneurysms or angiomas. We therefore recommend early microsurgical occlusion of the aneurysms and exstirpation or intravascular embolisation of the angioma. The best survival rate (76%) was achieved in IVH cases caused by angiomas. In aneurysms with IVH the survival rate was 35%, in IVH caused by other diseases 37%. The worst prognosis occurs in SAH with IVH without proven aneurysm or angioma. The survival rate of this group was only 8%.

Syringomyelia: a brief review of ontogenetic, experimental and clinical aspects.

The generally accepted definition of syringomyelia is that it is a chronically progressive illness characterized by the presence of cavities or syrinxes in the spinal cord. As manifold as the terminology of syringomyelia are the hypotheses of the etiology. Nowadays with MRI without and with gadolinium it is possible to recognize intramedullar cavities safely, the MR especially the cine-MR provides information on pathophysiological details of the flow and intracavitary pressure dependent pulsations of the CSF. Animal models and the findings of own experimental studies have enabled us to study a form of syringomyelia which very closely resembles that brought about by dysrhaphic malformations in the human being and to examine the effectiveness of certain types of surgical therapy. In this paper the term syringomyelia is only used for dysrhaphic cavities in the medulla. After our experience with 61 patients with syringomyelia now we perform the operative decompression of the craniocervical transition as the first step in the operative treatment of the progressive syringomyelia combined with severe craniocervical malformations. In cases with insufficient treatment response we suggest the syringoarachnoid shunting of persisting large intramedullar cavities.

T-bone plastique for treatment of brachy-turricephaly.

The "T-Bone Plastique", which is presented in this paper, allows a surgical correction even of extreme cases of brachy-turricephaly together with malformations of the occipital region in one operative session. Brachy-turricephaly is characterized by abnormal vertical height of the skull and a shortening of its anterior-posterior length, frequently combined with malformations of the occipital region. Resection of the prematurely closed coronal suture, bi-parietal trepanations with 90 degrees rotation and side-exchange of the parietal bone flaps, double transverse trepanation of the occipital bone and outward bending and shifting of the bone fragments enable a bony remodeling and normalization of the deformed skull. Using this operative technique in three children we achieved a significant improvement of the skull form with an aesthetically pleasing result, without any neurologic sequelae and with normal development of the children during follow-up.

[The use of personal computers for the collection, storage and analysis of data from neurosurgical intensive care monitoring]. / Der Einsatz von Personal Computern zur Erfassung, Speicherung und Analyse von Messwerten bei der neurochirurgischen Intensivüberwachung.

For data acquisition intensive care neurosurgery increasingly has recourse to modern electronics, which have become an integral part of many aspects of present-day neurosurgery. Despite their high technical standard, the devices in common use often lack flexibility. Their range of possible applications is defined by the manufacturer, and the user has little or no influence on them. Moreover, there are often no adequate interfaces to peripherals, and the storage capacity is limited. We would like to present a data acquisition system on a PC/AT basis, which operates up to 64 channels allowing parallel registration, storage, analysis, and of decisive importance, also various computations, i.e. correlation. Computation is rarely feasible on commercial devices, but it is essential for specific demands, such as implementation of PA/PM diagrams to determine intracranial compliance. In addition, the pertinent software permits implementation of Fourier analyses, offers separate statistical functions, and transfers data to other programs. The program is capable of automatic batch-processing, which greatly facilitates its use.

[Aneurysms as a rare cause of chronic subdural hematomas]. / Aneurysmen als seltene Ursache chronisch subduraler Hämatome.

Chronic subdural haematomas are nowadays usually diagnosed via computed tomography. Followups are also by this method. It is therefore inevitable that aneurysms or other vascular malformations are overlooked as rare but important causes of such haematomas. If anamnesis, findings and course are atypical, it is recommended to attempt additional angiographic clarification at least in such cases.