Bedside Sonographic Duplex Technique as a Monitoring Tool in Patients after Decompressive Craniectomy: A Single Centre Experience.

BACKGROUND AND OBJECTIVES: Bedside sonographic duplex technique (SDT) may be used as an adjunct to cranial computed tomography (CCT) to monitor brain-injured patients after decompressive craniectomy (DC). The present study aimed to assess the value of SDT in repeated measurements of ventricle dimensions in patients after DC by comparing both techniques. MATERIALS AND METHODS: Retrospective assessment of 20 consecutive patients after DC for refractory intracranial pressure (ICP) increase following subarachnoid hemorrhage (SAH), bleeding and trauma which were examined by SDT and CCT in the context of routine clinical practice. Whenever a repeated CCT was clinically indicated SDT examinations were performed within 24 hours and correlated via measurement of the dimensions of all four cerebral ventricles. Basal cerebral arteries including pathologies such as vasospasms were also evaluated in comparison to selected digital subtraction angiography (DSA). RESULTS: Repeated measurements of all four ventricle diameters showed high correlation between CCT and SDT (right lateral r = 0.997, p < 0.001; left lateral r = 0.997, p < 0.001; third r = 0.991, p < 0.001, fourth ventricle r = 0.977, p < 0.001). SDT performed well in visualizing basal cerebral arteries including pathologies (e.g., vasospasms) as compared to DSA. CONCLUSIONS: Repeated SDT measurements of the dimensions of all four ventricles in patients after DC for refractory ICP increase delivered reproducible results comparable to CCT. SDT may be considered as a valuable bedside monitoring tool in patients after DC.

Cerebral Ventricular Dimensions After Decompressive Craniectomy: A Comparison Between Bedside Sonographic Duplex Technique and Cranial Computed Tomography.

BACKGROUND: The objective of this study was to assess and compare ventricle diameters in patients after decompressive craniectomy by using cranial computed tomography (CCT) versus sonographic duplex technique (SDT). METHODS: A total of 102 consecutive patients after decompressive craniectomy following brain infarct, bleeding and trauma were examined by CCT and SDT. SDT was performed within 24 h after repeated postinterventional control CCT and the correlation between both methods was assessed via measurement of dimensions of all four ventricles. In addition, midline shifts and overall cerebral anatomy was evaluated. RESULTS: A high correlation was found between CCT and SDT in measuring the diameters of all four ventricles (right lateral r = 0.978, p < 0.001; left lateral r = 0.975, p < 0.001; third r = 0.987, p < 0.001 and fourth ventricle r = 0.954, p < 0.001). Deviations of midline structure was observed in SDT as well as in CCT (r = 0.992, p < 0.001). CONCLUSION: SDT in patients after decompressive craniectomy may represent an additional bedside tool to assess the dimensions of the ventricular system, anatomical structures, e.g., subdural hygromas, hematomas, midline shifts, gyri and sulci. The measurement of the dimensions of all four ventricles by using SDT delivers accurate values and may be considered as an alternative to CCT or a trigger for CCT prior to further treatment.

Is the shock index based classification of hypovolemic shock applicable in multiple injured patients with severe traumatic brain injury?-an analysis of the TraumaRegister DGU®.

BACKGROUND: A new classification of hypovolemic shock based on the shock index (SI) was proposed in 2013. This classification contains four classes of shock and shows good correlation with acidosis, blood product need and mortality. Since their applicability was questioned, the aim of this study was to verify the validity of the new classification in multiple injured patients with traumatic brain injury. METHODS: Between 2002 and 2013, data from 40 888 patients from the TraumaRegister DGU® were analysed. Patients were classified according to their initial SI at hospital admission (Class I: SI < 0.6, class II: SI ≥0.6 to <1.0, class III SI ≥1.0 to <1.4, class IV: SI ≥1.4). Patients with an additional severe TBI (AIS ≥ 3) were compared to patients without severe TBI. RESULTS: 16,760 multiple injured patients with TBI (AIShead ≥3) were compared to 24,128 patients without severe TBI. With worsening of SI class, mortality rate increased from 20 to 53% in TBI patients. Worsening SI classes were associated with decreased haemoglobin, platelet counts and Quick's values. The number of blood units transfused correlated with worsening of SI. Massive transfusion rates increased from 3% in class I to 46% in class IV. The accuracy for predicting transfusion requirements did not differ between TBI and Non TBI patients. DISCUSSION: The use of the SI based classification enables a quick assessment of patients in hypovolemic shock based on universally available parameters. Although the pathophysiology in TBI and Non TBI patients and early treatment methods such as the use of vasopressors differ, both groups showed an identical probability of recieving blood products within the respective SI class. CONCLUSION: Regardless of the presence of TBI, the classification of hypovolemic shock based on the SI enables a fast and reliable assessment of hypovolemic shock in the emergency department. Therefore, the presented study supports the SI as a feasible tool to assess patients at risk for blood product transfusions, even in the presence of severe TBI.

Presurgical mapping of basal cell carcinoma or squamous cell carcinoma by confocal laser endomicroscopy compared to traditional micrographic surgery: a single-centre prospective feasibility study.

BACKGROUND: At present, no ideal diagnostic tools exist in the market to excise cancer tissue with the required safety margins and to achieve optimal aesthetic results using tissue-conserving techniques. OBJECTIVES: In this prospective study, confocal laser endomicroscopy (CLE) and the traditional gold standard of magnifying glasses (MG) were compared regarding the boundaries of in vivo basal cell carcinoma and squamous cell carcinoma. MATERIALS & METHODS: Tumour diameters defined by both methods were measured and compared with those determined by histopathological examination. Nineteen patients were included in the study. RESULTS: The CLE technique was found to be superior to excisional margins based on MG only. Re-excision was required in 68% of the cases following excision based on MG evaluation, but only in 27% of the cases for whom excision margins were based on CLE. CONCLUSION: Our results are promising regarding the distinction between tumour and healthy surrounding tissue, and indicate that presurgical mapping of basal cell carcinoma and squamous cell carcinoma is possible. The tool itself should be developed further with special attention to early detection of skin cancer.

Noninvasive histological imaging of head and neck squamous cell carcinomas using confocal laser endomicroscopy.

Confocal laser endomicroscopy (CLE) is an imaging technique that uses miniaturized fiberoptic probes to allow real-time histological imaging of human tissue. An application of CLE in otorhinolaryngology has hardly been investigated so far. In our study, we analyzed the applicability of CLE to visualize cancerous and healthy tissue of the head and neck region. Formalin-fixed tissue specimens from 135 head and neck squamous cell carcinoma (HNSCC) patients and 50 healthy controls were investigated using CLE with and without topical application of acriflavine. Four head and neck surgeons, four pathologists, and four laymen evaluated the CLE images of the HNSCC cases regarding the tumor localization and its border to healthy tissue. The tumor localization and the tumor border were correctly identified in 97 % by the pathologists, 85 % by the head and neck surgeons, and 70 % by the laymen. The main difference in evaluation results was seen in the correct identification of the tumor site (p < 0.05), while there was no significant difference in the identification of the tumor border. CLE is a valuable tool for real-time histological imaging of HNSCCs. It can help to visualize the tumor border and, thereby, facilitate a more precise tumor surgery.

Automatic Tissue Differentiation Based on Confocal Endomicroscopic Images for Intraoperative Guidance in Neurosurgery.

Diagnosis of tumor and definition of tumor borders intraoperatively using fast histopathology is often not sufficiently informative primarily due to tissue architecture alteration during sample preparation step. Confocal laser microscopy (CLE) provides microscopic information of tissue in real-time on cellular and subcellular levels, where tissue characterization is possible. One major challenge is to categorize these images reliably during the surgery as quickly as possible. To address this, we propose an automated tissue differentiation algorithm based on the machine learning concept. During a training phase, a large number of image frames with known tissue types are analyzed and the most discriminant image-based signatures for various tissue types are identified. During the procedure, the algorithm uses the learnt image features to assign a proper tissue type to the acquired image frame. We have verified this method on the example of two types of brain tumors: glioblastoma and meningioma. The algorithm was trained using 117 image sequences containing over 27 thousand images captured from more than 20 patients. We achieved an average cross validation accuracy of better than 83%. We believe this algorithm could be a useful component to an intraoperative pathology system for guiding the resection procedure based on cellular level information.

Stereotactic LINAC-Radiosurgery for Glomus Jugulare Tumors: A Long-Term Follow-Up of 27 Patients.

BACKGROUND: The optimal treatment of glomus jugulare tumors (GJTs) remains controversial. Due to the critical location, microsurgery still provides high treatment-related morbidity and a decreased quality of life. Thus, we performed stereotactical radiosurgery (SRS) for the treatment of GJTs and evaluated the long-term outcome. METHODS: Between 1991 and 2011, 32 patients with GJTs underwent SRS using a linear accelerator (LINAC) either as primary or salvage therapy. Twenty-seven patients (median age 59.9 years, range 28.7-79.9 years) with a follow-up greater than five years (median 11 years, range 5.3-22.1 years) were selected for retrospective analysis. The median therapeutic single dose applied to the tumor surface was 15 Gy (range 11-20 Gy) and the median tumor volume was 9.5 ml (range 2.8-51 ml). RESULTS: Following LINAC-SRS, 10 of 27 patients showed a significant improvement of their previous neurological complaints, whereas 12 patients remained unchanged. Five patients died during follow-up due to old age or other, not treatment-related reasons. MR-imaging showed a partial remission in 12 and a stable disease in 15 patients. No tumor progression was observed. The actuarial overall survival rates after five, ten and 20 years were 100%, 95.2% and 79.4%, respectively. CONCLUSIONS: Stereotactic LINAC-Radiosurgery can achieve an excellent long-term tumor control beside a low rate of morbidity in the treatment of GJTs. It should be considered as an alternative therapy regime to surgical resection or fractionated external beam radiation either as primary, adjuvant or salvage therapy.

Endoscope-assisted keyhole surgery via an eyebrow incision for removal of large meningiomas of the anterior and middle cranial fossa.

BACKGROUND: Conventional open surgery of large meningiomas has proven to be challenging even in experienced hands. Intense retraction and dissection around neurovascular structures increase morbidity and mortality. In the present study, we retrospectively analyzed the surgical technique, and outcome in 40 patients with large anterior cranial fossa meningiomas extending to the middle fossa. All patients were approached via a supraorbital mini craniotomy. METHODS: It is a retrospective study of 40 patients (12 males, 28 females) who underwent surgery for large anterior cranial fossa meningiomas (diameter >5 cm) extending to the middle fossa in four different neurosurgical centers within 6 years. Depending on the localization of the tumor, the skin incision was between 2.5 and 3 cm long and was made without shaving the patient's eyebrow hair. Subsequently, a keyhole craniotomy was performed of approximately 0.8×1.2-1.4 cm in diameter. Preoperative and postoperative clinical and radiological data were analyzed and discussed. RESULTS: Headache and psycho-organic syndrome were the most common presenting symptom in all patients. Presenting symptoms were associated with psychological changes in 23 cases, visual impairment in 19 patients, and anosmia in 17 patients. In overall, 36 of 40 patients (90%) showed a good outcome and returned at long-term follow-up to their previous occupations. The elderly patients returned to their daily routine. CONCLUSION: With the appropriate keyhole approach as a refinement of the classic keyhole craniotomy to a smaller key"burr"hole, and with use of modern and new designed equipment, it is possible to perform complete resection of large anterior and middle fossa meningiomas with the same safety, efficiency and with less complication rates as described in the literature for large meningiomas even performed with classic keyhole craniotomies.

Optimal invasive key-hole neurosurgery with a miniaturized 3D chip on the tip: Microendoscopic device.

OBJECTIVE: The goal of the performed study was to evaluate the possibility of a three-dimensional endoscope to become a combined microscope-endoscope device in one. We analyzed the ergonomy of the device, the implementation into the surgical workflow, the image quality, and the future perspectives such devices could have for the next generation of neurosurgeons. MATERIALS AND METHODS: Within 6 months, 22 patients (10 male, 12 female, 20-65 age) underwent surgery in neuroaxis using the new 3D-microendoscope (ME). The new 3D-ME has (a) the ability to visualize the surgical field from out- to inside with all advantages offered by a microscope, and in the same moment, (b) its design is like a small diameter endoscope that allows stereoscopic views extracorporal, intracorporal, and panoramic "para-side" of the lesion. RESULTS: In general, transcranial 3D-"microendoscopy" was performed in all patients with high-resolution 3D quality. No severe complications were observed intra- or postoperatively. With the addition of depth perception, the anatomic structures were well seen and observed. CONCLUSION: The 3D-microendoscopy is a very promising surgical concept associated with new technological developments. The surgeon is able to switch to a modern visualization instrument reaching the most optimal surgical approach without compromising safety, effectiveness, and visual information.