Ocular Syphilis: Experience over 11 Years at a German Ophthalmology Reference Centre.

BACKGROUND: In accordance with worldwide data, the Robert Koch Institute (RKI) has reported a constant increase of syphilis cases in Germany over the past decade. METHODS: We analysed the data of all patients, referred to a Department of Ophthalmology in a tertiary referral centre in Düsseldorf, Germany between 2008 and 2019, who were tested for syphilis. The epidemiologic, demographic, clinical, diagnostic and therapeutic data were retrieved from the records and evaluated in a retrospective, descriptive, non-comparative study. RESULTS: Syphilis serology was positive in 32/1840 (1.7%) patients, and was evenly distributed over this period. 26 (81.3%) were male, 19 (59.4%) belonged to a risk group. Ocular syphilis was the primary diagnosis for 29 patients (90.6%). The most frequent manifestation was uveitis (n = 20, 62.5%). By the end of therapy, 19 patients (59.4%) had an improved visual acuity. CONCLUSION: The incidence of ocular syphilis cases has remained stable over the last decade.

MTT Heterogeneity in Perfusion CT Imaging as a Predictor of Outcome after Aneurysmal SAH.

BACKGROUND AND PURPOSE: Impairment of tissue oxygenation caused by inhomogeneous microscopic blood flow distribution, the so-called capillary transit time heterogeneity, is thought to contribute to delayed cerebral ischemia after aneurysmal SAH but has so far not been systematically evaluated in patients. We hypothesized that heterogeneity of the MTT, derived from CTP parameters, would give insight into the clinical course of patients with aneurysmal SAH and may identify patients at risk of poor outcome. MATERIALS AND METHODS: We retrospectively analyzed the heterogeneity of the MTT using the coefficient of variation in CTP scans from 132 patients. A multivariable logistic regression model was used to model the dichotomized mRS outcome. Linear regression was used to eliminate variables with high linear dependence. T tests were used to compare the means of 2 groups. Furthermore, the time of the maximum coefficient of variation for MTT after bleeding was evaluated for correlation with the mRS after 6 months. RESULTS: On average, each patient underwent 5.3 CTP scans during his or her stay. Patients with high coefficient of variation for MTT presented more often with higher modified Fisher (P = .011) and World Federation of Neurosurgical Societies grades (P = .014). A high coefficient of variation for MTT at days 3-21 after aneurysmal SAH correlated significantly with a worse mRS score after 6 months (P = .016). We found no correlation between the time of the maximum coefficient of variation for MTT after bleeding and the patients' outcomes after 6 months (P = .203). CONCLUSIONS: Heterogeneity of MTT in CTP after aneurysmal SAH correlates with the patients' outcomes. Because the findings are in line with the pathophysiologic concept of the capillary transit time heterogeneity, future studies should seek to verify the coefficient of variation for MTT as a potential imaging biomarker for outcome.

[Corneal neurotization]. / Korneale Neurotisation.

The previous treatment options for neurotrophic keratopathy (NK) were limited. Frequently performed surgical procedures for severe NK include amnionic membrane transplantation and tarsorrhaphy. Corneal neurotization describes the transposition of a healthy donor nerve along the limbal circumference to re-establish corneal sensation and trophic function. The nerve transfer can be performed either by directly transpositioning the supraorbital nerve as described here or by using a sural nerve interponate.

Influence of blood pressure variability on short-term outcome in patients with subarachnoid hemorrhage.

OBJECTIVE: Several recent investigations have demonstrated a significant influence of blood pressure variation during the immediate period after stroke. The present study was conducted to evaluate the effect of blood pressure, intracranial pressure and cerebral perfusion pressure variation on short-term outcome in patients after severe subarachnoid hemorrhage (SAH). MATERIAL AND METHODS: 105 patients suffering from severe SAH were included in the study. The Glasgow Coma Scale (GCS) Score and World Federation of Neurological Surgeons (WFNS) grading were used to describe the patients on admission, and the short-term outcome was assessed using the GCS and the Glasgow Outcome Scale (GOS) Score. In all patients, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were continuously recorded. For each recorded parameter (SBP, DBP, MAP, ICP and CPP) the first recorded value was defined as the baseline value (bas). The minimum (min), maximum (max) and average (mean) value was identified from all recorded values for each parameter and the range between minimum and maximum value was calculated (range). Based on the individual parameter range (absolute values) the variability of successive values was determined as the successive variation (sv). Finally, the values obtained were correlated to clinical outcome and analyzed statistically. RESULTS: In 105 patients the database offered an average of 330.4 single readings (median 318). SBPmax, and SBPrange were significantly lower in the group with an improving short-term GCS than in the group with constant or deteriorating GCS ( P=0.0079 and P=0.0006, respectively). SBPmin was significantly higher in the improved GCS group (P=0.0235). With regard to successive variation (SBPsv) we could not demonstrate a significant difference between both groups (mean SBPsv 15.7 vs. 14.7; P=0.1223), and no correlation with either GCS at discharge (P=0.91) or GOS at discharge (P=0.841) was detectable. There was no statistically significant difference in CPP and ICP between both outcome groups. CONCLUSION: Systolic blood pressure levels and range appear to be of importance for the management of patients suffering from SAH and may influence patient outcome.

A multimodal concept in patients after severe aneurysmal subarachnoid hemorrhage: results of a controlled single centre prospective randomized multimodal phase I/II trial on cerebral vasospasm.

OBJECTIVE: Recent publications suggest that a combination of head-shaking and cisternal irrigation might reduce symptomatic cerebral vasospasm after subarachnoid hemorrhage (SAH). The present clinical prospective randomized phase I/II study was initiated in order to analyze the prophylactic effect of intracisternal lysis in combination with kinetic treatment followed by intrathecal nimodipine lavage. METHODS: Twenty patients with aneurysmal SAH, WFNS grade 2 to 5 (GCS 13-3) and Fisher grade 3 or 4 were included in this prospective randomized study which had been approved by the local Ethics Research Committee. Following insertion of a ventricular drain, securing of the aneurysm by a microsurgical or endovascular route and the insertion of two lumbar catheters, intracisternal lysis with urokinase 120 000 IU/d was performed for 48 h in the patients of the study group. Intrathecal pressure was monitored by the second lumbar catheter. After intracisternal lysis, intrathecal nimodipine lavage was applied for 7 d. For comatose patients kinetic head-rotation was also performed. Vasospasm was clinically identified with a focus on delayed neurological deficits (DINDs) by daily transcranial Doppler (TCD), computerized tomography (CT), perfusion CT (pCT) and cerebral angiography (DSA). RESULTS: There was no DIND in the study group among the patients who were awake, while two DINDs occurred in the control group. The pooled TCD flow velocities over an average period of 14 d revealed no statistically significant difference between the groups. Vasospasm-related infarction on CT was seen in two patients of the control group. Evident vasospasm on DSA appeared in three patients of the study group compared with 7 patients in the control group. Moreover there was a neurological improvement in the study population as measured by mRS at 3-month follow-up (P=0.266). In two consecutive patients randomized to the study group a paresis of the lower extremities of unknown origin occurred. As a result of these complications the study was stopped in accordance with the local Ethics Research Committee guidelines. CONCLUSION: A multimodal approach with translumbar lysis in combination with kinetic therapy followed by intrathecal nimodipine lavage proved to be effective against cerebral vasospasm and for clinical outcome. However, due to the observed complications with the occurrence of paraparesis in two patients of the study group the trial was stopped. Nevertheless, the promising preliminary results suggest a further development of the clinical protocol using a modified multimodal concept to prevent and treat cerebral vasospasm after severe SAH.

Intra-arterial nimodipine for severe cerebral vasospasm after aneurysmal subarachnoid hemorrhage: influence on clinical course and cerebral perfusion.

BACKGROUND AND PURPOSE: The efficacy of intra-arterial administration of nimodipine (IAN) in patients with severe vasospasm after aneurysmal subarachnoid hemorrhage (SAH) remains unproved. The goal of the present study was to investigate the clinical effect and cerebral perfusion after IAN in patients with severe vasospasm refractory to hemodynamic treatment. MATERIALS AND METHODS: Twenty-six of 214 patients with aneurysmal SAH were included in the prospective study, approved by the local ethics committee. All patients met the criteria of medically refractory cerebral vasospasm. Effectiveness was monitored angiographically by digital subtraction angiography and by transcranial Doppler (TCD), perfusion CT (PCT), and neurologic examination during treatment course and follow-up. RESULTS: No angiographic effect was observed in 8 patients. The pooled PCT values revealed a reduction of time to peak (P = .03) and mean transit time (P = .17) 1 day after intervention. This effect did not persist during the following days. The pooled TCD analysis demonstrated a transient increase in flow 1 day after intervention (P = .03). No trend was evident during the next 7 days after intervention. Additional infarction was experienced by 61.1% of patients. CONCLUSIONS: IAN in a selective patient group resulted in a positive response with reduction of angiographic vasospasm and increase in cerebral perfusion as detected by PCT after 24 hours. Therefore, IAN appears more effective than intra-arterial papaverine. Nevertheless the efficacy of IAN is temporary. Therefore, the search for more effective treatment strategies to reduce critical vasospasm and to improve cerebral perfusion must be continued.

Supratentorial meningeal melanocytoma mimicking a convexity meningioma.

OBJECTIVE AND IMPORTANCE: Meningeal melanocytomas are rare benign neuro-ectodermal tumors arising from melanocytic cells in the leptomeninges. These leptomeningeal melanocytes are found at highest density underneath the brain stem and along the upper cervical spinal cord. Thus, most reported cases of meningeal melanocytomas are located in the posterior fossa and the spinal cord, respectively. CLINICAL PRESENTATION: We report on the rare case of a 55-year-old male patient with a large supratentorial meningeal melanocytoma mimicking a convexity meningioma and a smaller, similarly dura based lesion in the posterior fossa. INTERVENTION: Tumor control to date was achieved by surgery of the large lesion and radiosurgery of the small lesion. CONCLUSION: Complete tumor resection may be advantageous and second or recurrent lesions may be managed by repeat surgery or stereotactic radiosurgery.

[Splenectomy for thrombocytopenic purpura. Retrospective analysis of the postoperative course]. / Splenektomie bei idiopathischer thrombozytopenischer Purpura. Retrospektive Analyse des postoperativen Verlaufs.

BACKGROUND: Idiopathic thrombocytopenic purpura (ITP) comprises approximately 8% of all haemorrhagic diseases. Typical findings are a very low platelet count which manifests as petechial bleeding. Therapy consists of medication and removal of the spleen if conservative therapy fails. PATIENTS AND METHODS: Between 1988 and 1999, 47 patients with ITP were splenectomized in our surgical department. We examine the postoperative development of platelet counts and long-term results in 33 of these patients. RESULTS: After splenectomy, more then 75% of our patients had normal platelet counts. In long-term examination, 58% remained in stable condition with normal platelet counts. Retrospectively we tried to identify preoperative clinical features that could predict the long-term outcome of splenectomy in ITP but were unable to find reliable factors. CONCLUSION: Idiopathic thrombocytopenic purpura can be treated by surgical means but should be considered only when conservative treatment has failed. The long-term outcome of splenectomy is not predictable. Reliable predictive factors have to be identified through further research.