A Long-Term Comparative Analysis of Endovascular Coiling and Clipping for Ruptured Cerebral Aneurysms: An Individual Patient-Level Meta-Analysis Assessing Rerupture Rates.

Background: Although the initial functional outcome findings of the International Subarachnoid Aneurysm Trial (ISAT) study favored coiling at one year after aneurysmal subarachnoid hemorrhage (aSAH), concerns arose regarding limited long-term rerupture data. This meta-analysis is the first to analyze longitudinal individual patient data (IPD) of target aneurysm rerupture in terms of treatment modality. Methods: The present meta-analysis included studies that compared clipping with coiling of ruptured aneurysms regarding long-term rerupture. Rerupture rates' individual patient data (IPD) were extracted from published Kaplan-Meier curves utilizing the R package IPDfromKM in R Version 4.3.1. Results: A total of 3153 patients from two studies were included. The clipping arm included 1755 patients, whereas the coiling arm included 1398 patients. Median reconstructed follow-up was 6.1 years (IQR = 0.5-11.7). The rerupture rates in the clipping arm and the coiling arm were 0.5% and 1.5%, respectively (p = 0.002). Kaplan-Meier chart analysis of the 3153 patients revealed a shortened time to rerupture in the coiling arm (log-rank test: p = 0.01). The hazard ratio (HR) for coiling compared with clipping regarding rerupture was 3.62 (95% CI:1.21-10.86, p = 0.02). Conclusion: Target aneurysm rerupture was rare beyond the initial year. Pooled long-term IPD from the 3153 patients revealed that reruptures of target aneurysms are more common after coiling and might be considered in the pretherapeutic decision-making process for aSAH.

SNP array genomic analysis of matched pairs of brain and liver metastases in primary colorectal cancer.

PURPOSE: Brain metastasis formation is a rare and late event in colorectal cancer (CRC) patients and associated with poor survival. In contrast to other metastatic sites, the knowledge on chromosomal aberrations in brain metastases is very limited. METHODS: Therefore, we carried out single nucleotide polymorphism (SNP) array analyses on matched primary CRC and brain metastases of four patients as well as on liver metastases of three patients. RESULTS: Brain metastases showed more chromosomal aberrations than primary tumors or liver metastases. Commonly occurring aberrations were gain of 8q11.1-q24.3 (primary CRC), gain of 13q12.13-q12.3 (liver metastases), and gain of 20q11.1-q13.33 (brain metastases). Furthermore, we found one copy-neutral loss of heterozygosity (cn-LOH) region on chromosome 3 in primary CRC, three cn-LOH regions in liver metastases and 23 cn-LOH regions in brain metastases, comprising 26 previously undescribed sites. CONCLUSION: The more frequent occurrence of cn-LOHs and subsequently affected genes in brain metastases shed light on the pathophysiology of brain metastasis formation. Further pairwise genetic analyses between primary tumors and their metastases will help to define the role of affected genes in cn-LOH regions.

Distal Flow Diversion with Anti-Thrombotically Coated and Bare Metal Low-Profile Flow Diverters-A Comparison.

BACKGROUND AND PURPOSE: The establishment of low-profile flow diverting stents (FDS), for example, the Silk Vista Baby (SVB) and the p48MW, facilitated endovascular treatment of peripheral cerebral aneurysms. This study therefore aims to compare the performance and outcomes of the SVB with those of the p48MW HPC, with a special focus on hemodynamic aspects of peripheral segments and bifurcations. MATERIALS AND METHODS: The study cohort comprises 108 patients, who were either treated with the SVB or the p48MW HPC between June 2018 and April 2021. RESULTS: Sixty patients received a SVB and forty-eight patients a p48MW HPC. The SVB was used predominantly in the AcomA-complex, and the p48MW HPC in the MCA bifurcation. Immediately after implantation, significant hemodynamic downgrading (OKM A2-A3, B1-B3, C3) was achieved in 60% in the SVB group vs. 75.1% in the p48MW HPC group. At the second follow-up, after an average of 8.8 and 10.9 months, respectively, OKM D1 was observed in 64.4% of the SVB group vs. 27.3% in the p48MW HPC group. Only 1.7% vs. 6.8% of the aneurysms remained morphologically unaltered (OKM A1). Adverse events with persisting neurologic sequalae at last follow-up were largely comparable in both groups (5.0% vs. 4.2%). CONCLUSION: Immediately after implantation, the p48MW HPC had a more profound hemodynamic impact than the SVB; however, early complete occlusions were achieved in a greater proportion of lesions after implantation of the uncoated SVB.

Perioperative external ventricular drainage vs. no-EVD strategy in pediatric posterior fossa tumors-pilot study results.

INTRODUCTION: Pediatric brain tumors of the posterior fossa often present with occlusive hydrocephalus. Endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunting (VPS) has been established for definite hydrocephalus treatment. The aim of the study was to analyze the impact and safety of perioperative temporary external ventricular CSF drainage (EVD) placement on postoperative hydrocephalus outcome compared to a no-EVD strategy. PATIENTS AND METHODS: In a prospective database, 36 posterior fossa tumor patients of 2-18 years were included with a follow-up of 1 year. Fifty-eight percent presented with preoperative hydrocephalus. Patients were assigned to non-hydrocephalus group: group I (n = 15) and to preoperative hydrocephalus, group IIa with EVD placement (n = 9), and group IIb without EVD (n = 12). RESULTS: Median age of patients was 8.1 years (range 3.17 to 16.58 years). One-third of 21 hydrocephalus patients required ETV or VPS (n = 7). Occurrence of de novo hydrocephalus in group I after surgery was not observed in our cohort. Age and histology were no confounding factor for EVD placement between group IIa and IIb (p = 0.34). The use of EVD did not result in better control of hydrocephalus compared to no-EVD patients considering pre- and postoperative MRI ventricular indices (p = 0.4). Perioperative placement of an EVD resulted in a threefold risk for subsequent VPS or ETV (group IIa 55.5% vs group IIb 16.6%): relative risk for EVD patients compared to no-EVD patients with hydrocephalus was 3.3 (CI = 1.06-13.43, p = 0.09). CONCLUSION: Perioperative EVD placement appears to harbor a threefold relative risk of requiring subsequent permanent CSF diversion in children above 2 years. EVD was not more effective to control ventricular enlargement compared to tumor removal alone. The no-EVD strategy was safe and did not result in postoperative complications. Thus, to evaluate potential adverse effects on hydrocephalus outcome by EVD placement, a prospective study is warranted to falsify the results.

Feasibility of ApoC1 serum levels as tumor biomarker in glioblastoma patients: a pilot study.

Apolipoprotein C1 (ApoC1) has been detected immunohistochemically in glioblastoma tissue, probably expressed by activated monocytes and microglia. The present study was conceived to determine whether the amount of intratumoral ApoC1 expression leads to measurable changes of serum levels after glioblastoma resection or during recurrence. 176 blood samples from 70 glioblastoma patients were collected perioperatively and during subsequent therapy. ApoC1 serum levels were determined using an enzyme linked immunosorbent assay (ELISA). High absorption values due to lipemic or hemolytic serum were removed from the final dataset using a stem and leaf plot. Samples were grouped according to the treatment stage to compare mean ApoC1 serum levels. The number of patients with falling or increasing perioperative values was assessed. 167 ApoC1 serum values from 68 glioblastoma patients were amenable to statistical evaluation. Mean ApoC1 serum level was 91.9 µg/ml (n = 167, sd = 36.0). In samples from patients undergoing first glioblastoma resection, the mean preoperative value was significantly higher (94.8 µg/ml, n = 37, sd = 29.5) than after surgery (77.4 µg/ml, n = 41, sd = 23.2, p = 0.009). Individually, falling ApoC1 levels were detected in 25 and rising levels in 9 patients (p = 0.0061). Single absolute serum levels of ApoC1 do not allow an estimation of glioblastoma activity or tumor response. Although pathophysiologically of interest, ApoC1 serum levels did not qualify as a potential biomarker in glioblastoma management. Our results do not seem to encourage larger, multicenter studies.

The Mean ApoC1 Serum Level in Postoperative Samples from Neurosurgical Patients Is Lower than in Preoperative Samples and during Chemotherapy.

Serum levels of apolipoprotein ApoC1 have been described in a number of systemic tumor entities as potential biomarkers, but little is known about ApoC1 in neurosurgical patients. A total of 230 serum samples from 96 patients were analyzed using an ELISA technique. Patient diagnoses comprised 70 glioblastomas WHO IV°, 10 anaplastic astrocytomas III°, one anaplastic oligodendroglioma III°, one oligodendroglioma II°, one diffuse astrocytoma II°, one pilocytic astrocytoma I°, and a single case of a spindle cell tumor without WHO grading, as well as 11 spinal interventions. The mean ApoC1 level of the 230 samples was 132.03 µg/mL (median 86.83, SD 292.91). In the 176 glioblastoma samples, the mean ApoC1 level was 130.0 µg/mL (median 86.23, SD 314.9), which was neither different from the whole group nor from patients with spinal interventions (215.1 µg/mL, median 63.6, SD 404.9). In the postoperative samples, the mean ApoC1 level was significantly lower (85.81 µg/mL) than in the preoperative samples (129.64 µg/mL) and in samples obtained during adjuvant chemotherapy (168.44 µg/mL). While absolute ApoC1 serum levels in a patient do not allow for the distinction between neurosurgical histological entities, future analyses will examine whether the time course of ApoC1 in an individual patient can be related to certain treatment stages.

Usefulness and Limits of Tractography for Surgery in the Precentral Gyrus-A Case Report.

The resection of tumors within the primary motor cortex is a constant challenge. Although tractography may help in preoperative planning, it has limited application. While it can give valuable information on subcortical fibers, it is less accurate in the cortical layer of the brain. A 38-year-old patient presented with paresis of the right hand and focal epileptic seizures due to a tumor in the left precentral gyrus. Transcranial magnetic stimulation was not applicable due to seizures, so microsurgical resection was performed with preoperative tractography and intraoperative direct electrical stimulation. A histopathological assessment revealed a diagnosis of glioblastoma. Postoperative magnetic resonance imaging (MRI) showed complete resection. The paresis dissolved completely during follow-up. Surgery within the precentral gyrus is of high risk and requires multimodal functional planning. If interpreted with vigilance and consciousness of the underlying physical premises, tractography can provide helpful information within its limitations, which is especially subcortically. However, it may also help in the identification of functional cortex columns of the brain in the presence of a tumor.

The Relation of Surgical Procedures and Diagnosis Groups to Unplanned Readmission in Spinal Neurosurgery: A Retrospective Single Center Study.

BACKGROUND: Unplanned readmission has gained increasing interest as a quality marker for inpatient care, as it is associated with patient mortality and higher economic costs. Spinal neurosurgery is characterized by a lack of epidemiologic readmission data. The aim of this study was to identify causes and predictors for unplanned readmissions related to index diagnoses and surgical procedures. METHODS: In this study, from 2015 to 2017, spinal neurosurgical procedures were recorded for surgical and non-surgical treated patients. The main reasons for an unplanned readmission within 30 days following discharge were identified. Multivariate logarithmic regression revealed predictors of unplanned readmission. RESULTS: A total of 1172 patient records were examined, of which 4.27% disclosed unplanned readmissions. Among the surgical patients, the readmission rate was 4.06%, mainly attributable to surgical site infections, while it was 5.06% for the non-surgical patients, attributable to uncontrolled pain. A night-time surgery presented as the independent predictive factor. CONCLUSION: In the heterogeneous group of spinal neurosurgical patients, stratification into diagnostic groups is necessary for statistical analysis. Degenerative lumbar spinal stenosis and spinal abscesses are mainly affected by unplanned readmission. The surgical procedure dorsal root ganglion stimulation is an independent predictor of unplanned re-hospitalizations, as is the timing of surgery.

Management of Cavernous Carotid Artery Aneurysms: A Retrospective Single-Center Experience.

OBJECTIVE: While cavernous carotid aneurysms can cause neurological symptoms, their often-uneventful natural course and the increasing options of intravascular aneurysm closure call for educated decision-making. However, evidence-based guidelines are missing. Here, we report 64 patients with cavernous carotid aneurysms, their respective therapeutic strategies, and follow-up. METHODS: We included all patients with cavernous carotid aneurysms who presented to our clinic between 2014 and 2020 and recorded comorbidities (elevated blood pressure, diabetes mellitus, and nicotine consumption), PHASES score, aneurysm site, size and shape, therapeutic strategy, neurological deficits, and clinical follow-up. RESULTS: The mean age of the 64 patients (86% female) was 53 years, the mean follow-up time was 3.8 years. A total of 22 patients suffered from cranial nerve deficit. Of these patients, 50% showed a relief of symptoms regardless of the therapy regime. We found no significant correlations between aneurysm size or PHASES score and the occurrence of neurological symptoms. CONCLUSION: If aneurysm specific symptoms persist over a longer period of time, relief is difficult to achieve despite aneurysm treatment. Patients should be advised by experts in neurovascular centers, weighing the possibility of an uneventful course against the risks of treatment. In this regard, more detailed prospective data is needed to improve individual patient counseling.

Comparison of the unruptured intracranial aneurysm treatment score recommendations with clinical treatment results - A series of 322 aneurysms.

Intracranial aneurysms occur with a prevalence of 3-5 %. Subarachnoid hemorrhage (SAH) due to aneurysm rupture is a rare but possibly fatal complication, so that occlusion of unruptured intracranial aneurysms (UIA) must be considered. The Unruptured Intracranial Aneurysm Treatment Score (UIATS) offers support for clinical decision making and has been shown to correlate with real life decisions in clinical practice. However, there is no data concerning the correlation of patient outcome and UIATS. Patients presenting to our outpatient clinic between January 1st, 2014 and December 31st, 2017 were retrospectively analyzed. We recorded the Extended Glasgow Outcome Scale (GOS-E) for longest possible follow-up, the choice of treatment, complications and UIATS recommendation. We included 221 patients with 322 UIA. 124 (38.5 %) UIA were observed and 198 (61.5 %) were occluded, of which 62 (31.3 %) underwent open surgery and 136 (68.7 %) were treated endovascularly. Spearman's rank correlation between our treatment choice and conclusive UIATS recommendation was 0.362 (p < 0.001). If UIATS was inconclusive, there were significantly more treatment-associated deteriorations (10/66 versus 7/132, p = 0.020). Otherwise, UIATS was not significantly associated with outcome. Therefore, treatment choice for UIA remains an individual decision. However, inconclusive UIATS must trigger vigilance and may be a negative prognostic marker for complications.

Treatment of Supraophthalmic Internal Carotid Artery Fenestration with an Associated Aneurysm via Flow Diversion: A Case Report.

Cerebral artery fenestration with flow-associated aneurysm is rare among cerebrovascular pathologies. Treatment includes open neurosurgery and/or endovascular treatment. We report a case of a 53-year-old woman with an incidentally detected aneurysm during magnetic resonance tomography. As the underlying cause, a digital subtraction angiography revealed a left internal carotid artery fenestration. Elective endovascular treatment via flow diversion was indicated and a pipeline embolization device was implanted. Follow-up examinations presented a completely occluded additional caudal limb and a decreasing aneurysm size. No clinically adverse events occurred within twenty-four-month post-treatment. Therefore, sole flow diversion was a feasible treatment option in this case.

Unusual mechanical failures of intrathecal baclofen pump systems: symptoms, signs, and trouble shooting.

INTRODUCTION: Although intrathecal baclofen (ITB) therapy is an effective treatment for spasticity, it has several disadvantages and a risk of complications. METHODS: We present six pediatric patients who suffered from unusual mechanical failures of intrathecal baclofen pump systems. RESULTS: With these case-vignettes, we provide a systematic approach on how to interpret the symptoms of ITB complications and an advice which further diagnostic and therapeutic steps to follow. We underline the seriousness of baclofen overdose, underdosing or withdrawal.

Causes and Predictors of Unplanned Readmission in Cranial Neurosurgery.

OBJECTIVE: A better understanding of the risks and reasons for unplanned readmission is an essential component in reducing costs in the health care system and in optimizing patient safety and satisfaction. The reasons for unplanned readmission vary between different disciplines and procedures. The aim of this study was to identify reasons for readmission in view of different diagnoses in cranial neurosurgery. METHODS: In this single-center retrospective study, adult patients after neurosurgical treatment were analyzed and grouped according to the indication based on International Classification of Diseases and Related Health Problems, Tenth Revision, German Modification diagnosis codes. The main outcome measure was unplanned readmission within 30 days of discharge. Further logistic regression models were performed to identify factors associated with unplanned rehospitalization. RESULTS: Of the 2474 patients analyzed, 183 underwent unplanned rehospitalization. Readmission rates differed between the diagnosis groups, with 9.19% in neoplasm, 8.26% in hydrocephalus, 5.76% in vascular, 6.13% after trauma, and 8.05% in the functional group. Several causes were considered to be preventable, such as wound healing disorders, seizures, or social reasons. Younger age, length of first stay, surgical treatment, and side diagnoses were predictors for unplanned readmission. Diagnoses with an increased risk of readmission were glioblastoma, traumatic subdural hematoma, or chronic subdural hematoma. CONCLUSIONS: Reasons and predictors for an unplanned readmission differ considerably among the index diagnosis groups. In addition to well-known reasons for readmission, we identified social indication, meaning a lack of home care, which is particularly prevalent in oncologic and elderly patients. A transitional care program could benefit these vulnerable patients.

A late systemic and brain metastasis from subcutaneous leiomyosarcoma of the right forearm: a case report and review of the literature.

BACKGROUND: Leiomyosarcomas are rare malignant tumors which originate from smooth muscle cells and very seldom give rise to intracerebral metastases. Nearly all cases of intracranial metastases stem from leiomyosarcomas of the uterus. We present a 61-year-old Caucasian man who developed multiple intracranial and extracranial metastases from leiomyosarcoma of the right forearm, diagnosed and treated 9 years before the current presentation. CASE PRESENTATION: The Caucasian patient presented to the emergency department due to a progressive hemiparesis on the left side. Magnetic resonance imaging scans of the neurocranium showed multiple intracerebral masses with perifocal edema. One of these was located in the right parietal lobe, corresponding to the hemiparesis. The patient underwent microsurgical complete resection of the parietal mass and was subsequently subjected to further radiotherapy. Histopathological studies revealed metastasis of the former leiomyosarcoma. CONCLUSIONS: Leiomyosarcomas represent a rare entity of mesenchymal tumors. Intracerebral metastasis of these tumors is even less frequent. This case shows the importance of long-term follow-up in patients with leiomyosarcoma.

Rapid resolution of a traumatic venous epidural hematoma in a 3-year-old child: illustrative case.

BACKGROUND: Posterior fossa epidural hematoma rarely occurs in children after traumatic head injury. There is ongoing discussion about appropriate treatment, yet the radiological features regarding the time to resorption of the hematoma or required follow-up imaging are rarely discussed. OBSERVATIONS: The authors presented the case of a 3-year-old child who was under clinical observation and receiving analgetic and antiemetic treatment in whom near-complete hematoma resorption was shown by magnetic resonance imaging as soon as 60 hours after diagnosis. The child was neurologically stable at all times and showed no deficit after observational treatment. Hematoma resorption was much faster than expected. The authors discussed hematoma drainage via the sigmoid sinus. LESSONS: Epidural hematomas in children can be treated conservatively and are resorbed in a timely manner.

Epidemiologic and anatomic aspects comparing incidental and ruptured intracranial aneurysms: A single centre experience.

The feasibility of multicentric international data such as integrated in the PHASES score for patient counseling in unruptured intracranial aneurysms has recently been challenged. To determine, whether this data is applicable to local populations in a restricted catchment area, we performed a retrospective mono-centric analysis comparing patients with ruptured aneurysms to patients with incidental aneurysms. 200 patients with unruptured aneurysms and 197 patients after aneurysmal subarachnoid hemorrhage were analyzed for risk factors differing between the groups and to the general German population. Subgroup analysis was performed for 25 patients harboring multiple aneurysms, in 19 patients with intracavernous aneurysms and in 77 women of childbearing potential. While the preponderance of female patients was confirmed, significantly more men figured in the patient group with subarachnoid hemorrhage (36.4%) than among unruptured aneurysms (25%). Patients with bleeding events were significantly younger (51.6 years) than patients with incidental aneurysms (57.8 years). The rupture risk prediction of the PHASES score concerning aneurysm size below 7 mm and patient age over 70 years could not be confirmed, instead score points correlated to the clinical outcome after rupture. In our population, pregnant women were not overrepresented. Intracavernous carotid aneurysms contributed to the low risk profile of giant aneurysms. Thus, recommendations from pooled international data have to be adapted cautiously to local circumstances. We retained seven items with predictive value for outpatient counseling: age, smoking, hypertonus and concurrent vascular aberrations as patient characteristics and irregular shape, (increasing) largest diameter and the harboring vessel for the aneurysm.

CSF Surfactant Protein Changes in Preterm Infants After Intraventricular Hemorrhage.

Introduction: Surfactant proteins (SP) have been shown to be inherent proteins of the human CNS and are altered during acute and chronic disturbances of CSF circulation. Aim of the study was to examine the changes of surfactant protein concentrations in CSF of preterm babies suffering from intraventricular hemorrhage. Patients and Methods: Consecutive CSF samples of 21 preterm infants with intraventricular hemorrhages (IVH) and posthemorrhagic hydrocephalus (PHHC) were collected at primary intervention, after 5-10 days and at time of shunt insertion ~50 days after hemorrhage. Samples were analyzed for surfactant proteins A, B, C, and G by ELISA assays and the results were compared to 35 hydrocephalus patients (HC) without hemorrhage and 6 newborn control patients. Results and Discussion: Premature patients with IVH showed a significant elevation of surfactant proteins SP-A, C, and G compared to HC and control groups: mean values for the respective groups were SP-A 4.19 vs. 1.08 vs. 0.38 ng/ml. Mean SP-C 3.63 vs. 1.47 vs. 0.48 ng/ml. Mean SP-G 3.86 vs. 0.17 vs. 0.2 ng/ml. SP-A and G concentrations were slowly falling over time without reaching normal values. SP-C levels declined faster following neurosurgical interventions and reached levels comparable to those of hydrocephalus patients without hemorrhage. Conclusion: Intraventricular hemorrhages of premature infants cause posthemorrhagic CSF flow disturbance and are associated with highly significant elevations of surfactant proteins A, C, and G independent of total CSF protein concentrations.

Persistent hyperprolactinemia, transient hypopituitarism, and transient contralateral third nerve palsy after endovascular treatment of an internal carotid artery aneurysm: Case report and review of the literature.

Intracranial aneurysms have an estimated prevalence of about 3%. A rare subgroup are aneurysms of the internal carotid artery that develop medially into the sellar region. Due to the risk of rupture with subsequent subarachnoid hemorrhage and of compression of surrounding structures, mechanical occlusion is advised. Hypopituitarism is not a rare disease and most often related to pituitary adenoma. Only 0.17% of cases with hypopituitarism are caused by unruptured intracranial aneurysms. Today, the predominant treatment of these aneurysms is endovascular coiling or application of flow diverting stents. We present the case of a 60-year-old female patient, who was treated with endovascular coiling for a right-sided, intracavernous, incidental internal carotid artery aneurysm. On postinterventional day 6, she was readmitted with contralateral third nerve palsy, mild hyponatremia und thyreotropic insufficiency. The symptoms recovered after anti-edematous treatment with corticosteroids; only an asymptomatic hyperprolactinemia persisted. To the best of our knowledge, this is the first case report of transient contralateral cranial nerve palsy combined with transient hypopituitarism after endovascular treatment of an internal carotid aneurysm. As treatment we propose corticosteroids, if necessary in combination with nonsteroidal anti-inflammatory drugs, in order to inhibit inflammatory reactions of the aneurysm wall compromising the nearby, partially compressed neural structures.

Early unplanned readmission of neurosurgical patients after treatment of intracranial lesions: a comparison between surgical and non-surgical intervention group.

BACKGROUND: Recent health care policy making has highlighted the necessity for understanding factors that influence readmission. To elucidate the rate, reason, and predictors of readmissions in neurosurgical patients, we analyzed unscheduled readmissions to our neurosurgical department after treatment for cranial or cerebral lesions. METHODS: From 2015 to 2017, all adult patients who had been discharged from our Department of Neurosurgery and were readmitted within 30 days were included into the study cohort. The patients were divided into a surgical and a non-surgical group. The main outcome measure was unplanned inpatient admission within 30 days of discharge. RESULTS: During the observation period, 183 (7.4%) of 2486 patients had to be readmitted unexpectedly within 30 days after discharge. The main readmission causes were surgical site infection (34.4 %) and seizure (16.4%) in the surgical group, compared to natural progression of the original diagnosis (38.2%) in the non-surgical group. Most important predictors for an unplanned readmission were younger age, presence of malignoma (OR: 2.44), and presence of cardiovascular side diagnoses in the surgical group. In the non-surgical group, predictors were length of stay (OR: 1.07) and the need for intensive care (OR: 5.79). CONCLUSIONS: We demonstrated that reasons for readmission vary between operated and non-operated patients and are preventable in large numbers. In addition, we identified treatment-related partly modifiable factors as predictors of unplanned readmission in the non-surgical group, while unmodifiable patient-related factors predominated in the surgical group. Further patient-related risk adjustment models are needed to establish an individualized preventive strategy in order to reduce unplanned readmissions.

Familial glioblastoma clustering in adult patients: a case report of two non-twin siblings and review of the literature.

Purpose: Familial glioblastoma multiforme (gbm) has been described in children with hereditary tumor syndromes. The occurrence of gbm in adult members of the same family and in the absence of tumor syndromes is extremely rare. We describe the cases of a brother and a sister with multifocal gbm diagnosed at the age of 63 years. We discuss three further paired gbm in adult patients from the literature. Patients and results: The sister was diagnosed with multifocal primary gbm in 2014 at the age of 63 years and 6 months. In 2018, her younger brother had to be operated on for a multifocal primary gbm at the age of 63 years and 9 months. Extended neuropathological examination revealed most markers to be similar, except for the percentage of O6-methylguanine-DNA methyltransferase promotor methylation, the presence of intratumoral immune cells and the immunohistochemical expression of C12ORF75. Comparison with further published cases of familial adult GBM reveals that most of these patients are male, about 65 years old and the tumor is localized predominantly in the left temporal lobe. Conclusion: Paired adult familial gbm occurs mainly in the elderly male patient with an integrative diagnosis of primary gbm. Whereas a statistical coincidence seems to be most likely in these rare cases, supplementary and improved genetic studies may identify pathogenetic causes of gbm.