Development of a bleeding scale and hemostasis algorithm in cranial neurosurgery.

Effective hemostasis is crucial in neurosurgery as anatomical and functional considerations reduce tolerance for any bleeding. The classification of bleeding severities is a necessary step to enable neurosurgeons to counteract bleeding during surgery. Even though bleeding scales are used for a variety of surgical specialties, they cannot be transferred to cranial neurosurgery without adaption, and no consensus on the nature of such a classification exists to date. Moreover, there is plethora of topical hemostasis products with diverse mechanisms of action and application available. Clinical studies investigating those products used in neurosurgery did not define standardized procedures. This article demonstrates the systematic establishment of both a bleeding scale and a hemostasis algorithm to close this gap in the assessment of intracranial bleeding. The expert panel consisting of 7 members from different neurosurgical centers developed a qualitative bleeding scale with the peculiarities of neurosurgical procedures, based on the experience of each member in daily practice. The hemostasis algorithm is a recommendation for neurosurgeons to aid in the decision-making process to control any sort of bleeding, taking into account the rational use of available hemostatics, depending on type and location of bleeding, as well as the mechanism of action of such agents. Effectiveness of hemostasis, surgery times and economic costs can be optimized by applying the algorithm in daily practice.

Astroblastoma: report of two cases with unexpected clinical behavior and review of the literature.

Astroblastoma is a rare, mostly supratentorial glial tumor, occurring predominantly in children and young adults with female preponderance. Due to the rarity, with only about 230 reported cases, treatment strategies are still to be discussed. We describe two more cases to add to the clinical experiences with this tumor entity. In both of these cases, the clinical behavior did not follow the expectations based on histopathological classification. Case 1: A sixteen-year old female presented with a six month history of intermittent headaches, nausea and dizziness. MRI scans revealed a left parietooccipital mass lesion with bubbly contrast enhancement and marked peritumoral edema. After gross total tumor resection the histology gave the diagnosis of low grade astroblastoma. Fifteen months later, the patient was operated on a local recurrence and received postoperative radiotherapy, with the histology still being that of low grade astroblastoma. Two years later, a meningeally based tumor nodule frontal of the former tumor bed was removed, now diagnosed as high grade astroblastoma. Eighteen months later, a fourth operation with excision of two more meningeally based tumor nodules of high-grade astroblastoma followed. Chemotherapy was suggested, but the patient decided against it. The last MRI follow-up 14 months after last operation showed no further recurrence so far. Case 2: A 24-year old female presented with a four week history of vomiting and headaches with focal seizures affecting her left arm. CT and MRI scans revealed a superficial partly cystic right temporal mass lesion with few edema and macrocalcifications and adjacent bone atrophy. Despite dural invasion, total tumor resection could be performed. MRI scans six months later showed no recurrence. The patient refused further MRI controls but did not show any clinical signs or symptoms suggesting tumor recurrence four years after the operation. In order to find more predictive tools that might help to determine the individual clinical course and treatment, we performed a review of the literature, analyzing 29 cases with detailed data on clinical history, MRI/CT characteristics, histopathological subtyping, treatment details and a follow-up of at least 12 months. We found, that low-grade astroblastoma with marked peritumoral edema has a tendency to early recurrence and suggest that it should be treated by combined surgery and radiotherapy. In high-grade astroblastoma with well defined tumor borders and few peritumoral edema, the prognosis may be better than expected for a high-grade glioma, if GTR is possible.

Evaluation of an intraoperative ultrasound training model based on a cadaveric sheep brain.

BACKGROUND: The present study evaluates the effectiveness of an ultrasound (US) practice course based on a sheep brain cadaver. Neurosurgical education is considerably restrained following patient safety objections and work time restrictions. It is therefore of vital importance to offer residents an opportunity to practice certain US techniques in a controlled environment without ethical or legal restrictions. We developed an US training model based on a sheep brain cadaver in order to demonstrate the feasibility of such a model, facilitate crucial anatomic knowledge, and demonstrate a learning curve from it. METHODS: Over the course of 2 months from December 2012-January 2013, a total of 13 residents took part in a three part training session, each consisting of 20-30 min of individual US-training and performance evaluation based on a biological phantom. The first cadaver was a physiologic sheep brain. After initial familiarization with the US, the residents performed an US on a second cadaveric brain and tried to find a 0.5 cm big (in diameter) echogenic structure. In a third brain they were asked to identify a cyst (Fogarty catheter filled with water). RESULTS: Thirteen neurosurgical residents participated in the study. After the first training session, the learning curve improved significantly in the second and the third session. The ability to actuate the US device, the time needed to display crucial anatomic landmarks, and to locate the two different artificial masses increased, and respectively decreased remarkably by up to 80%. CONCLUSION: After 2 months and three training sessions, the handling of the US from the residents was excellent in the operating room. The accuracy and the dexterity in use of the US improved significantly. The participants found the model to be realistic and agreed on the need for further promotion of such courses.

Sellar and supra-sellar glioblastoma masquerading as a pituitary macroadenoma.

A few number of suprasellar gliomas have been reported thus far of which, some of them developed several years after radiation therapy for pituitary adenomas or craniopharyngiomas. Herein, we report a case of sellar glioblastoma with suprasellar extension with no prior radiation history who mimicked clinical and radiologic findings of a pituitary macroadenoma.

Recurrence of intracranial meningiomas: did better methods of diagnosis and surgical treatment change the outcome in the last 30 years?

OBJECTIVE: Meningiomas are benign intracranial tumors growing from the arachnoid cap cells. Although their behavior is usually benign, they tend to recur even after total removal, and their recurrence is dependent on different aspects. METHODS: Between 1991 and 2002, 463 patients with an intracranial meningioma were operated in the Department of Neurosurgery, University of Kiel, Kiel, Germany. We compared the outcome of these patients after operation and the different methods of radiation therapy and chemotherapy with the data from Buhl (1994), who analysed 661 patients with intracranial meningioma who were operated on in the Department of Neurosurgery, University of Essen, Essen, Germany, between 1968 and 1988, to find out whether better methods of diagnosis like magnetic resonance imaging scans, magnetic resonance spectroscopy, post-operative radiation therapy and chemotherapy have an influence on the recurrence and outcome after surgical treatment. RESULTS: The patients' mean age in both studies was between 50 and 59 years. Both studies underlined the preponderance of female patients for intracranial meningiomas. In the primary study, there were 506 female and 208 male patients, and in the new study, there were 366 female and 97 male patients. The gender distribution changed from 2.4 : 1 to 3.8 : 1. Complete removal of the tumor was possible in 86.7% in both studies. The recurrence rate in the first study was 11% (73/661), while it was 16% in the second study (73/463). The intracranial localization of the meningiomas was similar to the distribution of the histological subtypes and the rate of recurrence; only the malignant meningiomas showed a higher grade of recurrence in the last study. Indications for post-operative radiation therapy were given earlier in the last study owing to the experience from the primary study. The outcome of the patients after surgical removal was improving in the last years; the 30 day post-operative mortality after a primary operation on an intracranial meningioma decreased from 12.1 to 3%. After removal of a recurrent meningioma, the mortality declined from 20 to 12.5%. CONCLUSION: In the last 30 years, nothing important changed at the time of appearance of meningiomas, concerning the gender distribution and localisation as well as histological subtypes. With better operating modalities and additional treatment with radiation and gamma knife, the mortality decreased significantly from 12 to 3% and the outcome of the patients is still improving, so that even elderly patients with intracranial meningioma can undergo surgical treatment with minor risks.

Severe hyponatraemia in the setting of hypopituitarism associated with empty sella and herniation of the optic chiasm and gyrus rectus.

We present a patient with progressive weakness over months caused by untreated hyponatraemia. When hyponatraemia became severe, the patient could not move without help, was lethargic and had endocrinological dysfunction. Symptomatic therapy brought no improvement. MRI of the brain showed empty sella with gross herniation of the optic chiasma, gyrus rectus and third ventricle. After fluid and salt supplementation was combined with hydrocortisone, the patient regained his strength and could leave the hospital. Panhypopituitarism caused by empty sella should always be considered when hyponatraemia is not responsive to salt and fluid substitution alone. Additional hydrocortisone supplementation can be life saving.

Gliosarcoma: clinical experiences and additional information with MR spectroscopy.

Gliosarcomas represent about 2% of glioblastoma multiforme (WHO grade IV). They have mixed features of glial and sarcomatous components. The clinical presentation and prognosis are similar to glioblastoma. Between 1997 and 2006, 16 patients with intracranial gliosarcoma were treated in the Department of Neurosurgery in Kiel, Germany. Median age was 63 years (52-79 years). Eleven patients were men and five were women. Six tumors were in the frontal lobe, four in the temporal lobe, three parietal, two in the thalamic area and one in the occipital lobe. Pre-operatively, in two patients, we could perform magnetic resonance (MR) spectroscopy. There was lactate peak, which is a sign of local necrosis and hypoxia. Median survival time in our patient group was 7 months (2-11 months). On histological examination, we found glial fibrillary acid protein positive cells surrounded by sarcomatous tissue and reticular fibers. The proliferation index MIB-1 was between 20 and 70%. The prognosis in this patient group is still poor. MR spectroscopy and location of the tumor adjacent to the dura with inhomogeneous contrast enhancement might give hints pre-operatively for the differential diagnosis of gliosarcoma. Further works with adjuvant chemotherapy are necessary.

Outcome of cerebral amyloid angiopathic brain haemorrhage.

BACKGROUND: Abnormal amyloid protein can be deposited in the wall of cerebral arteries leading to fragility and intracerebral haematoma in patients with cerebral amyloid angiopathy. Diagnosis can be done only histologically. The indication of surgically treating intracerebral haemorrhage caused by amyloid angiopathy is controversial. There are studies showing a high mortality and a high rate of recurrent bleeding. Others show almost no recurrent bleeding and a very low mortality and a third party states that even when recurrent intracerebral haemorrhage occurs, re-evacuation should be performed. In the present retrospective study a population of 99 patients suffering from cerebral amyloid angiopathy-related cerebral haemorrhage has been studied, to investigate the surgical outcome. METHOD: Ninety-nine patients were histologically diagnosed with cerebral amyloid angiopathy in our department from 1991-2004. The outcome has been established by the Glascow Outcome Score. FINDINGS: It could be shown that intraventricular bleeding and age >75 years increased the mortality after operative evacuation. Recurrent bleeding occurred in 22% of patients. After re-evacuation at least half of the patients survived leading to the suggestion to re-operate a recurrent bleeding since patients have a chance to survive even when the Glascow Outcome Score is 3. The overall mortality in the observed population was 16% and 11% had a very good neurological recovery based on a Glascow Outcome Score of 4-5. The operative outcome in amyloid angiopathy related intracerebral haemorrhage is similar to this of intracerebral haemorrhage induced by other causes like hypertensive bleeding. CONCLUSIONS: Possible cerebral amyloid angiopathy is no contraindication for evacuation of brain-haematoma, and especially not in patients younger than 75 years old without an intraventricular haemorrhage.

Intraneural perineurioma of the VIIIth cranial nerve: case report.

OBJECTIVE: The authors describe the clinical and pathological features of the second reported case of an intraneural perineurioma involving a major intracranial nerve and the first case of this entity involving the VIIIth cranial nerve. CLINICAL PRESENTATION: A 59-year-old woman presented with a long history of dizziness, tinnitus, hearing loss, and unstable gait. A magnetic resonance imaging scan revealed a small intrameatal lesion, which showed no clear progression from 2000 to 2006. INTERVENTION: As a result of worsening symptoms and a suspected vestibular schwannoma, an attempt of tumor resection through a retrosigmoid approach was performed. This revealed diffusely infiltrated and fusiform enlarged vestibular and cochlear nerves, with no identifiable border between the main tumor mass and normal nerve. An en bloc nerve-tumor mass excision was performed. The pathological findings confirmed the diagnosis of an intraneuronal perineurioma. CONCLUSION: The experience with this unique case and the experience of others with the management of extracranial intraneural perineuriomas lead the authors to conclude that the most reasonable surgical management of this tumor at this location is a nerve-tumor cross-section resection.

De novo development of intraosseous cavernous hemangioma.

Intraosseous cavernous hemangiomas are rare and not often multifocal. De novo development of a skull cavernous hemangioma has not been described previously. We present a 20-year-old man who was operated upon for a skull cavernoma in the right frontal area and developed a new lesion 3 years later in the right occipital region. The first lesion was removed completely and the postoperative course was uneventful. Histology showed an intraosseous cavernous hemangioma. MRI follow-up revealed a new lesion in the right occipital region. At the time of the first operation this lesion was not seen on CT or MRI scan. Surgical removal was performed and histology again showed a cavernous hemangioma. The patient seems to be unique and it is important to keep young patients with the diagnosis of cavernous hemangioma under close follow-up. This supports the experience from parenchymatous cavernous hemangiomas that this malformation may become a dynamic disease.

Overexpression of midkine contributes to anti-apoptotic effects in human meningiomas.

Meningiomas are the second most common intracranial tumours. Most meningiomas grow slowly; however, atypical and anaplastic meningiomas show an aggressive biological behaviour. Overexpression of growth factors is considered to be a cause of carcinogenesis. Midkine and pleiotrophin are heparin-binding growth factors that promote growth, survival, migration and differentiation of various target cells. Both molecules are highly expressed during human embryogenesis but are rarely seen in the adult. We show that in relation to normal dura and arachnoid tissues, midkine was overexpressed in meningiomas on the mRNA and protein level, whereas pleiotrophin was not. Thereby, not only the intact but also the truncated form of midkine could be observed. The expression of midkine receptors was variable in different samples. Midkine stimulation of cultured meningioma cells induced phosphorylation of Akt, whereas no increase in phosphorylation of p42/44 MAPK or p38 MAPK could be detected. Midkine did not influence the proliferation of meningioma cells in vitro, but it did protect meningioma cells from camptothecin-mediated apoptotic cell death through reduction in the amounts of active caspase-3. These findings provide evidence for the overexpression of midkine in meningiomas which contributes to protection from cell death in these second most common intracranial tumours.

Chronic recurrent subarachnoid hemorrhage from a trigeminal nerve malignant peripheral nerve sheath tumor: case report.

OBJECTIVE: Clinically significant intratumoral or peritumoral bleeding from trigeminal nerve tumors is very rare. CLINICAL PRESENTATION: We report the case of a 59-year-old man who presented with recurrent subarachnoid hemorrhage from a left trigeminal nerve malignant peripheral nerve sheath tumor. He presented with decreased consciousness, left facial hypesthesia, and left facial weakness. Trigeminal neuralgia was present for 18 months. Cranial computed tomographic and magnetic resonance imaging scans revealed a left parapontine mass with cystic changes and intratumoral bleeding. Furthermore, signs of hemosiderosis of the subarachnoid space were noted. Lumbar puncture revealed fresh bleeding. Angiography detected no aneurysm or other causes of bleeding. The patient became fully alert within hours, the facial weakness improved within a few days. There was no evidence of vasospasm or persisting hydrocephalus. He underwent left-sided suboccipital craniotomy for macroscopically total tumor removal. INTERVENTION: The patient underwent total tumor removal via a left suboccipital approach. Intraoperatively, evidence of recurrent intratumoral bleeding was noted. Histological examination revealed a malignant peripheral nerve sheath tumor (World Health Organization Grade III). Postoperatively, the hypesthesia improved significantly. The patient was transferred to radiotherapy for external beam radiation. CONCLUSIONS: This is the first report regarding a malignant peripheral nerve sheath tumor of the trigeminal nerve that caused clinically significant subarachnoid hemorrhage caused by intratumoral bleeding.

Neuropsychological findings in patients with intraventricular tumors.

BACKGROUND: Intraventricular tumors are quite rare and become symptomatic with hydrocephalus-related signs such as headache, double vision, and seizures. Also, most of the patients show neuropsychological deficits, especially memory problems and lack of attention. METHODS: We reviewed the charts and computed tomographic/magnetic resonance images of 15 patients with tumors of the lateral and third ventricle, who were also examined by a neuropsychologist pre- and postoperatively. Neuropsychological testing included tests of attention, memory, executive functions, and concentration. RESULTS: Between 1995 and 2003, 7 patients with colloid cysts of the third ventricle (3 men, 4 women; mean age, 38 years), 5 patients with meningiomas of the lateral ventricle (2 men, 3 women; mean age, 51 years), and 3 patients with astrocytomas and ependymoma (2 men, 1 woman; mean age, 38 years) were treated. All patients with colloid cysts and meningiomas showed mental changes, especially attention and memory deficits. Symptoms improved markedly after surgical intervention. The 3 patients with astrocytoma and ependymoma showed normal results pre- and postoperatively. CONCLUSION: Neuropsychological testing is very useful in patients with intraventricular lesions and important for follow-up examinations. It should be included in every workup examination in this small patient group.

Expression of VEGF and its receptors in different brain tumors.

INTRODUCTION: Vascular endothelial growth factor (VEGF) and its receptors VEGFR-1 and -2 are considered to play a major in tumor angiogenesis, which is a prerequisite for growth of solid tumors. Glioblastoma multiforme is a prominent example of VEGF-induced tumor vascularization; however, little is known about VEGF and in particular VEGFR expression in other types of brain tumors. METHODS: VEGFR mRNA was quantified by real time RT-PCR in 12 different types of brain tumors and compared to VEGF protein content measured by ELISA. VEGF splice variants were determined by an RT-PCR method. RESULTS: VEGF protein was highest in glioblastoma and metastatic kidney tumors. In all types of tumors the diffusible splice forms VEGF(121) and VEGF(165) were expressed; VEGF(189) was minor in a few tumors. Expression of VEGF receptors did not necessarily correlate with VEGF content. Both were highly expressed in glioblastomas, but in meningiomas VEGF was low and VEGFR high, and in metastatic tumors the reverse. With few exceptions, in particular oligodendrogliomas, VEGFR-1 expression was parallel to VEGFR-2 expression. Interestingly, for the astrocytic gliomas, the expression of VEGFR correlated well to the tumor malignancy, even better than VEGF content. CONCLUSIONS: These results show that VEGF and VEGFR expression in various types of brain tumors differ and are not necessarily parallel.

Clinical and histological features of multiple meningiomas compared with solitary meningiomas.

Between 1991 and 2002, 456 patients with an intracranial meningioma were treated. Thirty-nine of these had more than one meningioma (8.6%). The mean age was 58 years (27-85 years). Sex distribution was 8.8:1 (35 female, four male). There was no associated spinal meningioma. No patient had neurofibromatosis. In 19 patients all meningiomas were removed. Twelve showed the same histology, seven had different histological features. In the remaining 20 patients only the symptomatic meningioma was removed. Recurrences occurred in 11 patients (28.2%). Six patients died during follow-up. Multiple meningiomas have their own clinical features. Besides a high female preponderance, PR expression was stronger in multiple meningiomas than in solitary meningiomas while p53 status and MIB-1 LI were similar between the two groups. Progesterone receptor, p53 status and MIB-1 LI were valuable markers for predicting a patient's outcome in multiple meningiomas. The number of meningiomas is growing in patients with recurrent meningiomas.

Surgical treatment for brain metastases: prognostic factors and survival in 177 patients.

Brain metastases are an increasingly frequent complication of cancer. Advances in diagnosis and treatment have led to wider indications for surgery. We present a single-institution series of 177 patients and discuss our results with regard to the literature. Special focus is on patients with advanced age, multiple brain metastases, extracranial metastases, and brain metastasis recurrence. All patients underwent craniotomy for the resection of solid tumor brain metastases between 1994 and 2001 in our department. Perioperative morbidity and mortality as well as survival were evaluated. The median patient age was 59 years (range 32-86 years). In 177 patients, 348 brain metastases were detected, of which 68.0% were supratentorial and 32.0% were infratentorial. According to univariate analysis, the following parameters were significantly associated with prolonged patient survival: (1) age <70 years, (2) one to three intracranial metastases, (3) favorable postoperative performance, (4) resection of all intracranial lesions, and (5) recraniotomy for brain metastasis recurrence. In contrast, the presence of extracranial metastases, metachronous diagnosis, and solitary brain metastases had no influence on survival. As expected, younger age and limited number of brain metastases (up to three) are favorable prognostic factors. Remarkably, the presence of extracranial metastases had no influence on patient survival.

Intracranial and spinal melanotic schwannoma in the same patient.

Melanotic schwannoma is a nerve sheath tumor composed of melanin - producing cells with ultrastructural features of Schwann cells, which is very rare. These tumors can appear intracranially and less common in the spinal canal. The prognosis is usually good although cases with metastases and death are described in the literature. We present the unusual and rare case of a young man with a spinal melanotic schwannoma at L5/S1 who presented 30 months later with an intracranial melanotic schwannoma.

Clinical experiences with oligoastrocytomas WHO grade II and III.

Between April 1991 and June 2002, 39 patients with an histologically proven oligoastrocytoma WHO grade II and III were operated on in our department. Twenty-two patients were male and 17 female. Mean age was 42 years (20-67 years). The tumor was localized in the frontal lobe in 22 patients, in the temporal lobe in seven patients, in the parietal lobe in nine patients and in the occipital lobe in one patient. The leading clinical symptoms were seizures in 33 patients. Seventeen patients were operated on under local anesthesia. One operation was performed in 22 patients, two operations in eight, three operations in five, four operations in three and six operations in one patient. Histological examination showed oligoastrocytoma WHO grade II in 12 patients and WHO grade III in 27 patients. Postoperative radiotherapy was performed in 33 patients and chemotherapy in six patients. One female patient developed spinal drop metastases 10 months after the operation. One patient with a primary oligoastrocytoma grade II and five patients with a primary oligoastrocytoma grade III died during follow-up. The follow-up period was between 6 months and 25 years (mean 7 years 6 months).

Ganglioneurocytoma of the third ventricle.

We present a very rare case of an intracranial ganglioneurocytoma. This 57-year-old female patient noticed some concentration difficulties for about 5 months. Visual acuity was 80% on both sides. CT and MRI of her head demonstrated a 3 x 2.5 x 2.8 cm3 lesion within the third ventricle with inhomogenous enhancement of contrast medium. After a right pterional approach the tumor could be removed completely. Postoperatively there was a paresis of the oculomotor nerve on the right side and psychological changes. Histological examination revealed neuronal differentiation with neurocytes and small ganglionic cells and the tumor was graded as a ganglioneurocytoma (WHO grade II). Follow-up examination 6 months after the operation showed improvement of her third nerve paresis and of her neuropsychological deficits. MRI showed no recurrence.