Multicentre approach to epidemiological aspects of craniosynostosis in Germany.

We know of no current published data on the prevalence of craniosynostosis in Germany, so our objective in this study was to contribute to the limited knowledge of its epidemiology by assessing time trends, the frequency of prenatal diagnosis, and the timing of diagnosis and treatment. Data were collected in Saxony-Anhalt during the period 2000-17, and we designed a retrospective multicentre cohort study. The prevalence was 4.8 cases of craniosynostosis/10 000 births, and did not increase during that time. We compared the data of 91 patients with those of 273 controls. There were 75 boys and 16 girls (ratio 4.7:1). Fifty-one children had isolated craniosynostosis, consisting of 46 with a single-suture, and five with a multisuture, synostosis. Twenty-nine were associated with other congenital malformations, and 11 were syndromic. Three cases had been diagnosed prenatally, and 34 had skull deformities diagnosed immediately after birth at a mean (SD) age of 3.4 (4.7) months. The mean (SD) age at the time of first admission to hospital in one of the three surgical centres of Saxony-Anhalt was 5.9 (5.5) months, and 65 patients were operated on at a mean age of 9.1 (6.3) months. In contrast to published reports we found a prevalence of 4.8 cases of craniosynostosis/10 000 births that did not increase during the period 2000-16. Although we found a low prenatal detection rate, the diagnosis and treatment in this cohort study seemed timely.

Combined effects of resveratrol and radiation in GH3 and TtT/GF pituitary adenoma cells.

OBJECTIVE: Resveratrol and radiation decrease viability in various tumor cells. This study aims to investigate combined effects of resveratrol and radiation on viability, induction of apoptosis and necrosis, and expression of apoptosis modulators in rodent GH3 and TtT/GF pituitary adenoma cells in vitro. METHODS: Cells were incubated with 10-100 µM resveratrol. Medium and medium with ethanol served as controls. After 2 h, cells were irradiated with 0-5 Gray (Gy) and further incubated for 48-72 h. Cell viability was quantified using a hemocytometer. Cell death was assessed with an enzyme-linked immunosorbent assay (ELISA) that detects free nucleosomes in cell lysates and free nucleosomes released to the culture medium. Expression of B-cell lymphoma-2 protein (BCL-2) and BCL-2 associated Xprotein (BAX) was measured using quantitative real time-polymerase chain reaction (qRT-PCR) to analyze changes in BAX/BCL-2 ratio. RESULTS: Resveratrol and irradiation with 4 Gy alone and in combination significantly decreased cell viability (p = 0.017 and less). In the ELISA, 10 µM resveratrol significantly induced apoptosis in TtT/GF cells at 0 Gy (p < 0.001), but not at 3 or 5 Gy. In the ELISA, 10 µM resveratrol significantly induced necrosis in GH3 cells at 0, 3 and 5 Gy (p < 0.001). While qRT-PCR did not demonstrate a significant effect of 10 µM resveratrol or radiation on expression of BAX or BCL-2, a significant increase in the BAX/BCL-2 ratio was found after irradiation with 5 Gy in GH3 cells (p = 0.0027). CONCLUSION: While moderate irradiation solely led to inhibited proliferation, resveratrol induced cell death in rodent pituitary adenoma cells.

Guidelines for the Treatment of Head Injury in Adults.

The workshop of scientific medical faculties (Arbeitsgemeinschaft wissenschaftlicher medizinischer Fakultäten [AWMF]) of Germany has asked societies of specific medical disciplines to jointly publish guidelines on the treatment of diseases and injuries. On behalf of the Deutsche Gesellschaft für Neurochirurgie, its commission on guidelines initiated an interdisciplinary approach to publish guidelines on the treatment of head injury in adults. These guidelines were published in German by the AWMF in late 2015. Because these guidelines have received widespread attention in Germany and became fundamental for research in head injuries, we have translated the German version into English to make it accessible to the international scientific community.

Decerebrate posturing following traumatic brain injury: MRI findings and their diagnostic value.

AIM: To determine the pathomorphological and clinical background to decerebrate posturing in humans following serious traumatic brain injury. MATERIALS AND METHODS: One hundred and twenty patients who had been unconscious for more than 24 h underwent diagnostic MRI within 8 days after trauma. The presence of decerebrate rigidity as the clinical parameter was correlated to MRI findings, such as traumatic lesions in defined brain areas. Significance was presumed as p < 0.05. RESULTS: On the day of MRI 43 (36%) patients exhibited decerebrate posturing: 19 (23%) cases were unilateral and 24 (77%) bilateral. There was a significant correlation between midbrain lesions and the presence of rigidity. If a midbrain lesion was found in the absence of pontine lesions, decerebrate rigidity could be concluded (p < 0.05). There was no significant correlation to the rigidity in the case of midbrain lesions accompanied by pontine lesions, and no correlation to the rigidity could be detected for other regions of the brain. Both the occurrence of decerebrate posturing and the detection of brainstem lesions at MRI correlated with the Glasgow Outcome Scale. The combination of both parameters improved the probability of predicting the outcome. CONCLUSION: The rate of decerebrate posturing increases significantly in the presence of midbrain lesions. The presence of pontine lesions appears to be of secondary importance. The chances of predicting the Glasgow Outcome Scale are improved by the combination of clinical information (decerebrate posturing) and radiological parameters (type of brainstem lesion).

Gadolinium-enhanced magnetic resonance angiography in brain death.

Confirmatory tests for the diagnosis of brain death in addition to clinical findings may shorten observation time required in some countries and may add certainty to the diagnosis under specific circumstances. The practicability of Gadolinium-enhanced magnetic resonance angiography to confirm cerebral circulatory arrest was assessed after the diagnosis of brain death in 15 patients using a 1.5 Tesla MRI scanner. In all 15 patients extracranial blood flow distal to the external carotid arteries was undisturbed. In 14 patients no contrast medium was noted within intracerebral vessels above the proximal level of the intracerebral arteries. In one patient more distal segments of the anterior and middle cerebral arteries (A3 and M3) were filled with contrast medium. Gadolinium-enhanced MRA may be considered conclusive evidence of cerebral circulatory arrest, when major intracranial vessels fail to fill with contrast medium while extracranial vessels show normal blood flow.

[Comparison of younger and elder patients after multiple trauma]. / Vergleich jüngerer und älterer Unfallopfer nach Mehrfachverletzun.

The purpose of this study was to clarify any influences by age on the outcome after multiple trauma. 520 patients (age > 20 years) were analysed after inclusion in a 3-year national multi-centre study for polytrauma injured subjects. The patients were recruited from 10 German neurosurgical university departments. Criteria for inclusion were head injury and coma at the time of admittance. The elderly were mostly injured by falls, and showed more often intracranial injuries and fractures of the pelvis. The majority of intracranial injuries were characterised by acute subdural haematomas in the elderly and contusions in younger patients. Hence, craniotomy within the first 24 hours was found more often in the elderly. There was a significant trend towards a craniotomy and placement of a pressure catheter in younger patients compared with the elderly. There were significantly lower values for the Glasgow Outcome Scale (GOS) in the elderly, especially in terms of lethality. The depth of coma was a strong predictor for GOS in both groups.

[Collaboration of general surgeons with neurosurgeons: what does a general surgeon need to know about neurosurgery?]. / Zusammenarbeit der Neurochirurgie mit der Allgemeinchirurgie: Was muss der Allgemeinchirurg von der Neurochirurgie wissen?

BACKGROUND: The most freq+uent disorders and injuries requiring the joint attention of general surgeons and neurosurgeons are presented and analysed in this review. METHODS: The priorities and prognosis concerning diagnostic and surgical measures for patients in coma with multiple injuries, extra- and intraspinal tumours and brain metastases are analysed. RESULTS: The urgency of general surgical and neurosurgical measures is not ruled by a preformatted pattern but by the vital needs of the individual patient. CONCLUSION: The differentiation of vital from non-vital operations or with regard to prognosis necessary from inadequate general surgical and neurosurgical measures is of fundamental importance. The successive order of general surgical and neurosurgical interventions must be adjusted to the needs of each individual patient.

The prognostic reliability of the Glasgow coma score in traumatic brain injuries: evaluation of MRI data.

PURPOSE: To clarify the predictive power of the Glasgow coma score (GCS) after traumatic brain injury (TBI) and in the context of brain stem lesions. METHODS: In 143 patients who had suffered severe TBI, the GCS was correlated to brain damage as visualized by cranial magnetic resonance imaging (MRI). This technique evaluates the damage to the brain stem in particular. The Brussels coma score (BCS) was also used. RESULTS: The GCS was not significantly correlated to brain stem lesions when it was only scored at the time of admission. When MRI was not used later on, the GCS showed a poor ability to predict the outcome. After 24 h, and on the day of MRI screening, the GCS was significantly correlated with two parameters: outcome (the higher the GCS, the better the outcome) and the frequency of patients without injuries to the brainstem in MRI (the higher the GCS, the higher this frequency). These correlations were much more evident when the BCS was used. The prognostic power of the GCS was found to vary over time; for example: a GCS of 3 at admission was associated with a favorable prognosis; a GCS of 4 signified a poor prognosis, irrespective of the time point at which the GCS was scored; and the prognostic power of a GCS of 5 deteriorated from the day of the MRI onwards, whereas the prognostic power of a GCS of 6 or 7 varied little over time. CONCLUSIONS: We only recommend the use of the GCS for prognostic evaluation in a multidimensional model. Study protocols should contain additional brain stem function parameters (BCS, pupil condition, MRI).

[Injuries to the upper cervical medulla in severe brain injuries]. / Verletzungen des oberen zervikalen Myelons beim schweren Schädel-Hirn-Trauma.

BACKGROUND: Cranial magnetic resonance imaging (MRI) was performed in 250 patients who had been unconscious post-trauma for at least 24 hours. The frequency and the characteristics of injuries to the upper cervical myelon were determined. PATIENTS AND METHODS: Between 1996 and 2009, MRI was carried out within 8 days of trauma. RESULTS: No lesions of the upper cervical medulla were found without accompanying damage to the medulla oblongata. Two groups were found to have a lesion in the upper cervical myelon. (i) In 3.2 % of the patients in a state of deep coma MRI revealed lesions in the entire brain stem. These died without waking from coma. (ii) 2 % of the patients were found to have additional damage to the distal medulla oblongata. These victims of high-speed traumas awoke from coma after 2-3 days. They revealed frontal contusions of the brain and traumatic subarachnoidal hemorrhages. Injuries to the bony upper cervical spine and/or the skull base were frequent. Four of them died, one patient survived with severe disabilities. CONCLUSION: Two types of lesions involving the upper cervical myelon could be differentiated, both of which occur only in association with lesions in the medulla oblongata.

[Predictive quality of the injury severity score in the systematic use of cranial MRI]. / Prädiktorqualität des Injury Severity Score bei systematischem Einsatz der kraniellen Kernspintomografie.

AIM: The ABBREVIATED INJURY SCORE (AIS) for the head is mostly coded on the basis of cranial computed tomography (CT). It defines, to a large extent, the predictive potency of the INJURY SEVERITY SCORE (ISS). The present study investigates whether the predictive capacity of the ISS can be improved by the systematic use of data from cranial MRI. METHOD: 167 patients, who had been in a coma for at least 24 hours following trauma, underwent an MRI examination within 8 days. All had been found to have an intracranial injury on initial CT. 49 % had also suffered extracranial injuries. The GLASGOW OUTCOME SCALE (GOS) was determined 6 months post trauma. AIS, ISS and GOS values were rated as ordinal measurements. A contingency table was used as the statistical method of analysis, with a significance assumed as p < 0.05 (Chi (2) test). RESULTS: The median ISS based on CT was 16 and did not correlate with the GOS. 63 % of the patients revealed brain stem lesions on MRI. If these were coded with an AIS of 5, the median ISS increased significantly to 29. Thus, the correlation to the GOS was now significant. At ISS scores of 5-9, 18 % of the patients died; at scores of 50-54 the rate of favourable treatment outcomes still amounted to 50 %. Since it is now known that brain stem lesions can also have a favourable prognosis, the AIS coding was modified and adapted to the mortality of the singular types of lesion. Hence the median ISS again decreased to 16. The correlation to the GOS was significant, and the predictive potency of the ISS further improved. The prognostic potency of the REVISED INJURY SEVERITY CLASSIFICATION (RISC) score was improved by use of adapted MRI data. CONCLUSION: If visible brain stem lesions on MRI were coded according to the AIS guidelines, there was a significant increase in the ISS which correlated significantly to the GOS. If the AIS coding was adjusted to the prognostic significance of individual brain stem lesions, there was a further improvement in the prognostic potency of the ISS. The study encourages the inclusion of data obtained from MRI diagnostics in the ISS calculation. There are alternative ways.

[Cranial magnetic resonance imaging and serum marker S-100 for expert opinions in severe brain injuries]. / Kranielle Kernspintomographie und S-100 Serumdiagnostik in der Begut- achtung schwerer Schädelhirntraumen.

Detailed imaging of the brain is necessary to come to an expert opinion on the consequences of severe brain injuries (BI). As lesions are not visualised on computerised tomography, magnetic resonance imaging (MRI) data and serum marker S-100 are currently favoured. Our study analyses the predictive qualities of MRI and S-100 for the outcome in severe BI in 100 patients. The location of brain stem lesions identified with the aid of MRI significantly correlated with the outcome. Special types of brain stem lesions could be distinguished. S-100 was a rough measure for the amount of destruction of CNS tissue, but the exact location of the destroyed tissue appeared to be more significantly related with the outcome than its volume. For an expert opinion on severe BI, follow up MRI after brain injury can definitely not exclude relevant lesions. Early MRI is recommended.

Evidence-based indications for ICP recording after head injury. A review.

The indication for invasive intracranial pressure (ICP) recording in comatose patients after head injury is a matter of discussion. In this review the evidence-based data are analysed. Monitoring appears useful especially in sedated patients, but there is no study which provides evidence of its overall benefit for the patient. The decision for or against ICP monitoring must therefore be based on weighing the potential benefits versus the risk for the individual patient according to the personal experience and judgement of the attending neurosurgeon.

Precursor T-lymphoblastic lymphoma within a recurrent pituitary adenoma.

Only single examples of lymphoma associated with pituitary adenoma have been reported. In our patient, a precursor T-lymphoblastic lymphoma developed within a recurrent pituitary adenoma 17 years after the first resection. Histomorphologically, lymphoma and adenoma components were tightly admixed. The features harbour remarkable similarity to the previous report by Kuhn et al.. In both patients the lymphomas were composed of T-cells, there was no evidence of further sites involved, and both adenomas expressed follicle-stimulating hormone. The hormone may have posed a proliferative and transforming effect on lymphatic cells and could have played a crucial role in "lymphomagenesis" as an exceptional phenomenon.

The predictive value of ICP as compared to magnetic resonance imaging in comatose patients after head injury.

INTRODUCTION: While highly increased intracranial pressure (ICP) is of high predictive value indicating a fatal outcome, the predictive value of moderately increased ICP early after head injury remains uncertain. We compared the predictive value of ICP to the predictive value of magnetic resonance imaging (MRI) early after head injury. METHODS: 55 patients with a Glasgow Coma Scale (GCS) of less than 8, for more than 24 hours after head injury were investigated. Outcome was classified according to the Glasgow Outcome Scale (GOS). All patients received registration of ICP upon arrival at the hospital and an initial cranial computerized tomography scan. An MRI study was subsequently performed within 10 days of admission. The highest mean ICP registered within one hour in the first day of admission and the location of lesions as identified by MRI were related with outcome. RESULTS: ICP was neither related with mortality nor with GOS of survivors. The location of lesions as depicted by MRI proved to be statistically significantly related with the GOS (p < 0.001). Age proved to be clearly and significantly related with outcome (p = 0.019). CONCLUSIONS: Our current MRI findings suggest that the location of the initial brain injury lesion correlates with outcome at 6 months. No such correlation could be identified for intracranial pressure on the first day after head injury (p = 0.766).

Early experiences with cervical disc prostheses.

UNLABELLED: The standard cervical disc surgery includes removal of the disc and fusion using an anterior approach. The loss of motion associated with fusion has prompted a search for other options. Early experiences and results after implantation of disc prostheses allowing for biomechanical motion of healthy discs are evaluated in this study. PATIENTS AND METHODS: 51 prostheses were implanted in 50 patients using an anterior approach. Follow-up ranged from one month to 14 months. RESULTS: The only significant complications were haemorrhages in two cases requiring surgical removal but otherwise all patients had an uneventful recovery. No infection or dislocation of the implants or formation of new spondylophytes have been noted yet. Resolution of pain and neurological disorders were excellent with a back-to-work rate of 80 % at three months after surgery. CONCLUSION: As the implantation of cervical disc prostheses carries no obvious risk higher than the risk of conventional anterior fusion, further analysis of its practicability and long-term outcome is recommended.

Pitfalls in surgery of meningeomas of the free tentorial edge.

Clinical experiences from 15 meningeomas located on the free edge of the tentorium are reported. Unexpected findings and complications found in five patients are presented in detail: Despite successful removal without postoperative morbidity after a presigmoid approach the preoperative loss of function of the ophthalmic nerve may cause increasing keratitis, which may result in blindness over the years after surgery. Before a presigmoid approach is performed, angiography or magnetic resonance angiography is advised, because the patient may have only one sigmoid sinus on the tumor side. An acute subdural hematoma as a complication of surgery may not only occur after, but also during surgery with the patient in the semi-sitting position. When a space occupying tumor of the tentorium is discovered, there may be an additional spinal one. If total removal of an extensive tumor of the free edge of the tentorium appears too hazardous, a two-stage strategy with a one year interval may lead to success.

Pineal epidermoid coinciding with pineocytoma.

Tumours of the pineal region are uncommon. We report on a 62-year-old male presenting with Parinaud's syndrome and aqueduct stenosis caused by a cystic tumour in the pineal region. During surgery, adjacent to the cystic tumour, a second smaller tumour was identified, which was clearly separate from the first tumour and from the pineal gland. Histological examination disclosed the cystic tumour as an epidermoid cyst, whereas the second tumour demonstrated histological and immunohistochemical features of a pineocytoma. The unique finding of two different types of tumours in the pineal region is evaluated with regard to the histogenesis of epidermoid cysts and pineocytomas.

[Optimized image processing with modified preprocessing of image data sets of a transparent imaging plate by way of the lateral view of the cervical spine]. / Optimierte Bildverarbeitung durch ein modifiziertes Pre-Processing von Bilddatensätzen eines transparenten Speicherfoliensystems am Beispiel der seitlichen HWS-Aufnahme.

PURPOSE: To improve the diagnostic quality of lateral radiographs of the cervical spine by pre-processing the image data sets produced by a transparent imaging plate with both-side reading and to evaluate any possible impact on minimizing the number of additional radiographs and supplementary investigations. MATERIAL AND METHODS: One hundred lateral digital radiographs of the cervical spine were processed with two different methods: processing of each data set using the system-imminent parameters and using the manual mode. The difference between the two types of processing is the level of the latitude value. Hard copies of the processed images were judged by five radiologists and three neurosurgeons. The evaluation applied the image criteria score (ICS) without conventional reference images. RESULTS: In 99 % of the lateral radiographs of the cervical spine, all vertebral bodies could be completed delineated using the manual mode, but only 76 % oft the images processed by the system-imminent parameters showed all vertebral bodies. Thus, the manual mode enabled the evaluation of up to two additional more caudal vertebral bodies. The manual mode processing was significantly better concerning object size and processing artifacts. This optimized image processing and the resultant minimization of supplementary investigations was calculated to correspond to a theoretical dose reduction of about 50 %. CONCLUSION: The introduction of optimized organ programs for the upper and lower cervical spine based on the 12-bit data of the images should improve the evaluation of the lateral radiograph of the cervical spine without reducing the latitude value.