Use of complementary therapies and supportive measures of patients with intracranial gliomas-a prospective evaluation in an outpatient clinic.

PURPOSE: Patients with intracranial gliomas frequently seek for complementary and alternative medicine (CAM), in addition to guideline-directed therapy. In this study, we therefore assessed patients' information needs regarding treatment and support, and evaluated their attitudes toward experimental trials and alternative therapies. METHODS: A prospective, cross-sectional, descriptive survey was conducted in our center. We developed an interview focusing on how patients obtain further information about therapy and the use of alternative/complementary therapies. RESULTS: A total of 102 patients participated in the survey. 50% (n = 51) of patients reported that they had not attempted any additional therapies. When patients attempted self-therapy, it was most commonly in the areas of nutrition (25%, n = 26) and dietary supplements (17%, n = 17). Alternative or complementary therapies were used by 14% (n = 14) of the patients. Younger age (Odds ratio (OR) 0.96 (95% Confidence interval (CI) 0.92-0.99, p = 0.012) and tumor entity (OR 5.01 (95% CI 1.66-15.11, p = 0.004) for grade 4 vs. 3 tumors and OR 7.22 (95% CI 1.99-26.28) for grade 4 vs. other tumors p = 0.003) were significantly associated with a greater interest in CAM. CONCLUSIONS: Interest in complementary and alternative medicine, as well as nutrition and dietary supplements is high (51%) among glioma patients, and significantly higher among younger patients and those with a worse diagnosis (WHO grade 4). A comprehensive approach to information, including paramedical topics, is needed to provide optimal patient counseling and care for glioma patients.

Influence of Blood Components on Neuroinflammation, Blood-Brain Barrier Breakdown, and Functional Damage After Acute Subdural Hematoma in Rats.

A central component of injury development after acute subdural hematoma (ASDH) is the increased intracranial pressure and consecutive mechanical reduction of cerebral blood flow (CBF). However, the role of different blood constituents in ASDH as additional lesioning factors remains unclear. This study examines the influence of blood components on neuroinflammation, blood-brain barrier (BBB) breakdown, and functional deficits in a rat model of ASDH. We infused corpuscular (whole blood, whole blood lysate, and red cell blood) and plasmatic (blood plasma, anticoagulated blood plasma, and aqueous isotonic solution) blood components into the subdural space while CBF was monitored. Rats then underwent behavioral testing. Lesion analysis and immunohistochemistry were performed 2 days after ASDH. Inflammatory reaction was assessed using staining for ionized calcium-binding adaptor molecule 1 and glial fibrillary acidic protein, interleukin-1ß, tumor necrosis factor-alpha, and membrane attack complex. Integrity of the BBB was evaluated with albumin and matrix metalloproteinase 9 (MMP9) staining. We observed a significant drop in CBF in the corpuscular group (75% ± 7.5% of baseline) with distinct post-operative deficits and larger lesion volume compared to the plasmatic group (13.6 ± 5.4 vs. 1.3 ± 0.4 mm3). Further, inflammation was significantly increased in the corpuscular group with stronger immunoreaction. After whole blood infusion, albumin and MMP9 immunoreaction were significantly increased, pointing toward a disrupted BBB. The interaction between corpuscular and plasmatic blood components seems to be a key factor in the detrimental impact of ASDH. This interaction results in neuroinflammation and BBB leakage. These findings underscore the importance of performing surgery as early as possible and also provide indications for potential pharmacological targets.

Treatment outcome of IDH1/2 wildtype CNS WHO grade 4 glioma histologically diagnosed as WHO grade II or III astrocytomas.

BACKGROUND: Isocitrate dehydrogenase (IDH)1/2 wildtype (wt) astrocytomas formerly classified as WHO grade II or III have significantly shorter PFS and OS than IDH mutated WHO grade 2 and 3 gliomas leading to a classification as CNS WHO grade 4. It is the aim of this study to evaluate differences in the treatment-related clinical course of these tumors as they are largely unknown. METHODS: Patients undergoing surgery (between 2016-2019 in six neurosurgical departments) for a histologically diagnosed WHO grade 2-3 IDH1/2-wt astrocytoma were retrospectively reviewed to assess progression free survival (PFS), overall survival (OS), and prognostic factors. RESULTS: This multi-center study included 157 patients (mean age 58 years (20-87 years); with 36.9% females). The predominant histology was anaplastic astrocytoma WHO grade 3 (78.3%), followed by diffuse astrocytoma WHO grade 2 (21.7%). Gross total resection (GTR) was achieved in 37.6%, subtotal resection (STR) in 28.7%, and biopsy was performed in 33.8%. The median PFS (12.5 months) and OS (27.0 months) did not differ between WHO grades. Both, GTR and STR significantly increased PFS (P < 0.01) and OS (P < 0.001) compared to biopsy. Treatment according to Stupp protocol was not associated with longer OS or PFS compared to chemotherapy or radiotherapy alone. EGFR amplification (P = 0.014) and TERT-promotor mutation (P = 0.042) were associated with shortened OS. MGMT-promoter methylation had no influence on treatment response. CONCLUSIONS: WHO grade 2 and 3 IDH1/2 wt astrocytomas, treated according to the same treatment protocols, have a similar OS. Age, extent of resection, and strong EGFR expression were the most important treatment related prognostic factors.

Swiss trial of decompressive craniectomy versus best medical treatment of spontaneous supratentorial intracerebral haemorrhage (SWITCH): an international, multicentre, randomised-controlled, two-arm, assessor-blinded trial.

RATIONALE: Decompressive craniectomy (DC) is beneficial in people with malignant middle cerebral artery infarction. Whether DC improves outcome in spontaneous intracerebral haemorrhage (ICH) is unknown. AIM: To determine whether DC without haematoma evacuation plus best medical treatment (BMT) in people with ICH decreases the risk of death or dependence at 6 months compared to BMT alone. METHODS AND DESIGN: SWITCH is an international, multicentre, randomised (1:1), two-arm, open-label, assessor-blinded trial. Key inclusion criteria are age ⩽75 years, stroke due to basal ganglia or thalamic ICH that may extend into cerebral lobes, ventricles or subarachnoid space, Glasgow coma scale of 8-13, NIHSS score of 10-30 and ICH volume of 30-100 mL. Randomisation must be performed <66 h after onset and DC <6 h after randomisation. Both groups will receive BMT. Participants randomised to the treatment group will receive DC of at least 12 cm in diameter according to institutional standards. SAMPLE SIZE: A sample of 300 participants randomised 1:1 to DC plus BMT versus BMT alone provides over 85% power at a two-sided alpha-level of 0.05 to detect a relative risk reduction of 33% using a chi-squared test. OUTCOMES: The primary outcome is the composite of death or dependence, defined as modified Rankin scale score 5-6 at 6 months. Secondary outcomes include death, functional status, quality of life and complications at 180 days and 12 months. DISCUSSION: SWITCH will inform physicians about the outcomes of DC plus BMT in people with spontaneous deep ICH, compared to BMT alone. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02258919.

Vagus nerve stimulation for the treatment of narcolepsy.

BACKGROUND AND OBJECTIVE: No study on neurostimulation in narcolepsy is available until now. Arousal- and wake-promoting effects of vagus nerve stimulation (VNS) have been demonstrated in animal experiments and are well-known as side effects of VNS therapy in epilepsy and depression. The objective was to evaluate the therapeutic effect of VNS on daily sleepiness and cataplexies in narcolepsy. METHODS: In our open-label prospective comparative study, we included narcolepsy patients who were treated with VNS because of depression or epilepsy and compared them to controls without narcolepsy treated with VNS for depression or epilepsy (18 patients in each group, aged 31.5 ± 8.2 years). We evaluated daily sleepiness (Epworth Sleepiness Scale, ESS) and the number of cataplexies per week before the implantation of VNS and at three and six month follow-ups. RESULTS: Compared to baseline (ESS: 15.9 ± 2.5) patients with narcolepsy showed a significant improvement on ESS after three months (11.2 ± 3.3, p < 0.05) and six months (9.6 ± 2.8, p < 0.001) and a trend to reduction of cataplexies. No significant ESS-improvement was observed in patients without narcolepsy (14.9 ± 3.9, 13.6 ± 3.7, 13.2 ± 3.5, p = 0.2 at baseline, three and six months, correspondingly). Side effects did not differ between the study groups. CONCLUSION: In this first evaluation of VNS in narcolepsy, we found a significant improvement of daily sleepiness due to this type of neurostimulation. VNS could be a promising non-medical treatment in narcolepsy.

Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms-A Global Multicenter Investigation of Perioperative Outcomes.

BACKGROUND AND OBJECTIVES: Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms. METHODS: Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics. RESULTS: Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers. CONCLUSION: Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

Favorable combinations of antiseizure medication with vagus nerve stimulation to improve health-related quality of life in patients with epilepsy.

BACKGROUND: Vagus nerve stimulation (VNS) is a non-pharmacological treatment of refractory epilepsy, which also has an antidepressive effect. The favorable combinations of VNS with specific mechanisms of action of antiseizure medication (ASM) on mood and health-related quality of life (HrQol) have not yet been studied. The objective was to identify favourable combinations of specific ASMs with VNS for the HrQoL and depression in refractory epilepsy. METHODS: We performed an observational study including patients with refractory epilepsy and an implanted VNS (N = 151). In the first 24 months after VNS implantation, all patients were on stable ASM therapy. We used the standardized questionnaires QOLIE10, EQVAS and EQ5D to evaluate HrQoL as well as the Beck Depression Inventory (BDI). Multiple regression analysis was performed to evaluate the synergistic combinations of ASM with VNS for HrQoL. RESULTS: At the year-two follow-up (N = 151, age 45.2 ± 17.0 years), significant improvement (p < 0.05) in BDI scores was found for combination of VNS with SV2A modulators (58.4 %) or AMPA antagonists (44.4 %). A significant increase of HrQoL by at least 30 % (p < 0.05) was measured for a combination of VNS with SV2A modulators (brivaracetam, levetiracetam) or slow sodium channel inhibitors (eslicarbazepine, lacosamide). CONCLUSION: The results of our study suggests a favorable effect of the combination of SV2A modulators or slow sodium channel inhibitors with VNS on the HrQoL in comparison to other ASMs. Besides the possible synergistic effects on the seizure frequency, the amelioration of behavioral side effects of SV2A modulators by VNS is an important factor of HrQoL-improvement in these combinations.

Radiotherapy concepts for spinal metastases-results from an online survey among radiation oncologists of the German Society for Radiation Oncology.

PURPOSE: Spinal metastases (SM) are a common radiotherapy (RT) indication. There is limited level I data to drive decision making regarding dose regimen (DR) and target volume definition (TVD). We aim to depict the patterns of care for RT of SM among German Society for Radiation Oncology (DEGRO) members. METHODS: An online survey on conventional RT and Stereotactic Body Radiation Therapy (SBRT) for SM, distributed via e­mail to all DEGRO members, was completed by 80 radiation oncologists between February 24 and April 29, 2022. Participation was voluntary and anonymous. RESULTS: A variety of DR was frequently used for conventional RT (primary: n = 15, adjuvant: n = 14). 30 Gy/10 fractions was reported most frequently. TVD in adjuvant RT was heterogenous, with a trend towards larger volumes. SBRT was offered in 65% (primary) and 21% (adjuvant) of participants' institutions. A variety of DR was reported (primary: n = 40, adjuvant: n = 27), most commonly 27 Gy/3 fractions and 30 Gy/5 fractions. 59% followed International Consensus Guidelines (ICG) for TVD. CONCLUSION: We provide a representative depiction of RT practice for SM among DEGRO members. DR and TVD are heterogeneous. SBRT is not comprehensively practiced, especially in the adjuvant setting. Further research is needed to provide a solid data basis for detailed recommendations.

Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases.

BACKGROUND AND OBJECTIVES: Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA. METHODS: A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately. RESULTS: Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients. CONCLUSION: This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.

Comparison of Ultra-High-Resolution and Normal-Resolution CT-Angiography for Intracranial Aneurysm Detection in Patients with Subarachnoid Hemorrhage.

RATIONALE AND OBJECTIVES: Ruptured intracranial aneurysms (IAs) are the leading cause for atraumatic subarachnoid hemorrhage. In case of aneurysm rupture, patients may face life-threatening complications and require aneurysm occlusion. Detection of the aneurysm in computed tomography (CT) imaging is therefore essential for patient outcome. This study provides an evaluation of the diagnostic accuracy of Ultra-High-Resolution Computed Tomography Angiography (UHR-CTA) and Normal-Resolution Computed Tomography Angiography (NR-CTA) concerning IA detection and characterization. MATERIALS AND METHODS: Consecutive patients with atraumatic subarachnoid hemorrhage who received Digital Subtraction Angiography (DSA) and either UHR-CTA or NR-CTA were retrospectively included. Three readers evaluated CT-Angiography regarding image quality, diagnostic confidence and presence of IAs. Sensitivity and specificity were calculated on patient-level and segment-level with reference standard DSA-imaging. CTA patient radiation exposure (effective dose) was compared. RESULTS: One hundred and eight patients were identified (mean age = 57.8 ±â€¯14.1 years, 65 women). UHR-CTA revealed significantly higher image quality and diagnostic confidence (P < 0.001) for all readers and significantly lower effective dose (P < 0.001). Readers correctly classified ≥55/56 patients on UHR-CTA and ≥44/52 patients on NR-CTA. We noted significantly higher patient-level sensitivity for UHR-CTA compared to NR-CTA for all three readers (reader 1: 41/41 [100%] vs. 28/34 [82%], reader 2: 41/41 [100%] vs. 30/34 [88%], reader 3: 41/41 [100%] vs. 30/34 [88%], P ≤ 0.04). Segment-level analysis also revealed significantly higher sensitivity for UHR-CTA compared to NR-CTA for all three readers (reader 1: 47/49 [96%] vs. 34/45 [76%], reader 2: 47/49 [96%] vs. 37/45 [82%], reader 3: 48/49 [98%] vs. 37/45 [82%], P ≤ 0.04). Specificity was comparable for both techniques. CONCLUSION: We found Ultra-High-Resolution CT-Angiography to provide higher sensitivity than Normal-Resolution CT-Angiography for the detection of intracranial aneurysms in patients with aneurysmal subarachnoid hemorrhage while improving image quality and reducing patient radiation exposure.

Nuclear Glycoprotein A Repetitions Predominant (GARP) Is a Common Trait of Glioblastoma Stem-like Cells and Correlates with Poor Survival in Glioblastoma Patients.

Glioblastoma (GB) is notoriously resistant to therapy. GB genesis and progression are driven by glioblastoma stem-like cells (GSCs). One goal for improving treatment efficacy and patient outcomes is targeting GSCs. Currently, there are no universal markers for GSCs. Glycoprotein A repetitions predominant (GARP), an anti-inflammatory protein expressed by activated regulatory T cells, was identified as a possible marker for GSCs. This study evaluated GARP for the detection of human GSCs utilizing a multidimensional experimental design that replicated several features of GB: (1) intratumoral heterogeneity, (2) cellular hierarchy (GSCs with varied degrees of self-renewal and differentiation), and (3) longitudinal GSC evolution during GB recurrence (GSCs from patient-matched newly diagnosed and recurrent GB). Our results indicate that GARP is expressed by GSCs across various cellular states and disease stages. GSCs with an increased GARP expression had reduced self-renewal but no alterations in proliferative capacity or differentiation commitment. Rather, GARP correlated inversely with the expression of GFAP and PDGFR-α, markers of astrocyte or oligodendrocyte differentiation. GARP had an abnormal nuclear localization (GARPNU+) in GSCs and was negatively associated with patient survival. The uniformity of GARP/GARPNU+ expression across different types of GSCs suggests a potential use of GARP as a marker to identify GSCs.

Current state of preoperative embolization for spinal metastasis - A survey by the EANS spine section.

Introduction: Preoperative embolization (PE) for spinal metastasis can be used to reduce tumor blood supply in selected patients. The decision whether and when to perform PE varies largely among spine surgeons and centers. Research question: The aim was to understand the current decision-making process in European spine centers. Material and methods: The European Association of Neurosurgical Societies (EANS) spine section designed a 13-item online survey. It was distributed to neurosurgical residents and board-certified neurosurgeons between 7th of February and May 5, 2023. Results: We analyzed 120 survey responses. Most participants were board-certified neurosurgeons (71%) or residents (26%) in university hospitals (76%). Routinely performed PE was stated not a common practice in 62%. Of those using PE, 25% indicated to perform it in selected cases requiring vertebral body replacement. Reasons for not performing PE included lack of time (44%), unclear benefits (25%), no significant bleeding without PE (19%), and significant bleeding despite PE (8%). Most participants opted for PE < 24h before surgery, but in a separate anesthesia (54%). More experienced participants were more likely to observe reduced blood loss (BL) after PE (p = 0.014). The most common reported complications were neurological deterioration due to spinal cord infarction (n = 15) and swelling due to tumor necrosis (n = 13). Discussion and conclusions: PE is still not a routine among European spine surgeons and is considered mostly for elective cases with hypervascularized tumors scheduled in a separate anesthesia <24h before tumor resection. Most participants noted reduced intraoperative BL, but also a risk of procedure-related complications.

Predictors of Neurological Worsening after Resection of Spinal Meningiomas.

BACKGROUND: Due to the slow-growing nature of spinal meningiomas, they are mostly asymptomatic for a long time, and become symptomatic after the compression of the spinal cord or nerve roots. The aim of this study was to identify predictors for a poor clinical outcome after the surgical resection of spinal meningiomas and thereby to allow a preoperative identification of high-risk spinal meningiomas. METHODS: Data acquisition was conducted as a single-center retrospective analysis. From 1 January 2004 to 31 December 2019, 121 patients who underwent surgical resection of a spinal meningioma were reviewed. Clinical and radiological data (such as tumor size, location, occupation ratio of the spinal canal, and the degree of spinal cord compression) were assessed. The functional clinical findings of the patients were recorded using the Karnofsky Performance Score, modified McCormick scale, and Frankel scale preoperatively, at discharge, and 3-6 months after surgery. RESULTS: The mean patient age was 66 ± 13 years. A total of 104 (86%) patients were female and 17 (14%) were male. The thoracic spine (68%) was the most common location, followed by the cervical (29%) and lumbar (3%) spine. Preoperatively, 11.7% of patients were categorized as McCormick 1, 35.8% as 2, 39.2% as 3, 11.7% as 4, and 1.7% as 5. The neurological function of the patients with a functional deficit prior to surgery improved in 46% of the patients, remained unchanged in 52%, and worsened in 2% at discharge. At early follow-up, the proportions were 54%, 28%, and 5%, respectively. Preoperative Frankel scale was a significant predictor of a postoperative deterioration. Patients with Frankel score A to C preoperatively had a 9.2 times higher chance of clinical deterioration postoperatively (OR = 9.16). We found that the Frankel scale weakly correlated with the degree of spinal cord compression. In this study, other radiological parameters, such as the degree of cord compression and spinal canal occupation ratio, did not show a significant effect on the outcome. CONCLUSIONS: Surgery of intraspinal meningiomas can be considered safe. Neurological function improves in a large proportion of patients after surgery. However, a relevant preoperative deficit according to the Frankel scale (grade A-C) was a significant predictor of a postoperative neurological deterioration.

Epidemiological trends of pyogenic spondylodiscitis in Germany: an EANS Spine Section Study.

Pyogenic spondylodiscitis presents significant diagnostic and therapeutic challenges. In Germany, a comprehensive understanding of its epidemiology and inpatient management outcomes is limited, hindering the optimisation of therapeutic strategies. This study aimed to characterise the evolving epidemiological trends of pyogenic spondylodiscitis in Germany, and concurrently evaluate inpatient management strategies and outcomes. We performed a retrospective population-based study of spondylodiscitis cases in Germany from 2005 to 2021, utilising data from the German Federal Statistical Office database. The parameters assessed were incidence trends, demographic characteristics, inpatient management strategies, and inpatient mortality. The study found a significant rise in the population-adjusted incidence of spondylodiscitis in Germany from 2005 to 2021, increasing by 104% from 5.4 to 11.0 cases per 100,000 individuals (p < 0.001). The highest number of diagnoses was recorded in 2019. Age group-adjusted data revealed the largest relative changes in the "90 + " age group, followed by the "80-89" and "70-79" age groups. These increases were not solely attributable to population changes but were also confirmed after calculating the age-group-adjusted incidence rates. Additionally, our statistical analysis demonstrated that both age and year significantly influenced the incidence of spondylodiscitis. Over the same period, inpatient mortality also surged significantly by 347% (p < 0.001), with the highest increase recorded in the 90 + age group, observing a 2450% rise (p < 0.001). The mean length of inpatient stay decreased by 15% (p < 0.05). Concurrently, there was a significant increase in surgical interventions using spinal stabilisation procedures (p < 0.001), which might suggest a shift in the treatment paradigm for spondylodiscitis. The results underscore a concerning rise in spondylodiscitis incidence and mortality in Germany, particularly affecting the ageing population. A notable shift towards surgical intervention was observed. The data highlights the urgent necessity for high-level evidence studies comparing surgical versus conservative treatment, thereby guiding optimised therapeutic strategies.

Conservative versus early surgical treatment in the management of pyogenic spondylodiscitis: a systematic review and meta-analysis.

Spondylodiscitis is the commonest spine infection, and pyogenic spondylodiscitis is the most common subtype. Whilst antibiotic therapy is the mainstay of treatment, some advocate that early surgery can improve mortality, relapse rates, and length of stay. Given that the condition carries a high mortality rate of up to 20%, the most effective treatment must be identified. We aimed to compare the mortality, relapse rate, and length of hospital stay of conservative versus early surgical treatment of pyogenic spondylodiscitis. All major databases were searched for original studies, which were evaluated using a qualitative synthesis, meta-analyses, influence, and regression analyses. The meta-analysis, with an overall pooled sample size of 10,954 patients from 21 studies, found that the pooled mortality among the early surgery patient subgroup was 8% versus 13% for patients treated conservatively. The mean proportion of relapse/failure among the early surgery subgroup was 15% versus 21% for the conservative treatment subgroup. Further, it concluded that early surgical treatment, when compared to conservative management, is associated with a 40% and 39% risk reduction in relapse/failure rate and mortality rate, respectively, and a 7.75 days per patient reduction in length of hospital stay (p < 0.01). The meta-analysis demonstrated that early surgical intervention consistently significantly outperforms conservative management in relapse/failure and mortality rates, and length of stay, in patients with pyogenic spondylodiscitis.

Impact of pre-hospital handling and initial time to cranial computed tomography on outcome in aneurysmal subarachnoid hemorrhage patients with out-of-hospital sudden cardiac arrest-a retrospective bi-centric study.

Background: Aneurysmal subarachnoid hemorrhage (SAH) presents occasionally with cardiac arrest (CA). The impact of pre-hospital and emergency room (ER) treatment on outcome remains unclear. Therefore, we investigated the impact of pre-hospital treatment, focusing on lay cardiopulmonary resuscitation (CPR), and ER handling on the outcome of SAH patients with out-of-hospital CA (OHCA). Methods: In this bi-centric retrospective analysis, we reviewed SAH databases for OHCA and CPR from January 2011 to June 2021. Patients were analyzed for general clinical and epidemiological parameters. CPR data were obtained from ambulance reports and information on ER handling from the medical records. Data were correlated with patient survival at hospital discharge as a predefined outcome parameter. Results: Of 1,120 patients with SAH, 45 (4.0%) were identified with OHCA and CPR, 38 of whom provided all required information and were included in this study. Time to resuscitation was significantly shorter with lay resuscitation (5.3 ± 5.2 min vs. 0.3 ± 1.2 min, p = 0.003). Nineteen patients were not initially scheduled for cranial computed tomography (CCT), resulting in a significantly longer time interval to first CCT (mean ± SD: 154 ± 217 min vs. 40 ± 23 min; p < 0.001). Overall survival to discharge was 31.6%. Pre-hospital lay CPR was not associated with higher survival (p = 0.632). However, we observed a shorter time to first CCT in surviving patients (p = 0.065). Conclusions: OHCA in SAH patients is not uncommon. Besides high-quality CPR, time to diagnosis of SAH appears to play an important role. We therefore recommend considering CCT diagnostics as part of the diagnostic algorithm in patients with OHCA.

Early Onset of Rapid Lesion Growth in an Acute Subdural Hematoma Model in Rats.

OBJECTIVE: Acute subdural hematoma (ASDH) leads to the highest mortality rates of all head injuries with secondary brain damage playing a pivotal role in terms of morbidity and mortality. In patients with ASDH, a delay in surgery leads to disproportional mortality. The benefit of (very) early therapy is therefore, a target of ongoing research. As the process of delayed brain damage in ASDH has not yet been described, this study therefore aimed to examine secondary lesion growth in an experimental rat model of ASDH to define the ideal timing for testing potential neuroprotective therapies. METHODS: Cerebral blood flow was monitored during ASDH induction with 300 µl of autologous blood. Lesion growth was characterized using Hematoxylin-Eosin- , Cresyl-Violet-, and Fluoro-Jade B-staining for early signs of neuronal degeneration. Histological evaluations were performed between 15 minutes and 24 hours after ASDH. RESULTS: There was a significant reduction of cerebral blood flow after ASDH. Fluoro-Jade B-positive cells were visible 15 minutes after ASDH in the lesioned hemisphere. Nonlinear growth of lesion volume from 3.7 ± 0.4 mm3 to 17.5 ± 0.6 mm3 was observed at 24 hours in Hematoxylin-Eosin-staining. CONCLUSIONS: The most damage develops between 15 minutes and 1 hour and again between 2 and 6 hours after ASDH. The time course of lesion growth supports the approach of early surgery for patients. It furthermore constitutes a basis for further ASDH research with more clearly defined time windows for therapy in animal models.

Retrospective evaluation of percutaneous 3D-navigated screw fixation for fragility fractures of the sacrum: technical notes and four-year experience.

The incidence of fragility fractures of the sacrum is increasing due to demographic changes. In this study, we introduce the 3D-navigated monoportal percutaneous sacroiliac screw fixation (PSS) as a technical advancement for treating fragility fractures of the sacrum. We included all patients who underwent the 3D-navigated monoportal PSS for fragility fractures of the sacrum. The fractures were classified using the Fragility Fractures of the Pelvis score (FFP). We provide a step-by-step illustration of the surgical technique. The objective of this study was to assess the feasibility and safety of the investigated technique. Forty-six patients (36 female, 10 male) with a median age of 81.5 years were included in the study. The fracture classification revealed 23 FFP2 (50%), 5 FFP3 (11%), and 18 FFP4 (39%) fractures. In 35 cases (76%), only transsacral screws were implanted in S1 and S2, with an average incision-to-suture time of 52.6 min. The remaining eleven patients underwent additional anterior pelvic ring fixation, lumbar instrumentation, or kyphoplasty. There were no instances of nerve root, vascular, or pelvic organ injuries. The median postoperative in-hospital stay was six days. Out of the 36 patients who were followed up, four patients required revision surgery due to screw loosening. No significant risk factor for screw loosening was identified in the multiple regression analysis. The presented monoportal PSS technique for fragility fractures of the sacrum is a promising minimally invasive approach with a low complication rate and excellent short-term outcomes.

How do spine surgeons cope with psychological distress: results of a cross-sectional study.

Cross Sectional Study/Online Survey. In this study, we sought to assess stress, psychological distress, resilience, and coping strategies among spine surgeons in German-speaking countries. Recent studies have reported high rates of stress and burnout among surgeons. A survey via Survey Monkey™ was conducted among spine surgeons practicing in German-speaking countries using validated questionnaires for perceived stress, mental burden, resilience, and quality of life. Data on working situation and demographics were also collected. 582 surgeons responded to the survey, representing 15% of those surveyed. 79% of respondents were satisfied with their professional success. Mental burden was higher than in the general population, as was perceived stress. Chairpersons were exposed to the lowest levels of perceived stress and mental burden. Mental distress was high (GHQ ≥ 12) in 59% of residents and 27% chairpersons. Self-reported psychological resilience was higher than levels found in the general population and highest among chairpersons. Quality of life was comparable to levels reported in the general population. There were statistically significant correlations between perceived stress and mental burden scores (r s = 0.65, p < 0.001). Career level (senior physicians vs. residents, OR 0.26; 95% CI 0.10-0.66), perceived stress (OR 1.54; 95% CI 1.33-1.77), self-reported resilience (OR 0.53; 95% CI 0.33-0.84), and mental composite score (SOR 0.86; 95% CI 0.83-0.90) were predictors of high mental burden. There was no interaction between perceived stress and resilience on mental burden (p = 0.835). Spine surgeons are exposed to higher levels of stress than the general population, which are associated with higher mental distress. More professional experience and higher levels of psychological resilience are associated with lower levels of stress.