PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial: study protocol for a randomized controlled trial.

BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is associated with poor neurological outcome and high mortality. A major factor influencing morbidity and mortality is brain swelling in the acute phase. Decompressive craniectomy (DC) is currently used as an option in order to reduce intractably elevated intracranial pressure (ICP). However, execution and optimal timing of DC remain unclear. METHODS: PICASSO resembles a multicentric, prospective, 1:1 randomized standard treatment-controlled trial which analyzes whether primary DC (pDC) performed within 24 h combined with the best medical treatment in patients with poor-grade SAH reduces mortality and severe disability in comparison to best medical treatment alone and secondary craniectomy as ultima ratio therapy for elevated ICP. Consecutive patients presenting with poor-grade SAH, defined as grade 4-5 according to the World Federation of Neurosurgical Societies (WFNS), will be screened for eligibility. Two hundred sixteen patients will be randomized to receive either pDC additional to best medical treatment or best medical treatment alone. The primary outcome is the clinical outcome according to the modified Rankin Scale (mRS) at 12 months, which is dichotomized to favorable (mRS 0-4) and unfavorable (mRS 5-6). Secondary outcomes include morbidity and mortality, time to death, length of intensive care unit (ICU) stay and hospital stay, quality of life, rate of secondary DC due to intractably elevated ICP, effect of size of DC on outcome, use of duraplasty, and complications of DC. DISCUSSION: This multicenter trial aims to generate the first confirmatory data in a controlled randomized fashion that pDC improves the outcome in a clinically relevant endpoint in poor-grade SAH patients. TRIAL REGISTRATION: DRKS DRKS00017650. Registered on 09 June 2019.

Endoscopic Assistance in the Deep and Narrow Spaces of the Brain-Microscopic Tumor Surgery Supported by the New Micro-Inspection Tool QEVO® (Technical Note).

Introduction: To evaluate the feasibility and efficacy of the innovative micro-inspection tool QEVO® (Carl Zeiss Meditec, Oberkochen, Germany) as an endoscopic adjunct to microscopes for better visualization of the surgical field in complex deep-seated intracranial tumors in infants and adults. Materials and Methods: We retrospectively assessed the surgical videos of 25 consecutive patients with 26 complex intracranial lesions (time frame 2018-2020). Lesions were classified according to their anatomical area: 1 = sellar region (n = 6), 2 = intra-ventricular (except IV.ventricle, n = 9), 3 = IV.ventricle and rhomboid fossa (n = 4), and 4 = cerebellopontine angle (CPA) and foramen magnum (n = 7). Indications to use the QEVO® tool were divided into five "QEVO® categories": A = target localization, B = tailoring of the approach, C = looking beyond the lesion, D = resection control, and E = inspection of remote areas. Results: Overall, the most frequent indications for using the QEVO® tool were categories D (n = 19), C (n = 17), and E (n = 16). QEVO® categories B (n = 8) and A (n = 5) were mainly applied to intra-ventricular procedures (anatomical area 2). Discussion: The new micro-inspection tool QEVO® is a powerful endoscopic device to support the comprehensive visualization of complex intracranial lesions and thus instantly increases intraoperative morphological understanding. However, its use is restricted to the specific properties of the respective anatomical area.

Massively calcified aneurysm of the anterior communicating artery: an unsuccessful clipping attempt followed by successful pCONus2-assisted coil occlusion.

We report the unique case of a 67-year-old female patient with an incidentally discovered massively calcified aneurysm of the anterior communicating artery. After interdisciplinary discussion, we decided to attempt clipping the aneurysm because interventional therapy did not seem feasible and anchoring a stent would also have been difficult because of the morphology of the aneurysm. The clipping attempt was unsuccessful because of the aneurysm's massive calcification with strong adherence to the sphenoid planum. The aneurysm was then successfully occluded using pCONus 2-assisted coiling. We illustrate this and consecutive procedures, and we reviewed the literature on aneurysm calcification.

Application of the Endoscopic Micro-Inspection Tool QEVO® in the Surgical Treatment of Anterior Circulation Aneurysms-A Technical Note and Case Series.

Introduction: The application of neuro-endoscopes in cerebral aneurysm surgery may help to avoid unintended aneurysm remnants and the accidental clipping of perforating arteries and aid the detection of blood collecting in the subdural spaces. Here, we present our experience with the novel endoscopic micro-inspection tool QEVO® (Carl Zeiss Meditec, Germany) in aneurysm surgery. Materials and Equipment: In all patients the surgical microscope KINEVO® (Carl Zeiss Meditec, Germany) and the Microinspection tool QEVO® were applied. Methods: The case series comprises 22 unruptured cerebral aneurysms of the anterior circulation. All aneurysms were treated surgically. All patients routinely underwent computed tomography and digital subtraction angiography within 10 days after surgery. Results: No aneurysm remnants, cerebral ischemic deficits, or subdural hematomas were detected. Discussion: In this technical note, we discuss the benefits and limitations of the QEVO® tool and illustrate the major paradigms by means of intraoperative photographs.

Evaluation of robot-guided minimally invasive implantation of 2067 pedicle screws.

Objective Recent studies have investigated the role of spinal image guidance for pedicle screw placement. Many authors have observed an elevated placement accuracy and overall improvement of outcome measures. This study assessed a bi-institutional experience following introduction of the Renaissance miniature robot for spinal image guidance in Europe. Methods The medical records and radiographs of all patients who underwent robot-guided implantation of spinal instrumentation using the novel system (between October 2011 and March 2015 in Mainz and February 2014 and February 2016 in Regensburg) were reviewed to determine the efficacy and safety of the newly introduced robotic system. Screw position accuracy, complications, exposure durations to intraoperative radiation, and reoperation rate were assessed. Results Of the 413 surgeries that used robotic guidance, 406 were via a minimally invasive approach. In 7 cases the surgeon switched to conventional screw placement, using a midline approach, due to referencing problems. A total of 2067 screws were implanted using robotic guidance, and 1857 screws were evaluated by postoperative CT. Of the 1857 screws, 1799 (96.9%) were classified as having an acceptable or good position, whereas 38 screws (2%) showed deviations of 3-6 mm and 20 screws (1.1%) had deviations > 6 mm. Nine misplaced screws, implanted in 7 patients, required revision surgery, yielding a screw revision rate of 0.48% of the screws and 7 of 406 (1.7%) of the patients. The mean ± SD per-patient intraoperative fluoroscopy exposure was 114.4 (± 72.5) seconds for 5.1 screws on average and any further procedure required. Perioperative and direct postoperative complications included hemorrhage (2 patients, 0.49%) and wound infections necessitating surgical revision (20 patients, 4.9%). Conclusions The hexapod miniature robotic device proved to be a safe and robust instrument in all situations, including those in which patients were treated on an emergency basis. Placement accuracy was high; peri- and early postoperative complication rates were found to be lower than rates published in other series of percutaneous screw placement techniques. Intraoperative radiation exposure was found to be comparable to published values for other minimally invasive and conventional approaches.

Extent of Resection in Newly Diagnosed Glioblastoma: Impact of a Specialized Neuro-Oncology Care Center.

Treatment of glioblastoma (GBM) consists of microsurgical resection followed by concomitant radiochemotherapy and adjuvant chemotherapy. The best outcome regarding progression free (PFS) and overall survival (OS) is achieved by maximal resection. The foundation of a specialized neuro-oncology care center (NOC) has enabled the implementation of a large technical portfolio including functional imaging, awake craniotomy, PET scanning, fluorescence-guided resection, and integrated postsurgical therapy. This study analyzed whether the technically improved neurosurgical treatment structure yields a higher rate of complete resection, thus ultimately improving patient outcome. PATIENTS AND METHODS: The study included 149 patients treated surgically for newly diagnosed GBM. The neurological performance score (NPS) and the Karnofsky performance score (KPS) were measured before and after resection. The extent of resection (EOR) was volumetrically quantified. Patients were stratified into two subcohorts: treated before (A) and after (B) the foundation of the Regensburg NOC. The EOR and the PFS and OS were evaluated. RESULTS: Prognostic factors for PFS and OS were age, preoperative KPS, O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation status, isocitrate dehydrogenase 1 (IDH1) mutation status and EOR. Patients with volumetrically defined complete resection had significantly better PFS (9.4 vs. 7.8 months; p = 0.042) and OS (18.4 vs. 14.5 months; p = 0.005) than patients with incomplete resection. The frequency of transient or permanent postoperative neurological deficits was not higher after complete resection in both subcohorts. The frequency of complete resection was significantly higher in subcohort B than in subcohort A (68.2% vs. 34.8%; p = 0.007). Accordingly, subcohort B showed significantly longer PFS (8.6 vs. 7.5 months; p = 0.010) and OS (18.7 vs. 12.4 months; p = 0.001). Multivariate Cox regression analysis showed complete resection, age, preoperative KPS, and MGMT promoter status as independent prognostic factors for PFS and OS. Our data show a higher frequency of complete resection in patients with GBM after the establishment of a series of technical developments that resulted in significantly better PFS and OS without increasing surgery-related morbidity.

Arsenic Trioxide inhibits the growth of human ovarian carcinoma cell line.

OBJECTIVE: To determine whether Arsenic Trioxide may be an effective treatment of human ovarian carcinoma, we examined if it induced apoptosis in human ovarian cancer cell line. METHODS: The human ovarian cell line SKOV3 was exposed to different concentrations of As2O3: 0 (control), 0.1 microM, 1 microM, 5 microM and 10 microM. The effect on cells proliferation and apoptotic parameters was examined. RESULTS: The most effective inhibitory Arsenic Trioxide concentrations were 5 microM and 10 microM, causing growth inhibition of 79% and 83%, respectively. The maximum inhibitory effect of Arsenic Trioxide on cellular proliferation was seen after 48 h. No morphological or molecular features of apoptosis have been observed. At the same time, there were no typical changes of cellular necrosis. CONCLUSIONS: The exact mechanism by which Arsenic Trioxide inhibits the growth of ovarian cancer cells is probably not by apoptosis. However, since As2O3 has been shown to inhibit ovarian cancer cellular growth, it should be further elucidated as a possible chemotherapeutic agent of ovarian cancer.