The use of quantitative pupillometry in brain death determination: preliminary findings.

PURPOSE: Quantitative pupillometry (QP) has been increasingly applied in neurocritical care as an easy-to-use and reliable technique for evaluating the pupillary light reflex (PLR). Here, we report our preliminary findings on using QP for clinical brain death (BD) determination. MATERIALS: This retrospective study included 17 patients ≥ 18 years (mean age, 57.3 years; standard deviation, 15.8 years) with confirmed BD, as defined by German Guidelines for the determination of BD. The PLR was tested using the NPi®-200 Pupillometer (Neuroptics, Laguna Hill, USA), a handheld infrared device automatically tracking and analyzing pupil dynamics over 3 s. In addition, pupil diameter and neurological pupil index (NPi) were also evaluated. RESULTS: Intracerebral bleeding, subarachnoid hemorrhage, and hypoxic encephalopathy were the most prevalent causes of BD. In all patients, the NPi was 0 for both eyes, indicating the cessation of mid-brain function. The mean diameter was 4.9 mm (± 1.3) for the right pupil and 5.2 mm (±1.2) for the left pupil. CONCLUSIONS: QP is a valuable tool for the BD certification process to assess the loss of PLR due to the cessation of brain stem function. Furthermore, implementing QP before the withdrawal of life-sustaining therapy in brain-injured patients may reduce the rate of missed organ donation opportunities. Further studies are warranted to substantiate the feasibility and potential of this technique in treating patients and identify suitable candidates for this technique during the BD certification process.

Correlation of visual field deficits and q-ball high-resolution fiber tractography of the optic radiation for adjacently located intracerebral lesions: preliminary results from a single-center prospective study.

Visual field deficits (VFDs) are common in patients with temporal and occipital lobe lesions. Diffusion tensor fiber tractography (DTI-FT) is widely used for surgery planning to reduce VFDs. Q-ball high-resolution fiber tractography (QBI-HRFT) improves upon DTI. This study aims to evaluate the effectiveness of DTI-FT and QBI-HRFT for surgery planning near the optic radiation (OR) as well as the correlation between VFDs, the nearest distance from the lesion to the OR fiber bundle (nD-LOR), and the lesion volume (LV). This ongoing prospective clinical trial collects clinical and imaging data of patients with lesions in deterrent areas. The present subanalysis included eight patients with gliomas near the OR. Probabilistic HRFT based on QBI-FT and conventional DTI-FT were performed for OR reconstruction based on a standard diffusion-weighted magnetic resonance imaging sequence in clinical use. Quantitative analysis was used to evaluate the lesion volume (LV) and nD-LOR. VFDs were determined based on standardized automated perimetry. We included eight patients (mean age 51.7 years [standard deviation (SD) 9.5]) with lesions near the OR. Among them, five, two, and one patients had temporodorsal, occipital, and temporal lesions, respectively. Four patients had normal vision preoperatively, while four patients had preexisting VFD. QBI-FT analysis indicated that patients with VFD exhibited a significantly smaller median nD-LOR (mean, -4.5; range -7.0; -2.3) than patients without VFD (mean, 7.4; range -4.3; 27.2) (p = 0.050). There was a trend towards a correlation between tumor volume and nD-LOR when QBI-FT was used (rs = -0.6; p = 0.056). A meticulous classification of the spatial relationship between the lesions and OR according to DTI-FT and QBI-FT was performed. The results indicated that the most prevalent orientations were the FT bundles located laterally and intrinsically in relation to the tumor. Compared with conventional DTI-FT, QBI-FT suggests reliable and more accurate results when correlated to preoperative VFDs and might be preferred for preoperative planning and intraoperative use of nearby lesions, particularly for those with larger volumes. A detailed analysis of localization, surgical approach together with QBI-FT and DTI-FT could reduce postoperative morbidity regarding VFDs. The display of HRFT techniques intraoperatively within the navigation system should be pursued for this issue.

The association of COVID-19 pandemic with the increase of sinogenic and otogenic intracranial infections in children: a 10-year retrospective comparative single-center study.

OBJECTIVE: Otitis media and sinusitis are common childhood infections, typically mild with good outcomes. Recent studies show a rise in intracranial abscess cases in children, raising concerns about a link to COVID-19. This study compares a decade of data on these cases before and after the pandemic. METHODS: This retrospective comparative analysis includes pediatric patients diagnosed with otitis media and sinusitis, who later developed intracranial abscesses over the past decade. We collected comprehensive data on the number of cases, patient demographics, symptoms, treatment, and outcomes. RESULTS: Between January 2013 and July 2023, our center identified 10 pediatric patients (median age 11.1years, range 2.2-18.0 years, 60% male) with intracranial abscesses from otitis media and sinusitis. Of these, 7 cases (70%, median age 9.7 years, range 2.2-18.0 years) occurred since the onset of the COVID-19 pandemic, while the remaining 3 cases (30%, median age 13.3 years, range 9.9-16.7 years) were treated before the pandemic. No significant differences were found in otolaryngological associations, surgical interventions, preoperative symptoms, lab findings, or postoperative antibiotics between the two groups. All patients showed positive long-term recovery. CONCLUSION: This study reveals 5-fold increase of pediatric otogenic and sinogenic intracranial abscess cases in the last three-years since the onset of the COVID-19 pandemic. While further investigation is needed, these findings raise important questions about potential connections between the pandemic and the severity of otitis media and sinusitis complications in children. Understanding these associations can improve pediatric healthcare management during infectious disease outbreaks.

Optimizing patient outcome in intracranial tumor surgery: a detailed prospective study of adverse events and mortality reduction strategies in neurosurgery.

INTRODUCTION: Brain tumor surgery represents a critical and high-risk area within the field of neurosurgery. Our study aims to offer a comprehensive analysis of adverse events (AEs) from a prospectively maintained database at a leading neurosurgical tertiary center, with a specific focus on different types of tumor entities. METHODS: From January 2022 to September 2023, our study focused on adult patients, who underwent surgery for intracranial tumors. Each patient in this demographic was thoroughly assessed for adverse events (AEs) by their attending physicians at discharge. An AE was defined as any event occurring within the first 30 days post-surgery. RESULTS: A total of 1173 patients with an average age of 57.4 ± 15.3 years underwent surgical procedures. The majority of these surgeries were elective, accounting for 93.4% (1095 out of 1173), while emergency surgeries constituted 13.9% (163 out of 1173). The incidence of surgery-related AEs was relatively low at 12.7%. The most common surgical indications were meningioma and glioma pathologies, representing 31.1% and 28.2% of cases, respectively. Dural leaks occurred in 1.5% of the cases. Postoperative hemorrhage was a significant complication, especially among glioma patients, with ten experiencing postoperative hemorrhage and eight requiring revision surgery. The overall mortality rate stood at 0.8%, corresponding to five patient deaths. Causes of death included massive postoperative bleeding in one patient, pulmonary embolism in two patients, and tumor progression in two others. CONCLUSIONS: Surgical interventions for intracranial neoplasms are inherently associated with a significant risk of adverse events. However, our study's findings reveal a notably low mortality rate within our patient cohort. This suggests that thorough documentation of AEs, coupled with proactive intervention strategies in neurosurgical practices, can substantially enhance patient outcomes.

Advances in the multidisciplinary surgical approach to primary spinal sarcomas: insights from a retrospective case series on outcomes and survival.

INTRODUCTION: The management of spinal sarcomas is complex, given their widespread involvement and high recurrence rates. Despite consensus on the need for a multidisciplinary approach with surgery at its core, there is a lack of definitive guidelines for clinical decision-making. This study examines a case series of primary spinal sarcomas, focusing on the surgical strategies, clinical results, and survival data to inform and guide therapeutic practices. METHODS: We conducted a retrospective analysis of patients who underwent surgical resection for primary spinal sarcomas between 2005 and 2022. The study focused on gathering data on patient demographics, surgical details, postoperative complications, overall hospital stay, and mortality within 90 days post-surgery. RESULTS: The study included 14 patients with a primary diagnosis of spinal sarcoma, with an average age of 48.6 ± 12.6 years. Chondrosarcoma emerged as the most common tumor type, representing 57.1% of cases, followed by Ewing sarcoma at 35.7%, and synovial sarcoma at 7.1%. Patients with chondrosarcoma were treated with en-bloc resection, while the patient with synovial sarcoma underwent intra-lesional excision and those with Ewing sarcoma received decompression and tumor debulking. Postoperative assessments revealed significant improvements in neurological conditions. Notably, functional status as measured by the Karnofski Performance Index (KPI), improved substantially post-surgery (from 61.4 to 80.0%) The mean follow-up was 34.9 ± 9.2 months. During this time period one patient experienced fatal bleeding after en-bloc resection complications involving the vena cava. None of the patient needed further surgery. CONCLUSIONS: Our 16-year study offers vital insights into managing primary spinal sarcomas, showcasing the effectiveness of surgical intervention, particularly en-bloc resection. Despite their rarity and complexity, our multidisciplinary treatment approach yields improved outcomes and highlights the potential for refined surgical strategies to become standardized care in this challenging domain.

Mortality, complication risks, and clinical outcomes after surgical treatment of spinal epidural abscess: a comparative analysis of patients aged 18-64 years, 65-79 years, and ≥ 80 years, with a 3-year follow-up.

Spinal epidural abscess (SEA) with pyogenic vertebral osteomyelitis (PVO) is a rare illness with a steadily increasing incidence. However, comparative analyses of young and older patients with SEA are lacking. We aimed to compare the clinical course of patients aged 18-64 years, 65-79 years, and ≥ 80 years undergoing surgery for SEA. Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Ninety-nine patients aged 18-64 years, 45 patients aged 65-79 years, and 32 patients ≥ 80 years were enrolled. Patients ≥ 80 years presented with a poorer baseline history (9.2 ± 2.4), as indicated by the CCI, than their younger counterparts (18-74 years: 4.8 ± 1.6;6.5 ± 2.5; p < 0.001). Patients aged 65-79 years and 80 years had a significantly longer length of stay. In-hospital mortality was significantly higher in those aged ≥ 80 years compared to their younger counterparts (≥ 80 years, n = 3, 9.4% vs. 18-64 years, n = 0, 0.0%; 65-79 years, n = 0, 0.0%; p < 0.001), while no differences in 90-day mortality or 30-day readmission were observed. After surgery, a significant decrease in C-reactive protein levels and leukocytes and amelioration of motor scores were observed in all the groups. Of note, older age (> 65 years), presence of comorbidities, and poor preoperative neurological condition were significant predictors of mortality. Surgical management led to significant improvements in laboratory and clinical parameters in all age groups. However, older patients are prone to multiple risks, requiring meticulous evaluation before surgery. Nevertheless, the risk profile of younger patients should not be underestimated. The study has the limitations of a retrospective design and small sample size. Larger randomized studies are warranted to establish the guidelines for the optimal management of patients from every age group and to identify the patients who can benefit from solely conservative management.

Reevaluating age restrictions of spinal metastasis surgery in elderly groups with over 2-year follow-up.

This study aimed to compare and assess clinical outcomes of spinal metastasis with epidural spinal cord compression (MESCC) in patients aged 65-79 years and ≥ 80 years with an acute onset of neurological illness who underwent laminectomy. A second goal was to determine morbidity rates and potential risk factors for mortality. This retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Data on patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality were also collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). A total of 99 patients with an overall mean age of 76.2 ± 3.4 years diagnosed with MESCC within a 16-year period, of which 65 patients aged 65-79 years and 34 patients aged 80 years and older were enrolled in the study. Patients aged 80 and over had higher age-adjusted CCI (9.2 ± 2.1) compared to those aged 65-79 (5.1 ± 1.6; p < 0.001). Prostate cancer was the primary cause of spinal metastasis. Significant neurological and functional decline was more pronounced in the older group, evidenced by Karnofsky Performance Index (KPI) scores (80+ years: 47.8% ± 19.5; 65-79 years: 69.0% ± 23.9; p < 0.001). Despite requiring shorter decompression duration (148.8 ± 62.5 min vs. 199.4 ± 78.9 min; p = 0.004), the older group had more spinal levels needing decompression. Median survival time was 14.1 ± 4.3 months. Mortality risk factors included deteriorating functional status and comorbidities, but not motor weakness, surgical duration, extension of surgery, hospital or ICU stay, or complications. Overcoming age barriers in elderly surgical treatment in MSCC patients can reduce procedural delays and has the potential to significantly improve patient functionality. It emphasizes that age should not be a deterrent for spine surgery when medically necessary, although older MESCC patients may have reduced survival.

Emergency surgical decompression for spontaneous spinal epidural hematoma in octogenarians: risk factors, clinical outcomes, and complications.

PURPOSE: Spontaneous spinal epidural hematoma (SSEH) is a rare but disabling disease. Although several cases have been reported in the literature, their treatment remains unclear, especially in patients with advanced age. We, therefore, aimed to describe the clinical outcomes of cervical SSEH in octogenarians with an acute onset of neurological illness undergoing laminectomy. METHODS: Electronic medical records from a single institution between September 2005 and December 2020 were retrieved. Data on patient demographics, neurological conditions, functional status, surgical characteristics, complications, hospital course, and 90-day mortality were also collected. RESULTS: Twenty-two patients aged ≥ 80 years with SSEH undergoing laminectomy were enrolled in this study. The mean Charlson comorbidity index was 9.1 ± 2.0, indicating a poor baseline reserve. Ten individuals (45.5%) were taking anticoagulant agents with a pathologic partial thromboplastin time (PTT) of 46.5 ± 3.4 s. Progressive neurological decline, as defined by the motor score (MS), was observed on admission (63.8 ± 14.0). The in-hospital and 90-day mortality were 4.5% and 9.1%, respectively. Notably, the MS (93.6 ± 8.3) improved significantly after surgery (p < 0.05). Revision surgery was necessary in 5 cases due to recurrent hematoma. Anticoagulant agents and pathological PTT are significant risk factors for its occurrence. Motor weakness and comorbidities were unique risk factors for loss of ambulation. CONCLUSIONS: Laminectomy and evacuation of the hematoma in octogenarians with progressive neurological decline induce clinical benefits. Emergent surgery seems to be the "state of the art" treatment for SSEH. However, potential complications associated with adverse prognostic factors, such as the use of anticoagulants, should be considered.

Outcomes of cervical spinal stenosis surgery in patients aged ≥ 65 years based on insurance status: a single-center cohort study from a tertiary center in Germany.

OBJECTIVE: The prevalence of degenerative disorders of the spine, such as cervical spinal stenosis with cervical spine myelopathy (CSM) in the geriatric population, has rapidly increased worldwide. To date, there has been no systematic analysis comparing outcomes in older patients suffering from progressive CSM and undergoing surgery depending on their health insurance status. We sought to compare the clinical outcomes and complications after anterior cervical discectomy and fusion (ACDF) or posterior decompression with fusion in patients aged ≥ 65 years with multilevel cervical spinal canal stenosis and concomitant CSM with special focus on their insurance status. METHODS: Clinical and imaging data were retrieved from patients' electronic medical records at a single institution between September 2005 and December 2021. Patients were allocated into two groups with respect to their health insurance status: statutory health insurance (SHI) vs. private insurance (PI). RESULTS: A total of 236 patients were included in the SHI group and 100 patients in the privately insured group (PI) group. The overall mean age was 71.7 ± 5.2 years. Regarding comorbidities, as defined with the age-adjusted CCI, SHI patients presented with higher rates of comorbidities as defined by a CCI of 6.7 ± 2.3 and higher prevalence of previous malignancies (9.3%) when compared to the PI group (CCI 5.4 ± 2.5, p = 0.051; 7.0%, p = 0.048). Both groups underwent ACDF (SHI: 58.5% vs. PI: 61.4%; p = 0.618), and the surgical duration was similar between both groups. Concerning the intraoperative blood transfusion rates, no significant differences were observed. The hospital stay (12.5 ± 1.1 days vs. 8.6 ± 6.3 days; p = 0.042) and intenisve care unit stay (1.5 ± 0.2 days vs. 0.4 ± 0.1 days; p = 0.049) were significantly longer in the PI group than in the SHI group. Similar in-hospital and 90-day mortality rates were noted across the groups. The presence of comorbidities, as defined with the age-adjusted CCI, poor neurological status at baseline, and SHI status, was significant predictor for the presence of adverse events, while the type of surgical technique, operated levels, duration of surgery, or blood loss was not. CONCLUSIONS: Herein, we found that surgeons make decisions independent of health insurance status and aim to provide the most optimal therapeutic option for each individual; hence, outcomes were similar between the groups. However, longer hospitalization stays were present in privately insured patients, while SHI patients presented on admission with poorer baseline status.

Perioperative morbidity and mortality in octogenarians sustaining traumatic osteoporotic type 4 and 5 thoracolumbar and lumbar fractures: a retrospective study with 3 years follow-up.

PURPOSE: This study aimed to guide the more efficient management of type 4 and 5 thoracolumbar or lumbar osteoporotic fractures (OF) in patients aged 80 years and older with an acute onset of neurological decline. This aim was achieved by assessing the clinical course and morbidity and mortality rates and identifying potential risk factors for patient mortality METHODS: Electronic medical records were retrieved from a single institution pertaining to the period between September 2005 and December 2020. Data on patient demographics, neurological conditions, surgical characteristics, complications, hospital course, and 90-day mortality were also collected. RESULTS: Over a 16-year period, 35 patients aged ≥80 years diagnosed with thoracolumbar and lumbar OF were enrolled in the study. The mean Charlson comorbidity index (CCI) was >6, indicating a poor baseline reserve (9.4 ± 1.9), while cardiovascular diseases were the most prevalent among comorbidities. The mean surgical duration was 231.6 ± 89.3 min, with a mean blood loss of 694.4± 200.3 mL. The in-hospital was 8.6% and 90-day mortality rates at 11.4%. Two patients underwent revision surgery for deep wound infection. Intraoperative and postoperative radiography and computed tomography (CT) imaging revealed correct screw placement. Proper alignment of the thoracolumbar spine was achieved in all the patients. Unique risk factors for mortality included the presence of comorbidities and the occurrence of postoperative complications. CONCLUSIONS: Emergent instrumentation in patients with acute onset of neurological decline and potentially unstable spines due to thoracolumbar and lumbar OF improved functional outcomes at discharge. Age should not be a determinant of whether to perform surgery.

Anterior cervical discectomy and fusion with plate versus posterior screw fixation after traumatic subaxial fractures in octogenarians: complications and outcomes with a 2-year follow-up.

INTRODUCTION: Surgical intervention for management of spinal instability after traumatic subaxial fractures in octogenarians requires a clear consensus on optimal treatments. This study aimed to provide a guide for more efficient management through comparison and assessment of clinical outcomes and complications of anterior cervical discectomy and fusion with plate (pACDF) and posterior decompression fusion (PDF) instrumentation alone in patients aged 80 years. METHODS: A single institution retrospective review of electronic medical records was undertaken between September 2005 and December 2021. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Logistic regression was used to identify potential risk factors for ACDF complications. RESULTS: The rate of comorbidities were similarly high between the pACDF (n=13) and PDF (n=15) groups (pACDF: 8.7 ± 2.4 points vs. 8.5 ± 2.3 points; p=0.555). Patients in the PDF group had significantly longer surgical duration (235 ± 58.4 min vs. 182.5 ± 32.1 min; p<0.001) and significantly higher volumes of intraoperative blood loss (661.5 ± 100.1 mL vs. 487.5 ± 92.1 mL; p<0.001). The in-hospital mortality was 7.7% for the pACDF group and 6.7% for the PDF group. On day 90, the mortality rate increased in both groups from baseline (pACDF: 15.4% vs. PDF: 13.3; p>0.05). Motor scores (MS) improved significantly after surgery in both groups (pACDF: preOP MS: 75.3 ± 11.1 vs. postOP MS: 82.4 ± 10.1; p<0.05; PDF: preOP MS: 80.7 ± 16.7 vs. postOP MS: 89.5 ± 12.1; p<0.05). Statistically significant predictors for postoperative complications included longer operative times (odds ratio 1.2, 95% confidence interval 1.1-2.1; p=0.005) and larger volume of blood loss (odds ratio 1.5, 95% confidence interval 1.2-2.2; p=0.003). CONCLUSIONS: Both pACDF and PDF can be considered safe treatment strategies for octogenarians with a poor baseline profile and subaxial fractures as they lead to patients substantial neurological improvements, and they are accompanied with low morbidity and mortality rates. Operation duration and intraoperative blood loss should be minimized to increase the degree of neurological recovery in octogenarian patients.

ACDF versus corpectomy in octogenarians with cervical epidural abscess: early complications and outcomes with 2 years of follow-up.

PURPOSE: Cervical spinal epidural abscess (CSEA) is a rare condition, manifesting as rapid neurological deterioration and leading to early neurological deficits. Its management remains challenging, especially in patients older than 80 years. Therefore, we aimed to compare the clinical course and determine morbidity and mortality rates after anterior cervical discectomy and fusion (ACDF) versus corpectomy in octogenarians with ventrally located CSEA at two levels. METHODS: In this single-center retrospective review, we obtained the following from electronic medical records between September 2005 and December 2021: patient demographics, surgical characteristics, complications, hospital clinical course, and 90-day mortality rate. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). RESULTS: Over 16 years, 15 patients underwent ACDF, and 16 patients underwent corpectomy with plate fixation. Between the two groups, patients who underwent corpectomy had a significantly poorer baseline reserve (9.0 ± 2.6 vs. 10.8 ± 2.7; p = 0.004) and had a longer hospitalization period (16.4 ± 13.1 vs. 10.0 ± 5.3 days; p = 0.004) since corpectomy lasted significantly longer (229.6 ± 74.9 min vs. 123.9 ± 47.5 min; p < 0.001). Higher in-hospital and 90-day mortality and readmission rates were observed in the corpectomy group, but the difference was not statistically significant. Both surgeries significantly improved blood infection parameters and neurological status at discharge. Revision surgery due to pseudoarthrosis was required in two patients after corpectomy. CONCLUSIONS: We showed that both ACDF and corpectomy for ventrally located CSEA can be considered as safe treatment strategies for patients aged 80 years and above. However, the surgical approach should be carefully weighed and discussed with the patients and their relatives.

Adverse events in spine surgery: a prospective analysis at a large tertiary center in Germany.

STUDY DESIGN: Prospective study OBJECTIVES: The occurrence of adverse events (AEs) during surgery is a major cause of increased economic costs, disability, or even death. This study aimed to prospectively identify and quantify AEs in patients undergoing spinal surgery at a neurosurgical tertiary care hospital. METHODS: Patients who underwent spinal surgery and were discharged between January 2019 and December 2022 were enrolled prospectively. Each patient underwent a peer-reviewed AE evaluation at discharge. An AE was defined as any event that occurred up to 30 days postoperatively and resulted in an undesirable outcome. Patients were allocated to four groups according to spinal pathology (degenerative, oncologic, traumatic, and infectious). RESULTS: During the study period, 1778 patients with a mean age of 55.4 ± 10.5 years underwent surgery. Elective surgery was performed in 90.8% (1615/1778) of patients, while emergency surgery was performed in 9.2% (163/1778). The overall rate of surgery-related AEs was relatively low (8.7%). Degenerative pathologies were the most frequent reasons for surgery (78.5%, 1396/1778). Wound infection was the most prevalent AE in patients with degenerative diseases (1.4%), of which 1.1% required revision surgery. Wound infection, dural leakage, and new neurological deficits had the same prevalence (2.1%) in patients with spinal tumors. Among patients with spinal trauma, two presented with postoperative epidural bleeding and underwent emergency surgery. Postoperative wound infection was the most prevalent AE in this group (9.5%), with 7.0% of affected patients requiring revision surgery. The overall rate of non-surgery-related AEs was 4.3%, and the overall mortality rate was low (0.4%). CONCLUSION: AEs in spinal surgery remained low, with a prevalence of 8.7%. Documentation of AEs as part of clinical routine may be a key tool for identifying the occurrence of surgery-related and non-surgery-related AEs.

Tensor- and high-resolution fiber tractography for the delineation of the optic radiation and corticospinal tract in the proximity of intracerebral lesions: a reproducibility and repeatability study.

PURPOSE: Fiber tracking (FT) is used in neurosurgical planning for the resection of lesions in proximity to fiber pathways, as it contributes to a substantial amelioration of postoperative neurological impairments. Currently, diffusion-tensor imaging (DTI)-based FT is the most frequently used technique; however, sophisticated techniques such as Q-ball (QBI) for high-resolution FT (HRFT) have suggested favorable results. Little is known about the reproducibility of both techniques in the clinical setting. Therefore, this study aimed to examine the intra- and interrater agreement for the depiction of white matter pathways such as the corticospinal tract (CST) and the optic radiation (OR). METHODS: Nineteen patients with eloquent lesions in the proximity of the OR or CST were prospectively enrolled. Two different raters independently reconstructed the fiber bundles by applying probabilistic DTI- and QBI-FT. Interrater agreement was evaluated from the comparison between results obtained by the two raters on the same data set acquired in two independent iterations at different timepoints using the Dice Similarity Coefficient (DSC) and the Jaccard Coefficient (JC). Likewise, intrarater agreement was determined for each rater comparing individual results. RESULTS: DSC values showed substantial intrarater agreement based on DTI-FT (rater 1: mean 0.77 (0.68-0.85); rater 2: mean 0.75 (0.64-0.81); p = 0.673); while an excellent agreement was observed after the deployment of QBI-based FT (rater 1: mean 0.86 (0.78-0.98); rater 2: mean 0.80 (0.72-0.91); p = 0.693). In contrast, fair agreement was observed between both measures for the repeatability of the OR of each rater based on DTI-FT (rater 1: mean 0.36 (0.26-0.77); rater 2: mean 0.40 (0.27-0.79), p = 0.546). A substantial agreement between the measures was noted by applying QBI-FT (rater 1: mean 0.67 (0.44-0.78); rater 2: mean 0.62 (0.32-0.70), 0.665). The interrater agreement was moderate for the reproducibility of the CST and OR for both DSC and JC based on DTI-FT (DSC and JC ≥ 0.40); while a substantial interrater agreement was noted for DSC after applying QBI-based FT for the delineation of both fiber tracts (DSC > 0.6). CONCLUSIONS: Our findings suggest that QBI-based FT might be a more robust tool for the visualization of the OR and CST adjacent to intracerebral lesions compared with the common standard DTI-FT. For neurosurgical planning during the daily workflow, QBI appears to be feasible and less operator-dependent.

Accessory nerve schwannoma extending into the fourth ventricle: case report and review of literature.

Accessory nerve schwannoma is a rare entity in patients presenting with cranial nerve (CN) deficits. Most of these tumours arise from the cisternal segment of the eleventh CN and extend caudally. Herein, we report the third case of an accessory schwannoma extending cranially into the fourth ventricle. A 61-year-old female presented with a history of variable headaches. Cerebral magnetic resonance imaging (cMRI) revealed a large inhomogeneous contrast-enhancing lesion at the craniocervical junction extending through the foramen of Magendi and concomitant hydrocephalus due to obstruction of the foramina of Luschkae. Microsurgical tumour resection was performed in the half-sitting position. Intraoperatively, the tumour arose from a vestigial fascicle of the spinal accessory nerve. At three month follow-up, neither radiological tumour recurrence nor neurological deficits were observed.

Spontaneous ankylosis of the sacroiliac joint: prevalence and risk factors.

PURPOSE: Evidence on spontaneous sacroiliac joint (SIJ) ankylosis is lacking. The aim of this analysis was to assess the prevalence of spontaneous SIJ ankylosis and examined different ankylosis patterns and risk factors for spontaneous SIJ ankylosis. METHODS: Pelvic computed tomography (CT) data of 102 consecutive patients with spinal pathologies were compared to CT of a control group consisting of 102 consecutive patients without spinal pathologies. SIJ ankylosis patterns and risk factors for SIJ ankylosis, such as age, sex, and previous spinal fusion surgery were examined. RESULTS: Overall, 117 men and 86 women were examined between 2019 and 2020. Non-spinal patients were significantly older (mean age 70.5 years, standard deviation [SD] 11.4) than those in the spinal group (mean age 65.3 years, SD 14.3; p = 0.005). The prevalence of SIJ ankylosis was 24.5% in the non-spinal group and 23.5% in the spinal group. The anterior ankylosis type prevalence was 91.7% in the spinal group, compared to 48.0% in the non-spinal group. Factors associated with SIJ ankylosis were older age (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.07, p = 0.004) and male sex (OR 5.14, 95% CI 2.29-11.55, p < 0.001). CONCLUSION: Spontaneous ankylosis of the SIJ was a frequent phenomenon in patients with and without spinal pathologies and more likely with older age and male sex. Anterior type SIJ ankylosis was substantially more frequent in patients with spinal pathologies. This may be due to strain exerted on the anterior SIJ aspects in patients with compromised posture due to spine degeneration.

Impact of Ventilation Modes on Bronchoscopic Chartis Assessment Outcome in Candidates for Endobronchial Valve Treatment.

BACKGROUND: Endobronchial valve therapy has proven to reduce lung hyperinflation and decrease disease burden in patients with severe lung emphysema. Exclusion of collateral ventilation (CV) of the targeted lobe by using an endobronchial assessment system (Chartis; PulmonX, Drive Redwood City, CA, USA) in combination with software-based fissure integrity analysis (FCS [fissure completeness score]) of computed tomography scans of the lung are established tools to select appropriate patients for endobronchial valve treatment. So far, there is no conclusive evidence if the ventilation mode during bronchoscopy impacts the outcome of Chartis assessments. METHODS: Patients with Chartis assessments and software-based quantification of FCS (StratX; PulmonX, Drive Redwood City, CA, USA) were enrolled in this retrospective study. During bronchoscopy, pulmonary fissure integrity was evaluated with the Chartis assessment system in each patient first under spontaneous breathing and subsequently under high-frequency (HF) jet ventilation. RESULTS: In total, 102 patients were analyzed. Four Chartis phenotypes CV positive (CV+), CV negative (CV-), low flow, and low plateau in spontaneous breathing and HF jet ventilation were identified. The frequency of each Chartis phenotype per lobe was similar in both settings. When comparing Chartis assessments in spontaneous breathing and HF jet ventilation, there was an overall good concordance rate for all analyzed fissures. In agreement, receiver operating characteristic analysis of the FCS showed an almost similar prediction for CV+ and CV- status independent of the ventilation modes. CONCLUSION: Chartis assessment in spontaneous breathing and HF jet ventilation had similar rates in detecting CV in lung emphysema. Our results suggest that both modes are equivalent for the assessment of CV.

Endoscopic Lung Volume Reduction with One-Way Valves in Patients with Severe Chronic Obstructive Pulmonary Disease with Hypercapnia.

BACKGROUND: Robust clinical evidence on the efficacy and safety of endoscopic lung volume reduction (ELVR) with one-way valves in patients with severe lung emphysema with chronic hypercapnic respiratory failure is lacking. OBJECTIVE: The aim of this study was to compare patient characteristics, clinical outcome measures, and incidences of adverse events between patients with severe COPD undergoing ELVR with one-way valves and with either a partial pressure of carbon dioxide (pCO2) of ≤45 mm Hg or with pCO2 >45 mm Hg. METHODS: This was a multicentre prospective study of patients with severe lung disease who were evaluated based on lung function, exercise capacity (6-min walk test [6-MWT]), and quality-of-life tests. RESULTS: Patients with pCO2 ≤45 mm Hg (n = 157) and pCO2 >45 mm Hg (n = 40) showed similar baseline characteristics. Patients with pCO2 ≤45 mm Hg demonstrated a significant increase in forced expiratory volume in 1 s (p < 0.001), a significant decrease in residual volume (RV) (p < 0.001), and significant improvements in the quality of life and 6-MWT at the 3-month follow-up. Patients with pCO2 >45 mm Hg had significant improvements in RV only (p < 0.05). There was a significant decrease in pCO2 between baseline and follow-up in hypercapnic patients, relative to the decrease in patients with pCO2 ≤45 mm Hg (p = 0.008). Patients who were more hypercapnic at baseline showed a greater reduction in pCO2 after valve placement (r = -0.38, p < 0.001). Pneumothorax was the most common adverse event in both groups. CONCLUSIONS: ELVR with one-way valves seems clinically beneficial with a remarkably good safety profile for patients with chronic hypercapnic respiratory failure.

Decompression only versus fusion in octogenarians with spinal epidural abscesses: early complications, clinical and radiological outcome with 2-year follow-up.

Despite increased life expectancy due to health care quality improvements globally, pyogenic vertebral osteomyelitis (PVO) treatment with a spinal epidural abscess (SEA) remains challenging in patients older than 80 years. We aimed to assess octogenarians for PVO prevalence with SEA and compare after-surgery clinical outcomes of decompression and decompression and instrumentation. A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Over 16 years, 35 patients aged ≥80 years with PVO and SEA were identified. Eighteen patients underwent surgical decompression ("decompression group"), and 17 underwent surgical decompression with instrumentation ("instrumentation group"). Both groups had a CCI >6 (mean±SD, 8.9±2.1 vs. 9.6±2.7, respectively; p=0.065). Instrumentation group patients had a significantly longer hospital stay but no ICU stay. In-hospital and 90-days mortality rates were similar in both groups. The mean follow-up was 26.6±12.4 months. No further surgeries were performed. Infection levels and neurological status were improved in both groups at discharge. At the second-stage analysis, significant improvements in the blood infection parameters and the neurological status were detected in the decompression group. Octogenarians with PVO and SEA have a high adverse events risk after surgical procedures. Surgical decompression might contribute to earlier clinical recovery in older patients. Thus, the surgical approach should be discussed with patients and their relatives and be carefully weighed.

The use of quantitative pupillometry in patients with pituitary tumors: a technical note.

BACKGROUND: Pituitary tumors may cause compression of the optic chiasm, resulting in decreased visual acuity. Therefore, decompression of the optic chiasm is a major goal of surgical treatment in such patients. Quantitative pupillometry has been used in various clinical settings for assessing the optic system but has not been applied in patients with pituitary tumors. This study aimed to evaluate the potential of this technique to improve treatment modalities in patients undergoing surgical resection of pituitary tumors. METHOD: Pupillometry using the automated NPi 200® Pupillometer was performed in seven patients who underwent surgical resection of large pituitary tumors at the University of Heidelberg in 2018. The neurological pupil index (NPi) was assessed preoperatively and postoperatively, and correlations with visual acuity and magnetic resonance imaging (MRI) findings regarding optic chiasm compression were determined. RESULTS: All patients experienced visual disturbance due to a large pituitary tumor. The NPi was < 4.0 in all patients in at least one pupil. Intraoperative MRI demonstrated successful decompression of the optic chiasm in all cases. Postoperatively, the NPi values increased, and this increase was correlated with improved visual acuity. CONCLUSIONS: We found that quantitative pupillometry can detect optic chiasm compression in patients with pituitary tumors. Furthermore, postoperative improvement of NPi values may indicate sufficient decompression of the optic chiasm. Further studies are warranted to substantiate the granularity of this technique to gain valuable information for patients with pituitary tumors who are indicated for surgery.