Presentations selected from submitted abstracts
Aims:The aim of this prospective study was to evaluate the value of diffusion tensor imaging in intraspinal cord tumors .Despites the advances made in microsurgical neurosurgery, operations of spinal cord tumors remains challenging. Diffusion weighted imaging is a MR technique that has seen vast application with many efforts undertaken to apply the technique in spinal cord pathologies. Methods:Diffusion tensor imaging was performed in 31 patients with intraspinal lesions. Patients underwent MR imaging on a 3.0T magnet (Verio, Siemens).A standardized MR imaging protocol for the cervical spine was used including T2 and T1-weighted as well as gadolinium enhanced T1 weighted imaging. For diffusion tensor imaging a SE EPI sequence was used in 2 orientations with b-factors of 0 and 900 mm2/sec. 3D Tractography were calculated for all patients. Patients were classified into 3 groups according to the fiber course with respect to the lesion. Furthermore the lesions were rated as resectable or non-resectable. Results:Of the 31 patients (16 male, 15 female; mean age 47,7 ± 17 years, range: 19-74 years), 17 patients showed intramedullary tumors, 12 Patients presented extramedullary intradural tumors and 2 patients had epidural masses. 8 patients had ependymomas, 6 patients had meningiomas, 3 patients had cavernomas, 1 patient showed a ODG another a LGG, 1 patient had a GBM. 1 patient had a chordoma. One patient presented with an hemangioblastoma, 3 patients showed schwannoma and of 1 patient had no histology but a hemangioblastoma was suspected. In 1 patient biopsy was inconclusive-imaging suspected an ependymoma. 2 patients showed Metastasis. One lesion was an epidural abscess with compression of the cord. One patients lesion was an MS Plaque. Additionally this patient presented with an Arachnoidal cyst. The lesions could be classified into 3 types according to the fiber course. In Type 1 (n=14) fibers did not pass through the lesion. In Type 2 (n=8) some fibers crossed the lesion, but most of the lesion volume did not contain fibers. In Type 3 (n=10) the fibers were completely encased by tumor. 20 tumors were considered resectable.Conclusion:These preliminary data suggest that DTI of spinal cord tumors can be capable of showing the effect of tumors on the cord with more sensitivity than conventional MRIand thus having the potential of predicting the resectability.Further prospective studies are needed to confirm these results and effects on patient outcome.
Aims: Anatomical identification of the corticospinal tract (CT) and the dorsal column (DC) of the exposed spinal cord is difficult when anatomical landmarks are distorted by tumour growth. Neurophysiological identification is complicated by the fact that direct stimulation of the DC may result in muscle motor responses due to the centrally activated H-reflex.
This study aims to provide a technique for intraoperative neurophysiological differentiation between CT and DC in the exposed spinal cord.
Methods: Recordings were obtained from 32 consecutive patients undergoing spinal cord tumour surgery from 07/2015–03/2017. A double train stimulation paradigm with an intertrain interval of 60ms was devised with recording of responses from limb muscles.
Results: In non-spastic patients (55% of cohort) an identical second response was noted following the first CT response, but the second response was absent after DC stimulation. In patients with preexisting spasticity (45%), CT stimulation again resulted in two identical responses, whereas DC stimulation generated a second response that differed substantially from the first one. The recovery times of interneurons in the spinal cord grey matter were much shorter for the CT than those for the DC. Therefore, when a second stimulus train was applied 60ms after the first, the CT-fibre interneurons had already recovered ready to generate a second response, whereas the DC interneurons were still in the refractory period.
Conclusions: Mapping of the spinal cord using double train stimulation allows neurophysiological distinction of CT from DC pathways during spinal cord surgery in patients with and without preexisting spasticity.
Surgery has shown to be the best therapeutic option for medically refractory cases of FCD-associated epilepsy. Seizure outcome primarily depends on the extent and completeness of resection, making intraoperative visualization and delineation of FCDs essential. Our study assesses the diagnostic yield of intraoperative ultrasound (IOUS) for such lesions.
15 consecutive patients with therapy-refractory epilepsy undergoing IOUS-assisted microsurgical resection of a radiologically suspected FCD were prospectively followed between January 2013 and July 2016. Morphological appearance on IOUS was compared to preoperative postprocessed MRI and the sonographic characteristics were analysed in relation to histological subtype. IOUS was studied in regard to its value to improve completeness of resection and improve postoperative seizure outcome.
In all cases of FCD the surgeon was able to identify the dysplastic area. Visualization of FCD I proved to be more difficult than FCD II and demarcation of its borders were less clear, resulting in residual dysplasia on postoperative coregistered MRI in two out of three patients. In every case of FCD type II, IOUS allowed clear intraoperative visualization and demarcation with high topographical-morphological correlation to preoperative postprocessed MRI. Postoperative MRI showed complete resection in every case of FCD II. Sonographic features and their severity correlate to the underlying histological degree of dysplasia (FCD IA / FCD IB < FCD IC < FCD IIA < FCD IIB). In one patient IOUS showed features atypical for FCD, which proved to be nonspecific gliosis on later histological analysis.
The distinct sonographic features on IOUS allow for intraoperative differentiation between FCD and non-FCD lesions as well as discrimination between the different histological subtypes of FCD. Sonographic demarcation depends on the underlying degree of dysplasia. IOUS allows for more tailored and improved extent of resection by clearly delineating the dysplastic area, which in turn correlates with favorable seizure outcome.
Aim: To investigate the safety and efficacy of surgical education for neurosurgical residents in the evacuation of chronic subdural hematomas (cSDH) by burr hole trepanation.
Methods: This is a retrospective analysis of prospectively collected data on consecutive patients receiving burr hole trepanation for uni- or bilateral cSDH. Patients operated by a supervised neurosurgery resident (teaching cases) were compared to patients operated by a board-certified faculty neurosurgeon (BCFN; nonteaching cases). The primary endpoint was surgical revision for any reason until last follow-up. The secondary endpoint was occurrence of any complication until last follow up. Clinical status, type of complications, mortality, length of surgery (LOS) and hospitalization (LOH) were tertiary endpoints.
Results: A total of n=253 cases were analyzed, of which n=217 (85.8%) were teaching and n=36 (14.2%) nonteaching cases. The study groups were balanced in terms of age, sex, surgical risk (ASA score) and preoperative status (Karnofsky Performance Scale (KPS), modified Rankin Scale (mRS), National Institute of Health Stroke Scale (NIHSS)). The cohort was followed for a mean of 242 days (standard deviation 302). In multivariate analysis, teaching cases were as likely as nonteaching cases to require revision surgery (OR 0.65, 95% CI 0.27 – 1.59; p=0.348) as well as to experience any complication until last follow-up (OR 0.79, 95% CI 0.37 – 1.67, p=0.532). Mean LOS was about ten minutes longer in teaching cases (53.0 ± 26.1min vs. 43.5 ± 17.8 min; p=0.036), but LOH was similar. There were no group differences in clinical status, mortality and type of complication at discharge and last follow-up.
Conclusions: Burr hole trepanation for cSDH can be safely performed by supervised neurosurgical residents enrolled in a structured training program, without increasing the risk for revision surgery, perioperative complications or worse outcome.
AIMS Consensus guidelines recommend dopamine (DA-) agonists as the first-line approach for treating prolactinomas. Although consideration of a primary surgical approach in selected patients with microadenomas is warranted, upfront surgery in patients with macroprolactinomas remains controversial, wherefore data from studies in large cohorts are sparse. In the present audit of practice in a dedicated tertiary referral center, we therefore investigated whether tumor size impacts on the long-term control of hyperprolactinemia following primary pituitary surgery with the aim of identifying risk factors for persistent long-term hyperprolactinemia and dependence on DA-agonists.
METHODS Retrospective case-note study of prospectively collected data on patients with micro- and macroprolactinomas treated with primary pituitary surgery without prior DA-agonists. The clinical, biochemical and radiological responses to first-line surgery were analyzed. The primary endpoint was patients’ dependence of DA-agonists at last follow-up. The secondary endpoint was postoperative complications. Independent risk factors for persistent long-term hyperprolactinemia and dependence on DA-agonists were calculated using multivariate logistic regression.
RESULTS A microadenoma was noted in 46 (54%) and macroadenoma in 40 (46%) patients. Median follow-up was 80 (range, 13–408) months. Long-term prolactin levels significantly decreased in all patients, independent of the initial tumor size. Long-term remission was obtained in 82% of patients with a micro- and 75% of patients with a macroprolactinoma (p = 0.60). Control of hyperprolactinemia required DA-agonists in 26% of patients with micro- vs 48% of those with macroadenomas (p = 0.05). There was no surgical related mortality and morbidity was minimal. Cavernous sinus invasion (OR 6.2, 95% CI 1.2-31.9, p = 0.03) but not tumor size (OR 1.2, 95% CI 0.4-4.1, p = 0.72) was an independent predictor for long-term dependence on DA-agonists following primary surgery.
CONCLUSION Our data indicate that in a dedicated tertiary referral center first-line surgery is a valuable alternative not only for micro- but also for macroprolactinomas that have not infiltrated the cavernous sinus.
Aims: Studies on the prevalence of pathological bone mineral densities (pBMD) in large cohorts of men and women with prolactinomas treated either primary surgically or medically are scarce. In the present study, we aimed at comparing the impact of the two therapeutic approaches on bone density in both sexes.
Methods: This cohort study included all consecutive prolactinoma patients with osteodensitometric data at study entry and at long-term follow-up (≥ 12 months). BMD was assessed by dual-energy X-ray absorptiometry. The primary endpoint was the impact of either approach on the prevalence of pBMD in both sexes. The secondary endpoint was the assessment of risk factors for long-term pBMD.
Results: 100 patients (40 men, 60 women) met inclusion criteria. At baseline, men had a significantly higher prevalence of pBMD than women (28 vs 2%, p < 0.001). Primary medical therapy was considered in 47 and first-line surgery in 53 patients. Median duration of follow-up was 79 months (range 13–408 months). Long-term prolactin values significantly decreased in both groups regardless of the primary treatment, with a persistent need for DA-agonists in 75% of men compared to 42% of the women (p = 0.001). The prevalence of pBMD in men remained significantly higher than in women (37% vs 7%, p < 0.001), independent of the primary treatment strategy. Persistent hyperprolactinemia and male sex were independent risk factors for pBMD at last follow-up in prolactinoma patients.
Conclusions: The prevalence of pBMD in men remains significantly higher than in women, independent of the primary treatment strategy. Osteoporosis prevention and treatment mainly focuses on women, but bone loss in men with prolactinomas should not be underestimated. A pBMD as “end organ damage” reflects the full range of the disease and might become a surrogate marker for the severity of long-lasting hyperprolactinemia.
Duration : 30 Minutes
Duration : 30 Minutes
Satellite Symposium organized by 1a medical ag & Aachen Scientific International PTE LTD
Presentations selected from submitted abstracts
Altered cerebral blood flow (CBF) has been observed during migraine attacks. Transcranial direct current stimulation (tDCS) has been used in patients with episodic migraine (EM) and resulted in a reduction of migraine days compared to baseline. Yet, it is unknown abnormal CBF can be modulated by non-invasive brain stimulation. We hypothesized that CBF will be different between sham and repetitive (4 weeks) real tDCS and that neuronal reorganization should be paralleled by a reduction in migraine days. On a 3 Tesla scanner, we examined 17 adult patients with EM by arterial spin labeling MRI using a 2D pseudo-continuous ASL sequence at three time points (baseline, FUP1 (maximally 4 weeks after tDCS), and FUP2 (6 months after baseline)). CBF difference images were achieved by simple subtraction to minimize spurious BOLD contaminations within the CBF signal. We calculated planned contrasts (t-tests, p < .01, corrected) for within-group differences (baseline vs. follow-up) and between-group differences (sham vs. real tDCS). For real tDCS, anodal tDCS was applied over the occipital cortex for 4 weeks (1200 seconds/day). Sham tDCS contained only a low (< 0.1 mA) current. Eight EM received real tDCS and nine EM received sham stimulation and ASL-MRI. Patients did not differ with respect to sex, age, handedness, and migraine attacks at baseline (all p > .05). None of the patients stopped the stimulation or had a migraine attack during stimulation. Only real tDCS lead to a significant (p < 0.05) reduction in migraine days (from 9 to 6.2). Two of the EM were migraine-free at FUP2. For real tDCS, CBF was higher at baseline compared to the FUP1 in pain processing brain regions (e.g. insula, medial prefrontal cortex, and thalamus). Comparing sham to real tDCS (at FUP1), higher CBF was seen for sham tDCS in the medial prefrontal cortex, subgenual anterior cingulate cortex, somatosensory cortex, insula, superior parietal lobe, and cuneus. Our results indicate altered CBF in the untreated group of patients. This was paralleled by the absence of any longitudinal reduction in migraine days. In contrast, real tDCS significantly reduces migraine days in EM and lowers CBF (compared to baseline and sham, respectively) in brain regions associated with pain processing, such as the insula and prefrontal cortex. In addition, brain regions linked to cognitive control showed lower CBF during real tDCS versus sham tDCS.
Glioblastoma (GBM) is one of the most frequent and most devastating brain tumor. We have previously shown that expression of different status of EGFR in GBM cell lines reduces 5-ALA-induced PpIX fluorescence by influencing the rate limiting enzyme Heme Oxygenase-1 (HO-1). We hypothesized that 5-ALA-induced Protoporphyrin IX (PpIX) fluorescence can be pharmacologically influenced by adding different drugs.
U87MG, U87wtEGFR, U87vIII (GBM cell lines) having different EGFR expression status, were exposed to exogenous 5-ALA (1mM) and different pharmacological conditions such as: exposition to DFO (iron chelator of Fe2+), SnPP (HO-1 inhibitor), Genistein (ABC transporter G2 inhibitor) and stimulation with EGF (epidermal growth factor). Cell lines were exposed to 5-ALA and PpIX fluorescence was monitored over time in the cells and in the cell culture medium (CM). After 24h, the medium was removed and PpIX washout was measured. As regards the treatments, cells were incubated with EGF (10ng/ml) for 18h and in the last 4h cells are co-treated with 5-ALA. Whereas the treatments with 5-ALA plus DFO and/or SnPP and Genistein were performed incubating cells for 8h. All samples were analyzed with the microplate reader.
5-ALA-induced fluorescence was observed in U87MG (low EGFR expression), U87wtEGFR cells (EGFR overexpression) and in U87vIII (EGFR overexpression/EGFRvIII+). We observed a significant increase of PpIX in all the cell lines between 8 and 24 hours of 5-ALA treatment. At the same time, we noticed that GBM cells start to release PpIX in the CM. After removal of the 5-ALA stimulation, there was a significant reduction of PpIX level, in particular in the first hour. Whereas we saw an increased amount of PpIX in the CM at the same time. After 24h the whole amount of PpIX was secreted by all the cell lines. On the contrary, treatment of U87MG cells with EGF lead to reduced cellular fluorescence, by promoting HO-1 transcription and expression. Remarkably, inhibition of HO-1 activity by SnPP treatment was able to restore the fluorescence in all cell lines. We observed a major increase of PpIX fluorescence in U87vIII respect to the other cells when we treat with drugs.
This approach could be used to determine the optimal time point for the PpIX visualization after 5-ALA induction. Moreover, it could be very interesting to test different combination of these drugs to better improve the accumulation of PpIX in GBM tumor cells and their visualization during the surgery.
Aim: Deep brain stimulation (DBS) has become an established treatment for diverse neurological diseases. Nevertheless, the technique of lead implantation differs widely among functional neurosurgeons. During recent years classical aids such as intraoperative microelectrode recording (MER) and macrostimulation (MS) in the awake patient were challenged. Our aim was to investigate the relevance of these techniques according to lead trajectory adjustment rates and comparing intraoperative response to stimulation between anatomically planned (PSP) and definite stimulation points (DSP), along with follow-up outcome.
Methods: We conducted a retrospective analysis of prospectively collected datasets of Parkinson’s disease (PD) patients that had bilateral lead placement in the subthalamic nucleus for DBS. The implantation was performed awake with MER and MS in all patients. Intraoperative motor outcomes between the stimulation sites were compared along with the lead trajectory adjustment rate. The outcome at six months according to the Unified PD Rating Scale-III (UPDRS-III), levodopa equivalent daily dose (LEDD) and DBS related adverse events (AE) was analyzed.
Results: In 47 of 101 patients and 59 of 202 leads intraoperative lead adjustment was performed respectively. 29% of the leads were adjusted due to MS but only 3% solely due to MER results. The mean response to MS improved significantly between PSP and DSP (37.07 ± 2.18% vs. 41.38 ± 2.15%; p < 0.001) with a more pronounced effect in initially poor responding electrodes (18.08 ± 3.78 % vs. 31.47 ± 2.78 %; p < 0.001), leading to a number needed to treat of 9.6 per electrode. After 6 months, follow-up UPDRS-III (23.3 ± 1.1 vs. 15.6 ± 0.8; p < 0.001) and LEDD (1262.3 ± 60.9 mg/d vs. 487.7 ± 39.2 mg/d; p < 0.001) showed significant improvement. The optimal intraoperative stimulation site covered the active electrode contact in 87% of leads. 15 stimulation or surgery related adverse events occurred.
Conclusion: The use of MER and MS have an important influence on the intraoperative lead placement. The intraoperatively identified stimulation site corresponds to the chronically active contact. Poor DBS outcome is prevented in a subgroup of leads. Follow-up UPDRS-III results, LEDD reductions and DBS related AE correspond to previously published data.
Chronic subdural hematoma has a high recurrence rate after surgery and postoperative scans often show substantial residuals, eventually leading to a higher rate of reoperation. However, the benefit of post-surgical imaging for patient outcome remains unknown. The aim of this study was to investigate the value of post-operative CT scans for outcome after surgical evacuation of chronic subdural hematoma.
We randomly assigned 368 patients with newly diagnosed chronic subdural hematoma within 48 hours after surgery to either a combined radiological and clinical follow up (CT arm) or a clinical follow up with scans only in case of neurological deterioration (No-CT arm). The primary outcome was the modified Rankin scale (mRS) score at 90 days; this categorical scale measures functional outcome, with scores ranging from 0 (no symptoms) to 6 (death).
A follow-up protocol with CT imaging did not improve the primary outcome; there was no significant between-arm difference for mRS as a categorical variable (p=0.79) or as numerical variable (p=0.37). The proportion of patients who survived without severe disability (mRS 0-3) was 89% in the CT arm and 93% in the No-CT arm (odds ratio 1.4, 95% confidence interval 3.72-0.82, p=0.15). Death occurred in 12 patients in the CT arm and in 8 patients in the No-CT arm (p=0.5). Re-operation for recurrent hematomas was performed in 59 patients in the CT arm and in 39 patients in the No-CT arm ( p=0.055). Complications were seen in 26 patients in the CT-Arm and in 19 patients in the No-CT arm (p=0.34).
Routinely scheduled CT scans after neurosurgical evacuation of chronic subdural haematoma have no benefit on outcome.
BACKGROUND: Spinal cerebrospinal fluid (CSF) leaks are the cause of spontaneous intracranial hypotension (SIH).
OBJECTIVE: To report the results of a large surgical series and to propose a surgical strategy, stratified on anatomical location of the leak, for sealing all CSF leaks around the 360° circumference of the dura through a single tailored posterior approach.
METHODS: All consecutive patients undergoing spinal surgery between February 2013 and October 2017 were included. All patients were refractory to conservative treatment and to epidural blood patching and workup had exactly localized the anatomical site of the leak. We used a posterior approach via a tailored hemilaminectomy or interlaminar fenestration and intra-operative electrophysiological monitoring in all cases. To seal the CSF leak either a mere extradural, foraminal, or transdural microsurgical trajectory was chosen. Neurological status was assessed before, at day 1, 30 and 90 after surgery, as well as mRS and working status at 3 months.
RESULTS: Forty-seven SIH patients had a neuroradiologically identified spinal CSF leak between the levels C6 and L1. Micorsurgically, we could localize (anterior n=35, lateral n=9, foraminal n=2) and seal all dural tears via a transdural (n=28), a direct extradural (n=16), or a foraminal (n=2) trajectory. The transdural trajectory necessitated cutting the dentate ligament accompanied by elevation and rotation of the spinal cord under continuous neuromonitoring (spinal cord release maneuver, SCRM). No patient experienced a permanent neurological deficit; 4 patients had transient deficits. We propose an anatomical stratification of CSF leaks into I ventro-medial, i.e. anterior to the spinal cord, II ventro-lateral, lateral and dorsal, and III foraminal. All CSF-leaks can be sealed via a single tailored fenestration and a respective transdural (I), direct extradural (II) and foraminal (III) microsurgical approach.
CONCLUSION: With the posterior microsurgical (tailored fenestration) strategy, it is possible to seal all defects around the 360° surface of the dura via 3 surgical trajectories, that are selected according to the exact anatomical location of the leak. Intraoperative neuromonitoring is mandatory for the SCRM.
BACKGROUND: The treatment of sellar lesions demands an interdisciplinary network consisting of endocrinologists, neurosurgeons, radiooncologists, radiosurgeons, ophthalmologists, otorhinolarngylogists, neuropathologists and neuroradiologists. Each of these specialists contributes valuable information to optimize treatment of these patients; however, a multicentre registry to collect the resulting biomedical data was lacking in Switzerland. While in other European Countries established centers provided the base for nationwide databases, this was not the case in our country. While due to the low incidence representative numbers of patients are hard to find for retrospective data analysis, this is automatically provided by a structured database, resulting in resourceful scientific contributions. Furthermore, it may be used as a base for prospective multicentric trials.
METHODS: Founded at the Kantonsspital Aarau in cooperation with the Clinical Trial Unit of the University Hospital of Basel with approval of the ethics comitee of the northwestern part of Switzerland, the Swiss Pituitary Registry (SwissPit) has been designed as an online electronic data capture system. All patients with lesions in the sellar region are eligible for inclusion in the database. Data generated by routine clinical follow-up and standard therapies, as well as details about adverse events and outcomes is entered by medical staff. In each participating center, a designated neurosurgeon and/or endocrinologist acts as a local investigator and helds responsibility for the quality of the entered data. Each centre is free to conduct single centre trials, while multicentric studies with exchange of data are coordinated by the project leaders after appropriate approval. After a thourough test of the database by the founders, a step-wise growth by inviting other centres is planed.
RESULTS: The SwissPit is online since January 2016. After the Kantonsspital Aarau, the University Hospital of Basel, the Kantonsspital Lucerne, the Kantonsspital St. Gallen and lately the University Hospital of Zurich have joined. Detailed data of more than 700 patients have since then been entered.
CONCLUSION: The SwissPit is the first multicentric Swiss database on sellar lesions working by the standards of Good Clinical Practice and in concordance with the revised Swiss laws. The members of SwissPit look forward to invite further investigators in other centres to join in 2018!
Duration : 30 Minutes
Presentations selected from submitted abstracts
Aims: Despite the treatment of chronic subdural haematomas (SDH) is one surgical procedure that neurosurgeons perform earliest in their training, the technical steps and strategy of treatment vary between centers. Although an abundance of literature about the treatment of chronic SDH is available, there is little evidence clarifying which treatment is most successful. The aim of this study was to examine and compare the current clinical standards.
Methods: Head of departments of all neurosurgical units in Austria, Germany and Switzerland, as listed on the national neurosurgical societies’ websites, were invited to participate with a personal token to access a web based survey. A total of 159 invitations were sent and up to 9 reminder e-mails.
Results: Eighty-four invitees (53%) completed the survey. The most standard surgical strategy was a single burr hole in 52 (65%) of the responding neurosurgical units, double burr holes were performed as primary procedure in 16 centers (20%), a small osteoplastic craniotomy in 4 (5%) and twist drill craniostomy in 8 (10%). Although 100% of Austrian respondents and 72% of German respondents preferred single burr hole, the double burr hole (p<0.01*) was preferred in Switzerland 91%. Seventy-two (90%) would place a drain in estimated 75-100% of cases or whenever possible/safe. Sixty-five use subdural-external drains and 7 use subgaleal-external drains. In Switzerland almost 50% preferred subgaleal drains while in Austria and Germany almost 100% preferred subdural drains (p<0.01*). Thirty-six (49%) agreed with the statement that watchful waiting was an option for the treatment of chronic subdural hematomas, except 19 (23.4%) that disagreed. Eighteen (23%) would consider corticosteroids and 34 (45%) tranexamic acid as part of their armamentarium for the treatment of subdural hematomas.
Conclusions: The results of this survey reflect the current evidence available in literature. The benefits of using of a drain seem generally accepted, although there was no agreement regarding the type of drain and surgical approach to the hematoma as well as the presence of some international differences.
Introduction: Novel oral anticoagulants (NOACs) were shown to be as effective as vitamin K antagonists for the prophylaxis and treatment of thromboembolism. Despite growing number of patients treated with NOACs, guidelines on the perioperative management are still lacking. The aim of the study was to present a cohort of patients treated with NOACs undergoing spine surgery, and to analyze the incidence of postoperative bleeding events and the factors might influence bleeding rates in these patients. Material and methods: Out of 2777 Patients undergoing spine surgery between January 2014 and December 2016, 82 (2.9%) were under NOACs preoperatively. The rate of peri- and postoperative bleeding events, postoperative thromboembolic events, hematologic findings, morbidity, and mortality were reviewed. A sub-analysis of factors that might influence the bleeding risk of these patients and the bleeding rate depending on the preoperatively discontinuation time of NOACs, with a cutoff of 24 and 48 hours, was additionally completed. Results: The overall rate of postoperative bleeding was 4.9 % (n=4) and the rate of postoperative anemia needing packed red blood cell (PRBC) substitution was 6.1% (n=5). The mean discontinuation time was 3.5 days (range 3 to 6 days) in the patients experiencing a bleeding event, as opposed to 4.2 days (range 0 to 20 days) in patients without a bleeding event (p>0.05). Preoperative discontinuation time of less than 24 hours increased significantly the rate of PRBC substitution perioperatively (p=0.007), but not the rate of postoperative bleeding and anemia. However, a combination therapy with other bloodthinner showed an increase incidence of bleeding events (p=0.066) and preexisting kidney failure affected significative the rate of postoperative anemia (p=0.014). Postoperative resumption time of NOACs did not seem to significantly affect bleeding events and postoperative anemia. The rate of postoperative pulmonary embolism and deep venous thrombosis events was 3.4% and 1.1%, respectively, and all of them happened with a NOACs resumption time >72 hours. The hospitalization time of patients resuming NOACs >72 hours after surgery was significative longer (p=0.037). Conclusions: The postoperative rate of bleeding and anemia in patients undergoing spinal surgery treated with NOACs is 4.9% and 6.1% respectively. Preoperative discontinuation time < 24 hours seems to significantly increase the use of PRBC substitution perioperatively.
Aneurysmal subarachnoid hemorrhage (aSAH) comprises only 5% of all strokes but is an important subtype due to the high morbidity and mortality in the relatively young population. The case fatality in aSAH is 50% due to the initial hemorrhage or subsequent complications like recurrent aneurysmal hemorrhage (rebleed) or delayed cerebral ischemia (DCI). One factor that might influence the initial brain damage of subsequent complications is the use of antiplatelet medication before the initial hemorrhage. Studies that have investigated outcome with antiplatelet use before aSAH show conflicting results and literature regarding aSAH patients who used antiplatelet agents before aneurysmal rupture is scarce. The management of these patients therefore remains an issue of debate, because evidence is lacking. Our goal was to assess the management of prehemorrhage use of antiplatelet agents in aSAH patients in an international panel of physicians.
We developed a survey of 11 questions about management of aSAH patients with antiplatelet use before the initial hemorrhage. A paper version of this survey was distributed to the attendees of the annual meeting of the European Association of Neurosurgical Societies (EANS), which took place in Venice, Italy at 1-5 October 2017.
Of the 478 surveys we distributed, we received 258 (54%) completed surveys. In about 80%, the departments of neurosurgery and neurology were responsible for acute management of aSAH patients. Department guidelines regarding management of prehemorrhage antiplatelet use in aSAH patients were present in 32%. Approximately two-thirds (65%) of all responders always stop the administration of antiplatelet agents at admission and only 4.3% always transfuse thrombocytes. When a guideline is present, the physicians tend to stop the antiplatelet medication more often and thrombocytes are transfused more often (p=0.056 and p=0.02, respectively).
Our survey showed that there is a significant variability in the management of aSAH patients who have been using antiplatelets before the hemorrhage. The presence of a hospital guideline appears to influence the decision of stopping the antiplatelet agent or to transfuse platelets. These findings emphasize the importance of randomised clinical trials for patients with aSAH and prehemorrhage use of antiplatelets.
Aims The aim of this study was to compare the accuracy of posterior subaxial cervico-thoracic fixation using three different techniques: intraoperative computed tomography (iCT-AIRO) scanner-guided navigation, 3D (O-arm) based spinal navigation and fluoroscopy based posterior stabilization.
Methods In the period between March 2015 and November 2017, a total of 140 screws were implanted in 17 patients with cervico-thoracic instability who underwent posterior fixation. 86 screws were inserted with the use of the iCT based spinal navigation (group A), 42 screws were implanted using the O-arm navigation system (group B), while 12 screws were inserted under the guidance of fluoroscopy (group C).
Screw positions were evaluated using postoperative CT scans according to the Neo et al (cervical pedicles) and Gertzbein and Robbins (thoracic) classifications. The screws in the cervical lateral mass were evaluated according to a new classification created by the authors. The assessment of the screw placement was retrospectively done and graded by an independent observer. Accurate positioning was defined then as screws that were correctly placed completely within the pedicle as well as screws with a breach of less than 2mm or screws that were correctly placed within the lateral mass as well as screws with incomplete perforation of the cortex.
Results Intraoperative computed tomography based navigation has permitted a more accurate intraoperative evaluation of the implanted screws and has allowed the immediate correction of misplaced screws. With the use of the iCT, the accuracy rate has reached 97.67% with a much better resolution of the imaged acquired, while with the O-arm navigation, the accuracy rate has reached 95.16%. In cervico-thoracic posterior stabilizations done with the aid of fluoroscopy, the intraoperative accuracy was not determined and only a final accuracy rate was measured which reached 91.66%.
Conclusions In subaxial cervico-thoracic posterior fixation either with lateral mass or pedicle screws, the use of iCT-based spinal navigation has demonstrated higher accuracy rates as well as higher quality images allowing more accurate evaluation than with the O-arm-based spinal navigation or fluoroscopy-based systems.
Traumatic brain injury (TBI) with isolated subarachnoid hemorrhage (iSAH) is a common pathology in the emergency department. In many centers, including our institution, a repeat CT scan is routinely performed at 24-72 hours to rule out further hemorrhage progression. In mild TBI patients (GCS 13-15) with iSAH findings, some authors suggest that a repeat head CT scan is of poor value. The aim of this study is to assess the clinical utility of the repeat CT scan in our hospital.
We reviewed the medical charts of all patients with mild TBI and isolated SAH, between January 2015 and October 2017. CT scan at admission and control at 24h to 72h were examined for each patient in order to detect any possible change. Exclusion criteria: age under 18, any other TBI entity on CT scan and GCS less than 13.
Neurological deterioration (GCS and or focal deficit), antiplatelet/anticoagulant therapy, coagulopathy, SAH location, associated injuries and length of stay in hospital were analyzed.
A total of 106 patients with iSAH met the inclusion criteria. 54 patients were female and 52 were male with a mean age of 68.2 years.
Radiological iSAH progression was found in 2 of 106 (1.89%) patients, one of them was under antiplatelet therapy. No neurological deterioration was observed. The mean length of stay in hospital was 12.5 days due other comorbidities. Ten of 106 (9.4%) patients were under anticoagulation therapy and 28 of 106 (26.4%) were under antiplatelet therapy. Of note, two patients out of 106 (1.89%) presented with haemostasis disease (advanced cirrhosis and deficit of factor VII) and no radiological or neurological progression was observed. One patient with extensive iSAH in the sylvian fissure (but no aneurysm) beneficiated a transcranial doppler with normal results.
iSAH in TBI seems to show radiological stability over 72 hours with no neurological deterioration, regardless of antiplatelet or anticoagulation therapy and coagulopathy. Clinical utility of a repeat head CT in such patients is questionable, considering its radiation exposure and cost-effectiveness. Hospital length of stay is due to patients' comorbidities other than TBI. Regardless of anticoagulation/antiplatelet therapy, a 24 hours neurologic observation and a symptomatic treatment solely could be a reasonable alternative. Medico legal controversies and lack of data warrant larger and more consistent studies in order to safely change our practice.
Aims: Spontaneous intracerebral hemorrhage (ICH) is a devastating disease that disproportionately affects the geriatric population. Clinical trials for ICH exclude patients older than 80, limiting our knowledge of the natural history of this condition in this age group. We aimed to characterize this specific ICH population and evaluate how risk factors for in-hospital mortality vary by age group.
Methods: This is a cross sectional study using administrative claims data from hospitals in California between 2005-2011. ICD-9-CM codes were used to (1) identify patients admitted with primary, non-traumatic ICH, (2) ascertain relevant comorbidities, and (3) ascertain in-hospital death. We stratified ICH cases according to age (less than 80 and equal or more than 80) and implemented univariate tests to compare age groups. For each age group, we utilized multivariate logistic regression to model the odds of in-hospital mortality after accounting for potential confounders.
Results: 61,190 ICH cases were admitted during the study period. Of these, 17,471 (29%) were ≥ 80 years old. In-hospital mortality was 27% overall, 31% for those aged ≥ 80 and 25% for those <80 (P<0.001). The elderly ICH population had more females, Caucasians, Medicare, hypertension, heart failure, chronic lung disease, and malignancy, and less smokers, hypercoagulability, and diabetes (all p<0.001). Atrial fibrillation (OR 1.27, CI 1.19-1.35, P<0.001), intubation (OR 14.31, CI 13.63-15.00, P<0.001), and race (OR 0.91, CI 0.90-0.93, P<0.001) were independently associated with mortality in both age cohorts. Chronic kidney disease (OR 1.41, CI 1.28-1.55, P<0.001), malignancy (OR 1.65, CI 1.52-1.78, P<0.001), and female sex (OR 1.12, CI 1.06-1.18, P<0.001) were risk factors for death in the <80 cohort. Heart failure (OR 1.14, CI 1.01-1.27, P=0.03) and type of insurance (OR 1.06, CI 1.02-1.12, P=0.009) were independent risk factors for mortality in the ≥80 cohort.
Conclusions: In California from 2005-2011, the elderly (≥ 80) population comprised 29% of admissions for ICH. Mortality was higher in this age group. Determinants of in-hospital death vary by age group. Further studies are needed to better characterize ICH in the elderly and understand their response to potential therapeutic interventions.
Aims: It remains unclear whether patients with unruptured intracranial aneurysms should be treated. Large size and associated cranial nerve palsies are considered predictors for rupture among unruptured aneurysms. [ref] Vessel wall enhancement (VWE), as determined by high-resolution magnetic resonance vessel wall imaging (HR-VWI), constitutes a robust marker of active aneurysm rupture. [ref] We sought to identify
Methods: We conducted a retrospective analysis of a prospective cohort of patients with A prospectively maintained database of unruptured aneurysms imaged with MR-VWI was retrospectively reviewed. Demographic information, medical comorbidities, and aneurysm properties were obtained. Two expert, blinded reviewers evaluated the presence of VWEscored the aneurysms for degree of wall enhancement (no or thin vs thick). A univariate and multivariate logistic regression modelmodelling was utilized was built to identify assess factors associated with VWE>that predicted thick aneurysm wall enhancement.
Results: : Of the 94 patients with unruptured aneurysms included in the final analysis, 34 (36%) had VWE and 60 (64%) did not. Intra- and inter-rater reliability for VWE ascertainment was excellent (kappa 0.86, 95% CI=0.75-0.97). Symptomatic presentation with thunderclap headaches (OR 8.55, p=0.007) and cranial nerve palsy (OR 219, p=0.002) was independently associated with aneurysm VWE. (both suspicious headache and cranial nerve palsy) was strongly associated with thick aneurysm wall enhancement (suspicious headache OR=8.6, 95% CI=1.9-45.7, p=0.007); cranial nerve palsy OR=219, 95% CI=13.6-13764, p=0.002). Larger aneurysm was also size as a continuous variable was also independently associated with thick wall enhancement (OR 1.26 / mm, 95% CI 1.11-297, (1.26, p=0.003).
Conclusions: Known predictors of aneurysm rupture such as thunderclap headache, cranial nerve palsy and larger aneurysm size are also were independent predictors of for thick WVE in unruptured aneurysms, as evaluated in MR-VWI. This suggests that WVE on MR-VWI may be a useful tool for identifying high risk unruptured aneurysms. wall enhancement.
Objective: High-field intraoperative MR (ioMRI) has become increasingly available in neurosurgery centers. There is little experience with the combination of ioMRI with intraoperative neurophysiological neuromonitoring (IONM). We provide a first series of pediatric patients undergoing brain tumor surgery with 3T ioMRI and IONM.
Methods: We included all consecutive children operated for brain tumors between October 2013 and April 2016 where concomitant ioMRI and somatosensory evoked potentials (SEP) and motor evoked potentials (MEP) were used. All cases were retrospectively analysed concerning neuromonitoring findings and related complications.
Results: During a period of 30 months, 17 children (average age 26 months; 3 females) were operated meeting the criteria. A total of 483 IONM needles were left in place during ioMRI. Of these needles, 119 were located on the scalp, 94 above the chest, and 270 below the chest. Two complications with skin burns (grade I) were observed. In all patients, neuromonitoring was still reliable after MRI. In one case, a threshold increase for MEP-stimulation (20 mA) was necessary after ioMRI; in two cases a reduction of 50% of the SEP amplitude at the end of the surgery was observed, when compared to the values obtained before ioMRI.
Conclusions: The combination of ioMRI and IONM can be safely performed in the pediatric population. IONM data acquisition after ioMRI was feasible and remained reliable.