David Bellut

Hydrocephalus in 389 patients with aneurysm-associated subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) often leads to hydrocephalus, which is commonly treated by placement of a ventriculoperitoneal (VP) shunt. There is controversy over which factors affect the need for such treatment. In this study, data were prospectively collected from 389 consecutive patients who presented with an aneurysm-associated SAH at a single center. External ventricular drainage placement was performed as part of the treatment for acute hydrocephalus, and VP shunts were placed in patients with chronic hydrocephalus. The data were retrospectively analyzed using two-sample t-tests, Fishers exact test and logistic regression analysis. Overall, shunt dependency occurred in 91 of the 389 patients (23.4%). Using logistic regression analysis, two factors were found to be significantly associated with VP shunt placement: an initial Glasgow Coma Scale (GCS) score of 8-14 (8-14 versus 3-7, p = 0.016; 15 versus 3-7, p = 0.55); and aneurysm coiling (p = 0.017). Patients with an initial GCS score of 8-14 after aneurysm-associated SAH had a 2.5-fold higher risk of receiving a VP shunt than those with a GCS score of 3-7. Those with a GCS of 15 had a 50% lower risk of becoming shunt dependent than did the subgroup with a GCS score of 8-14. To clarify and strengthen these observations, prospective, randomized trials are needed.

Monitoring of the Inflammatory Response After Aneurysmal Subarachnoid Haemorrhage in the Clinical Setting: Review of Literature and Report of Preliminary Clinical Experience

BACKGROUND Clinical and experimental studies showed a marked inflammatory response in aneurysmal subarachnoid haemorrhage (SAH), and it has been proposed to play a key role in the development of cerebral vasospasm (CVS). Inflammatory response and occurrence of CVS may represent a common pathogenic pathway allowing point of care diagnostics of CVS. Therefore, monitoring of the inflammatory response might be useful in the daily clinical setting of an ICU. The aim of the current report is to give a summary about factors contributing to the complex pathophysiology of inflammatory response in SAH and to discuss possible monitoring modalities. METHODS Review and analysis of the existing literature and definition of own study protocols. RESULTS In cerebrospinal fluid, interleukin (IL)-6 has been found to be significantly higher in patients with CVS during the peri-vasospasm period. While systemic inflammatory response syndrome, high C-reactive protein levels and leukocyte counts has been linked with the occurrence of CVS, less has been reported about cytokines levels in the jugular bulb of the internal jugular vein and in the peripheral blood. Preliminary evaluation of own data suggests, that IL-6 values in the peripheral blood and the arterio-jugular differences of IL-6 are increased with the inflammatory response after SAH. CONCLUSION Monitoring of the inflammatory response, in particular IL-6, might be a useful tool for the daily clinical management of patients with SAH and CVS.

Subdural Drainage versus Subperiosteal Drainage in Burr-Hole Trepanation for Symptomatic Chronic Subdural Hematomas

BACKGROUND Symptomatic chronic subdural hematoma (scSDH) is one of the most frequent diseases in neurosurgical practice, and its incidence is increasing. However, treatment modalities are still controversial. OBJECT The aim of this retrospective single-center study is to compare for the first time two surgical methods in the treatment of subdural hematoma that have been proven to be efficient in previous studies in a direct comparison. METHODS We analyzed the data of 143 scSDHs in 113 patients undergoing surgery for subdural hematoma with placement of subperiosteal or subdural drainage after double burr-hole trepanation for hematoma evacuation. RESULTS Overall, there were no statistically significant differences regarding general patient characteristics, preoperative and postoperative symptoms, postoperative hematoma remnant, rates of recurrences, mortality, complications, and outcome at discharge and at 3-month follow up between the groups. There was a close to significant tendency of lower mortality after placement of subperiosteal drainage system and a tendency towards lower rate of recurrent hematoma after placement of subdural drainage system. CONCLUSIONS Our study shows for the first time a direct comparison of two mainly used surgical techniques in the treatment of scSDH. Both methods proved to be highly effective, and general patient data, complications, outcome and mortality of both groups are equal or superior compared with previously published series. Because there is a clear tendency to less mortality and fewer serious complications, treatment with double burr-hole trepanation, irrigation, and placement of subperiosteal drainage is our treatment of choice in patients with predictable high risk of complications.

Impact of Ultra-Low-Field Intraoperative Magnetic Resonance Imaging on Extent of Resection and Frequency of Tumor Recurrence in 104 Surgically Treated Nonfunctioning Pituitary Adenomas

OBJECTIVE To analyze the impact of intraoperative ultra-low-field magnetic resonance imaging (MRI) on the extent of tumor resection in nonfunctioning pituitary adenomas (NFPAs). METHODS Retrospective analysis was performed of 104 consecutive cases undergoing intraoperative MRI-guided transsphenoidal surgery for NFPA. General patient data; endocrinologic parameters; neurologic examinations; preoperative and postoperative symptoms; preoperative, intraoperative, and postoperative imaging; and proliferation index were evaluated with an overall mean follow-up of 34 months. RESULTS The use of intraoperative MRI led to an increase of the overall remission rate by 52.2%, from 44.2% to 67.3%. Tumor characteristics such as size and invasiveness had an important impact on postoperative remission rate. In patients with macroadenoma and without previous pituitary surgery, a remission rate of 82.2% was achieved. Overall, the sensitivity of intraoperative MRI in the study was 32.4%. There were no false-positive interpretations. A higher proliferation index was found in the 15 patients with postoperative enlargement of residual adenomas or tumor recurrence compared with the other patients of the study group. CONCLUSIONS This study shows that the outcome of surgical treatment of NFPAs was improved by the use of intraoperative MRI owing to more radical resection. The remission rate seems to depend on tumor characteristics. Recurrent disease might be reduced by the use of intraoperative MRI leading to more complete surgical resection of NFPAs.

Extracranial–intracranial bypass in atherosclerotic cerebrovascular disease: report of a single centre experience

Despite the failure of the international extracranial–intracranial (EC–IC) bypass study in showing the benefit of bypass procedure for prevention of stroke recurrence, it has been regarded to be beneficial in a subgroup of well-selected patients with haemodynamic impairment. This report includes the EC–IC bypass experience of a single centre over a period of 14 years. All consecutive 72 patients with atherosclerotic occlusive cerebrovascular lesions associated with haemodynamic compromise treated by EC–IC bypass surgery were retrospectively reviewed. Pre-operatively, 61% of patients presented with minor stroke and the remaining 39% with recurrent transient ischemic attacks (TIAs) despite maximal medical therapy. Angiography revealed a unilateral internal carotid artery (ICA) stenosis/occlusion in 79%, bilateral ICA stenosis/occlusion in 15%, MCA stenosis/occlusion in 3% and other multiple vessel stenosis/occlusion in 3% of the cases. H215O positron emission tomography (PET) or 99mTc-HMPAO SPECT with acetazolamide challenge was performed for haemodynamic evaluation of the cerebral blood flow (CBF). All the patients had impaired haemodynamics pre-operatively in terms of reduced regional cerebrovascular reserve capacity and rCBF. Standard STA-MCA bypass procedure was performed in all patients. A total of 68 patients with 82 bypasses were reviewed with a mean follow-up period of 34 months. Stroke recurrence took place in 10 patients (15%) resulting in an annual stroke risk of 5%. Improved cerebral haemodynamics was documented in 81% of revascularised hemispheres. Patients with unchanged or worse haemodynamic parameters had significantly more post-operative TIAs or strokes when compared to those with improved perfusion reserves (30% vs.5% of patients, p < 0.05). In conclusion, EC–IC bypass procedure in selected patients with occlusive cerebrovascular lesions associated with haemodynamic impairment has revealed to be effective for prevention of further cerebral ischemia, when compared with a stroke risk rate of 15% reported to date in patients only under antiplatelet agents or anticoagulant therapy.

Preoperative angiotensin converting enzyme inhibitor usage in patients with chronic subdural hematoma: Associations with initial presentation and clinical outcome

The aim of this study is to analyze the association of preoperative usage of angiotensin converting enzyme (ACE) inhibitors with the initial presentation and clinical outcome of patients with chronic subdural hematoma (cSDH). Patients treated for cSDH between 2009 and 2013 at our institution were included in this retrospective case-control study. Medical charts were reviewed retrospectively and data were analyzed using descriptive and inferential statistics. Out of 203 patients (58 females, mean age 73.2years), 53 (26%) patients were on ACE inhibitors before their presentation with cSDH. Median initial hematoma volume in individuals with ACE inhibitors (179.2±standard error of the mean [SEM] 13.0ml) was significantly higher compared to patients without ACE inhibitors (140.4±SEM 6.2ml; p=0.007). There was an increased probability of surgical reintervention in the ACE inhibitor group (12/53, 23% versus 19/153, 12%; p=0.079), especially in patients older than 80years (6/23, 26% versus 3/45, 7%; p=0.026). ACE inhibitors are associated with higher hematoma volume in patients with cSDH and with a higher frequency of recurrences requiring surgery (especially in the very old). We hypothesize that these effects are due to ACE inhibitor induced bradykinin elevation causing increased vascular permeability of the highly vascularized neomembranes in cSDH.

Systemic interleukin-6 concentrations in patients with perimesencephalic non-aneurysmal subarachnoid hemorrhage

Patients with spontaneous non-aneurysmal subarachnoid hemorrhage (non-aSAH) are considered to have a benign illness in contrast to patients with aSAH. The occurrence of the systemic inflammatory response syndrome has been linked to worse outcomes in patients with aSAH. We analyzed systemic interleukin (IL)-6, a proinflammatory cytokine, to determine whether its concentration differs between patients with non-aSAH and those with aSAH, reflecting the more benign illness. Daily systemic IL-6 levels were measured in the acute phase in 11 patients with non-aneurysmal perimesencephalic SAH (pmSAH), with bleeding strictly located around the midbrain, and in nine patients with non-aneurysmal non-perimesencephalic (non-pmSAH), with hemorrhage extending into adjacent cisterns (group 1). IL-6 levels were compared with those from patients suffering from aSAH with cerebral vasospasm (CVS) (group 2) and without CVS (group 3). The mean IL-6 level (±standard error of the mean) was significantly lower in group 1 compared to group 2 (9.9±1.9 vs. 29.1±6.7 pg/mL, p=0.018). The difference in mean IL-6 level between group 1 and 3 fell short of significance (9.9±1.9 vs. 14.9±1.1 pg/mL, p=0.073). Patients in group 1 had a significantly better outcome (Glasgow Outcome Scale score 4-5) compared to group 2 (p<0.001) and a trend towards better outcome compared to group 3 (p=0.102). A subgroup analysis revealed a higher mean IL-6 concentration in patients with non-pmSAH compared to patients with pm-SAH (p=0.001). We concluded that systemic IL-6 concentration reflects the severity of the inflammatory stress response and course of the illness. The more benign illness and good prognosis of patients with pmSAH or non-pmSAH in contrast to patients with aSAH is reflected by the lower concentrations of IL-6.

Validating a therapy-oriented complication grading system in lumbar spine surgery: a prospective population-based study

The aim of the present study was to validate a therapy-oriented complication grading system in a well-defined neurosurgical patient population in which complications may entrain neurological deficits, which are severe but not treated. The prospective patient registry of the Department of Neurosurgery, University of Zurich provides extensive population-based data. In this study we focused on complications after lumbar spine surgeries and rated their severity by Clavien-Dindo grade (CDG). Analyzing 138 consecutive surgeries we noted 44 complications. As to treatment, CDG correlated with the length of hospital stay and treatment cost. As to patient outcome, CDG correlated with performance and outcome (McCormick). The present study demonstrates the correlation between outcome scales and the CDG. While the high correlation of CDG with costs seems self-evident, the present study shows this correlation for the first time. Furthermore, the study validates the CDG for a surgical subspecialty. As a further advantage, CDG registers any deviation from the normal postoperative course and allows comparison between surgical specialties.

Affective Symptoms and White Matter Changes in Brain Tumor Patients

BACKGROUND Affective symptoms are frequent in patients with brain tumors. The origin of such symptoms is unknown; either focal brain injury or reactive emotional distress may be responsible. This cross-sectional pilot study linked depressive symptoms and anxiety to white matter integrity. The objective was to test the hypothesis of a relationship between tissue damage and brain function in patients with brain tumors and to provide a basis for further studies in this field. METHODS Diffusion tensor imaging was performed in 39 patients with newly diagnosed supratentorial primary brain tumor. Patients completed the Beck Depression Inventory, and examiners rated them on the Hamilton Depression Rating Scale (HDRS). State and trait anxiety were measured using the State-Trait Anxiety Inventory. Correlations between fractional anisotropy (FA) and psychological measures were assessed on the basis of regions of interest; the defined regions of interest corresponded to clearly specified white matter tracts. RESULTS Statistical analysis revealed correlations between FA in the left internal capsule and scores on the HDRS, Beck Depression Inventory, and State-Trait Anxiety Inventory (P < 0.05). HDRS scores were also correlated with FA in the right medial uncinate fasciculus, and state anxiety scores were significantly correlated with FA in the left lateral and medial uncinate fasciculus (P < 0.05). CONCLUSIONS Our results suggest that neurobiologic mechanisms related to the integrity of tissue in specific white matter tracts may influence affective symptoms in patients with brain tumors, and these mechanisms can be investigated with diffusion tensor imaging. However, prospective observational studies are needed to investigate further the links between brain structures and the severity of affective symptoms in this patient population.

Ventricular Catheter Systems with Subcutaneous Reservoirs (Ommaya Reservoirs) in Pediatric Patients with Brain Tumors: Infections and Other Complications.

OBJECTIVE This study aims to describe complications related to ventricular catheter systems with subcutaneous reservoirs (VCSR) (such as Ommaya reservoirs) in pediatric patients with brain tumors. METHODS Retrospective analysis of consecutive patients with a total of 31 VCSR treated at the Childrens University Hospital of Zurich, Switzerland. RESULTS A total of 20 patients with a median age of 3.3 years at VCSR implantation received 31 VCSR. Overall, 19 complications in 11 patients were recorded: 7 patients had a VCSR-related infection with coagulase-negative staphylococci, 4 of these probably as a surgical complication and 3 probably related to VCSR use. Systemic perioperative prophylaxis was administered in 22 cases, and intraventricular vancomycin and gentamicin were given in 8 cases (none of which subsequently developed an infection). Other complications included wound dehiscence, catheter malplacement, and leakage of cerebrospinal fluid. Overall, 17 VCSR were explanted due to complications. CONCLUSION Infections were the most frequent VCSR-related complication. In our own institution, the high rate of complications led to the definition of a bundle of measures as a standard operating procedure for VCSR placement and use. Prospective studies in larger patient collectives are warranted to better identify risk factors and evaluate preventive measures such as the administration of perioperative antibiotics and the use of antimicrobial coating of catheters.