Jenny Kienzler

Long-term outcome after adjacent two-level anterior cervical discectomy and fusion using stand-alone plasmaphore-covered titanium cages.

BACKGROUND Reports on long-term outcome of stand-alone contiguous two-level anterior cervical discectomy and fusion (ACDF) using stand-alone Plasmaphore-coated titanium cages (PCTCs) are rare, and data on follow-ups > 3 years are missing. OBJECTIVE To evaluate the long-term outcome of adjacent two-level microsurgical ACDF using stand-alone PCTC. PATIENTS/MATERIAL AND METHODS A total of 33 consecutive patients presented with cervical degenerative disc disease (DDD) underwent contiguous two-level ACDF. Clinical long-term evaluation (mean: 61 ± 14 months) included documentation of neurologic deficits (motor deficits, sensory deficits, reflex status, and gait disturbance), neck pain, and radicular pain. Functional outcome was measured using the Odom criteria, patient-perceived outcome, and evaluation of work status. Radiographs were evaluated to assess intervertebral disc height, subsidence, level of fusion, sagittal balance, and implant position. RESULTS Surgery was performed at levels C5-C6 and C6-C7 in 30 patients and at C4-C5 and C5-C6 in 3 (mean age: 50.1 ± 7.7 years). Symptoms and neurologic deficits improved as follows: neurologic deficits (pre: 100%; post: 36%), radicular pain (pre: 85%; post: 15%), and neck pain (pre: 94%; post: 33%). Excellent and good functional and subjective outcome was noted in 75%. Cage subsidence was found to be more prominent in the lower (52%) than the upper (36%) mobile cervical segment. Two-level fusion was documented in most patients (n = 29 [88%]). Kyphotic deformity occurred in two cases (n = 2 [6%]). CONCLUSIONS Stand-alone contiguous two-level ACDF using PCPT proved to be effective, yielding good long-term clinical and functional outcomes. The relatively high rate of subsidence did not affect the good clinical and functional long-term outcome.

Outcome after In-Hospital Rebleeding of Rupture of Intracranial Aneurysms.

BACKGROUND After initial subarachnoidal hemorrhage (SAH), due to an intracranial aneurysm, rebleeding is known as a factor influencing the devastating outcome. This complication has been reported to occur in ∼ 4% of the patients admitted with aneurysmal SAH. Moreover, ultra-early rebleeding within the first 24 hours might occur in 9 to 17% of the cases (40-87% appearing in the first 6 hours). Risk factors influencing this situation include increasing aneurysm size, deterioration of neurologic deficits, angiography within 3 hours of bleeding, sentinel symptoms, and the loss of consciousness at initial bleeding. The aim of this retrospective study was to assess factors and potential risk factors related to rebleeding, specifically the interval from initial SAH to rebleeding. MATERIAL AND METHODS From a consecutive series of 243 patients who experienced aneurysmal SAH, we identified 28 patients (11.5%; 12 men, 16 women; mean age: 58 ± 10 years) who developed in-hospital rebleeding during this 49-month study (2009-2013). Demographic, radiologic, and clinical characteristics including hemodynamic parameters were analyzed. RESULTS Rebleeding was fatal in 20 of the 28 patients (71%) and caused severe neurologic deficits (Glasgow Outcome Scale: 3; modified Rankin Scale: 5) in 3 (29%) of the remaining 8 survivors. Rebleeding occurred within the first 4 hours in 15 patients (54%) within 7, 24, and 48 hours in 17 (61%), 6 (21%), and 1 (4%) patient, respectively. In this series, the medium arterial blood pressure was 98 ± 11 mm Hg at arrival at the emergency department, 88 ± 10 mm Hg before rebleeding, and it dramatically increased to 124 ± 22 mm Hg at rebleeding. For the patients with rebleeding after aneurysmal SAH, initial sentinel headache (79%) and loss of consciousness (68%) were the common presenting symptoms. The World Federation of Neurological Societies grade was documented on admission as follows: 1-3 (n = 14 [50%]); 4-5 (n = 14 [50%]). A Fisher grade 4 was documented in 82% of the cases on the initial computed tomography (CT) scan. Overall, 42% of the cases underwent endovascular (n = 6) or microsurgical occlusion of the aneurysm (n = 6). The rest of the patients (n = 16, 58%) did not underwent occlusion of the aneurysm because of poor clinical status. Digital substraction angiography was performed in 61% of the cases. CONCLUSION Possible factors increasing the risk of in-hospital rebleeding after aneurysmal SAH are high systolic blood pressure, sentinel headache, initial loss of consciousness, poor Hunt and Hess grade, high Fisher grade on initial CT, large aneurysm size, and the performance of angiography. Most of the rebleedings in patients in our center are likely to occur within 7 hours after admission. Based on our findings, we suggest that mobilization of the patient and maneuvers including invasive procedures should be restricted to a minimum during intensive care unit treatment prior to the occlusion of the ruptured aneurysm. Stabilization of blood pressure with adequate sedation and analgesia prior to occlusion can be considered preventive strategies against rebleeding.

Graphical and statistical analyses of the oculocardiac reflex during a non-invasive intracranial pressure measurement

Purpose This study aimed to examine the incidence of the oculocardiac reflex during a non-invasive intracranial pressure measurement when gradual external pressure was applied to the orbital tissues and eye. Methods Patients (n = 101) and healthy volunteers (n = 56) aged 20–75 years who underwent a non-invasive intracranial pressure measurement were included in this retrospective oculocardiac reflex analysis. Prespecified thresholds greater than a 10% or 20% decrease in the heart rate from baseline were used to determine the incidence of the oculocardiac reflex. Results None of the subjects had a greater than 20% decrease in heart rate from baseline. Four subjects had a greater than 10% decrease in heart rate from baseline, representing 0.9% of the total pressure steps. Three of these subjects were healthy volunteers, and one was a glaucoma patient. Conclusion The incidence of the oculocardiac reflex during a non-invasive intracranial pressure measurement procedure was very low and not associated with any clinically relevant effects.

Validation of Noninvasive Absolute Intracranial Pressure Measurements in Traumatic Brain Injury and Intracranial Hemorrhage

BACKGROUND Increased intracranial pressure (ICP) causes secondary damage in traumatic brain injury (TBI), and intracranial hemorrhage (ICH). Current methods of ICP monitoring require surgery and carry risks of complications. OBJECTIVE To validate a new instrument for noninvasive ICP measurement by comparing values obtained from noninvasive measurements to those from commercial implantable devices through this pilot study. METHODS The ophthalmic artery (OA) served as a natural ICP sensor. ICP measurements obtained using noninvasive, self-calibrating device utilizing Doppler ultrasound to evaluate OA flow were compared to standard implantable ICP measurement probes. RESULTS A total of 78 simultaneous, paired, invasive, and noninvasive ICP measurements were obtained in 11 ICU patients over a 17-mo period with the diagnosis of TBI, SAH, or ICH. A total of 24 paired data points were initially excluded because of questions about data independence. Analysis of variance was performed first on the 54 remaining data points and then on the entire set of 78 data points. There was no difference between the 2 groups nor was there any correlation between type of sensor and the patient (F[10, 43] = 1.516, P = .167), or the accuracy and precision of noninvasive ICP measurements (F[1, 43] = 0.511, P = .479). Accuracy was [-1.130; 0.539] mm Hg (CL = 95%). Patient-specific calibration was not needed. Standard deviation (precision) was [1.632; 2.396] mm Hg (CL = 95%). No adverse events were encountered. CONCLUSION This pilot study revealed no significant differences between invasive and noninvasive ICP measurements (P < .05), suggesting that noninvasive ICP measurements obtained by this method are comparable and reliable.

The Extended Subfrontal and Fronto-Orbito-Zygomatic Approach in Skull Base Meningioma Surgery: Clinical, Radiologic, and Cosmetic Outcome.

Objective:To review the outcome and cosmetic results of patients undergoing extended subfrontal and fronto-orbito-zygomatic craniotomy for resection of skull base meningiomas. Methods:All surgeries were performed in cooperation with an oral and maxillofacial surgeon between 2006 and 2012. Clinical presentation, surgical techniques and complications, cosmetic, clinical, and radiologic outcomes are presented. Results:This study included 25 consecutive patients with 26 operations. Total and subtotal tumor removal was obtained in 19 (73.1%) and 7 (26.9%) patients, respectively. Permanent postoperative complications were seen in 5 (19.2%) patients. Eight of 10 patients with preoperative visual impairment showed recovery at 6 months follow-up. Anosmia was improved in 50% and no worsening was seen in any case of hyposmia. All patients showed improved or complete correction of exophthalmos, cognitive deficits, and epilepsy. One patient (3.8%) developed a postoperative ptosis. No mortality was documented. All patients reported a favorable cosmetic satisfactory score over 6 (8.67 ± 1.6). Tumor recurrence rate was 7.7% (n = 2). Conclusions:The extended subfrontal and fronto-orbito-zygomatic approach, used for resection of meningiomas located in the orbita and the skull base can provide better visibility of the tumor. In addition, these approaches lead to highly satisfying cosmetic and clinical results.

A microsurgical bifurcation rabbit model to investigate the effect of high-intensity focused ultrasound on aneurysms: a technical note

BackgroundRecent clinical studies confirmed the high potential of MR-guided focused ultrasound (MRgFUS) in the field of functional neurosurgery. While its ability for precise thermo-ablation within soft tissue is widely recognized, the impact of high-intensity focused ultrasound (HIFU) on larger vessels is less explored. We used a bifurcation aneurysm model in rabbits to investigate the possible effects on the walls of vascular aneurysms and to assess the risk and prospect of this procedure for managing neurovascular disorders.MethodsExperimental bifurcation aneurysms were microsurgically created in New Zealand white rabbits and sonicated using MRgFUS.ResultsA temperature of max. 54°C could be achieved close to the aneurysm, and the shape and size of the aneurysm were noticeably changed, as shown by MR angiography.ConclusionsThe presented rabbit model proved suitable and capable of being extended to acquire data on the effect of HIFU on aneurysms and larger vessels. The fact that HIFU led to an alteration of the aneurysm without inducing rupture encourages further investigations.