Johannes Kerschbaumer

A Sandwich Technique for Prevention of Cerebrospinal Fluid Rhinorrhea and Reconstruction of the Sellar Floor after Microsurgical Transsphenoidal Pituitary Surgery.

BACKGROUND Cerebrospinal fluid (CSF) leaks are a well-known complication of transsphenoidal surgery. Several autologous and artificial grafts have been used to close the sellar floor in an attempt to prevent postoperative CSF rhinorrhea. OBJECTIVE To evaluate and describe a sandwich technique to close the sellar floor using autologous bone, absorbable gelatin sponge, and coated collagen fleece. METHODS We reviewed 50 consecutive patients between April 2010 and August 2011 who underwent transsphenoidal surgery ending with reconstruction of the sellar floor with a particular sandwich technique. Patients with an intraoperative CSF leak received an additional lumbar drain. RESULTS There were no cases of CSF rhinorrhea at postoperative follow-up after 6 weeks and no revision surgery. CONCLUSION The proposed sandwich technique for closure of the sellar floor to the sphenoid sinus is a suitable alternative to autologous grafts and seems to be effective in preventing CSF rhinorrhea.

Spinal ependymoma in adults: a multicenter investigation of surgical outcome and progression-free survival

OBJECTIVE Spinal ependymomas are rare glial neoplasms. Because their incidence is low, only a few larger studies have investigated this condition. There are no clear data concerning prognosis and therapy. The aim of the study was to describe the natural history, perioperative clinical course, and local tumor control of adult patients with spinal ependymomas who were surgically treated under modern treatment standards. METHODS The authors performed a multicenter retrospective study. They identified 158 adult patients with spinal ependymomas who had received surgical treatment between January 2006 and June 2013. The authors analyzed the clinical and histological aspects of these cases to identify the predictive factors for postoperative morbidity, tumor resectability, and recurrence. RESULTS Gross-total resection (GTR) was achieved in 80% of cases. At discharge, 37% of the patients showed a neurological decline. During follow-up the majority recovered, whereas 76% showed at least preoperative status. Permanent functional deterioration remained in 2% of the patients. Transient deficits were more frequent in patients with cervically located ependymomas (p = 0.004) and in older patients (p = 0.002). Permanent deficits were independently predicted only by older age (p = 0.026). Tumor progression was observed in 15 cases. The 5-year progression-free survival (PFS) rate was 80%, and GTR (p = 0.037), WHO grade II (p = 0.009), and low Ki-67 index (p = 0.005) were independent prognostic factors for PFS. Adjuvant radiation therapy was performed in 15 cases. No statistically relevant effects of radiation therapy were observed among patients with incompletely resected ependymomas (p = 0.079). CONCLUSIONS Due to its beneficial value for PFS, GTR is important in the treatment of spinal ependymoma. Gross-total resection is feasible in the majority of cases, with acceptable rates of permanent deficits. Also, Ki-67 appears to be an important prognostic factor and should be included in a grading scheme for spinal ependymomas.

Preoperative prediction of language function by diffusion tensor imaging

For surgery of eloquent tumors in language areas, the accepted gold standard is functional mapping through direct cortical stimulation (DCS) in awake patients. Ever since, neuroscientists are searching for reliable noninvasive detection of function in the human brain, with variable success. The potential of diffusion tensor imaging (DTI) in combination with computational cortical parcellation to predict functional areas in language eloquent tumors has not been assessed so far. We present a proof-of-concept report involving awake surgery for a temporodorsal tumor. Postoperatively, the imaging was extensively studied and a predictive value of multimodal MR imaging for the possible extent of resection was analyzed. After resection using DCS, the extent of resection and functional outcome were correlated with the processed imaging. Preoperative imaging of our patient was taken to compute the lesion volume as a seed for tractography (DTI) and combined with a tractography of the entire hemisphere. For better spatial resolution, an elastic image fusion was performed to correct the distortion of DTI data. After subtotal resection and imaging analysis, the status of the superior part of the lesion could be identified and predicted as functional cortex. There was a strong correlation between the tumor remnant during surgery and the imaging parameters of DTI connectivity of the eloquent tissue. A combination of complex DTI processing may be able to predict function in a patient suffering eloquent brain tumors and thus allow estimation of extent of resection.

Disseminated Intravascular Coagulation in Secondary Glioblastoma due to Excessive Intraoperative Bleeding: Case Report and Review of the Literature.

BACKGROUND Disseminated intravascular coagulation (DIC) describes a pathologic activation of coagulation mechanisms, leading to thrombi in various organs with contribution to multiple organ failure. In clinical practice, diagnosis of DIC can often be made by laboratory values, including prolonged coagulation times, thrombocytopenia, or high levels of fibrin degradation products. DIC is frequently observed after neurotrauma, but rarely occurs in patients with primary brain tumors. There are only few case reports of DIC in patients with primary brain tumors, all sharing the highly elevated mortality. We report the case of a young patient presenting with secondary glioblastoma, who developed multiorgan failure induced by DIC after extensive intraoperative bleeding. CASE DESCRIPTION A 30-year-old patient was admitted in poor general condition with insomnia, severe headache, and vomiting. She had undergone surgery for secondary glioblastoma twice. Magnetic resonance imaging revealed a left temporoparietal mass lesion with indication for resection. Surgery then was complicated by diffuse intraoperative bleeding due to a high content of microvascular proliferation as shown in the histopathologic workup. Subsequently, an uncontrollable multiorgan failure developed, causing the patients death 4 days after surgery. CONCLUSIONS Although a rare complication, excessive intraoperative bleeding, especially in surgery for brain tumors located next to the ventricular system, DIC should be kept in mind as a possible diagnosis.

Accuracy Validation of Neuronavigation Comparing Headholder-Based System with Head-Mounted Array—A Cadaveric Study

BACKGROUND Neuronavigation is widely used for intracranial neurosurgical procedures and is commonly based on the standard reference array being fixed to the headholder. Some cases require the reference array to be attached directly to the head. The aim of this cadaveric study was to compare operational accuracy of a head-mounted reference array with the standard headholder-based system. METHODS Navigation accuracy was evaluated with 10 cadaveric specimens. Each specimen was prepared with 8 titanium microscrews that served as reference points on the external skull, and computed tomography was performed. Registration of all specimens was done using surface matching with infrared laser on three-dimensional reconstructed high-resolution computed tomography. In all 10 specimens, the head-mounted reference array and headholder-based system were compared by 10 repetitive measurements. The deviation was evaluated for each screw and compared using nonparametric Mann-Whitney U test between groups and screws. A Bland-Altman plot was generated for comparison. RESULTS A total of 1600 measurements were conducted. Mean deviation was 1.97 mm (95% confidence interval, 1.90-2.03 mm) with the head-mounted reference array and 2.10 mm (95% confidence interval, 2.04-2.18 mm) with the headholder based system. There was no significant difference between methods in 9 of 10 specimens. In 1 specimen, the head-mounted array was superior. The deviation in either method showed a significant correlation, indicating high pertinence for registration (P < 0.001). CONCLUSIONS Navigation with the head-mounted reference array demonstrated comparable accuracy to the headholder-based system and can be used without reduced accuracy. Careful registration is mandatory.

The Volume of the Third Ventricle as a Prognostic Marker for Shunt Dependency After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND Hydrocephalus is a common sequelae of aneurysmal subarachnoid hemorrhage (aSAH). However, in daily routine it is difficult to predict a patients need for ventricular shunt placement in the course of the disease. OBJECTIVE The purpose of this study was to identify radiologic predictors for development of a shunt-dependent hydrocephalus after aSAH. METHODS A cohort of 217 patients with aSAH with adequate pretreatment computed tomography (CT) imaging was retrospectively reviewed. All variables, including demographic data, treatment, and initial CT imaging were gathered and grading was performed using Hunt and Hess, Graeb, LeRoux, and modified Fisher scores. Analysis of the radiographic parameters consisted of straight measurement and three-dimensional volumetry using manual segmentation. Univariate and multivariate statistical analyses were performed to identify predictive parameters. RESULTS Of 217 patients, 36 (17.5%) required a ventricular shunt (VS). A receiver operating characteristic analysis between the volume of the third ventricle and shunt-dependent hydrocephalus showed a significant cutoff at a volume of 2.3 cm3 with a 4.3-fold higher risk for shunt dependency (P < 0.001). However, the treatment modality and classification according to the mentioned scores were not associated with the need for VS after aSAH. In univariate and multivariate analysis, the volume of the third ventricle on admission remained a significant prognostic marker for the need of a VS. CONCLUSIONS Our data suggest that the volume of the third ventricle in the initial CT is a strong predictor for shunt dependency after aSAH.

Comment on: Neurocognitive function varies by IDH1 genetic mutation status in patients with malignant glioma prior to surgical resection

© The Author(s) 2017. Published by Oxford University Press on behalf of the Society for Neuro-Oncology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com doi:10.1093/neuonc/now291 Advance Access date 28 February 2017 increase in natural abundance 2H would result in only 1% of protons in fatty acids from the ketogenic diet to be replaced by 2H. The kinetic isotope effect (KIE) as referred to by Boros et al would reduce rates of enzymatic reactions breaking carbon-deuterium bonds. As such, the presumed high deuterium content of our ketogenic diet as suggested by Boros et al would slow down ketone body metabolism via KIEs on ketolytic enzymes yet also produce deuterated metabolic water. The extent of ketone body metabolism is exactly what we measured in vivo with 13C MR spectroscopy. In contrast to what Boros et al suggest, the relative rate of ketone body oxidation was similar between tumorous and nontumorous brain tissue, and was increased when animals were put on the ketogenic diet (Supplementary Table 2).1 Interestingly, if the level of the elusive deuterated water was indeed high, if anything it could have had a tumor growth–inhibiting effect, as observed by Rodrigues et al after providing 50% (v/v) H2O for 9 days in glioma-bearing rats (which is several orders of magnitude above the 2H enrichment anticipated from a diet with slightly increased 2H content).2

Clinical Neuropathology image 5-2016: nNeurofibrillary tangle-rich ganglioglioma.

No Abstract available.