Nazife Dinc

Effect of heparin on secondary brain injury in patients with subarachnoid hemorrhage: an additional ‘H’ therapy in vasospasm treatment

Objective Secondary brain injury leads to high morbidity and mortality rates in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, evidence-based treatment strategies are sparse. Since heparin has various effects on neuroinflammation, microthromboembolism and vasomotor function, our objective was to determine whether heparin can be used as a multitarget prophylactic agent to ameliorate morbidity in SAH. Methods Between June 1999 and December 2014, 718 patients received endovascular treatment after rupture of an intracranial aneurysm at our institution; 197 of them were treated with continuous unfractionated heparin in therapeutic dosages after the endovascular procedure. We performed a matched pair analysis to evaluate the effect of heparin on cerebral vasospasm (CVS), cerebral infarction (CI), and outcome. Results The rate of severe CVS was significantly reduced in the heparin group compared with the control group (14.2% vs 25.4%; p=0.005). CI and multiple ischemic lesions were less often present in patients with heparin treatment. These effects were enhanced if patients were treated with heparin for >48 hours, but the difference was not significant. Favorable outcome at 6-month follow-up was achieved in 69% in the heparin group and in 65% in the control group. Conclusions Patients receiving unfractionated continuous heparin after endovascular aneurysm occlusion have a significant reduction in the rate of severe CVS, have CI less often, and tend to have a favorable outcome more often. Our findings support the potential beneficial effects of heparin as a multitarget therapy in patients with SAH, resulting in an additional ‘H’ therapy in vasospasm treatment.

Stereotactic Biopsy of Pineal Lesions

BACKGROUND Stereotactic biopsies are carried out to obtain tumor tissue of unknown entity from cerebral lesions. Thus, tumor tissue can be examined, resulting in correct diagnosis and treatment. These procedures go in hand with high accuracy, high diagnostic yield, and low complication rates. OBJECTIVES The aim of this study is to evaluate the results and complications of stereotactic biopsies carried out for lesions of the pineal region. METHODS We performed a retrospective analysis of our prospective database and included 14 patients who underwent stereotactic biopsy of a pineal lesion between 2006 and February 2016. The Leksell stereotactic frame was used in all patients, and entry and target points were calculated using the BrainLab stereotactic system. We evaluated histopathologic results and postoperative complications such as hydrocephalus and hemorrhage. RESULTS Histopathologic diagnosis was established in all patients. On postoperative computed tomography, 7 patients (50%) showed a circumscribed blood collection at the site of biopsy. Six patients (42.8%) required a cerebrospinal fluid drain preoperatively. Two patients needed external ventricular drain postoperatively (14.2%). One of these patients showed a small hemorrhage area that caused the hydrocephalus. The other patient showed only postoperative swelling. Preoperatively, 2 patients (14.2%) already had a ventriculoperitoneal (VP) shunt, whereas postoperatively, another 4 patients (28.5%) needed a VP shunt. Thus, of the 14 patients, 6 (42.8%) required a VP shunt. CONCLUSIONS Because of their localization, pineal lesions may result in emergence of a hydrocephalus. Stereotactic biopsies in this area may increase this effect and, thus, even VP shunts are necessary in some patients.

Outcome, Prognostic Factors, and Follow-Up Results After Subarachnoid Hemorrhage from Pericallosal Artery Aneurysms

OBJECTIVE Pericallosal artery aneurysms (PAAs) are usually rare (2%-5%), and treatment is challenging for both surgical and endovascular modalities. We performed this analysis to determine the outcome and prognostic factors after subarachnoidal hemorrhage (SAH) caused by ruptured PAAs. METHODS A total of 32 patients with ruptured PAA were admitted to our hospital between 1999 and 2014, added to our prospective database, and analyzed retrospectively. Outcome was measured based on the modified Rankin Scale (mRS) at 6 months after ictus (favorable mRS score, 0-2 vs. unfavorable mRS score, 3-6). RESULTS Only 16 (50%) patients had a good clinical status at admission (World Federation of Neurological Surgeons Grading System [WFNS] grades I-III), whereas 12 patients (37.5%) were comatose (WFNS grade V). In 18 patients (56%), intracerebral hemorrhage was confirmed, in 18 patients (56%) cerebrospinal fluid drainage was required immediately after admission, and in 5 cases (16%) decompressive craniectomy was performed. There were 17 patients (53.1%) who achieved a favorable outcome (mRS score 0-2) at follow-up. Unfavorable outcome was associated with smoking, cerebral infarction, and worse admission status after multiple logistic regression analysis. CONCLUSIONS Poor admission status, cerebral infarction, and smoking seem to be crucial factors for unfavorable outcome after SAH from PAA.

Biopsies of pediatric brainstem lesions display low morbidity but strong impact on further treatment decisions.

OBJECTIVE The course of malignant brain stem gliomas in childhood is rarely positive. Because of limited therapeutic options and potentially hazardous biopsies oncologist often relay on MRI diagnoses only for further therapy decisions. In this study we show that brain stem biopsies display a low morbidity rate and neuropathological assessment has a considerable impact on further treatment decision. METHODS Within 18-months five children with brainstem symptoms and the radiological diagnosis of a malignant brainstem glioma, were identified. From this time point it was possible to analyze all samples with the 450K methylome analysis. Other neuropathological techniques included classical histology with immunohistochemistry. Surgery was performed as biopsy, either microsurgical, frame-guided (Leksell), robot-assisted (ROSA) or navigated (BrainLab, two children). RESULTS Mean age of the children was 7.5years (range: newborn to 12years). There was no biopsy-related morbidity or mortality. The mean number of taken samples was 12 (range: 1-25). Histologic diagnosis could be established in all children, however, 450K methylome diagnosis was positive in only two out of five patients. CONCLUSION Despite the technically difficult biopsies, all specimens were sufficient for immunohistochemical diagnosis, however, 450K methylome analysis could only be better established where multiple small samples were taken, instead of few larger ones. Based on the preoperative radiological diagnosis suggesting malignant brainstem glioma, all children would have been treated with combined radiation and temozolomid chemotherapy. Nevertheless, due to the availability of histology and molecular diagnostics, individualized therapy could be performed, preventing in two out of five children from unnecessary radiation and chemotherapy.

Intracranial Ameloblastoma Arising from the Maxilla: An Interdisciplinary Surgical Approach

Background Ameloblastomas are a rare tumor entity accounting for only 10% of all odontogenic tumors. They mostly originate from the mandible. Only a few cases are known to grow aggressively and to invade the orbit, nasal cavity, or even the brain. Patient and Methods/Case Report We present the case of a 57‐year‐old patient who was admitted with a huge tumor involving the nasal cavity, the left maxilla, and the anterior fossa. Histologic diagnosis was made by biopsy. A combined two‐stage neurosurgical maxillofacial approach was planned. First the intracranial tumor mass was removed using bifrontal trepanation. A duraplasty was sewn in to cover the brain. In the second procedure, a combined bifrontal and midfacial approach was used by craniofacial plastic surgeons and neurosurgeons. A perisinusoidal tumor mass and retropharyngeal tumor mass was removed up to the skull base. The left orbit was completely exenterated, and a fibular bone‐muscle graft was used for palatal, orbital, and facial reconstruction. The facial vein and artery were carefully prepared to feed the bone‐muscle graft by end‐to‐end anastomoses. Conclusion Ameloblastomas are very rare slow‐growing tumors that show a tendency to recur. They are responsible for only 1% of all oral tumors. Their growth can be enormous, and they can extend into sinusoidal cavities, the orbit, and the brain. Complex and extensive palliative surgery can ease the concerns of these patients and prolong their survival.

International multicentre validation of the arteriovenous malformation-related intracerebral haemorrhage (AVICH) score

Objective The recently published arteriovenous malformation-related intracerebral haemorrhage (AVICH) score showed better outcome prediction for patients with arteriovenous malformation (AVM)-related intracerebral haemorrhage (ICH) than other AVM or ICH scores. Here we present the results of a multicentre, external validation of the AVICH score. Methods All participating centres (n=11) provided anonymous data on 325 patients to form the Spetzler-Martin (SM) grade, the supplemented SM (sSM) grade, the ICH score and the AVICH score. Modified Rankin score (mRS) at last follow-up (mean 25.6 months) was dichotomized into favourable (mRS 0-2, n=210) and unfavourable (mRS 3-6;n=115). Univariate and AUROC analyses were performed to validate the AVICH score. Results Except nidus structure and AVM size, all single parameters forming the SM, sSM, ICH and AVICH score and the scores itself were significantly different between both outcome groups in the univariate analysis. The AVICH score was confirmed to be the highest predictive outcome score with an AUROC of 0.765 compared with 0.705 for the ICH score and 0.682 for the sSM grade. Conclusion The multicentre-validated AVICH score predicts clinical outcome superior to pre-existing scores. We suggest the routine use of this score for future clinical outcome prediction and in clinical research. Trial registration number NCT02920645.

Posterior fossa AVMs: Increased risk of bleeding and worse outcome compared to supratentorial AVMs

Infratentorial AVMs are often considered as potentially hazardous as they are thought to present more often with hemorrhage, may harbor AVM-associated aneurysms more frequently and to be associated with poor outcome. The aim of our study is to compare features of supratentorial and infratentorial AVMs. We retrospectively analyzed 316 consecutive patients with cerebral AVM presenting to our neurovascular center between 2005 and 2015. Location and angioarchitecture of the AVM including AVM-associated aneurysms, bleeding events, and outcome during follow up were analyzed. Outcome was assessed using the modified Rankin Scale (mRS) and stratified into favorable (mRS 0-2) and unfavorable (mRS 3-6). 41.6% of the patients with a supratentorial AVM (stAVM) and 69.2% of the patients with an infratentorial AVM (itAVM) were presented with a hemorrhage initially (p < .001). Patients with itAVMs were older at presentation (mean 48.1 vs. 37.9 years, p < .001). ItAVMs furthermore were smaller (95.1% <3 cm nidus-diameter, p < .001) and had lower Spetzler-Martin-Grades (p = .04). Associated aneurysms were more frequent in itAVMs (38.5% vs. 20.7%, p < .004) and were associated with an increased risk of hemorrhage at presentation (30.9% vs. 18.7%, p = .013). Outcome was poor in 10.8% of the patients with stAVM and in 28.3% of patients with itAVM (p < .001). The risk of a new hemorrhage-associated deficit was significantly higher in itAVMs (p < .001). Most posterior fossa AVMs are associated with an increased hemorrhage rate. Thus they are a predictor for poor outcome and should be treated even if unruptured to maintain good neurological function.

Prognostic risk factors for postoperative hemorrhage in stereotactic biopsies of lesions in the basal ganglia

OBJECTIVE The risk of hemorrhages after stereotactic biopsy is known to be low. Nevertheless hemorrhages in eloquent areas result in neurological deficit for the patients. Since the basal ganglia resemble a particularily high vascularized and eloquent location, which is often the source of hypertensive hemorrhages, we aimed to analyse possible risk factors for hemorrhage after stereotactic biopsy in this region. PATIENTS AND METHODS We performed a retrospective analysis including patients who underwent stereotactic biopsies of lesions in the basal ganglia between January 2012 and January 2017. 63 patients were included in this study. We accessed age, gender, histopathological diagnosis, hypertension, blood pressure intraoperative, anticoagulative medication and postoperative hemorrhage. RESULTS Fishers exact test revealed no significant p-values concerning anticoagulative therapy, gender, smoking and hypertension concerning postoperative hemorrhage. Wilcoxon-Mann-Whitney-Test showed no significant correlation for systolic blood pressure intraoperative, number of tissue samples and age with hemorrhage. A trend for lymphoma in correlation with postoperative hemorrhage was in patients with Lymphoma (Wilcoxon-Mann-Whitney Test). CONCLUSION Stereotactic biopsies even in eloquent areas as the basal ganglia are a safe procedure even if patients suffer under hypertension or are smoker. None of the here examined risk factors showed a significant correlation with postoperative hemorrhage. Accessing tumor tissue for histopathological diagnosis is mandatory for adequate therapy.

Stereotactic biopsy of cerebellar lesions: straight versus oblique frame positioning

Abstract Objective: Biospies of brain lesions with unknown entity are an everyday procedure among many neurosurgical departments. Biopsies can be performed frame-guided or frameless. However, cerebellar lesions are a special entity with a more complex approach. All biopsies in this study were performed stereotactically frame guided. Therefore, only biopsies of cerebellar lesions were included in this study. We compared whether the frame was attached straight versus oblique and we focused on diagnostic yield and complication rate. Methods: We evaluated 20 patients who underwent the procedure between 2009 and 2017. Median age was 56.5 years. 12 (60%) Patients showed a left sided lesion, 6 (30%) showed a lesion in the right cerebellum and 2 (10%) patients showed a midline lesion. Results: The stereotactic frame was mounted oblique in 12 (60%) patients and straight in 8 (40%) patients. Postoperative CT scan showed small, clinically silent blood collection in two (10%) of the patients, one (5%) patient showed haemorrhage, which caused a hydrocephalus. He received an external ventricular drain. In both patients with small haemorrhage the frame was positioned straight, while in the patient who showed a larger haemorrhage the frame was mounted oblique. In all patients a final histopathological diagnosis was established. Conclusion: Cerebellar lesions of unknown entity can be accessed transcerebellar either with the stereotactic frame mounted straight or oblique. Also for cerebellar lesions the procedure shows a high diagnostic yield with a low rate of severe complications, which need further treatment.