Patrick Schuss

Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Factors Influencing Functional Outcome—A Single-Center Series

OBJECTIVE Patients presenting with poor-grade aneurysmal subarachnoid hemorrhage (SAH) have commonly been reported to have a poor prognosis; however, several reports suggest a favorable outcome in a subgroup of patients. We analyzed our database to identify factors determining functional outcome after poor-grade SAH. METHODS During the period 2004-2014, 248 patients with poor-grade SAH were treated in our institution. Poor-grade SAH was defined as World Federation of Neurological Surgeons grades IV-V on admission. Data including patient characteristics, treatment modality, radiologic features, and functional neurologic outcome were assessed and further analyzed. Outcome was assessed according to the modified Rankin Scale after 6 months and stratified into favorable (modified Rankin Scale score 0-2) versus unfavorable (modified Rankin Scale score 3-6). A multivariate analysis was performed to identify predictors of functional outcome. RESULTS A favorable outcome was achieved in 24% of patients with poor-grade SAH. Patients with a favorable outcome were significantly younger (P = 0.005), harbored significantly smaller aneurysms (P = 0.004), and had a lower initial World Federation of Neurological Surgeons grade (P < 0.0001). An unfavorable outcome was significantly more frequent in patients with additional space-occupying hematoma compared with patients without additional space-occupying hematoma (P = 0.0009). On multivariate analysis, patient age, World Federation of Neurological Surgeons grade V, signs of cerebral herniation, aneurysm size, and presence of space-occupying hematoma were identified as significant predictors of unfavorable outcome in patients with poor-grade SAH. CONCLUSIONS A favorable outcome was achieved in 24% of severely ill patients with poor-grade SAH. Therefore, treatment of patients with poor-grade SAH should not be omitted. Careful individualized decision making is necessary for each patient.

Occipital nerve block prior to occipital nerve stimulation for refractory chronic migraine and chronic cluster headache: Myth or prediction?:

Background Occipital nerve stimulation (ONS) results in beneficial outcomes, with marked pain relief, in otherwise intractable chronic migraine (CM) and chronic cluster headache (CCH). Some studies have reported that a positive response to occipital nerve block (ONB) administered prior to ONS predicts a positive response to ONS. However, other studies concerned with proper patient selection claimed no predictive value for ONB. The aim of this study was to re-evaluate the usefulness and predictive value of ONB prior to ONS. Methods Literature searches on the predictive value of ONB were performed in MEDLINE and PubMed. Patient data were extracted and a pooled analysis was performed. Results The literature review revealed 133 patients with CM and seven patients with CCH who received preoperative ONB. To date, a randomized controlled study examining the relationship between ONB and ONS has not been conducted in patients with CM. Conclusions Current literature suggests that ONB does not sufficiently predict ONS responsiveness in patients with refractory CM and CCH; this important issue requires further investigation.

Surgical Treatment of Spinal Dural Arteriovenous Fistula: Management and Long-Term Outcome in a Single-Center Series.

OBJECTIVE To perform a retrospective chart review of surgically treated patients with spinal dural arteriovenous fistula (SDAVF), a rare disease but the most common vascular malformation of the spine, focusing on clinical characteristics and functional outcome during long-term follow-up. METHODS Between June 1990 and April 2012, 29 patients with SDAVFs were treated surgically in a single institution. Patient characteristics, time from onset of symptoms to treatment, radiologic features, treatment-related complications, and functional outcome were analyzed. Outcome was assessed according to the Aminoff-Logue scale during follow-up. Results of magnetic resonance imaging scans performed during long-term follow-up were correlated with functional outcome. RESULTS There were 3 female (10%) and 26 male (90%) patients with SDAVFs treated surgically. Mean age was 61 years ± 11. Location of the fistula was at the thoracic level in 20 patients (69%), at the lumbar level in 8 patients (28%), and at the sacral level in 1 patient (3%). Mean postoperative Aminoff-Logue scale scores regarding gait and micturition improved after treatment compared with preoperatively (P = 0.02; P = 0.03). After surgical treatment, 22 patients (76%) achieved improvement in neurologic symptoms. In 6 patients (21%), neurologic status was the same as preoperatively. In 1 patient (3%), neurologic status worsened. Medullary signal alteration of diagnostic magnetic resonance imaging scans did not correlate with functional outcome (P = 0.2). Mean follow-up time was 63 months ± 55. All SDAVFs were treated in a single session without recurrence during the long-term follow-up period. CONCLUSIONS Surgical treatment of SDAVFs is safe and effective and leads to an improvement of neurologic symptoms in most patients. Surgical treatment of SDAVFs also provides long-term stability.

Acute Traumatic Subdural Hematoma: Surgical Management in the Presence of Cerebral Herniation–A Single-Center Series and Multivariate Analysis

BACKGROUND Traumatic acute subdural hematoma (aSDH) is a severe disease. Surgical treatment is still controversially discussed, especially in patients with additional signs of cerebral herniation. However, previously investigated patient populations were heterogeneous. We therefore performed an analysis of our institutional data in a large homogenous selection of patients with traumatic aSDH to analyze factors determining clinical outcome. METHODS Between 2010 and 2014, 196 patients with aSDH underwent surgical treatment in our department. Information including patient characteristics, treatment modality, radiologic features, and functional outcome were analyzed. Outcome was assessed according to the Glasgow Outcome Scale (GOS) at 6 months and was dichotomized into favorable (GOS score, 1-3) and unfavorable (GOS score 4-5) outcome. Furthermore, a multivariate analysis was performed to identify independent predictors of functional outcome. RESULTS Overall, 26% of patients with aSDH achieved favorable outcome. In further analysis, unilateral or bilateral dilated pupils as a sign of cerebral herniation were present in 47% of the included patients. In the multivariate analysis, age >70 years and the presence of cerebral herniation were significant prognostic predictors for unfavorable outcome in patients with aSDH. However, 15% of patients with aSDH and signs of cerebral herniation achieved favorable outcome during follow-up. CONCLUSIONS We provide detailed data on patients with aSDH and signs of cerebral herniation. Despite mydriasis, favorable outcome may be achieved in many patients. Nevertheless, careful individual decision making is necessary for each patient, especially when signs of cerebral herniation have persisted for a long time.

Accuracy and Safety of Ventriculostomy Using Two Different Procedures of External Ventricular Drainage: A Single-Center Series

Background and Study Aims Patients with acute hydrocephalus are treated by either insertion of a conventional external ventricular drain (EVD) or percutaneous needle trephination (PNT) at our institution, depending on the acuteness of intervention and the severity of illness. We compared both procedures regarding accuracy and safety necessitating surgical revision of EVD or PNT. Methods Between January 2012 and January 2014, 451 ventriculostomies were performed in 301 patients at our institution. All patients underwent routine computed tomography after insertion of the ventricular drain during the treatment course. Patient characteristics, underlying pathology, ventriculostomy modality, radiologic features, catheter tip location, and treatment‐related complications were analyzed. Results A total of 307 of 451 ventriculostomy procedures (68%) were performed as conventional EVD, and 144 (32%) were performed as PNT. Overall, 11% of patients with conventional EVD underwent surgical revision due to lacking accuracy, infection, or hemorrhage; 7% of patients with PNT underwent surgical revision (p = 0.2). However, multivariate analysis revealed that only “hospital stay > 21 days” as an independent variable was significantly associated with surgical revision after ventriculostomy. Conclusion The present data indicate that PNT has a similar safety profile in emergency situations in critically ill patients who need immediate treatment for acute hydrocephalus when compared with the conventional EVD procedure.

Transsphenoidal pituitary surgery: comparison of two sellar reconstruction techniques and their effect on postoperative cerebrospinal fluid leakage

Transsphenoidal surgery is a common procedure in patients with pituitary adenomas. Several techniques have been previously postulated to achieve sufficient sellar reconstruction to avoid cerebrospinal fluid (CSF) leakage. We analyzed our institutional database concerning two sellar reconstruction techniques and development of postoperative CSF leakage. From 2009 to 2015, 255 patients underwent transsphenoidal pituitary surgery at our institution. According to the technique used for sellar reconstruction, patients were divided into two groups: (1) with muscle patch and fibrin glue and (2) with fibrin glue alone. Postoperative CSF leakage occurred in 7% of the patients. Occurrence of postoperative CSF leakage did not differ significantly between both sellar reconstruction techniques (p = 0.2). Patients who underwent sellar reconstruction with fibrin glue alone had significantly shorter operating time (p < 0.0001), as well as shorter length of hospital stay (p = 0.01). On multivariate analysis, occurrence of intraoperative CSF leakage was the only predictor for postoperative CSF leakage (p < 0.0001). The present data suggests that sellar reconstruction after transsphenoidal pituitary surgery seems to be equally effective in preventing postoperative CSF leakage. However, the use of fibrin glue alone results in shorter hospital stay and operating time without exposing patients to more frequent CSF leakage.