Commentary [Decompressive craniectomy in patients with cerebral infarction due to malignant vasospasm after aneurysmal subarachnoid hemorrhage]

Commentary: article "Decompressive craniectomy in patients with cerebral infarction due to malignant vasospasm after aneurysmal subarachnoid hemorrhage" on page 251 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3505309

Acute management of poor condition subarachnoid hemorrhage patients

Poor condition subarachnoid hemorrhage (SAH) patients present a high mortality and morbidity. In this study, we reviewed the acute interventional (surgical and endovascular) management of 109 SAH-poor condition patients, who were treated as early as logistically possible after confirming stable circulation parameters. Patients over the age of 70 years, without clinical response to painful stimulation were excluded. We recognized at least 3 different postinterventional therapeutic approaches: (1) Norm- or hypovolemic, normotensive hemodilution in 30 patients with space-occupying intracranial hematomas as well as in 31 cases with acute cerebro-spinal-fluid obstruction. (2) Normovolemic, hypertensive hemodilution after unilateral decompressive craniotomy in 23 surgical- and 2 endovascular-treated patients with focalized space occupying lesions and reduced cerebral perfusion. (3) Hypovolemic, normo-, or hypertensive hemodilution after bilateral decompressive craniotomy in 23 cases with massive brain-swelling. We observed a reduced mortality (21%). The overall late outcome was favorable in 56% and unfavorable in 23%. Selective aggressive treatment adapted to increase the cerebral perfusion, seems to be an effective therapy to improve the survival and outcome of several poor condition SAH-patients

Acute management of poor condition subarachnoid hemorrhage patients

Poor condition subarachnoid hemorrhage (SAH) patients present a high mortality and morbidity. In this study, we reviewed the acute interventional (surgical and endovascular) management of 109 SAH-poor condition patients, who were treated as early as logistically possible after confirming stable circulation parameters. Patients over the age of 70 years, without clinical response to painful stimulation were excluded. We recognized at least 3 different postinterventional therapeutic approaches: (1) Norm- or hypovolemic, normotensive hemodilution in 30 patients with space-occupying intracranial hematomas as well as in 31 cases with acute cerebro-spinal-fluid obstruction. (2) Normovolemic, hypertensive hemodilution after unilateral decompressive craniotomy in 23 surgical- and 2 endovascular-treated patients with focalized space occupying lesions and reduced cerebral perfusion. (3) Hypovolemic, normo-, or hypertensive hemodilution after bilateral decompressive craniotomy in 23 cases with massive brain-swelling. We observed a reduced mortality (21%). The overall late outcome was favorable in 56% and unfavorable in 23%. Selective aggressive treatment adapted to increase the cerebral perfusion, seems to be an effective therapy to improve the survival and outcome of several poor condition SAH-patients

Survival analysis of HDR brachytherapy versus reoperation versus temozolomide alone: a retrospective cohort analysis of recurrent glioblastoma multiforme

Objectives Tumour recurrence of glioblastoma multiforme (GBM) after initial treatment with surgical resection, radiotherapy and chemotherapy is an inevitable phenomenon. This retrospective cohort study compared the efficacy of interstitial high dose rate brachytherapy (HDR-BRT), re-resection and sole dose dense temozolomide chemotherapy (ddTMZ) in the treatment of recurrent glioblastoma after initial surgery and radiochemotherapy. Design Retropective cohort study. Setting Primary level of care with two participating centres. The geographical location was central Germany. Participants From January 2005 to December 2010, a total of 111 patients developed recurrent GBM after initial surgery and radiotherapy with concomitant temozolomide. The inclusion criteria were as follows: (1) histology-proven diagnosis of primary GBM (WHO grade 4), (2) primary treatment with resection and radiochemotherapy, and (3) tumour recurrence/progression. Interventions This study compared retrospectively the efficacy of interstitial HDR-BRT, re-resection and ddTMZ alone in the treatment of recurrent glioblastoma. Primary and secondary outcome measures Median survival, progression free survival and complication rate. Results Median survival after salvage therapy of the recurrence was 37, 30 and 26 weeks, respectively. The HDR-BRT group did significantly better than both the reoperation (p<0.05) and the ddTMZ groups (p<0.05). Moderate to severe complications in the HDR-BRT, reoperation and sole chemotherapy groups occurred in 5/50 (10%), 4/36 (11%) and 9/25 (36%) cases, respectively. Conclusions CT-guided interstitial HDR-BRT attained higher survival benefits in the management of recurrent glioblastoma after initial surgery and radiotherapy with concurrent temozolomide in comparison with the other treatment modalities. The low risk of complications of the HDR-BRT and the fact that it can be delivered percutaneously in local anaesthesia render it a promissing treatment option for selected patients which should be further evaluated

Zeitpunkt der Kranioplastik nach supratentorieller dekompressiver Kraniektomie : eine retrospektive Analyse

Die supratentorielle dekompressive Kraniektomie mit Eröffnung und Erweiterungsplastik der Dura mater ist heutzutage eine wichtige Therapiemaßnahme in der Behandlung des konservativ nicht kontrollierbaren Hirndrucks. Unter Kranioplastik versteht man den chirurgischen Verschluss des entstandenen Knochendefekts zum Schutz des direkt unter der Kopfhaut liegenden Gehirns, zur ästhetischen Wiederherstellung der Konturen sowie zur Verbesserung einer neurologischen Symptomatik („syndrome of the trephined“). In der vorliegenden Arbeit werden die Daten von insgesamt 242 Patienten, die einer Kranioplastik unterzogen worden waren, retrospektiv analysiert. Die Patienten wurden im Zeitraum 2001-2008 in der neurochirurgischen Abteilung der Städtischen Kliniken Frankfurt am Main-Höchst operiert. Um Aufschluss über das postoperative, funktionelle und kosmetische Ergebnis zu erhalten, wurde im Anschluss an die Aktenauswertung bei diesen Patienten eine telefonische Befragung durchgeführt. Ziel der Arbeit war es, die bisherigen Erfahrungen der Kalottenplastik und insbesondere der autogenen orthotopen Knochendeckelreimplantation im Hinblick auf die verschiedenen Kranioplastik Zeitpunkte zu untersuchen und unter klinischen Aspekten zu bewerten. Die Frage des Kranioplastik Zeitpunktes ist essentiell für die Therapieplanung. Das autologe Schädelknochentransplantat hat bessere Eigenschaften und Qualitäten als alle anderen alloplastischen Materialien. In Anbetracht der perfekten Histokompatibilität, der optimalen biomechanischen Eigenschaften, der guten anatomischen Fusion mit dem umgebenden Knochen und der Möglichkeit der partiellen oder totalen Revitalisation des Transplantats, besteht kein Zweifel, dass der autologe Knochen immer zu verwenden ist, wenn die Möglichkeit dazu besteht. Die Analyse der Patientengruppen ergab, dass die ultra frühe Kranioplastik der Patienten mit großen Defekten nach dekompressiver Kraniektomie ein besseres Outcome im langfristigen Follow-up hat. Diese Patienten hatten keine gesteigerte Infektions- oder andere Komplikationsraten. Das Timing der Kranioplastik spielt eine Rolle in der Komplikationsrate nur bei den Patienten, die sekundär eine Komplikation erlitten haben. Patienten, die nach der Kraniektomie eine Nachblutung, einen Infarkt oder eine Infektion erlitten haben, hatten eine signifikant höhere Infektionsrate bei ultra früher Kranioplastik. Insbesondere soll betont werden, dass der Trend einer Häufung von Wundheilungsstörungen und Infektionen mit der Folge einer erneuten Explantation des Knochendeckels bei Patienten nach autogener Knochendeckelreimplantation mit mehr als 2 Risikofaktoren und bei Patienten mit kompliziertem Verlauf nach Kraniektomie festgestellt wurde. Gemäß den Ergebnissen dieser Patientenserie kann die ultra frühe Kranioplastik bei ausgewählten Patienten mittels Reimplantation des Eigenknochens als ein sicheres und hilfreiches Verfahren für die schnellere Rehabilitation und Besserung der neurologischen Funktion und der Prognose bewertet werden. Ähnlich gute Ergebnisse zeigten die Pantienten in der Gruppe 1 der ultra frühen Kranioplastik die aufgrund einer Liquorzirkulationsstörung ein VP Shunt System als kombinierte Therapie in der gleichen Sitzung erhalten haben. Somit kann zusammenfassend festgehalten werden: Die Ergebnisse dieser Arbeit bestätigen, dass die Kranioplastik nach einer supratentoriellen dekompressiven Kraniektomie mit Reimplantation des eigenen Schädelknochens zum frühesten möglichen Zeitpunkt ein sicheres und effektives Verfahren darstellt und bei ausgewählten Patienten sogar bessere Ergebnisse als die späte Kranioplastik haben kann. Eine mögliche Erklärung dafür könnte das Auftreten und die Persistenz von neurologischen Defiziten im Rahmen des „syndrome of the trephined“ bei Patienten bieten, bei denen eine späte Kranioplastik durchgeführt wurde. In diesem Patientengut hatten die Patienten mit ultra-früher Kranioplastik das beste neurologische Outcome, die Komplikationsrate war in allen Gruppen vergleichbar. Um Komplikationen zu vermeiden, sollten Patienten mit einer vorausgegangenen lokalen Infektion spät kranioplastiert werden. Das neurologische Outcome der Patienten, bei denen ein kombiniertes Verfahren Kranioplastik –VP Shunt durchgeführt wurde, war vergleichbar mit anderen Patientengruppen. Somit ist eine Kranioplastik bei Patienten mit konvexen, über Kalottenniveau prolabierten Kraniektomielappen aufgrund eines Hydrocephalus keine Kontraindikation.Decompressive craniectomy is a worthy additional tool to manage intracranial hypertension refractory to other treatments. However, after resolution of the intracranial hypertension, these skull defects should be appropriately treated. Cranioplasty can successfully repair such large defects not only by improving the patient’s cosmetic, but also by protecting the uncovered brain tissue. The therapeutic impact of this procedure can be clearly assessed in patients with the “syndrome of the trephined” (also called “sinking skin flap syndrome”). At the present, there are no recognized cranioplasty guidelines, neither for the timing nor for the materials to be employed in this surgical procedure. On the other side, large cranial defects may lead to disturbance of the cortical blood perfusion and impair the cerebrospinal fluid circulation delaying the patient’s clinical recovery. This study retrospectively reviewed 242 consecutive patients who underwent cranioplasty in the last 7 years at the neurosurgical department of the SKFH. The indications for craniectomy, the timing and materials employed for the cranial repair procedures were analysed in all patients as well as their early and long-dated prognosis. The patients were divided into three groups depending on the timing of the cranioplasty (ultra early group until 6 weeks, early group 7 to 12 weeks and delayed group after 13 weeks following craniectomy). The immediate patient’s outcome after cranioplasty was assessed reviewing medical records and the late outcome was evaluated with a telephone questionnaire. The group’s comparison revealed that the immediate outcome of patients with early cranioplasty was better than those from the other groups. Patients with disturbance of consiousness who showed a rush recovery and improvement of their neurological function following cranioplasty represented 78.8%, 46 % and 12 % of the ultra early, early and delayed cranioplasty groups respectively. The late outcome (6 months after cranioplasty) was also better in patients who underwent an early cranioplasty. This study found a good late outcome (independent patients with a GOS 4 or 5) in 84.4 %, 40.3 % and 20.6 % of the ultra early, early and delayed cranioplasty groups respectively. The analysis of the registered postoperative complications revealed that there were not significant differences between the examined groups. This study found that ultra early cranioplasty by re-implanting the own previously removed and frozen skull bone, was a safe and helpful strategy. This led to a rush improvement of the patient’s neurological function and late outcome. An appropriated patient’s selection and differentiation was an important key for an additional improvement of the neurological results in this group. The outcome from patients who underwent a combined cranioplasty and ventriculo-peritoneal shunt procedure was comparable with those of other groups. This implicates that cranioplasty is not contraindicated and should not be delayed in patients with hydrocephalus related convex skin flap craniotomy defects

New developments in drug therapy and research of cerebral vasospasm

In this manuscript a comprehensive coverage of recent developments in the drug therapy of vasospasm while providing the background information that neuroscientists need to understand its rationale. The range of new agents available for treatment of cerebral vasospasm is expanding rapidly along with rapid advances in pharmacology and physiology that are uncovering the mechanisms of this disease. Although there are many publications for treatment of cerebral vasospasm, most are focusing on different aspects of vasospasm treatment and many have limited value due to insufficient quality. Moreover, the complexity of this, in many cases deleterious condition, is enormous and the information needed to understand drug effects is accordingly often not readily available in a single source. A number of pharmacological and medical therapies are currently in use or being investigated in an attempt to reverse cerebral vasospasm, but only a few have proven to be useful. Current research efforts promise the eventual production of new medical therapies. At last, recommendations for the use of different treatment stages based on currently available clinical data are provided

Preliminary results of minimally invasive decompression, tlif and percutaneous pedicle screw insertion in stenotic spondylolisthesis with severe facet joint osteoarthritis

Object: Minimally invasive spine (MIS) procedures are increasingly being recognized as equivalent to open procedures with regard to clinical and radiographic outcomes. These techniques are also believed to result in less pain and disability in the immediate postoperative period. There are, however, little data to assess whether these procedures in combination with minimally invasive transforaminal interbody fusion (MI-TLIF) and percutaneous pedicle screw insertion are effective in complex cases of stenotic degenerative spondylolisthesis with severe facet joint osteoarthritis (FJO). Methods: This study retrospectively reviewed all patients who underwent lumbar instrumentation, fusion and decompression for degenerative spondylolisthesis with severe stenosis and facet joint osteoarthritis (FJO) between June 2010 and June 2011. Blood loss, operative time and intraoperative complications were assessed in all surgically treated patients who were treated with MIS decompression, MI-TLIF and percutaneous transpedicular instrumentation. Clinical outcome was measured using the Oswestry Disability Index (ODI) and Visual Analogue Scale (VAS) for back pain, leg pain, and activity level. Satisfaction was assessed with VAS for satisfaction. Radiological follow-up includes x-ray films, computed tomography and in some cases magnetic tomography scan. Results: Twenty four cases with severe stenotic changes accompanied by severe FJO were treated with minimally invasive procedure. The minimum follow-up was 6 months with a mean of 8 months. The mean preoperative ODI score was 46.8, decreasing to a mean of 23 postoperatively. The mean VAS leg and back pain scores were 67.5 improving to means of 25.8. Twenty one out of 24 cases experienced a clinical benefit according to VAS for satisfaction and ODI. Complications included wound healing disturbance (4%), CSF fistula (4%) and contralateral radiculopathy due to articular bone spurs (8%). The accuracy of pedicle screws was high and only one revision surgery was performed. Conclusion: MIS for severe stenotic spondylolisthesis leads to adequate and safe decompression of lumbar stenosis and results in a highly significant reduction of symptoms and disability. MIS-TLIF and percutaneous pedicle screw insertion constitute a promising treatment alternative for patients with severe stenosis and facet joint osteoarthriti

Spinal Intradural Intramedullary Dissemination in the Absence of Intracranial Relapse of a Previously Radically Treated Temporal Lobe Glioblastoma Multiforme

Intracranial glioblastoma multiforme (GBM) constitutes the most frequent and unfortunately aggressive primary central nervous system malignancy. Despite the high tendency of these tumors to show local relapse within the brain after primary therapy, dissemination into the spinal axis is an infrequent event. If spinal metastases occur they are leptomeningeal in the vast majority of cases and always in the context of intracranial progressive disease. Spinal intramedullary metastases of intracranial GBM have rarely been described to date. We report the unique case of a young woman with subacute progressive paraparesis due to spinal intramedullary metastases of a temporal lobe GBM despite the remarkable absence of intracranial tumor relapse. The patient had undergone gross total resection of a left temporal GBM in contact with the ventricles and cisternal space followed by radio- and chemotherapy 13 months before. At the moment of diagnosis of spinal intramedullary metastases, there were no signs of intracranial tumor recurrence as revealed by MRI scans. Since a high level of suspicion may be needed to detect this rare evolution of intracranial GBM and other differential diagnoses must be ruled out at presentation, we discuss the important features of this case regarding clinical manifestation, diagnosis, surgery, and management. Furthermore, we mention possible factors that may have contributed to the development of these metastases in the context of intracranial remission