Analysis of potential risk factors for the occurrence of brainstem symptoms in subjects with giant intracranial aneurysms of the posterior circulation

Object. Giant intracranial aneurysms of the posterior circulation (GPCirA) often cause compression of the brainstem and adjacent structures, resulting in neurological deficits. Using data from the Giant Intracranial Aneurysm (GIA) Registry, we designed a study to investigate potential predictors of cranial nerve deficits (CND), motor deficit (MD) and the modified Rankin Score (mRS) in subjects with GPCirA. Methods. All data were extracted from the database of the GIA Registry, which is an international multicenter prospective observational study exclusively focusing on intracranial aneurysms with diameters of at least 25mm. In magnetic resonance imaging of 30 subjects with unruptured GPCirA we examined GPCirA volume and diameters, presence of hydrocephalus and partial thrombosis (PT), and the amount of displacement of the brainstem as measured by the distance between the McRae Line (McRL) and the tip of GPCirA (∆MT). We also examined potential associations between these specific factors and neurological deficit. Results. Half of the patients presented with CND and 33.3% of the cases had MD. Patients with CND were different from those without CND in age (51y SD 15.0 vs. 69.0y SD 21.0; p=0.01) and in ∆MT (50.7mm, IQR 39.2-53.9 vs. 39.0mm, IQR 32.3-45.9; p=0.02). Patients with MD differed significantly from those without only in ∆MT (50.5 mm, IQR 40.8-54.6 vs 39.1mm, IQR 32.8-50.5; p=0.04). Patients with poor modified Rankin Score (mRS) had larger volumes (14.9 cm3, IQR 8.6-18.7) compared to those with a good clinical condition (mRS 0-2) (6.8 cm3, IQR 4.4-11.7; p=0.03). We found no differences between GPCirA locations (basilar apex, the basilar trunk, the vertebrobasilar junction and the vertebral artery) when we compared prevalences of neurological deficits. After performing multivariate regression analysis, adjusting for patient age, the occurrence of hydrocephalus and PT, higher degrees of disability were significantly associated with aneurysm volume (OR=1.13; 95% CI 1.0-1.3; p=0.04), but not with ∆MT. There were no associations between the presence of CND or MD and any of the examined variables. Conclusions. Our data highlight that the GPCirA volume was the only predictor of patient neurological condition. None of the other examined factors, such like the brainstem displacements, the occurrence of hydrocephalus or PT or the location of GPCirA predicted the patient clinical condition. So, we feel that our results might suggest that, when we want to decide whether to treat or not GPCirA, we should always take into account firstly the volume of the aneurysms and we should examine in second line the other potential risk factors.Hintergrund. Intrakranielle Riesen-Aneurysmen im hinteren Stromkreis (GPCirA) rufen häufig einen erheblichen Masseneffekt auf den Hirnstamm hervor. Dadurch können neurologische Defizite verursacht werden. Es gibt keine systematische Analyse, um die Hauptgründe dieses Phänomens zu untersuchen. Hauptziel dieser Arbeit ist es, Risikofaktoren zu identifizieren, die verantwortlich für das Auftreten von Hirnnervenschädigung, motorischen Defiziten und die Behinderung von Patienten mit GPCirA sind. Methodik. Präoperative MRTs von 30 unrupturierten GPCirA wurden retrospektiv analysiert. Die folgenden Faktoren wurden untersucht: das GPCirA Volumen, die GPCirA Durchmesser, das Vorkommen von Hydrozephalus, partielle Thrombosierung (PT), das PT Volumen und der Grad der Hirnstammverlagerung. Letzterer wurde als die Distanz zwischen der McRae Linie und der obersten Aneurysma-Spitze (∆MT) definiert. Wir haben mögliche Assoziationen zwischen den bereits genannten Faktoren und den neurologischen Defiziten untersucht. Ergebnisse. Die Hälfte der Patienten hatten Hirnnervendefizite (n=15, 50.0%) und 33.3% motorische Defizite. Die Patienten mit Hirnnervenschädigung waren signifikant jünger (51y, SD 15.0 vs. 69.0y, SD 21.0; p=0.01) und hatten signifikant größere ∆MT als die Patienten ohne Hirnnervenschädigung (50.7mm, IQR 39.2-53.9 vs. 39.0mm, IQR 32.3-45.9; p=0.02). Die Patienten mit motorischem Defizit hatten größere ∆MT (50.5 mm, IQR 40.8-54.6 vs 39.1mm, IQR 32.8-50.5; p=0.04) im Vergleich zu den Fällen ohne motorisches Defizit. Patienten mit mRS 3-5 hatten größere GPCirA Volumina (14.9 cm3, IQR 8.6-18.7) als die Patienten mit mRS 0-2 (6.8 cm3, IQR 4.4-11.7; p=0.03). In der Regressionsanalyse zeigte sich, dass größere Aneurysma-Volumina mit einem höheren Behinderungsgrad assoziiert waren (OR=1.13; 95% CI 1.0-1.3; p=0.04), aber nicht mit der ∆MT. Keine der untersuchten Faktoren war mit dem Auftreten von der Hirnnervenschädigung oder motorischem Defizit assoziiert. Es zeigte sich auch keine Korrelation zwischen Aneurysma-volumen und ∆MT. Letztlich gab es keine signifikanten Unterschiede zwischen den verschiedenen Lokalisationen der Aneurysmata im hinteren Stromgebiet in Bezug auf das Auftreten von neurologischen Defiziten. Schlussfolgerungen. Aus den Ergebnissen dieser klinischen Studie lässt sich ableiten, dass nur das Volumen der GPCirA einen signifikanten Prädiktor für das Auftreten von neurologischen Defiziten darstellt, jedoch keiner der anderen untersuchten Risikofaktoren hatte einen signifikanten Einfluss auf den klinischen Zustand der Patienten. Diese Ergebnisse sind von klinischer Relevanz, da behandelnde Ärzte mit ihnen in der Lage sind, zusätzliche Argumente für und gegen eine Intervention bei GPCirA Patienten zu finden.

Impact of Ventilation Modes on Bronchoscopic Chartis Assessment Outcome in Candidates for Endobronchial Valve Treatment

Background: Endobronchial valve therapy has proven to reduce lung hyperinflation and decrease disease burden in patients with severe lung emphysema. Exclusion of collateral ventilation (CV) of the targeted lobe by using an endobronchial assessment system (Chartis; PulmonX, Drive Redwood City, CA, USA) in combination with software-based fissure integrity analysis (FCS [fissure completeness score]) of computed tomography scans of the lung are established tools to select appropriate patients for endobronchial valve treatment. So far, there is no conclusive evidence if the ventilation mode during bronchoscopy impacts the outcome of Chartis assessments. Methods: Patients with Chartis assessments and software-based quantification of FCS (StratX; PulmonX, Drive Redwood City, CA, USA) were enrolled in this retrospective study. During bronchoscopy, pulmonary fissure integrity was evaluated with the Chartis assessment system in each patient first under spontaneous breathing and subsequently under high-frequency (HF) jet ventilation. Results: In total, 102 patients were analyzed. Four Chartis phenotypes CV positive (CV+), CV negative (CV-), low flow, and low plateau in spontaneous breathing and HF jet ventilation were identified. The frequency of each Chartis phenotype per lobe was similar in both settings. When comparing Chartis assessments in spontaneous breathing and HF jet ventilation, there was an overall good concordance rate for all analyzed fissures. In agreement, receiver operating characteristic analysis of the FCS showed an almost similar prediction for CV+ and CV- status independent of the ventilation modes. Conclusion: Chartis assessment in spontaneous breathing and HF jet ventilation had similar rates in detecting CV in lung emphysema. Our results suggest that both modes are equivalent for the assessment of CV

atTRACTive: Semi-automatic white matter tract segmentation using active learning

Accurately identifying white matter tracts in medical images is essential for various applications, including surgery planning and tract-specific analysis. Supervised machine learning models have reached state-of-the-art solving this task automatically. However, these models are primarily trained on healthy subjects and struggle with strong anatomical aberrations, e.g. caused by brain tumors. This limitation makes them unsuitable for tasks such as preoperative planning, wherefore time-consuming and challenging manual delineation of the target tract is typically employed. We propose semi-automatic entropy-based active learning for quick and intuitive segmentation of white matter tracts from whole-brain tractography consisting of millions of streamlines. The method is evaluated on 21 openly available healthy subjects from the Human Connectome Project and an internal dataset of ten neurosurgical cases. With only a few annotations, the proposed approach enables segmenting tracts on tumor cases comparable to healthy subjects (dice=0.71), while the performance of automatic methods, like TractSeg dropped substantially (dice=0.34) in comparison to healthy subjects. The method is implemented as a prototype named atTRACTive in the freely available software MITK Diffusion. Manual experiments on tumor data showed higher efficiency due to lower segmentation times compared to traditional ROI-based segmentation

Surgical management of ventrally located cervical epidural abscess: A comparative analysis between patients aged 18–64 years and ≥65 years

Background: We aimed to compare the clinical course of patients aged 18–65 years and ≥65years who underwent anterior cervical discectomy and fusion (ACDF) or corpectomy for ventrally located CSEA. Methods: Clinical and imaging data were retrospectively collected from the institutional database between September 2005 and December 2021. Results: A total of 35 and 26 patients aged 18–64 and ≥ 65 years, respectively who were diagnosed with ventrally located CSEA were included. The overall mean age was 63.9 ± 3.2 years, with a predominance of the male sex (n = 43/61, 70.5%). Patients aged ≥65 years presented with significantly higher rates of comorbidities (10.3 ± 2.8), as indicated by the CCI, than their younger counterparts (18–64 years: 6.2 ± 2.6; p < 0.001). No differences in the surgical approach or characteristics were observed among the groups. Notably, patients aged ≥65 years had a significantly longer intensive care unit as well as overall hospital stay. In-hospital and 90-day mortality were similar across both groups. Following both types of surgery, a significant improvement was observed in the blood infection parameters and neurological status at discharge compared with the baseline measurements. Older age, higher rates of comorbidities, and higher grades of disability were significant predictors for mortality. Conclusions: Emergency surgical evacuation should be undertaken for CSEA in the presence of acute neurological deterioration regardless of the age. Factors, such as age, comorbidities, and neurological status on admission appear to be important predictors of disease outcomes. However, the risk profile of younger patients should not be underestimated

Prospective insights into spinal surgery outcomes and adverse events: A comparative study between patients 65–79 years vs. ≥80 years from a German tertiary center

Introduction: In light of an aging global population, understanding adverse events (AEs) in surgeries for older adults is crucial for optimal outcomes and patient safety. Research question: Our study compares surgical outcomes and AEs in patients aged 65–79 with those aged ≥80, focusing on clinical outcomes, morbidity and mortality rates, and age-related risk factors for AEs. Material and methods: Our study, from January 2019 to December 2022, involved patients aged 65–79 and ≥ 80 undergoing spinal surgery. Each patient was evaluated for AEs post-discharge, defined as negative clinical outcomes within 30 days post-surgery. Patients were categorized based on primary spinal diagnoses: degenerative, oncological, traumatic, and infectious. Results: We enrolled 546 patients aged 65–79 and 184 octogenarians. Degenerative diseases were most common in both groups, with higher infection and tumor rates in the younger cohort. Octogenarians had a higher Charlson Comorbidity Index and longer ICU/hospital stays. Surgery-related AE rates were 8.1% for 65-79-year-olds and 15.8% for octogenarians, with mortality around 2% in both groups. Discussion and conclusion: Our prospective analysis shows octogenarians are more susceptible to surgical AEs, linked to greater health complexities. Despite higher AEs in older patients, low mortality rates across both age groups highlight the safety of spinal surgery. Tracking AEs is crucial for patient communication and impacts healthcare accreditation and funding

Spinal Meningioma Surgery in Octogenarians: Functional Outcomes and Complications over a 2-Year Follow-Up Period

Background and Objectives: Population aging in industrial nations has led to an increased prevalence of benign spinal tumors, such as spinal meningiomas (SMs), in the elderly. The leading symptom of SM is local pain, and the diagnosis is confirmed after acute neurological decline. However, little is known about the optimal treatment for this frail patient group. Therefore, this study sought to assess the clinical outcome, morbidity, and mortality of octogenarians with SMs and progressive neurological decline undergoing surgery and to determine potential risk factors for complications. Materials and Methods: Electronic medical records dated between September 2005 and December 2020 from a single institution were retrieved. Data on patient demographics, neurological conditions, functional status, degree of disability, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Results: Thirty patients aged &ge;80 years who were diagnosed with SMs underwent posterior decompression via laminectomy and microsurgical tumor resection. The patients presented with a poor baseline history (mean CCI 8.9 &plusmn; 1.6 points). Almost all SMs were located in the thoracic spine (n = 25; 83.3%). Progressive preoperative neurological decline was observed in 21/30 (n = 21; 70%) patients with McCormick Scores (mMCS) &ge;3, and their mean motor score (MS) was 85.9 &plusmn; 12.3. in the in-hospital and 90-day mortality rates were 6.7% and 10.0%, respectively. The MS (93.6 &plusmn; 8.3) and mMCS (1.8 &plusmn; 0.9) improved significantly postoperatively (p &lt; 0.05). The unique risk factor for complications was the severity of comorbidities. Conclusions: Decompressive laminectomy and tumor removal in octogenarians with progressive neurological decline improved patient functional outcomes at discharge. Surgery seems to be the &ldquo;state of the art&rdquo; treatment for symptomatic SMs in elderly patients, even those with poor preoperative clinical and neurologic conditions, whenever there is an acceptable risk from an anesthesiological point of view

Radiological Features in Type II Odontoid Fractures in Older Adults After High- and Low-Energy Trauma.

STUDY DESIGN: Retrospective study. OBJECTIVES: Although type II odontoid fractures mainly occur due to high-energy trauma (HET), the number of odontoid type II fractures after low-energy trauma (LET) in the elderly is on the rise. However, there is a paucity of conclusive evidence on the relationship between trauma mechanism and cervical spine alignment in the elderly population. Consequently, we examined cervical alignment and osteoporotic and osteoarthritic patterns in elderly individuals (aged ≥65 years) with type II odontoid fractures. METHODS: We retrospectively assessed cervical spine alignment in 76 elderly individuals who experienced type II odontoid fractures after HET (n = 36) and LET (n = 40) between 2005 and 2020. Osteoporotic and osteoarthritic changes on computed tomography and cervical alignment parameters on sagittal plane radiographs were examined. RESULTS: Moderate and severe osteoporosis of the dens-body junction and osteoarthritis of the atlanto-odontoid joint were more prevalent in the LET than the HET group ( CONCLUSION: Significantly higher rates of osteoporotic and degenerative changes were observed after LET. Furthermore, previous cervical malalignment represents a risk factor for type II odontoid fractures after LET

Decompression only versus fusion in octogenarians with spinal epidural abscesses: early complications, clinical and radiological outcome with 2-year follow-up.

Despite increased life expectancy due to health care quality improvements globally, pyogenic vertebral osteomyelitis (PVO) treatment with a spinal epidural abscess (SEA) remains challenging in patients older than 80 years. We aimed to assess octogenarians for PVO prevalence with SEA and compare after-surgery clinical outcomes of decompression and decompression and instrumentation. A retrospective review of electronic medical records at a single institution was conducted between September 2005 and December 2020. Patient demographics, surgical characteristics, complications, hospital course, and 90-day mortality were collected. Comorbidities were assessed using the age-adjusted Charlson comorbidity index (CCI). Over 16 years, 35 patients aged ≥80 years with PVO and SEA were identified. Eighteen patients underwent surgical decompression ( decompression group ), and 17 underwent surgical decompression with instrumentation ( instrumentation group ). Both groups had a CCI \u3e6 (mean±SD, 8.9±2.1 vs. 9.6±2.7, respectively; p=0.065). Instrumentation group patients had a significantly longer hospital stay but no ICU stay. In-hospital and 90-days mortality rates were similar in both groups. The mean follow-up was 26.6±12.4 months. No further surgeries were performed. Infection levels and neurological status were improved in both groups at discharge. At the second-stage analysis, significant improvements in the blood infection parameters and the neurological status were detected in the decompression group. Octogenarians with PVO and SEA have a high adverse events risk after surgical procedures. Surgical decompression might contribute to earlier clinical recovery in older patients. Thus, the surgical approach should be discussed with patients and their relatives and be carefully weighed

Clinical implications and radiographic characteristics of the relation between giant intracranial aneurysms of the posterior circulation and the brainstem

Giant intracranial aneurysms of the posterior circulation (GPCirA) are rare entities compressing the brainstem and adjacent structures. Previous evidence has shown that the amount of brainstem shift away from the cranial base is not associated with neurological deficits. This raises the question whether other factors may be associated with neurological deficits

Assessment of efficacy and safety of endoscopic lung volume reduction with one-way valves in patients with a very low FEV1

Introduction Endoscopic lung volume reduction (ELVR) with one-way valves produces beneficial outcomes in patients with severe emphysema. Evidence on the efficacy remains unclear in patients with a very low forced expiratory volume in 1 s (FEV1) (≤20% predicted). We aim to compare clinical outcomes of ELVR, in relation to the FEV1 restriction. Methods All data originated from the German Lung Emphysema Registry (Lungenemphysem Register), which is a prospective multicentric observational study for patients with severe emphysema after lung volume reduction. Two groups were formed at baseline: FEV1 ≤20% pred and FEV1 21–45% pred. Pulmonary function tests (FEV1, residual volume, partial pressure of carbon dioxide), training capacity (6-min walk distance (6MWD)), quality of life (modified Medical Research Council dyspnoea scale (mMRC), COPD Assessment Test (CAT), St George's Respiratory Questionnaire (SGRQ)) and adverse events were assessed and compared at baseline and after 3 and 6 months. Results 33 patients with FEV1 ≤20% pred and 265 patients with FEV1 21–45% pred were analysed. After ELVR, an increase in FEV1 was observed in both groups (both p<0.001). The mMRC and CAT scores, and 6MWD improved in both groups (all p<0.05). The SGRQ score improved significantly in the FEV1 21–45% pred group, and by trend in the FEV1 ≤20% pred group. Pneumothorax was the most frequent complication within the first 90 days in both groups (FEV1 ≤20% pred: 7.7% versus FEV1 21–45% pred: 22.1%; p=0.624). No deaths occurred in the FEV1 ≤20% pred group up to 6 months. Conclusion Our study highlights the potential efficacy of one-way valves, even in patients with very low FEV1, as these patients experienced significant improvements in FEV1, 6MWD and quality of life. No death was reported, suggesting a good safety profile, even in these high-risk patients