Korrelation des Resektionsausmaßes der Corticoamygdalohippokampektomie mit dem postoperativen Anfallsoutcome

Pharmacoresistant mesial temporal lobe epilepsy (MTLE) is the most common indication for performing an operative intervention in the context of epilepsy surgery and has an outstanding effectiveness in this context. Due to their established position in the therapy of focal epilepsy, the important question arose in the course of the optimal extent of resection of the neocortex and the mesiotemporal structures, which guarantees a seizure-free after surgery with simultaneous minimal neurological deficits. At the current point in time, based on the literature available on this problem, no clear statement can be discerned that describes and defines the extent of the resection to be favored. This doctoral thesis therefore examines the following research question as to whether there is a correlation between the resection extent of the corticoamygdalohippocampectomy and the postoperative seizure outcome. In the neurosurgical clinic of the University Hospital Erlangen, 151 patients (75 men, 76 women; median age 37.97 with an SD of 11.88) with the diagnosis of pharmacoresistant temporal lobe epilepsy were included in the retrospective data analysis, which spanned a period from 2002 to 2015. Under this collective, 16 patients underwent a selective amgydalohippocampectomy (SAH), 27 a corticoamygdalohippocampectomy (CAH), and the remaining 108 patients underwent a tailored resection together with an amydalohippocampectomy. For each patient, the hippocampal length (mm) were firstly determined based on preoperative MR-Imaging, followed by the determination of both the length of the neocortex resection (mm) and the hippocampectomy (mm) which were recruited using the intraoperative MR. In addition, follow-up examinations were carried out at a time interval of 3 to 168 months, which made the last postoperative seizure outcome according to the Engel classification available for each patient. Based on this data, it was then statistically evaluated whether there was a correlation between the extent of the resection and the postoperative seizure outcome. The median resection length of the neocortex resection corresponded to 38.85 mm with an SD of 12.63 mm. On the other hand, the median extent of the hippocampectomy was 29.04 mm with an SD of 5.86 mm. The median follow-up compromised 51.14 months with an SD of 40.91 months. Within the sample, 66.1% (n = 100) achieved a postoperative seizure outcome according to Engel I, of which 48% (n = 68) met the criteria of the Engel IA category. The empirical data analysis was carried out in two steps. First of all the chi-square test was used to verify if the dichotomous variables hippocampectomy ( 25 mm) or resection of neocortex ( 30 mm) have different occurrences regarding the postoperative seizure outcome (E IA vs. not seizure-free and E I vs. not seizure-free) or whether these are independent from each other. The comparison of the variables neocortex resection ( 30 mm) with the expression pattern E IA vs. not seizure-free result with a pre-determined significance level of p < 0.05 a significant result. Category E IA was found for n = 23 under the cohort neocortical resection < 30 mm, whereas the expression pattern not seizurefree was ascertainable at n = 11. With a chi-square value according to Pearson of 9.065 and the moderate effect sizes Phi-coefficient and Cramer´s-V of 0.245, these results confirmed a significant test result with a significance level of p = 0.003. In this way it was statistically proven that a lower degree of neocortex resection (< 30 mm) correlates with a better postoperative seizure outcome, according to Engel IA. In addition, no significant results were demonstrated based on the confrontation of the variables hippocampectomy ( 25 mm) with the postoperative seizure outcome, so that the extent of the hippocampectomy has no influence on the postoperative seizure outcome. In a second step, after subdivision of the patient cohort according to the existing properties, hippocampectomy short or long ( 25 mm) and neocortex resection short or long ( 30 mm) four different resection groups were created. A Welch-ANOVA was then carried out to test whether the resection groups differ in terms of the seizure outcome achieved. The results of this test showed significant differences regarding the postoperative seizure outcome (Welch test F (3, 29.85) = 4.55, p = 0.010). Accordingly, with the addition of the Games-Howell post-hoc test, it was demonstrated that a significant difference (p < 0.05) with regard to the seizure outcome achieved between Group I and Group III (3.59, 95% - CI [0.36, 6.81]) and between Group I and Group IV (2.14, 95% - CI [0.23, 4.05]). This in turn serves as evidence that a restrictive neocortical resection (< 30 mm), which was carried out as an example in Group I, correlates with a higher probability of occurrence of Engel IA, whereas the extent of the hippocampectomy has no influence on the postoperative outcome. An excellent postoperative seizure outcome according to the Engel IA category after epilepsy surgery on the temporal lobe (CAH, SAH, tailored resection) was observed more frequently in the present retrospective data analysis in those patients for whom the extent of the neocortex resection was less than 30 mm. On the basis of the asymptotic significance p = 0.003, a highly significant test result was proven, so that a correlation between the extent of neocortex resection and the postoperative seizure outcome according to the Engel classification can be assumed. This significant result was additionally underlined by the results of the Welch-ANOVA, which demonstrated that a more restrictive neocortex resection, which was carried out as an example in resection Group I, correlated with a higher probability of occurrence of Engel IA. Accordingly, using two different statistical analyzes, absolutely consistent results were demonstrated, so that the significant test results achieved are of particular importance. Since a lower cortex resection in reverse leads to a smaller resection extent of the eloquent cortex, the achievement of a postoperative seizure freedom is made possible and the occurrence of postoperative neurological and neurocognitive deficits is minimized, whereby the goal of epilepsy surgery is fully realized.Die pharmakoresistente mesiale Temporallappenepilepsie (MTLE) stellt im Kontext der Epilepsiechirurgie die häufigste Indikation für die Durchführung eines operativen Engriffes dar und weist in diesem Zusammenhang eine herausragende Effektivität auf. Aufgrund ihrer etablierten Position in der Therapie der fokalen Epilepsien kam daher im Verlauf die bedeutende Frage nach dem optimalen Resektionsausmaß des Neokortex und der mesiotemporalen Strukturen auf, welches eine postoperative Anfallsfreit bei gleichzeitig minimalen neurologischen Defiziten gewährleistet. Zum aktuellen Zeitpunkt ist anhand der vorliegenden Literatur zu dieser Problematik keine klare Aussage erkennbar, die das zu favorisierende Resektionsausmaß beschreibt und festlegt. Diese Doktorarbeit untersucht daher die folgende Forschungsfrage, ob eine Korrelation zwischen dem Resektionsausmaß der Corticoamygdalohippokampektomie und dem postoperativen Anfallsoutcome besteht. In der Neurochirurgischen Klinik des Universitätsklinikums Erlangen wurden in dem Zeitraum von 2002 bis 2015 151 Patienten (75 Männer, 76 Frauen; Alters-Median 37.97 bei einer Standardabweichung (SD) von 11.88) mit der Diagnose einer pharmakoresistenten Temporallappenepilepsie in die retrospektive Datenanalyse eingeschlossen. Unter diesem Kollektiv wurde bei 16 Patienten eine selektive Amydalohippokampektomie (SAH), bei 27 eine Corticoamygdalohippokampektomie (CAH) und bei den restlichen 108 verbliebenen Patienten eine Tailored Resection zusammen mit einer Amydalohippokampektomie durchgeführt. Für jeden Patienten wurden zum einen anhand der präoperativen MR-Bildgebung die Hippokampuslänge (Millimeter = mm) und zum anderen das Längenmaß der Neokortexresektion (mm) sowie der Hippokampektomie (mm) bestimmt, welche mittels des intraoperativen MR rekrutiert wurden. Zusätzlich erfolgten Follow-Up-Untersuchungen in einem zeitlichen Intervall von 3 bis 168 Monaten, wodurch für jeden Patienten das zuletzt erhobene postoperative Anfallsoutcome nach der Engel-Klassifikation erhältlich war. Anhand dieser Daten wurde anschließend statistisch ausgewertet, ob eine Korrelation zwischen dem Resektionsausmaß und dem postoperativen Anfallsoutcome besteht. Die mediane Resektionslänge der Neokortexresektion entsprach 38.85 mm bei einer SD von 12.63 mm. Auf der anderen Seite betrug das mediane Ausmaß der Hippokampektomie 29.04 mm bei einer SD von 5.86 mm. Das mediane Follow-Up umfasste 51.14 Monate bei einer SD von 40.91 Monaten. Innerhalb der Stichprobe erzielten 66.1% (n = 100) ein postoperatives Anfallsoutcome gemäß Engel I, wovon 48% (n = 68) die Kriterien der Kategorie Engel IA erfüllten. Die empirische Datenanalyse erfolgte in zwei Schritten. Zunächst wurde der Chi-Quadrat-Test herangezogen, um zu prüfen, ob die dichotomen Variablen Hippokampektomie ( 25 mm) bzw. Neokortexresektion ( 30 mm) einen Zusammenhang mit den verschiedenen Ausprägungshäufigkeiten bezüglich (bzgl.) des postoperativen Anfallsoutcome (E IA vs. nicht anfallsfrei bzw. E I vs. nicht anfallsfrei) aufweisen, oder ob diese unabhängig voneinander sind. Dabei erbrachte die Gegenüberstellung der Variablen Neokortexresektion ( 30 mm) mit dem Ausprägungsmuster E IA vs. nicht anfallsfrei bei einem vorab determinierten Signifikanzniveau von p < 0.05 ein signifikantes Ergebnis. So wurde unter der Kohorte Neokortexresektion < 30 mm die Kategorie E IA bei n = 23 nachgewiesen, wohingegen das Ausprägungsmuster nicht anfallsfrei bei n = 11 feststellbar war. Bei einem Chi-Quadrat-Wert nach Pearson von 9.065 und den moderaten Effektstärken Phi-Koeffizient und Cramer`s-V von 0.245 belegten diese Resultate bei einem Signifikanzniveau von p = 0.003 ein signifikantes Testergebnis. Auf diese Weise wurde statistisch nachgewiesen, dass ein geringeres Ausmaß der Neokortexresektion (< 30 mm) mit einem besseren postoperativen Anfallsoutcome, gemäß Engel IA, korreliert. Daneben wurde anhand der Konfrontation der Variablen Hippokampektomie ( 25 mm) mit dem postoperativen Anfallsoutcome keine signifikanten Ergebnisse nachgewiesen, so dass das Ausmaß der Hippokampektomie keinen Einfluss auf das postoperative Anfallsoutcome nimmt. In einem zweiten Schritt wurde nach Unterteilung der Patientenkohorte gemäß der bereits vorhandenen Eigenschaften Hippokampektomie kurz beziehungsweise (bzw.) lang ( 25 mm) und Neokortexresektion kurz bzw. lang ( 30 mm) vier verschiedene Resektionsgruppen erstellt. Anschließend wurde eine Welch-ANOVA durchgeführt, um zu testen, ob sich die Resektionsgruppen hinsichtlich der erzielten Anfallsoutcomes unterscheiden. Die Resultate dieser Testung belegten signifikante Unterschiede bzgl. der erzielten postoperativen Anfallsoutcomes (Welch-Test F (3, 29.85) = 4.55, p = 0.010). Demnach wurde unter Hinzunahme des Games-Howell post-hoc Tests nachgewiesen, dass ein signifikanter Unterschied (p < 0.05) hinsichtlich der erzielten Anfallsoutcome zwischen Gruppe I und Gruppe III (3.59, 95% - Konfidenzintervall (CI) [0.36, 6.81]) sowie zwischen Gruppe I und Gruppe IV (2.14, 95% - CI [0.23, 4.05]) besteht. Dies wiederum fungiert als Beleg, dass eine restriktive Neokortexresektion (< 30 mm), welche exemplarisch in Gruppe I durchgeführt wurde, mit einer höheren Auftretenswahrscheinlichkeit von Engel IA korreliert, wohingegen das Ausmaß der Hippokampektomie auf das postoperative Anfallsoutcome keinen Einfluss nimmt. Ein exzellentes postoperatives Anfallsoutcome gemäß der Kategorie Engel IA nach einem epilepsiechirurgischen Eingriff am Temporallappen (CAH, SAH, tailored resection) wurde in der vorliegenden retrospektiven Datenanalyse bei denjenigen Patienten häufiger beobachtet, bei denen das Ausmaß der Neokortexresektion weniger als 30 mm betrug. Anhand der asymptotischen Signifikanz p = 0.003 wurde ein hoch signifikantes Testergebnis belegt, so dass infolgedessen von einer Korrelation zwischen dem Ausmaß der Neokortexresektion und dem postoperativen Anfallsoutcome nach Engel auszugehen ist. Dieses signifikante Ergebnis wurde zusätzlich durch die Resultate der Welch-ANOVA unterstrichen, die belegten, dass eine restriktivere Neokortexresektion, welche exemplarisch in der Resektionsgruppe I durchgeführt wurde, mit einer höheren Auftretenswahrscheinlichkeit von Engel IA korreliert. Demnach wurden unter Anwendung von zwei verschiedenen statistischen Analysen absolut kongruente Ergebnisse nachgewiesen, so dass die erzielten signifikanten Testergebnisse somit einen besonderen Stellenwert einnehmen. Da eine geringere Kortexresektion im Umkehrschluss zu einem geringeren Resektionsausmaß des eloquenten Kortex führt, wird das Erzielen einer postoperativen Anfallsfreiheit ermöglicht und das Auftreten von postoperativen neurologischen und neurokognitiven Defiziten minimiert, wodurch das Ziel der Epilepsiechirurgie vollends verwirklicht wird

Implant selection in cervical spondylodiscitis plays a non-detrimental role - a single-center retrospective case series of 24 patients [Abstract]

Oral e-Poster Presentations - Booth 3: Spine 2 (Tumors), September 26, 2023, 4:10 PM - 4:50 PM Background: Cervical spondylodiscitis is an uncommon entity, with an incidence of 0.5 to 2.5 per 100.000 population, which is potentially extremely harmful. This type of discogenic and vertebral infection might cause a high rate of neurological impairment. Radical surgical debridement of the infected segment with fusion and intravenous antibiotic regimen remains the gold standard in most spine centers. We aimed to analyze the overall outcome in a tertiary spine center. Methods: In this study, we retrospectively included all patients suffering from cervical spondylodiscitis between 01/2017 and 05/2022, treated at the university hospital of Augsburg. Clinical and radiological parameters as well as type of implant were collected and evaluated. Descriptive statistics were performed using SPSS, and relevant correlations were examined using the t-test for independent samples and the Chi-square test. Results: 24 patients were identified and included. 17 patients (71%) suffered from sepsis on admission, 17 patients (71%) were diagnosed with epidural abscess on primary imaging and 5 patients (21%) had more than one discitis focus in a distant spinal segment. The presence of epidural abscess was significantly associated with systemic sepsis (OR=6.2; p=0.03) and myelopathy symptoms (OR= 14.4; p=0.00). Septic status was significantly associated with the occurrence of discitis in other spine segments (p=0.02), higher CCI (p=0.03) and Clavien Dindo scores (p=0.01), as well as a longer ICU stay (p=0.04) and the occurrence of nonunion (p=0.06). The most commonly detected germ was a multisensitive staphylococcus aureus (10 patients, 42%). A total of 6 patients (25%) died after a median of 20 days despite antibiogram-accurate therapy. The follow-up data of 15 patients (63%) was available with the evidence of permanent neurological damage in 9 patients (38%). The type of osteosynthesis was not significantly associated with subsidence (p=0.13), nonunion (p=0.21) or revision surgery (p=0.20). However the extent of instrumentation correlated significantly with the rate of nonunion (p=0.05). Conclusions: Cervical spondylodiscitis presents a severe infectious disease that occurs in multimorbid elderly patients and, despite adequate surgical and antibiotic treatment, is often associated with permanent neurological damage or a fatal outcome. Implant selection did not play a decisive role for the clinical and radiological outcome in this study

Hydrocephalus, cerebral vasospasm, and delayed cerebral ischemia following non-aneurysmatic spontaneous subarachnoid hemorrhages: an underestimated problem

Non-aneurysmal subarachnoid hemorrhage (NASAH) is rare and mostly benign. However, complications such as cerebral vasospasm (CV), delayed cerebral ischemia (DCI), or post-hemorrhagic hydrocephalus (HC) may worsen the prognosis. The aim of this study was to evaluate the rate of these complications comparing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH. Monocentric, retrospective analysis of patients diagnosed with NASAH from 01/2010 to 01/2021. Diagnosis was set only if vascular pathologies were excluded in at least one digital subtraction angiography, and NASAH was confirmed by cranial computed tomography (cCT) or lumbar puncture (LP). One hundred patients (62 female) with a mean age of 54.9 years (27–84) were identified. Seventy-three percent had a World Federation of Neurological Surgeons (WFNS) grading scale score I, while 9% were WFNS score IV or V at the time of admission. SAH was diagnosed by cCT in 86%, in 14% by lumbar puncture. Twenty-five percent necessitated short-term CSF diversion by extraventricular drainage or lumbar drainage, whereof 7 suffered from long-term HC treated with ventriculoperitoneal shunting (VPS). One patient without a short-term CSF drainage developed long-term HC. Ten percent developed CV, four of whom received intraarterial spasmolysis. Radiological DCI was diagnosed in 2%; none of these correlated with CV. Despite a mortality of 3% occurring solely in NPM SAH, the analyzed complication rate was comparable in both groups. We observed post-hemorrhagic complications in 35% of cases during the first 3 weeks after bleeding, predominantly in patients with NPM SAH. For this reason, close observation and cranial imaging within this time may be indicated not to overlook these complications

Correlation between the resection extent of the corticoamygdalohippocampectomy and the postoperative seizure outcome

Die pharmakoresistente mesiale Temporallappenepilepsie (MTLE) stellt im Kontext der Epilepsiechirurgie die häufigste Indikation für die Durchführung eines operativen Engriffes dar und weist in diesem Zusammenhang eine herausragende Effektivität auf. Aufgrund ihrer etablierten Position in der Therapie der fokalen Epilepsien kam daher im Verlauf die bedeutende Frage nach dem optimalen Resektionsausmaß des Neokortex und der mesiotemporalen Strukturen auf, welches eine postoperative Anfallsfreit bei gleichzeitig minimalen neurologischen Defiziten gewährleistet. Zum aktuellen Zeitpunkt ist anhand der vorliegenden Literatur zu dieser Problematik keine klare Aussage erkennbar, die das zu favorisierende Resektionsausmaß beschreibt und festlegt. Diese Doktorarbeit untersucht daher die folgende Forschungsfrage, ob eine Korrelation zwischen dem Resektionsausmaß der Corticoamygdalohippokampektomie und dem postoperativen Anfallsoutcome besteht. In der Neurochirurgischen Klinik des Universitätsklinikums Erlangen wurden in dem Zeitraum von 2002 bis 2015 151 Patienten (75 Männer, 76 Frauen; Alters-Median 37.97 bei einer Standardabweichung (SD) von 11.88) mit der Diagnose einer pharmakoresistenten Temporallappenepilepsie in die retrospektive Datenanalyse eingeschlossen. Unter diesem Kollektiv wurde bei 16 Patienten eine selektive Amydalohippokampektomie (SAH), bei 27 eine Corticoamygdalohippokampektomie (CAH) und bei den restlichen 108 verbliebenen Patienten eine Tailored Resection zusammen mit einer Amydalohippokampektomie durchgeführt. Für jeden Patienten wurden zum einen anhand der präoperativen MR-Bildgebung die Hippokampuslänge (Millimeter = mm) und zum anderen das Längenmaß der Neokortexresektion (mm) sowie der Hippokampektomie (mm) bestimmt, welche mittels des intraoperativen MR rekrutiert wurden. Zusätzlich erfolgten Follow-Up-Untersuchungen in einem zeitlichen Intervall von 3 bis 168 Monaten, wodurch für jeden Patienten das zuletzt erhobene postoperative Anfallsoutcome nach der Engel-Klassifikation erhältlich war. Anhand dieser Daten wurde anschließend statistisch ausgewertet, ob eine Korrelation zwischen dem Resektionsausmaß und dem postoperativen Anfallsoutcome besteht. Die mediane Resektionslänge der Neokortexresektion entsprach 38.85 mm bei einer SD von 12.63 mm. Auf der anderen Seite betrug das mediane Ausmaß der Hippokampektomie 29.04 mm bei einer SD von 5.86 mm. Das mediane Follow-Up umfasste 51.14 Monate bei einer SD von 40.91 Monaten. Innerhalb der Stichprobe erzielten 66.1% (n = 100) ein postoperatives Anfallsoutcome gemäß Engel I, wovon 48% (n = 68) die Kriterien der Kategorie Engel IA erfüllten. Die empirische Datenanalyse erfolgte in zwei Schritten. Zunächst wurde der Chi-Quadrat-Test herangezogen, um zu prüfen, ob die dichotomen Variablen Hippokampektomie ( 25 mm) bzw. Neokortexresektion ( 30 mm) einen Zusammenhang mit den verschiedenen Ausprägungshäufigkeiten bezüglich (bzgl.) des postoperativen Anfallsoutcome (E IA vs. nicht anfallsfrei bzw. E I vs. nicht anfallsfrei) aufweisen, oder ob diese unabhängig voneinander sind. Dabei erbrachte die Gegenüberstellung der Variablen Neokortexresektion ( 30 mm) mit dem Ausprägungsmuster E IA vs. nicht anfallsfrei bei einem vorab determinierten Signifikanzniveau von p < 0.05 ein signifikantes Ergebnis. So wurde unter der Kohorte Neokortexresektion < 30 mm die Kategorie E IA bei n = 23 nachgewiesen, wohingegen das Ausprägungsmuster nicht anfallsfrei bei n = 11 feststellbar war. Bei einem Chi-Quadrat-Wert nach Pearson von 9.065 und den moderaten Effektstärken Phi-Koeffizient und Cramer`s-V von 0.245 belegten diese Resultate bei einem Signifikanzniveau von p = 0.003 ein signifikantes Testergebnis. Auf diese Weise wurde statistisch nachgewiesen, dass ein geringeres Ausmaß der Neokortexresektion (< 30 mm) mit einem besseren postoperativen Anfallsoutcome, gemäß Engel IA, korreliert. Daneben wurde anhand der Konfrontation der Variablen Hippokampektomie ( 25 mm) mit dem postoperativen Anfallsoutcome keine signifikanten Ergebnisse nachgewiesen, so dass das Ausmaß der Hippokampektomie keinen Einfluss auf das postoperative Anfallsoutcome nimmt. In einem zweiten Schritt wurde nach Unterteilung der Patientenkohorte gemäß der bereits vorhandenen Eigenschaften Hippokampektomie kurz beziehungsweise (bzw.) lang ( 25 mm) und Neokortexresektion kurz bzw. lang ( 30 mm) vier verschiedene Resektionsgruppen erstellt. Anschließend wurde eine Welch-ANOVA durchgeführt, um zu testen, ob sich die Resektionsgruppen hinsichtlich der erzielten Anfallsoutcomes unterscheiden. Die Resultate dieser Testung belegten signifikante Unterschiede bzgl. der erzielten postoperativen Anfallsoutcomes (Welch-Test F (3, 29.85) = 4.55, p = 0.010). Demnach wurde unter Hinzunahme des Games-Howell post-hoc Tests nachgewiesen, dass ein signifikanter Unterschied (p < 0.05) hinsichtlich der erzielten Anfallsoutcome zwischen Gruppe I und Gruppe III (3.59, 95% - Konfidenzintervall (CI) [0.36, 6.81]) sowie zwischen Gruppe I und Gruppe IV (2.14, 95% - CI [0.23, 4.05]) besteht. Dies wiederum fungiert als Beleg, dass eine restriktive Neokortexresektion (< 30 mm), welche exemplarisch in Gruppe I durchgeführt wurde, mit einer höheren Auftretenswahrscheinlichkeit von Engel IA korreliert, wohingegen das Ausmaß der Hippokampektomie auf das postoperative Anfallsoutcome keinen Einfluss nimmt. Ein exzellentes postoperatives Anfallsoutcome gemäß der Kategorie Engel IA nach einem epilepsiechirurgischen Eingriff am Temporallappen (CAH, SAH, tailored resection) wurde in der vorliegenden retrospektiven Datenanalyse bei denjenigen Patienten häufiger beobachtet, bei denen das Ausmaß der Neokortexresektion weniger als 30 mm betrug. Anhand der asymptotischen Signifikanz p = 0.003 wurde ein hoch signifikantes Testergebnis belegt, so dass infolgedessen von einer Korrelation zwischen dem Ausmaß der Neokortexresektion und dem postoperativen Anfallsoutcome nach Engel auszugehen ist. Dieses signifikante Ergebnis wurde zusätzlich durch die Resultate der Welch-ANOVA unterstrichen, die belegten, dass eine restriktivere Neokortexresektion, welche exemplarisch in der Resektionsgruppe I durchgeführt wurde, mit einer höheren Auftretenswahrscheinlichkeit von Engel IA korreliert. Demnach wurden unter Anwendung von zwei verschiedenen statistischen Analysen absolut kongruente Ergebnisse nachgewiesen, so dass die erzielten signifikanten Testergebnisse somit einen besonderen Stellenwert einnehmen. Da eine geringere Kortexresektion im Umkehrschluss zu einem geringeren Resektionsausmaß des eloquenten Kortex führt, wird das Erzielen einer postoperativen Anfallsfreiheit ermöglicht und das Auftreten von postoperativen neurologischen und neurokognitiven Defiziten minimiert, wodurch das Ziel der Epilepsiechirurgie vollends verwirklicht wird.Pharmacoresistant mesial temporal lobe epilepsy (MTLE) is the most common indication for performing an operative intervention in the context of epilepsy surgery and has an outstanding effectiveness in this context. Due to their established position in the therapy of focal epilepsy, the important question arose in the course of the optimal extent of resection of the neocortex and the mesiotemporal structures, which guarantees a seizure-free after surgery with simultaneous minimal neurological deficits. At the current point in time, based on the literature available on this problem, no clear statement can be discerned that describes and defines the extent of the resection to be favored. This doctoral thesis therefore examines the following research question as to whether there is a correlation between the resection extent of the corticoamygdalohippocampectomy and the postoperative seizure outcome. In the neurosurgical clinic of the University Hospital Erlangen, 151 patients (75 men, 76 women; median age 37.97 with an SD of 11.88) with the diagnosis of pharmacoresistant temporal lobe epilepsy were included in the retrospective data analysis, which spanned a period from 2002 to 2015. Under this collective, 16 patients underwent a selective amgydalohippocampectomy (SAH), 27 a corticoamygdalohippocampectomy (CAH), and the remaining 108 patients underwent a tailored resection together with an amydalohippocampectomy. For each patient, the hippocampal length (mm) were firstly determined based on preoperative MR-Imaging, followed by the determination of both the length of the neocortex resection (mm) and the hippocampectomy (mm) which were recruited using the intraoperative MR. In addition, follow-up examinations were carried out at a time interval of 3 to 168 months, which made the last postoperative seizure outcome according to the Engel classification available for each patient. Based on this data, it was then statistically evaluated whether there was a correlation between the extent of the resection and the postoperative seizure outcome. The median resection length of the neocortex resection corresponded to 38.85 mm with an SD of 12.63 mm. On the other hand, the median extent of the hippocampectomy was 29.04 mm with an SD of 5.86 mm. The median follow-up compromised 51.14 months with an SD of 40.91 months. Within the sample, 66.1% (n = 100) achieved a postoperative seizure outcome according to Engel I, of which 48% (n = 68) met the criteria of the Engel IA category. The empirical data analysis was carried out in two steps. First of all the chi-square test was used to verify if the dichotomous variables hippocampectomy ( 25 mm) or resection of neocortex ( 30 mm) have different occurrences regarding the postoperative seizure outcome (E IA vs. not seizure-free and E I vs. not seizure-free) or whether these are independent from each other. The comparison of the variables neocortex resection ( 30 mm) with the expression pattern E IA vs. not seizure-free result with a pre-determined significance level of p < 0.05 a significant result. Category E IA was found for n = 23 under the cohort neocortical resection < 30 mm, whereas the expression pattern not seizurefree was ascertainable at n = 11. With a chi-square value according to Pearson of 9.065 and the moderate effect sizes Phi-coefficient and Cramer´s-V of 0.245, these results confirmed a significant test result with a significance level of p = 0.003. In this way it was statistically proven that a lower degree of neocortex resection (< 30 mm) correlates with a better postoperative seizure outcome, according to Engel IA. In addition, no significant results were demonstrated based on the confrontation of the variables hippocampectomy ( 25 mm) with the postoperative seizure outcome, so that the extent of the hippocampectomy has no influence on the postoperative seizure outcome. In a second step, after subdivision of the patient cohort according to the existing properties, hippocampectomy short or long ( 25 mm) and neocortex resection short or long ( 30 mm) four different resection groups were created. A Welch-ANOVA was then carried out to test whether the resection groups differ in terms of the seizure outcome achieved. The results of this test showed significant differences regarding the postoperative seizure outcome (Welch test F (3, 29.85) = 4.55, p = 0.010). Accordingly, with the addition of the Games-Howell post-hoc test, it was demonstrated that a significant difference (p < 0.05) with regard to the seizure outcome achieved between Group I and Group III (3.59, 95% - CI [0.36, 6.81]) and between Group I and Group IV (2.14, 95% - CI [0.23, 4.05]). This in turn serves as evidence that a restrictive neocortical resection (< 30 mm), which was carried out as an example in Group I, correlates with a higher probability of occurrence of Engel IA, whereas the extent of the hippocampectomy has no influence on the postoperative outcome. An excellent postoperative seizure outcome according to the Engel IA category after epilepsy surgery on the temporal lobe (CAH, SAH, tailored resection) was observed more frequently in the present retrospective data analysis in those patients for whom the extent of the neocortex resection was less than 30 mm. On the basis of the asymptotic significance p = 0.003, a highly significant test result was proven, so that a correlation between the extent of neocortex resection and the postoperative seizure outcome according to the Engel classification can be assumed. This significant result was additionally underlined by the results of the Welch-ANOVA, which demonstrated that a more restrictive neocortex resection, which was carried out as an example in resection Group I, correlated with a higher probability of occurrence of Engel IA. Accordingly, using two different statistical analyzes, absolutely consistent results were demonstrated, so that the significant test results achieved are of particular importance. Since a lower cortex resection in reverse leads to a smaller resection extent of the eloquent cortex, the achievement of a postoperative seizure freedom is made possible and the occurrence of postoperative neurological and neurocognitive deficits is minimized, whereby the goal of epilepsy surgery is fully realized

The use of strain, strain rate, and displacement by 2D speckle tracking for assessment of systolic left ventricular function in goats: applicability and influence of general anesthesia

BACKGROUND: Assessment of left ventricular (LV) systolic function can be achieved by conventional echocardiographic methods, but quantification of contractility, regional myocardial function, and ventricular synchrony is challenging. The goal of this study was to investigate the applicability of two-dimensional speckle tracking (2DST) to characterize segmental and global wall motion for assessment of LV function and LV synchrony in healthy goats. We aimed to describe the techniques, report normal values of a variety of 2DST indices, and determine the influence of general anesthesia. METHODS: Prospective study on 22 healthy female Saanen goats (3.7 ± 1.1 y, 60.2 ± 10.5 kg [mean ± SD]). All goats underwent two transthoracic echocardiographic examinations, the first standing and unsedated and the second 7.4 ± 3.5 days later during isoflurane anesthesia and positioned in sternal recumbency. Data analyses were performed offline, blinded, and in random order. Left ventricular longitudinal, radial and circumferential strain and strain rate as well as longitudinal and radial displacement were measured using 2DST methods. Summary statistics were generated and differences of 2DST variables between myocardial segments and treatments (i.e., awake vs. anesthetized) were assessed statistically (alpha level=0.05). RESULTS: Echocardiographic analyses by 2DST were feasible in all goats and at both time points. Longitudinal systolic strain, strain rate and displacement followed a gradient from apex to base. Absolute systolic strain was generally lower and strain rate was higher in awake goats compared to anesthetized goats. Circumferential and radial indices did not consistently follow a segmental pattern. Generally, peak strain occurred later in anesthetized goats compared to awake goats. General anesthesia did not significantly influence LV synchrony. CONCLUSIONS: 2SDT is a valid method for non-invasive characterization of LV wall motion in awake and anesthetized goats. The results of this study add to the understanding of LV mechanical function, aid in the diagnosis of global and segmental LV systolic dysfunction, and will be useful for future cardiovascular studies in this species. However, effects of anesthesia and species-specific characteristics should be considered when goats are used as animal models for human disease

Implementation of a three-dimensional (3D) robotic digital microscope (AEOS) in spinal procedures

Abstract Three-dimensional exoscopes have been designed to overcome certain insufficiencies of operative microscopes. We aimed to explore the clinical use in various spinal surgeries. We performed surgery on patients with different spine entities in a neurosurgical department according to the current standard operating procedures over a 4-week period of time. The microsurgical part has been performed with Aesculap AEOS 3D microscope. Three neurosurgeons with different degree of surgical expertise completed a questionnaire with 43 items based on intraoperative handling and feasibility after the procedures. We collected and analyzed data from seventeen patients (35% male/65% female) with a median age of 70 years [CI 47–86] and median BMI of 25.8 kg/m2 [range 21–33]. We included a variety of spinal pathologies (10 degenerative, 4 tumor and 3 infectious cases) with different level of complexity. Regarding setup conflicts we observed issues with adjustment of the monitor position or while using additional equipment (e.g. fluoroscopy in fusion surgery) (p = 0.007/p = 0.001). However image resolution and sharpness as well as 3D-depth perception were completely satisfactory for all surgeons in all procedures. The utilization of the exoscopic arm was easy for 76.5% of the surgeons, and all of them declared a significant improvement of the surgical corridor. The 3D-exoscope implementation appears to achieve very satisfactory results in spinal procedures especially with minimally invasive approaches

Management of perimesencephalic nonaneurysmal subarachnoid hemorrhage: a national survey

Abstract Perimesencephalic nonaneurysmal subarachnoid hemorrhage (NASAH) is a rare type of subarachnoid hemorrhage (SAH), usually associated with minor complications compared to aneurysmal SAH. Up to date, data is scarce and consensus on therapeutic management and follow-up diagnostics of NASAH is often missing. This survey aims to evaluate the clinical management among neurosurgical departments in Germany. 135 neurosurgical departments in Germany received a hardcopy questionnaire. Encompassing three case vignettes with minor, moderate and severe NASAH on CT-scans and questions including the in-hospital treatment with initial observation, blood pressure (BP) management, cerebral vasospasm (CV) prophylaxis and the need for digital subtraction angiography (DSA). 80 departments (59.2%) answered the questionnaire. Whereof, centers with a higher caseload state an elevated complication rate (Chi2 < 0.001). Initial observation on the intensive care unit is performed in 51.3%; 47.5%, 70.0% in minor, moderate and severe NASAH, respectively. Invasive BP monitoring is performed more often in severe NASAH (52.5%, 55.0%, 71.3% minor, moderate, severe). CV prophylaxis and transcranial doppler ultrasound (TCD) are performed in 41.3%, 45.0%, 63.8% in minor, moderate and severe NASAH, respectively. Indication for a second DSA is set in the majority of centers, whereas after two negative ones, a third DSA is less often indicated (2nd: 66.2%, 72.5%, 86.2%; 3rd: 3.8%, 3.8%, 13.8% minor, moderate, severe). This study confirms the influence of bleeding severity on treatment and follow-up of NASAH patients. Additionally, the existing inconsistency of treatment pathways throughout Germany is highlighted. Therefore, we suggest to conceive new treatment guidelines including this finding

Resection of supratentorial brain metastases with intraoperative radiotherapy - is it safe? Analysis and experiences of a large single center cohort

IntroductionIntraoperative Radiotherapy (ioRT) is an emerging treatment option in oncologic surgery for various diseases including intraaxial brain lesions to improve surgical outcome and accelerate the adjuvant oncologic therapy. Despite its use in glioma surgery, the application and data regarding ioRT in the treatment of brain metastases (BMs) is sparse. Here were report the largest series of supratentorial BMs treated with resection and ioRT according to functional outcome and adverse events.MethodsWe performed a retrospective chart review analysis of patients undergoing surgery for BMs following an interdisciplinary tumor board decision in every case with ioRT at our institution. Patient properties, functional status (Karnofsky Performance Score/KPS) before and after surgery as well as oncologic (disease, recursive partitioning analysis, lesion size) and operative parameters were analyzed until hospital discharge. Adverse events (AE) were recorded until 30 days after surgery and rated according to the Clavien Dindo Grading (CDG) scale.Results70 patients (40 female) with various oncologic diseases were identified and analyzed. Six underwent prior RT. Mean age was 66 ± 11 years. Preoperative median KPS was 80% with a mean BM volume of 3.2 ± 1.2 cm3. Nine patients (13%) experienced in total 14 AEs, including 2 cases (3%) of postoperative death (CDG5) and 2 with new postoperative epilepsy necessitating additional pharmacotreatment (CDG2). Five patients suffered from new neurologic deficit (CDG1) not needing further surgical or medical treatment. After surgery, the neurological status in 7 patients (10%) deteriorated while it improved in 21 cases (30%). Patients experiencing AEs had longer hospitalization and poorer postoperative KPS mdn. 90 vs. 80%. There was no statistically significant deterioration of the functional status during the immediate postoperative course in the whole patient cohort.ConclusionSurgery for supratentorial BMs with ioRT seems safe and feasible. Further studies on the benefit regarding oncologic outcome need to be performed