BACKGROUND Surgery is a widely accepted option for the treatment of pharmacoresistant epilepsies ... more BACKGROUND Surgery is a widely accepted option for the treatment of pharmacoresistant epilepsies of extratemporal origin. OBJECTIVE To analyze clinical and epileptological results and to provide prognostic factors influencing seizure outcome. METHODS This retrospective single-center study comprises a consecutive series of 383 patients, most of whom had an identifiable lesion on MRI, who underwent resective surgery for extratemporal epilepsy. Data including diagnostic modalities, surgical treatment, histopathology, prognostic factors, and epileptological outcome were analyzed. RESULTS Resective procedures were located as follows: frontal (n = 183), parietal (n = 44), occipital (n = 24), and insular (n = 24). In 108 cases resection included more than 1 lobe. Histopatholological evaluation revealed focal cortical dysplasias (n = 178), tumors (n = 110), cavernomas (n = 27), gliosis (n = 42), and nonspecific findings (n = 36). A distinct epileptogenic lesion was detected in 338 (88.7%) patients. After a mean follow-up of 54 mo, 227 (62.5%) patients remained free from disabling seizures (Engel class I), and 178 (49%) were completely seizure free (Engel class Ia). There was no perioperative mortality. Permanent morbidity was encountered in 46 cases (11.8%). The following predictors were significantly associated with excellent seizure outcome (Engel I): lesion visible on magnetic resonance imaging (MRI; P = .02), noneloquent location (P = .01), complete resection of the lesion (P = .001), absence of epileptic activity postoperatively (P = .001), circumscribed histological findings (P = .001), lower age at surgery (P = .008), and shorter duration of epilepsy (P = .02). CONCLUSION Surgical treatment of extratemporal epilepsy provides satisfying epileptological results with an acceptable morbidity. Best results can be achieved in younger patients with circumscribed MRI lesions, which can be resected completely.
BACKGROUND Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of... more BACKGROUND Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Current treatments of cerebral vasospasm are insufficient. Cisternal blood clearance is a promising treatment option. However, a generally applicable, safe, and effective method to access the cisterns of the brain is lacking. OBJECTIVE To report on stereotactic catheter ventriculocisternostomy (STX-VCS) as a method to access the cisterns of the brain for clearance of subarachnoid hemorrhage in patients with aSAH and coiled aneurysms. METHODS In 9 aSAH patients at high risk for DCI (Hunt and Hess grade ≥3, modified Fisher grade ≥3), access to the basal cisterns of the brain was created by STX-VCS. Fibrinolytic and/or spasmolytic lavage therapy was administered. RESULTS STX-VCS was feasible and safe in all patients. Subarachnoid blood was rapidly cleared by irrigation with urokinase. Vasospasm occurred in 2 patients and was interrupted by irrigation with nimodipine. There was 1 fatality due to pneumogenic sepsis. Minor DCI occurred in 1 patient. Eight survived without DCI and are independent (modified Rankin score [mRS] ≤ 3) at 6 mo after aSAH. CONCLUSION STX-VCS allows for rapid clearance of subarachnoid hemorrhage in patients with coiled aneurysms.
Study Design: A radiation exposure study in vitro. Objective: This study aimed to compare the rad... more Study Design: A radiation exposure study in vitro. Objective: This study aimed to compare the radiation exposure of 2 different 3-dimensional (3D) C-arm devices on an anthropomorphic phantom. Summary of Background Data: Minimally invasive pedicle screw placement requires intraoperative imaging techniques for visualization of the unexposed spine. Mobile 3D C-arms compose a 3D image data set out of multiple successive fluoroscopic images. Methods: We compared the 3D C-arm devices Siremobil Iso-C 3D (Siemens Sector Healthcare, Erlangen, Germany) and Vision FD Vario 3D (Ziehm Imaging, Nuremberg, Germany) regarding their radiation exposure. For this purpose, dosimeters were attached on an anthropomorphic phantom at various sites (eye lenses, thyroid gland, female, and male gonads). With each C-arm, 10 automated 3D scans as well as 400 fluoroscopic images were performed on the cervical and lumbar spine, respectively. Results: The Vision FD Vario 3D generally causes higher radiation exposures than the Siremobil Iso-C 3D. Significantly higher radiation exposures were assessed at the eye lenses performing cervical (294.1 vs. 84.6 μSv) and lumbar 3D scans (22.5 vs. 11.2 μSv) as well as at the thyroid gland performing cervical 3D scans (4405.2 vs. 2761.9 μSv). Moreover, the Vision FD Vario 3D caused significantly higher radiation exposure at the eye lenses for standard cervical fluoroscopic images (3.2 vs. 0.4 μSv). Conclusions: 3D C-arms facilitate minimally invasive and accurate pedicle screw placement by providing 3D image datasets for intraoperative 3D imaging and navigation. However, the hereby potentially increased radiation exposure has to be considered. In particular, the Vision FD Vario 3D appears to generally evoke higher radiation exposures than the Siremobil Iso-C 3D. Well-indicated application of ionizing radiation and compliance with radiation protection principles remain mandatory to keep radiation exposure to patient and staff as low as reasonably achievable.
BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortalit... more BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and poor disability outcome. Data on quality of life (QoL) among survivors are scarce because patients with poor-grade aSAH are underrepresented in clinical studies reporting on QoL after aSAH. OBJECTIVE: To provide prospective QoL data on survivors of poor-grade aSAH to aid clinical decision making and counseling of relatives. METHODS: The herniation World Federation of Neurosurgical Societies scale study was a prospective observational multicenter study in patients with poor-grade (World Federation of Neurosurgical Societies grades 4 & 5) aSAH. We collected data during a structured telephone interview 6 and 12 months after ictus. QoL was measured using the EuroQoL - 5 Dimensions - 3 Levels (EQ-5D-3L) questionnaire, with 0 representing a health state equivalent to death and 1 to perfect health. Disability outcome for favorable and unfavorable outcomes was measured with the modified Rankin Scale. RESULTS: Two hundred-fifty patients were enrolled, of whom 237 were included in the analysis after 6 months and 223 after 12 months. After 6 months, 118 (49.8%) patients were alive, and after 12 months, 104 (46.6%) patients were alive. Of those, 95 (80.5%) and 89 (85.6%) reached a favorable outcome with mean EQ-5D-3L index values of 0.85 (±0.18) and 0.86 (±0.18). After 6 and 12 months, 23 (19.5%) and 15 (14.4%) of those alive had an unfavorable outcome with mean EQ-5D-3L index values of 0.27 (±0.25) and 0.19 (±0.14). CONCLUSION: Despite high initial mortality, the proportion of poor-grade aSAH survivors with good QoL is reasonably large. Only a minority of survivors reports poor QoL and requires permanent care.
The number of implantable bidirectional neural interfaces available for neuroscientific research ... more The number of implantable bidirectional neural interfaces available for neuroscientific research applications is still limited, despite the rapidly increasing number of customized components. We previously reported on how to translate available components into ”ready-to-use” wireless implantable systems utilizing components off-the-shelf (COTS). The aim of the present study was to verify the viability of a micro-electrocorticographic ($\mu $ECoG) device built by this approach. Functionality for both neural recording and stimulation was evaluated in an ovine animal model using acoustic stimuli and cortical electrical stimulation, respectively. We show that auditory evoked responses were reliably recorded in both time and frequency domain and present data that demonstrates the cortical electrical stimulation functionality. The successful recording of neuronal activity suggests that the device can compete with existing implantable systems as a neurotechnological research tool.
a 61-year-old woman developed progressive exophthalmos of the left ocular bulb over a period of s... more a 61-year-old woman developed progressive exophthalmos of the left ocular bulb over a period of several weeks. she complained of conjunctival irritation, increased lacrimation, and associated gait disturbance. Ophthalmologic examination showed no visual field deficit and a visus of 0.8 versus 1.0 on her right eye. These findings remained stable at follow-up 4 weeks later. at clinical examination no neurological deficit was observed. Magnetic resonance imaging (MRI) revealed a left-sided orbital, intra-conal lesion. Lateral orbital decompression (according to Kronlein) was performed with resection of the lateral orbital wall and the orbital roof. Opening the periorbita, the capsulated tumour was situated in the intra-conal fat tissue. The tumour capsule was mostly of a white colour with some vascular injections and also adherent veins. after coagulation and opening of the capsule, the tumour was of a tough and adherent consistence, appearing white-greyish. intra-capsular tumour reduction without manipulation of the optic nerve could be achieved. The post-operative course was uneventful without visual impairment. Mild ptosis and diplopia resolved completely within several days. Imaging
Intradural petrous bone drilling has become a widespread practice, providing extended exposure in... more Intradural petrous bone drilling has become a widespread practice, providing extended exposure in the removal of cerebellopontine angle (CPA) or petroclival tumors. Adjacent neurovascular structures are at risk, however, when drilling is performed in this deep and narrow area. Hence, this study evaluates the use of Piezosurgery (PS) as a non-rotating tool for selective bone cutting in CPA surgery. A Piezosurgery® device was used in 36 patients who underwent microsurgery for extra-axial CPA or petroclival tumors in our Neurosurgical Department between 2013 and 2019. The clinical and radiological data were retrospectively analyzed. The use of PS was evaluated with respect to the intraoperative applicability and limitations as well as efficacy and safety of the procedure. Piezosurgical petrous bone cutting was successfully performed in the removal of meningiomas or extra-axial metastases arising from the dura of the petroclival region (21 patients) or petrous bone (15 patients). PS proved to be very helpful in the deep and narrow CPA region, considerably reducing the surgeon's distress toward bone removal in close proximity to cranial nerves and vessels in comparison to common rotating drills. The use of PS was safe without injuries to neurovascular structures. Gross total resection was achieved in 67% of petroclival and 100% of petrous bone tumors. Piezosurgery proved to be an effective and safe method for selective petrous bone cutting in CPA surgery avoiding rotating power and associated risks. This technique can particularly be recommended for bone cutting in close vicinity to critical neurovascular structures.
BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortalit... more BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and poor disability outcome. Data on quality of life (QoL) among survivors are scarce because patients with poor-grade aSAH are underrepresented in clinical studies reporting on QoL after aSAH. OBJECTIVE: To provide prospective QoL data on survivors of poor-grade aSAH to aid clinical decision making and counseling of relatives. METHODS: The herniation World Federation of Neurosurgical Societies scale study was a prospective observational multicenter study in patients with poor-grade (World Federation of Neurosurgical Societies grades 4 & 5) aSAH. We collected data during a structured telephone interview 6 and 12 months after ictus. QoL was measured using the EuroQoL - 5 Dimensions - 3 Levels (EQ-5D-3L) questionnaire, with 0 representing a health state equivalent to death and 1 to perfect health. Disability outcome for favorable and unfavorable outcomes was measured with the modified Ra...
SummaryThe diversity of molecular states and cellular plasticity of immune cells in the glioblast... more SummaryThe diversity of molecular states and cellular plasticity of immune cells in the glioblastoma environment is still poorly understood. Here, we performed scRNA sequencing of the immune compartment and mapped potential cellular interactions leading to an immunosuppressive microenvironment and dysfunction of T cells. Through inferring the dynamic adaptation during T cell activation, we identified three different terminal states with unique transcriptional programs. Modeling of driver genes for terminal T cell fate identified IL-10 signaling alterations in a subpopulation of HAVCR2(+) T cells. To explore in depth cellular interactions, we established an in-silico model by the integration of spatial transcriptomic and scRNA-sequencing, and identified a subset of HMOX1+ myeloid cells defined by IL10 release leading to T cell exhaustion. We found a spatial overlap between HMOX(+) myeloid and HAVCR2(+) T cells, suggesting that myeloid-lymphoid interaction causes immunosuppression pre...
BACKGROUND Surgery is a widely accepted option for the treatment of pharmacoresistant epilepsies ... more BACKGROUND Surgery is a widely accepted option for the treatment of pharmacoresistant epilepsies of extratemporal origin. OBJECTIVE To analyze clinical and epileptological results and to provide prognostic factors influencing seizure outcome. METHODS This retrospective single-center study comprises a consecutive series of 383 patients, most of whom had an identifiable lesion on MRI, who underwent resective surgery for extratemporal epilepsy. Data including diagnostic modalities, surgical treatment, histopathology, prognostic factors, and epileptological outcome were analyzed. RESULTS Resective procedures were located as follows: frontal (n = 183), parietal (n = 44), occipital (n = 24), and insular (n = 24). In 108 cases resection included more than 1 lobe. Histopatholological evaluation revealed focal cortical dysplasias (n = 178), tumors (n = 110), cavernomas (n = 27), gliosis (n = 42), and nonspecific findings (n = 36). A distinct epileptogenic lesion was detected in 338 (88.7%) patients. After a mean follow-up of 54 mo, 227 (62.5%) patients remained free from disabling seizures (Engel class I), and 178 (49%) were completely seizure free (Engel class Ia). There was no perioperative mortality. Permanent morbidity was encountered in 46 cases (11.8%). The following predictors were significantly associated with excellent seizure outcome (Engel I): lesion visible on magnetic resonance imaging (MRI; P = .02), noneloquent location (P = .01), complete resection of the lesion (P = .001), absence of epileptic activity postoperatively (P = .001), circumscribed histological findings (P = .001), lower age at surgery (P = .008), and shorter duration of epilepsy (P = .02). CONCLUSION Surgical treatment of extratemporal epilepsy provides satisfying epileptological results with an acceptable morbidity. Best results can be achieved in younger patients with circumscribed MRI lesions, which can be resected completely.
BACKGROUND Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of... more BACKGROUND Cerebral vasospasm leading to delayed cerebral infarction (DCI) is a central source of poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Current treatments of cerebral vasospasm are insufficient. Cisternal blood clearance is a promising treatment option. However, a generally applicable, safe, and effective method to access the cisterns of the brain is lacking. OBJECTIVE To report on stereotactic catheter ventriculocisternostomy (STX-VCS) as a method to access the cisterns of the brain for clearance of subarachnoid hemorrhage in patients with aSAH and coiled aneurysms. METHODS In 9 aSAH patients at high risk for DCI (Hunt and Hess grade ≥3, modified Fisher grade ≥3), access to the basal cisterns of the brain was created by STX-VCS. Fibrinolytic and/or spasmolytic lavage therapy was administered. RESULTS STX-VCS was feasible and safe in all patients. Subarachnoid blood was rapidly cleared by irrigation with urokinase. Vasospasm occurred in 2 patients and was interrupted by irrigation with nimodipine. There was 1 fatality due to pneumogenic sepsis. Minor DCI occurred in 1 patient. Eight survived without DCI and are independent (modified Rankin score [mRS] ≤ 3) at 6 mo after aSAH. CONCLUSION STX-VCS allows for rapid clearance of subarachnoid hemorrhage in patients with coiled aneurysms.
Study Design: A radiation exposure study in vitro. Objective: This study aimed to compare the rad... more Study Design: A radiation exposure study in vitro. Objective: This study aimed to compare the radiation exposure of 2 different 3-dimensional (3D) C-arm devices on an anthropomorphic phantom. Summary of Background Data: Minimally invasive pedicle screw placement requires intraoperative imaging techniques for visualization of the unexposed spine. Mobile 3D C-arms compose a 3D image data set out of multiple successive fluoroscopic images. Methods: We compared the 3D C-arm devices Siremobil Iso-C 3D (Siemens Sector Healthcare, Erlangen, Germany) and Vision FD Vario 3D (Ziehm Imaging, Nuremberg, Germany) regarding their radiation exposure. For this purpose, dosimeters were attached on an anthropomorphic phantom at various sites (eye lenses, thyroid gland, female, and male gonads). With each C-arm, 10 automated 3D scans as well as 400 fluoroscopic images were performed on the cervical and lumbar spine, respectively. Results: The Vision FD Vario 3D generally causes higher radiation exposures than the Siremobil Iso-C 3D. Significantly higher radiation exposures were assessed at the eye lenses performing cervical (294.1 vs. 84.6 μSv) and lumbar 3D scans (22.5 vs. 11.2 μSv) as well as at the thyroid gland performing cervical 3D scans (4405.2 vs. 2761.9 μSv). Moreover, the Vision FD Vario 3D caused significantly higher radiation exposure at the eye lenses for standard cervical fluoroscopic images (3.2 vs. 0.4 μSv). Conclusions: 3D C-arms facilitate minimally invasive and accurate pedicle screw placement by providing 3D image datasets for intraoperative 3D imaging and navigation. However, the hereby potentially increased radiation exposure has to be considered. In particular, the Vision FD Vario 3D appears to generally evoke higher radiation exposures than the Siremobil Iso-C 3D. Well-indicated application of ionizing radiation and compliance with radiation protection principles remain mandatory to keep radiation exposure to patient and staff as low as reasonably achievable.
BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortalit... more BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and poor disability outcome. Data on quality of life (QoL) among survivors are scarce because patients with poor-grade aSAH are underrepresented in clinical studies reporting on QoL after aSAH. OBJECTIVE: To provide prospective QoL data on survivors of poor-grade aSAH to aid clinical decision making and counseling of relatives. METHODS: The herniation World Federation of Neurosurgical Societies scale study was a prospective observational multicenter study in patients with poor-grade (World Federation of Neurosurgical Societies grades 4 & 5) aSAH. We collected data during a structured telephone interview 6 and 12 months after ictus. QoL was measured using the EuroQoL - 5 Dimensions - 3 Levels (EQ-5D-3L) questionnaire, with 0 representing a health state equivalent to death and 1 to perfect health. Disability outcome for favorable and unfavorable outcomes was measured with the modified Rankin Scale. RESULTS: Two hundred-fifty patients were enrolled, of whom 237 were included in the analysis after 6 months and 223 after 12 months. After 6 months, 118 (49.8%) patients were alive, and after 12 months, 104 (46.6%) patients were alive. Of those, 95 (80.5%) and 89 (85.6%) reached a favorable outcome with mean EQ-5D-3L index values of 0.85 (±0.18) and 0.86 (±0.18). After 6 and 12 months, 23 (19.5%) and 15 (14.4%) of those alive had an unfavorable outcome with mean EQ-5D-3L index values of 0.27 (±0.25) and 0.19 (±0.14). CONCLUSION: Despite high initial mortality, the proportion of poor-grade aSAH survivors with good QoL is reasonably large. Only a minority of survivors reports poor QoL and requires permanent care.
The number of implantable bidirectional neural interfaces available for neuroscientific research ... more The number of implantable bidirectional neural interfaces available for neuroscientific research applications is still limited, despite the rapidly increasing number of customized components. We previously reported on how to translate available components into ”ready-to-use” wireless implantable systems utilizing components off-the-shelf (COTS). The aim of the present study was to verify the viability of a micro-electrocorticographic ($\mu $ECoG) device built by this approach. Functionality for both neural recording and stimulation was evaluated in an ovine animal model using acoustic stimuli and cortical electrical stimulation, respectively. We show that auditory evoked responses were reliably recorded in both time and frequency domain and present data that demonstrates the cortical electrical stimulation functionality. The successful recording of neuronal activity suggests that the device can compete with existing implantable systems as a neurotechnological research tool.
a 61-year-old woman developed progressive exophthalmos of the left ocular bulb over a period of s... more a 61-year-old woman developed progressive exophthalmos of the left ocular bulb over a period of several weeks. she complained of conjunctival irritation, increased lacrimation, and associated gait disturbance. Ophthalmologic examination showed no visual field deficit and a visus of 0.8 versus 1.0 on her right eye. These findings remained stable at follow-up 4 weeks later. at clinical examination no neurological deficit was observed. Magnetic resonance imaging (MRI) revealed a left-sided orbital, intra-conal lesion. Lateral orbital decompression (according to Kronlein) was performed with resection of the lateral orbital wall and the orbital roof. Opening the periorbita, the capsulated tumour was situated in the intra-conal fat tissue. The tumour capsule was mostly of a white colour with some vascular injections and also adherent veins. after coagulation and opening of the capsule, the tumour was of a tough and adherent consistence, appearing white-greyish. intra-capsular tumour reduction without manipulation of the optic nerve could be achieved. The post-operative course was uneventful without visual impairment. Mild ptosis and diplopia resolved completely within several days. Imaging
Intradural petrous bone drilling has become a widespread practice, providing extended exposure in... more Intradural petrous bone drilling has become a widespread practice, providing extended exposure in the removal of cerebellopontine angle (CPA) or petroclival tumors. Adjacent neurovascular structures are at risk, however, when drilling is performed in this deep and narrow area. Hence, this study evaluates the use of Piezosurgery (PS) as a non-rotating tool for selective bone cutting in CPA surgery. A Piezosurgery® device was used in 36 patients who underwent microsurgery for extra-axial CPA or petroclival tumors in our Neurosurgical Department between 2013 and 2019. The clinical and radiological data were retrospectively analyzed. The use of PS was evaluated with respect to the intraoperative applicability and limitations as well as efficacy and safety of the procedure. Piezosurgical petrous bone cutting was successfully performed in the removal of meningiomas or extra-axial metastases arising from the dura of the petroclival region (21 patients) or petrous bone (15 patients). PS proved to be very helpful in the deep and narrow CPA region, considerably reducing the surgeon's distress toward bone removal in close proximity to cranial nerves and vessels in comparison to common rotating drills. The use of PS was safe without injuries to neurovascular structures. Gross total resection was achieved in 67% of petroclival and 100% of petrous bone tumors. Piezosurgery proved to be an effective and safe method for selective petrous bone cutting in CPA surgery avoiding rotating power and associated risks. This technique can particularly be recommended for bone cutting in close vicinity to critical neurovascular structures.
BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortalit... more BACKGROUND: Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with high mortality and poor disability outcome. Data on quality of life (QoL) among survivors are scarce because patients with poor-grade aSAH are underrepresented in clinical studies reporting on QoL after aSAH. OBJECTIVE: To provide prospective QoL data on survivors of poor-grade aSAH to aid clinical decision making and counseling of relatives. METHODS: The herniation World Federation of Neurosurgical Societies scale study was a prospective observational multicenter study in patients with poor-grade (World Federation of Neurosurgical Societies grades 4 & 5) aSAH. We collected data during a structured telephone interview 6 and 12 months after ictus. QoL was measured using the EuroQoL - 5 Dimensions - 3 Levels (EQ-5D-3L) questionnaire, with 0 representing a health state equivalent to death and 1 to perfect health. Disability outcome for favorable and unfavorable outcomes was measured with the modified Ra...
SummaryThe diversity of molecular states and cellular plasticity of immune cells in the glioblast... more SummaryThe diversity of molecular states and cellular plasticity of immune cells in the glioblastoma environment is still poorly understood. Here, we performed scRNA sequencing of the immune compartment and mapped potential cellular interactions leading to an immunosuppressive microenvironment and dysfunction of T cells. Through inferring the dynamic adaptation during T cell activation, we identified three different terminal states with unique transcriptional programs. Modeling of driver genes for terminal T cell fate identified IL-10 signaling alterations in a subpopulation of HAVCR2(+) T cells. To explore in depth cellular interactions, we established an in-silico model by the integration of spatial transcriptomic and scRNA-sequencing, and identified a subset of HMOX1+ myeloid cells defined by IL10 release leading to T cell exhaustion. We found a spatial overlap between HMOX(+) myeloid and HAVCR2(+) T cells, suggesting that myeloid-lymphoid interaction causes immunosuppression pre...
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