The use of FL for the resection of brain tumors is safe and feasible. Presumably, the visualization of the tumor margin depends on the histopathology and on the pre-treatment status. A randomized evaluation of FL under the YELLOW 560 nm filter is planned to prospectively analyze the extent of resection in patients with malignant brain tumors.
Objective Postoperative spinal epidural hematoma (pSEH) with symptomatic compression of nervous structures after spinal decompression surgery is a rare complication. Delayed evacuation may result in severe neurologic impairment. We present a large single-center analysis of the prevalence, potential risk factors, and functional recovery after pSEH. Methods A retrospective review of our institutional database of spinal decompression surgery over 15 years yielded 6,024 consecutive patients. A total of 42 patients who had undergone surgical revision due to postoperative neurologic deterioration or intractable radiating pain and radiographically confirmed pSEH were allocated to the pSEH group. A matched 3:1 control group was formed (126 patients with the same surgical procedure, same year, same sex, and similar age). Charts, surgical reports, and radiographic data were reviewed for demographics, duration of symptoms, history of medical treatment, medication, comorbidities, radiographic extension, surgical strategy, and pre- and postoperative neurologic performance. Median follow-up was 3 months. Risk factors for pSEH, complete recovery, and recovery of neurologic symptoms were analyzed with univariable and multivariable logistic regression models. Results The prevalence of pSEH in this population was 0.69% (n = 42) with these locations: 7 of 1,284 (0.54%) cervical, 1 of 774 (0.12%) thoracic, and 34 of 3,966 (0.85%) lumbar. Use of anticoagulants (p = 0.003), pathologic coagulation values in the preoperative blood test (p = 0.034), and cigarette smoking (p = 0.003) were identified as independent risk factors of pSEH. Surgery in more than one level showed a trend toward an increased risk of pSEH. Pain as the only symptom (p = 0.0001) was a significant predictor of complete recovery. Patients symptomatic with paraplegia (p = 0.026) had a significantly higher risk of a poor neurologic outcome without full recovery of neurologic symptoms. Conclusion The prevalence of pSEH was lower than previously reported incidences. Use of anticoagulants, pathologic coagulation values, and cigarette smoking were identified as independent risk factors of pSEH. Functional outcome was related to the duration between hematoma evacuation and the clinical presentation of symptomatic pSEH.
Treatment of glioblastoma (GBM) consists of microsurgical resection followed by concomitant radiochemotherapy and adjuvant chemotherapy. The best outcome regarding progression free (PFS) and overall survival (OS) is achieved by maximal resection. The foundation of a specialized neuro-oncology care center (NOC) has enabled the implementation of a large technical portfolio including functional imaging, awake craniotomy, PET scanning, fluorescence-guided resection, and integrated postsurgical therapy. This study analyzed whether the technically improved neurosurgical treatment structure yields a higher rate of complete resection, thus ultimately improving patient outcome. Patients and methods: The study included 149 patients treated surgically for newly diagnosed GBM. The neurological performance score (NPS) and the Karnofsky performance score (KPS) were measured before and after resection. The extent of resection (EOR) was volumetrically quantified. Patients were stratified into two subcohorts: treated before (A) and after (B) the foundation of the Regensburg NOC. The EOR and the PFS and OS were evaluated. Results: Prognostic factors for PFS and OS were age, preoperative KPS, O6-methylguanine-DNA-methyltransferase (MGMT) promoter methylation status, isocitrate dehydrogenase 1 (IDH1) mutation status and EOR. Patients with volumetrically defined complete resection had significantly better PFS (9.4 vs. 7.8 months; p = 0.042) and OS (18.4 vs. 14.5 months; p = 0.005) than patients with incomplete resection. The frequency of transient or permanent postoperative neurological deficits was not higher after complete resection in both subcohorts. The frequency of complete resection was significantly higher in subcohort B than in subcohort A (68.2% vs. 34.8%; p = 0.007). Accordingly, subcohort B showed significantly longer PFS (8.6 vs. 7.5 months; p = 0.010) and OS (18.7 vs. 12.4 months; p = 0.001). Multivariate Cox regression analysis showed complete resection, age, preoperative KPS, and MGMT promoter status as independent prognostic factors for PFS and OS. Our data show a higher frequency of complete resection in patients with GBM after the establishment of a series of technical developments that resulted in significantly better PFS and OS without increasing surgery-related morbidity.
Brain metastases (BM) develop in about 30% of all cancer patients. Surgery plays an important role in confirming neuropathological diagnosis, relieving mass effects and improving the neurological status. To select patients with the highest benefit from surgical resection, prognostic indices (RPA, GPA) have been formulated which are solely focused on survival without considering neurological improvement. In this study we analyzed the impact of surgical resection on the neurological status in addition to overall survival in 206 BM patients. Surgical mortality and morbidity was 0.0% and 10.3% respectively. New neurologic deficits occurred in 6.3% of all patients. The median overall survival was 6.3 months. Poor RPA class and short time interval between diagnosis of cancer and the occurrence of BM were independent factors predictive for poor survival. Improvement of neurological performance was achieved in 56.8% of all patients, with the highest improvement rate seen in patients presenting with increased intracranial pressure and hemiparesis. Notably, the neurological benefits were independent from RPA class. In conclusion, surgical resection leads to significant neurological improvement despite poor RPA class and short overall survival. Considering the low mortality and morbidity rates, resection should be considered as a valid option to increase neurological function and quality of life for patients with BM.
Continuous intra-arterial nimodipine infusion is an effective treatment for patients with severe cerebral vasospasm who fail to respond to HHT and oral nimodipine alone. Key to the effective administration of continuous intra-arterial nimodipine is multimodal neuromonitoring and the individual adaptation of dosage and time of infusion for each patient.
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