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  • 1
    Language: English
    In: Acta Neurochirurgica, 2010, Vol.152(7), pp.1099-1116
    Description: Byline: Volker Seifert (1) Keywords: Petroclival meningioma; Skull base surgery; Quality of life; Complex brain tumour surgery Abstract: Background Within the realm of neurosurgery, petroclival meningiomas are regarded as probably the most difficult tumour to be treated by microsurgery. This is due to the not infrequently large size of the tumours which, although predominantly located in the posterior fossa, may occupy more than one cranial compartment, with often significant space-occupying effect and brain stem compression. Frequent tight brain stem adherence as well as encasement of the basilar artery, its perforators and cranial nerves adds to the sometimes extreme difficulties of surgical tumour removal. Counselling patients as well as pre- and intraoperative decision making in petroclival meningiomas is even more difficult because upon clinical and radiological tumour detection, despite sometimes surprisingly large tumours, clinical symptoms are often only mild. Summarising the complicated development of petroclival meningioma surgery over the last 60 years, this paper represents the conceptual thinking of the author in regard to the treatment of petroclival meningiomas which has evolved over more than two decades, based on a special interest in these treacherous tumours, and accumulated experiences in the treatment of over 150 patients. Surgical concepts and the operative decision-making process are demonstrated in four illustrative cases. Methods Over a period of slightly over 20 years, between January 1988 and December 2008, 161 patients with petroclival meningiomas were managed clinically by the author or under his direct surveillance in four academic neurosurgical institutions. The observation period ranged from 4 to 242 months. Thirteen patients were lost to follow-up so, all together, complete data were available for 148 patients. In 119 patients (80%), the tumour was large. Giant tumours accounted for 7% and 11 patients, medium-sized tumours were found in 12 patients (8%) and small tumours in only six patients (4%). Sixty-two percent of the patients had invasion of Meckel's cave or some part of the cavernous sinus, mainly the posterior region to different degrees. All giant tumours and one third of the large tumours extended into more than one cranial fossa. Results The treatment modalities in the 148 patients were as follows: microsurgery alone was performed in 71 patients (48%), microsurgery and adjuvant radiosurgery in 22 patients (15%) so in 93 patients (63%), altogether, microsurgery was the primary treatment. Twenty-nine patients (20%) underwent radiosurgery as their only treatment, and two patients (1%), during the very early phase of the study period, received radiotherapy. Twenty-four patients (16%) were only observed without any additional therapy. Gross total resection was achieved in 34 patients (37%), and subtotal resection, defined as removal of more than 90% of the tumour volume, was performed in another 36 patients (39%). Radical tumour removal was possible in 76% of the patients. There was no procedure-related death within 3 months post-surgery the early post-op surgical complication rate was 31% with new neurological deficits or worsening of pre-existing deficits. During the observation period, almost all patients recovered significantly bringing the percentage of permanent neurological deficits, again mainly cranial nerve deficits, down to 22%. Conclusions Based on the experiences of the author, the following treatment principles in petroclival meningiomas are proposed: small tumours in asymptomatic patients should be observed. If tumour growth is detected on serial magnetic resonance imaging or treatment is desired by the patient, surgery should be the first choice. Radiosurgery in growing small tumours should be reserved to patients with advanced age or significant co-morbidities. In medium-sized tumours and symptomatic patients, radical surgery should be attempted, if possible by judicious intraoperative judgement. In large and giant petroclival meningiomas, tumour resection as radical as possible judged intraoperatively with decompression of neural structures should be performed, followed by observation and, in the case of growing tumour remnants, radiosurgery. Thus, by a combined application of advanced microsurgical techniques, thoughtful, intraoperative decision making with limited surgical aggressively and, in selected patients, with small tumours or small tumour remnants simple observation or alternative or adjunct radiosurgery, excellent results as measured by tumour control and preservation of quality of life can be achieved. Author Affiliation: (1) Department of Neurosurgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany Article History: Registration Date: 05/03/2010 Received Date: 04/03/2010 Accepted Date: 05/03/2010 Online Date: 25/04/2010
    Keywords: Petroclival meningioma ; Skull base surgery ; Quality of life ; Complex brain tumour surgery
    ISSN: 0001-6268
    E-ISSN: 0942-0940
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  • 2
    Language: English
    In: Neuroscience Letters, 22 August 2012, Vol.524(1), pp.20-24
    Description: ► We examine changes in levels of CSF ADMA and ET-1 after subarachnoid hemorrhage. ► ADMA and ADMA/ET-1-ratio are associated with vasospasm after SAH. ► ET-1 seems to sustain an imbalance between vasodilators and vasoconstrictors. ► ET-1 levels are influenced by the impact of subarachnoid bleed. ► ADMA and ET-1 were not associated with delayed cerebral ischemia after SAH. Under physiological conditions, vasoconstrictors and vasodilators are counterbalanced. After aneurysmal subarachnoid hemorrhage (SAH) disturbance of this equilibrium may evoke delayed cerebral vasospasm (CVS) leading to delayed cerebral ischemia (DCI). Most studies examined either the vasoconstrictor endothelin-1 (ET-1) or the vasodilative pathway of nitric oxide (NO) and did not include investigations regarding the relationship between vasospasm and ischemia. Asymmetric dimethyl- -arginine (ADMA), an endogenous inhibitor of nitric oxide synthase (NOS), decreases the concentration of NO. Studies have correlated increasing concentrations of ADMA with the course and degree of CVS after SAH. We sought to determine, if ADMA and endothelin-1 (ET-1) are associated with CVS and/or DCI after SAH. CSF concentrations of ADMA and ET-1 were retrospectively determined in 30 patients after SAH and in controls. CVS was detected clinically and by arteriogaphy. DCI was monitored by follow-up CT scans. 17 patients developed arteriographic CVS and 4 patients developed DCI. ADMA but not ET-1 concentrations were correlated with occurrence and degree of CVS. However, ET-1 concentrations were correlated with WFNS grade on admission. Neither ADMA nor ET-1 correlated with DCI in this cohort. ET-1 concentrations seem to be associated with the impact of the SAH bleed. ADMA may be directly involved in the development and resolution of CVS after SAH via inhibition of NOS disturbing the balance of vasodilative and -constrictive components.
    Keywords: Subarachnoid Hemorrhage ; Vasospasm ; Nitric Oxide ; Nitric Oxide Synthase Inhibitor ; Adma ; Endothelin-1 ; Medicine ; Anatomy & Physiology
    ISSN: 0304-3940
    E-ISSN: 1872-7972
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  • 3
    Language: English
    In: Neuroscience Letters, 15 June 2011, Vol.497(1), pp.49-54
    Description: ► TFPI-2 expression is absent in the majority of high grade glioma cell lines. ► Knockdown of TFPI-2 enhances glioma cell proliferation, migration and invasion. ► The anti-invasive properties of TFPI-2 are associated with MMP-1 and MMP-2 inhibition. ► TFPI-2 is an important tumor suppressor and frequently lost during gliomagenesis. Glioblastoma is the most malignant primary brain tumor. Due to its highly promigratory and proinvasive properties, standard therapy including surgery, chemotherapy and radiation fails in eradicating this highly aggressive type of cancer. Here, we evaluated the role of TFPI-2, a Kunitz-type serine protease inhibitor, which has been previously described as a tumor suppressor gene in several types of cancer, including glioma. TFPI-2 expression was absent in five of nine investigated high-grade glioma cell lines. Lentiviral knockdown of TFPI-2 in two of the TFPI-2-expressing cell lines (MZ-18 and Hs 638) was associated with pronounced changes in the cellular behavior: glioma cell proliferation, migration and invasion were significantly increased in TFPI-2 knockdown cells in comparison to empty vector-transfected control cells. Since TFPI-2 might exert its tumor suppressor function by inhibiting MMPs, we subsequently analyzed the effects of specific MMP inhibitors on cell invasion of TFPI-2 KD cells vs. control cells. The data obtained from these experiments suggest that the anti-invasive properties of TFPI-2 are associated with inhibition of MMP-1 and MMP-2, while inhibition of MMP-9 seems to play a minor role in this context. Our findings underscore the important role of TFPI-2 as a tumor suppressor gene and indicate that TFPI-2 may be a useful diagnostic marker for the aggressive phenotype of glial tumors.
    Keywords: Brain Tumor ; Tumor Suppressor ; Tumor Microenvironment ; Ecm Degradation ; Cell Proliferation ; Mmps ; Medicine ; Anatomy & Physiology
    ISSN: 0304-3940
    E-ISSN: 1872-7972
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  • 4
    Language: English
    In: Journal of Neurology, Neurosurgery & Psychiatry, 24 August 2011, Vol.82(8), p.876
    Description: Endovascular treatments such as transluminal balloon angioplasty and intra-arterial nimodipine represent rescue therapy for cerebral vasospasm (CVS) after aneurysmal subarachnoid haemorrhage (SAH). Both indication and data regarding its efficacy in the prevention of cerebral infarct are, however, inconsistent. Therefore, an MR based perfusion weighted imaging/diffusion weighted imaging (PWI/DWI) mismatch was used to indicate this treatment and to characterise its effectiveness.
    Keywords: Subarachnoid Hemorrhage ; Neuroimaging ; Perfusion ; Cardiovascular System ; Data Processing ; Aneurysm ; Arteries ; Magnetic Resonance Imaging ; Brain ; Vasoconstriction ; Neurosurgery ; Balloons ; Angiography ; Nimodipine ; Cerebral Infarction ; Neurology & Neuropathology;
    ISSN: 0022-3050
    ISSN: 00223050
    E-ISSN: 1468-330X
    E-ISSN: 1468330X
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  • 5
    Language: English
    In: Clinical Neurophysiology, May 2014, Vol.125(5), pp.e22-e23
    Description: To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.clinph.2013.12.034 Byline: Kunihiko Kodama, Mani Javadi, Volker Seifert, Andrea Szelenyi Abstract: During the surgical removal of infratentorial lesions intraoperative neuromonitoring is mostly focused on cranial nerves and brainstem auditory potentials. Despite the known risk of perforating vessel injury during microdissection within the vicinity of the brainstem, there are few reports about intraoperative neuromonitoring with somatosensory (SEP) and motor (MEP) evoked potentials assessing the medial lemniscus and corticospinal tract. This study analyses the occurrence of intraoperative changes in MEP and SEP with regard to lesion location and postoperative neurological outcome.
    Keywords: Medicine
    ISSN: 1388-2457
    E-ISSN: 1872-8952
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  • 6
    Language: English
    In: PLoS ONE, 01 January 2015, Vol.10(4), p.e0124534
    Description: Routine postoperative imaging (PI) following surgery for intracranial meningiomas is common practice in most neurosurgical departments. The purpose of this study was to determine the role of routine PI and its impact on clinical decision making after resection of meningioma.Patient and tumor characteristics, details of radiographic scans, symptoms and alteration of treatment courses were prospectively collected for patients undergoing removal of a supratentorial meningioma of the convexity, falx, tentorium, or lateral sphenoid wing at the authors' institution between January 1st, 2010 and March 31st, 2012. Patients with infratentorial manifestations or meningiomas of the skull base known to be surgically difficult (e.g. olfactory groove, petroclival, medial sphenoid wing) were not included. Maximum tumor diameter was divided into groups of 〈 3 cm (small), 3 to 6 cm (medium), and 〉 6 cm (large).206 patients with meningiomas were operated between January 2010 and March 2012. Of these, 113 patients met the inclusion criteria and were analyzed in this study. 83 patients (73.5%) did not present new neurological deficits, whereas 30 patients (26.5%) became clinically symptomatic. Symptomatic patients had a change in treatment after PI in 21 cases (70%), while PI was without consequence in 9 patients (30%). PI did not result in a change of treatment in all asymptomatic patients (p〈0.001) irrespective of tumor size (p〈0.001) or localization (p〈0.001).PI is mandatory for clinically symptomatic patients but it is safe to waive it in clinically asymptomatic patients, even if the meningioma was large in size.
    Keywords: Sciences (General)
    E-ISSN: 1932-6203
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  • 7
    Language: English
    In: Journal of Neurology, 2013, Vol.260(8), pp.2149-2155
    Description: Intravenous thrombolysis (IVT) is an established treatment in patients suffering from acute ischemic stroke (AIS). IVT might increase the risk of postoperative complications if applied prior to decompressive craniectomy (DC). Therefore, we analyzed the management of patients with and without IVT prior to DC. Between 1999 and 2011, DC was performed in 115 patients after AIS. Patients with and without IVT prior to DC were compared regarding perioperative management, postoperative complications and outcome. Postoperative complications were stratified into non-bleeding and bleeding complications. Outcome was assessed using the modified Rankin scale after three months. Two multivariate analyses were performed to identify predictors for postoperative complications and predictors for unfavourable outcome (mRS 4–6). Fifty-two of 115 patients underwent IVT prior to DC (45 %). Forty-four patients were on antiplatelet therapy prior to DC (38 %). Frequency of bleeding complications did not differ significantly in patients with IVT prior to DC compared to patients without. However, bleeding complications occurred significantly more often in patients with antiplatelet use prior to DC ( p  = 0.0003, OR 4.5). In the multivariate analysis “preoperative use of acetylsalicylic acid” was the only independent predictor associated with bleeding complications ( p  = 0.002, OR 3.9). IVT prior to DC did not predict unfavourable outcome. There was no evidence in this observational study that IVT prior to DC places patients at undue risk of bleeding complications after subsequent DC. Patients with or without IVT prior to DC suffered significantly more often from postoperative bleeding complications if antiplatelet therapy was applied before onset of AIS.
    Keywords: Decompressive craniectomy ; Stroke ; Tissue plasminogen activator ; Thrombolysis
    ISSN: 0340-5354
    E-ISSN: 1432-1459
    Source: Springer Science & Business Media B.V.
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  • 8
    Language: English
    In: Journal of the Neurological Sciences, 15 September 2013, Vol.332(1-2), pp.128-135
    Description: Erythropoietin (EPO) was proven as a promising approach for experimental subarachnoid hemorrhage (SAH). Clinical data are, however, inconclusive so far. A detailed characterization of specific EPO effects could facilitate the design of trials. The aim of the present investigation was, therefore, to characterize these effects on prevention of delayed proximal cerebral vasospasm (CVS), impaired microcirculation and cerebral blood flow (CBF) after experimental SAH. 27 male Sprague–Dawley rats were randomized in 3 groups: Sham, SAH control, and SAH EPO. SAH was induced by injection of 0.2 ml autologous blood into the cisterna magna on days 1 and 2. Animals of the SAH EPO group received 5000 iU rh EPO α 6 h after the 2nd SAH intravenously. Surviving animals were examined on day 5 by MR perfusion weighted imaging (PWI). Cerebral blood flow (CBF) and volume (CBV) were determined by PWI, proximal CVS by basilar artery (BA) diameter, and neuroprotection by hippocampal cell count (CA1–CA4). BA diameter was significantly reduced in both SAH groups, but improved significantly after EPO (Sham: 144 ± 3 μm, SAH control: 79 ± 6 μm, SAH EPO 109 ± 4 μm). The rrCBV ratio was 8.78 ± 0.72 Sham, 5.14 ± 1.73 SAH control, and 6.80 ± 0.44 SAH EPO. The improvement by EPO did not reach statistical significance. RrCBF ratio was also significantly reduced in both SAH groups, but was significantly improved by EPO (Sham: 8.78 ± 0.34, SAH control: 4.26 ± 1.05, SAH EPO 5.85 ± 0.46). Surviving neuronal cells were significantly reduced in SAH controls in all areas, but in SAH EPO only in CA1. The present data suggest that an EPO application in a timely distance to the SAH is sufficient to prevent delayed proximal CVS, but that the doses were insufficient to improve microcirculation or to be directly neuroprotective.
    Keywords: Erythropoietin ; Delayed Ischemic Neurological Deficit ; Rat Double-Hemorrhage Model ; Subarachnoid Hemorrhage ; Vasospasm ; Animal Model ; Medicine
    ISSN: 0022-510X
    E-ISSN: 1878-5883
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  • 9
    In: Spine, 2012, Vol.37(16), pp.E1001-E1008
    Description: STUDY DESIGN.: A retrospective clinical analysis of patients operated on for spinal tumors. OBJECTIVE.: To report on the importance of intraoperative neurophysiological monitoring (INM) throughout the entire surgical procedure. SUMMARY OF BACKGROUND DATA.: Postoperative neurological deterioration, despite unaltered neurophysiological monitoring, has been reported. This might be related to timely restricted monitoring. Thus, the likelihood of alterations in INM from positioning to wound closure was analyzed. METHODS.: Two hundred three patients (age range, 54.9 ± 17.4 yr) undergoing intradural tumor removal were sampled in a prospective database and analyzed for the occurrence of alterations in intraoperative somatosensory- and motor-evoked potentials. RESULTS.: INM alterations were observed in 47 of 203 (23.2%) patients. These alterations were related to tumor resection in 29 (14.3%) cases, whereas these were unrelated to tumor removal in 18 patients: laminotomy in 5 (2.5%) patients, dura opening in 7 (3.5%) patients, dura closure in 5 (2.5%) patients, and laminoplasty in 1 (0.5%) patient caused INM changes. CONCLUSION.: This study demonstrates that monitoring beyond tumor resection is of essential importance in order to detect all critical phases of surgical procedure and to counteract accordingly.
    Keywords: Adolescent–Adverse Effects ; Adult–Methods ; Aged–Adverse Effects ; Aged, 80 and Over–Pathology ; Child–Physiopathology ; Child, Preschool–Surgery ; Evoked Potentials, Motor–Etiology ; Evoked Potentials, Somatosensory–Physiopathology ; Female–Prevention & Control ; Germany–Diagnosis ; Humans–Physiopathology ; Infant–Surgery ; Laminectomy–Surgery ; Magnetic Resonance Imaging–Surgery ; Male–Surgery ; Middle Aged–Surgery ; Monitoring, Intraoperative–Surgery ; Neurosurgical Procedures–Surgery ; Predictive Value of Tests–Surgery ; Retrospective Studies–Surgery ; Spinal Cord–Surgery ; Spinal Cord Injuries–Surgery ; Spinal Cord Neoplasms–Surgery ; Time Factors–Surgery ; Treatment Outcome–Surgery ; Young Adult–Surgery;
    ISSN: 0362-2436
    E-ISSN: 15281159
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  • 10
    In: Nursing Research, 2015, Vol.64(4), pp.300-305
    Description: BACKGROUND: The prevalence of sacral pressure ulcers in patients with spinal cord injuries is high. The sacral area is vulnerable to compressive pressure because of immobility and because the sacrum and posterior superior iliac prominence lie closely under the skin with no muscle layer in between. OBJECTIVE: The aim of this study was to assess peak sacral pressure before and after use of PURAP, a liquid-based pad that covers only the sacral area and can be applied on any bed surface. METHODS: Healthy volunteers (n = 12) and patients with spinal cord injuries (n = 10) took part; the patients had undergone spine surgery within 7 days before data collection. Participants were in bed, pretest pressure maps were generated, PURAP was placed for 15 minutes, and then posttest pressure maps were generated. Peak pressure was obtained every second and averaged over the entire period. Patients rated whether their comfort had improved when PURAP was in use. RESULTS: For healthy volunteers, mean pretest peak sacral pressure was 74.7 (SD = 16.2) mmHg; the posttest mean was 49.1 (SD = 7.5) mmHg (p 〈 .001, Wilcoxon signed-rank test). For patients with spinal cord injuries, mean pretest peak sacral pressure was 105.7 (SD = 22.4) mmHg; the posttest mean was 81.4 (SD = 18.3) mmHg (p 〈 .001, Wilcoxon signed-rank test). The pad reduced the peak sacral pressure in the patient group by 23% (range = 11%–42%) and in the volunteers by 32% (range = 19%–46%). Overall, 70% of the patients reported increased comfort with PURAP. DISCUSSION: Peak sacral pressure was reduced when PURAP was used. It covers only the sacral area but could help many patients with spinal cord injury because the prevalence of sacral pressure ulcers is high in this group. PURAP may be economically advantageous in countries and hospitals with limited financial resources needed for more expensive mattresses and cushions.
    Keywords: Spinal Injuries ; Pressure Sores ; Rehabilitation ; Quantitative Research ; Pressure Ulcers ; Spinal Cord Injuries ; United States–Us;
    ISSN: 0029-6562
    E-ISSN: 15389847
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