Failure of regular external ventricular drain exchange to reduce CSF infection.
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Antibiotic Prophylaxis↗
Biomedical subjects
D Stolke
Publications and source records attributed to D Stolke.
Palliative occipito-cervical stabilization in patients with malignant tumors of the occipito-cervical junction and the upper cervical spine.
BACKGROUND: Occipital-cervical stability may be impaired in patients with primary malignant or metastatic tumors of the cranio-cervical junction and the upper cervical spine. The purpose of this study was to evaluate occipital-cervical fixation with pre-bent titanium-loops and sublaminar wiring in order to achieve a rigid and safe stabilisation of the occipito-cervical region in this group of patients. METHOD: 20 patients with severe impairment of occipito-cervical stability due to primary malignant or metastatic cervical bone involvement were included in this study. For palliation of symptoms, resulting from destructive instability, a stabilization procedure using Ransford Loops with sublaminar cable fixation was used in these patients as a palliative therapeutic concept. FINDINGS: Pain which was the major symptom in all patients treated, showed good and immediate response to the stabilization procedures. All 20 patients were either pain free or had good improvement with less intake of analgesic drugs. Signs of spinal cord compression like spasticity and quadraparesis were less likely to improve after surgery. However in 3 of 5 patients neurological function improved after surgery whereas in 2 patients no improvement was achieved. INTERPRETATION: In all patients with impaired occipito-cervical stability due to primary malignant or metastatic tumors of the occipito-cervical junction and the upper cervical spine, immediate stabilization resulting in an improvement of pain was achieved. Occipito-cervical stabilization using contoured Ransford loops is a promising palliative therapeutic concept in this group of patients.
Adult↗
Dependence of the risk of encephalopathy on the radiotherapy volume after combined surgery and radiotherapy of invasive pituitary tumours.
The effectiveness of radiotherapy in reducing tumour recurrence of pituitary adenomas is well documented. On the other hand, the risk of side effects to the surrounding central nervous system normal tissue should not be underestimated. This retrospective study includes 58 patients with subtotally resected pituitary tumours. Photon from a 5,7 MV linear accelerator of a 60 cobalt unit with a source-isocenter distance of 80 cm were used throughout for treatment. The doses per fraction ranged from 45 Gy to 60 Gy. For a direct comparison of the different fractionation schedules, the biological effective total dose with 2 Gy per fraction was calculated for all the different application schemes with doses per fraction longer or smaller than 2 Gy. To do this, a fractionation sensitivity of the normal cerebral tissue by an square / square value of 2 Gy was assumed. Encephalopathy developed in 17 cases (28 percentage) after follow-up times of more than 5 years. Pathological CT- or MRI-findings were seen in 13 cases. Two factors were important for the genesis of radiogenic encephalopathy: 1. Multivariate analysis revealed that the risk of encephalopathy was associated with the radiation volume. 2. The location of the upper field border line was the strongest prognostic factor associated with the risk of encephalopathy (p<0.05).
Adolescent↗
[Recommendations for the management of unruptured intracranial aneurysms].
Optimal management of patients with unruptured intracranial aneurysms (UIAs) remains controversial. Recent studies have found conflicting data regarding the natural history and the treatment outcome of UIAs. Based on the recommendations published by the American Heart Association, the Section of Vascular Neurosurgery of the German Society of Neurosurgery has formed a task force to summarize the available data and to develop a practical framework for the management of UIAs. For UIAs, only evidence from nonrandomized historical cohort comparisons and case series without control subjects are available, supporting only grade C recommendations (options), but no standards (grade A) and no guidelines (grade B). The present recommendations have been developed as a neurosurgical, neuroradiological and neurological consensus. They are based on the existing data of both treatment risks and the risks of the natural history of UIAs.
Autoradiography↗
In-vivo measurement of cytochrome using NIRS during acute focal cerebral ischaemia and reperfusion in rats.
OBJECTIVES: Near-infrared spectroscopy (NIRS) based technology allows in-vivo monitoring of focal tissue cytochrome aa3 (cytochrome-c-oxidase). The aim of this study was to assess early cell alteration during acute focal cerebral ischaemia and reperfusion. METHODS: Focal cerebral ischaemia was induced in 12 rats using an endovascular occlusion technique of the middle cerebral artery (MCA). Occlusion time was 60 minutes followed by reperfusion for another 60 minutes. Monitoring of oxygen saturation (SO2) and oxidized cytochrome complex (oxid. Cytaa3 ) was performed by NIRS via a parietal burr hole before (baseline), during occlusion and reperfusion. Twenty-four hours after MCA occlusion (MCAO) infarction was confirmed by TTC staining. RESULTS: In all animals SO2 and oxid. Cytaa 3 immediately decreased to zero during occlusion indicating complete ischaemia. According to the results of NIRS measurements during reperfusion animals were subdivided into two groups. All animals of group A demonstrated identical or even higher levels of SO2 and oxid. Cytaa3 compared to baseline. On the contrary, both parameters in group B remained at a distinct lower level compared to baseline (p < 0.05). Average reperfusion/baseline ratios for SO2 and oxid. Cytaa 3 were 0.8 (+/- 0.4) and 0.4 (+/- 0.2), respectively. The results of TTC-staining were distributed to the above mentioned two groups as follows: group A, only lesions in the basal ganglia or little cortical infarction (n = 8); group B, lesions in the basal ganglia and cortical area (n =4). CONCLUSIONS: After 1 hour MCAO a subgroup of animals with associated cortical infarction was identified, whose oxid. Cytaa3 values did not reach baseline values during reperfusion indicating early intracellular disturbance.
Animals↗
Surgical removal of brain stem cavernous malformations: surgical indications, technical considerations, and results.
OBJECTIVES: This study was undertaken to review the indications for surgical treatment of brain stem cavernomas and to develop strategies to minimise the complications of surgery. PATIENTS AND RESULTS: Twelve patients underwent surgical resection of a brain stem cavernoma due to symptoms caused by one or more haemorrhages. Age ranged from 18 to 47 years (mean 29.2 years). Long term follow up (mean 3.7 years) included a complete neurological examination and annual MRI studies. The annual haemorrhage rate was 6.8 %/patient/year and a rate of 1.9 rehaemorrhages/patient/year was found. Surgery was performed under microsurgical conditions with endoscopic assistance, use of neuronavigation, and neurophysiological monitoring. Navigation proved to be reliable when applied in an early stage of operative procedure with minimal brain retraction. Endoscopy was a useful tool in some cases to confirm complete resection of the lesion and to ascertain haemostasis. Ten patients had a new neurological deficit in the early postoperative period, nine of these were transient. At the last follow up the neurological state was improved in five patients, unchanged in six, and worse in one compared with the preoperative conditions. The preoperative average Rankin score was 2.2 points and had improved at the last follow up by 0.6 points to 1.6 points. CONCLUSIONS: Symptomatic brain stem cavernomas should be considered for surgical treatment after the first bleeding. Careful selection of the optimal operative approach and a meticulous microsurgical technique are mandatory. The additional use of modern tools such as neuronavigation, endoscopic assistance, and monitoring can contribute to the safety of the procedure.
Adolescent↗
White matter disease in children treated for malignant brain tumors.
OBJECTS: The objects of the study reported were to recognize different patterns of white matter disease (WMD) in the follow-up of children after surgery, radiation and/or chemotherapy for malignant primary brain tumors and to evaluate statistical data on the incidence of WMD and various risk factors. METHODS: Magnetic resonance imaging (MRI) records were evaluated retrospectively in the routine follow-up (range 6 months to 15 years after surgery) of 44 children with malignant primary brain tumors treated with surgery and radiotherapy and/or chemotherapy. RESULTS: WMD was diagnosed in 28 children and subclassified into circumscribed white matter lesions (WML) and diffuse atrophy. WML were the most common finding ( n=13), followed by atrophy ( n=7) and the combination of both ( n=8). Statistical analysis revealed slightly more frequent atrophy in children younger than 5 years. WML could be linked with supratentorial location of the tumor, follow-up longer than 5 years, and the presence of a ventricular shunt. Intrathecal chemotherapy was also a factor, but because of the small sample size of the group this might not be valid. None of the children had neurological deficits attributed to these findings, but the impact on neuropsychological development was not determined.
Adolescent↗
[Transsphenoidal hypophysectomy of a patient with an ACTH-producing pituitary adenoma and an "empty sella" after pretreatment with etomidate].
HISTORY AND ADMISSION FINDINGS: A seventy-year-old woman was admitted to our hospital under suspicion of an adrenal Cushings's syndrome. Initial laboratory values showed elevated cortisol (834 nmol/l; normal: 180-640) which could not be suppressed after administration of 2 mg dexamethasone (632 nmol/l). Computed tomography of the abdomen showed a 19 x 34 mm mass in the region of the left adrenal gland. INVESTIGATIONS: ACTH levels were normal (42 ng/ml; 17-52). Serum cortisol remained high at 1021 nmol/l after administration of 8 mg dexamethasone. Four more doses of 2 mg dexamethasone were applied on 3 consecutive days, leading to a mild suppression of serum cortisol to 705 nmol/l, with urine cortisol levels dropping from 1915 to 101 nmol/l/24 h. The CRH-test produced a rise of serum cortisol from 895 to 1475 nmol, with ACTH rising from 42 to 68 pg/ml, a laboratory constellation consistent with the diagnosis of centrally located Cushing's syndrome (Cushing's disease). MRI failed to show an adenoma of the pituitary gland so that sinus petrosus sampling was done to confirm the diagnosis (ACTH central/peripheral 7:1; normal range < 2:1). TREATMENT AND COURSE: Serum cortisol rose to 1070 nmol/l and the patient developed pneumonia and contracted tinea. Prior to surgery we lowered the excessive cortisol levels with etomidate and successfully treated the pneumonia with antibiotics. Postoperatively clinical symptoms of Cushing's syndrome disappeared. The patient now presented with total insufficiency of the anterior pituitary. CONCLUSION: Exact hormone testing that may involve sinus petrosus sampling is necessary in diagnosing Cushing's syndrome. Even if radiological procedures cannot show an adenoma of the pituitary, transsphenoidal resection should be considered. Etomidate can lower excessive cortisol levels in seriously ill patients.
Adenoma↗
Spinal intramedullary metastases. Report of two cases and review of the literature.
Two cases of intramedullary metastasis were observed in our department within a short period of time that change the picture of uncommon locations of spinal metastases as described in literature. The patients presented primarily with rapidly progressing flaccid paraparesis of the lower extremities. Both additionally described diffusely located hypesthesia and pallhypesthesia of the limbs. One complained about sphincter disturbance. Both were treated by laminectomy and microsurgical extirpation of the tumor. In the first case reported here, an intramedullary metastasis of an epithelioid sarcoma in the conus medullaris region was ascertained which may be regarded as the first such reported case. In the second case report, histologic findings confirmed a thoracic intramedullary metastasis of a mastocarcinoma. At follow-up 6 and 8 months postoperatively, we observed full recovery of neurologic function in one patient and partial recovery in the other. Intramedullary metastases are extremely rare. Clinical presentation may show rapid onset and outcome is related to rapid resection and adjuvant therapy. In contrast to intracerebral metastases, this is a remarkable incidence of sarcomatous intramedullary metastatic disease.
Breast Neoplasms↗
[Interdisciplinary quality management in the treatment of severely injured patients. Validation of a QM system for the diagnostic and therapeutic process in early clinical management].
A multidisciplinary quality management system (QMS) for the early treatment of severely injured patients was validated in a trauma center in Germany. In the presented prospective study a QMS developed at another trauma center was implemented at the department of trauma surgery of the University of Essen for the presented study. The essential elements of the QMS were the establishment of (1) an adequate protocol for documentation, (2) 20 criteria for the assessment of treatment quality, (3) regular statistical analysis of treatment quality and (4) a quality circle comprising all medical specialties for data discussion. From 5/98-9/99 a cohort of 447 patients with an average injury severity score (ISS) of 22 +/- 17 was treated in the emergency department. The impact of the QMS was assessed in 4 periods (1: 5/1998-8/1998; 2: 9-12/1998; 3: 1-4/1999; 4: 5-8/1999). The quality circle met 8 times. For the improvement of the process 16 long-term changes were introduced. In 60% (n = 12) of the 20 assessment criteria significant improvements were detected. In diagnostics there were significant reductions of the time needed for basic radiological and sonographic check-up (from 24 +/- 12 min in the first to 14 +/- 8 min in the last period) and of the duration until performance of a cranial computed tomography in severe traumatic brain injury (sTBI; from 45 +/- 22 to 28 +/- 8 min). The rate of delayed diagnoses remained low (4% in the first, 5% in the last period). Further positive changes were the time savings in transfusion (from 35 +/- 20 to 20 +/- 4 min) and emergency operations (from 67 +/- 20 to 48 +/- 4 min) in hemorrhagic shock as well as for craniotomies (77 +/- 41 to 54 +/- 19 min) in sTBI. Apart from the significant time reductions other improvements were found. Overall mortality was diminished from 17% in the first to 10% in the last observation period. In conclusion the study revealed that the quality of the early therapy of severely injured patients was significantly improved by implementation of a multidisciplinary quality management system especially with respect to treatment efficiency.
Adolescent↗
The Department of Neurosurgery at the University Hospital of Essen Medical School.
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Faculty, Medical↗
Management-related morbidity and mortality in unselected aneurysms of the basilar trunk and vertebrobasilar junction.
OBJECTS: To analyze the management-related morbidity and mortality in unselected aneurysms of the basilar trunk and vertebrobasilar junction. The secondary objective was to investigate the factors associated with favourable or unfavourable surgical outcome in order to define subgroups for surgical and endovascular treatment. METHODS: 24 consecutive patients with aneurysms of the basilar trunk and vertebrobasilar junction were included in this study. They comprised 2.7% of all aneurysms treated during the study period between 1990 and 1997. 22 patients presented with acute subarachnoid hemorrhage (SAH) and 2 patients with symptoms of brainstem compresssion. All patients were managed using a standard protocol including surgery at the earliest possible moment, aggressive tripe-H therapy in patients with symptomatic vasospasm and mandatory follow-up angiography. 23 patients underwent surgical clipping and one patient endovascular coiling of the aneurysm. 12 patients had an excellent outcome. 6 patients had a good outcome, resulting in a total of satisfactory outcomes in 18 patients (75%). 4 patients (17%) had moderate to severe deficits. Two patients died (8%). Both patients had fusiform basilar trunk aneurysms. Good or excellent outcome was observed in 7 of 8 patients with aneurysms of the vertebrobasilar junction, 13 of 14 patients with moderate or minor SAH or without SAH (Fisher grade 0 to 2) and all patients with small sized aneurysm (n = 6). Factors mostly associated with poor outcome or death after surgical treatment were aneurysm location at the basilar trunk, large aneurysm size or fusiforme aneurysm type and severe SAH. CONCLUSIONS: Location, aneurysm size and the severity of SAH may help to predict the subgroup which highly benefits from surgical clipping of these rare vascular lesions.
Adult↗
Carotid cavernous fistula due to a ruptured intracavernous aneurysm of the internal carotid artery: treatment with selective endovascular occlusion of the aneurysm.
Intracavernous carotid artery aneurysms causing a carotid-cavernous fistula (CCF) are rare. These aneurysms usually cause neurological symptoms due to gradual expansion without rupture. If they do rupture they most often lead to a CCF instead of bleeding into the subarachnoid space. A patient is described with a ruptured intracavernous aneurysm causing a CCF resulting in acute onset of unilateral ophthalmoplegia. Selective coil embolisation of the aneurysm led to complete occlusion of the CCF with preservation of the internal carotid artery; symptoms resolved completely.
Acute Disease↗
Intradiscal pressure recordings in the cervical spine.
OBJECTIVE: Experimental investigations analyzing the biomechanics of the cervical spine are less common than similar studies of other regions of the spine. There are no reports on cervical intradiscal pressure (PID) measurements in vitro. We therefore wanted to establish normal values for PID under physiological conditions by simultaneous muscle force simulation. Moreover, the impact of ventral cervical fusion should be elucidated, because in clinical studies, it is a well-known phenomenon that the adjacent segments often show increased degenerative changes. We present a pilot study. METHODS: Seven human cervical spine specimens were tested biomechanically in a specially developed spine tester. Only pure moments were used for flexion/extension, axial rotation, and lateral bending (maximal moment +/- 0.5 Nm). PID was measured simultaneously in C3-C4 and C5-C6. The specimens were tested as intact specimens and after discectomy and fusion in C4-C5. Both test situations were repeated with simulation of muscle forces. RESULTS: We found characteristic load-pressure curves for each of the three motion axes. In neutral position, PID correlated well with former published data from in vivo measurements. After fusion of C4-C5, there was a marked increase of PID in both adjacent segments (e.g., < or = 180% for axial rotation). With muscle force simulation, the increase was even higher (e.g., < or = 400% for axial rotation). CONCLUSION: For the first time, PID could be measured in the cervical spine in an experimental setting. The results obtained using normal specimens under physiological conditions confirmed those reported in two clinical studies. After cervical fusion, a marked increase in PID could be found in both adjacent segments. Presuming that an increase in PID had a negative effect on metabolism of the intervertebral disc, our results may help to explain why progressive degeneration occurs in these segments.
Adult↗
Volume dependence of late effects after radiotherapy of invasive pituitary adenomas.
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Adenoma↗
Worldwide ethnic distribution of the G protein beta3 subunit 825T allele and its association with obesity in Caucasian, Chinese, and Black African individuals.
Recently, it was demonstrated that one allele (825T) of the gene encoding the G protein beta3 subunit (GNB3) is associated with hypertension in Germans. This study investigates a possible association with obesity in young male Germans, Chinese, and black South Africans with low, intermediate, and high 825T allele frequencies, respectively. In each of these three distinct cohorts, the 825T allele frequency was increased significantly in overweight (body mass index [BMI] > or =25 kg/m2) and obese individuals (BMI >27 kg/m2) compared to those with normal weight. The 825T allele frequencies in these three BMI groups were, respectively, 29.5, 39.3, and 47.7% in Germans, 46.8, 53.9, and 58.6% in Chinese, and 83.1, 87.7, and 90.9% in South Africans. In each of these three distinct groups, the 825T allele was significantly associated with obesity with odds ratios between 2 and 3. More urban than rural black Africans were overweight despite similar 825T allele frequencies in both populations, which underscores the role of both genetic and environmental factors. BP values in young male whites increased significantly with increasing BMI values but were independent of the C825T polymorphism, suggesting that hypertension associated with the 825T allele could be a consequence of obesity. Genotyping of 5254 individuals from 55 native population samples from Africa, the Americas, Europe, Asia, Australia, and New Guinea demonstrated highest 825T allele frequencies in black Africans (82%) and intermediate values in east Asians (47%). It is anticipated that high frequencies of the 825T allele in Africans and Asians may contribute to an obesity and hypertension epidemic if Westernization of lifestyles continues.
Adolescent↗
Dual-switch valve: clinical performance of a new hydrocephalus valve.
The Dual-Switch valve (DSV) is the first construction on the market which changes between two different valve-chambers in parallel depending on the posture of the patient. In the lying position the valve acts like a conventional differential pressure valve, in the vertical position the high-pressure chamber only opens, when the pressure exceeds the hydrostatic pressure difference between the formanen of Monro and the peritoneal cavity. The new device has been implanted in 32 adult patients with hydrocephalus of different etiology. The clinical results are excellent to good accompanied by a remarkable slight reduction of the ventricular size. Apart from one case with a nonsymptomatic transient hygroma, we saw no valve related complications like overdrainage, underdrainage or dysfunction. Contrary to conventional differential-pressure valves, adjustable devices and other hydrostatic constructions like the Anti-Siphon-device (ASD) or Deltavalve, the DSV reliably controls the IVP independently of the posture of the patient, the CSF viscosity or the subcutaneous pressure. In contrast to the Orbis-Sigma-valve (OSV) or the Diamond-valve, the DSV does not control the flow but the physiological IVP avoiding the increased risk of mechanical failure. The results of this study give strong evidence that the shunt-therapy of adult hydrocephalic patients can be significantly improved by the DSV.
Adult↗
Osteoplastic laminotomy using titanium microplates for reconstruction of the laminar roof: a technical note.
A technique to reconstruct the posterior elements of the spinal canal in osteoplastic laminotomy is described. The use of titanium microplates allows a stable fixation of the laminar arch with optimal realignment of the lamina cut ends. The titanium implants are fully compatible with magnetic resonance imaging. The author's experience with thirty patients is reported. The method proved to be simple and effective with distinct advantages over conventional techniques.
Adolescent↗